Acute diarrhea medical therapy: Difference between revisions

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__NOTOC__
__NOTOC__
{{Acute diarrhea}}
{{Acute diarrhea}}
{{CMG}}; {{AE}}
{{CMG}}; {{AE}} {{Cherry}}


==Overview==
==Overview==
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
The majority of cases of acute [[diarrhea]] are self-limited and require only supportive care. Symptomatic treatment for [[diarrhea]] includes consumption of adequate amounts of water, mixed with electrolytes to replace water and salt depletion. According to the ACG Clinical Guideline, use of [[Oral rehydration therapy|balanced electrolyte rehydration]] is recommended in patients with traveller’s diarrhea, excessively watery and severe diarrhea. Medical supervision is required in infants with diarrhea, moderate or severe diarrhea in young children, [[Dysentery|bloody diarrhea]], diarrhea for more than two weeks and diarrhea associated with non-cramping [[abdominal pain]], [[fever]] and [[weight loss]]. [[Empiric therapy]] is used as an initial treatment for diagnostic testing, after testing has failed to confirm a diagnosis, when there is no specific treatment or when specific treatment fails to effect a cure. Pharmacotherapy for acute diarrhea includes the use of [[Antibiotic|antibiotics]], [[Anticholinergic|anticholinergics]], antimotility agents and other nonspecific antidiarrheal agents ([[Probiotic|probiotics]]).
==Medical Therapy==
According to the ACG Clinical Guideline, the following points need to be kept in mind while treating acute diarrhea in patients:<ref name="pmid27068718">{{cite journal |vauthors=Riddle MS, DuPont HL, Connor BA |title=ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults |journal=Am. J. Gastroenterol. |volume=111 |issue=5 |pages=602–22 |year=2016 |pmid=27068718 |doi=10.1038/ajg.2016.126 |url=}}</ref>
* Use of balanced electrolyte rehydration is recommended in patients with traveller’s diarrhea, excessively watery and severe diarrhea<ref name="pmid3185638">{{cite journal |vauthors=Carpenter CC, Greenough WB, Pierce NF |title=Oral-rehydration therapy--the role of polymeric substrates |journal=N. Engl. J. Med. |volume=319 |issue=20 |pages=1346–8 |year=1988 |pmid=3185638 |doi=10.1056/NEJM198811173192009 |url=}}</ref>
* [[Oral rehydration therapy|Oral sugar-electrolyte solutions]] help in the limitation of diarrhea<ref name="pmid2203965">{{cite journal |vauthors=Avery ME, Snyder JD |title=Oral therapy for acute diarrhea. The underused simple solution |journal=N. Engl. J. Med. |volume=323 |issue=13 |pages=891–4 |year=1990 |pmid=2203965 |doi=10.1056/NEJM199009273231307 |url=}}</ref><ref name="pmid6464119">{{cite journal |vauthors=de Zoysa I, Kirkwood B, Feachem R, Lindsay-Smith E |title=Preparation of sugar-salt solutions |journal=Trans. R. Soc. Trop. Med. Hyg. |volume=78 |issue=2 |pages=260–2 |year=1984 |pmid=6464119 |doi= |url=}}</ref>
* In case of profound [[dehydration]], especially in the elderly and infants, IV rehydartion is preferred<ref name="pmid1435668">{{cite journal |vauthors=Duggan C, Santosham M, Glass RI |title=The management of acute diarrhea in children: oral rehydration, maintenance, and nutritional therapy. Centers for Disease Control and Prevention |journal=MMWR Recomm Rep |volume=41 |issue=RR-16 |pages=1–20 |year=1992 |pmid=1435668 |doi= |url=}}</ref>
* In majority of cases of acute diarrhea, consumption of soups, sports drinks, water and juices compensates for fluid and electrolyte loss
* Patients should be advised to do the following until symptoms subside:<ref name="pmid4022687">{{cite journal |vauthors=Santosham M, Burns B, Nadkarni V, Foster S, Garrett S, Croll L, O'Donovan JC, Pathak R, Sack RB |title=Oral rehydration therapy for acute diarrhea in ambulatory children in the United States: a double-blind comparison of four different solutions |journal=Pediatrics |volume=76 |issue=2 |pages=159–66 |year=1985 |pmid=4022687 |doi= |url=}}</ref>
** Hydrate with liquids that are [[caffeine]] free and contain [[glucose]]
** Avoid [[lactose]]
** Chew gum that is free of [[sorbitol]]
** Eat raw fruit
* [[Probiotic|Probiotics]] do not play a role in the management of diarrhea, except in cases of post-antibiotic infection.
* A combination of [[loperamide]] and [[Antibiotic|antibiotics]] is preferred in patients with traveler’s diarrhea for better treatment efficacy.
* [[Bismuth subsalicylate|Bismuth subsalicylates]] control symptoms of [[Nausea and vomiting|vomiting]] and [[diarrhea]] and improve functionality in travellers with diarrhea.
* Antibiotic use for diarrhea due to [[Virus|viral infections]] is not recommended and does not shorten the course of symptoms.
* 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]]
* [[Blood sugar]] control is advised in case of diarrhea due to [[diabetic neuropathy]]
 
