Infectious Diarrhea
Infectious Diseases Society of America
A detailed clinical and exposure history should be obtained from people with diarrhea, under any circumstances, including when there is a history of similar illness in others.
People with diarrhea who attend or work in child care centers, long-term care facilities, patient care, food service, or recreational water venues (eg, pools and lakes) should follow jurisdictional recommendations for outbreak reporting and infection control.
People with fever or bloody diarrhea should be evaluated for enteropathogens for which antimicrobial agents may confer clinical benefit, including Salmonella enterica subspecies, Shigella, and Campylobacter.
Enteric fever should be considered when a febrile person (with or without diarrhea) has a history of travel to areas in which causative agents are endemic, has consumed foods prepared by people with recent endemic exposure, or has laboratory exposure to S enterica subspecies enterica serovar Typhi and S enterica subspecies enterica serovar Paratyphi.
People of all ages with acute diarrhea should be evaluated for dehydration, which increases the risk of life-threatening illness and death, especially among the young and older adults.
When the clinical or epidemic history suggests a possible Shiga toxin–producing organism, diagnostic approaches should be applied that detect Shiga toxin (or the genes that encode them) and distinguish Escherichia coli O157:H7 from other Shiga toxin–producing E coli (STEC) in stool. In addition, Shigella dysenteriae type 1 and, rarely, other pathogens may produce Shiga toxin and should be considered as a cause of hemolytic-uremic syndrome (HUS), especially in people with suggestive international travel or personal contact with a traveler.
Stool testing should be performed for Salmonella, Shigella, Campylobacter, Yersinia, C difficile, and STEC in people with diarrhea accompanied by fever, bloody or mucoid stools, severe abdominal cramping or tenderness, or signs of sepsis. Bloody stools are not an expected manifestation of infection with C difficile. STEC O157 should be assessed by culture, and non-O157 STEC should be detected by Shiga toxin or genomic assays. Sorbitol-MacConkey agar or an appropriate chromogenic agar alternative is recommended to screen for O157:H7 STEC; detection of Shiga toxin is needed to detect other STEC serotype.
Blood cultures should be obtained from infants <3 months of age, people of any age with signs of septicemia or when enteric fever is suspected, people with systemic manifestations of infection, people who are immunocompromised, people with certain high-risk conditions such as hemolytic anemia, and people who traveled to or have had contact with travelers from enteric fever–endemic areas with a febrile illness of unknown etiology.
Test for Y enterocolitica in people with persistent abdominal pain (especially school-aged children with right lower quadrant pain mimicking appendicitis who may have mesenteric adenitis), and in people with fever at epidemiologic risk for yersiniosis, including infants with direct or indirect exposures to raw or undercooked pork products.
Test stool specimens for Vibrio species in people with large-volume rice water stools or either exposure to salty or brackish waters, consumption of raw or undercooked shellfish, or travel to cholera-endemic regions within 3 days prior to onset of diarrhea.
Travelers with diarrhea lasting 14 days or longer should be evaluated for intestinal parasitic infections. Testing for C difficile should be performed in travelers treated with antimicrobial agent(s) within the preceding 8 to 12 weeks. In addition, gastrointestinal tract disease including inflammatory bowel disease (IBD) and postinfectious irritable bowel syndrome (IBS) should be considered for evaluation.
Testing may be considered for C difficile in people >2 years of age who have a history of diarrhea following antimicrobial use and in people with healthcare-associated diarrhea. Testing for C difficile may be considered in people who have persistent diarrhea without an etiology and without recognized risk factors. A single diarrheal stool specimen is recommended for detection of toxin or a toxigenic C difficile strain (eg, nucleic acid amplification testing). Multiple specimens do not increase yield.
The empiric antimicrobial therapy in adults should be either a fluoroquinolone such as ciprofloxacin, or azithromycin, depending on the local susceptibility patterns and travel history. Empiric therapy for children includes a third-generation cephalosporin for infants <3 months of age and others with neurologic involvement, or azithromycin, depending on local susceptibility patterns and travel history.
Reduced osmolarity oral rehydration solution (ORS) is recommended as the first-line therapy of mild to moderate dehydration in infants, children, and adults with acute diarrhea from any cause, as well as in people with mild to moderate dehydration associated with vomiting or severe diarrhea.
Isotonic intravenous fluids such as lactated Ringer's and normal saline solution should be administered when there is severe dehydration, shock, or altered mental status and failure of ORS therapy or ileus.
In severe dehydration, intravenous rehydration should be continued until pulse, perfusion, and mental status normalize and the patient awakens, has no risk factors for aspiration, and has no evidence of ileus.
Human milk feeding should be continued in infants and children throughout the diarrheal episode.
Resumption of an age-appropriate usual diet is recommended during or immediately after the rehydration process is completed.
Antimotility drugs (eg, loperamide) should not be given to children <18 years of age with acute diarrhea. Loperamide may be given to immunocompetent adults with acute watery diarrhea, but should be avoided at any age in suspected or proven cases where toxic megacolon may result in inflammatory diarrhea or diarrhea with fever.
Rotavirus vaccine should be administered to all infants without a known contraindication.
Typhoid vaccination is recommended as an adjunct to hand hygiene and the avoidance of high-risk foods and beverages, for travelers to areas where there is moderate to high risk for exposure to Salmonella enterica subspecies enterica serovar Typhi, people with intimate exposure (eg, household contact) to a documented S enterica subspecies enterica serovar Typhi chronic carrier, and microbiologists and other laboratory personnel routinely exposed to cultures of S enterica subspecies enterica serovar Typhi. Booster doses are recommended for people who remain at risk.
A live attenuated cholera vaccine, which is available as a single-dose oral vaccine in the United States, is recommended for adults 18 to 64 years of age who travel to cholera-affected areas.
Reference
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):1963-73. https://academic.oup.com/cid/article/65/12/e45/4557073
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: John Anello, Brian Feinberg, John Heinegg, et. al. New Clinical Practice Guidelines, December 2017 - Medscape - Dec 06, 2017.
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