S McGee, W B Abernethy, D L Simel
The rational clinical examination. Is this patient hypovolemic?
JAMA. 1999 Mar 17;281(11):1022-9.
Abstract/Text
OBJECTIVE: To review, systematically, the physical diagnosis of hypovolemia in adults.
METHODS: We searched MEDLINE (January 1966-November 1997), personal files, and bibliographies of textbooks on physical diagnosis and identified 10 studies investigating postural vital signs or the capillary refill time of healthy volunteers, some of whom underwent phlebotomy of up to 1150 mL of blood, and 4 studies of patients presenting to emergency departments with suspected hypovolemia, usually due to vomiting, diarrhea, or decreased oral intake.
RESULTS: When clinicians evaluate adults with suspected blood loss, the most helpful physical findings are either severe postural dizziness (preventing measurement of upright vital signs) or a postural pulse increment of 30 beats/min or more. The presence of either finding has a sensitivity for moderate blood loss of only 22% (95% confidence interval [CI], 6%-48%) but a much greater sensitivity for large blood loss of 97% (95% CI, 91%-100%); the corresponding specificity is 98% (95% CI, 97%-99%). Supine hypotension and tachycardia are frequently absent, even after up to 1150 mL of blood loss (sensitivity, 33%; 95% CI, 21%-47%, for supine hypotension). The finding of mild postural dizziness has no proven value. In patients with vomiting, diarrhea, or decreased oral intake, the presence of a dry axilla supports the diagnosis of hypovolemia (positive likelihood ratio, 2.8; 95% CI, 1.4-5.4), and moist mucous membranes and a tongue without furrows argue against it (negative likelihood ratio, 0.3; 95% CI, 0.1-0.6 for both findings). In adults, the capillary refill time and poor skin turgor have no proven diagnostic value.
CONCLUSIONS: A large postural pulse change (> or =30 beats/min) or severe postural dizziness is required to clinically diagnose hypovolemia due to blood loss, although these findings are often absent after moderate amounts of blood loss. In patients with vomiting, diarrhea, or decreased oral intake, few findings have proven utility, and clinicians should measure serum electrolytes, serum blood urea nitrogen, and creatinine levels when diagnostic certainty is required.
Michael J Steiner, Darren A DeWalt, Julie S Byerley
Is this child dehydrated?
JAMA. 2004 Jun 9;291(22):2746-54. doi: 10.1001/jama.291.22.2746.
Abstract/Text
CONTEXT: The ability to assess the degree of dehydration quickly and accurately in infants and young children often determines patient treatment and disposition.
OBJECTIVE: To systematically review the precision and accuracy of symptoms, signs, and basic laboratory tests for evaluating dehydration in infants and children.
DATA SOURCES: We identified 1561 potential articles by multiple search strategies of the MEDLINE database through PubMed. Searches of bibliographies of retrieved articles, the Cochrane Library, textbooks, and private collections of experts in the field yielded an additional 42 articles.
STUDY SELECTION: Twenty-six of 1603 reviewed studies contained original data on the precision or accuracy of findings for the diagnosis of dehydration in young children (1 month to 5 years).
DATA EXTRACTION: Two of the 3 authors independently reviewed and abstracted data for estimating the likelihood ratios (LRs) of diagnostic tests. We eliminated 13 of the 26 studies because of the lack of an accepted diagnostic standard or other limitation in study design. The other 13 studies were included in the review.
DATA SYNTHESIS: The most useful individual signs for predicting 5% dehydration in children are an abnormal capillary refill time (LR, 4.1; 95% confidence interval [CI], 1.7-9.8), abnormal skin turgor (LR, 2.5; 95% CI, 1.5-4.2), and abnormal respiratory pattern (LR, 2.0; 95% CI, 1.5-2.7). Combinations of examination signs perform markedly better than any individual sign in predicting dehydration. Historical points and laboratory tests have only modest utility for assessing dehydration.
CONCLUSIONS: The initial assessment of dehydration in young children should focus on estimating capillary refill time, skin turgor, and respiratory pattern and using combinations of other signs. The relative imprecision and inaccuracy of available tests limit the ability of clinicians to estimate the exact degree of dehydration.
