Clinical practice guideline and pathway for the evaluation and management of children with diarrhea in family and community practice

Background@#Diarrhea is among the common causes of morbidity and mortality in children. It is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual). It does not include frequent passing of formed stool and passing of loose, pasty stools by breastfed babies. It is usually a symptom of an infection in the intestinal tract, caused by variety of organisms, which is spread through contaminated food or drinking water, or from person-to-person as a result of poor hygiene. Diarrhea can last several days and can leave the body without the water and salts that are necessary for survival causing significant number of mortality and morbidity among children. At the level of primary care, diagnosis, management and treatment of food- and waterborne-diseases, which commonly present as diarrhea, lack the necessary protocols and standards, thus, the creation of this clinical pathway. @*Objective@#The main goal of this clinical pathway was to provide guidance to family and community physicians, and other primary care physicians in managing acute diarrhea among immunocompetent pediatric patients.@*Methods@#ADAPTE process was used in CPG development. Existing guidelines on acute diarrhea among pediatric patients were retrieved and appraised using the AGREE II tool. Recommendation statements from the guidelines that passed the AGREE II tool were reviewed. Recommendation statements that will help answer the clinical questions posed in the creation of the clinical pathway were adapted. For clinical questions were not answered by the available guideline recommendations, a de novo method was conducted. The adapted recommendation statements and the supporting summary of evidences were sent for external review prior to consensus development. Suggestions provided in both steps were discussed and incorporated in the final manuscript, as appropriate.@*Key Recommendation Statements@#These key recommendation statements addressing the clinical assessment, diagnosis, interventions (pharmacologic and nonpharmacologic), and patient outcomes that are relevant in the outpatient or primary care setting in the Philippines were based on the summarized key evidences from the systematic review of literature conducted using the ADAPTE process. Clinical Assessment Recommendation 1. A focused medical history that includes questions on duration, frequency, characteristics, associated symptoms, consumption of raw, ill-prepared, or rotten food; intake of antibiotics, contaminated food or water; and history of travel should be obtained. (Strong recommendation, High quality evidence) Recommendation 2. Physical examination should be done to assess the nutritional status, degree of dehydration, severity of disease, and presence of complications and comorbid conditions. (Strong recommendation, High quality evidence) Recommendation 3. Degree of dehydration should be classified into No Dehydration, Mild to Moderate Dehydration, or Severe Dehydration. (Weak recommendation, Moderate quality evidence) Recommendation 4. Children with acute infectious diarrhea who have any of the following conditions should be admitted to the hospital: severe dehydration, inability to tolerate fluids orally, suspected electrolyte abnormalities, altered consciousness, abdominal distention, respiratory distress, pneumonia, meningitis/encephalitis, sepsis, moderate to severe malnutrition, suspected surgical condition, or conditions for safe follow-up and home management are not met. (Strong recommendation, High quality evidence) Diagnostic Tests Recommendation 5. Routine diagnostic tests are not necessary among children with acute diarrhea. (Strong recommendation, Low quality evidence) Recommendation 6. Stool examination may only be requested if the patient present with moderate to severe condition, bloody diarrhea, or amoebiasis and parasitism is being considered at time of epidemic. (Strong recommendation, High quality evidence) Recommendation 7. Diagnostic tests may be requested if concomitant conditions like pneumonia, urinary tract infection, sepsis or meningitis are suspected; or if abdominal distension is observed post-hydration. (Strong recommendation, High quality evidence) Recommendation 8. Stool culture, serologic test, rapid diagnostic test, PCR determination and serum biomarkers are not recommended in family and community practice. (Strong recommendation, High quality evidence) Pharmacologic Treatment Recommendation 9. Reduced osmolarity oral rehydration solution (ORS), commercial or home-made is recommended to replace previous and ongoing losses. (Strong recommendation, High quality evidence) Recommendation 10. The volume and frequency of reduced osmolarity oral rehydration solution (ORS) should be dependent on patient’s age or weight, severity of dehydration and ongoing losses. (Strong recommendation, High quality evidence) Recommendation 11. Severe dehydration should be managed in the hospital with intravenous hydration. (Strong recommendation, High quality of evidence) Recommendation 12. Routine empiric antibiotic treatment is not recommended in children with acute infectious diarrhea. (Strong recommendation, Very low quality evidence) Recommendation 13. Antibiotic treatment may be given to children with Cholera, Shigella, typhoidal Salmonella, amoebiasis, and giardiasis. The choice of antibiotic must be guided by the local Antibiotic Surveillance Program. (Strong recommendation, High quality evidence) Recommendation 14. In general, antibiotic treatment should not be given in children with non-typhoidal Salmonella. It may be given in children with underlying conditions i.e., immunodeficiency, corticosteroid or immunosuppressive therapy. (Strong recommendation, Very low quality evidence) Recommendation 15. Among children older than six months, zinc supplementation of 10-20 mg per day for 10-14 days may be offered to reduce the duration and severity of diarrhea, and recurrence in the next two to three months (Strong recommendation, High quality evidence) Recommendation 16. Racecadotril may be offered to reduce ongoing loss of water and electrolytes. (Strong recommendation, High quality evidence) Recommendation 17. Probiotics may be offered to reduce the duration of diarrhea. Lactobacillus rhamnosus GG (LGG), Saccharomyces boulardii and Lactobacillus reuteri are strains with evidence of effectiveness. (Strong recommendation, High quality evidence) Recommendation 18. Anti-emetics and antidiarrheal drugs are generally not recommended because of their side-effects. (Strong recommendation, High quality evidence) Non-pharmacologic Interventions Recommendation 19. Among children with acute diarrhea, age-appropriate feeding should be continued. There is no need to modify or restrict diet. (Strong recommendation, Moderate quality of evidence) Recommendation 20. Among infants with diarrhea, breastfeeding must be continued. (Strong recommendation, High quality evidence) Recommendation 21. If diet was restricted because of frequent vomiting, early refeeding must be done. (Strong recommendation, Moderate quality evidence) Recommendation 22. All members of the family must be encouraged regular hand washing with soap and water. (Strong recommendation, Moderate quality evidence) Recommendation 23. Family members must observe proper food handling, have access to safe drinking water, and observe proper waste disposal. (Strong recommendation, Low quality evidence) Recommendation 24. Community level intervention that encourages hand washing, proper food handling, appropriate waste disposal and ensuring safe drinking water must be done. (Strong recommendation, Low quality evidence) Expected Patient Outcomes Recommendation 25. After each encounter the patient or guardian must understand the nature of acute diarrhea, its management and potential complications. (Strong recommendation, Low quality evidence) Recommendation 26. The management plan must be a mutual agreement between the family physician and the guardian. (Strong recommendation, Low quality evidence) Recommendation 27. For the management of a child with acute diarrhea, the family physician must target for resolution of dehydration, resolution of diarrhea, prevention of relapse, hospitalization, complications and early detection of adverse events. (Strong recommendation, High quality evidence) @*Dissemination and Implementation@#This clinical pathway will be published in the “The Filipino Family Physician” journal, which is accessible in the PAFP journal website. PAFP’s Committee on Research will disseminate the clinical pathway through distribution to its subspecialty and affiliate societies, chapters, training programs, and primary care practitioners; and continuing development sessions of the PAFP. Monitoring of the uptake of the clinical pathway will be through the number of downloads at the website and requests for copies. This clinical pathway may be used as a guide by family and community physician and primary care physicians in a primary care setting. Tabular presentation of the clinical pathway was included as a tool for implementation. Monitoring of implementation will be via continuous quality improvements activities, which can be a self-initiated activity of the member as recommended in the Universal Healthcare, or as a chapter or group activity.

