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Acute Diarrhea in Adults and Children

A Global Perspective

Review team: Michael Farthing, MD (Chair, UK), Mohammed A. Salam, MD (Special Advisor,
Bangladesh), Greger Lindberg, MD (Sweden), Petr Dite, MD (Czech Republic), Igor Khalif, MD
(Russia), Eduardo Salazar-Lindo, MD (Peru), Balakrishnan S. Ramakrishna, MD
(India), Khean-Lee Goh, MD (Malaysia), Alan Thomson, MD (Canada), Aamir G. Khan, MD
(Pakistan), Justus Krabshuis, (France), and Anton LeMair, MD (Netherlands)

1. Introduction and epidemiologic features
2. Clinical manifestations and diagnosis
3. Treatment options and prevention
4. Clinical practice

List of Tables
Table 1 Clinical features of infection with selected diarrheal pathogens
Table 2 Assessment of dehydration using the Dhaka method
Table 3 Nonspecic antidiarrheal agents
Table 4 Antimicrobial agents for the treatment of specic causes of diarrhea

List of Figures
Figure 1 Therapeutic approach to acute bloody diarrhea in children
Figure 2 Cascade for acute, severe, watery diarrheacholera-like, with severe dehydration. See above for the recipe for
home-made oral uid
Figure 3 Cascade for acute, mild/moderate, watery diarrheawith mild/moderate dehydration. See above for the recipe
for home-made oral uid
Figure 4 Cascade for acute bloody diarrheawith mild/moderate dehydration

From the University of Sussex, Vice-Chancellors Oce.

The authors declare that they have nothing to disclose.
Reprints: Michael Farthing, MD, University of Sussex, Vice-Chancellors Oce, Sussex House, Brighton BN1 9RH, UK (e-mail: m.farthing@
Copyright r 2013 by Lippincott Williams & Wilkins

12 | J Clin Gastroenterol  Volume 47, Number 1, January 2013

J Clin Gastroenterol  Volume 47, Number 1, January 2013 WGO Global Guideline Acute Diarrhea

INTRODUCTION AND EPIDEMIOLOGIC In this guideline, specic pediatric details are provided
FEATURES in each section as appropriate.
According to the World Health Organization (WHO)
and UNICEF, there are about 2 billion cases of diarrheal Cascadesa Resource-sensitive Approach
disease worldwide every year, and 1.9 million children A gold standard approach is feasible for regions and
younger than 5 years of age perish from diarrhea each year, countries in which the full scale of diagnostic tests and
mostly in developing countries. This amounts to 18% of all medical treatment options are available. However, such
the deaths of children below the age of 5 and means that resources are not available in large parts of the world. With
>5000 children are dying every day as a result of diarrheal their diagnostic and treatment cascades, the WGO guide-
diseases. Of all child deaths from diarrhea, 78% occur in lines provide a resource-sensitive approach.
the African and Southeast Asian regions.
Each child below 5 years of age experiences an average
of 3 annual episodes of acute diarrhea. Globally in this age CLINICAL MANIFESTATIONS AND DIAGNOSIS
group, acute diarrhea is the second leading cause of death Although there may be clinical clues, a denitive
(after pneumonia), and both the incidence and the risk of etiological diagnosis is not possible clinically (Table 1).
mortality from diarrheal diseases are greatest among chil-
dren in this age group, particularly during infancy Clinical Evaluation
thereafter, rates decline incrementally. Other direct con- The initial clinical evaluation of the patient should
sequences of diarrhea in children include growth faltering, focus on:
malnutrition, and impaired cognitive development in  Assessing the severity of the illness and the magnitude
resource-limited countries. (degree) of dehydration (Table 2)
During the past 3 decades, changes in water supply,  Determining likely causes on the basis of the history and
sanitation, and personal hygiene are believed to have con- clinical ndings, including stool characteristics
tributed to a decline in the mortality rate in developing
countries. In some countries, such as Bangladesh, the
reduction in the case fatality rate can be attributed largely to Laboratory Evaluation
improved case management, rather than changes in water For acute enteritis and colitis, maintaining adequate
supply, sanitation, or personal hygiene. Oral rehydration salts intravascular volume and correcting uid and electrolyte
(ORS) and nutritional improvements probably have a greater disturbances take priority over identifying the causative
impact on mortality rates than the incidence of diarrhea. agent. Presence of visible blood in febrile patients generally
Interventions such as exclusive breastfeeding (which prevents indicates infection due to invasive pathogens, such as
diarrhea), continuation of breastfeeding until 24 months of Shigella, Campylobacter jejuni, Salmonella, or Entamoeba
age, and improved complementary feeding (by way of histolytica. Stool cultures are usually unnecessary for
improved nutrition), along with improved sanitation, are immune-competent patients who present with watery diar-
expected to aect mortality and morbidity simultaneously. rhea, but may be necessary to identify Vibrio cholerae when
The recommended routine use of zinc in the management of there is a clinical and/or epidemiological suspicion of
childhood diarrhea, not currently practiced in many coun- cholera, particularly during the early days of outbreaks/
tries, is expected to reduce disease incidence. epidemics (also to determine antimicrobial susceptibility)
In industrialized countries, relatively few patients die and to identify the pathogen causing dysentery.
from diarrhea, but it continues to be an important cause of Epidemiologic clues to infectious diarrhea can be found
morbidity that is associated with substantial health care by evaluating the incubation period, history of recent travel
costs. However, the morbidity from diarrheal diseases has in relation to the regional prevalence of dierent pathogens,
remained relatively constant during the past 2 decades. unusual food or eating circumstances, professional risks,

