Here are the key points regarding probiotics and acute diarrhea/traveler's diarrhea from the guideline:
- The guideline recommends do not treating acute diarrhea with probiotics and prebiotics except for postantibiotic diarrhea.
- For traveler's diarrhea prophylaxis, the guideline recommends do not using prebiotics, probiotics, and synbiotics (combinations of prebiotics and probiotics).
- The reasoning given is that probiotics/prebiotics are not effective for preventing or treating acute diarrhea/traveler's diarrhea based on the evidence reviewed. They are not recommended because they do not provide benefit, not because they necessarily cause harm.
- Probiotics are generally considered safe when taken as
Here are the key points regarding probiotics and acute diarrhea/traveler's diarrhea from the guideline:
- The guideline recommends do not treating acute diarrhea with probiotics and prebiotics except for postantibiotic diarrhea.
- For traveler's diarrhea prophylaxis, the guideline recommends do not using prebiotics, probiotics, and synbiotics (combinations of prebiotics and probiotics).
- The reasoning given is that probiotics/prebiotics are not effective for preventing or treating acute diarrhea/traveler's diarrhea based on the evidence reviewed. They are not recommended because they do not provide benefit, not because they necessarily cause harm.
- Probiotics are generally considered safe when taken as
Here are the key points regarding probiotics and acute diarrhea/traveler's diarrhea from the guideline:
- The guideline recommends do not treating acute diarrhea with probiotics and prebiotics except for postantibiotic diarrhea.
- For traveler's diarrhea prophylaxis, the guideline recommends do not using prebiotics, probiotics, and synbiotics (combinations of prebiotics and probiotics).
- The reasoning given is that probiotics/prebiotics are not effective for preventing or treating acute diarrhea/traveler's diarrhea based on the evidence reviewed. They are not recommended because they do not provide benefit, not because they necessarily cause harm.
- Probiotics are generally considered safe when taken as
Here are the key points regarding probiotics and acute diarrhea/traveler's diarrhea from the guideline:
- The guideline recommends do not treating acute diarrhea with probiotics and prebiotics except for postantibiotic diarrhea.
- For traveler's diarrhea prophylaxis, the guideline recommends do not using prebiotics, probiotics, and synbiotics (combinations of prebiotics and probiotics).
- The reasoning given is that probiotics/prebiotics are not effective for preventing or treating acute diarrhea/traveler's diarrhea based on the evidence reviewed. They are not recommended because they do not provide benefit, not because they necessarily cause harm.
- Probiotics are generally considered safe when taken as
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June 16, 2016
New Guideline for Prevention and Management of
Acute Diarrhea Douglas K. Rex, MD reviewing Riddle MS et al. Am J Gastroenterol 2016 May. Recommendations include those on preventing traveler's diarrhea, which patients often ask about. Sponsoring Organization: American College of Gastroenterology (ACG) Audience: Gastroenterologists, primary care providers Background and Objective In this new comprehensive guideline, researchers developed graded recommendations on diagnosis, management, and prevention of acute diarrheal infections based on a systematic review of evidence. Key Recommendations
In acute diarrhea (duration, 114 days), perform stool cultures and new cultureindependent molecular assays (if available) when a patient is at high risk of spreading disease or during outbreaks.
Consider stool diagnostic tests in presence of dysentery, moderate-to-severe disease, or
symptom duration >7 days.
Supplement traditional diagnostic stool tests (culture, microscopy with or without special stains, immunofluorescence, antigen testing), which are usually negative in acute diarrhea, with FDA-approved culture-independent molecular methods if available.
Do not conduct antibiotic sensitivity testing in acute diarrhea.
The use of a fecal leukocyte test or fecal lactoferrin to guide more appropriate use of cultures is imprecise and probably unnecessary.
With a few exceptions, most patients can adequately rehydrate with water, juice, sports drinks, soups, and salty crackers.
Do not treat acute diarrhea with probiotics and prebiotics except for postantibiotic diarrhea.
Treat mild-to-moderate traveler's diarrhea (TD) with bismuth subsalicylate except where contraindicated (e.g., use of other salicylates). Warn patients about the harmless black tongue and black stools that result.
Loperamide remains an excellent treatment for TD. Titrate the dose to avoid posttreatment constipation, and do not give for >48 hours. Loperamide may even be safe in a dysentery presentation that would increase the risk for an invasive pathogen, provided it is combined with antibiotic therapy.
Do not conduct empiric antibiotic therapy in acute diarrheal infection, except in cases of TD in which a bacterial cause is deemed highly likely. Most community-acquired acute diarrhea is viral in origin.
Treat TD with a single-dose or 3-day course of quinolones or single-dose azithromycin
(1000 mg), except for suspected or cultured Shigella, which requires a 5-day course.
Endoscopic evaluation is not recommended for this duration of symptoms.
