NHG Guideline on acute diarrhoea

The Guideline on Acute Diarrhoea published by the Dutch College of General Practitioners (NHG) provides recommendations for diagnosing and treating acute (presumably infectious) diarrhoea. It rightly devotes much attention to effective rehydration with ORS of dehydrated patients or patients at increased risk of dehydration, as this is a delicate and intensive approach for patients and their carers. The use of ORS is limited in practice by its unpleasant taste, but there are less unpleasant variants available. Recommendations concerning loperamide are cautious, much more so than those in the Dutch Informatorium Medicamentorum10 and Kinderformularium11, which recommend a lower age limit of three years for safe use. In view of the serious side-effects that may occur, this caution is justified, and one might even ask whether the recommendations should not have been even more cautious, the more so since there is rarely an indication for use of this agent by children. Instead of prescribing loperamide, the family doctor can recommend it as a self-care product, to reduce costs. The ‘Website of the month’ section of this issue is devoted to a website about loperamide: www.imodium.nl (Gebu 2015; 49: 25).
The efficacy of probiotics in the treatment of acute antibiotic-induced diarrhoea has not been proven (Gebu 2014; 48: 23-24). The use of the over-the-counter astringent gelatin tannate, a mixture of gelatin and tannic acid (Tasectan®), has been criticised before because of the lack of evidence for its efficacy (Gebu 2013; 47: 110). Activated coal is being used as a universal antidote for nearly all auto-intoxications, as it prevents absorption of nearly all drugs. Hence, the warning against the use of this agent could have been phrased in stronger terms.
If there is an indication for prescribing antibiotics to a child, the family doctor should also consult a paediatrician.
There is rarely a need to prescribe antibiotics, and the guideline recommends azitromycin if an antibiotic is required. However, azitromycin is associated with an increased risk of cardiovascular side-effects and cardiac death (Gebu 2013; 47: 21-22). Since no randomised trials are available to support its use, the decision will have to be made by each individual doctor.
A recently published Dutch case-control study found that healthy children are often carriers of Dientamoeba fragilis without experiencing any complaints.12 It is therefore questionable whether the presence of this parasite in faeces should be an indication for treatment.

1. Belo JN, et al. NHG-Standaard ’Acute diarree’ (derde herziening). Huisarts Wet 2014; 57: 462-471.
2. Kneepkens CM, et al. Peuterdiarree. Ned Tijdschr Geneeskd 1996; 140: 2026-2028.
3. Scholten P, et al. Chronische diarree; het belang van de anamnese. Ned Tijdschr Geneeskd 2006; 150: 405-408.
4. Fonseca BK, et al. Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of randomized controlled trials. Arch Pediatr Adolesc Med 2004; 158: 483-490.
5. Bellemare S, et al. Oral rehydration versus intravenous therapy for treating dehydration due to gastroenteritis in children: a meta-analysis of randomised controlled trials. BMC Med 2004; 2: 11.
6. Gottlieb T, et al. Diarrhoea in adults (acute). Clin Evid (Online) 2011.
7. Li ST, et al. Loperamide therapy for acute diarrhea in children: systematic review and meta-analysis. PLoS Med 2007; 4: e98.
8. Allen SJ, et al. Probiotics for treating acute infectious diarrhoea. Cochrane Database Syst Rev 2010:CD003048.
9. SWAB richtlijn ’Antimicrobiële therapie voor acute infectieuze diarree’ (2014). SWAB. Via: http://www.swab.nl/swab/cms3.nsf/uploads/B5B9ED1BD30F42DFC1257CB80019C398/$FILE/Herziene%20SWAB%20richtlijn%20Acute%20Diarree.pdf
10. Informatorium Medicamentorum. Den Haag: KNMP, 2015.
11. www.kinderformularium.nl.
12. Jong MJ de, et al. Dientamoeba fragilis and chronic abdominal pain in children: a case-control study. Arch Dis Child 2014; 99: 1109-1113.

*The literature refers to the Dutch tekst


  • mw drs Z. Damen-van Beek