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Frequent, loose, and watery bowel movements. Common causes include gastrointestinal infections, irritable bowel syndrome, medicines, and malabsorption.

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Are probiotics effective against diarrhea?

Probiotics – including certain lactic acid bacteria in particular – can shorten episodes of diarrhea by about one day. Overall, probiotic products are well tolerated.

Informed Health Online [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: February 5, 2014

Probiotics for persistent diarrhoea in children

Persistent diarrhoea is defined as a diarrhoeal episode that starts acutely but then lasts for 14 days or more, and it is an important cause of morbidity and mortality in children under five years old in developing countries throughout the world. The cause of persistent diarrhoea is not completely understood but is likely to be complex; this in turn makes management of the condition difficult. Probiotics are bacteria and yeasts that are similar to the normal bacteria found in a healthy gut. These so called friendly bacteria have been used in several studies to treat acute infectious diarrhoea with encouraging results. This review found four trials involving children with persistent diarrhoea. Two studies with a combined total of 324, showed that probiotics shorten the duration of diarrhoea and reduce the stool frequency on day‐5. One study (235 children) suggested that probiotics reduce the hospital stay. Three out of four trials reported that no adverse events occurred. However, this review is limited by few trials with small number of participants, and therefore may not represent a reliable estimate of probiotics' effect.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children

Children with diarrhoea lose body water and sometimes become dehydrated. A solution of sugar and salt dissolved in water is widely used to treat dehydration caused by diarrhoea. This reviews shows that a solution of lower osmolarity than the current international standard means fewer children subsequently require an intravenous drip.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

Antibiotic treatment reduces duration and severity of travellers' diarrhoea.

Using a pilot system we have categorised this review as: Current question ‐ update pending. (See "Published notes" section for an explanation).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Rotavirus vaccines can prevent diarrhoea caused by rotavirus, but we are still not clear about safety and whether they prevent deaths

Rotavirus diarrhoea causes illness and death in young children. The benefits of the vaccine were different depending on the type of vaccine. The reviewers are unable to make conclusive recommendations regarding the use of rotavirus vaccines.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Oral immunoglobulin for the treatment of rotavirus diarrhea in low birth weight infants

Rotavirus infection can cause significant problems including diarrhea in the newborn. This is particularly true in babies weighing less than 2500 g (low birth weight infants). Rotavirus infection is becoming more common in newborn babies and can spread from one baby to another in the neonatal unit. Administration of antibodies against rotavirus to babies may be one of the methods to treat this infection and to prevent the spread of infection in the neonatal unit. In this review, we did not identify any trial that used antibodies to treat rotavirus infection. More research is needed to address these issues.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2011

Interventions to improve water quality, particularly when implemented at the household level, are effective in preventing diarrhoea in settings where it is endemic

Diarrhoea is a major cause of death and disease, especially among young children in low‐income countries. Loss of fluid (dehydration) is the major threat, though diarrhoea also reduces the absorption of the nutrients, causing poor growth in children, reduced resistance to infection, and potentially long‐term gut disorders. This review examined trials of interventions to improve the microbiological quality of drinking water. These include conventional improvements at the water source (eg protected wells, bore holes, and stand posts) and point‐of‐use interventions at the household level (eg chlorination, filtration, solar disinfection, and combined flocculation and disinfection). The review covered 38 independent comparisons from 30 trials that involved more than 53,000 people. In general, such interventions were effective in reducing episodes of diarrhoea. Household interventions were more effective in preventing diarrhoea than those at the source. However, differences in the interventions and the settings in which they were introduced, as well as the methods and measurements of effect, limit the extent to which generalizations can be made. Further research, including blinded trials and longer‐term assessments, is necessary to understand the full impact of these interventions.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

