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PubMed1995

Epidemiology of infectious and iatrogenic nosocomial diarrhea in a cohort of general medicine patients.

BACKGROUND: Nosocomial diarrhea is a common problem in hospitals, but the epidemiology, causes, and consequences of infectious and iatrogenic nosocomial diarrhea are rarely documented in follow-up or surveillance studies of nosocomial infections. The objective of this study was to describe the epidemiology of nosocomial diarrhea in a cohort study of hospitalized patients. METHODS: The setting was a general medicine ward with a total of 30 beds in private or semiprivate rooms in a county hospital. A prospective cohort study of all consenting patients in the study ward was performed during an 11-month period. Patients were interviewed and cultures were obtained to check for stool pathogens within 48 hours of admission, and patients were followed up during their stay in the study ward. Data from medical notes, laboratory tests, antibiotic logs, and patient interviews were collected daily. RESULTS: Among the 382 eligible patients, nosocomial diarrhea developed in 126 (32.9%): 37 cases were of infectious origin, 57 were iatrogenic, and 32 were of unknown origin. The most common causes of nosocomial diarrhea were Clostridium difficile and antibiotic therapy. Multivariate analysis revealed four risk factors for infectious nosocomial diarrhea: age, length of stay, number of antibiotics, and nasogastric tube feedings. Multivariate analysis also revealed four risk factors for iatrogenic nosocomial diarrhea: number of antibiotics, current gastrointestinal conditions, current renal conditions, and recent surgery. Comorbidity associated with nosocomial diarrhea included increased risk of acquiring another type of nosocomial infection, increased risk of death, and increased length of stay. CONCLUSIONS: Nosocomial diarrhea was found to be common and associated with an additional burden of comorbidity. Analyses indicated different risk factors, depending on the etiology of nosocomial diarrhea (infectious or iatrogenic). Further studies are recommended to document the epidemiology and cost analysis of nosocomial diarrhea in other hospital populations.

Adult↗
PubMed2005

Acute diarrhea during pelvic irradiation: is small-bowel volume effect different in gynecologic patients with prior abdomen operation or not?

OBJECTIVE: To evaluate volume effect of small bowel for diarrhea during pelvic irradiation in gynecologic patients with or without prior abdomen operation. METHODS: From January 1996 through December 2003, 759 patients undergoing 4-field pelvic irradiation for cervical or uterine cancer were analyzed. Whole pelvic (WP), modified whole pelvic (MWP), or lower pelvic (LP) irradiation were delivered initially. According to contrast medium within small bowel in simulation films, we categorized the small-bowel volume of full dose related to WP fields as small-volume and large-volume groups. We recorded the severity of diarrhea until 39.6 Gy/22 fractions of pelvic irradiation. The actuarial rates of overall and moderate to severe diarrhea were compared among different groups. RESULTS: Significantly more large-volume distribution (85%) was noted in patients >60 years without prior operation (P < 0.001). Large-volume distribution was 53%, 65%, and 82% in post-operative patients with no diarrhea, mild diarrhea, and moderate to severe diarrhea (P = 0.002), respectively. The corresponding rate was 79%, 77%, and 80% in patients without prior abdomen operation (P = 0.869). In multivariate analysis, prior operation with LP fields (P = 0.005) and prior operation with small volume (P = 0.031) were significantly protective factors for overall diarrhea. The latter was also a protective factor for moderate to severe diarrhea (P = 0.026). Prior operation could diminish overall diarrhea in patients without simultaneous large-field (WP or MWP) and large-volume. Large volume was a significant factor of overall (P = 0.014) and moderate to severe (P = 0.004) diarrhea in large-field patients with operation. The volume effect did not exist in those patients without operation. CONCLUSION: Age and operation can change small-bowel distribution. Prior operation may attenuate diarrhea if irradiated volume of small bowel is small. There is a volume effect in post-operative rather than non-operative patients receiving large-field irradiation. More practical dose-volume evaluation of small bowel may be applied for volume effect in gynecologic patients without prior operation.

Abdomen↗
PubMed1998

Laboratory surveillance method for nosocomial Clostridium difficile diarrhea.

