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
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.
Andi L Shane, Rajal K Mody, John A Crump, Phillip I Tarr, Theodore S Steiner, Karen Kotloff, Joanne M Langley, Christine Wanke, Cirle Alcantara Warren, Allen C Cheng, Joseph Cantey, Larry K Pickering
2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea.
Clin Infect Dis. 2017 Nov 29;65(12):1963-1973. doi: 10.1093/cid/cix959.
Abstract/Text
These guidelines are intended for use by healthcare professionals who care for children and adults with suspected or confirmed infectious diarrhea. They are not intended to replace physician judgement regarding specific patients or clinical or public health situations. This document does not provide detailed recommendations on infection prevention and control aspects related to infectious diarrhea.
© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.
Nipam Shah, Herbert L DuPont, David J Ramsey
Global etiology of travelers' diarrhea: systematic review from 1973 to the present.
Am J Trop Med Hyg. 2009 Apr;80(4):609-14.
Abstract/Text
Fifty-one published studies of travelers' diarrhea (TD) were examined to look for regional differences in pathogens identified. Enterotoxigenic E. coli was detected in 1,678/5,518 (30.4%) of TD cases overall, with rates in Latin America/Caribbean (L. America), Africa, south Asia, and Southeast Asia of 1,109/3,302 (33.6%), 389/1,217 (31.2%), 153/499 (30.6%), and 36/500 (7.2%), respectively (P < 0.001). Enteroaggregative E. coli was the second most common agent in L. America, found in 166/689 (24.1%), compared with 3/165 (1.8%) in Africa and 33/206 (16%) in south Asia (P < 0.001). Other significantly regional differences were seen for enteropathogenic E. coli, diffusely adherent E. coli, Campylobacter, Shigella spp., Salmonella, Aeromonas spp., Plesiomonas, Vibrios, rotavirus, noroviruses, Giardia, and Entoamoeba histolytica. The regional differences in pathogen identification identified will serve as a baseline for antimicrobial therapy recommendations and vaccines strategies.
G De Bruyn, S Hahn, A Borwick
Antibiotic treatment for travellers' diarrhoea.
Cochrane Database Syst Rev. 2000;(3):CD002242. doi: 10.1002/14651858.CD002242.
Abstract/Text
BACKGROUND: Traveller's diarrhoea is a syndrome frequently encountered in persons crossing an international boundary. Diarrhoea can lead to significant discomfort and interference with travel plans. Bacterial pathogens are a frequent cause of this syndrome. Several antibiotics have been tested for efficacy in reducing the duration and severity of the illness.
OBJECTIVES: The aims of this review were to assess the effects of antibiotics on traveller's diarrhoea in relation to duration of illness, severity of illness, and adverse effects of medications.
SEARCH STRATEGY: The Cochrane Collaboration Trials Register, MEDLINE, and EMBASE were searched. Additional trials were identified by hand searching. Content experts were contacted.
SELECTION CRITERIA: All trials in any language in which travellers older than 5 years were randomly allocated to treatment for acute non-bloody diarrhoea with antibiotics and where the causative organism is not known at allocation.
DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and extracted data.
MAIN RESULTS: Twenty published studies met inclusion and quality criteria for inclusion. Twelve studies were placebo-controlled. A meta-analysis for the primary outcome was not feasible. All of the 10 trials reported a significant reduction in duration of diarrhoea in participants treated with antibiotics compared with placebo. Data from two trials demonstrated a small reduction for antibiotic treated patients in the number of unformed stools passed per each 24 hour period from randomisation up to 72 hours. Data from six trials demonstrated a greater number of participants being cured of diarrhoea by 72 hours (odds ratio [OR] 5. 9, 95% confidence interval [CI] 4.06 to 8.57). Data regarding side effects were available from five trials. There was wide variation in the prevalence of side effects reported in different trials. Persons taking antibiotics experienced more side effects than those taking placebo (OR 2.37, 95% CI 1.5 to 3.75).
REVIEWER'S CONCLUSIONS: Antibiotic treatment is associated with shorter duration of diarrhoea but higher incidence of side-effects. Trials generally do not report duration of post-treatment diarrhoea using time-to-event analyses, and should do.
Mark S Riddle, Sarah Arnold, David R Tribble
Effect of adjunctive loperamide in combination with antibiotics on treatment outcomes in traveler's diarrhea: a systematic review and meta-analysis.
Clin Infect Dis. 2008 Oct 15;47(8):1007-14. doi: 10.1086/591703.
Abstract/Text
BACKGROUND: A previous Cochrane Collaboration review established an effective advantage of antibiotic therapy, compared with placebo, for treatment of traveler's diarrhea. The goal of the present study was to conduct a systematic review of the literature to establish the effect on treatment outcomes of using antimotility agents in conjunction with antibiotic therapy.
METHODS: The meta-analysis was conducted through searches of electronic databases and pertinent reference lists (including other review articles) and consultation with experts in the field. Clinical trials on therapy of infectious diarrhea in adult populations that met eligibility criteria were studied. Data were extracted and verified by 2 independent investigators and were analyzed for outcomes of clinical cure at 24 h, 48 h, and 72 h and time to last unformed stool. Study quality, heterogeneity, and publication bias were assessed. When appropriate, effect estimates among studies were pooled and sensitivity analyses were performed.
