Acute diarrhea medical therapy

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

Overview

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

Medical Therapy

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

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

Empiric Therapy

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

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

Pharmacotherapy

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

Symptomatic Treatment

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

Pathogen Specific Therapy

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

Immunocompetent patients

  • 1. Shigella species
  • Preferred regimen (2):
  • 2. Non-typhi species of Salmonella
  • 3. Campylobacter species
  • 4. Escherichia coli species
  • 4.1. Enterotoxigenic
  • 4.2. Enteropathogenic
  • 4.3. Enteroinvasive
  • 4.4. Enterohemorrhagic
  • Preferred regimen: Avoid antimotility drugs; the role of antibiotics unclear, and administration should be avoided.
  • 5. Aeromonas/Plesiomonas
  • 6. Yersinia species
  • 7. Vibrio cholerae O1 or O139
  • Preferred regimen (1): Doxycycline 300-mg single dose
  • Preferred regimen (2): Tetracycline 500 mg qid for 3 days
  • Preferred regimen (3): TMP-SMZ 160 and 800 mg, respectively, bid for 3 days
  • Preferred regimen (4): single-dose Fluoroquinolone
  • 8. Toxigenic Clostridium difficile
  • Preferred regimen: Offending antibiotic should be withdrawn if possible; Metronidazole, 250 mg qid to 500 mg tid for 3 to 10 days
  • 1. Giardia
  • 2. Cryptosporidium species
  • Preferred regimen: If severe, consider Paromomycin, 500 mg tid for 7 days
  • 3. Isospora species
  • Preferred regimen: TMP-SMZ, 160 and 800 mg, respectively, bid for 7 to 10 days
  • 4. Cyclospora species
  • Preferred regimen: TMP/SMZ, 160 and 800 mg, respectively, bid for 7 days
  • 5. Microsporidium species
  • Preferred regimen: Not determined
  • 6. Entamoeba histolytica

Immunocompromised patients

  • 1. Shigella species:
  • Preferred regimen (2):
  • 2. Non-typhi species of Salmonella
  • 3. Campylobacter species
  • Preferred regimen: Erythromycin, 500 mg bid for 5 days (may require prolonged treatment)
  • 4. Escherichia coli species
  • 4.1. Enterotoxigenic
  • 4.2. Enteropathogenic
  • 4.3. Enteroinvasive
  • 4.4. Enterohemorrhagic
  • Preferred regimen: Avoid antimotility drugs; role of antibiotics unclear, and administration should be avoided.
  • 5. Aeromonas/Plesiomonas
  • 6. Yersinia species
  • 7. Vibrio cholerae O1 or O139
  • 8. Toxigenic Clostridium difficile
  • Preferred regimen: Offending antibiotic should be withdrawn if possible; Metronidazole, 250 mg qid to 500 mg tid for 3 to 10 days
  • 1. Giardia
  • 2. Cryptosporidium species
  • Preferred regimen: Paromomycin, 500 mg tid for 14 to 28 days, then bid if needed; highly active antiretroviral therapy including a protease inhibitor is warranted for patients with AIDS
  • 3. Isospora species
  • Preferred regimen: TMP-SMZ, 160 and 800 mg, respectively, qid for 10 days, followed by TMP-SMZ thrice weekly, or weekly Sulfadoxine (500 mg) and Pyrimethamine (25 mg) indefinitely for patients with AIDS
  • 4. Cyclospora species
  • Preferred regimen: TMP-SMZ, 160 and 800 mg, respectively, qid for 10 days, followed by TMP-SMZ thrice weekly indefinitely
  • 5. Microsporidium species
  • Preferred regimen: Albendazole, 400 mg bid for 3 weeks; highly active antiretroviral therapy including a protease inhibitor is warranted for patients with AIDS
  • 6. Entamoeba histolytica

References

  1. Riddle MS, DuPont HL, Connor BA (2016). "ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults". Am. J. Gastroenterol. 111 (5): 602–22. doi:10.1038/ajg.2016.126. PMID 27068718.
  2. Carpenter CC, Greenough WB, Pierce NF (1988). "Oral-rehydration therapy--the role of polymeric substrates". N. Engl. J. Med. 319 (20): 1346–8. doi:10.1056/NEJM198811173192009. PMID 3185638.
  3. Avery ME, Snyder JD (1990). "Oral therapy for acute diarrhea. The underused simple solution". N. Engl. J. Med. 323 (13): 891–4. doi:10.1056/NEJM199009273231307. PMID 2203965.
  4. de Zoysa I, Kirkwood B, Feachem R, Lindsay-Smith E (1984). "Preparation of sugar-salt solutions". Trans. R. Soc. Trop. Med. Hyg. 78 (2): 260–2. PMID 6464119.
  5. 5.0 5.1 Duggan C, Santosham M, Glass RI (1992). "The management of acute diarrhea in children: oral rehydration, maintenance, and nutritional therapy. Centers for Disease Control and Prevention". MMWR Recomm Rep. 41 (RR-16): 1–20. PMID 1435668.
  6. Santosham M, Burns B, Nadkarni V, Foster S, Garrett S, Croll L, O'Donovan JC, Pathak R, Sack RB (1985). "Oral rehydration therapy for acute diarrhea in ambulatory children in the United States: a double-blind comparison of four different solutions". Pediatrics. 76 (2): 159–66. PMID 4022687.
  7. Riddle MS, Arnold S, Tribble DR (2008). "Effect of adjunctive loperamide in combination with antibiotics on treatment outcomes in traveler's diarrhea: a systematic review and meta-analysis". Clin. Infect. Dis. 47 (8): 1007–14. doi:10.1086/591703. PMID 18781873.
  8. Steffen R (1990). "Worldwide efficacy of bismuth subsalicylate in the treatment of travelers' diarrhea". Rev. Infect. Dis. 12 Suppl 1: S80–6. PMID 2406861.
  9. 9.0 9.1 9.2 9.3 Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV; et al. (2001). "Practice guidelines for the management of infectious diarrhea". Clin Infect Dis. 32 (3): 331–51. doi:10.1086/318514. PMID 11170940.
  10. DuPont HL (1997). "Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology". Am. J. Gastroenterol. 92 (11): 1962–75. PMID 9362174.
  11. 11.0 11.1 Dryden MS, Gabb RJ, Wright SK (1996). "Empirical treatment of severe acute community-acquired gastroenteritis with ciprofloxacin". Clin. Infect. Dis. 22 (6): 1019–25. PMID 8783703.
  12. 12.0 12.1 Wiström J, Jertborn M, Ekwall E, Norlin K, Söderquist B, Strömberg A, Lundholm R, Hogevik H, Lagergren L, Englund G (1992). "Empiric treatment of acute diarrheal disease with norfloxacin. A randomized, placebo-controlled study. Swedish Study Group". Ann. Intern. Med. 117 (3): 202–8. PMID 1616214.
  13. Bennish ML, Salam MA, Haider R, Barza M (1990). "Therapy for shigellosis. II. Randomized, double-blind comparison of ciprofloxacin and ampicillin". J. Infect. Dis. 162 (3): 711–6. PMID 2201742.
  14. Sirinavin S, Garner P (2000). "Antibiotics for treating salmonella gut infections". Cochrane Database Syst Rev (2): CD001167. doi:10.1002/14651858.CD001167. PMID 10796610.
  15. Khan WA, Seas C, Dhar U, Salam MA, Bennish ML (1997). "Treatment of shigellosis: V. Comparison of azithromycin and ciprofloxacin. A double-blind, randomized, controlled trial". Ann. Intern. Med. 126 (9): 697–703. PMID 9139555.

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