Approach To The Adult With Acute Diarrhea in Resource-Limited Settings - UpToDate

25/9/23, 22:21 Approach to the adult with acute diarrhea in resource-limited settings - UpToDate
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Abordaje del adulto con diarrea aguda en entornos de recursos

limitados
AUTORES: Regina LaRocque, MD, MPH, Mark Pietroni, MA, FRCP, FFPH, DTM&H, Mohammod Jobayer Chisti, MBBS, MMed, PhD
EDITOR DE SECCIÓN: Stephen B Calderwood, MD
EDITOR ADJUNTO: Elinor L Baron, MD, DTMH
Todos los temas se actualizan a medida que hay nueva evidencia disponible y nuestro proceso de revisión por pares se completa.
Revisión de la literatura vigente hasta: agosto de 2023.

Este tema se actualizó por última vez: 10 de agosto de 2023.
INTRODUCCIÓN
Las enfermedades diarreicas son una de las principales causas de muerte a nivel mundial [ 1,2 ]. La mayoría de los casos
de diarrea están asociados con fuentes de agua y alimentos contaminados, y más de dos mil millones de personas en
todo el mundo no tienen acceso a servicios sanitarios básicos [ 3 ].
La Organización Mundial de la Salud (OMS) proporciona directrices para el tratamiento de las enfermedades diarreicas
en países con recursos limitados en "El tratamiento de la diarrea: manual para médicos y otros trabajadores sanitarios
superiores" [4 ] . También se encuentran disponibles directrices específicas de la OMS para el tratamiento de la
shigelosis epidémica [ 5 ] y el cólera [ 6,7 ]. Las recomendaciones en este tema son consistentes con esas pautas.
Este tema revisa la evaluación clínica, el tratamiento y la prevención de la diarrea aguda, incluidas la diarrea acuosa y la
disentería, en adultos en países con recursos limitados.
La evaluación clínica y el tratamiento de niños con diarrea aguda en países con recursos limitados y de personas con
diarrea en entornos ricos en recursos se analizan en otra parte. (Ver "Enfoque para el niño con diarrea aguda en
entornos con recursos limitados" y "Causas de la diarrea infecciosa aguda y otras enfermedades transmitidas por
alimentos en entornos ricos en recursos" y "Enfoque para el adulto con diarrea aguda en entornos ricos en recursos" y "
Enfoque para el adulto con diarrea crónica en entornos con abundantes recursos" y "Enfoque diagnóstico de la diarrea
en niños en entornos ricos en recursos" y "Resumen de las causas de la diarrea crónica en niños en entornos con
abundantes recursos" .)
CLASIFICACIÓN DE LA DIARREA
La diarrea se define como la evacuación de heces blandas o acuosas, normalmente al menos tres veces en un período
de 24 horas [ 8 ]. La diarrea aguda se define como diarrea de ≤14 días de duración, a diferencia de la diarrea persistente
(>14 días y ≤30 días) o crónica (>30 días). La diarrea invasiva, o disentería, se define como diarrea con sangre visible, a
diferencia de la diarrea acuosa. La disentería se asocia comúnmente con fiebre y dolor abdominal.
EPIDEMIOLOGÍA
Worldwide incidence — Diarrhea is an important cause of morbidity and mortality worldwide. The Global Burden of
Disease Study found that in 2019, diarrhea contributed to over 1.5 million deaths around the world, and was a leading
cause of morbidity and mortality in children younger than five years; diarrheal illness contributed to the loss of 45.5
million disability-adjusted life years and caused 10 percent of deaths in this age group [2]. Death rates from diarrhea
have declined with improvements in sanitation and more widespread use of oral rehydration solution. Nevertheless,
nearly seven billion cases of diarrheal disease occur worldwide each year [9].
https://www.uptodate.com/contents/approach-to-the-adult-with-acute-diarrhea-in-resource-limited-settings/print?search=DIARREA&topicRef=27… 1/21
Diarrheal illness occurs at a baseline frequency in resource-limited countries, superimposed with epidemic cases of
diarrhea, either dysentery or watery diarrhea. Epidemics are generally due to Shigella dysenteriae serotype 1 (Sd1) and
Vibrio cholerae, but Escherichia coli O157:H7 can also be responsible for diarrheal outbreaks in resource-limited settings
[10]. Major outbreaks due to Sd1 have occurred in Africa, South Asia, and Central America. In 1994, an explosive
outbreak among Rwandan refugees in Zaire caused approximately 20,000 deaths during the first month alone [11].
Epidemics due to V. cholerae have occurred throughout Africa, Asia, the Middle East, South and Central America, and the
Caribbean [12]. (See "Cholera: Clinical features, diagnosis, treatment, and prevention", section on 'Epidemiology' and
"Shigella infection: Epidemiology, clinical manifestations, and diagnosis".)
Risk factors
Crowding and poor sanitation — Individuals in refugee camps and unplanned urban settlements, with limited access
to water and sanitation facilities, are at particular risk of diarrheal epidemics. Contaminated food and water play an
important role in such epidemics. Direct contact with an infected individual may also contribute to the spread of
epidemic dysentery due to S. dysenteriae.
HIV infection — Human immunodeficiency virus (HIV) infection is prevalent in many of the resource-limited areas
where acute diarrheal diseases occur, and diarrhea-related morbidity and mortality may be increased in these
individuals. Several enteric bacteria, such as Campylobacter, Salmonella, Shigella, enteroaggregative E. coli, and Vibrio
species, occur with increased frequency and/or severity in individuals with HIV/acquired immunodeficiency syndrome
(AIDS) [13,14]. Coinfection with multiple pathogens may also occur. Nontyphoidal salmonellosis is a particular concern in
individuals with HIV infection, who have a higher risk for recurrent or extraintestinal infection. (See "Nontyphoidal
Salmonella bacteremia".)
Although individuals with HIV are susceptible to a broader variety of enteric pathogens, common causes of infectious
diarrhea should be considered first among adults with acute diarrhea in resource-limited settings. (See "Evaluation of
the patient with HIV and diarrhea".)
MICROBIOLOGY
A variety of bacteria, viruses, and parasites can cause acute diarrhea in resource-limited settings.
Information about the host, the type of diarrhea, and the clinical setting may be useful in indicating possible pathogens.
However, a microbiologic diagnosis is not made in the majority of clinical cases in resource-limited countries and is not
routinely required for clinical management.
Epidemic diarrhea — S. dysenteriae and V. cholerae are the most common organisms associated with epidemic diarrhea.
Epidemic refers to an increase, often sudden, in the number of cases of a disease above what is normally expected in
that population in that area. Outbreak carries the same definition as epidemic, but it is often used for a more limited
geographic area.