Reintroducing a normal diet following acute diarrhoea

Many children in developing countries die from acute diarrhoea. Although it is usually caused by infectious viruses or bacteria, the exact organism is rarely known, as it is impractical to test for the organism. Treating the diarrhoea is thus standard therapy, with the recommended policy of using oral rehydration therapy and dietary supplements. Because the gut can be damaged by the infection, many doctors recommend a period of fasting followed by gradual reintroduction of food, although the evidence for when exactly a “normal” diet should be reintroduced is lacking. The authors here looked at children who received ‘early’ refeeding (within 12 hours of the start of rehydration) or ‘late’ refeeding (after 12 hours from the start of rehydration). The authors identified 12 trials that met their inclusion criteria, with a total of 1283 children under 5 years; of these, 1226 were used in the analysis (724 given early refeeding; 502 given late refeeding). There was no significant difference between the two refeeding groups in the number of participants who needed unscheduled intravenous fluids (813 participants, 6 trials), who experienced episodes of vomiting (466 participants, 5 trials), and who developed persistent diarrhoea i.e. greater than 14 days in duration (522 participants, 4 trials). The mean length of hospital stay was also similar (246 participants, 2 trials).There is therefore no evidence to suggest that early refeeding increases the risk of complications after acute diarrhoea such as the need for IV fluids, or increases the risk of developing persistent diarrhoea. Further studies are needed to fully examine other parameters such as duration of diarrhoea, and effect on weight gain.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2011

Interventions to improve disposal of human excreta for preventing diarrhoea

Diarrhoea is a major cause of death and disease, especially among young children in low‐income countries. Many of the microbial agents associated with diarrhoea are transmitted via the faecal‐oral route and are associated with exposure to human faeces. This review examined trials of interventions to improve the safe disposal of human faeces to prevent diarrhoea. In low‐income settings, among the estimated 2.6 billion people who lack basic sanitation, this mainly consists of introducing or expanding the number and use of latrines and other facilities to contain or dispose of faeces. We identified 13 studies of such interventions involving more than 33,400 people in six countries. These trials provide some evidence that excreta disposal interventions are effective in preventing diarrhoeal diseases. However, major differences among the studies, including the conditions in which they were conducted and the types of interventions deployed, as well as methodological deficiencies in the studies themselves, makes it impossible to estimate with precision the protective effective of sanitation against diarrhoea. Further research, including randomized controlled trials, is necessary to understand the full impact of these interventions.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Use of antimotility drugs (Loperamide, Diphenoxylate, Codeine) to control prolonged diarrhoea in people with HIV/AIDS.

People with HIV/AIDS often develop prolonged diarrhoea which are sometimes not caused by infections. This is more so in the sub‐Saharan Africa where drugs for controlling HIV itself i.e. antiretroviral drugs (ARV) may not be widely available or affordable. prolonged diarrhoea often results in prolonged illness and death due to loss of fluids, if not treated effectively and on time. Antimotility drugs and adsorbents are readily available and are used to try to control this condition while efforts are made to receive ARVs. We did not find enough evidence to support or refute their use in controlling this condition.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2008

Diarrhea: Overview

Diarrhea is often the result of a viral, bacterial or other type of infection. In Germany and other countries, diarrhea is most commonly caused by rotaviruses. For mild diarrhea, it is often enough to simply drink plenty of fluids so you do not dehydrate, and wait for it to run its course.

Informed Health Online [Internet] - Institute for Quality and Efficiency in Health Care (IQWiG).

Version: February 5, 2014

Probiotics for treating acute infectious diarrhoea

Episodes of acute infectious diarrhoea remain a major disease burden throughout the world, especially in developing countries. They are due to infection by many different organisms. Most episodes are self‐limiting and usually investigations are not done to identify the infectious agent. The main risk to health is dehydration and management aims to improve and maintain hydration status. However, rehydration fluids do not reduce the stool volume or shorten the episode of diarrhoea. Probiotics are "friendly" bacteria that improve health and are not harmful in themselves. A number of randomized controlled trials have been done to see whether probiotics are beneficial in acute infectious diarrhoea. We have searched for as many of these trials as possible and collected together the data in a systematic way to try to discover whether or not probiotics are beneficial in acute diarrhoea. We identified 63 trials, which included a total of 8014 people ‐ mainly infants and children. Probiotics were not associated with any adverse effects. Nearly all studies reported a shortened duration of diarrhoea and reduced stool frequency in people who received probiotics compared to the controls. Overall, probiotics reduced the duration of diarrhoea by around 25 hours, the risk of diarrhoea lasting four or more days by 59% and resulted in about one fewer diarrhoeal stool on day 2 after the intervention. However, there was very marked variability in the study findings and so these estimates are approximate. We concluded that these results were very encouraging but more research is needed to identify exactly which probiotics should be used for which groups of people, and also to assess the cost effectiveness of this treatment.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2011

