Antiamoebic drugs for treating amoebic colitis

A high-dimensional platform for observing neutrophil-parasite interactions

Diarrheal diseases with infectious etiology remain a major cause of death globally, particularly in low-income countries. Entamoeba histolytica is a pathogenic protozoan parasite that is the causative agent of amebiasis. Amebiasis has a wide presentation in clinical severity with many factors, including the bacterial microbiota, contributing to this variation. The innate immune response also plays a critical role in regulating the severity of E. histolytica infection, with neutrophils reported to have a protective role. Despite this, the precise mechanism of how neutrophils mediate amebic killing is poorly understood. Thus, modern platforms that allow for inquiry of granulocyte-ameba interactions will increase our understanding of this disease. Herein, we describe an assay for neutrophil killing of E. histolytica by utilizing high-dimensional spectral flow cytometry. Neutrophils were isolated from wild-type 5-week-old C57BL/6 mice and co-cultured with E. histolytica at various multiplicity of infections (MOIs). After co-culture, neutrophils and E. histolytica were stained for spectral flow cytometry. Cell populations were identified using surface markers and fluorescence minus one (FMO) controls. We have previously shown that animals colonized with a component of the human microbiota, Clostridium scindens, were protected from E. histolytica. This protection was associated with elevated neutrophil count. Here, we explored amebic killing capacity and observed that neutrophils from animals with C. scindens possessed heightened amebic killing compared with controls. Thus, this study establishes a novel platform that can provide an in-depth analysis of granulocyte-parasite interactions in various contexts, including during alteration of the intestinal microbiota.IMPORTANCEThe tools for studying host immune cell-E. histolytica interactions are limited. Factors, such as parasite heterogeneity, infectivity, and difficulties with culture systems and animal models, make interrogation of these interactions challenging. Thus, Entamoeba researchers can benefit from next-generation models that allow for the analysis of both host and parasite cells. Here, we demonstrate the use of a novel platform that allows for the determination of parasite-host cell interactions and customizable high-dimensional phenotyping of both populations. Indeed, spectral flow cytometry can approach >40 markers on a single panel and can be paired with custom-developed parasite antibodies that can be conjugated to fluorochromes via commercially available kits. This platform affords researchers the capability to test highly precise hypotheses regarding host-parasite interactions.

Identification and Characterization of Entamoeba histolytica Choline Kinase

PURPOSE

Entamoeba histolytica is one of the death-causing parasites in the world. Study on its lipid composition revealed that it is predominated by phosphatidylcholine and phosphatidylethanolamine. Further study revealed that its phosphorylated metabolites might be produced by the Kennedy pathway. Here, we would like to report on the characterizations of enzymes from this pathway that would provide information for the design of novel inhibitors against these enzymes in future.

METHODOLOGY

E. histolytica HM-1:IMSS genomic DNA was isolated and two putative choline/ethanolamine kinase genes (EhCK1 and EhCK2) were cloned and expressed from Escherichia coli BL21 strain. Enzymatic characterizations were further carried out on the purified enzymes.

RESULTS

EhCK1 and EhCK2 were identified from E. histolytica genome. The deduced amino acid sequences were more identical to its homologues in human (35-48%) than other organisms. The proteins were clustered as ethanolamine kinase in the constructed phylogeny tree. Sequence analysis showed that they possessed all the conserved motifs in choline kinase family: ATP-binding loop, Brenner's phosphotransferase motif, and choline kinase motif. Here, the open reading frames were cloned, expressed, and purified to apparent homogeneity. EhCK1 showed activity with choline but not ethanolamine. The biochemical characterization showed that it had a Vmax of 1.9 ± 0.1 µmol/min/mg. Its Km for choline and ATP was 203 ± 26 µM and 3.1 ± 0.4 mM, respectively. In contrast, EhCK2 enzymatic activity was only detected when Mn2+ was used as the co-factor instead of Mg2+ like other choline/ethanolamine kinases. Highly sensitive and specific antibody against EhCK1 was developed and used to confirm the endogenous EhCK1 expression using immunoblotting.

CONCLUSIONS

With the understanding of EhC/EK importance in phospholipid metabolism and their unique characteristic, EhC/EK could be a potential target for future anti-amoebiasis study.

