Bacterial Gastroenteritis
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Bacterial gastroenteritis has many causes, can range from mild to severe, and typically manifests with symptoms of vomiting, diarrhea, and abdominal discomfort. It is usually self-limited, but improper management of an acute infection can lead to a protracted course.
An index of suspicion can be generated for a specific set of potential causative pathogens by considering the following stool characteristics:
Appearance
Volume
Frequency
Presence or absence of blood
pH
Presence or absence of reducing substances
White blood cell (WBC) count
Serum WBC count
Diarrhea is defined as daily stools with a mass greater than 15 g/kg for children younger than 2 years and greater than 200 g for children 2 years or older. Adult stool patterns vary from 1 stool every 3 days to 3 stools per day; therefore, consider individual stool patterns.
Systemic features that can guide empiric therapy and help narrow the differential diagnosis of the causative organism include the following:
Onset and duration of symptoms
Presence or absence of vomiting
Presence or absence of fever
Presence or absence of abdominal pain
Specific bacterial pathogens may be associated with the following:
Ingestion of particular foods
Exposure to water
Exposure to animals
Travel to particular countries
Preexisting conditions
Physical findings may include the following:
Dehydration (primary cause of morbidity and mortality)
Malnutrition (typically a sign of a chronic process)
Abdominal pain
Borborygmi
Perianal erythema
See Clinical Presentation for more details.
Diagnostic approaches may include the following assessments:
Stool pH
Presence of reducing substances in stool
Fecal leukocytes
Antilisteriolysin O (ALLO)
Identification of pseudomembranes in the colon by direct visualization (diagnostic for C difficile)
Stool culture
A high index of suspicion is needed to choose the appropriate culture medium. Media used to isolate bacteria responsible for gastroenteritis include the following:
Blood agar: All aerobic bacteria and yeast; detects cytochrome oxidase production
MacConkey EMB agar: Inhibits gram-positive organisms; permits lactose fermentation
XLD agar and HE agar: Inhibit gram-positive organisms and nonpathogenic gram-negative bacilli; permit lactose fermentation and H2S production
Skirrow agar: Selective for Campylobacter species
SM agar: Selective for enterohemorrhagic E coli
CIN agar: Selective for Yersinia enterocolitica
Thiosulfate-citrate-bile-sucrose (TCBS) agar: Selective for Vibrio species
CCFE agar: Selective for C difficile
See Workup for more detail.
Because most infectious diarrheas are self-limited, medical care is primarily supportive and may include the following:
Oral rehydration: Live Lactobacillus GG and heat-killed Lactobacillus LB reduce the duration of diarrhea in children when added to oral rehydration solution [1, 2]
When oral rehydration is unsuccessful, intravenous (IV) rehydration should be provided
Close monitoring for secondary complications
For some bacterial gastroenteritis infections, antimicrobial therapy is required
For refractory cases of Cryptosporidium infection, antimotility agents are useful
Standard antimicrobial therapies for bacterial gastroenteritis include the following:
Aeromonas species: Cefixime and most third- and fourth-generation cephalosporins
Bacillus species: None necessary for self-limited gastroenteritis; vancomycin and clindamycin for severe disease
Campylobacter species: Erythromycin; therapy started more than 4 days after onset of symptoms appears to produce no clinical benefit
C difficile: Discontinuance of the potential causative antibiotics; if this is impossible or ineffective, oral metronidazole or (in seriously ill patients who do not respond to metronidazole) vancomycin
Clostridium perfringens: None
Listeria species: None necessary unless invasive disease occurs; ampicillin and trimethoprim-sulfamethoxazole (TMP-SMX) for invasive disease
Plesiomonas species: TMP-SMX or any cephalosporin
Vibrio cholerae: Tetracycline; in resistant cases, TMP-SMX, erythromycin, doxycycline, chloramphenicol, or furazolidone
Yersinia species: TMP-SMX, fluoroquinolones, or aminoglycosides; reserved for complicated cases
E coli: TMP-SMX if diarrhea is moderate or severe; for systemic complications, a parenteral second-generation or third-generation cephalosporin
Salmonella species: None necessary for nontyphoid, uncomplicated diarrhea but may be considered for infants younger than 3 months and for high-risk patients (eg, those who are immunocompromised or have sickle cell disease); for drug-sensitive strains, ampicillin or, alternatively, TMP-SMX, fluoroquinolones, or third-generation cephalosporins
Shigella species: None necessary for most mild infections; for moderate-to-severe cases, ampicillin for drug-sensitive strains and TMP-SMX for ampicillin-resistant strains or in cases of penicillin allergy; fluoroquinolones may be considered in patients with highly resistant organisms
Dietary measures include the following:
Begin with the BRAT diet (ie, bananas, rice, applesauce, toast)
Introduce lean meats and clear fluids as soon as possible [3]
When giving lactose-containing dairy products, be alert for signs of malabsorption
For infants, continue breastfeeding throughout the illness
See Treatment and Medication for more detail.
