Use Of Antimotility Agents Research Articles

Factors affecting dialysis duration in children with Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome.

Predicting disease severity can be informative for management of HUS. Dialysis requirement, volume depletion, elevated white blood cell counts, very young age, and use of antimotility agents are known factors associated with severe HUS. A retrospective cohort analysis was performed to identify factors associated with dialysis duration using electronic medical record and chart review of 76 children ≤ 18years of age at presentation with STEC-HUS identified through billing data from July 2008 to April 2020 at James Whitcomb Riley Hospital for Children, Indiana University, Indiana. Novel findings associated with prolongeddialysis duration were age ≥ 6years old at presentation (p = 0.041) and lack of drop in platelets below 60,000/mm3 anytime during the illness (p = 0.015). In addition, children with NSAID exposure trended longer on dialysis: 15days with vs. 10days without (p = 0.117). Known risk factors for severe disease including elevated peak white blood cell (WBC) count and higher hematocrit at presentation were also associated with longer dialysis duration: children with peak WBC > 20,000/mm3 were on dialysis for 15 vs. 9.5days (p = 0.002) and in children on dialysis ≥ 14days hematocrit at presentation was 29.6% vs. 24.2% (p = 0.03). Children requiring dialysis for 20days or longer were more likely to be on anti-hypertensive medications (p = 0.025) and have chronic kidney disease at 12-month follow up (p = 0.044). Age ≥ 6, elevated WBC count > 20,000/mm3, higher hematocrit at presentation, lack of drop in platelets to < 60,000/mm3, and possibly NSAID exposure during illness are associated with longer dialysis duration in STEC-HUS. A higher resolution version of the Graphical abstract is available as Supplementary information.

Pediatric sigmoid colonic perforation with Campylobacter enterocolitis: a case report and review of the literature

BackgroundCampylobacter-related infectious gastroenteritis is common and usually self-limited. Intestinal perforation is a rare complication of the infectious colitis caused by Campylobacter, and only handful of cases have been reported. This is the first published case report of pediatric Campylobacter intestinal perforation located in the sigmoid colon.Case presentationA 15-year-old previously Taiwanese healthy boy presented with 5 days of fever up to 39.8 °C, with right lower quadrant abdominal pain and watery diarrhea. Although he received antimotility agents and antipyretics at a local clinic to relieve symptoms, he came to the emergency department with signs of shock manifesting as hypothermia to 35.2 °C, tachycardia, and low blood pressure. Laboratory testing demonstrated leukocytosis with left shift and significant elevation of C-reactive protein. Stool and blood cultures were obtained, and he was admitted for fluid challenge and antibiotic treatment. On the second day of admission, he suffered from sudden onset of severe, diffuse abdominal pain. Physical examination revealed muscle guarding, rebounding tenderness, and silent bowel sound. Abdominal X-ray showed subdiaphragmatic free air at standing view. The patient underwent emergent exploratory laparotomy, which revealed sigmoid colon perforation about 0.5 cm. Enterolysis and repair of sigmoid colon were performed. Intraoperative stool specimen nucleic acid amplification testing had turned positive for Campylobacter spp. with negative results for other bacterial pathogens. His symptoms improved and he tolerated food well, and was discharged 15 days after admission.ConclusionsWe present this case because of the rarity of Campylobacter-induced sigmoid colon perforation in the pediatric population. It is important to keep in mind that sigmoid colon perforation can be due to an infectious cause, and one of the culprits can be Campylobacter. Infectious colitis caused by Campylobacter spp. should be managed cautiously and the use of antimotility agents in such conditions should be considered judiciously.

Beyond 10years, with or without an intestinal graft: Present and future?

