3.07 - Gastrointestinal Infection [New]

A) Adults

Disease / Etiology

Preferred

Alternative

Comments

Infectious Diarrhea

Acute severe diarrhoea

Campylobacter

Yersinia

Salmonella

Aeromonas

Plesiomonas spshigella

shigelloides

Acute mild to moderate diarrhea

Virus: norovirus (usually)

Bacteria (Salmonella)

Parasite (rarely)

To replace fluids.

No antibiotics required.

Empirical treatment*

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

Azithromycin 500 mg PO q24H for 3 days

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.

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

Co-trimoxazole (480mg) 2 tablets PO q12H

Azithromycin 1gm PO STAT

Vancomycin PO 125mg QID for 10 days

Cefoperazone 2 gm IV q12H

OR

Ceftriaxone 2 gm IV q24H

+

Metronidazole 500 mg IV q8H

Azithromycin 500mg PO q24H

Doxycycline 300mg PO STAT

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.

Duration: immunocompetent 5-7 days

Immunocompromised 14 days

Salmonella enterica

Typhi or paratyphi

Vibrio cholerae

Clostridium difficile

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

(non severe)

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

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*

Hospital acquired

Ceftriaxone 2gm IV q24h

+

Metronidazole 500mg IV q8h

Piperacillin / Tazobactam 4.5 gm IV q6H

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

luminal agent to eliminate residual colonic colonization:

Paromomycin* 500mg PO q8H for 7 days

*afebrile >48 hours, adequate clinical response

Amoebic abscess:

Entamoeba histolytica

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

***not available in UMMC

*Proton pump inhibitors

Pantoprazole 40mg q12H

Omeprazole 20mg q12H

Esomeprazole 20mg q12H

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

B) Paediatrics

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, K‐L, Chang, J, Leow, AH‐R. High‐dose proton pump inhibitor and amoxicillin dual therapy with or without bismuth for 14 days as rescue therapies after Helicobacter pylori treatment failure. J Dig Dis. 2020; 21: 566– 570. https://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.