Bacterial gastroenteritis is a very common disorder. It has many causes, can range from mild to severe, and usually manifests with symptoms of vomiting, diarrhea, and abdominal discomfort. Other causes of some of these symptoms include viral infections, improper diet, malabsorption syndromes, various enteropathies, and inflammatory bowel disease. (See Etiology,Presentation, Workup, and Treatment.)
Bacterial gastroenteritis is usually self-limited, but improper management of an acute infection can lead to a protracted course. By far, the most common complication is dehydration. (See Prognosis and Presentation.) [4, 5, 6, 7]
Salmonella, Shigella, and Campylobacter species are the top three leading causes of bacterial diarrhea worldwide, followed closely by Aeromonas species.
Aeromonas and Shigella infection have a higher incidence in summer and fall, and Campylobacter infection usually occurs in summer months. Yersinia infection occurs most frequently in winter months and in colder climates.
Bacteria employ several mechanisms to invoke a pathologic response. Invasive bacteria cause mucosal ulceration and abscess formation with a subsequent inflammatory cascade. Bacterial toxins control enteral and extraenteral cellular processes. For example, the heat-labile and heat-stable enterotoxins of Escherichia coli activate enteral adenylate cyclase and guanylate cyclase signaling systems.
Verotoxin, which enterohemorrhagic E coli and Shigella species produce, causes systemic disorders such as seizures and hemolytic-uremic syndrome (HUS). Other noninvasive bacteria adhere to the gut wall, causing inflammation.
Organisms such as E coli and Clostridium species are normal enteric flora, pathogenic strains of which can cause gastroenteritis.
Vibrio parahaemolyticus, a seafood-transmitted bacterium, appears to be an emerging foodborne pathogen in North America, with over 45,000 cases every year in the United States alone. [8] The rise in incidence may be attributed in part to the climate change effects on the quantity and distribution of this pathogen. A new lineage of V parahaemolyticus has been identified (sequence type 631) that may rapidly become the predominant type endemic to the Atlantic coast of North America. [8]
Studies have suggested that the use of acid-suppressing medications (proton pump inhibitors [PPIs], although not H2 receptor antagonists [H2RAs]) may increase the risk of developing gastroenteritis by reducing the acidic environment that serves as an initial defense mechanism against gastrointestinal infections. This effect has also been noted to be dose dependent (ie, an increased dose of PPI therapy is associated with an increased risk of infection). PPI use has also been associated with a higher risk of gastroenteritis hospitalization. [49]
PPI therapy has also been suggested to be an independent risk factor for the development and recurrence of C difficilecolitis [9] as well as increases the risk Campylobacter gastroenteritis. [10]
Bacterial gastroenteritis is a very common problem in primary care and emergency department settings, especially in children younger than 5 years. [6, 7] Diarrhea accounts for as many as 5% of pediatric office visits and 10% of hospitalizations in this age group.