BACKGROUND: Clostridium difficile is the most common infectious cause of endemic nosocomial diarrhea, but traditional surveillance methods for this infection can be time-consuming. The purpose of this article is to (1) describe a laboratory surveillance method for nosocomial diarrhea and nosocomial Clostridium difficile diarrhea (CDD) that does not require chart review and (2) describe some of the epidemiology of these infections at a university-affiliated, public hospital by using this surveillance method. METHODS: The main assumption underlying the surveillance method is that all patients with nosocomial diarrhea have a C. difficile stool toxin assay performed. On the basis of this assumption, the frequency of testing stool samples for toxin is considered a surrogate for the occurrence of nosocomial diarrhea; it is also assumed that the results of the stool toxin assay distinguish between those with (positive assay) and without (negative assay) CDD. During the study period (January 1, 1993, to August 30, 1996) surveillance for nosocomial CDD was performed by monitoring results of C. difficile stool toxin assays done with the Cytoclone A and B enzyme immunoassay. Each month a list of results of all assays performed was reviewed and patients were excluded on the basis of the following criteria. First, patients with assays done within the first 4 days of admission were assumed to have community-acquired diarrhea and excluded. Among patients with assays done > 4 days after admission, patients with two or more assays done within a 7-day period were counted only once; repeated assays (positive or negative) in the 14 days after an initial positive assay (indicating nosocomial CDD) were excluded, but assays done more than 14 days after a positive or a negative assay were counted separately (representing a relapse or new episode of diarrhea). Patients remaining on the list after all the exclusion criteria were applied represented those with nosocomial diarrhea. RESULTS: The mean (+/- SD) frequency of episodes of nosocomial diarrhea per month for each study year (1993, 1994, 1995, and first 8 months of 1996) was 52.6 +/- 16.2, 51.4 +/- 10.5, 49.2 +/- 9.3, 57.8 +/- 11.6, respectively (p = 0.48 by ANOVA); the mean frequency of nosocomial diarrhea per 1000 admissions per month was 48.4 +/- 14.5, 47.7 +/- 10.9, 44.0 +/- 9.6, and 51.6 +/- 9.3, respectively (p = 0.52); and the mean frequency of nosocomial CDD episodes per 100 episodes of nosocomial diarrhea was 24.7 +/- 8.5, 18.9 +/- 4.8, 17.4 +/- 5.7, and 12.2 +/- 7.2, respectively (p = 0.003). The median time (days) after admission to the onset of nosocomial CDD (first positive assay) for each study year was 14.5, 13.0, 12.0, and 13.0, respectively. CONCLUSIONS: Although not all of the underlying assumptions of the method have been verified, the similarity of the findings in the present study to those of previously published studies of nosocomial CDD suggests that the method is valid. Alternatives to traditional methods of performing nosocomial infection surveillance need to be developed so that infection control practitioners can focus more of their efforts on prevention activities.

Analysis of Variance↗
PubMed1998

Acute treatment-related diarrhea during postoperative adjuvant therapy for high-risk rectal carcinoma.

PURPOSE: The combination of pelvic radiotherapy and 5-fluorouracil-based chemotherapy is associated with an increase in acute gastrointestinal toxicity during rectal adjuvant therapy, most notably an increased incidence of diarrhea. Previous randomized, prospective studies have limited their analysis to presenting rates of severe and life-threatening diarrhea (Grade 3 or greater), and few data are available detailing the extent of mild to moderate diarrhea. To provide baseline data for future studies, we conducted a detailed analysis of diarrhea from a prior clinical trial of adjuvant therapy for rectal cancer. METHODS AND MATERIALS: In a multiinstitutional clinical trial, 204 eligible patients with rectal carcinoma that either was deeply invasive (T3-T4) or involved regional lymph nodes were randomized to receive either postoperative pelvic radiotherapy alone (45 to 50.4 Gy) or pelvic radiotherapy and bolus 5-fluorouracil-based chemotherapy. Toxicity was assessed prospectively. RESULTS: For the 99 eligible patients who received pelvic radiotherapy alone, rates of Grades 0, 1, 2, 3, and 4 diarrhea during treatment were 59, 20, 17, 4, and 0%, respectively. For the 96 eligible patients who received radiotherapy and 5-fluorouracil, the overall rates of grades 0, 1, 2, 3, and 4 diarrhea were 21, 34, 23, 20, and 2%, respectively. The increased rates of diarrhea during adjuvant rectal therapy were manifested across all toxicity levels for patients receiving chemotherapy and pelvic radiotherapy. Of primary clinical importance is the substantial increase in severe or life-threatening diarrhea (Grade 3 or more) (22 vs. 4%,p = 0.001) Additionally, increased rates of any diarrhea and also severe or life-threatening diarrhea were observed in patients who had a low anterior resection compared with those who had an abdominoperineal resection (p < 0.001 and p = 0.006, respectively). CONCLUSION: These results will be of value as a baseline for investigators who want to use treatment toxicity as an end point in cancer control or cancer therapy trials utilizing similar treatment techniques. Patients receiving 5-fluorouracil and pelvic radiotherapy compared with patients receiving pelvic radiotherapy alone and patients with a prior history of a low anterior resection compared with patients who had a prior history of an abdominoperineal resection experienced increased rates of Grades 1 through 4 acute treatment-related diarrhea, and the most important increase occurred as Grade 3 toxicity.

