Approach to the adult with acute diarrhea in developing countries
- Regina LaRocque, MD, MPH
Regina LaRocque, MD, MPH
- Assistant Professor of Medicine
- Harvard Medical School
- Mark Pietroni, MA, MBBChir, FRCP, DTM&H
Mark Pietroni, MA, MBBChir, FRCP, DTM&H
- Medical Director
- International Centre for Diarrhoeal Disease Research, Bangladesh
The Global Burden of Disease study estimated that there were 1.4 million deaths due to diarrheal diseases in 2010 . According to this report, diarrheal diseases represent one of the five leading causes of death worldwide and are the second leading cause of death in children under five years of age (behind acute respiratory infections). Most cases of diarrhea are associated with contaminated food and water sources, and around 2.4 billion people globally have no access to basic sanitation .
The World Health Organization (WHO) provides guidelines for the management of diarrheal illness in developing countries in "The Treatment of Diarrhea: A Manual for Physicians and Other Senior Health Workers" . Specific WHO guidelines for the management of epidemic shigellosis  and cholera  are also available. The recommendations in this topic are consistent with those guidelines.
This topic reviews the clinical assessment, treatment, and prevention of acute diarrhea, including watery diarrhea and dysentery, in adults in developing countries.
The clinical assessment and management of children with acute diarrhea in developing countries and of individuals with diarrhea in resource-rich settings are discussed elsewhere. (See "Approach to the child with acute diarrhea in developing countries" and "Epidemiology and causes of acute diarrhea in developed countries" and "Approach to the adult with acute diarrhea in developed countries" and "Approach to the adult with chronic diarrhea in developed countries" and "Evaluation of diarrhea in children" and "Overview of the causes of chronic diarrhea in children".)
CLASSIFICATION OF DIARRHEA
Diarrhea is defined as the passage of loose or watery stools, typically at least three times in a 24-hour period . Acute diarrhea is defined as diarrhea of ≤14 days in duration, in contrast to persistent (>14 days and ≤30 days) or chronic (>30 days) diarrhea. Invasive diarrhea, or dysentery, is defined as diarrhea with visible blood, in contrast to watery diarrhea. Dysentery is commonly associated with fever and abdominal pain.
- Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380:2095.
- World Health Organization. Water Sanitation and Health. Geneva, Switzerland: World Health Organization, 2004.
- World Health Organization. The treatment of diarrhoea, a manual for physicians and other senior health workers. -- 4th revision. Geneva, Switzerland: World Health Organization, 2005.
- Guidelines for the control of shigellosis, including epidemics due to Shigella dysenteriae type 1. Geneva, Switzerland: World Health Organization, 2005.
- Cholera outbreak: assessing the outbreak response and improving preparedness. Geneva, Switzerland: World Health Organization, 2004.
- Guerrant RL, Van Gilder T, Steiner TS, et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis 2001; 32:331.
- Walker CL, Black RE. Diarrhoea morbidity and mortality in older children, adolescents, and adults. Epidemiol Infect 2010; 138:1215.
- Public health impact of Rwandan refugee crisis: what happened in Goma, Zaire, in July, 1994? Goma Epidemiology Group. Lancet 1995; 345:339.
- Harris JB, LaRocque RC, Qadri F, et al. Cholera. Lancet 2012; 379:2466.
- Cholera, Zimbabwe--update. Wkly Epidemiol Rec 2009; 84:109.
- Effler E, Isaäcson M, Arntzen L, et al. Factors contributing to the emergence of Escherichia coli O157 in Africa. Emerg Infect Dis 2001; 7:812.
- Angulo FJ, Swerdlow DL. Bacterial enteric infections in persons infected with human immunodeficiency virus. Clin Infect Dis 1995; 21 Suppl 1:S84.
- Wanke CA, Mayer H, Weber R, et al. Enteroaggregative Escherichia coli as a potential cause of diarrheal disease in adults infected with human immunodeficiency virus. J Infect Dis 1998; 178:185.
- Niyogi SK. Shigellosis. J Microbiol 2005; 43:133.
- Ndlovu N, Tarupiwa A, Mudzori JT. Antimicrobial resistence of Shigella species isolated during 2004 and 2005 from selected sites in Zimbabwe. Cent Afr J Med 2006; 52:93.
- Talukder KA, Khajanchi BK, Islam MA, et al. The emerging strains of Shigella dysenteriae type 2 in Bangladesh are clonal. Epidemiol Infect 2006; 134:1249.
- Ramamurthy T, Garg S, Sharma R, et al. Emergence of novel strain of Vibrio cholerae with epidemic potential in southern and eastern India. Lancet 1993; 341:703.
