Guerrant R L, Shields D S, Thorson S M, Schorling J B, Gröschel D H
Am J Med. 1985 Jun 28;78(6B):91-8. doi: 10.1016/0002-9343(85)90370-5.
The appropriate approach to the diagnosis and management of acute infectious diarrhea is determined by the frequency and setting of the illness, the recognizable causes or syndromes, the cost and yield of available diagnostic tests, and the treatability of the disease. Acute diarrhea affects everyone throughout the world from one to more than six times each year, depending on age, location, and living conditions. The range of identifiable viral, bacterial, and parasitic etiologies is great, and the cost of indiscriminate use of etiologic studies for diagnosis is prohibitive. Because of its insensitivity for many organisms and poor selection of cases for testing, routine stool culture has been one of the most costly and ineffective microbiologic tests; the cost per positive result has traditionally exceeded $900 to $1,000. The appropriate treatment for the vast majority of cases (independent of their cause) is simple and effective: oral glucose- and electrolyte-containing rehydration solution. On the basis of an appropriate history and understanding of pathogenesis, fecal specimens can be selectively obtained and promptly examined for leukocytes and parasites, and the common noninflammatory diarrheas can be separated from the inflammatory infections in order to focus further studies on the latter group. The bacteria for which specific antimicrobial therapy should be considered usually cause inflammatory diarrhea in the United States. Therefore, only when the history or fecal leukocyte findings indicates an inflammatory process is it appropriate to culture for the routine invasive bacterial pathogens. In sporadic inflammatory diarrhea, culture methods should include those for Campylobacter jejuni as well as Salmonella and Shigella. Several special circumstances may prompt a consideration of parasites (including Giardia, Entamoeba, Strongyloides, Cryptosporidium), Vibrio, Yersinia, Clostridium difficile, enterotoxigenic Escherichia coli, food-borne agents, or sexually transmitted pathogens. The practical value of specific identification of rotaviruses (by enzyme-linked immunosorbent assay, Rotazyme, or electron microscopy) is primarily epidemiologic, particularly in hospitalized infants or young children. Using such a selective approach to fecal culture will greatly increase its yield and can reduce the cost per positive result from $1,000 to less than $150.
急性感染性腹泻的诊断和管理方法取决于疾病的发生频率和背景、可识别的病因或综合征、现有诊断检测的成本和收益以及疾病的可治疗性。急性腹泻在世界各地影响着每个人，每年发作一至六次以上，具体次数取决于年龄、地理位置和生活条件。可识别的病毒、细菌和寄生虫病因范围很广，不加区分地使用病因学研究进行诊断的成本过高。由于其对许多病原体不敏感且检测病例选择不佳，常规粪便培养一直是最昂贵且无效的微生物检测之一；传统上每个阳性结果的成本超过900至1000美元。绝大多数病例（无论病因如何）的适当治疗方法简单有效：口服含葡萄糖和电解质的补液溶液。根据适当的病史和对发病机制的了解，可以有选择地采集粪便标本，并迅速检查白细胞和寄生虫，将常见的非炎性腹泻与炎性感染区分开来，以便将进一步的研究重点放在后一组。在美国，通常应考虑使用特定抗菌治疗的细菌通常会引起炎性腹泻。因此，只有当病史或粪便白细胞检查结果表明存在炎性过程时，才适合培养常规侵袭性细菌病原体。在散发性炎性腹泻中，培养方法应包括针对空肠弯曲菌以及沙门氏菌和志贺氏菌的方法。几种特殊情况可能促使考虑寄生虫（包括贾第虫、溶组织内阿米巴、粪类圆线虫、隐孢子虫）、弧菌、耶尔森菌、艰难梭菌、产肠毒素大肠杆菌、食源性病原体或性传播病原体。轮状病毒特异性鉴定（通过酶联免疫吸附测定、Rotazyme或电子显微镜）的实际价值主要是流行病学方面的，特别是在住院婴儿或幼儿中。采用这种选择性粪便培养方法将大大提高其检出率，并可将每个阳性结果的成本从1000美元降低到不到150美元。