TABLE 1. Clinical Features of Infection With Selected Diarrheal Pathogens

Clinical Features
Abdominal Fecal Evidence of Vomiting, Heme- Bloody
Pathogens Pain Fever Inammation Nausea positive Stool Stool
Shigella ++ ++ ++ ++ +/ +
Salmonella ++ ++ ++ + +/ +
Campylobacter ++ ++ ++ + +/ +
Yersinia ++ ++ + + + +
Norovirus ++ +/ ++
Vibrio +/ +/ +/ +/ +/ +/
Cyclospora +/ +/ +
Cryptosporidium +/ +/ + +
Giardia ++ +
Entamoeba histolytica + + +/ +/ ++ +/
Clostridium dicile + + ++ + +
Shiga toxin-producing ++ 0 0 + ++ ++
Escherichia coli (including
, Not common; + , occurs; +/ , variable; ++ , common; 0, atypical/often not present.

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Farthing et al J Clin Gastroenterol  Volume 47, Number 1, January 2013

TABLE 2. Assessment of Dehydration Using the Dhaka Method

Assessment Plan A Plan B Plan C
General condition Normal Irritable/less active* Lethargic/comatose*
Eyes Normal Sunken
Mucosa Normal Dry
Thirst Normal Thirsty Unable to drink*
Radial pulse Normal Low volume* Absent/uncountable*
Skin turgor Normal Reduced*
Diagnosis No dehydration Some dehydration Severe dehydration
At least 2 signs, including at least 1 Signs of some dehydration plus at
key sign (*) are present least 1 key sign (*) are present
Treatment Prevent dehydration Rehydrate with ORS solution Rehydrate with intravenous uids
unless unable to drink and ORS
Reassess periodically Frequent reassessment More frequent reassessment
*Key signs.
ORS indicates oral rehydration salts.

recent use of antimicrobials, institutionalization, and human ORT consists of:

