Sandbox:Mydah: Difference between revisions

Latest revision as of 22:10, 26 August 2020

Associate Editor(s)-in-Chief: Mydah Sajid, MD [1]

Dysentery in adults resident survival guide

Overview

Dysentery is described as blood with stools. It occurs due to inflammatory reaction causing damage to the intestinal tract. The patient also has a fever, abdominal cramping, discomfort, increased bowel movements, fecal urgency, and tenesmus. The underlying cause is mostly an infection due to bacteria. The main aim of the physician is to assess the severity of gastrointestinal symptoms, dehydration, and hypovolemia. In patients with severe symptoms, prompt investigations, and treatment should be carried out to reduce morbidity. This section provides a short and straight to the point overview of the dysentery in adults.

Causes

Life-threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

Does not include any known cause

Common Causes

Shigellosis^[1]
Shiga toxin-producing E. coli (STEC) (eg, E. coli O157:H7) infection
Amebic dysentery caused by Entamoeba histolytica^[1]
Salmonella infection
Campylobacter infection^[1]
Enteric viruses (eg, cytomegalovirus [CMV] or adenovirus)^[2]
Inflammatory bowel disease
Ischemic colitis

Evaluation

Shown below is an algorithm summarizing the diagnosis of dysentery according to the American College of Gastroenterology guidelines.^[2]^[1]^[3]^[4]

Treatment

Shown below is an algorithm summarizing the treatment of dysentery according to the Infectious Diseases Society of America clinical practice guidelines.^[1]^[5]^[6]

Characterize the symptoms:

Duration of diarrhea
Frequency and consistency of stools
Presence of mucus and blood in the stools

To evaluate cause ask the following questions:

Food history
Occupational exposure (e.g. daycare center, poultry farm)
Exposure to animals (pets, poultry, zoo, turtles)
Recent travel to endemic areas
Medication history (use of proton pump inhibitor increase susceptibility to infection with Shigella)

Does the patient have any of the following clinical signs or history?

Old age (more than 70 years)
Presence of co-morbidities (advance heart disease, severe immunocompromised state)
Fever (>101.3 degrees Fahrenheit)
Presence of severe symptoms
Need for hospitalization
Signs of dehydration (dry mucous membranes, sunken eyes, decreased skin turgor, orthostatic hypotension, oliguria, dark-colored urine, and drowsiness )

abdominal tenderness on palpation, rebound tenderness, abdominal distention, and abdominal rigidity.

Yes

No

Perform the following stool tests:

Bacterial culture for Salmonella, Shigella, and Campylobacter.
Test for Shigella toxin and E. coli O157: H7
Test for fecal leukocytes and lactoferrin.

Does the patient have any of the following:

Clinical signs suggestive of inflammatory bowel disease

Symptoms present for more than a week despite conservative management

The patient is a health care worker or food handler (which can be a potential health hazard)

Is the fecal leukocytes or lactoferrin test positive?

Yes

No

Yes

No

* Perform routine stool culture.

Specific tests should be performed depending upon the patient’s history.

No need to perform Stool culture and additional tests.

Test for Entamoeba histolytica

Amebic dysentery highly unlikely. Look for other causative agents.

Characterize the symptoms of the patient:

Presence of severe diarrhea along with systemic symptoms.
Two or more clinical signs for dehydration (i.e. Sunken eyes, dry mucous membrane, reduced skin turgor, increased thirst ).

Yes

No

Fluid replacement therapy.
Empirical antibiotics therapy.
The drug of choice is fluoroquinolones (500mg Levofloxacin (oral) once daily for 3 days). If the symptoms do not improve in a few days, the patient should be switched to either azithromycin (oral) or cephalosporin.
Bismuth sulphate and loperamide to relieve abdominal cramps and discomfort.

Oral fluid replacement therapy. Give ORS solution for every bowel movement. Approximately 2 liters of ORS solution is given to the patient.

Antimicrobial therapy should be initiated on the basis of stool culture results.

Bismuth sulphate and loperamide can be given to relieve abdominal symptoms.

Reassess hydration status after every 6 hours.

Assess patient for symptoms of hypovolemia (i.e. altered mental status with lethargy and unconsciousness, weak pulses , and inability to drink)

Yes

No

Patient has severe hypovolemia.

Give parenteral fluid replacement with 5 % dextrose or normal saline solution.
Give rapid infusion initially and then slow infusion.
The aim is to give 200 ml/kg in 24 hours with 100ml/kg in the first 4 hours of infusion.
Reassess hemodynamic and hydration status of the patient after 6 hours.

Patient has mild hypovolemia.

Give oral fluid replacement therapy.

2.2 to 4 liters of ORS is given in the first 4 hours.

Reassess hemodynamic and hydration status of the patient after 6 hours.

Do's

Important clues regarding the etiology of dysentery can be narrowed down while taking history. If the patient has dysentery more than 16 hours after having an outdoor food consider Enterotoxigenic E.coli. There is an increased risk of acquiring the ''Salmonella'' infection in individuals exposed to turtles and poultry. People working in daycare have an increased risk of infection with enteric viruses and ''Shigella''.^[1]
Physicians can take a rectal swab in patients in whom stool samples cannot be obtained and immediate diagnosis is required.^[7] Though the rectal swab has less sensitivity than stool culture in identifying the causative agent.^[8]
If the clinician is suspecting a particular bacteria, it should be mentioned while ordering the test. Certain bacteria require special culture media to grow and methods to be visualized. ''Campylobacter jejuni'' grows on the specific ‘CAMP’ agar plates at a particular temperature and environmental conditions. If infection with ''Yersinia'' is suspected, it should be specified as it is commonly overlooked.^[9]
Physicians need to monitor the patients for the complications of the infection with certain bacteria. Bacteremia and reactive arthritis can occur with infection with non- typhoidal ''Salmonella'' and ''Shigella''.^[10] The hemolytic-uremic syndrome can occur due to E 0157:H7 or ''Shigella''. A neurological complication Guillain-Barré syndrome can occur with ''Campylobacter'' infection.

