Acute diarrhea medical therapy: Difference between revisions

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Latest revision as of 20:16, 29 July 2020

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]
- Hydrate with liquids that are caffeine free and contain glucose
- Avoid lactose
- Chew gum that is free of sorbitol
- Eat raw fruit
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

Empiric trials of antimicrobial therapy is administered if the prevalence of bacterial or protozoal infection is high in a specific community or situation:
- Metronidazole for diarrhea due to protozoa
- Fluoroquinolone for enteric 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 antibiotics. Loperamide is generally used in patients due to low abuse potential.^[7]

Octreotide, the somatostatin analog is useful in cases of diarrhea due to:
- Carcinoid tumors
- Peptide-secreting tumors
- 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^[8]
- 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 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 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

Bacterial ^[5]^[9]^[10]

1. Shigella species

Preferred regimen (1):^[11]^[12]^[13]

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, 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^[14]

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)

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; the 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^[9]

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 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 patients

Bacterial ^[9]

1. Shigella species:

Preferred regimen (1):^[15]^[11]^[12]

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 prosthesis, 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 ^[9]

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 Diiodohydroxyquin, 650 mg tid for 20 days, or Paromomycin, 500 mg tid for 7 days

References

↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ ^5.0 ^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.
↑ 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.
↑ 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.
↑ Steffen R (1990). "Worldwide efficacy of bismuth subsalicylate in the treatment of travelers' diarrhea". Rev. Infect. Dis. 12 Suppl 1: S80–6. PMID 2406861.
↑ ^9.0 ^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.
↑ 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.
↑ ^11.0 ^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.
↑ ^12.0 ^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.
↑ 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.
↑ Sirinavin S, Garner P (2000). "Antibiotics for treating salmonella gut infections". Cochrane Database Syst Rev (2): CD001167. doi:10.1002/14651858.CD001167. PMID 10796610.
↑ 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

[pmid27068718-1] 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.

[pmid3185638-2] 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.

[pmid2203965-3] 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.

[pmid6464119-4] 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.

[pmid1435668-5] 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.

[pmid4022687-6] 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.

[pmid18781873-7] 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.

[pmid2406861-8] Steffen R (1990). "Worldwide efficacy of bismuth subsalicylate in the treatment of travelers' diarrhea". Rev. Infect. Dis. 12 Suppl 1: S80–6. PMID 2406861.

[pmid11170940-9] 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.

[pmid9362174-10] 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.

[pmid8783703-11] 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.

[pmid1616214-12] 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.

[pmid2201742-13] 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.

[pmid10796610-14] Sirinavin S, Garner P (2000). "Antibiotics for treating salmonella gut infections". Cochrane Database Syst Rev (2): CD001167. doi:10.1002/14651858.CD001167. PMID 10796610.

[pmid9139555-15] 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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@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Acute diarrhea}}
-{{CMG}}; {{AE}}
+{{CMG}}; {{AE}} {{Cherry}}
 ==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. 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]]).
+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==
-The medical management of acute diarrhea includes the following steps:
+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>
-* [[Fluid]] and electrolyte resuscitation (oral, if not IV)<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>
+* 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 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>
-* 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>
+* 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
+* 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 therapy]] for acute diarrhea is used in the following situations:
+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:
@@ Line 45: / Line 51: @@
 ===Pharmacotherapy===
-Pharmacotherapy for acute diarrhea includes the following agents:
+Pharmacotherapy for acute diarrhea includes the use of the following agents:
 * [[Antibiotics]]
 * [[Anticholinergics]]
@@ Line 68: / Line 74: @@
 ===Pathogen Specific Therapy===
-Antibiotic therapy dosing is different for immunocompetent and immunocompromised individuals. Medical therapy that is specific for the cause of diarrhea in case of bacterial and parasitic causes is given below. There is no pathogen specific therapy for acute diarrhea due to viruses as treatment in those cases is mostly symptomatic.
+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="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="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><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><ref name="pmid11170940">{{cite journal |vauthors=Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV, Hennessy T, Griffin PM, DuPont H, Sack RB, Tarr P, Neill M, Nachamkin I, Reller LB, Osterholm MT, Bennish ML, Pickering LK |title=Practice guidelines for the management of infectious diarrhea |journal=Clin. Infect. Dis. |volume=32 |issue=3 |pages=331–51 |year=2001 |pmid=11170940 |doi=10.1086/318514 |url=}}</ref>
+*'''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'''
@@ Line 83: / Line 89: @@
 :*'''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<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>
+::*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'''
@@ Line 99: / Line 105: @@
 ::*'''4.4. Enterohemorrhagic'''
-:::*Preferred regimen: Avoid antimotility drugs; the 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'''
@@ Line 105: / Line 111: @@
 :*'''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'''
@@ Line 114: / Line 120: @@
 :*'''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'''
 ::*Preferred regimen: [[Metronidazole]] 250-750 mg tid  for 7-10 days
@@ Line 148: / Line 154: @@
 :*'''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'''
@@ Line 202: / Line 208: @@
 {{WH}}
 {{WS}}
-[[Category: (name of the system)]]
+[[Category:Medicine]]
+[[Category:Gastroenterology]]
+[[Category:Up-To-Date]]