From the Guidelines
For a patient presenting with diarrhea in urgent care, the initial evaluation should include a thorough history, physical examination, and targeted laboratory tests, with a focus on oral rehydration and symptomatic management for mild to moderate cases. The most recent and highest quality study 1 provides guidelines for the diagnosis and management of infectious diarrhea, emphasizing the importance of stool testing for certain pathogens in specific circumstances. Key considerations include:
- Complete blood count, basic metabolic panel, and stool studies (including culture, ova and parasites, and Clostridioides difficile testing if indicated) as basic tests.
- Oral rehydration with electrolyte solutions and symptomatic management for mild to moderate cases without signs of severe dehydration or systemic illness.
- Loperamide (2mg after each loose stool, maximum 8mg/day) or Bismuth subsalicylate (524mg every 30-60 minutes, maximum 8 doses/day) for non-bloody diarrhea without fever.
- Antibiotics (such as Ciprofloxacin or azithromycin) may be indicated for specific bacterial causes or severe presentations.
- Patients should maintain hydration, temporarily avoid dairy products and high-fiber foods, and follow up if symptoms worsen or persist beyond 3-4 days.
- Severe cases with signs of dehydration, bloody diarrhea, high fever, or immunocompromised status may require intravenous fluids and hospital admission, as suggested by 1 and 1. It's also important to consider the mode of spread of diarrheal diseases and educate patients on careful hand hygiene, particularly if they are involved in food preparation, child or adult education, or healthcare, as noted in 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Diagnostic Tests for Diarrhea
When a patient presents with diarrhea in urgent care, the following tests can be considered:
- Stool culture: However, according to 2, stool culture orders should be reduced, especially for nosocomial diarrhea, as they are often low-yield.
- Stool ova and parasites (O&P): Similar to stool cultures, 2 suggests reducing O&P orders for nosocomial diarrhea.
- Clostridium difficile (C. difficile) toxin test: This test is recommended for patients with clinically significant diarrhea, especially if they have been exposed to antibiotics 3, 4.
- Endoscopy: This can be used to diagnose pseudomembranous colitis, but it is expensive and invasive 3.
- Enzyme immunoassay (EIA) for toxins A/B: This test is not recommended as a stand-alone assay due to its low sensitivity 4.
- Molecular tests: These are recommended for the diagnosis of C. difficile infection (CDI) in patients with clinically significant diarrhea 4.
Treatment Considerations
When treating a patient with diarrhea, the following should be considered:
- Antibiotic use: Certain antibiotics, such as clindamycin, cephalosporins, and penicillins, can increase the risk of C. difficile infection 3.
- Azithromycin: While generally considered safe, azithromycin can increase the risk of C. difficile infection, especially with repeated courses 5.
- Metronidazole or vancomycin: These antibiotics are effective in treating symptomatic C. difficile infection 3.
- Infection control measures: Hand hygiene, isolation, and environmental disinfection can help prevent the spread of C. difficile 3.
Evaluation of Chronic Diarrhea
For patients with chronic diarrhea, the following tests can be considered:
- Complete blood count
- C-reactive protein
- Anti-tissue transglutaminase immunoglobulin A (IgA)
- Total IgA
- Basic metabolic panel
- Stool studies to categorize diarrhea as watery, fatty, or inflammatory 6.