Abstract
Introduction
An estimated 4.6 billion cases of diarrhoea occurred worldwide in 2004, resulting in 2.2 million deaths.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for acute diarrhoea in adults living in resource-rich countries? What are the effects of treatments for acute mild-to-moderate diarrhoea in adults from resource-rich countries travelling to resource-poor countries? What are the effects of treatments for acute mild-to-moderate diarrhoea in adults living in resource-poor countries? What are the effects of treatments for acute severe diarrhoea in adults living in resource-poor countries? We searched: Medline, Embase, The Cochrane Library, and other important databases up to January 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 72 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics, antimotility agents, antisecretory agents, bismuth subsalicylate, diet, intravenous rehydration, nasogastric tube rehydration, oral rehydration solutions (amino acid oral rehydration solution, bicarbonate oral rehydration solution, reduced osmolarity oral rehydration solution, rice-based oral rehydration solution, standard oral rehydration solution), vitamin A supplementation, and zinc supplementation.
Key Points
Diarrhoea is an alteration in normal bowel movement, characterised by increased frequency, volume, and water content of stools, often defined clinically as an increase in stool frequency to three or more liquid or semi-formed motions in 24 hours.
An estimated 4.6 billion cases of diarrhoeal illness occurred worldwide in 2004, causing 2.2 million deaths, 1.5 million of which were in children.
This review examines the effects of treatments in adults.
In people from resource-poor countries, antisecretory agents, such as racecadotril, seem to be as effective at improving symptoms of diarrhoea as antimotility agents, such as loperamide, but with fewer adverse effects.
Empirical treatment with antibiotics also seems to reduce the duration of diarrhoea and improve symptoms in this population, although it can produce adverse effects such as rash, myalgia, and nausea.
Instructing people to refrain from taking any solid food for 24 hours does not seem to be a useful treatment, although the evidence for this is sparse.
We don't know how effective oral rehydration solutions or antibiotics plus antimotility agents are in this population, as we did not find any RCTs.
Antisecretory agents, antibiotics, and antimotility agents also seem to be effective in treating people from resource-rich countries who are travelling to resource-poor countries.
Antibiotics plus antimotility agents may be more effective than antibiotics alone at reducing the duration of diarrhoea in people with travellers' diarrhoea.
Bismuth subsalicylate is effective in treating travellers' diarrhoea, but less so than loperamide, and with more adverse effects (primarily black tongue and black stools).
We don't know the effectiveness of oral rehydration solutions or restricting diet in reducing symptoms of diarrhoea in people travelling to resource-poor countries.
For people from resource-poor countries with mild or moderate diarrhoea, antisecretory agents seem to be as beneficial as antimotility agents, and cause fewer adverse effects (particularly rebound constipation).
We didn't find sufficient evidence to allow us to judge the efficacy of antibiotics, antibiotics plus antimotility agents, or oral rehydration solutions in this population.
Oral rehydration solutions are considered to be beneficial in people from resource-poor countries who have severe diarrhoea.
Studies have shown that amino acid-based and rice-based oral rehydration solutions are beneficial, but the evidence is less clear about the efficacy of bicarbonate or reduced osmolarity solutions.
Rice-based oral rehydration solutions seem more beneficial compared with glucose-based oral rehydration solutions in reducing the duration of severe diarrhoea in resource-poor countries.
We don't know whether intravenous rehydration is more beneficial than oral rehydration or enteral rehydration through a nasogastric tube.
We don't know whether antimotility agents, antisecretory agents, antibiotics, or antibiotics plus antimotility agents are effective for treating people with severe diarrhoea in resource-poor countries.
We found no evidence on the use of zinc or vitamin A supplementation in adults in a resource-poor setting.
About this condition
Definition
Diarrhoea is an alteration in normal bowel movement, characterised by increased frequency, volume, and water content of stools. It is often clinically defined as an increase in stool frequency to three or more liquid or semi-formed motions in 24 hours. Acute diarrhoea is usually defined as diarrhoea of 14 days' duration or less, while persistent diarrhoea is of over 14 days' duration. Diarrhoea of over 30 days' duration is frequently defined as "chronic". This review examines the effects of treatments for diarrhoea in adults.
