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Diarrhea Stefano Guandalini, MD, Director, University of Chicago Celiac Disease Program, Section Chief of Gastroenterology, Hepatology and Nutrition;

Professor, Department of Pediatrics, University of Chicago Comer Children's Hospital Richard E Frye, MD, PhD, Assistant Professor, Departments of Pediatrics and Neurology, University of Texas Health Science Center at Houston; M Akram Tamer, MD, Program Director, Professor, Department of Pediatrics, University of Miami Updated: Jan 5, 2009 Introduction Background Acute diarrhea is defined as the abrupt onset of abnormally high fluid content in the stool (more than the normal value of approximately 10 mL/kg/d). This situation typically implies an increased frequency of bowel movements, which can range from 4-5 to more than 20 times per day. The augmented water content in the stools is due to an imbalance in the physiology of the small and large intestinal processes involved in the absorption of ions, organic substrates, and thus water. A common disorder in its acute form, diarrhea has many causes and may be mild to severe. Childhood acute diarrhea is usually caused by infection; however, numerous disorders may cause this condition, including a malabsorption syndrome and various enteropathies. Acute-onset diarrhea is usually self-limited; however, an acute infection can have a protracted course. By far, the most common complication of acute diarrhea is dehydration. Although the term "acute gastroenteritis" is commonly used synonymously with "acute diarrhea," the former term is a misnomer. The term gastroenteritis implies inflammation of both the stomach and the small intestine, whereas, in reality, gastric involvement is rarely if ever seen in acute diarrhea (including diarrhea with an infectious origin); enteritis is also not consistently present. Examples of infectious acute diarrhea syndromes that do not cause enteritis include Vibrio cholerae– induced diarrhea and Shigella -induced diarrhea. Thus, the term acute diarrhea is preferable to acute gastroenteritis. Diarrheal episodes are classically distinguished into acute and chronic (or persistent) based on their duration. Acute diarrhea is thus defined as an episode that has an acute onset and lasts no longer than 14 days; chronic or persistent diarrhea is defined as an episode that lasts longer than 14 days. The distinction, supported by the World Health Organization (WHO), has implications not only for classification and epidemiological studies but also from a practical standpoint because protracted diarrhea often has a different set of causes, poses different problems of management, and has a different prognosis. Pathophysiology Diarrhea is the reversal of the normal net absorptive status of water and electrolyte absorption to secretion. Such a derangement can be the result of either an osmotic force that acts in the lumen to drive water into the gut or the result of an active secretory state induced in the enterocytes. In the former case, diarrhea is osmolar in nature, as is observed after the ingestion of nonabsorbable sugars such as lactulose or lactose in lactose malabsorbers. Instead, in the typical active secretory state, enhanced anion secretion (mostly by the crypt cell compartment) is best exemplified by enterotoxin-induced diarrhea. In osmotic diarrhea, stool output is proportional to the intake of the unabsorbable substrate and is usually not massive; diarrheal stools promptly regress with discontinuation of the offending nutrient, and the stool ion gap is high, exceeding 100 mOsm/kg. In fact, the fecal osmolality in this circumstance is accounted for not only by the electrolytes but also by the unabsorbed nutrient(s) and their degradation products. The ion gap is obtained by subtracting the concentration of the electrolytes from total osmolality, according to the formula: ion gap = osmolality – [(Na + K) × 2]. In secretory diarrhea, the epithelial cells’ ion transport processes are turned into a state of active secretion. The most common cause of acute-onset secretory diarrhea is a bacterial infection of the gut. Several mechanisms may be at work. After colonization, enteric pathogens may adhere to or invade the epithelium; they may produce enterotoxins (exotoxins that elicit secretion by increasing an intracellular second messenger) or cytotoxins. They may also trigger release of cytokines attracting inflammatory cells, which, in turn, contribute to the activated secretion by inducing the release of agents such as prostaglandins or platelet-activating factor. Features of secretory diarrhea include a high purging rate, a lack of response to fasting, and a normal stool ion gap (ie, 100 mOsm/kg or less), indicating that nutrient absorption is intact. Frequency United States In the United States, one estimate assumes a cumulative incidence of 1 hospitalization for diarrhea per 23-27 children by age 5 years, with more than 50,000 hospitalizations in 2000. By these estimates, rotavirus is associated with 4-5% of all childhood hospitalizations, and 1 in 67 to 1 in 85 children are hospitalized due to rotavirus by age 5 years. Furthermore, acute diarrhea is responsible for 20% of physician referrals in children younger than 2 years and for 10% in children younger than 3 years. International

diarrhea is defined as daily stools with a weight greater than 200 g. In developing countries. • A prospective study conducted in the United States in 604 children aged 3-36 months in community settings found that the highest incidence of acute diarrhea was in January and August. Table 1. however. Stool Characteristics and Determining Their Source Stool Small Bowel Large Bowel Characteristics Appearance Watery Mucoid and/or bloody Volume Large Small . Table 1 outlines these characteristics and demonstrates that an index of suspicion can be easily generated for a specific set of organisms.In developing countries.6 million yearly deaths in children younger than age 5 years. diarrhea is defined as daily stools with a volume greater than 10 mL/kg. diarrhea morbidity in published reports from 1990-2000 slightly increased worldwide compared with previous reports. Yersinia enterocolitis typically infects children younger than 1 year. In fact. Age and nutritional status appear to be the most important host factors in determining the severity and the duration of diarrhea. which can be observed with infection with Giardia lamblia. it still remains high. and long-term consequences of the vicious cycle of enteric infections. Furthermore. breastfed children may normally have 5-6 stools per day. however. Astrovirus and norovirus usually infect children younger than 5 years. Rotavirus and adenovirus are particularly prevalent in children younger than 2 years. Very young children are particularly susceptible to secondary dehydration and secondary nutrient malabsorption. self-limited condition. poverty also adds an enormous additional burden. o In children younger than 2 years. with 18% of the 10. life-threatening dehydration as a result of the high body-water turnover and limited renal compensatory capacity of very young children. diarrhea.21 episodes per person-year. a reduction in the overall frequency of diarrheal episodes is hoped for in the near future. the younger the child. the higher is the risk for severe. o In children older than 2 years. Age Viral diarrhea is most common in young children. and a greater number of work days lost than nonrotavirus gastroenteritis. an average of 3 episodes per child per year in children younger than 5 years is reported. Because the single most common cause of infectious diarrhea worldwide is rotavirus. for example. with a median duration of 2 d and a median of 6 stools per day). Mortality/Morbidity Mortality from acute diarrhea is overall globally declining but remains high. • Knowledge of the characteristics of consistency. volume. Childhood mortality associated with diarrhea has constantly but slowly declined during the past 2 decades. some areas report 6-8 episodes per year per child. subsiding within a few days. In these settings. malnutrition is an important additional risk factor for diarrhea. lasting <14 d. • Flatulence associated with foul-smelling stools that float suggests fat malabsorption. Whether younger age also means a risk of running a prolonged course is an unsettled issue. Sex Most cases of infectious diarrhea are not sex specific. fever. and because a vaccine has been in use for over 2 years now. Clinical History • Acute diarrhea in developed countries is almost invariably a benign. For example. and recurrent episodes of diarrhea lead to growth faltering. Most estimates have diarrhea as the second cause of childhood mortality. and the Aeromonas organism is a significant cause of diarrhea in young children. rotavirus is more commonly associated with vomiting. and frequency can be helpful in determining whether the source is from the small or large bowel. • Diarrhea implies an increase in stool volume and diminished stool consistency. Despite a progressive reduction in global diarrheal disease mortality over the past 2 decades. color. this typically means loose-to-watery stools passed 4 or more times per day. persistent postenteritis diarrhea has a strong inverse correlation with age. In practice. o Individual stool patterns widely vary. Females have a higher incidence of Campylobacter species infections and hemolytic uremic syndrome (HUS). with an overall incidence of 2. mostly because of the widespread use of oral rehydration solutions. The clinical presentation and course of illness depend on the etiology of the diarrhea and on the host.[1 ]Close to 90% of episodes were acute (ie. in countries where the toll of diarrhea is highest. and malnutrition are devastating.

