Acute diarrhea medical therapy: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
m (Bot: Removing from Primary care)
 
(15 intermediate revisions by one other user not shown)
Line 1: Line 1:
__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]]).  
 
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==
==Medical Therapy==
* Fluid resuscitation (oral, if not IV)
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>
* Patients should be advised to do the following until symptoms subside:
* 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]]
** Hydrate with liquids that are [[caffeine]] free and contain [[glucose]]
** Avoid [[lactose]]
** Avoid [[lactose]]
** Chew gum that is free of [[sorbitol]]
** Chew gum that is free of [[sorbitol]]
** Eat raw fruit
** Eat raw fruit
* For patients with [[lactose intolerance]], a lactose-free diet is advised
* [[Probiotic|Probiotics]] do not play a role in the management of diarrhea, except in cases of post-antibiotic infection.
* For patients with malabsorption diseases, a gluten free diet is advised
* A combination of [[loperamide]] and [[Antibiotic|antibiotics]] is preferred in patients with traveler’s diarrhea for better treatment efficacy.
* Consultation with [[oncology]], surgery and/or gastroenterology may be required for intestinal [[neoplasm]]
* [[Bismuth subsalicylate|Bismuth subsalicylates]] control symptoms of [[Nausea and vomiting|vomiting]] and [[diarrhea]] and improve functionality in travellers with diarrhea.
* Control blood sugar ([[diabetic neuropathy]])
* 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]]


===Empirical Therapy===
===Empiric 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.
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


* 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.
* 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


* 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.
* 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>


* The somatostatin analogue [[octreotide]] has proven effectiveness in [[carcinoid tumors]] and other peptide-secreting tumors, dumping syndrome, and chemotherapy-induced diarrhea.
* [[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 adsorbants, such as activated charcoal, and binding resins like [[bismuth]] and stool modifiers, such as medicinal fiber.
* 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===
* [[Antibiotics]] (malabsorption diseases)
Pharmacotherapy for acute diarrhea includes the use of the following agents:
* [[Anticholinergics]] (IBS)
* [[Antibiotics]]  
* Antimolality agents
* [[Anticholinergics]]  
* Antibiotic therapy (severe disease)
* Antimotility agents
* [[Metoclopramide]] (diabetic neuropathy)
* [[Metoclopramide]]: in case of diarrhea due to diabetic neuropathy
* Nonspecific antidiarrheal agents
* Nonspecific [[Antidiarrhoeal|antidiarrheal]] agents


===Symptomatic Treatment===
===Symptomatic Treatment===
* 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.
* 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 diarrhea indicate medical supervision is required:
* The following types of acute diarrhea indicate medical supervision is required:
** Diarrhea in infants;
** Diarrhea in [[Infant|infants]]
** Moderate or severe diarrhea in young children;
** Moderate or severe diarrhea in young children
** Diarrhea associated with [[blood]];
** [[Dysentery|Bloody diarrhea]]
** Diarrhea that continues for more than two weeks;
** Diarrhea for more than two weeks
** Diarrhea that is associated with more general illness such as non-cramping [[abdominal pain]], [[fever]], [[weight loss]], etc;
** Diarrhea associated with non-cramping [[abdominal pain]], [[fever]] and [[weight loss]]
** [[Traveler's diarrhea|Diarrhea in travelers]], since they are more likely to have exotic infections such as parasites;
** [[Human parasitic diseases|Parasitic diarrhea]]  
** Diarrhea in food handlers, because of the potential to infect others;
** Diarrhea in food handlers due to high potential to infect others
** Diarrhea in institutions such as hospitals, child care centers, or geriatric and convalescent homes.
** Diarrhea in institutions such as:
*** Hospitals
*** Child care centers
*** Geriatric and convalescent homes


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>
===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]].


===Pathogen Specific===
====Immunocompetent patients====
====Immunocompetent====
*'''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>
*'''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'''
:* '''1. Shigella species'''
::*Preferred regimen (1):
::*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)
:::*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
:::*Pediatric dose: [[TMP-SMZ]], 5 and 25 mg/kg, respectively bid for 3 days
Line 105: Line 89:


:*'''2. Non-typhi species of Salmonella'''
:*'''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
::*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'''
:*'''3. Campylobacter species'''
Line 121: Line 105:


::*'''4.4. Enterohemorrhagic'''
::*'''4.4. Enterohemorrhagic'''
:::*Preferred regimen: Avoid antimotility drugs; role of antibiotics unclear, and administration should be avoided.
:::*Preferred regimen: Avoid antimotility drugs; the role of [[Antibiotic|antibiotics]] unclear, and administration should be avoided.


:*'''5. Aeromonas/Plesiomonas'''
:*'''5. Aeromonas/Plesiomonas'''
Line 127: Line 111:


:*'''6. Yersinia species'''
:*'''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]]
::*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]]


:*'''7. Vibrio cholerae O1 or O139'''
:*'''7. Vibrio cholerae O1 or O139'''
Line 136: Line 120:


:*'''8. Toxigenic Clostridium difficile'''
:*'''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
::*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>
*'''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'''
:*'''1. Giardia'''
::*Preferred regimen: [[Metronidazole]] 250-750 mg tid  for 7-10 days
::*Preferred regimen: [[Metronidazole]] 250-750 mg tid  for 7-10 days
Line 158: Line 142:
::*Preferred regimen (2): [[Metronidazole]] 750 mg tid for 5 to 10 days {{and}} [[Paromomycin]] 500 mg tid for 7 days
::*Preferred regimen (2): [[Metronidazole]] 750 mg tid for 5 to 10 days {{and}} [[Paromomycin]] 500 mg tid for 7 days


====Immunocompromised====
====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>
*'''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:'''
:* '''1. Shigella species:'''
::*Preferred regimen (1):
::*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)
:::*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
:::*Pediatric dose:[[TMP-SMZ]], 5 and 25 mg/kg, respectively bid for 7 to 10 days
Line 170: Line 154:


:*'''2. Non-typhi species of Salmonella'''
:*'''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
::*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


:*'''3. Campylobacter species'''
:*'''3. Campylobacter species'''
Line 218: Line 202:
:*'''6. Entamoeba histolytica'''
:*'''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
::*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==
Line 229: Line 208:
{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category: (name of the system)]]
 
[[Category:Medicine]]
[[Category:Gastroenterology]]
[[Category:Up-To-Date]]

Latest revision as of 20:16, 29 July 2020

Acute Diarrhea Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Acute Diarrhea from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Guidelines for Management

Case Studies

Case #1

Acute diarrhea medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Acute diarrhea medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Acute diarrhea medical therapy

CDC on Acute diarrhea medical therapy

Acute diarrhea medical therapy in the news

Blogs on Acute diarrhea medical therapy

Directions to Hospitals Treating Psoriasis

Risk calculators and risk factors for Acute diarrhea medical therapy

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.

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Acute_diarrhea_medical_therapy&oldid=1634315"