eMedicine Specialties > Gastroenterology > Colon

Gastroenteritis, Bacterial: Follow-up

Author: Jennifer Lynn Bonheur, MD, Attending Physician, Division of Gastroenterology, Lenox Hill Hospital
Coauthor(s): Mukul Arya, MD, Associate Professor of Internal Medicine, Assistant Director of Therapeutic Endoscopy, Department of Gastroenterology and Internal Medicine, Wyckoff Heights Medical Center/Weill Medical College; Richard E Frye, MD, PhD, Assistant Professor, Departments of Pediatrics and Neurology, University of Texas Health Science Center at Houston; M Akram Tamer, MD, Program Director, Professor, Department of Pediatrics, University of Miami
Contributor Information and Disclosures

Updated: Feb 19, 2009

Follow-up

Further Inpatient Care

• Admit neonates or young infants with moderate dehydration, suspected infection with enterohemorrhagic E coli, or bloody diarrhea.
• Oral rehydration in cases of gastroenteritis is a time-consuming task that requires vigilance. Evaluate the caretaker of a child who requires oral rehydration for compliance. Consider admission if any doubt in potential compliance exists.
• Older patients, often with other illnesses, require careful observation and consideration for admission.

Further Outpatient Care

• Follow-up care in cases of bacterial gastroenteritis depends on the severity of the infection and the age of the patient.
  • Uncomplicated diarrhea may not require follow-up if the patient or caretaker is reliable and has adequate access to medical care if needed.
  • Monitor young children, elderly patients, and debilitated individuals closely to ensure complications do not occur.
  • Monitor patients requiring labor-intensive oral rehydration to ensure that the proper diet has been reintroduced.
  • Neonates require strict follow-up care within a few days of illness to ensure that malabsorption and dehydration do not occur.

Deterrence/Prevention

• Salmonella typhi vaccine is recommended for travelers to countries with a high incidence of this infection, persons with intimate exposure to a documented typhoid fever carrier, and workers with frequent exposure to these bacteria. Live attenuated, killed whole-cell, and capsular polysaccharide vaccines are available.
• Vibrio vaccine is available but only protects 50% of immunized persons for 3-6 months. It is not indicated for widespread use.
• In February 2006, the United States Food and Drug Administration (FDA) approved an oral vaccine for rotavirus (RotaTeq) for use in infants. It is currently the only vaccine approved in the United States for the prevention of rotavirus gastroenteritis as of the date of this publication. On February 21, 2006, the American Academy of Pediatrics (AAP) and the Advisory Committee on Immunization Practices (ACIP) recommended RotaTeq to be part of regularly scheduled childhood immunizations. RotaTeq is administered in a 3-dose series starting between age 6 to 12 weeks and completing before age 32 weeks.Clinical trials demonstrated prevention of 74% of all rotavirus gastroenteritis cases, of nearly all severe rotavirus gastroenteritis cases, and of nearly all hospitalizations. Previously marketed rotavirus vaccine (RotaShield) was associated with intussusception, but RotaTeq did not show an increased risk compared with placebo in clinical trials.
• In April 2008, the FDA approved Rotarix, another oral vaccine, for prevention of rotavirus gastroenteritis. Rotarix administration is currently recommended as 2 separate doses to patients between age 6 and 24 weeks. Rotarix was efficacious in a large study showing that it protected patients with severe rotavirus gastroenteritis as well as decreasing the rate of severe diarrhea or gastroenteritis of any cause.¹⁷
• Avoidance of undercooked meats and seafood, as well as contaminated water supplies, when traveling may help reduce the risk of transmission of food and water-borne infectious causes of gastroenteritis and associated symptoms.

