PHILIPPINE CLINICAL PRACTICE GUIDELINE FOR ACUTE

INFECTIOUS DIARRHEA
This is a summary of the CPG for acute infectious diarrhea. This pocket guideline serves as a quick
reference for the healthcare worker and does not contain the rationale or appendices of the full version.

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Recommendations were assessed using the GRADE criteria. After each statement in this guideline, the
strength of recommendation and quality of evidence are presented in brackets.

DIAGNOSTIC
DIAGNOSTIC

I. When is the diagnosis of acute infectious diarrhea suspected?

Definitions

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Acute infectious diarrhea is suspected if a patient present with passage of 3 or more loose, watery or bloody
stools within 24 hours that may be accompanied by any of the following symptoms: nausea, vomiting, abdominal
pain, and fever. (Operational definition) (Strong, Low to Moderate)

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Acute diarrhea is the passage of three or more loose, watery or bloody stools from an immunocompetent person’s
normal baseline in a 24-hour period lasting less than 14 days. The patient should not have received any antibiotics
within the last three months, has had no previous hospitalizations and/or has not developed diarrhea after more
than 48 hours of hospital admission.1 In considering if a patient has diarrhea, the change from the previous
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consistency of stool is the more important parameter to observe compared to change in frequency.

According to the WHO, a young infant has diarrhea if the stools have changed from the usual pattern. The normally
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frequent or semi-solid stools of a breastfed baby is not considered diarrhea.2

II. What pre-treatment clinical evaluations are recommended for immunocompetent patients presenting with
acute infectious diarrhea?
Extensive clinical history should include consumption of raw, ill-prepared, or rotten food and/or intake of
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contaminated food and/or water as this could provide clues to the possible etiologies. (Strong, low to
moderate)
Complete physical examination should be done to assess the severity of the disease, degree of dehydration
presence of complication and presence of comorbid condition. (See question 4 for discussion.) (Strong, low to
moderate)
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III. What is the clinical utility of diagnostic tests in children and adults with acute infectious diarrhea?
Diagnostic tests should be based on the assessment of the patient’s clinical status. (Strong, low)
Routine stool examination should not be done in most cases of acute watery diarrhea except in cases where
parasitism is suspected or in the presence of bloody diarrhea. (Strong, low)
Stool cultures are indicated only for: severe cases (significant dehydration, high fever, persistent vomiting or
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severe abdominal pain, dysenteric stool), high risk for transmission of enteric pathogens (food handlers),
increased risk of complications, for epidemiologic purposes, where there is suspicion of an outbreak that is
enteric in origin. The yield is highest when requested within 3 days of symptoms and before administration
of antibiotics. (Strong, low)
There is insufficient evidence to support the use of biomarkers (CRP, calprotectin, ESR, PCT, total serum
WBC) in distinguishing the cause of acute infectious diarrhea. (Strong, low)
Rapid diagnostic tests may be used during suspected outbreaks of diarrhea and shigella, but confirmation
with stool culture is still recommended. (Strong, low)
 Clinical correlation is necessary in interpreting tests done using molecular diagnostics. Although sensitivity is
high, the tests are unable to distinguish between viable and non-viable organisms. (Strong, low)

IVA. What are the clinical parameters that would indicate presence of dehydration in children with acute
infectious diarrhea?
Physical examination findings indicative of hydration status include the following: vital signs (tachycardia,

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tachypnea), level of consciousness (depressed sensorium), presence of depressed fontanel, presence of
sunken eyeballs, presence of tears, skin turgor, capillary refill time, abnormal respiratory pattern, and history
of urine output. (Strong, moderate)

Table 1. Clinical manifestation of dehydration in children according to severity.

