INFECTIOUS

DIARRHEA

LECTURE NOTE FOR 3 RD YEAR HO STUDENTS :

BY : GELETA ABEBE (MD GP)

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INFECTIOUS DIARRHEA
Objectives:
 Able to classify diarrheal diseases based on type
and duration.

 To identify common causes of diarrheal

diseases, clinical manifestations and
complications

 Manage diarrheal diseases and their

complications 2
INFECTIOUS DIARRHEA
 INTRODUCTION
Diarrhea is abnormal frequency and liquidity of fecal
discharges.
WHO defines diarrhea as passage of loose stool >=three times
per day.

Diarrhea can be
1. Infectious – by enteric pathogens
2. Noninfectious
-anatomical defects short bowel syndrome, villous atrophy
-malabsoption such as disaccharidase deficiency, celiac disease
-allergy, food intolerance 3
INFECTIOUS DIARRHEA

 The term gastroenteritis denotes infection of the

gastrointestinal tract caused by bacterial, viral, or parasitic
pathogens .

 Most are food-borne illnesses.

 common manifestations are diarrhea and vomiting, abdominal

pain and fever.

 The term diarrheal disorders is more commonly used to

denote infectious diarrhea

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EPIDEMIOLOGY
 Account for a large proportion (18%) of childhood deaths,

with an estimated 1.8 million deaths per year globally.

-The 2nd commonest cause of death in Ethiopia

80% of diarrheal deaths occur in the 1st 2yrs.

 More than 20% of acute watery diarrhea and dysentry become

persistent.

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The decline in diarrheal mortality is the result of

-improved case management of diarrhea,
-improved nutrition of infants and children.

These interventions have included widespread

use of home- and hospital-based oral rehydration therapy, as well
as improved nutritional management of children with diarrhea.

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 Classification and etiology
1.ACUTE WATERY DIARRHEA- defined as watery diarrhea
lasting less than 14 days.
Etiologic agents
- Viral-Rotavirus (the commonest), calcivirus, adenovirus, CMV

- Bacterial-ETEC, EAEC, V. cholerae, salmonella etc

- Parasititic- Giardia lamblia , cryptosporidium , isospora beli,

strongloidiasis, cyclospora
- Fungal- candida albicans

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2. DYSENTRY- defined as bloody diarrhea of acute onset( 15
days)
Causes are usually bacteria
-Shigella, EIEC,EHEC , salmonella, campylobacter jejuni
clostridium difficile, yersinia enterocolitica

-shigella ,E. coli and Entamoeba histolytica are the commonest

causes

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INFECTIOUS DIARRHEA
3. PERSISTENT DIARRHEA is defined as diarrhea of acute
onset staying for more than 14 days
Etiologic agents
Bacterial - most causes of acute watery diarrhea and dysentry
tend to cause persistent diarrhea-shigella, salmonella C. jejuni,
EAEC
Parasitic-Giardia lamblia
cryptosporidium, isospora beli, microsporidia.
 These parasitic causes are more common in HIV patients.

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 PATHOGENESIS OF INFECTIOUS DIARRHEA
- either an inflammatory or noninflammatory response in the
intestinal mucosa.

1.noninflammatory diarrhea
-through enterotoxin production- Secretory diarrhea
-destruction of villus (surface) cells by viruses,
-adherence by parasites
-adherence and/or translocation by bacteria.

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2. Inflammatory diarrhea -
-directly invade the intestine or produce cytotoxins with
consequent fluid, protein, and cells (erythrocytes, leukocytes)
that enter the intestinal lumen.
-Some possess more than one virulence property
e.g. rotavirus, enter the cells by either direct invasion or calcium-
dependent endocytosis. This can result in villus shortening and
loss of enterocyte absorptive surface through cell shortening
and loss of microvilli.

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mechanisms of diarrhea
1. Osmotic Diarrhea.
- the presence of nonabsorbable solutes in the GIT

- E.g. lactose intolerance due to lactase deficiency i.e. lactose is

not absorbed in the small bowel.

 The colonic bacteria ferment the nonabsorbed lactose to short-

chain organic acids, generating an osmotic load and causing

water to be secreted into the lumen.
 Osmotic diarrhea stops with fasting, has a low pH, and is

positive for reducing substances.

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2. Secretory Diarrhea.
by activation of the intracellular mediators such as cAMP,
cGMP, and intracellular calcium, which stimulate active
chloride secretion from the crypt cells and inhibit the neutral
coupled sodium chloride absorption.
These mediators alter the paracellular ion flux because of
toxin-mediated injury to the tight junctions.
-classic examples-cholera and Escherichia coli enterotoxins.