Prevention of diarrhoea in children with HIV infection or who were born to an HIV‐infected mother

Diarrhoea is a common cause of illness in children, especially in low and middle‐income countries where it accounts for nearly 2.5 million deaths per year. Infants and children with HIV infection or maternal exposure through birth or breastfeeding to HIV infection may be more vulnerable to diarrhoea due to weakened immune systems, nutritional deficiencies or from having other infections. This review evaluated three interventions to assess whether they can prevent death or illness from diarrhoea in infants and children with HIV infection or exposure: vitamin A, zinc and cotrimoxazole. Vitamin A and zinc may correct micronutrient deficiencies that are prevalent in children with HIV infection or exposure, as well as prevent other infections. Cotrimoxazole is an antibiotic that helps prevent opportunistic infections in immunocompromised hosts, and may also prevent other infections. This review found nine studies that addressed these interventions in infants or children with HIV infection.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Strategies to encourage hand washing can reduce the incidence of diarrhoea by about one third

Diarrhoea is a serious global public health problem, particularly in low‐income and middle‐income countries. The World Health Organization estimates that over three million episodes occur each year, with many people dying, especially children aged less than five years in low‐ and middle‐income countries. Persistent diarrhoea can also contribute to malnutrition, reduced resistance to infections, and sometimes impaired growth and development. The organisms causing diarrhoea can be transmitted from infected faeces to people through food and water, person‐to‐person contact, or direct contact. Hand washing after defecation and handling faeces, and before preparing and eating food can reduce the risk of diarrhoea. This review looked at trials of interventions to increase the use of hand washing in institutions in high‐income countries and in communities in low‐ or middle‐income countries, and found many of the interventions like educational programmes, leaflets, and discussions to be effective.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Oral zinc supplementation for treating diarrhoea in children

In developing countries, millions of children suffer from severe diarrhoea every year. This is due to infection and malnutrition, and many die from dehydration due to the diarrhoea. Giving fluids by mouth (using an oral rehydration solution) has been shown to save children's lives, but it seems to have no effect on the length of time the children suffer with diarrhoea. Children in developing countries are often zinc deficient. This systematic review of 24 trials involving more than 9000 children shows that zinc supplementation may reduce the duration of diarrhoea in children aged six months or more.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Polymer‐based oral rehydration solution (ORS) ORS for acute diarrhoea

Acute diarrhoea is a common cause of death and illness in developing countries. Oral rehydration solutions (ORS) have had a massive impact worldwide in reducing the number of deaths related to diarrhoea.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

Antibiotics for non‐typhoidal Salmonella diarrhoea

Non‐typhoidal Salmonella (NTS) can cause diarrhoea in people. In this review, we investigated the benefits and safety of antibiotics for treatment of NTS versus placebo or no antibiotic treatment. We found that in otherwise healthy people, treatment with antibiotics did not have any benefit over treatment with no antibiotics. Furthermore, treatment with antibiotics made it more likely that patients would continue to excrete the same organisms for up to one month after treatment. We are unable to comment on the use of antibiotics in very young people, very old people and people who are unable to fight off infection because the trials we identified did not include these patients.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

The use of probiotics to prevent C. difficile diarrhea associated with antibiotic use

Antibiotics are among the most prescribed medications worldwide. Antibiotic treatment may disturb the balance of organisms that normally inhabit the gut. This can result in a range of symptoms, most notably, diarrhea. Clostridium difficile is one particularly dangerous organism that may colonize the gut if the normal healthy balance has been disturbed. Clostridium difficile‐related disease varies from asymptomatic infection, diarrhea, colitis, and pseudo‐membranous colitis to death. The cost of treatment is expensive and the financial burden on the medical system is substantial.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Antibiotic therapy for Clostridium difficile‐associated diarrhea in adults