Parameters No signs of Mild to Moderate Severe dehydration

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dehydration dehydration
Fluid deficit
(% body weight)
Infant <5% 5-10% >10%

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Child 3% 6% 9%
Conditiona Well, alert Restless, irritable Lethargic or unconscious
Thirst Drinks normally, not Thirsty, drinks eagerly Drinks poorly, or not able to
thirsty drink
Fontanel/Eyesa

Tears
Normal

Present
T Slightly depressed/
slightly sunken
Present or Decreased
Sunken

No tears
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Cutaneous Perfusion/ <2 seconds Around 2 seconds > 3 seconds
Capillary Refill
Respiration Normal Deep, may be rapid Deep and rapid
2mo-12mo:≥50breaths/min
12mo-5yo: ≥40breaths/min
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Skin Pincha Goes back quickly Goes back slowly Goes back very slowly
History of Urine Output Normal Decreased Little (<0.3 ml/kg/hr in 16hrs)
(<0.5ml/kg/hr x8hours) or none (no urine output in
12hrs)
Interpretation If the patient has two or If the patient has two or
more signs, there is more signs, there is SEVERE
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MILD to MODERATE DEHYDRATION

DEHYDRATION
a
These parameters are unreliable for patients with severe malnutrition. Use other parameters to distinguish malnutrition from dehydration.3-7

IVB. What are the clinical parameters that would indicate presence of dehydration in adults with acute
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infectious diarrhea?
Clinical and laboratory parameters indicative of hydration status include the following (Strong, low):
- Clinical parameters: fatigue, thirst, sunken eyes, orthostatic hypotension, increased respiratory
rate, cold, clammy sin, lethargy, dry oral mucosa, muscle weakness, decreased skin turgor (>2
seconds)
- Laboratory parameters: Increased urine specific gravity (≥1.010), increased urine osmolality
(>800msom/kg), increased serum osmolality (≥ 295 msom/kg), increased BUN/creatinine ration
(>20 mg/dL), metabolic acidosis (pH <7.35, HCO3 < 22)
 Table 2. Clinical manifestations of dehydration in adults according to severity.
Mild Moderate Severe
fatigue +/- + +
thirst +/- + +
sunken eyes - + +
blood pressure Normal BP orthostatic shock

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hypotension
respiratory rate (breaths Normal 21 - 25 ≥ 25
per minute)
heart rate (without fever) ≥80 bpm ≥100 bpm faint or thready
Peripheral (circulation) warm to touch extremities cold, clammy skin
level of consciousness Alert lethargic

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coma/stupor
oral mucosa moist dry
muscle weakness None mild-moderate severe
skin turgor (anterior ≤ 2 seconds > 2 seconds

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forearm, anterior thigh,
subclavicular, sternum,
anterior chest)
capillary refill (middle ≤2 seconds > 2 seconds
finger at heart height)
urine output (ml/kg/hr)
References8-10
≥ 0.5
T < 0. 5
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Table 3: Other parameters used in assessing dehydration in adults.
Mild Moderate Severe
body weight change reduction of 3% to 5% of Current dehydration corresponded to changes of
body weight within seven more than 5% of body weight
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days
or less,
OR
an increase of 3% to 5% of
body weight within seven
days as an indication that
a person was dehydrated
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before rehydration
Urine Specific Gravity ≥1.010 ≥1.020
Urine Osmolality >800
(mosm/kg)
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Serum Osmolality 295-300 >300

(mosm/kg)
BUN/Creatinine Ratio >20
(mg/dL)
ABG (pH < 7.35, HCO3 < - - +
22)
References8,9,11,12
 V. What laboratory test should be done to assess for the presence of complications with acute infectious
diarrhea?
Complications such as acute kidney injury and electrolyte imbalances can occur in pediatric and adult
patients with acute infectious diarrhea. For patients suspected to have complications of acute infectious
diarrhea, the following laboratory tests may be requested: complete blood count, urinalysis, serum
electrolytes (Na, K, Cl), BUN and creatinine, serum bicarbonate or total CO2 if available or ABG (optional).

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(Strong, Low)

VI. What is the role of colonoscopy in the evaluation of acute infectious gastroenteritis in adult and pediatric
patients?
Colonoscopy is not warranted in the initial evaluation of acute infectious diarrhea. (Strong, Moderate)

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 TREATMENT: CHILDREN
TREATMENT: CHILDREN

IA. Who should be admitted among children presenting with acute infectious diarrhea?
Children with acute infectious diarrhea with any of the following clinical history and physical findings should
be admitted: (Strong, Very Low to Low)

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• Based on clinical history: unable to tolerate fluids, suspected electrolyte abnormalities, conditions
for a safe follow-up and home management are not met.
• Based on physical findings: altered consciousness, abdominal distention, respiratory distress,
hypothermia (temperature <36C)
Pediatric patients with acute infectious diarrhea with the following co-existing medical conditions should be
admitted: presence of co-existing infection/s (such as pneumonia, meningitis/encephalitis, sepsis),

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moderate to severe malnutrition, suspected surgical condition. (Strong, Very Low to Low)

IIA. What is the recommended management for dehydration among children with acute infectious
gastroenteritis?