Acute Disease↗
PubMed1993

Enteric viruses and diarrhea in HIV-infected patients. Enteric Opportunistic Infections Working Group.

BACKGROUND: Diarrhea occurs frequently among persons with the acquired immunodeficiency syndrome, but the cause often remains unknown. We used a group of diagnostic assays to determine which viruses were etiologic agents of diarrhea in a group of persons infected with the human immunodeficiency virus (HIV). METHODS: Stool and serum specimens were obtained from HIV-infected patients enrolled in a longitudinal study in Atlanta. Fecal specimens from patients with diarrhea and from control patients without diarrhea were screened by electron microscopy, polyacrylamide-gel electrophoresis, and enzyme immunoassays for rotaviruses, enteric adenoviruses, caliciviruses, picobirnaviruses, and astroviruses. Paired serum samples were tested for antibody responses to Norwalk virus and picobirnavirus. RESULTS: Viruses were detected in 35 percent of 109 fecal specimens from patients with diarrhea but in only 12 percent of 113 specimens from those without diarrhea (P < 0.001). Specimens from patients with diarrhea were more likely than those from patients without diarrhea to have astrovirus (12 percent vs. 2 percent, P = 0.003); picobirnavirus (9 percent vs. 2 percent, P = 0.017); caliciviruses, including small round structured viruses (6 percent vs. 1 percent, P = 0.062); and adenoviruses (9 percent vs. 3 percent, P = 0.047). They were also more likely to have a mixed viral infection (6 percent vs. 0 percent, P = 0.006). With the use of polyacrylamide-gel electrophoresis to analyze concentrated RNA extracts from stool, picobirnavirus was detected in fecal specimens from 6 of the 65 patients with diarrhea and was associated with prolonged viral shedding and chronic diarrhea. No rotaviruses, enteric adenoviruses, or instances of seroconversion to positivity for Norwalk virus were observed. CONCLUSIONS: Novel enteric viruses such as astrovirus and picobirnavirus may be more important etiologic agents of diarrhea in HIV-infected patients than previously recognized and may be more common than either bacterial or parasitic enteropathogens.

Adenoviruses, Human↗
PubMed1991

Chronic diarrhea with normal stool and colonic examinations: organic or functional?

To investigate whether the clinical history and basic laboratory test results can differentiate between an organic or functional cause of chronic diarrhea and thus avoid unnecessary hospital admissions and invasive procedures, we reviewed the charts of 58 adult patients admitted during 6 years because of chronic diarrhea who had normal stool and colonic examinations. The final diagnoses were irritable bowel syndrome in 34 patients, organic diarrhea in 21, and unknown cause in three. The following clinical data did not help in the differential diagnosis: age, sex, duration of diarrhea, presence of continuous diarrhea, abdominal pain, stool frequency or volume, and presence of stool mucus. Significant weight loss, nocturnal diarrhea, and the absence of tenesmus were associated with an organic cause. One or more laboratory alterations (increased erythrocyte sedimentation rate, anemia, hypokalemia, and low serum albumin level) were found in 62% of patients with organic diarrhea but in only 3% of those with functional disease; p less than 0.001. In 20 of 21 patients with organic diarrhea, an syndromic diagnosis (fat malabsorption, n = 13; inflammatory bowel disease, n = 4; and secretory diarrhea, n = 3) could be obtained with three simple tests (stool fat, rectal biopsy, and fecal water osmolality and electrolyte determination, respectively). Our study confirms that a detailed history and a few simple laboratory data can help to distinguish between functional and organic diarrhea and so avoid extensive investigation. The syndromic diagnosis of organic diarrhea can also be approximated with relatively easy tests.

