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PRACTICE: Roger Jones and Greg Rubin Acute diarrhoea in adults BMJ 2009; 338: b1877 [Full text]

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Response to the management of diarrhea in adults

Rina Muller   (22 June 2009)

Do not forget to request C. difficile testing in travellers

Fiona J Cooke, Effrosyni Gkrania-Klotsas, Sani Aliyu, Nick Brown   (14 July 2009)

Response to the management of diarrhea in adults 22 June 2009
Rina Muller, Senior Lecturer Primary Health Care North West University, Potchefstroom Campus, Potchefstroom, 2531 Send response to journal: Re: Response to the management of diarrhea in adults	The Editor British Medical Journal Re: Acute diarrhea in adults published by Jones R & Rubin G: 15 June 2009 (BMJ 2009; 338: b1877) I would like to congratulate both authors addressing acute diarrhea in adults very effectively. As an Advance Practice Nurse in Primary Health Care, diarrhea in adults is a common complaint we need to address while working in a clinic. The potential pitfalls identified are very important. Inadequate initial assessment could happen very often in our practical situation especially when dealing with a large queue of waiting patients. Failure to reassess can contribute to the development of severe illness and prolong the possibility of early diagnosis and treatment of severe disease e.g. Colorectoral cancer. The danger of concentrating only on conditions related to the gastro-intestinal canal was also emphasized. We should surely be aware of conditions like hyperthyroidism and diabetes as causes of chronic diarrhea. As I practice in a limited resource environment, where laboratory culture and sensitivity services are not available I would like to know how what the authors think should be the best management for the patient’s benefits. Should we first prescribe metronidazole, if not finding any red flag symptoms and reassess after 7 days and if symptoms do not resolve, refer the patient. Or, is it better to wait another 7 days with no treatment, reassess and refer if chronic diarrhea is still persistent? Rina Muller, South Africa Competing interests: None declared
Do not forget to request C. difficile testing in travellers 14 July 2009
Fiona J Cooke, SpR Microbiology Addenbrooke's Hospital, Cambridgre CB2 2QQ, Effrosyni Gkrania-Klotsas, Sani Aliyu, Nick Brown Send response to journal: Re: Do not forget to request C. difficile testing in travellers	Do not forget to request C. difficile testing in travellers The case reported by Jones and Rubin in their recent article on Acute Diarrhoea in Adults 1could be linked to organisms commonly associated with 'traveller's diarrhea.' However, the authors have not considered the possibility that his diarrhoea might be due to C.difficile infection (CDI). This is especially pertinent in travelers who have taken antibiotics (particularly fluoroquinolones) for gastrointestinal upset, or antibiotic prophylaxis while overseas. Six cases of travel-associated CDI were identified retrospectively at the Tropical Medicine Referral Unit in Madrid, Spain during the period 2001–2007 2. One patient had persistent diarrhoea (duration 2–4weeks), 3 patients had chronic diarrhoea (duration >4 weeks) and the other 2 patients experienced recurrent diarrhoea. Although there are no records of travel-associated CDI in our hospital, community-onset cases account for approx 25% of the total number of CDI. This may be an under-estimate, as we perform stool tests for C. difficile toxin only if specifically requested. Recent studies describing community CDI in patients without healthcare contact or recent antibiotics 3 4 re-inforce the need to specifically request C. difficile testing on travelers and other patients with diarrhoea persisting for more than 7 days in the community 5. Fiona Cooke, SpR Microbiology (fiona.cooke@addenbrookes.nhs.uk) Effrosyni Gkrania-Klotsas, Consultant in Infectious Diseases Sani Aliyu, Consultant in Microbiology and Infectious Diseases Nick Brown, Consultant in Microbiology Departments of Microbiology and Infectious Diseases, Addenbrooke’s Hospital, Cambridge, Conflicts of interest: none declared. 1. Jones R, Rubin G. Acute diarrhoea in adults. Bmj 2009;338:b1877. 2. Norman FF, Perez-Molina J, Perez de Ayala A, Jimenez BC, Navarro M, Lopez-Velez R. Clostridium difficile-associated diarrhoea after antibiotic treatment for traveler's diarrhoea. Clin Infect Dis 2008;46(7):1060-3. 3. Wilcox MH, Mooney L, Bendall R, Settle CD, Fawley WN. A case- control study of community-associated Clostridium difficile infection. J Antimicrob Chemother 2008;62(2):388-96. 4. DuPont HL, Garey K, Caeiro JP, Jiang ZD. New advances in Clostridium difficile infection: changing epidemiology, diagnosis, treatment and control. Curr Opin Infect Dis 2008;21(5):500-7. 5. BMJ best practice http://bestpractice.bmj.com/best- practice/monograph/601/follow-up/complications.html Competing interests: None declared