Long-term outcomes in children undergoing intestinal transplantation remain unclear. Seventy-one children underwent intestinal transplantation in our center from 1989 to 2007. We report on 10-year posttransplant outcomes with (group 1, n=26) and without (group 2, n=9) a functional graft. Ten-year patient and graft survival rates were 53% and 36%, respectively. Most patients were studying or working, one third having psychiatric disorders. All patients in group 1 were weaned off parenteral nutrition with mostly normal physical growth and subnormal energy absorption. Graft histology from 15 late biopsies showed minimal abnormality. However, micronutrient deficiencies and fat malabsorption were frequent; biliary complications occurred in 4 patients among the 17 who underwent liver transplantation; median renal clearance was 87mL/min/1.73m2 . Four patients in group 1 experienced late acute rejection. Among the 9 patients in group 2, 4 died after 10years and 2 developed significant liver fibrosis. Liver transplantation and the use of a 3-drug regimen including sirolimus or mycophenolate mofetil were associated with improved graft survival. Therefore, intestinal transplantation may enable a satisfactory digestive function in the long term. The prognosis of graft removal without retransplantation is better than expected. Regular monitoring of micronutrients, early psychological assessment, and use of sirolimus are recommended.

168 Fecal Microbiota Transplant in Graft-versus-Host Disease of the Intestines: A Comprehensive Pooled Analysis

INTRODUCTION: Graft versus host disease (GVHD) of the intestines is a feared complication after hematopoietic stem cell transplantation (HSCT), and carries high morbidity and mortality. Recently fecal microbiota transplant (FMT) has been explored as a treatment modality for intestinal GVHD. The aim of our study was to pool data from individual feasibility studies to explore the efficacy and safety of FMT for gut GVHD. METHODS: A systematic search was performed for studies in PubMed, Embase, Cochrane database and ClinicalTrials.gov. All studies that reported data on FMT in patients who had previously undergone HSCT were included. Two independent authors conducted the systematic search. Pooled analysis was conducted for safety and efficacy of FMT in HSCT patients. RESULTS: A total of 15 studies comprising a total of 99 patients reported FMT outcomes after HSCT. Indication of FMT was restoration of microbiome in 41, Clostridium difficile infection in 21, and intestinal GVHD in 37 patients. All studies were single center pilot trials. Five studies with 37 patients reported efficacy outcomes for intestinal GVHD. A total of 57 FMTs were performed. All patients had previously failed at least one immunosuppressant regimen. All patients were either steroid resistant or steroid dependent. Overall complete response rate of 62.1% was observed (23 patients). Three additional patients partially responded to FMT. Positive response was accompanied by a decrease in stool volumes and frequency in all patients; reduction in use of anti-motility agents, and cessation of total parenteral nutrition was observed in all responders. All studies reported successful tapering of immunosuppressant and steroid dosage. FMT was generally well tolerated. No treatment-related mortality was reported. Minor adverse events included abdominal pain, nausea, mucosal tears, and minor aspiration without sequelae. Serious adverse events included bleeding in one patient, and grade 3 abdominal pain in one patient (resolved within 24 hours of capsule ingestion). Infections were reported in three patients after FMT (two with bacteremia), but could not be attributed to FMT with certainty. CONCLUSION: FMT is a promising modality for management of intestinal GVHD and carries low morbidity. It appears to be safe and acceptable as a salvage therapy for intestinal GVHD based on the current limited data. The need to withhold antibiotics to allow persistent engraftment may prove challenging in this severely immunocompromised population.

Pre-Transplant Hemoglobin and Creatinine Clearance Correlate with Progression Free Survival in Patients with Myeloma Undergoing Autologous Stem Cell Transplantation

