Current status of anti-diarrheal and anti-secretory drugs in the management of acute childhood diarrhea

Antidiarrheal Activity of Dialium guineense Willd Fruit Pulp in Wistar Rats

Objective. This study is aimed at evaluating the effects of Dialium guineense Willd fruit pulp powder on diarrhea induced by castor oil in Wistar rats. Materials and Methods. Three different tests were carried out. A preventive test by administration of a single dose of 250, 500, 1000, 2000, and 4000 mg/kg before the induction of diarrhea by castor oil. Another preventive test after repeated administration of Dialium guineense at 250, 500, and 1000 mg/kg/day for 8 days, before the induction of diarrhea, was done. The third test was a curative test with a single dose of 250, 500, 1000, and 2000 mg/kg after the induction of diarrhea by castor oil. Results. D. guineense fruit pulp at 1000, 2000, and 4000 mg/kg administered before the induction of diarrhea, has significantly delayed diarrhea; reduced the frequency of defecation, reduced the amount of diarrheal stools, and also reduced the purging index, with a degree of inhibition comparable to that of loperamide. But the water content of the stools of the group treated with D. guineense does not change significantly compared to the controls. D. guineense has reduced significantly from 500 mg/kg the diarrhea induced by castor oil after 8 days of treatment. It appears that the doses of 250 and 500 mg/kg, which were not effective with the single-dose preventive test, significantly delayed diarrhea; reduces the frequency of diarrheal stools and also reduces the purging index. D. guineense administered, after the induction of diarrhea, by castor oil has significantly reduced the diarrhea from 250 mg/kg. Conclusion. The fruit pulp of D. guineense has showed antidiarrheal activities in Wistar rats by reducing the frequency of defecation, the amount of diarrheal fecal matter emitted as well as the water content. It also delayed the onset of diarrhea and significantly reduced the purging index like loperamide.

Evaluation of Antidiarrheal Activity of 80% Methanolic Extract of the Leaves of Cordia africana (Lamiaceae) in Mice

Background

Diarrheal disease is a major cause of morbidity and mortality throughout the world, particularly in developing countries. Currently available drugs are linked with adverse effects, contraindications, and risk of resistance. Traditionally, the leaf concoction of Cordia africana is claimed to be used for diarrhea. However, the safety and efficacy of the leaf extract have not been scientifically approved yet. Therefore, the study was conducted to validate its antidiarrheal activity and safety profile in mice.

Method

The hydromethanolic extract was obtained by the cold maceration technique in 80% methanol. Phytochemical screening tests were done for secondary metabolites by using standard tests. The antidiarrheal activity of the test extract at the doses of 100, 200, and 400 mg/kg was evaluated by using castor oil-induced diarrheal, gastrointestinal transit, and enteropooling models in mice.

Result

In an acute toxicity study, there were no visible signs of toxicity and mortality following a single oral administration of 2000 mg/kg. Phytochemical screening tests revealed the presence of alkaloids, saponins, flavonoids, terpenoids, phenols, and tannins. The hydromethanolic extract significantly prolonged the onset of diarrhea and reduced the weight of wet and total feces at 100 (P < 0.01), 200 (P < 0.001), and 400 mg/kg (P < 0.001) in the castor oil-induced diarrheal model. However, in the gastrointestinal transit model, a significant (P < 0.001) reduction in the charcoal meal travel was observed in the middle (200 mg/kg) and higher (400 mg/kg) test doses. Similarly, the extract produced a significant (P < 0.001) reduction in the weight and volume of intestinal contents at the aforementioned doses.

Conclusion

The study demonstrated that the test extract showed promising antidiarrheal activity. Hence, this study supports its antidiarrheal use in Ethiopian folklore medicine.

