The widening array of recognized enteric pathogens and the increasing demand for cost-containment sharpen the need for careful clinical and public health guidelines based on the best evidence currently available. Adequate fluid and electrolyte replacement and maintenance are key to managing diarrheal illnesses. Thorough clinical and epidemiological evaluation must define the severity and type of illness (e.g., febrile, hemorrhagic, nosocomial, persistent, or inflammatory), exposures (e.g., travel, ingestion of raw or undercooked meat, seafood, or milk products, contacts who are ill, day care or institutional exposure, recent antibiotic use), and whether the patient is immunocompromised, in order to direct the performance of selective diagnostic cultures, toxin testing, parasite studies, and the administration of antimicrobial therapy (the latter as for traveler's diarrhea, shigellosis, and possibly Campylobacter jejuni enteritis). Increasing numbers of isolates resistant to antimicrobial agents and the risk of worsened illness (such as hemolytic uremic syndrome with Shiga toxin-producing Escherichia coli O157:H7) further complicate antimicrobial and antimotility drug use. Thus, prevention by avoidance of undercooked meat or seafood, avoidance of unpasteurized milk or soft cheese, and selected use of available typhoid vaccines for travelers to areas where typhoid is endemic are key to the control of infectious diarrhea.

/pdf/practice-guidelines-for-the-management-of-infectious-427wu61von.pdf

Practice Guidelines for the Management of Infectious Diarrhea

An otherwise healthy 23-year-old man presents after the acute onset of watery diarrhea that has persisted for two days. He reports associated nausea and cramping but no emesis and is febrile, with a temperature of 38.7°C (101.7°F). How should he be evaluated and treated?

/pdf/acute-infectious-diarrhea-mul38s5rm4.pdf

Acute Infectious Diarrhea

Infectious diarrhoea is the most common cause of diarrhoea worldwide and is the leading cause of death in childhood. Gastrointestinal infections have their major impact in the developing world. In the developed world, despite improvements in public health and economic wealth, the incidence of intestinal infection remains high and continues to be an important clinical problem.

During the past 10 years there have been some major improvements in our knowledge base regarding the treatment of infectious diarrhoea. Oral rehydration therapy (ORT) remains central to case management but advances have been made by the introduction of hypotonic solutions and there is early evidence that resistant starch may be the substrate of the future. The search for antisecretory drugs continues, with real progress having been made by the introduction of a new class of drugs, the enkephalinase inhibitors. Other new drugs are in the early phases of development. The role of antimicrobial agents in the management of infective diarrhoea continues to be clarified with the emergence of new agents and simplified treatment regimens. Probiotics are popular with diarrhoea sufferers and have been shown to have some efficacy but further scrutiny is required to determine the magnitude of their effects.

Infectious diarrhoea is the most common cause of diarrhoea worldwide and is responsible for more deaths than gastrointestinal cancers, peptic ulcer, or inflammatory bowel disease. Diarrhoeal disease is the leading cause of childhood death and the second most common cause of death worldwide.

Gastrointestinal infections have their major impact in the developing world: diarrhoeal diseases are responsible, directly or indirectly, for approximately three million deaths each year among children under five years of age—that is, 1 every 10 seconds. There are an estimated 1.8 billion episodes of childhood diarrhoea per year and virtually all of these acute diarrhoeal episodes are related to infectious …

https://gut.bmj.com/content/gutjnl/53/2/296.full.pdf

Management of infectious diarrhoea

Background: Treatment of shigellosis is currently limited by the high prevalence of multidrug-resistant strains of Shigella. Objective: To determine the efficacy of azithromycin in the treatment of...

Treatment of shigellosis: V. Comparison of azithromycin and ciprofloxacin. A double-blind, randomized, controlled trial.

Clinical applications of quinolones.

Ciprofloxacin, 500 mg every 12 h, was compared with ampicillin, 500 mg every 6 h, both given for 5 days, in the treatment of 121 adult males hospitalized with severe shigellosis. Treatment was randomized and double-blinded. At the completion of treatment, there was resolution or marked improvement in symptoms in 57 (95%) of 60 ciprofloxacin-treated patients, 23 (88%) of 26 ampicillin-treated patients infected with an ampicillin-susceptible strain of Shigella, and 15 (43%) of 35 ampicillin-treated patients infected with an ampicillin-resistant strain of Shigella (ampicillin-R group) (P less than .01, ciprofloxacin or ampicillin groups vs. ampicillin-R group). Bacteriologic failure was less common (P less than .025) in the ciprofloxacin group (0/60) than in the ampicillin (3/26, 12%) or ampicillin-R groups (5/35, 14%). Ciprofloxacin-treated patients had a mean of 29 stools during the study, compared with 46 for ampicillin-treated patients (P = .004). Thus ciprofloxacin seems to be an effective, and perhaps superior, alternative to ampicillin in treating patients with shigellosis.

Michael Barza

Papers

Therapy for Shigellosis. II. Randomized, Double-Blind Comparison of Ciprofloxacin and Ampicillin