3.07 - Gastrointestinal Infection [New]

A) Adults

Disease / Etiology

Preferred

Alternative

Comments

Infectious Diarrhea

 
Acute mild to moderate diarrhea 
Virus: norovirus (usually)
Bacteria (Salmonella)
Parasite (rarely)

 

To replace fluids. 
No antibiotics required.
 

Mild: ≤ 3 unformed stools, minimal symptoms

Moderate: ≥ 3 unformed stools and/or symptomatic

Severe: fever (> 38.5oC), ≥ 6 unformed stool. Severe diarrheal in the elderly, faecal leucocytes ± bloody stools. 

To take blood and stool cultures before starting antibiotics.

 *In immunocompetent children and adults, empiric antimicrobial therapy usually not indicated, except for the following:

 a. Infants <3 months of age with suspicion of a bacterial etiology.

 b. Ill immunocompetent people with fever documented in a medical setting, abdominal pain, bloody diarrheal, and bacillary dysentery (frequent scant bloody stools, fever, abdominal cramps, tenesmus) presumptively due to Shigella.

 c. People who have recently travelled internationally with body temperatures ≥38.5°C and/or signs of sepsis. 

 
Acute severe diarrhoea 
Campylobacter 
Yersinia
Salmonella
Aeromonas
Plesiomonas spshigella 
shigelloides







Empirical treatment*
Ciprofloxacin 500 mg - 750 mg PO q12H for 3 - 5 days.












Azithromycin 500 mg PO q24H for 3 days 





Targeted treatment

 
   Campylobacter 
   Yersinia
   Aeromonas
   Plesiomonas spshigella 
   shigelloides






 
Azithromycin 1000mg single dose or 500mg q24H for 3 days*

Co-trimoxazole (480mg) 2 tablets PO q12H
 
Cefoperazone 2 gm IV q12H 
OR 
Ceftriaxone 2 gm IV q24H 

Metronidazole 500 mg IV q8H

  
Duration: 4 - 6 weeks. 

Modify antibiotics according to culture.
Convert to oral once clinically improved. 
If no culture available, oral Co-amoxiclav can be used.

Salmonella enterica 


  Typhi or paratyphi

Co-trimoxazole (480mg) 2 tablets PO q12H 

Azithromycin 500mg PO q24H 

Duration: immunocompetent 5-7 days  
Immunocompromised 14 days




 
   Vibrio cholerae 
 
Azithromycin 1gm PO STAT
 
Doxycycline 300mg PO STAT




 

Clostridium difficile


   (non severe)

Vancomycin PO 125mg QID for 10 days 



 

Discontinue therapy with inciting antibiotic agent as soon as possible as this may influence Clostridium difficile Infection recurrence.

If recurrent, refer National Antibiotic Guideline 2019.

https://www.pharmacy.gov.my/v2/sites/default/files/document-upload/national-antimicrobial-guideline-2019-full-version-3rd-edition.pdf



   
   If persistent, to refer to ID team


Prophylaxis against travelers’ diarrhea

Antibiotic is NOT recommended

Prophylactic antibiotics afford no protection against non-bacterial pathogens and can remove normally protective micro-flora from the bowel, increasing the risk of infection with resistant bacteria pathogens. Travelers may become colonized with (ESBL)–producing bacteria. Prophylactic antibiotics limit the therapeutic options if TD occurs

Disease / Etiology

Preferred

Alternative

Comments

Spontaneous Bacterial Peritonitis (SBP) 

 

E.coli (43%),
klebsiella(11%),
S. pneumoniae(9%) and other strep(19%), enterobactericiaea(4%),
staphylococcus(3%),
pseudomonas(1%),
micelleneous(10%)

 

Co-amoxiclav 1.2 gm IV q8H 


Cefuroxime 750-1500mg IV q8H

 + 

Metronidazole 500 mg IV q8H

Suggest refer to ID team


Perforated Gastric / Duodenal Ulcers 

 

Community acquired 

 

 

 

 

 

Hospital acquired




 


Co-amoxiclav 1.2 gm IV q8H

 

 

 

 

 

Cefoperazone 1 - 2 gm IV q12H 

+

Metronidazole 500 mg IV q8H


 


Cefuroxime 750-1500mg IV q8H



Metronidazole 500 mg IV q8H

 


