Acute diarrhea resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mugilan Poongkunran M.B.B.S [2]

Overview

Acute diarrhea is the alteration of the volume, water content and frequency (≥ 3 episodes per day) of bowel movements for a duration of less than 14 days. When the diarrhea lasts more than 14 days it is referred to as persistent diarrhea; and when it lasts more than 30 days it is considered as chronic.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• E. coli (O157:H7)
• Human immunodeficiency virus
• Inflammatory bowel disease

Common Causes

Inflammatory Causes

• Bacterial : Campylobacter, Clostridium difficile, E. coli (O157:H7), Salmonella typhi, Salmonella(nontyphoidal), Shigella, Vibrio parahaemolyticus
• Viral : Cytomegalovirus
• Parasitic : Entamoeba histolytica

Noninflammatory Causes

• Bacterial : E.coli (toxigenic), Vibrio cholerae
• Viral : Rotavirus, Norovirus
• Parasitic : Giardia, Cryptosporidium, Cyclospora
• Performed toxin : Staphylococcus aureus, Bacillus cereus, Clostridium perfringens

Management

Initial Management

Shown below is an algorithm depicting the initial management of acute diarrhea is based on the 2001 IDSA practice guidelines for the management of infectious diarrhea.

Characterize the symptoms: ❑ Onset ❑ Duration ❑ Pattern (continuous or intermittent) ❑ Stool characteristic (watery, bloody, mucous or greasy) ❑ Frequency of bowel movements ❑ Dysenteric symptoms (fever, tenesmus, blood and/or pus in stool) Associated symptoms: ❑ Abdominal pain ❑ Nausea and vomiting ❑ Weight loss Epidemiological factors: ❑ Travel ❑ Food (raw meat, eggs, shellfish, unpasteurized cheese or milk) ❑ Outbreaks ❑ Sexual history ❑ Day care attendance ❑ Previous evaluations ❑ Medications, radiation therapy or surgery ❑ Underlying medical condition (cancer, diabetes, hyperthyroidism or AIDS)

Examine the patient: ❑ Temperature ❑ Pulse ❑ Blood pressure ❑ Respiratory rate ❑ Signs of volume depletion (decreased skin turgor, dry mucosa) ❑ Abdominal tenderness ❑ Level of consciousness

Assessment of volume status General condition Normal Irritable/less active* Lethargic/comatose§ Eyes Normal Sunken - Mucosa Normal Dry - Thirst Normal Thirsty Unable to drink§ Radial pulse Normal Low volume* Absent/ uncountable§ Skin turgor Normal Reduced - † Some dehydration = At least two signs, including at least one key sign (*) are present. ‡ Severe dehydration = Signs of “some dehydration” plus at least one key sign (§) are present.

No dehydration

Some dehydration

Severe dehydration

Start altered diet ❑ Stop lactose products ❑ Avoid alcohol and high osmolar supplements ❑ Drink 8-10 large glasses of clear fluids (Fruit juices, soft drinks etc) ❑ Eat frequent small meals (Rice, potato, banana, pastas etc) Can start oral rehydration therapy (ORT) for replacement of stool losses

❑ Start ORT at a volume of 50-100 mL/kg ❑ Start altered diet ❑ Reassess status every 4 hr

❑ Start IV fluids: Ringer lactate at 30ml/kg in the first 1/2hr and 70ml/kg for the next 2 1/2 hr, if unavailable use normal saline ❑ CBC ❑ Electrolytes ❑ Assess status every 15 mins until strong pulse felt and then every 1 hr

Patient stable and able to drink ❑ Start ORT at a volume of 100 mL/kg over 4 hour ❑ Calculate the continuing stool and emesis losses every hour for additional maintenance ORT therapy ❑ Reassess status every 4 hr

Additional Management

Shown below is an algorithm depicting additional management of acute diarrhea based on the 2001 IDSA practice guidelines for the management of infectious diarrhea.

Determine if the patient has any of the following: ❑ Diarrhea for more than 1 day ❑ Inflammation signs (fever, abdominal pain and/or bloody stools ❑ Recent antibitics use ❑ Recent attendance of day care ❑ Hospitalization ❑ Severe dehydration

❑ Proceed for selective fecal testing

Traveler's diarrhea

Community acquired diarrhea

Nosocomial diarrhea (3 days following hospitalization)

Persistent diarrhea for more than 7 days

Empiric treatment with quinolone or TMX/SMZ

HIV negative

HIV positive

PANEL A: ❑ Order cultures for: Salmonella Shigella Campylobacter E. coli O157:H7 ❑ Test for shiga toxin (if bloody stools) ❑ Test for clostridium toxin (if antibiotics or chemotherapy taken recently)

PANEL B: ❑ Test for clostridium toxin ❑ Do tests in panel A in case of nosocomial outbreaks and in the presence of bloody stools

PANEL C: ❑ Test for parasites: Giardia Cryptosporidum Cyclospora Isospora belli ❑ Inflammatory screen: Fecal lactoferrin test, or Microscopy for leukocytes

❑ Order panel A ❑ Order panel C ❑ Test for microsporidia ❑ Test for mycobaterium avium complex

In case of no resolution of symptoms: ❑ Order Panel A

❑ Quinolone if suspected shigellosis ❑ Macrolide for suspected resistant campylobacter No antimicrobial and no antimotility if suspected STEC

