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