Giardia. Table 2. It also outlines incubation periods and usual duration of symptoms of common organisms. Entamoeba species) may be associated with a protracted course. enterohemorrhagic) • Shigella species • Salmonella species • Campylobacter species • Yersinia species • Aeromonas species • Plesiomonas species Enterotoxigenic bacteria Toxic bacteria • E coli • Clostridium difficile • Klebsiella • Clostridium perfringens • Cholera species • Vibrio species Parasites Parasites • Giardia species • Entamoeba organisms • Cryptosporidium species • Associated systemic symptoms include the following: o Some enteric infections commonly have systemic symptoms.Frequency Blood pH Reducing substances WBCs Serum WBCs Organisms Increased Possibly positive but never gross blood Possibly <5.5 Negative Commonly >10/high power field Possible leukocytosis. C difficile. bandemia Invasive bacteria • Escherichia Coli (enteroinvasive. Certain organisms (eg. Organisms and Frequency of Symptoms Organism Incubat Durat Vomit Fev Abdominal ion ion ing er Pain Rotavirus 1-7 d 4-8 d Yes Low No Adenovirus 8-10 d 5-12 d Delaye Low No d Norovirus 1-2 d 2d Yes No No Astrovirus 1-2 d 4-8 d +/+/No Calicivirus 1-4 d 4-8 d Yes +/No Aeromonas None 0-2 wk +/+/No species Campylobacter 2-4 d 5-7 d No Yes Yes species C difficile Variable Variabl No Few Few e C perfringens Minimal 1 d Mild No Yes Enterohemorrhag 1-8 d 3-6 d No +/Yes ic E coli Enterotoxigenic E 1-3 d 3-5 d Yes Low Yes coli Plesiomonas None 0-2 wk +/+/+/species Salmonella 0-3 d 2-7 d Yes Yes Yes species . whereas others less commonly are associated with systemic features. o Table 2 outlines the frequency of some of these symptoms with particular organisms.5 Possibly positive <5/high power field Normal Viral • Rotavirus • Adenovirus • Calicivirus • Astrovirus • Norovirus Highly increased Commonly grossly bloody >5.

calicivirus. V cholerae  Travel to Japan -Vibrio parahaemolyticus  Travel to Mexico -Aeromonas. Shigella. and Cryptosporidium species. Aeromonas organisms are associated with exposure to the marine environment. Plesiomonas. o Exposure to turtles is associated with Salmonella organisms. highest for persons traveling to Africa. Salmonella.Enterotoxigenic E coli and Aeromonas. Salmonella. Plesiomonas. and Yersinia species  New Guinea -Clostridium species • Animal exposure can contribute to diarrhea. therefore. o Travel to Central and South America and Eastern European countries is also associated with a relatively high risk of contracting diarrhea. V cholerae. enterotoxigenic E coli  Travel to Asia -V cholerae  Travel to Australia -Yersinia species  Travel to Canada -Yersinia species  Travel to Europe -Yersinia species  Travel to India -Entamoeba species. Y enterocolitica  Seafood . and Campylobacter. o Increase in daycare usage has raised the incidence of rotavirus and Cryptosporidium species. Giardia. o Swimming pools have been associated with outbreaks of infection with Shigella species. o Risk of contracting diarrhea while traveling is. o Rotavirus and Shigella. o Organisms that cause food poisoning include the following:  Dairy food -Campylobacter and Salmonella species  Eggs -Salmonella species  Meats -C perfringens and Aeromonas.Shigella species 0-2 d 2-5 d No High Yes Vibrio species 0-1 d 5-7 d Yes No Yes Y enterocolitica None 1-46 d Yes Yes Yes Giardia species 2 wk 1+ wk No No Yes Cryptosporidium 5-21 d Month No Low Yes species s Entamoeba 5-7 d 1-2+ No Yes No species wk • Daycare considerations are as follows: o Certain organisms are spread quickly in daycare. o Ingestion of raw or contaminated food is a common cause. and Entamoeba organisms are resistant to water chlorination. • Certain medical conditions predispose patients to infection. and Salmonella species  Ground beef . exposure to contaminated water should raise index of suspicion for these parasites.Enterohemorrhagic E coli  Poultry -Campylobacter species  Pork -C perfringens. o Exposure to young dogs or cats is associated with Campylobacter organisms. o Other organisms that are prevalent in particular parts of the world include the following:  Nonspecific foreign travel history . Campylobacter. astrovirus. o Giardia. Entamoeba. Cryptosporidium. and Shigella species  Underdeveloped tropical visit -C perfringens  Travel to Africa -Entamoeba species.Astrovirus and Aeromonas. • Food history can be helpful. These organisms include rotavirus. • A history of camping suggests exposure to water sources contaminated with Giardia organisms. and Vibrio species  Oysters . Plesiomonas. by far. o Enterotoxigenic E coli is the leading cause of traveler's diarrhea. and Campylobacter organisms are prevalent worldwide and need to be considered regardless of specific travel history. including the following: . Vibrio cholerae  Travel to South America and Central America -Entamoeba species. • Travel history may indicate a cause for diarrhea. o Water is a major reservoir for many organisms that cause diarrhea. Giardia.Calicivirus and Plesiomonas and Vibrio species  Vegetables -Aeromonas species and C perfringens • Water exposure can contribute to diarrhea.

