Enteritis / Colitis

[thegenius]

You guys give abx to all of your enteritis / colitis patients who have normal vitals, normalish (maybe watery diarrhea max) BM's and normal labs? I usually don't in most cases...but I've had a bunch of these exact cases over the past month and many have come back to the ED after I give them bentyl, probiotics, motrin, and maybe an anti-emetic. Kind of frustrating

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[southerndoc]

I've sold out to Press-Ganey and the fact that C diff is more common than we care to admit. Unless I'm really sure it's viral (they have a sore throat, nasal congestion, etc.), then I will prescribe metronidazole.

 

[thegenius]

I've sold out to Press-Ganey and the fact that C diff is more common than we care to admit. Unless I'm really sure it's viral (they have a sore throat, nasal congestion, etc.), then I will prescribe metronidazole.

We fortunately have a quick C-Diff assay at my ER so I can tell pt's if they have C Diff within ~45 minutes.

(BTW, flagyl is no longer preferred first line oral agent for C diff...as there is too much recurrence. First line is now oral vancomycin.)

 

[Rekt]

I put colitis up there with the old lady/female with a dirty urine. Antibiotics are likely completely pointless, but it gives us an excuse diagnosis and makes the patient happy to get a prescription.

 

[Dr Mantis Toboggan]

We fortunately have a quick C-Diff assay at my ER so I can tell pt's if they have C Diff within ~45 minutes.

(BTW, flagyl is no longer preferred first line oral agent for C diff...as there is too much recurrence. First line is now oral vancomycin.)

Sure, but can anyone reliably get this filled for their patients? Seems always off formulary etc for me

 

[Groove]

You guys give abx to all of your enteritis / colitis patients who have normal vitals, normalish (maybe watery diarrhea max) BM's and normal labs? I usually don't in most cases...but I've had a bunch of these exact cases over the past month and many have come back to the ED after I give them bentyl, probiotics, motrin, and maybe an anti-emetic. Kind of frustrating

If their sx are only a few days, no leukocytosis, no left shift, no blood, afebrile, VSS, then I only Rx supportive meds. Otherwise, I will write abx.

 

[turkeyjerky]

Are you guys talking about CT diagnosed enteritis or patients who come in w/ diarrhea and you're clinically diagnosing?

If they come in w/ diarrhea, I usually restrict abx to patients who are febrile, adults w/ bloody diarrhea, recent travel or immunosuppressed. Maybe if someone has really severe diarrhea (eg the type of patient who's up to the bathroom several times during their ED stay and you can actually get a stool sample from, not the type who tells you it's severe)

If it's on a CT scan (which I obviously don't get often when someone comes in for diarrhea, but for abdominal pain), then I'll be a little bit more prone to give abx w/o a good reason for it. I'll usually have labs in this case, so if they have a leukocytosis or are old I might throw some abx at them.

Genius, are patients coming back sick? Or just w/ persistent symptoms. If it's the latter, I'd say its more of a failure to educate properly about the course of disease (or unrealistic expectations).

I haven't really seen ALL that much community acquired c diff (at least w/o recent abx exposure), but granted I don't really test for it much at all (can't recall the last time I had a patient successfully produce a sample...)

 

[dadaddadaBATMAN]

Are you guys talking about CT diagnosed enteritis or patients who come in w/ diarrhea and you're clinically diagnosing?

If they come in w/ diarrhea, I usually restrict abx to patients who are febrile, adults w/ bloody diarrhea, recent travel or immunosuppressed. Maybe if someone has really severe diarrhea (eg the type of patient who's up to the bathroom several times during their ED stay and you can actually get a stool sample from, not the type who tells you it's severe)

If it's on a CT scan (which I obviously don't get often when someone comes in for diarrhea, but for abdominal pain), then I'll be a little bit more prone to give abx w/o a good reason for it. I'll usually have labs in this case, so if they have a leukocytosis or are old I might throw some abx at them.

Genius, are patients coming back sick? Or just w/ persistent symptoms. If it's the latter, I'd say its more of a failure to educate properly about the course of disease (or unrealistic expectations).

I haven't really seen ALL that much community acquired c diff (at least w/o recent abx exposure), but granted I don't really test for it much at all (can't recall the last time I had a patient successfully produce a sample...)