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For breastfed infants, breastfeeding should be continued in addition to hydration therapy. (Best practice
statement)
Sports, carbonated, caffeinated and sweetened drinks are not recommended. (Best practice statement)

Table 4. Recommended management for children according to level of dehydration.

No dehydration
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Mild-moderate dehydration

recommended to replace on-going route is recommended to

Severe dehydration
Reduced oral rehydration solution is Reduced osmolarity ORS via oral Rapid intravenous rehydration is
recommended with either plain
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losses replace ongoing losses. If oral Lactated Ringer’s Solution or
rehydration is not feasible, 0.9% Sodium Chloride (with or
nasogastric tube is preferred without 5% glucose).
before IV hydration.
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If commercial ORS is not available,

home-made ORS may be given
(Strong, Low) (Strong, Low) (Strong, Low)

Frequency of monitoring (Strong, Low)

a. Check the child from time to time during rehydration to ensure ORS is being taken satisfactorily
and that signs of dehydration are not worsening.
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b. Evaluate status of hydration at least hourly.

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 Assessment on Degree of Dehydration

No Signs of Dehydration Mild to Moderate Dehydration

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1. Continue age appropriate diet 1. Approximate amount of ORS required (weight in kg
2. Provide fluid as tolerated x 75 ml) given in four hours.
3. Replace ongoing losses with ORS: PLUS
< 2 yrs old: 50 - 100 ml ORS after each loose 2. Replace losses with ORS:
stool < 2 yrs old: 50 -100 ml ORS after each loose stool
2-10 yrs old: 100 ml ORS after each loose 2-10 yrs old: 100 ml ORS after each loose stool

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stool >10 yrs old: as much fluid as they want
>10 yrs old: as much fluid as they want

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Reassess Degree of Dehydration.
(Repeat treatment as necessary up to 2 trials.)

YES
T NO
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ORS
Tolerated?

ORS thru NGT

Continue with present
hydration and reassess
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frequently
Not possible

LRS or 0.9% NaCl (with or

without 5% glucose) at
75ml/kg in four hours
intravenously
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YES
Stop IV Fluids and
complete Rehydration
with ORS
ORS
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Tolerated?

NO

Repeat for up to 2
trials

Fig.1 Protocol for mild dehydration and moderate dehydration (Adapted from WHO, 2005, ESPHGAN 2014)
 Assessment of Dehydration

Severe Dehydration

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LRS or 0.9% NaCl given over 3-6 hours as follows:

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Evaluate hydration every 15- 30 minutes, until hydration improves, thereafter

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they should be reassessed every hour.

Still with
severe
dehydration
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YES

NO
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 Consider ORS or continuous intravenous infusion
Use IVF fluid not less than D5 0.45% NaCl (at least 77mEq/L Na+) at maintenance rate

Maintenance fluid requirement is computed based on any of the following

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computations:
1.) Daily water requirement: 1500ml/m2 BSA / day
2.) Holliday-Segar Method (Weight-Based Method)

Body Fluid Per Day

Weight
0-10kg 100ml/kg

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11-20kg 1,000ml+50ml/kg for each kg
>10kg
>20kg 1,500ml+ 20ml/kg for each >20kg

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3.) Modified Finberg Method (Ludan/Basal Caloric Expenditure Method)
Body Fluid Per Day
Weight
3-10kg 100ml/kg/day

11-20kg

20-30kg
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75ml/kg/day

50-60ml/kg/day
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30-60kg 40-50ml/kg/day

PLUS
Ongoing losses in 24 hours
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Once the child is urinating, add 20meq KCL/L IVF

If more than 24 hours on intravenous hydration, adjust based on ongoing
reassessments
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NO
YES
Sufficient oral
intake for
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Discontinue IVF
losses?

