Acute diarrhea medical therapy: Difference between revisions

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==Medical Therapy==
==Medical Therapy==
*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
* Fluid resuscitation (oral, if not IV)
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
* Patients should be advised to do the following until symptoms subside:
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
** Hydrate with liquids that are [[caffeine]] free and contain [[glucose]]
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
** Avoid [[lactose]]
===Disease Name===
** Chew gum that is free of [[sorbitol]]
** Eat raw fruit
* For patients with [[lactose intolerance]], a lactose-free diet is advised
* For patients with malabsorption diseases, a gluten free diet is advised
* Consultation with [[oncology]], surgery and/or gastroenterology may be required for intestinal [[neoplasm]]
* Control blood sugar ([[diabetic neuropathy]])


* '''1 Stage 1 - Name of stage'''
===Empirical Therapy===
** 1.1 '''Specific Organ system involved 1'''
Empirical therapy is used as an initial treatment before diagnostic testing or after diagnostic testing has failed to confirm a diagnosis or when there is no specific treatment or when specific treatment fails to effect a cure.  
*** 1.1.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
*** 1.1.2 '''Pediatric'''
**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose) 
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 (Specific population e.g. ''''''children < 8 years of age'''''')
***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose) 
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 1.2 '''Specific Organ system involved 2'''
*** 1.2.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
*** 1.2.2  '''Pediatric'''
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)


* 2 '''Stage 2 - Name of stage'''
* Empirical trials of antimicrobial therapy like [[metronidazole]] for protozoal diarrhea or [[fluoroquinolone]] for enteric bacterial diarrhea if the prevalence of bacterial or protozoal infection is high in a specific community or situation.
** 2.1 '''Specific Organ system involved 1 '''
 
**: '''Note (1):'''
* Most cases of diarrhea, except for high-volume secretory states, respond to a sufficiently high dose of [[opium]] or [[morphine]].  [[Codeine]], synthetic opioids [[diphenoxylate]] and [[loperamide]] are less potent.  However loperamide is generally used because of its less abuse potential.
**: '''Note (2)''':
 
**: '''Note (3):'''
* The somatostatin analogue [[octreotide]] has proven effectiveness in [[carcinoid tumors]] and other peptide-secreting tumors, dumping syndrome, and chemotherapy-induced diarrhea.
*** 2.1.1 '''Adult'''
 
**** Parenteral regimen
* Intraluminal agents include adsorbants, such as activated charcoal, and binding resins like [[bismuth]] and stool modifiers, such as medicinal fiber.
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
 
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
===Pharmacotherapy===
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
* [[Antibiotics]] (malabsorption diseases)
**** Oral regimen
* [[Anticholinergics]] (IBS)
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
* Antimolality agents
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
* Antibiotic therapy (severe disease)
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
* [[Metoclopramide]] (diabetic neuropathy)
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days
* Nonspecific antidiarrheal agents
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days  
 
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
===Symptomatic Treatment===
*** 2.1.2 '''Pediatric'''
* Symptomatic treatment for diarrhea involves the patient consuming adequate amounts of water to replace that loss, preferably mixed with [[electrolyte]]s to provide essential [[salt]]s and some amount of [[nutrient]]s.  For many people, further treatment is unnecessary.
**** Parenteral regimen
* The following types of diarrhea indicate medical supervision is required:
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
** Diarrhea in infants;
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
** Moderate or severe diarrhea in young children;
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) ''''''(Contraindications/specific instructions)''''''
** Diarrhea associated with [[blood]];
**** Oral regimen
** Diarrhea that continues for more than two weeks;
***** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days (maximum, 500 mg per dose)
** Diarrhea that is associated with more general illness such as non-cramping [[abdominal pain]], [[fever]], [[weight loss]], etc;
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
** [[Traveler's diarrhea|Diarrhea in travelers]], since they are more likely to have exotic infections such as parasites;
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
** Diarrhea in food handlers, because of the potential to infect others;
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
** Diarrhea in institutions such as hospitals, child care centers, or geriatric and convalescent homes.
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days (maximum, 500 mg per dose)
 
