In the Journals

ACG issues new guideline on management of acute diarrhea infections

The American College of Gastroenterology has released updated guideline recommendations for the diagnosis, treatment and prevention of acute diarrheal infections in adults in both U.S. domestic and travel settings.

“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,” Herbert L. DuPont, MD, of the University of Texas Health Science Center in Houston, and colleagues wrote. “It replaces a previously published ACG Guideline on the same topic, and supplements previously published Infectious Disease Society of America ... and World Gastroenterology Organization guidelines.”

Herbert L. DuPont

DuPont and colleagues considered literature published through February 2015 and used GRADE criteria to determine the quality of evidence and the strength of their 18 recommendations.

Diagnosis

The guideline authors strongly recommended that when patients are at high risk for spreading disease, or during known or suspected outbreaks, stool culture and, if available, culture-independent methods should be used for diagnostic evaluation. “Until new methods have evolved in which genotypic advanced characterization platforms are widely available, it is recommended that culture-based and culture-independent testing be used in parallel when practicable to support public health purposes,” they wrote.

They also strongly recommended stool diagnostic studies for patients with dysentery, moderate-to-severe disease and symptoms lasting more than a week to determine etiology and direct therapy; and FDA-approved culture-independent methods as an adjunct to traditional diagnostic methods to determine etiology. Moreover, they strongly recommended against antibiotic sensitivity testing for managing patients with acute diarrheal infection as “the clinical impact of this has yet to be manifest in a significant enough way to warrant ... testing across the board, especially in the individual patient.”

Treatment

The authors strongly recommended that in elderly patients with severe diarrhea or travelers with cholera-like watery diarrhea, balanced electrolyte rehydration should be used vs. other oral rehydration options.

They strongly recommend against using probiotics or prebiotics for acute diarrhea due to lack of evidence, but “there is supporting evidence for the role of probiotics in prevention of acute diarrhea associated with antibiotic use,” they wrote.

Bismuth subsalicylates are recommended for controlling symptoms in mild to moderate illness, and loperamide is recommended as an adjunct therapy in patients receiving antibiotics for traveler’s diarrhea. “The most valuable use of loperamide in the self-treatment of [traveler’s diarrhea] is as a combination drug with antibacterial drugs where the antimotility drug quickly reduces the number of diarrhea stools passed while the antibiotic cures the enteric infection,” they wrote.

Anti-microbial therapy is recommended for traveler’s diarrhea with a high likelihood of bacterial pathogens, but not for routine acute diarrheal infection. Moreover, antibiotics should be discouraged for community-acquired diarrhea, as studies suggest most cases originate from viral infections.

Evaluating persistent symptoms

In patients whose diarrheal symptoms last between 14 and 30 days, the authors do not recommend serological and clinical laboratory testing, and in such patients with persistent symptoms who have a negative stool work-up, endoscopic evaluation is also not recommended. In these patients, “the role of clinical laboratory studies and endoscopy is uncertain and should be dictated by clinical suspicion and disease severity, within the context of most likely etiologies,” the authors wrote.

Prevention

Patient-level counseling for preventing acute enteric infections may be considered in individuals at high risk for complications and their close-contacts, and pretravel counseling for avoiding high risk foods and beverages is recommended to prevent traveler’s diarrhea, although the evidence supporting the latter recommendation is mixed.

Similarly, “the evidence of hand washing and use of alcohol-based hand sanitizers in preventing [traveler’s diarrhea] is mixed,” but they may be effective in preventing enteric infections caused by low-dose pathogens in settings like a cruise ship with a norovirus outbreak, an institutional outbreak, or in endemic diarrhea prevention, they wrote.

Finally, the authors strongly recommend that prophylactic bismuth subsalicylates can be considered for travelers without contraindications for prevention of traveler’s diarrhea, as it has been shown to reduce the occurrence of traveler’s diarrhea at 2.1 g per day taken for up to 3 weeks. Prophylactic probiotics, prebiotics and synbiotics are not recommended due to insufficient evidence, and antibiotic chemoprophylaxis may be considered for prevention of traveler’s diarrhea, but only in high risk groups and for short durations. – by Adam Leitenberger

Disclosure: DuPont reports participation on advisory boards for Salix and Romark, is a data and safety monitoring Board Member for PaxVax, has served as a consultant for Glaxo Smith Kline and has received grant support through his university from Glaxo Smith Kline, Sanofi Pasteur, Takeda and Seres Health. Please see the full guideline for a list of all other committee members’ relevant financial disclosures.