Don'ts

The empirical antimicrobial treatment for dysentery does not include treatment for E. histolytica. Metronidazole (500mg thrice daily for 7 to days) should be administered to patients only when trophozoites or cysts are visualized under a microscope in the stool sample.^[11]
A complete metabolic profile is not routinely performed in patients with dysentery. Serum electrolytes and glucose levels should only be measured in patients who present with complications (i.e. altered mental status, seizures, anuria, oliguria, and ileus ).

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 ^1.4 ^1.5 Riddle MS, DuPont HL, Connor BA (2016). "ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults". Am J Gastroenterol. 111 (5): 602–22. doi:10.1038/ajg.2016.126. PMID 27068718.
↑ ^2.0 ^2.1 Shane AL, Mody RK, Crump JA, Tarr PI, Steiner TS, Kotloff K; et al. (2017). "2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea". Clin Infect Dis. 65 (12): e45–e80. doi:10.1093/cid/cix669. PMC 5850553. PMID 29053792.
↑ Thielman NM, Guerrant RL (2004). "Clinical practice. Acute infectious diarrhea". N Engl J Med. 350 (1): 38–47. doi:10.1056/NEJMcp031534. PMID 14702426.
↑ Kane SV, Sandborn WJ, Rufo PA, Zholudev A, Boone J, Lyerly D; et al. (2003). "Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation". Am J Gastroenterol. 98 (6): 1309–14. doi:10.1111/j.1572-0241.2003.07458.x. PMID 12818275.
↑ Victora CG, Bryce J, Fontaine O, Monasch R (2000). "Reducing deaths from diarrhoea through oral rehydration therapy". Bull World Health Organ. 78 (10): 1246–55. PMC 2560623. PMID 11100619.
↑ Christopher PR, David KV, John SM, Sankarapandian V (2010). "Antibiotic therapy for Shigella dysentery". Cochrane Database Syst Rev (8): CD006784. doi:10.1002/14651858.CD006784.pub4. PMC 6532574 Check |pmc= value (help). PMID 20687081.
↑ Jean S, Yarbrough ML, Anderson NW, Burnham CA (2019). "Culture of Rectal Swab Specimens for Enteric Bacterial Pathogens Decreases Time to Test Result While Preserving Assay Sensitivity Compared to Bulk Fecal Specimens". J Clin Microbiol. 57 (6). doi:10.1128/JCM.02077-18. PMC 6535583 Check |pmc= value (help). PMID 30944186.
↑ Kotar T, Pirš M, Steyer A, Cerar T, Šoba B, Skvarc M; et al. (2019). "Evaluation of rectal swab use for the determination of enteric pathogens: a prospective study of diarrhoea in adults". Clin Microbiol Infect. 25 (6): 733–738. doi:10.1016/j.cmi.2018.09.026. PMID 30315956.
↑ Guerrant RL, Shields DS, Thorson SM, Schorling JB, Gröschel DH (1985). "Evaluation and diagnosis of acute infectious diarrhea". Am J Med. 78 (6B): 91–8. doi:10.1016/0002-9343(85)90370-5. PMID 4014291.
↑ Rodríguez M, de Diego I, Martínez N, Rosario Rodicio M, Carmen Mendoza M (2006). "Nontyphoidal Salmonella causing focal infections in patients admitted at a Spanish general hospital during an 11-year period (1991-2001)". Int J Med Microbiol. 296 (4–5): 211–22. doi:10.1016/j.ijmm.2006.01.068. PMID 16621698.
↑ Misra NP, Gupta RC (1977). "A comparison of a short course of single daily dosage therapy of tinidazole with metronidazole in intestinal amoebiasis". J Int Med Res. 5 (6): 434–7. doi:10.1177/030006057300100209. PMID 590600.

[pmid27068718-1] 1.0 ^1.1 ^1.2 ^1.3 ^1.4 ^1.5 Riddle MS, DuPont HL, Connor BA (2016). "ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults". Am J Gastroenterol. 111 (5): 602–22. doi:10.1038/ajg.2016.126. PMID 27068718.

[pmid29053792-2] 2.0 ^2.1 Shane AL, Mody RK, Crump JA, Tarr PI, Steiner TS, Kotloff K; et al. (2017). "2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea". Clin Infect Dis. 65 (12): e45–e80. doi:10.1093/cid/cix669. PMC 5850553. PMID 29053792.

[pmid14702426-3] Thielman NM, Guerrant RL (2004). "Clinical practice. Acute infectious diarrhea". N Engl J Med. 350 (1): 38–47. doi:10.1056/NEJMcp031534. PMID 14702426.

[pmid12818275-4] Kane SV, Sandborn WJ, Rufo PA, Zholudev A, Boone J, Lyerly D; et al. (2003). "Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation". Am J Gastroenterol. 98 (6): 1309–14. doi:10.1111/j.1572-0241.2003.07458.x. PMID 12818275.

[pmid11100619-5] Victora CG, Bryce J, Fontaine O, Monasch R (2000). "Reducing deaths from diarrhoea through oral rehydration therapy". Bull World Health Organ. 78 (10): 1246–55. PMC 2560623. PMID 11100619.

[pmid20687081-6] Christopher PR, David KV, John SM, Sankarapandian V (2010). "Antibiotic therapy for Shigella dysentery". Cochrane Database Syst Rev (8): CD006784. doi:10.1002/14651858.CD006784.pub4. PMC 6532574 Check |pmc= value (help). PMID 20687081.