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days (maximum,500 mg per dose)
A severity score is used to aid diagnosis.<ref name="pmid2371542">{{cite journal |author=Ruuska T, Vesikari T |title=Rotavirus disease in Finnish children: use of numerical scores for clinical severity of diarrhoeal episodes |journal=Scand. J. Infect. Dis. |volume=22 |issue=3 |pages=259–67 |year=1990 |pmid=2371542 |doi=}}</ref>
** 2.2  '<nowiki/>'''''Other Organ system involved 2''''''
 
**: '''Note (1):'''
===Pathogen Specific===
**: '''Note (2)''':
====Immunocompetent====
**: '''Note (3):'''
*'''Bacterial''' <ref name="pmid11170940">{{cite journal| author=Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV et al.| title=Practice guidelines for the management of infectious diarrhea. | journal=Clin Infect Dis | year= 2001 | volume= 32 | issue= 3 | pages= 331-51 | pmid=11170940 | doi=10.1086/318514 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11170940  }} </ref>
*** 2.2.1 '''Adult'''
 
**** Parenteral regimen
:* '''1. Shigella species'''
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
::*Preferred regimen (1):
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
:::*Adult dose: [[TMP-SMZ]], 160 and 800 mg, respectively bid for 3 days (if susceptible ) {{or}} [[Fluoroquinolone]] (e.g., 300 mg [[Ofloxacin]], 400 mg [[Norfloxacin]], {{or}} 500 mg [[Ciprofloxacin]] bid for 3 days)
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
:::*Pediatric dose: [[TMP-SMZ]], 5 and 25 mg/kg, respectively bid for 3 days
**** Oral regimen
 
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
::*Preferred regimen (2):
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
:::*Adult dose: [[Nalidixic acid]] 1 g/d for 5 days {{or}} [[Ceftriaxone]]; [[Azithromycin]]
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
:::*Pediatric dose: [[Nalidixic acid]],  55 mg/kg/d for 5 days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
:*'''2. Non-typhi species of Salmonella'''
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
::*Preferred regimen: Not recommended routinely, but if severe or patient is younger than 6 monthes or older than 50 year old or has prostheses, valvular heart disease, severe atherosclerosis, malignancy, or uremia, [[TMP-SMZ]] (if susceptible) {{or}} [[Fluoroquinolone]], bid for 5 to 7 days; [[Ceftriaxone]], 100 mg/kg/d in 1 or 2 divided doses
*** 2.2.2 '''Pediatric'''
 
**** Parenteral regimen
:*'''3. Campylobacter species'''
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
::*Preferred regimen: [[Erythromycin]] 500 mg bid for 5 days
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
 
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
:*'''4. Escherichia coli species'''
**** Oral regimen
::*'''4.1. Enterotoxigenic'''
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days (maximum, 500 mg per dose)
:::*Preferred regimen: [[TMP-SMZ]], 160 and 800 mg, respectively, bid, for 3 days (if susceptible), {{or}} [[Fluoroquinolone]] (e.g., 300 mg [[Ofloxacin]], 400 mg [[Norfloxacin]], or 500 mg [[Ciprofloxacin]] bid for 3 days)
***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
 
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days (maximum, 500 mg per dose)
::*'''4.2. Enteropathogenic'''
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
:::*Preferred regimen: [[TMP-SMZ]], 160 and 800 mg, respectively, bid, for 3 days (if susceptible), {{or}} [[Fluoroquinolone]] (e.g., 300 mg [[Ofloxacin]], 400 mg [[Norfloxacin]], or 500 mg [[Ciprofloxacin]] bid for 3 days)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days (maximum, 500 mg per dose)
 
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days (maximum,500 mg per dose)
::*'''4.3. Enteroinvasive'''
:::*Preferred regimen: [[TMP-SMZ]], 160 and 800 mg, respectively, bid, for 3 days (if susceptible), {{or}} [[Fluoroquinolone]] (e.g., 300 mg [[Ofloxacin]], 400 mg [[Norfloxacin]], or 500 mg [[Ciprofloxacin]] bid for 3 days)
 
::*'''4.4. Enterohemorrhagic'''
:::*Preferred regimen: Avoid antimotility drugs; role of antibiotics unclear, and administration should be avoided.
 
