Journal List > Infect Chemother > v.42(6) > 1035037

The Korean Society of Infectious Diseases, Korean Society for Chemotherapy, and The Korean Society of Clinical Microbiology: Clinical Guideline for the Diagnosis and Treatment of Gastrointestinal Infections

Abstract

There are many various diseases in the gastrointestinal infections, and we tried to make a diagnosis and treatment guideline for common diseases based on available diagnostic tools and antimicrobial susceptibility of major pathogens causing gastrointestinal infections in our country. This guideline was developed by the committee of Korean Society for Chemotherapy, and covers infectious diarrhea, antibiotic associated diarrhea, enteric fever, hepatobiliary infection, and complicated intraabdominal infection.

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Table 1.
Recommendation of Strength and Quality of Evidence
Definition
Strength of Recommendation
A Good evidence to support a recommendation for (or against use)
B Moderate evidence to support a recommendation for (or against use)
C Poor evidence to support a recommendation
Quality of Evidence
I ≥1 properly randomized controlled trial
II ≥1 well-designed clinical trial without randomization or cohort or case-controlled analytic studies (preferably >1 center) or multiple time-series or dramatic results from uncontrolled experiments
III opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
Table 2.
Microorganisms Identified in Infectious Diarrhea
Pathogen Number (%)
Lee JI (n=6788) [3] Cho SH (n=3785) [4] KCDC (n=8556) [2]
S. aureus 859 (12.7) 841 (24) 526 (6.1)
E. coli 275 (4.1) 2,037 (58.1) 1,926 (23.5)
Shigella spp. 32 (0.9) 86 (1.0)
Salmonella spp. 56 (0.8) 328 (9.4) 345 (4.0)
C. perfringens 161 (2.4) 111 (3.2) 467 (5.5)
V. parahaemolyticus 154 (4.4) 377 (4.4)
C. jejuni 309 (0.9) 89 (1.0)
B. cereus 246 (2.9)
Norovirus 2,465 (28.8)
Others 38 (0.6) 252 (7.2) 2,029 (23.7)
Table 3.
Antimicrobial Therapy in Bacterial Diarrhea
Microorganism Antibiotics
Shigella ciprofloxacin 750 mg once daily for 3 days or azithromycin 500 mg once daily for 3 days
Nontyphoidal Salmonella levofloxacin 500 mg (other fluoroquinolone) once daily for 7-10 days or azithromycin 500 mg once daily for 7 days
C. jejuni azithromycin 500 mg once daily for 3 days
V. cholerae doxycycline 300 mg single dose or erythromycin 250 mg 3 times daily for 3 days or azithromycin 500 mg once daily for 3 days
noncholeraic Vibrio ciprofloxacin 750 mg once daily for 3 days or azithromycin 500 mg once daily for 3 days
E. coli (except EHEC) ciprofloxacin 750 mg once daily for 3 days or azithromycin 500 mg once daily for 3 days
Table 4.
Suggested Approaches to Recurrent C. difficile Associated Diarrhea
Second recurrence*
Vancomycin in tapered and pulsed doses
125 mg 4 times daily for 14 days
125 mg 2 times daily for 7 days
125 mg once daily for 7 days
125 mg every 2 days for 8 days (4 doses)
125 mg once every 3 days for 15 days (5 doses)
Third recurrence
Vancomycin at a dose of 125 mg orally 4 times daily for 14 days, followed by rifaximin at a dose of 400 mg 2 times daily for 14 days
Other options for recurrent infection
Intravenous immunoglobulin at a dose of 150- 400 mg/kg once every 3 weeks for a total of 2 or 3 doses
Therapy with other microoganisms, including ‘fecal transplantation’
Therapy with probiotic such as Saccharomyces boulardii
Nitazoxanide

* A probiotic such as Saccharomyces boulardii or lactobacilli species may be added during the final 2 weeks of the vancomycin taper and for at least 4 weeks thereafter (preferablly 8 weeks). However, the efficacy of probiotics in preventing recurrent C. difficile infection is unclear because of inconsistent study results. Bacteremia or fungemia may rarely complicate the use of probiotics in immunocompromised, critically ill patients.

