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Diagnostic Approach to Infective Diarrhoea in the Community and Rational Antibiotic Therapy. Dr. A. Ayyagari Prof. & Head Department of Microbiology SGPGIMS, Lucknow (U.P.) India. Introduction. Major public health problem in India under 5 years. 1/3 of admission and 17% of death)

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Diagnostic Approach to Infective Diarrhoea in the Community and Rational Antibiotic Therapy

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Diagnostic approach to infective diarrhoea in the community and rational antibiotic therapy l.jpg

Diagnostic Approach to Infective Diarrhoea in the Community and Rational Antibiotic Therapy

Dr. A. Ayyagari

Prof. & Head

Department of Microbiology

SGPGIMS, Lucknow (U.P.) India

Diarrhoea 2003, SGPGIMS, Lucknow


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Introduction

  • Major public health problem in India under 5 years. 1/3 of admission and 17% of death)

  • Definition “passage of loose, liquid or watery stool”.

  • Acute diarrhoea (GE)- sudden onset which usually last 3-7 days, may 10-14 days.

  • Non inflammatory e.g. V. cholerae (no abnormal histology)

  • Inflammatory- with blood and mucus e.g. Shigella

Diarrhoea 2003, SGPGIMS, Lucknow


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Diarrhoea 2003, SGPGIMS, Lucknow


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Chronic Diarrhoea (>14 days)

  • Inflammatory- ulcerative colitis, Crohn’s disease, radiation colitis

  • Osmotic- Whipple’s disease, Celiac sprue, Pancreatic insufficiency

  • Secretory- Carcinoid syndrome, ZE syndrome, VIP adenomas etc.

  • Altered motility- IBS, neurologic disease, fecal impaction

  • Factitious- laxative abuse

Diarrhoea 2003, SGPGIMS, Lucknow


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Cause of Acute diarrhoea (<14 days)

  • Infectious diarrhoea

  • Medications

  • Ischemic colitis

  • Sup. Mesenteric arterial or venous thrombosis

  • Acute diverticulitis

Diarrhoea 2003, SGPGIMS, Lucknow


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Infectious diarrhoea- Mechanisms & causes

Diarrhoea 2003, SGPGIMS, Lucknow


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Infectious diarrhoea- Mechanisms & causes

Diarrhoea 2003, SGPGIMS, Lucknow


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Diarrhoea in HIV/AIDS patient

BacteriaVirusParasite

C. jejuniiCMVCryptosporidium

Shigella spEnteric adenoIsospora belli

Salmonella Calici virusCyclospora

C. difficleHIV Microsporidia

EAEC

Mycobacterium avium complex

Diarrhoea 2003, SGPGIMS, Lucknow


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Diagnostic approach to Infective Diarrhoea

  • History

    Dietary details, travel history, source of drinking water, sexual preferences

  • Physical examination

    BP, pulse rate, pulse volume, Abd. Exam, hepatosplenomegaly, lymphadenopathy

Diarrhoea 2003, SGPGIMS, Lucknow


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Lab Diagnosis- Sample collection

-collected in acute stage

-before the start of the treatment

-before the radiological examination

-no contamination with urine water or any other infective material

-In wide mouthed leak proof screw capped container (25 ml) with a spoon (do not soil the rim of the container)

-amount 5 ml of liquid stool/pea size of formed stool

-Number – max. 3 samples (2 after normal movement and 1 after cathartic)

Diarrhoea 2003, SGPGIMS, Lucknow


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Lab Diagnosis- Sample Transport

  • Cary blair transport media (pH 8.4)- Campy., Vibrio

  • Buffered glycerol transport media (pH 7.0)- Shigella

  • V.R media (pH 8.6)- V. cholerae

  • Hank’s balanced salt solution- Virus

  • Stuart and Amies- general purpose transport media

Diarrhoea 2003, SGPGIMS, Lucknow


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Microscopy

Wet mount- Ova and trophozoites of parasites

WBCs indicate invasive pathogens

Phase contrast microsciopy- Campylobacter

Immune electron microscopy- Viruses

Staining methods -

Oocyst

Acis-fast stains- Cold/hot Kinyoun modified stain,

Giemsa stain, PAS stain, Direct fluorescence stain,

E. histolytica-Trichrome stain

Microsporidium- ModifiedTrichrome

Gram stain

Diarrhoea 2003, SGPGIMS, Lucknow


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Lab Diagnosis- Enrichment medium

Diarrhoea 2003, SGPGIMS, Lucknow


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Formed/semiformed stool

(1:10 dilution in 2-3 ml PBS or 0.1% peptone water)

Liquid stool

(Cholera suspected by characteristic Motility and immobilisation by specific sera)



Grams stain if required MacConkey Selenite F broth

 XLD/DCA GN broth

Typical morphology DSRA 

Further processing Subculture on ofDCA/MAC

Pure LF cononies within 6 hour

All NLF col(oxidase negative) on MacConkey, should be S/c on DCA

All black centered colony on DCA

All non sorbitol fermenter colony (EHEC)

Diarrhoea 2003, SGPGIMS, Lucknow


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Classification of Enteropathogenic E. coli

Diarrhoea 2003, SGPGIMS, Lucknow


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Antibiotic Associated Diarrhea

  • Most common cause of diarrhea among hospitalized patients (Range-1 in 10 to 1 in 10000)

  • 3-5 billion annual infection annually, 3 million deaths/ year.