Four species of Shigella cause bloody diarrhea; they are distinguished serologically as S. dysenteriae, S. flexneri, S. boydii,
and S. sonnei (see "Shigella infection: Epidemiology, clinical manifestations, and diagnosis").
S. dysenteriae serotype 1 (Sd1) is uniquely responsible for epidemic dysentery. Important features accounting for the
association between Sd1 and large, regional epidemics of dysentery include [15-17]:
• Sd1 produces a potent cytotoxin (Shiga toxin) that causes patchy destruction of the colonic epithelium
• The low infective dose (10 to 100 organisms) facilitates person-to-person spread of infection
• Illness due to Sd1 is more severe and more prolonged than illness due to other species of Shigella
• Sd1 resistance to antimicrobials is more common than in other species of Shigella; in addition, resistance to
WHO recommended antibiotics is more common in Asian countries compared to Sub-Sahara Africa
● Cholera is a secretory diarrheal disease caused by enterotoxin-producing strains of V. cholerae. More than 200
serogroups of V. cholerae have been identified to date, but historically, the O1 serogroup has caused the vast
majority of disease. The O139 serogroup emerged as a cause of disease in 1992 [18], but has remained limited to a
few countries in Asia. (See "Cholera: Clinical features, diagnosis, treatment, and prevention".)
Countries are said to be endemic for cholera if cholera cases have been reported in three of the previous five years.
An outbreak of cholera occurs when a higher-than-expected number of cases are reported in a given area during a
specific period of time. Outbreaks may occur in endemic or non-endemic areas and are more limited in scope
compared to epidemics. In Africa, some countries appear to have cholera nearly every year, while other countries
suffer from outbreaks every few years [19-21].
Rarely, enterohemorrhagic E. coli may cause epidemics of bloody diarrhea, similar to Sd1.
Acute watery diarrhea — A variety of pathogens can cause acute watery diarrhea in resource-limited settings
( table 1). In a non-epidemic situation, enterotoxigenic E. coli is the most common cause. In addition to causing
epidemic disease, V. cholerae is endemic in approximately 50 countries in Asia, Africa, and Central and South America,
where predictable seasonal outbreaks occur. Norovirus, Campylobacter species, nontyphoidal Salmonellae, Aeromonas
species, and enteroaggregative E. coli are other pathogens that can cause acute watery diarrhea.
Acute bloody diarrhea — Worldwide, Shigella species, particularly S. flexneri, are the most important causes of acute
bloody diarrhea. Other causes in resource-limited settings include Campylobacter jejuni, enteroinvasive and
enterohemorrhagic E. coli, nontyphoidal Salmonella species, Entamoeba histolytica, and Schistosoma mansoni ( table 1).
CLINICAL FEATURES
Typical findings — As above, diarrhea is the passage of loose stools, typically at least three times in a 24-hour period
[8]. Watery diarrhea is characteristically nonbloody, whereas dysentery is defined as diarrhea with visible blood.
In an outbreak setting, these clinical features can be used to distinguish cholera (watery diarrhea) from epidemic
dysentery due to S. dysenteriae serotype 1 (Sd1), as the distinction has therapeutic and public health implications
( table 2). (See 'Antibiotic therapy' below.)
A "rice-water" appearance of stool flecked with mucous is suggestive of cholera ( picture 1) [12]. Furthermore, diarrhea
caused by V. cholerae may present very suddenly with vomiting and abdominal cramping but not frank pain or tenesmus.
Fever is uncommon in cholera. (See "Cholera: Clinical features, diagnosis, treatment, and prevention".)
In contrast, shigellosis is typically characterized by the frequent passage of small liquid stools that contain visible blood,
with or without mucous [22]. Abdominal cramps and tenesmus are common, along with fever and anorexia. (See
"Shigella infection: Epidemiology, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)
However, within these two categories of diarrhea, the specific infectious causes cannot be determined based on signs or
symptoms. The clinical illnesses caused by the various pathogens associated with watery diarrhea are typically
indistinguishable. Similarly, Shigellosis cannot be distinguished reliably from other causes of bloody diarrhea on the
basis of clinical features alone, nor can illness caused by Sd1 be distinguished with certainty from that caused by other
Shigella species.
Complications of acute diarrheal diseases in adults — The sequelae of severe volume depletion are the most
important systemic complications of acute diarrheal disease in adults. Various clinical features can be helpful in
determining the severity of hypovolemia, with sunken eyes, dry mouth and tongue, thirst, and decreased skin turgor
seen with moderate hypovolemia and decreased consciousness/coma, inability to drink, and a weak pulse seen in more
severe stages.
Hypovolemia and accompanying electrolyte imbalances are the most important complications of cholera. In contrast,
severe volume depletion does not usually occur with Shigella infection; however, patients with Shigella infection often
present with hyponatremia (potentially due to syndrome of inappropriate antidiuretic hormone secretion [SIADH]) [23].
Other systemic complications of diarrheal illness may occur in adults ( table 3):
● Bacteremia (see "Nontyphoidal Salmonella bacteremia")
● Hemolytic-uremic syndrome (see "Shigella infection: Epidemiology, clinical manifestations, and diagnosis", section
on 'Hemolytic-uremic syndrome (HUS)' and "Shiga toxin-producing Escherichia coli: Clinical manifestations,
diagnosis, and treatment", section on 'Complications')
● Guillain-Barré syndrome (see "Guillain-Barré syndrome in adults: Pathogenesis, clinical features, and diagnosis"
and "Campylobacter infection: Clinical manifestations, diagnosis, and treatment", section on 'Guillain-Barré
syndrome')
● Reactive arthritis (see "Reactive arthritis", section on 'Clinical manifestations')
Serious complications may occur with Shigella infection, including sepsis, seizures, rectal prolapse, toxic megacolon, and
the hemolytic-uremic syndrome.
Among individuals with HIV infection in resource-limited settings, bacteremia with non-typhoidal Salmonella enterica is a
particular concern [24].
DIFFERENTIAL DIAGNOSIS
Acute diarrhea in adults in resource-limited settings is most frequently caused by an infectious agent. In addition to the
pathogens above, diarrhea may also occur in the context of other systemic infections, such as influenza, HIV infection,
dengue fever, and malaria.
Non-infectious etiologies of diarrhea are often missed and should be considered in patients with repeated episodes of
