What is the treatment for acute infectious diarrhea?

From the Guidelines

Treatment of acute infectious diarrhea should prioritize oral rehydration therapy and supportive care, with antimotility agents like loperamide considered for adults but avoided in children and cases with suspected toxic megacolon or inflammatory diarrhea. The primary goal is to prevent dehydration and manage symptoms. According to the 2017 Infectious Diseases Society of America clinical practice guidelines 1, ancillary treatment with antimotility, antinausea, or antiemetic agents can be considered once the patient is adequately hydrated. Key considerations include:

• Oral rehydration solutions for all patients to prevent dehydration
• Loperamide for immunocompetent adults with acute watery diarrhea, but not for children under 18 years or cases with fever and bloody stools
• Antinausea and antiemetic agents like ondansetron for children over 4 years and adolescents to facilitate oral rehydration
• Avoidance of antimotility drugs in cases where toxic megacolon may result
• Maintenance of a bland diet, avoiding dairy, fatty foods, and caffeine initially, then gradually reintroducing normal foods
• Medical attention for severe dehydration, bloody stools, persistent fever, or symptoms lasting more than 5-7 days. The use of antibiotics is generally not recommended for uncomplicated cases but may be indicated for specific infections like traveler's diarrhea or in immunocompromised patients, as suggested by guidelines from 2001 1. Prevention measures such as proper handwashing, safe food handling, and drinking clean water are also crucial. In terms of specific medication dosages, loperamide can be given as 4 mg initially followed by 2 mg after each loose stool (maximum 16 mg/day) for adults, but the exact dosage may vary based on individual patient needs and response to treatment. Overall, the management of acute infectious diarrhea should focus on supportive care, hydration, and symptom management, with careful consideration of the use of antimotility agents and antibiotics based on patient-specific factors and the latest clinical guidelines.

From the FDA Drug Label

Infectious Diarrhea caused by Escherichia coli (enterotoxigenic strains), Campylobacter jejuni, Shigella boydii†, Shigella dysenteriae, Shigella flexneri or Shigella sonnei† when antibacterial therapy is indicated.

Ciprofloxacin is indicated for the treatment of infectious diarrhea caused by susceptible strains of certain microorganisms, including Escherichia coli, Campylobacter jejuni, and Shigella species, when antibacterial therapy is indicated 2.

Key points:

• Ciprofloxacin is effective against certain strains of bacteria that cause infectious diarrhea
• Antibacterial therapy should only be used when indicated, and culture and susceptibility tests should be performed to guide treatment
• The use of ciprofloxacin should be based on the results of these tests, or in the absence of such data, on local epidemiology and susceptibility patterns 2.

From the Research

Treatment Approaches

• The primary treatment for acute infectious diarrhea is symptomatic therapy, focusing on preventing dehydration 3, 4, 5, 6.
• Oral rehydration solutions (ORS) are the cornerstone of therapy for dehydration secondary to acute infectious diarrhea, and their efficacy is based on the ability of glucose to stimulate Na and fluid absorption in the small intestine 7.
• Antimotility agents are generally not indicated, except in specific cases where they may be useful in reducing the number of bowel movements and diminishing the magnitude of fluid loss 4, 5.

Antibiotic Therapy

• Empirical antibiotic therapy should be considered for severely ill patients with a high frequency of stools, fever, bloody diarrhea, underlying immune deficiency, advanced age, or significant comorbidities 3, 6.
• Specific antibiotic treatment is not systematically indicated, except for invasive or dysenteric diarrhea and in immunosuppressed patients 4.
• Antibiotics are effective against shigellosis, campylobacteriosis, C. difficile colitis, traveler's diarrhea, and protozoal infections 6.

Diagnostic Approaches

• Diagnosis of diarrhea requires clinical assessment and history, including underlying illnesses, severity of symptoms, presence and extent of dehydration, and other clinical symptoms 4, 6.
• Specific diagnostic investigation can be reserved for patients with severe dehydration, more severe illness, persistent fever, bloody stools, immunosuppression, and for cases of suspected nosocomial infection or outbreak 6.

Emerging Therapies

• The macrocyclic antibiotic fidaxomicin can reduce the rate of recurrent disease in Clostridium difficile infections (CDI) 3.
• Evidence for the benefits of faecal microbiota transplantation as a treatment option for multiple recurrences of CDI is increasing 3.
• A dual-action, modified high-amylose maize starch (HAMS)-hypoosmolar ORS solution is being established as a potential standard ORS for the treatment of dehydration from acute diarrhea 7.