From the Guidelines
For diarrhea with fever, the most appropriate initial treatment is to stay hydrated with oral rehydration solutions like Pedialyte or a homemade mixture, and consider antimicrobial therapy with azithromycin, especially if symptoms are severe or if there is suspicion of bacterial etiology, as recommended by the 2017 Infectious Diseases Society of America clinical practice guidelines 1. The treatment approach should prioritize hydration and symptom management, with a focus on reducing the risk of complications, particularly in high-risk populations such as children, the elderly, and those with compromised immune systems. Key considerations include:
- Staying hydrated with oral rehydration solutions like Pedialyte or a homemade mixture of 6 teaspoons sugar and 1/2 teaspoon salt in 1 liter of water 1
- Taking acetaminophen (Tylenol) for fever, following package dosing instructions
- Avoiding anti-diarrheal medications like loperamide (Imodium) when having fever, as they can worsen certain infections 1
- Consuming bland foods like bananas, rice, applesauce, and toast (BRAT diet) while avoiding dairy, fatty, and spicy foods
- Seeking medical attention if experiencing severe symptoms such as high fever (above 102°F/39°C), bloody stools, severe abdominal pain, signs of dehydration (decreased urination, extreme thirst, dizziness), or if symptoms persist beyond 48-72 hours Antimicrobial therapy with azithromycin may be considered, especially if symptoms are severe or if there is suspicion of bacterial etiology, as recommended by the guidelines 1. It is essential to note that the use of antimotility agents, such as loperamide, should be avoided in children under 18 years of age and in cases of suspected or proven toxic megacolon, inflammatory diarrhea, or diarrhea with fever 1. Overall, the treatment approach should prioritize hydration, symptom management, and reducing the risk of complications, with antimicrobial therapy considered on a case-by-case basis, guided by the most recent and highest-quality evidence 1.
From the FDA Drug Label
Dehydration Fluid and electrolyte depletion often occur in patients who have diarrhea In such cases, administration of appropriate fluid and electrolytes is very important. The use of loperamide hydrochloride does not preclude the need for appropriate fluid and electrolyte therapy to contact their healthcare provider if they see blood in their stools, or if they develop a fever or abdominal distention
Treatment of Diarrhea with Fever:
- The treatment of diarrhea with fever should include the administration of appropriate fluid and electrolytes.
- Loperamide hydrochloride can be used to treat diarrhea, but it is only symptomatic and does not address the underlying cause of the diarrhea.
- Patients should be advised to contact their healthcare provider if they develop a fever or abdominal distention.
- The use of loperamide hydrochloride does not preclude the need for appropriate fluid and electrolyte therapy 2
From the Research
Treatment of Diarrhea with Fever
- The treatment of acute diarrhea is still primarily supportive, with symptomatic therapy being the most important component 3.
- Empirical antibiotic therapy should be considered for severely ill patients with a high frequency of stools, fever, bloody diarrhea, underlying immune deficiency, advanced age, or significant comorbidities 3, 4, 5.
- Oral rehydration therapy with early refeeding is the preferred treatment for dehydration 6, 4, 7.
- Antimotility agents should be avoided in patients with bloody diarrhea, but loperamide/simethicone may improve symptoms in patients with watery diarrhea 4.
- Probiotic use may shorten the duration of illness 4.
- Antibiotics are effective in the treatment of shigellosis, campylobacteriosis, Clostridium difficile, traveler's diarrhea, and protozoal infections, but should only be used when appropriate 3, 4, 5.
Diagnostic Evaluation
- Diagnostic investigation should be reserved for patients with severe dehydration, persistent fever, bloody stool, immunosuppression, and for cases of suspected nosocomial infection or outbreak 4, 5, 7.
- Laboratory tests may include complete blood count, creatinine and electrolytes evaluation, determination of leukocytes and lactoferrin presence in the stools, stool culture, and C. difficile testing 5.
- Molecular studies are preferred over traditional stool cultures, unless an outbreak is suspected 7.