Diarrhea in Kittens and Young Cats

World Small Animal Veterinary Association World Congress Proceedings, 2011

Susan Little, DVM, DABVP (Feline)
Bytown Cat Hospital, Ottawa, ON, Canada

Diarrhea is one of the most common health problems of kittens and young cats.
Common causes include dietary change and infectious disease. The diagnostic
plan can be divided into 1st tier and 2nd tier tests:
First tier:
CBC, FeLV/FIV
Direct fecal smears
Fecal flotation-centrifugation
Giardia fecal antigen
T. foetus testing (large bowel diarrhea)
Response to treatment with a broad spectrum dewormer such as
fenbendazole
Second tier:
Fecal/rectal cytology
Clostridium enterotoxin (large bowel diarrhea)
Fecal culture (small bowel diarrhea)
Cryptosporidium testing (small bowel diarrhea)
Comprehensive fecal examinations are critical for diagnosis. Fecal specimens
for examination should always be fresh (< 1 hour old). Fecal flotation techniques
are best for common nematode ova, coccidia oocysts and Giardia cysts.
Gravitational flotation is widely used but is less efficient than centrifugation
flotation for detection of parasites shed in low numbers. Therapeutic deworming
with a broad-spectrum product should be performed even if no parasite ova are
found.
Direct fecal smears (fecal wet mount) should always be performed to detect
Giardia and Tritrichomonas trophozoites as well as Campylobacter. Fecal/rectal
cytology smears can be examined for Clostridium endospores and Campylobacter.
If neutrophils are present, culture for Campylobacter, Clostridium or Salmonella
may be warranted.
Selected Infectious Causes of Diarrhea

Giardia spp. are flagellate protozoans found in the intestinal tract of humans and
many animal species worldwide. The trophozoite is the active, motile form found
in the intestinal tract. The cyst is the environmentally resistant stage responsible
for transmission when ingested via contaminated fomites, food, or water. Giardia
infection may cause acute diarrhea in kittens characterized by pale malodorous
feces, sometimes containing mucus. Infections in adults may be asymptomatic.
Diagnosis of Giardia has traditionally relied upon microscopic identification of
cysts or trophozoites in feces, but sensitivity is low (85.3%). A single negative test
cannot rule out infection. A higher sensitivity (97.8%) can be achieved by using a
centrifugation flotation technique for cyst detection in combination with a patient-
side Giardia immunoassay kit (SNAP Giardia, IDEXX Laboratories).
The primary goal of treatment is to stop diarrhea and reduce or eliminate cyst
shedding, especially since the infection is zoonotic. Elimination of infection is not
always possible. Treatment options include metronidazole (25 mg/kg, PO, BID for
7 days) and fenbendazole (50 mg/kg, PO, SID for 3–5 days). Cysts can be
inactivated on contaminated surfaces by thorough cleaning followed by steam
cleaning or quaternary ammonium products (1 minute contact time).
Tritrichomonas foetus is a flagellated protozoan found in the distal ileum and
colon. T. foetus infection is most common in young cats (< 2 years) in population-
dense environments such as shelters and catteries. Prevalence of infection
ranges from 10–31%, depending on the population sampled and the diagnostic
tests employed. Presumably, trichomonads are transmitted among cats via feces
in the litter box and are ingested from the paws and hair coat during grooming.
Trichomonads do not forms cysts, unlike Giardia, and so cannot survive prolonged
periods in the environment.
Infected cats often have chronic waxing and waning, malodorous large bowel
diarrhea, but asymptomatic carriers have also been documented. The diarrhea is
semi-formed to liquid and is often described as 'cow patty' in consistency and may
contain mucus or fresh blood. Increased frequency of defection, flatulence and
tenesmus may also be seen. Severely affected cats may dribble feces and have
perineal inflammation. Infected cats generally maintain good body condition and a
normal appetite.
T. foetus cannot be diagnosed with routine techniques such as fecal flotation.
Fecal samples for analysis should be freshly voided or collected with a fecal loop,
free of cat litter and kept at room temperature. Samples may also be collected via
saline flush of the colon. Only grossly abnormal fecal samples should be tested
and antibiotic therapy should be stopped one week before samples are collected.
T. foetus infection may be diagnosed by several methods: fecal smear (cheapest,
least sensitive), fecal culture (most time-consuming), or PCR (most expensive, but
most sensitive).
T. foetus trophozoites look similar to Giardia and misdiagnosis is not
uncommon. Key morphologic features distinguish the two pathogens. T. foetus
has a single undulating membrane, a single nucleus, and the organism moves with
a rigorous forward motion. Giardia has characteristic 'owl eyes', a concave ventral
disc and a 'falling leaf' motion.
The only drug therapy shown to have efficacy against T. foetus is ronidazole.
Ronidazole is not approved in most countries for use in companion animals and is
typically banned for use in food animals due to concerns that it is carcinogenic in
humans. The recommended dose is 30 mg/kg, PO, SID for 14 days. The drug is
rapidly and well absorbed from the gastrointestinal tract and has a long half-life,
which predisposes some cats to neurotoxicity. Clinical signs include lethargy,
inappetence, ataxia and seizures. Signs typically resolve if the drug is withdrawn
immediately, but they may worsen before they improve and costly intensive care
may be required for recovery. To lessen the risk of neurotoxicity, the ronidazole
dose should be based on a current, accurate body weight.
Cryptosporidium felis is an obligate intracellular parasite infecting the small
intestine. Infective oocysts are ingested from contaminated feces during
grooming of contaminated body parts and from contaminated food and water.
The prepatent period is 3 to 6 days and the oocysts are infective as soon as they
are shed, making this a very contagious disease. Clinical signs in kittens range
from mild, self-limiting to chronic intermittent small bowel diarrhea. Severe
diarrhea with weight loss and anorexia may also occur.
C. felis may be diagnosed by fecal flotation if there are large numbers of oocysts
but this test is often negative due to intermittent shedding. The small size of the
oocyst makes microscopic identification difficult. A modified Ziehl-Neelsen acid
fast stain of a thin fecal smear may help in the identification of the oocysts.
Immunofluorescent antibody and PCR testing are available from some
laboratories.
There are no completely effective and safe treatments for C. felis. Azithromycin
(7–10 mg/kg, PO, BID for at least 10 days) appears safe, but efficacy is unknown.
Paromomycin, an oral aminoglycoside, may be effective but reported adverse
effects include acute renal failure and deafness. Nitazoxanide is approved for
treatment in humans. The administration of nitazoxanide to cats at 25 mg/kg, PO,
BID for at least 5 days and up to 28 days may be effective but the drug commonly
causes vomiting and foul smelling diarrhea.
Environmental control of C. felis is difficult as the oocysts are extremely hardy.
They are resistant to chlorination and most disinfectants. The parasite is difficult
to filter from water due to its small size and survives treatment at municipal water
treatment facilities. Steam cleaning of housing and utensils may be beneficial and
oocysts are susceptible to 5% ammonia solutions if the contact time is eighteen
hours.
Diagnosis of bacterial diarrhea in kittens is problematic because many agents
are routinely isolated from healthy cats. Diarrhea caused by Salmonella or
Campylobacter should be considered in kittens living in high density environments,
those fed raw meat diets, and those with systemic illness (fever, dehydration,
leukocytosis). Antibiotics are often injudiciously administered without a valid
diagnosis. Indiscriminate antibiotic usage can lead to alterations in the
commensal intestinal microflora and exacerbation of diarrhea or development of
antibiotic resistance.
Dietary Therapy