Unusually high clarithromycin resistance in Mycobacterium abscessus subsp. abscessus isolated from human gastric epithelium

Mycobacterium abscessus subsp. abscessus is a rapidly growing facultative intracellular pathogen that usually infects human lung and skin epithelium. Recently, we and another group have shown that it also has the potential to colonize human gastric epithelium, but its significance with respect to gastric diseases remains unclear. Although Helicobacter pylori still remains the only definite gastric pathogen, recent studies have shown that M. abscessus subsp. abscessus also has the potential to colonize human gastric epithelium. M. abscessus subsp. abscessus is known to exhibit multidrug resistance and clarithromycin has been used as the drug of choice. We aimed to determine the clarithromycin resistance profile of 117 (74 rough and 43 smooth) gastric M. abscessus subsp. abscessus strains and to detect the point mutations in rrl and erm (41) genes conferring the resistance. Our data showed 79.48% (19 smooth and 74 rough) of M. abscessus subsp. abscessus strains were resistant to clarithromycin (MIC90 ≤ 512 μg/mL), while 20.51% (24 smooth) were susceptible (MIC90 ≤ 8 μg/mL). Nucleotide sequence analysis of the rrl gene with reference strains of M. abscessus subsp. abscessus did not show any mutation that is relevant to the clarithromycin resistance. However, analysis of erm (41) gene showed that M. abscessus subsp. abscessus strains, which were susceptible to clarithromycin had C, C, G, and C at their nucleotide positions 28, 159, 238, and 330, respectively, while the resistant strains showed T, T, A, and A at the same positions. Based on antibiogram and sequence analysis data we recommend further studies involving genomic analysis to identify the other genes involved in high clarithromycin resistance in gastric M. abscessus subsp. abscessus along with the mechanisms involved.

MANAGEMENT OF ENTAMOEBA INVADENS IN THE HERPETOLOGICAL COLLECTION AT THE SINGAPORE ZOO

Amebiasis caused by Entamoeba invadens is an important disease in reptile collections, causing severe morbidity and mortality. Surveillance of the parasite at the Singapore Zoo was carried out over a 4-yr period by PCR testing on reptiles that presented with lethargy and enteritis for disease investigation. Asymptomatic reptiles sharing the same enclosures as positive individuals were also tested as part of outbreak investigation. Animals in the collection that tested positive for the parasite were treated with metronidazole at various doses, with the addition of paromomycin for two cases, until a negative PCR test result was obtained at the end of the treatment course. A total of 97 samples from 49 individuals across 19 species of reptiles were obtained, of which 24 samples (24.7%) from 19 animals were positive for E. invadens. Of these positive samples, 11 samples were for disease investigation, eight samples for outbreak surveillance, and five samples for treatment monitoring. Treatment was initiated for 10 animals, four of which were showing clinical signs of disease. The parasite was cleared in nine of these 10 animals (90%), with eight animals receiving metronidazole as a sole therapeutic agent. A total of nine animals died of the disease, four of which (44.4%) presented dead or died within 24 h of presentation. Necrotizing enteritis was a consistent postmortem finding resulting in gastrointestinal perforation in two cases, and coelomic adhesions and hepatic trophozoites were each seen in five animals. The results suggest that the management of Entamoeba epizootics in the collection requires prompt outbreak investigation. Diagnosis of the disease with advanced diagnostic tools like PCR, endoscopy, and ultrasonography and treatment with metronidazole in both symptomatic and asymptomatic animals may reduce mortalities during an outbreak.

Intestinal Parasitic Infections in 2023

Intestinal parasites include intestinal protozoa and intestinal helminths. Intestinal parasitic infections (IPIs) pose a global health problem affecting over one billion people worldwide. Although these infections are predominantly seen in the developing world, they are frequently seen in the developed countries, particularly in immunocompromised patients. Patients' clinical presentations generally include diarrhea, dysentery, abdominal pain, nausea, vomiting, nutritional deficiency, iron deficiency anemia, anal and perianal itching, and rarely intestinal obstruction. The intestinal parasites have similarities in their mode of transmission and life cycle. The stool test is the primary way of diagnosing IPIs. Treatment is given with various anti-parasitic agents. However, appropriate preventive measures are essential for successfully controlling the IPIs.