Very often, gastroenteritis is underreported in the adult population. Each year, gastroenteritis in adults accounts for 8 million doctor visits and 250,000 hospitalizations. Episodes of gastroenteritis do not occur at random but usually take place in outbreaks. Traveler’s diarrhea affects 20-50% of people traveling from industrialized to developing countries. [7, 11, 12]
From 2000 to 2009, the number of hospitalized patients with any Clostridium difficile infection (CDI) discharge diagnoses more than doubled, from approximately 139,000 to 336,600, and the number with a primary CDI diagnosis more than tripled, from 33,000 to 111,000. [13]
Among CDIs identified in the Center for Disease Control and Prevention’s (CDC’s) Emerging Infections Program data in 2010, 94% were associated with receiving health care; of these, 75% had onset among persons not currently hospitalized, including recently discharged patients, outpatients, and nursing home residents. [13]
Worldwide, millions of children and adults are affected by diarrhea each year. In developing countries, where sanitation is suboptimal, epidemics of bacterial gastroenteritis can develop and cause significant mortality. [5, 7, 11, 12, 14]
In a retrospective Australian study (2001-2013), investigators analyzing bacterial toxin-mediated foodborne outbreaks found that Clostridium perfringens was the most common cause (76%), and that the most common settings were commercial preparation food services (48%) and elderly care facilities (39%). [15] The main contributing factor across all outbreaks was inadequate temperature control of the food.
Most infectious diarrheas do not affect one sex more than the other. [39] Aeromonas species are a significant cause of bacterial gastroenteritis in young children. Very young children are particularly susceptible to secondary dehydration and malabsorption. Yersinia species infect children younger than 1 year almost exclusively, though it has been reported that the preparation and ingestion of chitterlings (the small intestine of pigs) may pose an increased risk of infection with Yersinia enterocolitica serotype O:3. [16, 17]
With proper management, the prognosis for bacterial gastroenteritis is very good, especially in industrialized countries. Mortality predominantly is due to dehydration and secondary malnutrition from a protracted course. Treat severe dehydration with parenteral fluids.
Once malnutrition from secondary malabsorption begins, prognosis becomes grim unless the patient is hospitalized and supplemental parenteral nutrition is started. Neonates and young infants are at particular risk for dehydration, malnutrition, and malabsorption syndromes.
Even though the mortality rate from bacterial gastroenteritis is low in industrialized countries, people can, and do, die from complications. Prognosis in countries without modern medical care or for patients with serious preexisting medical conditions is more guarded.
Diarrhea and vomiting are so commonplace that nonphysicians usually underappreciate the potential mortality and morbidity of bacterial gastroenteritis. In the United States each year, several hundred people die from complications of bacterial gastroenteritis; the majority are elderly persons.
The CDC reported that enteritis deaths more than doubled in the United States between 1999 and 2007, from about 7,000 to 17,000. Adults older than 65 years accounted for 83% of deaths. C difficile was the most common bacterial infectious cause of gastroenteritis-associated deaths, being tied to 14,500 of them (up from 2700 in 1999). [18]
Gastroenteritis-causing pathogens are the second leading cause of morbidity and mortality worldwide. Many developing countries do not have the resources to properly treat diarrhea and vomiting associated with bacterial gastroenteritis, leading to a disproportionately high mortality rate.
Common complications that can occur with various organisms in cases of bacterial gastroenteritis are as follows:
Aeromonas caviae – Intussusception, gram-negative sepsis, and hemolytic uremic syndrome (HUS)
Bacillus species – Fulminant liver failure (very rare) and rhabdomyolysis (very rare)
Campylobacter species – Bacteremia, meningitis, cholecystitis, urinary tract infection, pancreatitis, and Reiter syndrome
C difficile – Chronic diarrhea, toxic megacolon, and ileus
C perfringens serotype C – Enteritis necroticans
Enterohemorrhagic E coli – Hemorrhagic colitis
Enterohemorrhagic E coli O157:H7 – HUS
Listeria species – Bacteremia and meningitis
Plesiomonas species – Septicemia
Salmonella species – Enteric fever, bacteremia, meningitis, osteomyelitis, myocarditis, and Reiter syndrome
Shigella species – Seizures, HUS, bowel perforation, and Reiter syndrome
Vibrio species – Rapid dehydration
Yersinia enterocolitica – Appendicitis, bowel perforation, intussusception, peritonitis, toxic megacolon, cholangitis, bacteremia, and Reiter syndrome
Enteric fever
S typhi causes enteric fever. This syndrome has an insidious onset of malaise, fever, abdominal pain, and bradycardia. Diarrhea and rash (rose spots) appear after 1 week of symptoms. Bacteria may have disseminated at that time, and treatment is required to prevent systemic complications such as hepatitis, myocarditis, cholecystitis, and gastrointestinal bleeding.