malaria Rotavirus .Immunocompromised or immunosuppressed state Physical • Dehydration o Dehydration is the principal cause of morbidity and mortality. or guarding. depressed consciousness. one should not dismiss other causes that can lead to the same presentation. o With focal abdominal pain worsened by palpation." Causes Although infectious agents are by far the most common cause for sporadic or endemic episodes of acute diarrhea. fat. lack of tears. o Assess every patient with diarrhea for signs. • Borborygmi: Significant increases in peristaltic activity can cause an audible and/or palpable increase in bowel activity. antibiotic administration Plesiomonas species . • Causes of acute diarrhea include the following: o Infections  Enteric infections (including food poisoning  Extraintestinal infections o Drug-induced  Antibiotic-associated  Laxatives  Antacids that contain magnesium  Opiate withdrawal  Other drugs o Food allergies or intolerances  Cow's milk protein allergy  Soy protein allergy  Multiple food allergies  Olestra  Methylxanthines (caffeine.Hospitalization Giardia species -Agammaglobulinemia. chronic pancreatitis. • Failure to thrive and malnutrition o Reduced muscle and fat mass or peripheral edema may be clues to the presence of carbohydrate. and severity. malnutrition. dry mucous membranes. cystic fibrosis Cryptosporidia species . sunken anterior fontanel. rebound tenderness. and/or protein malabsorption. symptoms.Liver diseases or malignancy Salmonella species . o Secondary bile acid malabsorption can result in a severe diaper dermatitis that is often characterized as a "burn.Intestinal dysmotility. o Secondary carbohydrate malabsorption often results in acidic stools. vitamin B3 . • Abdominal pain o Nonspecific nonfocal abdominal pain and cramping are common with some organisms. achlorhydria. immunosuppression. resulting in lactose intolerance o Chemotherapy or radiation-induced enteritis o Surgical conditions  Acute appendicitis  Intussusception o Vitamin deficiencies  Niacin deficiency  Folate deficiency o Vitamin toxicity  Vitamin C  Niacin. particularly in young children. hemolytic anemia (especially sickle cell disease). sunken eyes. o Giardia organisms can cause intermittent diarrhea and fat malabsorption. o Lethargy. theophylline) o Disorders of digestive/absorptive processes  Sucrase-isomaltase deficiency  Late-onset (adult-type) hypolactasia. achlorhydria. o Pain usually does not increase with palpation.o o o o o o C difficile . • Perianal erythema o Frequent stools can cause perianal skin breakdown. poor skin turgor. and delayed capillary refill are obvious and important signs of dehydration. theobromine.Hospitalization. be alert for possible complications or for another noninfectious diagnosis.

• Examine any exudates found in stool for leukocytes.0-3% of cases  Y enterocolitica . which is usually secondary to viral illness and transient in nature. presence of fecal leukocytes eliminates consideration of enterotoxigenic E coli. hyacinths.5 or less or presence of reducing substances indicates carbohydrate intolerance. allergic. copper. mistletoe. Vibrio species.0-2% of cases  Vibrio parahaemolyticus . Although stool cultures are useful when positive.Unknown  Aeromonas hydrophila . azalea. zinc) Ingestion of plants (eg. • History of raw seafood ingestion or foreign travel should prompt additional screening for Vibrio and Plesiomonas species. Amanita species mushrooms • Infectious causes of acute diarrhea in developed countries o Viruses  Rotavirus . Shigella. Such exudates highly suggest colitis (80% positive predictive value). determine if the type of E coli is O157:H7. • Look for C difficile in persons with episodes of diarrhea characterized by colitis and/or blood in the stools.1-2% of cases  C difficile . A high index of suspicion is needed to choose the appropriate medium. daffodils.0-2% of cases o Parasites  Cryptosporidium . • Many different culture mediums are used to isolate bacteria. yield is low. refrigerate at 4°C or place in a transport medium. Colitis can be infectious. • Bloody diarrhea with a history of ground beef ingestion must raise suspicion for enterohemorrhagic E coli. to be shed into stool. and viruses.25-40% of cases  Calicivirus . and Campylobacter organisms and Y enterocolitica in the presence of clinical signs of colitis or if fecal leucocytes are found.0-1% of cases  V cholerae . • With stool not cultured within 2 hours of collection. Remember that acute-onset diarrheal episodes associated with C difficile may also occur without a history of antibiotic use. If E coli is found in the stool. Absence of fecal leukocytes does not eliminate the possibility of enteroinvasive organisms.1-3% of cases Differential Diagnoses Appendicitis Intussusception Carcinoid Tumor Irritable Bowel Syndrome Congenital Microvillus Atrophy Malabsorption Syndromes Crohn Disease Meckel Diverticulum Cystic Fibrosis Protein Intolerance Giardiasis Shigella Infection Hyperthyroidism Short Bowel Syndrome Intestinal Enterokinase Deficiency Ulcerative Colitis Intestinal Protozoal Diseases Workup Laboratory Studies • In patients with diarrhea.4-9% of cases  Enteric-type adenovirus .3-7% of cases  E Coli . a stool pH level of 5. but not only.1-20% of cases  Norovirus . cause of HUS. Common Bacteria and Optimum Culture Mediums Organism Detection Method Microbiologic Characteristics Aeromonas Blood agar Oxidase-positive flagellated gram-negative o o . or part of inflammatory bowel disease (Crohn disease.1-3% of cases  G lamblia . However. This type of E coli is the most common.Ingestion of heavy metals or toxins (eg.2-4% of cases o Bacteria  Campylobacter jejuni . • Always culture stool for Salmonella. • Enteroinvasive infections of the large bowel cause leukocytes. tin. Table 3.10% of cases  Astrovirus .6-8% of cases  Salmonella .3-5% of cases  Shigella . Table 3 lists common bacteria and optimum culture mediums for their growth. ulcerative colitis). predominantly neutrophils.

