Approach to the adult with acute diarrhea in resource-rich settings
- Christine A Wanke, MD
Christine A Wanke, MD
- Professor of Medicine and Public Health
- Tufts University School of Medicine
Diarrheal diseases represent one of the five leading causes of death worldwide [1,2]. Morbidity and mortality can be significant even in resource-rich settings, where diarrhea is more often than not a "nuisance disease" in the normally healthy individual [3,4].
Most cases of acute diarrhea in adults are of infectious etiology. One of the dilemmas in assessing patients with acute diarrhea is deciding when to perform stool testing and if and when to initiate therapy. The approach to such patients will be reviewed here and generally focuses on distinguishing those infectious etiologies for which treatment is beneficial from other causes (algorithm 1). The evaluation of persistent and chronic diarrhea, which is often of a noninfectious etiology, and specific causes of acute diarrhea and chronic diarrhea are discussed separately. (See "Epidemiology and causes of acute diarrhea in resource-rich countries" and "Approach to the adult with chronic diarrhea in resource-rich settings".)
Diarrhea in travelers in or returning from resource-limited settings and the approach to diarrhea in residents of resource-limited settings are discussed in detail elsewhere. (See "Travelers' diarrhea: Microbiology, epidemiology, and prevention" and "Travelers' diarrhea: Clinical manifestations, diagnosis, and treatment" and "Approach to the adult with acute diarrhea in resource-limited countries".)
Diarrhea is defined as the passage of loose or watery stools, typically at least three times in a 24-hour period . It reflects increased water content of the stool, whether due to impaired water absorption and/or active water secretion by the bowel.
The following definitions have been suggested according to the duration of symptoms:
- Bern C, Martines J, de Zoysa I, Glass RI. The magnitude of the global problem of diarrhoeal disease: a ten-year update. Bull World Health Organ 1992; 70:705.
- Yip R, Sharp TW. Acute malnutrition and high childhood mortality related to diarrhea. Lessons from the 1991 Kurdish refugee crisis. JAMA 1993; 270:587.
- Cohen ML. The epidemiology of diarrheal disease in the United States. Infect Dis Clin North Am 1988; 2:557.
- Ho MS, Glass RI, Pinsky PF, et al. Diarrheal deaths in American children. Are they preventable? JAMA 1988; 260:3281.
- Guerrant RL, Van Gilder T, Steiner TS, et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis 2001; 32:331.
- Musher DM, Musher BL. Contagious acute gastrointestinal infections. N Engl J Med 2004; 351:2417.
- Dryden MS, Gabb RJ, Wright SK. Empirical treatment of severe acute community-acquired gastroenteritis with ciprofloxacin. Clin Infect Dis 1996; 22:1019.
- Feldman RA, Banatvala N. The frequency of culturing stools from adults with diarrhoea in Great Britain. Epidemiol Infect 1994; 113:41.
- Wanke CA. Small intestinal infections. Curr Opin Gastroenterol 1994; 10:59.
- DuPont HL. Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1997; 92:1962.
- Thielman NM, Guerrant RL. Clinical practice. Acute infectious diarrhea. N Engl J Med 2004; 350:38.
- Koplan JP, Fineberg HV, Ferraro MJ, Rosenberg ML. Value of stool cultures. Lancet 1980; 2:413.
- Bresee JS, Marcus R, Venezia RA, et al. The etiology of severe acute gastroenteritis among adults visiting emergency departments in the United States. J Infect Dis 2012; 205:1374.
- Rohner P, Pittet D, Pepey B, et al. Etiological agents of infectious diarrhea: implications for requests for microbial culture. J Clin Microbiol 1997; 35:1427.
- Savola KL, Baron EJ, Tompkins LS, Passaro DJ. Fecal leukocyte stain has diagnostic value for outpatients but not inpatients. J Clin Microbiol 2001; 39:266.
- Guerrant RL, Shields DS, Thorson SM, et al. Evaluation and diagnosis of acute infectious diarrhea. Am J Med 1985; 78:91.
- DeGirolami PC, Ezratty CR, Desai G, et al. Diagnosis of intestinal microsporidiosis by examination of stool and duodenal aspirate with Weber's modified trichrome and Uvitex 2B strains. J Clin Microbiol 1995; 33:805.
- Hart AS, Ridinger MT, Soundarajan R, et al. Novel organism associated with chronic diarrhoea in AIDS. Lancet 1990; 335:169.
- Chitkara YK, McCasland KA, Kenefic L. Development and implementation of cost-effective guidelines in the laboratory investigation of diarrhea in a community hospital. Arch Intern Med 1996; 156:1445.
- Huicho L, Sanchez D, Contreras M, et al. Occult blood and fecal leukocytes as screening tests in childhood infectious diarrhea: an old problem revisited. Pediatr Infect Dis J 1993; 12:474.
- Herbert ME. Medical myth: Measuring white blood cells in the stools is useful in the management of acute diarrhea. West J Med 2000; 172:414.
- Kane SV, Sandborn WJ, Rufo PA, et al. Fecal lactoferrin is a sensitive and specific marker in identifying intestinal inflammation. Am J Gastroenterol 2003; 98:1309.
- Siegel DL, Edelstein PH, Nachamkin I. Inappropriate testing for diarrheal diseases in the hospital. JAMA 1990; 263:979.
- Avery ME, Snyder JD. Oral therapy for acute diarrhea. The underused simple solution. N Engl J Med 1990; 323:891.
- Carpenter CC, Greenough WB, Pierce NF. Oral-rehydration therapy--the role of polymeric substrates. N Engl J Med 1988; 319:1346.