self-limiting or acute diarrhea or chronic diarrhea. Such causes include inflammatory bowel disease and malabsorptive
syndromes. (See "Approach to the adult with chronic diarrhea in resource-abundant settings".)
CLINICAL ASSESSMENT
The initial evaluation of adults with acute diarrhea should include a careful history and physical examination in order to
assess the type of diarrhea and the severity of hypovolemia.
Based on the appearance of the stool, diarrhea can be classified as watery or bloody.
The physical examination should focus on characterizing the degree of volume depletion ( table 4) [4]:
● Early hypovolemia – Signs and symptoms may be absent; WHO terms this 'no dehydration'
● Moderate hypovolemia – Thirst, restless or irritable behavior, decreased skin turgor, sunken eyes; WHO terms this
'some dehydration'
● Severe hypovolemia – Diminished consciousness, lack of urine output, cool moist extremities, rapid and feeble
pulse, low or undetectable blood pressure, peripheral cyanosis; WHO terms this 'severe dehydration'
Laboratory studies are not typically needed. However, when available, certain diagnostic tests can help to identify the
microbial etiology, which is especially useful in an epidemic situation.
● Routine microscopy of fresh stool is inexpensive and can identify the presence of numerous fecal leukocytes with
any number of red blood cells, suggesting an invasive bacterial infection.
● Microscopic evidence of Entamoeba trophozoites containing high counts of red blood cells provides sufficient basis
for treating for amoebic dysentery instead of shigellosis ( picture 2). Notably, finding cysts or trophozoites
without red blood cells in a bloody stool does not indicate that Entamoeba is the cause of illness, since
asymptomatic infection is frequent among healthy persons in resource-limited countries. (See "Intestinal
Entamoeba histolytica amebiasis".)
● Cholera can be diagnosed using dark-field microscopy, in which motile Vibrios appear as "shooting stars," or by
using a commercially available rapid dipstick.
Serum electrolyte and glucose testing is not routinely required for the treatment of an adult patient with an
uncomplicated case of acute watery diarrhea. Testing may be considered in patients with ileus, confusion, or seizure, or
in those with no urine output in response to fluid replacement.
TREATMENT
Treatment of adults with acute diarrhea consists of correcting fluid and electrolyte losses and administering appropriate
nutrition. Antibiotic therapy is warranted in some circumstances, as outlined below.
Rehydration — Fluid management, including the type and quantity of fluids to administer, in an adult patient with
diarrhea depends on the level of volume depletion ( algorithm 1) [25].
None to moderate hypovolemia — In the vast majority of cases, volume depletion from acute diarrhea of any
etiology, except when it is severe, can be effectively treated with oral rehydration salts (ORS) ( algorithm 1) [26]. An
improved, reduced osmolarity ORS solution, containing 75 mEq/L of sodium and 75 mmol/L of glucose ( table 5), is
officially recommended by the World Health Organization (WHO) and The United Nations Children’s Fund (UNICEF). This
reduced osmolarity solution reduces the need for supplemental IV fluid therapy by 33 percent compared with the
previous standard WHO ORS solution [27,28]. (See "Oral rehydration therapy".)
The use of glucose polymers (primarily rice, but also wheat, sorghum, or maize) in ORS has been shown to decrease
mean 24-hour stool output in adults with cholera when compared to the traditional, high osmolarity ORS [29,30].
However, the preparation of such polymer-based ORS is more tedious than that of traditional ORS, and further data are
needed to assess its efficacy compared with the reduced osmolarity ORS solution.
Severe hypovolemia — Adults with severe hypovolemia should receive intravenous fluids ( algorithm 1 and
table 6) [4]. Preferred solutions include Ringer's lactate (with or without with 5 percent dextrose) or Cholera saline
("Dhaka solution") [31]. Normal saline may be used but is less preferable because it does not contain potassium to
replace losses nor a base to correct acidosis.
Antibiotic therapy
Watery diarrhea — Antimicrobial therapy is not typically indicated for the treatment of acute watery diarrhea in adults
in resource-limited settings, as most cases resolve spontaneously.
An important exception is the treatment of severe cholera in outbreak settings, for which antibiotics can decrease the
duration of illness and the volume of fluid losses, thus simplifying patient management during a complex emergency
[12]. Reports of resistance in V. cholerae are increasing; data on local susceptibility should therefore be used to guide
treatment choices. Antibiotic treatment of cholera is discussed in detail elsewhere ( table 7). (See "Cholera: Clinical
features, diagnosis, treatment, and prevention".)
Dysentery — In contrast to the treatment of watery diarrhea, adults with bloody diarrhea should be treated promptly
with an antimicrobial that is effective against Shigella ( table 8) [4]. Patients who do not respond after 48 hours or
deteriorate within 24 to 48 hours can be switched to a different antimicrobial agent. If there is still no response,
treatment for amebic dysentery due to E. histolytica can be given. Although initial empiric treatment for amebic
dysentery is not routinely warranted, it should be given at any point if trophozoites are visualized on stool microscopy.
Treatment for amebic dysentery usually entails metronidazole (500 to 750 mg orally three times daily for 7 to 10 days)
followed by an intraluminal agent; this is discussed elsewhere. (See "Intestinal Entamoeba histolytica amebiasis".)
Treatment should be particularly targeted at those with higher risks of complications, including individuals with AIDS
and older adults. The choice of antimicrobial should be based on recent susceptibility data from Shigella strains isolated
in the area. If no such data are available, ciprofloxacin or azithromycin are reasonable first-line antibiotics, although
clinicians should be aware that failure due to resistance is possible and second-line drugs may be required.
In several trials of patients with dysentery, antibiotics reduced the duration of diarrhea and fever in infections caused by
Shigella, which is the most common cause of dysentery in resource-limited settings and can otherwise be associated with
severe complications [5,32]. Antibiotic therapy for shigellosis is discussed in detail elsewhere. (See "Shigella infection:
Treatment and prevention in adults", section on 'Antibiotic treatment'.)
Antimicrobial resistance — Antimicrobial resistance in enteric pathogens in resource-limited settings is increasingly

