Diarrhoea

Prescribing Notes:

• First-line treatment for acute diarrhoea is to prevent dehydration.
• Antidiarrhoeal drugs should not be given in patients with acute infective diarrhoea, pus or blood in stools, high fever, active inflammatory bowel disease or pseudomembranous colitis.
• Ask about recent antibiotic therapy. If antibiotics have been taken recently, avoid loperamide, and provide a worsening statement. Clostridioides difficile infection (CDI) causes diarrhoea as the main symptom. Most cases will have had a recent course of antibiotics. Some antibiotics have a higher risk of C. diff (e.g. co-amoxiclav, ciprofloxacin, clindamycin and cephalosporins), but any antibiotic can upset normal gut flora and result in loose stools. C. diff bacteria produce a toxin that acts on the bowel to cause diarrhoea. Anything that stops diarrhoea (eg loperamide/opiates) results in toxin retention and potentially worsening disease. Refer to formulary recommendations for Clostridioides difficile for further information. 
• Faecal impaction can give rise to “overflow diarrhoea” and must be excluded as part of the differential diagnosis.
• Anti-motility drugs should not be given with overflow diarrhoea.
• Older patients with acute or prolonged diarrhoea are particularly likely to require fluid replacement. 
• Loperamide is preferred to codeine phosphate because it is less likely to produce central side effects and addiction.
• Loperamide orodispersible tablets are approved for specialist initiation in patients who have had colectomies and who have had either an end ileostomy or have an ileoanal J-pouch. See formulary recommendations for short bowel syndrome for more information.
• Antimotility drugs are not recommended for acute diarrhoea in young children.
• Bulk forming drugs, such as isphagula are useful in controlling diarrhoea associated with diverticular disease.

Prescribing Notes:

• Antidiarrhoeal drugs should not be given in patients with acute infective diarrhoea, pus or blood in stools, high fever, active inflammatory bowel disease or pseudomembranous colitis.
• Faecal impaction can give rise to “overflow diarrhoea” and must be excluded as part of the differential diagnosis.
• Anti-motility drugs should not be given with overflow diarrhoea.
• Loperamide is preferred to codeine phosphate because it is less likely to produce central side effects and addiction.
• Seek specialist advice for medicine administration via enteral feeding tubes.
• Loperamide orodispersible tablets are approved for specialist initiation in patients who have had colectomies and who have had either an end ileostomy or have an ileoanal J-pouch. See formulary recommendations for short bowel syndrome for more information.
• Bulk forming drugs, such as isphagula are useful in controlling diarrhoea associated with diverticular disease.

Prescribing Notes:

• Antibiotics are not usually indicated for salmonellosis; in complicated cases, an infection specialist (infectious diseases physician or microbiologist) should be contacted for advice, for example <1 year old or >50 years of age, immunocompromised, cardiac valve disease, endovascular grafts, haemoglobinopathy, other vascular abnormality or peripheral vascular disease. If antibiotic treatment is indicated, prescribe ciprofloxacin 500mg twice a day for 1 day only (check with microbiology laboratory that the isolate is sensitive), consider important safety issues and potentially long lasting side-effects prior to prescribing.
• See MHRA Drug Safety Update January 2024: Fluoroquinolones must only be used in situations when other antibiotics, that are commonly recommended for the infection, are inappropriate such as:  
  • there is resistance to other first-line antibiotics recommended for the infection 
  • other first-line antibiotics are contraindicated in an individual patient 
  • other first-line antibiotics have caused side effects in the patient requiring treatment to be stopped 
  • treatment with other first-line antibiotics has failed.

Prescribing Notes:

• No antibacterial treatment is usually necessary for mild symptoms. Antibiotics worsen outcomes in patients with E.coli 0157 infection.
• Patients should be advised not to take any opiates, NSAIDs, loperamide or antibiotics.
• Self-treatment with a short course of an antibacterial is not routinely recommended.
• Prophylaxis is rarely, if ever, indicated. Consider Pepto Bismol two tablets four times daily as prophylaxis OR for two days treatment.
• Consider a request for a stool sample if considered clinically helpful.

Prescribing Notes:

• First-line treatment for acute diarrhoea is rehydration therapy.
• For infants who are weaned, one sachet (200ml) should be given after each loose bowel motion.
• Families should be advised to ensure that in addition to rehydration therapy, the child receives a sugar containing liquid during episodes of diarrhoea e.g. sugar containing cordial.
• There can be variation in the licensing of different loperamide formulations with respect to age and indication.
• Antimotility drugs should not be given in acute inflammatory bowel disease or pseudomembranous colitis, as they may increase the risk of developing toxic megacolon, nor in acute infective diarrhoea with bloody stools.
• Ask about recent antibiotic therapy. If antibiotics have been taken recently, avoid loperamide, and provide a worsening statement. Clostridioides difficile infection (CDI) causes diarrhoea as the main symptom. Most cases will have had a recent course of antibiotics. Some antibiotics have a higher risk of C. diff (e.g. co-amoxiclav, ciprofloxacin, clindamycin and cephalosporins), but any antibiotic can upset normal gut flora and result in loose stools. C. diff bacteria produce a toxin that acts on the bowel to cause diarrhoea. Anything that stops diarrhoea (eg loperamide/opiates) results in toxin retention and potentially worsening disease. Refer to formulary recommendations for Clostridioides difficile for further information. 

