Acute diarrhea medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
The majority of cases of 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, 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
- Antibiotics
- Anticholinergics
- Antimotility agents
- Metoclopramide: in case of diarrhea due to diabetic neuropathy
- Nonspecific antidiarrheal agents
-
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
The medical management of acute diarrhea includes the following steps:
- Fluid and electrolyte resuscitation (oral, if not IV)[1]
- Oral sugar-electrolyte solutions help in the limitation of diarrhea[2][3]
- In case of profound dehydration, especially in the elderly and infants, IV rehydartion is preferred[4]
- Patients should be advised to do the following until symptoms subside[5]
- 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 therapy 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
- 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 protozoal diarrhea
- 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.[6]
- 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[7]
- Stool modifiers: Medicinal fiber
Pharmacotherapy
Pharmacotherapy for acute diarrhea includes the following agents:
- Antibiotics
- Anticholinergics
- Antimotility agents
- Metoclopramide: in case of diarrhea due to diabetic neuropathy
- Nonspecific antidiarrheal agents
Symptomatic Treatment
- Symptomatic treatment for 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:
- 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
Immunocompetent patients
- 1. Shigella species
-
- 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 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[13]
- 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 [8]
- 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 [8]
- 1. Shigella species:
-
- Adult dose: TMP-SMZ, 160 and 800 mg, respectively bid for 7 to 10 days (if susceptible ) OR Fluoroquinolone (e.g., 300 mg Ofloxacin, 400 mg Norfloxacin, OR 500 mg Ciprofloxacin bid for 7 to 10 days)
- Pediatric dose:TMP-SMZ, 5 and 25 mg/kg, respectively bid for 7 to 10 days
- Preferred regimen (2):
- Adult dose: Nalidixic acid 1 g/d for 7 to 10 days OR Ceftriaxone; Azithromycin
- Pediatric dose: Nalidixic acid, 55 mg/kg/d for 7 to 10 days
- 2. Non-typhi species of Salmonella
- Preferred regimen: Not recommended routinely, but if severe or patient is younger than 6 monthes or older than 50 old or has prostheses, valvular heart disease, severe atherosclerosis, malignancy, or uremia, TMP-SMZ (if susceptible) OR Fluoroquinolone, bid for 14 days (or longer if relapsing); ceftriaxone, 100 mg/kg/d in 1 or 2 divided doses
- 3. Campylobacter species
- Preferred regimen: Erythromycin, 500 mg bid for 5 days (may require prolonged treatment)
- 4. Escherichia coli species
- 4.1. Enterotoxigenic
- Preferred regimen: TMP-SMZ, 160 and 800 mg, respectively, bid for 3 days (if susceptible), OR Fluoroquinolone (e.g., 300 mg Ofloxacin, 400 mg Norfloxacin, or 500 mg Ciprofloxacin bid for 3 days) (Consider fluoroquinolone as for enterotoxigenic E. coli)
- 4.2. Enteropathogenic
- Preferred regimen: TMP-SMZ, 160 and 800 mg, respectively, bid,for 3 days (if susceptible), OR Fluoroquinolone (e.g., 300 mg Ofloxacin, 400 mg Norfloxacin, or 500 mg Ciprofloxacin bid for 3 days)
- 4.3. Enteroinvasive
- Preferred regimen: TMP-SMZ, 160 and 800 mg, respectively, bid,for 3 days (if susceptible), OR Fluoroquinolone (e.g., 300 mg Ofloxacin, 400 mg Norfloxacin, or 500 mg Ciprofloxacin bid for 3 days)
- 4.4. Enterohemorrhagic
- Preferred regimen: Avoid antimotility drugs; role of antibiotics unclear, and administration should be avoided.
- 5. Aeromonas/Plesiomonas
- Preferred regimen: TMP-SMZ, 160 and 800 mg, respectively, bid for 3 days (if susceptible), Fluoroquinolone (e.g., 300 mg ofloxacin, 400 mg norfloxacin, or 500 mg Ciprofloxacin bid for 3 days)
- 6. Yersinia species
- Preferred regimen: Doxycycline, Aminoglycoside (in combination) or TMP-SMZ or Fluoroquinolone
- 7. Vibrio cholerae O1 or O139
- Preferred regimen: Doxycycline, 300-mg single dose; or Tetracycline, 500 mg qid for 3 days; or TMP-SMZ, 160 and 800 mg, respectively, bid for 3 days; or single-dose Fluoroquinolone
- 8. Toxigenic Clostridium difficile
- Preferred regimen: Offending antibiotic should be withdrawn if possible; Metronidazole, 250 mg qid to 500 mg tid for 3 to 10 days
- Parasites [8]
- 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
- 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
- ↑ 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.
- ↑ 4.0 4.1 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.
- ↑ 8.0 8.1 8.2 8.3 8.4 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.
- ↑ 10.0 10.1 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.
- ↑ 11.0 11.1 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.