Diarrhea
Resident Survival Guide |
Diarrhea Microchapters |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] M.Umer Tariq [3]
Synonyms and keywords: Loose stools
Overview
Diarrhea can be classified as acute or chronic. Although chronic diarrhea has multiple definitions, a current working definition is the production of loose stools for longer than 4 weeks. Frequent defecation with normal consistency is termed psuedodiarrhea. There are 3 basic categories of chronic diarrhea: watery, fatty (malabsorption), and inflammatory (with blood and pus).
Classification
Diarrhea can be classified as acute or chronic depending on the duration of onset of symptoms. Acute and chronic diarrhea can be further classified as follows:
Chronic diarrhea
Chronic diarrhea may be classified into:[1][2][3][4]
- Watery diarrhea
A normal gap is between 50 and 100 mosm/kg.[6]
- Fatty diarrhea
- Maldigestion results from pancreatic exocrine insufficiency
Differential Diagnosis of Diarrhea of other diseases
To review the differential diagnosis of diarrhea, click here.
To review the differential diagnosis of acute diarrhea, click here.
To review the differential diagnosis of chronic diarrhea, click here.
To review the differential diagnosis of traveler's diarrhea, click here.
To review the differential diagnosis of acute watery diarrhea, click here.
To review the differential diagnosis of acute bloody diarrhea, click here.
To review the differential diagnosis of acute fatty diarrhea, click here.
To review the differential diagnosis of chronic watery diarrhea, click here.
To review the differential diagnosis of chronic bloody diarrhea, click here.
To review the differential diagnosis of chronic fatty diarrhea, click here.
To review the differential diagnosis of acute diarrhea and fever, click here.
To review the differential diagnosis of chronic diarrhea and fever, click here.
To review the differential diagnosis of acute diarrhea and abdominal pain, click here.
To review the differential diagnosis of chronic diarrhea and abdominal pain, click here.
To review the differential diagnosis of acute diarrhea and weight loss, click here.
To review the differential diagnosis of chronic diarrhea and weight loss, click here.
To review the differential diagnosis of acute diarrhea, fever, and abdominal pain, click here.
To review the differential diagnosis of chronic diarrhea, fever, and abdominal pain, click here.
To review the differential diagnosis of acute diarrhea, abdominal pain, and weight loss, click here.
To review the differential diagnosis of chronic diarrhea, abdominal pain, and weight loss, click here.
Diarrhea
The following table outlines the major differential diagnoses of diarrhea.[7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36]
Abbreviations: GI: Gastrointestinal, CBC: Complete blood count, WBC: White blood cell, RBC: Red blood cell, Plt: Platelet, Hgb: Hemoglobin, ESR: Erythrocyte sedimentation rate, CRP: C–reactive protein, IgE: Immunoglobulin E, IgA: Immunoglobulin A, ETEC: Escherichia coli enteritis, EPEC: Enteropathogenic Escherichia coli, EIEC: Enteroinvasive Escherichia coli, EHEC: Enterohemorrhagic Escherichia coli, EAEC: Enteroaggregative Escherichia coli, Nl: Normal, ASCA: Anti saccharomyces cerevisiae antibodies, ANCA: Anti–neutrophil cytoplasmic antibody, DNA: Deoxyribonucleic acid, CFTR: Cystic fibrosis transmembrane conductance regulator, SLC10A2: Solute carrier family 10 member 2, SeHCAT: Selenium homocholic acid taurine or tauroselcholic acid, IEL: Intraepithelial lymphocytes, MRCP: Magnetic resonance cholangiopancreatography, ANA: Antinuclear