Gastrointestinal Infections in the Elderly: Diagnosis and Treatment

1. Infectious Disease in the Elderly and Long Term Care Facilitiesmodule 1Gastrointestinal diseases UNMC Section of Infectious Diseases Brandi L. Lesiak, PA-C, MPAS Kim Meyer, PA-C, MPAS Claudia Chaperon APRN, PhD Ed Vandenberg M.D., CMD. Updated 11-23-06

2. PROCESS A series of modules and questions Step #1: Powerpoint module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break

3. Overview of Goals • To review the major points of Unit one -GI infections: gastroenteritis/colitis, hepatitis -GU infections: UTIs Unit two -Respiratory: URIs, influenza, pneumonia, & sinusitis -Skin/soft tissue: shingles, scabies • To emphasize the role these infections play in the elderly/nursing home patients

4. Objectives for module one Upon completion, the learner will be able to: • List the common causes of gastroenteritis • Describe the diagnostic features of noninvasive and invasive organisms • List the diagnostic tests and treatment for infectious causes of gastroenteritis

5. Right here!! Gastrointestinal infections“Where will you be when your diarrhea comes back?

6. Case #1 • 76 year old female in your nursing home begins having diarrhea, 6-8 stools per day • She has a low-grade temp, mild abdominal cramping, no N/V or other symptoms • She was recently treated for cellulits secondary to a cat bite with Augmentin for 10 days, ending 5 days ago • What are the possible causes of her diarrhea? • What tests would you order?

7. Gastroenteritis/colitis • Epidemiology: • Most infections occur after oral ingestion • Elderly at greatest risk for mortality • Outbreaks in long-tern care facilities are of major concern

8. Gastroenteritis/colitis • Reservoirs • Human (person to person spread) • Fecal-oral route • Food/water • Epidemic common-vehicle • Common in LTCF setting

9. Source of Gastrointestinal Pathogen Reservoir : Food/Water • Nontyphoid Salmonella • C. perfringens • C. botulinum • Yersinia enterocolitica • Campylobacter • Bacillus cereus • E. coli 0157 Reservoir: Humans • Salmonella typhi • Viral gastroenteritis • Shigella • Staph aureus • Amoebae • E. coli • Giardia

10. Vehicle Undercooked chicken…  Eggs………………………  Unpasteurized milk……  Water…………………....... Fried rice…………………. Shellfish………………….. Sushi……………………… Beef, gravy………………. Pathogen or toxin Salmonella spp Salmonella spp Salmonella, Campylobacter, Yersinia Giardia, Norwalk virus, Campylobacter, Cryptosporidium, Cyclospora, Aeromonas Bacillus cereus Vibrio spp, Norwalk virus Campylobacter, C. perfringens, Anisakis spp Salmonella spp, Campylobacter, C. perfringens Common Food Vehicles for Specific Pathogens or Toxins

11. Gastroenteritis/colitis Pathologic Classification of Pathogens: • Enterotoxin-mediated watery diarrhea syndrome • Partial mucosal invasion • Complete mucosal invasion

12. Enterotoxin-mediated watery diarrhea syndrome • Preformed toxin: • Staph aureus • Bacillus cereus • Toxin made in host • Clostridium perfringens • Vibrio cholera • Enterotoxigenic Escherichia coli

13. The Dysentery Syndrome =partial mucosal invasion • Organisms include: • Shigella** • Campylobacter • Entamoeba histolytica • Clostridium difficile** • Enterohemorrhagic E. coli**

14. Clostridium difficile • A gram-positive spore-forming anaerobic bacillus • The most common identifiable pathogen causing antibiotic-associated diarrhea and colitis

15. Clostridium difficile • Pathogenesis • Disruption of normal bacterial flora of colon by antibiotics, especially clindamycin, ampicillin, amoxicillin, fluroquinolone and the cephalosporins • Some strains of C. difficile are non-toxinogenic, but the majority make 2 exotoxins: toxin A and toxin B • Toxin A is mainly responsible for disease

16. Clostridium difficile • Epidemiology • 3 million cases of diarrhea and colitis in U.S. each year • Most in hospitals and long-term facilities • Transmission ….patient to patient • Cultured from environmental surfaces in rooms of infected patients: hands, clothes and stethoscopes • Hospital personnel may carry the bacteria from room to room and promote infection

17. Clostridium difficile • Endoscopy…diffusely thickened or edematous colonic mucosa • Clinical manifestations: • Presentation…..variable : diarrhea, colitis without pseudo- membranes, psedomembranous colitis, and fulminant colitis • Systemic symptoms…. variable: • cramps, diarrhea, fever, nausea, anorexia, fatigue – Diarrhea………………variable: minimal to profuse diarrhea. • Laboratory…………..variable: leukocytosis with left shift and fecal leukocytes or no change