detects cytochrome oxidase production o MacConkey EMB agar . as well as in cases in which a search for a cause is believed to be mandatory (eg. Shigella organisms cause a marked bandemia with a variable total white blood cell count. dry mucous membranes. chronic medical conditions. (GPR). • Adenovirus antigens can be detected by enzyme immunoassay.Inhibits gram-positive organisms.Selective for enterohemorrhagic E coli o CIN agar . decreased tears. Perform stool examination every 3 days or every other day. permits lactose fermentation H2S production o Skirrow agar . xylose-lysineNonlactose non–H2S-producing GNR species deoxycholate (XLD). in patients with acquired immunodeficiency syndrome [AIDS] or patients who are otherwise severely immunocompromised). and false-positive results occur. and decreased urine output • Mental status changes • Inadequate responses to oral rehydration therapy (ORT) or caregiver unable to administer ORT . enzyme immunoassay (EIA) for toxin. permits lactose fermentation o XLD agar. Leukocytosis is often but not constantly observed with enteroinvasive bacteria.Inhibits gram-positive organisms and nonpathogenic GNB. or concurrent illness • Fever of 38ºC or higher in infants younger than 3 months or 39ºC or higher in children aged 3-36 months • Visible blood in the stool • High-output diarrhea • Persistent emesis • Signs of dehydration as reported by caregiver. Salmonella species. produces latex agglutination (LA) for protein pseudomembranous colitis C perfringens None available Anaerobic spore-forming GPR. • Examination of stools for ova and parasites is best for finding parasites. In these circumstances. toxin-mediated diarrhea.Selective for Campylobacter species o SM agar . • At times. Campylobacter jejuni 90% and Campylobacter coli 5% of infections C difficile Cycloserine-cefoxitin-fructose-egg (CCFE) Anaerobic spore-forming gram-positive rod agar. a protein-losing enteropathy can be found in patients with extensive inflammation in the course of enteroinvasive intestinal infections (eg.Selective for Vibrio species o CCFE agar . Procedures • Intestinal biopsy: This procedure may be indicated in the presence of chronic or protracted diarrhea. • The leukocyte count is usually not elevated in viral-mediated and toxin-mediated diarrhea. low serum albumin levels and high fecal alpha1-antitrypsin levels can be found. enteroinvasive E coli).Selective for Y enterocolitica o TCBS agar .All aerobic bacteria and yeast. including sunken eyes.[2 ] Indications for medical evaluation of children with acute diarrhea include the following: • Older than 3 months • Weight of more than 8 kg • History of premature birth. toxinmediated diarrhea E coli MacConkey eosin-methylene blue (EMB) or Lactose-producing GNR Sorbitol-MacConkey (SM) agar Plesiomonas Blood agar Oxidase-positive GNR species Salmonella Blood. MacConkey EMB.species Campylobact Skirrow agar er species bacillus (GNB) Rapidly motile curved gram-negative rod (GNR). The false-negative rate is approximately 50%. or Hektoen enteric (HE) agar • Culture mediums used to isolate bacteria include the following: o Blood agar . Treatment Medical Care In 2003 the Center for Disease Control (CDC) put forth new recommendations for the management of acute pediatric diarrhea in both the outpatient and inpatient settings including indication for referral.Selective for C difficile • Rotavirus antigen can be identified by enzyme immunoassay and latex agglutination assay of the stool. Only serotypes 40 and 41 are able to induce diarrhea. HE agar . particularly in the presence of blood in the stools.

576. In fact. The composition of almost all other beverages (carbonated or not) that are commercially available and frequently used in children with diarrhea is completely inadequate for rehydration or for maintaining hydration. in particular the United States. This method is time intensive and requires a dedicated caregiver. administer through nasogastric tube or intravenously administer 5% dextrose (one fourth normal saline) with 20 mEq/L potassium chloride ORT is the cornerstone of treatment. followed by 100 mL/kg oral rehydration solution over 4 hours or 5% dextrose (half normal saline) intravenously at twice maintenance fluid rates o Replacement of losses  Less than 10 kg body weight . considering the sodium content. Coca-Cola. in the vast majority of episodes of acute diarrhea.60-120 mL oral rehydration solution for each diarrhea stool or vomiting episode  More than 10 kg body weight . especially for small-bowel infections that produce a large volume of watery stool output. resumption of feeding is strongly recommended. in which intravenous rehydration unduly continues to be widely privileged. Oral rehydration is now universally recommended to be completed within 4 hours. Hepatology and Nutrition (ESPGHAN).120-140 mL oral rehydration solution for each diarrhea stool or vomiting episode • Mild-to-moderate dehydration o Rehydration therapy . The ideal solution has a low osmolarity (210-250) and a sodium content of 50-60 mmol/L. Treatment of dehydration due to diarrhea includes the following: • Minimal or no dehydration o Rehydration therapy .[3 ]However.120-140 mL oral rehydration solution for each diarrhea stool or vomiting episode • Severe dehydration o Rehydration therapy .60-120 mL oral rehydration solution for each diarrhea stool or vomiting episode  More than 10 kg body weight . and most effective way to provide rehydration and maintain hydration in children with acute diarrhea worldwide.120-140 mL oral rehydration solution for each diarrhea stool or vomiting episode  If unable to drink. cooperation improves enough to take small sips from a cup. Antimicrobial therapy is indicated for some nonviral diarrhea because most is self-limiting and does not require therapy. Educate caregivers in methods necessary to replace this amount of fluid. many studies convincingly demonstrate that early refeeding hastens recovery. Administer small amounts of fluid at frequent intervals to minimize discomfort and vomiting. Antimotility agents are not indicated for infectious diarrhea. seem to be lagging behind despite studies that demonstrate beyond doubt the efficacy of ORT in emergency care settings. most physiologic. Therapies recommended for some nonviral diarrheas include the following: . and 694-773. Pepsi-Cola. refeeding can be accomplished without the use of any special (eg. and by the American Academy of Pediatrics. Encouragement from the physician is necessary to promote compliance. Also. the global use of ORT is still insufficient.60-120 mL oral rehydration solution for each diarrhea stool or vomiting episode  More than 10 kg body weight . The syringe can be quickly used to place small amounts of fluid in the mouth of a child who is uncooperative. by the ad hoc committee of European Society for Pediatric Gastroenterology. A 5-mL or 10-mL syringe without a needle is a very useful tool. as recommended by the WHO.The report also includes information on assessment of dehydration and what steps should be taken to adequately treat acute diarrhea. water. except for refractory cases of Cryptosporidium infection. ORT with a glucose-based ORS must be viewed as by far the safest. respectively. Once the child becomes better hydrated.Not applicable o Replacement of losses  Less than 10 kg body weight . robust evidence suggests that. and apple juice have an osmolarity of 493. Administer maintenance fluids plus replacement of losses. At completion of hydration. and nutrients.Intravenous lactated Ringer solution or normal saline (20 mL/kg until perfusion and mental status improve).Oral rehydration solution (50-100 mL/kg over 3-4 h) o Replacement of losses  Less than 10 kg body weight . For instance. which is invariably extremely low. lactose-free or soy-based) formulas. and osmolarity that is often dangerously elevated. Not all commercial ORT formulas promote optimal absorption of electrolytes. Developed countries.