common [33,34] and is, in part, due to the misuse and overuse of antibiotics in the treatment of diarrheal diseases.
Multidrug resistance has been identified in nontyphoidal Salmonella, Shigella spp, and V. cholerae [35-39]; resistance
complicates the antibiotic treatment of severely ill patients and the management of diarrheal outbreaks. One study of
diarrheal stool samples in rural western Kenya determined that most persons had been treated with an antimicrobial to
which their isolate was resistant [40]. When possible, the selection of antimicrobial treatment for acute diarrheal
diseases should therefore be based on recent susceptibility testing of strains from the area. Restriction of public retail
availability of antimicrobial agents may also play a role in containing resistance. (See "Shigella infection: Treatment and
prevention in adults", section on 'Antibiotic resistance' and "Cholera: Clinical features, diagnosis, treatment, and
prevention".)
Dietary recommendations — The continuous provision of nutritious food is important for all patients with diarrhea.
Small meals can be provided frequently, as soon as the patient is able to tolerate.
PREVENTION
Acute diarrheal diseases can be prevented with a variety of measures focused on preventing the spread of organisms
from person to person and within the community [41,42]. These include:
● Hand washing with soap

● Ensuring the availability of safe drinking water
● Appropriate disposal of human waste
● Breastfeeding of infants and young children
● Safe handling and processing of food
● Control of flies (particularly for Sd1)
Two killed whole-cell oral cholera vaccines are internationally licensed and prequalified by the World Health Organization
(WHO). A WHO global cholera vaccine stockpile of the lower cost bivalent vaccine was created in 2013 and has led to
increasing use of killed oral cholera vaccines globally; the monovalent vaccine has been used primarily in travelers from
resource-rich countries. (See "Cholera: Clinical features, diagnosis, treatment, and prevention".)
Candidate vaccines for shigellosis are undergoing testing.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world are
provided separately. (See "Society guideline links: Acute diarrhea in adults".)
SUMMARY AND RECOMMENDATIONS
● Epidemiology − Diarrheal illness in resource-limited settings is extremely common, but incidence rates for adults
have not been systematically calculated. Cases of diarrhea can occur as baseline endemic disease or in the setting
of epidemics. Poor sanitation is a major risk factor for the prevalence of diarrhea in both endemic and epidemic
forms. (See 'Epidemiology' above.)
● Microbiology − Multiple pathogens can cause watery and bloody diarrhea (dysentery) ( table 1). Shigella
dysenteriae serotype 1 and Vibrio cholerae are the most important causes of diarrheal epidemics, and certain clinical
features can distinguish between the two ( table 2). (See 'Microbiology' above and 'Clinical features' above.)
● Complications − Severe volume depletion is the most important complication of acute diarrheal illness in adults.
However, several other systemic complications can occur, including bacteremia, hemolytic-uremic syndrome,
Guillain-Barré syndrome, and reactive arthritis. (See 'Complications of acute diarrheal diseases in adults' above.)
● Clinical assessment − The clinical assessment of the adult patient with acute diarrhea should focus on
characterizing the type of diarrhea (watery versus bloody) and the degree of volume depletion. A microbiologic
diagnosis is not needed in the majority of clinical cases of adults with diarrheal illness in resource-limited countries.
(See 'Clinical assessment' above.)
● Rehydration − Adequate fluid and electrolyte replacement and maintenance are essential to the management of
all diarrheal illnesses ( algorithm 1 and table 5). (See 'Rehydration' above.)
● Role of antibiotic therapy
• Watery diarrhea − For most patients with acute watery diarrhea, we suggest not routinely administering
empiric antimicrobial therapy (Grade 2B). One exception is in the epidemic setting, in which antibiotic therapy
against cholera can decrease the duration of illness and the volume of fluid losses and thus simplify patient
management during a complex emergency ( table 7). (See 'Watery diarrhea' above and "Cholera: Clinical
features, diagnosis, treatment, and prevention".)
• Bloody diarrhea − For adults with bloody diarrhea, we suggest prompt empiric antibiotic treatment (Grade 2B).
An antimicrobial that is effective against Shigella should be used ( table 8). (See 'Dysentery' above and
"Shigella infection: Treatment and prevention in adults", section on 'Antibiotic treatment'.)
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Bangladesh: resistance to azithromycin and ceftriaxone and decreased susceptibility to ciprofloxacin. J Health Popul
Nutr 2007; 25:158.
38. Tjaniadi P, Lesmana M, Subekti D, et al. Antimicrobial resistance of bacterial pathogens associated with diarrheal
patients in Indonesia. Am J Trop Med Hyg 2003; 68:666.
39. Surveillance Update. ICDDR,B:Health and Science Bulletin 2010; 8:19.

