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
The medical management of acute diarrhea includes the following steps:
- Fluid and electrolyte resuscitation (oral, if not IV):
- Oral sugar-electrolyte solutions help in the limitation of diarrhea
- In case of profound dehydration, especially in the elderly and infants, IV rehydartion is preferred
- 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
- Blood sugar control is advised in case of diarrhea due to diabetic neuropathy
Empiric Therapy
Empiric therapy is used in the following situations:
- As an initial treatment before 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
- Empiric trials of antimicrobial therapy is administered if the prevalence of bacterial or protozoal infection is high in a specific community or situation:
- Metronidazole for protozoal diarrhea
- Fluoroquinolone for enteric bacterial diarrhea
- In case of nonbloody diarrhea in patients, antimotility agents such as diphenoxylate and loperamide are preferred in patients. Loperamide is generally used in patients due to low abuse potential.
- Octreotide, the somatostatin analogue is useful in cases of diarrhea due to:
- Carcinoid tumors
- Peptide-secreting tumors
- Dumping syndrome
- Chemotherapy-induced diarrhea
- Intraluminal agents include:
- Adsorbants: activated charcoal
- Binding resins: Bismuth subsalicylate is used to reduce diarrhea and vomitting, but is used with caution in patients with renal dysfunction due to high risk of bismuth encephalopathy
- Stool modifiers: Medicinal fiber
Pharmacotherapy
Pharmacotherapy for acute diarrhea includes the following agents:
- Antibiotics
- Anticholinergics
- Antimotility agents
- Metoclopramide: in case of diarrhea due to diabetic neuropathy
- Nonspecific antidiarrheal agents
Symptomatic Treatment
- Symptomatic treatment for 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 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 andconvalescent homes
Pathogen Specific
Immunocompetent
- Bacterial [1]
- 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 [1]
- 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 [1]
- 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 [1]
- 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
- ↑ 1.0 1.1 1.2 1.3 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.