:*'''5. Aeromonas/Plesiomonas'''
::*Preferred regimen: [[TMP-SMZ]], 160 and 800 mg, respectively, bid for 3 days (if susceptible), [[Fluoroquinolone]] (e.g., 300 mg [[Ofloxacin]], 400 mg [[Norfloxacin]], or 500 mg [[Ciprofloxacin]] bid for 3 days)
 
:*'''6. Yersinia species'''
::*Preferred regimen: Antibiotics are not usually required; [[Deferoxamine]] therapy should be withheld; for severe infections or associated bacteremia treat as for immunocompromised hosts, using combination therapy with [[Doxycycline]], [[Aminoglycoside]], [[TMP-SMZ]], {{or}} [[Fluoroquinolone]]
 
:*'''7. Vibrio cholerae O1 or O139'''
::*Preferred regimen (1): [[Doxycycline]] 300-mg single dose
::*Preferred regimen (2): [[Tetracycline]] 500 mg qid for 3 days
::*Preferred regimen (3): [[TMP-SMZ]] 160 and 800 mg, respectively, bid for 3 days
::*Preferred regimen (4): single-dose [[Fluoroquinolone]]
 
:*'''8. Toxigenic Clostridium difficile'''
::*Preferred regimen: Offending antibiotic should be withdrawn if possible; [[Metronidazole]], 250 mg qid to 500 mg tid for 3 to 10 days
 
*'''Parasites''' <ref name="pmid11170940">{{cite journal| author=Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV et al.| title=Practice guidelines for the management of infectious diarrhea. | journal=Clin Infect Dis | year= 2001 | volume= 32 | issue= 3 | pages= 331-51 | pmid=11170940 | doi=10.1086/318514 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11170940  }} </ref>
:*'''1. Giardia'''
::*Preferred regimen: [[Metronidazole]] 250-750 mg tid  for 7-10 days
 
:*'''2. Cryptosporidium species'''
::*Preferred regimen: If severe, consider [[Paromomycin]], 500 mg tid for 7 days
 
:*'''3. Isospora species'''
::*Preferred regimen: [[TMP-SMZ]], 160 and 800 mg, respectively, bid for 7 to 10 days
 
:*'''4. Cyclospora species'''
::*Preferred regimen: [[TMP/SMZ]], 160 and 800 mg, respectively, bid for 7 days
 
:*'''5. Microsporidium species'''
::*Preferred regimen: Not determined
 
:*'''6. Entamoeba histolytica'''
::*Preferred regimen (1): [[Metronidazole]] 750 mg tid for 5 to 10 days {{and}} [[Diiodohydroxyquinoline|Diiodohydroxyquin]] 650 mg tid for 20 days
::*Preferred regimen (2): [[Metronidazole]] 750 mg tid for 5 to 10 days {{and}} [[Paromomycin]] 500 mg tid for 7 days
 
====Immunocompromised====
*'''Bacterial''' <ref name="pmid11170940">{{cite journal| author=Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV et al.| title=Practice guidelines for the management of infectious diarrhea. | journal=Clin Infect Dis | year= 2001 | volume= 32 | issue= 3 | pages= 331-51 | pmid=11170940 | doi=10.1086/318514 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11170940  }} </ref>
:* '''1. Shigella species:'''
::*Preferred regimen (1):
:::*Adult dose: [[TMP-SMZ]], 160 and 800 mg, respectively bid for 7 to 10 days (if susceptible ) {{or}} [[Fluoroquinolone]] (e.g., 300 mg [[Ofloxacin]], 400 mg [[Norfloxacin]], {{or}} 500 mg [[Ciprofloxacin]] bid for 7 to 10 days)
:::*Pediatric dose:[[TMP-SMZ]], 5 and 25 mg/kg, respectively bid for 7 to 10 days
 
::*Preferred regimen (2):
:::*Adult dose: [[Nalidixic acid]]  1 g/d for 7 to 10 days {{or}} [[Ceftriaxone]]; [[Azithromycin]]
:::*Pediatric dose:  [[Nalidixic acid]],  55 mg/kg/d for 7 to 10 days
 
:*'''2. Non-typhi species of Salmonella'''
::*Preferred regimen: Not recommended routinely, but if severe or patient is younger than 6 monthes or older than 50 old or has prostheses, valvular heart disease, severe atherosclerosis, malignancy, or uremia, [[TMP-SMZ]] (if susceptible) {{or}} [[Fluoroquinolone]], bid for 14 days (or longer if relapsing); [[ceftriaxone]], 100 mg/kg/d in 1 or 2 divided doses
 