Complications

• Common complications that can occur with various organisms in cases of bacterial gastroenteritis are as follows:
  • Aeromonas caviae - Intussusception, gram-negative sepsis, and HUS
  • Bacillus species - Fulminant liver failure (very rare) and rhabdomyolysis (very rare)
  • Campylobacter species - Bacteremia, meningitis, cholecystitis, urinary tract infection, pancreatitis, and Reiter syndrome
  • C difficile - Chronic diarrhea, toxic megacolon, and ileus
  • C perfringens serotype C - Enteritis necroticans
  • Enterohemorrhagic E coli - Hemorrhagic colitis
  • Enterohemorrhagic E coli O157:H7 - HUS
  • Listeria species - Bacteremia and meningitis
  • Plesiomonas species - Septicemia
  • Salmonella species - Enteric fever, bacteremia, meningitis, osteomyelitis, myocarditis, and Reiter syndrome
  • Shigella species - Seizures, HUS, perforation, and Reiter syndrome
  • Vibrio species - Rapid dehydration
  • Yersinia enterocolitica - Appendicitis, perforation, intussusception, peritonitis, toxic megacolon, cholangitis, bacteremia, and Reiter syndrome
• S typhi causes enteric fever. This syndrome has an insidious onset of malaise, fever, abdominal pain, and bradycardia. Diarrhea and rash (rose spots) appear after 1 week of symptoms. Bacteria may have disseminated at that time, and treatment is required to prevent systemic complications, such as hepatitis, myocarditis, cholecystitis, or gastrointestinal bleeding.
• Damage to vascular endothelial cells by verotoxin causes HUS. Thrombocytopenia, microangiopathic hemolytic anemia, and acute renal failure are characteristic of HUS. Symptoms usually develop 1 week after onset of diarrhea, when organisms may be absent.
• Reiter syndrome can complicate acute infections. Arthritis, urethritis, conjunctivitis, and mucocutaneous lesions are characteristic. Affected individuals usually do not demonstrate all features.
• Carrier states are observed after some bacterial gastroenteritis infections. After Salmonella diarrhea, 1-4% of individuals with nontyphoid and enteric fever infections become carriers. Carrier stage for Salmonella species is more likely to develop in females, infants, and individuals with biliary tract disease. Asymptomatic C difficile carriage may be seen in many hospitalized patients receiving antibiotics and in 50% of infants.
• Hyponatremic seizures can be avoided by rehydrating with oral rehydration solution instead of free water.
• A study suggested that infectious gastroenteritis may play a role in the initiation and/or exacerbation of inflammatory bowel disease.¹⁸ Similarly, irritable bowel syndrome may develop more often following bacterial gastroenteritis. This topic is highly controversial, and no conclusive evidence currently exists to support or refute this hypothesis.

Prognosis

• With proper management, prognosis is very good, especially in developed countries.
• Mortality predominantly is due to dehydration and secondary malnutrition from a protracted course. Treat severe dehydration with parenteral fluids.
• Once malnutrition from secondary malabsorption begins, prognosis becomes grim unless the patient is hospitalized and supplemental parenteral nutrition is started.
• Neonates and young infants are at particular risk for dehydration, malnutrition, and malabsorption syndromes.
• Even though the mortality rate is low in developed countries, people can, and do, die from complications. Prognosis in countries without modern medical care or for patients with serious preexisting medical conditions is more guarded.

Patient Education

• Education is most important for prevention and treatment of bacterial gastroenteritis.
• Proper oral rehydration therapy helps to prevent dehydration and speed recovery of the intestinal mucosa.
• Diet restrictions that prevent secondary malabsorption are extremely important; relapse typically occurs due to diet noncompliance.
• Emphasize proper hygiene and food preparation practices to caretakers in order to prevent future infections and spread of bacterial gastroenteritis.

Miscellaneous

Medicolegal Pitfalls

• Dehydration is the most common complication from gastroenteritis in the United States. Continuing losses without compensatory intake can result in severe dehydration. In high-risk populations, maintain close follow-up in order to ensure proper therapy is provided. For example, oral rehydration is a time-consuming task that requires vigilance. If the physician has any doubt concerning the compliance of the caretaker with proper rehydration therapy, consider admission to the hospital.
• Chronic diarrhea and carbohydrate malabsorption can develop with a prolonged bout of diarrhea, especially if dietary concerns are not sustained.
  • Although some claim that changes in dietary regimen are not necessary, improper diet can result in prolonged recovery or development of carbohydrate malabsorption, especially if the acute episode is overshadowed by an undiagnosed chronic bacterial or malabsorption syndrome.
  • Thus, a prolonged course of diarrhea should prompt investigation of complicating factors. Results from tests such as stool acidity and reducing substances can indicate carbohydrate malabsorption. Failure to recognize this complication can result in significant rapid weight loss with wasting of fat and muscle mass.

Special Concerns

• Studies have suggested that the use of acid-suppressing medications (proton pump inhibitors (PPIs) though not H2 receptor antagonists [H2RAs]) may increase the risk of developing gastroenteritis by reducing the acidic environment which serves as an initial defense against gastrointestinal infections. This effect has also been noted to be dose-dependent ( ie, increased dose of PPI therapy is associated with an increased risk of infection).
• PPI therapy has also been suggested to be an independent risk factor for the development and recurrence of C difficile colitis.¹⁹

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