antibodies, AMA: Anti-mitochondrial antibody, LDH: Lactate dehydrogenase, CPK: Creatine phosphokinase, PCR: Polymerase chain reaction, ELISA: Enzyme–linked immunosorbent assay, LT: Heat–labile enterotoxin, ST: Heat–stable enterotoxin, RT-PCR: Reverse–transcriptase polymerase chain reaction, CD4: Cluster of differentiation 4, HIV: Human immunodeficiency virus, RUQ: Right-upper quadrant, VIP: Vasoactive intestinal peptide, GI: Gastrointestinal, FAP: Familial adenomatous polyposis, HNPCC: Hereditary nonpolyposis colorectal cancer, MTP: Microsomal triglyceride transfer protein, Scl‑70: Anti–topoisomerase I, TSH: Thyroid-stimulating hormone, T4: Thyroxine, T3: Triiodothyronine, DTR: Deep tendon reflex, RNA: Ribonucleic acid
Categories | Cause | Clinical manifestation | Lab findings | Extra intestinal findings | Cause/Pathogenesis | Gold standard diagnosis | ||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Symptoms | GI signs | |||||||||||||||||||||||
Duration | Diarrhea | Fever | Abdominal pain | Weight loss | ||||||||||||||||||||
Stool exam | CBC | Other lab findings | ||||||||||||||||||||||
Acute | Chronic | Watery | Bloody | Fatty | WBC | RBC | Ova/Parasite | Osmotic gap | Other | WBC | Hgb | Plt | ||||||||||||
Gastrointestinal | Crohn's disease | – | + | + | + | + | ± | + | + |
|
+ | + | – | Nl | – | ↑ | ↓ | ↑ |
|
|
|
| ||
Ulcerative colitis | – | + | + | + | + | ± | + | + | + | + | – | Nl | – | ↑ | ↓ | ↑ |
|
|
| |||||
Celiac disease | – | + | ± | – | ± | – | + | + |
|
– | – | – | Nl |
|
Nl | ↓ | Nl |
|
| |||||
Cause | Duration | Diarrhea | Fever | Abdominal pain | Weight loss | GI signs | Stool exam | CBC | Other lab findings | Extra intestinal findings | Cause/Pathogenesis | Gold standard diagnosis | ||||||||||||
Acute | Chronic | Watery | Bloody | Fatty | WBC | RBC | Ova/Parasite | Osmotic gap | Other | WBC | Hgb | Plt | ||||||||||||
Cystic fibrosis | – | + | – | – | + | ± | + | + | – | – | – | Nl |
|
Nl | ↓ | Nl |
|
|
| |||||
Chronic pancreatitis | – | + | + | – | + | – | + | + | – | – | – | Nl |
|
Nl | Nl | Nl |
|
|||||||
Bile acid malabsorption | – | + | + | – | + | – | – | + | – | – | – | Nl |
|
Nl | Nl | Nl |
|
|
| |||||
Microscopic colitis | – | + | + | – | – | – | + | + | – | – | – | Nl | – | Nl | ↓ | Nl |
|
|
| |||||
Cause | Duration | Diarrhea | Fever | Abdominal pain | Weight loss | GI signs | Stool exam | CBC | Other lab findings | Extra intestinal findings | Cause/Pathogenesis | Gold standard diagnosis | ||||||||||||
Acute | Chronic | Watery | Bloody | Fatty | WBC | RBC | Ova/Parasite | Osmotic gap | Other | WBC | Hgb | Plt | ||||||||||||
Infective colitis | – | + | + | + | – | + | + | + |
|
+ | + | + | Nl |
|
↑ | ↓ | ↑ | |||||||
Ischemic colitis | + | + | + | + | – | + | + | + |
|
+ | + | – | Nl | – | ↑ | ↓ | ↑ |
|
|
| ||||
Lactose intolerance | + | + | + | – | – | – | + | – | – | – | – | ↑ | – | Nl | Nl | Nl |
|
|
| |||||
Irritable bowel syndrome | – | + | ± | – | ± | – | ± | – | – | – | – | Nl | – | Nl | Nl | Nl | Nl |
|
| |||||
Infection | Bacterial | Cause | Duration | Diarrhea | Fever | Abdominal pain | Weight loss | GI signs | Stool exam | CBC | Other lab findings | Extra intestinal findings | Cause/Pathogenesis | Gold standard diagnosis | ||||||||||
Acute | Chronic | Watery | Bloody | Fatty | WBC | RBC | Ova/Parasite | Osmotic gap | Other | WBC | Hgb | Plt | ||||||||||||
Whipple's disease | – | + | + | – | + | ± | + | + | – | – | – | Nl |
|
↓ | ↓ | ↓/↑ |
|
| ||||||
Tropical sprue | + | + | + | – | + | + | + | + |
|
+ | – | – | Nl |
|
Nl | ↓ | Nl |
| ||||||
Small bowel bacterial overgrowth | – | + | + | – | + | – | + | + | + | – | – | Nl |