Piperacillin / Tazobactam 4.5 gm IV q6H

  


Hepatic Abscess

 

Pyogenic abscess:

Enteric gram-negative bacilli, particularly E. coli and K. pneumoniae

-Streptococcus milleri group (including Streptococcus anginosus

Streptococcus constellatus

and Streptococcus intermedius

( need to promptly search for simultaneous infection at other loci)


Community acquired

 

 

 

 

 

   Hospital acquired
 









Ceftriaxone 2gm IV q24h

+

Metronidazole 500mg IV q8h

 



Piperacillin / Tazobactam 4.5 gm IV q6H


 

















Co-amoxiclav 1.2 gm IV q8H


Abscess drainage is the optimal therapy for pyogenic liver abscesses.

Ensure blood cultures are taken and de-escalate antibiotic accordingly.

Total Antibiotic duration:14-42 days depending on response to therapy
Longer courses (up to several months) may be required in the patient who is inadequately drained or treated without drainage

IV antibiotics should be de-escalated to oral once clinical improvement occurs*

*afebrile >48 hours, adequate clinical response

 

Amoebic abscess:
Entamoeba histolytica


Tissue agent: Metronidazole 750mg PO q8H for 7-10 days

luminal agent to eliminate residual colonic colonization:

Paromomycin* 500mg  PO q8H for 7 days



Tissue agent:

Tinidazole*  800mg PO q8H or

2 gm PO q24H for 3 - 5 days

 

Luminal agents:

Iodoquinol* 650mg PO q8H for 20 days

Diloxanide furoate* 500mg PO q8H for 10 days


 

* Tinidazole, Paromomycin, Iodoquinol, Diloxanide furoate not available in the country.


Helicobacter pylori infection1,2,3
 


First line

Triple therapy:

Proton pump inhibitor* PO q12H

+

Amoxicillin 1g PO q12H

+

Clarithromycin  500m PO q12H

OR

Metronidazole  400mg PO q12H

 

For 14 days

 

**Second line

Bismuth quadruple regime

Proton pump inhibitor PO q12H

+

Bismuth***

+

Tetracycline*** 500mg PO q6H

+

Metronidazole 400mg PO q8H

 

For 14 days

 

Fluoroquinolone triple therapy

Proton Pump Inhibitor PO q12H

+

Levofloxacin 500mg q24H

+

Amoxicillin 1g PO q12H

Or

Metronidazole 400mg PO q12H

For 14 days

 

Rescue therapy(High dose dual Therapy2,3,4)

 

Amoxicillin 1gm PO q6-8H

+

Proton Pump Inhibitor PO q6-8H for 14 days

 

Penicillin allergy

 

Proton Pump Inhibitor

Clarithromycin  500m PO q12H

+

Metronidazole  400mg PO q12H



*Proton pump inhibitors

Pantoprazole 40mg q12H

Omeprazole 20mg q12H

Esomeprazole 20mg q12H

**consider 2nd line if Clarithromycin resistant > 15%

 

***not available in UMMC
 

1.    Randel, Amber. "H. pylori infection: ACG updates treatment recommendations." American family physician 97.2 (2018): 135-137.

2.    Goh KL, Manikam J, Qua CS. High-dose rabeprazole-amoxicillin dual therapy and rabeprazole triple therapy with amoxicillin and levofloxacin for 2 weeks as first and second line rescue therapies for Helicobacter pylori treatment failures. Aliment Pharmacol Ther. 2012 May;35(9):1097-102. doi: 10.1111/j.1365-2036.2012.05054.x. Epub 2012 Mar 8. PMID: 22404486.

3.    Goh, KL,  Chang, J,  Leow, AHR.  Highdose proton pump inhibitor and amoxicillin dual therapy with or without bismuth for 14 days as rescue therapies after Helicobacter pylori treatment failureJ Dig Dis.  202021566– 570https://doi.org/10.1111/1751-2980.12929

4.    Hwong-Ruey Leow A, Chang JV, Goh KL. Searching for an optimal therapy for H pylori eradication: High-dose proton-pump inhibitor dual therapy with amoxicillin vs. standard triple therapy for 14 days. Helicobacter. 2020 Oct;25(5):e12723. doi: 10.1111/hel.12723. Epub 2020 Jul 26. PMID: 32713104.