chemotherapy. a very transient use of lactose-free formulas (5-6 d) can be considered. TMP-SMX is first-line medication. o If the infectious etiology in individuals with such symptoms is not certain. However. and is not indicated for nontyphoid-uncomplicated diarrhea. immunocompromised. applesauce. ceftriaxone. and its poor protein content may be a contraindication. • Plesiomonas species: Use TMP-SMX or any cephalosporin. it also promotes faster recovery and provides improved nutrition. Use ceftriaxone and cefotaxime for invasive disease. however. is associated with relapse. • Yersinia species: TMP-SMX. and complications can be more serious and fulminate. resistance occurs. effectiveness is not proven. • Cryptosporidium parvum: Administer paromomycin. reserve for complicated cases. o In an incident of worsening of diarrhea proven to be secondary to a clinically important lactose malabsorption in infants positive for rotavirus. Treatment does not shorten disease duration. o A strong body of evidence now suggests that resuming the prediarrhea diet is perfectly safe and must be encouraged. rice. TMP-SMX is first-line medication. sickle cell disease). where withdrawal of breastfeeding during diarrhea has been shown to have a deleterious effect on the development of dehydration in infants with acute watery diarrhea. Asymptomatic carriers in nonendemic areas should receive iodoquinol or paromomycin. and erythromycin is second-line antibiotic. In fact. cefixime. • V cholerae: Treat infected individuals and contacts. • C perfringens: Do not treat with antibiotics. • Lactose ingestion o Although rotavirus can cause secondary transient lactose intolerance. a newer anthelmintic. o Symptoms resembling appendicitis. • G lamblia: Metronidazole or nitazoxanide can be used. seek consultation with a surgeon. If antibiotics cannot be stopped or this does not result in resolution. rice. • E coli: Trimethoprim-sulfamethoxazole (TMP-SMX) should be administered if moderate or severe diarrhea is noted. it is not recommended. • Entamoeba histolytica: Metronidazole followed by iodoquinol or paromomycin is administered in symptomatic patients. • C difficile: Discontinue potential causative antibiotics. or immunosuppressive drugs because atypical organisms are more likely. Medication • .Aeromonas species: Use cefixime and most third-generation and fourth-generation cephalosporins. however. however. Consultations • Surgeon o Certain organisms cause abdominal pain and bloody stools. ceftriaxone. and cefotaxime are recommended for invasive disease. applesauce. use lactose-containing formulas in all individuals with diarrhea. Nitazoxanide. obviously respecting any (usually temporary) lack of appetite. Doxycycline is the first-line antibiotic. no evidence shows that this diet is useful. or toxic megacolon may be appreciated. This is even more important in developing countries. is effective against C parvum. • Bananas. therefore. • Shigella species: Treatment shortens illness duration and shedding but does not prevent complications. and cefotaxime are used. Diet Breastfed infants with acute diarrhea should be continued on breast milk without any need for interruption. breastfeeding not only has a well-known protective effect against the development of enteritis. Cefixime. • Infectious-disease specialist: Consider consultation with an infectious-disease specialist for any patient who is immunocompromised because of HIV infection. Vancomycin is reserved for the child who is seriously ill. antibiotic treatment may increase likelihood of hemolytic-uremic syndrome (HUS). use oral metronidazole or vancomycin. resistance occurs. hemorrhagic colitis. Treat infants younger than 3 months and high-risk patients (eg. • Salmonella species: Treatment prolongs carrier state. Parenteral second-generation or third-generation cephalosporin is indicated for systemic complications. • Campylobacter species: Erythromycin shortens illness duration and shedding. and toast diet o A banana. and toast (BRAT) diet was introduced in the United States in 1926 and has enjoyed vast popularity. this finding is believed to be generally not clinically relevant. intussusception.

and G lamblia. The effect is not only strain-dependent but also dose-dependent.[2 ] Pharmacological treatment is rarely of any use. Dosing Adult 400 mg/d PO qd for 7-10 d Pediatric 8 mg/kg/d PO qd for 7-10 d Interactions Aminoglycosides increase nephrotoxic potential. with doses of at least 5 billion/d. estimates suggest that rotavirus infections cause over 50. However. B). Their use is confined to specific etiologies and/or clinical circumstances. help destroy offending organisms.Diarrheal diseases have been the object of numerous forms of treatment. we suggest the use of probiotic strains with proven efficacy and in appropriate doses for the management of children with acute gastroenteritis as an adjunct to rehydration therapy (II. • Agents for whom antimicrobial therapy is indicated only in selected circumstances.Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions . A recent position paper jointly published by the ESPGHAN and the European Society for Pediatric Infectious Disease (ESPID) stated. the evidence is now clear that. now well-identified probiotic strains (mostly Lactobacillus GG and Saccharomyces boulardii but also Lactobacillus reuteri) in the treatment of acute watery diarrhea (primarily rotaviral) in infants and young children in developed countries. the best option for treatment of acute-onset diarrhea is the early use of oral rehydration therapy (ORT). with lack of evidence of efficacy in invasive bacterial diarrhea. Data from well-conducted randomized controlled trials on efficacy of probiotics in children with diarrhea are definitely positive. for centuries. some strains of probiotics (lactic acid bacteria or mycetes thought to benefit the host in some circumstances when ingested in adequate doses) have been found to be effective as an adjunct when treating children with acute diarrhea. Inhibits bacterial cell wall synthesis by binding to 1 or more PBPs. probenecid may increase effects by decreasing clearance Contraindications Documented hypersensitivity Precautions Pregnancy B . and antidiarrheal drugs are often harmful. in most cases. in consideration of the high morbidity of the infection. They consistently show a statistically significant benefit and moderate clinical benefit of a few. Furthermore. if febrile or with positive blood culture findings Probiotics Recently. Such a beneficial effect seems to result in a reduction of the duration of diarrhea of little more than one day and seems to be exerted mostly on rotoviral diarrhea. Cefixime (Suprax) Potent long-acting oral cephalosporin with increased gram-negative coverage. and pathogenic similarities with Shigella o Yersinia infections in subjects with sickle cell disease o Salmonella infections in very young infants. because there is no evidence of efficacy for many preparations. The following probiotics showed benefit in meta-analyses of randomized controlled trials: Lactobacillus GG (I.000 hospital admissions annually in the United States alone. in addition to the immune system. include the following: o Infections by enteropathogenic E coli. However. B). Currently. probiotics may reduce the risk of spreading rotavirus infection by shortening diarrhea duration and volume of watery stool output and by reducing the fecal shedding of rotavirus.’’[4 ] Antibiotic and antiparasitics agents Antimicrobial agents. However. Shigella species. Bacteria eventually lyse because of ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested. In terms of recommended antimicrobial treatment in the immunocompetent host. A) and S boulardii (II. even a reduction of this order is indeed desirable because it affords considerable savings in terms of loss of working days and direct health costs. genetic. enteric bacterial and protozoan pathogens can be grouped as follows: • Agents for whom antimicrobial therapy is always indicated: The consensus includes only V cholerae. Shortening the duration of diarrhea by one day may not appear to be hugely beneficial. both dietetic and pharmacologic. ‘‘Probiotics may be an effective adjunct to the management of diarrhea. based on the serologic. when running a prolonged course o Enteroinvasive E coli.