immunodeciency virus infection risks.  Rehydrationwater and electrolytes are administered to
Stool analysis and culture costs can be reduced by replace losses.
improving the selection and testing of the specimens sub-  Maintenance uid therapy to take care of ongoing losses
mitted on the basis of interpreting the case information once rehydration is achieved (along with appropriate
such as patient history, clinical aspects, visual stool nutrition).
inspection, and estimated incubation period. ORT is contraindicated in the initial management of
Screening usually refers to noninvasive fecal tests. severe dehydration and also in children with paralytic ileus,
Certain laboratory studies may be important when the frequent and persistent vomiting (> 4 episodes per hour),
underlying diagnosis is unclear or diagnoses other than and painful oral conditions such as moderate to severe
acute gastroenteritis are possible. Where applicable, rapid thrush (oral candidiasis). However, nasogastric admin-
diagnostic tests may be considered for quick cholera testing istration of ORS solution is potentially lifesaving when
at the patients bedside. intravenous rehydration is not possible and the patient is
being transported to a facility where such therapy can be
Pediatric Details administered.
Identication of a pathogenic bacterium, virus, or Rice-based ORS is superior to standard ORS for
parasite in a stool specimen from a child with diarrhea does adults and children with cholera and can be used to treat
not indicate in all cases that it is the cause of illness. such patients wherever its preparation is convenient. It is
Measurement of serum electrolytes may be required in not superior to standard ORS in the treatment of children
some children with a longer duration of diarrhea with mod- with acute noncholera diarrhea, especially when food is
erate or severe dehydration, particularly with an atypical given shortly after rehydration, as is recommended to pre-
clinical history or ndings. Hypernatremic dehydration is vent malnutrition.
more common in well-nourished children and those infected
with rotavirus and features irritability, increased thirst dis- Supplemental Zinc Therapy, Multivitamins, and
proportionate to clinical dehydration, and a doughy feel to Minerals in Children
the skin. This requires specic rehydration methods. Zinc deciency is widespread among children in
developing countries. Routine zinc therapy as an adjunct to
TREATMENT OPTIONS AND PREVENTION ORT is useful for modest reduction of the severity but more
importantly to reduce diarrhea episodes in children in
Rehydration in Adults and Children developing countries. The recommendation for all children
Oral rehydration therapy (ORT) is the administration of with diarrhea is 20 mg of zinc per day for 10 days. However,
appropriate solutions by mouth to prevent or correct diar- infants aged 2 months or younger should receive 10 mg/d
rheal dehydration. ORT is a cost-eective method of man- for 10 days.
aging acute gastroenteritis and it reduces hospitalization Supplementation with zinc sulfate in recommended
requirements in both developed and developing countries. doses reduces the incidence of diarrhea during the following
Global ORS coverage rates are still <50%, and eorts 3 months and reduces nonaccidental deaths by as much as
must be made to improve coverage. 50%. It is more important in the management of diarrhea
ORS, used in ORT, contain specic amounts of in malnourished children and in persistent diarrhea. The
important salts that are lost in diarrhea stool. The new WHO and UNICEF recommend routine zinc therapy for
lower-osmolarity ORS (recommended by the WHO and children with diarrhea, irrespective of the type.
UNICEF) has reduced concentrations of sodium and glu- All children with persistent diarrhea should receive
cose and is associated with less vomiting, less stool output, supplementary multivitamins and minerals, including
lesser chance of hypernatremia, and a reduced need for magnesium, each day for 2 weeks. Locally available com-
intravenous infusions in comparison with standard ORS. mercial preparations are often suitable; tablets that can be
This formulation is recommended irrespective of age and crushed and given with food are least costly. These should
the type of diarrhea, including cholera. provide as broad a range of vitamins and minerals as

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possible, including at least 2 recommended daily allowances shortens the duration of acute diarrheal illness in children
of folate, vitamin A, zinc, magnesium, and copper (WHO by approximately 1 day.
2005). Several meta-analyses of controlled clinical trials have
been published that show consistent results in systematic
Diet reviews, suggesting that probiotics are safe and eective.
The practice of withholding food for >4 hours is The evidence from studies on viral gastroenteritis is more
inappropriatenormal feeding should be continued for convincing than the evidence on bacterial or parasitic
those with no signs of dehydration, and food should be infections. Mechanisms of action are strain specic: there is
started immediately after correction of some (moderate) evidence for ecacy of some strains of lactobacilli (eg,
and severe dehydration, which usually takes 2 to 4 hours, L. casei GG and L. reuteri ATCC 55730) and for S. boulardii.
using ORT or intravenous rehydration. The timing of administration is also of importance.

