Clinical Guideline for the Diagnosis and Treatment of Gastrointestinal Infections

doi:10.3947/ic.2010.42.6.323

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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

Special Article

Infect Chemother 2010;42(6):323-361.

Published online: 31 December 2010

DOI: https://doi.org/10.3947/ic.2010.42.6.323

Clinical Guideline for the Diagnosis and Treatment of Gastrointestinal Infections

The Korean Society of Infectious DiseasesKorean Society for ChemotherapyThe Korean Society of Clinical Microbiology

Correspondence to The Committee of the Korean Society for Chemotherapy for Diagnosis and Treatment Guidelines of Gastrointestinal Infection. Korean Society for Chemotherapy, Asterium #1203, Majellan 21, Samseong-dong 158-10 Kangnam-gu, Seoul 135-880, Korea Tel : +82-2-557-1755, Fax : +82-2-6499-1755, E-mail : ksc@ksac.or.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Diarrhea, Enteric fever, Hepatobiliary, Peritonitis, Guideline

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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 (%)
Pathogen	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
Multi-drug resistant (nalidixic acid susceptible)	Fluoroquinolone	15	5-7	Cefixime	20	7-14
Nalidixic acid resistant	Cefixime	20	7-14	Fluoroquinolone	20	10-14
Nalidixic acid resistant	Azithromycin	8-10	7	Fluoroquinolone	20	10-14
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
Multi-drug resistant (nalidixic acid susceptible)	Fluoroquinolone	15	10-14	Cefotaxime	80	10-14
Nalidixic acid resistant	Ceftriaxone	60	10-14	Fluoroquinolone	20	10-14
Nalidixic acid resistant	Cefotaxime	80	10-14	Fluoroquinolone	20	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)

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