Infectious Diarrhea

Publication Date: November 29, 2017

Key Points

Key Points

The greatest burden of infectious diarrhea occurs in low and middle income countries, where inadequate sanitation and hygiene are prevalent.
  • Nonetheless, economic development also creates opportunities for introduction and transmission of enteric pathogens, including global travel, food importations, mass production and distribution of food, municipal water systems serving large segments of the population, and widespread use of childcare, long-term care, and recreational water facilities.
  • Other risk factors include hospitalization, animal exposures, especially in public venues, as well as certain sexual practices (Figure 1).

Acute gastroenteritis is a frequent cause of outpatient visits and hospitalizations in the United States, with an estimated annual burden of 179 million outpatient visits, nearly 500,000 hospitalizations, and over 5,000 deaths.
  • Norovirus and Salmonella enterica subspecies were the leading pathogens among the 24 gastroenteritis pathogens transmissible by food that were assessed. Whereas norovirus (58%) exceeded S. enterica subspecies (11%) as a cause of illness, S. enterica subspecies exceeded norovirus as a cause of hospitalization (35% versus 28%) and death (28% versus 11%).
  • Rotavirus was the most common pathogen among children younger than 5 years before rotavirus vaccine introduction.
Highly effective measures are available to prevent and treat diarrheal disease and its complications. Avoiding dehydration by ensuring adequate fluid and electrolyte intake for replacement and maintenance is the mainstay of diarrheal illness management. Increasing resistance to antimicrobial agents and risk of worsening illness (such as diarrhea associated with Clostridium difficile) can result from antimicrobial and antimotility drug use and highlight the need for appropriate use of these interventions.

Most acute diarrhea episodes in previously healthy, immunocompetent people are of short duration and self-resolving, and are of viral or unknown etiology. Therefore, laboratory investigation generally is not warranted. However, many factors may justify the expense and complexity of laboratory testing including epidemiologic (Table 1) and clinical features (Table 2) which encompass diarrhea in immunocompromised people, noninfectious and extraintestinal manifestations associated with enteric pathogens (Table 4) the potential for results of laboratory investigation to impact management, and suspicion of an outbreak situation.

Diagnosis

...Diagnosis

...detailed clinical and exposure history sh...

...diarrhea who attend or work in child care cent...

...fever or bloody diarrhea should be evaluated fo...

...ic fever should be considered when a febrile perso...

...le of all ages with acute diarrhea should be...

...he clinical or epidemic history sug...

...iagnostic approaches that can distinguish b...

...ition, Shigella dysenteriae type 1, and rarely...

...ld evaluate people for post-infectious and extra...


...Diagnostics...

...g should be performed for Salmonella,...

...stools are not an expected manifestation of...

...bitol-MacConkey agar or an appropriate chromog...

...s should be obtained from infants...

...ing should be performed under clearly identif...

...er set of bacterial, viral, and parasitic age...

...differential diagnosis is recommended in im...

...eople with acquired immune deficienc...

...c testing is not recommended in most cases o...

...ifficile should be performed in tr...

...al consideration should be included i...

...ll specimens that test positive for bacterial pat...

Also, a culture may be required in situatio...

...ns from people involved in an outbreak of enteric...

...-independent, including panel based m...

..., cultures of bone marrow (particularly v...

...ic tests should not be used to diagnose ent...

...sting may be considered for C. difficile in...

...C. difficile may be considered in people who have...

...gle diarrheal stool specimen is recommended for...

The optimal specimen for laboratory...

...ar techniques generally are more sensitive and...

Fecal leukocyte examination and stool...

...tests are NOT recommended to establish an e...

...may be considered for people with post-dia...

...heral white blood cell count and diffe...

...be useful clinically. ( W ,...

...onitoring of hemoglobin and platelet cou...

...ripheral blood smear for the presence of re...

...ndoscopy or proctoscopic examination should b...

...enal aspirate may be considered in select...

...(e.g., ultrasonography, computed tomogr...

...ow-up testing is not recommended in most p...

...and analysis of serial stool specimens...

...ctitioners should collaborate with...

...d laboratory re-evaluation may be indica...

...tious conditions, including IBD and IB...

...ssment of fluid and electrolyte balance, nutrition...


...e 1. Exposure or Condition Associa...


...linical Presentations Suggestive of...


...3. Laboratory Diagnostics for Organ...


...siderations when Evaluating People wi...


Treatment

...Treatment...

...Empiric Management of...

...nt children and adults, empiric ant...

...or the following: Infants 38.5° Celsius...

...ic antimicrobial therapy in adults should...

...for children includes a third gen...

...ic antibacterial treatment should be conside...

...atic contacts of people with bloody...

...with clinical features of sepsis w...

...ntimicrobial therapy should be narrowed when...

If an isolate is unavailable and there...

...timicrobial therapy for people with infe...

...icrobial therapy for people with infection...

...t people with acute watery diarrhea a...

...ion may be made in people who are i...

...ontacts of people with acute or persist...


...Directed Managem...

...obial treatment should be modified or...

...ity oral rehydration solution (ORS) is recom...

...dministration of ORS may be considered in inf...

...dehydration, shock, or altered ment...

...ileus (S, M)705

...with ketonemia, an initial course of intravenous...

...evere dehydration, intravenous rehydration...

...aining deficit can be replaced by usi...

...ldren, and adults with mild-to-mod...

...patient is rehydrated, maintenance flu...

...eding should be continued in infants and child...

...esumption of an age-appropriate usual...

...y treatment with antimotility, antinausea, or anti...

...timotility drugs (e.g., loperamide) s...

...may be given to immunocompetent adul...

...be avoided at any age in suspected or proven...

...sea and antiemetic (e.g., ondansetron) drugs ma...

...ic preparations may be offered to reduce t...

...supplementation reduces the duration of diarr...

...tic people who practice hand hygiene and...

...tomatic people who practice hand hygie...

...e 4. Post-infectious Manifestations Associate...

...5. Recommended Antimicrobial Agents by Path...

...6. Fluid and Nutritional Management of Diarrh...

...should be performed after using th...

...sed sanitizers should be followed in th...

...election of a hand hygiene product...

...iate food safety practices are recomme...

...care providers should direct educational...

...with diarrhea should avoid swimming, water-...

...otavirus vaccine should be administered...

Typhoid vaccination is recommended as an adjunct...

...er doses are (S, H)705...

...enuated cholera vaccine, which is available a...

...ses listed in the table of National Notifiabl...


Prevention

...Prev...

...hygiene should be performed after using...


...tion control measures including use...


...selection of a hand hygiene product sho...


...propriate food safety practices are rec...


...re providers should direct educationa...


...th diarrhea should avoid swimming, water-...


...ccine should be administered to all infants...


...wo typhoid vaccines (oral and injectable)...


...doses are recommended for people who remain...


...ttenuated cholera vaccine, which is availabl...


...iseases listed in the table of National...


...ble 7. Infectious Diseases Designated...