Figure 2. Treatment protocol for severe dehydration (Adapted from WHO, 2005, ESPHGAN 2014)
 IIIA. What are the indications for empiric antibiotic treatment in children with acute infectious diarrhea?
Primary management in acute infectious diarrhea in children is still rehydration therapy. Routine empiric
antibiotic therapy is NOT recommended. (Strong, Very Low)
Antimicrobials may be recommended for the following conditions: suspected cases of cholera, cases of
bloody diarrhea and diarrhea associated with other acute infections (e.g. pneumonia, meningitis, etc.)
(Strong, Very Low)

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IVA. What are the recommended antimicrobials for the following etiologies of acute infectious diarrhea in
children?
21. Table 5. Directed therapy for specific organisms causing acute infectious diarrhea in children
Etiologic agent Antimicrobial
Suspected or confirmed cholera • Azithromycin 10 mg/kg/dose, once a day for 3 days or 20mg/kg x

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(Strong, low to moderate) 1 dose (max dose 500 mg/24 hr)
• Doxycycline 300 mg single dose (FOR >8 years old: 2mg/kg; max
100mg)
• Alternatives (when susceptible) include:

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- Co-trimoxazole 10mg/kg/day of trimethoprim and 50
mg/kg/day of sulfamethoxazole twice a day for 5 days (Max
dose: 160mg/dose BID) OR
- Chloramphenicol 50-100 mg/kg/day four times a day for 3
days (max dose: 750 mg) OR

Suspected or culture-proven
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- Erythromycin 12.5 mg/kg/dose four times a day x 3 days
(max dose 4g/24 hours)
• Ceftriaxone IV 50-75 mg/kg/d every 12-24 hours (max dose
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shigella (Strong, Moderate) 2g/24 hr) for 2-5 days
• Ciprofloxacin 30 mg/kg/d divided into 2 doses x 3 days (max dose
of IV 800 mg/24hrs).
• Azithromycin 10 mg once a day for three days (max 500mg/dose)
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Non-typhoidal Salmonella (NTS) Antibiotic treatment is NOT recommended for children with non-
(Strong, Low) typhoidal Salmonella EXCEPT in high risk children with certain underlying
conditions to prevent secondary bacteremia, including:
• neonates or young infants (<3 months)
• underlying immune-deficiency
• anatomical or functional asplenia
• corticosteroid or immunosuppressive therapy, IBD, or
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achlorhydria
Amoebiasis (strong, very low) Metronidazole 10 mg/kg/dose 3 times a day (max dose 750 mg/dose) for
5 to 10 days is recommended for confirmed cases of amoebiasis.
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 VA. What non-specific medications may be given in children with acute infectious gastroenteritis?
Zinc supplementation (20mg/day for 10-14 days) should be given routinely as adjunctive therapy for acute
infectious diarrhea in children more than 6 months old. (Strong, Low to Moderate)
Zinc supplementation is NOT routinely given as adjunctive therapy for acute infectious diarrhea in children
less than 6 months old. (Strong, Low to Moderate)
Racecadotril (1.5 mg/kg/dose) 3 times a day during the first 3 days of watery diarrhea may be given to infants

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and children as adjunctive therapy to shorten duration of diarrhea. (Weak, Low)
Loperamide is NOT recommended for children with acute infectious gastroenteritis due to serious adverse
events. (Strong, Moderate)

VIA. What is the role of anti-emetics in the management of vomiting in children with acute infectious diarrhea?
Anti-emetics are NOT recommended in children presenting with vomiting with acute infectious diarrhea due

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to safety issues. (Strong, Low)

VIIA. What is the role of probiotics in the management of acute infectious diarrhea in children?
Probiotics are recommended as an adjunct therapy in children throughout the duration of the diarrhea in

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children. Probiotics have been shown to reduce symptom severity and duration of diarrhea. (Strong,
Moderate)
Probiotics may be extended for 7 more days after completion of antibiotics. (Strong, Moderate)
The following probiotics may be used:
a. Saccharomyces boulardii 1010 units (Strong, Moderate)
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b. Lactobacilllus rhamnosus GG 1010 units (Strong, Moderate)
c. Lactobacillus reuteri (Weak, Very Low)
d. There is insufficient evidence to recommend Bacillus clausii.
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VIIIA. What is the recommended diet for children with acute infectious diarrhea?
Breastfeeding should be continued in breastfed infants. (Strong, Low to Moderate)
In general, feeding should be continued. However, if feeding is not tolerated, early refeeding may be started
as soon as the child is able. Resumption of age-appropriate usual diet is recommended during or immediately
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after rehydration process is completed. (Strong, Low to Moderate)

