training on clinical care of hiv, aids and opportunistic infections unit 5 persistent diarrhoea

Training on Clinical Care of HIV, AIDS and Opportunistic Infections

Unit 5

Persistent Diarrhoea


Learning Objectives

Participants will be able to:

• Provide empirical treatment for persistent diarrhoea

• Use and interpret stool exams in patients who do not respond to empirical therapy

• Provide appropriate treatment for identified infections

Unit 5: Persistent Diarrhoea, Slide 2


Definition: Persistent Diarrhoea

• Liquid stools

• 3 or more times per day

• Continuous or intermittent

• At least 2 weeks duration

• HIV positiveDefined in the MoHSS Guidelines for the Clinical Management

of HIV and AIDS, 2001.



Case History - Nangura

• Nangura is a 28 year old woman with HIV who presents with diarrhoea and nausea. She has had 4 liquid stools per day most days for about 2 weeks. She otherwise feels well and is urinating normally. She thinks the symptoms may be improving over the past 2 or 3 days.



Case History (2)

• Nangura was diagnosed with HIV 6 months ago. Her most recent CD4 count 4 months ago was 46.

• Her opportunistic infection history includes tuberculosis treated last year, and oral candidiasis 6 months ago that resolved with nystatin suspension.

• She developed hepatitis when she started nevirapine and HAART was discontinued until she recovered. Three weeks ago, she began stavudine (d4T) + lamivudine (3TC) + Lopinavir/ritonavir. She has taken cotrimoxazole daily for 6 months.



Case Exam

• On exam, Nangura is afebrile. She appears agitated, but she relates this to her long wait to see you. BP 110/60. Pulse 94. RR 16. Weight 50 kg. Her mouth appears mildly dry with some chapping of the lips. Her skin retracts promptly on pinching.



Additional History - Nangura

• She reports no fevers.

• She reports no visible blood in the stools.

• She has no recent sick contacts.

• She reports no recent antibiotic use besides cotrimoxazole.



First Assess for Dehydration

Clinical Feature Moderate Severe

General Irritable Cold, Sweaty

Pulse Rapid Rapid, Feeble

Respiration Deep Deep, Rapid

Skin Elasticity Poor Very Poor

Eyes Sunken Deeply Sunken

Mucous Membranes Dry Very Dry

Urine Flow Reduced None > 6 hours

Table 3 - MoHSS, Guidelines for the Clinical Management of HIV and AIDS, 2001.

Slide 8


Rehydration in Primary Care Setting

• Mild or moderate dehydration – Oral rehydration• Oral Rehydration Solution (ORS) packets preferred• ‘Home’ recipe

• ½ tsp salt with• 8 tsp sugar in• 1 liter boiled water

• Severe dehydration – initial IV rehydration preferred

• If unable to correct, refer to level 2



Potassium Replacement

• Oral rehydration solution (ORS)

• Fruits – like bananas, oranges, etc.

• Vegetables including potatoes and leafy greens like spinach



Nutrition

• Maintain intake of healthy balanced diet during episodes of diarrhoea



Some Clinical Categories of Diarrhoea

Bloody with fever Bloody without fever

Any CD4 count Any CD4 count

CD4 < 200 CD4 < 200

Non-bloody with fever Non-bloody without fever

Any CD4 count Any CD4 count

CD4 < 200 CD4 < 200

Slide 12


Bloody Diarrhoea with Fever

Any CD4 count• Bacillary dysentery

• Shigella*• Salmonella*• Campylobacter*• Invasive E. coli*

• Clostridium difficile colitis*

• Schistosoma mansoni• Ulcerative colitis*

CD4 < 200• CMV**

*Specific treatment available

** May respond to HAART

Slide 13


Bloody Diarrhoea without Fever

Any CD4 count• Amebic dysentery*

• Entameba histolytica

• Bacillary dysentery*• Strongyloides

stercoralis*• Ulcerative colitis*

CD4 < 200• CMV**



Slide 14


Non-Bloody Diarrhoea with Fever

Any CD4 count• Bacillary dysentery*• Crohn’s* Disease• C. difficile*

CD4 < 200• CMV**• MTB* or MOTT**• KS* ** and

Lymphoma*• HIV enteropathy**



Slide 15


Non-Bloody Diarrhoea without Fever

Any CD4 count• Protozoa

• Giardia*

• Helminths

• Ascaris*

• (Hookworm*)

• Strongyloides *

• Schistosomiasis (Bilharzia)*

• Non-invasive bacteria*

• Intestinal viruses

• Drug toxicity

• Other causes

CD4 < 200• Opportunistic protozoa

• Isospora*

• Cryptosporidia**

• Microsporidia**

• Opportunistic viruses

• CMV**

• Adenovirus**

• HIV enteropathy**

• KS**



Slide 16


Non-Bloody Diarrhoea without Fever (2)