- Santosham M, Burns B, Nadkarni V, et al. Oral rehydration therapy for acute diarrhea in ambulatory children in the United States: a double-blind comparison of four different solutions. Pediatrics 1985; 76:159.
- Duggan C, Santosham M, Glass RI. The management of acute diarrhea in children: oral rehydration, maintenance, and nutritional therapy. Centers for Disease Control and Prevention. MMWR Recomm Rep 1992; 41:1.
- de Zoysa I, Kirkwood B, Feachem R, Lindsay-Smith E. Preparation of sugar-salt solutions. Trans R Soc Trop Med Hyg 1984; 78:260.
- 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.
- Bennish ML, Salam MA, Haider R, Barza M. Therapy for shigellosis. II. Randomized, double-blind comparison of ciprofloxacin and ampicillin. J Infect Dis 1990; 162:711.
- Khan WA, Seas C, Dhar U, et al. Treatment of shigellosis: V. Comparison of azithromycin and ciprofloxacin. A double-blind, randomized, controlled trial. Ann Intern Med 1997; 126:697.
- Wong CS, Jelacic S, Habeeb RL, et al. The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections. N Engl J Med 2000; 342:1930.
- Nelson JM, Smith KE, Vugia DJ, et al. Prolonged diarrhea due to ciprofloxacin-resistant campylobacter infection. J Infect Dis 2004; 190:1150.
- 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.
- Salam I, Katelaris P, Leigh-Smith S, Farthing MJ. Randomised trial of single-dose ciprofloxacin for travellers' diarrhoea. Lancet 1994; 344:1537.
- Taylor DN, Sanchez JL, Candler W, et al. Treatment of travelers' diarrhea: ciprofloxacin plus loperamide compared with ciprofloxacin alone. A placebo-controlled, randomized trial. Ann Intern Med 1991; 114:731.
- Pichler HE, Diridl G, Stickler K, Wolf D. Clinical efficacy of ciprofloxacin compared with placebo in bacterial diarrhea. Am J Med 1987; 82:329.
- Sirinavin S, Garner P. Antibiotics for treating salmonella gut infections. Cochrane Database Syst Rev 2000; :CD001167.
- David KV, John SM, Sankarapandian V. Antibiotic therapy for Shigella dysentery. Cochrane Database Syst Rev 2010; :CD006784.
- Ternhag A, Asikainen T, Giesecke J, Ekdahl K. A meta-analysis on the effects of antibiotic treatment on duration of symptoms caused by infection with Campylobacter species. Clin Infect Dis 2007; 44:696.
- Petruccelli BP, Murphy GS, Sanchez JL, et al. Treatment of traveler's diarrhea with ciprofloxacin and loperamide. J Infect Dis 1992; 165:557.
- Murphy GS, Bodhidatta L, Echeverria P, et al. Ciprofloxacin and loperamide in the treatment of bacillary dysentery. Ann Intern Med 1993; 118:582.
- Riddle MS, Arnold S, Tribble DR. Effect of adjunctive loperamide in combination with antibiotics on treatment outcomes in traveler's diarrhea: a systematic review and meta-analysis. Clin Infect Dis 2008; 47:1007.
- DuPont HL, Hornick RB. Adverse effect of lomotil therapy in shigellosis. JAMA 1973; 226:1525.
- Steffen R. Worldwide efficacy of bismuth subsalicylate in the treatment of travelers' diarrhea. Rev Infect Dis 1990; 12 Suppl 1:S80.
- Graham DY, Estes MK, Gentry LO. Double-blind comparison of bismuth subsalicylate and placebo in the prevention and treatment of enterotoxigenic Escherichia coli-induced diarrhea in volunteers. Gastroenterology 1983; 85:1017.
- DuPont HL, Sullivan P, Pickering LK, et al. Symptomatic treatment of diarrhea with bismuth subsalicylate among students attending a Mexican university. Gastroenterology 1977; 73:715.
- DuPont HL, Flores Sanchez J, Ericsson CD, et al. Comparative efficacy of loperamide hydrochloride and bismuth subsalicylate in the management of acute diarrhea. Am J Med 1990; 88:15S.
- Johnson PC, Ericsson CD, DuPont HL, et al. Comparison of loperamide with bismuth subsalicylate for the treatment of acute travelers' diarrhea. JAMA 1986; 255:757.
- Salazar-Lindo E, Santisteban-Ponce J, Chea-Woo E, Gutierrez M. Racecadotril in the treatment of acute watery diarrhea in children. N Engl J Med 2000; 343:463.
- Gallelli L, Colosimo M, Tolotta GA, et al. Prospective randomized double-blind trial of racecadotril compared with loperamide in elderly people with gastroenteritis living in nursing homes. Eur J Clin Pharmacol 2010; 66:137.
- Prado D, Global Adult Racecadotril Study Group. A multinational comparison of racecadotril and loperamide in the treatment of acute watery diarrhoea in adults. Scand J Gastroenterol 2002; 37:656.
- Site of evaluation
- Physical examination
- General laboratory tests
- Stool cultures
- - Indications
- - Performance
- Additional testing in specific circumstances
- - Bloody diarrhea
- - Persistent diarrhea
- - Health care-associated diarrhea
- - Immunocompromised patients
- - Outbreak settings
- - Men who have sex with men
- - Molecular testing available
- Indications for imaging
- Fluid repletion
- Dietary recommendations
- Empiric antibiotic therapy
- - Indications
- - Choice of agent
- - Efficacy
- Specific antibiotic therapy
- Symptomatic therapy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS