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Percentage of to year-olds who have work credentials or have completed a work experience program, by highest level of education: NOTE: Survey respondents were noninstitutionalized to year-olds who were not enrolled in high school at the time of sampling although they could be enrolled in college.

They do not include postsecondary degrees and certificates. Although rounded numbers are displayed, the figures are based on unrounded estimates.

In , the percentages of to year-olds with certifications, with licenses, and who had completed work experience programs were higher for those with a college degree referred to as college graduates than for those without a college degree referred to as non-college graduates.

Skip Navigation. Search box. Most patients do not require laboratory workup, and routine stool cultures are not recommended.

Treatment focuses on preventing and treating dehydration. Diagnostic investigation should be reserved for patients with severe dehydration or illness, persistent fever, bloody stool, or immunosuppression, and for cases of suspected nosocomial infection or outbreak.

Oral rehydration therapy with early refeeding is the preferred treatment for dehydration. Probiotic use may shorten the duration of illness.

When used appropriately, antibiotics are effective in the treatment of shigellosis, campylobacteriosis, Clostridium difficile , traveler's diarrhea, and protozoal infections.

Prevention of acute diarrhea is promoted through adequate hand washing, safe food preparation, access to clean water, and vaccinations.

Acute diarrhea is defined as stool with increased water content, volume, or frequency that lasts less than 14 days.

In patients with acute diarrhea, stool cultures should be reserved for grossly bloody stool, severe dehydration, signs of inflammatory disease, symptoms lasting more than three to seven days, immunosuppression, and suspected nosocomial infections.

Testing for Clostridium difficile toxins A and B should be performed in patients who develop unexplained diarrhea after three days of hospitalization.

Routine testing for ova and parasites in acute diarrhea is not necessary in developed countries, unless the patient is in a high-risk group i.

The first step to treating acute diarrhea is rehydration, preferably oral rehydration. Antibiotics usually a quinolone reduce the duration and severity of traveler's diarrhea.

Infectious causes of acute diarrhea include viruses, bacteria, and, less often, parasites. Noninfectious causes include medication adverse effects, acute abdominal processes, gastroenterologic disease, and endocrine disease.

Clinically, acute infectious diarrhea is classified into two pathophysiologic syndromes, commonly referred to as noninflammatory mostly viral, milder disease and inflammatory mostly invasive or with toxin-producing bacteria, more severe disease.

More likely to promote intestinal secretion without significant disruption in the intestinal mucosa. More likely to disrupt mucosal integrity, which may lead to tissue invasion and destruction.

Nausea, vomiting; normothermia; abdominal cramping; larger stool volume; nonbloody, watery stool. Enterotoxigenic Escherichia coli , Clostridium perfringens , Bacillus cereus , Staphylococcus aureus , Rotavirus , Norovirus , Giardia , Cryptosporidium , Vibrio cholerae.

Information from references 7 and 8. Viral infections are the most common cause of acute diarrhea. When a specific organism is identified, the most common causes of acute diarrhea in the United States are Salmonella, Campylobacter, Shigella , and Shiga toxin—producing Escherichia coli enterohemorrhagic E.

The onset, duration, severity, and frequency of diarrhea should be noted, with particular attention to stool character e. The patient should be evaluated for signs of dehydration, including decreased urine output, thirst, dizziness, and change in mental status.

Vomiting is more suggestive of viral illness or illness caused by ingestion of a preformed bacterial toxin. Symptoms more suggestive of invasive bacterial inflammatory diarrhea include fever, tenesmus, and grossly bloody stool.

A food and travel history is helpful to evaluate potential exposures. Children in day care, nursing home residents, food handlers, and recently hospitalized patients are at high risk of infectious diarrheal illness.

Pregnant women have a fold increased risk of listeriosis, 12 which is primarily contracted by consuming cold meats, soft cheeses, and raw milk.

Sexual practices that include receptive anal and oral-anal contact increase the possibility of direct rectal inoculation and fecal-oral transmission.

The history should also include gastroenterologic disease or surgery; endocrine disease; radiation to the pelvis; and factors that increase the risk of immunosuppression, including human immunodeficiency virus infection, long-term steroid use, chemotherapy, and immunoglobulin A deficiency.

Salmonella , Shigella , Campylobacter , Shiga toxin—producing E. Fried rice. Raw ground beef or seed sprouts.

Shiga toxin—producing E. Raw milk. Salmonella , Campylobacter , Shiga toxin—producing E. Seafood, especially raw or undercooked shellfish.