[pmid30944186-7] Jean S, Yarbrough ML, Anderson NW, Burnham CA (2019). "Culture of Rectal Swab Specimens for Enteric Bacterial Pathogens Decreases Time to Test Result While Preserving Assay Sensitivity Compared to Bulk Fecal Specimens". J Clin Microbiol. 57 (6). doi:10.1128/JCM.02077-18. PMC 6535583 Check |pmc= value (help). PMID 30944186.

[pmid30315956-8] Kotar T, Pirš M, Steyer A, Cerar T, Šoba B, Skvarc M; et al. (2019). "Evaluation of rectal swab use for the determination of enteric pathogens: a prospective study of diarrhoea in adults". Clin Microbiol Infect. 25 (6): 733–738. doi:10.1016/j.cmi.2018.09.026. PMID 30315956.

[pmid4014291-9] Guerrant RL, Shields DS, Thorson SM, Schorling JB, Gröschel DH (1985). "Evaluation and diagnosis of acute infectious diarrhea". Am J Med. 78 (6B): 91–8. doi:10.1016/0002-9343(85)90370-5. PMID 4014291.

[pmid16621698-10] Rodríguez M, de Diego I, Martínez N, Rosario Rodicio M, Carmen Mendoza M (2006). "Nontyphoidal Salmonella causing focal infections in patients admitted at a Spanish general hospital during an 11-year period (1991-2001)". Int J Med Microbiol. 296 (4–5): 211–22. doi:10.1016/j.ijmm.2006.01.068. PMID 16621698.

[pmid590600-11] Misra NP, Gupta RC (1977). "A comparison of a short course of single daily dosage therapy of tinidazole with metronidazole in intestinal amoebiasis". J Int Med Res. 5 (6): 434–7. doi:10.1177/030006057300100209. PMID 590600.