Barium Sulfate↗
PubMed1992

Occurrence of acute diarrhea in atopic and nonatopic infants: the role of prolonged breast-feeding.

A cohort of 336 infants was followed from birth for a total of 717 child-years for development of atopy and occurrence of acute diarrhea. During follow-up 94 (28%) of the infants developed atopic eczema or gastrointestinal allergy associated with food allergens, or both. Infants with food allergy had significantly (p = 0.0074) more episodes of acute diarrhea than infants with no atopy, but there was no apparent temporal correlation between the occurrence of acute diarrhea and appearance of gastrointestinal allergy or atopic eczema. Serum IgE levels in children up to 2 years of age who had diarrhea and atopic eczema were lower than those in atopic eczema children with no diarrhea, but infants with gastrointestinal allergy who had acute diarrhea tended to have higher IgE levels than those without diarrhea. Breast-feeding over 6 months of age reduced the incidence of diarrhea in the first year of life in both atopic and nonatopic infants, but had no significant effect on the total incidence of diarrhea during the 2 year follow-up, as infants breast-fed longer had more diarrhea in the second year of life. Prolonged breast-feeding also reduced the severity of diarrhea in atopic infants aged 7-12 months but not for older infants.

Acute Disease↗
PubMed1999

Immune response of children who develop persistent diarrhea following rotavirus infection.

A prospective study was conducted with Bangladeshi children with rotavirus (RV) diarrhea to assess whether nutritional and clinical parameters, RV serotypes, levels of interleukin-10 (IL-10), tumor necrosis factor alpha (TNF-alpha), and gamma interferon (IFN-gamma), and RV-specific antibody titers in plasma and stool were associated with the development of persistent diarrhea. Children with watery diarrhea for 6 to 8 days, selected from the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), were enrolled in the study and monitored until diarrhea improved. Children were classified as having acute diarrhea (AD) if diarrhea resolved within 14 days of onset and as having persistent diarrhea (PD) if diarrhea persisted for more than 14 days after onset. Uninfected, control children (n = 13) from the Nutrition Follow-Up Unit of ICDDR,B were also enrolled. Of the 149 children with diarrhea enrolled, 29 had diarrhea with RV alone, of which 19 had AD and 10 developed PD. Samples of stool and blood were collected from all children on enrollment. Stool samples were collected again from children when they developed PD. Of the 10 children who had an initial RV infection and then developed PD, only one had persistent RV infection. Plasma levels of IL-10 and TNF-alpha were higher in children with diarrhea compared to uninfected controls but were similar in children with AD and PD. Plasma IFN-gamma levels were higher in children who developed PD than in those with AD (P = 0.008) or uninfected controls (P = 0.001). In stools, the levels of TNF-alpha, the only cytokine detected, were similar in the three groups of children. RV-specific immunoglobulin G (IgG) titers in plasma were higher in uninfected children than in those with AD (P < 0.001) or PD (P = 0.024) but titers were similar in children with AD and PD. RV-specific IgA titers in plasma and stool were similar in the three groups of children. From all observed parameters, only elevated plasma IFN-gamma levels were associated with subsequent development of PD. However, a larger sample size is necessary to substantiate this observation.

Acute Disease↗
PubMed1989

Determination by DNA hybridization of Shiga-like-toxin-producing Escherichia coli in children with diarrhea in Thailand.

Specific DNA probes were used to identify Shiga-like-toxin (SLT) I- and II-producing Escherichia coli from children less than 5 years of age with bloody diarrhea, in infants with diarrhea, and in controls of the same age without diarrhea in Thailand. At one hospital, SLT-producing E. coli was identified in 4 (7%) of 54 children with bloody diarrhea from whom other enteric pathogens were not identified and from 3 (6%) of 50 children without diarrhea. In the positive specimens, SLT-producing E. coli constituted only 0.3 to 4% of the 100 to 300 colonies on the replica blots. Non-toxin-encoding 933J and 933W bacteriophagelike DNA sequences were detected by colony hybridization with E. coli isolates from 18 (33%) of 54 children with bloody diarrhea and 23 (46%) of 50 controls. At another hospital, SLT-producing E. coli was not identified in 115 infants with diarrhea and 119 controls without diarrhea. One infant with diarrhea was infected with E. coli O76:H7 that hybridized with the enterohemorrhagic E. coli probe but not with the SLT probes. E. coli producing SLT I or SLT II was isolated in small numbers from a similar proportion of Thai children with bloody diarrhea in whom no other enteric pathogen was identified and from controls without diarrhea.

