NR 602 Soap Note -Acute Diarrhea

NR 602 Soap Note -Acute Diarrhea

NR 602 Soap Note -Acute Diarrhea

Acute Diarrhea

The term acute gastroenteritis was formerly used to describe acute diarrhea, but this term is technically a misnomer because the etiology of diarrhea does not technically involve the stomach (Guandalini and Assiri, 2014). With acute diarrhea, there is a disruption of the normal intestinal net absorptive versus secretory mechanisms of fluids and electrolytes, resulting in excessive loss of fluid into the intestinal lumen. This can lead to dehydration, electrolyte imbalance, and in severe cases, death in those also malnourished. In children younger than 2 years old, this translates to a daily stool volume of more than 10?mL/kg (this definition excludes the normal breastfeeding stooling of five or six stools per day). In children older than 2 years old, diarrheal stooling is described as occurring four or more times in 24 hours. The duration can last up to 14 days.

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Tables 33-11 and 33-14 discuss the characteristics of diarrheal diseases caused by bacteria, viruses, and parasites that a primary care provider is more likely to encounter and needs to differentiate. Infections due to Cryptosporidium, E. coli O157:H7, Giardia, Listeria, Salmonella, Shigella, and V. cholerae are required to be reported to the CDC. The enteric pathogens encountered more in day care settings include rotavirus, astrovirus, calicivirus, Campylobacter, Shigella, Giardia, and Cryptosporidium species (Guandalini and Assisri, 2014).

