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Bacterial Gastroenteritis Clinical Presentation

  • Author: Jennifer Lynn Bonheur, MD; Chief Editor: BS Anand, MD  more...
 
Updated: Oct 13, 2015
 

History

Stool characteristics

Diarrhea is defined as daily stools with a mass greater than 15g/kg for children younger than 2 years and greater than 200 g for children 2 years or older. Adult stool patterns vary from 1 stool every 3 days to 3 stools per day; therefore, consider individual stool patterns.

Consistency, color, volume, and frequency are very important in determining whether the stool source is from the small or large bowel. Table 1, below, outlines these characteristics and demonstrates that an index of suspicion can be generated easily for a specific set of organisms.

Table 1. Stool Characteristics and Sources (Open Table in a new window)

Stool Characteristics Small Bowel Large Bowel
Appearance Watery Mucus and/or blood
Volume Large Small
Frequency Increased Increased
Blood Possibly heme-positive but never gross blood Possibly grossly bloody
pH Possibly < 5.5 >5.5
Reducing substances Possibly positive Negative
White blood cell (WBC) count < 5/high-power field (HPF) Possibly >10/HPF
Serum WBC count Normal Possible leukocytosis, bandemia
Organisms Preformed toxins:



Bacillus species, Staphylococcus aureus



Invasive bacteria:



E coli and Shigella, Salmonella, Campylobacter, Yersinia, Aeromonas, and Plesiomonas species



Toxic bacteria:



E coli, cholera, C perfringens, Vibrio species, Listeria monocytogenes



Toxic bacteria:



C difficile



Other causes:



rotavirus, adenovirus, calicivirus, astrovirus, Norwalk virus, and Giardia and Cryptosporidium species



Other causes:



Entamoeba species



Systemic symptoms

Associated systemic symptoms can guide empiric therapy. Some enteric infections have characteristic systemic symptoms, whereas the associated systemic features of others do not occur reliably. Table 2, below, outlines the frequency of these symptoms with various organisms.

The characteristics of symptom onset and symptom duration can narrow the differential diagnosis of the organism. The onset of symptoms within 6 hours of exposure to the bacterial source indicates a preformed toxin, probably produced by a species of Staphylococcus or Bacillus. Table 2 outlines the incubation periods and duration of common bacteria.

Table 2. Symptoms and Their Characteristics (Open Table in a new window)

Organism Incubation Duration Vomiting Fever Abdominal Pain
Aeromonas species None 0-2 weeks +/- +/- No
Bacillus species 1-16 hours 1-2 days Yes No Yes
Campylobacter species 2-4 days 5-7 days No Yes Yes
C difficile Variable Variable No Few Few
C perfringens 0-1 1 day Mild No Yes
Enterohemorrhagic E coli 1-8 days 3-6 days No +/- Yes
Enterotoxigenic E coli 1-3 days 3-5 days Yes Low Yes
Listeria species 20 hours 2 days Few Yes +/-
Plesiomonas species None 0-2 weeks +/- +/- +/-
Salmonella species 0-3 days 2-7 days Yes Yes Yes
Shigella species 0-2 days 2-7 days No High Yes
S aureus 2-6 hours 1 day Yes No Yes
Vibrio species 0-1 days 5-7 days Yes No Yes
Y enterocolitica 0-6 1-46 days Yes Yes Yes

Food-borne bacteria

Particular foods are associated with certain bacteria. Ingestion of raw or contaminated food, particularly raw milk and meat, is a common cause of bacterial gastroenteritis. The following list outlines organisms that cause food poisoning:

  • Dairy - Campylobacter, Salmonella, Listeria, and Staphylococcus species
  • Eggs - Salmonella species
  • Meats - C perfringens and Salmonella, Aeromonas, Campylobacter, and Staphylococcus species
  • Ground beef - Enterohemorrhagic E coli
  • Poultry - Campylobacter species
  • Pork - C perfringens and Y enterocolitica
  • Seafood - Aeromonas, Plesiomonas, Vibrio species, and astrovirus
  • Oysters - Plesiomonas and Vibrio species and calicivirus
  • Vegetables - Aeromonas species and C perfringens
  • Alfalfa sprouts - Enterohemorrhagic E coli and Salmonella species
  • Fried rice - Bacillus species
  • Custards, mayonnaise - Staphylococcus species

A study by Calbo et al reported a foodborne nosocomial outbreak due to extended-spectrum β-lactamase (ESBL)–producing Klebsiella pneumoniae.[17] This may be the first reported hospital outbreak that provides evidence that food can be a transmission vector for ESBL K pneumoniae.

