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May 6, 2011
Immunosuppressed PatientsInfection with HIV and other immunocompromised states such as receiving chemotherapy, steroids, or other immunosuppressive agents usually necessitate empiric antimicrobials for all bacterial causes of diarrhea, as these patients are at increased risk for certain infections and may exhibit more severe illness. Alcoholics and patients with cirrhosis should avoid raw shellfish because of increased risk for severe infections due to Vibrio species. Listeria monocytogenes may be found in soft cheeses, cold deli meats, and raw dairy products. Infection is fecal-oral, and bacteremia or meningitis is often preceded by enteritis. All immunocompromised patients and pregnant women should avoid such foods.
TravelersTravelers to underdeveloped countries are exposed to a variety of novel bacteria and parasites and are often subject to poor food and water handling. The likelihood of acquiring diarrhea in certain geographic areas is as high as 50%. The most common pathogen is ETEC but other bacteria and parasites cause disease as well. Strategies for prevention include avoidance of water, fresh fruits, and vegetables. The use of antimicrobial prophylaxis is usually not recommended, except in patients with at-risk comorbidities, but may be considered in travelers to high-risk areas who have underlying illnesses or those in whom diarrheal would prove problematic (short trips for important business, politicians, honeymooners). If preventive medicine is requested by the traveler, bismuth subsalicylate (2 tablets with meals and before bed) is 62% effective in eliminating diarrhea.
Hospitalized PatientRoutine stool samples for culture as well as ova and parasite studies in hospitalized patients who develop diarrhea after their third day of admission are rarely positive and are not cost effective. Stool should be sent for C. difficile toxin assay, and if found negative, noninfectious causes such as medication and enteric feeding should be considered.*74/348/5*