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Hello! What follows is my summary of this article:
Thielman NM, Guerrant RL. Acute infectious diarrhea. N Engl J Med. Jan 2004;350(1):38-46. from the 2006 LLSA reading list.
as well as my own personal opinion as to how this article should influence clinical practice in the ED. Please participate, and let me know if this is useful! 😀
HIGHLIGHTS OF THE ARTICLE:
Case Study
An otherwise healthy 23-year-old man presets after the acute onset of watery diarrhea that has persisted for two days. He reports associated nausea and cramping but no emesis and is febrile, with a temperature of 38.7. How should he be evaluated and treated?
Definition of Acute diarrhea Less than 14 days of 200g of stool per day, or 3-4 times per day, can be accompanied by nausea, vomiting, abdominal cramping, fever
Most often responsible pathogens salmonella, camplyobacter, shigella, cryptosporidium, vibrio, yersenia, listeria, cyclospora
Diagnostic tests available for: Clostridium Difficile, giardia, rotavirus, entamoeba histolytica
Diagnostic yield of stool cultures 1.5-5.6% of the time, therefore $952-1200 per positive test!
Most bouts of diarrhea last only 1 day, so usually dont bother working up if onset is within 24hrs unless dehydrated, tenesmus, febrile, or blood/pus (microscopy reveals neutrophils) in stool
Diagnostic Clues
(for a fun song, check out - This site )
Winter VIRUSES norovirus in elderly, rotavirus in kids (this should decrease over the next few years since the vaccine just got approved), supportive hydration
Beef hx with Acute, bloody, No fever, HUS - Shiga toxin-producing E. coli
Immunocompromise, sickle cell, atherosclerosis, prosthesis salmonella (check blood and stool)
Appendicitis-like symptoms -Y. entercolitica (wouldnt ever actually take a chance with this in the ED myself!)
Fried Rice - B. cereus (preformed toxin)
Raw seafood history - vibrio
Antibiotic use (and nosocomial) C. Difficile
Traveler to 3rd world country emperic single dose quinolones unless S. asia, where resistance to quiniolones is high
Traveler/hiker with extended diarrhea giardia & cryptosporidium
AIDS with <50 CD4s - along with everything else, MAC, CMV
Already ruled out infectious agents but inflammatory diarrhea? Consider inflammatory bowel disease
Treatment Notes
Salty crackers/soups & lots of water for most patients
For kids - Bananas, Rice, Applesauce, Toast (BRAT) diet, fluids, & avoidance of milk products (diarrhea can cause temporary lactose intolerance)
Anti-motility agents (ie, lopermaine, bismuth, kaolin) can be useful for limiting disease but also may cause prolonged disease for systemic illnesses, HUS, toxic megacolon, longer infectiousness, recurrence DO NOT USE IN KIDS
Implications of this article for the ED (IMHO only!!!):
- We should probably never bother to order a stool culture if the diarrhea is that bad, will probably admit to GI or ID and they can make that call. We can, however, take a quick peek under the microscope (for neutrophils, etc) to rule out/in the nasties before deciding whether to send home or admit.
- A quick history is often more useful than any test in determining treatment/course of action, and hydration level should always be assessed
- Repeat visits for diarrhea may indicate something more serious (HIV, giardia, cryptosporidium, IBD) that we can pick up
- Prescribing of anti-motility agents are perhaps best avoided in the ED there is no follow-up and the side effects are potentially grave
- The ED is often the first line of defense in public outbreaks, so we should stay alert for patterns and report anything suspicious
Please discuss my recommendations for the ED. Do you agree or disagree? Why or why not?
Thielman NM, Guerrant RL. Acute infectious diarrhea. N Engl J Med. Jan 2004;350(1):38-46. from the 2006 LLSA reading list.
as well as my own personal opinion as to how this article should influence clinical practice in the ED. Please participate, and let me know if this is useful! 😀
HIGHLIGHTS OF THE ARTICLE:
Case Study
An otherwise healthy 23-year-old man presets after the acute onset of watery diarrhea that has persisted for two days. He reports associated nausea and cramping but no emesis and is febrile, with a temperature of 38.7. How should he be evaluated and treated?
Definition of Acute diarrhea Less than 14 days of 200g of stool per day, or 3-4 times per day, can be accompanied by nausea, vomiting, abdominal cramping, fever
Most often responsible pathogens salmonella, camplyobacter, shigella, cryptosporidium, vibrio, yersenia, listeria, cyclospora
Diagnostic tests available for: Clostridium Difficile, giardia, rotavirus, entamoeba histolytica
Diagnostic yield of stool cultures 1.5-5.6% of the time, therefore $952-1200 per positive test!
Most bouts of diarrhea last only 1 day, so usually dont bother working up if onset is within 24hrs unless dehydrated, tenesmus, febrile, or blood/pus (microscopy reveals neutrophils) in stool
Diagnostic Clues
(for a fun song, check out - This site )
Winter VIRUSES norovirus in elderly, rotavirus in kids (this should decrease over the next few years since the vaccine just got approved), supportive hydration
Beef hx with Acute, bloody, No fever, HUS - Shiga toxin-producing E. coli
Immunocompromise, sickle cell, atherosclerosis, prosthesis salmonella (check blood and stool)
Appendicitis-like symptoms -Y. entercolitica (wouldnt ever actually take a chance with this in the ED myself!)
Fried Rice - B. cereus (preformed toxin)
Raw seafood history - vibrio
Antibiotic use (and nosocomial) C. Difficile
Traveler to 3rd world country emperic single dose quinolones unless S. asia, where resistance to quiniolones is high
Traveler/hiker with extended diarrhea giardia & cryptosporidium
AIDS with <50 CD4s - along with everything else, MAC, CMV
Already ruled out infectious agents but inflammatory diarrhea? Consider inflammatory bowel disease
Treatment Notes
Salty crackers/soups & lots of water for most patients
For kids - Bananas, Rice, Applesauce, Toast (BRAT) diet, fluids, & avoidance of milk products (diarrhea can cause temporary lactose intolerance)
Anti-motility agents (ie, lopermaine, bismuth, kaolin) can be useful for limiting disease but also may cause prolonged disease for systemic illnesses, HUS, toxic megacolon, longer infectiousness, recurrence DO NOT USE IN KIDS
Implications of this article for the ED (IMHO only!!!):
- We should probably never bother to order a stool culture if the diarrhea is that bad, will probably admit to GI or ID and they can make that call. We can, however, take a quick peek under the microscope (for neutrophils, etc) to rule out/in the nasties before deciding whether to send home or admit.
- A quick history is often more useful than any test in determining treatment/course of action, and hydration level should always be assessed
- Repeat visits for diarrhea may indicate something more serious (HIV, giardia, cryptosporidium, IBD) that we can pick up
- Prescribing of anti-motility agents are perhaps best avoided in the ED there is no follow-up and the side effects are potentially grave
- The ED is often the first line of defense in public outbreaks, so we should stay alert for patterns and report anything suspicious
Please discuss my recommendations for the ED. Do you agree or disagree? Why or why not?
