Management of acute infectious diarrhea

In acute infectious diarrhea, it's usually okay to start with ciprofloxacin or azithromycin in adults or azithromycin or ceftriaxone...
Mahitab Hany, BS Pharm, PGDipClinPharm, PGDipClinNutrition

QUESTIONS WILL COME UP ABOUT HOW TO MANAGE ACUTE INFECTIOUS DIARRHEA? due to new Infectious Disease Society of America (IDSA) guidelines. Infectious diarrhea is usually self-limiting and often viral. But when a patient presents with fever, bloody stools, abdominal pain, or sepsis, suggest a stool test to evaluate for a bacterial cause such as E. coli, Campylobacter, Salmonella, Shigella, etc. Follow these steps...

         Recommend a rapid diagnostic test if these new tests are available at your hospital. Look for terms such as "stool PCR" or "GI PCR panel" in physician's order or check with your lab. Expect to have results in just a few hours with these new tests.

Start empiric antibiotics for most hospitalized patients, especially those with immunodeficiency, recent travel, or in infants under 3 months. In these cases, it's usually okay to start with ciprofloxacin or azithromycin in adults or azithromycin or a third-generation cephalosporin (ceftriaxone, etc) in kids.

Table (1). Antibiotic Therapy for Acute Diarrhea
ORGANISM THERAPY EFFECTIVENESS PREFERRED MEDICATION ALTERNATIVE MEDICATIONS COMMENTS
Bacterial
Campylobacter Proven in dysentery and sepsis, possibly effective in enteritis Azithromycin (Zithromax), 500 mg once per day for 3 to 5 days Erythromycin, 500 mg four times per day for 3 to 5 days Consider prolonged treatment if the patient is immunocompromised
Ciprofloxacin (Cipro), 500 mg twice per day for 5 to7 days
Clostridium difficile Proven Metronidazole (Flagyl), 500 mg three times per day for 10 days Vancomycin, 125 mg four times per day for 10 days If an antimicrobial agent is causing the diarrhea, it should be discontinued if possible
Enteropathogenic/enteroinvasive Escherichia coli Possible Ciprofloxacin, 500 mg twice per day for 3 days TMP/SMX DS, 160/800 mg twice per day for 3 days —
Enterotoxigenic E. coli Proven Ciprofloxacin, 500 mg twice per day for 3 days TMP/SMX DS, 160/800 mg twice per day for 3 days Enterotoxigenic E. coli is the most common cause of traveler's diarrhea
Azithromycin, 500 mg per day for 3 days
Salmonella, non-Typhi species Doubtful in enteritis; proven in severe infection, sepsis, or dysentery — Options for severe disease: Ciprofloxacin, 500 mg twice per day for 5 to 7 days In addition to patients with severe disease, it is appropriate to treat patients younger than 12 months or older than 50 years, and patients with a prosthesis, valvular heart disease, severe atherosclerosis, malignancy, or uremia
TMP/SMX DS, 160/800 mg twice per day for 5 to 7 days
Azithromycin, 500 mg per day for 5 to 7 days Patients who are immunocompromised should be treated for 14 days
Shiga toxin–producing E. coli Controversial No treatment No treatment The role of antibiotics is unclear; they are generally avoided because of their association with hemolytic uremic syndrome
Antimotility agents should be avoided
Shigella Proven in dysentery Ciprofloxacin, 500 mg twice per day for 3 days, or 2-g single dose Azithromycin, 500 mg twice per day for 3 days Use of TMP/SMX is limited because of resistance
TMP/SMX DS, 160/800 mg twice per day for 5 days Patients who are immunocompromised should be treated for 7 to 10 days
Ceftriaxone (Rocephin), 2- to 4-g single dose
Vibrio cholerae Proven Doxycycline, 300-mg single dose Azithromycin, 1-g single dose Doxycycline and tetracycline are not recommended in children because of possible tooth discoloration
Tetracycline, 500 mg four times per day for 3 days
TMP/SMX DS, 160/800 mg twice per day for 3 days
Yersinia Not needed in mild disease or enteritis, proven in severe disease or bacteremia — Options for severe disease: —
Doxycycline combined with an aminoglycoside
TMP/SMX DS, 160/800 mg twice per day for 5 days
Ciprofloxacin, 500 mg twice per day for 7 to 10 days
Protozoal
Cryptosporidium Possible Therapy may not be necessary in immunocompetent patients with mild disease or in patients with AIDS who have a CD4 cell count greater than 150 cells per mm3 Option for severe disease: Nitazoxanide (Alinia), 500 mg twice per day for 3 days (may offer longer treatment for refractory cases in patients with AIDS) Highly active antiretroviral therapy, which achieves immune reconstitution, is adequate to eradicate intestinal disease in patients with AIDS
Cyclospora or Isospora Proven TMP/SMX DS, 160/800 mg twice per day for 7 to 10 days — —
AIDS or immunosuppression: TMP/SMX DS, 160/800 mg twice to four times per day for 10 to 14 days, then three times weekly for maintenance
Entamoeba histolytica Proven Metronidazole, 750 mg three times per day for 5 to 10 days, plus paromomycin, 25 to 35 mg per kg per day in 3 divided doses for 5 to 10 days Tinidazole (Tindamax), 2 g per day for 3 days, plus paromomycin, 25 to 35 mg per kg per day in 3 divided doses for 5 to 10 days If the patient has severe disease or extraintestinal infection, including hepatic abscess, serology will be positive
Giardia Proven Metronidazole, 250 to 750 mg three times per day for 7 to 10 days Tinidazole, 2-g single dose Relapses may occur
Microsporida Proven Albendazole (Albenza), 400 mg twice per day for 3 weeks — Highly active antiretroviral therapy, which achieves immune reconstitution, is adequate to eradicate intestinal disease in patients with AIDS
DS = double strength; TMP/SMX = trimethoprim/sulfamethoxazole.
Information from reference, Am Fam Physician. 2014 Feb 1;89(3):180-189.

Generally avoid using antibiotics if you suspect toxin-producing E. coli in patients with bloody diarrhea withOUT a fever. Antibiotics are linked to a higher risk of hemolytic uremic syndrome in this case. And don't give loperamide (Imodium) or other antimotility agents to patients with a fever or bloody stools or suspected C. difficle due to concerns of prolonging the infection or toxic megacolon.

Be aware that probiotics, such as Lactobacillus (Lacteol Forte) or Saccharomyces boulardii, may shorten the duration of diarrhea by about a day. But AVOID them in immunocompromised patients due to reported cases of bacteremia and fungemia. Keep in mind to use contact precautions; gloves, gowns, and proper hand hygiene. Choose soap and water over alcohol-based rubs for suspected Cryptosporidium, Norovirus, or spore-formers such as C. difficle.

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