Purina Nutrition Exchange: November 2024

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Managing Acute Diarrhea: Weigh Antibiotic Use Carefully & Consider Other Tools

Katie Tolbert, DVM, PhD, DACVIM (SAIM, SA Nutrition), Clinical Associate Professor, Gastrointestinal Laboratory in the Department of Small Animal Clinical Sciences, Texas A&M University

Q: How is the work of your university laboratory changing the understanding of how gastrointestinal (GI) conditions should be managed in veterinary patients?

A: The sole mission of our not-for-profit laboratory is to improve the lives of cats and dogs that have GI, hepatic and pancreatic diseases and to address their unmet needs. One of our biggest areas of interest is to better understand the microbiome—how it functions in health and how changes might relate to certain health conditions. When the microbiome is in a state of imbalance, or dysbiosis, we’re learning how intervention can return patients to a healthy state and how doing so benefits them. Therapies such as diet and probiotics often have the potential to be more benign than therapies that once were commonly used, such as antibiotics.

Q: Acute diarrhea is one of the more common GI conditions seen by veterinarians. What best practices do you recommend when managing these patients?

A: The first step is taking a thorough patient history to help uncover potential triggers. Pinpointing events that are out of the ordinary for the pet is key. Think how often we hear clients say things like, ‘My dog got into the trash,’ or ‘My dog was fed a chicken leg,’ or ‘My cat came in with a mouse four days ago.’

The next step is to rule out infectious causes of the diarrhea, such as toxigenic bacteria, viruses, or parasites, as these cases can be very serious and progress quickly and may require hospitalization and supportive care. However, most of these patients do not come in febrile and we don’t see negative changes in their blood work. More often than not, we do not identify a cause of diarrhea and it is termed “idiopathic diarrhea.”

The next step is devising a management plan. An important component of recovery from diarrhea is feeding the patient a highly digestible diet to reduce the workload of the gut. When selecting a diet, practitioners should consider the added value of nutrients or ingredients that can help support the immune system such as prebiotic fibers or colostrum. These ingredients can help support the host intestinal microflora and prime the immune system. Finally, we can also give them a probiotic to help ameliorate diarrhea.

When I was in veterinary school, it was common to treat acute diarrhea with antibiotics. Now, we know that most animals don’t need an antibiotic and that it potentially causes harm. Of course, there can be exceptions. If a patient has signs of systemic illness, fever, abnormal blood work or vital parameters that are not responding to supportive care with fluids and other measures in the hospital, antibiotic use may be warranted.

Q: Antibiotics are obviously indispensable in veterinary practice, but their use can adversely affect the health of an animal’s microbiome. When antibiotic use is warranted to manage a patient with acute diarrhea, what steps can be taken to manage their adverse effects?

A: I tell practitioners to make sure their approach is as targeted as possible. There is no reason to use a broad-spectrum antibiotic that’s going to target both gram-negative and gram-positive aerobes and anaerobes if a culture or other diagnostic test suggests a gram-negative anaerobe is the culprit. Treat the infections as specifically as you can and in the case of a skin infection, consider topical rather than systemic treatment.

When antibiotic use is warranted, concurrent use of specific probiotics might help preserve or restore the microbiome or promote stool consistency. We need more studies, but the preliminary evidence is compelling. Another potential option is fecal microbial transplantation. Again, more investigation is needed, but early studies suggest this strategy can provide relief for dogs experiencing prolonged diarrhea a‘er antibiotic usage, especially if they have dysbiosis.

Diet + Probiotics = One-Two Punch to Acute Diarrhea

Avi Shaprut, DVM, Veterinary Communications Consultant, Purina Pro Plan Veterinary Diets

For many veterinarians, seeing dogs with acute diarrhea is a daily clinic occurrence. Whether the cause is dietary indiscretion, stress, parasitism or the side effect of an antibiotic, acute diarrhea in a dog adversely affects both patients and their owners. By the time clients call the veterinary hospital, they are usually highly motivated to seek a swift solution.

