Case Definition

Diarrhea may be categorized into acute diarrhea, persistent diarrhea, and dysentery.

Red Flags

Consider hospital referral or early follow-up for the following signs of severe diarrhea or dysentery (suspect salmonella, shigella, campylobacter, cholera, amoebiasis):

1. Very young, elderly, or sick patientsC

2. FeverA,C,E,G,L

3. Bloody/mucoid stoolsA,C,E,G,L

4. DehydrationC,E or >5 stools/dayE

5. Rectal painA,G,L

6. Suspected cholera (dehydration, tachycardia, electrolyte imbalances/acidosis, abdominal cramps, vomiting, acute secretory rice water diarrhea with fishy smellT

7. Suspected Entamoeba (persistent bloody diarrhea)A,L,N

8. Suspected amoebic liver abscessN

Management

Non-pharmacologic recommendations

Provide education on food handling, hand sanitation, bleach cleaning of surfacesG,T, and ask about recent antibiotic useG

For infants: continue breastfeeding, and ensure next day clinical follow-upC.

Oral rehydration solutions (ORS)

Oral rehydration packets (using a clean potable water source) or PedialyteA,B,C,G,R,T. Use ORS for 12 hours, followed by solid food (i.e. rice) to supply potassium and calories for repairI,R.

Homemade rehydration solutions: Mix 6-8 tsp sugar with 1 tsp salt in 1 liter boiled water (ensure parent tastes first, and that solution tastes sweet). Avoid fructose or artificial sweeteners. Add half-cup of orange juice or half a mashed banana to each liter to add potassium and improve taste).

Salt-sugar-lemon juice-water solutionM
The above are all preferable to sports drinks (excess sugar, few electrolytes, and may cause osmotic diarrhea).

Use IV Ringer’s lactate or normal saline for severe dehydrationA,E, T and consider hospitalization if toxicE

Pharmacologic management

Options for dysentery

Adults: Ciprofloxacin 500mg bid x 10dA,E,G,R(may add metronidazoleE,R)

Pediatrics: Ciprofloxacin or TMP-SMXA,E,Gboth acceptable

Options for cholera

Adults: Doxycycline 300mg once

Pregnancy: Cipro 1g once or azithromycin 1g once

Pediatrics: Doxycycline 100-200mg once (8-12 years), azithromycin 20mg/kg once (<8 years)

Persistent diarrhea (1 weekE or >48 hoursC, duration)

Adults: Metronidazole 250 mg po TID for 5-7 daysG,H,I

Pediatrics: Metronidazole 15mg/kg/day for 5-7 daysG,H,I or albendazole 400 mg once daily for 5 daysH

Suspected amoebic diarrhea: Metronidazole 500-750mg TID (15mg/kg/dose TID in children)A,G,L,N,Q,R for 7-10 daysG

Additional considerations

Pediatrics: Multi-vitamin, vitamin A supplementT

Zinc 20 mg/day if >6 months old, or 10 mg/day if <6 months old for 10-14 daysT to decrease the length and severity of episode and prevent recurrenceG.

Consider symptomatic treatment with KaopectateM, Pepto-Bismol or ImodiumC

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Organization A

Locations: Nicaragua
Trips per year: 4
Format of trips: Mobile medical clinics and standing clinics
Setting: Rural
Type of Organization: Secular

Organization B

Locations: Guatemala
Trips per year: Variable
Format of trips: Clinics
Setting: Rural
Type of Organization: Secular

Organization C

Locations: Haiti
Trips per year: Variable
Format of trips: Clinic
Setting: Urban
Type of Organization: Faith-based

Organization D

Locations: Dominican Republic
Trips per year: 3
Format of trips: Clinic
Setting: Rural
Type of Organization: Secular

Organization E

Locations: Haiti
Trips per year: 7
Format of trips: Not mentioned
Setting: Rural
Type of Organization: Secular

Organization F

Locations: Honduras, Ecuador, Belize, Guyana, Guatemala
Trips per year: 5
Format of trips: Mobile brigades
Setting: Rural and Urban
Type of Organization: Faith-based

Organization G

Locations: Ecuador, Guatemala, Dominican Republic
Trips per year: 100 (spread over 6 sites)
Format of trips: Mobile brigades
Setting: Rural and Urban
Type of Organization: Secular

Organization H

Locations: Ecuador
Trips per year: 3
Format of trips: Mobile brigades in schools/Clinics in health centers
Setting: Rural
Type of Organization: Secular

Organization I

Locations: Honduras
Trips per year: 1
Format of trips: Mobile brigades in 20 villages
Setting: Rural
Type of Organization: Faith-based

Organization J

Locations: Jamaica, Haiti
Trips per year: 4
Format of trips: Mobile brigades, Permanent clinics/hospital medicine
Setting: Rural and urban
Type of Organization: Secular

Organization K

Locations: Haiti
Trips per year: 4
Format of trips: Clinic
Setting: Rural
Type of Organization: Secular

Organization L

Locations: Guatemala, Nicaragua
Trips per year: 3
Format of trips: Mobile clinics
Setting: Rural
Type of Organization: Faith-based

Organization M

Locations: Nicaragua, Honduras
Trips per year: 51
Format of trips: Mobile brigades, Hospital-based
Setting: Rural
Type of Organization: Faith-based

Organization N

Locations: Guatemala
Trips per year: 12
Format of trips: Hospital
Setting: Rural
Type of Organization: Secular

Organization O

Locations: Honduras
Trips per year: Up to 50
Format of trips: Mobile brigades in school and churches
Setting: Rural
Type of Organization: Faith-based

Organization P

Locations: Haiti
Trips per year: Variable
Format of trips: Mobile brigades and clinics
Setting: Rural and urban
Type of Organization: Secular

Organization Q

Locations: Dominican Republic, Haiti
Trips per year: 12 to 15
Format of trips: Mobile brigades
Setting: Rural
Type of Organization: Secular

Organization R

Locations: Honduras, Nicaragua, Panama
Trips per year: Hundreds
Format of trips: Mobile brigades in community centre or school
Setting: Rural
Type of Organization: Secular

Organization S

Locations: Honduras
Trips per year: 4
Format of trips: Mobile brigades, Specialty hospital services
Setting: Rural
Type of Organization: Secular

Organization T

Locations: Haiti
Trips per year: Approximately 40
Format of trips: Mobile clinics in 14 villages and Standing clinic
Setting: Rural
Type of Organization: Faith-based