Clinical Infectious Diseases
I N V I T E D C O M M E N TA R Y
2017 Infectious Diseases Society of America Infectious
Diarrhea Guidelines: A View From the Clinical Laboratory
Ferric C. Fang1,a and Robin Patel2,a
1
Departments of Laboratory Medicine and Microbiology, University of Washington School of Medicine, Seattle; and 2Division of Clinical Microbiology, Department of Laboratory Medicine and
Pathology, Mayo Clinic, Rochester, Minnesota
Keywords.  gastroenteritis; culture-independent diagnostic tests; multiplex panels; IDSA guidelines; diagnosis.
An estimated 2–4 billion episodes of
acute diarrhea occur worldwide each
year. The 2017 Infectious Diseases Society
of America (IDSA) guidelines on the
diagnosis and management of infectious
diarrhea [1] provide a welcome update
of previous guidelines published in 2001
[2]. We would like to underscore selected
aspects of the new guidelines from the
perspective of the clinical microbiology
laboratory.
CULTURE-INDEPENDENT
DIAGNOSTIC TESTS ARE A
GAME-CHANGER
As noted in the 2001 guidelines, a spe-
cific diagnosis can benefit a patient
with infectious diarrhea by directing
appropriate therapy and allowing the
judicious use of antimicrobial agents
[2]. A  specific diagnosis can provide
information regarding the likely course
of illness, which can be important for
patient satisfaction and life planning,
as well as guide management in special
circumstances, such as when diarrhea
occurs in food workers or children in
Received 7 August 2017; editorial decision 7 August 2017;
accepted 10 August 2017; published online October 19, 2017.
a
F. C. F. is the Deputy Editor and R. P. an Associate Editor of
Clinical Infectious Diseases.
Correspondence: F.  C. Fang, Department of Microbiology,
Box 357735, University of Washington School of Medicine,
1959 NE Pacific St, Seattle, WA 98195-7735 (fcfang@uw.edu).
Clinical Infectious Diseases®  2017;65(12):1974–6
© The Author 2017. Published by Oxford University Press for
the Infectious Diseases Society of America. All rights reserved.
For permissions, e-mail: journals.permissions@oup.com.
DOI: 10.1093/cid/cix730
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daycare. Moreover, a specific diagnosis DIAGNOSTIC TESTING SHOULD
BE SELECTIVELY UTILIZED
can facilitate public health surveillance IN APPROPRIATE CLINICAL
efforts; authors of the earlier guideline SETTINGS
expressed hope that the development of
Although culture-independent diag-
rapid diagnostic tests would eventually
nostic tests (CIDTs) offer laboratory
improve the diagnosis, management,
workflow advantages over conven-
and prevention of infectious diarrhea.
tional testing [11] and efficiencies in
Importantly, both the 2001 and 2017
establishing a diagnosis, reagent costs
guidelines acknowledge that the ability
are undeniably greater. Hence it is im-
to accurately predict a specific micro-
portant to limit diagnostic testing for
bial etiology on the basis of epidemio-
infectious diarrhea to settings in which
logical or clinical features is limited.
the tests are likely to yield the most clin-
The hope expressed in 2001 has become
ically useful results. The 2017 guide-
a reality in 2017. Multiple US Food
lines include individuals with fever,
and Drug Administration–approved
bloody or mucoid diarrhea, severe ab-
or–cleared multiplex gastrointestinal
dominal cramping, or signs of sepsis,
panels are now available to rapidly de-
as well as immunocompromised hosts
tect a broad range of bacterial, viral, and
[1]. Additional specific criteria for diag-
parasitic causes of diarrhea from a single
nostic testing can be found in the 2016
fecal specimen [3, 4]. With few excep-
American College of Gastroenterology
tions, these molecular assays are consid-
guidelines for acute diarrhea, which
erably more sensitive than conventional
specify patients with dysentery, those
nonmolecular methods [5–9] and fre-
with moderate to severe disease, or
quently identify pathogens unsuspected
those with symptoms lasting >7  days,
by clinicians [10]. Furthermore, their
and in the setting of outbreaks involv-
ease of use makes such testing available
ing food handlers, healthcare workers,
to patients in a variety of healthcare set-
daycare attendees or employees, and
tings, many of whom would previously
residents of institutions [12].