18. Clostridium difficile • Diagnosis: • Stool culture (rarely used) • Tissue culture assay for cytotoxicity of toxin B (most sensitive and specific test, but takes 1-3 days and need special equipment) • EIA – most commonly used, -sensitivity 71-94% -(because of low sensitivity send 3 samples)

19. Clostridium difficile • Treatment: • Discontinue antibiotic if possible • Supportive therapy • Avoid antiperistaltic and opiate drugs • Oral metronidazole is treatment of choice • Avoid oral vancomycin if possible to prevent selection out of VRE

20. Complete Mucosal Invasion • Organisms include: • Salmonella • Yersinia • Listeria

21. Viral Gastroenteritis • Rotavirus and Norwalk virus most common in outbreaks among elderly • Not detected on routine stool cultures • Special testing available • Rotavirus direct Ag • Norwalk RNA • Sudden onset of nausea and vomiting Treatment: • Supportive care/hydration/hand washing

22. Diarrhea - Workup

23. Role of Antibiotics in Specific Causes of Bacterial Gastroenteritis

24. Gastrointestinal infections (1) • Supportive care/treatment • Adequate hydration is imperative, especially in elderly patients • Slow down bowel motility? • attapulgite ( Kaopectate) or bismuth subsalicylate both dosed as 1- 2 tablespoon every 30 min with each loose stool • As always, good hand washing is very important! • Infection control measures • Appropriate contact isolation

25. Case #1 • 76 year old female in your nursing home begins having diarrhea, 6-8 stools per day • She has a low-grade temp, mild abdominal cramping, no N/V or other symptoms • She was recently treated for cellulits secondary to a cat bite with Augmentin for 10 days, ending 5 days ago • What are the possible causes of her diarrhea? • What tests would you order?

26. Case #1 • Stool is checked and positive for C. Diff toxin What important measures should you take? • Contact isolation very important • Watch for signs of dehydration • Keep pt well-hydrated • Alcohol-based hand gels do not kill C. Diff— you need to use soap and water! • Patient history and knowledge of any recent infection outbreaks important

27. The End of Module One on Infectious Gastrointestinal diseases in the elderly

28. Post-test • An 80-year-old woman is transferred from the hospital to a chronic-care facility. She has Alzheimer’s disease with severe memory impairment, malnutrition, and a pressure ulcer. You subsequently receive a report that a stool specimen obtained several weeks ago during hospitalization was positive for Clostridium difficile toxin A. • The patient is eating well, and weight is increasing. She has had a well-formed stool at least every other day since admission, and her roommates have not had diarrhea. She is afebrile, and no abdominal pain is noted during physical examination. Leukocyte count is normal, and no fecal leukocytes are detected. Which of the following is the most appropriate next step? Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.

29. Which of the following is the most appropriate next step? A. Monitor the patient for a recurrence of diarrhea. B. Submit another stool specimen for C. difficile testing. C. Begin prophylaxis with Saccharomyces boulardii D. Begin therapy with metronidazole. E. Begin therapy with vancomycin

30. Answer: A. Monitor the patient for a recurrence of diarrhea. C.difficile–associated diarrhea is common in hospitalized older adults and residents of nursing homes. An even greater proportion of frail nursing-home residents carry toxin A–producing strains for prolonged periods, without symptoms. All such colonized nursing-home residents do not appear to be at the same risk for diarrhea. Recent antibiotic use is the greatest risk factor for development of diarrhea, followed by the presence of a feeding tube, incontinence, and more than three comorbid illnesses.

31. Monitoring for a recurrence of diarrhea is most appropriate for this patient. Multiple strains of C. difficile have been documented in nursing homes with little evidence of transmission among patients. Universal handwashing, gloving, and disinfection are appropriate strategies for routine containment. Confinement of patients to their rooms is not indicated unless diarrhea is documented as a problem in the facility.

32. Stool testing for C. difficile toxins is not indicated in patients with formed stools. If the patient has diarrhea and a recent history of antibiotic therapy, submission of multiple specimens is useful if a single specimen is negative for toxin A. Treatment should be reserved for patients with persistent or recurrent diarrhea. Metronidazole is inexpensive and as effective as vancomycin for antibiotic-associated diarrhea. A second antibiotic course usually is effective for the 5% to 30% of patients with recurrent diarrhea following therapy. If retreatment is not effective, reestablishment of nonpathogenic flora to rid the gut of C. difficile has been attempted. Prophylactic colonization with S. boulardii has had some success in preventing recurrent diarrhea. • end

33. Readings and Resources Recommended readings and resources; Geriatrics at Your Fingertips 8th edition 2006-2007 pages 78-79