What are the guideline sources, guidelines and references for Acute diarrhea ?
Guideline sources The following summarized guidelines for the evaluation and management of acute diarrhea are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA 2017) and the American College of Gastroenterology (ACG 2016). 1 2 3 3 4 5 6 Definition Acute diarrhea is a clinical syndrome that is defined as the passage of 3 or more unformed stools per day for less than 2 weeks. 3 Epidemiology Frequent causes include viruses (norovirus, rotavirus), bacteria (Campylobacter, C. difficile, Salmonella, E. coli, Shigella), parasites (Giardia, Cryptosporidium), side-effects of medications (antibiotics, colchicine), abdominal surgeries, gastroenterologic diseases (ulcerative colitis, Crohn's disease, diverticulitis, appendicitis), and endocrine diseases (hyperthyroidism, carcinoid tumors). 4 Pathophysiology https://web.pathway.md/diseases/rec0RaPLxgg1546ED 1/7 6/23/23, 1:44 AM Acute diarrhea Pathway In the United States, the incidence of acute diarrhea is approximately 60,000 cases per 100,000 person-years. 3 Disease course Untreated, severe diarrhea may lead to dehydration, renal failure, and shock. 5 Prognosis and risk of recurrence In developing countries, it is a common cause of death, especially in children. 6 Guidelines 1. Diagnostic investigations Clinical history: Obtain a detailed clinical and exposure history in patients presenting with acute diarrhea. B Evaluate for postinfectious and extraintestinal manifestations of enteric infections in patients with acute diarrhea. B Physical examination: assess patients with acute diarrhea for dehydration, which increases the risk of life-threatening illness and death, especially in young and elderly patients. A Complete blood count: consider obtaining a peripheral WBC count and differential in patients with acute diarrhea. C Blood cultures: obtain blood cultures in patients of any age with signs of septicemia or when enteric fever is suspected, patients with systemic manifestations of infection, patients who are immunocompromised, patients with certain high-risk conditions such as hemolytic anemia, infants < 3 months of age, and patients who traveled to or have had contact with travelers from enteric fever-endemic areas with a febrile illness of unknown etiology. B Clostridioides difficile testing: consider testing for C. difficile infection in patients with persistent diarrhea without an etiology and recognized risk factors. C Show 2 more Indications for diagnostic testing: As per IDSA 2017 guidelines, obtain stool testing for Salmonella, Shigella, Campylobacter, Yersinia, C. difficile, and Shiga toxin-producing E. coli in patients with diarrhea accompanied by fever, bloody or mucoid stools, severe abdominal cramping or tenderness, or signs of sepsis. B Show 3 more Updated evidence: GastroPOC In adult patients hospitalized with suspected gastroenteritis, molecular point-of-care testing was superior to routine clinical care with respect to duration of single-occupancy room isolation. https://web.pathway.md/diseases/rec0RaPLxgg1546ED 2/7 6/23/23, 1:44 AM Acute diarrhea Pathway Nathan J Brendish et al. Lancet Infect Dis. 2023 Apr 25. As per ACG 2016 guidelines: Obtain stool testing in patients with acute diarrhea who are at high risk of spreading disease to others, and during known or suspected outbreaks. B Consider obtaining stool testing, if available, in patients with dysentery, moderate-severe disease, and symptoms lasting > 7 days, in order to clarify the etiology of the patient's illness and enable specific directed therapy. B Culture-independent stool testing: As per IDSA 2017 guidelines, perform culture-independent, including panel-based multiplex molecular diagnostics from stool and blood specimens, and, when indicated, culture-dependent diagnostic testing, when there is a clinical suspicion of enteric fever or diarrhea with bacteremia. B Show 5 more As per ACG 2016 guidelines, consider culture-independent methods of diagnosis, if available, as an adjunct to traditional methods to identify infectious causes of acute diarrhea. B Diagnostic imaging: Consider obtaining diagnostic imaging to detect aortitis, mycotic aneurysms, or extravascular foci of infection in patients with S. enterica or Yersinia infections and: sustained fever or bacteremia despite adequate antimicrobial therapy underlying atherosclerosis recent-onset chest, back, or abdominal pain. C Fecal leukocytes: avoid using fecal leukocyte examination to establish the cause of acute infectious diarrhea. D Fecal lactoferrin: avoid using fecal lactoferrin to establish the cause of acute infectious diarrhea. D Fecal calprotectin: insufficient evidence to make a recommendation on the value of fecal calprotectin measurements in people with acute infectious diarrhea. C Antibiotic sensitivity testing: avoid obtaining routine antibiotic sensitivity testing for individuals with acute diarrheal infection. D 2. Diagnostic procedures Upper GI endoscopy: consider obtaining a duodenal aspirate in