Can I start racecadotril (acetorphan) for suspected bacterial diarrhea with no signs of infection on stool test?

Management of Diarrhea Without Signs of Bacterial Infection

Racecadotril is not recommended for diarrhea when stool examination shows no signs of infection, as empiric antimicrobial therapy is not recommended in most people with acute watery diarrhea without recent international travel. 1

Initial Assessment and Management

• For acute diarrhea without signs of infection, the primary treatment should focus on:
  • Oral rehydration therapy using reduced osmolarity oral rehydration solution (ORS) as first-line therapy 1, 2
  • Monitoring for signs of dehydration including changes in weight, laboratory results, urine output, and complaints of thirst 2
  • Dietary modifications (BRAT diet - bread, rice, applesauce, toast) 2

Evidence-Based Approach

Why Not Racecadotril?

1. According to the Infectious Diseases Society of America (IDSA) 2017 guidelines, empiric treatment should be avoided in people with persistent watery diarrhea lasting 14 days or more 1

2. The Cochrane review (2019) concluded that "racecadotril seems to be a safe drug but has little benefit in improving acute diarrhea in children under five years of age" and "current evidence does not support routine use of racecadotril in management of acute diarrhea" 3

3. The IDSA guidelines specifically state that "in most people with acute watery diarrhea and without recent international travel, empiric antimicrobial therapy is not recommended" 1

Recommended Alternatives

For symptomatic management of non-infectious diarrhea:

• Hydration: Reduced osmolarity ORS is the cornerstone of treatment for mild to moderate dehydration 1, 2

• Antimotility agents: Loperamide may be used in adults with non-bloody diarrhea after adequate hydration, with an initial dose of 4 mg followed by 2 mg every 4 hours (not exceeding 16 mg/day) 2

  • However, antimotility drugs should be avoided in cases of suspected inflammatory diarrhea 2

• Probiotics: Can be used as adjunctive therapy, though evidence for specific strains varies 2

Clinical Decision Algorithm

1. Confirm absence of infection:

   • Ensure stool examination is truly negative for all pathogens
   • Check for fever, bloody stools, or abdominal pain that might suggest an inflammatory process

2. Assess severity:

   • Mild diarrhea (<4 bowel movements per day): Conservative management with hydration 1
   • Moderate to severe diarrhea: More aggressive rehydration and symptomatic treatment 2

3. Treatment approach:

   • Start with oral rehydration solution
   • Consider loperamide for adults with non-bloody diarrhea
   • Monitor for 48 hours; if no improvement, reassess for missed diagnoses

Important Caveats

• If symptoms persist beyond 48 hours or worsen, further investigation is warranted 2
• Racecadotril, while having antisecretory properties 4, 5, is not supported by current guidelines for routine use in non-infectious diarrhea
• Antimicrobial therapy should be modified or discontinued when a clinically plausible organism is identified 1
• Medical attention should be sought if there is no improvement within 48 hours, worsening symptoms, or development of warning signs (severe vomiting, dehydration, persistent fever, abdominal distension, blood in stool) 2

The evidence clearly supports focusing on rehydration therapy rather than empiric use of racecadotril when stool examination shows no signs of infection.