IDSA: Vincent T. Andriole ID Board Review Course 10/19/2011 1 GASTROINTESTINAL INFECTIONS John G. Bartlett Johns Hopkins University School of Medicine Conflicts: None GI INFECTIONS H. pylori Agents of diarrhea • Secretary vs. inflammatory • Norovirus • Major bacterial agents • Outbreaks • Clostridium difficile
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IDSA: Vincent T. Andriole ID Board Review Course
10/19/2011
1
GASTROINTESTINAL INFECTIONS
John G. BartlettJohns Hopkins University
School of Medicine
Conflicts: None
GI INFECTIONS
H. pyloriAgents of diarrhea• Secretary vs. inflammatory• Norovirus• Major bacterial agents• Outbreaks• Clostridium difficile
IDSA: Vincent T. Andriole ID Board Review Course
10/19/2011
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HELICOBACTER PYLORI
HELIOBACTER PYLORI1979: R. Warren – chronic gastritis1982: B. Marshall (registrar) results
of 100 biopsies presented at AGA1987: A. Morris drank H. pylori
sequential endoscopy studies1992: D. Graham – Controlled Abx
trial1992-present: peptic ulcer, gastric
cancer, gastric lymphoma, etc.2005: Nobel Prize – Warren and
Marshall
IDSA: Vincent T. Andriole ID Board Review Course
10/19/2011
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HELICOBACTER PYLORI:Ingestion by a healthy volunteer
Day Observation-17 to –2 Gastric pH 1 – 1.7 (23x)0 Ingestion H. pylori1 pH 1, asymptomatic3 – 12 Epig pain + vomiting8 Gastric biopsy8 – 27 pH 6 – 8 (7x)25 – 50 Doxycycline61 H. pylori present
*Morris A: Am J Gastro. 82:192, 1987
IDSA: Vincent T. Andriole ID Board Review Course
10/19/2011
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IDSA: Vincent T. Andriole ID Board Review Course
10/19/2011
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HELICOBACTER PYLORI
Causes: PUD, gastric ca, gastric lymphoma (dyspepsia?, GERD?)
cholecystectomy if gall stones• Concern – Abx resistance
IDSA: Vincent T. Andriole ID Board Review Course
10/19/2011
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SALMONELLA: PREVENTION
• Avoid raw or undercooked eggs• Temperature standards – food
preparation• Surveillance food handlers• Large outbreaks – contaminated
food – eggs, ice cream , peanut paste
IDSA: Vincent T. Andriole ID Board Review Course
10/19/2011
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NATIONWIDE SALMONELLA OUTBREAKS(Maki D. NEJM 2009;360:949)
Date: April-August 2008Agent: Salmonella Saint PaulNumber: 1407 persons, 43 states
282 hospitalized, 2 deathsEstimated number: >20,000Source: Jalapeno and serrano peppers,
Mexico farmEconomic cost: $200 million - tomatoes
IDSA: Vincent T. Andriole ID Board Review Course
10/19/2011
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OUTBREAK #2
Date: September 1, 2008Agent: Salmonella TyphimuriumNumber: 529 pts, 43 states
116 hospitalized and 8 deathsEstimated number: >20,000Source: Peanut butter in >400 food
products
FOODBORNE DISEASE: US
No. affected: 76 millionHospitalization: 350,000
Deaths: 5,000Healthcare cost: $7 billion
Why
IDSA: Vincent T. Andriole ID Board Review Course
10/19/2011
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FOODBORNE DISEASE: US
No. affected: 76 millionHospitalization: 350,000
Deaths: 5,000Healthcare cost: $7 billion
Why
Industrial scale productionMuch imported
Mass transportation of goodsEating out
FOOD IRRADIATION*
Irradiation kills pathogens without change in taste, loss of nutrition or risk
Endorsements: WHO, CDC, FDA, AMA, European Commission on Food
*Osterholm M: Role of irradiation in food safety. (NEJM 2004;350:1898)
IDSA: Vincent T. Andriole ID Board Review Course
10/19/2011
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BOTTLED WATER
Cost: $4.00/gallon – Gasoline/$3.50/gallonSafety regulations: FDA
Tap water: EnvironmentalProtection Agency (more stringent)
Consumer: Cannot tell (easily) where it came from, safety or pollutants
Comments: “No simple way to know about bottled water” (Jane Houlihan)“Bottled water is as safe as tap” (JK Doss, President of the International Water Association)
Which of the following drugs is a concern for resistance when used to treat C. difficile?
1. Elixhauser A, et al. Healthcare Cost and Utilization Project: Statistical Brief #50. April 2008. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb50.pdf. Accessed March 10, 2010. 2. Redelings MD, et al. Emerg Infect Dis. 2007;13:1417-1419.
Incidence and Mortality Increasing in US
Annual M
ortality Rate
per Million Population
# of
CD
I C
ases
per
100
,000
Dis
char
ges
NAP-1: EPIDEMIC STRAIN*
Characteristic Comment
Toxin A & B Produces 16-23 x more toxin in vitro**
tcdC deletion Represses productionToxin A & B
FQ resistance Rare in historic strains
*McDonald C. NEJM 2005;353:2433**Warny M. Lancet 2005;366:1079