May 2017 The Diarrhea Differential Elizabeth Liz Holston

May, 2017 The Diarrhea “Differential” Elizabeth (Liz) Holston, RN, MPH, CIC, CPHQ Infection Prevention Scripps Green Hospital

Agenda • Objectives for this session • Diarrhea: definitions • Diarrheal Illness: Why important? • Causes of diarrheal illness and commonly used testing • Challenges of testing for C difficile • Implications for Infection Prevention in the hospital setting • How to help your lab provide accurate results • Discussion 2

Objectives 1. Define diarrhea 2. Identify frequent causes of diarrhea, infectious and non infectious, acute vs. chronic 3. Explain clinical importance of diarrheal illness and implications for infection prevention in the hospital setting 4. Identify commonly used lab tests for diarrheal illness, and the challenges of testing for C difficile 3

Impact of Diarrhea Globally: • 88% diarrhea associated deaths are attributable to unsafe water, poor sanitation, inadequate hygiene. • • Most diarrheal deaths are preventable using simple low cost interventions Second leading cause of death for children <5 yrs. Diarrhea kills >2000 children daily – more than AIDS, malaria and measles combined. In USA • CDC estimated 76 million episodes/year of just foodborne illness, 325, 000 hospitalizations, 5000 deaths/year • • 1. 5 million OP visits, >1 billion $$ in direct medical costs. Leading causes include Norovirus, non-typhoidal Salmonella. spp; C difficile, and Campylobacter 4

When is it “Diarrhea”? Diarrhea is : “the passage of loose or watery stools, at least three times in a 24 -hour period. ” Note the following categories based upon the duration of symptoms: • Acute — 14 days or fewer in duration • Persistent diarrhea — more than 14 but fewer than 30 days in duration • Chronic — more than 30 days in duration Invasive diarrhea, often called dysentery: diarrhea with visible blood or mucus, in contrast to watery diarrhea. Dysentery is commonly associated with fever and abdominal pain. 5

Physiological Impact of Diarrhea Ø Depletes body fluids resulting in profound dehydration, electrolyte imbalance. (Which electrolytes? ) Ø Diarrhea is especially dangerous for: • Children, elderly and immunocompromised (Why? ) Ø Signs/Symptoms: ü Excessive thirst ü Dry mouth or skin ü Weakness, dizziness, lightheaded ü Fatigue ü Dark colored urine 6

The Diarrhea Differential: Common Causes Infectious: • Bacterial: C difficile, Shigella, enterotoxigenic E coli, Campylobacter, Salmonella, Shigella, protozoa (Giardia), Vibrio Cholerae • Viral: Norovirus, rotavirus, adenoviruses, astrovirus, cytomegalovirus, viral hepatitis Non-infectious: • Digestive disorders: • • • Inflammatory bowel disease: Crohn’s disease, ulcerative colitis, Celiac disease, Irritable bowel syndrome • Food intolerance, artificial sweeteners • Lactose intolerance • • Medications: cancer drugs, antibiotics Surgery: e. g. post-cholecystectomy • Colon cancer 7

The Diarrhea Differential: Infectious or not? 1. Nausea and vomiting initially, then diarrhea ~ 4 hrs pp 2. Mouth sores, abdominal pain, diarrhea, weight loss and fever 3. Sudden onset, loose/explosive diarrhea, vomiting / feel ill. Resolves in about 48 -72 hours 4. Chronic/intermittent lower abdominal pain, diarrhea and/or constipation 5. Loose stools begin after use of antibiotics, stops after antibiotics stopped 6. After repeated antibiotic use, significant diarrhea begins after day 3 in the hospital. 7. Chronic diarrhea, may be bloody at times, diagnosed by colonoscopy. No fever 8. Occasional loose stool, flatulence, especially after eating. 9. Fever, bloody or mucoid stools 8