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3. Decreased absorptive surface
e.g. short bowel syndrome, Rota virus, Celiac disease
4. Mucosal invasion e.g. Shigella, E. histolytica, salmonella,
yersinia, C. jejuni

5. Motility disorders
e.g. increased motility with decreased transit time ( thyrotoxicosis,
irritable bowel syndrome---) or decreased motility causing stasis
with proliferation of pathogens leading to inflammatory
diarrhea 17
INFECTIOUS DIARRHEA
 RISK FACTORS FOR GASTROENTERITIS
1. Host factor
-young age, immune deficiency, measles, malnutrition
-micronutrient malnutrition;
e.g with vitamin A deficiency, the risk of dying from diarrhea,
measles, and malaria is increased by 20–24%.
-Zinc deficiency increases the risk of mortality from diarrhea,
pneumonia, and malaria by 13–21%.
-Arround 20% of acute diarrheal diseases become persistent
( 50% of deaths due to diarrhea)

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2.Environmental factors

Inappropriate breast feeding practice

 no EBF for the 1st 6months
 early interruption
 Bottle feeding
Failure to dispose feaces hygienically
Failure to wash hands after defecation and handling infants stool.
Seasonality- bacterial infections in warmer and rainy seasons

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3. Other factors
- Asymptomatic carriers

- Epidemic prone like V. cholerae

- Poverty, maternal educational status

=frequent episodes of acute diarrhea result in : -nutritional

compromise
-persistent diarrhea,
-protein-calorie malnutrition, and
-secondary infections.
-environmental contamination and increased exposure
to enteropathogens.
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INFECTIOUS DIARRHEA
Clinical manifestations
GI–nausea, vomiting, diarrhea, cramp, tenesmus
Systemic– loss of appetite, myalgia, weight loss
Immune-mediated like arthritis, paralysis
e.g.
 Reactive arthritis-Salmonella, Shigella, C.jejuni
 Guillain Barre Syndrome- C.jejuni
 Hemolytic uremic syndrome- E.coli, Shigella

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Complications of diarrhea
-Dehydration & Shock
-Acute renal failure
-Malnutrition
-Sepsis, DIC
-Metabolic acidosis
-Paralytic ileus
-Convulsions and coma (electrolyte disturbance, cerebral
thrombosis)
-Persistent diarrhea 22
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Hx

 Patient Evaluation  Abd.pain/distension

History  Hx of seizure
 type of diarrhea  Previous Hx of DD
 Vomiting (character)  Feeding Hx
 Fever  Developmental Hx
 Associated illness  Immunization
e.g. cough, rash, UTI  Social & family Hx
 Urine out put
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P/E G/E and V/S b. Loss of nutrients
Look for signs of: Hypoglycemia
a. water loss Convulsions , mental changes
- Loss of skin turgor c. Loss of bicarbonate
- Weak/absent pulse Vomiting & retching
- Tachycardia
Deep respiration
- Sunken eyes
Decreased myocardial
- Sunken fontanelle
contractility
- Delayed capillary refilling
- Cold skin d. Potassium loss
- Anuria, oliguria Abdominal distension
- mental changes Paralytic ileus

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Management of diarrheal diseases:
The main goal is prevention and treatment of dehydration and
other complications.

Antibiotics are needed only in a few cases in children under

5yrs of age.

Stool examination- is not indicated in young children except

for those with dysentery and persistent
diarrhea(anemia{h.worm},giardia)

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Severe dehydration
- treat with Rx plan C- give rapid IV rehydration followed by

oral rehydration therapy.

- While the drip is being set up, give additional ORS solution if

the child can drink.

- The best IV fluid solution is Ringer's lactate Solution (also

called Hartmann’s Soln)

- If not available, normal saline solution (0.9% NaCl) can be

used.

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5% dextrose solution is not effective.
1.Give 100 ml/kg of Ringer’s lactate or Normal saline divided as
shown below.
-If <12months- give 30ml/kg in 1hr followed by 70ml/kg in the
next 5hrs.
 If no significant improvement after 30ml/kg repeat the same

dose in 1hr then reassess.

2.Replace the ongoing loss by ORS 5-10ml/kg per loose stool if
able to drink.
3. Continue feeding
-Reassess after 6 hrs and classify.

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-Suspect cholera in children over 2 years old who have profuse
acute watery diarrhea and signs of severe dehydration, if
cholera is occurring in the local area.

➤Give an oral antibiotic - Possible choices are: cotrimoxazole,

erythromycin, and chloramphenicol.