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@@ Line 1: / Line 1: @@
 __NOTOC__
 {{AE}} {{MSJ}}
-==Sore throat in adults resident survival guide==
+==Dysentery in adults resident survival guide==
 ===Overview===
-Sore throat is one of the most common complaints among patients visiting their primary care physicians. In the United States, approximately 12 million ambulatory care visits are due to sore throat annually<ref name="pmid18958997">{{cite journal| author=Schappert SM, Rechtsteiner EA| title=Ambulatory medical care utilization estimates for 2006. | journal=Natl Health Stat Report | year= 2008 | volume=  | issue= 8 | pages= 1-29 | pmid=18958997 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18958997  }} </ref>. It mostly occurs in children and adolescents. The etiology is mostly acute self- limiting viral infection. Group A streptococcal infection is the most common causative bacteria for acute pharyngitis in adults<ref name="pmid3534166">{{cite journal| author=Komaroff AL, Pass TM, Aronson MD, Ervin CT, Cretin S, Winickoff RN | display-authors=etal| title=The prediction of streptococcal pharyngitis in adults. | journal=J Gen Intern Med | year= 1986 | volume= 1 | issue= 1 | pages= 1-7 | pmid=3534166 | doi=10.1007/BF02596317 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3534166  }} </ref>. As a physician, it is important to identify clinical signs for life-threatening airway obstruction and deep tissue infection and treat them promptly. This section provides a short and straight to the point overview of the sore throat in adults.
+[[Dysentery]] is described as [[blood]] with [[Human feces|stools]]. It occurs due to inflammatory reaction causing damage to the [[Gastrointestinal tract|intestinal tract]]. The patient also has a [[fever]], abdominal cramping, discomfort, increased [[Intestine|bowel]] movements, fecal urgency, and [[tenesmus]]. The underlying cause is mostly an infection due to [[bacteria]]. The main aim of the [[physician]] is to assess the severity of gastrointestinal symptoms, [[dehydration]], and [[hypovolemia]]. In [[patient|patients]] with severe symptoms, prompt investigations, and treatment should be carried out to reduce morbidity. This section provides a short and straight to the point overview of the [[dysentery]] in adults.
 ===Causes===
 ====Life-threatening Causes====
 Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
-* Does not include any known cause
+*Does not include any known cause
 ====Common Causes====
-* Viral upper respiratory tract infection (Adenovirus, rhinovirus, coronavirus, enterovirus, influenza A and B, parainfluenza virus, respiratory syncytial virus, and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). <ref name="pmid2494921">{{cite journal| author=Huovinen P, Lahtonen R, Ziegler T, Meurman O, Hakkarainen K, Miettinen A | display-authors=etal| title=Pharyngitis in adults: the presence and coexistence of viruses and bacterial organisms. | journal=Ann Intern Med | year= 1989 | volume= 110 | issue= 8 | pages= 612-6 | pmid=2494921 | doi=10.7326/0003-4819-110-8-612 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2494921  }} </ref><ref name="pmid11172144">{{cite journal| author=Bisno AL| title=Acute pharyngitis. | journal=N Engl J Med | year= 2001 | volume= 344 | issue= 3 | pages= 205-11 | pmid=11172144 | doi=10.1056/NEJM200101183440308 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11172144  }} </ref><ref name="pmid32329971">{{cite journal| author=Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR | display-authors=etal| title=Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 22 | pages= 2081-2090 | pmid=32329971 | doi=10.1056/NEJMoa2008457 | pmc=7200056 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32329971  }} </ref>
+*[[Shigellosis]]<ref name="pmid27068718">{{cite journal| author=Riddle MS, DuPont HL, Connor BA| title=ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. | journal=Am J Gastroenterol | year= 2016 | volume= 111 | issue= 5 | pages= 602-22 | pmid=27068718 | doi=10.1038/ajg.2016.126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27068718  }} </ref>
-* Group A streptococcal (GAS) infection
+*[[Escherichia coli enteritis|Shiga toxin-producing E. coli]] (STEC) (eg, E. coli O157:H7) infection
-* Group C and G Streptococcus infection<ref name="pmid23091044">{{cite journal| author=Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G | display-authors=etal| title=Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2012 | volume= 55 | issue= 10 | pages= 1279-82 | pmid=23091044 | doi=10.1093/cid/cis847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23091044  }} </ref>
+*[[Amoebiasis|Amebic dysentery]] caused by [[Entamoeba histolytica]]<ref name="pmid27068718">{{cite journal| author=Riddle MS, DuPont HL, Connor BA| title=ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. | journal=Am J Gastroenterol | year= 2016 | volume= 111 | issue= 5 | pages= 602-22 | pmid=27068718 | doi=10.1038/ajg.2016.126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27068718  }} </ref>
-* Arcanobacterium haemolyticum<ref name="pmid23091044">{{cite journal| author=Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G | display-authors=etal| title=Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2012 | volume= 55 | issue= 10 | pages= 1279-82 | pmid=23091044 | doi=10.1093/cid/cis847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23091044  }} </ref>
+*[[Salmonella]] infection
-* Fusobacterium necrophorum<ref name="pmid25686164">{{cite journal| author=Centor RM, Atkinson TP, Ratliff AE, Xiao L, Crabb DM, Estrada CA | display-authors=etal| title=The clinical presentation of Fusobacterium-positive and streptococcal-positive pharyngitis in a university health clinic: a cross-sectional study. | journal=Ann Intern Med | year= 2015 | volume= 162 | issue= 4 | pages= 241-7 | pmid=25686164 | doi=10.7326/M14-1305 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25686164  }} </ref>
+*[[Campylobacter]] infection<ref name="pmid27068718">{{cite journal| author=Riddle MS, DuPont HL, Connor BA| title=ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. | journal=Am J Gastroenterol | year= 2016 | volume= 111 | issue= 5 | pages= 602-22 | pmid=27068718 | doi=10.1038/ajg.2016.126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27068718  }} </ref>