Usually when I scan these folks it’s because it’s an 83 yo memaw with diarrhea and vague abdominal pain which may or may not be present currently, and I don’t trust that I’m getting an actual history. I shamelessly admit that I will sometimes use this as an excuse to admit to obs with abx and Ivf, because that population has a lot of bad things happen (that are admittedly probably not preventable) and I prefer not to hold the hot potato. Usually it’s read as a nonspecific colitis accompanied by some slight leukocytosis. I do sometimes feel a little guilty about this, but it doesn’t last

 

[pkwraith]

Never for enteritis, especially if they have blood in their stool. Occasinally for colitis if they're really tender or have a good white count.

Would not be surprised if c diff is now more prevalent with the prevalent antibiotic prescription pattern, I guess.

My personal experience from my stool cultures that have actually resulted is probably 90% viral (astro, noro, etc), 7% bacterial that requires no antibiotics or you will active harm them if you give them antibioics (EHEC), 2% bacterial that may have a little benefit but probably dont ne
ed th.e.m (campylobater), and 1% that may acutally benefit from antibiotics. .

 

[GeneralVeers]

This is why it should be ethical to have Placebacillin. We need to be able to prescribe them something that makes them happy, but does no harm at the same time.

 

[turkeyjerky]

Never for enteritis, especially if they have blood in their stool. Occasinally for colitis if they're really tender or have a good white count.

Would not be surprised if c diff is now more prevalent with the prevalent antibiotic prescription pattern, I guess.

My personal experience from my stool cultures that have actually resulted is probably 90% viral (astro, noro, etc), 7% bacterial that requires no antibiotics or you will active harm them if you give them antibioics (EHEC), 2% bacterial that may have a little benefit but probably dont ne
ed th.e.m (campylobater), and 1% that may acutally benefit from antibiotics. .

Should I be more worried about giving abx to adults w/ dysentery? I don't treat afebrile peds who have bloody diarrhea w/ abx due to the increased risk of HUS (either perceived or real), but I've never been too worried about it in adults.

 

[Porfirio]

Zofran ODT, Bentyl

 

[RoyBasch]

I've sold out to Press-Ganey and the fact that C diff is more common than we care to admit. Unless I'm really sure it's viral (they have a sore throat, nasal congestion, etc.), then I will prescribe metronidazole.

If you are specifically and only trying to cover for c. diff, why not use PO vancomycin instead? More effective, cannot be enterally absorbed systemically so virtually no possibility of side effects.

from IDSA:
"

1. Either vancomycin or fidaxomicin is recommended over metronidazole for an initial episode of CDI. The dosage is vancomycin 125 mg orally 4 times per day or fidaxomicin 200 mg twice daily for 10 days (strong recommendation, high quality of evidence) (Table 1).

"

Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for...

www.idsociety.org

 

[RoyBasch]

To answer the original question, I use ABx on diarrhea sometimes. There usually has to be some feature that concerns me for a bacterial etiology. Things I specifically inquire:

Recent Abx use or hospitalization, concern for c. diff. I do have access to c diff testing but it can take a while to turn around, so easier to do empiric PO vancomycin.

Recent foreign travel. More concern for travelers diarrhea, will prescribe cipro.

Fever or hematochezia. Will prescribe antibiotics.

Patient is ill appearing. If they are sick enough to be admitted, they are getting empiric IV Abx. If they are really toxic (suspect C diff, confirmed toxic megacolon on CT) then they get fidaxomycin PO, IV flagyl, +/- vanc enema (usually in consultation with surgery or CRC if available at the facility I'm at).

Radiographically on CT, isolated colitis with enteritis, history and exam not suggestive of IBD (or cannot rule out), empiric ABx (usally PO vanc and cipro)

If the patient has no ABx use, no hospitalization, no fever, no foreign travel, no blood, is young/healthy, well appearing, short duration of symptoms, particularly if there is associated vomiting, I am not likely to use ABx, particularly for short duration of symptoms. If CT shows enterocolitis, I feel fairly confident the etiology is more likely Viral, again no ABx. I send the patients home with stool specimen collection kit and tell them to bring a sample to their PCP or GI in 3 days if they are still symptomatic. If they truly still have diarrhea by the time they follow up (usually more than 3 days) they probably really do need the GI PCR panel to determine if there is beyond a trivial viral etiology. I believe most of these patients get better quickly and never follow up or provide a sample to anyone.