Vibrio cholerae , Vibrio parahaemolyticus. Undercooked beef, pork, or poultry. Staphylococcus aureus , Clostridium perfringens , Salmonella , Listeria beef, pork, poultry , Shiga toxin—producing E.

Rotavirus , Cryptosporidium , Giardia , Shigella. Shigella , Salmonella , Campylobacter , protozoal disease. Cryptosporidium , Microsporida, Isospora , Cytomegalovirus , Mycobacterium aviumintracellulare complex, Listeria.

Endocrine: Hyperthyroidism, adrenocortical insufficiency, carcinoid tumors, medullary thyroid cancer. Gastrointestinal: Ulcerative colitis, Crohn disease, irritable bowel syndrome, celiac disease, lactose intolerance, ischemic colitis, colorectal cancer, short bowel syndrome, malabsorption, gastrinoma, VIPoma, bowel obstruction, constipation with overflow.

Other: Appendicitis, diverticulitis, human immunodeficiency virus infection, systemic infections, amyloidosis, adnexitis.

Antibiotics especially broad-spectrum , laxatives, antacids magnesium- or calcium-based , chemotherapy, colchicine, pelvic radiation therapy.

Less common: Proton pump inhibitors, mannitol, nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, cholesterol-lowering medications, lithium.

Giardia , Cryptosporidium , Cyclospora. Campylobacter , Salmonella , Shigella , E. Onset of symptoms within 6 hours: Staphylococcus , B.

Onset of symptoms within 8 to 16 hours: C. Many other pathogens e. Information from references 1 , 7 , 8 , 14 , and Information from references 1 and The primary goal of the physical examination is to assess the patient's degree of dehydration.

Generally ill appearance, dry mucous membranes, delayed capillary refill time, increased heart rate, and abnormal orthostatic vital signs can be helpful in identifying more severe dehydration.

Fever is more suggestive of inflammatory diarrhea. The abdominal examination is important to assess for pain and acute abdominal processes.

A rectal examination may be helpful in assessing for blood, rectal tenderness, and stool consistency.

Because most watery diarrhea is self-limited, testing is usually not indicated. It is unclear how much fecal occult blood testing affects pretest probability.

Nevertheless, it is a rapid and inexpensive test, and when tests are positive for fecal occult blood in conjunction with the presence of fecal leukocytes or lactoferrin, the diagnosis of inflammatory diarrhea is more common.

Testing stool for leukocytes to screen for inflammatory diarrhea poses several challenges, including the handling of specimens and the standardization of laboratory processing and interpretation.

There is a wide variability in sensitivity and specificity. Therefore, this testing has fallen out of favor. Lactoferrin is a marker for leukocytes that is released by damaged or deteriorating cells, and increases in the setting of bacterial infections.

The indiscriminate use of stool cultures in the evaluation of acute diarrhea is inefficient results are positive in only 1. Although there is no consensus on which patients need a culture, it is reasonable to perform a culture if the patient has grossly bloody stool, severe dehydration, signs of inflammatory disease, symptoms lasting more than three to seven days, or immunosuppression.

Routine analysis for ova and parasites in patients with acute diarrhea is not cost-effective, especially in developed countries. The role of endoscopy in the diagnosis and management of acute diarrhea is limited.

Endoscopic evaluation may be considered if the diagnosis is unclear after routine blood and stool tests, if empiric therapy is ineffective, or if symptoms persist.

Figure 1 provides an algorithm for the treatment of acute diarrhea. Information from references 1 , 14 , and Next, the focus should turn to the replacement of ongoing losses and the continuation of maintenance fluids.

An oral rehydration solution ORS must contain a mixture of salt and glucose in combination with water to best use the intestine's sodium-glucose coupled cellular transport mechanism.

The reduced osmolarity ORS decreases stool outputs, episodes of emesis, and the need for intravenous rehydration, 32 without increasing hyponatremia, compared with the standard ORS.

If oral rehydration is not feasible, intravenous rehydration may be necessary. Early refeeding decreases intestinal permeability caused by infections, reduces illness duration, and improves nutritional outcomes.

Although the BRAT diet bananas, rice, applesauce, and toast and the avoidance of dairy are commonly recommended, supporting data for these interventions are limited.

Instructing patients to refrain from eating solid food for 24 hours also does not appear useful. The antimotility agent loperamide Imodium may reduce the duration of diarrhea by as much as one day and increase the likelihood of clinical cure at 24 and 48 hours when given with antibiotics for traveler's diarrhea.

Loperamide may cause dangerous prolongation of illness in patients with some forms of bloody or inflammatory diarrhea and, therefore, should be restricted to patients with nonbloody stool.