4. Prescribe zinc supplementation as soon as vomiting stops .

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Some Dehydration -Rx plan B
1. Give ORS 75ml/kg over 4hrs and reassess.
2. Replace ongoing loss with ORS of 5-10ml/loose stool
3. Supplement with zinc
4. Give more food and fluid
NO DEHYDRATION
1.Give ORS 5-10ml/kg per loose stool at home
2. Give more food and fluid
3. Tell to come if diarrhea become bloody, develop fever,
unable to feed or become more sick.

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INFECTIOUS DIARRHEA
 DYSENTRY
the commonest causes of dysentry are Shigella and E. Histolytic.
1.Treat dehydration as above.
2. stool examination -only for pts with dysentry and persistent
diarrhea
– leukocytes(pus cells) are seen
Stool culture- to determine the cause if possible.
give cotrimoxazole for 5 days if S/E is not available.
- if no response in 2 days give metronidazole
3.Supplement with zinc.

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INFECTIOUS DIARRHEA
 PERSISTENT DIARRHEA
Classified according to IMNCI as
Severe persistent diarrhea if there are signs of some or severe
dehydration
persistent diarrhea if there are no signs of dehydration.
1. Assess the child for signs of dehydration and give fluids
according to Treatment Plans B or C, as appropriate.
 Low osmolality ORS is preferred to standard ORS for Rx of

dehydration with persistent diarrhea.

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 ORS solution is effective for most children with persistent
diarrhea.
-In some glucose absorption is impaired and ORS solution is not
effective.
 When given ORS, their stool volume increases markedly, thirst

increases, signs of dehydration develop or worsen, and the

stool contains a large amount of unabsorbed glucose.
-These children require IV rehydration until ORS solution can be
taken without causing the diarrhea to worsen

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2. Routine treatment of persistent diarrhea with antibiotics is not
effective and should not be given.
-Examine for non-intestinal infections such as pneumonia,
sepsis, urinary tract infection, oral thrush, and otitis media and
treat appropriately.
-Give micronutrients and vitamins accordingly.
-Treat persistent diarrhea with blood in the stool with an oral
drugs effective for Shigella and E. histolytica.

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➤Give treatment for amoebiasis (oral metronidazole: 7.5 mg/kg,
3 times a day, for 5 days) only if:
— S/E of fresh faeces reveals trophozoites of E. histolytica
within red blood cells;
OR-antibiotics-effective for Shigella cotrimoxazole
- for giardiasis (metronidazole: 5 mg/kg, 3 times a day, for 5
days) if cysts or trophozoites of Giardia lamblia are seen in the
faeces.

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3. Feeding
 Breastfeeding should be continued for as often and as long as

the child wants.

 Other food should be withheld for 4–6 hours for children with

dehydration who are being rehydrated following Treatment

Plans B or C.
 Children treated in hospital require special diets until their

diarrhea lessens and they are gaining weight. The goal is to

give a daily intake of at least 110 calories/kg

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Feeding in Infants aged under 6 months
1. Encourage EBF. Help mothers who are not breastfeeding
exclusively to do so.
• If not breastfeeding, give a breast milk substitute that is low in
lactose, such as yoghurt, or is lactose-free.
-Once the child improves, help the mother to re-establish
lactation.
• If the mother is not breastfeeding because she is HIV-positive,
she should receive appropriate counseling about the correct use
of breast milk substitutes.

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 If feeding fails with the 1st diet, the 2nd should be started.
 Signs of dietary failure are

-an increase in stool frequency (usually to >10 watery stools a

day), often with a return of signs of dehydration (this usually
occurs shortly after a new diet is begun), OR
- a failure to establish daily weight gain within 7 days.
 Give additional fresh fruit and well cooked vegetables to

children who are responding well

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4. How to give zinc supplements
— Tell the mother how much zinc to give:
Up to 6 months 1/2 tablet (10 mg) per day
6 months and more 1 tablet (20 mg) per day
for 10–14 days
— Show the mother how to give the zinc supplements:
• Infants, dissolve the tablet in a small amount of clean water,
expressed milk or ORS.
• Older children, tablet can be chewed or dissolved.

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 Contents of ORS(WHO)
standard modern
Glucose 20g/l 13.5g/l
Na+ 90mmol/l 75mmol/l
K+ 20mmol/l 20mmol/l
Cl- 80mmol/l 65mmol/l
Base 30mmol/l 10mmol/l
Osmolality 311mosm/l 245mosm/l

NB: soft beverages, juices should not be used as replacement

or maintenance due to their high osmolality and low Na+
content.
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Prevention strategies:

1.Promotion of EBF
2. Improved complementary feeding practices
3. Improved water and sanitation
4. Hand washing while food preparation and handling
5.Promotion of personal and domestic hygiene
6. Improved case management of diarrhea

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THANK YOU

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