===Empiric Therapy===
Empiric anti-microbial therapy is not recommended for routine acute diarrhea cases. [[Empiric therapy]] for acute diarrhea is used in the following situations:
* As an initial treatment for diagnostic testing 
* After diagnostic testing has failed to confirm a diagnosis 
* When there is no specific treatment 
* When specific treatment fails to effect a cure
* Cases of traveller’s diarrhea as they have a high likelihood of infection due to [[Bacteria|bacterial]] causes
 
* Empiric trials of [[Antimicrobial|antimicrobial therapy]] is administered if the prevalence of [[Bacteria|bacterial]] or [[Protozoa|protozoal]] infection is high in a specific community or situation:
** [[Metronidazole]] for diarrhea due to [[protozoa]] 
** [[Quinolone|Fluoroquinolone]] for [[enteric]] [[Bacteria|bacterial]] diarrhea
 
* In case of non-bloody diarrhea in patients, antimotility agents such as [[diphenoxylate]] and [[loperamide]] are preferred in patients.They may be used in combination with [[Antibiotic|antibiotics]]. [[Loperamide]] is generally used in patients due to low abuse potential.<ref name="pmid18781873">{{cite journal |vauthors=Riddle MS, Arnold S, Tribble DR |title=Effect of adjunctive loperamide in combination with antibiotics on treatment outcomes in traveler's diarrhea: a systematic review and meta-analysis |journal=Clin. Infect. Dis. |volume=47 |issue=8 |pages=1007–14 |year=2008 |pmid=18781873 |doi=10.1086/591703 |url=}}</ref>
 
* [[Octreotide]], the [[somatostatin]] analog is useful in cases of diarrhea due to:
** [[Carcinoid syndrome|Carcinoid tumors]]
** Peptide-secreting tumors
** [[Gastric dumping syndrome|Dumping syndrome]]
** [[Chemotherapy]]-induced diarrhea
 
* Intraluminal agents include:
** Adsorbents: activated [[charcoal]]
** Binding resins: [[Bismuth subsalicylate]] is used to reduce diarrhea and vomiting, but is used with caution in patients with renal dysfunction due to high risk of bismuth [[encephalopathy]]<ref name="pmid2406861">{{cite journal |vauthors=Steffen R |title=Worldwide efficacy of bismuth subsalicylate in the treatment of travelers' diarrhea |journal=Rev. Infect. Dis. |volume=12 Suppl 1 |issue= |pages=S80–6 |year=1990 |pmid=2406861 |doi= |url=}}</ref>
** Stool modifiers: Medicinal fiber
 
===Pharmacotherapy===
Pharmacotherapy for acute diarrhea includes the use of the following agents:
* [[Antibiotics]]
* [[Anticholinergics]]
* Antimotility agents
* [[Metoclopramide]]: in case of diarrhea due to diabetic neuropathy
* Nonspecific [[Antidiarrhoeal|antidiarrheal]] agents
 