patients in whom there is a suspected diagnosis of Giardia, Strongyloides, Cystoisospora, or microsporidia infection. C Lower GI endoscopy: Consider performing colonoscopy or a proctoscopic examination: in patients with persistent, unexplained diarrhea who have AIDS in patients with certain underlying medical conditions in patients with acute diarrhea with clinical colitis or proctitis https://web.pathway.md/diseases/rec0RaPLxgg1546ED 3/7 6/23/23, 1:44 AM Acute diarrhea Pathway in patients with persistent diarrhea who engage in anal intercourse. B 3. Medical management General principles: avoid empiric anti-microbial therapy for acute diarrheal infection, except in cases of travellers' diarrhea, where the likelihood of bacterial pathogens is high enough to justify the potential side effects of antibiotics. D Show 2 more Treatment of dehydration: As per IDSA 2017 guidelines, administer reduced osmolarity oral rehydration solution as the first-line therapy for mild-to-moderate dehydration in pediatric and adult patients with acute diarrhea from any cause, and in patients with mild-to-moderate dehydration associated with vomiting or severe diarrhea. B Show 5 more As per ACG 2016 guidelines, provide balanced oral electrolyte rehydration for most patients with acute diarrhea who can keep up with fluid and salt consumption PO. B Symptomatic therapy: As per IDSA 2017 guidelines, consider providing symptomatic treatment with antimotility, antinausea, or antiemetic agents once the patient is adequately hydrated, but avoid using them as a substitute for fluid and electrolyte therapy. C Show 3 more As per ACG 2016 guidelines, consider bismuth subsalicylates to control rates of passage of stool and help travellers function better during bouts of mild-to-moderate diarrheal illness. B Empiric antibiotic therapy (bloody diarrhea): Avoid empiric antimicrobial therapy for bloody diarrhea while waiting for results of investigations in immunocompetent pediatric and adult patients D , except in the following situations: infants < 3 months of age with suspicion of a bacterial etiology ill immunocompetent patients with fever documented in a medical setting, abdominal pain, bloody diarrhea, and bacillary dysentery, as evidenced by frequent scant bloody stools, fever, abdominal cramps, and tenesmus, presumptively due to Shigella patients who have recently travelled internationally with body temperatures 38.5 C and/or signs of sepsis D Show 4 more Empiric antibiotic therapy (watery diarrhea): avoid empiric antimicrobial therapy in most patients with acute watery diarrhea and without recent international travel. D Show 2 more Choice of antibiotic agent: treat patients with clinical features of sepsis who are suspected of having enteric fever empirically with broad-spectrum antimicrobial therapy after blood, stool, and urine culture collection. B Show 5 more https://web.pathway.md/diseases/rec0RaPLxgg1546ED 4/7 6/23/23, 1:44 AM Acute diarrhea Pathway 4. Nonpharmacologic interventions Probiotics: As per IDSA 2017 guidelines, consider offering probiotic preparations to reduce the symptom severity and duration in immunocompetent adult and pediatric patients with infectious or antimicrobial-associated diarrhea. C As per ACG 2016 guidelines, avoid the use of probiotics or prebiotics for the treatment of acute diarrhea in adults, except in cases of postantibiotic-associated illness. D 5. Specific circumstances Patients with traveler's diarrhea: avoid obtaining diagnostic testing in most patients with uncomplicated traveler's diarrhea, unless treatment is indicated. D Show 2 more Patients with STEC infection: Obtain a peripheral blood smear to assess for the presence of RBC fragments when HUS is suspected. A Monitor Hgb and platelet counts, electrolytes, and BUN and creatinine in patients with E. coli O157 or another Shiga toxin-producing E. coli infection (especially Shiga toxin-producing E. coli that produce Shiga toxin 2 or are associated with bloody diarrhea), in order to detect hematologic and renal function abnormalities that are early manifestations of HUS and precede renal injury. A Immunocompromised patients: Develop a broad differential diagnosis in immunocompromised patients with diarrhea, especially those with moderate and severe primary or secondary immune deficiencies, and obtain evaluation of stool specimens by culture, viral studies, and examination for parasites. B Perform additional testing for other organisms including, but not limited to, Cryptosporidium, Cyclospora, Cystoisospora, microsporidia, Mycobacterium avium complex, and CMV, in patients with acquired immune deficiency syndrome and persistent diarrhea. B Patients with asymptomatic infection: consider treating all asymptomatic patients with S. enterica subspecies enterica serovar Typhi in their stool, in order to reduce potential for transmission. C Show 2 more 6. Patient education Food safety practices: counsel patients on appropriate food safety practices to avoid cross- contamination of other foods or cooking surfaces and