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Acute Diarrhea in Adults and Children A Global.7
Acute Diarrhea in Adults and Children A Global.7
Review team: Michael Farthing, MD (Chair, UK), Mohammed A. Salam, MD (Special Advisor,
Bangladesh), Greger Lindberg, MD (Sweden), Petr Dite, MD (Czech Republic), Igor Khalif, MD
(Russia), Eduardo Salazar-Lindo, MD (Peru), Balakrishnan S. Ramakrishna, MD
(India), Khean-Lee Goh, MD (Malaysia), Alan Thomson, MD (Canada), Aamir G. Khan, MD
(Pakistan), Justus Krabshuis, (France), and Anton LeMair, MD (Netherlands)
CONTENTS
1. Introduction and epidemiologic features
2. Clinical manifestations and diagnosis
3. Treatment options and prevention
4. Clinical practice
List of Tables
Table 1 Clinical features of infection with selected diarrheal pathogens
Table 2 Assessment of dehydration using the “Dhaka method”
Table 3 Nonspecific antidiarrheal agents
Table 4 Antimicrobial agents for the treatment of specific causes of diarrhea
List of Figures
Figure 1 Therapeutic approach to acute bloody diarrhea in children
Figure 2 Cascade for acute, severe, watery diarrhea—cholera-like, with severe dehydration. See above for the recipe for
home-made oral fluid
Figure 3 Cascade for acute, mild/moderate, watery diarrhea—with mild/moderate dehydration. See above for the recipe
for home-made oral fluid
Figure 4 Cascade for acute bloody diarrhea—with mild/moderate dehydration
INTRODUCTION AND EPIDEMIOLOGIC In this guideline, specific pediatric details are provided
FEATURES in each section as appropriate.
According to the World Health Organization (WHO)
and UNICEF, there are about 2 billion cases of diarrheal Cascades—a Resource-sensitive Approach
disease worldwide every year, and 1.9 million children A gold standard approach is feasible for regions and
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younger than 5 years of age perish from diarrhea each year, countries in which the full scale of diagnostic tests and
mostly in developing countries. This amounts to 18% of all medical treatment options are available. However, such
the deaths of children below the age of 5 and means that resources are not available in large parts of the world. With
>5000 children are dying every day as a result of diarrheal their diagnostic and treatment cascades, the WGO guide-
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diseases. Of all child deaths from diarrhea, 78% occur in lines provide a resource-sensitive approach.
the African and Southeast Asian regions.
Each child below 5 years of age experiences an average
of 3 annual episodes of acute diarrhea. Globally in this age CLINICAL MANIFESTATIONS AND DIAGNOSIS
group, acute diarrhea is the second leading cause of death Although there may be clinical clues, a definitive
(after pneumonia), and both the incidence and the risk of etiological diagnosis is not possible clinically (Table 1).
mortality from diarrheal diseases are greatest among chil-
dren in this age group, particularly during infancy— Clinical Evaluation
thereafter, rates decline incrementally. Other direct con- The initial clinical evaluation of the patient should
sequences of diarrhea in children include growth faltering, focus on:
malnutrition, and impaired cognitive development in Assessing the severity of the illness and the magnitude
resource-limited countries. (degree) of dehydration (Table 2)
During the past 3 decades, changes in water supply, Determining likely causes on the basis of the history and
sanitation, and personal hygiene are believed to have con- clinical findings, including stool characteristics
tributed to a decline in the mortality rate in developing
countries. In some countries, such as Bangladesh, the
reduction in the case fatality rate can be attributed largely to Laboratory Evaluation
improved case management, rather than changes in water For acute enteritis and colitis, maintaining adequate
supply, sanitation, or personal hygiene. Oral rehydration salts intravascular volume and correcting fluid and electrolyte
(ORS) and nutritional improvements probably have a greater disturbances take priority over identifying the causative
impact on mortality rates than the incidence of diarrhea. agent. Presence of visible blood in febrile patients generally
Interventions such as exclusive breastfeeding (which prevents indicates infection due to invasive pathogens, such as
diarrhea), continuation of breastfeeding until 24 months of Shigella, Campylobacter jejuni, Salmonella, or Entamoeba
age, and improved complementary feeding (by way of histolytica. Stool cultures are usually unnecessary for
improved nutrition), along with improved sanitation, are immune-competent patients who present with watery diar-
expected to affect mortality and morbidity simultaneously. rhea, but may be necessary to identify Vibrio cholerae when
The recommended routine use of zinc in the management of there is a clinical and/or epidemiological suspicion of
childhood diarrhea, not currently practiced in many coun- cholera, particularly during the early days of outbreaks/
tries, is expected to reduce disease incidence. epidemics (also to determine antimicrobial susceptibility)
In industrialized countries, relatively few patients die and to identify the pathogen causing dysentery.
from diarrhea, but it continues to be an important cause of Epidemiologic clues to infectious diarrhea can be found
morbidity that is associated with substantial health care by evaluating the incubation period, history of recent travel
costs. However, the morbidity from diarrheal diseases has in relation to the regional prevalence of different pathogens,
remained relatively constant during the past 2 decades. unusual food or eating circumstances, professional risks,
possible, including at least 2 recommended daily allowances shortens the duration of acute diarrheal illness in children
of folate, vitamin A, zinc, magnesium, and copper (WHO by approximately 1 day.
2005). Several meta-analyses of controlled clinical trials have
been published that show consistent results in systematic
Diet reviews, suggesting that probiotics are safe and effective.