===Symptomatic Treatment===
* Symptomatic treatment for acute diarrhea includes consumption of adequate amounts of water, mixed with electrolytes to replace water and salt depletion. In many cases, further treatment is not required.
* The following types of acute diarrhea indicate medical supervision is required:
** Diarrhea in [[Infant|infants]]
** Moderate or severe diarrhea in young children
** [[Dysentery|Bloody diarrhea]]
** Diarrhea for more than two weeks
** Diarrhea associated with non-cramping [[abdominal pain]], [[fever]] and [[weight loss]]
** [[Human parasitic diseases|Parasitic diarrhea]]
** Diarrhea in food handlers due to high potential to infect others
** Diarrhea in institutions such as:
*** Hospitals
*** Child care centers
*** Geriatric and convalescent homes
 
===Pathogen Specific Therapy===
Medical therapy that is specific for the cause of acute diarrhea in case of [[Bacteria|bacterial]] and [[Parasitism|parasitic]] [[Infection|infections]] in immunocompetent and immunocompromised individuals is given below. There is no [[pathogen]] specific therapy for acute diarrhea due to [[Virus|viruses]] as treatment in those cases is mostly [[symptomatic]].
 
====Immunocompetent patients====
*'''Bacterial''' <ref name="pmid1435668" /><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><ref name="pmid9362174">{{cite journal |vauthors=DuPont HL |title=Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology |journal=Am. J. Gastroenterol. |volume=92 |issue=11 |pages=1962–75 |year=1997 |pmid=9362174 |doi= |url=}}</ref>
 
:* '''1. Shigella species'''
::*Preferred regimen (1):<ref name="pmid8783703">{{cite journal |vauthors=Dryden MS, Gabb RJ, Wright SK |title=Empirical treatment of severe acute community-acquired gastroenteritis with ciprofloxacin |journal=Clin. Infect. Dis. |volume=22 |issue=6 |pages=1019–25 |year=1996 |pmid=8783703 |doi= |url=}}</ref><ref name="pmid1616214">{{cite journal |vauthors=Wiström J, Jertborn M, Ekwall E, Norlin K, Söderquist B, Strömberg A, Lundholm R, Hogevik H, Lagergren L, Englund G |title=Empiric treatment of acute diarrheal disease with norfloxacin. A randomized, placebo-controlled study. Swedish Study Group |journal=Ann. Intern. Med. |volume=117 |issue=3 |pages=202–8 |year=1992 |pmid=1616214 |doi= |url=}}</ref><ref name="pmid2201742">{{cite journal |vauthors=Bennish ML, Salam MA, Haider R, Barza M |title=Therapy for shigellosis. II. Randomized, double-blind comparison of ciprofloxacin and ampicillin |journal=J. Infect. Dis. |volume=162 |issue=3 |pages=711–6 |year=1990 |pmid=2201742 |doi= |url=}}</ref>
:::*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)
:::*Pediatric dose: [[TMP-SMZ]], 5 and 25 mg/kg, respectively bid for 3 days
 
::*Preferred regimen (2):
:::*Adult dose: [[Nalidixic acid]]  1 g/d for 5 days {{or}} [[Ceftriaxone]]; [[Azithromycin]]
:::*Pediatric dose:  [[Nalidixic acid]],  55 mg/kg/d for 5 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 year old or has [[prosthesis]], [[valvular heart disease]], severe [[atherosclerosis]], [[Cancer|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<ref name="pmid10796610">{{cite journal |vauthors=Sirinavin S, Garner P |title=Antibiotics for treating salmonella gut infections |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD001167 |year=2000 |pmid=10796610 |doi=10.1002/14651858.CD001167 |url=}}</ref>
 
:*'''3. Campylobacter species'''
::*Preferred regimen: [[Erythromycin]] 500 mg bid for 5 days
 
:*'''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)
 
::*'''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)


OR
::*'''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)


Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
::*'''4.4. Enterohemorrhagic'''
:::*Preferred regimen: Avoid antimotility drugs; the role of [[Antibiotic|antibiotics]] unclear, and administration should be avoided.


