Skip to main content

Infectious Cause of Chronic Diarrhea

Infectious Causes of Chronic Diarrhea

Bacterial Etiologies
Risk Factors
Testing Information
  • Bloody diarrhea
  • Close contact with person with confirmed bacterial gastroenteritis (household, daycare)
  • Animal exposure: farm animals, petting zoo, pet reptiles, new pets
  • Undercooked meat or poultry, unpasteurized dairy products, raw shellfish
  • Community outbreaks of specific bacterial gastroenteritis as determined by the health department
  • History of international travel
  • Ingestion of potentially contaminated water (from pools, lakes, streams, ponds, etc.)
If risk factors are absent, do NOT order infectious testing
  • Routine stool culture includes:
    • Culture for:
      • Salmonella sp.
      • Shigella sp.
      • Yersinia sp.
      • Campylobacter sp.
      • E. coli 0157:H7
    • Shiga-toxin testing for enterohemorrhagic E. coli
      • Note: rectal swabs are not accepted for Shiga-toxin testing at CM lab
    • GI pathogen panels are NOT routinely recommended
Organism
Treatment Indications
Special Considerations

E.coli 0157:H7 / other Shiga-toxin producing E. coli (STEC)

Do not treat
  • Ensure follow-up with PCP within 5 to 7 days of onset of illness to obtain CBC and ask about urine output
  • Hemolytic uremic syndrome (HUS) is a rare but serious sequelae. (See information about HUS)
  • Contact Nephrology with evidence of or additional questions about HUS

Salmonella sp.

Do not treat except in patients with risk for invasive disease:

  • < 3 months of age
  • Chronic GI disease
  • Malignant neoplasms
  • Hemoglobinopathies
  • HIV infection
  • Immunocompromised
  • Severe symptoms (severe diarrhea or prolonged fever)
  • Disseminated infection /
 septicemia

 
  • Blood cultures should be considered for patients at risk of severe illness:
    • <3 months
    • Immunocompromised
    • Has hemolytic anemia
    • Evidence of disseminated infection, septicemia, or enteric fever

Campylobacter sp.

Useful to treat for:

  • Infants
  • Immunocompromised

 
  • Immunoreactive complications, such as Guillain-Barré syndrome, reactive arthritis, myocarditis, pericarditis, and erythema nodosum, can occur during convalescence and do not warrant antimicrobial therapy.

Shigella sp.

Most useful to treat for:

  • Severe symptoms (severe diarrhea or prolonged fever)
  • Immunocompromised
  • Daycare attendance

 
  • Empiric therapy may need modification as resistance can be common. Consider discussion with ID if questions.
  • Febrile seizure may occur in patients with Shigella infection

Yersinia sp.

Useful to treat for:

  • Neonates
    Immunocompromised
  • Septicemia or extraintestinal disease
  

Clostridioides difficile

Risk Factors
Testing Information
  • Antibiotic use within the past 12 weeks
  • Highest risk:
    • fluoroquinolones
    • clindamycin
    • third-generation cephalosporins
    • exposure to multiple antibiotic classes
  • Prolonged hospitalization (> 7 days) or < 72 hours from discharge following a prolonged hospitalization
  • Bowel surgery/GI tract manipulation within the past 30 days
  • Inflammatory bowel disease and use of acid-reducing medications
  • Ongoing immunosuppressant medication use including chemotherapy
    • Exposure to someone known to be colonized or known or suspected to have infection with C. difficile
  • C. difficile infection generally does not occur in patients < 3 years of age

  • Clostridioides difficile GDH/Toxin:

    • In patients < 1 year of age, specimens will not be tested due to high incidence of C. difficile colonization in this age group

    • Non-liquid samples are tested only when toxic megacolon is suspected

Parasitic Etiologies
Risk Factors
Testing Information
  • Bloody diarrhea with international travel (Entamoeba histolytica)
  • Close contact to a person with confirmed parasitic gastroenteritis
  • Community outbreaks of specific parasitic gastroenteritis (especially Cryptosporidium)
  • International travels in the last month
  • Ingestion of potentially contaminated water (from pools, lakes, streams, ponds, etc.)

  • If risk factors are absent, do NOT order infectious testing

  • Ova and Parasite testing:
    • If no foreign travel:

      • Cryptosporidium/Giardia Antigen

    • If foreign travel: 
      • Complete O&P 
  • GI pathogen panel is NOT routinely recommended due to significant potential for false positive results

Viral Etiologies
Risk Factors
Testing Information
  • Bacterial/parasitic etiologies ruled out
  • Daycare attendance
  • Unvaccinated (rotavirus)
  • Recent travel (particularly to cruise ships)

  • Common viral testing:

    • Rotavirus stool rapid antigen

    • Norovirus PCR

  • GI Pathogen Panel is NOT routinely recommended due to significant potential for false positive results
References:
1. American Academy of Pediatrics, Committee on Infectious Diseases. Red Book: 2021–2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021. doi:10.1542/9781610025782
2. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017;65(12):e45-e80. doi:10.1093/cid/cix669 

These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.

Children's Mercy
Health Care Providers
Evidence Based Practice / Clinical Pathways
Clinical Practice Guidelines, Care Process Models, and Enhanced Recovery After Surgery Pathways
Chronic Diarrhea
Infectious Cause of Chronic Diarrhea