utensils during grocery shopping, food preparation, and storage; advise patients to ensure that foods containing meats and eggs are cooked and maintained at proper temperatures. B https://web.pathway.md/diseases/rec0RaPLxgg1546ED 5/7 6/23/23, 1:44 AM Acute diarrhea Pathway Pretravel counseling: counsel patients who are planning to travel regarding high-risk food/beverage avoidance to prevent traveler's diarrhea. B 7. Preventative measures Hand hygiene: As per IDSA 2017 guidelines, counsel patients to perform hand hygiene after using the bathroom, changing diapers, before and after preparing food, before eating, after handling garbage or soiled laundry items, and after touching animals or their feces or environments, especially in public settings such as petting zoos. B Show 2 more As per ACG 2016 guidelines, recognize that frequent and effective hand washing and alcohol- based hand sanitizers is of limited value in preventing most forms of traveler's diarrhea, but may be useful where low-dose pathogens are responsible for the illness (such as during a cruise ship outbreak of norovirus infection, institutional outbreak, or in endemic diarrhea prevention). B Rotavirus immunization: provide rotavirus immunization to all infants without a known contraindication. A Typhoid immunization: Provide typhoid immunization, as an adjunct to hand hygiene and the avoidance of high-risk foods and beverages, in the following clinical scenarios: patients who are planning travel to areas with moderate to high risk for exposure to S. enterica subspecies enterica serovar Typhi patients with intimate exposure to a documented S. enterica subspecies enterica serovar Typhi chronic carrier microbiologists and other laboratory personnel routinely exposed to cultures of S. enterica subspecies enterica serovar Typhi. A Cholera immunization: provide cholera immunization (live attenuated vaccine) to patients 18-64 years of age who travel to cholera-affected areas, unless contraindicated. A Antibiotic prophylaxis: consider short-term antibiotic prophylaxis in selected situations for patients at high-risk of bacterial diarrheal illness. B Bismuth subsalicylates: consider bismuth subsalicylates for the prevention of diarrhea in travelers who do not have any contraindications to use and can adhere to the frequent dosing requirements. B 8. Follow-up and surveillance Public health reporting: report all diseases listed in the table of National Notifiable Diseases Surveillance System at the national level, including those that cause diarrhea, to the appropriate state, territorial, or local health department with submission of isolates of certain pathogens such as Salmonella, Shiga toxin-producing E. coli, Shigella, and Listeria, to ensure implementation of control and prevention practices. A https://web.pathway.md/diseases/rec0RaPLxgg1546ED 6/7 6/23/23, 1:44 AM Acute diarrhea Pathway Show 2 more Follow-up testing: avoid obtaining follow-up testing in most patients following resolution of diarrhea. D Show 2 more Management of nonresponse to treatment: As per IDSA 2017 guidelines, consider performing a clinical and laboratory reevaluation, also taking into account noninfectious conditions including lactose intolerance, in patients who do not respond to an initial course of therapy. C Show 2 more As per ACG 2016 guidelines, avoid obtaining serological testing or endoscopy in individuals with persistent diarrheal symptoms for < 30 days. D References 1. Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol. 2016 May;111 5 602 22. Open 2. Shane AL, Mody RK, Crump JA et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis. 2017 Nov 29;65 12):e45-e80. Open 3. DuPont HL. Acute infectious diarrhea in immunocompetent adults. N Engl J Med. 2014 Apr 17;370 16 1532 40. Open 4. Wendy Barr, Andrew Smith. Acute diarrhea. Am Fam Physician. 2014 Feb 1;89 3 180 9. Open 5. Surawicz CM. Mechanisms of diarrhea. Curr Gastroenterol Rep. 2010 Aug;12 4 236 41. Open 6. Gottlieb T, Heather CS. Diarrhoea in adults (acute). BMJ Clin Evid. 2011 Feb 15;2011. pii: 0901. Open 7. Riddle MS, Connor BA, Beeching NJ et al. Guidelines for the prevention and treatment of travelers' diarrhea: a graded expert panel report. J Travel Med. 2017 Apr 1;24(suppl_1 S57 S74. Open 8. American Society for Clinical Pathology. Choosing Wisely ASCP recommendations. Choosing Wisely. 2019. Open 9. Infectious Diseases Society of America. Choosing Wisely IDSA recommendations. Choosing Wisely. 2015. Open 10. Gregory Juckett, Rupal Trivedi. Evaluation of chronic diarrhea. Am Fam Physician. 2011 Nov 15;84 10 1119 26. Open 11. J Aranda-Michel, R A Giannella. Acute diarrhea: a practical review. Am J Med. 1999 Jun;106 6 670 6. Open 12. Yasmine Gaber. Diarrhoea and the COVID 19 pandemic. Arab J Gastroenterol. 2020 Sep;21 3 146 150. Open 13. ASGE Standards of Practice Committee, Bo Shen, Khalid Khan et al. The role of endoscopy in the management of patients with diarrhea. Gastrointest Endosc. 2010 May;71 6 887 92. Open https://web.pathway.md/diseases/rec0RaPLxgg1546ED 7/7