Thiazolidin-4-one-based derivatives - Efficient tools for designing antiprotozoal agents. A review of the last decade

Thiazolidin-4-one derivatives have a wide range of therapeutic implementations and clinical significance for medicinal chemistry. This heterocyclic ring has been reported to possess a variety of biological activities, including antiprotozoal activities that have inspired scientists to integrate this scaffold with different pharmacophoric fragments to design novel and effective antiprotozoal compounds. There are reviews describing thiazolidin-4-ones small molecules as good candidates with a single type of antiprotozoal activity, but none of these show collected news associated with the antiprotozoal activity of thiazolidin-4-ones and their SAR analysis from the last decade. In this review we are focusing on the antitoxoplasmic, anti-trypanosomal, antimalarial, antileishmanial, and antiamoebic activity of these derivatives, we attempt to summarize and analyze the recent developments with regard to the antiprotozoal potential of 4-TZD covering the structure-activity relationship and main molecular targets. The importance of various structural modifications at C2, N3, and C5 of the thiazolidine-4-one core has also been discussed in this review. We hope that all information concluded in this review can be useful for other researchers in constructing new effective antiprotozoal agents.

Alcohol Abuse Drug Disulfiram Is Effective against Cyst Stages of Entamoeba histolytica Parasite

New anti-Entamoeba histolytica multistage drugs are needed because only one drug class, nitroimidazoles, is available for treating invasive disease, and it does not effectively eradicate the infective cyst stage. Zinc ditiocarb (ZnDTC), a main metabolite of the FDA-approved drug disulfiram, was recently shown to be highly effective against the invasive trophozoite stage. In this brief report, we show that ZnDTC is active against cysts, with similar potency to first-line cysticidal drug paromomycin.

An Overview of Mucosa-Associated Protozoa: Challenges in Chemotherapy and Future Perspectives

Parasitic infections caused by protozoans that infect the mucosal surfaces are widely neglected worldwide. Collectively, Entamoeba histolytica, Giardia lamblia, Cryptosporidium spp. and Trichomonas vaginalis infect more than a billion people in the world, being a public health problem mainly in developing countries. However, the exact incidence and prevalence data depend on the population examined. These parasites ultimately cause pathologies that culminate in liver abscesses, malabsorption syndrome, vaginitis, and urethritis, respectively. Despite this, the antimicrobial agents currently used to treat these diseases are limited and often associated with adverse side effects and refractory cases due to the development of resistant parasites. The paucity of drug treatments, absence of vaccines and increasing problems of drug resistance are major concerns for their control and eradication. Herein, potential candidates are reviewed with the overall aim of determining the knowledge gaps and suggest future perspectives for research. This review focuses on this public health problem and focuses on the progress of drug repositioning as a potential strategy for the treatment of mucosal parasites.

Cdc42/Rac Interactive Binding Containing Effector Proteins in Unicellular Protozoans With Reference to Human Host: Locks of the Rho Signaling

Small GTPases are the key to actin cytoskeleton signaling, which opens the lock of effector proteins to forward the signal downstream in several cellular pathways. Actin cytoskeleton assembly is associated with cell polarity, adhesion, movement and other functions in eukaryotic cells. Rho proteins, specifically Cdc42 and Rac, are the primary regulators of actin cytoskeleton dynamics in higher and lower eukaryotes. Effector proteins, present in an inactive state gets activated after binding to the GTP bound Cdc42/Rac to relay a signal downstream. Cdc42/Rac interactive binding (CRIB) motif is an essential conserved sequence found in effector proteins to interact with Cdc42 or Rac. A diverse range of Cdc42/Rac and their effector proteins have evolved from lower to higher eukaryotes. The present study has identified and further classified CRIB containing effector proteins in lower eukaryotes, focusing on parasitic protozoans causing neglected tropical diseases and taking human proteins as a reference point to the highest evolved organism in the evolutionary trait. Lower eukaryotes’ CRIB containing proteins fall into conventional effector molecules, PAKs (p21 activated kinase), Wiskoit-Aldrich Syndrome proteins family, and some have unique domain combinations unlike any known proteins. We also highlight the correlation between the effector protein isoforms and their selective specificity for Cdc42 or Rac proteins during evolution. Here, we report CRIB containing effector proteins; ten in Dictyostelium and Entamoeba, fourteen in Acanthamoeba, one in Trypanosoma and Giardia. CRIB containing effector proteins that have been studied so far in humans are potential candidates for drug targets in cancer, neurological disorders, and others. Conventional CRIB containing proteins from protozoan parasites remain largely elusive and our data provides their identification and classification for further in-depth functional validations. The tropical diseases caused by protozoan parasites lack combinatorial drug targets as effective paradigms. Targeting signaling mechanisms operative in these pathogens can provide greater molecules in combatting their infections.