D Siegel, P T Cohen, M Neighbor, H Larkin, M Newman, D Yajko, K Hadley
Predictive value of stool examination in acute diarrhea.
Arch Pathol Lab Med. 1987 Aug;111(8):715-8.
Abstract/Text
We prospectively evaluate the value of fecal blood and fecal leukocytes in predicting whether acute diarrhea in adults is associated with a stool culture positive for a bacterial pathogen. One hundred thirteen patients, aged 19 to 50 years, seen in a two-year period in an urban adult outpatient setting underwent stool culture for the presenting symptom of diarrhea. Heterosexual men represented 48% of the cohort, women represented 17%, and homosexual men represented 35%. Overall, 53 (47%) of the patients had positive stool cultures for enteric pathogens. Campylobacter jejuni was the most common organism in the entire cohort, but Shigella species were most common in homosexual men. The best predictive variables for a stool culture positive for a bacterial pathogen were the presence of both fecal leukocytes and fecal blood in the stool, compared with only one or neither. When both were present, the sensitivity was 81%, the specificity 74%, and the predictive values of a positive and negative test were 81% and 83%, respectively; the likelihood ratio was 4.87. When homosexual men and the rest of the cohort were analyzed separately, the combination of fecal leukocytes and fecal blood remained the best method of predicting a positive stool culture in both. Examination of stool for fecal leukocytes and fecal blood is a rapid, reliable, and inexpensive way to differentiate between bacterial and other causes of acute diarrhea in the adult acute care setting.
Y K Chitkara, K A McCasland, L Kenefic
Development and implementation of cost-effective guidelines in the laboratory investigation of diarrhea in a community hospital.
Arch Intern Med. 1996 Jul 8;156(13):1445-8.
Abstract/Text
BACKGROUND: Fecal cultures are often inappropriately requested in the investigation of diarrhea.
OBJECTIVES: To develop and determine the efficacy of practice guidelines for the ordering and processing of stool cultures that are submitted for the diagnosis of community-acquired diarrhea.
METHODS: The results of stool cultures that were submitted to the microbiology laboratory of a tertiary care nonteaching community hospital were retrospectively reviewed. Following the implementation of guidelines, the efficacy was evaluated by comparison of fecal culture results in a prospective manner.
RESULTS: Analysis of results of stool cultures that were obtained from 3072 patients during a 3-year period revealed that (1) the sensitivity (40%) and predictive value (20%) of finding neutrophils in smear preparations were too low to be clinically useful, (2) routine cultures from patients with nosocomial diarrhea were uniformly negative, and (3) multiple specimens from a patient rarely provided additional information. Based on these findings, new guidelines were developed and implemented with the cooperation of clinical staff. Three-month follow-up results showed that the total number of specimens, the number of specimens from patients with nosocomial diarrhea, and multiple specimens declined by 37.7%, 70.6%, and 50%, respectively. However, the isolation rate of pathogens increased from 11.7% to 18.7%.
CONCLUSIONS: The application of practice guidelines that include elimination of smear examination of rectal swabs, exclusion of routine cultures from patients with nosocomial diarrhea, and rejection of repeated cultures can result in significant cost saving without adversely affecting patient care.
R L Guerrant, T Van Gilder, T S Steiner, N M Thielman, L Slutsker, R V Tauxe, T Hennessy, P M Griffin, H DuPont, R B Sack, P Tarr, M Neill, I Nachamkin, L B Reller, M T Osterholm, M L Bennish, L K Pickering, Infectious Diseases Society of America
Practice guidelines for the management of infectious diarrhea.
Clin Infect Dis. 2001 Feb 1;32(3):331-51. doi: 10.1086/318514. Epub 2001 Jan 30.
Abstract/Text
S W Choi, C H Park, T M Silva, E I Zaenker, R L Guerrant
To culture or not to culture: fecal lactoferrin screening for inflammatory bacterial diarrhea.
J Clin Microbiol. 1996 Apr;34(4):928-32.
Abstract/Text
Because of its low yield in unselected specimens, stool culture is often cost ineffective. We tested 55 fecal samples from Fairfax Hospital (46 patients with diarrhea and 9 from controls without diarrhea) for lactoferrin by latex agglutination (LFLA) with the Leukotest (Techlab, Blacksburg, Va.) as a marker for inflammatory diarrhea. Of the 28 samples with Salmonella, Shigella, or Campylobacter infection, 93% had detectable fecal lactoferrin at > or = 1:50 (61% had LFLA titers of > or = 1:400), while 83% of 18 samples with rotavirus or no detectable pathogen were LFLA negative at a titer of 1:50 (100% were negative at 1:400). All 9 controls without diarrhea were LFLA negative at 1:50. The use of fecal lactoferrin to screen for inflammatory diarrhea selects specimens for which stool culture is fivefold more likely to yield an invasive bacterial pathogen (reducing the cost per positive result by over $800) and thus may greatly enhance a cost-effective approach to evaluating diarrheal illness.
Christopher R Polage, Jay V Solnick, Stuart H Cohen
Nosocomial diarrhea: evaluation and treatment of causes other than Clostridium difficile.
Clin Infect Dis. 2012 Oct;55(7):982-9. doi: 10.1093/cid/cis551. Epub 2012 Jun 14.
Abstract/Text
Diarrhea is common among hospitalized patients but the causes are distinct from those of diarrhea in the community. We review existing data about the epidemiology of nosocomial diarrhea and summarize recent progress in understanding the mechanisms of diarrhea. Clinicians should recognize that most cases of nosocomial diarrhea have a noninfectious etiology, including medications, underlying illness, and enteral feeding. Apart from Clostridium difficile, the frequency of infectious causes such as norovirus and toxigenic strains of Clostridium perfringens, Klebsiella oxytoca, Staphylococcus aureus, and Bacteroides fragilis remains largely undefined and test availability is limited. Here we provide a practical approach to the evaluation and management of nosocomial diarrhea when tests for C. difficile are negative.
Nathan M Thielman, Richard L Guerrant
Clinical practice. Acute infectious diarrhea.
N Engl J Med. 2004 Jan 1;350(1):38-47. doi: 10.1056/NEJMcp031534.
Abstract/Text
B P Petruccelli, G S Murphy, J L Sanchez, S Walz, R DeFraites, J Gelnett, R L Haberberger, P Echeverria, D N Taylor
Treatment of traveler's diarrhea with ciprofloxacin and loperamide.
J Infect Dis. 1992 Mar;165(3):557-60.
Abstract/Text
To determine the efficacy of loperamide given with long- and short-course quinolone therapy for treating traveler's diarrhea, 142 US military personnel were randomized to receive a single 750-mg dose of ciprofloxacin with placebo, 750 mg of ciprofloxacin with loperamide, or a 3-day course of 500 mg of ciprofloxacin twice daily with loperamide. Culture of pretreatment stool specimens revealed campylobacters (41%), salmonellae (18%), enterotoxigenic Escherichia coli (ETEC, 6%), and shigellae (4%). Of the participants, 87% completely recovered within 72 h of entry. Total duration of illness did not differ significantly among the three treatment groups, but patients in the 3-day ciprofloxacin plus loperamide group reported a lower cumulative number of liquid bowel movements at 48 and 72 h after enrollment compared with patients in the single-dose ciprofloxacin plus placebo group (1.8 vs. 3.6, P = .01; 2.0 vs. 3.9, P = .01). While not delivering a remarkable therapeutic advantage, loperamide appears to be safe for treatment of non-ETEC causes of traveler's diarrhea. Two of 54 patients with Campylobacter enteritis had a clinical relapse after treatment that was associated with development of ciprofloxacin resistance.
G S Murphy, L Bodhidatta, P Echeverria, S Tansuphaswadikul, C W Hoge, S Imlarp, K Tamura
Ciprofloxacin and loperamide in the treatment of bacillary dysentery.
Ann Intern Med. 1993 Apr 15;118(8):582-6.
Abstract/Text
OBJECTIVE: To compare the safety and efficacy of loperamide plus ciprofloxacin with those of ciprofloxacin alone in the treatment of bacillary dysentery.
DESIGN: Double-blind, placebo-controlled, randomized clinical trial.
SETTING: Hospital in Thailand.
PARTICIPANTS: Eighty-eight adults with dysentery seeking medical care between November 1990 and February 1992. Patients who had received prior antibiotics or antimotility drugs were excluded.