Prescribing Notes:

• There can be variation in the licensing of different loperamide formulations with respect to age and indication.
• For patients who cannot swallow capsules or tablets, loperamide capsules may be opened and contents dispersed in water prior to administration (Off-label), or loperamide tablets may be dispersed in water prior to administration (Off-label).
• For doses less than 2mg disperse contents in water and give a proportion to deliver the intended dose (Off-label), this recommendation is based on local experience in practice.
• Seek specialist advice for administration via enteral feeding tubes.
• Additional information on paediatric GI conditions and initial management are available on the NHS Lothian RefHelp website. These are developed by the RHCYP Paediatric Gastroenterology, Hepatology and Nutrition (PGHAN) service, providing specialist services for Lothian, Fife and the Borders as part of the South-East Scotland Regional PGHAN Network (SESPGHAN).

Prescribing Notes:

• Refer previously healthy children with acute, painful or bloody diarrhoea to exclude E. Coli 0157.
• Antibiotics are not usually indicated for campylobacter enteritis. In children if there is bloody diarrhoea, the infection is prolonged and associated with systemic symptoms, the patient should be referred to hospital for investigation and treatment if appropriate.
• Refer to hospital guidelines for the treatment of enteric fever (typhoid or paratyphoid).
• Antibiotics are not usually indicated for shigellosis or salmonellosis.
• Refer patients with confirmed salmonellosis to hospital for investigation and treatment where there are signs of sepsis, or any patients who are immunosuppressed, malnourished, have haemoglobinopathy or age <6 months.

Prescribing Notes:

• No antibacterial treatment is usually necessary for mild symptoms. Antibiotics worsen outcomes in patients with E. Coli 0157 infection. For severe and/or systemic symptoms, hospital advice should be sought. Any bloody diarrhoea should be investigated in secondary care.
• Patients should be advised not to take any opiates, NSAIDs, loperamide or antibiotics.
• Self-treatment with a short course of an antibacterial is not routinely recommended.
• Prophylaxis is rarely, if ever, indicated.
• Consider a request for a stool sample if considered clinically helpful.

Prescribing Notes:

• Any unused oral rehydration sachet solution should be discarded no later than 1 hour after preparation unless stored in a fridge when it can be kept for maximum of 24 hours.
• For infants who are weaned, one sachet (200ml) should be given after each loose bowel motion.
• Eat as normally as possible. Ideally include fruit juices and soups which will provide sugar and salt and also foods high in carbohydrate such as bread, pasta etc.
• Antidiarrhoeal drugs should not be given in acute inflammatory bowel disease or pseudomembranous colitis, as they may increase the risk of developing toxic megacolon, nor in acute infective diarrhoea with bloody stools.
• Clostridioides difficile infection (CDI) causes diarrhoea as the main symptom. Most cases will have had a recent course of antibiotics. Some antibiotics have a higher risk of C. diff (e.g. co-amoxiclav, ciprofloxacin, clindamycin and cephalosporins), but any antibiotic can upset normal gut flora and result in loose stools. C. diff bacteria produce a toxin that acts on the bowel to cause diarrhoea. Anything that stops diarrhoea (eg loperamide/opiates) results in toxin retention and potentially worsening disease. When an antidiarrhoeal product is requested, ask about recent antibiotic therapy and recommend oral rehydration salts in the first instance. If antibiotics have been taken recently, avoid loperamide, advise the customer to contact their GP and provide a worsening statement. 

Examples of Counselling Points
The diarrhoea normally stops within 48-72 hours without treatment.
Always wash hands after going to the toilet/changing nappies.
Replacement of fluids is of particular importance especially in children and the elderly.
Review medicines whose efficacy may be affected by a bout of diarrhoea e.g. oral contraceptives, warfarin.
Medicine sick day rules, advise patient to stop taking certain medications and re-start once well again. Medicines include ACE inhibitors, ARBs, NSAIDs, diuretics and metformin. Cards are available from the Improvement Hub (ihub) website.

When to advise patient to contact GP
Children <1 year: diarrhoea of duration greater than 1 day.
Children 1-3 years: diarrhoea of duration greater than 2 days.
Adults and children >3 years: duration of diarrhoea greater than 3 days.
Persistent diarrhoea following foreign travel to high risk area.
Concerns about dehydration e.g. not passing much urine, drowsiness or confusion.
In severe cases referral should be recommended immediately.
Associated with severe vomiting and fever.
Suspected drug-induced reaction to prescribed medicine.
History of change in bowel habit.
Presence of blood or mucus in the stools.
Patients with chronic diarrhoea.