HUS
Damage to the vascular endothelial cells by verotoxin causes HUS. Thrombocytopenia, microangiopathic hemolytic anemia, and acute renal failure are characteristic of HUS. Symptoms usually develop 1 week after the onset of diarrhea, when organisms may be absent.
Reiter syndrome
Reiter syndrome can complicate acute infections. Arthritis, urethritis, conjunctivitis, and mucocutaneous lesions are characteristic. Affected individuals usually do not demonstrate all the features.
Dehydration
Dehydration is the most common complication from gastroenteritis in the United States. Continuing fluid losses without compensatory intake can result in severe dehydration. Hyponatremic seizures can be avoided by rehydrating with oral rehydration solution instead of free water.
Inflammatory bowel disease
A study suggested that infectious gastroenteritis may play a role in the initiation and/or exacerbation of inflammatory bowel disease. [19] Similarly, irritable bowel syndrome may develop more often following bacterial gastroenteritis. This topic is highly controversial, and no conclusive evidence currently exists to support or refute this hypothesis.
Carrier states
Carrier states are observed after some bacterial gastroenteritis infections. After Salmonella diarrhea, 1-4% of individuals with nontyphoid and enteric fever infections become carriers. The carrier stage for Salmonella species is more likely to develop in females, infants, and individuals with biliary tract disease. Asymptomatic C difficile carriage may be seen in many hospitalized patients receiving antibiotics and in 50% of infants.
Education is most important for the prevention and treatment of bacterial gastroenteritis. Proper oral rehydration therapy helps to prevent dehydration and hastens recovery of the intestinal mucosa.
Diet restrictions that prevent secondary malabsorption are extremely important; relapse typically occurs due to dietary noncompliance.
Emphasize proper hygiene and food preparation practices to caretakers in order to prevent future infections and spread of bacterial gastroenteritis.
For patient education information, see Gastroenteritis (Stomach Flu) and Foreign Travel.
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Stool Characteristics
Small Bowel
Large Bowel
Appearance
Watery
Mucus and/or blood
Volume
Large
Small
Frequency
Increased
Increased
Blood
Possibly heme-positive but never gross blood
Possibly grossly bloody
pH
Possibly < 5.5
>5.5
Reducing substances
Possibly positive
Negative
White blood cell (WBC) count
< 5/high-power field (HPF)
Possibly >10/HPF
Serum WBC count
Normal
Possible leukocytosis, bandemia
Organisms
Preformed toxins:
Bacillus species, Staphylococcus aureus
Invasive bacteria:
E coli and Shigella, Salmonella, Campylobacter, Yersinia, Aeromonas, and Plesiomonas species
Toxic bacteria:
E coli, cholera, C perfringens, Vibrio species, Listeria monocytogenes
Toxic bacteria:
C difficile
Other causes:
rotavirus, adenovirus, calicivirus, astrovirus, Norwalk virus, and Giardia and Cryptosporidium species
Other causes:
Entamoeba species
Organism
Incubation
Duration
Vomiting
Fever
Abdominal Pain
Aeromonas species
None
0-2 weeks
+/-
+/-
No
Bacillus species
1-16 hours
1-2 days
Yes
No
Yes
Campylobacter species
2-4 days
5-7 days
No
Yes
Yes
C difficile
Variable
Variable
No
Few
Few
C perfringens
0-1
1 day
Mild
No
Yes
Enterohemorrhagic E coli
1-8 days
3-6 days
No
+/-
Yes
Enterotoxigenic E coli
1-3 days
3-5 days
Yes
Low
Yes
Listeria species
20 hours
2 days
Few
Yes
+/-
Plesiomonas species
None
0-2 weeks
+/-
+/-
+/-
Salmonella species
0-3 days
2-7 days
Yes
Yes
Yes
