A multicenter randomized controlled trial of a liquid loperamide product versus placebo in the treatment of acute diarrhea in children

Pharmacologic Treatment of Opioid Use Disorder: a Review of Pharmacotherapy, Adjuncts, and Toxicity

Opioid use disorder continues to be a significant source of morbidity and mortality in the USA and the world. Pharmacologic treatment with methadone and buprenorphine has been shown to be effective at retaining people in treatment programs, decreasing illicit opioid use, decreasing rates of hepatitis B, and reducing all cause and overdose mortality. Unfortunately, barriers exist in accessing these lifesaving medications: users wishing to start buprenorphine therapy require a waivered provider to prescribe the medication, while some states have no methadone clinics. As such, users looking to wean themselves from opioids or treat their opioid dependence will turn to alternative agents. These agents include using prescription medications, like clonidine or gabapentin, off-label, or over the counter drugs, like loperamide, in supratherapeutic doses. This review provides information on the pharmacology and the toxic effects of pharmacologic agents that are used to treat opioid use disorder. The xenobiotics reviewed in depth include buprenorphine, clonidine, kratom, loperamide, and methadone, with additional information provided on lofexidine, akuamma seeds, kava, and gabapentin.

Oral administration of tannins and flavonoids in children with acute diarrhea: a pilot, randomized, control-case study

BACKGROUND

AG is the most common cause of pediatric consultations among children between 2 and 5 years of age and it still leads to high mortality and morbidity. Its management is based on rehydration therapy, but this treatment is not effective in reducing duration of diarrhea. For this reason, other safer and less expensive interventions, which could be added to oral rehydration therapy, are of great interest.

METHODS

A pilot, randomized, case-controlled trial was conducted in 60 children affected by AG (< 7 days) with mild-moderate dehydration, according to WHO recommendations, from1 year to 17 years old. Patients were divided into 2 Groups: Group 1 consisting of 30 children treated with Actitan F and standard oral rehydration (SOR); Group 2 consisting of 30 children who received only SOR. Both groups received treatment for seven days, respectively. Patients of Group 1 stopped for their own choice, SOR after the first 24 h and continued only with Actitan F.

RESULTS

After 24 h of treatment, the median number of stools was 3.5 for Group 1, and 4 for Group 2. In Group 1 the difference between the number of stools at baseline (n = 5) and after 24 h of treatment (n = 3.5) was significant (p < 0.0001). At the end of treatment, the median duration of diarrhea in Group 1 was 5 days, compared with 4 days in the Group 2, this difference was not statically significant (p 0.48).

CONCLUSIONS

Oral administration of Actitan F associated with SOR seems safe and effective treatment in shortening the duration of AG in children. Further studies confirming these data are needed.

TRIAL REGISTRATION

NCT03356327 (retrospectively registered).

A Review on the Management of Acute Gastroenteritis in Children

Acute gastroenteritis represents a frequent cause of morbidity among children in Hong Kong. Despite the large number of potential etiologic agents, principles of management of gastroenteritis are uniform and aim to prevent the two major complications - dehydration and malnutrition. A review of the literature was performed. Selected articles were appraised, graded, and synthesised qualitatively. Statements on recommendations were generated. Current evidence emphasises the use of oral rehydration and the early reintroduction of age-appropriate foods. Apart from these two, important aspects of management reviewed included laboratory investigations, role of anti-diarrhoeal agents, and use of antimicrobial agents. Criteria for admission of high-risk children are also addressed.

Management of Acute Diarrheal Illness During Deployment: A Deployment Health Guideline and Expert Panel Report

BACKGROUND

Acute diarrheal illness during deployment causes significant morbidity and loss of duty days. Effective and timely treatment is needed to reduce individual, unit, and health system performance impacts.

METHODS

This critical appraisal of the literature, as part of the development of expert consensus guidelines, asked several key questions related to self-care and healthcare-seeking behavior, antibiotics for self-treatment of travelers' diarrhea, what antibiotics/regimens should be considered for treatment of acute watery diarrhea and febrile diarrhea and/or dysentery, and when and what laboratory diagnostics should be used to support management of deployment-related travelers' diarrhea. Studies of acute diarrhea management in military and other travelers were assessed for relevance and quality. On the basis of this critical appraisal, guideline recommendations were developed and graded by the Expert Panel using good standards in clinical guideline development methodology.