In most cases of simple diarrhea, a highly digestible diet (moderate to low fat,
moderate protein, moderate carbohydrate) is recommended. These diets may
also contain substances to improve intestinal health (e.g., soluble fibres, omega-3
fatty acids, anti-oxidants, etc.) and do not contain gluten, lactose, colourings and
preservatives. Meat source proteins are more digestible than plant source. A
single source carbohydrate diet is more digestible than one with multiple
sources. If one highly digestible diet is ineffective or not accepted, another
should be tried. Canned high protein, low carbohydrate diets will be effective in
some cases.
Probiotics such as Enterococcus faecium and Lactobacillus acidophilus may
influence the gut microflora by inhibiting pathogenic microorganisms or by
immune enhancement. They are generally recommended for otherwise healthy
kittens and cats (with an intact mucosal barrier) with acute or chronic diarrhea
due to parasitism, viral or bacterial infection, weaning, or dietary change. In one
study, the percentage of shelter cats with diarrhea for more than 2 days was
significantly lower when treated with E. faecium SF68 (FortiFlora) versus a
placebo. In most countries, there are no quality control regulations for probiotics
so that only brands with proven efficacy should be used.
References
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Management. St. Louis, Saunders. 2012:459–465.

2. Marks SL, Willard MD. Diarrhea in kittens. In: August JR, ed. Consultations in Feline Internal Medicine,
5th ed. St. Louis, Elsevier/Saunders. 2006:133.

3. Scorza AV, Lappin MR. Gastrointestinal protozoal infections. In: August JR, ed. Consultations in
Feline Internal Medicine. 6th ed. St. Louis, Elsevier/Saunders. 2010:201.

4. Tangtrongsup S, Scorza V. Update on the diagnosis and management of Giardia spp infections in
dogs and cats. Top Companion Anim Med 2010;25:155.

5. Tolbert MK, Gookin J. Tritrichomonas foetus: a new agent of feline diarrhea. Comp Contin Educ Pract
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6. Wynn SG. Probiotics in veterinary practice. J Am Vet Med Assoc 2009;234:606.

Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)

Susan Little, DVM, DABVP (Feline)

Bytown Cat Hospital
Ottawa, ON, Canada

URL: https://www.vin.com/doc/?id=5124223