Shigella species
0-2 days
2-7 days
No
High
Yes
S aureus
2-6 hours
1 day
Yes
No
Yes
Vibrio species
0-1 days
5-7 days
Yes
No
Yes
Y enterocolitica
0-6
1-46 days
Yes
Yes
Yes
Organism
Detection Method
Microbiologic Characteristics
Aeromonas species
Blood agar
Oxidase-positive, flagellated GNB
Bacillus species
Blood agar
Facultatively aerobic, spore-forming GPR; beta hemolytic; reduces nitrates; ferments carbohydrates
Campylobacter species
Skirrow agar
Rapidly motile, curved GNR; Campylobacter jejuni 90% of infections, Campylobacter coli 5% of infections
C difficile
CCFE agar, EIA for toxin, LA for protein
Anaerobic, spore-forming GPR; toxin-mediated diarrhea; produces pseudomembranous colitis
C perfringens
None available
Anaerobic, spore-forming GPR; toxin-mediated diarrhea
E coli
MacConkey, EMB, or SM agar
Lactose-producing GNR
Listeria species
Blood agar
Flagellated GPB
Plesiomonas species
Blood agar
Oxidase-positive GNR
Salmonella species
Blood, MacConkey, EMB, XLD, or HE agar
Nonlactose, non–H2S-producing GNR
Shigella species
Blood, MacConkey, EMB, XLD, or HE agar
Nonlactose and H2S-producing GNR; verotoxin (neurotoxin)
Staphylococcus species
Blood agar
Heat-stable, preformed toxin-mediated GPC
Vibrio species
Blood or TCBS agar
Oxidase-positive, motile, curved GNB
Y enterocolitica
CIN agar
Nonlactose-producing, oval GNR
CCFE = cycloserine-cefoxitin-fructose-egg; CIN = cefsulodin-irgasan-novobiocin; EIA= enzyme immunoassay; EMB = e-methylene blue; GNB = gram-negative bacillus; GNR = gram-negative rod; GPB = gram-positive bacillus; GPC = gram-positive cocci; GPR = gram-positive rod; H2S = hydrogen sulfide; HE = Hektoen enteric; LA = latex agglutination; SM = Sorbitol-MacConkey; TCBS = thiosulfate-citrate-bile-sucrose; XLD = xylose-lysine-deoxycholate.
Jennifer Lynn Bonheur, MD Attending Physician, Division of Gastroenterology, Lenox Hill Hospital
Jennifer Lynn Bonheur, MD is a member of the following medical societies: American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, New York Society for Gastrointestinal Endoscopy, New York Academy of Sciences, Sigma Xi
Disclosure: Nothing to disclose.
Mukul Arya, MD Associate Professor of Internal Medicine, Weill Cornell Medical College; Assistant Director of Therapeutic Endoscopy, Department of Gastroenterology and Internal Medicine, Wyckoff Heights Medical Center
Mukul Arya, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.
M Akram Tamer, MD Professor, Program Director, Department of Pediatrics, University of Miami, Leonard M Miller School of Medicine
M Akram Tamer, MD is a member of the following medical societies: American Medical Association, Florida Medical Association
Disclosure: Nothing to disclose.
BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine
BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.
Simmy Bank, MD Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine
Disclosure: Nothing to disclose.
Richard E Frye, MD, PhD Assistant Professor, Departments of Pediatrics and Neurology, University of Texas Medical School at Houston
Richard E Frye, MD, PhD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and International Neuropsychological Society
Disclosure: Nothing to disclose.
John Gunn Lee, MD Director of Pancreaticobiliary Service, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, University of California at Irvine School of Medicine
John Gunn Lee, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
Bacterial Gastroenteritis
Research & References of Bacterial Gastroenteritis|A&C Accounting And Tax Services
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