Approach to acute nonbloody diarrhea in adults in resource-rich settings

HIV: human immunodeficiency virus.

* Loperamide and bismuth salicylates are both effective in reducing the duration and frequency of diarrhea; loperamide is somewhat more effective. Loperamide is often avoided when C. difficile is suspected. Patients taking loperamide should be cautioned not to exceed the maximum daily dose.

¶ Routine stool culture identifies Salmonella, Campylobacter, and Shigella. If other bacterial organisms (such as Vibrio, Listeria, Yersinia, or Aeromonas) are suspected based on exposures, the laboratory should be notified for specific plating of the specimen.

Δ Some laboratories perform multiplex molecular stool testing for multiple organisms simultaneously; the indications for such testing are similar to those for stool cultures. Any specimens that test positive for a bacterial pathogen on a multiplex molecular panel (or other culture-independent test) should be submitted for confirmatory culture; this is important for susceptibility testing and for public health purposes.

◊ Testing for C. difficile is warranted for individuals who have had antibiotic use or hospitalization within the prior three months; in addition, testing for C. difficile is often performed in patients with inflammatory bowel disease.

§ For most patients with non-travel-associated diarrhea, we do not administer empiric antibiotic therapy routinely, since the potential benefits do not outweigh potential drawbacks in most patients with acute diarrhea. For select patients with severe or persistent disease or high-risk host features, empiric antibiotic treatment is reasonable since symptom reduction may have a greater relative benefit in such patients. In such cases, we suggest treatment with azithromycin or a fluoroquinolone. We favor azithromycin for patients with fever and in patients suspected to be at risk for a fluoroquinolone-resistant pathogen (eg, in patients with diarrhea after travel to Southeast Asia, or during outbreaks of resistant pathogens). Empiric antibiotic therapy should be tailored to stool culture results when available.