The Diarrhea Differential: Infectious or not? 1. Nausea and vomiting initially, then diarrhea ~ 4 hrs pp: Salmonella 2. Mouth sores, abdominal pain, diarrhea, weight loss and fever: Crohns disease 3. Sudden onset, loose/explosive diarrhea, vomiting / feel ill. Resolves in about 48 -72 hours. Noro virus 4. Chronic/intermittent lower abdominal pain, diarrhea and/or constipation. Irritable bowel syndrome 5. Loose stools begin after use of antibiotics, stops after antibiotics stopped. Antibiotic induced diarrhea 6. After repeated antibiotic use, significant diarrhea begins after day 3 in the hospital. C difficile 7. Chronic diarrhea, may be bloody at times, diagnosed by colonoscopy. No fever. Colitis 8. Occasional loose stool, flatulence, especially after eating. Food intolerance 9. Fever, bloody or mucoid stools: Inflammatory bowel infection 9

Causes of Diarrhea- acute onset Cause Features Treatment Loose stool, low-grade fever, feel ill Fever (temperature >101°F or 38. 4°C), bloody stools Not common in developed countries, may be seen in returning traveler or camper None, usually resolves within 48 hours Usually none, antibiotics in selected situations Antibiotics in most cases Infectious diarrhea Viral infection Bacterial infection Parasite Non-infectious diarrhea Antibiotics Loose stool begins after antibiotic started, usually resolves with a few days after stopped Food intolerance (eg, lactose Diarrhea, abdominal pain, and/or intolerance) gas after consuming food Inflammatory bowel disease (eg, Mouth sores, diarrhea, Crohn's disease, ulcerative abdominal pain, weight loss, and colitis) fever Irritable bowel syndrome Chronic lower abdominal pain, diarrhea and/or constipation Celiac disease (gluten sensitivity) None to diarrhea, weight loss, abdominal pain, gas Usually none Determine if food intolerance is the cause See a healthcare provider for full evaluation and treatment Symptomatic treatment Complete avoidance of wheat, rye, barley 10

Enteric Pathogens Pathogen Small bowel Colon Bacteria Salmonella* Campylobacter* Escherichia coli¶ Shigella Clostridium perfringens Clostridium difficile Staphylococcus aureus Yersinia Aeromonas hydrophila Vibrio parahaemolyticus Bacillus cereus Enteroinvasive E. coli Vibrio cholerae Plesiomonas shigelloides Klebsiella oxytoca(rare) Virus Protozoa Rotavirus Cytomegalovirus* Norovirus Adenovirus Astrovirus Herpes simplex virus Cryptosporidium* Entamoeba histolytica Microsporidium* Cystoisospora Cyclospora Giardia lamblia 11

Assessment and Testing Patient History! Enteric pathogens: • • Shigella spp Shiga Toxin Gene E. coli O 157: H 7 Campylobacter spp. Undercooked poultry, Salmonella spp. : (non-typhoidal) poultry, eggs, milk, also meat, fresh produce. (pet reptiles) Yersinia C difficile Norovirus (Norwalk virus) Other bugs/parasites: • Giardia Hepatitis CMV PCR Stool leucocyte 12

C difficile Testing • Enzyme immunoassay. (EIA) faster than other tests, lower sensitivity • Polymerase chain reaction. (PCR) molecular test can rapidly detect the C. difficile toxin B gene in a stool sample and is highly accurate. • GDH/EIA. Some hospitals use a glutamate dehydrogenase (GDH) in conjunction with an EIA test. GDH is a sensitive assay, but non specific, and usually followed by direct cytotoxin testing or culture. • Cell cytotoxicity assay. A cytotoxicity test looks for the effects of the C. difficile toxin on human cells grown in a culture. Sensitive, but more cumbersome requires 24 to 48 hours for test results. 13

C difficile Testing: Colonization vs. Infection 1. Typical tests for C difficile and their weakness • • Ø Ø Toxin + Antigen (EIA) Enzyme immunoassay Toxin PCR (NAAT) Neither of these are diagnostic by themselves. Need clinical correlation 2. C difficile “Indeterminate” test results 3. Hospital Onset after day 3 4. What are hospitals doing to reduce # of HO cases due to likely colonization. 14

Implications for Infection Prevention • Transmission Precautions? • What type of precautions? • When? • How long? • Environmental considerations for cleaning? • What about hand hygiene? 15

How to help your lab provide accurate results 1. Timely collection 2. Proper labeling 3. Send it down fresh 16

Discussion 17