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Management of Travellers' Diarrhoea in Adults In MANAGEMENT OF TRAVELLERS’ DIARRHOEA IN ADULTS IN PRIMARY CARE Homerton University Hospital and Hospital for Tropical Diseases December 2016 (review date December 2017) Presence of Assess as per NICE • Diarrhoea +/- nausea / vomiting and >3 loose stools per day guidelines on acute • PLUS travel outside of Western Europe / N America / Australia / diarrhoea New Zealand NO https://cks.nice.org • OR diarrhoea in men who have sex with other men (MSM) even in .uk/diarrhoea- the absence of foreign travel adults-assessment YES Refer to Homerton Infectious Diseases (ID) clinic (box Duration > 2 weeks 3) & commence stool investigations (MC&S, OCP +/- YES C difficle toxin test) NO Features of severe illness: • Fever >38.5 +/- bloody diarrhoea +/- severe abdominal pain OR • Immunocompromised (chemotherapy/ after tissue transplant/HIV with a low CD4 count) • Underlying intestinal pathology (inflammatory bowel disease/ ileostomy/short bowel syndrome) • Conditions where reduced oral intake may be dangerous (diabetes, sickle cell disease, elderly) YES Refer to YES • Dehydrated? Homerton • Evidence of sepsis? A&E (box 3) • Fever plus travel to malaria-endemic area NO • Acute abdomen/ signs suggestive of appendicitis? • Unable to manage at home/ clinician concern NO Diarrhoea with risk factors for severe illness/ Non-severe illness complications Investigations Investigations • Stool MC&S • Stool MC&S • Stool OC&P x 2 • Stool OC&P x 2 • C. difficile toxin test - if recent • C. difficile toxin test - if recent hospitalisation hospitalisation or antibiotics or antibiotics • Consider LGV infection in MSM: refer to • Consider LGV infection in MSM: refer to GU GU clinic if appropriate clinic if appropriate Treatment Treatment • Advise on rehydration (box 2) • Advise on rehydration (box 2) • Anti-motility agents: can be used if non- • Avoid anti-motility agents bloody diarrhoea, no features of severity1 • Consider empirical antibiotics if bloody • Empirical antibiotics NOT needed diarrhoea: (box 1) Refer to ID clinic if in doubt (box 3) OC&P = ova, cysts & parasites, MC&S = microscopy, culture & sensitivity Further information: BMJ 2016; 353:i1937 PCR = polymerase chain reaction Barrett, Brown, Travellers diarrhoea- clinical review- LGV = lymphogranuloma venereum Box 1: Treatment Infection Antibiotics Additional notes Empirical therapy Ciprofloxacin 500mg bd for • ONLY treat if there are risk factors for severe illness or in selected patients 3 days OR azithromycin 1g complications only single dose • Avoid ciprofloxacin if travel was to southeast Asia Campylobacter/ Nil usually needed (see • If prolonged diarrhoea or severe illness - ciprofloxacin Salmonella/ additional notes) 500mg bd for 3 days (avoid ciprofloxacin if travel was to Shigella southeast Asia) OR azithromycin 1g single dose • 7 days antibiotics in immunocompromised patients or Shigella dysenteriae infection Verocytotoxin PCR Nil • Avoid anti-motility agents. positive OR • If severe symptoms (even without fever) refer to E coli o157 /o104 Homerton Hospital medical registrar to investigate for cultured possible haemolytic uraemic syndrome. Giardia Tinidazole 2 grams • If pregnant or breastfeeding, prescribe Metronidazole (4x500mg) single dose 400mg tds for 5 days as an alternative. • Advise patient alcohol can not be taken with tinidazole or metronidazole. Amoebiasis Tinidazole 2 grams OD for 3 • OR Metronidazole 400 mg tds for 10 days if pregnant or (Entamoeba days breastfeeding (avoid all alcohol with both agents) histolytica only) • Refer to ID clinic to complete treatment with diloxanide furoate or paromomycin (unlicensed drugs) Box 2: Additional notes Situation Advice Risk of dehydration Drink water plus oral rehydration salts. Aim to drink usual amount plus replacement of loss fluid volume. Food preparation Food handlers should not be involved in food preparation/serving while experiencing diarrhoea or for at least 48 hours after its resolution. Isolation of certain organisms may require microbiological clearance (see below). Repeat stool culture following Microbiological clearance is not usually required. Discuss cases involving treatment food handlers with local health protection unit. Clinical notification to the local health Not required unless protection unit (HPU) of Public Health • Part of an outbreak (eg several family members affected) England (0203 837 7084) • Increased risk of an outbreak (eg if patient has poor hygiene or works as a food handler or in clinical care) • Positive culture for: E coli o157, Shigella flexneri, dysenteriae or boydii (PHE are electronically notified about most other common infections) Box 3: Referral details By email By post [email protected] Dr Aileen E Boyd, Consultant of Microbiology & Infectious Diseases. Homerton University Hospital, Homerton Row, London E9 6SR.
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