Prevention of Acute Diarrhea

Pediatric Details
In the prevention of adult and childhood diarrhea,
Breastfed infants and children should continue to
there is only suggestive evidence that Lactobacillus GG, L.
receive food, even during the rehydration phase. However,
casei DN-114 001, and S. boulardii are eective in some
for nonbreastfed, dehydrated children and for adults,
specic settings (see tables 8 and 9 in WGOs Guideline
rehydration is the rst priority and can be accomplished in
on probiotics at
2 to 4 hours.
Probiotics Antibiotic-associated Diarrhea
Probiotics are live microorganisms, such as Lactobacillus In antibiotic-associated diarrhea, there is strong evi-
GG (ATCC 53103), with demonstrated benecial health dence of ecacy for S. boulardii or L. rhamnosus GG in
eects in humans. However, the eects are strain specic adults or children who are receiving antibiotic therapy. One
and need to be veried for each strain in human studies. study indicated that L. casei DN-114 001 is eective in
Extrapolation from the results of even closely related hospitalized adult patients for preventing antibiotic-asso-
strains is not possible, and signicantly dierent eects ciated diarrhea and Clostridium dicile diarrhea.
have been reported. Use of probiotics may not be appro-
priate in resource-constrained settings, mostly in develop- Radiation-induced Diarrhea
ing countries. There is inadequate research evidence to be certain
that VSL#3 (L. casei, Lactobacillus plantarum, Lactobacillus
Pediatric Details acidophilus, Lactobacillus delbrueckii, Bidobacterium lon-
Controlled clinical intervention studies and meta- gum, Bidobacterium breve, Bidobacterium infantis, and
analyses support the use of specic probiotic strains and Streptococcus thermophilus) is eective in the treatment of
products in the treatment and prevention of rotavirus radiation-induced diarrhea.
diarrhea in infants.
Nonspecific Antidiarrheal Treatment
Probiotics for the Treatment of Acute Diarrhea None of these drugs addresses the underlying causes or
It has been conrmed that dierent probiotic strains eects of diarrhea (loss of water, electrolytes, and
(see tables 8 and 9 in WGOs Guideline on probiotics at nutrients). Antiemetics are usually unnecessary in acute diarrhea management, and some that have sedative eects
html) including Lactobacillus reuteri ATCC 55730, may make ORT dicult.
Lactobacillus rhamnosus GG, Lactobacillus casei DN-114
001, and Saccharomyces cerevisiae (boulardii) are useful in Pediatric Details
reducing the severity and duration of acute infectious In general, antidiarrheals have no practical benets for
diarrhea in children. The oral administration of probiotics children with acute or persistent diarrhea (Table 3).

TABLE 3. Nonspecific Antidiarrheal Agents

Antimotility agents Should be used mostly for mild to moderate travelers diarrhea
(without clinical signs of invasive diarrhea)
Loperamide (4-6 mg/d) is the agent of choice Inhibits intestinal peristalsis and has mild antisecretory properties
for adults
Should be avoided in bloody or suspected inammatory diarrhea
(febrile patients)
Signicant abdominal pain also suggests inammatory diarrhea
(this is a contraindication for loperamide use)
Pediatric details: Not recommended for use in childrenhas been
demonstrated to increase disease severity and complications,
particularly in children with invasive diarrhea
Antisecretory agents Not useful in adults with cholera
Racecadotril is an enkephalinase inhibitor Pediatric details: It has been found useful in children with diarrhea,
(nonopiate) with antisecretory activity and is now licensed in many countries in the world for use in children
Kaolin-pectin, activated charcoal, attapulgite Inadequate proof of ecacy in acute adult diarrhea, adds to the
costs, and thus should not be used

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Antimicrobials in Adults and Children Symptomatic giardiasis (anorexia and weight loss,
(Table 4) persistent diarrhea, failure to thrive).
 Consider antimicrobial treatment for:
Important Notes Shigella, Salmonella, Campylobacter (dysenteric form),
 All doses shown are for oral administration. or parasitic infections.
 Selection of an antimicrobial should be based on the Nontyphoidal salmonellosis among at-risk populations
susceptibility patterns of strains of the pathogens in the (malnutrition, infants and elderly, immunocompromised
locality/region. patients, and those with liver diseases and lymphoprolifer-
 Antimicrobials are reliably helpful and their routine use ative disorders) and in dysenteric presentation.
is recommended in the treatment of severe (clinically Moderate/severe travelers diarrhea or diarrhea with fever
recognizable): and/or with bloody stools.
Cholera, shigellosis, typhoid, and paratyphoid fevers. Antimicrobials are also indicated for associated health
Dysenteric presentation of campylobacteriosis and problems such as pneumonia.
nontyphoidal salmonellosis when they cause persistent
diarrhea, and when host immune status is compromised Pediatric Details
for any reason such as severe malnutrition, chronic liver  If drugs are not available in liquid form for use in young
disease, or lymphoproliferative disorders. children, it may be necessary to use tablets and estimate
Invasive intestinal amebiasis. the doses given.

