Acute diarrhea medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
OR
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
OR
The majority of cases of [disease name] are self-limited and require only supportive care.
OR
[Disease name] is a medical emergency and requires prompt treatment.
OR
The mainstay of treatment for [disease name] is [therapy].
OR The optimal therapy for [malignancy name] depends on the stage at diagnosis.
OR
[Therapy] is recommended among all patients who develop [disease name].
OR
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
OR
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
OR
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
OR
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
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.[1]
Pathogen Specific
Immunocompetent
- Bacterial [2]
- 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 [2]
- 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 [2]
- 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 [2]
- 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
Contraindicated medications
Diarrhea is considered an absolute contraindication to the use of the following medications:
References
- ↑ Ruuska T, Vesikari T (1990). "Rotavirus disease in Finnish children: use of numerical scores for clinical severity of diarrhoeal episodes". Scand. J. Infect. Dis. 22 (3): 259–67. PMID 2371542.
- ↑ 2.0 2.1 2.2 2.3 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.