 


B) Paediatrics

Disease / Etiology

Preferred

Alternative

Comments


Primary Peritonitis :
S pneumonia
Strep pyogenes
Staph aureus
Escherichia coli
Klebsiella pneumoniae

Ceftriaxone 50 mg/kg IV q12H
+
Metronidazole 7.5 mg/kg IV q8H

Piperacillin / Tazobactam 100 mg/kg (Piperacillin component) IV q6 - 8H
OR Clindamycin 10 mg/kg (max 1.2 gm) IV q6H
+
Gentamicin
1 week – 10 years old:
8 mg/kg IV q24H for Day 1 then 6 mg/kg IV q24H
> 10 years old:
7 mg/kg IV q24H for Day 1 then 5 mg/kg IV q24H
OR
Amikacin
1 week to 10 years:
25 mg/kg IV Day 1 then 18 mg/kg IV q24H
> 10 years old:
20 mg/kg IV Day 1, then 15 mg/kg (max 1.5 gm) IV q24H




Secondary Peritonitis:
E coli
Klebsiella
Enterococcus
Enterobacter
Pseudomonas
Proteus spp

Anaerobes - Bacteroides
Candida spp (rare)


Cefepime 50 mg/kg IV q12H
+
Metronidazole 7.5 mg/kg IV q8H

Piperacillin / Tazobactam 100 mg/kg (Piperacillin component) IV q6 - 8H
OR
Imipenem 15 mg/kg (max 500 mg) IV q6H
  
Peritonitis secondary to gut perforation is often polymicrobial.

Documented non-VRE and Enterococcus faecalis: Vancomycin 15 mg/kg IV q8H

Liver Abscess


Pyogenic Hepatic Abscess:
Staph aureus 
Escherichia coli
Enterococcus spp 
Klebsiella
Pseudomonas

Proteus
Bacteroides
Strep milleri


Cloxacillin 50 mg/kg IV q6H
+
Ceftriaxone 50 mg/kg IV q12H OR Ceftazidime 50 mg/kg IV q8H
+
Metronidazole 7.5 mg/kg IV q8H

 
Piperacillin / Tazobactam
100 mg/kg (Piperacillin component) IV q6-8H
 
Often associated with multiple abscesses within spleen.

Cholangitis


Escherichia coli
Klebsiella
Enterococcus
Enterobacter
Pseudomonas
Proteus

Bacteroides

Ceftriaxone 50 mg/kg IV
q12H
+
Metronidazole 7.5 mg/kg IV q8H
+
Gentamicin / Amikacin

Piperacillin / Tazobactam 100 mg/kg (Piperacillin component) IV q6 - 8H
+
Gentamicin
1 week – 10 years old:
8 mg/kg IV q24H for Day 1 then 6 mg/kg IV q24H
> 10 years old:
7 mg/kg IV q24H for Day 1 then 5 mg/kg IV q24H
OR
Amikacin
1 week to 10 years:
25 mg/kg IV Day 1 then 18 mg/kg IV q24H
> 10 years old:
20 mg/kg IV Day 1, then 15 mg/kg (max 1.5 gm) IV q24H

 

Cholecystitis

 
Escherichia coli 
Klebsiella 
Enterococcus 
Enterobacter 
Pseudomonas 
Proteus

Bacteroides
 
Ceftriaxone 50 mg/kg IV
q12H 

Metronidazole 7.5 mg/kg IV q8H 

Gentamicin / Amikacin
 
Piperacillin / Tazobactam 100 mg/kg (Piperacillin component) IV q6 - 8H 

Gentamicin 
1 week – 10 years old: 
8 mg/kg IV q24H for Day 1 then 6 mg/kg IV q24H 
> 10 years old: 
7 mg/kg IV q24H for Day 1 then 5 mg/kg IV q24H 
OR 
Amikacin 
1 week to 10 years: 
25 mg/kg IV Day 1 then 18 mg/kg IV q24H 
> 10 years old: 
20 mg/kg IV Day 1, then 15 mg/kg (max 1.5 gm) IV q24H

 
Majority are acalculous; associated with other systemic diseases like typhoid, Streptococcal infection, Staph aureus