  • 1.5 episodes per person/ year > 50% death: elderly

  • Self limiting, ~ 50% within 3 days.

Diarrhoea 2003, SGPGIMS, Lucknow


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Antibiotics implicated in AAD

  • Frequently: Ampicillin, Amoxicillin-clavulenate, 2nd & 3rd generation Cephalosporin, Clindamycin

  • Uncommon: Tetracycline, sulfonamides, Quinalone, Erythromycin, Chloramphenicol, TMP,

  • Antineoplastic agents > Methotrexate, Other agents (Anon, 1993)- Dexorubin, cyclophosphamide

  • Tube feeding- Nosocomial CD collitis.

Diarrhoea 2003, SGPGIMS, Lucknow


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Lab Diagnosis of AAD

  • Specimen- Stool (fresh sample), colonic biopsy

  • Non specific-  leucocytes in stool in AAD & PMC

  • Colonoscopy/ sigmoidoscopy (erythema, edema, friability, adhered yellow plaques) in PMC. Endoscopy ? Normal in mild cases

  • Radiographic imaging

  • Surveillance of nosocomial infection-

    • Swab from inanimate surroundings & hospital personnel

Diarrhoea 2003, SGPGIMS, Lucknow


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Stool Tests for C. difficile Infection

Diarrhoea 2003, SGPGIMS, Lucknow


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Viruses causing Acute Gastroenteritis

Other viruses- Torovirus [ss(+)RNA], Picovirna virus [dsRNA], Enterovirus 22 [ss(+)RNA],

Aichi virus [ss(+)RNA

Diarrhoea 2003, SGPGIMS, Lucknow


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Diagnosis of Viral diarrhoea

Non Rota-

  • Direct and immune Em

  • Antigen detection- EIA with hyper immune sera , EIA with monoclonal antibody

  • Antibody detection

  • Culture

  • Hybridization probes- for adeno viruses

  • RT-PCR for HuCV

    Rota-

    EIA, membrane EIA, LA, EM, culture, RT-PCR

Diarrhoea 2003, SGPGIMS, Lucknow


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Rational Antibiotic Therapy

Most cases are self limiting and subside with supportive therapy

Indication of antibiotic therapy

  • Cholera

  • Febrile bloody diarrhoea

  • Travelers diarrhoea

  • extremes of age

  • Food handlers

  • Immunocompromised

  • Day care attendee

  • Residents of institutional facility

  • Epidemic outbreaks

Diarrhoea 2003, SGPGIMS, Lucknow


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Rational Antibiotic Therapy

Problems of empiric therapy-

  • Not effective in EHEC, salmonella enterocolitis

  • In children- most cases are viral

  • Emerging drug resistance

  • Side effects

  • Alteration of gut flora

  • Induction of disease producing phage e.g; Shigatoxin phage induced by quinolones

Diarrhoea 2003, SGPGIMS, Lucknow


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Therapeutic recomendations

  • Shigella- TMP-SMZ, Cipro, Norflox

  • Salmonella-Quinolones, Ceftrixone

  • V.cholerae - Doxycycline, Tetracycline, Erythromycin

  • E. coli-Cipro, norflox

  • C. difficile-Metronidazole, Vanco

  • Cryptosporidium- Paromomycin

  • Isospora- TMP-SMZ,

  • Cyclospora-TMP-SMZ

Diarrhoea 2003, SGPGIMS, Lucknow


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Control measures

WHO, UNICEF- oral rehydration therapy.

Short-term:

(a) ORT – 1978 started in 85-86 (National program), 92-93 (included in maternal and child health program)

(b) normal food intake, breast fed

(c)Chemotherapy- Infective; Cholera

Toxins; Shigella, E. coli, Campylobacter

Invasive; Salmonella

Diarrhoea 2003, SGPGIMS, Lucknow


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Control measures

Long-term:

  • Nutrition

  • Sanitation- to stop the transmission

    Oro-Faecal

    Water supply

    Food

  • Health education- environment, clean drinking water

  • Immunization

  • Fly control

Diarrhoea 2003, SGPGIMS, Lucknow


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Vibrio cholerae on TCBS

Diarrhoea 2003, SGPGIMS, Lucknow


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Salmonella on XLD

Diarrhoea 2003, SGPGIMS, Lucknow


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Cryptosporidium parvum in stool(Modified acid fast)

Diarrhoea 2003, SGPGIMS, Lucknow


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Isospora belli-Direct smear(Kinyoun stain)

Diarrhoea 2003, SGPGIMS, Lucknow


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Cyclospora cayetanensis-oocyst (modified acid fast)

Diarrhoea 2003, SGPGIMS, Lucknow


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Microsporidian spores(Modified Trichrome blue stain)

Diarrhoea 2003, SGPGIMS, Lucknow


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Clostridium difficile growth under UV light

Diarrhoea 2003, SGPGIMS, Lucknow


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