-* Mycoplasma and Chlamydia species<ref name="pmid2494921">{{cite journal| author=Huovinen P, Lahtonen R, Ziegler T, Meurman O, Hakkarainen K, Miettinen A | display-authors=etal| title=Pharyngitis in adults: the presence and coexistence of viruses and bacterial organisms. | journal=Ann Intern Med | year= 1989 | volume= 110 | issue= 8 | pages= 612-6 | pmid=2494921 | doi=10.7326/0003-4819-110-8-612 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2494921  }} </ref>
+*Enteric viruses (eg, [[cytomegalovirus]] [CMV] or [[adenovirus]])<ref name="pmid29053792">{{cite journal| author=Shane AL, Mody RK, Crump JA, Tarr PI, Steiner TS, Kotloff K | display-authors=etal| title=2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. | journal=Clin Infect Dis | year= 2017 | volume= 65 | issue= 12 | pages= e45-e80 | pmid=29053792 | doi=10.1093/cid/cix669 | pmc=5850553 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29053792  }} </ref>
-* Corynebacterium diphtheriae
+*[[Inflammatory bowel disease]]
-* Acute HIV infection<ref name="pmid3258508">{{cite journal| author=Tindall B, Barker S, Donovan B, Barnes T, Roberts J, Kronenberg C | display-authors=etal| title=Characterization of the acute clinical illness associated with human immunodeficiency virus infection. | journal=Arch Intern Med | year= 1988 | volume= 148 | issue= 4 | pages= 945-9 | pmid=3258508 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3258508  }} </ref>
+*[[Ischemic colitis]]
-* Neisseria gonorrhoeae
-* Epstein-Barr virus and other herpes viruses cytomegalovirus (CMV) and herpes simplex virus (HSV)<ref name="pmid8387178">{{cite journal| author=McMillan JA, Weiner LB, Higgins AM, Lamparella VJ| title=Pharyngitis associated with herpes simplex virus in college students. | journal=Pediatr Infect Dis J | year= 1993 | volume= 12 | issue= 4 | pages= 280-4 | pmid=8387178 | doi=10.1097/00006454-199304000-00004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8387178  }} </ref>
-* allergic rhinitis, sinusitis
-* gastroesophageal reflux disease
-* smoking
-* inhalation of dry air (particularly in winters)
-* Vocal strain<ref name="pmid22890476">{{cite journal| author=Renner B, Mueller CA, Shephard A| title=Environmental and non-infectious factors in the aetiology of pharyngitis (sore throat). | journal=Inflamm Res | year= 2012 | volume= 61 | issue= 10 | pages= 1041-52 | pmid=22890476 | doi=10.1007/s00011-012-0540-9 | pmc=3439613 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22890476  }} </ref>
-* Medications: Angiotensin-converting enzyme inhibitors, chemotherapeutic drugs<ref name="pmid22890476">{{cite journal| author=Renner B, Mueller CA, Shephard A| title=Environmental and non-infectious factors in the aetiology of pharyngitis (sore throat). | journal=Inflamm Res | year= 2012 | volume= 61 | issue= 10 | pages= 1041-52 | pmid=22890476 | doi=10.1007/s00011-012-0540-9 | pmc=3439613 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22890476  }} </ref>
 ===Evaluation===
-Shown below is an algorithm summarizing the diagnosis of [[sore throat]] in adults<ref name="pmid11255529">{{cite journal| author=Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR, American Academy of Family Physicians. American College of Physicians-American Society of Internal Medicine | display-authors=etal| title=Principles of appropriate antibiotic use for acute pharyngitis in adults. | journal=Ann Intern Med | year= 2001 | volume= 134 | issue= 6 | pages= 506-8 | pmid=11255529 | doi=10.7326/0003-4819-134-6-200103200-00018 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11255529  }} </ref><ref name="pmid22566485">{{cite journal| author=Fine AM, Nizet V, Mandl KD| title=Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. | journal=Arch Intern Med | year= 2012 | volume= 172 | issue= 11 | pages= 847-52 | pmid=22566485 | doi=10.1001/archinternmed.2012.950 | pmc=3627733 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22566485  }} </ref><ref name="pmid10678338">{{cite journal| author=Webb KH, Needham CA, Kurtz SR| title=Use of a high-sensitivity rapid strep test without culture confirmation of negative results: 2 years' experience. | journal=J Fam Pract | year= 2000 | volume= 49 | issue= 1 | pages= 34-8 | pmid=10678338 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10678338  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=10923583 Review in: J Fam Pract. 2000 Jul;49(7):660] </ref>:
+Shown below is an algorithm summarizing the diagnosis of [[dysentery]] according to the American College of Gastroenterology guidelines.<ref name="pmid29053792">{{cite journal| author=Shane AL, Mody RK, Crump JA, Tarr PI, Steiner TS, Kotloff K | display-authors=etal| title=2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. | journal=Clin Infect Dis | year= 2017 | volume= 65 | issue= 12 | pages= e45-e80 | pmid=29053792 | doi=10.1093/cid/cix669 | pmc=5850553 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29053792  }} </ref><ref name="pmid27068718">{{cite journal| author=Riddle MS, DuPont HL, Connor BA| title=ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. | journal=Am J Gastroenterol | year= 2016 | volume= 111 | issue= 5 | pages= 602-22 | pmid=27068718 | doi=10.1038/ajg.2016.126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27068718  }} </ref><ref name="pmid14702426">{{cite journal| author=Thielman NM, Guerrant RL| title=Clinical practice. Acute infectious diarrhea. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 1 | pages= 38-47 | pmid=14702426 | doi=10.1056/NEJMcp031534 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14702426  }} </ref><ref name="pmid12818275">{{cite journal| author=Kane SV, Sandborn WJ, Rufo PA, Zholudev A, Boone J, Lyerly D | display-authors=etal| title=Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation. | journal=Am J Gastroenterol | year= 2003 | volume= 98 | issue= 6 | pages= 1309-14 | pmid=12818275 | doi=10.1111/j.1572-0241.2003.07458.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12818275  }} </ref>
 {{Family tree/start}}
-{{familytree | | | | | | | | A01 |A01=<div style="float: left; text-align: left; height: 28em; width: 19em; padding:1em;"> Are Alarming clinical signs for upper airway obstruction or deep neck infection present?
+{{Family tree | | | | A01 | | | |A01= <div style="float: center; text-align: left;">Characterize the symptoms:
-* “Hot potato” voice
+* Duration of [[diarrhea]]
-* Drooling
+* Frequency and consistency of [[Human feces|stools]]
-* Stridor
+* Presence of [[mucus]] and [[blood]] in the [[Human feces|stools]] }}
-* Respiratory distress
+{{Family tree | | | | |!| | | | | }}
-* “Tripod position”
+{{Family tree | | | | B01 | | | |B01= <div style="float: center; text-align: left;">To evaluate cause ask the following questions:
-* Fever and chills
+* Food history