If diarrhea persists for more than 7 days, or for patients being treated in the hospital due to severe diarrhea,
lactose free diet may be given to children who are predominantly bottle-fed to reduce treatment failure and
decrease the duration of diarrhea. (Strong, Very Low to Low).
No change in diet is recommended. (Strong, Low)
Diluted lactose milk is NOT recommended. (Strong, Low)
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IXA. What is the recommended management for complications of acute infectious diarrhea in children?
Acute kidney injury is a serious and potentially life-threatening complication therefore it is best to refer the
patient immediately to a specialist at the first sign of AKI. (Best Practice Statement)
ORS is safe and effective therapy for nearly all children with hyponatremia.
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Hospital treatment and close monitoring is recommended for patients suspected to have hyponatremia.
Referral to specialist is advised.
 TREATMENT:
TREATMENT:ADULTADULT

IB. Who should be admitted among adults presenting with acute infectious diarrhea?
The following adult patients with the following clinical history and physical findings should be admitted
(Strong, Low to Moderate)
• Poor tolerance to oral rehydration

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• Moderate to severe dehydration
• Acute kidney injury and/or electrolyte abnormalities
• Unstable comorbid conditions (e.g. uncontrolled diabetes, congestive heart failure, unstable coronary
artery disease, chronic kidney disease, chronic liver disease, immunocompromised conditions)
• Frail, elderly (60 years old and above) and/or with poor nutritional status
• Patients with unique social circumstances (living alone, with residence far from a hospital)

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IIB. What is the recommended management for dehydration in adults?

Table 6. Recommended management for adults according to level of dehydration.

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Mild dehydration Oral rehydration solution is recommended at 1.5 to 2 times estimated amount of
volume deficits plus concurrent gastrointestinal losses. (Strong, low)
Moderate dehydration 500 to 1000 ml of PLRS IV in the first two hours is recommended. (Strong, Low)

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Once hemodynamically stable, give 2 – 3 ml/kg/hr PLRS for patients with actual or
estimated body weight of < 50 kg and 1.5 – 2 ml/kg/hr PLRS for patients with actual
or estimated body weight of > 50 kg. Use ideal body weight for overweight or obese
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patients. (Strong, Low)

PLR boluses vol/vol to replace ongoing losses or oral rehydration solution if

tolerated may be used for moderate dehydration. (Strong, Low)
Severe dehydration 1000 to 2000 ml of PLRS within the first hour is recommended. (Strong, Low)
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Once hemodynamically stable, give 2 – 3 ml/kg/hr PLRS for patients with actual or
estimated body weight of < 50 kg and 1.5 – 2 ml/kg/hr PLRS for patients with actual
or estimated body weight of > 50 kg. Use ideal body weight for overweight or obese
patients. (Strong, Low)
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We recommend vol/vol replacement with PLR boluses to replace ongoing losses for
severe dehydration because at this point the mental status of the patient may
already be compromised therefore the risk for aspiration is high. (Strong, Low)

Sports drinks and soda are not recommended to replace losses. (Strong, Low)
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The use of actual/estimated body weight for maintenance fluid rate calculations and ideal body weight for
overweight or obese patients is suggested. (Weak, Low)
Patients who are elderly and those at risk of fluid overload (patients with heart failure, kidney disease) should
be referred to a specialist for a more individualized fluid management. (Strong, Low)
Recommendations for type of fluid:
− The use of Plain Lactated Ringer’s Solution (chloride – restrictive IVF) as fluid of choice in the
hydration and fluid resuscitation of dehydrated patients caused by gastroenteritis is
 recommended. However, if Plain Lactated Ringer’s Solution is not available, Plain Normal Saline
Solution may still be used. (Strong, Low)
− During the initial resuscitation, hourly monitoring of the vital signs, mental status, peripheral
perfusion, and urine output must be done. Subsequent frequency of monitoring will be based on
the judgment of the clinician. (Strong, Very low)
− The routine use of albumin, HES, or dextran and gelatins as fluids for resuscitation of dehydrated

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patients is not recommended. (Strong, Moderate)

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Fig. 3 Algorithm for initial assessment of dehydration for adult patients.
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Fig 4. Algorithm for fluid resuscitation of adult patients.