Water-borne bacteria

Water is a major reservoir for many organisms that cause diarrhea. Swimming pools have been associated with outbreaks of Shigella organisms, and Aeromonas species are associated with exposure to the marine environment.

Animal-borne bacteria

Animals can transmit particular bacteria. Exposure to young dogs or cats is associated with Campylobacter transmission. Exposure to turtles is associated with Salmonella transmission.

Travel-associated infections

Travel history is an important and useful clue in determining bacterial etiology. Enterotoxigenic E coli is the leading cause of traveler's diarrhea. RotavirusShigella, Salmonella, and Campylobacter species are prevalent worldwide and need to be considered, regardless of specific travel history.

The risk of contracting diarrhea while traveling is the highest in Africa. Travel to Portugal, Spain, and Eastern European countries is also associated with a relatively high risk. Organisms associated with travel to particular locations are as follows:

  • Nonspecific - Enterotoxigenic E coli and Aeromonas, Giardia, Plesiomonas, Salmonella, and Shigella species
  • Developing tropics - C perfringens
  • Africa - Entamoeba species and Vibrio cholerae
  • Americas (South and Central) - Entamoeba species and V cholerae
  • Asia - V cholerae
  • Australia - Yersinia species
  • Canada - Yersinia species
  • Europe - Yersinia species
  • India - Entamoeba species and V cholerae
  • Japan - V parahaemolyticus
  • Mexico - Aeromonas, Entamoeba, Plesiomonas, and Yersinia species
  • New Guinea - Clostridium species

Bacteria associated with preexisting conditions

Preexisting medical conditions can predispose patients to infections with particular organisms. The following list outlines such medical conditions and their associated organisms:

  • C difficile - Hospitalization with antibiotic administration
  • Plesiomonas species - Liver diseases or malignancy
  • Salmonella species - Intestinal dysmotility, malnutrition, achlorhydria, hemolytic anemia (especially sickle cell disease), immunosuppression, and malaria
  • Rotavirus - Hospitalization
  • Giardia species - Agammaglobulinemia, chronic pancreatitis, achlorhydria, and cystic fibrosis
  • Cryptosporidia - Immunocompromise and immunosuppression

Outbreaks

Outbreaks are caused by particular bacteria, including enterohemorrhagic E coli O157:H7, Listeria monocytogenes, C perfringens, and Salmonella species.

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Physical Examination

Dehydration is the primary cause of morbidity and mortality in cases of gastroenteritis. Assess every patient for signs, symptoms, and severity of dehydration. Lethargy, depressed consciousness, dry mucous membranes, sunken eyes, poor skin turgor, and delayed capillary refill should raise the suspicion for dehydration.

Malnutrition is typically a sign of a chronic process. Reduced muscle and fat mass is found. This is usually due to the development of secondary carbohydrate intolerance.

Abdominal pain is a common symptom in gastroenteritis. Nonspecific, nonfocal abdominal pain and cramping are common with some organisms. This pain usually does not increase with palpation. Focal abdominal pain worsened by palpation, rebound tenderness, or guarding should alert the clinician to possible complications or to another noninfectious gastrointestinal diagnosis.

Borborygmi, defined as a significant increase in peristaltic activity with small bowel diarrhea, can cause an audible and/or palpable increase in bowel activity.

Perianal erythema results from many stools causing a constantly wet area. Failure to properly dry the buttocks and perianal area results in erythema and skin breakdown.

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Contributor Information and Disclosures
Author

Jennifer Lynn Bonheur, MD Attending Physician, Division of Gastroenterology, Lenox Hill Hospital

Jennifer Lynn Bonheur, MD is a member of the following medical societies: American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, New York Society for Gastrointestinal Endoscopy, New York Academy of Sciences, Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

M Akram Tamer, MD Professor, Program Director, Department of Pediatrics, University of Miami, Leonard M Miller School of Medicine

M Akram Tamer, MD is a member of the following medical societies: American Medical Association, Florida Medical Association

Disclosure: Nothing to disclose.

Mukul Arya, MD Associate Professor of Internal Medicine, Weill Cornell Medical College; Assistant Director of Therapeutic Endoscopy, Department of Gastroenterology and Internal Medicine, Wyckoff Heights Medical Center

Mukul Arya, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

Simmy Bank, MD Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

Richard E Frye, MD, PhD Assistant Professor, Departments of Pediatrics and Neurology, University of Texas Medical School at Houston

Richard E Frye, MD, PhD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and International Neuropsychological Society

Disclosure: Nothing to disclose.