TABLE 33-11

Diarrheal Illnesses Due to Common Bacterial or Viral Pathogens

Etiology	Incubation Period	Signs and Symptoms	Duration of Illness	Route of Transmission	Laboratory Testing	Treatment and Complications*
Campylobacter jejuni	2 to 5 days, but can be longer	Diarrhea (foul smelling), cramps, fever, nausea and vomiting; diarrhea may be bloody in neonates Occurs in warm weather months	2 to 10 days	Raw and undercooked poultry, unpasteurized milk, contaminated water; low inoculum dose produces infection	Routine stool culture; Campylobacterrequires special media and incubation temperature; positive gross blood, leukocytes; CBC: ? WBCs	Rehydration is the mainstay. Azithromycin and erythromycin shorten the duration of the illness when given early, and usually eradicates the organism from stool within 2 to 3 days.
Clostridium difficile	Unknown	Variety of symptoms and severity are seen: mild to explosive diarrhea, bloody stools, abdominal pain, fever, nausea, vomiting Mild to moderate illness is characterized by watery diarrhea, low-grade fever, and mild abdominal pain	During or after several weeks of antibiotic use; can occur without being associated with such treatment	Acquired from the environment or from stool of other colonized or infected people by the fecal-oral route	Stool cultures; enzyme immunoassay for toxin A, or A and B; positive gross blood, leukocytes; CBC: ? WBCs; ESR normal	Discontinue current antibiotic (any antibiotic, but notably ampicillin, clindamycin, second- and third-generation cephalosporins). Fluids and electrolyte replacement are usually sufficient. If antibiotic is still needed or illness is severe, treat with oral metronidazole (drug of choice in children) or vancomycin for 7 to 10 days. Supplement with probiotics. Lactobacillus GG, Saccharomyces boulardii are recommended (Jones, 2010; Shane, 2010). Complications include pseudomembranous colitis, toxic megacolon, colonic perforation, relapse, intractable proctitis, death in debilitated children.
Enterohemorrhagic Escherichia coli(EHEC) including E. coli O157:H7 and other Shiga toxin–producing E. coli(STEC)	1 to 8 days	Severe diarrhea that is often bloody, abdominal pain and vomiting Usually little or no fever More common in children <4 years old	5 to 10 days	Undercooked beef, especially hamburger, unpasteurized milk and juice, raw fruits, vegetables (e.g., sprouts, spinach, lettuce), salami (rarely) Contaminated water; petting zoos	Stool culture; E. coliO157:H7 requires special media to grow. If E. coliO157:H7 is suspected, specific testing must be requested. Shiga toxin testing may be done using commercial kits; positive isolates should be forwarded to public health laboratories for confirmation and serotyping. Stool grossly positive for blood.	Supportive care: Monitor CBC, platelets, and kidney function closely. E. coli O157:H7 infection is also associated with HUS, which can cause lifelong complications. Studies indicate that antibiotics may promote the development of HUS.
Enterotoxigenic E. coli(ETEC) and enteroadherent E. coli (frequent cause of traveler’s diarrhea)	1 to 3 days	Watery diarrhea, abdominal cramps, some vomiting; often cause of mild traveler’s diarrhea	3 to >7 days	Water or food contaminated with human feces	Stool culture. ETEC requires special laboratory techniques for identification. If suspected, must request specific testing.	Supportive care: Antibiotics are rarely needed except in severe cases. Recommended antibiotics include TMP-SMX and quinolones. See www.cdc.gov/travel.
Listeria monocytogenes	Variable, ranging from 1 day to more than 3 weeks	Rare, but serious Fever, muscle aches, and nausea or diarrhea Pregnant women may have mild flulike illness, and infection can lead to premature delivery or stillbirth Older adults or immunocompromised patients may have bacteremia or meningitis Infants infected from mother at risk for sepsis or meningitis	Variable	Thrives in salty and acidic conditions, such as fresh soft cheeses, ready-to-eat deli meats, hot dogs; also unpasteurized milk, inadequately pasteurized milk; multiplies at low temperatures, even in properly refrigerated foods	Blood or cerebrospinal fluid cultures. Asymptomatic fecal carriage occurs; therefore, stool culture usually not helpful. Antibody to listeriolysin O may be helpful to identify outbreak retrospectively.	Initial therapy with IV ampicillin and an aminoglycoside usually gentamicin, recommended for severe infections.
Adenovirus, enteric	3 to 10 days	Children >4 years old	Variable	Fecal-oral, throughout year; can remain viable on inanimate objects	Stool specimen for adenovirus antigen via rapid commercial immunoassay techniques or per electron microscopy	Supportive care: Monitor intake and hydration status Preventive care: Good hand washing and diapering precaution
Norovirus	12 to 48 hours	Abrupt-onset watery diarrhea, nausea, vomiting, abdominal cramps	24 to 60 hours Often associated with closed venues (child care centers, cruise ships)	Fecal-oral; contaminated food (ice, shellfish, ready-to-eat foods [e.g., salads, bakery products], or water)	No commercial assay available; CDC can support laboratory evaluation or state and local health department laboratories can perform RT-PCR assays.	Supportive care: May need to treat dehydration and/or electrolyte imbalance. Preventive care: Hand hygiene, clean surfaces and food preparation areas; no swimming in recreational venues for 2 weeks after symptoms resolve.
Rotavirus	1 to 3 days; prevalent during cooler months in temperate climates	Acute-onset fever, vomiting, and watery diarrhea occur 2 to 4 days later in children <5 years old, especially those between 3 to 24 months old	3 to 8 days	Fecal-oral; viable on inanimate objects; rarely contaminated water or food	Enzyme immunoassay and latex agglutination assays for group A rotavirus antigen; virus can be found by electron microscopy and specific nucleic acid amplification methods.	Supportive care: May need to correct dehydration and electrolyte imbalances. Oral IG has been used in those immunocompromised. Preventive care: Rotavirus vaccine; hygiene and diapering precautions in day care facilities.
Salmonella spp.	1 to 3 days	Diarrhea, fever, abdominal cramps, rebound tenderness, vomiting. S. typhi and S. paratyphi produce typhoid with insidious onset characterized by fever, headache, constipation, malaise, chills, and myalgia; diarrhea is uncommon, and vomiting is not usually severe	4 to 7 days	Contaminated eggs, poultry, unpasteurized milk or juice, cheese, contaminated raw fruits and vegetables (alfalfa sprouts, melons) S. typhiepidemics are often related to fecal contamination of water supplies or street-vended foods	Routine stool cultures; positive leukocytes and gross blood. CBC: WBC can be slightly ? with left shift, ?, or normal.	Supportive care: Only consider antibiotics (other than for S. typhior S. paratyphi) for infants <3 months old, those with chronic GI disease, malignant neoplasm, hemoglobinopathies, HIV, other immunosuppressive illnesses or therapies. If indicated, consider ampicillin or amoxicillin, azithromycin, or TMP-SMX; if resistance shown to any of those, use IM ceftriaxone, cefotaxime; or azithromycin or quinolones. A vaccine exists for S. typhi in certain cases.
Shigella spp.	Varies from 1 to 7 days, but typically is 1 to 3 days	Abdominal cramps, fever, and diarrhea; Stools may contain blood and mucus Seen most commonly in those 6 months old to 3 years old	4 to 7 days	Food or water contaminated with human fecal material Usually person-to-person spread, fecal-oral transmission Ready-to-eat foods touched by infected food workers (e.g., raw vegetables, salads, sandwiches)	Routine stool cultures; gross blood, leukocytes. CBC: normal or slightly ? WBCs with left shift	Supportive care: If antibiotics indicated (severe disease, dysentery, immunocompromised), test first for susceptibility. Oral ampicillin (amoxicillin less so) or TMP-SMX recommended in the United States; for organism resistance, use IM ceftriaxone for 2 to 5 days; PO ciprofloxacin; azithromycin (oral cephalosporins not useful). If child is at risk of malnutrition, supplement with vitamin A (200,000 international units). No swimming in recreational pools/slides for 1 week after symptoms resolve.
Yersinia enterocolyticaand Y. pseudotuberculosis	Typically 4 to 6 days with a range of 1 to 14 days	Appendicitis-like symptoms (diarrhea and vomiting, fever, and RLQ pain) occur primarily in older children and young adults May have a scarlatiniform rash or erythema nodosum with Y. pseudotuberculosis Seen in all ages	1 to 3 weeks, usually self-limiting	Undercooked pork, unpasteurized milk, tofu, contaminated water Infection has occurred in infants whose caregivers handled chitterlings	Stool, vomitus, or blood culture. Yersiniarequires special medium to grow. If suspected, must request specific testing. Serology is available in research and reference laboratories.	Supportive care: If septicemia or other invasive disease occurs, antibiotic therapy with gentamicin or cefotaxime (doxycycline and ciprofloxacin also effective) after susceptibility testing is done.