40. Brooks JT, Ochieng JB, Kumar L, et al. Surveillance for bacterial diarrhea and antimicrobial resistance in rural western
Kenya, 1997-2003. Clin Infect Dis 2006; 43:393.
41. Fewtrell L, Kaufmann RB, Kay D, et al. Water, sanitation, and hygiene interventions to reduce diarrhoea in less
developed countries: a systematic review and meta-analysis. Lancet Infect Dis 2005; 5:42.
42. Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand washing for preventing diarrhoea. Cochrane Database Syst
Rev 2008; :CD004265.
Topic 13954 Version 25.0
GRAPHICS
Causas de la diarrea entre adultos en entornos de recursos limitados
síndrome clínico Patógenos comunes Comentarios
Diarrea acuosa aguda Escherichia coli enterotoxigénica (ETEC) Causa más común de diarrea acuosa aguda.
Vibrio cholerae O1 or O139
Norovirus Vomiting may be a prominent feature
Campylobacter species
Nontyphoidal Salmonella enterica
Aeromonas species
Enteroaggregative Escherichia coli (EAEC)
Enterotoxigenic Bacteroides fragilis
Acute bloody diarrhea Shigella species Most common cause of acute bloody diarrhea
Campylobacter species
Enteroinvasive Escherichia coli (EIEC)
Enterohemorrhagic Escherichia coli (EHEC)
Nontyphoidal Salmonella enterica Rare
Entamoeba histolytica
Schistosoma mansoni
Courtesy of Regina C LaRocque, MD, MPH, and Mark Pietroni, MA, FRCP, FFPH, DTM&H.
Graphic 86525 Version 3.0
Comparison of clinical features of epidemic dysentery and cholera
Epidemic dysentery Cholera
Causative organism Shigella dysenteriae type 1 Vibrio cholerae O1
(Vibrio cholerae O139)
Infective dose 10 to 100 organisms 1000 to 1,000,000 organisms
Clinical features Bloody diarrhea Watery diarrhea
Abdominal cramps Dehydration
Fever Vomiting
Rectal pain
Complications Seizures Severe hypovolemia/shock
Rectal prolapse Electrolyte abnormalities
Hemolytic-uremic syndrome
Sepsis
Treatment Antibiotics Rehydration
Transmission Food and water Food and water
Person-to-person
Case fatality rate 10 to 20 percent (untreated) 40 percent (untreated)
5 percent (treated) <1 percent (treated)
Acute watery diarrhea
Watery stools of <14 days duration, with no visible blood constitutes acute watery
diarrhea.
(A) Green watery stool. Green colored stool, often seen in rotavirus gastroenteritis.
(B) Rice water stool. White colored stool characteristic of severe cholera.
Potential complications of acute diarrheal disease in adults
Complication Associated bacterial agent Comments
Bacteremia Shigella species, Nontyphoidal Salmonella Particular concern in HIV-infected

