<h2>Practice points</h2><ul><li>A number of probiotic strains may be useful in treating or preventing diarrhoea of varying aetiologies. Benefits may be strain-specific</li><li>Probiotic supplements are best taken with meals to enhance bacterial survival</li><li>Zinc may prevent or reduce diarrhoeal symptoms in children. Trials are lacking for adults</li></ul><ul><li><h2>Description</h2></li><li> <ul><li>Alteration in normal bowel movements characterised by an increase in the water content, volume, or frequency of stools.1 Most episodes are self-limiting2</li><li>Common accompanying symptoms include: weakness, lethargy and dehydration; electrolyte abnormalities may develop3</li><li>Surveys indicate the prevalence of diarrhoea in Australia is between 6.4–7.4%4,5<ul><li>Highest among women and young children4,5</li></ul> </li><li>Aetiology can be infectious (viral, bacterial, parasitic) or non-infectious (medication effects, gastroenterological disease, acute abdominal processes)6</li></ul> </li></ul>

<h2>Management principles</h2><ul><li>Initially focus on preventing and treating dehydration. Diagnostic investigation should be reserved for severe illness or comorbidities6</li><li>Monitor condition with supportive medical advice</li><li>If symptoms persist or worsen, if there is blood in the stool or severe abdominal pain, fever or inability to increase fluid intake, seek medical advice.7 </li><li>Acute diarrhoea can be dangerous for infants and young children due to increased risk of severe dehydration8</li></ul>

Management

<h2>Primary recommendations</h2><h2>PROBIOTICS</h2>Mechanism of action11<ul><li>Bacteriocin and short chain fatty acid production</li><li>Lower gut pH</li><li>Competitive inhibition of adhesion of pathogens</li><li>Stimulation of mucosal barrier function and immunomodulation</li><li>Influences aspects of the acquired and innate immune response</li></ul>ResearchEvidence suggests that probiotics may be a useful adjunct to diarrhoea management and rehydration therapy in both adults and children:<ul><li>Acute diarrhoea (prevention): meta-analysis found probiotics were associated with a 35% reduction in risk (overall reduction: children 57%; adults 26%). Protective effect did not vary significantly among strains used: Saccharomyces boulardii, Lactobacillus rhamnosus GG, L. acidophilus, L. bulgaricus, other strains used alone or in combinations of two or more strains12</li><li>Antibiotic-associated diarrhoea (AAD) (prevention): meta-analysis found probiotics significantly reduce risk of ADD in adults and children with with a relative risk (RR) of 0.58.13 Many trials used blends of probiotic genera, primarily Lactobacillus, alone or in combination. In one study comparing LGG, S.boulardii, and L. acidophilus plus Bifi dobacterium lactis, none of the species or combinations showed substantial superiority over the others.</li><li> A 2015 Cochrane Review found a protective effect of probiotics on paediatric AAD with a RR 0.46. Among the probiotics evaluated, L. rhamnosus or S. boulardii at 5 to 40 billion CFUs/d may be appropriate.14 Randomised controlled trials have found L. reuteri significantly lowers incidence of diarrhoea in adults and children undergoing antibiotic therapy15,16</li><li> Traveller’s diarrhoea (prevention): meta-analysis found probiotics significantly prevent traveller’s diarrhoea (RR 0.85 for pooled data). S. boulardii and a mixture of L. acidophilus and B. bifidum had significant efficacy17</li><li> Infectious diarrhoea (treatment): meta-analysis found probiotics reduced mean duration of diarrhoea, risk for diarrhoea lasting &gt;4 days, and stool frequency on day 2. Most studies tested lactic acid bacteria and Bifidobacteria. The most common organisms evaluated were L. casei strain GG, S. boulardii and Enterococcus lactic acid bacteria (LAB) SF6818</li></ul>Dosage<ul><li>Typically found in tablet/capsule or powder form</li><li>Strength of probiotic preparations is quantified number of viable colony-forming units (CFUs): therapeutic effects between 109 (1 billion)–1011 (150 billion) CFUs19</li></ul>Adverse effects<ul><li>Orally, probiotic species are well tolerated with few confirmed adverse reactions in immunocompetent individuals19</li></ul>Key interactions<ul><li> Probiotics (L. acidophilus; L. reuteri, S. boulardii) may decrease diarrhoeal side effects of antibiotics (positive interaction)15,20</li></ul> For more information on key interactions visit: <a href="~/link.aspx?_id=4471DACF65C148EA8FD82B23FD6712D4&_z=z">https://www.blackmoresinstitute.org/interactions</a>

