Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults

Publication Date: May 1, 2016
Last Updated: March 14, 2022

Epidemiology and public health considerations

Diagnostic evaluation using stool culture and culture-independent methods if available should be used in situations where the individual patient is at high risk of spreading disease to others, and during known or suspected outbreaks. (Strong  “We recommend”, Low)


Stool diagnostic studies may be used if available in cases of dysentery, moderate-to-severe disease, and symptoms lasting >7 days to clarify the etiology of the patient’s illness and enable specific directed therapy. (Strong  “We recommend”Very low)
Traditional methods of diagnosis (bacterial culture, microscopy with and without special stains and immunofluorescence, and antigen testing) fail to reveal the etiology of the majority of cases of acute diarrheal infection. If available, the use of Food and Drug Administration-approved culture-independent methods of diagnosis can be recommended at least as an adjunct to traditional methods. (Strong  “We recommend”Low)
Antibiotic sensitivity testing for management of the individual with acute diarrheal infection is currently not recommended. (Strong  “We recommend”Very low)

Treatment of acute disease

Oral rehydration

The usage of balanced electrolyte rehydration over other oral rehydration options in the elderly with severe diarrhea or any traveler with cholera-like watery diarrhea is recommended. Most individuals with acute diarrhea or gastroenteritis can keep up with fluids and salt by consumption of water, juices, sports drinks, soups, and saltine crackers. (Strong  “We recommend”, Moderate)

Probiotics and prebiotics

The use of probiotics or prebiotics for treatment of acute diarrhea in adults is not recommended, except in cases of postantibiotic-associated illness. (Strong  “We recommend”Moderate)

Non-antibiotic therapies

Bismuth subsalicylates (BSSs) can be administered to control rates of passage of stool and may help travelers function better during bouts of mild to moderate illness. (Strong  “We recommend”High)
In patients receiving antibiotics for traveler’s diarrhea (TD), adjunctive loperamide therapy can be administered to decrease duration of diarrhea and increase chance for a cure. (Strong  “We recommend”Moderate)

Antibiotic therapy

The evidence does not support empiric anti-microbial therapy for routine acute diarrheal infection, except in cases of TD where the likelihood of bacterial pathogens is high enough to justify the potential side effects of antibiotics. (Strong  “We recommend”High)
Use of antibiotics for community-acquired diarrhea should be discouraged as epidemiological studies suggest that most community-acquired diarrhea is viral in origin (norovirus, rotavirus, and adenovirus) and is not shortened by the use of antibiotics. (Strong  “We recommend”Very low)

Evaluation of persisting symptoms

Serological and clinical lab testing in individuals with persistent diarrheal symptoms (between 14 and 30 days) is not recommended. (Strong  “We recommend”Very low)

Endoscopic evaluation is not recommended in individuals with persisting symptoms (between 14 and 30 days) and negative stool work-up. (Strong  “We recommend”Very low)



Patient level counseling on prevention of acute enteric infection is not routinely recommended but may be considered in the individual or close-contacts of the individual who is at high risk for complications. (Conditional (weak)  “We suggest”Very low)
Individuals should undergo pretravel counseling regarding high risk food/beverage avoidance to prevent TD. (Conditional (weak)  “We suggest”Very low)

Hand washing

Frequent and effective hand washing and alcohol-based hand sanitizers are of limited value in preventing most forms of traveler’s diarrhea but may be useful where low-dose pathogens are responsible for the illness as for an example during a cruise ship outbreak of norovirus infection, institutional outbreak, or in endemic diarrhea prevention. (Conditional (weak)  “We suggest”, Low)


Bismuth subsalicylates have moderate effectiveness and may be considered for travelers who do not have any contraindications to use and can adhere to the frequent dosing requirements. (Strong  “We recommend”High)

Probiotics, prebiotics, and synbiotics for prevention of traveler’s diarrhea are not recommended. (Conditional (weak)  “We suggest”Low)

Antibiotic chemoprophylaxis has moderate to good effectiveness and may be considered in high-risk groups for short-term use. (Strong  “We recommend”High)

Recommendation Grading




Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults

Authoring Organization

Publication Month/Year

May 1, 2016

Last Updated Month/Year

June 1, 2023

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Document Objectives

This guideline provides recommendations for the diagnosis, management, and prevention of acute gastrointestinal infection focusing primarily on immune-competent adult individuals and does not consider Clostridium difficile-associated infections, which has recently been reviewed in a separate American College of Gastroenterology (ACG) Clinical Guideline

Target Patient Population

Patients with infectious diarrhea except C. diff infection

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D003967 - Diarrhea, D001424 - Bacterial Infections, D005767 - Gastrointestinal Diseases, D017714 - Community-Acquired Infections, D041981 - Gastrointestinal Tract


diarrhea, infection, gastrointestinal, infectious diarrhea

Source Citation

Riddle, Mark S MD, DrPH; DuPont, Herbert L MD; Connor, Bradley A MD. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults, American Journal of Gastroenterology: May 2016 - Volume 111 - Issue 5 - p 602-622 doi: 10.1038/ajg.2016.126

Supplemental Methodology Resources

Data Supplement