enterica, Campylobacter fetus individuals
Hemolytic-uremic syndrome Shigella species, Shiga toxin-producing Shiga toxins are responsible for damage
Escherichia coli to endothelial cells and hemolytic-uremic
syndrome
Guillain-Barré syndrome Campylobacter jejuni
Reactive arthritis Campylobacter species, Salmonella

species, Shigella flexneri
Assessment of severity of volume depletion among patients with acute diarrhea
Examination Mild hypovolemia Moderate hypovolemia Severe hypovolemia
Look at:
Mental status Alert Restless, irritable Lethargic or unconscious
Eyes Normal Sunken Very sunken and dry
Tears Present Absent Absent
Mouth/tongue Moist, slightly dry Dry Very dry
Thirst Increased thirst Thirsty, drinks eagerly Drinks poorly or not able to
drink
Feel:
Skin pinch Goes back rapidly Goes back slowly Goes back very slowly
(tenting)
Pulse Normal Rapid, weak Very fast, weak or

nonpalpable
Extent of volume loss
<5% of body weight From 5 to 10% of body weight >10% of body weight
Estimated fluid deficit
<50 mL/kg 50-100 mL/kg >100 mL/kg
Adapted from: Swerdlow DL, Ries AA. JAMA 1992; 267:1495 and World Health Organization. The treatment of diarrhea: A manual for physicians and other
senior health workers, 4th revision. WHO/FCH/CAH/05.1. World Health Organization, Geneva 2005. (Available at
http://whqlibdoc.who.int/publications/2005/9241593180.pdf).
Entamoeba histolytica trophozoite: Microscopy
Trophozoites of E. histolytica with ingested erythrocytes stained with