• Lactose intolerance and fat malabsorption• Can cause diarrhoea or occur following

diarrhoea from another cause

• Irritable bowel syndrome

• Colonic malignancy



Empiric Therapy of Severe or Persistent Diarrhoea

Bloody with fever Bloody without fever

Nalidixic acid (bacillary dysentery) +/-metronidazole

(C. difficile)

Metronidazole

(Amebic dysentery or C. difficile colitis)

Non-bloody with feverPersistent non-bloody without fever

Nalidixic acid

(bacillary dysentery)

Metronidazole +/- albendazole

(Giardia +/- helmiths)

Slide 18


Stool Examinations

• Can be done at same time as empiric therapy where available

• Can be done if empiric therapy at primary care level is not successful

• Can be done for chronic diarrhoea



Stool Examinations (2)

• Gram Stain (1 sample)• For WBC

• Bacterial Culture (1 sample)• Salmonella, Shigella, Campylobacter, Clostridium

• Wet Mount (3 samples)• Motile protozoa• Helminth eggs

• Acid Fast Stain (3 samples)• MTB, MOTT, Isospora, Cryptosporidium

• C. difficile toxin (sent to South Africa only)



Parasites and Their Treatment

Aetiology Treatment

Giardia lambliaMetronidazole 400 mg tds x 5d

E. histolyticaMetronidazole 400 mg tds x 10d

Strongyloides stercoralis Albendazole 400 mg bd X 2-7d

Ascaris, hookworm Albendazole 400 mg once

Isospora belli Cotrimoxazole (80/400) 2 tab bd or qds x 7-21 d

Cryptosporidium Immune Restoration with ARVs

Microsporidium Immune Restoration with ARVs

Slide 21


Bacteria and Their Treatment

Aetiology Treatment

Salmonella

Chloramphenicol250-500 mg qid x 7-14 dOR Nalidixic Acid 1g qid x 5d

ShigellaNalidixic Acid 1g qid x 5d

CampylobacterErythromycin 500mg qid x 7d

Clostridium difficileStop other antibioticsMetronidazole 400mg tds x 10d

E. coliNalidixic Acid1g qid x 5d

MoHSS, Guidelines for the Clinical Management of HIV and AIDS, 2001.



• Consider empiric C. difficile treatment if:• Patient is toxic• History of recent antibiotic use• Stool sent for culture• ELISA for C. difficile toxin available in South

Africa

• Consider cotrimoxazole for isospora

• Consider albendazole 400 mg bd for 2-3 weeks for one type of microsporidia

Persistent Diarrhoea: No Organism Identified



• If not on HAART consider starting:• Immune restoration can help improve

diarrhoea from Cryptosporidia, Microsporidia, and HIV enteropathy

• Unexplained chronic diarrhoea for < 1 month is a WHO Clinical Stage 3 condition

• If on HAART or other medications, consider drug toxicity

Persistent Diarrhoea: No Organism Identified (2)



• Consider colonoscopy with biopsy if available:• Cytomegalovirus (CMV)• Kaposi’s Sarcoma (KS)• Lymphoma• Other malignancy• Inflammatory bowel disease

• Consider anti-motility medication (e.g. loperamide) IF:• No organism identified after careful search• Diarrhoea is non-bloody• Patient not elderly or a child

Persistent Diarrhoea: No Organism Identified (3)



Persistent Diarrhoea: Nutrition

• Continue fluid replacement as needed• Emphasize nutrition to overcome maldigestion

or malabsorbtion• Trial of lactose free diet• Trial of reduced fats

• But use fats to maximize calories if fat restriction does not reduce diarrhoea

• Maximize calories• Every food and drink item should include useful calories

• Balanced diet and/or vitamin supplements



HIV Wasting Syndrome

• Unexplained involuntary weight loss (>10% body weight) with obvious wasting or BMI<18.5 PLUS

• Unexplained chronic diarrhoea for > 1 month OR

• Reports of fever or night sweats for > 1 month (T>37.5°C) without known cause and lack of response to antibiotics or antimalarials

• WHO Clinical Stage 4Unit 5: Persistent Diarrhoea, Slide 27


Case Follow-up

• Nangura was advised to take more liquids and given nutritional counselling to maintain food intake while minimizing dairy products.

• Stool studies were negative for bacteria and parasites.

• The diarrhoea was attributed to the recently started lopinavir/ritonavir

• She has been given anti-diarrhoeal agents as needed. Despite intermittent diarrhoea and gas pains, she has gained weight and strength.



Key Points

1. First correct any dehydration

2. Consider empiric therapy of persistent diarrhoea

3. If unsuccessful, use stool laboratory studies to identify a cause and guide treatment


training on clinical care of hiv, aids and opportunistic infections unit 5 persistent diarrhoea

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