RESULTS: Nine studies consisting of 12 different adjunctive loperamide antibiotic regimens were included for analysis. Among 6 paired studies comparing antibiotics alone versus antibiotics in combination with loperamide, the odds of clinical cure at 24 h and 48 h favored combination therapy, with summary odds ratios of 2.6 (95% confidence interval, 1.8-3.6; P = .20 by chi(2) heterogeneity statistic) and 2.2 (95% confidence interval, 1.5-3.1; P = .20, by chi(2) heterogeneity statistic), respectively, with no evidence of heterogeneity. Factors that possibly affect advantage of combination therapy over solo therapy included increased frequency of pretreatment diarrhea and higher prevalence of noninvasive pathogens.
CONCLUSION: Antibiotic therapy with adjunctive loperamide offers an advantage over antibiotics alone by decreasing the illness duration and increasing the probability of early clinical cure.
David R Tribble, John W Sanders, Lorrin W Pang, Carl Mason, Chittima Pitarangsi, Shahida Baqar, Adam Armstrong, Paul Hshieh, Anne Fox, Elisabeth A Maley, Carlos Lebron, Dennis J Faix, James V Lawler, Gautam Nayak, Michael Lewis, Ladaporn Bodhidatta, Daniel A Scott
Traveler's diarrhea in Thailand: randomized, double-blind trial comparing single-dose and 3-day azithromycin-based regimens with a 3-day levofloxacin regimen.
Clin Infect Dis. 2007 Feb 1;44(3):338-46. doi: 10.1086/510589. Epub 2006 Dec 28.
Abstract/Text
BACKGROUND: Traveler's diarrhea in Thailand is frequently caused by Campylobacter jejuni. Rates of fluoroquinolone (FQ) resistance in Campylobacter organisms have exceeded 85% in recent years, and reduced fluoroquinolone efficacy has been observed.
METHODS: Azithromycin regimens were evaluated in a randomized, double-blind trial of azithromycin, given as a single 1-g dose or a 3-day regimen (500 mg daily), versus a 3-day regimen of levofloxacin (500 mg daily) in military field clinics in Thailand. Outcomes included clinical end points (time to the last unformed stool [TLUS] and cure rates) and microbiological end points (pathogen eradication).
RESULTS: A total of 156 patients with acute diarrhea were enrolled in the trial. Campylobacter organisms predominated (in 64% of patients), with levofloxacin resistance noted in 50% of Campylobacter organisms and with no azithromycin resistance noted. The cure rate at 72 h after treatment initiation was highest (96%) with single-dose azithromycin, compared with the cure rates of 85% noted with 3-day azithromycin and 71% noted with levofloxacin (P=.002). Single-dose azithromycin was also associated with the shortest median TLUS (35 h; P=.03, by log-rank test). Levofloxacin's efficacy was inferior to azithromycin's efficacy, except in patients with no pathogen identified during the first 24 h of treatment or in patients with levofloxacin-susceptible Campylobacter isolates, in whom it appeared to be equal to azithromycin. The rate of microbiological eradication was significantly better with azithromycin-based regimens (96%-100%), compared with levofloxacin (38%) (P=.001); however, this finding was poorly correlated with clinical outcome. A higher rate of posttreatment nausea in the 30 min after receipt of the first dose (14% vs. <6%; P=.06) was observed as a mild, self-limited complaint associated with single-dose azithromycin.
CONCLUSIONS: Single-dose azithromycin is recommended for empirical therapy of traveler's diarrhea acquired in Thailand and is a reasonable first-line option for empirical management in general.
Joaquim Ruiz, Francesc Marco, Ines Oliveira, Jordi Vila, Joaquim Gascón
Trends in antimicrobial resistance in Campylobacter spp. causing traveler's diarrhea.
APMIS. 2007 Mar;115(3):218-24. doi: 10.1111/j.1600-0463.2007.apm_567.x.
Abstract/Text
The aim of this study was to analyze the evolution of the levels of resistance to nine antimicrobial agents in clinical isolates of Campylobacter spp. causing traveler's diarrhea during the period from 1993 to 2003. The antimicrobial resistance levels to ampicillin, amoxicillin plus clavulanic acid, chloramphenicol, tetracycline, erythromycin, gentamicin, clindamicin, nalidixic acid and ciprofloxacin were established by the method of Kirby-Bauer. Two subperiods (1993-1998 and 1999-2003) were chosen to compare the evolution of the levels of antimicrobial resistance. Mantel-Haenszel or Fisher's exact test was performed to determine statistical significance. High levels of resistance to four out of nine antimicrobial agents tested were detected: ampicillin (66.3%), nalidixic acid (52.2%), ciprofloxacin (46.7%), and tetracycline (42.4%). In addition, resistance levels of 20.6% to amoxicillin plus clavulanic acid were detected. An increase in the resistance levels between the two subperiods analyzed for those five antimicrobial agents was observed. This increase was statistically significant for ampicillin, nalidixic acid, and ciprofloxacin. Two cases of therapeutic failure during treatment with ciprofloxacin were detected. The level of resistance to the most commonly used antibacterial agents in the developing world is increasing in Campylobacter spp., the increase in the resistance to quinolones being of special concern.
David R Hill, Charles D Ericsson, Richard D Pearson, Jay S Keystone, David O Freedman, Phyllis E Kozarsky, Herbert L DuPont, Frank J Bia, Philip R Fischer, Edward T Ryan, Infectious Diseases Society of America
The practice of travel medicine: guidelines by the Infectious Diseases Society of America.
Clin Infect Dis. 2006 Dec 15;43(12):1499-539. doi: 10.1086/508782. Epub 2006 Nov 8.
Abstract/Text