Diarrhea may be a side effect of many commonly used antibiotics, and in some cases may be due to overgrowth of a bacterium called Clostridium difficile (C. difficile) in the colon after other bacteria have been killed. The seriousness of C. difficile‐associated diarrhea (CDAD) can range from being a nuisance, to a life threatening or even fatal disease. The treatment of CDAD is usually cessation of the initiating antibiotic and immediate administration of a different antibiotic. However each of these steps, cessation of the original antibiotic, immediate retreatment, and the choice of a new antibiotic are poorly supported by currently available evidence. Fifteen studies (total 1152 participants) of antibiotic treatment of CDAD were included in this review. Nine different antibiotics were investigated: vancomycin, metronidazole, fusidic acid, nitazoxanide, teicoplanin, rifampin, rifaximin, bacitracin and fidaxomicin (OPT‐80). Most of the studies were compared vancomycin with other antibiotics. Vancomycin was found to be superior to placebo (fake medicine) for improvement of the symptoms of CDAD including resolution of diarrhea. Most of the studies found no statistically significant difference in effectiveness between vancomycin and other antibiotics including metronidazole, fusidic acid, nitazoxanide or rifaximin. Teicoplanin was found to be superior to vancomycin for curing the C. difficile infection. Teicoplanin may be an attractive choice for the treatment of CDAD. However, it is expensive compared to the other antibiotics and is of limited availability. Side effects including surgery and death occurred infrequently in the included studies. There was a total of 18 deaths among 1152 patients in this systematic review. These deaths were attributed to underlying disease rather than CDAD or antibiotic treatment. One study reported a partial colectomy (removal of the diseased part of the colon) after failed CDAD treatment. It is questionable whether mild CDAD needs to be treated. The included studies provide little evidence for antibiotic treatment of severe CDAD as many studies attempted to exclude these patients. Considering the goals of CDAD therapy: improvement of the patient's clinical condition and prevention of spread of C. difficile infection to other patients, one should choose the antibiotic that brings both symptomatic cure and bacteriologic cure. A recommendation to achieve these goals cannot be made because of the small numbers of patients in the included studies and the poor methodological quality of these studies. Over time there have been emerging therapies for the treatment of clostridium difficile such as resins, new biological compounds and probiotics as alternatives to antibiotics. These interventions along with antibiotic therapy for Clostridium difficile‐associated diarrhea need further investigation. 

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2011

Probiotics for the prevention of pediatric antibiotic‐associated diarrhea (AAD)

Antibiotic‐associated diarrhea (AAD) occurs when antibiotics disturb the natural balance of "good" and "bad" bacteria in the intestinal tract causing harmful bacteria to multiply beyond their normal numbers. The symptoms of AAD include frequent watery bowel movements and crampy abdominal pain. Probiotics are found in dietary supplements or yogurts and contain potentially beneficial bacteria or yeast. Probiotics may restore the natural balance of bacteria in the intestinal tract. Sixteen studies were reviewed and provide the best available evidence. The studies tested 3432 children (2 weeks to 17 years of age) who were receiving probiotics co‐administered with antibiotics to prevent AAD. The participants received probiotics (Lactobacilli spp., Bifidobacterium spp., Streptococcus spp., or Saccharomyces boulardii alone or in combination), placebo (pills not including probiotics), other treatments thought to prevent AAD (i.e. diosmectite or infant formula) or no treatment. The studies were short‐term, ranging in length from 10 days to 3 months. Analyses showed that probiotics may be effective for preventing AAD. Probiotics were generally well tolerated, and minor side effects occurred infrequently, with no significant difference between probiotic and control groups. Side effects reported in the studies include rash, nausea, gas, flatulence, vomiting, increased phlegm, chest pain, constipation, taste disturbance, and low appetite. The current data suggest that Lactobacillus rhamnosus and Saccharomyces boulardii at a high dosage of 5 to 40 billion CFU/day may prevent the onset of ADD, with no serious side effects documented in otherwise healthy children. This benefit for high dose probiotics needs to be confirmed by a large well designed randomized study. No conclusions about the effectiveness and safety of other probiotic agents for pediatric AAD can be drawn. More refined studies are also needed that evaluate strain specific probiotics and report both the effectiveness (e.g. incidence and duration of diarrhea) and safety of probiotics.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

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