Acute diarrhoea in adults
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1877 (Published 15 June 2009) Cite this as: BMJ 2009;338:b1877
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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
Competing interests: No competing interests
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
Competing interests: No competing interests