|
Nl | ↓ | Nl |
|
| ||||||
Pseudomembranous enterocolitis | + | – | + | ± | – | + | + | ± | + | + | – | Nl |
|
↑ | ↓ | ↓ |
|
|
| |||||
Cause | Duration | Diarrhea | Fever | Abdominal pain | Weight loss | GI signs | Stool exam | CBC | Other lab findings | Extra intestinal findings | Cause/Pathogenesis | Gold standard diagnosis | ||||||||||||
Acute | Chronic | Watery | Bloody | Fatty | WBC | RBC | Ova/Parasite | Osmotic gap | Other | WBC | Hgb | Plt | ||||||||||||
Campylobacteriosis | + | – | + | + | – | + | + | – |
|
+ | + | – | Nl |
|
↑ | Nl | Nl | Nl | ||||||
Salmonellosis | + | + | + | + | – | + | + | – | + | + | – | Nl |
|
↑ | Nl | ↑ | ||||||||
Shigellosis | + | – | + | + | – | + | + | – |
|
+ | + | – | Nl |
|
↑/↓ | ↓ | ↓ |
|
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Cause | Duration | Diarrhea | Fever | Abdominal pain | Weight loss | GI signs | Stool exam | CBC | Other lab findings | Extra intestinal findings | Cause/Pathogenesis | Gold standard diagnosis | ||||||||||||
Acute | Chronic | Watery | Bloody | Fatty | WBC | RBC | Ova/Parasite | Osmotic gap | Other | WBC | Hgb | Plt | ||||||||||||
Escherichia coli enteritis | ETEC | + | – | + | – | – | + | – | – |
|
+ | – | – | Nl |
|
↑ | Nl | Nl | – | – |
|
|||
EPEC | + | + | + | + | – | + | + | + |
|
+ | + | – | Nl |
|
↑ | Nl | Nl | – | – |
| ||||
EIEC | + | – | + | + | – | + | + | – |
|
+ | + | – | Nl |
|
↑ | Nl | Nl | – | – | |||||
EHEC | + | – | + | + | – | – | + | – |
|
+ | + | – | Nl |
|
↑ | ↓ | ↓ | |||||||
EAEC | + | + | + | + | – | – | + | – |
|
+ | + | – | Nl |
|
↑ | ↓ | ↓ | – |
|
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Cause | Duration | Diarrhea | Fever | Abdominal pain | Weight loss | GI signs | Stool exam | CBC | Other lab findings | Extra intestinal findings | Cause/Pathogenesis | Gold standard diagnosis | ||||||||||||
Acute | Chronic | Watery | Bloody | Fatty | WBC | RBC | Ova/Parasite | Osmotic gap | Other | WBC | Hgb | Plt | ||||||||||||
Yersinia enterocolitica | + | – | + | + | – | + | + | – |
|
+ | + | – | Nl |
|
↑ | Nl | Nl | – | ||||||
Vibrio cholera | + | – | + | – | – | – | + | – | + | – | – | Nl |
|
↑ | Nl | Nl |
|
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Aeromonas | + | + | + | + | – | + | + | – |
|
+ | + | – | Nl |
|
↑ | Nl | Nl | – |
|
| ||||
Cause | Duration | Diarrhea | Fever | Abdominal pain | Weight loss | GI signs | Stool exam | CBC | Other lab findings | Extra intestinal findings | Cause/Pathogenesis | Gold standard diagnosis | ||||||||||||
Acute | Chronic | Watery | Bloody | Fatty | WBC | RBC | Ova/Parasite | Osmotic gap | Other | WBC | Hgb | Plt | ||||||||||||
Plesiomonas | + | – | + | + | – | + | + | – |
|
+ | + | – | Nl |
|
↑ | Nl | Nl | – |
|
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Mycobacterium avium complex | + | + | + | + | – | + | + | – | + | + | – | Nl | – | ↓ | ↓ | Nl |
|
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Food poisoning | + | – | + | ± | – | + | + | ± | + | ± | – | Nl |
|
↑ | Nl | Nl | – |
|
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Virus | Cause | Duration | Diarrhea | Fever | Abdominal pain | Weight loss | GI signs | Stool exam | CBC | Other lab findings | Extra intestinal findings | Cause/Pathogenesis | Gold standard diagnosis | |||||||||||
Acute | Chronic | Watery | Bloody | Fatty | WBC | RBC | Ova/Parasite | Osmotic gap | Other | WBC | Hgb | Plt | ||||||||||||
Norovirus | + | – | + | – | – | + | + | – | – | – | – | Nl |
|
↓ | Nl | Nl | – |
| ||||||
Rotavirus | + | – | + | – | – | + | – | – |
|
+ | – | – | Nl | – | Nl | Nl | Nl |
| ||||||