All of this is assuming I cannot get a stool PCR back in a reasonable time, which is usually the case. However, sometimes a patient provides a sample, it's daytime business hours and the lab can run it, and if you can get a definitive answer with yes there is a bacterial etiology, then obviously ill treat. If it's negative, then I'm done.

 

[thegenius]

Sure, but can anyone reliably get this filled for their patients? Seems always off formulary etc for me

Yes it can be problematic at times.

 

[bravotwozero]

This is why it should be ethical to have Placebacillin. We need to be able to prescribe them something that makes them happy, but does no harm at the same time.

Just tell your patients to take probiotics and call it a day. And that's not even placebo, has some evidence behind it. Even mentioned in Tintinalli.

 

[thegenius]

Just tell your patients to take probiotics and call it a day. And that's not even placebo, has some evidence behind it. Even mentioned in Tintinalli.

“Ma’am....it’s the GOOD bacteria. The GOOD bacteria fight the bad bacteria and then you are all better!”

“Oh really? Bacteria know if they are good or bad? Well ok then. I’ll take the medicine.”

 

[southerndoc]

If you are specifically and only trying to cover for c. diff, why not use PO vancomycin instead? More effective, cannot be enterally absorbed systemically so virtually no possibility of side effects.

Too many insurers in my area require prior approval for it. I got tired of getting phone calls. If it's confirmed C diff, I still prescribe it. If it's suspected or if CT diagnosed colitis, then metronidazole it is.

@thegenius We also have a "rapid" C diff PCR. Supposedly takes <30 mins to run. Usually it's more like 3-4 hours before the result comes back. The test can be run quickly, but getting the lab tech to actually do it timely is another story.

 

[xaelia]

Nearly never antibiotics for routine diarrhea.

C. diff depends; PO vancomycin/fidoxamicin is so costly, not unreasonable to do metronidazole as a first-line in someone otherwise healthy.

"Colitis" per CT read depends; systemic illness/comorbidities/immunosuppression.

 

[thegenius]

To answer the original question, I use ABx on diarrhea sometimes. There usually has to be some feature that concerns me for a bacterial etiology. Things I specifically inquire:

Recent Abx use or hospitalization, concern for c. diff. I do have access to c diff testing but it can take a while to turn around, so easier to do empiric PO vancomycin.

Recent foreign travel. More concern for travelers diarrhea, will prescribe cipro.

Fever or hematochezia. Will prescribe antibiotics.

Patient is ill appearing. If they are sick enough to be admitted, they are getting empiric IV Abx. If they are really toxic (suspect C diff, confirmed toxic megacolon on CT) then they get fidaxomycin PO, IV flagyl, +/- vanc enema (usually in consultation with surgery or CRC if available at the facility I'm at).

Radiographically on CT, isolated colitis with enteritis, history and exam not suggestive of IBD (or cannot rule out), empiric ABx (usally PO vanc and cipro)

If the patient has no ABx use, no hospitalization, no fever, no foreign travel, no blood, is young/healthy, well appearing, short duration of symptoms, particularly if there is associated vomiting, I am not likely to use ABx, particularly for short duration of symptoms. If CT shows enterocolitis, I feel fairly confident the etiology is more likely Viral, again no ABx. I send the patients home with stool specimen collection kit and tell them to bring a sample to their PCP or GI in 3 days if they are still symptomatic. If they truly still have diarrhea by the time they follow up (usually more than 3 days) they probably really do need the GI PCR panel to determine if there is beyond a trivial viral etiology. I believe most of these patients get better quickly and never follow up or provide a sample to anyone.

All of this is assuming I cannot get a stool PCR back in a reasonable time, which is usually the case. However, sometimes a patient provides a sample, it's daytime business hours and the lab can run it, and if you can get a definitive answer with yes there is a bacterial etiology, then obviously ill treat. If it's negative, then I'm done.

This is an awfully convoluted algorithm. Way too many moving parts. So that means you must be a good doctor!

Can you turn this into an app...I would love the patient to just input all of these decision points and numbers, I'll fill in the labs and CT findings, and would love for this app to say "YES - GIVE ABX" or "DON'T DO IT!!!"