astemizole) Precautions Pregnancy C . diarrhea) Erythromycin (E. terfenadine.Documented hypersensitivity to penicillins.Fetal risk revealed in studies in animals but not established or not studied in humans. inhibiting bacterial cell wall growth. and pain at site of injection Cefotaxime (Claforan) Third-generation cephalosporin antibiotic with activity against gram-positive and some gram-negative bacteria. coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis Contraindications Documented hypersensitivity. and cyclosporine. thrombophlebitis.E. vomiting. may cause rashes.S. cisapride. Useful for Campylobacter species and vibrio enteritis. diarrhea. may potentiate anticoagulant effects of warfarin. inhibits CYP3A4. may cause skin rashes. Dosing Adult 1-2 g IV/IM q24h Pediatric 50 mg/kg/d IV/IM divided qd/bid for 7-10 d. E-Mycin. Erythrocin) Bacteriostatic macrolide with activity against most gram-positive organisms and atypical respiratory organisms. reduced renal function.Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Caution in patients with allergies to penicillin antibiotics. Ery-Tab. or estolate) PO qid 400-800 mg (ethylsuccinate) PO qid Pediatric 50 mg/kg/d PO/IV divided qid for 7-10 d Interactions Coadministration may increase toxicity of theophylline. inhibiting bacterial cell wall growth. not to exceed 2 g/d Interactions Probenecid increases ceftriaxone serum concentration Contraindications Documented hypersensitivity. and GI upset (eg. stearate.. Dosing Adult 1-2 g IV/IM q6-8h for 7-10 d Pediatric 50 mg/kg/dose IV/IM tid for 7-10 d Interactions Probenecid may increase levels. may use if benefits outweigh risk to fetus Precautions . hepatic impairment. Dosing Adult 250-500 mg (base. Binds to PBPs. carbamazepine. Binds to PBPs. administer with food to minimize nausea and diarrhea Ceftriaxone (Rocephin) A third-generation cephalosporin antibiotic with activity against gram-positive and some gram-negative bacteria.Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Caution in patients with allergies to penicillin antibiotics. do not use in neonates who are hyperbilirubinemic Precautions Pregnancy B . coadministration with furosemide and aminoglycosides may increase nephrotoxicity Contraindications Documented hypersensitivity Precautions Pregnancy B . caution with concomitant administration of CYP3A4 substrates (eg. Eryc. nausea. digoxin.

Alternative drug for children because availability in liquid suspension. Often used in combination with other antimicrobial agents except for C difficile enterocolitis). sertraline. preexisting optic neuropathy or hepatic damage Precautions Pregnancy C . Yodoxin) Antiparasitic agents with wide coverage.Fetal risk revealed in studies in animals but not established or not studied in humans. malaise. thus. may cause rashes. gram-negative anaerobes.Caution in liver disease. adjust dose in hepatic disease. may use if benefits outweigh risk to fetus Precautions Caution in G-6-PD deficiency when administering prolonged treatments. fluoxetine. Nitrofuran with antiprotozoal activity. monitor for seizures and development of peripheral neuropathy . toxicity of meperidine. not to exceed adult dose Interactions May increase toxicity of anticoagulants. not to exceed adult dose Interactions None reported Contraindications Documented hypersensitivity. nausea. trazodone. stomach pain. vomiting. causes disulfiramlike reactions when taken with alcohol. estolate formulation may cause cholestatic jaundice. vomiting. Dosing Adult 100 mg PO qid for 7-10 d Pediatric 5 mg/kg/d PO divided qid for 7-10 d Interactions Increases levodopa blood concentrations and. and diarrhea Metronidazole (Flagyl) Very active against Giardia species. cimetidine may increase toxicity of metronidazole. Dosing Adult 650 mg PO tid pc for 20 d Pediatric 30-40 mg/kg/d PO divided tid pc for 20 d. thrombophlebitis. and Entamoeba species. GI adverse effects are common (administer pc).Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Do not use in pregnancy during first trimester. Imidazole ringbased antibiotic active against various anaerobic bacteria and protozoa. paroxetine. or fever occurs Furazolidone (Furoxone) Antiparasitic agent with wide coverage. Dosing Adult 250-500 mg PO tid for 10 d Pediatric 30-50 mg/kg/d PO divided tid for 10 d. Most common adverse effects are GI upset and brown discoloration of urine.Fetal risk revealed in studies in animals but not established or not studied in humans. inhibits enzyme monoamine oxidase. MAOIs. discontinue use if nausea. sympathomimetic amines. disulfiramlike reaction may occur with orally ingested ethanol Contraindications Documented hypersensitivity Precautions Pregnancy B . commonly causes nausea. and phenytoin. and TCAs increases when taken with furazolidone Contraindications Documented hypersensitivity Precautions Pregnancy C . vomiting. diarrhea) Iodoquinol (Vytone. may use if benefits outweigh risk to fetus Precautions Avoid long-term use. abdominal colic. lithium. potential for toxicity. and GI upset (eg.

myasthenia gravis. Cotrim) Folate-synthesis blocker with wide antibiotic coverage. do not use for long-term therapy. and loop diuretics Contraindications Documented hypersensitivity.Fetal risk revealed in studies in animals but not established or not studied in humans. hypocalcemia. may use if benefits outweigh risk to fetus Precautions Because of narrow therapeutic index and toxic hazards associated with extended administration. age <2 mo Precautions Pregnancy C . abdominal pain. psoriasis Precautions Pregnancy C . anorexia. may use if benefits outweigh risk to fetus . megaloblastic anemia due to folate deficiency. active in intestinal amebiasis. Dosage form contains 5:1 ratio of sulfamethoxazole to trimethoprim. may use if benefits outweigh risk to fetus Precautions Hemolysis (frequently dose-related) may occur in individuals who are G-6-PD deficient. and Hymenolepis nana. penicillins. Septra. Dosing Adult 160 mg (based on trimethoprim component) PO bid for 7-10 d Pediatric 10 mg/kg/d (based on trimethoprim component) PO bid for 7-10 d Interactions May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly). coadministration with dapsone may increase blood levels of both drugs. may potentiate effects of methotrexate in bone marrow depression. not to exceed 4 g/d Pediatric Administer as in adults Interactions Nephrotoxic potential may increase with concurrent administration of other aminoglycosides. and diarrhea.Fetal risk revealed in studies in animals but not established or not studied in humans. amphotericin B. adjust dose in renal impairment Quinacrine (Atabrine) Very effective antiparasitic against Giardia species. caution in renal failure. eczematous eruptions and discoloration of skin. Effective in E coli infections. coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly individuals. Dosing Adult 100 mg PO tid for 5-7 d Pediatric 6 mg/kg/d PO divided tid for 5 d Interactions Can cause disulfiram-type reaction when mixed with alcohol Contraindications Documented hypersensitivity. hypoglycemic response to sulfonylureas may increase with coadministration. T solium. Dosing Adult 25-30 mg/kg/d PO divided tid for 7 d. Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. vomiting.Fetal risk revealed in studies in animals but not established or not studied in humans. may cause nausea. Dipylidium caninum.Paromomycin (Humatin) Amebicidal and antibacterial aminoglycoside obtained from a strain of Streptomyces rimosus. Taenia saginata. intestinal obstruction Precautions Pregnancy C . phenytoin levels may increase with coadministration. Recommended for treatment of Diphyllobothrium latum. cephalosporins. may increase levels of zidovudine Contraindications Documented hypersensitivity. poor palatability Sulfamethoxazole and trimethoprim (Bactrim. and conditions that depress neuromuscular transmission.