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Fig. 5 Algorithm for maintenance and replacement therapy.

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 IIIB. What are the indications for empiric antimicrobial treatment in adults with acute infectious diarrhea?
Empiric antimicrobial treatment is NOT recommended for acute diarrhea with the following clinical
features: mild to moderate dehydration only, non-bloody stools, symptoms less than 3 days. (Strong,
Low)
Empiric antimicrobial treatment is recommended for patients with acute diarrhea with moderate to
severe dehydration plus any of the following clinical features: fever alone, fever and bloody stools,

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symptoms persisting for more than 3 days. (Strong, Low)
The following antimicrobials are recommended for empiric treatment of acute infectious diarrhea:
o Azithromycin 1g single dose OR
o Ciprofloxacin 500 mg twice daily for 3-5 days
o Once suspected organism is confirmed, antimicrobial therapy may be modified accordingly.

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IVB. What are the recommended antimicrobials for the following etiologies of acute infectious diarrhea in
adults?
Table 7. Directed therapy for selected etiologic agents causing diarrhea in adults.
Etiologic agent Antimicrobial

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Suspected or confirmed cholera • Azithromycin 1g single dose (Strong, high)
• Ciprofloxacin 1-2 gm single dose or 500 mg BID for 3 days
(Strong, low to moderate)
• Alternative: Doxycyline 100 mg BID for 3 days (Strong, low to
moderate)
Suspected or culture-proven
shigella
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• Ceftriaxone 1 g once a day for 5 days (Strong, Moderate to high)
OR
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• Ciprofloxacin 500mg twice a day for 5 days (Strong, Moderate to
high)
OR
• Azithromycin 1g single dose (Strong, Moderate to high)
*Once with culture, antimicrobial therapy can be modified accordingly.
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Suspected or confirmed non- • Ciprofloxacin 500mg twice a day for 5 days

typhoidal salmonella dysentery in (Strong recommendation, low to high quality evidence)
adults • Ceftriaxone 1g IV OD for 5 days
*Once with culture results, antimicrobial therapy may be modified
accordingly.
Confirmed amoebiasis • Metronidazole 500-750 mg tab three times a day for 10 days.
(Strong, High)
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• Alternative: Tinidazole 2 g OD for 3 days; secnidazole 2 g single

dose (Strong, High)
• Diloxanide furoate 500mg three times a day may be added to
metronidazole, if available.
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 VB. What non-specific medications may be given in adults with acute infectious diarrhea?
Loperamide is NOT recommended in adults with acute infectious diarrhea. (Weak, Low)
Racecadotril (100 mg three times a day) may be given to decrease the frequency and duration of diarrhea.
(Weak, Low)

VIB. What is the role of probiotics in the treatment of acute diarrhea among adults?

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There is insufficient evidence to recommend probiotics in adults. (Weak, Very low to low)

VIIB. What is the recommended management for complications of acute infectious diarrhea in adults?
Acute kidney injury is a serious and potentially life-threatening complication therefore it is best to refer the
patient immediately to a specialist at the first sign of AKI. (Best Practice Statement)
Hospital treatment and close monitoring is recommended for patients with severe

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hyponatremia/hypernatremia and/or symptomatic patients regardless of degree of sodium imbalance.
Approach to therapy depends on the risk stratification. Referral to specialist is advised. (Best Practice
Statement)

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Hospital treatment and close monitoring is recommended for patients with severe hypo/hypkalemia and/or
symptomatic patients regardless of degree of potassium imbalance. Referral to specialist is advised. (Best
Practice Statement)

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 PREVENTION
PREVENTION

I. What interventions are effective in the prevention of acute infectious diarrhea?

Hand hygiene
The promotion of hand hygiene in all settings, on all occasions is recommended to reduce transmission of

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causes of acute infectious diarrhea. (Strong, Low)
− Handwashing with soap and water is the best method to reduce the number of microbes.
− If soap and water are not available, alcohol based hand sanitizers (at least 60%) may be used.
Hand sanitizers and moist hand wipes or towelletes are not recommended when hands are visible
dirty or greasy.
All efforts should be made to provide access to clean water, soap and hand drying materials. (Strong,