OR
:*'''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)


The majority of cases of [disease name] are self-limited and require only supportive care.
:*'''6. Yersinia species'''
::*Preferred regimen: [[Antibiotic|Antibiotics]] are not usually required; [[Deferoxamine]] therapy should be withheld; for severe infections or associated [[bacteremia]] treat as for [[Immunocompromised|immunocompromised hosts]], using combination therapy with [[Doxycycline]], [[Aminoglycoside]], [[TMP-SMZ]], {{or}} [[Fluoroquinolone]]


OR
:*'''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]]


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


OR
*'''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


The mainstay of treatment for [disease name] is [therapy].
:*'''2. Cryptosporidium species'''
::*Preferred regimen: If severe, consider [[Paromomycin]], 500 mg tid for 7 days


OR
:*'''3. Isospora species'''
 
::*Preferred regimen: [[TMP-SMZ]], 160 and 800 mg, respectively, bid for 7 to 10 days
The optimal therapy for [malignancy name] depends on the stage at diagnosis.


OR
:*'''4. Cyclospora species'''
::*Preferred regimen: [[TMP/SMZ]], 160 and 800 mg, respectively, bid for 7 days


[Therapy] is recommended among all patients who develop [disease name].
:*'''5. Microsporidium species'''
::*Preferred regimen: Not determined


OR
:*'''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


Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
====Immunocompromised patients====
*'''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):<ref name="pmid9139555">{{cite journal |vauthors=Khan WA, Seas C, Dhar U, Salam MA, Bennish ML |title=Treatment of shigellosis: V. Comparison of azithromycin and ciprofloxacin. A double-blind, randomized, controlled trial |journal=Ann. Intern. Med. |volume=126 |issue=9 |pages=697–703 |year=1997 |pmid=9139555 |doi= |url=}}</ref><ref name="pmid8783703">{{cite journal |vauthors=Dryden MS, Gabb RJ, Wright SK |title=Empirical treatment of severe acute community-acquired gastroenteritis with ciprofloxacin |journal=Clin. Infect. Dis. |volume=22 |issue=6 |pages=1019–25 |year=1996 |pmid=8783703 |doi= |url=}}</ref><ref name="pmid1616214">{{cite journal |vauthors=Wiström J, Jertborn M, Ekwall E, Norlin K, Söderquist B, Strömberg A, Lundholm R, Hogevik H, Lagergren L, Englund G |title=Empiric treatment of acute diarrheal disease with norfloxacin. A randomized, placebo-controlled study. Swedish Study Group |journal=Ann. Intern. Med. |volume=117 |issue=3 |pages=202–8 |year=1992 |pmid=1616214 |doi= |url=}}</ref>
:::*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


OR
::*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


Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
:*'''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 [[prosthesis]], [[valvular heart disease]], severe [[atherosclerosis]], [[Cancer|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


OR
:*'''3. Campylobacter species'''
::*Preferred regimen: [[Erythromycin]], 500 mg bid for 5 days (may require prolonged treatment)


Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
:*'''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)


OR
::*'''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)


Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
::*'''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)


==Medical Therapy==
::*'''4.4. Enterohemorrhagic'''
*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
:::*Preferred regimen: Avoid antimotility drugs; role of antibiotics unclear, and administration should be avoided.
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
 
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
:*'''5. Aeromonas/Plesiomonas'''
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
::*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)
===Disease Name===
 
:*'''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


* '''1 Stage 1 - Name of stage'''
:*'''5. Microsporidium species'''
** 1.1 '''Specific Organ system involved 1'''
::*Preferred regimen: [[Albendazole]], 400 mg bid for 3 weeks; highly active antiretroviral therapy including a protease inhibitor is warranted for patients with AIDS
*** 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'''
:*'''6. Entamoeba histolytica'''
** 2.1 '''Specific Organ system involved 1 '''
::*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
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.1.1 '''Adult'''
**** Parenteral regimen
***** 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
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (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
*** 2.1.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** 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) ''''''(Contraindications/specific instructions)''''''
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** 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)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days (maximum, 500 mg per day)
***** 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)
** 2.2  '<nowiki/>'''''Other Organ system involved 2''''''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.2.1 '''Adult'''
**** Parenteral regimen
***** 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
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (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
*** 2.2.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** 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)
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** 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)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** 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)


==References==
==References==
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Latest revision as of 20:16, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