Bacterial Toxins↗
PubMed1997

Banana flakes control diarrhea in enterally fed patients.

Diarrhea occurs frequently in the critically ill tube-fed population and may result from a multitude of causes. Despite the availability of antidiarrheal medications, diarrhea associated with enteral feedings remains a problem for clinicians and for the patients affected by it. We tested the hypothesis that administration of banana flakes would control diarrhea in critically ill patients receiving enteral feedings. Thirty-one patients with diarrhea and receiving enteral feedings were randomized to receive either banana flakes or medical treatment for diarrhea. Medical treatments included the use of pharmacological agents according to the discretion of the patient's physician or reducing feeding rates. Both banana flakes and medical treatments reduced the severity of diarrhea in critically ill tube-fed patients. Over the course of treatment, mean diarrhea scores were 21.64 +/- 7.81 for the banana flake group and 25.41 +/- 9.76 for the medical group. These differences were not statistically significant. Both groups achieved similar levels of nutrition support. The banana flake group had less diarrhea clinically, with 57% of the subjects diarrhea free on their last study day as opposed to 24% of the medically treated subjects. This occurred despite a threefold increase in the number of patients testing positive for Clostridium difficile toxin in the banana flake group. We conclude that banana flakes can be used as a safe, cost-effective treatment for diarrhea in critically ill tube-fed patients. Banana flakes can be given concurrently with a workup for C. difficile colitis, thereby expediting treatment of diarrhea.

Adult↗
PubMedDate not supplied

Tube feeding-related diarrhea in acutely Ill patients.

Acutely ill patients received tube feeding for an average of 15.8 days and, on average, 35% of those days were spent in the intensive care unit (ICU). Patients were prospectively assigned either a fiber-free formula (FFF-OSMOLITE HN, Ross; n = 50) or a fiber-supplemented (soy polysaccharide 14.4 g/L) formula (FSF = JEVITY, Ross; n = 50). Diarrhea was defined as three or more loose or watery stools per day and occurred in 30% of all patients. Diarrhea developed in 29 (41%) of the 71 patients who received antibiotics during, or within 2 weeks prior to, the feeding period, whereas only 1 (3%) of the 29 patients not receiving antibiotics developed diarrhea (p less than 0.005); and this patient developed diarrhea on the day of death. Among the 30 patients with diarrhea, stool Clostridium difficile (CD) toxin was positive in 15 (50%), negative in 11 (37%), and was not measured in four. The mean serum albumin was significantly lower in patients with diarrhea (2.43) than in those without diarrhea (2.75) (p = 0.043). There were no significant differences in age, sex, diagnoses, number of feeding days, and percent ICU days between patients with and without diarrhea. While not statistically significant, patients who received FSF were observed to have a lower incidence of diarrhea, a lower percentage of diarrhea days per total feeding days, and a lower frequency of positive CD toxin assays than patients who received FFF. In this patient population, antibiotic usage was the factor most strongly associated with diarrhea during tube feedings.

Acute Disease↗
PubMed2004

Differences in rates of diarrhea in patients with human immunodeficiency virus receiving lopinavir-ritonavir or nelfinavir.