-* Severe unilateral sore throat
+* Occupational exposure (e.g. daycare center, poultry farm)
-* Bulging of the pharyngeal wall or soft palate
+* Exposure to animals (pets, poultry, zoo, turtles)
-* History of penetrating trauma to the neck
+* Recent travel to endemic areas
-* Lockjaw
+* Medication history (use of [[proton pump inhibitor]] increase susceptibility to [[infection]] with [[Shigella]]) }}
-* Crepitus
+{{Family tree | | | | |!| | | | | }}
-* Neck stiffness }}
+{{Family tree | | | | C01 | | | |C01= <div style="float: center; text-align: left;">Does the patient have any of the following clinical signs or history?
-{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
+* Old age (more than 70 years)
-{{familytree | | | B01 | | | | | | | | B02 | | |B01= Yes| B02= No}}
+* Presence of co-morbidities (advance [[heart disease]], severe immunocompromised state)
-{{familytree | | | |!| | | | | | | | | |!| }}
+* [[Fever]] (>101.3 degrees Fahrenheit)
-{{familytree | | | C01 | | | | | | | | |C02| |C01= Stabilize ABC and refer patient urgently to emergency or inpatient care unit|C02= Are clinical signs for Viral URTI (including conjunctivitis, coryza, cough, viral exanthem and voice hoarseness) present?}}
+* Presence of severe symptoms
-{{familytree | | | | | | | | | | | |,|-|^|.| | }}
+* Need for hospitalization
-{{familytree | | | | | | | | | | | D01 | | D02|D01= Yes| D02= No }}
+* Signs of [[dehydration]] (dry mucous membranes, sunken [[Eye|eyes]], decreased [[skin]] turgor, [[orthostatic hypotension]], [[oliguria]], dark-colored [[urine]], and [[Somnolence|drowsiness]] )
-{{familytree | | | | | | | | | | | |!| | |!| | }}
+abdominal tenderness on [[palpation]], [[rebound tenderness]], [[abdominal distention]], and abdominal rigidity. }}
-{{familytree | | | | | | | | | | | E01 | | E02|E01= Manage patient with supportive care.| E02=<div style="float: left; text-align: left; height: 18em; width: 19em; padding:1em;">Does patient have clinical features of GAS throat infection?
+{{Family tree | |,|-|-|^|-|-|-|-|.| | }}
-* Fever (temperature ≥100.4 degrees F)
+{{Family tree | D01 | | | | | | D02 |D01= Yes |D02= No}}
-* Acute onset of sore throat
+{{Family tree | |!| | | | | | | |!| | }}
-* Inflammation and edema of tonsillopharyngeal and uvular mucosa
+{{Family tree | E01 | | | | | | E02 |E01= <div style="float: center; text-align: left;">Perform the following [[Human feces|stool]] tests:
-* Tonsillar and peritonsillar yellow or white exudates
+* Bacterial culture for [[Salmonella]], [[Shigella]], and [[Campylobacter]].
-* Painful cervical lymphadenopathy
+* Test for [[Shigella]] toxin and [[Escherichia coli|E. coli]] O157: H7
-* Scarlatiniform rash
+* Test for fecal [[leukocytes]] and [[lactoferrin]]. |E02= <div style="float: center; text-align: left;">Does the patient have any of the following:
-* History of GAS exposure}}
+* Clinical signs suggestive of [[inflammatory bowel disease]]
-{{familytree | | | | | | | | | | | |,|-|-|-|-|+|-|-|-|-|-|.| }}
+* Symptoms present for more than a week despite conservative management
-{{familytree | | | | | | | | | | |F01| | | | F02 | | | | F03 |F01= Yes| F02= Uncertain| F03= No}}
+* The patient is a health care worker or food handler (which can be a potential health hazard) }}
-{{familytree | | | | | | | | | | |!| | | | | |!| | | | | |!| }}
+{{Family tree | |!| | | | | |,|-|^|-|.| }}
-{{familytree | | | | | | | | | | |!| | | | |G02| | | | |!|G02= Apply Centor criteria for patient's clinical signs and symptoms. Is score ≥3? }}
+{{Family tree | F01 | | | | |F02| |F03| |F01= Is the fecal [[leukocytes]] or [[lactoferrin]] test positive? |F02= Yes |F03= No }}
-{{familytree | | | | | | | | | | |!| | |,|-|^|-|.| | | | |!| }}
+{{Family tree |,|-|^|-|.| | | |!| | | |!| }}
-{{familytree | | | | | | | | | | |!| | |H01| |H02| | |!| | |H01= Yes|H02= No }}
+{{Family tree |G01| |G02| |G03| |G04| G01=Yes |G02= No |G03=
-{{familytree | | | | | | | | | | |!| | | |!| | |!| | | | |!| }}
+* Perform routine [[Human feces|stool]] culture.
-{{familytree | | | | | | | | | | |!| | | |!| | |!| | | | |!| | }}
+* Specific tests should be performed depending upon the patient’s history. |G04= No need to perform [[Human feces|Stool]] culture and additional tests. }}
-{{familytree | | | | | | | | | | |I01|-|'| | |`|-|-|-|-| I02 | I01= Perform Rapid antigen detection test| I02= Consider other viral, bacterial or noninfectious causes of sore throat. The illness is mostly self-limiting and specific tests for diagnosis are not carried out. }}
+{{Family tree |!| | | |!| | | }}
-{{familytree | | | | | | | |,|-|-|^|-|-|-|.| | | | }}
+{{Family tree |F01| |F02| |F01= Test for [[Entamoeba histolytica]] |F02= [[Amoebiasis|Amebic dysentery]] highly unlikely. Look for other causative agents. }}
-{{familytree | | | | | | | |J01| | | | |J02| | |J01= Positive|J02= Negative }}
-{{familytree | | | | | | | | | | | | | | |!| | | | }}
-{{familytree | | | | | | | | | | | | | | |H01| | |H01= <div style="float: left; text-align: left; height: 25em; width: 19em; padding:1em;">Perform throat culture in patients with any of the following risk factors:
-* Patient with weak immune system or history of complications of GAS infection i.e. acute rheumatic fever.
-* Patients in close contact with individuals who have a high risk of complications (i.e. infants and immunocompromised elderly population)
-* Young adults living in close proximity (i.e. college dormitories)
-* Patients residing in endemic areas of acute rheumatic fever
-* Patient with negative RADT but with Centor criteria scores ≥3 }}
-{{Family tree/end}}
 ===Treatment===
-Shown below is an algorithm summarizing the treatment of sore throat in adults according to the Infectious Diseases Society of America guidelines.<ref name="pmid23091044">{{cite journal| author=Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G | display-authors=etal| title=Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2012 | volume= 55 | issue= 10 | pages= 1279-82 | pmid=23091044 | doi=10.1093/cid/cis847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23091044  }} </ref><ref name="pmid26785402">{{cite journal| author=Harris AM, Hicks LA, Qaseem A, High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention| title=Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. | journal=Ann Intern Med | year= 2016 | volume= 164 | issue= 6 | pages= 425-34 | pmid=26785402 | doi=10.7326/M15-1840 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26785402  }} </ref>