Decisions based on health economic analysis

@#Family and community practitioners sometimes will decide on what community-oriented interventions to propose and implement. The cost and effectiveness of such interventions are often debated by policy makers. A set of formal, quantitative methods for comparing alternative strategies in resource use and expected outcomes is known as health economic analysis. This article presents a tool to help family and community practitioners decide on the cost and effectiveness of such interventions.

Clinical pathway for the diagnosis and management of patients with COVID-19 in family practice

Background@#Coronavirus disease 2019 (COVID-19) has rapidly spread worldwide, causing a pandemic. The Philippines ranks 3rd in Southeast Asia with more than 15,000 confirmed cases, and a case fatality rate of 6.01%, close to the global average of 6.33%.@*Objective@#This clinical pathway was developed to guide family and community physicians on the diagnosis and initial management of COVID-19 in terms of 1) clinical history and physical examination; 2) laboratory and ancillary procedures to be requested; 3) pharmacologic interventions; 4) non-pharmacologic interventions, and 5) patient outcomes to expect.@*Method@#The PAFP Clinical Pathways Group reviewed the published medical literature to identify, summarize, and operationalize the evidence in clinical publication on the management of patients with COVID-19 in family and community practice.@*Recommendations@#The recommendations are time-bound tasks on patient care processes, in terms of history and physical examination, laboratory tests, pharmacologic and non-pharmacologic interventions. The recommendations are presented as a table and algorithm.@*Implementation@#At the clinic level, self-audit using the recommendations of this clinical pathway as the standard may be done. At the organizational level, the PAFP should establish a new model of quality improvement initiative where self-practice audits are included as part of the program.