❑ Treat clostridium difficile

Treat according the test results

Treat according to the test results

❑ Order additional diagnostic tests if needed (CBC, blood cultures, electrolytes, urinanalysis)

❑ Consider non infectious and extraintestinal causes of diarrhea if no pathogen is identified by the diagnostic workup: IBS, IBD, laxative abuse, partial obstruction, rectosigmoid abscess Whipple's disease, pernicious anemia, diabetes, malabsorption, scleroderma, celiac sprue

Diagnostic Clues

Diagnostic Clue	Possible Pathogen
Fever and inflammation in community acquired diarrhea	Shigella
Right side abdominal pain with afebrile bloody/non bloody diarrhea	Shiga toxin producing E. coli (STEC) O157
Seafood or sea coast exposure	Vibrio species
Persistent abdominal pain and fever	Yersina entercolitica
Post diarrhea hemolytic uremic syndrome (HUS)	STEC O157

Specific Antibiotics

Shigella	TMP-SMZ, 160 and 800 mg, respectively (pediatric dose, 5 and 25 mg/kg, respectively) BID for 3 days, or Fluoroquinolone (300 mg ofloxacin, 400 mg norfloxacin, or 500 mg ciprofloxacin) BID for 3 days, or Ciprofloxacin 750 mg OD for 3 days, or Azithromycin 500 mg OD for 3 days, or Nalidixic acid 1 g/day (55 mg/kg/d for pediatric) for 5 days
Salmonella (typhoid fever)	Levofloxacin or any fluoroquinolone 500 mg OD for 7 days, or Azithromycin 500 mg OD for 7 days
Salmonella (not typhi)	Antibiotics are not recommended routinely Levofloxacin or any fluoroquinolone 500 mg OD for 7-10 days, or Azithromycin 500 mg OD for 7 days, or Levofloxacin or Azithromycin should be given for 14 days in immunocompromised patients
Campylobacter	Erythromycin 500 mg BID for 5 days, or Erythromycin 500 mg QID for 3 days, or Azithromycin 500 mg OD for 3 days
E coli Enterotoxigenic Enteropathogenic Enteroinvasive	TMP-SMZ, 160 and 800 mg, respectively, or Fluoroquinolone (300 mg ofloxacin, 400 mg norfloxacin, or 500 mg ciprofloxacin) BID for 3 days Ciprofloxacin 750 mg OD for 1-3 days, or Azithromycin 1000 mg single dose, or Rifaximin 500 mg OD for 3 days
STEC	Avoid antibiotics
Yersinia	Antibiotics are not recommended routinely
Vibrio cholera	Doxycycline 300 mg single dose, or Tetracycline 500 mg QID for 3 days, or Erythromycin 250 mg TID for 3 days, or Azithromycin 500 mg OD for 3 days, or TMP-SMZ, 160 and 800 mg, respectively, or Single dose fluoroquinolone
Giardia	Metronidazole 250-750 mg TID for 7 to 10 days
Entamoeba histolytica	Metronidazole 750 mg TID for 5 to 10 days, PLUS Diiodohydroxyquin 650 mg TID for 20 days, or Paromomycin 500 mg TID for 7 days

Do's

• For acute diarrhea, maintaining adequate intravascular volume and correcting fluid and electrolyte disturbances take priority over identifying the causative agent from detailed history and clinical findings, including stool characteristics.
• Assess ABCD periodically depending on the patient status and check for any warning signs during the course of management.
• When using normal saline due to unavailability of ringer lactate in diarrhea patients, oral rehydration therapy ORT should be initiated as soon as they are able to drink, to replace bicarbonate and potassium losses.
• A nasogastric tube can be used to deliver ORT in patients who have a normal mental status but may be too weak to adequately drink the necessary volume of fluid.
• Always check for warning signs before initiating anti-motility drugs.
• Order a sigmoidoscopy for the evaluation of proctitis in homosexual men.
• Test for STEC O157 and for shiga toxin in the stool in the case of hemolytic uremic syndrome.
• Report to the public health authorities in case of suspected outbreaks and order routine cultures for antimicrobial resistance and serotype identification.

Don'ts

• Don't treat patients with severe diarrheal dehydration using 5% dextrose with 1/4 normal saline, as using solutions with lower amounts of sodium (such as 38.5 mmol/L in 1/4 saline with 5% dextrose ) would lead to sudden and severe hyponatremia with a high risk of death.
• ORT is contraindicated in the initial management of severe dehydration and also in patients with frequent and persistent vomiting (more than four episodes per hour), and painful oral conditions such as moderate to severe thrush.
• Antimotolity drugs should not be used in patients with significant abdominal pain, fever and bloody diarrhea that suggests inflammatory diarrhea, especially in suspected or documented shiga toxin producing E. coli (STEC).
• Do not initiate empirical antibiotic therapy without fecal culture results except in:
  • The initial management of traveler's diarrhea (fluoroquinolone in adults and trimethoprim sulfamethoxazole in children)
  • High suspicion of giardia in diarrhea lasting more than 10-14 days without an identifiable cause, and with history of travel or drinking unfiltered water
• Experts have different opinions regarding ordering inflammatory screen (fecal leukocytes and lactoferrin) for community and nosocomial diarrhea. Do not order inflammatory screen unless in the case of persistent or recurrent diarrhea in order to rule out IBD.