have waited for days to have their diag-
nosis confirmed, if it was confirmed DETECTION OF BACTERIAL
at all. Conveniently, a single stool spe- PATHOGENS BY CIDTS SHOULD
cimen is all that is required, abrogating BE FOLLOWED BY DIRECTED
CULTURES
the need for invasive procedures such
as a duodenal aspirate for diagnosis of The 2001 and 2017 guidelines both em-
giardiasis, or for the aliquoting of stool phasize that bacterial isolates are essential
into multiple containers for different to allow typing studies that inform public
tests. health outbreak investigations. For some
 organisms, isolates are also needed for anti-
microbial susceptibility testing. For these
reasons, directed or “reflexive” cultures
should be performed for pathogens such
as Salmonella, Shigella, and Campylobacter
species and Escherichia coli O157:H7 when
these bacteria are detected by CIDTs [13,
14]. This testing can be performed by
public health or clinical microbiology lab-
oratories. The greater sensitivity of CIDTs
is anticipated to greatly enhance public
health efforts and has already been useful
in identifying an unsuspected outbreak of
Cyclospora infection and in increasing case
detection during a Shigella outbreak [8, 15].
ANTIMICROBIAL THERAPY
SHOULD BE GUIDED BY
DIAGNOSTIC TESTING
The 2017 guidelines provide a strong
recommendation that “antimicrobial
treatment should be modified or dis-
continued when a clinically plausible
organism is identified.” A number of the
organisms detected by CIDTs have been
shown to respond to antimicrobial ther-
apy, including Campylobacter, Shigella,
and Salmonella species; enterotoxigenic/
enteropathogenic/enteroaggregative/
enteroinvasive E.  coli; Yersinia enteroco-
litica; Vibrio species; Clostridium diffi-
cile; Cryptosporidium, Cyclospora, and
Giardia species; and Entamoeba histolyt-
ica [16–32]. In addition, antibiotics are
contraindicated when Shiga toxin–pro-
ducing E. coli is detected, to avoid precip-
itating or exacerbating hemolytic uremic
syndrome [33]. Thus, the rapid detection
of pathogens in patients with infectious
diarrhea can benefit patients by opti-
mizing the selection of an antimicrobial
agent and reducing unnecessary ther-
apy. Of note, the new guidelines include
a recent Centers for Disease Control and
Prevention recommendation to avoid
fluoroquinolones for the treatment of
Shigella infections if the minimum inhibi-
tory concentration (MIC) of ciprofloxacin
is ≥0.12  µg/mL [34]. However, this may
prove to be impractical in view of rapidly
rising rates of azithromycin resistance in
Shigella isolates obtained from men who
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have sex with men [35, 36]. Furthermore,
in our opinion, the high fecal concentra-
tions of fluoroquinolones [37] make it
likely that these agents will remain effect-
ive against strains with MICs ≥0.12  µg/
mL that are still at or below the current
susceptibility breakpoint of 1 µg/mL.
With the increasing availability of
rapid and highly sensitive diagnostic pan-
els, a likely microbial etiology can now be
established in more patients presenting
with acute diarrhea than ever before [8].
This can facilitate appropriate treatment,
avoid unnecessary antimicrobial use,
and expedite recognition of foodborne
and other outbreaks. Many of the goals
articulated in the 2001 IDSA infectious
diarrhea guidelines are now possible in
2017 as a result of advances in diagnos-
tic technology. Configurations of individ-
ual multiplex gastrointestinal panels will
likely evolve over time as experience with
these new technologies and their perfor-
mance grows. Hopefully, the costs will
also decrease, which would make testing
even more accessible.
Note
Potential conflicts of interest.  F. C. F. has par-
ticipated in research studies supported by BioFire,
Cepheid, ELITech, and Luminex (formerly
Nanosphere). R.  P.  has participated in research
studies supported by CD Diagnostics, BioFire,
Curetis, Merck, Hutchison Biofilm Medical
Solutions, Accelerate Diagnostics, Allergan,
and The Medicines Company; is a consultant to
Curetis; receives travel reimbursement from the
American Society for Microbiology (ASM), an
editor’s stipend from ASM, and honoraria from the
National Board of Medical Examiners, UpToDate,
and the Infectious Diseases Board Review Course;
has a patent on Bordetella pertussis/parapertussis
polymerase chain reaction issued, has a patent
on a device/method for sonication with royalties
paid by Samsung to Mayo Clinic, and a patent on
an antibiofilm substance issued; and serves on an
Actelion data monitoring board. Both authors
receive editors’ stipends from IDSA. Both authors
have submitted the ICMJE Form for Disclosure
of Potential Conflicts of Interest. Conflicts that
the editors consider relevant to the content of the
manuscript have been disclosed.
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