Incidence/ Prevalence
The World Health Organization (WHO) estimated an overall incidence of 4.6 billion cases of diarrhoeal illness worldwide for 2004. This incidence was associated with 2.2 million deaths. Deaths due to diarrhoeal illness occur predominantly in children, with an estimated 1.5 million deaths in under 5-year-olds each year, making diarrhoeal illness the second leading cause of death in this age group. In the USA, the estimated incidence for infectious intestinal disease is 0.44 episodes per person per year (1 episode per person every 2.3 years), resulting in about one consultation with a doctor per person every 28 years. A community study in the UK reported an incidence of 19 cases per 100 person-years, of which 3.3 cases per 100 person-years resulted in consultation with a general practitioner. Both estimates derive from population-based studies, including both adults and children. The epidemiology of travellers' diarrhoea is not well understood. Incidence is higher in travellers visiting resource-poor countries, but it varies widely by location and season of travel. The incidence of diarrhoea in adults in resource-poor countries is largely unknown owing to the lack of large-scale surveillance studies in these countries.
Aetiology/ Risk factors
The cause of diarrhoea depends on geographical location, standards of food hygiene, sanitation, water supply, and season. Commonly identified causes of sporadic diarrhoea in adults in resource-poor countries include Campylobacter, Salmonella, Shigella, Escherichia coli, Yersinia, protozoa, and viruses (see table 1 ). No pathogens are identified in more than half of people with diarrhoea. In returning travellers, about 50% of episodes are caused by bacteria such as enterotoxigenic E coli, Salmonella, Shigella, Campylobacter, Vibrio, enteroadherent E coli, Yersinia, and Aeromonas (see table 1 ).
Table 1.
Percentage of individuals with diarrhoea (cases) or controls with given aetiological agent found on stool testing
| Population | GP attendants in the Netherlands | European and North American travellers in Kenya, India*, or Jamaica with diarrhoea | ||
| Age | 15–29 years | 30–59 years | 60 years or over | Age range not stated |
| Number | (170 cases/72 controls) | (313 cases/244 controls) | (102 cases/102 controls) | (1079 cases) |
| Percentage (%) positive for: | ||||
| Adenovirus | 1.0/0.0 | 0.6/1.4 | 0.3/0.0 | 2.8 |
| Aeromonas species | – | – | – | 1.9 |
| Astrovirus | 0.6/0.0 | 0.6/0.0 | 3.9/2.0 | – |
| Blastocystis hominis | 27.2/34.7 | 23.9/34.4 | 16.7/37.3 | – |
| Campylobacter species | 14.7/0.0 | 10.5/1.2 | 7.8/0.0 | 4.2 |
| Cryptosporidium species | 3.0/0.0 | 0.6/0.0 | 0.0/0.0 | 0.6 |
| Cyclospora species | 0.6/0.0 | 0.3/0.0 | 0.0/0.1 | – |
| Dientamoeba fragilis | 8.3/18.1 | 8.9/17.4 | 9.8/13.7 | – |
| Entamoeba histolytica/ dispar | 0.0/2.8 | 1.0/0.8 | 1.0/0.0 | 1.5 |
| Enterotoxigenic Escherichia coli | – | – | – | 25.5 |
| Giardia lablia | 3.0/0.0 | 5.7/1.2 | 3.9/3.9 | 0.7 |
| Norwalk-like virus | 5.9/1.4 | 3.9/0.8 | 1.0/1.0 | – |
| Plesiomonas species | – | – | – | 6.3 |
| Rotavirus | 4.1/1.4 | 1.9/1.6 | 2.9/0.0 | 2.6 |
| Salmonella species | 3.5/0.0 | 2.6/0.0 | 3.9/1.0 | 6.3 |
| Sapporo-like virus | 2.9/0.0 | 0.6/0.7 | 0.0/0.0 | – |
| Shigella species | 0.0/0.0 | 0.0/0.0 | 0.0/0.0 | 6.6 |
| Vibrio species | – | – | – | 3.1 |
| Verocytoxin-producing Escherichia coli | 0.0/1.6 | 0.7/0.4 | 0.0/1.1 | – |
| Yersinia species | 1.2/0.0 | 0.3/1.6 | 2.0/2.0 | – |
*In India, stool samples were not obtained from May to September because of lack of tourism.