Evaluation of Various Solvent Extracts of Tetrastigma leucostaphylum (Dennst.) Alston Leaves, a Bangladeshi Traditional Medicine Used for the Treatment of Diarrhea

Tetrastigma leucostaphylum (TL) is an important ethnic medicine of Bangladesh used to treat diarrhea and dysentery. Hence, current study has been designed to characterize the antidiarrheal (in vivo) and cytotoxic (in vitro) effects of T. leucostaphylum. A crude extract was prepared with methanol (MTL) and further partitioned into n-hexane (NTL), dichloromethane (DTL), and n-butanol (BTL) fractions. Antidiarrheal activity was investigated using castor oil induced diarrhea, enteropooling, and gastrointestinal transit models, while cytotoxicity was evaluated using the brine shrimp lethality bioassay. In antidiarrheal experiments, all doses (100, 200, and 400 mg/kg) of the DTL extract significantly reduced diarrheal stool frequency, volume and weight of intestinal contents, and gastrointestinal motility in mice. Similarly, in the cytotoxicity assay, all extracts exhibited activity, with the DTL extract the most potent (LC50 67.23 μg/mL). GC-MS analysis of the DTL extract identified 10 compounds, which showed good binding affinity toward M3 muscarinic acetylcholine, 5-HT3, Gut inhibitory phosphodiesterase, DNA polymerase III subunit alpha, and UDP-N-acetylglucosamine-1 carboxyvinyltransferase enzyme targets upon molecular docking analysis. Although ADME/T analyses predicted the drug-likeness and likely safety upon consumption of these bioactive compounds, significant toxicity concerns are evident due to the presence of the known phytotoxin, 2,4-di-tert-butylphenol. In summary, T. leucostaphylum showed promising activity, helping to rationalize the ethnomedicinal use and importance of this plant, its safety profile following both acute and chronic exposure warrants further investigation.

Antidiarrheal Activity of 80% Methanolic Leaf Extract of Justicia schimperiana

Background

Diarrhea is one of the leading causes of preventable death in developing countries and mainly affects children and infants. It has been reported that the leaf of Justicia schimperiana is used as an antidiarrheal agent in Libo Kemekem district, northwest Ethiopia.

Method

The 80% methanolic leaf extract of J. schimperiana was evaluated for its activity against castor oil-induced diarrhea, enteropooling, and gastrointestinal motility in mice.

Results

Significant reduction (p < 0.001) in the total defecation and diarrheal drops was produced by all the test doses of the extract. Percentage inhibition of wet feces was 42.58, 65.07, and 74.96% at 100, 200, and 400 mg/kg doses of the extract, respectively. The extract also significantly inhibited castor oil-induced enteropooling at all test doses. The percent reduction in mean weight of intestinal contents was 66.96, 67.83, and 76.52% at 100, 200, and 400 mg/kg doses of the extract, respectively. The extract significantly reduced gastrointestinal movement of charcoal meal as well at 200 (p < 0.01) and 400 mg/kg (p < 0.001) doses.

Conclusion

In conclusion, the methanolic leaf extract of J. schimperiana has an antidiarrheal activity and this supports the use of this plant in the treatment of diarrhea in the traditional settings.

Probiotics and prebiotics in infectious gastroenteritis

Acute gastroenteritis (AGE) is worldwide a common problem in infants and children. While AGE is still an important cause of morbidity and mortality in developing countries, it is mainly a problem with high socioeconomic impact in the rest of the world. Oral rehydration solutions (ORS) and rapid refeeding remain the cornerstone of the management. However, ORS does not decrease the duration of diarrhea. There is evidence that selected strains of probiotics decrease the duration of AGE with 24 h, both in ambulatory care and in hospitalized children, resulting also in a decrease of the duration of hospitalization. Synbiotics are equally effective as probiotics alone, but prebiotics are not effective. Both pro- and prebiotics have limited to no efficacy in the prevention of AGE. The administration of pre- and probiotics is considered to be safe, even in newborns. Only these pre-, pro and synbiotics that have been clinically tested can be recommended.

