What is the recommended treatment for diarrhea?

Treatment of Diarrhea

The first-line treatment for diarrhea is oral rehydration therapy with reduced osmolarity oral rehydration solution (ORS), which should be used for mild to moderate dehydration in infants, children, and adults with acute diarrhea from any cause. 1

Assessment of Dehydration Severity

Determine the level of dehydration to guide treatment approach:

• Mild to moderate dehydration: Dry mucous membranes, decreased skin turgor, decreased urine output
• Severe dehydration: Altered mental status, tachycardia, hypotension, shock

Treatment Algorithm

1. Rehydration Therapy

For Mild to Moderate Dehydration:

• First-line: Reduced osmolarity oral rehydration solution (ORS) 1
• For adults who cannot tolerate oral intake, consider nasogastric administration of ORS 1
• Continue ORS until clinical dehydration is corrected 1

For Severe Dehydration:

• Immediate intervention: Isotonic intravenous fluids (lactated Ringer's or normal saline) at 60-100 ml/kg in first 2-4 hours 1, 2
• Continue IV rehydration until pulse, perfusion, and mental status normalize 1
• Once stabilized, transition to ORS to replace remaining deficit 1

2. Dietary Management

• Infants: Continue breastfeeding throughout diarrheal episode 1
• All patients: Resume age-appropriate usual diet during or immediately after rehydration 1
• Avoid fatty, heavy, spicy foods and caffeine 1
• Small, light meals are recommended 1
• Consider avoiding lactose-containing foods in prolonged episodes 1

3. Pharmacologic Therapy

Antimotility Agents:

• Adults: Loperamide 4 mg initial dose followed by 2 mg after each loose stool (maximum 16 mg/day) may be given to immunocompetent adults with acute watery diarrhea 1, 3
• Contraindications: Do not use in children <18 years, in cases of bloody diarrhea, high fever, or inflammatory diarrhea 1, 3
• Cardiac warning: Avoid doses higher than recommended due to risk of cardiac adverse reactions including QT prolongation 3

Antiemetics:

• Ondansetron may be given to children >4 years and adolescents with vomiting to facilitate oral rehydration 1

Probiotics:

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

Zinc Supplementation:

• Recommended for children 6 months to 5 years in areas with high prevalence of zinc deficiency or with signs of malnutrition 1

Antimicrobials:

• Not recommended for routine treatment of uncomplicated, watery diarrhea 1
• Consider only for specific indications such as:
  • Dysentery (bloody diarrhea with fever)
  • Cholera
  • Traveler's diarrhea (moderate to severe)
  • Immunocompromised patients

Special Considerations

Cancer Treatment-Induced Diarrhea

• For mild diarrhea: Loperamide (4 mg initial dose, then 2 mg every 4 hours) 1
• For severe diarrhea: Consider octreotide (100-150 μg SC TID) and IV fluids 1

When to Seek Medical Care

Advise patients to seek medical attention if:

• No improvement within 48 hours 1
• Symptoms worsen 1
• Development of warning signs: severe vomiting, high fever, bloody stools, or signs of dehydration 1

Common Pitfalls to Avoid

1. Overuse of antimicrobials in uncomplicated diarrhea, which can worsen symptoms and contribute to resistance 4, 5

2. Underutilization of ORT in favor of IV fluids when oral rehydration would be sufficient 6

3. Delaying reintroduction of feeding after rehydration, which can prolong recovery 6

4. Using antimotility agents in children under 18 years or in cases of bloody diarrhea 1

5. Inadequate fluid replacement during ongoing losses - continue ORS to replace ongoing losses until diarrhea resolves 1

The evidence strongly supports that proper rehydration is the cornerstone of diarrhea management, with appropriate use of antimotility agents in adults when indicated, while maintaining nutrition throughout the illness.