Acute infectious diarrhea

The

new england journal

of

medicine

clinical practice

Acute Infectious Diarrhea
Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D.
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with theauthors’ clinical recommendations.

An otherwise healthy 23-year-old man presents after the acute onset of watery diarrhea that has persisted for two days. He reports associated nausea and cramping but no emesis and is febrile, with a temperature of 38.7°C (101.7°F). How should he be evaluated and treated?

the clinical problem
From the Department of Medicine, Division of Infectious Diseases andInternational Health, Duke University Medical Center, Durham, N.C. (N.M.T.); and the Department of Medicine, Division of Infectious Diseases and International Health and the Center for Global Health, University of Virginia School of Medicine, Charlottesville (R.L.G.). Address reprint requests to Dr. Guerrant at the Center for Global Health, HSC #801379, University of Virginia School of Medicine,Charlottesville, VA 22908, or at rlg9a@virginia.edu. N Engl J Med 2004;350:38-47.
Copyright © 2004 Massachusetts Medical Society.

Despite reductions in mortality worldwide, diarrhea still accounts for more than 2 million deaths annually1 and is associated with impaired physical and cognitive development in resource-limited countries.2 In the United States, an estimated 211 million to 375 millionepisodes of acute diarrhea occur each year (1.4 episodes per person per year); such episodes are responsible for more than 900,000 hospitalizations and 6000 deaths annually.3,4 Acute diarrhea, defined as an increased frequency of defecation (three or more times per day or at least 200 g of stool per day) lasting less than 14 days, may be accompanied by nausea, vomiting, abdominal cramping,clinically significant systemic symptoms, or malnutrition. We focus here on acute infectious diarrhea in immunocompetent adults in industrialized countries.

strategies and evidence
microbiology

The Foodborne Diseases Active Surveillance Network (FoodNet) of the Centers for Disease Control and Prevention (CDC) collects data on the incidence of diarrhea attributable to nine enteropathogens in 13percent of the U.S. population (37.4 million people) living in nine states. Of these, the pathogens responsible for the most cases of diarrhea in 2002 were salmonella (16.1 cases per 100,000 population), campylobacter (13.4 cases per 100,000 population), shigella (10.3 cases per 100,000 population), Escherichia coli O157:H7 (1.7 cases per 100,000 population), and cryptosporidium (1.4 cases per100,000 population); vibrio, yersinia, listeria, and cyclospora were reported in fewer than 1 person per 100,000.5 Other enteropathogens for which diagnostic testing is readily available include Clostridium difficile, giardia, rotavirus, and Entamoeba histolytica. Additional agents of infectious diarrhea for which clinical diagnostic testing is not routinely available include enterotoxigenic,enteropathogenic, enteroaggregative, and enteroinvasive strains of E. coli, toxin-producing Clostridium perfringens, Staphylococcus aureus, Bacillus cereus, and noroviruses.
evaluation

Thorough clinical evaluation of a patient who presents with acute diarrhea is essential in order to guide a cost-effective, evidence-based approach to initial diagnostic test38
n engl j med 350;1 www.nejm.org january 1,2004

Downloaded from www.nejm.org on July 19, 2008 . Copyright © 2004 Massachusetts Medical Society. All rights reserved.

clinical practice

ing and therapy. In six studies conducted between 1980 and 1997, the diagnostic yield of stool cultures ranged from 1.5 to 5.6 percent.6 The estimated cost of $952 to $1,200 per positive culture can be reduced through improved selection and...