Clinical Review & Education
JAMA Network Clinical Guideline Synopsis
Diagnosis and Management of Infectious Diarrhea
Michelle W. Parker, MD; Ndidi Unaka, MD, MEd
GUIDELINE TITLE 2017 Infectious Diseases Society of America
Clinical Practice Guidelines for the Diagnosis and Management
of Infectious Diarrhea
DEVELOPERS Expert panel assembled by the Infectious
Diseases Society of America (IDSA)
RELEASE DATE October 19, 2017
PRIOR VERSION 2001
FUNDING SOURCE IDSA
TARGET POPULATIONS Infants, children, adolescents, and
adults in the United States with acute or persistent infectious
diarrhea
SELECTED MAJOR RECOMMENDATIONS:
• Test stool for bacterial pathogens in patients with fever,
bloody or mucoid stools, severe abdominal cramping or
tenderness, or signs of sepsis (strong, moderate).
• Avoid antimicrobials for most patients with acute watery
diarrhea or bloody diarrhea who are healthy and age 3
months or older (strong, low).
Summary of the Clinical Problem
Although the highest morbidity and mortality occurs in low- to middle-
income nations, infectious diarrhea accounts for approximately 180
million illnesses annually in the United States.1 Risk factors such as in-
ternational travel, antibiotic use, child care settings, and exposure to
animals modify the potential pathogens, for which there may be nu-
anced differences in testing and management recommendations. Ap-
propriate management in the setting of highly resourced health sys-
tems should focus on judicious use of resources and identification of
patients who might benefit from adjunctive therapies.
Characteristics of the Guideline Source
This guideline was developed and funded by the IDSA. Committee
members included representatives from multiple national organiza-
tions and were a gastroenterologist and internal medicine and pedi-
atric infectious disease physicians with additional multidisciplinary ex-
pertise in areas such as epidemiology, preventive medicine, nutrition,
and enteric disease. Representatives with primary expertise in outpa-
tient primary care or general hospital medicine were absent. Methods
expertise was provided by committee representation, review, and fi-
nal approval by the IDSA Standards and Practice Guidelines Commit-
tee. A formal conflict of interest management policy was followed.
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• Avoid antimicrobials for patients with Escherichia coli O157 or
Shiga toxin 2–producing organisms or if the toxin genotype is
unknown (strong, moderate).
• Use reduced-osmolarity oral rehydration solution (ORS) as
first-line therapy for mild to moderate dehydration, even
with vomiting (strong, moderate).
• Consider nasogastric administration of ORS for moderate
dehydration (weak, low).
• Administer isotonic intravenous fluids for severe
dehydration, shock, or altered mental status and failure of
ORS therapy (strong, high) or ileus (strong, moderate).
• Antinausea or antiemetic medications may be given to
facilitate oral rehydration in patients older than 4 years
(weak, moderate).
• Probiotics may be offered to immunocompetent patients to
reduce the severity and duration of diarrhea
(weak, moderate).
• Oral zinc supplementation reduces the duration of diarrhea
in children age 6 months to 5 years who may have a zinc
deficiency (strong, moderate).
• Report all nationally notifiable organisms to territorial, state,
or local health departments to ensure infection control and
prevention practices (strong, high).
Evidence Base
The guideline committee developed 21 clinical questions to be ad-
dressed to provide recommendations on the diagnosis and man-
agement of infectious diarrhea in the United States. A literature
search was performed in MEDLINE and Embase. Inclusion criteria
were (1) randomized clinical trials published from 2001 to 2013 (sys-
tematic reviews and practice guidelines were considered if appro-
priate randomized clinical trials were unavailable), (2) English-
language studies based in North America or with European authors
with the objective of outlining diagnostic guidelines, and (3) ar-
ticles focused on international travel–associated infections (with-
out geographical restrictions).
Stooltestingforbacterialpathogensshouldbeobtainedinpatients
withfever,bloodystools,orabdominaltenderness,giventhehigherlike-
lihood of positive test results. Positive results of stool studies can help
determine the utility of antimicrobials (specifically for Salmonella en-
terica subspecies, Shigella, and Campylobacter) and prevent unneces-
sary testing and imaging. Negative results of stool studies may prompt
consideration of noninfectious causes. Even in the absence of fever or
bloodystools,testingforbacteria,viruses,andparasitesshouldbecon-
sidered in immunocompromised patients, those with high risk of dis-
ease, or during a suspected outbreak.
(Reprinted) JAMA Pediatrics Published online June 11, 2018 E1
 Clinical Review & Education JAMA Network Clinical Guideline Synopsis