INTERVENTION: All 88 patients with dysentery were treated with ciprofloxacin, 500 mg twice daily for 3 days. Forty-two of these patients were randomly assigned to receive loperamide, a 4-mg initial dose followed by 2 mg after every loose stool (as many as eight caplets [16 mg] daily), and 46 were randomly assigned to receive placebo.
MEASUREMENTS: Stools were collected daily until resolution of diarrhea and again after 10 days. The time to passage of the last unformed stool, number of unformed stools, and symptoms were recorded after treatment.
RESULTS: Shigella or enteroinvasive Escherichia coli (53%), Vibrio parahaemolyticus (16%), and Salmonella (7%) were the most common bacterial enteric pathogens identified in 88 patients with dysentery. In patients infected with Shigella or enteroinvasive E. coli, the median duration of diarrhea was 19 hours (25th to 75th percentiles, 6 to 42 hours) for those receiving loperamide plus ciprofloxacin compared with 42 hours (21 to 46 hours) for those receiving ciprofloxacin alone (P = 0.028). The median number of diarrheal stools for those receiving ciprofloxacin and loperamide was 2.0 (1 to 5 stools) compared with 6.5 (2 to 9 stools) for those receiving ciprofloxacin alone (P = 0.016). None of the participants had a temperature greater than 38 degrees C after 24 hours of treatment. None of the patients was infected with the same bacterial enteric pathogen more than 1 day after receiving treatment.
CONCLUSIONS: Loperamide decreases the number of unformed stools and shortens the duration of diarrhea in dysentery caused by Shigella in adults treated with ciprofloxacin.
C S Wong, S Jelacic, R L Habeeb, S L Watkins, P I Tarr
The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections.
N Engl J Med. 2000 Jun 29;342(26):1930-6. doi: 10.1056/NEJM200006293422601.
Abstract/Text
BACKGROUND: Children with gastrointestinal infections caused by Escherichia coli O157:H7 are at risk for the hemolytic-uremic syndrome. Whether antibiotics alter this risk is unknown.
METHODS: We conducted a prospective cohort study of 71 children younger than 10 years of age who had diarrhea caused by E. coli O157:H7 to assess whether antibiotic treatment in these children affects the risk of the hemolytic-uremic syndrome and to assess the influence of confounding factors on this outcome. Estimates of relative risks were adjusted for possible confounding effects with the use of logistic-regression analysis.
RESULTS: Among the 71 children, 9 (13 percent) received antibiotics and the hemolytic-uremic syndrome developed in 10 (14 percent). Five of these 10 children had received antibiotics. Factors significantly associated with the hemolytic-uremic syndrome were a higher initial white-cell count (relative risk, 1.3; 95 percent confidence interval, 1.1 to 1.5), evaluation with stool culture soon after the onset of illness (relative risk, 0.3; 95 percent confidence interval, 0.2 to 0.8), and treatment with antibiotics (relative risk, 14.3; 95 percent confidence interval, 2.9 to 70.7). The clinical and laboratory characteristics of the 9 children who received antibiotics and the 62 who did not receive antibiotics were similar. In a multivariate analysis that was adjusted for the initial white-cell count and the day of illness on which stool was obtained for culture, antibiotic administration remained a risk factor for the development of the hemolytic uremic syndrome (relative risk, 17.3; 95 percent confidence interval, 2.2 to 137).
CONCLUSIONS: Antibiotic treatment of children with E. coli O157:H7 infection increases the risk of the hemolytic-uremic syndrome.
K Ikeda, O Ida, K Kimoto, T Takatorige, N Nakanishi, K Tatara
Effect of early fosfomycin treatment on prevention of hemolytic uremic syndrome accompanying Escherichia coli O157:H7 infection.
Clin Nephrol. 1999 Dec;52(6):357-62.
Abstract/Text
OBJECTIVE: To clarify the effect of early fosfomycin treatment, an antimicrobial agent in common use in Japan, on children with E. coli O157 with the aim of preventing hemolytic uremic syndrome (HUS).
PATIENTS AND METHODS:
DESIGN: Non-randomized prospective study for development of HUS among inpatients with E. coli O157.
SETTING: The hospitals where the 292 inpatients were treated.
