Lisa A. Spacek, M.D., Ph.D. and Khalil G. Ghanem, M.D., Ph.D.
- Diarrhea is common in HIV+ pts in Zambia and is typically managed empirically.
- Etiology for acute diarrhea in Zambia predominantly bacterial.
- Etiology of persistent diarrhea appears to be predominantly protozoal (microsporidia, Isospora, and Cryptosporidium).
- Use of cotrimoxazole for prophylaxis in HIV+ pts leads to decrease in diarrhea incidence and may lead to shift in causative agents as well.
- Acute diarrhea (<14 days): Typically managed symptomatically unless there is blood in stools, severe dehydration, and/or suspicion for cholera.
- Persistent diarrhea (>14 days) WHO/IMAI Recommendations: If no blood in stool, treat with cotrimoxazole + metronidazole. If no response, refer. If not able to refer, treat with albendazole or mebendazole. If pt responds to antimicrobial, treat for 2 weeks total.
- Bloody diarrhea: Should be empirically treated with a quinolone for 5 days given presumption of Shigella-related disease. Metronidazole also recommended if concern for amebic colitis. Severe acute, non-bloody diarrhea may also be empirically treated in this manner.
- Dehydration: All pts with diarrhea should be evaluated for dehydration. Depending on level of dehydration, management options include encouraging usual fluid and food intake, oral rehydration solution (ORS), or IV hydration for severe cases.
- Suspected cholera: If cholera suspected based on clinical presentation and consistent recent local epidemiology, initiate treatment based on known susceptibilities if possible. If not possible, empiric treatment with erythromycin (500 mg four times a day x 3-5 days) is reasonable. Azithromycin (1000 mg x 1) and quinolone therapy (ciprofloxacin 1000mg x 1) are also likely to be efficacious.
- ARV side effect: Diarrhea can be a side effect from many ARVs, especially PIs. Typically, but not always, diarrhea related to medications will improve over time. If pt does not have significant dehydration, can usually be managed symptomatically.
- Prevention of diarrhea is critical and can be achieved through use of water safety precautions such as hand hygiene, household-based water treatment methods, appropriate water storage devices, and proper disposal of feces.
- Stool microscopy/diagnostics should be pursued if possible in cases of dysentery, persistent or refractory diarrhea, significant illness, or diagnostic uncertainty.
Zambia Information Author: Larry William Chang, MD, MPH
- Acute: Salmonella, Shigella, Campylobacter, Clostridium difficile, E. coli (enteroaggregative EAEC), S. aureus, Vibrio parahemolyticus, Yersinia, norovirus & other viruses (calicivirus, astrovirus, adenovirus).
- Chronic: Cryptosporidium, microsporidia, MAC, CMV, Cyclospora, Giardia, Isospora, Entamoeba histolytica, Strongyloides, HIV enteropathy, & causes of acute diarrhea (especially Salmonella).
- CD4 <50: Cryptosporidium,microsporidia, CMV, MAC.
- Pathogen-negative, chronic, large-volume diarrhea: KS or lymphoma.
- Non-infectious causes: adverse drug reactions (PIs), inflammatory bowel disease, dietary (milk, sorbitol, caffeine), malabsorption, endocrine disease.
- Characterized by increase in water content, volume, or frequency of stools.
- Small bowel diarrhea, non-inflammatory, watery large volume; colitis, inflammatory, dysentery, fever, tenesmus, cramping, small volume.
- Definitions: acute <14d; persistent >14d; chronic >30d.
- DDx depends on duration, CD4 count, Sx (fever, tenesmus, blood), travel, food ingestion (seafood), ABx use (including OI prophylaxis).
- Acute diarrhea incubation period: <2h-chemical agents; 2-7hrs- preformed toxin (S. aureus, B. cereus); 8-14hrs- C. perfringens; >14hrs- most bacterial and viral pathogens.
- 2 major causes of vomiting: viral pathogens & preformed toxins of S. aureus and B. cereus.
- Bloody diarrhea: Shigella, Salmonella, hemorrhagic E. coli, C. jejuni, E. histolytica, CMV, KS .
- Fever common: Shigella, Salmonella, invasive E. coli, C. jejuni, Vibrio parahemolyticus (seafood consumption), CMV.
- Fever less common: S. aureus, B. cereus, C. perfringens, enterotoxigenic E. coli, & E. coli 0157:H7, microsporidia, Cryptosporidium (if present, usually low-grade), C. difficile.
- Empiric Rx for severe acute diarrhea: consider ciprofloxacin 500 mg PO twice-daily +/- metronidazole 500 mg PO 3 times daily. Avoid empiric therapy if E. coli O157:H7 suspected; may increase toxin production and risk of HUS.
- See below for pathogen-specific therapy.
- Diet: rehydration, frequent small feedings; low-fat; avoid caffeine and milk products. Use fiber supplements to increase stool bulk.
- If non-bloody & not C. difficile, antiperistaltic agents can be used: loperamide (Imodium) 4 mg PO x1 then 2 mg prn, max 16 mg/d OR atropine/diphenoxylate (Lomotil)1-2 PO 3-4 times daily prn.
- Severe chronic diarrhea: codeine 30 mg po q4-6h prn; deodorized tincture of opium (DTO) 0.6 ml PO 3-4 times daily prn.
- No etiology found in 30% of pts. w/ AIDS and chronic diarrhea. Diarrhea usually responds to antiperistaltics.
Trimethoprim + Sulfamethoxazole
||Preferred for Isospora and Cyclospora; alternative for Salmonella, Shigella, and E. coli.
||Empiric Rx for severe acute diarrhea; preferred agent for Salmonella, Shigella, & E. coli (not 0157:H7)
||Treatment for Campylobacter, resistance rarely reported.
||Use for certain microsporidiosis, Encephalitozoonidae infection
||Preferred for mild C. difficile, E. histolytica, G. lamblia
||Active against CMV, but valganciclovir now preferred over IV ganciclovir.
||Preferred agent for treatment of CMV
||Cryptosporidium; may be the most effective agent second to HAART.
|Vancomycin ||Preferred (PO) for severe C. difficile (WBC>20K).
||Preferred for amoebiasis and giardiasis. As effective as metronidazole, better tolerated.
- Guerrant RL, Van Gilder T, Steiner TS, et al. ;
Practice guidelines for the management of infectious diarrhea ;
Clin Infect Dis ;
2001 ; Vol.
32 ; pp.
Basis for recommendation
Comments:IDSA treatment guidelines for infectious diarrhea