STUDY OBJECTIVE: To determine and compare rates of diarrhea in patients receiving an antiretroviral regimen containing lopinavir-ritonavir versus nelfinavir and in patients who received these drugs sequentially. DESIGN: Retrospective cohort analysis. SETTING: Hospital-based human immunodeficiency virus (HIV) clinic. PATIENTS: Four hundred one participants in the HIV Atlanta VA Cohort Study who were prescribed lopinavir-ritonavir or nelfinavir from 1996-2002. MEASUREMENTS AND MAIN RESULTS: Chart review identified episodes of diarrhea that potentially were associated with an antiretroviral agent. Data collected included antidiarrheal agents dispensed, baseline viral load and CD4+ cell counts, demographic variables, and previous therapy Diarrhea associated with an antiretroviral regimen occurred in 175 (49%) of 354 patients receiving nelfinavir and 17 (17%) of 99 patients receiving lopinavir-ritonavir (p < 0.001). Treatment for the diarrhea occurred in 118 (33%) of 354 patients receiving nelfinavir and 9 (9%) of 99 receiving lopinavir-ritonavir (p < 0.001). Patients in the lopinavir-ritonavir group were more likely to have received highly active antiretroviral therapy and azithromycin than patients receiving nelfinavir, and they had lower baseline CD4+ cell counts (p < or = 0.01 for each comparison). The average number of months/person-year of diarrhea treatment was 2.0 for the nelfinavir group and 0.13 for the lopinavir-ritonavir group. Of the 10 antiretroviral-naive patients who received lopinavir-ritonavir, none needed treatment for diarrhea, whereas 78 (36%) of 217 antiretroviral-naive patients who received nelfinavir required treatment for diarrhea. Of the 52 patients who had been taking nelfinavir and were switched to lopinavir-ritonavir, they were more likely to start antidiarrheal treatment while taking nelfinavir (14 [27%]) than while receiving lopinavir-ritonavir (3 [6%]) (p = 0.004). CONCLUSIONS: Patients receiving lopinavir-ritonavir were significantly less likely to have diarrhea or to require treatment for diarrhea than patients receiving nelfinavir. The same results occurred when the drugs were given to the same patients sequentially (nelfinavir followed by lopinavir-ritonavir). The diarrhea associated with lopinavir-ritonavir was less frequent, less severe, and shorter in duration than diarrhea associated with nelfinavir.

Adult↗
PubMed1991

AIDS enteropathy: occult enteric infections and duodenal mucosal alterations in chronic diarrhea.

OBJECTIVE: To investigate occult enteric infections and morphologic changes in the small intestine in patients with advanced human immunodeficiency virus (HIV) infection and chronic diarrhea of undefined cause. DESIGN: Case-control study. SETTING: Referral-based clinic and hospital in tertiary care center. PATIENTS: Twenty-two patients with advanced HIV infection (19 with the acquired immunodeficiency syndrome [AIDS], 3 with AIDS-related complex) with chronic diarrhea, selected because of previously negative stool evaluations for bacterial or parasitic pathogens, were compared with 13 patients with advanced HIV infection (9 with AIDS, 4 with AIDS-related complex) without diarrhea by analysis of endoscopic biopsies using light and electron microscopy, viral culture, and morphometric studies. Both groups were convenience samples and had at least 7 months follow-up. MEASUREMENTS AND MAIN RESULTS: Eleven of twenty-two patients with HIV infection and chronic diarrhea but only 1 of 13 patients without diarrhea showed occult enteric pathogens (that is, undetected by routine studies) after extensive evaluation of duodenal and colorectal biopsies. Mycobacterium avium-intracellulare and microsporidia were the most common occult agents in study patients with diarrhea (5 each). Patients with diarrhea and occult enteric infections had greater weight loss (mean, 14.3 kg compared with 6.2 kg; P less than 0.05) and shorter survival (1 of 11 compared with 8 of 11 still alive; P less than 0.004) than those with diarrhea but no identified pathogens (defined as "AIDS enteropathy"). Duodenal morphometry showed decreased villus-to-crypt ratios because of villus atrophy and crypt elongation in HIV-infected patients both with and without diarrhea compared with normal controls (P less than 0.001 for each). All three groups showed comparable frequencies of epithelial mitoses. CONCLUSIONS: Further endoscopic biopsy evaluation of patients with AIDS who had unexplained chronic diarrhea showed an occult infectious cause in half of the cases. However, altered villus and crypt architecture in advanced HIV infection was independent of the presence of diarrhea or enteric infection and therefore did not correlate with AIDS enteropathy. Subnormal epithelial proliferation in response to injury could be a factor, but the underlying cause of the architectural changes remains obscure. We suggest that T-cell dysfunction may play a role.

AIDS-Related Complex↗
PubMed2005

A randomized, double-blind, placebo-controlled trial of rifaximin to prevent travelers' diarrhea.

