Can racecadotril (acetorphan) be given in diarrhea with significant leukocytosis (10-15 pus cells)?

Racecadotril in Diarrhea with Significant Leukocytosis (10-15 pus cells)

Racecadotril should not be used as the primary treatment for diarrhea with significant leukocytosis (10-15 pus cells), as this indicates infectious or inflammatory diarrhea that requires appropriate antimicrobial therapy rather than symptomatic management alone.

Rationale for Avoiding Racecadotril in Infectious Diarrhea

The presence of 10-15 pus cells in stool indicates an inflammatory or infectious process that requires specific management:

• According to the Infectious Diseases Society of America (IDSA) 2017 guidelines, the presence of fecal leukocytes suggests inflammatory diarrhea that may require antimicrobial therapy rather than just symptomatic management 1.

• While racecadotril is mentioned in some guidelines as an antisecretory agent, it is not specifically recommended for diarrhea with evidence of infection or inflammation 1.

• The IDSA guidelines note that antimotility drugs should be avoided in cases of suspected or proven inflammatory diarrhea or diarrhea with fever, where they could potentially worsen outcomes 1.

Appropriate Management Approach

For diarrhea with significant leukocytosis (10-15 pus cells), the following approach is recommended:

1. Consider antimicrobial therapy based on clinical presentation and local epidemiology

   • Fluoroquinolones, azithromycin, or rifaximin depending on suspected pathogen 1
   • Azithromycin is preferred for severe or dysenteric diarrhea 1

2. Avoid antimotility and antisecretory agents in suspected inflammatory diarrhea

   • The IDSA guidelines strongly recommend against antimotility drugs in inflammatory diarrhea or diarrhea with fever 1
   • This caution would extend to racecadotril, which is primarily indicated for watery, non-inflammatory diarrhea

3. Focus on hydration

   • Oral rehydration is the cornerstone of management for all types of diarrhea 1
   • IV fluids may be necessary in cases of significant dehydration

When Racecadotril May Be Appropriate

Racecadotril could be considered in specific circumstances:

• For watery, non-inflammatory diarrhea without evidence of infection 2
• After resolution of the infectious process, if persistent secretory diarrhea remains
• In grade 1 immunotherapy-induced diarrhea, as mentioned in the ESMO guidelines 1

Conclusion

The presence of 10-15 pus cells in stool strongly suggests inflammatory or infectious diarrhea. In such cases, antimicrobial therapy directed at the likely pathogen should be the primary approach, with careful attention to hydration status. Racecadotril, while effective for watery non-inflammatory diarrhea, is not recommended as the primary treatment for diarrhea with significant leukocytosis, as it may mask symptoms without addressing the underlying infection.