Witnessing traumatic events and post-traumatic stress disorder: Insights from an animal model

It is becoming increasingly recognized that post-traumatic stress disorder (PTSD) can be acquired vicariously from witnessing traumatic events. Recently, we published an animal model called the "Trauma witness model" (TWM) which mimics PTSD-like symptoms in rats from witnessing daily traumatic events (social defeat of cage mate) [14]. Our TWM does not result in any physical injury. This is a major procedural advantage over the typical intruder paradigm in which it is difficult to delineate the inflammatory response of tissue injury and the response elicited from emotional distress. Using TWM paradigm, we examined behavioral and cognitive effects in rats [14] however, the long-term persistence of PTSD-like symptoms or a time-course of these events (anxiety and depression-like behaviors and cognitive deficits) and the contribution of olfactory and auditory stress vs visual reinforcement were not examined. This study demonstrates that some of the features of PTSD-like symptoms in rats are reversible after a significant time lapse of the witnessing of traumatic events. We also have established that witnessing is critical to the PTSD-like phenotype and cannot be acquired solely due to auditory or olfactory stresses.

Use and/or misuse of antibiotics in management of diarrhea among children in Enugu, Southeast Nigeria

BACKGROUND

Diarrheal diseases are a leading cause of under-5 morbidity and mortality worldwide.

OBJECTIVE

To determine the use and/or misuse of antibiotics on children with diarrheal disease by caregivers.

METHOD

An observational prospective study involving 210 children and their caregivers seen at the pediatric outpatient clinic of a tertiary hospital between January and May 2012 was undertaken.

RESULTS

The mean age of the children was 18.07 ± 14.29 months. One hundred twenty-four (59%) were male, whereas 86 (41%) were female. Almost half of the children (46.7%) used unprescribed antibiotics during an episode of diarrhea.

CONCLUSIONS

Antibiotics are being abused in children with diarrhea and caregivers need to be educated against this urgently.

Probiotics and prebiotics in pediatric diarrheal disorders

INTRODUCTION

In pediatrics, prebiotics and/or probiotics are added to infant formula, mainly to prevent diseases such as diarrheal disorders. Probiotic food supplements and medication are frequently used in the treatment of diarrheal disorders. This paper reviews the recent published evidence on these topics.

AREAS COVERED

Relevant literature published using PubMed and CINAHL was collected and reviewed. Recent review papers were give special attention.

EXPERT OPINION

The addition of pre- and/or probiotics to infant formula seems not harmful, but the evidence for benefit is limited. Most probiotics are commercialized as food supplements, and therefore do not qualify for medication legislation. Worldwide, Saccharomyces boulardii is the only strain which is registered as "medication" in the majority of countries. Efficacy data can only be considered if performed with the commercialized product. Some products reduce the risk for antibiotic-associated diarrhea and reduced the duration of acute infectious diarrhea with about 24 h. Overall, data in the other indications (inflammatory bowel disease, irritable bowel syndrome) are disappointing, although there are some recent promising results. The use of food supplements as medication opens the discussion to create a category of "medical food."

In vitro antibacterial and time-kill assessment of crude methanolic stem bark extract of Acacia mearnsii de wild against bacteria in shigellosis

Shigellosis is an important cause of worldwide morbidity and mortality among young children and old people for which treatment with antimicrobial agents is limited. Hence, the need for curative potentials obtainable from medicinal plants becomes inevitable. This study was carried out to assess the antibacterial potentials of crude methanolic extract of the stem bark of Acacia mearnsii against some selected bacteria of clinical importance in shigellosis. The bacteria were inhibited by the extract to produce concentration dependent inhibition zones. The extract exhibited a varied degree of antibacterial activity against all the tested isolates. The MIC values for Gram negative (0.0391–0.3125) mg/mL and those of Gram positive bacteria (0.0781–0.625) mg/mL indicated that the Gram negative bacteria were more inhibited by the extract than the Gram positive bacteria. Average log reduction in viable cell count in time-kill assay ranged between −2.456 Log₁₀ to 2.230 Log₁₀ cfu/mL after 4 h of interaction, and between −2.921 Log₁₀ and 1.447 Log₁₀ cfu/mL after 8 h interaction in 1× MIC and 2× MIC of the extract. The study provided scientific justification for the use of the crude methanolic extract from the stem bark of A. mearnsii in shigellosis. The degree of the antibacterial activity indicated that the crude extract is a potential source of bioactive compounds that could be useful for the development of new antimicrobial agents capable of decreasing the burden of drug resistance and cost of management of diseases of clinical and public health importance in South Africa.

