Acute Diarrhea in Adults



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Am Fam Physician. 2014 Feb 1;89(3):180-189.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Patient information: See related handout on diarrhea, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Acute diarrhea in adults is a common problem encountered by family physicians. The most common etiology is viral gastroenteritis, a self-limited disease. Increases in travel, comorbidities, and foodborne illness lead to more bacteria-related cases of acute diarrhea. A history and physical examination evaluating for risk factors and signs of inflammatory diarrhea and/or severe dehydration can direct any needed testing and treatment. Most patients do not require laboratory workup, and routine stool cultures are not recommended. Treatment focuses on preventing and treating dehydration. Diagnostic investigation should be reserved for patients with severe dehydration or illness, persistent fever, bloody stool, or immunosuppression, and for cases of suspected nosocomial infection or outbreak. Oral rehydration therapy with early refeeding is the preferred treatment for dehydration. Antimotility agents should be avoided in patients with bloody diarrhea, but loperamide/simethicone may improve symptoms in patients with watery diarrhea. Probiotic use may shorten the duration of illness. When used appropriately, antibiotics are effective in the treatment of shigellosis, campylobacteriosis, Clostridium difficile, traveler's diarrhea, and protozoal infections. Prevention of acute diarrhea is promoted through adequate hand washing, safe food preparation, access to clean water, and vaccinations.

Acute diarrhea is defined as stool with increased water content, volume, or frequency that lasts less than 14 days.1 Diarrheal illness accounts for 2.5 million deaths per year worldwide.2 In the United States, an estimated 48 million foodborne diarrheal illnesses occur annually, resulting in more than 128,000 hospitalizations and 3,000 deaths.3,4 In the developing world, infectious causes of acute diarrhea are largely related to contaminated food and water supplies.5 In the developed world, technological progress and an increase in mass production of food have paradoxically contributed to the persistence of foodborne illness, despite higher standards of food production.6

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In patients with acute diarrhea, stool cultures should be reserved for grossly bloody stool, severe dehydration, signs of inflammatory disease, symptoms lasting more than three to seven days, immunosuppression, and suspected nosocomial infections.

C

25, 26

Testing for Clostridium difficile toxins A and B should be performed in patients who develop unexplained diarrhea after three days of hospitalization.

C

25, 27

Routine testing for ova and parasites in acute diarrhea is not necessary in developed countries, unless the patient is in a high-risk group (i.e., diarrhea lasting more than seven days, especially if associated with infants in day care or travel to mountainous regions; diarrhea in patients with AIDS or men who have sex with men; community waterborne outbreaks; or bloody diarrhea with few fecal leukocytes).

C

11, 29

The first step to treating acute diarrhea is rehydration, preferably oral rehydration.

C

1

Combination loperamide/simethicone may provide faster and more complete relief of acute nonspecific diarrhea and gas-related discomfort than either medication alone.

B

39

Antibiotics (usually a quinolone) reduce the duration and severity of traveler's diarrhea.

A

42


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In patients with acute diarrhea, stool cultures should be reserved for grossly bloody stool, severe dehydration, signs of inflammatory disease, symptoms lasting more than three to seven days, immunosuppression, and suspected nosocomial infections.

C

25, 26

Testing for Clostridium difficile toxins A and B should be performed in patients who develop unexplained diarrhea after three days of hospitalization.

C

25, 27

Routine testing for ova and parasites in acute diarrhea is not necessary in developed countries, unless the patient is in a high-risk group (i.e., diarrhea lasting more than seven days, especially if associated with infants in day care or travel to mountainous regions; diarrhea in patients with AIDS or men who have sex with men; community waterborne outbreaks; or bloody diarrhea with few fecal leukocytes).

C

11, 29

The first step to treating acute diarrhea is rehydration, preferably oral rehydration.

C

1

Combination loperamide/simethicone may provide faster and more complete relief of acute nonspecific diarrhea and gas-related discomfort than either medication alone.

The Authors

WENDY BARR, MD, MPH, MSCE, is associate residency director at the Lawrence (Mass.) Family Medicine Residency, and is an assistant professor of family medicine at Tufts University School of Medicine, Boston, Mass.

ANDREW SMITH, MD, is a faculty member at the Lawrence Family Medicine Residency.

Address correspondence to Wendy Barr, MD, MPH, MSCE, Lawrence Family Medicine Residency, 34 Haverhill St., Lawrence, MA 01841 (e-mail: wbarr@glfhc.org). Reprints are not available from the authors.

The authors thank Michelle Olivieri, BBA, for her editorial assistance.

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