Introduction Melphalan 200 mg/m2 (Mel200) and autologous stem cell transplant (ASCT) prolongs progression free survival (PFS) in multiple myeloma (MM). Pharmacokinetic (PK) studies report a 5-fold interpatient variability in melphalan exposure with increased exposure leading to increased toxicity yet superior survival. Clinical factors including renal impairment, low hematocrit and low fat free mass (FFM) are associated with decreased melphalan clearance. However, these variables have not been directly correlated with clinical outcomes. Objective We hypothesized that these clinical variables associated with increased melphalan exposure may predict for improved survival yet increased treatment toxicity. Methods We analyzed 133 MM patients who received Mel200. The average hemoglobin (Hb) from Day -2 and -1, creatinine clearance (CrCl) on day -2 and FFM on day -2 were obtained. PFS and toxicities were compared between patients with Hb and FFM above and below the median (10.65 g/dL and 52.9 kg respectively) and those with and without renal impairment (CrCl Results FFM did not predict PFS. By contrast, PFS was significantly longer in patients with a Hb below the median (35 vs. 16 months, p=0.02). Additionally, a low CrCl suggested a trend towards better PFS (31 vs. 23 months, p=0.25). When these 2 factors were combined, patients with both a low Hb and CrCl experienced longer PFS compared to those with a high Hb and CrCl (35 vs. 13 months, p=0.03, Figure 1). In a multivariate analysis, low Hb (HR 0.52, p=0.034), low CrCl (HR 0.37, p=0.023), and a combined low Hb and CrCl (HR 0.15, p=0.003) were strongly associated with improved PFS. We then evaluated whether renal function and Hb level impacted the severity and incidence of common toxicities related to ASCT. Patients with a low Hb experienced more infections (33.3 vs. 14.1%; p=0.01) and total parenteral nutrition (TPN) use (17.2 vs. 4.9% p=0.045. Patients with a low CrCl experienced longer time to platelet engraftment (12 vs. 11 days; p=0.0035), longer duration of hospitalization (17 vs. 15 days; p=0.01), increased TPN use (22.5 vs. 6.7%; p=0.02), increased use of anti-motility agents (84.6 vs. 63.8%; p=0.02), and longer duration of diarrhea (7 vs. 4 days; p Conclusion Consistent with PK studies showing increased melphalan exposure, we show that hemoglobin and creatinine clearance, individually and when combined, represent important determinants of clinical outcomes after ASCT. Because melphalan binds to proteins in the red blood cell membrane, higher plasma concentrations are observed in patients with low hemoglobin. Likewise, renal impairment leads to delayed melphalan clearance and higher concentrations. Consideration of these clinical factors that affect melphalan exposure and implementation of PK-directed dosing may be beneficial in achieving optimal outcomes.

Pre-Transplant Hemoglobin and Creatinine Clearance Correlate with Treatment Free Survival in Patients with Myeloma Receiving Mel200 and Autologous Stem Cell Transplantation