The antisecretory drug racecadotril, widely used in Europe but unavailable in the United States, appears to be more tolerable and as effective as loperamide.

Because acute diarrhea is most often self-limited and caused by viruses, routine antibiotic use is not recommended for most adults with nonsevere, watery diarrhea.

Additionally, the overuse of antibiotics can lead to resistance e. However, when used appropriately, antibiotics are effective for shigellosis, campylobacteriosis, C.

Antibiotic treatment of traveler's diarrhea usually a quinolone is associated with decreased severity of illness and a two-or three-day reduction in duration of illness.

Table 4 summarizes antibiotic therapy for acute diarrhea. If an antimicrobial agent is causing the diarrhea, it should be discontinued if possible.

Enterotoxigenic E. Options for severe disease: Ciprofloxacin, mg twice per day for 5 to 7 days. In addition to patients with severe disease, it is appropriate to treat patients younger than 12 months or older than 50 years, and patients with a prosthesis, valvular heart disease, severe atherosclerosis, malignancy, or uremia.

The role of antibiotics is unclear; they are generally avoided because of their association with hemolytic uremic syndrome. Vibrio cholerae.

Doxycycline and tetracycline are not recommended in children because of possible tooth discoloration. Not needed in mild disease or enteritis, proven in severe disease or bacteremia.

Therapy may not be necessary in immunocompetent patients with mild disease or in patients with AIDS who have a CD4 cell count greater than cells per mm 3.

Option for severe disease: Nitazoxanide Alinia , mg twice per day for 3 days may offer longer treatment for refractory cases in patients with AIDS.

Highly active antiretroviral therapy, which achieves immune reconstitution, is adequate to eradicate intestinal disease in patients with AIDS.

Metronidazole, mg three times per day for 5 to 10 days, plus paromomycin, 25 to 35 mg per kg per day in 3 divided doses for 5 to 10 days. Tinidazole Tindamax , 2 g per day for 3 days, plus paromomycin, 25 to 35 mg per kg per day in 3 divided doses for 5 to 10 days.

If the patient has severe disease or extraintestinal infection, including hepatic abscess, serology will be positive.

Information from references 1 , 14 , 16 , 44 , and Probiotics are thought to work by stimulating the immune system and competing for binding sites on intestinal epithelial cells.

Their use in children with acute diarrhea is associated with reduced severity and duration of illness an average of about one less day of illness.

Effects of strain-specific probiotics need to be verified in adult studies before a specific evidence-based recommendation can be made.

Research in children suggests that zinc supplementation 20 mg per day for 10 days in children older than two months may play a crucial role in treating and preventing acute diarrhea, particularly in developing countries.

Good hygiene, hand washing, safe food preparation, and access to clean water are key factors in preventing diarrheal illness. Effective and safe vaccines exist for rotavirus, typhoid fever, and cholera, and are under investigation for Campylobacter , enterotoxigenic E.

To contain disease outbreaks, designated diseases should be reported to public health authorities. In the United States, reportable diarrheal illnesses include those caused by Vibrio cholerae , Cryptosporidium , Giardia , Salmonella , Shigella , and Shiga toxin—producing E.

Keywords were acute diarrhea, evaluation of acute diarrhea, Clostridium difficile , testing in acute diarrhea, and diagnostic testing in acute diarrhea.

Search dates: March to April , and December Already a member or subscriber? Log in. Reprints are not available from the authors. Practice guidelines for the management of infectious diarrhea.

Clin Infect Dis. The global burden of diarrhoeal disease, as estimated from studies published between and Bull World Health Organ.

Foodborne illness acquired in the United States. Emerg Infect Dis. Foodborne illness acquired in the United States—unspecified agents.

DuPont HL. Diarrheal diseases in the developing world. Infect Dis Clin North Am. Changing epidemiology of food-borne disease: a Minnesota perspective.

Acute diarrhea: a practical review. Am J Med. Laboratory approaches to infectious diarrhea. Gastroenterol Clin North Am. Use of stool collection kits delivered to patients can improve confirmation of etiology in foodborne disease outbreaks.

Centers for Disease Control and Prevention. Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food—10 states, Guidelines on acute infectious diarrhea in adults.

Am J Gastroenterol. Hof H. History and epidemiology of listeriosis. Janakiraman V. Listeriosis in pregnancy: diagnosis, treatment, and prevention.

Rev Obstet Gynecol. Clinical practice. Acute infectious diarrhea. N Engl J Med. Ilnyckyj A. Clinical evaluation and management of acute infectious diarrhea in adults.

Acute diarrhea in adults and children: a global perspective. J Clin Gastroenterol.

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