From the Guidelines
Diarrhea in immunocompromised patients is a complex condition that requires a broad differential diagnosis, including infectious and non-infectious causes, and prompt evaluation and management to prevent severe complications, as recommended by the 2017 Infectious Diseases Society of America clinical practice guidelines 1. The causes of diarrhea in immunocompromised patients can be divided into:
- Infectious causes, such as: + Bacterial infections: C. difficile, Salmonella, Shigella, Campylobacter, Yersinia, and STEC 1 + Viral infections: norovirus, rotavirus, adenovirus, and cytomegalovirus (CMV) 2 + Parasitic infections: Cryptosporidium, Cyclospora, Cystoisospora, microsporidia, and Mycobacterium avium complex 3, 1
- Non-infectious causes, such as: + Medication side effects: mycophenolate, tacrolimus, and certain antibiotics 2 + Other causes: graft-versus-host disease, radiation enteritis, and malabsorption syndromes A broad differential diagnosis is recommended in immunocompromised people with diarrhea, especially those with moderate and severe primary or secondary immune deficiencies, for evaluation of stool specimens by culture, viral studies, and examination for parasites 3, 1. Initial management should focus on fluid and electrolyte replacement while identifying the cause, and diagnostic workup should include stool studies, blood tests, and possibly endoscopy in persistent cases 1. Symptomatic treatment includes loperamide 4mg initially then 2mg after each loose stool (maximum 16mg/day) for non-infectious causes, and probiotics may help restore gut flora 2. Immunocompromised patients with diarrhea should seek medical attention promptly as they're at higher risk for dehydration, electrolyte abnormalities, and systemic infection, and maintaining good hand hygiene and food safety practices is essential for prevention 2, 1.
From the FDA Drug Label
Pseudomembranous Colitis: Clostridium difficile associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including Ciprofloxacin Tablets USP, 250 mg, 500 mg and 750 mg, and may range in severity from mild diarrhea to fatal colitis.
that diarrhea is a common problem caused by antibiotics which usually ends when the antibiotic is discontinued. Sometimes after starting treatment with antibiotics, patients can develop watery and bloody stools (with or without stomach cramps and fever) even as late as two or more months after having taken the last dose of the antibiotic
The causes of diarrhea in an immunocompromised patient taking ciprofloxacin include:
- Clostridium difficile associated diarrhea (CDAD): a potentially life-threatening condition that can occur with the use of nearly all antibacterial agents, including ciprofloxacin.
- Antibiotic-associated diarrhea: a common problem caused by antibiotics, which can range from mild to severe and may occur even after the antibiotic is discontinued. These conditions can lead to severe and potentially life-threatening complications, especially in immunocompromised patients 4.
From the Research
Causes of Diarrhea in Immunocompromised Patients
The causes of diarrhea in immunocompromised patients can be diverse and complex. Some of the key factors include:
- Infections, such as Clostridium difficile, which can cause colitis and appendicitis 5
- Gastrointestinal multiplex polymerase chain reaction (PCR) panels, which can help diagnose and manage healthcare-associated diarrhea (HCAD) in immunocompromised patients 6
- Underlying immunodeficiencies, which can lead to increased susceptibility to infection by specific organisms 7
- Chemotherapy-related injury, which can cause enterocolitis in immunocompromised patients 7
Diagnostic Approaches
Diagnostic approaches for diarrhea in immunocompromised patients may involve:
- Stepwise diagnostic algorithms to ensure diagnostic stewardship, optimal patient care, and resource utilization 6
- Complete blood count, creatinine and electrolytes evaluation, determination of leukocytes and lactoferrin presence in the stools, stool culture, and C. difficile testing 8
- GI multiplex PCR panels, which can help detect recognized pathogens and allow for improved outcomes using pathogen-targeted therapy 6
Treatment Options
Treatment options for diarrhea in immunocompromised patients may include:
- Antibiotic therapy, which can be effective against shigellosis, campylobacteriosis, C. difficile colitis, traveler's diarrhea, and protozoal infections 8
- Oral rehydration solutions, which can help prevent dehydration 9
- Antidiarrheal agents, such as opiate derivatives and bismuth subsalicylate, which can help reduce the number of bowel movements and diminish the magnitude of fluid loss 9
- Pathogen-targeted therapy, which can be used to treat specific infections 6