Establishment of quantitative RNAi-based forward genetics in Entamoeba histolytica and identification of genes required for growth

While Entamoeba histolytica remains a globally important pathogen, it is dramatically understudied. The tractability of E. histolytica has historically been limited, which is largely due to challenging features of its genome. To enable forward genetics, we constructed and validated the first genome-wide E. histolytica RNAi knockdown mutant library. This library allows for Illumina deep sequencing analysis for quantitative identification of mutants that are enriched or depleted after selection. We developed a novel analysis pipeline to precisely define and quantify gene fragments. We used the library to perform the first RNAi screen in E. histolytica and identified slow growth (SG) mutants. Among genes targeted in SG mutants, many had annotated functions consistent with roles in cellular growth or metabolic pathways. Some targeted genes were annotated as hypothetical or lacked annotated domains, supporting the power of forward genetics in uncovering functional information that cannot be gleaned from databases. While the localization of neither of the proteins targeted in SG1 nor SG2 mutants could be predicted by sequence analysis, we showed experimentally that SG1 localized to the cytoplasm and cell surface, while SG2 localized to the cytoplasm. Overexpression of SG1 led to increased growth, while expression of a truncation mutant did not lead to increased growth, and thus aided in defining functional domains in this protein. Finally, in addition to establishing forward genetics, we uncovered new details of the unusual E. histolytica RNAi pathway. These studies dramatically improve the tractability of E. histolytica and open up the possibility of applying genetics to improve understanding of this important pathogen.

Giant Amoebic Liver Abscess: A Rare Diagnosis in a Rural Setting of Sub-Saharan Africa

Background

Extraintestinal amoebiasis is an uncommon complication of Entamoeba histolytica infection, occurring in about 5-10% of patient. Prompt diagnosis and management is essential to prevent complications. However, diagnosis and management in resource-limited settings is very challenging owing to limited diagnostic tools and nonspecific clinical symptoms. Therefore, our case report underscores the role of incisive clinical evaluation, basic investigation, and nonsurgical management of giant amoebic abscess in resource-limited settings. Case Presentation. A 13-year-old female Cameroonian presented with subacute onset of upper abdominal pain, high fever, and chest pain for one week. Before presentation, she had been on treatment at a local traditional practitioner during which her symptoms worsen. After clinical evaluation and basic investigation, she was diagnosed with a giant amoebic liver abscess. She was resuscitated and placed on nonsurgical management. Follow-up after 1 month was significant for complete recovery.

Conclusion

Amoebic liver abscess is a rare complication of Entamoeba histolytica infection with devastating complications. The diagnosis of this disease requires high index of suspicion in resource-limited settings. Good clinical evaluation and timely nonsurgical therapy can provide recovery to some patients.

Bioinformatic Analysis of Two TOR (Target of Rapamycin)-Like Proteins Encoded by Entamoeba histolytica Revealed Structural Similarities with Functional Homologs

The target of rapamycin (TOR), also known as FKBP-rapamycin associated protein (FRAP), is a protein kinase belonging to the PIKK (phosphatidylinositol 3-kinase (PI3K)-related kinases) family. TOR kinases are involved in several signaling pathways that control cell growth and proliferation. Entamoeba histolytica, the protozoan parasite that causes human amoebiasis, contains two genes encoding TOR-like proteins: EhFRAP and EhTOR2. To assess their potential as drug targets to control the cell proliferation of E. histolytica, we studied the structural features of EhFRAP and EhTOR2 using a biocomputational approach. The overall results confirmed that both TOR amoebic homologs share structural similarities with functional TOR kinases, and show inherent abilities to form TORC complexes and participate in protein-protein interaction networks. To our knowledge, this study represents the first in silico characterization of the structure-function relationships of EhFRAP and EhTOR2.