TABLE 4. Antimicrobial Agents for the Treatment of Specific Causes of Diarrhea

First choice
Cause Alternative(s)
Cholera Doxycycline
Adults: 300 mg once
Children: 2 mg/kg (not recommended)
Adults: 1.0 g as a single dose, only once
Children: 20 mg/kg as 1 single dose
Adults: 500 mg 12-hourly for 3 d or 2.0 g as a single dose only once
Children: 15 mg/kg every 12 h for 3 d
*The minimum inhibitory concentration has increased in many countriesmultiple-dose therapy over
Shigellosis Ciprooxacin
Adults: 500 mg 2 /d for 3 d or 2.0 g as a single dose only once
Adults: 400 mg 3-4 times/d for 5 d
Children: 20 mg/kg 4/d for 5 d
Adults: 2-4 g as a single daily dose
Children: 50-100 mg/kg 1/d intramuscularly for 2-5 d
Amebiasisinvasive Metronidazole
intestinal Adults: 750 mg 3 /d for 5 d*
Children: 10 mg/kg 3/d for 5 d*
*10 d for severe disease
Giardiasis Metronidazole
Adults: 250 mg 3 /d for 5 d
Children: 5 mg/kg 3/d for 5 d
Can also be given in a single dose50 mg/kg orally; maximum dose 2 g
Can be used in accordance with the manufacturers recommendationssingle, 2-g dose
For adults (not available in the United States)
Campylobacter Azithromycin
Adults: 500 mg 1 /d for 3 d
Children: single dose of 30 mg/kg early after disease onset
Fluoroquinolones such as ciprooxacin
Adults: 500 mg 1 /d for 3 d

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 Consider antimicrobial treatment for:  Maintain hydration using ORS solution.

