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    Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults (beta)

    Official guideline from the American College of Gastroenterology.

    Summary by Shawn Shah, MD & Carl Crawford, MD
    Strong recommendation
    Moderate recommendation
    Conditional recommendation
    Weak recommendation
    High quality evidence
    Moderate-high quality evidence
    Moderate quality evidence
    Low quality evidence
    Very low quality evidence


    Stool testing
    1. Stool should be tested (using stool culture and culture-independent methods if available) if high risk of spread and during known or suspected outbreaks.
    2. May use stool diagnostic studies as available if dysentery, moderate-severe disease, and symptoms >7 days to diagnose and guide therapy.
    3. Traditional stool testing has limitations → FDA-approved culture-independent methods can be recommended at least as adjunct to traditional methods.
    4. Antibiotic sensitivity testing for acute diarrhea not recommended.


    1. Balanced electrolyte rehydration over other oral rehydration is recommended in elderly with severe diarrhea, or any traveler with cholera-like watery diarrhea; most can keep up with fluids + salt with water, juices, sports drinks, soups, and saltines.
    1. Probiotics and prebiotics not recommended except if in post-antibiotic associated diarrhea.
    2. Bismuth subsalicylate can be used to decrease frequency of BMs in travelers with mild-moderate symptoms.
    3. Loperamide should be used with antibiotics for traveler's diarrhea to decrease duration and increase chance for cure.
    4. Evidence does not support empiric antimicrobials for routine acute infection, except in TD if risk of bacterial infection outweights side effects of antibiotics.
    5. Community-acquired acute diarrheal infections are typically viral (e.g., norovirus, rotavirus, or adenovirus) → antibiotics are discouraged (does not shorten duration).

    Persisting Symptoms

    1. Serologic and clinical lab testing for persistent symptoms (between 14-30 days) not recommended.
    2. Endoscopy for persistent symptoms (between 14-30 days) and negative stool evaluation not recommended.


    1. Patient level counseling on prevention not routinely recommended, but may consider if patient or close contacts are at high risk for complications.
    2. Pre-travel, counsel patients on high-risk foods/beverages to avoid to prevent traveler's diarrhea.
    3. Hand sanitation is of limited value in preventing TD but may be useful where low infective dose pathogens are endemic or cause outbreaks (e.g. cruise ships or institutions).
    1. Bismuth subsalicylate is moderately effective for TD prophylaxis; may be considered if no contraindications and can adhere to frequent dosing.
    2. Probiotics, prebiotics, and synbiotics not recommended for TD prevention.
    3. May consider short-term antibiotic chemoprophylaxis in high-risk groups (moderate to good effectiveness).
    What do the icons mean?  
    Research PaperRiddle MS, Dupont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol. 2016;111(5):602-22.