Updated Infectious Diseases Society of America (IDSA) guidelines on diagnosing and managing acute gastroenteritis include advice that with the new, more sensitive tests, front-line physicians may need to consult specialists when the results come back with organisms they have not seen before.
These culture-independent tests cut the diagnostic time by days, guideline coauthor Larry Pickering, MD, from the Division of Infectious Diseases, Department of Pediatrics, Emory University, Atlanta, Georgia, told Medscape Medical News. But because of their high sensitivity, they may show unfamiliar organisms. Infectious disease experts can clarify what the results mean and how they should be approached.
The new guidelines by Andi L. Shane, MD, MPH, associate professor of pediatric infectious diseases at Emory and Children’s Healthcare of Atlanta, and colleagues were published online today in Clinical Infectious Diseases. They are also available free on the IDSA website.
The rapid test results now allow physicians to quickly determine appropriate therapies, potentially notify public health authorities of an outbreak, and predict some of the clinical manifestations that will occur if they have not already occurred, Dr Pickering said.
The new tests likely will also result in more diagnoses of acute gastroenteritis, which leads to nearly 500,000 hospitalizations and more than 5000 deaths in the United States every year, he said. “Some of these organisms we just didn’t detect before,” he added.
Three New Vaccines
Also new since the previous version of the guidelines, released in 2001, are three vaccines against diarrheal organisms. The most common is the rotavirus vaccine. Before that was uniformly recommended, rotavirus was one of the primary causes of diarrheal disease in children.
“It’s been amazing how that’s reduced the morbidity, mortality and hospitalization, and costs,” Dr Pickering said. The others are the travel vaccines for typhoid fever and cholera, and the guidelines also clarify when they should be administered. Success of the vaccines suggests continued vigilance by primary care providers in completing patient immunizations, he said.
The guidelines include seven tables for quick reference on how and where people acquire the pathogens, clinical presentation, and recommended treatment. Often the organisms are acquired at child care centers, nursing homes, or other places where people gather in close quarters, or after contact with animals, water, or unsafe foods.
As a consequence, Dr Pickering says, hospitalists and primary care physicians should take thorough histories for patients with diarrhea that include questions on where patients have been recently, whether they have traveled, whether they have compromised immune systems, and whether they have received antibiotics.
Although the guidelines don’t mention asking whether patients have received antibiotics from their dentist, Dr Pickering said that should be included in their questioning, as recent research reported by Medscape Medical News has pointed to a gap in dental antibiotics being reported to other providers.
Thorough histories may point out similar cases and facilitate more timely reporting of outbreaks.
Who Should Be Tested
The tables also help clinicians decide who should be tested.
Most people with diarrhea will not need to be tested for acute gastroenteritis, the guideline writers emphasize, but those who do include children younger than 5 years, the elderly, people with immune deficiencies, people returning from travels, and people with bloody diarrhea, severe abdominal pain, or signs of sepsis.
Rehydration for patients with diarrhea in vulnerable population groups also is emphasized in the guidelines.
“We’ve got to make sure the appropriate oral rehydration is given, and if that doesn’t work, then intravenous rehydration,” Dr Pickering said.
The guidelines point out conditions that may have originated with a diarrheal organism.
“For example, people who get Campylobacter may get Guillain-Barre syndrome after that,” he noted. “If it occurs 2 or 3 weeks later, they may not think that they’ve had Campylobacter.”
Clostridium difficile has become an increasingly common cause of diarrhea, and although these guidelines touch on the bacterium, a separate updated guideline specifically addressing it will be published by the end of the year, Dr Pickering said.
The guidelines point out the significant role primary care physicians and hospitalists play in diagnosing acute gastroenteritis.
“We, as front-line physicians, need to work closely with the health departments and notify them when these organisms are identified and work with our hospital laboratories to make sure that’s done,” Dr Pickering said.
Dr Shane or her institution have received support from the National Institute of Allergy and Infectious Diseases, the Gerber Foundation, SLACK, and the International Scientific Association for Probiotics and Prebiotics. Coauthors report possession of stocks and bonds from Ariad and SIS Pharmaceuticals; receiving support from the US Army, CSL Behring, National Health & Medical Research, the Centers for Disease Control and Prevention, the National Institutes of Health, UK Biotechnology and Biological Sciences Research Council, the Bill & Melinda Gates Foundation, New Zealand Health Research Council, Merck, GlaxoSmithKline, the Canadian Institutes of Health Research, Pfizer, PCIRN, Dynavax, Afexa, Crohn’s and Colitis Canada, Bristol-Myers Squibb, Wyeth, Pendopharm, and the National Institute of Diabetes and Digestive and Kidney Diseases; and consulting for Merck, Rebiotix, Acetlion, Sanofi Pasteur, Pfizer, and Thera Pharmaceuticals. One coauthor reports receiving a patent from the University of Virginia.
Clin Infect Dis. Published online October 19, 2017. Full text
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