What is the treatment for acute diarrhea in an inpatient setting?

Treatment of Acute Diarrhea in Inpatient Setting

The cornerstone of treatment for acute diarrhea in an inpatient setting is appropriate rehydration therapy based on the degree of dehydration, with oral rehydration solution (ORS) as first-line therapy for mild to moderate cases and intravenous fluids for severe dehydration. 1

Assessment of Hydration Status

First, assess the patient's hydration status to guide treatment:

• Mild dehydration (3-5% fluid deficit):

  • Clinical signs: Slightly dry mucous membranes, normal to slightly decreased skin turgor
  • Mental status: Alert

• Moderate dehydration (6-9% fluid deficit):

  • Clinical signs: Dry mucous membranes, decreased skin turgor, sunken eyes
  • Mental status: Normal to lethargic

• Severe dehydration (≥10% fluid deficit):

  • Clinical signs: Very dry mucous membranes, significantly decreased skin turgor, sunken eyes, cool extremities, decreased capillary refill
  • Mental status: Lethargic to obtunded
  • May present with shock or near-shock

Rehydration Protocol

For Mild Dehydration (3-5% fluid deficit):

• Administer ORS 50 mL/kg over 2-4 hours 1
• Start with small volumes and gradually increase
• Reassess hydration status after 2-4 hours

For Moderate Dehydration (6-9% fluid deficit):

• Administer ORS 100 mL/kg over 2-4 hours 1
• Use same administration technique as for mild dehydration
• Reassess hydration status after 2-4 hours

For Severe Dehydration (≥10% fluid deficit):

• This is a medical emergency requiring immediate IV rehydration
• Administer IV boluses of 20 mL/kg of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize 1
• May require multiple boluses or two IV lines in severe cases
• Once the patient is alert, transition to oral rehydration for remaining deficit 1
• Continue IV rehydration until pulse, perfusion, and mental status normalize and patient has no risk factors for aspiration or ileus 1

For Patients Without Dehydration:

• Skip rehydration phase and proceed directly to maintenance therapy 1

Replacement of Ongoing Fluid Losses

• Replace ongoing stool and vomit losses continuously during both rehydration and maintenance phases
• For measurable losses: 1 mL ORS per gram of diarrheal stool 1
• For estimated losses: 10 mL/kg ORS for each watery stool and 2 mL/kg for each episode of emesis 1
• Continue replacement until diarrhea and vomiting resolve 1

Dietary Management

• Continue feeding during diarrheal episodes - do not withhold food 1
• For breastfed infants: continue nursing on demand
• For bottle-fed infants: use full-strength, lactose-free or lactose-reduced formulas upon rehydration
• For older children and adults: continue regular diet with emphasis on starches, cereals, yogurt, fruits, and vegetables
• Avoid foods high in simple sugars and fats 1

Pharmacological Therapy

Antimicrobial Therapy

• Antibiotics are not routinely indicated for acute diarrhea 1
• Consider antibiotics only in specific situations:
  • Dysentery (bloody diarrhea)
  • High fever
  • Watery diarrhea lasting >5 days
  • When stool cultures or microscopy indicate a specific treatable pathogen
  • In immunocompromised patients with severe illness 1

Antimotility Agents

• Loperamide may be considered in adults only after adequate hydration, but should not be given to:
  • Children <18 years of age 1
  • Patients with inflammatory diarrhea or fever 1
  • Patients with suspected toxic megacolon 2
• Loperamide should be used with caution due to risk of cardiac adverse reactions, especially at higher than recommended doses 2

Antiemetics

• Ondansetron may be used in children >4 years and adolescents to facilitate oral rehydration when vomiting is prominent 1

Probiotics

• May be offered to reduce symptom severity and duration in immunocompetent patients 1

Special Considerations

Management of Vomiting

• For patients with vomiting, administer small, frequent volumes of ORS (e.g., 5 mL every minute)
• Use spoon or syringe with close supervision
• Correction of dehydration often reduces vomiting frequency 1
• Consider nasogastric ORS administration for patients who cannot tolerate oral intake 1

Common Pitfalls to Avoid

1. Overuse of antibiotics - most acute diarrhea is viral and self-limiting
2. Inappropriate use of antimotility agents in children or in inflammatory diarrhea
3. Withholding food during diarrheal episodes
4. Failing to replace ongoing losses during both rehydration and maintenance phases
5. Delaying IV therapy in severely dehydrated patients

Criteria for Hospital Admission

• Infants <3 months of age
• Severe dehydration
• Severe malnutrition
• Toxic appearance
• Persistent vomiting despite appropriate ORS administration
• Suspected surgical abdomen 3

Discharge Criteria

• Resolution of dehydration
• Ability to maintain hydration with oral intake
• Adequate urine output
• Improving clinical status

By following this systematic approach to the management of acute diarrhea in the inpatient setting, clinicians can effectively reduce morbidity and mortality associated with this common condition.