From the Guidelines
A thorough workup for diarrhea with fever should begin with stool testing for Salmonella, Shigella, Campylobacter, Yersinia, C. difficile, and STEC, as recommended by the 2017 Infectious Diseases Society of America clinical practice guidelines 1. When evaluating a patient with diarrhea and fever, it is essential to consider the presence of bloody or mucoid stools, severe abdominal cramping or tenderness, or signs of sepsis, as these factors may guide the need for additional testing, such as blood cultures 1. Key considerations in the workup include:
- Stool testing for bacterial pathogens, including Salmonella, Shigella, Campylobacter, Yersinia, C. difficile, and STEC, which is recommended for people with diarrhea accompanied by fever, bloody or mucoid stools, severe abdominal cramping or tenderness, or signs of sepsis 1
- Blood cultures should be obtained from infants <3 months of age, people of any age with signs of septicemia or when enteric fever is suspected, people with systemic manifestations of infection, people who are immunocompromised, people with certain high-risk conditions such as hemolytic anemia, and people who traveled to or have had contact with travelers from enteric fever–endemic areas with a febrile illness of unknown etiology 1
- A broader set of bacterial, viral, and parasitic agents should be considered regardless of the presence of fever, bloody or mucoid stools, or other markers of more severe illness in the context of a possible outbreak of diarrheal illness 1 The selection of agents for testing should be based on a combination of host and epidemiologic risk factors and ideally in coordination with public health authorities 1.
From the Research
Diarrhea with Fever
- Diarrhea can be categorized as inflammatory or noninflammatory, and both types have infectious and noninfectious causes 2.
- Infectious noninflammatory diarrhea is often viral in etiology and is the most common presentation; however, bacterial causes are also common and may be related to travel or foodborne illness 2.
- History for patients with acute diarrhea should include onset and frequency of symptoms, stool character, a focused review of systems including fever and other symptoms, and evaluation of exposures and risk factors 2.
Treatment Options
- Oral rehydration is an effective and inexpensive treatment for dehydration due to gastroenteritis in children 3.
- Intravenous rehydration therapy (IVT) may be necessary in cases of severe dehydration or sepsis 3, 2.
- Antidiarrheal agents can be symptomatic therapy for acute watery diarrhea and can help decrease inappropriate antibiotic use 2.
- Empiric antibiotics are rarely warranted, except in sepsis and some cases of travelers' or inflammatory diarrhea 2.
Evaluation and Management
- The evaluation of the patient with diarrhea can be complex and the treatment challenging 4.
- A simplified 5-step approach to the patient with diarrhea is provided and applied in a case-oriented manner applicable to everyday clinical practice 4.
- Most episodes of acute diarrhea in countries with adequate food and water sanitation are uncomplicated and self-limited, requiring only an initial evaluation and supportive treatment 2.
- Additional diagnostic evaluation and management may be warranted when diarrhea is bloody or mucoid or when risk factors are present, including immunocompromise or recent hospitalization 2.