Diarrhea with Blood!!!??

[adagio]

Hi, in kaplan, as well as in the videos, they say that if we have a case of bloody diarrhea + severe disease (Fever+Blood+Pain+Hypotension/Increased pulse), then in that case the BEST NEXT STEP is to give Fluroquinolones ....

How come we can do that if EHEC is a possibility?!?!!? Shouldnt antibiotics not be given until we have the stool culture?

( I read on uptodate that antibiotics in EHEC would increase the incidence of HUS, meaning, that even if the patient do not present with HUS, then still, in the case of EHEC, we CANT GIVE Abs.

This is very confusing, would like to hear your opinion. Thanks

---

Members don't see this ad.

 

[Bacchus]

I just looked at a GI lecture given to us and the clinician told us chance of HUS is increased if treatment is not within 3 days. Side note: Using Fosfomycin instead may potentially reduce that risk:

—Treatment with TMP/SMZ, fluoroquinolones or beta-lactams increases the risk of HUS, unless given within 3 days of onset of diarrhea

—Fosfomycinmay reduce risk of HUS, especially within the first 2 days of illness

Just quoting him, there is no source given for the information.
​

 

[adagio]

Hi Bacchus, thanks for your time in replying. So basically you are saying that antibiotics within the three first days (EVEN IF ITS EHEC) do not increase HUS risk? and this would make us give abs empirically to a person with (Severe bloody diarrhea)?

I think this is a big point on the boards, so lets see what other members thing.

Thank you so much for dropping by my friend.

 

[myhandsarecold]

in this case, you can just get stool antigen and urine antigen tests, withhold the abx, and do supportive care (clear liquids, IVF, antiemetics, antinausea, and soft mechanical diet as tolerated). we had one of these cases and i suspected it was EHEC because there was possible food poisoning in the history. anyways, the bloody diarrhea stopped without much intervention other than aggressive hydration.

 

[adagio]

Hi my friend, I realzie that if theres suspicion (in the real world) u would not give abs. But in Step 2, the history comes usually a bloody diarrhea in a person and its severe, what would u do next (even if history doesnt say anything that guides towards EHEC, still its a possibility) so my question is not for the real world, rather, for the sake of the step 2


Many many thanks

 

[Fuzuli]

That would be one of the shortcomings of empirical therapy Let's go over an example:

"A 30 year old man has present to ED with severe bloody diarrhea. His vitals are: T: 38.6C, BP: 90/60 mm Hg, pulse: 110/min."

- What would be the best next step?

The next step should be opening a large bore IV access and start resuscitating the patient with SF or Ringer's lactate. This may seem obvious, but even if stool analysis or antibiotics are given as choices, this would still trump over them.

"A 30 year old man has present to ED with severe bloody diarrhea. His vitals are: T: 38.6C, BP: 90/60 mm Hg, pulse: 110/min. A 18 G IV access is made and 1 L of bolus SF is given to the patient. After 15 minutes, his vitals are now: T:38.4C, BP: 100/65 mm Hg, pulse: 90/min."

- What would be the best next step?

a) Give IV ciprofloxacin
b) Stool sample analysis for leukocytes and FOB
c) Stool ELISA for C. difficile toxin
d) Stool ovum & parasite scan x 3
e) Stool ELISA for parasitic antigens

I would choose A, since there's nothing to suggest for EHEC and this is a severe case of diarrhea. After giving empiric antibiotics, stool samples should be obtained for leukocyte and FOB analysis.

"A 30 year old man has present to ED with severe bloody diarrhea. His vitals are: T: 38.6C, BP: 90/60 mm Hg, pulse: 110/min. A 18 G IV access is made and 1 L of bolus SF is given to the patient. After 15 minutes, his vitals are now: T:38.4C, BP: 100/65 mm Hg, pulse: 90/min. The patient's history reveals that he has recently been to a rural Duck Monalds burger joint and ate a double patty BigMonalds with extra large fries."

- What would be next best step?

a) Give IV ciprofloxacin
b) Stool sample analysis for leukocytes and FOB
c) Stool ELISA for C. difficile toxin
d) Stool ovum & parasite scan x 3
e) Stool ELISA for parasitic antigens

Like you've mentioned, antibiotics are contraindicated if there's a suspected EHEC, and an uncooked burger is the classic hint. In this case, I would hold empirical antibiotics and directly proceed for B. After that, confirmatory tests for EHEC (serotyping for O157 or testing for toxin itself or toxin genes) is appropriate.

- What if the patient's history showed that he had a bout of pneumonia 2 weeks ago and his physician prescribed him PO levofloxacin for a week?

In this case, testing for C. difficile toxin is appropriate because of the likelyhood of pseudomembranous enterocolitis.

Hope this helps.

 

[adagio]

Dear fuzuli, this is a very informative post (its a shame SDN doesnt have a thank you button). Thank you soo much, its a very interesting step by step discussion. I want to add also these scenarios:

Diarrhea+Hypotension+No blood ---> IV fluids

Diarrhea, no blood, and hypotensive, and we resuscitated the guy ---> next best step: LEUKOCYTES and FOB (You agree?) ----> If positive: It has the same value as Bloody diarrhea, meaning its invasive pathogen ---> Empiric Cipro (you agree?)

 

[adagio]

I also want to tell the friends here that C.Diff CAN occur WITHOUT previous Antibiotic administration, in a long term hospitalized patients, so keep that in mind.

 

[Deferoxamine]

LOL at this thread title.

 

[Fuzuli]

Dear fuzuli, this is a very informative post (its a shame SDN doesnt have a thank you button). Thank you soo much, its a very interesting step by step discussion. I want to add also these scenarios:

You're welcome

Diarrhea, no blood, and hypotensive, and we resuscitated the guy ---> next best step: LEUKOCYTES and FOB (You agree?) ----> If positive: It has the same value as Bloody diarrhea, meaning its invasive pathogen ---> Empiric Cipro (you agree?)

Yes, choosing not to do fecal leukocytes and FOB (and C. difficile toxin when necessary) is a choice of exclusion. If the patient has anything that may indicate a more severe pathology (like hypotension, fever, recent travel, recent travel, recent antibiotics, ...), the next best step would be to obtain stool sample. If not, observation should be appropriate.

 

[adagio]

You're welcome



Yes, choosing not to do fecal leukocytes and FOB (and C. difficile toxin when necessary) is a choice of exclusion. If the patient has anything that may indicate a more severe pathology (like hypotension, fever, recent travel, recent travel, recent antibiotics, ...), the next best step would be to obtain stool sample. If not, observation should be appropriate.

Multiply-multiplied thanks for your great post.