Fetal risk shown in humans. frequently obtain CBC counts. but PO form is poorly absorbed Tetracycline (Sumycin) Treats gram-positive and gram-negative organisms as well as mycoplasmal. chlamydial. can decrease effects of oral contraceptives. Good agent in older children who present with severe Yersinia species infection. causing breakthrough bleeding and increased risk of pregnancy. reserve for individuals whose symptoms are not responding to less expensive and almost equally effective metronidazole. magnesium. caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy). use only if benefits outweigh risk to fetus Precautions Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment. hemolysis may occur in individuals who are G-6-PD deficient. reduce dose in renal impairment. persons with chronic alcoholism. give fluids to prevent crystalluria and stone formation Vancomycin (Vancocin) Effective treatment (when PO) for antibiotic-associated colitis due to C difficile. patients with AIDS may not tolerate or respond. However. and rickettsial infections. which is essential to anaerobic energy metabolism. calcium. iron. Dosing Adult 250-500 mg PO q6h Mild-to-moderate infections: 500 mg PO bid or 250 mg PO qid for 7-14 d Severe infections: 500 mg PO qid for 7-14 d Pediatric <8 years: Not recommended >8 years: 25-50 mg/kg/d (10-20 mg/lb) divided PO qid Interactions Bioavailability decreases with antacids containing aluminum. use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth. may use if benefits outweigh risk to fetus Precautions IV preparation requires dose adjustment for renal failure. goiter.Fetal risk revealed in studies in animals but not established or not studied in humans. elderly individuals.Precautions Discontinue at first appearance of rash or sign of adverse reaction. severe hepatic dysfunction Precautions Pregnancy D . and hypoglycemia may occur with sulfonamides. caution in folate deficiency (eg. those receiving anticonvulsant therapy. Dosing Adult 500 mg PO bid for 3 d . discontinue if significant hematologic changes occur. consider drug serum level determinations in prolonged therapy. Elicits antiprotozoal activity by interfering with pyruvate-ferredoxin oxidoreductase (PFOR) enzyme-dependent electron transfer reaction. not to exceed 2 g/d Interactions None reported Contraindications Documented hypersensitivity Precautions Pregnancy C . Fanconilike syndrome may occur with outdated tetracyclines Nitazoxanide (Alinia) Inhibits growth of C parvum sporozoites and oocysts and G lamblia trophozoites. diuresis. or bismuth subsalicylate. Dosing Adult 500 mg PO qid for 10-14 d Pediatric 40-50 mg/kg/d PO divided qid for 10-14 d. can increase hypoprothrombinemic effects of anticoagulants Contraindications Documented hypersensitivity. Available as a 20-mg/mL oral susp. those with malabsorption syndrome).

It also contains attachment protein P1A (genotype P[8]). caution when coadministered with other highly plasma protein–bound drugs with narrow therapeutic indices Rifaximin (Xifaxan. urticaria. Administration of the vaccine stimulates the production of antibodies with specific protective properties. administer with food. rash. may use if benefits outweigh risk to fetus Precautions May promote intestinal bacterial overgrowth and cause superinfection. vomiting. Both are indicated to prevent rotavirus gastroenteritis. G3. G3. aerobic and anaerobic).Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions May cause abdominal pain. nearly all severe rotavirus gastroenteritis cases. postmarketing reports include allergic dermatitis. no significant interactions shown in single dose studies with midazolam and oral contraceptives Contraindications Documented hypersensitivity to rifaximin or rifamycin antimicrobial agents (eg. 10-wk intervals. Rotarix) Currently. RedActiv.Pediatric <1 year: Not established 1-3 years: 100 mg (5 mL) PO q12h for 3 d with food 4-11 years: 200 mg (10 mL) PO q12h for 3 d with food >11 years: Administer as in adults Interactions Tizoxanide (nitazoxanide metabolite) is >99. Rotarix protects against rotavirus gastroenteritis caused by G1. a major cause of severe diarrhea in infants. discontinue if diarrhea persists more than 24-48 h or worsens. Rifampin structural analog. G2. do not . and pruritus Vaccines These agents elicit active immunization to increase resistance to infection. not effective for travelers' diarrhea due to suspected pathogens other than E coli. and G4 serotypes. Binds to beta-subunit of bacterial DNA-dependent RNA polymerase. 2 PO administered live-virus vaccines are marketed in the United States. RotaTeq is a pentavalent vaccine that contains 5 live reassortant rotaviruses and is administered as a 3-dose regimen against G1. the 4 most common rotavirus group A serotypes. angioneurotic edema. Gram-negative. rifampin) Precautions Pregnancy C . limited data exist.Fetal risk revealed in studies in animals but not established or not studied in humans. or headache. which act as antigens. diarrhea. thereby inhibiting RNA synthesis. Dosing Adult Not indicated Pediatric <6 weeks: Not established RotaTeq 6-12 weeks: 2 mL PO as a single dose. Dosing Adult 200 mg PO tid Pediatric <12 years: Not established >12 years: Administer as in adults Interactions Induces CYP450 3A4 in vitro. broad-spectrum antibiotic specific for enteric pathogens of the gastrointestinal tract (ie. and G9 strains and is administered as a 2-dose series in infants aged 6-24 wk. and nearly all hospitalizations. Indicated for E coli (enterotoxigenic and enteroaggregative strains) associated with travelers' diarrhea. Flonorm) Nonabsorbed (<0.9% bound to plasma protein and may potentially increase toxicity of other highly plasma protein–bound drugs Contraindications Documented hypersensitivity Precautions Pregnancy B . Gram-positive. Vaccines consist of microorganisms or cellular components. Clinical trials found that the vaccines prevented 74-78% of all rotavirus gastroenteritis cases.4%). seek immediate medical care if fever and/or bloody stools emerge (tablets not effective). Rotavirus vaccine (RotaTeq. followed by 2 additional doses at 4.

