The global burden of diarrhoea is still a major cause of morbidity and mortality worldwide. In in 2017, 1.6 million people died globally and there were 75 deaths per 100 000 inhabitants in 2019.
Diarrhoeal diseases are the third-leading cause of child mortality globally behind pneumonia and preterm birth complications. Viruses are the leading cause of diarrhoea, mainly in paediatric age. Bacterial infections are decreasing in high-income countries with significant reduction in the incidence of salmonella by 40%. Approximately 30% of episodes are still of unknown aetiology. The aetiology changes based on geographical area (low/ high income), setting (rural vs urban), underlying conditions (malnutrition), and patients’ age.
Aetiology of acute diarrhoea has age-related pathology. Viral aetiology is the most common with rotavirus as the leading cause of diarrhoea and fatality in childhood. Bacteria are more common in older children, adults and the elderly. What is changing the epidemiology of acute diarrhoea worldwide? Nucleic acid amplification tests (Multiplex PCR) have 98% sensitivity and 99% specificity. Multiplex PCR can indicate 11 bacteria, five viruses, four parasites and show rapid results, within a few hours.
They have elevated diagnostic yield pathogen positivity to 56% vs conventional methods which show only 16%.
Rotavirus (RV) vaccination could prevent up to 96% of RV-related hospitalisations in children under one year of age and 55% in children aged 1-4 years. Children with rotavirus gastroenteritis (RVGE) had less severe clinical features and shortened hospitalisation. Older, unimmunised children and the elderly may benefit from a herd effect. SARS-CoV-2 as an enteric pathogen has gastrointestinal (GI) symptoms more common in children vs adults. Diarrhoea is the most common GI symptom, which is usually self-limiting, with a duration of 3-5 days (usually mild) with 3-4 bowel movements per day. Rare severe cases have 18-30 movements per day, infrequently reported in adults.
SARS-CoV-2 is an enteric virus to be included in the list of pathogens. In children with SARS-CoV-2 infection, diarrhoea may be the expression of severe clinical features. The Covid pandemic changed the epidemiology of acute diarrhoea worldwide, having a huge impact on the virus and a minor impact on bacteria and parasites. The Covid pandemic also affected RV vaccination coverage.
Management of acute gastroenteritis is done through rehydration, antidiarrhoeals, anti-infectives such as antibiotics, antiprotozoals, antivirals, anthelminthics, and nutrition. Symptomatic relief includes antiemetics, antipyretics and spasmolytics. Agents that minimise the symptoms of diarrhoea by specific or ill-defined or non-specific mechanisms of action, aim to improve stool consistency, reduce stool frequency and reduce stool weight.
Pathogenesis of infectious and noninfectious diarrhoea includes loss of intestinal epithelial barrier function and disturbances in gastrointestinal transit. Treatment aims to create a mechanical barrier over the mucosa, reduce mucosa contact with allergies, irritants pathogens, and their virulence factors and triggering factors, as well as to slow the rapid transport. Diosmectite is an absorbent natural, aluminum-magnesium silicate clay with a lamellar structure. It binds endo and exotoxins, viruses and bacteria. It modifies physical properties of gastric and intestine mucus and reduces inflammation. It has no systemic effect and does not produce any microbiota-related physiological alterations. Diosmectite strongly reduced the enterotoxic effects and the stress induced by SARS-CoV-2 and spike protein. Diosmectite inhibits the interaction between SARS-CoV-2 and enterocytes by trapping viral particles. Better understanding of new diarrhoea pathogens mechanisms such as SARS-CoV-2 is still needed and will lead to better use of antidiarrhoeal arsenal in Covid-19 patients with diarrhoea.
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References available on request.