Specific handwashing measures and alcohol-based hand sanitizers have limited value for most TD but could be useful in preventing cruise ship outbreaks of norovirus and institutional outbreaks, or in areas of endemic diarrhea.
For prophylaxis of TD, consider bismuth subsalicylate two tablets (2.1 g) four times daily at meals and bedtime to provide 60% risk reduction for trips up to 2 weeks but usually not for longer trips; lower doses are associated with reduced protection.
Do not use prebiotics, probiotics, and synbiotics (combinations of prebiotics and
probiotics) for TD prophylaxis.
Antibiotic prophylaxis for TD is recommended, but only in high-risk groups and for shortterm use. This limited role for chemoprophylaxis is being reevaluated with increasing awareness of the high frequency and impact of postinfectious irritable bowel syndrome and the availability of rifaximin, which has desirable features and safety profile compared with quinolones for prophylaxis.
COMMENT Although it seems that gastroenterologists evaluate fewer patients with acute diarrhea than with chronic diarrhea, we do sometimes see acute diarrhea, and patients often ask about how to prevent traveler's diarrhea. A useful feature of this guideline is an algorithm that details a management approach to acute diarrhea based on watery versus dysenteric presentation and duration of symptoms and which covers both diagnostic assessment and treatment.
EDITOR DISCLOSURES AT TIME OF PUBLICATION
Disclosures for Douglas K. Rex, MD at time of publicationConsultant / Advisory
boardCovidien; Olympus Corporation America; Endo-Aid Ltd.; Endochoice; Boston Scientific; Paion AG; Ironwood Pharmaceuticals; Colonary Solutions; Novo Nordisk Inc.; Medscape GastroenterologyGrant / Research support:Braintree LaboratoriesEditorial boardsWorld Journal of
Gastroenterology; The Journal of Clinical Gastroenterology; Techniques in Gastrointestinal
Endoscopy; Gastroenterology & Hepatology; Expert Review of Gastroenterology & Hepatology; Medscape Gastroenterology; World Journal of Gastrointestinal Pharmacology and Therapeutics; Annals of Gastroenterology & Hepatology; World Journal of Gastrointestinal Oncology; Comparative Effectiveness Research; Journal of Anesthesia & Clinical Research; Gastroenterology; World Journal of Gastrointestinal Pathophysiology; Gastroenterology Research and Practice; GI & Hepatology News; Gastroenterology Report; Clinical Epidemiology Reviews; JSM Gastroenterology and Hepatology (associate editor); GI Journal Watch; Austin Journal of Gastroenterology; World Journal of Gastrointestinal Pharmacology & TherapeuticsLeadership positions in professional societiesAmerican Society for Gastrointestinal Endoscopy (Councilor); US Multi-Society Task Forces (AGA, ACG, ASGE) (Chair)
CITATION(S): 1.
Riddle MS et al. ACG clinical guideline: Diagnosis, treatment, and prevention of acute diarrheal infections in adults. Am J Gastroenterol 2016 May; 111:602. (http://dx.doi.org/10.1038/ajg.2016.126)
Rep l y
Amanda S PharmD Other Healthcare Professional, Pharmacology/Pharmacy19 Jun 2016 11:37 PM
Kaopectate in its usual formulation actually contains bismuth subsalicylate, the same active ingredient as pepto bismol (although it used to be formulated with different active ingredients- kaolin and pectin). Loperamide (in Imodium) certainly would cause constipation more frequently than bismuth subsalicylate due to its mechanism of action (slowing gastric motility through activation of opioid receptors in the gut vs antimicrobial + antisecretory effect). But ultimately, unless the dose is different, drugs with the same active ingredient should have the same side effect profile. Whew, and there's a fun pharmacology review for the day :)
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Juan Urdapilleta Physician, Internal Medicine, Argentina18 Jun 2016 4:27 PM
Breve y conciso excelente
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Kareem Essam Physician, Gastroenterology, Cairo university17 Jun 2016 11:33 PM
What is the role of metronidazole in acute diarrhea?
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IVAN SARAIVA Physician, Internal Medicine17 Jun 2016 10:54 PM
Probiotics containing Lactobacillus seem to be safe, but there has been reports of sepsis associated with Saccharomyces boulardii probiotics (rare and mostly limited to patients with imune impairment).
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Hazel Moyer Retired17 Jun 2016 3:44 PM
Although Immodium and Kaopectate both contain Loperamide, Immodium results in constipation. Kaopectate does not which makes it far superior to Immodium. Who wants to trade diarrhea for constipation? No one.
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SALLY BURBANK Physician, Internal Medicine17 Jun 2016 11:21 AM
Do probiotics actually do HARM in acute diarrhea or TD, or do they merely not help? What is the reasoning behind specifically advising against probiotics?