Although melphalan 200mg/m2 (Mel200) and autologous stem cell transplantation (ASCT) significantly prolong progression-free survival for multiple myeloma (MM) patients, clinical outcomes and toxicities vary greatly. Pharmacokinetic studies report a 5-fold interpatient variability in melphalan exposure with increased exposure being associated with higher rates of toxicity yet superior survival. Renal impairment, low hematocrit and low fat free mass (FFM) have been shown to decrease melphalan clearance and increase exposure. Specifically, melphalan binds to proteins in the red blood cell membrane, leading to higher plasma concentrations in anemic patients. Likewise, since renal elimination contributes significantly to melphalan clearance (approximately 40%), the presence of renal impairment also leads to higher concentrations. Given this, we hypothesized that clinical variables associated with increased melphalan exposure would predict not only for improved post-ASCT survival but also increased treatment toxicity.To test this hypothesis, we analyzed 133 MM patients who received Mel200 and ASCT. In addition to standard clinical parameters, the following laboratory values were obtained: average hemoglobin (Hgb) from Day -2 and -1, creatinine clearance (CrCl) on Day -2, and FFM. Hemoglobin and FFM were grouped as low or high relative to their sample medians, and CrCl was divided into two groups (≥ 60 or < 60 ml/min). The median age was 59 (34-77) years and most patients were male (n=72, 54%), IgG subtype (n=68, 55%), and ISS stage 3 (n=58, 59%). Fifty percent (n=66) of patients received more than 1 prior treatment, the majority of which were IMiD- (n=78, 59%) or PI-(n=69, 52%) based. The median time to transplant was 8 months (3-144), and 55 (41%) patients received post-transplant maintenance. Pre-transplant response was VGPR (n=23, 18%) or PR (n=53, 41%) in most patients.For the entire cohort, the median hemoglobin, FFM, and CrCl were 10.65 g/dL, 52.9 kg, and 73 ml/min, respectively. No difference in treatment free survival (TFS) was observed between a low and high FFM (21 vs. 27 months, p=0.36). However, the median TFS was significantly longer in patients with a lower hemoglobin (<10.65 g/dL) compared to those with a higher hemoglobin (≥ 10.65 g/dL) (35 vs. 16 months, p=0.02). Additionally, a lower CrCl (<60 ml/min) suggested a trend towards better TFS (31 vs. 23 months, p=0.25). Patients with both a lower hemoglobin and CrCl experienced longer TFS compared to those with a higher hemoglobin and CrCl (35 vs. 13 months, p=0.03; Figure 1). Multivariate Cox proportional hazards models with adjustment for prognostic and clinical factors were used to estimate hazard ratios (HR) and 95% confidence intervals for TFS and overall survival (OS). Lower hemoglobin (HR 0.52, p=0.034), lower CrCl (HR 0.37, p=0.023), and a combined low hemoglobin and CrCl (HR 0.15, p=0.003) were strongly associated with improved TFS. Low hemoglobin was associated with improved OS (HR 0.41; p=0.032) and low hemoglobin and CrCl together were suggestive of improved OS (HR 0.27; p=0.08). We next evaluated rates of toxicity with lower hemoglobin and low CrCl. Patients with a lower hemoglobin experienced more infections (33.3 vs. 14.1%; p=0.01), febrile neutropenia (65.6 vs. 48.4%; p=0.07), antibiotic use (73.4 vs. 58.7%, p=0.09), total parenteral nutrition (TPN) use (17.2 vs. 4.9% p=0.045), and longer duration of diarrhea (6 vs. 4.5 days p=0.07). Patients with a low CrCl experienced longer time to platelet engraftment (12 vs. 11 days; p=0.0035), longer duration of hospitalization (17 vs. 15 days; p=0.01), increased TPN use (22.5 vs. 6.7%; p=0.02), increased use of anti-motility agents (84.6 vs. 63.8%; p=0.02), and longer duration of diarrhea (7 vs. 4 days; p<0.0001).We show for the first time that hemoglobin and creatinine clearance represent important determinants of clinical outcomes after Mel200 and ASCT. A lower hemoglobin and creatinine clearance, individually and when combined, were associated with longer TFS yet increased short term toxicity. This is consistent with PK studies showing increased melphalan exposure in patients with low hematocrit or renal impairment. In the future, consideration of clinical factors that affect melphalan exposure and implementation of PK-directed dosing may be beneficial in achieving optimal outcomes. DisclosuresPatel:Celgene: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Janssen: Honoraria.

Melphalan 200 Mg/m2 in Patients with Renal Impairment Is Associated with Increased Short Term Toxicity but Improved Response and Longer Treatment-Free Survival

