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Pharmacotherapy of infectious diarrheas
PharmDr. Ondřej Zendulka, Ph.D.
Infectious diarrhea
Epidemiology• diet or direct contact with pathogenEtiology• variety of pathogens – bacteria, viruses, parasites•ATB therapy induction•most common Salmonella sp., Campylobacter sp.
Pathogen 2005
2006 2007 2008
2009
Salmonella 32927 25102 18204 11009 10805Shigella 278 289 349 229 178Other enteral bact.
2704 2471 2831 3305 3178
Campylobacter 30268 22713 24254 20175 20371 Viral intest. inf. 3670 5597 6025 6639 6066
Infectious diarrhea
Pathophysiology• dehydration, electrolyte and acidobasic imbalance• nausea and vomitus usually present • exudative diarrhea with inflammation, rarely secretory diarrhea (cholera)Symptoms• abdominal discomfort – loss of appetite, flatulence• number of stools from 1 to tens per day• sometimes only painful tenesmuses• fever
Infectious diarrhea
Salmonella• most common is S. enteritidis• source: infected food• incubation period: 8-48h• symptoms: abdominal pain, fever, stool gets dark green
colour• therapy: cotrimoxazol, quinolones, aminopenicillines http://www.youtube.com/watch?v=j5GvvQJVD_Y
Infectious diarrhea
Campylobacter• 90% by C. jejuni• source: infected food or direct transfer• incubation period: 1-7 days• therapy: macrolides, (quinolones)
Infectious diarrhea
Shigella• 95% by S. sonnei• source: infected food or direct transfer• incubation period: 1-3(7) days• symptoms: fever, abdominal pain prior defecation,
vomiting• therapy: serious infections ATB (aminopen, cotrimoxazol,
quinolones), rehydratation
Infectious diarrhea
Viral diarrheas• pathogen: rota-, adeno-, astro-,kalci-, toroviruses• source: contaminated objects, direct contact• incubation period: 1-2 days• symptoms: mild infections, !children, elderls• therapy: symptomatic
Infectious diarrhea
Parasitic diarrheas• rarely: Giardia lamblia, Ascaris lumbricoides• therapy: metroniadzole, mebendazole, albendazole
Infectious diarrhea
ATB associated diarrheas• type of ATB and period of administration plays role• intestinal dysmicrobia• pseudomembraneous colitis• linkosamides, penicillines, cephalosporines, quinolones• therapy: metronidazole, vancomycin
Infectious diarrhea - therapy
Rehydration• black tea, still mineral water (nonlaxative)•rehydration solution: 1L of water
8 spoons of sugar1 spoon of saltjuice from 2 orangesdrink 250-500 ml/hour
Infectious diarrhea - therapy
Diet• individual with regard to tolerance• lipid restriction• possible decrease in absorption of drugs (peroral contraception)• diet bisquits, potatoes, rice, bananas, apples
Infectious diarrhea - therapy
Eubiotics• increase of intestinal enzyme activity• intreference with pathogen microflora• immunomodulants• probiotics – Lactobacillus, Bifidobacterias, Sacharomycetes• prebiotics – oligo- and polysacharides
Infectious diarrhea - therapy
rifaximin (NORMIX)• inhibits DNA dependent RNA polymerase• wide spectrum• absorption from GIT 1%• flatulence, abdominal pain, loss of weight• prophylaxis prior to surgery on intestine
Infectious diarrhea - therapy
nifuroxazid (Endiex, Ercefuryl)• interferes with synthesis of NA and bacterial metabolism• not active against: Proteus, Pseudomonas, Enterobacter• not absorbed from GIT • flatulence, abdominal pain, loss of weight• prophylaxis prior to surgery on intestine
chloroxine (Endiaron)• significant bacteriostatic, fungistatic and antiprotozoal properties• does not induce resistance• does not influence natural intestinal flora• not for children less than 40kg
Infectious diarrhea - therapy
Infectious diarrhea - therapy
Antimotility agentsloperamide (Imodium, Loperon)• opioid receptor agonist• no influence on microflora•high afinity to intestine, low bioavalability, high first pass effect• urticaria, rush, constipation+ diosmectite (Imodium plus)
- natural silicate, intestinal absorbent
Infectious diarrhea - therapy
Antimotility agentsdiphenoxylate (Reasec)• pethidin similar+ atropin in subtherapeutic dose
Intestinal absorbents• diosmectite (Smecta)• activated charcoal (Carbocit, Carbosorb)
- 1-2 tablespoons, 3-4x day