:*'''3. Campylobacter species'''
::*Preferred regimen: [[Erythromycin]], 500 mg bid for 5 days (may require prolonged treatment)
 
:*'''4. Escherichia coli species'''
::*'''4.1. Enterotoxigenic'''
:::*Preferred regimen: [[TMP-SMZ]], 160 and 800 mg, respectively, bid for 3 days (if susceptible), {{or}} [[Fluoroquinolone]] (e.g., 300 mg [[Ofloxacin]], 400 mg [[Norfloxacin]], or 500 mg [[Ciprofloxacin]] bid for 3 days) (Consider fluoroquinolone as for enterotoxigenic E. coli)
 
::*'''4.2. Enteropathogenic'''
:::*Preferred regimen: [[TMP-SMZ]], 160 and 800 mg, respectively, bid,for 3 days (if susceptible), {{or}} [[Fluoroquinolone]] (e.g., 300 mg [[Ofloxacin]], 400 mg [[Norfloxacin]], or 500 mg [[Ciprofloxacin]] bid for 3 days)
 
::*'''4.3. Enteroinvasive'''
:::*Preferred regimen: [[TMP-SMZ]], 160 and 800 mg, respectively, bid,for 3 days (if susceptible), {{or}} [[Fluoroquinolone]] (e.g., 300 mg [[Ofloxacin]], 400 mg [[Norfloxacin]], or 500 mg [[Ciprofloxacin]] bid for 3 days)
 
::*'''4.4. Enterohemorrhagic'''
:::*Preferred regimen: Avoid antimotility drugs; role of antibiotics unclear, and administration should be avoided.
 
:*'''5. Aeromonas/Plesiomonas'''
::*Preferred regimen: [[TMP-SMZ]], 160 and 800 mg, respectively, bid for 3 days (if susceptible), [[Fluoroquinolone]] (e.g., 300 mg [[ofloxacin]], 400 mg [[norfloxacin]], or 500 mg [[Ciprofloxacin]] bid for 3 days)
 
:*'''6. Yersinia species'''
::*Preferred regimen: [[Doxycycline]], [[Aminoglycoside]] (in combination) or [[TMP-SMZ]] or [[Fluoroquinolone]]
 
:*'''7. Vibrio cholerae O1 or O139'''
::*Preferred regimen: [[Doxycycline]], 300-mg single dose; or [[Tetracycline]], 500 mg qid for 3 days; or [[TMP-SMZ]], 160 and 800 mg, respectively, bid for 3 days; or single-dose [[Fluoroquinolone]]
 
:*'''8. Toxigenic Clostridium difficile'''
::*Preferred regimen: Offending antibiotic should be withdrawn if possible; [[Metronidazole]], 250 mg qid to 500 mg tid for 3 to 10 days
 
*'''Parasites''' <ref name="pmid11170940">{{cite journal| author=Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV et al.| title=Practice guidelines for the management of infectious diarrhea. | journal=Clin Infect Dis | year= 2001 | volume= 32 | issue= 3 | pages= 331-51 | pmid=11170940 | doi=10.1086/318514 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11170940  }} </ref>
:*'''1. Giardia'''
::*Preferred regimen: [[Metronidazole]], 250-750 mg tid  for 7-10 days
 
:*'''2. Cryptosporidium species'''
::*Preferred regimen: [[Paromomycin]], 500 mg tid for 14 to 28 days, then bid if needed; highly active antiretroviral therapy including a protease inhibitor is warranted for patients with AIDS
 
:*'''3. Isospora species'''
::*Preferred regimen: [[TMP-SMZ]], 160 and 800 mg, respectively, qid for 10 days, followed by [[TMP-SMZ]] thrice weekly, or weekly [[Sulfadoxine]] (500 mg) and [[Pyrimethamine]] (25 mg) indefinitely for patients with AIDS
 
:*'''4. Cyclospora species'''
::*Preferred regimen: [[TMP-SMZ]], 160 and 800 mg, respectively, qid for 10 days, followed by [[TMP-SMZ]] thrice weekly indefinitely
 