trichrome.
Reproduced from: Centers for Disease Control and Prevention. DPDx: Amebiasis
(Entamoeba histolytica). Available at:
https://www.cdc.gov/dpdx/amebiasis/index.html.
Approach to fluid management in adult with

hypovolemia
ORS: oral rehydration salts.
Courtesy of Regina C LaRocque, MD, MPH, and Mark Pietroni, MA, MBBChir, FRCP, DTM&H.
Composition of hypo-osmolar oral rehydration solution (per one liter of clean water)
Sodium chloride (NaCl) 2.6 g
Sodium citrate 2.9 g
Potassium chloride (KCl) 1.5 g
Glucose 13.5 g
Composition (mEq/L) of common solutions used for rehydration
Route Solution Na+ K+ Cl- HCO3- Citrate Ca++ Glucose/carbohydrate
Intravenous Normal saline 154 - 154 - - - -
Ringer's Lactate 130 4 111 28 - 3 -
Ringer's Lactate + 5 percent 130 4 109 28 - 3 278

dextrose
Cholera saline ("Dhaka solution") 133 13 98 48 - - 140
Oral Standard ORS 90 20 80 - 10 - 111
Hypo-osmolar ORS 75 20 65 - 10 - 75
ReSoMal* (Reduced Osmolarity 45 40 76 - 7 - 125

ORS for Malnourished Children)
ORS is reviewed in detail separately. (See "Oral rehydration therapy").
ORS: oral rehydration solution(s).
* Also contains Mg 6 mmol/L, Zn 300 umol/L, Cu 45 umol/L.
Data from: World Health Organization. The treatment of diarrhea: A manual for physicians and other senior health workers - 4th revision. World Health
Organization, Geneva 2005. Available at: http://whqlibdoc.who.int/publications/2005/9241593180.pdf.
Oral antibiotics for suspected cholera
Typical pediatric
Class Antibiotic Adult dose Comment(s)
dose*
Tetracyclines Doxycycline 4 to 6 mg/kg (single 300 mg (single dose) Antibiotic resistance to all
dose) tetracyclines is common [1] .
Empiric use is appropriate in
epidemics caused by
Tetracycline 50 mg/kg/day in 4 500 mg 4 times per day for 3 documented susceptible
equally divided days isolates.
doses, for 3 days Not recommended for pregnant
women and children less than 8
years of age.
Macrolides Azithromycin 20 mg/kg (single 1 g (single dose) Single dose azithromycin is

dose) preferred therapy [2] .
Erythromycin 40 mg/kg/day in 4 500 mg 4 times per day for 3 Rare reports of macrolide
equally divided days resistance.
doses, for 3 days
Fluoroquinolones Ciprofloxacin 20 mg/kg (single 1 g (single dose) Reduced susceptibility to

dose) fluoroquinolones has been
In areas with isolates that have
reduced susceptibility to reported in Asia and Africa [2,4] .
fluoroquinolones: Not recommended for pregnant
women and children less than 8
500 mg twice daily for 3
years of age.
days [3]
* Not to exceed maximum dose.
References:
1. Yamamoto T, Nair GB, Albert MJ, et al. Survey of in vitro susceptibilities of Vibrio cholerae O1 and O139 to antimicrobial agents. Antimicrob Agents
Chemother 1995; 39:241.
2. Saha D, Karim MM, Khan WA, et al. Single-dose azithromycin for the treatment of cholera in adults. N Engl J Med 2006; 354:2452.
3. Khan WA, Saha D, Ahmed S, et al. Efficacy of Ciprofloxacin for Treatment of Cholera Associated with Diminished Susceptibility to Ciprofloxacin to Vibrio
cholerae O1. PLoS One 2015; 10:e0134921.
4. Islam MS, Midzi SM, Charimari L, et al. Susceptibility to fluoroquinolones of Vibrio cholerae O1 isolated from diarrheal patients in Zimbabwe. JAMA
2009; 302:2321.
Antibiotic treatment of Shigella infection in adults
Antibiotic Dose Duration*
Levofloxacin 500 mg orally once daily 3 days
Ciprofloxacin 500 mg orally twice daily or 750 mg orally once 3 days

daily
Azithromycin 500 mg orally once daily 3 days
Cefixime 200 mg orally twice daily 5 days
Ceftriaxone 1 to 2 g intravenously once daily 5 days
Trimethoprim-sulfamethoxazole (co-trimoxazole) 160/800 mg (one double-strength tablet) orally 5 days