- Stoll BJ, Glass RI, Huq MI, et al. Epidemiologic and clinical features of patients infected with Shigella who attended a diarrheal disease hospital in Bangladesh. J Infect Dis 1982; 146:177.
- Gordon MA. Salmonella infections in immunocompromised adults. J Infect 2008; 56:413.
- World Health Organization. First steps for managing an oubreak of acute diarrhea. Geneva, Switzerland: World Health Organization, 2004.
- Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ 2000; 78:1246.
- Hahn S, Kim S, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children. Cochrane Database Syst Rev 2002; :CD002847.
- Alam NH, Majumder RN, Fuchs GJ. Efficacy and safety of oral rehydration solution with reduced osmolarity in adults with cholera: a randomised double-blind clinical trial. CHOICE study group. Lancet 1999; 354:296.
- Gregorio GV, Gonzales ML, Dans LF, Martinez EG. Polymer-based oral rehydration solution for treating acute watery diarrhoea. Cochrane Database Syst Rev 2009; :CD006519.
- Ramakrishna BS, Venkataraman S, Srinivasan P, et al. Amylase-resistant starch plus oral rehydration solution for cholera. N Engl J Med 2000; 342:308.
- Wiström J, Jertborn M, Ekwall E, et al. Empiric treatment of acute diarrheal disease with norfloxacin. A randomized, placebo-controlled study. Swedish Study Group. Ann Intern Med 1992; 117:202.
- Steffen R, Sack DA, Riopel L, et al. Therapy of travelers' diarrhea with rifaximin on various continents. Am J Gastroenterol 2003; 98:1073.
- Salam I, Katelaris P, Leigh-Smith S, Farthing MJ. Randomised trial of single-dose ciprofloxacin for travellers' diarrhoea. Lancet 1994; 344:1537.
- Mattila L, Peltola H, Siitonen A, et al. Short-term treatment of traveler's diarrhea with norfloxacin: a double-blind, placebo-controlled study during two seasons. Clin Infect Dis 1993; 17:779.
- Christopher PR, David KV, John SM, Sankarapandian V. Antibiotic therapy for Shigella dysentery. Cochrane Database Syst Rev 2010; :CD006784.
- Okeke IN, Laxminarayan R, Bhutta ZA, et al. Antimicrobial resistance in developing countries. Part I: recent trends and current status. Lancet Infect Dis 2005; 5:481.
- Kariuki S, Hart CA. Global aspects of antimicrobial-resistant enteric bacteria. Curr Opin Infect Dis 2001; 14:579.
- Mandomando I, Espasa M, Vallès X, et al. Antimicrobial resistance of Vibrio cholerae O1 serotype Ogawa isolated in Manhiça District Hospital, southern Mozambique. J Antimicrob Chemother 2007; 60:662.
- Taneja N, Mohan B, Khurana S, Sharma M. Antimicrobial resistance in selected bacterial enteropathogens in north India. Indian J Med Res 2004; 120:39.
- Rahman M, Shoma S, Rashid H, et al. Increasing spectrum in antimicrobial resistance of Shigella isolates in Bangladesh: resistance to azithromycin and ceftriaxone and decreased susceptibility to ciprofloxacin. J Health Popul Nutr 2007; 25:158.
- Tjaniadi P, Lesmana M, Subekti D, et al. Antimicrobial resistance of bacterial pathogens associated with diarrheal patients in Indonesia. Am J Trop Med Hyg 2003; 68:666.
- Surveillance Update. ICDDR,B:Health and Science Bulletin 2010; 8:19.
- Brooks JT, Ochieng JB, Kumar L, et al. Surveillance for bacterial diarrhea and antimicrobial resistance in rural western Kenya, 1997-2003. Clin Infect Dis 2006; 43:393.
- Fewtrell L, Kaufmann RB, Kay D, et al. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. Lancet Infect Dis 2005; 5:42.
- Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand washing for preventing diarrhoea. Cochrane Database Syst Rev 2008; :CD004265.
- World Health Organization. Potential use of oral cholera vaccines. http://www.who.int/topics/cholera/vaccines/use/en/index.html (Accessed on July 13, 2012).
- CLASSIFICATION OF DIARRHEA
- Worldwide incidence
- Risk factors
- - Crowding and poor sanitation
- - HIV infection
- Epidemic diarrhea
- Acute watery diarrhea
- Acute bloody diarrhea
- CLINICAL FEATURES
- Complications of acute diarrheal diseases in adults
- DIFFERENTIAL DIAGNOSIS
- CLINICAL ASSESSMENT
- - None to moderate hypovolemia
- - Severe hypovolemia
- Antibiotic therapy
- - Watery diarrhea
- - Dysentery
- - Antimicrobial resistance
- Dietary recommendations
- SUMMARY AND RECOMMENDATIONS