RESULTS

New definitions for defining the severity of diarrhea during deployment were established. A total of 13 graded recommendations on the topics of prophylaxis, therapy and diagnosis, and follow-up were developed. In addition, four non-graded consensus-based statements were adopted.

CONCLUSIONS

Successful management of acute diarrheal illness during deployment requires action at the provider, population, and commander levels. Strong evidence supports that single-dose antimicrobial therapy is effective in most cases of moderate to severe acute diarrheal illness during deployment. Further studies are needed to address gaps in available knowledge regarding optimal therapies for treatment, prevention, and laboratory testing of acute diarrheal illness.

Guidelines for the prevention and treatment of travelers' diarrhea: a graded expert panel report

BACKGROUND

: Travelers' diarrhea causes significant morbidity including some sequelae, lost travel time and opportunity cost to both travelers and countries receiving travelers. Effective prevention and treatment are needed to reduce these negative impacts.

METHODS

: This critical appraisal of the literature and expert consensus guideline development effort asked several key questions related to antibiotic and non-antibiotic prophylaxis and treatment, utility of available diagnostics, impact of multi-drug resistant (MDR) colonization associated with travel and travelers' diarrhea, and how our understanding of the gastrointestinal microbiome should influence current practice and future research. Studies related to these key clinical areas were assessed for relevance and quality. Based on this critical appraisal, guidelines were developed and voted on using current standards for clinical guideline development methodology.

RESULTS

: New definitions for severity of travelers' diarrhea were developed. A total of 20 graded recommendations on the topics of prophylaxis, diagnosis, therapy and follow-up were developed. In addition, three non-graded consensus-based statements were adopted.

CONCLUSIONS

: Prevention and treatment of travelers' diarrhea requires action at the provider, traveler and research community levels. Strong evidence supports the effectiveness of antimicrobial therapy in most cases of moderate to severe travelers' diarrhea, while either increasing intake of fluids only or loperamide or bismuth subsalicylate may suffice for most cases of mild diarrhea. Further studies are needed to address knowledge gaps regarding optimal therapies, the individual, community and global health risks of MDR acquisition, manipulation of the microbiome in prevention and treatment and the utility of laboratory testing in returning travelers with persistent diarrhea.

Nonprescription Medication Use by Infants and Children: Product Labeling Versus Evidence-Based Medicine

Nonprescription or over-the-counter (OTC) medication use has been an increasing market over the past years. In addition to adult use of these medications, children also account for this trend. Although relatively safe when used according to package labeling and professional direction, serious adverse drug events and toxicity associated withOTC use among infants and children are becoming more common. The purpose of this review is to help the health care practitioner select and counsel on pediatric OTC products based on labeling and efficacy data in 3 main areas: cough and cold, analgesics, and treatment of gastroenteritis.

ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults

Acute diarrheal infections are a common health problem globally and among both individuals in the United States and traveling to developing world countries. Multiple modalities including antibiotic and non-antibiotic therapies have been used to address these common infections. Information on treatment, prevention, diagnostics, and the consequences of acute diarrhea infection has emerged and helps to inform clinical management. In this ACG Clinical Guideline, the authors present an evidence-based approach to diagnosis, prevention, and treatment of acute diarrhea infection in both US-based and travel settings.

Summary of the Committee to Advise on Tropical Medicine and Travel (CATMAT) Statement on Travellers' Diarrhea

Background

Most travellers' diarrhea (TD) infections occur during travel to low- and middle-income countries. Type of travel, duration of stay, age of traveller and presence of certain medical conditions are important factors to consider for risk of TD. The Committee to Advise on Tropical Medicine and Travel (CATMAT) assembled a TD working group to develop recommendations on prevention and treatment of TD in travellers. This document is a summary of the Statement on Travellers' Diarrhea.

Methods

Following a systematic review of the literature, recommendations on the prevention and treatment of TD were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to evaluate data quality, benefits and harms of the intervention, and values and preferences of the traveller. Other recommendations were based on a review of the literature and expert opinion.