Empiric antimicrobials are not recommended for most immuno-

Table. Guideline Rating
competentpatients.Populationsinwhichempiricantibioticsshouldbe
considered include infants 3 months or younger with suspected bac- Standard Rating

terialinfection,ill-appearingimmunocompetentpatientswhensuspect- Establishing transparency Good

ing Shigella, and recent travelers who are febrile (38.5°C) or have signs Management of conflict of interest Good
in the guideline development group
of sepsis. Antibiotics should be avoided for those with Shiga toxin– Guideline development group composition Fair
producing E coli O157, as there is evidence of harm.2
Clinical practice guideline–systematic review intersection Good
Reduced-osmolarity ORS is still first-line therapy for all pa-
Establishing evidence foundations and rating strength Good
tients with acute diarrhea and associated mild to moderate dehy- for each of the guideline recommendations
dration. Oral rehydration is as safe and efficacious as intravenous flu- Articulation of recommendations Good
ids in children younger than 5 years,3 and reduced-osmolarity ORS External review Fair
is associated with fewer unscheduled intravenous fluid infusions, de- Updating Good
creased stool losses and vomiting, and no increased risk of hypona- Implementation issues Good
tremia. Administration of ORS via nasogastric tube may be consid-
ered in patients with an impaired ability to take fluids orally. sage of antimicrobial stewardship and the dangers of breeding resis-
Continuing to offer human milk to infants and early resumption of tance. The recommendation to consider nasogastric rehydration has
an age-appropriate diet remains a strong recommendation.4 Pa- a weak evidence base, as it has been poorly studied; however, it allows
tients with signs of severe dehydration, shock, altered mental sta- for family-centered care and shared decision making, and may facili-
tus, or ileus should receive intravenous isotonic fluids. tate an earlier transition to oral feeding if it is successful.
Ancillary therapy such as antiemetics can be considered in specific
cases. In children older than 4 years, ondansetron hydrochloride is safe Discussion
and associated with resolution of vomiting, reduced rates of hospital- Thisguidelineprovidesaclearquestion-basedupdatetothe2001guide-
ization,anddecreasedneedforrehydrationviaintravenousfluids.5 Sev- lines, and conforms to Institute of Medicine standards regarding the
eralstudieshighlighttheroleofprobioticsindecreasingstoolfrequency, development and evidence base (Table). New recommendations pri-
the risk of illness lasting more than 4 days, and the duration of diarrhea marily surround ancillary management targeted at symptomatic relief.
byapproximately1day.Finally,oralzincsupplementationmaydecrease A randomized clinical trial not included in the guideline because of the
the duration of acute diarrhea by 10 hours in children aged 6 months date of publication found fewer failures of treating and preventing de-
to 5 years in a resource-limited setting; this positive effect is even more hydration in children with gastroenteritis who were given a dilute apple
profound in children who are malnourished6 and therefore at risk of juicesolutioncomparedwiththosegivenotherelectrolytemaintenance
zinc deficiency. solutions.7

Benefits and Harms Areas in Need of Future Study or Ongoing Research

The ease and availability of testing and treatment options in the United
States make the judicious and cost-effective use of resources impor-
tant considerations. This guideline addresses these issues by highlight-
ing specific patient populations for whom diagnostic testing or medi-
cation adjuncts may be beneficial, and others in which they would be
unwarranted. Although the use of ondansetron or probiotics may have
abroadertargetpopulation,physiciansinhigh-incomecountriesshould
be discriminating with the use of zinc supplementation, given the nar-
row population of children who may have a zinc deficiency. The guide-
linediscouragesunnecessaryantimicrobialtherapy,furtheringthemes-
As diagnostic capabilities evolve, more evidence to aid in the applica-
tion of molecular-based testing will be important. Although such test-
ingdoesmorerapidlyidentifytreatablebacterialpathogens,itdoesnot
yield isolates for public health investigations or antimicrobial suscep-
tibility data, and may detect colonization as opposed to an active infec-
tion that is more conclusively identified with traditional culture-based
diagnostics. In addition, new areas of research such as the interactions
of gastrointestinal infections with the microbiome could continue to
shape future recommendations or help determine those at increased
risk for severe illness or secondary complications.

ARTICLE INFORMATION
Author Affiliations: Division of Hospital Medicine,
Cincinnati Children’s Hospital Medical Center,
Cincinnati, Ohio (Parker, Unaka); Department of
Pediatrics, University of Cincinnati College of
Medicine, Cincinnati, Ohio (Parker, Unaka).
Corresponding Author: Michelle W. Parker, MD,
Division of Hospital Medicine, Cincinnati Children’s
Hospital Medical Center, 3333 Burnet Ave, MLC 3024,
Cincinnati, OH, 45229 (michelle.parker@cchmc.org).
Published Online: June 11, 2018.
doi:10.1001/jamapediatrics.2018.1172
Conflict of Interest Disclosures: None reported.
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293-301.
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Provincial Pediatric Enteric Infection Team
(APPETITE). Shiga toxin–producing Escherichia coli
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Klassen TP, Craig W. Oral versus intravenous
rehydration for treating dehydration due to
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delayed refeeding for children with acute diarrhoea.
Cochrane Database Syst Rev. 2011;7(7):CD007296.
5. Fedorowicz Z, Jagannath VA, Carter B.
Antiemetics for reducing vomiting related to acute
gastroenteritis in children and adolescents.
Cochrane Database Syst Rev. 2011;9(9):CD005506.
6. Lazzerini M, Ronfani L. Oral zinc for treating
diarrhoea in children. Cochrane Database Syst Rev.
2013;1(1):CD005436.
7. Freedman SB, Willan AR, Boutis K, Schuh S.
Effect of dilute apple juice and preferred fluids vs
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