Renal impairment (RI) is a common complication of multiple myeloma (MM) and is reported in up to 40 percent of patients. There is limited data on the outcomes of melphalan 200 mg/m2 (MEL200) and autologous stem cell transplantation (ASCT) in patients with serum creatinine > 2 g/dL since they have been excluded from most studies. Therefore we retrospectively evaluated the impact of RI on outcome of patients with MM treated with MEL200 and ASCT at our institution.One hundred and forty nine consecutive patients who received MEL200 and ASCT between 2000 and 2011 were included in the analysis. Forty-six patients had a CrCl< 60 ml/min and 103 had a CrCl ≥ 60 ml/min. Baseline characteristics were similar between the two groups including measures of disease risk and treatment history. Median creatinine clearance was 50 ml/min (20-59) in the RI cohort and 83 ml/min (60-128) in the normal renal function cohort. Patients with a CrCl < 60 ml/min experienced a longer median time to neutrophil (10 vs. 9 days, p=0.008) and platelet (12 vs. 10 days p<0.001) engraftment despite a similarmean dose of infused CD34+ cells between the two groups. The median duration of hospitalization was significantly longer in patients with RI (16 (11-47) versus 14 (12-36) days, p=0.02). More patients in the CrCl < 60 ml/min group experienced diarrhea, required the use of anti-motility agents, required total parenteral nutrition administration, and developed infection, as compared to the CrCl >60 ml/min group. Response was measured using the International Myeloma Working Group criteria and was assessed immediately prior to transplant and again between 90 to 180 days after transplant. Although there was an increase in the number of patients achieving CR in both groups, this was found to be significant only in the CrCl<60 group (p=0.02). In addition, the overall response rate increased in the CrCl<60ml/min group. No difference in overall survival was seen between the two groups. Median treatment free survival was 37 months in the RI group and 17 months in normal renal function group (p=0.0025). A multivariate cox regression analysis revealed that creatinine clearance <60 ml/min (HR 3.5, p=0.0004) and prior proteasome inhibitor therapy (HR 2.441, p=0.025) were factors that predicted longer treatment free survival. Number of prior therapies (HR 0.7, p=0.03) predicted for a shorter treatment free survival.This represents one of the largest analyses of outcomes of MEL200 in MM patients with RI. We report that although short-term toxicity is increased in the RI group, long-term outcomes may be superior to those patients without renal impairment. We propose that this may be due to greater melphalan exposure in patients with RI. Based on these findings, we would consider MEL200 safe and effective in select patients with creatinine clearance between 30 and 60 ml/min. DisclosuresNo relevant conflicts of interest to declare.

Metabolic support of the enterocutaneous fistula patient.

Enterocutaneous fistula (ECF) is a challenging clinical problem with many etiologies; however, the most common cause is iatrogenic, complicating abdominal surgery. Advances in the overall care of the ECF patient have resulted in dramatic reductions in morbidity and mortality over the last five decades. A structured approach to the management of ECF has been shown to result in improved outcomes. Initial physiologic stabilization of the postoperative patient, focused on hemodynamic and fluid support as well as aggressive sepsis control are the critical initial maneuvers. Subsequent optimization of nutrition and wound care allows the patient to regain a positive nitrogen balance, and allow for healing. Judicious use of antimotility agents as well as advanced wound care techniques helps to maximize healing as well as quality of life, and prepare patients for subsequent definitive surgery.

Prescribing for acute diarrhoea

This article provides an overview of the main drugs used in the treatment of acute diarrhoea. There is reference to some of the prescribing issues associated with oral rehydration therapy and the use of antimotility agents. Other prescribing issues associated with acute diarrhoea are also discussed. The reader has the opportunity to self-check his/her own knowledge with a pre-reading self-assessment.