Recommendations

Using the GRADE methodology, CATMAT concluded that oral cholera vaccine should not be routinely recommended to prevent TD in Canadian travellers. This recommendation was based on moderate quality data that showed this vaccine was not effective in preventing TD in travellers compared to placebo. Bismuth subsalicylate (BSS), fluoroquinolones or rifaximin are options for the prevention of TD based on high-quality data for BSS and fluoroquinolones and moderate evidence for rifaximin. For the treatment of TD, loperamide (alone or in combination with antibiotics), fluoroquinolones, azithromycin and rifaximin are all options, with varying degrees of data quality. Based on available evidence and expert opinion, CATMAT recommends handwashing or the use of hand sanitizer, as well as prudent choice and preparation of food and beverages as best practices for preventing diarrhea while travelling. At this time, a recommendation cannot be made for either the use of probiotics and prebiotics to prevent TD or the use of BSS to treat TD due to insufficient available evidence.

Conclusion

With the exception of BSS for prevention of TD (strong recommendation for use), CATMAT conditionally recommends the use of each of the other GRADE-evaluated preventive and therapeutic products assessed in this Statement. These CATMAT recommendations should be considered as options in the prevention and treatment of TD based on the particular situation of the traveller.

Resolution of acute gastroenteritis symptoms in children and adults treated with a novel polyphenol-based prebiotic

AIM: To test efficacy and durability of a polyphenol-based prebiotic treatment for acute gastroenteritis in a 300 patient double-blinded clinical study.

METHODS: A two-arm randomized, double-blinded, placebo-controlled clinical study was conducted at two public health centers in Managua, Nicaragua. Potential subjects who qualified based on inclusion and exclusion criteria were randomly assigned to one of two treatment arms. Two thirds of the subjects (n = 200) received a single titrated 0.5-2 ounce liquid dose of a novel polyphenol-based prebiotic (Aliva^TM) diluted with 2 to eight ounces of oral rehydration solution (ORS). One third of the subjects (n = 100) were randomized to receive two liquid ounces of a taste and color-matched placebo diluted in eight ounces of ORS. The outcome variables measured included stool consistency, stomach discomfort, gas and bloating, and heartburn/indigestion. The study subjects ranked their stool consistency and the severity of their subjective symptoms at specified intervals from immediately prior to treatment, to five days post treatment. All subjects recorded their symptoms in a study diary. The study subjects also recorded the time and consistencies of all stools in their study diary. Stool consistency was compared to the picture and descriptions on the Bristol Stool Chart, and any stool rated greater than Type 4 was considered unformed. The clinical study team reviewed the study diaries with subjects during daily follow-up calls and close-out visits, and recorded the data in case report forms.

RESULTS: After receiving a single dose, Aliva treated subjects reported shorter median time to their last unformed stool (1 h 50 min) than placebo treated subjects (67 h 50 min.), a statistically significant difference [95%CI: -3178-(-2018), P = 0.000]. Aliva treated subjects also reported shorter median their time to last unformed stool (TTLUS) (1hrs 50 min) than placebo treated subjects (67 h 50 min), which was also a statistically significant difference (P = 0.000).The percentage of subjects recording TTLUS was greater for those who received Aliva vs placebo at 30 min (P = 0.027), 2 h (P = 0.000), 24 h (P = 0.000), 48 h (P = 0.000), 72 h (P = 0.000), and 5 d (P = 0.000) post dose. There were 146 study subjects 14 years old or older, which was the criteria set for reliable self-reporting of subjective symptoms. Of those 146 subjects, 142 reported stomach pain and discomfort during screening. From 90 minutes [95%CI: -1.8-(-0.01), P = 0.048] through 5 d [95%CI: -3.4-(-1.9), P = 0.000), the subjects treated with Aliva experienced significantly less stomach pain and discomfort than those who received placebo. Of those same 146 participants, 114 subjects reported gas and bloating during screening. Similarly, subjects who received Aliva experienced significantly less gas and bloating from 2 h [95%CI: -1.7-(-0.39), P = 0.030] through 5 d (95%CI: -2.0-0.42, P = 0.005) compared with the placebo arm.

CONCLUSION: In this double-blind, randomized clinical study, subjects with acute gastroenteritis receiving Aliva prebiotic showed significant and sustained improvement of multiple symptoms vs those receiving placebo.

Travel-related infections in children

Malaria, diarrhea, respiratory infections, and cutaneous larva migrans are common travel-related infections observed in children and adolescents returning from trips to developing countries. Children visiting friends and relatives are at the highest risk because few visit travel clinics before travel, their stays are longer, and the sites they visit are more rural. Clinicians must be able to prepare their pediatric-age travelers before departure with preventive education, prophylactic and self-treating medications, and vaccinations. Familiarity with the clinical manifestations and treatment of travel-related infections will secure prompt and effective therapy.

