L5 Gastroenteritis 3 (Bacterial and Protozoal)

Gastroenteritis 3 –
bacterial and protozoal
Dr Suzy FitzGerald
Consultant Microbiologist
22nd September 2022
[email protected]
Staphylococcus aureus
Ingestion of pre-formed heat stable enterotoxin
Rapid onset (2-6 hours)

Short-lived (6-12 hours)
• Malaise
• Nausea, vomiting
• Abdominal pain, diarrhoea
• NO fever
Bacillus cereus
Aerobic spore-forming Gram positive bacilli
Heat-stable
2 enterotoxins – diarrhoeal toxin, emetic toxin
Emetic syndrome - ingestion of toxin in food (e.g., rice)

Illness within 1-5 hours, lasts 6-24 hours
Diarrhoeal syndrome – toxin produced in small bowel

Illness within 8-16 hours, lasts 24 hours
Clostridioides
Anaerobic spore-forming Gram-positive bacilli
C. perfringens
• Food poisoning
C. difficile
• Antibiotic related diarrhoea
Clostridioides perfringens
Food-poisoning
Pre-cooked meat
Heat-resistant spores
Enterotoxin production
Incubation period 8-12 hours

Abdominal cramps
Diarrhoea
Self-limiting (1-2 days)
Clostridioides difficile
Anaerobic Gram-positive bacillus
Spore-forming
Toxin producing – toxins A and B
Multiple strains
• 027, 078 hypervirulent
Colonisation of bowel
• Healthy infants – 60-70%
• Community – 1-2%
• Hospital in-patients 20-30%
Pathogenesis
Toxin mediated
Colonic inflammation and mucosal damage

Intestinal fluid secretion
Leffler and Lamont, NEJM 2015
Risk factors
Antimicrobials
• Broad-spectrum penicillins e.g., co-amoxiclav (Augmentin®)
• Clindamycin
• Cephalosporins
• Fluoroquinolones
Advanced age
Hospitalisation
Recent GI surgery or procedure
Immunosuppression
?Proton pump inhibitor (PPI)
Leffler and Lamont, NEJM 2015
Clinical features
Watery diarrhoea
Abdominal cramping/pain
Colitis
Fever
Elevated WCC
Complications healthjade.com
• Pseudomembranous colitis
• Toxic megacolon
• Colonic perforation
• Death
University of Pittsburgh, Department of Pathology

Diagnosis
Test all diarrhoeal stools (> 2 years of age)
Two-step testing algorithm:
First step
ELISA for glutamate dehydrogenase (GDH)
- detects presence of C. difficile
- does not distinguish between strains that produce toxin and those that do
not
OR
PCR
- detects presence of gene which encodes for toxin
- does not detect presence of toxin
Second step
ELISA for toxin detection
Management
Stop precipitating antibiotics, if possible
If on PPI, review indication
Treat first episode according to severity, duration 10-14 days

• Non-severe (WCC <15) – vancomycin po or fidaxomicin po
• Severe – vancomycin po, metronidazole iv, surgical review,
?intravenous immunoglobulin
Fidaxomycin – similar efficacy to vancomycin; less recurrence
Bezlotoxumab – monoclonal antibody against toxin B; reduced recurrence

Louie et al, NEJM 2011
Recurrent infection
Recurrence in 20-30%
- can be relapse or re-infection
Risk factors for recurrence

• Concomitant antimicrobial use during CDI treatment
• 027 infection
• Elderly
Treatment
• 1st recurrence – fidaxomycin po
• 2nd and subsequent recurrences – tapering vancomycin po; fidaxomicin
po; consider FMT
Faecal microbiota transplant
zazzle.com
Prevention of spread
Single room isolation
Contact precautions – aprons, gloves
Hand hygiene – wash hands with soap and water
Environmental cleaning
Getty Images/iStockphoto
Vibrio cholerae
Developing countries
• Endemic in Asia and Africa (returning travellers)
• Also causes epidemics
Contaminated food and water