Echovirus | + | – | + | – | – | + | + | – | – | – | – | Nl | – | Nl | Nl | Nl | – |
| ||||||
Adenovirus | + | – | + | – | – | + | + | – | – | – | – | Nl |
|
Nl | Nl | Nl | – |
| ||||||
CMV colitis | + | + | – | + | – | ± | + | – |
|
+ | + | – | Nl |
|
↓ | Nl | Nl |
|
| |||||
HIV | – | + | + | – | – | + | + | + | + | – | – | Nl | – | ↓ | ↓ | Nl |
|
|
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Parasite | Cause | Duration | Diarrhea | Fever | Abdominal pain | Weight loss | GI signs | Stool exam | CBC | Other lab findings | Extra intestinal findings | Cause/Pathogenesis | Gold standard diagnosis | |||||||||||
Acute | Chronic | Watery | Bloody | Fatty | WBC | RBC | Ova/Parasite | Osmotic gap | Other | WBC | Hgb | Plt | ||||||||||||
Entamoeba histolytica | + | + | + | + | – | + | + | – | + | + | + | Nl | – | ↑ | Nl | Nl | – |
|
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Giardia | – | + | + | – | + | – | + | + | – | – | + | Nl | – | Nl | Nl | Nl | – |
| ||||||
Cryptosporidium | – | + | + | – | – | – | + | + | – | – | + | Nl |
|
Nl | Nl | Nl |
|
|
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Microsporidia | + | + | + | – | – | + | + | – | – | – | + | Nl |
|
Nl | Nl | Nl |
|
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Isospora | + | + | + | – | + | + | + | + | + | + | + | Nl |
|
↑ | Nl | Nl |
|
|
| |||||
Tumors | Cause | Duration | Diarrhea | Fever | Abdominal pain | Weight loss | GI signs | Stool exam | CBC | Other lab findings | Extra intestinal findings | Cause/Pathogenesis | Gold standard diagnosis | |||||||||||
Acute | Chronic | Watery | Bloody | Fatty | WBC | RBC | Ova/Parasite | Osmotic gap | Other | WBC | Hgb | Plt | ||||||||||||
Carcinoid tumor | – | + | + | + | – | – | + | + | – | + | – | ↓ | – | Nl | Nl | Nl |
|
|
| |||||
VIPoma | + | + | + | – | + | – | + | + |
|
– | – | – | ↓ | – | Nl | Nl | Nl |
|
|
| ||||
Zollinger–Ellison syndrome | – | + | + | + | + | – | + | + | – | – | – | ↓ | – | Nl | ↓ | Nl |
|
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Somatostatinoma | – | + | + | – | – | – | + | + | – | – | – | ↓ | – | Nl | Nl | Nl |
|
|
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Cause | Duration | Diarrhea | Fever | Abdominal pain | Weight loss | GI signs | Stool exam | CBC | Other lab findings | Extra intestinal findings | Cause/Pathogenesis | Gold standard diagnosis | ||||||||||||
Acute | Chronic | Watery | Bloody | Fatty | WBC | RBC | Ova/Parasite | Osmotic gap | Other | WBC | Hgb | Plt | ||||||||||||
Lymphoma | – | + | + | + | – | + | + | + | – | + | – | Nl | – | Nl | ↓ | Nl |
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Colorectal cancer | – | + | + | + | + | – | + | + |
|
– | + | – | Nl | – | Nl | ↓ | Nl |
|
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Medication/Toxicity | Medications | + | + | + | – | ± | ± | + | + | – | – | – | ↑/↓ | – | ↑ | Nl | Nl |
|
– |
| ||||
Factitious diarrhea | + | + | + | – | – | – | + | + | – | – | – | ↑/↓ | – | Nl | Nl | Nl |
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Cause | Duration | Diarrhea | Fever | Abdominal pain | Weight loss | GI signs | Stool exam | CBC | Other lab findings | Extra intestinal findings | Cause/Pathogenesis | Gold standard diagnosis | ||||||||||||
Acute | Chronic | Watery | Bloody | Fatty | WBC | RBC | Ova/Parasite | Osmotic gap | Other | WBC | Hgb | Plt | ||||||||||||
Heavy metal ingestion | – | + | + | – | – | – | + | + | – | – | – | Nl | – | Nl | Nl | Nl |
|
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Organophosphate poisoning | + | + | + | – | – | – | + | – | – | – | – | Nl | – | Nl | Nl | Nl |
|
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|