The safety of drugs used in acid-related disorders and functional gastrointestinal disorders

Medicines are frequently used in the management of acid-related disorders and functional gastrointestinal disorders. With the exception of complicated peptic ulcer disease, these disorders are not associated with appreciable mortality. Drug treatments have consequently been held to the highest standards of safety. Some medicines have been withdrawn or restricted based on assessments and perceptions of risk. However, the risk of serious toxicity is low for most of the agents discussed in this article. Assessments are made of the safety and adverse-event profiles of certain drug classes and, where appropriate, individual medicines. For conditions with a low risk of mortality or serious morbidity, clinicians need to balance the risks of potential adverse events with the anticipated benefits of a successful outcome of specific drug treatment.

Measurement issues in trials of pediatric acute diarrheal diseases: a systematic review

BACKGROUND

Worldwide, diarrheal diseases rank second among conditions that afflict children. Despite the disease burden, there is limited consensus on how to define and measure pediatric acute diarrhea in trials.

OBJECTIVES

In RCTs of children involving acute diarrhea as the primary outcome, we documented (1) how acute diarrhea and its resolution were defined, (2) all primary outcomes, (3) the psychometric properties of instruments used to measure acute diarrhea and (4) the methodologic quality of included trials, as reported.

METHODS

We searched CENTRAL, Embase, Global Health, and Medline from inception to February 2009. English-language RCTs of children younger than 19 years that measured acute diarrhea as a primary outcome were chosen.

RESULTS

We identified 138 RCTs reporting on 1 or more primary outcomes related to pediatric acute diarrhea/diseases. Included trials used 64 unique definitions of diarrhea, 69 unique definitions of diarrhea resolution, and 46 unique primary outcomes. The majority of included trials evaluated short-term clinical disease activity (incidence and duration of diarrhea), laboratory outcomes, or a composite of these end points. Thirty-two trials used instruments (eg, single and multidomain scoring systems) to support assessment of disease activity. Of these, 3 trials stated that their instrument was valid; however, none of the trials (or their citations) reported evidence of this validity. The overall methodologic quality of included trials was good.

CONCLUSIONS

Even in what would be considered methodologically sound clinical trials, definitions of diarrhea, primary outcomes, and instruments employed in RCTs of pediatric acute diarrhea are heterogeneous, lack evidence of validity, and focus on indices that may not be important to participants.

Prescription trends for treatment of paediatric gastroenteritis at a Japanese hospital between 1997 and 2007

OBJECTIVE

We aimed to investigate recent trends in prescriptions for the treatment of paediatric gastroenteritis in Japan over a 10-year period (1997-2007).

METHODS

In this retrospective cohort study, we collected data for 2295 prescriptions for 1241 putative cases of paediatric gastroenteritis, which were treated between 1997 and 2007 at Hamamatsu University Hospital, Hamamatsu, Japan.

RESULTS

The most frequently prescribed drugs were probiotics (n = 621), followed by anti-emetics (n = 474). In most years between 1997 and 2007, more cases were treated with probiotics than with any other drug type (30.6-63.3% of cases), with the percentage increasing between 2005 and 2007. In contrast, the frequencies of anti-emetic and antipyretic prescriptions remained fairly stable, and prescriptions for antibiotics decreased slightly over the study period. Anti-emetics were commonly used in this hospital.

CONCLUSION

Although experimental evidence upon which to base recommendations is lacking, Japanese evidence-based guidelines are critical for improving the quality of treatment of paediatric gastroenteritis.

The 2005 meta-analysis of homeopathy: the importance of post-publication data

BACKGROUND

There is a discrepancy between the outcome of a meta-analysis published in 1997 of 89 trials of homeopathy by Linde et al and an analysis of 110 trials by Shang et al published in 2005, these reached opposite conclusions. Important data were not mentioned in Shang et al's paper, but only provided subsequently.

QUESTIONS

What was the outcome of Shang et al's predefined hypotheses? Were the homeopathic and conventional trials comparable? Was subgroup selection justified? The possible role of ineffective treatments. Was the conclusion about effect justified? Were essential data missing in the original article?

METHODS

Analysis of post-publication data. Re-extraction and analysis of 21 higher quality trials selected by Shang et al with sensitivity analysis for the influence of single indications. Analysis of comparability. Sensitivity analysis of influence of subjective choices, like quality of single indications and of cut-off values for 'larger samples'.

