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Case definition

Diarrhea may be categorized into acute diarrhea, persistent diarrhea, and dysentery. Acute diarrhea is defined as less than 14 days of diarrhea AND more than 3 episodes per day

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 patients
2. Fever
3. Bloody/mucoid stools
4. Dehydration or >5 stools/day
5. Rectal pain
6. Suspected cholera (dehydration, tachycardia, electrolyte imbalances/acidosis, abdominal cramps, vomiting, acute secretory rice water diarrhea with fishy smell
7. Suspected Entamoeba (persistent bloody diarrhea)
8. Suspected amoebic liver abscess

Clinical management

Evaluate for dehydration: general condition, sunken eyes, thirst, skin pinch to assess turgor
Evaluate for malnutrition using growth chart. Measure midarm circumference of children 1-5 years old with Shakir’s tape

Provide education on food handling, hand sanitation, bleach cleaning of surfaces, and ask about recent antibiotic use

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

Oral rehydration solutions (ORS)

Oral rehydration packets (using a clean potable water source) or Pedialyte. Use ORS for 12 hours, followed by solid food (i.e. rice) to supply potassium and calories for repair.

Homemade rehydration solutions: Mix 6-8 tsp sugar with 1 tsp salt in 1 liter boiled water. 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 solution
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 dehydration and consider hospitalization if toxic

Pharmacologic management

Zinc 20mg po OD x 10 days if under 5 years (10mg po OD if under 6 months)

Options for dysentery

Adults: Ciprofloxacin 500mg bid x 10 days (may add metronidazole)
Pediatrics: Ciprofloxacin or TMP-SMX both acceptable

Options for cholera

Doxycycline 300mg once
Pregnancy: Cipro 1g once or azithromycin 1g once
Pediatrics: Doxycycline 100-200mg once (8-12 years), azithromycin 20mg/kg once

Persistent diarrhea (>1 week or >48 hours duration)

Adults: Metronidazole 250 mg po TID for 5-7 days
Pediatrics: Metronidazole 15mg/kg/day for 5-7 days or albendazole 400 mg once daily for 5 days
Suspected amoebic diarrhea: Metronidazole 500-750mg TID (15mg/kg/dose TID in children) for 7-10 days

Adapted from:

World Health Organization. The treatment of diarrhea: A manual for physicians and other senior health workers (4th revision). 2015.

World Gastroenterology Organization (WGO). World Gastroenterology Organization global guidelines: acute diarrhea in adults and children. Milwaukee (WI): World Gastroenterology Organization (WGO): 2012; p. 24.