BACKGROUND: Travelers' diarrhea causes substantial morbidity and postinfectious irritable bowel syndrome. OBJECTIVE: To evaluate nonabsorbable rifaximin for prevention of travelers' diarrhea. DESIGN: Randomized, double-blind, placebo-controlled clinical trial. SETTING: Guadalajara, Mexico. PARTICIPANTS: U.S. students. INTERVENTION: On arrival in Guadalajara, Mexico, 210 U.S. adults received rifaximin (200 mg/d, 200 mg twice daily, or 200 mg 3 times daily) or placebo for 2 weeks. MEASUREMENTS: Participants were followed daily for 3 weeks for enteric disease and symptoms and daily for 5 weeks for drug side effects. Changes in intestinal coliform flora were studied. RESULTS: Travelers' diarrhea developed in 14.74% of participants taking rifaximin and 53.70% of those taking placebo (rate ratio, 0.27 [95% CI, 0.17 to 0.43]). Rifaximin provided 72% and 77% protection against travelers' diarrhea and antibiotic-treated travelers' diarrhea, respectively (P < 0.001 for both), and all rifaximin doses were superior to placebo. In the groups that did not report travelers' diarrhea, rifaximin significantly reduced the occurrence of mild diarrhea (P = 0.02) and moderate and severe intestinal problems (P = 0.009 for pain or cramps; P = 0.02 for excessive gas). Rates of adverse events were comparable in the rifaximin and placebo groups. Minimal changes in coliform flora were found during rifaximin therapy. LIMITATIONS: Rifaximin safely prevented travelers' diarrhea in Mexico, where most cases are caused by diarrhea-producing Escherichia coli. A study is needed in Asia to determine whether rifaximin can prevent diarrhea caused by invasive bacterial pathogens. CONCLUSIONS: Rifaximin prevents travelers' diarrhea with minimal changes in fecal flora, and more liberal chemoprophylaxis against this disease should be considered. Future studies should evaluate whether rifaximin is effective in preventing postinfectious irritable bowel syndrome.

Adult↗
PubMed2000

Effects of pectin on diarrhea in critically ill tube-fed patients receiving antibiotics.

BACKGROUND: Anaerobic colonic flora are necessary for the fermentation of fiber into short-chain fatty acids and constitute the bulk of fecal mass. Lack of dietary fiber in most enteral feedings, compounded by antibiotic therapy, suppresses normal colonic metabolism, resulting in diarrhea. Pectin, a water-soluble fiber, stimulates epithelial growth in the colon and thus reduces diarrhea. METHODS: Forty-four critically ill patients receiving enteral nutrition and antibiotic therapy were randomized to receive fiber-containing or fiber-free tube feedings and pectin or placebo. Data on frequency, consistency, and volume of fecal output; energy (caloric) intake; and administration of specific medications were collected for 9 days. Diarrhea was defined as 2 or more days with scores of 12 or higher on the Hart and Dobb diarrhea scale. RESULTS: Subjects in the 4 groups did not differ significantly in age, sex, severity of illness, or energy intake. Twelve subjects (27.3%) experienced diarrhea. Significantly fewer subjects in the fiber-free/placebo and fiber/pectin groups experienced diarrhea than did subjects in the fiber/placebo group (P = .02). On the basis of repeated-measures analysis of variance of daily mean scores, the severity of diarrhea did not differ significantly among the study groups over time (P = .16). CONCLUSIONS: The reduced rate of diarrhea found in this study may be related to the stringent definition of diarrhea used. The therapeutic dose of pectin for reducing diarrhea needs further exploration. The trend was toward less diarrhea in the fiber/pectin group, but the study needs to be replicated with a larger sample.

Adult↗
PubMedDate not supplied

[Etiology of community - acquired acute diarrhea in children].

THE AIM: of the study was to analyse the etiology of home acute diarrhea in children. MATERIAL AND METHODS: 2636 children with community-acquired acute diarrhea were included in the study. Stool samples were analysed for the presence of Salmonella spp, Shigella spp, rotaviruses and adenoviruses. RESULTS: etiology of acute diarrhea was established in 1149 out of 2636 children (43.6%). Among the children with known etiology - rotaviral diarrhea was most frequently diagnosed (24.67%), whereas salmonellosis - in 7.06% of cases, EPEC C - 6.37%, EPEC B - 2.92%, EPEC A - 1.89%, adenoviral diarrhea in 0.68%. Mean age of children with bacterial acute diarrhea (Salmonella, EPEC A, B, C) was higher as compared to the mean age of children with rotaviral acute diarrhea (p < 0.002). Rotaviral acute diarrhea was more frequently diagnosed in girls (p < 0.025), whereas bacterial - in boys (p < 0.044). The highest prevalence of acute rotaviral diarrhea was found in winter/spring, with peak in April. CONCLUSIONS: commonly used diagnostic procedure does not allow to establish the etiology of acute home diarrhea in children in most cases. Rotavirus is found in the majority of diagnosed cases. It seems reasonable to expand the spectrum of diagnostic tests in cases of acute diarrhea in children.

