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Community-acquired Infectious Diarrhea

West Virginia Department of Health and Human Resources Information for Physicians Recommended Strategies for Management of Community-acquired Infectious Diarrhea

Initiate rehydration.

Oral rehydration is preferred because the patient can self-regulate the amount according to thirst. Prescribe Pedialyte, Ceralyte or generic oral rehydration solutions approaching the WHO-recommended electrolyte concentrations. 

Assess the patient.

Do not miss the patient with profuse, dehydrating, febrile, or bloody diarrhea, especially in infants, elderly and immunocompromised patients. Assess for:

  • When / how the illness began (i.e., abrupt or gradual onset);

  • Character of the stools (watery, bloody, mucous, purulent, greasy, etc.);

  • Frequency / quantity of bowel movements;

  • Presence of fever, tenesmus, blood or pus (i.e., dysenteric symptoms);

  • Signs and symptoms of dehydration (thirst, tachycardia, orthostasis, decreased urination, lethargy, decreased skin turgor, etc.); AND

  • Other symptoms (nausea, vomiting, abdominal pain, cramps, headache, myalgias, altered sensorium, etc.).

Do not miss important epidemiological clues:

 

Ask about:

Epidemiological association(s) include, but are not limited to:

Travel to a developing area;

Enterotoxigenic E coli, in addition to other pathogens

Daycare attendance or employment

E coli O157:H7, Shigella, Giardia

Consumption of unsafe foods such as raw meats, eggs or shellfish; unpasteurized milk or juice

Salmonella, Campylobacter, E coli O157:H7, Giardia, Cryptosporidium, Yersinia enterocolitica, Vibrio species

Swimming in or drinking from untreated surface water such as a lake or stream

Campylobacter, Cryptosporidium, Giardia

Visiting a farm or petting zoo or having contact with reptiles or pets with diarrhea

Salmonella, Campylobacter, E coli O157:H7, Cryptosporidium

Knowledge of other ill persons such as in a dormitory, office or attendees at a social function

Outbreak – discuss with public health immediately!

Recent or regular medications, including antibiotics

Clostridium dificile, antibiotic-resistant Salmonella or Campylobacter

Underlying medical conditions predisposing to infectious diarrhea, such as AIDS, immunosuppressive conditions

Microsporidia, M avium complex, in addition to other pathogens

Receptive anal intercourse or oral-anal sexual contact

Giardia, Cryptosporidium, Campylobacter, Shigella. Also consider sexually transmitted pathogens such as Chlamydia, gonorrhoeae, Herpes, etc.

Employment as a foodhandler

Transmission to patrons of the food establishment


Perform selective fecal studies.
 

Any diarrheal illness lasting greater than one day, especially if accompanied by fever, bloody stools, systemic illness, recent antibiotic use, day-care attendance, overseas travel, hospitalization, or dehydration should prompt evaluation of a fecal specimen, as follows:

Community-acquired or Traveler’s diarrhea;

test for:

Persistent diarrhea > 7 days;
also consider

parasitic pathogens:


Salmonella

Shigella

Campylobacter

E coli O157:H7

Giardia

Cryptosporidium

Cyclospora

Isospora belli

Special circumstances:

  • History of recent antibiotic use or chemotherapy ± test for C difficile toxins A + B.

  • Prolonged diarrhea in HIV (+) individual ± test for Microsporidia and M avium complex, in addition to other bacterial and parasitic pathogens, as appropriate.

  • Undercooked seafood or seacoast exposure ± test for Vibrio species.

  • Persistent abdominal pain and fever ± test for Yersinia enterocolitica.

  • Post-diarrheal hemolytic uremic syndrome ± test for Shiga toxin-producing E coli and for Shiga toxin. 

  • Some experts recommend empiric therapy for traveler’s diarrhea. Some also consider empirical treatment of diarrhea that lasts longer than 10-14 days for suspected giardiasis, if other evaluations are negative and, especially if history of travel or water exposure is suggestive. Otherwise, consider treatment of patients with febrile diarrhea, especially those believed to have moderate to severe invasive disease after obtaining a stool culture, as above. Use a fluoroquinolone or, in children, trimethoprim-sulfamethoxazole, and adjust according to antimicrobial susceptibilities, when available. Antimicrobial resistance is increasing rapidly among Salmonella, Camplylobacter and Shigella species.

  • Antimicrobial therapy may be harmful to some patients with E coli O157:H7 infection or uncomplicated Salmonella infection. Some experts recommend withholding treatment from patients in the U.S. with bloody diarrhea. Culture before treating! 

 

Antimotility drugs are contraindicated in patients with bloody diarrhea or proven infection with Shiga toxin-producing E coli O157:H7. Use with caution, if at all. 

Cases of Salmonella, Shigella, Campylobacter, Giardia, Cryptosporidium, E coli O157:H7 or Shiga toxin-producing E coli, and Yersinia enterocolitica or Vibrio species should be reported to the local health department. Outbreaks of any pathogen should be reported immediately. The local health department is responsible for investigation of cases and outbreaks to:

  • Identify additional cases and refer for evaluation and treatment, as needed.

  • Identify and remove sources of infection in the community. 

For more information:

Guerrant, R.L., Van Gilder, T., Steiner, T.S., et.al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis, 2001; 32:331-50. 

Communicate with your local health department. 

Avoid antimotility drugs. 

Institute selective therapy.

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