Prevalence of cholera in pediatric patients with acute dehydrating diarrhea

OBJECTIVE

To estimate the prevalence of culture-confirmed cholera in patients with acute dehydrating diarrhea, at a tertiary care center in north India, during a 6-month period from March to August, 2006.

METHODS

We studied 145 children, who presented to the pediatric emergency services of a tertiary care teaching hospital in north India with acute dehydrating diarrhea. Each patient had his/her stool sample collected for Vibrio cholerae culture and hanging drop preparation for darting motility. The stool specimen for hanging drop analysis was immediately transported to the emergency laboratory, where a trained technician prepared the slides and examined them for darting motility characteristic of Vibrio cholerae.

RESULTS

V. cholerae was isolated in 36 (24.8%) patients. Forty-nine (33.7%) patients had a positive hanging drop examination. Hanging drop examination had a sensitivity and specificity of 85.8% and 81.7%, respectively. Severe dehydration (OR 4.3; P<0.01) and hanging drop positivity (OR 12.42; P<0.001) were associated with higher odds of cholera after adjustment for other risk factors.

CONCLUSION

Cholera is an important cause of acute watery diarrhea in pediatric patients in urban north India and should be ruled out in all children presenting with acute dehydrating diarrhea, particularly those with severe dehydration. Hanging drop test is useful for diagnosis in the emergency setting.

Use of racecadotril as outpatient treatment for acute gastroenteritis: a prospective, randomized, parallel study

OBJECTIVE

To compare the efficacy of therapy with racecadotril plus oral rehydration versus oral rehydration alone in children with gastroenteritis in an outpatient setting care.

STUDY DESIGN

Prospective, randomized, open and parallel study performed in a Pediatric Emergency Service of a tertiary care hospital. The study included 189 patients, ages 3 to 36 months, with acute gastroenteritis: 94 were administered an oral rehydration solution (OR), 94 received oral rehydration solution plus racecadotril (OR + R). The principal variable studied was the number of bowel movements in 48 hours after initiating treatment.

RESULTS

The groups were comparable clinically and epidemiologically at enrollment. No significant differences were found in the number of bowel movements between the 2 groups 48 hours after initiating treatment (4.1 +/- 2.7 bowel movements in the OR group vs 3.8 +/- 2.4 bowel movements in the OR + R group). No differences were found in the average duration of gastroenteritis (4.7 +/- 2.2 days in the OR group, 4.0 +/- 2.1 days in the OR + R group; P = .15). The incidence of adverse events was similar in both groups (19 patients [20.2%] in the OR group, 18 patients [19.1%] in the OR + R group).

CONCLUSIONS

In our study group, the use of racecadotril did not improve the symptoms of diarrhea compared with standard rehydration therapy.

A randomized controlled trial of glucose versus amylase resistant starch hypo-osmolar oral rehydration solution for adult acute dehydrating diarrhea

Background

Reduction of gross diarrhea rate in excess of that seen over time with intravenous therapy and appropriate antibiotics is not usually achieved by oral glucose-electrolyte rehydration therapy for cholera and cholera-like diarrheas.