Drug Repurposing of the Alcohol Abuse Medication Disulfiram as an Anti-Parasitic Agent

Parasitic infections contribute significantly to worldwide morbidity and mortality. Antibiotic treatment is essential for managing patients infected with these parasites since control is otherwise challenging and there are no vaccines available for prevention. However, new antimicrobial therapies are urgently needed as significant problems exist with current treatments such as drug resistance, limited options, poor efficacy, as well as toxicity. This situation is made worse by the challenges of drug discovery and development which is costly especially for non-profitable infectious diseases, time-consuming, and risky with a high failure rate. Drug repurposing which involves finding new use for existing drugs may help to more rapidly identify therapeutic candidates while drastically cutting costs of drug research and development. In this perspective article, we discuss the importance of drug repurposing, review disulfiram pharmacology, and highlight emerging data that supports repurposing disulfiram as an anti-parasitic, exemplified by the major diarrhea-causing parasite Entamoeba histolytica.

Acute abdominal syndrome revealing an intestinal amoebiasis: Report of two cases in Tunisia

Amoebiasis is a parasitosis, mainly caused by Entamoeba histolytica (E. histolytica). It is a common disease in tropical and subtropical regions. E. histolytica possesses different mechanisms of pathogenicity, and might lead to the invasion and lysis of the intestinal epithelium. Outside of the high-risk regions, acute intestinal amoebiasis is a very rare condition, often leading to misdiagnosis and death, if not promptly treated. We discuss the cases of 18 and 43 year-old men without medical history, who presented to the emergency department complaining of acute abdominal pain along with fever. Following imaging features and clinical presentation, appendicitis and a complicated form of Crohn's disease were respectively suspected. Given the severity of the symptoms, an explorative laparotomy was performed showing in both cases an inflammatory aspect of the intestine. Histological examination concluded intestinal amoebiasis, a diagnosis that wasn't suspected at first. The learning point of these cases is considering invasive intestinal amoebiasis in patients presenting with an acute abdominal syndrome, even with no history of traveling abroad or immunodeficiency.

COVID-19 and Corticosteroids: Unfamiliar but Potentially Fatal Infections That Can Arise following Short-Course Steroid Treatment

Corticosteroid use is increasing worldwide as recent studies confer survival benefit of corticosteroids in the management of patients with severe COVID-19. Strongyloides and amebic infections are neglected diseases that can progress to catastrophic complications in patients exposed to corticosteroids, even with short treatment courses. To prevent lethal outcomes, clinicians should be aware of the threat these two parasitic infections pose to at-risk patients receiving corticosteroids, especially in the era of COVID-19.

Development of amoebic liver abscess in early pregnancy years after initial amoebic exposure: a case report

BACKGROUND

Infection with Entamoeba histolytica and associated complications are relatively rare in developed countries. The overall low prevalence in the Western world as well as the possibly prolonged latency period between infection with the causing pathogen and onset of clinical symptoms may delay diagnosis of and adequate treatment for amoebiasis. Amoebic liver abscess (ALA) is the most common extraintestinal manifestation of invasive amoebiasis. Pregnancy has been described as a risk factor for development of invasive amoebiasis and management of these patients is especially complex.

CASE PRESENTATION

A 30-year-old Caucasian woman in early pregnancy presented to our emergency department with abdominal pain alongside elevated inflammatory markers and liver function tests. Travel history revealed multiple journeys to tropic and subtropic regions during the past decade and a prolonged episode of intermittently bloody diarrhea during a five month stay in Indonesia seven years prior to admission. Sonographic and magnetic resonance imaging revealed a 5 × 4 cm hepatic abscess. After ultrasound-guided transcutaneous liver drainage, both abscess fluids and blood cultures showed neither bacterial growth nor microscopic signs of parasitic disease. Serological testing confirmed an infection with Entamoeba histolytica, which was treated with metronidazole, followed by eradication therapy with paromomycin. Subsequent clinical, laboratory and imaging follow-up exams showed regression of the ALA. In addition, the pregnancy completed without complications and a healthy baby boy was born 7 months after termination of treatment.

CONCLUSIONS

This case of invasive amoebiasis in early pregnancy outside of endemic regions and several years after exposure demonstrates the importance of broad differential diagnostics in the context of liver abscesses. The complex interdisciplinary decisions regarding the choice of imaging techniques as well as interventional and antibiotic therapy in the context of pregnancy are discussed. Furthermore, we present possible explanations for pregnancy as a risk factor for an invasive course of amoebiasis.