+Shown below is an algorithm summarizing the treatment of [[dysentery]] according to the Infectious Diseases Society of America clinical practice guidelines.<ref name="pmid27068718">{{cite journal| author=Riddle MS, DuPont HL, Connor BA| title=ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. | journal=Am J Gastroenterol | year= 2016 | volume= 111 | issue= 5 | pages= 602-22 | pmid=27068718 | doi=10.1038/ajg.2016.126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27068718  }} </ref><ref name="pmid11100619">{{cite journal| author=Victora CG, Bryce J, Fontaine O, Monasch R| title=Reducing deaths from diarrhoea through oral rehydration therapy. | journal=Bull World Health Organ | year= 2000 | volume= 78 | issue= 10 | pages= 1246-55 | pmid=11100619 | doi= | pmc=2560623 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11100619  }} </ref><ref name="pmid20687081">{{cite journal| author=Christopher PR, David KV, John SM, Sankarapandian V| title=Antibiotic therapy for Shigella dysentery. | journal=Cochrane Database Syst Rev | year= 2010 | volume=  | issue= 8 | pages= CD006784 | pmid=20687081 | doi=10.1002/14651858.CD006784.pub4 | pmc=6532574 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20687081  }} </ref>
-{{Family tree/start}}
+{{familytree/start }}
-{{familytree | | | | | | | | A01 |A01=Does patient have strong clinical suspicion for viral URTI?}}
+{{familytree | | | | | | | | A01 |A01= <div style="float: center; text-align: left;">Characterize the symptoms of the [[patient]]:
+* Presence of severe [[diarrhea]] along with systemic symptoms.
+* Two or more clinical signs for [[dehydration]] (i.e. Sunken [[Eye|eyes]], dry [[mucous membrane]], reduced [[skin]] turgor, increased [[thirst]] ). }}
 {{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
-{{familytree | | | B01 | | | | | | | | B02 | | |B01=No|B02=Yes}}
+{{familytree | | | B01 | | | | | | | | B02 | | |B01= Yes |B02= No }}
-{{familytree | | | |!| | | | | | | | | |!| }}
+{{familytree | | | |!| | | | | | | | | |!| | | }}
-{{familytree | | | C01 | | | | | | | | |C02| |C01=Is patient having clinical picture suggestive of GAS pharyngitis along with positive RADT?|C02=Manage patient with supportive care including analgesics, hot fluids, lozenges, and soft diet.}}
+{{familytree | | | C01 | | | | | | | | C02 | | |C01= <div style="float: left; text-align: left;">
-{{familytree | |,|-|^|.| | | | | | | | | | }}
+* [[Fluid replacement]] therapy.
-{{familytree |D01 | | D02 | | | | | | |D01=Yes|D02=No }}
+* Empirical [[Antibiotic|antibiotics]] therapy.
-{{familytree | |!| | |!| | | | | | | | }}
+* The drug of choice is [[Quinolone|fluoroquinolones]] (500mg [[Levofloxacin (oral)]] once daily for 3 days).  If the symptoms do not improve in a few days, the patient should be switched to either [[azithromycin (oral)]] or [[cephalosporin]].
-{{familytree |E01| |E02| | | | | | |E01=<div style="float: left; text-align: left; height: 16em; width: 19em; padding:1em;">Treat patients with empirical antibiotic course for 10 days
+* Bismuth sulphate and [[loperamide]] to relieve abdominal cramps and discomfort. |C02= <div style="float: left; text-align: left;">
-* The drug of choice is 500mg oral penicillin V two or three times a day.
+* Oral [[fluid replacement]] therapy. Give [[Oral rehydration therapy|ORS]] solution for every [[Intestine|bowel]] movement. Approximately 2 liters of [[Oral rehydration therapy|ORS]] solution is given to the [[patient]].
-* Benzathin G penicillin intramuscular injection can be administered as a single dose.
+* Antimicrobial therapy should be initiated on the basis of [[Human feces|stool]] culture results.
-* Cephalosporins or Macrolides should be given to patients experiencing allergic reactions with penicillin. |E02=<div style="float: left; text-align: left; height: 16em; width: 25em; padding:1em;">Provide supportive care to the patients.
+* Bismuth sulphate and [[loperamide]] can be given to relieve abdominal symptoms.
-* If the patients have risk factors suggestive of other causes (i.e. acute HIV infection, gonorrhea, or non-infectious causes), perform relevant investigations. }}
+* Reassess hydration status after every 6 hours. }}
-{{Family tree/end}}
+{{familytree | | | |!| | | | | | | | }}
+{{familytree | | | D01 | | | | | | |D01= Assess [[patient]] for symptoms of [[hypovolemia]] (i.e. [[altered mental status]] with [[lethargy]] and [[unconsciousness]], weak [[Pulse|pulses]] , and inability to drink) }}
+{{familytree | |,|-|^|.| | | | }}
+{{familytree | D01 | | D02 | |D01= Yes |D02= No }}
+{{familytree | |!| | | |!| | | }}
+{{familytree | E01 | | E02 | |E01= <div style="float: left; text-align: left;">Patient has severe [[hypovolemia]].
+* Give [[Intravenous therapy|parenteral]] [[fluid replacement]] with 5 % dextrose or [[Saline (medicine)|normal saline]] solution.
+* Give rapid infusion initially and then slow infusion.
+* The aim is to give 200 ml/kg in 24 hours with 100ml/kg in the first 4 hours of infusion.
+* Reassess [[Hemodynamics|hemodynamic]] and hydration status of the [[patient]] after 6 hours. |E02= <div style="float: left; text-align: left;"> [[Patient]] has mild [[hypovolemia]].
+* Give oral [[fluid replacement]] therapy.
+* 2.2 to 4 liters of [[Oral rehydration therapy|ORS]] is given in the first 4 hours.
+* Reassess [[Hemodynamics|hemodynamic]] and hydration status of the [[patient]] after 6 hours. }}
+{{familytree/end}}
 ===Do's===
-* Physicians should administer antibiotics with judicious care in patients with a sore throat due to the risk of developing adverse reactions and bacterial resistance in the community. A physician should only prescribe antibiotics in patients with high clinical suspicion for GAS or those with positive rapid antigen detection test and throat culture<ref name="pmid9270458">{{cite journal| author=Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL| title=Reattendance and complications in a randomized trial of prescribing strategies for sore throat: the medicalizing effect of prescribing antibiotics. | journal=BMJ | year= 1997 | volume= 315 | issue= 7104 | pages= 350-2 | pmid=9270458 | doi=10.1136/bmj.315.7104.350 | pmc=2127265 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9270458  }} </ref>.
+* Important clues regarding the etiology of dysentery can be narrowed down while taking history. If the patient has dysentery more than 16 hours after having an outdoor food consider [[Enterotoxigenic Escherichia coli|Enterotoxigenic ''E.coli'']]. There is an increased risk of acquiring the [[''Salmonella'']] infection in individuals exposed to turtles and poultry. People working in daycare have an increased risk of infection with enteric [[Virus|viruses]] and [[''Shigella'']].<ref name="pmid27068718">{{cite journal| author=Riddle MS, DuPont HL, Connor BA| title=ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. | journal=Am J Gastroenterol | year= 2016 | volume= 111 | issue= 5 | pages= 602-22 | pmid=27068718 | doi=10.1038/ajg.2016.126 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27068718  }} </ref>
