Management of Intractable Diarrhea in a 76-Year-Old Man Returning from Africa
For a 76-year-old man with intractable diarrhea after returning from Africa, immediate empiric treatment with azithromycin is recommended as first-line therapy, along with aggressive hydration and diagnostic stool testing. 1
Initial Assessment and Classification
When evaluating intractable diarrhea in a returned traveler, it's important to classify the severity:
- Severe diarrhea: Incapacitating or completely preventing planned activities; includes all dysentery (bloody stools) 1
- Persistent diarrhea: Lasting ≥14 days 1, 2
In an elderly patient (76 years old), the risk of dehydration and complications is significantly higher, making prompt and effective management crucial.
Initial Management Algorithm
1. Immediate Interventions
- Hydration: Aggressive fluid and electrolyte replacement is essential, particularly in an elderly patient
- Empiric antibiotic therapy:
- First-line: Azithromycin 1000 mg single dose (preferred for severe diarrhea and for travelers returning from Africa) 1, 3
- Alternative: Fluoroquinolones (ciprofloxacin 750 mg single dose or 500 mg twice daily for 3 days) may be considered for non-dysenteric cases, but resistance is increasing, particularly for Campylobacter 1, 3
2. Symptomatic Treatment
- Loperamide: Can be used as adjunctive therapy with antibiotics to reduce symptoms (not as monotherapy in severe cases) 1
- Bismuth subsalicylate: May help reduce stool frequency 1
3. Diagnostic Workup (Concurrent with Treatment)
- Stool samples: Collect three samples for comprehensive microbiological testing 2
- Bacterial culture
- Ova and parasite examination
- Clostridium difficile toxin testing (especially if patient has received antibiotics recently)
- Molecular testing for broad range of pathogens 1
- Special considerations: Alert laboratory about travel history to ensure appropriate handling of samples 1
Pathogen-Specific Considerations
Bacterial Causes
- Enteric bacteria (E. coli, Campylobacter, Salmonella, Shigella) are common causes of traveler's diarrhea 1
- Quinolone resistance is increasingly reported in Campylobacter isolates from many regions 1
Parasitic Causes
- Consider amoebic colitis (Entamoeba histolytica) which can cause bloody diarrhea with more indolent onset 1
- If initial treatment fails, consider empiric antiprotozoal therapy with tinidazole or metronidazole 1, 2
Persistent Symptoms
If diarrhea persists despite empiric therapy (approximately 3% of cases) 2:
- Endoscopic evaluation is indicated
- Consider non-infectious causes such as post-infectious irritable bowel syndrome or inflammatory bowel disease 1, 4
Special Considerations for Elderly Patients
- Monitor closely for dehydration, electrolyte abnormalities, and renal function
- Consider hospitalization if signs of significant dehydration, hemodynamic instability, or severe electrolyte disturbances
- Medication interactions should be evaluated when selecting antimicrobial therapy
- Higher risk of complications including ischemic colitis which can mimic or coexist with infectious diarrhea 4
Infection Control
- Source isolation is recommended for patients with infectious diarrhea to prevent nosocomial spread 1
- Use appropriate precautions (gloves, apron, hand hygiene) when caring for the patient 1
Pitfalls to Avoid
- Delaying antibiotic treatment in elderly patients with severe symptoms can lead to increased morbidity and mortality
- Overlooking parasitic causes which may require specific testing and treatment
- Failing to notify laboratory about travel history, which may affect sample processing methods 1
- Assuming initial treatment failure is due to incorrect diagnosis rather than considering antibiotic resistance or concurrent conditions
By following this structured approach to management, you can effectively address intractable diarrhea in elderly returned travelers while minimizing complications and improving outcomes.