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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

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

introduction
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

chronic diarrhoea 14 days
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

cause of acute diarrhoea 14 days
Cause of Acute diarrhoea (<14 days)
  • Infectious diarrhoea
  • Medications
  • Ischemic colitis
  • Sup. Mesenteric arterial or venous thrombosis
  • Acute diverticulitis

Diarrhoea 2003, SGPGIMS, Lucknow

infectious diarrhoea mechanisms causes
Infectious diarrhoea- Mechanisms & causes

Diarrhoea 2003, SGPGIMS, Lucknow

slide7

Infectious diarrhoea- Mechanisms & causes

Diarrhoea 2003, SGPGIMS, Lucknow

diarrhoea in hiv aids patient
Diarrhoea in HIV/AIDS patient

Bacteria Virus Parasite

C. jejunii CMV Cryptosporidium

Shigella sp Enteric adeno Isospora belli

Salmonella Calici virus Cyclospora

C. difficle HIV Microsporidia

EAEC

Mycobacterium avium complex

Diarrhoea 2003, SGPGIMS, Lucknow

diagnostic approach to infective diarrhoea
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

lab diagnosis sample collection
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

lab diagnosis sample transport
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

microscopy
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

lab diagnosis enrichment medium
Lab Diagnosis- Enrichment medium

Diarrhoea 2003, SGPGIMS, Lucknow

slide14
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 of DCA/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

classification of enteropathogenic e coli
Classification of Enteropathogenic E. coli

Diarrhoea 2003, SGPGIMS, Lucknow

antibiotic associated diarrhea
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

antibiotics implicated in aad
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

lab diagnosis of aad
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

stool tests for c difficile infection
Stool Tests for C. difficile Infection

Diarrhoea 2003, SGPGIMS, Lucknow

viruses causing acute gastroenteritis
Viruses causing Acute Gastroenteritis

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

Aichi virus [ss(+)RNA

Diarrhoea 2003, SGPGIMS, Lucknow

diagnosis of viral diarrhoea
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

rational antibiotic therapy
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

rational antibiotic therapy23
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

therapeutic recomendations
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

control measures
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

control measures26
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

vibrio cholerae on tcbs
Vibrio cholerae on TCBS

Diarrhoea 2003, SGPGIMS, Lucknow

salmonella on xld
Salmonella on XLD

Diarrhoea 2003, SGPGIMS, Lucknow

isospora belli direct smear kinyoun stain
Isospora belli-Direct smear(Kinyoun stain)

Diarrhoea 2003, SGPGIMS, Lucknow

clostridium difficile growth under uv light
Clostridium difficile growth under UV light

Diarrhoea 2003, SGPGIMS, Lucknow

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