Table 5.
Annual Reported Cases in Korea (No. of Patients)
’98 ’99 ’00 ’01 ’02 ’03 ’04 ’05 ’06 ’07 ’08 ’09
Typhoid fever 380 308 234 401 221 199 174 190 200 223 188 168
Paratyphoid fever 12 11 7 36 413 88 45 31 50 45 44 36
Table 6.
Antimicrobial Resistance Rates of Salmonella enterica serotype Typhi Isolates from 1999 to 2004 (%)
1999 (n=224) 2000 (n=153) 2001 (n=147) 2002 (n=66) 2003 (n=76) 2004 (n=34)
Amikacin 0.1 0.0 0.6 1.0 0.0 0.0
Ampicillin 9.0 22.1 28.6 14.8 7.9 3.0
Ampicillin/sulbactam 1.0 0.3 5.2 2.8 0.0 0.0
Cefixime 0.8 0.4 2.3 3.2 2.6 0.0
Chloramphenicol 4.7 6.8 11.7 3.3 6.6 3.0
Ciprofloxacin 0.0 0.0 0.7 0.3 6.6 3.0
Ceftriaxone 0.0 0.0 0.7 0.3 0.0 0.0
Cefotixin 0.2 0.2 1.5 0.9 0.0 0.0
Gentamicin 0.9 0.4 2.9 1.9 0.0 0.0
Kanamycin 1.2 0.6 4.3 1.6 0.0 0.0
Nalidixic acid 1.2 8.5 14.9 11.9 10.5 6.0
Streptomycin 13.5 60.7 41.1 26.9 14.5 6.0
Trimethoprim/sulfamethoxazole 2.4 1.2 4.3 7.7 5.3 3.0
Tetracycline 21.7 29.0 41.3 24.7 2.7 3.0
Table 7.
Suggested Antibiotic Treatment Regimens for Typhoid Fever
Primary drug
Alternative drug
Antibiotics Daily dose (mg/kg) Days Antibiotics Daily dose (mg/kg) Days
Uncomplicated typhoid fever (oral drug)
Fully susceptible Fluoroquinolone (ciprofloxacin, ofloxacin) 15 5-7 Trimethoprim/sulfamethoxazole 8/40 14
Multi-drug resistant (nalidixic acid susceptible) Fluoroquinolone 15 5-7 Azithromycin 8-10 7
Cefixime 20 7-14
Nalidixic acid resistant Cefixime 20 7-14 Fluoroquinolone 20 10-14
Azithromycin 8-10 7
Severe typhoid fever (parenteral drug)
Fully susceptible Fluoroquinolone 15 10-14 Trimethoprim/sulfamethoxazole 8/40 10-14
Multi-drug resistant (nalidixic acid susceptible) Fluoroquinolone 15 10-14 Ceftriaxone 60 10-14
Cefotaxime 80 10-14
Nalidixic acid resistant Ceftriaxone 60 10-14 Fluoroquinolone 20 10-14
Cefotaxime 80 10-14
Table 8.
Complications of Typhoid Fever
Abdominal Respiratory
Gastrointestinal perforation Bronchitis
Gastrointestinal hemorrhage Pneumonia (Salmonella enterica serotype Typhi, Streptococcus pneumoniae)
Hepatitis [175-177]
Cholecystitis (usually subclinical) Empyema [178, 180]
Pancreatitis Hemoptysis [181]
Cardiovascular Hematologic
Asymptomatic electrocardiographic changes Anemia
Myocarditis Disseminated intravasular coagulation
Endocarditis Hemophagocytic syndrome
Pericarditis [178] Others
Shock Chronic carriage
Aneurysm with or without rupture Focal abscess (liver[182], ovary, epidura [179], psoas muscle, spine, thyroid, scrotum)
Neuropsychiatric
Encephalopathy
Delirium Mediastinitis
Psychotic states Miscarriage
Meningitis [179] Pharyngitis
Impairment of coordination Relapse
Guillain-Barre syndrome
Table 9.
Empirical Antimicrobial Dosage for Intraabdominal Infections in Adults
Antimicrobials Dosage
β-lactam/β-lactamase inhibitor combination
 ampicillin/sulbactam 1.5-3 g every 6 hr
 piperacillin/tazobactam 3.375 g every 6 hr
 ticarcillin/clavulanic acid 3.1 g every 6 hr
Carbapenems
 imipenem/cilastatin 500 mg every 6 hr or 1 g every 8 hr
 meropenem 1 g every 8 hr
 doripenem 500 mg every 8 hr
 ertapenem 1 g every 24 hr
Cephalosporins
 cefazolin 1-2 g every 8 hr
 cefuroxime 1.5 g every 8 hr
 cefoxitin 2 g every 6 hrs
 cefotaxime 1-2 g every 6-8 hr
 ceftriaxone 1-2 g every 12-24 hr
 ceftazidime 2 g every 8 hr
 cefepime 2 g every 8-12 hr
 cefoperazone/sulbactam 1-2 g every 12 hr
Fluoroquinolones
 ciprofloxacin 400 mg every 12 hr
 levofloxacin 750 mg every 24 hr
 moxifloxacin 400 mg every 24 hr
Aminoglycoisde
 gentamicin, tobramycin 5-7 mg/kg every 24 hr
 amikacin 15-20 mg/kg every 24 hr
Glycopeptide
 vancomycin 15-20 mg/kg every 8-12 hr
 teicoplanin 12 mg/kg every 24 hr
Linezololid 600 mg every 12 hr
Quinupristin/dalfopristin 7.5 mg/kg every 8 hr
Tigecycline initial 100 mg, then 50 mg every 12 hr
Metronidazole 500 mg every 8-12 hr or 1,500 mg every 24 hr
Aztreonam 1-2 g every 6-8 hr
Table 10.
Microorganisms Commonly Identified in Complicated Intraabdominal Infection
Microorganism Patients, % [255-257] Microorganisms, % [250] Microorganisms, % [251]
Facultative & Aerobic Gram-negative bacilli
Escherichia coli 71 45 69
Klebsiella species 14 17
 Pseudomonas aeruginosa 14 1 15
 Proteus mirabilis 5 2.3
Enterobacter species 5 5 7.5
Anaerobics
Bacteroides fragilis 35
 Other Bacteroides species 71
Clostridium species 29
Prevotella species 12
Peptostreptococcus species 17
Fusobacterium species 9
Eubacterium species 17
Gram-positive aerobic cocci
Streptococcus species 38 7
Enterococcus faecalis 12 3
Enterococcus faecium 3
Enterococcus species 8
Staphylococcus aureus 4
Table 11.
Empirical Antibiotics Recommendation in Community Acquired Complicated intraabdominal Infection
Mild-to-moderate severity High severity
Cefoxitin (A-II) Ceftazidime or cefepime + metronidazole (A-I)
Cefuroxime+metronidazole (A-II) Piperacillin/tazobactam (A-I)
Ceftriaxone or cefotaxime+metronidazole (A-II) Imipenem/cilastatin (A-I)
Ciprofloxacin or levofloxacin +metronidazole (A-II) Meropenem (A-I)
Ertapenem (B-II)
Moxifloxacin (B-II)
Tigecycline (B-II)
TOOLS
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