Primary

<h2>Secondary recommendations</h2><h2>ZINC</h2>Mechanism of action21<ul><li>Regulates T-cell functions and promotes production of antibodies and circulating lymphocytes against intestinal pathogens</li><li>Promotes immunity and mucosal resistance to infection</li><li> Restores mucosal barrier integrity and enterocyte brush-border enzyme activity</li></ul>ResearchWhile evidence for the use of zinc supplementation in adult diarrhoea is needed, there is good evidence for use in children although the majority of studies investigate use in developing countries:<ul><li>Meta-analyses have found zinc supplementation: <ul><li> Reduced the frequency and severity of diarrhoea, and the duration of diarrhoeal attacks in children between the ages of 3 months and 5 years22</li><li>Modestly reduced incidence of diarrhoea (9%) and more significantly reduced prevalence (19%), and occurrence of multiple episodes (28%)23</li></ul> </li><li>A randomised controlled trial found zinc 15 mg plus iron 60 mg and folic acid 250 μg/d taken from 10-24 weeks gestation until one month postpartum significantly reduced duration of diarrhoea in infants compared to placebo24</li></ul>Dosage and formulation<ul><li>Typically found in tablet form</li><li>Children ≤5 years - 10-20 mg/d (studies in children with a high prevalence of zinc deficiency)</li><li>Australian RDI: Children: 3–13 mg/d (upper limit 4–35 mg/d), Adults: 8–14 mg/d (upper limit 40 mg/d)26</li><li>Deficiency: 25–50 mg elemental zinc/d20</li></ul>Adverse effects<ul><li>High doses (50-150 mg/d) may cause gastrointestinal symptoms19</li></ul>Key interactions<ul><li>Hypoglycaemic drugs: zinc may increase drug effect20</li><li>Penacillamine: zinc may decrease drug effect unless doses are separated by 2 hours20</li><li>Tetracycline or quinolone antibiotics (not doxycycline): zinc may decrease absorption and blood levels of these drug unless doses are separated by 2 hours20</li><li>ACE inhibitors, angiotensin receptor blockers, thiazide diuretics: may cause increased urinary zinc excretion with long-term use20</li></ul> For more information on key interactions visit: <a href="~/link.aspx?_id=4471DACF65C148EA8FD82B23FD6712D4&_z=z">https://www.blackmoresinstitute.org/interactions</a>

Secondary

<h2>Diet and lifestyle recommendations </h2><ul><li>Hand washing is an effective way to prevent spread of infection7</li><li>Follow food safety precautions7</li><li>Keep hydrated with adequate fluids containing water, salt and sugar7</li><li> Consume boiled starches, cereals, vegetables, bananas and soups7</li><li> In children, lactose restriction may alleviate symptoms, particularly in more severe episodes9</li><li>Avoid diuretics such as caffeine that may worsen dehydration10</li></ul>