The majority of cases of acute diarrhea are self-limited and require only supportive care. Symptomatic treatment for diarrhea includes consumption of adequate amounts of water, mixed with electrolytes to replace water and salt depletion. According to the ACG Clinical Guideline, use of balanced electrolyte rehydration is recommended in patients with traveller’s diarrhea, excessively watery and severe diarrhea. Medical supervision is required in infants with diarrhea, moderate or severe diarrhea in young children, bloody diarrhea, diarrhea for more than two weeks and diarrhea associated with non-cramping abdominal pain, fever and weight loss. Empiric therapy is used as an initial treatment for diagnostic testing, after testing has failed to confirm a diagnosis, when there is no specific treatment or when specific treatment fails to effect a cure. Pharmacotherapy for acute diarrhea includes the use of antibiotics, anticholinergics, antimotility agents and other nonspecific antidiarrheal agents (probiotics).

Medical Therapy

According to the ACG Clinical Guideline, the following points need to be kept in mind while treating acute diarrhea in patients:[1]

  • Use of balanced electrolyte rehydration is recommended in patients with traveller’s diarrhea, excessively watery and severe diarrhea[2]
  • Oral sugar-electrolyte solutions help in the limitation of diarrhea[3][4]
  • In case of profound dehydration, especially in the elderly and infants, IV rehydartion is preferred[5]
  • In majority of cases of acute diarrhea, consumption of soups, sports drinks, water and juices compensates for fluid and electrolyte loss
  • Patients should be advised to do the following until symptoms subside:[6]
  • Probiotics do not play a role in the management of diarrhea, except in cases of post-antibiotic infection.
  • A combination of loperamide and antibiotics is preferred in patients with traveler’s diarrhea for better treatment efficacy.
  • Bismuth subsalicylates control symptoms of vomiting and diarrhea and improve functionality in travellers with diarrhea.
  • Antibiotic use for diarrhea due to viral infections is not recommended and does not shorten the course of symptoms.
  • 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
  • Blood sugar control is advised in case of diarrhea due to diabetic neuropathy

Empiric Therapy

Empiric anti-microbial therapy is not recommended for routine acute diarrhea cases. Empiric therapy for acute diarrhea is used in the following situations:

  • As an initial treatment for diagnostic testing
  • After diagnostic testing has failed to confirm a diagnosis
  • When there is no specific treatment
  • When specific treatment fails to effect a cure
  • Cases of traveller’s diarrhea as they have a high likelihood of infection due to bacterial causes
  • In case of non-bloody diarrhea in patients, antimotility agents such as diphenoxylate and loperamide are preferred in patients.They may be used in combination with antibiotics. Loperamide is generally used in patients due to low abuse potential.[7]
  • Intraluminal agents include:
    • Adsorbents: activated charcoal
    • Binding resins: Bismuth subsalicylate is used to reduce diarrhea and vomiting, but is used with caution in patients with renal dysfunction due to high risk of bismuth encephalopathy[8]
    • Stool modifiers: Medicinal fiber

Pharmacotherapy

Pharmacotherapy for acute diarrhea includes the use of the following agents:

Symptomatic Treatment

  • Symptomatic treatment for acute diarrhea includes consumption of adequate amounts of water, mixed with electrolytes to replace water and salt depletion. In many cases, further treatment is not required.
  • The following types of acute diarrhea indicate medical supervision is required:
    • Diarrhea in infants
    • Moderate or severe diarrhea in young children
    • Bloody diarrhea
    • Diarrhea for more than two weeks
    • Diarrhea associated with non-cramping abdominal pain, fever and weight loss
    • Parasitic diarrhea
    • Diarrhea in food handlers due to high potential to infect others
    • Diarrhea in institutions such as:
      • Hospitals
      • Child care centers
      • Geriatric and convalescent homes

Pathogen Specific Therapy

Medical therapy that is specific for the cause of acute diarrhea in case of bacterial and parasitic infections in immunocompetent and immunocompromised individuals is given below. There is no pathogen specific therapy for acute diarrhea due to viruses as treatment in those cases is mostly symptomatic.