:*'''5. Microsporidium species'''
::*Preferred regimen: [[Albendazole]], 400 mg bid for 3 weeks; highly active antiretroviral therapy including a protease inhibitor is warranted for patients with AIDS
 
:*'''6. Entamoeba histolytica'''
::*Preferred regimen: [[Metronidazole]], 750 mg tid for 5 to 10 days, plus either [[Diiodohydroxyquinoline|Diiodohydroxyquin]], 650 mg tid for 20 days, or [[Paromomycin]], 500 mg tid for 7 days
 
===Contraindicated medications===
{{MedCondContrAbs
 
|MedCond =Diarrhea|Ethacrynic acid}}


==References==
==References==

Revision as of 14:15, 5 February 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

There is no treatment for [disease name]; the mainstay of therapy is supportive care.

OR

Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].

OR

The majority of cases of [disease name] are self-limited and require only supportive care.

OR

[Disease name] is a medical emergency and requires prompt treatment.

OR

The mainstay of treatment for [disease name] is [therapy].

OR   The optimal therapy for [malignancy name] depends on the stage at diagnosis.

OR

[Therapy] is recommended among all patients who develop [disease name].

OR

Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].

OR

Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].

OR

Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].

OR

Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

Medical Therapy

  • Fluid resuscitation (oral, if not IV)
  • Patients should be advised to do the following until symptoms subside:
  • For patients with lactose intolerance, a lactose-free diet is advised
  • For patients with malabsorption diseases, a gluten free diet is advised
  • Consultation with oncology, surgery and/or gastroenterology may be required for intestinal neoplasm
  • Control blood sugar (diabetic neuropathy)

Empirical Therapy

Empirical therapy is used as an initial treatment before diagnostic testing or after diagnostic testing has failed to confirm a diagnosis or when there is no specific treatment or when specific treatment fails to effect a cure.

  • Empirical trials of antimicrobial therapy like metronidazole for protozoal diarrhea or fluoroquinolone for enteric bacterial diarrhea if the prevalence of bacterial or protozoal infection is high in a specific community or situation.
  • Most cases of diarrhea, except for high-volume secretory states, respond to a sufficiently high dose of opium or morphine. Codeine, synthetic opioids diphenoxylate and loperamide are less potent. However loperamide is generally used because of its less abuse potential.
  • The somatostatin analogue octreotide has proven effectiveness in carcinoid tumors and other peptide-secreting tumors, dumping syndrome, and chemotherapy-induced diarrhea.
  • Intraluminal agents include adsorbants, such as activated charcoal, and binding resins like bismuth and stool modifiers, such as medicinal fiber.

Pharmacotherapy

Symptomatic Treatment

  • Symptomatic treatment for diarrhea involves the patient consuming adequate amounts of water to replace that loss, preferably mixed with electrolytes to provide essential salts and some amount of nutrients. For many people, further treatment is unnecessary.
  • The following types of diarrhea indicate medical supervision is required:
    • Diarrhea in infants;
    • Moderate or severe diarrhea in young children;
    • Diarrhea associated with blood;
    • Diarrhea that continues for more than two weeks;
    • Diarrhea that is associated with more general illness such as non-cramping abdominal pain, fever, weight loss, etc;
    • Diarrhea in travelers, since they are more likely to have exotic infections such as parasites;
    • Diarrhea in food handlers, because of the potential to infect others;
    • Diarrhea in institutions such as hospitals, child care centers, or geriatric and convalescent homes.

A severity score is used to aid diagnosis.[1]