Diet & lifestyle

<h2>References</h2>1. Guerrant RL, Van Gilder T, Steiner TS, et al. Practice Guidelines for the Management of Infectious diarrhea. Clin Infect Dis 2001; 32(3):331-51. 2. Fischer Walker CL, Sack D, Black RE. Etiology of diarrhea in older children, adolescents and adults: a systematic review. PLoS Negl Trop Dis 2010; 4(8):e768. 3. Bartel B, Gau E. Nosocomial diarrhea: a review of pathophysiology, etiology, and treatment Strategies. Hosp Pract 2012; 40(1):130-8. 4. Hall GV, Kirk MD, Ashbolt R, et al. Frequency of infectious gastrointestinal illness in Australia, 2002: regional, seasonal and demographic variation. Epidemiol Infect 2006 Feb; 134(1):111-8. 5. Scallan E, Majowicz SE, Hall G, et al. Prevalence of diarrhoea in the community in Australia, Canada, Ireland, and the United States. Int J Epidemiol 2005; 34(2):454-60. 6. Barr W, Smith A. Acute diarrhea in adults. Am Fam Physician. 2014; 89(3):180-9. 7. Up-To-Date 2016. Patient information: Acute diarrhea in adults (Beyond the Basics). http://www.uptodate.com/contents/acute-diarrhea-in-adults-beyond-the-basics Accessed 29 May 2016. 8. State of Victoria. 2016 BetterHealth Channel - Diarrhoea 9. Gaffey MF, Wazny K, Bassani DG, et al. Dietary management of childhood diarrhea in low- and middle-income countries: a systematic review. Am J Public Health 2013; 13(Suppl 3):S17. 10. Natural Medicines 2016. Diarrhea Professional Monograph. 11. Kechagia M, Basoulis D, Konstantopoulou S, et al. Health benefits of probiotics: a review. ISRN Nutrition 2013; (2013):481651. 12. Sazawal S, Hiremath G, Dhingra U, et al. Efficacy of probiotics in prevention of acute diarrhoea: a meta-analysis of masked, randomised, placebo-controlled trials. Lancet Infect Dis 2006; 6:374-82. 13. Hempel S, Newberry SJ, Maher AR et al. Probiotics for the Prevention and Treatment of Antibiotic-Associated Diarrhea. A Systematic Review and Meta-analysis. JAMA 2012;307(18):1959-69 14. Goldenberg JZ, Lytvyn L, Steurich J, Parkin P, Mahant S, Johnston BC. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database of Systematic Reviews 2015, Issue 12. Art. No.: CD004827. DOI:10.1002/14651858.CD004827.pub4. 15. Lionetti E et al. Lactobacillus reuteri therapy to reduce side-effects during anti-Helicobacter pylori treatment in children: a randomised placebo controlled trial. Aliment Pharmacol Ther. 2006;24:1461-1468 16. Cimperman L, Bayless G, Best K, et al. A randomized, double-blind, placebo-controlled pilot study of Lactobacillus reuteri ATCC 55730 for the prevention of antibiotic-associated diarrhea in hospitalized adults. J Clin Gastroenterol. 2011 Oct;45(9):785-9. 17. McFarland LV. Meta-analysis of probiotics for the prevention of traveller’s diarrhea. Travel Med Infect Dis 2007; 5(2):97-105. 18. Allen SJ, Martinez EG, Gregorio GV, et al. Probiotics for treating acute infectious diarrhoea. Cochrane Database Syst Rev 2010; (11):CD003048. 19. Braun L, Cohen M. Herbs &amp; Natural Supplements. 4th ed. Chatswood: Elsevier; 2015. 20. Blackmores Institute Complementary Medicines Interaction Guide; 2016. 21. Lazzerini M, Ronfani L. Oral zinc for treating diarrhoea in children. Cochrane Database Syst Rev 2013; (6):CD005436. 22. Aggarwal R, Sentz J, Miller MA. Role of zinc administration in prevention of childhood diarrhea and respiratory illnesses: a meta-analysis. Pediatrics 2007; 119(6):1120-30. 23. Patel AB, Mamtani M, Badhoniya N, et al. What zinc supplementation does and does not achieve in diarrhea prevention: a systematic review and meta-analysis. BMC Infect Dis 2011; 11:122.24. Iannotti LL, Zavaleta N, Leon Z, et al. Maternal zinc supplementation reduces diarrheal morbidity in peruvian infants. J Pediatr 2010; 156(6):960-4. 25. National Health and Medical Research Council (NHMRC). Nutrient Reference Values. http://www.nrv.gov.au Accessed 18 May 2016

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