Prognosis
In resource-rich countries, death from infectious diarrhoea is rare, although serious complications, including severe dehydration and renal failure, can occur and may necessitate admission to hospital. Elderly people and those in long-term care have an increased risk of death. In resource-poor countries, diarrhoea is reported to cause more deaths in children under 5 years of age than any other condition. Few studies have examined which factors predict poor outcome in adults.
Aims of intervention
To reduce the infectious period, length of illness, risk of dehydration, risk of transmission to others, and rates of severe illness; and to prevent complications and death, with minimum adverse effects.
Outcomes
Mortality; cure; illness duration (time from start of treatment to last loose stool; time to first formed stool; duration of diarrhoea; duration of fever, duration of excretion of organisms); symptom control (number of loose stools a day; stool volume; relief of cramps, nausea, and vomiting; incidence of vomiting; incidence of severe illness; need for unscheduled fluids); microbiological efficacy (eradication of pathogens); presence of bacterial resistance; rate of hospital admission; adverse effects.
Methods
Clinical Evidence search and appraisal January 2010. The following databases were used to identify studies for this systematic review: Medline 1966 to January 2010, Embase 1980 to January 2010, and The Cochrane Database of Systematic Reviews 2009, Issue 4 (1966 to date of issue). An additional search within The Cochrane Library was carried out for the Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA). We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the contributor for additional assessment, using predetermined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews of RCTs and RCTs in any language, at least single blinded, and containing more than 20 individuals of whom more than 80% were followed up. There was no minimum length of follow-up required to include studies. We excluded all studies described as "open", "open label", or not blinded unless blinding was impossible. We did not exclude studies that included people with HIV/AIDS. We included systematic reviews of RCTs and RCTs where harms of an included intervention were studied applying the same study design criteria for inclusion as we did for benefits. In addition we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the MHRA, which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table ). The categorisation of the quality of the evidence (into high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).
Table 1.
GRADE evaluation of interventions for diarrhoea in adults (acute)
| Important outcomes | Symptom control, duration of illness, hospital admission rates, cure rates, adverse effects | ||||||||
| Number of studies (participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of treatments for acute diarrhoea in adults living in resource-rich countries? | |||||||||
| 1 (152) | Symptom control | Diphenoxylate v placebo | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (152 | Duration of illness | Diphenoxylate v placebo | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 2 (670) | Duration of illness | Loperamide hydrochloride v placebo | 4 | 0 | 0 | 0 | 0 | High | |
| 2 (670) | Duration of illness | Loperamide hydrochloride v loperamide oxide | 4 | 0 | 0 | 0 | 0 | High | |
| 5 (1400) | Duration of illness | Loperamide oxide v placebo | 4 | 0 | 0 | 0 | 0 | High | |
| 1 (168)] | Duration of illness | Racecadotril v placebo | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (71) | Symptom control | Racecadotril v placebo | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 3 (288) | Duration of illness | Racecadotril v loperamide | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (157) | Symptom control | Racecadotril v loperamide | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 5 (676) | Duration of illness | Antibiotics v placebo | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for incomplete reporting of results. Consistency point deducted for conflicting results |
| 5 (676) | Symptom control | Antibiotics v placebo | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for incomplete reporting of results. Consistency point deducted for conflicting results |
| 4 (574) | Cure rates | Antibiotics v placebo | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for incomplete reporting of results. Consistency point deducted for different results at different endpoints |
| 1 (71) | Duration of illness | Restricted diets v unrestricted diets | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| What are the effects of treatments for mild-to-moderate diarrhoea in adults from resource-rich countries traveling to resource-poor countries? | |||||||||
| 2 (277) | Duration of illness | Loperamide hydrochloride v placebo | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 2 (227) | Duration of illness | Loperamide hydrochloride alone v trimethoprim-sulfamethoxazole | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 1 (447) | Cure rates | Empirical antibiotics v placebo (multiple destination studies) | 4 | 0 | 0 | 0 | 0 | High | |
| 5 (1178) | Duration of illness | Empirical antibiotics v placebo (multiple destination studies) | 4 | 0 | 0 | 0 | 0 | High | |
