Diagnosis and Management of Infectious Diarrhea
Publication Date: November 29, 2017
Last Updated: December 16, 2022
Diagnosis
Clinical, Demographic, and Epidemiologic Features
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. ( S , M)
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People with diarrhea who attend or work in child care centers, long-term care facilities, patient care, food service, or recreational water venues (e.g., pools and lakes) should follow jurisdictional recommendations for outbreak reporting and infection control. ( S , H)
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People with fever or bloody diarrhea should be evaluated for enteropathogens for which antimicrobial agents may confer clinical benefit, including S. enterica subspecies, Shigella, and Campylobacter. ( S , L)
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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. ( S , M)
In this document, S. Typhi represents the more formal and detailed name S. enterica subspecies enterica serovar Typhi, and Salmonella Paratyphi corresponds to the Paratyphi serovar.
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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. ( S , H)
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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. ( S , M)
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If available, diagnostic approaches that can distinguish between Shiga toxin 1 and Shiga toxin 2, which is typically more potent, could be used. ( W , M)
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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. ( S , M)
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Clinicians should evaluate people for post-infectious and extraintestinal manifestations associated with enteric infections. ( S , M)
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Treatment
Empiric Management of Infectious Diarrhea (Table 5)
In immunocompetent children and adults, empiric antimicrobial therapy for bloody diarrhea while waiting for results of investigations is NOT recommended ( S , L)
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except for the following:
- Infants <3 months of age with suspicion of a bacterial etiology.
- Ill immunocompetent people with fever documented in a medical setting, abdominal pain, bloody diarrhea, and bacillary dysentery (frequent scant bloody stools, fever, abdominal cramps, tenesmus) presumptively due to Shigella.
- People who have recently travelled internationally with body temperatures >38.5° Celsius and/or signs of sepsis.
(https://wwwnc.cdc.gov/travel/ yellowbook/2016/the-pre-travel-consultation/travelers-diarrhea)
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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. ( S , M)
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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. ( S , M)
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Empiric antibacterial treatment should be considered in immunocompromised people with severe illness and bloody diarrhea ( S , L)
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Asymptomatic contacts of people with bloody diarrhea should not be offered empiric treatment but should be advised to follow appropriate infection prevention and control measures ( S , M)
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People with clinical features of sepsis who are suspected of having enteric fever should be treated empirically with broad-spectrum antimicrobial therapy after blood, stool, and urine culture collection. ( S , L)
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Antimicrobial therapy should be narrowed when antimicrobial susceptibility testing results become available. ( S , H)
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If an isolate is unavailable and there is a clinical suspicion of enteric fever, antimicrobial choice may be tailored to susceptible patterns from the setting where acquisition occurred. ( W , L)
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Antimicrobial therapy for people with infections attributed to STEC O157 and other STEC that produce Shiga toxin 2 (or if the toxin genotype is unknown) should be avoided. ( S , M)
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Antimicrobial therapy for people with infections attributed to other STEC that do not produce Shiga toxin 2 (generally non-O157 STEC) is debatable due to insufficient evidence of benefit or the potential harm associated with some classes of antimicrobial agents. ( S , L)
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In most people with acute watery diarrhea and without recent international travel, empiric antimicrobial therapy is not recommended. ( S , L)
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An exception may be made in people who are immunocompromised or young infants who are ill-appearing. Empiric treatment should be avoided in people with persistent watery diarrhea >14 days or more. ( S , L)
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Asymptomatic contacts of people with acute or persistent watery diarrhea should not be offered empiric or preventive therapy but should be advised to follow appropriate infection prevention and control measures. ( S , M)
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Overview
Title
Diagnosis and Management of Infectious Diarrhea
Authoring Organization
Infectious Diseases Society of America