-* Antibiotics reduce the severity of symptoms and fasten the rate of recovery in the patients. The primary goal of treatment with antibiotics is to reduce the incidence of complications with GAS infection<ref name="pmid14819035">{{cite journal| author=BRINK WR, RAMMELKAMP CH, DENNY FW, WANNAMAKER LW| title=Effect in penicillin and aureomycin on the natural course of streptococcal tonsillitis and pharyngitis. | journal=Am J Med | year= 1951 | volume= 10 | issue= 3 | pages= 300-8 | pmid=14819035 | doi=10.1016/0002-9343(51)90274-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14819035  }} </ref>.
+* Physicians can take a rectal swab in patients in whom stool samples cannot be obtained and immediate diagnosis is required.<ref name="pmid30944186">{{cite journal| author=Jean S, Yarbrough ML, Anderson NW, Burnham CA| title=Culture of Rectal Swab Specimens for Enteric Bacterial Pathogens Decreases Time to Test Result While Preserving Assay Sensitivity Compared to Bulk Fecal Specimens. | journal=J Clin Microbiol | year= 2019 | volume= 57 | issue= 6 | pages=  | pmid=30944186 | doi=10.1128/JCM.02077-18 | pmc=6535583 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30944186  }} </ref> Though the rectal swab has less sensitivity than [[Human feces|stool]] culture in identifying the causative agent.<ref name="pmid30315956">{{cite journal| author=Kotar T, Pirš M, Steyer A, Cerar T, Šoba B, Skvarc M | display-authors=etal| title=Evaluation of rectal swab use for the determination of enteric pathogens: a prospective study of diarrhoea in adults. | journal=Clin Microbiol Infect | year= 2019 | volume= 25 | issue= 6 | pages= 733-738 | pmid=30315956 | doi=10.1016/j.cmi.2018.09.026 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30315956  }} </ref>
-* The Infectious Disease Society of America (IDSA) has recommended the use of aspirin, nonsteroidal anti-inflammatory drugs (NS-AIDs), or acetaminophen as supportive therapy for alleviation of pain<ref name="pmid23091044">{{cite journal| author=Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G | display-authors=etal| title=Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2012 | volume= 55 | issue= 10 | pages= 1279-82 | pmid=23091044 | doi=10.1093/cid/cis847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23091044  }} </ref>. The randomized clinical trials have shown NSAIDs as a more effective option for the relief of symptoms compared to acetaminophen<ref name="pmid12862143">{{cite journal| author=Lala I, Leech P, Montgomery L, Bhagat K| title=Use of a simple pain model to evaluate analgesic activity of ibuprofen versus paracetamol. | journal=East Afr Med J | year= 2000 | volume= 77 | issue= 9 | pages= 504-7 | pmid=12862143 | doi=10.4314/eamj.v77i9.46696 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12862143  }} </ref>.
+* If the clinician is suspecting a particular [[bacteria]], it should be mentioned while ordering the test. Certain [[bacteria]] require special culture media to grow and methods to be visualized. [[''Campylobacter jejuni'']] grows on the specific ‘CAMP’ agar plates at a particular temperature and environmental conditions. If infection with [[''Yersinia'']] is suspected, it should be specified as it is commonly overlooked.<ref name="pmid4014291">{{cite journal| author=Guerrant RL, Shields DS, Thorson SM, Schorling JB, Gröschel DH| title=Evaluation and diagnosis of acute infectious diarrhea. | journal=Am J Med | year= 1985 | volume= 78 | issue= 6B | pages= 91-8 | pmid=4014291 | doi=10.1016/0002-9343(85)90370-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4014291  }} </ref>
-===Dont's===
+* Physicians need to monitor the patients for the complications of the infection with certain [[bacteria]].  [[Bacteremia]] and [[reactive arthritis]] can occur with infection with non- typhoidal [[''Salmonella'']] and [[''Shigella'']].<ref name="pmid16621698">{{cite journal| author=Rodríguez M, de Diego I, Martínez N, Rosario Rodicio M, Carmen Mendoza M| title=Nontyphoidal Salmonella causing focal infections in patients admitted at a Spanish general hospital during an 11-year period (1991-2001). | journal=Int J Med Microbiol | year= 2006 | volume= 296 | issue= 4-5 | pages= 211-22 | pmid=16621698 | doi=10.1016/j.ijmm.2006.01.068 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16621698  }} </ref> The [[hemolytic-uremic syndrome]] can occur due to E 0157:H7 or [[''Shigella'']]. A neurological complication [[Guillain-Barré syndrome]] can occur with [[''Campylobacter'']] infection.
-* The oral glucocorticoids should not be prescribed to patients as their adverse effects outweigh their benefits as an oral analgesics<ref name="pmid23091044">{{cite journal| author=Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G | display-authors=etal| title=Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2012 | volume= 55 | issue= 10 | pages= 1279-82 | pmid=23091044 | doi=10.1093/cid/cis847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23091044  }} </ref>. Glucocorticoids should only be considered in patients with significant odynophagia and dysphagia.
+===Don'ts===
+* The empirical antimicrobial [[treatment]] for [[dysentery]] does not include [[treatment]] for [[Entamoeba histolytica|''E. histolytica'']].  [[Metronidazole]] (500mg thrice daily for 7 to days) should be administered to [[patient|patients]] only when trophozoites or cysts are visualized under a [[microscope]] in the [[Human feces|stool]] sample.<ref name="pmid590600">{{cite journal| author=Misra NP, Gupta RC| title=A comparison of a short course of single daily dosage therapy of tinidazole with metronidazole in intestinal amoebiasis. | journal=J Int Med Res | year= 1977 | volume= 5 | issue= 6 | pages= 434-7 | pmid=590600 | doi=10.1177/030006057300100209 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=590600  }} </ref>
+* A complete metabolic profile is not routinely performed in [[patient|patients]] with [[dysentery]]. [[Serum]] electrolytes and [[glucose]] levels should only be measured in [[patient|patients]] who present with complications (i.e. [[altered mental status]], [[Seizure|seizures]], [[anuria]], [[oliguria]], and [[ileus]] ).
 ==References==
 {{Reflist}}