Methodology and Principal Findings

This prospective randomized clinical trial at a tertiary referral hospital in southern India was undertaken to determine whether amylase resistant starch, substituting for glucose in hypo-osmolar oral rehydration solution, would reduce diarrhea duration and weight in adults with acute severe dehydrating diarrhea. 50 adult males with severe watery diarrhea of less than three days' duration and moderate to severe dehydration were randomized to receive hypo-osmolar ORS (HO-ORS) or HO-ORS in which amylase resistant high amylose maize starch 50g/L substituted for glucose (HAMS-ORS). All remaining therapy followed standard protocol. Duration of diarrhea (ORS commencement to first formed stool) in hours was significantly shorter with HAMS-ORS (median 19, IQR 10-28) compared to HO-ORS (median 42, IQR 24-50) (Bonferroni adjusted P, P_adj<0.001). Survival analysis (Kaplan-Meier) showed faster recovery from diarrhea in the HAMS-ORS group (P<0.001, log rank test). Total diarrhea fecal weight in grams (median, IQR) was not significantly lower in the HAMS-ORS group (2190, 1160-5635) compared to HO-ORS (5210, 2095-12190) (P_adj = 0.08). However, stool weight at 13-24 hours (280, 0-965 vs. 1360, 405-2985) and 25–48 hours (0, 0-360 vs. 1080, 55-3485) were significantly lower in HAMS-ORS compared to HO-ORS group (P_adj = 0.048 and P = 0.012, respectively). ORS intake after first 24 hours was lower in the HAMS-ORS group. Subgroup analysis of patients with culture isolates of Vibrio cholerae indicated similar significant differences between the treatment groups.

Conclusions

Compared to HO-ORS, HAMS-ORS reduced diarrhea duration by 55% and significantly reduced fecal weight after the first 12 hours of ORS therapy in adults with cholera-like diarrhea.

Trial Registration

Current Controlled Trials ISRCTN72841333

Probiotics in infectious diarrhoea in children: are they indicated?

Infectious gastroenteritis continues to be a leading cause of mortality and morbidity worldwide. The cornerstone of treatment remains replacement of water and electrolyte losses with oral rehydration solution. Until a few years ago, probiotics were discussed primarily in the context of alternative medicine, but they are now entering mainstream medical practice since a decrease of the severity and duration of infectious gastroenteritis in approximately 24 hours has been shown for some strains. Therefore, probiotics are a potential add-on therapy in acute gastro-enteritis. The shortening of the duration of diarrhoea and the reduction in hospital stay result in a social and economic benefit. Evidence found in viral gastroenteritis is more convincing than in bacterial or parasitic infection. Mechanisms of action are strain specific and only those commercial products for which there is evidence of clinical efficacy should be recommended. Timing of administration is also of importance. In acute gastroenteritis, there is evidence for efficacy of some strains of lactobacilli (e.g. Lactobacillus caseii GG and Lactobacillus reuteri) and for Saccharomyces boulardii. Probiotics are "generally regarded as safe", but side effects such as septicaemia and fungaemia have very rarely been reported in high-risk situations. Although most studies conclude in a statistically significant shortening of the duration of diarrhea, the clinical relevance of this finding is limited. In conclusion, selected strains of probiotics result in a statistically significant but clinically moderate benefit in shortening the duration of diarrhoea caused by acute infectious gastroenteritis.

Systematic review: racecadotril in the treatment of acute diarrhoea in children

BACKGROUND

Racecadotril (acetorphan) is an antisecretory drug that exerts its antidiarrhoeal effects by inhibiting intestinal enkephalinase.

AIM

To summarize studies testing the efficacy and safety of racecadotril for treating children with acute gastroenteritis.

METHODS

Reports were gathered by searching electronic databases MEDLINE, EMBASE, the Cochrane Library (all up to April 2007), relevant journals, and bibliographies of reviewed articles. Only randomized-controlled trials were included.

RESULTS

Three randomized-controlled trials (471 participants) met the inclusion criteria. Two trials reported stool output, and data suggested less stool output in the racecadotril group than in the control group. The duration of diarrhoea was significantly reduced in the three trials reporting this outcome. Achievement of a cure by day 5 was similar in both groups. Adverse effects were similar in both groups.

CONCLUSIONS

The small number of included trials provided some evidence in favour of the use of racecadotril over placebo or no intervention, to reduce the stool output and duration of diarrhoea in children with acute gastroenteritis. However, more data in out-patients are needed. The safety as well as the cost-effectiveness of the therapy should be explored, before routine therapy with racecadotril is recommended.