CASES: A total of 292 inpatients aged six to eleven years with E. coli O157 infection, 36 (12.3%) of whom were HUS cases.
RESULTS: Most of the HUS inpatients (91.7%) developed this complication between the sixth and ninth day of illness. We therefore analyzed the effects of antimicrobial therapy, especially that of fosfomycin, on prevention of HUS within the first five days of illness, because fosfomycin was the most frequently used (88.0%). To clarify the effect of fosfomycin alone on prevention of HUS, we carried out an analysis using the data for 130 inpatients who received fosfomycin alone or did not receive any antimicrobial agents, within the first five days of illness. multivariate analysis, controlled for age, gender and presence of fever, showed that all adjusted odds ratios for the development of HUS with the use of fosfomycin within the first three days of illness were less than 1.0, with the use of fosfomycin on the second day of illness achieving statistical significance (adjusted OR, 0.09; 95% CI, 0.01-0.79). Furthermore, inpatients who took fosfomycin within the first two days of illness developed HUS significantly less often than those who did not (adjusted OR, 0.15; 95% CI, 0.03-0.78). On the other hand, fosfomycin therapy on and after the third day of illness was not associated with the prevention of HUS.
CONCLUSION: The early use of fosfomycin within the first two days of illness might prevent the development of HUS.
C Sánchez, E García-Restoy, J Garau, F Bella, N Freixas, M Simó, J Lite, P Sánchez, E Espejo, E Cobo
Ciprofloxacin and trimethoprim-sulfamethoxazole versus placebo in acute uncomplicated Salmonella enteritis: a double-blind trial.
J Infect Dis. 1993 Nov;168(5):1304-7.
Abstract/Text
The role of ciprofloxacin and trimethoprim-sulfamethoxazole (TMP-SMZ) was evaluated in empiric treatment of uncomplicated Salmonella enteritis in a comparative, double-blind trial. Patients were randomized to receive ciprofloxacin (500 mg), TMP-SMZ (160/800 mg), or placebo orally twice daily for 5 days. There were 65 evaluatable patients with acute, uncomplicated, culture-confirmed Salmonella enteritis. Duration of diarrhea, abdominal pain, or vomiting and time to defervescence were not significantly different for patients treated with ciprofloxacin, TMP-SMZ, or placebo; there also were no significant differences with respect to full resolution of symptoms for ciprofloxacin versus placebo (point estimate, 0.2 days; 95% confidence interval [CI], -0.5 to 0.9 days) or for TMP-SMZ versus placebo (point estimate, 0.2 days; 95% CI, -1.0 to 0.6 days). The rate of clearance of salmonellae from stools was not significantly different among the groups.
M A Neill, S M Opal, J Heelan, R Giusti, J E Cassidy, R White, K H Mayer
Failure of ciprofloxacin to eradicate convalescent fecal excretion after acute salmonellosis: experience during an outbreak in health care workers.
Ann Intern Med. 1991 Feb 1;114(3):195-9.
Abstract/Text
OBJECTIVE: To determine the efficacy of ciprofloxacin therapy in eradicating convalescent fecal excretion of salmonellae after acute salmonellosis.
DESIGN: Randomized, placebo-controlled, double-blind trial of ciprofloxacin, with prospective follow-up of nonparticipants.
SETTING: An acute care community hospital experiencing an outbreak of salmonellosis.
PATIENTS: Twenty-eight health care workers developed acute infection with Salmonella java; 15 participated in a placebo-controlled trial of ciprofloxacin, beginning on day 9 after infection.
INTERVENTIONS: Eight patients were randomly assigned to receive ciprofloxacin, 750 mg, and 7 patients to receive placebo; both were administered orally twice daily for 14 days. Nonparticipants who received therapy were placed on the same ciprofloxacin regimen.
MEASUREMENTS AND MAIN RESULTS: Study participants had follow-up stool cultures every 3 days initially and then weekly for 3 weeks; nonparticipants were followed until three consecutive cultures were negative. All eight ciprofloxacin recipients showed eradication of S. java from stool cultures within 7 days of beginning therapy (compared with 1 of 7 placebo recipients), and their stool cultures remained negative up to 14 days after discontinuing therapy (P less than 0.01). However, 4 of 8 relapsed; their stool cultures became positive between 14 and 21 days after therapy. In addition, 3 of 3 hospitalized patients treated with ciprofloxacin who did not participate in the controlled trial also relapsed. Thus, the total relapse rate was 7 of 11 (64%; 95% CI, 31% to 89%). In 4 of these 7 patients, relapse was associated with a longer duration of fecal excretion of salmonellae than that of the placebo group. Relapse could not be explained on the basis of noncompliance, development of resistance, or presence of biliary disease.