Antimotility agents for chronic diarrhoea in people with HIV/AIDS

AIDS-related diarrhoea is a common cause of morbidity and mortality in HIV positive individuals, especially in the sub-Saharan Africa where 70% of deaths from HIV occur. It often compromises quality of life both in those receiving antiretroviral therapy (ART) and the ART naive. Empirical antidiarrhoeal treatment may be required in about 50% of cases which are non-pathogenic or idiopathic and in cases resulting from antiretroviral therapy. Antimotility agents (Loperamide, Diphenoxylate, Codeine) and adsorbents (Bismuth Subsalicylate, Kaolin/Pectin, Attapulgite) are readily available, and have been found to be useful in this condition and so, are often used. Antimotilitics are opioids, decreasing stool output by reducing bowel activity thereby increasing fecal transit time in the gut, promoting fluid and electrolyte retention while adsorbents act by binding to fluids, toxins and other substances to improve stool consistency and eliminate the toxins. Due to its potential impact on the management of chronic diarrhoea in persons with HIV/AIDS, we reviewed the effectiveness of antimotility agents in controlling chronic diarrhoea in immunocompromised states caused by HIV/AIDS. To assess the effectiveness of antimotility agents in controlling chronic diarrhoea in people with HIV/AIDS. We searched Medline, EMBASE, the Cochrane Controlled Trials Register, the Cochrane HIV/AIDS Register and AIDSearch databases in November 2006. We also contacted WHO, CDC, pharmaceutical companies and experts in the field for information on previous or on-going trials and checked reference list from retrieved studies, irrespective of language and publication status. Randomised controlled trials comparing an antimotility agent or an adsorbent with another antimotility agent, placebo, an adsorbent or no treatment in children and adults diagnosed with HIV and presenting with diarrhoea of three or more weeks duration. Two authors independently undertook study selection and examined full articles of potentially eligible studies. One trial was found assessing the use of an adsorbent (attapulgite) compared to a placebo for chronic diarrhoea in people with HIV/AIDS. It included 91 adults (Aged 18 to 60), diagnosed with AIDS and experiencing diarrhoea for at least 7 days. There was no evidence that attapulgite is superior to placebo in controlling diarrhoea by reducing stool frequency and normalising stool consistency on days 1 (0.34 (95% CI 0.01 - 8.15)), 3 (1.35 (95% CI 0.51 - 3.62)) and 5 (1.74 (95% CI 0.89 - 3.38)). This was a small trial and may not have had enough power to show evidence of effects. Five deaths were reported which was not classified according to the arms of the study.Studies assessing the use of antimotility agents were not found. This review highlights the absence of evidence for the use of antimotility agents and adsorbents in controlling diarrhoea in people with HIV/AIDS. While no trials assessing the use of Antimotilitics were found, the retrieved study showed that attapulgite was not better than placebo in controlling diarrhoea in HIV/AIDS patients . For optimum patient care, these agents can still be used, with greater emphasis placed on adjunct therapies like massive fluid replacement while evidence for practice is awaited from further studies and reviews.

The Management of Acute Diarrhoea in a Healthy Adult Population Deploying on Military Operations

Acute diarrhoea is consistently the number one presentation to secondary care facilities on UK military operational deployments. It can result in potentially life threatening consequences as seen on Operation Herrick...

Hemolytic Uremic Syndrome

Hemolytic uremic syndrome (HUS) is a thrombotic microangiopathy defined by thrombocytopenia, nonimmune microangiopathic hemolytic anemia, and acute renal failure. The most frequent form is associated with infections by Shiga-like toxin-producing bacteria (STEC-HUS). Rarer cases are triggered by neuraminidase-producing Streptococcus pneumoniae (pneumococcal-HUS). The designation of aHUS is used to refer to those cases in which an infection by Shiga-like toxin-producing bacteria or S. pneumoniae can be excluded. Studies performed in the last two decades have documented that hyperactivation of the complement system is the pathogenetic effector mechanism leading to the endothelial damage and the microvascular thrombosis in aHUS. Recent data suggested the involvement of the complement system in the pathogenesis of STEC-HUS and pneumococcal-HUS as well. Clinical signs and symptoms may overlap among the different forms of HUS; however, pneumococcal-HUS and aHUS have a worse prognosis compared with STEC-HUS. Early diagnosis and identification of underlying pathogenetic mechanism allows instating specific support measures and therapies. In clinical trials in patients with aHUS, complement inhibition by eculizumab administration leads to a rapid and sustained normalization of hematological parameters with improvement in long-term renal function. This review summarizes current concepts about the epidemiological findings, the pathological and clinical aspects of STEC-HUS, pneumococcal-HUS, and aHUS, and their diagnosis and management.