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Opium withdrawal | + | + | + | – | – | – | + | – |
|
– | – | – | Nl | – | Nl | Nl | Nl |
| ||||||
Iatrogenic | Cause | Duration | Diarrhea | Fever | Abdominal pain | Weight loss | GI signs | Stool exam | CBC | Other lab findings | Extra intestinal findings | Cause/Pathogenesis | Gold standard diagnosis | |||||||||||
Acute | Chronic | Watery | Bloody | Fatty | WBC | RBC | Ova/Parasite | Osmotic gap | Other | WBC | Hgb | Plt | ||||||||||||
Short bowel syndrome | + | + | + | – | + | – | – | + | – | – | – | Nl |
|
Nl | ↓ | ↑ |
|
|
|
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Radiation enteritis | + | + | + | + | + | – | + | + | + | + | – | Nl |
|
Nl | ↓ | Nl |
|
|
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Dumping syndrome | – | + | + | – | + | – | – | + |
|
– | – | – | Nl | – | Nl | Nl | Nl |
|
| |||||
Others | Cause | Duration | Diarrhea | Fever | Abdominal pain | Weight loss | GI signs | Stool exam | CBC | Other lab findings | Extra intestinal findings | Cause/Pathogenesis | Gold standard diagnosis | |||||||||||
Acute | Chronic | Watery | Bloody | Fatty | WBC | RBC | Ova/Parasite | Osmotic gap | Other | WBC | Hgb | Plt | ||||||||||||
Abetalipoproteinemia | – | + | + | – | + | – | + | + | – | – | – | Nl | – | Nl | Nl | Nl |
|
|
| |||||
Hyperthyroidism | – | + | + | – | – | ± | + | + | – | – | – | – | Nl |
|
Nl | Nl | Nl |
|
|
|||||
Diabetic neuropathy | – | + | + | – | + | – | + | + | – | – | – | Nl |
|
Nl | ↓ | Nl |
|
| ||||||
Systemic sclerosis | – | + | + | ± | + | – | + | + | – | + | – | Nl |
|
Nl | ↓ | Nl |
|
|
Medical Therapy
- Fluid resuscitation (oral, if not IV)
- Patients should be advised to do the following until symptoms subside:
- For patients with lactose intolerance, a lactose-free diet is advised
- For patients with malabsorption diseases, a gluten free diet is advised
- Consultation with oncology, surgery and/or gastroenterology may be required for intestinal neoplasm
- Control blood sugar (diabetic neuropathy)
Empirical Therapy
Empirical therapy is used as an initial treatment before diagnostic testing or after diagnostic testing has failed to confirm a diagnosis or when there is no specific treatment or when specific treatment fails to effect a cure.
- Empirical trials of antimicrobial therapy like metronidazole for protozoal diarrhea or fluoroquinolone for enteric bacterial diarrhea if the prevalence of bacterial or protozoal infection is high in a specific community or situation.
- Most cases of diarrhea, except for high-volume secretory states, respond to a sufficiently high dose of opium or morphine. Codeine, synthetic opioids diphenoxylate and loperamide are less potent. However loperamide is generally used because of its less abuse potential.
- The somatostatin analogue octreotide has proven effectiveness in carcinoid tumors and other peptide-secreting tumors, dumping syndrome, and chemotherapy-induced diarrhea.
- Intraluminal agents include adsorbants, such as activated charcoal, and binding resins like bismuth and stool modifiers, such as medicinal fiber.
Pharmacotherapy
- Antibiotics (malabsorption diseases)
- Anticholinergics (IBS)
- Antimolality agents
- Antibiotic therapy (severe disease)
- Metoclopramide (diabetic neuropathy)
- Nonspecific antidiarrheal agents
Symptomatic Treatment
- Symptomatic treatment for diarrhea involves the patient consuming adequate amounts of water to replace that loss, preferably mixed with electrolytes to provide essential salts and some amount of nutrients. For many people, further treatment is unnecessary.