| 9 (1315) | Duration of illness | Empirical antibiotics v placebo (Central America) | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 1 (195) | Symptom control | Empirical antibiotics v placebo (North and West Africa) | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (47) | Duration of illness | Empirical antibiotics v placebo (Asia) | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (142) | Duration of illness | Empirical antibiotics v each other (multiple destination studies) | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (94) | Duration of illness | Empirical antibiotics v each other (Central America) | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (102) | Symptom control | Empirical antibiotics v each other (North and West Africa) | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (79) | Duration of illness | Empirical antibiotics v each other (Asia) | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 6 (unclear) | Cure rates | Antibiotics plus antimotility agents v antibiotics alone | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for heterogeneity among RCTs (regimens used, variable effects, and pathogens) |
| 5 (unclear) | Duration of illness | Antibiotics plus antimotility agents v antibiotics alone | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for heterogeneity among RCTs (regimens used, variable effects, and pathogens) |
| 1 (227) | Duration of illness | Antibiotics plus antimotility agents v antimotility agents alone | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 1 (142) | Duration of illness | Different antibiotics plus antimotility agents regimens v each other | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for incomplete reporting of results and sparse data |
| 1 (111) | Symptom control | Bismuth subsalicylate v placebo | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (245) | Duration of illness | Bismuth subsalicylate v placebo | 4 | 0 | 0 | 0 | 0 | High | |
| 1 (203) | Duration of illness | Bismuth subsalicylate v loperamide | 4 | 0 | 0 | 0 | 0 | High | |
| 1 (219) | Symptom control | Bismuth subsalicylate v loperamide | 4 | 0 | 0 | 0 | 0 | High | |
| 2 (355) | Duration of illness | Zaldaride maleate v placebo | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for unclear generalisability |
| 1 (179) | Symptom control | Zaldaride maleate v loperamide | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (105) | Duration of illness | Restricted diet v unrestricted diet | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for inclusion of intervention (different antibiotics) |
| What are the effects of treatments for mild-to-moderate diarrhoea in adults living in resource-poor countries? | |||||||||
| 2 (185) | Symptom control | Antimotility agents v placebo | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (945) | Duration of illness | Racecadotril v loperamide | 4 | 0 | 0 | 0 | 0 | High | |
| 2 (446) | Symptom control | Antibiotics v placebo | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for incomplete reporting of results and for no intention-to-treat analysis |
| 1 (57) | Symptom control | Citrate oral rehydration solution v bicarbonate oral rehydration solution | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (60) | Symptom control | Commercial oral rehydration solution v standard oral rehydration solution | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for no direct statistical analysis between groups |
| What are the effects of treatments for severe diarrhoea in adults living in resource-poor countries? | |||||||||
| 1 (88) | Duration of illness | Antibiotics plus antimotility agents v antibiotics | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (110) | Duration of illness | Racecadotril v placebo | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (110) | Symptom control | Racecadotril v placebo | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 2 (565) | Duration of illness | Berberine v placebo or no treatment | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for assessing different outcomes |
| 2 (565) | Duration of illness | Berberine plus tetracycline v tetracycline | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for measuring different outcomes |
| 1 (165) | Symptom control | Berberine v placebo or no treatment | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (46) | Duration of illness | Chlorpromazine v placebo | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for narrow inclusion criteria |
| 1 (410) | Symptom control | Chlorpromazine v placebo | 4 | –1 | 0 | –3 | 0 | Very low | Quality point deducted for incomplete reporting of results. Directness points deducted for assessing different outcomes and in a different population, and for additional interventions |
| 2 (205) | Symptom control | Amino acid oral rehydration solution v standard oral rehydration solution | 4 | –2 | 0 | –2 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness points deducted for assessing different outcomes and generalisability of results (comparing response in people with cholera with less severe forms of diarrhoea) |
| 4 (228) | Duration of illness | Rice-based oral rehydration solution v glucose-based oral rehydration solution | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for weak methods (allocation concealment, blinding). Directness point deducted for unclear generalisability of results (RCTs in people positive for Vibrio cholerae) |