Probiotic Research Triggers Paradigm Shift

For many years, dispensing antibiotics to dogs with acute diarrhea was considered a rational and evidence-based management approach. Even when diarrhea has a noninfectious cause, such as stress or dietary indiscretion, the balance between “good” and “bad” bacteria is thrown off-kilter, leading the potentially “bad” bacteria to proliferate. A short course of certain antibiotics was believed to bring about a quick resolution of clinical signs.

The problem is that metronidazole administration can disrupt the gastrointestinal microbiome for days, weeks, months—or even longer.¹ Furthermore, diarrhea often recurs when the antibiotic is discontinued, leading veterinarians to extend the course of antibiotics and trigger further microbiome impairment. Meanwhile, a recent study demonstrated that antibiotics were not statistically different versus placebo at resolving diarrhea.²

Today, veterinary GI experts recommend a highly digestible diet for dogs with acute diarrhea because it facilitates optimal nutrient absorption and can provide prebiotic fibers to promote digestive health. However, for most patients with nonspecific acute diarrhea, a probiotic such as Purina® Pro Plan® Veterinary Supplements FortiFlora® Canine Probiotic Supplement in combination with a diet such as Purina® Pro Plan® Veterinary Diets EN Gastroenteric® Canine Formula or EN Gastroenteric® Fiber Balance Canine Formula, may be a great first option for therapy. For clients who question this approach, I explain that probiotics and diet are likely more effective than antibiotics in their pet’s case and do not have harmful effects on the microbiome.

Prebiotics and probiotics can promote the presence of beneficial bacteria, which can decrease the opportunity for harmful bacteria to proliferate and result in diarrhea. Fortunately, today’s pet owners are much more familiar with the concept of microbiome health, thanks to its extensive coverage in the popular press. Clients are more likely to understand why this dietary approach can help manage their dog’s clinical signs, and they also likely recognize that a probiotic or a diet change can often be better for their dog’s overall health.

Offer Supplements with a Side of Client Education

Sylvalyn Hammond, DVM, All Creatures Veterinary Clinic Charleston, South Carolina

While most clients are receptive to giving supplements to their pets, I tell them to proceed with caution in the world of pet supplements. A company’s marketing may be great, but their products may not be! I always stress the importance of using supplements from reputable brands that have a National Animal Supplement Council (NASC) seal on their packaging. I also believe it’s important to equip clients with information and experience-based recommendations that only we as veterinarians can provide.

Clearly Communicate the Role of Supplements

I recommend supplements for patients for a variety of conditions and position them as part of a multimodal management program. I stress that supplements can’t cure conditions but can help with their long-term management. Some examples:

• Joint management. If possible, I start supplementation early with a product that contains glucosamine, chondroitin sulfate and the omega-3 fatty acids EPA and DHA. I stress that the goal is to keep dogs mobile and maintain their joint range of motion.

• Anxiety. I tell clients about my own German Shepherd whom I rescued during veterinary school. He became very stressed when I had to leave him. I started him on Purina® Pro Plan® Veterinary Supplements Calming Care as soon as it came on the market and maintained him on it full-time. When he had to be boarded, I would also give him an antianxiety medication like trazodone to help him handle the additional stress.

• Acute diarrhea. In my experience, probiotic supplements like Purina® Pro Plan® Veterinary Supplements FortiFlora® are a fantastic first-line option for managing these patients. The supplement can be used short-term or continuously if the dog is prone to frequent episodes.

Cut Through the Clutter with Credible Client Education

For the client whose pet has been diagnosed with a new condition, it is simply not enough to give them a box of supplements or a bottle of medication. I strongly believe in sending patients home with discharge instructions so the owner can read about the condition and the treatment plan when they’re in a calmer environment. I also use an app called Scribble AI that records what I tell them in the exam room, then creates a readable transcript I can send home. I also download resources from reputable websites and print them or text the client links.

I have my own Instagram handle (@thehonestvet) and have found social media to be a vital means of client education. The more we as veterinarians can offer our own recommendations, the better we can dissuade clients from information that isn’t factual.

I tell people that client communication is the most common procedure I perform. The best treatment plan won’t help a patient if the client doesn’t understand the plan and what it will do for their pet.