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The practice of withholding food for >4 hours is The evidence from studies on viral gastroenteritis is more
inappropriate—normal feeding should be continued for convincing than the evidence on bacterial or parasitic
those with no signs of dehydration, and food should be infections. Mechanisms of action are strain specific: there is
started immediately after correction of some (moderate) evidence for efficacy of some strains of lactobacilli (eg,
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and severe dehydration, which usually takes 2 to 4 hours, L. casei GG and L. reuteri ATCC 55730) and for S. boulardii.
using ORT or intravenous rehydration. The timing of administration is also of importance.
Antimicrobials in Adults and Children —Symptomatic giardiasis (anorexia and weight loss,
(Table 4) persistent diarrhea, failure to thrive).
Consider antimicrobial treatment for:
Important Notes —Shigella, Salmonella, Campylobacter (dysenteric form),
All doses shown are for oral administration. or parasitic infections.
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Selection of an antimicrobial should be based on the —Nontyphoidal salmonellosis among at-risk populations
susceptibility patterns of strains of the pathogens in the (malnutrition, infants and elderly, immunocompromised
locality/region. patients, and those with liver diseases and lymphoprolifer-
Antimicrobials are reliably helpful and their routine use ative disorders) and in dysenteric presentation.
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is recommended in the treatment of severe (clinically —Moderate/severe traveler’s diarrhea or diarrhea with fever
recognizable): and/or with bloody stools.
—Cholera, shigellosis, typhoid, and paratyphoid fevers. —Antimicrobials are also indicated for associated health
—Dysenteric presentation of campylobacteriosis and problems such as pneumonia.
nontyphoidal salmonellosis when they cause persistent
diarrhea, and when host immune status is compromised Pediatric Details
for any reason such as severe malnutrition, chronic liver If drugs are not available in liquid form for use in young
disease, or lymphoproliferative disorders. children, it may be necessary to use tablets and estimate
—Invasive intestinal amebiasis. the doses given.
Severely malnourished?
Better in 2 days?
Better in 2 days?
Level 1
Level 2
Level 3
Low Level 4
Level 5
ORT
Level 6
FIGURE 2. Cascade for acute, severe, watery diarrhea—cholera-like, with severe dehydration. See above for the recipe for home-made
oral fluid. ORT indicates oral rehydration therapy.
and people may not be competent in assessing their Family knowledge about diarrhea must be reinforced
conditions. in areas such as prevention, nutrition, ORT/ORS use, zinc
Principles of self-medication: supplementation, and when and where to seek care.
Maintain adequate fluid intake. Indications for medical consultation or in-patient care are:
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Consumption of solid food should be guided by appetite Caregiver’s report of signs consistent with dehydration
in adults; small, but more frequent meals for children. Changing mental status
Antidiarrheal medication with loperamide (flexible dose History of premature birth, chronic medical conditions,
according to loose bowel movements) may diminish or concurrent illness
diarrhea and shorten the duration. Young age ( less than 6 mo or <8 kg weight)
Antimicrobial treatment is reserved for prescription only Fever Z381C for infants less than 3 months old or
in residents’ diarrhea or for inclusion in travel kits (add Z391C for children aged 3 to 36 months
loperamide). Visible blood in stool
Where feasible, families in localities with a high prev- High-output diarrhea, including frequent and substantial
alence of diarrheal diseases should be encouraged to store a volumes
few ORS packets and zinc tablets if there are children below Persistent vomiting, severe dehydration, persistent fever
the age of 5 in the family, so that home therapy can be Suboptimal response to ORT or inability of caregiver to
initiated as soon as diarrhea starts. administer ORT
No improvement within 48 hours—symptoms exacer-
bate and overall condition gets worse
Home-made Oral Fluid Recipe No urine in the previous 12 hours
Preparing 1 L of oral fluid using salt, sugar, and water
at home. The ingredients to be mixed are: Cascades
One level teaspoon of salt. A cascade is a hierarchical set of diagnostic or ther-
Eight level teaspoons of sugar. apeutic techniques for the same disease, ranked by the
One liter (5 cupfuls) of clean drinking water or water that resources available. Cascades for acute diarrhea are shown
has been boiled and then cooled. in Figures 2–4.
Level 1
Level 2
High
Nasogastric tube ORS—if persistent, vomiting
Resources
Level 3
Low
ORT
Level 4
FIGURE 3. Cascade for acute, mild/moderate, watery diarrhea—with mild/moderate dehydration. See above for the recipe for home-
made oral fluid. ORT indicates oral rehydration therapy.
Level 1
Level 2
ORT + antibiotics
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High
Empirical antibiotics for moderate/severe illness
Resources
Low Level 3
ORT
Level 4
FIGURE 4. Cascade for acute bloody diarrhea—with mild/moderate dehydration. ORT indicates oral rehydration therapy.
Cautions Notes
If facilities for referral are available, patients with Nasogastric therapy requires skilled staff.
severe dehydration (at risk of acute renal failure or Often, intravenous fluid treatment is more easily
death) should be referred to the nearest health care available than nasogastric tube feeding. (Caution: there
facility with access to intravenous fluids (levels 5 and 6 is a risk of infection with contaminated intravenous
cannot replace the need for referral in case of severe infusion equipment.)
dehydration). Pediatric details
Levels 5 and 6 must be seen as interim measures and are Nasogastric feeding is not very feasible for healthy and
better than no treatment if no intravenous facilities are active older children, but it is suitable for malnourished,
available. lethargic children.
When intravenous therapy is used, it must be ensured Nasogastric administration (ORS and diet) is especially
that disposable sterile syringes, needles, and drip sets are helpful in long-term severely malnourished children
used, to avoid the risk of hepatitis B and C. (anorexia).