twice daily
Ampicillin 500 mg orally every 6 hours 5 days
Selection of antibiotic therapy for Shigella infection in adults should be based on the results of antimicrobial susceptibility
testing, if possible. If an agent needs to be chosen empirically, the risk of resistance based on patient demographics and local
rates of resistance should be taken into account. Refer to the topic on treatment of Shigella infection in adults for additional
details.
*Para pacientes con infección por Shigella Dysenteriae tipo 1 o con coinfección por VIH, tratamos de 5 a 7 días; En el raro caso de
bacteriemia, lo tratamos durante 14 días.
Gráfico 68382 Versión 7.0
Contributor Disclosures
Regina LaRocque, MD, MPH Grant/Research/Clinical Trial Support: CDC [Grant support]. All of the relevant financial relationships
listed have been mitigated. Mark Pietroni, MA, FRCP, FFPH, DTM&H No relevant financial relationship(s) with ineligible companies to
disclose. Mohammod Jobayer Chisti, MBBS, MMed, PhD No relevant financial relationship(s) with ineligible companies to
disclose. Stephen B Calderwood, MD Consultant/Advisory Boards: Day Zero Diagnostics [Whole genome sequencing for microbial
identification and determination of antimicrobial susceptibility]. All of the relevant financial relationships listed have been
mitigated. Elinor L Baron, MD, DTMH No relevant financial relationship(s) with ineligible companies to disclose.
El grupo editorial revisa las divulgaciones de los contribuyentes para detectar conflictos de intereses. Cuando se encuentran, estos se
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respaldar el contenido. Se requiere que todos los autores tengan contenido con las referencias adecuadas y deben cumplir con los
estándares de evidencia de UpToDate.
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25/9/23, 22:21 Approach to the adult with acute diarrhea in resource-limited settings - UpToDate

Reimpresión oficial de UpToDate ®

Abordaje del adulto con diarrea aguda en entornos de recursos

Revisión de la literatura vigente hasta: agosto de 2023.

● Bacteremia (see "Nontyphoidal Salmonella bacteremia")

● Reactive arthritis (see "Reactive arthritis", section on 'Clinical manifestations')

Antimicrobial resistance — Antimicrobial resistance in enteric pathogens in resource-limited settings is increasingly

● Hand washing with soap

Candidate vaccines for shigellosis are undergoing testing.

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● Role of antibiotic therapy

Use of UpToDate is subject to the Terms of Use.

7. World Health Organization. Cholera. http://www.who.int/cholera/en/ (Accessed on December 04, 2018).

9. IHME. Diarrheal diseases — Level 3 cause. https://www.healthdata.org/results/gbd_summaries/2019/diarrheal-disea

39. Surveillance Update. ICDDR,B:Health and Science Bulletin 2010; 8:19.

Causas de la diarrea entre adultos en entornos de recursos limitados

síndrome clínico Patógenos comunes Comentarios

Vibrio cholerae O1 or O139

Norovirus Vomiting may be a prominent feature

Nontyphoidal Salmonella enterica

Enteroaggregative Escherichia coli (EAEC)

Enterotoxigenic Bacteroides fragilis

Enteroinvasive Escherichia coli (EIEC)

Enterohemorrhagic Escherichia coli (EHEC)

Nontyphoidal Salmonella enterica Rare

Graphic 86525 Version 3.0

Comparison of clinical features of epidemic dysentery and cholera

Epidemic dysentery Cholera

Causative organism Shigella dysenteriae type 1 Vibrio cholerae O1

(Vibrio cholerae O139)

Infective dose 10 to 100 organisms 1000 to 1,000,000 organisms

Clinical features Bloody diarrhea Watery diarrhea

Abdominal cramps Dehydration

Complications Seizures Severe hypovolemia/shock

Rectal prolapse Electrolyte abnormalities

Treatment Antibiotics Rehydration

Transmission Food and water Food and water

Case fatality rate 10 to 20 percent (untreated) 40 percent (untreated)

5 percent (treated) <1 percent (treated)

Graphic 86522 Version 2.0

Acute watery diarrhea

Graphic 52564 Version 2.0

Potential complications of acute diarrheal disease in adults

Complication Associated bacterial agent Comments

Bacteremia Shigella species, Nontyphoidal Salmonella Particular concern in HIV-infected

Guillain-Barré syndrome Campylobacter jejuni

Reactive arthritis Campylobacter species, Salmonella

Graphic 86528 Version 2.0

Assessment of severity of volume depletion among patients with acute diarrhea

Examination Mild hypovolemia Moderate hypovolemia Severe hypovolemia

Mental status Alert Restless, irritable Lethargic or unconscious

Eyes Normal Sunken Very sunken and dry

Tears Present Absent Absent

Mouth/tongue Moist, slightly dry Dry Very dry

Pulse Normal Rapid, weak Very fast, weak or

Extent of volume loss

Estimated fluid deficit

<50 mL/kg 50-100 mL/kg >100 mL/kg

Graphic 74796 Version 5.0

Entamoeba histolytica trophozoite: Microscopy

Trophozoites of E. histolytica with ingested erythrocytes stained with

Graphic 57615 Version 4.0