From the Guidelines
For the treatment of diarrhea, loperamide (Imodium) at 4mg initially followed by 2mg after each loose stool (maximum 16mg daily) is recommended as a first-line treatment for mild to moderate diarrhea in immunocompetent adults, as stated in the 2017 guidelines by the Infectious Diseases Society of America 1. The choice of agent depends on the cause and severity of diarrhea, as well as the patient's age and underlying health conditions.
- For bacterial infections, antibiotics such as azithromycin (1000 mg by mouth or 500 mg by mouth) or ciprofloxacin (750 mg by mouth or 500 mg by mouth) may be prescribed, as recommended in the 2017 guidelines for the prevention and treatment of travelers' diarrhea 1.
- Probiotics like Lactobacillus or Saccharomyces boulardii can help restore gut flora balance.
- For chronic diarrhea, bile acid sequestrants like cholestyramine (4g before meals) may be effective for those with bile acid malabsorption.
- Adsorbents such as kaolin-pectin can bind toxins and irritants in the intestine, but their use is not recommended in children due to potential side effects, as reported in the 1992 study by the Centers for Disease Control and Prevention 1. It's essential to maintain hydration with oral rehydration solutions while using these medications, especially in severe cases or in vulnerable populations like children and the elderly, as emphasized in the 1992 report by the Centers for Disease Control and Prevention 1. The medications work through different mechanisms:
- Antimotility agents like loperamide slow intestinal transit.
- Antibiotics eliminate pathogenic bacteria.
- Probiotics restore beneficial gut bacteria.
- Adsorbents bind irritants. In general, the use of nonspecific antidiarrheal agents should be approached with caution, and their effectiveness in reducing diarrhea volume or duration is not well established, as noted in the 1992 study by the Centers for Disease Control and Prevention 1. However, loperamide has been shown to be safe and effective in adults, as reported in the 2001 study published in Alimentary Pharmacology and Therapeutics 1. Ultimately, the choice of agent should be based on the individual patient's needs and the severity of their symptoms, with a focus on maintaining hydration and preventing complications.
From the FDA Drug Label
Clostridium difficile associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including cefpodoxime proxetil, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile. C. difficile produces toxins A and B which contribute to the development of CDAD Hypertoxin producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C difficile, and surgical evaluation should be instituted as clinically indicated.
The different agents for treating diarrhea are:
- Antibiotic treatment of C difficile
- Fluid and electrolyte management
- Protein supplementation
- Surgical evaluation 2
From the Research
Agents for Treating Diarrhea
- Racecadotril: has proven efficacy in the treatment of acute diarrhea in children, but treatment outcomes in adults are less convincing 3
- Loperamide: has a prominent place in the treatment of acute and chronic diarrhea, but attention should be paid to correct dosing and contra-indications 3, 4
- Probiotics: are indicated in children and in the prevention of antibiotics-induced diarrhea, but there is no evidence to support their use in the treatment of acute diarrhea in adults 3
- Oral rehydration systems: have a part to play in pediatric treatment 3, 5, 4
- Antibiotics: are used without hesitation only in invasive diarrhea, and are effective in preventing travelers' diarrhea 6, 5, 4, 7
- Astringents and absorbents: are no longer supported in guidelines 3
- Bismuth subsalicylate (BSS)-containing compounds: are about 62% effective in the prevention of travelers' diarrhea 7
- Aztreonam and rifaximin: are effective antibiotics for treating travelers' diarrhea 7
- Azithromycin: shows promising results for treating travelers' diarrhea 7
- Zaldaride: is a calmodulin inhibitor that can be used to treat less severe travelers' diarrhea 7