Immunocompetent patients

  • 1. Shigella species
  • Preferred regimen (2):
  • 2. Non-typhi species of Salmonella
  • 3. Campylobacter species
  • 4. Escherichia coli species
  • 4.1. Enterotoxigenic
  • 4.2. Enteropathogenic
  • 4.3. Enteroinvasive
  • 4.4. Enterohemorrhagic
  • Preferred regimen: Avoid antimotility drugs; the 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 patients

  • 1. Shigella species:
  • Preferred regimen (2):
  • 2. Non-typhi species of Salmonella
  • 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

References

  1. ↑ 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. ↑ Carpenter CC, Greenough WB, Pierce NF (1988). "Oral-rehydration therapy--the role of polymeric substrates". N. Engl. J. Med. 319 (20): 1346–8. doi:10.1056/NEJM198811173192009. PMID 3185638.
  3. ↑ Avery ME, Snyder JD (1990). "Oral therapy for acute diarrhea. The underused simple solution". N. Engl. J. Med. 323 (13): 891–4. doi:10.1056/NEJM199009273231307. PMID 2203965.
  4. ↑ de Zoysa I, Kirkwood B, Feachem R, Lindsay-Smith E (1984). "Preparation of sugar-salt solutions". Trans. R. Soc. Trop. Med. Hyg. 78 (2): 260–2. PMID 6464119.
  5. ↑ 5.0 5.1 Duggan C, Santosham M, Glass RI (1992). "The management of acute diarrhea in children: oral rehydration, maintenance, and nutritional therapy. Centers for Disease Control and Prevention". MMWR Recomm Rep. 41 (RR-16): 1–20. PMID 1435668.
  6. ↑ Santosham M, Burns B, Nadkarni V, Foster S, Garrett S, Croll L, O'Donovan JC, Pathak R, Sack RB (1985). "Oral rehydration therapy for acute diarrhea in ambulatory children in the United States: a double-blind comparison of four different solutions". Pediatrics. 76 (2): 159–66. PMID 4022687.
  7. ↑ Riddle MS, Arnold S, Tribble DR (2008). "Effect of adjunctive loperamide in combination with antibiotics on treatment outcomes in traveler's diarrhea: a systematic review and meta-analysis". Clin. Infect. Dis. 47 (8): 1007–14. doi:10.1086/591703. PMID 18781873.
  8. ↑ Steffen R (1990). "Worldwide efficacy of bismuth subsalicylate in the treatment of travelers' diarrhea". Rev. Infect. Dis. 12 Suppl 1: S80–6. PMID 2406861.
  9. ↑ 9.0 9.1 9.2 9.3 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.
  10. ↑ DuPont HL (1997). "Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology". Am. J. Gastroenterol. 92 (11): 1962–75. PMID 9362174.
  11. ↑ 11.0 11.1 Dryden MS, Gabb RJ, Wright SK (1996). "Empirical treatment of severe acute community-acquired gastroenteritis with ciprofloxacin". Clin. Infect. Dis. 22 (6): 1019–25. PMID 8783703.
  12. ↑ 12.0 12.1 Wiström J, Jertborn M, Ekwall E, Norlin K, Söderquist B, Strömberg A, Lundholm R, Hogevik H, Lagergren L, Englund G (1992). "Empiric treatment of acute diarrheal disease with norfloxacin. A randomized, placebo-controlled study. Swedish Study Group". Ann. Intern. Med. 117 (3): 202–8. PMID 1616214.
  13. ↑ Bennish ML, Salam MA, Haider R, Barza M (1990). "Therapy for shigellosis. II. Randomized, double-blind comparison of ciprofloxacin and ampicillin". J. Infect. Dis. 162 (3): 711–6. PMID 2201742.
  14. ↑ Sirinavin S, Garner P (2000). "Antibiotics for treating salmonella gut infections". Cochrane Database Syst Rev (2): CD001167. doi:10.1002/14651858.CD001167. PMID 10796610.
  15. ↑ Khan WA, Seas C, Dhar U, Salam MA, Bennish ML (1997). "Treatment of shigellosis: V. Comparison of azithromycin and ciprofloxacin. A double-blind, randomized, controlled trial". Ann. Intern. Med. 126 (9): 697–703. PMID 9139555.

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