Acute Disease↗
PubMedDate not supplied

Clinical patterns of diarrhea in AIDS: etiology and prognosis.

OBJECTIVE: To define the etiology and prognosis of diarrhea (acute, intermittent or chronic) in AIDS patients. DESIGN: A retrospective analysis of patients with AIDS and diarrhea. Patterns of diarrhea were defined a priori. Endpoints of interest were etiology, rate of response to therapy, development of chronic diarrhea, and survival probability. Data were analyzed by means of univariate and multivariate tests (chi-square, ANOVA, Student's t test, Kaplan-Meier, logrank and logistic regression analysis). SETTING: A 170-bed tertiary-care university hospital which is one of the three most important referral centers for AIDS patients in Mexico City. PATIENTS: The records of the 279 AIDS patients admitted to the hospital between 1983 and 1989 were reviewed; 225 cases were suitable for analysis. MEASUREMENTS: The presence of a diarrheal episode, the diagnostic studies to which the patient was submitted, the etiology, the response to therapy and the survival time from the point at which the diarrhea started were all recorded. Diarrheal patterns were stratified by clinical patterns and outcomes compared. Possible clinical predictors of chronic diarrhea were analyzed. RESULTS: Seventy seven percent of the patients suffered at least one diarrheal episode. Diarrhea was in fact the most common AIDS-related complication in our series, and in 51% of the total cases (114/225), it was the first HIV-related symptom. The diarrheal pattern was intermittent in 47% of the cases, chronic in 36% and acute in the remaining 17%. An etiology was established in only 59% of the episodes, and Cryptosporidium was the etiologic agent most frequently isolated (30%). Other opportunistic pathogens prevailed in chronic and intermittent diarrheas. Chronic persistent diarrhea was related to a lower survival probability (60% at one year vs 90% for intermittent and 95% for acute diarrhea, p < 0.0001). When the performance of different diagnostic studies was analyzed, the combination of stool culture, serial parasitic examination and sigmoidoscopy with biopsies provided a high diagnostic accuracy (59%). Regardless of etiology, the rate of therapeutic success was directly related to the previous duration of diarrhea and the absolute lymphocyte count (p < 0.01). CONCLUSIONS: There are three distinct diarrheal patterns common to AIDS patients. Although the etiologic agents do not vary significantly, each pattern has unique characteristics regarding the timing of presentation, their survival and therapeutic success rate. Such differences should be taken into account when therapeutic trials are designed.

AIDS-Related Opportunistic Infections↗
PubMed1997

[Reporting maternal behavior during diarrhea in Bedouin children].

Diarrhea is still a major cause of morbidity and mortality among children in developing countries. The Bedouin population of southern Israel is in transition from a nomadic to a settled life-style. We examined maternal knowledge and reported behavior when their children had diarrhea. Mothers defined diarrhea as the passing of 4-5 stools per day. The most frequent signs of the illness were an increased number of watery stools with changes in either color or form. The most frequent symptom that prompted mothers to seek medical aid was blood in the stool. All mothers reported increasing fluid intake in their children during diarrhea, and most reported giving herbal tea. About half of the women avoided milk products and used special foods for the treatment of diarrhea. A quarter of the women reported stopping or decreasing the frequency of breast feeding during diarrhea. Reported cessation of breast feeding during diarrhea was associated with changing to special foods, and failure to note the onset of diarrhea or to recognize signs of dehydration. The withdrawal of breast feeding during episodes of illness and diarrhea is related to lack of knowledge regarding diarrhea. These data indicate that even in this population, with free access to preventive and curative medical care, there should be greater efforts to educate mothers to detect diarrheal disease and to maintain breast feeding during the diarrhea.

Arabs↗