John Gunn Lee, MD Director of Pancreaticobiliary Service, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, University of California at Irvine School of Medicine

John Gunn Lee, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Table 1. Stool Characteristics and Sources
Stool Characteristics Small Bowel Large Bowel
Appearance Watery Mucus and/or blood
Volume Large Small
Frequency Increased Increased
Blood Possibly heme-positive but never gross blood Possibly grossly bloody
pH Possibly < 5.5 >5.5
Reducing substances Possibly positive Negative
White blood cell (WBC) count < 5/high-power field (HPF) Possibly >10/HPF
Serum WBC count Normal Possible leukocytosis, bandemia
Organisms Preformed toxins:



Bacillus species, Staphylococcus aureus



Invasive bacteria:



E coli and Shigella, Salmonella, Campylobacter, Yersinia, Aeromonas, and Plesiomonas species



Toxic bacteria:



E coli, cholera, C perfringens, Vibrio species, Listeria monocytogenes



Toxic bacteria:



C difficile



Other causes:



rotavirus, adenovirus, calicivirus, astrovirus, Norwalk virus, and Giardia and Cryptosporidium species



Other causes:



Entamoeba species



Table 2. Symptoms and Their Characteristics
Organism Incubation Duration Vomiting Fever Abdominal Pain
Aeromonas species None 0-2 weeks +/- +/- No
Bacillus species 1-16 hours 1-2 days Yes No Yes
Campylobacter species 2-4 days 5-7 days No Yes Yes
C difficile Variable Variable No Few Few
C perfringens 0-1 1 day Mild No Yes
Enterohemorrhagic E coli 1-8 days 3-6 days No +/- Yes
Enterotoxigenic E coli 1-3 days 3-5 days Yes Low Yes
Listeria species 20 hours 2 days Few Yes +/-
Plesiomonas species None 0-2 weeks +/- +/- +/-
Salmonella species 0-3 days 2-7 days Yes Yes Yes
Shigella species 0-2 days 2-7 days No High Yes
S aureus 2-6 hours 1 day Yes No Yes
Vibrio species 0-1 days 5-7 days Yes No Yes
Y enterocolitica 0-6 1-46 days Yes Yes Yes
Table 3. Common Bacteria and Optimum Culture Media
Organism Detection Method Microbiologic Characteristics
Aeromonas species Blood agar Oxidase-positive, flagellated GNB
Bacillus species Blood agar Facultatively aerobic, spore-forming GPR; beta hemolytic; reduces nitrates; ferments carbohydrates
Campylobacter species Skirrow agar Rapidly motile, curved GNR; Campylobacter jejuni 90% of infections, Campylobacter coli 5% of infections
C difficile CCFE agar, EIA for toxin, LA for protein Anaerobic, spore-forming GPR; toxin-mediated diarrhea; produces pseudomembranous colitis
C perfringens None available Anaerobic, spore-forming GPR; toxin-mediated diarrhea
E coli MacConkey, EMB, or SM agar Lactose-producing GNR
Listeria species Blood agar Flagellated GPB
Plesiomonas species Blood agar Oxidase-positive GNR
Salmonella species Blood, MacConkey, EMB, XLD, or HE agar Nonlactose, non–H2S-producing GNR
Shigella species Blood, MacConkey, EMB, XLD, or HE agar Nonlactose and H2S-producing GNR; verotoxin (neurotoxin)
Staphylococcus species Blood agar Heat-stable, preformed toxin-mediated GPC
Vibrio species Blood or TCBS agar Oxidase-positive, motile, curved GNB
Y enterocolitica CIN agar Nonlactose-producing, oval GNR
CCFE = cycloserine-cefoxitin-fructose-egg; CIN = cefsulodin-irgasan-novobiocin; EIA= enzyme immunoassay; EMB = e-methylene blue; GNB = gram-negative bacillus; GNR = gram-negative rod; GPB = gram-positive bacillus; GPC = gram-positive cocci; GPR = gram-positive rod; H2S = hydrogen sulfide; HE = Hektoen enteric; LA = latex agglutination; SM = Sorbitol-MacConkey; TCBS = thiosulfate-citrate-bile-sucrose; XLD = xylose-lysine-deoxycholate.
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