RESULTS

The quality of trials of homeopathy was better than of conventional trials. Regarding smaller trials, homeopathy accounted for 14 out of 83 and conventional medicine 2 out of 78 good quality trials with n<100. There was selective inclusion of unpublished trials only for homeopathy. Quality was assessed differently from previous analyses. Selecting subgroups on sample size and quality caused incomplete matching of homeopathy and conventional trials. Cut-off values for larger trials differed between homeopathy and conventional medicine without plausible reason. Sensitivity analyses for the influence of heterogeneity and the cut-off value for 'larger higher quality studies' were missing. Homeopathy is not effective for muscle soreness after long distance running, OR=1.30 (95% CI 0.96-1.76). The subset of homeopathy trials on which the conclusion was based was heterogeneous, comprising 8 trials on 8 different indications, and was not matched on indication with those of conventional medicine. Essential data were missing in the original paper.

CONCLUSION

Re-analysis of Shang's post-publication data did not support the conclusion that homeopathy is a placebo effect. The conclusion that homeopathy is and that conventional is not a placebo effect was not based on comparative analysis and not justified because of heterogeneity and lack of sensitivity analysis. If we confine ourselves to the predefined hypotheses and the part of the analysis that is indeed comparative, the conclusion should be that quality of homeopathic trials is better than of conventional trials, for all trials (p=0.03) as well as for smaller trials (p=0.003).

Acute infectious pediatric gastroenteritis: beyond oral rehydration therapy

Worldwide diarrheal diseases are a leading cause of childhood morbidity and mortality. Improvements in gastroenteritis management have reduced the annual number of pediatric deaths attributable to gastroenteritis from 5 million in 1982 to 2 million over 20 years. Recent advances are likely to contribute further to a reduction in morbidity and mortality secondary to acute infectious gastroenteritis. A new generation of vaccines against rotavirus is entering into routine use. Research into antisecretory agents has demonstrated that this class of medications may play a significant role in the future management of acute infectious gastroenteritis. A significant body of literature has recently emerged supporting the use of the antiemetic agent ondansetron. In developing countries, the routine use of zinc is now recommended by many experts, while, in developed countries, the use of probiotic agents has been associated with significant benefits in acute infectious gastroenteritis. Finally, more aggressive intravenous rehydration strategies are being employed; however, at present, limited data from randomized clinical trials are available to support its routine use.

Loperamide therapy for acute diarrhea in children: systematic review and meta-analysis

BACKGROUND

Loperamide is widely used in adults for acute diarrhea. However, its use in children has been discouraged by the World Health Organization and the American Academy of Pediatrics owing to concerns over safety and efficacy in young children.

METHODS AND FINDINGS

To assess the efficacy and adverse effects of loperamide compared with placebo for acute diarrhea in children, we reviewed Medline, EMBase, the Cochrane Central Register of Controlled Trials, and bibliographies of known clinical trials and of review articles, and we also interviewed key investigators in the field. We undertook a systematic review and meta-analysis of randomized controlled trials of children younger than 12 y of age with acute diarrhea, comparing loperamide with placebo. Included trials reported data on diarrhea duration or severity, or provided data on adverse effects. Compared with patients who received placebo, patients allocated to loperamide were less likely to continue to have diarrhea at 24 h (prevalence ratio 0.66, 95% confidence interval [CI]: 0.57 to 0.78), had a shorter duration of diarrhea by 0.8 d (95% CI: 0.7 to 0.9 d), and had a lower count of stools at 24 h (0.84, 95% CI: 0.77 to 0.92). Results were similar when random-effects summaries were estimated. Serious adverse events, defined as ileus, lethargy, or death, were reported in eight out of 927 children allocated to loperamide (0.9%, 95% CI: 0.4% to 1.7%). Serious adverse events were not reported in any of the 764 children allocated to placebo (0%, 95% CI: 0% to 0.5%). Among the children allocated to loperamide, serious adverse events were reported only among children younger than 3 y.

CONCLUSIONS

In children who are younger than 3 y, malnourished, moderately or severely dehydrated, systemically ill, or have bloody diarrhea, adverse events outweigh benefits even at doses <or=0.25 mg/kg/d. In children who are older than 3 y with no/minimal dehydration, loperamide may be a useful adjunct to oral rehydration and early refeeding.

