GI Diarrhea and Gastroenteritis ============================ "Clinicians are remarkably tolerant of other people's diarrhea." "People with diarrhea don't want to have diarrhea." --David Shlim, M.D. þ Giardia - Flagyl 250 mg TID x 5 days þ Community-Acquired C. Difficile - Flagyl 500 TID (or 250 QID) for 10-14 days for mild-modt c diff - Vanco 125 qid 10-14d for severe - Severe is wbc > 15k, Cr > 1.5 x baseline - Recurrence 20% - Treat first recurrence the same, second with Vanco - First, the ultimate goal of treatment is to discontinue all antibiotics and allow the normal bowel microflora to restore itself. Early studies of antibiotic- associated colitis (published before C. difficile was identified as the causative agent) reported complete recovery in most patients after the discontinuation of clindamycin.34,35 Second, not all patients in whom recurrent diarrhea develops when they stop taking metronidazole or vancomycin have recurrent C. difficile infection. Other conditions, such as postinfectious irritable bowel syndrome, microscopic colitis, and inflammatory bowel disease, may be responsible. Third, a positive toxin assay in a patient with minimal or no symptoms should not prompt treatment. Repeated stool assays are not recommended after therapy, except in patients with moderate or severe diarrhea. Fourth, in patients with persistent diarrhea despite several weeks of treatment with metronidazole or vancomycin, another cause should be sought, since C. difficile is rarely if ever resistant to metronidazole or vancomycin. [Kelly CP, LaMont JT. Clostridium difficile — More Difficult Than Ever. New England Journal of Medicine 2008;359:1932-40.] þ Stool Tests for C diff - Standard EIA only 80% sensitive [Guerrero, D. M., C. Chou, et al. (2011). "Clinical and Infection Control Implications of Clostridium difficile Infection With Negative Enzyme Immunoassay for Toxin." Clin Infect Dis 53(3): 287-290.] In a prospective study of 132 patients with a diagnosis of Clostridium difficile infection (CDI) by polymerase chain reaction, 43 (32%) had enzyme immunoassay (EIA) results negative for toxin. EIA-negative patients with CDI did not differ in clinical presentation from EIA-positive patients and presented a similar risk for transmission of spores. þ Petting zoos - are great places to get Salmonella, E. coli, cryptosporidium þ Shlim's Diarrhea Algorhithm: - History of Diarrhea ==> Stool Exam (optional) ==> Give Antibiotic See Also Food Poisoning: Organisms Diagnosis Treatment Noninfectious Diarrhea Galactosemia Iron poisoning