See Table 33-12 for dosages.

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Clinical Findings

History

• Pattern of diarrhea:
• Appearance of stool:
• Associated symptoms:
• Number of wet diapers in the past 24 hours and approximate time of last void
• Dietary consumption: …
• Food allergies
• Family members or close friends with similar illness or other GI diseases
• Day care, school attendance, recreational swimming exposure (even if chlorinated): Illness patterns and contacts at these locations; walking in soil without shoes
• Travel history: …
• Attendance at picnics or other outings where food was consumed
• Most recent weight and previous growth pattern
• Medications: Antibiotics, laxatives, antacids, opiates (withdrawal), vitamins (toxicity)
• Pica (metals, plants)
• Chemotherapy
• Recent surgeries (abdominal)

Physical Examination

• Complete a physical examination including vital signs and assessment of behavior/mental status changes
• Assess for dehydration (seeTable 33-1)

Diagnostic Studies

Diagnostic studies are ordered if the symptoms (discussed earlier) of more serious infection are present. …

Differential Diagnosis

Diarrhea from viral etiology and antibiotic use are the most common causes of diarrhea in all age groups. …

Management

The foundation of all treatment of acute diarrhea is fourfold:

• Restore and maintain hydration…
• …
• …
• …

TABLE 33-12

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Antibiotics More Commonly Used for Diarrheal Infections

Drug	Dosage	Indication
…	25-50?mg divided in three doses, PO, for 7 to 10 days (maximum daily dose 1.5?g)	Salmonella, Shigella
…	50-100?mg/kg/day divided into four doses for 5 to 10 days (maximum daily dose 4 g)	Salmonella, Shigella
…	10?mg/kg/day first day, then 5?mg/kg/day days 2 to 5, PO (up to maximum daily dose of 500?mg on day 1; 250?mg on days 2 to 5)	Clostridium jejuni, Escherichia coliO157:H7
…	IM: 75-100?mg in three or four doses	Salmonella
…	IM: 50-75?mg in one or two doses, maximum single dose 1000?mg	Salmonella, Shigella
… (in pediatric patients, not routinely first-line therapy)	>18 years old: 20-30?mg/kg/day divided into two divided doses, PO (maximum daily dose 1.5?g) for 5 to 10 days for E. coli. Same dosage divided in two doses and treated for 7 to 10 days for Salmonella and Shigella; for 5 to 7 days for Campylobacter	E. coli O157:H7, Listeria, Shigella, Salmonella, Campylobacter
…	<8 years old: 2?mg/kg/dose every 12 hours for 3 days >8 years old: 2-4?mg/kg/day in one or two doses, PO for 7 to 10 days (maximum daily dose 200?mg)	Yersinia enterocolitis
…	30-50?mg/kg/day in two to four divided doses PO for 5 to 7 days (maximum daily dose 2?g)	C. jejuni
…	Amebiasis: 30-50?mg/kg/day in three divided doses for 7 to 10 days Clostridium difficile: 30?mg/kg/day in four divided doses for 7 to 14 days Giardiasis: 15?mg/kg/day three times a day for 5 to 7 days	C. difficile (first-line drug), Entamoeba histolytica, Giardia lamblia, C. jejuni, E. coli O157:H7
…	>8 years old: 25-50?mg/kg/day in four divided doses PO for 7 to 10 days (maximum dose 3?g)	Y. enterocolitis
…	Cyclosporiasis: 10?mg/kg/day in two divided doses for 7 to 10 days Shigellosis: Not recommended	Y. enterocolitis, Salmonella, Shigella, E. coli O157:H7, Cyclospora cayetanensis
…	40?mg/kg/day in four divided doses PO for 7 to 10 days (maximum 500?mg daily dose)	C. difficile

Data from Ahmed Bhutta Z: Acute gastroenteritis in children. In Kliegman RM, Behrman RE, Jenson HB, et?al: Nelson textbook of pediatrics, ed 18, Philadelphia, 2011; Schleiss MR, Chen SF: Principles of antiparasitic therapy. In Kliegman RM, Behrman RE, Jenson HB, et?al: Nelson textbook of pediatrics, ed 19, Philadelphia, 2011; Red book: 2012 report of the committee on infectious diseases, ed 29, Elk Grove Village, IL, 2012, American Academy of Pediatrics.

• Treat any related conditions, such as sepsis and cardiovascular collapse.

Some adjunct medications and treatments have received wider use in countries outside of the United States and show efficacy in some studies. Some of these include:

• Antidiarrheals  …
• Probiotics:Lactobacillus casei strain GG or S. boulardii (a yeast) …
• Dioctahedral smectite, …
• Oral enteric peppermint oil capsules …
• Zinc is commonly prescribed to shorten the duration of acute diarrhea in children from developing countries…