Pathogen Specific

Immunocompetent

  • 1. Shigella species
  • Preferred regimen (1):
  • Preferred regimen (2):
  • 2. Non-typhi species of Salmonella
  • Preferred regimen: Not recommended routinely, but if severe or patient is younger than 6 monthes or older than 50 year old or has prostheses, valvular heart disease, severe atherosclerosis, malignancy, or uremia, TMP-SMZ (if susceptible) OR Fluoroquinolone, bid for 5 to 7 days; Ceftriaxone, 100 mg/kg/d in 1 or 2 divided doses
  • 3. Campylobacter species
  • 4. Escherichia coli species
  • 4.1. Enterotoxigenic
  • 4.2. Enteropathogenic
  • 4.3. Enteroinvasive
  • 4.4. Enterohemorrhagic
  • Preferred regimen: Avoid antimotility drugs; role of antibiotics unclear, and administration should be avoided.
  • 5. Aeromonas/Plesiomonas
  • 6. Yersinia species
  • 7. Vibrio cholerae O1 or O139
  • Preferred regimen (1): Doxycycline 300-mg single dose
  • Preferred regimen (2): Tetracycline 500 mg qid for 3 days
  • Preferred regimen (3): TMP-SMZ 160 and 800 mg, respectively, bid for 3 days
  • Preferred regimen (4): single-dose Fluoroquinolone
  • 8. Toxigenic Clostridium difficile
  • Preferred regimen: Offending antibiotic should be withdrawn if possible; Metronidazole, 250 mg qid to 500 mg tid for 3 to 10 days
  • 1. Giardia
  • 2. Cryptosporidium species
  • Preferred regimen: If severe, consider Paromomycin, 500 mg tid for 7 days
  • 3. Isospora species
  • Preferred regimen: TMP-SMZ, 160 and 800 mg, respectively, bid for 7 to 10 days
  • 4. Cyclospora species
  • Preferred regimen: TMP/SMZ, 160 and 800 mg, respectively, bid for 7 days
  • 5. Microsporidium species
  • Preferred regimen: Not determined
  • 6. Entamoeba histolytica

Immunocompromised

  • 1. Shigella species:
  • Preferred regimen (1):
  • Preferred regimen (2):
  • 2. Non-typhi species of Salmonella
  • Preferred regimen: Not recommended routinely, but if severe or patient is younger than 6 monthes or older than 50 old or has prostheses, valvular heart disease, severe atherosclerosis, malignancy, or uremia, TMP-SMZ (if susceptible) OR Fluoroquinolone, bid for 14 days (or longer if relapsing); ceftriaxone, 100 mg/kg/d in 1 or 2 divided doses
  • 3. Campylobacter species
  • Preferred regimen: Erythromycin, 500 mg bid for 5 days (may require prolonged treatment)
  • 4. Escherichia coli species
  • 4.1. Enterotoxigenic
  • 4.2. Enteropathogenic
  • 4.3. Enteroinvasive
  • 4.4. Enterohemorrhagic
  • Preferred regimen: Avoid antimotility drugs; role of antibiotics unclear, and administration should be avoided.
  • 5. Aeromonas/Plesiomonas
  • 6. Yersinia species
  • 7. Vibrio cholerae O1 or O139
  • 8. Toxigenic Clostridium difficile
  • Preferred regimen: Offending antibiotic should be withdrawn if possible; Metronidazole, 250 mg qid to 500 mg tid for 3 to 10 days
  • 1. Giardia
  • 2. Cryptosporidium species
  • Preferred regimen: Paromomycin, 500 mg tid for 14 to 28 days, then bid if needed; highly active antiretroviral therapy including a protease inhibitor is warranted for patients with AIDS
  • 3. Isospora species
  • Preferred regimen: TMP-SMZ, 160 and 800 mg, respectively, qid for 10 days, followed by TMP-SMZ thrice weekly, or weekly Sulfadoxine (500 mg) and Pyrimethamine (25 mg) indefinitely for patients with AIDS
  • 4. Cyclospora species
  • Preferred regimen: TMP-SMZ, 160 and 800 mg, respectively, qid for 10 days, followed by TMP-SMZ thrice weekly indefinitely
  • 5. Microsporidium species
  • Preferred regimen: Albendazole, 400 mg bid for 3 weeks; highly active antiretroviral therapy including a protease inhibitor is warranted for patients with AIDS
  • 6. Entamoeba histolytica

Contraindicated medications

Diarrhea is considered an absolute contraindication to the use of the following medications:

References

  1. ↑ Ruuska T, Vesikari T (1990). "Rotavirus disease in Finnish children: use of numerical scores for clinical severity of diarrhoeal episodes". Scand. J. Infect. Dis. 22 (3): 259–67. PMID 2371542.
  2. ↑ 2.0 2.1 2.2 2.3 Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV; et al. (2001). "Practice guidelines for the management of infectious diarrhea". Clin Infect Dis. 32 (3): 331–51. doi:10.1086/318514. PMID 11170940.

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