Swine multifocal ulcerative colitis and crypt abscesses associated with Entamoeba polecki subtype 3 and Salmonella Typhimurium

Piglets aged approximately 50 days exhibited diarrhea and wasting. Multiple white foci were detected in the colon of a dead piglet; histopathological findings revealed multifocal ulcers and crypt abscesses with Entamoeba trophozoites and gram-negative bacilli in the piglet. These pathogens were identified as Entamoeba polecki subtype 3 and Salmonella enterica serovar Typhimurium, respectively. Numerous E. polecki subtype 3 trophozoites were located on the edge of the ulcerative and necrotic lesions in the lamina propria. Crypt abscesses were associated with S. Typhimurium. These results suggest that E. polecki subtype 3 caused multifocal ulcerative colitis accompanied by crypt abscesses with S. Typhimurium in the piglet. This study is the first report of colitis with E. polecki subtype 3 and S. Typhimurium coinfection.

Entamoeba histolytica and amoebic liver abscess in northern Sri Lanka: a public health problem

Entamoeba histolytica (E. histolytica) is a facultative protozoan parasite implicated in amoebic liver abscesses (ALA), the most common extraintestinal manifestation of this infection. E. histolytica is endemic to sub-tropical and tropical countries and has been a major public health concern in northern Sri Lanka (SLK) for the last three decades. This has been attributed to a multitude of factors such as poor sanitation, hygiene, male sex, middle age, overcrowding, unsanitary practices in the production of indigenous alcoholic beverages, and alcohol consumption. Additionally, while rates of E. histolytica have declined substantially throughout the rest of the island, largely due to better infrastructure, it remains pervasive in the northern peninsula, which is generally less developed. Infection arises primarily from fecal-oral transmission through the consumption of contaminated drinking water containing cysts. Upon ingestion, cysts multiply into trophozoites and colonize the host colonic mucosa using lectin and cysteine proteases as virulence factors, leading to host invasion. Symptoms occur along a spectrum, from asymptomatology, to pyrexia, abdominal cramping, and amoebic dysentery. Colonization of the colon results in the formation of distinct flask-shaped ulcers along the epithelium, and eventual penetration of the lamina propria via the production of matrix metalloproteinases. ALA then develops through trophozoite migration via the mesenteric hepatic portal circulation, where microabscesses coalesce to form a single, large right-lobe abscess, commonly on the posterior aspect. The progression of infection to invasive disease is contingent on the unique interplay between host and pathogen factors, such as the strength of host-immunity to overcome infection and inherent pathogenicity of the Entamoeba species. As a preventable illness, E. histolytica complications such as ALA impose a significant burden on the healthcare system. This mini-review highlights epidemiological trends, risk factors, diagnostic modalities, treatment approaches, and opportunities for prevention of E. histolytica-induced ALA, to help address this endemic problem on the island of SLK.

Clinical Management of Infectious Diarrhea

BACKGROUND

Infectious diarrhea is the most common cause of diarrhea worldwide and is responsible for more deaths than other gastrointestinal tract diseases such as gastrointestinal cancers, peptic ulcer disease or inflammatory bowel disease. Diarrheal disease still represents the 8th leading cause of death worldwide, with more than 1,6 million attributed fatalities in 2016 alone. The majority of cases can be divided into three principal clinical presentations: acute watery diarrhea lasting 5-10 days and normally self-limiting, bloody diarrhea (dysentery), and persistent diarrhea with or without intestinal malabsorption.

METHODS

We performed an electronic search on PUBMED of the scientific literature concerning infectious diarrhea and its clinical management.

AIM

In this review article, we analyze the most important causes of infectious diarrhea and their constellation of signs and symptoms, providing an update on the diagnostic tools available in today's practice and on the different treatment options.

CONCLUSION

Even though the majority of intestinal infections are self-limiting in immunocompetent individuals, specific diagnosis and identification of the causative agent remain crucial from public health and epidemiological perspectives. Specific diagnostic investigation can be reserved for patients with severe dehydration, more severe illness, persistent fever, bloody stools, immunosuppression, and for cases of suspected nosocomial infection or outbreak and it includes complete blood count, creatinine and electrolytes evaluation, determination of leukocytes and lactoferrin presence in the stools, stool culture, together with C. difficile testing, PCR, ova and parasites' search, endoscopy and abdominal imaging. Since acute diarrhea is most often self-limited and caused by viruses, routine antibiotic use is not recommended for most adults with mild, watery diarrhea. However, when used appropriately, antibiotics are effective against shigellosis, campylobacteriosis, C. difficile colitis, traveler's diarrhea, and protozoal infections. Furthermore, antibiotics use should be considered in patients who are older than 65 years, immunocompromised, severely ill, or septic.