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 patients3

2. Fever1,3,5,7,12

3. Bloody/mucoid stools1,3,5,7,12

4. Dehydration3,5 or >5 stools/day5

5. Rectal pain1,7,12

6. Suspected cholera (dehydration, tachycardia, electrolyte imbalances/acidosis, abdominal cramps, vomiting, acute secretory rice water diarrhea with fishy smell20

7. Suspected Entamoeba (persistent bloody diarrhea)1,12,14

8. Suspected amoebic liver abscess14

Management

Non-pharmacologic recommendations

Provide education on food handling, hand sanitation, bleach cleaning of surfaces7,20, and ask about recent antibiotic use7

For infants: continue breastfeeding, and ensure next day clinical follow-up3.

Oral rehydration solutions (ORS)

Oral rehydration packets (using a clean potable water source) or Pedialyte1,2,3,7,18,20. Use ORS for 12 hours, followed by solid food (i.e. rice) to supply potassium and calories for repair9,18.

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 solution13
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 dehydration1,5, 20 and consider hospitalization if toxic5

Pharmacologic management

Options for dysentery

Adults: Ciprofloxacin 500mg bid x 10d1,5,7,18(may add metronidazole5,18)

Pediatrics: Ciprofloxacin or TMP-SMX1,5,7both 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 week5 or >48 hours3, duration)

Adults: Metronidazole 250 mg po TID for 5-7 days7,8,9

Pediatrics: Metronidazole 15mg/kg/day for 5-7 days7,8,9 or albendazole 400 mg once daily for 5 days8

Suspected amoebic diarrhea: Metronidazole 500-750mg TID (15mg/kg/dose TID in children)1,7,12,14,17,18 for 7-10 days7

Additional considerations

Pediatrics: Multi-vitamin, vitamin A supplement20

Zinc 20 mg/day if >6 months old, or 10 mg/day if <6 months old for 10-14 days20 to decrease the length and severity of episode and prevent recurrence7.

Consider symptomatic treatment with Kaopectate13, Pepto-Bismol or Imodium3

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1. Organization A

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

2. Organization B

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

3. Organization C

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

4. Organization D

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

5. Organization E

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

6. 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

7. 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

8. 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

9. Organization I

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

10. 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

11. Organization K

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

12. Organization L

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

13. Organization M

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

14. Organization N

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

15. 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

16. Organization P

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

17. Organization Q

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

18. 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

19. Organization S

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

20. 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