The American College of Gastroenterology has released updated guideline recommendations for the diagnosis, treatment and prevention of acute diarrheal infections in adults in both U.S. domestic and travel settings.

“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,” Herbert L. DuPont, MD, of the University of Texas Health Science Center in Houston, and colleagues wrote. “It replaces a previously published ACG Guideline on the same topic, and supplements previously published Infectious Disease Society of America ... and World Gastroenterology Organization guidelines.”

Herbert L. DuPont

DuPont and colleagues considered literature published through February 2015 and used GRADE criteria to determine the quality of evidence and the strength of their 18 recommendations.

Diagnosis

The guideline authors strongly recommended that when patients are at high risk for spreading disease, or during known or suspected outbreaks, stool culture and, if available, culture-independent methods should be used for diagnostic evaluation. “Until new methods have evolved in which genotypic advanced characterization platforms are widely available, it is recommended that culture-based and culture-independent testing be used in parallel when practicable to support public health purposes,” they wrote.

They also strongly recommended stool diagnostic studies for patients with dysentery, moderate-to-severe disease and symptoms lasting more than a week to determine etiology and direct therapy; and FDA-approved culture-independent methods as an adjunct to traditional diagnostic methods to determine etiology. Moreover, they strongly recommended against antibiotic sensitivity testing for managing patients with acute diarrheal infection as “the clinical impact of this has yet to be manifest in a significant enough way to warrant ... testing across the board, especially in the individual patient.”

Treatment

The authors strongly recommended that in elderly patients with severe diarrhea or travelers with cholera-like watery diarrhea, balanced electrolyte rehydration should be used vs. other oral rehydration options.

They strongly recommend against using probiotics or prebiotics for acute diarrhea due to lack of evidence, but “there is supporting evidence for the role of probiotics in prevention of acute diarrhea associated with antibiotic use,” they wrote.

Bismuth subsalicylates are recommended for controlling symptoms in mild to moderate illness, and loperamide is recommended as an adjunct therapy in patients receiving antibiotics for traveler’s diarrhea. “The most valuable use of loperamide in the self-treatment of [traveler’s diarrhea] is as a combination drug with antibacterial drugs where the antimotility drug quickly reduces the number of diarrhea stools passed while the antibiotic cures the enteric infection,” they wrote.

Anti-microbial therapy is recommended for traveler’s diarrhea with a high likelihood of bacterial pathogens, but not for routine acute diarrheal infection. Moreover, antibiotics should be discouraged for community-acquired diarrhea, as studies suggest most cases originate from viral infections.

Evaluating persistent symptoms

In patients whose diarrheal symptoms last between 14 and 30 days, the authors do not recommend serological and clinical laboratory testing, and in such patients with persistent symptoms who have a negative stool work-up, endoscopic evaluation is also not recommended. In these patients, “the role of clinical laboratory studies and endoscopy is uncertain and should be dictated by clinical suspicion and disease severity, within the context of most likely etiologies,” the authors wrote.

Prevention

Patient-level counseling for preventing acute enteric infections may be considered in individuals at high risk for complications and their close-contacts, and pretravel counseling for avoiding high risk foods and beverages is recommended to prevent traveler’s diarrhea, although the evidence supporting the latter recommendation is mixed.

Similarly, “the evidence of hand washing and use of alcohol-based hand sanitizers in preventing [traveler’s diarrhea] is mixed,” but they may be effective in preventing enteric infections caused by low-dose pathogens in settings like a cruise ship with a norovirus outbreak, an institutional outbreak, or in endemic diarrhea prevention, they wrote.

Finally, the authors strongly recommend that prophylactic bismuth subsalicylates can be considered for travelers without contraindications for prevention of traveler’s diarrhea, as it has been shown to reduce the occurrence of traveler’s diarrhea at 2.1 g per day taken for up to 3 weeks. Prophylactic probiotics, prebiotics and synbiotics are not recommended due to insufficient evidence, and antibiotic chemoprophylaxis may be considered for prevention of traveler’s diarrhea, but only in high risk groups and for short durations. – by Adam Leitenberger

Disclosure: DuPont reports participation on advisory boards for Salix and Romark, is a data and safety monitoring Board Member for PaxVax, has served as a consultant for Glaxo Smith Kline and has received grant support through his university from Glaxo Smith Kline, Sanofi Pasteur, Takeda and Seres Health. Please see the full guideline for a list of all other committee members’ relevant financial disclosures.