When Shigella, Salmonella, Campylobacter (dysenteric  Treat symptoms (if necessary, consider bismuth
form) are the only pathogen isolated from children with subsalicylate or loperamide in cases of nondysenteric
persistent diarrhea. travelers diarrhea).
Nontyphoidal salmonellosis in infants.
 Alternative antimicrobials for treating cholera in children 4. Stratify subsequent management:
are trimethoprim/sulfamethoxazole (TMP/SMX; 5 mg/kg  Epidemiological clues: food, antibiotics, sexual
TMP + 25 mg/kg SMX, 12-hourly for 3 d) and noroxacin. activity, travel, day care attendance, other illness,
outbreaks, season.
Prevention of Diarrhea With Vaccines
 Clinical clues: bloody diarrhea, abdominal pain,
 Salmonella typhi: 2 typhoid vaccines (with limited cost dysentery, wasting, fecal inammation.
eectiveness) are currently approved for clinical use.
 Shigella organisms: 3 vaccines have been shown to be 5. Obtain a fecal specimen for analysis:
immunogenic and protective in eld trials. Parenteral
vaccines may be useful for travelers and military  If there is severe, bloody, inammatory, or persistent
personnel but are impractical for use in developing diarrhea, and at the beginning of an outbreak/
countries. More promising is a single-dose live-attenu- epidemic.
ated vaccine currently under development in several 6. Consider antimicrobial therapy for specic pathogens.
laboratories. 7. Report to the public health authorities.
 V. cholerae: the current price and need for multiple doses
(at least 2) and shorter protective ecacy are limitations.  In outbreaks, save culture plates and isolates; freeze
A new, cheaper killed-cell vaccine is likely to be available fecal specimens and food or water specimens at
soon; oral cholera vaccines are still being investigated, 701C
and their use is recommended only in complex emergen-  Notiable in the United States: cholera, cryptospor-
cies such as epidemics. Their use in endemic areas idiosis, giardiasis, salmonellosis, shigellosis, and
remains controversial. In travelers diarrhea, oral cholera infection with Shiga toxinproducing E. coli.
vaccine is only recommended for those working in
refugee or relief camps, because the risk of cholera for Approach in Children With Acute Diarrhea
the usual traveler is very low. In 2002, WHO and UNICEF revised their recom-
 Enterotoxigenic Escherichia coli vaccines: the most mendations for routine use of hypoosmolar ORS, and in
advanced enterotoxigenic E. coli vaccine candidate 2004 recommended routine use of zinc as an adjunct to
consists of a killed whole-cell formulation plus a ORT for treatment of childhood diarrhea, irrespective of
recombinant cholera toxin B subunit. No vaccines are etiology. Since then, >40 countries throughout the world
currently available for protection against Shiga toxin have adopted the recommendations. In countries where
producing E. coli infection. both the new ORS and zinc have been introduced, the rate
of ORS usage has dramatically increased. The principles of
Pediatric Details appropriate treatment for children with diarrhea and
 Salmonella typhi: no available vaccine is currently dehydration are:
suitable for routine use for children in developing 1. No unnecessary laboratory tests or medications.
countries. 2. Use ORS for rehydration:
 Rotavirus: in 1998, a rotavirus vaccine, RotaShield
(Wyeth), was licensed in the United States for routine Perform ORT rapidly, within 3 to 4 hours.
immunization of infants. In 1999, production was Routine adjunct zinc therapy for children aged 5
stopped after the vaccine was causally linked to years or younger.
intussusception in infants. Other rotavirus vaccines are 3. When dehydration is corrected, rapid realimentation:
being developed, and preliminary trials are promising.
Currently, 2 vaccines have been approved: a live oral Normal food or age-appropriate unrestricted diet.
vaccine, RotaTeq, made by Merck for use in children, Continue breastfeeding.
and GSKs Rotarix.
 Measles immunization can substantially reduce the inci- 4. Administer additional ORS for ongoing losses through
dence and severity of diarrheal diseases. Every infant should diarrhea (Fig. 1).
be immunized against measles at the recommended age.

Home Management of Acute Diarrhea in Adults

and Children
CLINICAL PRACTICE Milder and uncomplicated cases of nondysenteric
Approach in Adults With Acute Diarrhea diarrhea in both adults and children can be treated at home,
1. Perform initial assessment. regardless of the etiologic agent, using home-based uid or
2. Manage dehydration. ORS as appropriate. Parents/caregivers of children should
3. Prevent dehydration in patients with no signs of be educated to recognize signs of dehydration and when to
dehydration, using home-based uids or ORS solution. take children to a health facility for treatment. Early
intervention and administration of home-based uids/ORS
 Rehydration of patients with some dehydration using reduces dehydration, malnutrition, and other complications
ORS and correct dehydration of a severely dehydrat- and leads to fewer clinic visits and potentially fewer hos-
ing patient with an appropriate intravenous uid. pitalizations and deaths.

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Farthing et al J Clin Gastroenterol  Volume 47, Number 1, January 2013

Severely malnourished?

Yes: refer to hospital No: give antimicrobial for


Better in 2 days?

Yes: complete 3days treatment No: see next

Initially dehydrated, age < 1 y, or

measles in past 6 weeks?

Yes: refer to hospital No: change to second

antimicrobial for Shigella

Better in 2 days?

Yes: complete 3days treatment No: refer to hospital or

treat for amebiasis

FIGURE 1. Therapeutic approach to acute bloody diarrhea in children.

Level 1

Intravenous fluids + antibiotics + diagnostic tests:

stool microscopy/culture
Based on tests: tetracycline, fluoroquinolone

Level 2

Intravenous fluids + antibiotics

Empirical: tetracycline, fluoroquinolone, or other

Level 3

High Intravenous fluids + ORT


Low Level 4

Nasogastric tube ORS if persistent, vomiting

Level 5


Level 6

Home-made oral fluid: salt, sugar, and clean water

FIGURE 2. Cascade for acute, severe, watery diarrheacholera-like, with severe dehydration. See above for the recipe for home-made
oral fluid. ORT indicates oral rehydration therapy.