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Moderate)

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Water safety Interventions

Drinking water should be clean and safe. Measures recommended in providing clean and safe water include
boiling, chemical disinfection, ultraviolet and filtration. (Strong, Moderate)
 Any drinking water should comply with the Philippine National Standards for Drinking water. (Best Practice
Statement).
Proper food handling
There is no specific recommended screening test for food handlers in the Philippines
No person shall be employed in any food establishment without a health certificate issued by the
city/municipal health officer based on the “Implementing Rules and Regulations of Chapter III Food

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Establishments On The Code on Sanitation Of the Philippines (P.D. 856)”. (Best Practice Statement)
Food industry workers need to notify their employers if with any of the following: Hepatitis A, diarrhea,
vomiting, fever, sore throat, skin rash and other skin lesions, discharge from ears, eyes or nose. (Best Practice
Statement)

Proper Excreta Disposal

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Combination of safe stool disposal and hand hygiene are key behaviors to prevent infectious diarrhea. (Strong,
Low to moderate)
Per DOH recommendation, the following are the approved excreta disposal facilities (Strong, Low to
Moderate)

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− Flush toilet connected to: community sewer, imhoff tank, septic tank, digester tank, chemical tank
− Pit privy: VIP latrine, Pit type and “antipolo” toilet
− Any disposal device approved by the Secretary of health or his duly authorized representative.
Open defecation is not recommended. (Strong, low to moderate)

Vaccines T
Killed Oral cholera vaccine may be given to children and adults living in an endemic area and during outbreaks
to prevent acute infectious diarrhea caused by cholera. (Strong, Moderate to high)
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Universal immunization of infants against rotavirus is recommended. Rotavirus vaccines are effective in
preventing rotavirus diarrhea and rotavirus diarrhea-associated hospitalization. (Strong, Moderate)

Supplements
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The following probiotics may be given to children and adult to prevent occurrence of acute infectious diarrhea
(Strong, low)
− Bifidocaterium lactis
− Lactobacillus rhamnosus GG
− Lactobacillus reuteri
Zinc supplementation is recommended to prevent acute infectious diarrhea for 6 months to 12 years old.
(Strong, Moderate)
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Vitamin A supplementation may be given to children (6 months and above) to prevent incidence of acute
infectious diarrhea. The recommended doses are (Strong, Low):
− 100,000 IU every 4-6 months for infants 6-12 months
− 200,000 IU every 4-6 months for children over 12 months
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Breastfeeding
Exclusive breastfeeding is recommended during the first 6 months of life to prevent diarrhea. (Strong,
Moderate)
All healthcare providers should promote breastfeeding. (Strong, Moderate)
 OUTBREAK
Outbreak detection and management
Outbreak is suspected in the following scenarios:
o “Cases of acute infectious diarrhea in excess of what would normally be expected in a defined
community, geographical area or season lasting a few days or weeks or for several years”(World
Health Organization)

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o “A single case of communicable disease that has been absent from a population, or caused by an
agent not previously recognized in the community, or the emergence of a previously known
disease”(Center for Disease Control)
Suspected cases of outbreaks should be reported immediately to disease reporting unit or disease
surveillance coordinators.
Collection of demographic data and specimen is mandatory. Stool samples via rectal swab or bulk stool

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should be sent to designated laboratories for analysis and confirmation. Water and food samples may
also be collected, to determine the source of outbreak.
Response to outbreak should involve epidemiologic investigation and formation of hypotheses,
treatment of cases, implementation of control and prevention measures, and risk communication.

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REFERENCES

1. ACG clinical guideline: diagnosis, treatment and prevention of acute diarrheal infections in adults. ACG. 2016,
Am J Gastroenterol, p. doi:10.1038/ajg.2016.126.
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2. WHO. Integrated management of childhoold illness: distance learning course. Module 4: Diarrhoea.
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Switzerland : WHO Press, 2014.

3. Joint Statemetn: Clinical Management of Acute Diarrhea. Geneva: World Health Organization, Department of
Chil and Adolescent Health and Developemnt, and United Nations Children's Fund, Program DIvision,
Geneva2004. WHO/UNICEF.
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