- The following types of diarrhea indicate medical supervision is required:
- Diarrhea in infants;
- Moderate or severe diarrhea in young children;
- Diarrhea associated with blood;
- Diarrhea that continues for more than two weeks;
- Diarrhea that is associated with more general illness such as non-cramping abdominal pain, fever, weight loss, etc;
- Diarrhea in travelers, since they are more likely to have exotic infections such as parasites;
- Diarrhea in food handlers, because of the potential to infect others;
- Diarrhea in institutions such as hospitals, child care centers, or geriatric and convalescent homes.
A severity score is used to aid diagnosis.[37]
Pathogen Specific
Immunocompetent
- Bacterial [38]
- 1. Shigella species
- Preferred regimen (1):
- 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
- 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; 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 [38]
- 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
- Bacterial [38]
- 1. Shigella species:
- Preferred regimen (1):
- Adult dose: TMP-SMZ, 160 and 800 mg, respectively bid for 7 to 10 days (if susceptible ) OR Fluoroquinolone (e.g., 300 mg Ofloxacin, 400 mg Norfloxacin, OR 500 mg Ciprofloxacin bid for 7 to 10 days)
- Pediatric dose:TMP-SMZ, 5 and 25 mg/kg, respectively bid for 7 to 10 days
- Preferred regimen (2):
- Adult dose: Nalidixic acid 1 g/d for 7 to 10 days OR Ceftriaxone; Azithromycin
- Pediatric dose: Nalidixic acid, 55 mg/kg/d for 7 to 10 days
- 2. Non-typhi species of Salmonella
- Preferred regimen: Not recommended routinely, but if severe or patient is younger than 6 monthes or older than 50 old or has prostheses, valvular heart disease, severe atherosclerosis, malignancy, or uremia, TMP-SMZ (if susceptible) OR Fluoroquinolone, bid for 14 days (or longer if relapsing); ceftriaxone, 100 mg/kg/d in 1 or 2 divided doses
- 3. Campylobacter species
- Preferred regimen: Erythromycin, 500 mg bid for 5 days (may require prolonged treatment)
- 4. Escherichia coli species
- 4.1. Enterotoxigenic
- Preferred regimen: TMP-SMZ, 160 and 800 mg, respectively, bid for 3 days (if susceptible), OR Fluoroquinolone (e.g., 300 mg Ofloxacin, 400 mg Norfloxacin, or 500 mg Ciprofloxacin bid for 3 days) (Consider fluoroquinolone as for enterotoxigenic E. coli)
- 4.2. Enteropathogenic
- Preferred regimen: TMP-SMZ, 160 and 800 mg, respectively, bid,for 3 days (if susceptible), OR Fluoroquinolone (e.g., 300 mg Ofloxacin, 400 mg Norfloxacin, or 500 mg Ciprofloxacin bid for 3 days)
- 4.3. Enteroinvasive
- Preferred regimen: TMP-SMZ, 160 and 800 mg, respectively, bid,for 3 days (if susceptible), OR Fluoroquinolone (e.g., 300 mg Ofloxacin, 400 mg Norfloxacin, or 500 mg Ciprofloxacin bid for 3 days)
- 4.4. Enterohemorrhagic
- Preferred regimen: Avoid antimotility drugs; role of antibiotics unclear, and administration should be avoided.
- 5. Aeromonas/Plesiomonas
- Preferred regimen: TMP-SMZ, 160 and 800 mg, respectively, bid for 3 days (if susceptible), Fluoroquinolone (e.g., 300 mg ofloxacin, 400 mg norfloxacin, or 500 mg Ciprofloxacin bid for 3 days)
- 6. Yersinia species
- Preferred regimen: Doxycycline, Aminoglycoside (in combination) or TMP-SMZ or Fluoroquinolone
- 7. Vibrio cholerae O1 or O139
- Preferred regimen: Doxycycline, 300-mg single dose; or Tetracycline, 500 mg qid for 3 days; or TMP-SMZ, 160 and 800 mg, respectively, bid for 3 days; or single-dose Fluoroquinolone
- 8. Toxigenic Clostridium difficile
- Preferred regimen: Offending antibiotic should be withdrawn if possible; Metronidazole, 250 mg qid to 500 mg tid for 3 to 10 days
- Parasites [38]
- 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
Related Chapters
External Links
References
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