Traveler's diarrhea in the pediatric population: etiology and impact

Children who travel are at risk of developing the same, well-known illnesses that affect adult travelers. The etiology, treatment, and actual risk of these illnesses are not well defined in children. The limited amount of data available forces clinicians to extrapolate appropriate treatment for children. Recommendations for children have not been standardized. The role and judicious use of antimicrobials in the treatment of pediatric traveler's diarrhea have evolved during recent decades and will be reviewed here. The past 2 decades have seen an unprecedented, sustained growth in travel. The epidemiology related to travel medicine has evolved to describe travelers and their illnesses more specifically. The development of the field of travel medicine has led to greater understanding and improved, targeted treatment of travel-related illnesses. Most of the data available today describe traveler's diarrhea in adults. Children traveling to distant destinations from their home country have not been well studied, yet treatment parameters exist in practice and will be reviewed here.

Effect of oral administration of tormentil root extract (Potentilla tormentilla) on rotavirus diarrhea in children: a randomized, double blind, controlled trial

OBJECTIVES

To determine the effectiveness of tormentil root extract (TRE) for treatment of rotavirus diarrhea in children.

BACKGROUND

Rotavirus, one of the most widely spread pathogens of acute, dehydrating diarrhea in children, is estimated to cause >800 000 annual deaths of young children in developing countries. Currently no rotavirus vaccine is available. Management involves rehydration therapy. Available antiperistaltic or antisecretory drugs to reduce the severity of diarrhea can cause serious side effects in children.

METHODS

A randomized, double blinded, placebo-controlled trial was conducted at Children's Hospital for Infectious Diseases #3, St. Petersburg, Russia in 40 children ranging in age from 3 months to 7 years with rotavirus diarrhea. We constructed 2 groups for comparison: a treatment group that consisted of 20 children treated with tormentil root extract; and a control group of 20 children who received a placebo. All patients received 3 drops of tormentil root extract or placebo per year of life, three times daily until discontinuation of diarrhea, or a maximum of 5 days. An objective method was used to evaluate diarrhea, and physical examination was used to assess degree of dehydration in children.

RESULTS

The duration of diarrhea in the tormentil root extract treatment group was 3 days, compared with 5 days in the control group (P < 0.0001). In the treatment group 8 of 20 (40%) children were diarrhea-free 48 h after admission to the hospital, compared with 1 of 20 (5%) in the control group (P < 0.0001). Subjects in the treatment group received smaller volumes of parenteral fluids than subjects in the control group.

CONCLUSIONS

The administration of tormentil root extract in controlled doses shortened the duration of rotavirus diarrhea and decreased the requirement for rehydration solutions. Tormentil root extract appears to be an effective measure to treat rotavirus diarrhea in children.

[Drug treatment of acute infectious diarrhea in infants and children]

In this paper written by the Groupe francophone d'hépatologie, gastroentérologie et nutrition pédiatriques, recommendations are given on the indications of drugs in infant and child infectious acute diarrhea, based upon the current scientific knowledge on their effectiveness and tolerance. This paper complements an article on nutritional treatment of acute diarrhea written by the Comité de nutrition de la Société française de pédiatrie, and published in the same issue of the Archives de Pédiatrie.

Guidelines for adults on self-medication for the treatment of acute diarrhoea

Acute uncomplicated diarrhoea is commonly treated by self-medication. Guidelines for treatment exist, but are inconsistent, sometimes contradictory, and often owe more to dogma than evidence. An ad hoc multidisciplinary group has reviewed the literature to determine best practice. In general it is recognized that treatment of acute episodes relieves discomfort and social dysfunction. There is no evidence that it prolongs the illness. Self-medication in otherwise healthy adults is safe. Oral loperamide is the treatment of choice. Older anti-diarrhoeal drugs are also effective in the relief of symptoms but carry the risk of unwanted adverse effects. Oral rehydration solutions do not relieve diarrhoea, and confer no added benefit for adults who can maintain their fluid intake. Probiotic agents are, at present, limited in efficacy and availability. Antimicrobial drugs, available without prescription in some countries, are not generally appropriate for self-medication, except for travellers on the basis of medical advice prior to departure. Medical intervention is recommended for the management of acute diarrhoea in the frail, the elderly (> 75 years), persons with concurrent chronic disease, and children. Medical intervention is also required when there is no abatement of the symptoms after 48 h, or when there is evidence of deterioration such as dehydration, abdominal distension, or the onset of dysentery (pyrexia > 38.5 degrees C and/or bloody stools).