| 4 (at least 409) | Symptom control | Rice-based oral rehydration solution v glucose-based oral rehydration solution | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for weak methods (allocation concealment, blinding). Directness point deducted for unclear generalisability of results (RCTs in people positive for V cholerae) |
| 1 (123) | Symptom control | Rice-based oral rehydration solutions v low-glucose oral rehydration solution | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for unclear generalisability of results (RCT in people positive for V cholerae) |
| 1 (123) | Duration of illness | Rice-based oral rehydration solutions v low-glucose oral rehydration solution | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for unclear generalisability of results (RCT in people positive for V cholerae) |
| 1 (123) | Duration of illness | Low-sodium rice-based oral rehyration solution v rice-based oral rehydration solution | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for unclear generalisability of results (RCT in people positive for V cholerae) |
| 1 (123) | Symptom control | Low-sodium rice-based oral rehyration solution v rice-based oral rehydration solution | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for unclear generalisability of results (RCT in people positive for V cholerae) |
| 1 (48) | Duration of illness | Other polymer-based oral rehydration solution v glucose-based oral rehydration solution | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for unclear generalisability of results (RCT in people positive for V cholerae) |
| 1 (50) | Symptom control | Other polymer-based oral rehydration solution v glucose-based oral rehydration solution | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for subjective outcome |
| 2 (310) | Duration of illness | Bicarbonate oral rehydration solution v standard oral rehydration solution | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for incomplete reporting of results. Directness points deducted for additional intervention in one groups and generalisability of results (comparing response in people with cholera with less severe forms of diarrhoea) |
| 2 (310) | Symptom control | Bicarbonate oral rehydration solution v standard oral rehydration solution | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for incomplete reporting of results. Directness points deducted for additional intervention in one groups and generalisability of results (comparing response in people with cholera with less severe forms of diarrhoea) |
| 1 (60) | Duration of illness | Bicarbonate oral rehydration solution v chloride standard oral rehydration solution | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for generalisability of results (comparing response in people with cholera with less severe forms of diarrhoea) |
| 1 (60) | Symptom control | Bicarbonate oral rehydration solution v chloride standard oral rehydration solution | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for generalisability of results (comparing response in people with cholera with less severe forms of diarrhoea) |
| 4 (575) | Duration of illness | Reduced osmolarity oral rehydration solution v standard oral rehydration solution | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for generalisability of results (comparing response in people with cholera with less severe forms of diarrhoea) |
| 4 (575) | Symptom control | Reduced osmolarity oral rehydration solution v standard oral rehydration solution | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for generalisability of results (comparing response in people with cholera with less severe forms of diarrhoea) |
| 1 (20) | Duration of illness | Intravenous rehydration v enteral rehydration | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for generalisability of results (comparing response in people with cholera with less severe forms of diarrhoea) |
| 1 (20) | Symptom control | Intravenous rehydration v enteral rehydration | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for generalisability of results (comparing response in people with cholera with less severe forms of diarrhoea) |
Type of evidence: 4 = RCT. Consistency: similarity of results across studies.Directness: generaliseability of population or outcomes.Effect size: based on relative risk or odds ratio.
Glossary
- Acute diarrhoea
An episode of diarrhoea lasting 14 days or less.
- Empirical treatment
Treatment guided by professional experience, or given before or without reference to the results of microbiological investigations.
- High-quality evidence
Further research is very unlikely to change our confidence in the estimate of effect.
- Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
- Moderate-quality evidence
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
- Severe diarrhoea
A diarrhoeal illness associated with profuse or dehydrating stool losses, blood, fever, or illness in infants, elderly people, or immunocompromised people.
- Travellers' diarrhoea
Diarrhoea occurring during or shortly after travel in people who have crossed a national boundary.
- Very low-quality evidence
Any estimate of effect is very uncertain.
Gastroenteritis in children
Disclaimer
The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients. To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.
Contributor Information
Thomas Gottlieb, Department of Microbiology and Infectious Diseases, Concord Hospital, Sydney, Australia.
Christopher Stewart Heather, Concord Repatriation General Hospital, Sydney, Australia.
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