Person-to-person transmission uncommon
- large infectious dose (108 organisms)
thelancet.com
Pathogenesis
Binds to specific receptors in small intestine
Enters mucosal cell
Rapid secretion Na+, K+, bicarbonate
Virulence factors
• Pili
• Cholera toxin
Clinical features
Incubation period 2-3 days
Abrupt onset
‘Rice-water’ stools, effortless vomiting
Dehydration
Hypovolaemia
Cardiac arrhythmia
Renal failure
Mortality
• Untreated 60%
• Treated <1%
Diagnosis in lab
Gram stain
• small curved Gram-negative bacilli
Culture on
• selective agar - TCBS
(Thiosulphate Citrate Bile salt Sucrose)
• V. cholerae – yellow colonies
eolabs.com
Management
Prompt rehydration
• Fluids
• Electrolytes
Antibiotics reduce toxin production, hasten elimination

• Tetracyclines
• Co-trimoxazole
Vaccine of limited use

Hygiene, sanitation
Protozoal gastroenteritis
Giardia lamblia – see protozoal infections in IC lecture
Cryptosporidium parvum – see protozoal infections in IC lecture
Entamoeba histolytica
Asymptomatic infection – majority (90%)
Amoebic dysentry
Extra-intestinal disease
Worldwide
Highest burden in developing countries
Disease in developed countries
• Migrants from endemic areas
• Travellers to endemic areas
Exists in cyst and trophozoite forms
Ingestion of cyst in contaminated food or water

Excyst in small intestine to form trophozoites
Trophozoites invade and penetrate colonic mucosa
Tissue destruction and increased intestinal secretion
May ascend portal venous system to cause liver abscess

en.wikipedia.org
Amoebic dysentry
Subacute onset – 1-3 weeks
Diarrhoea, usually bloody

Abdominal pain
Weight loss (50%)
Fever (10-30%)
Diagnosis
Stool microscopy
• Detection of cysts or trophozoites
• 3 samples from separate days
Antigen detection
• Stool
• Serum
Serology
• Positive serology will not distinguish between acute and past infection
Amoebic liver abscess
Returning travellers – 8-20 weeks
Right upper quadrant (RUQ) pain – may radiate

Fever
Diarrhoea (30%)
Hepatomegaly (50%)
howshealth.com
Diagnosis
Imaging
• Ultrasound, CT, MRI
• 70-80% solitary lesions
• Usually in right lobe of liver
Serology
Antigen detection
Aspirate
• ‘Anchovy paste’
• Trophozoites on microscopy in 20%
Radiopaedia.org
Treatment of amoebiasis
Oral metronidazole
Paromomycin to eradicate intraluminal cysts
Liver abscess
• May require aspiration if risk of rupture
Approach to patient with infectious
gastroenteritis
History
• Symptoms, duration
• Contact with other cases
• Travel
• Occupation
• Food and antimicrobial history
Examination
Laboratory investigation
Rehydration, antimicrobials (if indicated)

Notification to Public Health
Exclusion from work, school etc. – usually 48 hours

L5 Gastroenteritis 3 (Bacterial and Protozoal)

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Gastroenteritis 3 –

bacterial and protozoal

Rapid onset (2-6 hours)

2 enterotoxins – diarrhoeal toxin, emetic toxin

Emetic syndrome - ingestion of toxin in food (e.g., rice)

Diarrhoeal syndrome – toxin produced in small bowel

Incubation period 8-12 hours

Colonic inflammation and mucosal damage

University of Pittsburgh, Department of Pathology

Treat first episode according to severity, duration 10-14 days

Fidaxomycin – similar efficacy to vancomycin; less recurrence

Bezlotoxumab – monoclonal antibody against toxin B; reduced recurrence

Risk factors for recurrence

Contact precautions – aprons, gloves

Hand hygiene – wash hands with soap and water

Contaminated food and water

Antibiotics reduce toxin production, hasten elimination

Vaccine of limited use

Cryptosporidium parvum – see protozoal infections in IC lecture

Ingestion of cyst in contaminated food or water

May ascend portal venous system to cause liver abscess

Subacute onset – 1-3 weeks

Diarrhoea, usually bloody

Returning travellers – 8-20 weeks

Right upper quadrant (RUQ) pain – may radiate

Rehydration, antimicrobials (if indicated)

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