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June 16, 2016

New Guideline for Prevention and Management of


Acute Diarrhea
Douglas K. Rex, MD reviewing Riddle MS et al. Am J Gastroenterol 2016 May.
Recommendations include those on preventing traveler's diarrhea, which patients often ask
about.
Sponsoring Organization: American College of Gastroenterology (ACG)
Audience: Gastroenterologists, primary care providers
Background and Objective
In this new comprehensive guideline, researchers developed graded recommendations on
diagnosis, management, and prevention of acute diarrheal infections based on a systematic
review of evidence.
Key Recommendations

In acute diarrhea (duration, 114 days), perform stool cultures and new cultureindependent molecular assays (if available) when a patient is at high risk of spreading disease or
during outbreaks.

Consider stool diagnostic tests in presence of dysentery, moderate-to-severe disease, or


symptom duration >7 days.

Supplement traditional diagnostic stool tests (culture, microscopy with or without special
stains, immunofluorescence, antigen testing), which are usually negative in acute diarrhea, with
FDA-approved culture-independent molecular methods if available.

Do not conduct antibiotic sensitivity testing in acute diarrhea.

The use of a fecal leukocyte test or fecal lactoferrin to guide more appropriate use of
cultures is imprecise and probably unnecessary.

With a few exceptions, most patients can adequately rehydrate with water, juice, sports
drinks, soups, and salty crackers.

Do not treat acute diarrhea with probiotics and prebiotics except for postantibiotic
diarrhea.

Treat mild-to-moderate traveler's diarrhea (TD) with bismuth subsalicylate except where
contraindicated (e.g., use of other salicylates). Warn patients about the harmless black tongue
and black stools that result.

Loperamide remains an excellent treatment for TD. Titrate the dose to avoid
posttreatment constipation, and do not give for >48 hours. Loperamide may even be safe in a
dysentery presentation that would increase the risk for an invasive pathogen, provided it is
combined with antibiotic therapy.

Do not conduct empiric antibiotic therapy in acute diarrheal infection, except in cases of
TD in which a bacterial cause is deemed highly likely. Most community-acquired acute diarrhea is
viral in origin.

Treat TD with a single-dose or 3-day course of quinolones or single-dose azithromycin


(1000 mg), except for suspected or cultured Shigella, which requires a 5-day course.

Endoscopic evaluation is not recommended for this duration of symptoms.

Specific handwashing measures and alcohol-based hand sanitizers have limited value for
most TD but could be useful in preventing cruise ship outbreaks of norovirus and institutional
outbreaks, or in areas of endemic diarrhea.

For prophylaxis of TD, consider bismuth subsalicylate two tablets (2.1 g) four times daily
at meals and bedtime to provide 60% risk reduction for trips up to 2 weeks but usually not for
longer trips; lower doses are associated with reduced protection.

Do not use prebiotics, probiotics, and synbiotics (combinations of prebiotics and


probiotics) for TD prophylaxis.

Antibiotic prophylaxis for TD is recommended, but only in high-risk groups and for shortterm use. This limited role for chemoprophylaxis is being reevaluated with increasing awareness
of the high frequency and impact of postinfectious irritable bowel syndrome and the availability
of rifaximin, which has desirable features and safety profile compared with quinolones for
prophylaxis.

COMMENT
Although it seems that gastroenterologists evaluate fewer patients with acute diarrhea than with
chronic diarrhea, we do sometimes see acute diarrhea, and patients often ask about how to
prevent traveler's diarrhea. A useful feature of this guideline is an algorithm that details a
management approach to acute diarrhea based on watery versus dysenteric presentation and
duration of symptoms and which covers both diagnostic assessment and treatment.

EDITOR DISCLOSURES AT TIME OF PUBLICATION

Disclosures for Douglas K. Rex, MD at time of publicationConsultant / Advisory


boardCovidien; Olympus Corporation America; Endo-Aid Ltd.; Endochoice; Boston Scientific; Paion
AG; Ironwood Pharmaceuticals; Colonary Solutions; Novo Nordisk Inc.; Medscape
GastroenterologyGrant / Research support:Braintree LaboratoriesEditorial boardsWorld Journal of

Gastroenterology; The Journal of Clinical Gastroenterology; Techniques in Gastrointestinal


Endoscopy; Gastroenterology & Hepatology; Expert Review of Gastroenterology & Hepatology;
Medscape Gastroenterology; World Journal of Gastrointestinal Pharmacology and Therapeutics;
Annals of Gastroenterology & Hepatology; World Journal of Gastrointestinal Oncology;
Comparative Effectiveness Research; Journal of Anesthesia & Clinical Research; Gastroenterology;
World Journal of Gastrointestinal Pathophysiology; Gastroenterology Research and Practice; GI &
Hepatology News; Gastroenterology Report; Clinical Epidemiology Reviews; JSM Gastroenterology
and Hepatology (associate editor); GI Journal Watch; Austin Journal of Gastroenterology; World
Journal of Gastrointestinal Pharmacology & TherapeuticsLeadership positions in professional
societiesAmerican Society for Gastrointestinal Endoscopy (Councilor); US Multi-Society Task
Forces (AGA, ACG, ASGE) (Chair)

CITATION(S):
1.

Riddle MS et al. ACG clinical guideline: Diagnosis, treatment, and prevention of acute
diarrheal infections in adults. Am J Gastroenterol 2016 May; 111:602.
(http://dx.doi.org/10.1038/ajg.2016.126)

Rep l y

Amanda S PharmD Other Healthcare Professional, Pharmacology/Pharmacy19 Jun 2016 11:37 PM


Kaopectate in its usual formulation actually contains bismuth subsalicylate, the same active ingredient
as pepto bismol (although it used to be formulated with different active ingredients- kaolin and pectin).
Loperamide (in Imodium) certainly would cause constipation more frequently than bismuth
subsalicylate due to its mechanism of action (slowing gastric motility through activation of opioid
receptors in the gut vs antimicrobial + antisecretory effect). But ultimately, unless the dose is
different, drugs with the same active ingredient should have the same side effect profile.
Whew, and there's a fun pharmacology review for the day :)

Rep l y

Juan Urdapilleta Physician, Internal Medicine, Argentina18 Jun 2016 4:27 PM


Breve y conciso excelente

Rep l y

Kareem Essam Physician, Gastroenterology, Cairo university17 Jun 2016 11:33 PM


What is the role of metronidazole in acute diarrhea?

Rep l y

IVAN SARAIVA Physician, Internal Medicine17 Jun 2016 10:54 PM


Probiotics containing Lactobacillus seem to be safe, but there has been reports of sepsis associated
with Saccharomyces boulardii probiotics (rare and mostly limited to patients with imune impairment).

Rep l y

Hazel Moyer Retired17 Jun 2016 3:44 PM


Although Immodium and Kaopectate both contain Loperamide, Immodium results in constipation.
Kaopectate does not which makes it far superior to Immodium. Who wants to trade diarrhea for
constipation? No one.

Rep l y

SALLY BURBANK Physician, Internal Medicine17 Jun 2016 11:21 AM


Do probiotics actually do HARM in acute diarrhea or TD, or do they merely not help? What is the
reasoning behind specifically advising against probiotics?