West Virginia Department of Health
and Human Resources
Information for Physicians Recommended Strategies for Management of
Community-acquired Infectious Diarrhea
Initiate rehydration.
Oral rehydration is preferred because the patient can self-regulate the
amount according to thirst. Prescribe Pedialyte, Ceralyte or generic oral
rehydration solutions approaching the WHO-recommended electrolyte
concentrations.
Assess the patient.
Do not miss the patient with profuse, dehydrating, febrile, or
bloody diarrhea, especially in infants, elderly and immunocompromised
patients. Assess for:
-
When / how the illness began (i.e., abrupt or gradual onset);
-
Character of the stools (watery, bloody, mucous, purulent, greasy,
etc.);
-
Frequency / quantity of bowel movements;
-
Presence of fever, tenesmus, blood or pus (i.e., dysenteric
symptoms);
-
Signs and symptoms of dehydration (thirst, tachycardia, orthostasis,
decreased urination, lethargy, decreased skin turgor, etc.); AND
-
Other symptoms (nausea, vomiting, abdominal pain, cramps, headache,
myalgias, altered sensorium, etc.).
Do not miss important epidemiological clues:
Ask about:
|
Epidemiological association(s)
include, but are not limited to:
|
|
Travel to a developing area; |
Enterotoxigenic E coli, in
addition to other pathogens |
|
Daycare attendance or employment |
E coli
O157:H7, Shigella, Giardia |
|
Consumption of unsafe foods such
as raw meats, eggs or shellfish; unpasteurized milk or juice |
Salmonella,
Campylobacter, E coli O157:H7, Giardia, Cryptosporidium,
Yersinia enterocolitica, Vibrio species |
|
Swimming in or drinking from
untreated surface water such as a lake or stream |
Campylobacter,
Cryptosporidium, Giardia |
|
Visiting a farm or petting zoo or
having contact with reptiles or pets with diarrhea |
Salmonella,
Campylobacter, E coli O157:H7, Cryptosporidium |
|
Knowledge of other ill persons
such as in a dormitory, office or attendees at a social function |
Outbreak – discuss with public
health immediately! |
|
Recent or regular medications,
including antibiotics |
Clostridium dificile, antibiotic-resistant
Salmonella or Campylobacter |
|
Underlying medical conditions
predisposing to infectious diarrhea, such as AIDS, immunosuppressive
conditions |
Microsporidia,
M avium complex, in addition to other pathogens |
|
Receptive anal intercourse or
oral-anal sexual contact |
Giardia,
Cryptosporidium, Campylobacter, Shigella. Also
consider sexually transmitted pathogens such as Chlamydia,
gonorrhoeae, Herpes, etc. |
|
Employment as a foodhandler |
Transmission to patrons of the
food establishment |
Perform selective fecal studies.
Any diarrheal illness lasting greater than one day,
especially if accompanied by fever, bloody stools, systemic illness,
recent antibiotic use, day-care attendance, overseas travel,
hospitalization, or dehydration should prompt evaluation of a fecal
specimen, as follows:
|
Community-acquired or Traveler’s
diarrhea;
test for: |
Persistent diarrhea > 7
days;
also consider
parasitic pathogens: |
Salmonella
Shigella
Campylobacter
E coli O157:H7
|
Giardia
Cryptosporidium
Cyclospora
Isospora belli
|
Special circumstances:
-
History of recent
antibiotic use or chemotherapy ± test for C difficile toxins A
+ B.
-
Prolonged diarrhea in
HIV (+) individual ± test for Microsporidia and M avium
complex, in addition to other bacterial and parasitic pathogens, as
appropriate.
-
Undercooked seafood or
seacoast exposure ± test for Vibrio species.
-
Persistent abdominal
pain and fever ± test for Yersinia enterocolitica.
-
Post-diarrheal
hemolytic uremic syndrome ± test for Shiga toxin-producing E coli
and for Shiga toxin.
Institute selective therapy.
-
Some experts recommend
empiric therapy for traveler’s diarrhea. Some also consider
empirical treatment of diarrhea that lasts longer than 10-14 days for
suspected giardiasis, if other evaluations are negative and,
especially if history of travel or water exposure is suggestive.
Otherwise, consider treatment of patients with febrile diarrhea,
especially those believed to have moderate to severe invasive disease
after obtaining a stool culture, as above. Use a fluoroquinolone or,
in children, trimethoprim-sulfamethoxazole, and adjust according to
antimicrobial susceptibilities, when available. Antimicrobial
resistance is increasing rapidly among Salmonella, Camplylobacter
and Shigella species.
-
Antimicrobial therapy
may be harmful to some patients with E
coli O157:H7 infection or uncomplicated Salmonella
infection. Some experts recommend withholding treatment from patients
in the U.S. with bloody diarrhea. Culture before treating!
Avoid antimotility drugs.
Antimotility drugs are contraindicated in
patients with bloody diarrhea or proven infection with Shiga
toxin-producing E coli O157:H7. Use with caution, if at all.
Communicate with your local health department.
Cases of Salmonella, Shigella, Campylobacter,
Giardia, Cryptosporidium, E coli O157:H7 or Shiga
toxin-producing E coli, and Yersinia enterocolitica or Vibrio
species should be reported to the local health department. Outbreaks of
any pathogen should be reported immediately. The local health department
is responsible for investigation of cases and outbreaks to:
-
Identify additional
cases and refer for evaluation and treatment, as needed.
-
Identify and remove
sources of infection in the community.
For more information:
Guerrant, R.L., Van Gilder, T., Steiner, T.S., et.al.
Practice guidelines for the management of infectious diarrhea. Clin Infect
Dis, 2001; 32:331-50.
|
View
or print printer-friendly PDF file (requires Adobe
Acrobat 3.0 or greater)