previously marketed rotavirus vaccine (RotaShield) was associated with intussusception. highdose corticosteroids) may decrease immune response Contraindications Documented hypersensitivity. or bloody diarrhea. low-grade fever (<100. the FDA approved Rotarix. Admit a child with severe dehydration. however.000 patients who received Rotarix or placebo at age 2 months and at age 4 months reported a decreased risk of intussusception in patients who received Rotarix. • In February 2006. 2006.552 infants who received placebo.[5 ] • A study that involved over 63. ORT requires vigilance. proven to be successful even in children who vomit or have mild-to-moderate dehydration. An older rotavirus vaccine (RotaShield) was associated with an increased incidence of intussusception and is no longer on the market. [5 ] The intussusception data was determined over a 31-day observation period (inpatient or outpatient) after each dose of the Rotarix vaccine. do not mix in same syringe with other vaccines or solutions. In addition. and bronchospasm. uncorrected congenital GI malformation that would predispose to intussusception Precautions Pregnancy C . for prevention of rotavirus gastroenteritis. may use if benefits outweigh risk to fetus Precautions Common adverse effects include diarrhea. • In April 2008. which reported that Rotarix protected patients with severe rotavirus gastroenteritis and decreased the rate of severe diarrhea or gastroenteritis of any cause. alkylating agents.673 infants compared with 31. If the caregiver cannot comply with protocol. the AAP and the Advisory Committee on Immunization Practices (ACIP) recommended RotaTeq to be part of regularly scheduled childhood immunizations. Rotarix was efficacious in a large study. and Rotarix did not show an increase in intussusception in 31. • Oral rehydration therapy (ORT) is the universally recommended form of treatment.000 patients. . this also included a 100-day surveillance period for all serious adverse events.Fetal risk revealed in studies in animals but not established or not studied in humans. cytotoxic drugs. antimetabolites. RotaTeq is administered in a 3-dose series starting between age 6-12 weeks and completing before 32 weeks. • Closely monitor children who require labor-intensive ORT. suspected infection with enterohemorrhagic E coli. Further Outpatient Care • Follow-up care depends on the severity of diarrhea and the child's age. administer a second dose after an interval of at least 4 wk and before 24 wk of age Interactions Immunosuppressive therapies (eg. vomiting. inflamed nasal passages.1°C]) itself and mild upper respiratory infection do not preclude vaccination Follow-up Further Inpatient Care • Admit neonates or young infants with moderate dehydration. • Neonates require strict follow-up care within a few days of illness to ensure that malabsorption and dehydration do not occur.administer after age 32 wk Rotarix 6 weeks: 1 mL PO as a single dose. in the opinion of the physician. • Uncomplicated diarrhea in a school-aged child may not require follow-up care if the caregiver is reliable and has quick access to a physician. On February 21. It is currently the only vaccine approved in the United States for prevention of rotavirus gastroenteritis as of the date of this publication. the FDA is requiring the Rotarix manufacturer to report data on postmarketing safety in a study that involves over 40. handle and discard empty tube according to biological waste procedures. The current recommendation is to administer 2 separate doses of Rotarix to patients aged 6-24 weeks. febrile illness may be reason for delaying use except when. Although more patients who received Rotarix were observed to have seizures or pneumonia-related deaths. consider admission. this link has not been directly established to Rotarix. another oral vaccine. • Closely monitor young children to ensure that complications do not occur. but RotaTeq did not show an increased risk compared with placebo in clinical trials. Deterrence/Prevention • Vaccines are indicated for persons with high risk of exposure to some pathogens. otitis media. Also. irradiation. refrigerate and protect from light. the United States Food and Drug Administration (FDA) approved an oral vaccine for rotavirus (RotaTeq).5°F [38. RotaTeq did not show an increased risk compared with placebo in clinical trials (monitor for signs of intestinal blockage). withholding the vaccine entails a greater risk.

myocarditis. emphasize proper hygiene and food preparation practices to prevent future infections and spread. RS o Rotavirus . 1-4% of individuals with nontyphoid and enteric fever infections become carriers. Live-attenuated.Chronic diarrhea o C perfringens serotype C . • With caregiver. meningitis. intussusception. and treatment is required to prevent systemic complications such as hepatitis. see eMedicine's patient education articles Irritable Bowel Syndrome. urinary tract infection. RS o Vibrio species .Seizures.The Salmonella typhi vaccine is recommended for travelers to countries with a high risk of this infection. and mucocutaneous lesions. HUS. Complications • Common complications include the following: o Aeromonas caviae . when the organism may be absent. and acute renal failure characterize HUS. o After diarrhea caused by Salmonella organisms. Also. cholecystitis. malnutrition.Chronic diarrhea o Entamoeba species . and malabsorption syndromes. Neonates and young infants are at particular risk of dehydration. Reiter syndrome (RS) o C difficile . gram-negative sepsis.Hemorrhagic colitis o Enterohemorrhagic E coli O157:H7 .Enteritis necroticans o Enterohemorrhagic E coli . • HUS is caused by damage to vascular endothelial cells by verotoxin (released by enterohemorrhagic E coli and by Shigella organisms). peritonitis. Stomach. Diarrhea and rash (rose spots) appear after 1 week of symptoms. liver abscess • Enteric fever is caused by S typhi. Inflammatory Bowel Disease. Prognosis • In developed countries. however. children can die from complications. • For excellent patient education resources. • RS can complicate acute infections and is characterized by arthritis. and bradycardia.Colonic perforation. and early refeeding speeds recovery of intestinal mucosa. visit eMedicine's Esophagus. typically for as long as 1-2 weeks. o Rotavirus is excreted asymptomatically in feces of children who were previously infected. cholecystitis. bacteremia. with proper management.Isotonic dehydration.HUS o Plesiomonas species . perforation. Once malnutrition from secondary malabsorption begins. urethritis. fever. Symptoms usually develop one week after onset of diarrhea. • Carrier states are observed after some bacterial infections. hemolytic-uremic syndrome (HUS) o Campylobacter species -Bacteremia. toxic megacolon. Patient Education • Education is most important for prevention and treatment.Intussusception. prognosis for children in countries without modern medical care and children with comorbid conditions is more guarded. carbohydrate intolerance o Giardia species . Thrombocytopenia. infants. This syndrome has an insidious onset of malaise. Bacteria may have disseminated at that time.Chronic fat malabsorption o Cryptosporidium species . perforation. cholangitis. conjunctivitis. The carrier stage for Salmonella organisms is more likely for females.Appendicitis. It is not indicated for use.Septicemia o Salmonella species . and workers with frequent exposure to this bacteria. or GI bleeding. prognosis is very good. and Intestine Center. and capsular polysaccharide vaccines are available. • Even though the mortality rate is low in developed countries. prognosis turns grim unless the patient is hospitalized and supplemental parenteral nutrition is started. abdominal pain. and Diarrhea. • Death is caused predominantly by dehydration and secondary malnutrition from a protracted course.Rapid dehydration o Y enterocolitica . killed whole-cell. Individuals with RS usually do not demonstrate all features. persons with intimate exposure to a documented typhoid fever carrier. microangiopathic hemolytic anemia. pancreatitis. and individuals with biliary tract disease. • Proper ORT prevents dehydration. Severe dehydration must be managed with parenteral fluids. • . • The Vibrio species vaccine is available but only protects 50% of immunized persons for 3-6 months. o Asymptomatic C difficile carriage may be observed in as many as 20% of hospitalized patients receiving antibiotics and in 50% of infants.