Diarrhea: Causes, Management, and Prevention Strategies

Diarrhea, which is defined as 3 or more loose watery stools a day, is common and can be classified as acute, persistent, or chronic. Acute diarrhea, the most common type, generally lasts 1 to 2 days and resolves on its own.^1,2 It is estimated that about 179 million cases of acute diarrhea occur in the United States annually.¹ Persistent diarrhea lasts 2 to 4 weeks, and chronic diarrhea continues for at least 4 weeks.² Pharmacists can play an important role in helping patients and counseling on prevention strategies.

Diarrhea Causes and Complications

A variety of conditions and diseases can cause diarrhea (Table 1^1,2). Blood and stool tests and a colonoscopy can determine the cause. However, many cases resolve on their own without testing. Patients should be educated about the signs and symptoms of dehydration, a serious adverse effect of diarrhea, in adults and children, as the condition can be life-threatening if untreated (Table 2). Patients with diarrhea accompanied by bloody stools, fever, or severe abdominal pain should be seen by a health care provider immediately, as this may be a sign of a serious infection.¹

Treatment Options

Diarrhea usually resolves on its own without treatment. However, it is important to prevent dehydration. Oral rehydration solutions, such as Pedialyte for infants and children and Gatorade for adults, should be used to replenish electrolytes lost through mild to moderate diarrhea. OTC loperamide may be given to healthy adults with acute watery diarrhea, but it should be avoided in patients with bloody stools or fever⁴ younger than 18 years.⁴ Individuals with severe dehydration may need to be hospitalized and given intravenous fluids, such as lactated Ringer’s and normal saline. Once patients are adequately hydrated, they can resume a normal diet. Breast milk or formula should be continued throughout the diarrhea episode.⁴

Empiric antibiotic therapy should be started while waiting for stool test results for children with bloody diarrhea who have abdominal pain or fever, recently traveled internationally, or are younger than 3 months.⁴Adults should receive azithromycin or ciprofloxacin, and children should be administered a third-generation azithromycin or cephalosporin. Antibiotics should be avoided in patients with Shiga toxin-producing Escherichia coli,as there can be an increased risk of developing a type of kidney failure known as hemolytic uremic syndrome.

Prevention Strategies

Pharmacists can educate patients on strategies to prevent diarrhea. Individuals should wash their hands with soap and water for at least 20 seconds, and hand sanitizer that contains at least 60% alcohol should be used when soap and water are not available. Advise patients to practice swim health to prevent diarrhea caused by Cryptosporidium.⁵ Adults and children should not swim while sick with diarrhea. Swim diapers are important for children who are not toilet trained, and pool water should not be swallowed.

Probiotics (eg, Culturelle) may prevent diarrhea that results from taking antibiotics,⁴ so tell patients to wait at least 2 hours after taking an antibiotic to use a probiotic. While traveling abroad, individuals should only eat food that is cooked and served hot,⁶ and avise patients to drink only beverages from factory-sealed containers and avoid ice. The CDC’s travel health notices can be consulted for up-to-date information on food safety.⁶

Patients should be counseled on the risks of long-term proton pump inhibitor (PPI) use, which include Clostridium difficile infections and diarrhea. Monitor patients taking PPIs, and recommend tapering the dose for individuals who have completed a 4-week course of treatment with resolved symptoms.⁷

Tell parents to ensure that their children are vaccinated to protect against rotavirus, which can cause severe watery diarrhea. Two vaccines, Rotarix and RotaTeq, are available, and the first dose is most effective if it is given before a child is 15 weeks of age.⁸

Jennifer Gershman, PharmD, CPh, is a drug information pharmacist and Pharmacy Times^®contributor who resides in South Florida.

References

• Diarrhea. National Institute of Diabetes and Digestive and Kidney Diseases website. niddk.nih.gov/health-information/digestive-diseases/diarrhea. Accessed May 27, 2018.
• Mayo Clinic staff. Diarrhea. Mayo Clinic website. mayoclinic.org/diseases-conditions/diarrhea/symptoms-causes/syc-20352241. Accessed May 27, 2018.
• McDonald EG, Milligan J, Frenette C, Lee TC. Continuous proton pump inhibitor therapy and the associated risk of recurrent Clostridium difficile infection. JAMA Intern Med. 2015;175(5):784-791. doi: 10.1001/jamainternmed.2015.42.
• Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017;65(12):e45-e80. doi: 10.1093/cid/cix669.
• Hlavsa MC, Cikesh BL, Roberts VA, et al. Outbreaks associated with treated recreational water-United States, 2000-2014. MMWR Morb Mortal Wkly Rep.2018;67(19):547-551. doi: 10.15585/mmwr.mm6719a3.
• Travelers’ diarrhea. CDC website. wwwnc.cdc.gov/travel/page/travelers-diarrhea. Updated October 23, 2017. Accessed May 29, 2018.
• Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors: evidence-based clinical practice guideline. Can Fam Physician. 2017;63(5):354-364.
• Vaccination. CDC website. cdc.gov/rotavirus/vaccination.html. Updated April 23, 2018. Accessed May 29, 2018.