CONCLUSIONS: Despite its excellent antimicrobial activity against salmonellae and its favorable pharmacokinetic profile, ciprofloxacin at a dosage of 750 mg orally twice daily had an unacceptably high failure rate in patients with acute salmonellosis and may have prolonged fecal excretion of salmonellae. The late occurrence of relapses indicates the need to obtain stool cultures up to 21 days after therapy to document fecal eradication in acute salmonellosis.
S J Allen, B Okoko, E Martinez, G Gregorio, L F Dans
Probiotics for treating infectious diarrhoea.
Cochrane Database Syst Rev. 2004;(2):CD003048. doi: 10.1002/14651858.CD003048.pub2.
Abstract/Text
BACKGROUND: Probiotics are microbial cell preparations or components of microbial cells that have a beneficial effect on the health and well being of the host. Probiotics may offer a safe intervention in acute infectious diarrhoea to reduce the duration and severity of the illness.
OBJECTIVES: To assess the effects of probiotics in proven or presumed infectious diarrhoea.
SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group's trials register (December 2002), the Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2002), MEDLINE (1966 to 2002), EMBASE (1988 to 2002), and reference lists from studies and reviews. We also contacted organizations and individuals working in the field, and pharmaceutical companies manufacturing probiotic agents.
SELECTION CRITERIA: Randomized controlled trials comparing a specified probiotic agent with placebo or no probiotic in people with acute diarrhoea that is proven or presumed to be caused by an infectious agent.
DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial methodological quality and extracted data.
MAIN RESULTS: Twenty-three studies met the inclusion criteria with a total of 1917 participants, mainly in countries with low overall mortality rates. Trials varied in relation to the probiotic(s) tested, dosage, methodological quality, and the diarrhoea definitions and outcomes. Probiotics reduced the risk of diarrhoea at 3 days (relative risk 0.66, 95% confidence interval 0.55 to 0.77, random effects model; 15 studies) and the mean duration of diarrhoea by 30.48 hours (95% confidence interval 18.51 to 42.46 hours, random effects model, 12 studies). Subgroup analysis by probiotic(s) tested, rotavirus diarrhoea, national mortality rates, and age of participants did not fully account for the heterogeneity.
REVIEWERS' CONCLUSIONS: Probiotics appear to be a useful adjunct to rehydration therapy in treating acute, infectious diarrhoea in adults and children. More research is needed to inform the use of particular probiotic regimens in specific patient groups.
Emil C Reisinger, Carlos Fritzsche, Robert Krause, Guenter J Krejs
Diarrhea caused by primarily non-gastrointestinal infections.
Nat Clin Pract Gastroenterol Hepatol. 2005 May;2(5):216-22. doi: 10.1038/ncpgasthep0167.
Abstract/Text
Infectious diseases that do not primarily affect the gastrointestinal tract can cause severe diarrhea. The pathogenesis of this kind of diarrhea includes cytokine action, intestinal inflammation, sequestration of red blood cells, apoptosis and increased permeability of endothelial cells in the gut microvasculature, and direct invasion of gut epithelial cells by various infectious agents. Of the travel-associated systemic infections presenting with fever, diarrhea occurs in patients with malaria, dengue fever and SARS. Diarrhea also occurs in patients with community-acquired pneumonia, when it is suggestive of legionellosis. Diarrhea can also occur in patients with systemic bacterial infections. In addition, although diarrhea is rare in patients with early Lyme borreliosis, the incidence is higher in those with other tick-borne infections, such as ehrlichiosis, tick-borne relapsing fever and Rocky Mountain spotted fever. Unfortunately, it is often not established whether diarrhea is an initial symptom or develops during the course of the disease. The real incidence of diarrhea in some infectious diseases must also be questioned because it could represent an adverse reaction to antibiotics.