Predictors of hemolytic uremic syndrome in children during a large outbreak of Escherichia coli O157:H7 infections.

To evaluate risk factors for progression of Escherichia coli O157:H7 infection to the hemolytic uremic syndrome (HUS). We conducted a retrospective cohort study among 278 Washington State children <16 years old who developed symptomatic culture-confirmed E coli O157:H7 infection during a large 1993 outbreak. The purpose of the study was to determine the relative risk (RR) of developing HUS according to demographic characteristics, symptoms, laboratory test results, and medication use in the first 3 days of illness. Thirty-seven (14%) children developed HUS. In univariate analysis, no associations were observed between HUS risk and any demographic characteristic, the presence of bloody diarrhea or of fever, or medication use. In multivariate analysis, HUS risk was associated with, in the first 3 days of illness, use of antimotility agents (odds ratio [OR] = 2.9; 95% confidence interval [CI] 1.2-7.5) and, among children <5.5 years old, vomiting (OR = 4. 2; 95% CI 1.4-12.7). Among the 128 children tested, those whose white blood cell (WBC) count was >/=13 000/microL in the first 3 days of illness had a 7-fold increased risk of developing HUS (RR 7. 2; 95% CI 2.8-18.5). Thirteen (38%) of the 34 patients with a WBC count >/=13 000/microL developed HUS, but only 5 (5%) of the 94 children whose initial WBC count was <13 000/microL progressed to HUS. Among children who did not develop HUS, use of antimotility agents in the first 3 days of illness was associated with longer duration of bloody diarrhea. Prospective studies are needed to further evaluate measures to prevent the progression of E coli O157:H7 infection to HUS and to assess further clinical and laboratory risk factors. These data argue against the use of antimotility agents in acute childhood diarrhea. Our finding that no intervention decreased HUS risk underscores the importance of preventing E coli O157:H7 infections.

Acute infectious diarrhea

Diarrhea continues to be a major cause of mortality and morbidity in third world countries as well as a major symptomatic complaint in the primary care setting in the United States. The etiologic pathogen depends on an exposure history to include recent travel to foreign countries, consuming fecally contaminated water or food, prior use of antibiotics, or homosexual behavior. A careful history from patients directed at attempting to identify particular risk factors may help in making a diagnosis. Not all patients require a diagnostic workup. A large number of patients may only require oral rehydration, careful observation over time with or without use of antimotility agents. In toxic appearing patients or patients with fever, however, bloody stools, abdominal pain or tenesmus, a selective diagnostic workup is indicated. Antimicrobial treatments are not always required, some pathogens clearly call for treatment while some have less clear indications and other pathogens are not responsive to antimicrobial agents at all. Finally, one needs to remember that the differential diagnosis of acute diarrhea includes many noninfectious origins.

Pharmacists' Self-Medication for Travelers' Diarrhea

Visitors to developing areas of the world are at high risk for contracting travelers' diarrhea (TD). Despite proven effectiveness in the prevention of TD, prophylactic use of anti-diarrheal agents is controversial. Most authorities recommend against the routine use of drugs for the prevention of TD. This article presents data from surveys of pharmacists and their spouses participating in vacation-study tours to countries associated with a high risk of TD. Patterns of antidiarrheal drug use are compared with the recommended practices regarding both prophylactic and symptomatic therapy. Generally, the subjects in this study adhered closely to recommended practices. Nevertheless, although a majority employed dietary restrictions for TD prevention, 22.8 percent took antidiarrheal drugs prophylactically. Nearly half took antidiarrheal agents for symptomatic use. The ingredients most frequently mentioned matched current recommendations. Inappropriate practices included the use of prophylactic agents without dietary restrictions, and the use of antimotility agents prophylactically. Patterns of dietary and antidiarrheal drug use are compared, including intended versus actual, prophylactic versus symptomatic, and prescription versus nonprescription product use. The controversy regarding the use of prophylactic drug therapy for TD is discussed.