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Self-medication is safe in otherwise healthy adults. Antidiarrheal agents

It relieves discomfort and social dysfunction. There is Among hundreds of over-the-counter products pro-
no evidence that it prolongs the illness. However, this moted as antidiarrheal agents, only loperamide and bismuth
may not be appropriate in developing countries, where subsalicylate have sucient evidence of ecacy and safety.
diarrhea requiring specic interventions is more prevalent Family knowledge
and people may not be competent in assessing their Family knowledge about diarrhea must be reinforced
conditions. in areas such as prevention, nutrition, ORT/ORS use, zinc
Principles of self-medication: supplementation, and when and where to seek care.
 Maintain adequate uid intake. Indications for medical consultation or in-patient care are:
 Consumption of solid food should be guided by appetite  Caregivers report of signs consistent with dehydration
in adults; small, but more frequent meals for children.  Changing mental status
 Antidiarrheal medication with loperamide (exible dose  History of premature birth, chronic medical conditions,
according to loose bowel movements) may diminish or concurrent illness
diarrhea and shorten the duration.  Young age ( less than 6 mo or <8 kg weight)
 Antimicrobial treatment is reserved for prescription only  Fever Z381C for infants less than 3 months old or
in residents diarrhea or for inclusion in travel kits (add Z391C for children aged 3 to 36 months
loperamide).  Visible blood in stool
Where feasible, families in localities with a high prev-  High-output diarrhea, including frequent and substantial
alence of diarrheal diseases should be encouraged to store a volumes
few ORS packets and zinc tablets if there are children below  Persistent vomiting, severe dehydration, persistent fever
the age of 5 in the family, so that home therapy can be  Suboptimal response to ORT or inability of caregiver to
initiated as soon as diarrhea starts. administer ORT
 No improvement within 48 hourssymptoms exacer-
bate and overall condition gets worse
Home-made Oral Fluid Recipe  No urine in the previous 12 hours
Preparing 1 L of oral uid using salt, sugar, and water
at home. The ingredients to be mixed are: Cascades
 One level teaspoon of salt. A cascade is a hierarchical set of diagnostic or ther-
 Eight level teaspoons of sugar. apeutic techniques for the same disease, ranked by the
 One liter (5 cupfuls) of clean drinking water or water that resources available. Cascades for acute diarrhea are shown
has been boiled and then cooled. in Figures 24.

Level 1

Intravenous fluids (consider) + ORT

Level 2

Nasogastric tube ORSif persistent, vomiting
Level 3


Level 4

Home-made oral fluid: salt, sugar, and clean water

FIGURE 3. Cascade for acute, mild/moderate, watery diarrheawith mild/moderate dehydration. See above for the recipe for home-
made oral fluid. ORT indicates oral rehydration therapy.

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Farthing et al J Clin Gastroenterol  Volume 47, Number 1, January 2013

Level 1

ORT + antibiotics + diagnostic tests: stool microscopy/culture

Consider causes: S. dysenteriae, E. histolytica,
severe bacterial colitis

Level 2

High ORT + antibiotics

Empirical antibiotics for moderate/severe illness

Low Level 3


Level 4

Home-made oral fluid: salt, sugar, and clean water

FIGURE 4. Cascade for acute bloody diarrheawith mild/moderate dehydration. ORT indicates oral rehydration therapy.

Cautions Notes
 If facilities for referral are available, patients with  Nasogastric therapy requires skilled sta.
severe dehydration (at risk of acute renal failure or  Often, intravenous uid treatment is more easily
death) should be referred to the nearest health care available than nasogastric tube feeding. (Caution: there
facility with access to intravenous uids (levels 5 and 6 is a risk of infection with contaminated intravenous
cannot replace the need for referral in case of severe infusion equipment.)
dehydration). Pediatric details
 Levels 5 and 6 must be seen as interim measures and are  Nasogastric feeding is not very feasible for healthy and
better than no treatment if no intravenous facilities are active older children, but it is suitable for malnourished,
available. lethargic children.
 When intravenous therapy is used, it must be ensured  Nasogastric administration (ORS and diet) is especially
that disposable sterile syringes, needles, and drip sets are helpful in long-term severely malnourished children
used, to avoid the risk of hepatitis B and C. (anorexia).

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