What are the guidelines for managing acute diarrhea?

Management Guidelines for Acute Diarrhea

The cornerstone of acute diarrhea management is oral rehydration therapy with reduced osmolarity oral rehydration solution (ORS), which should be used as first-line treatment for mild to moderate dehydration in all patients with acute diarrhea. 1, 2

Assessment of Dehydration

• Mild dehydration (3-5%): Increased thirst, slightly dry mucous membranes
• Moderate dehydration (6-9%): Loss of skin turgor, dry mucous membranes
• Severe dehydration (≥10%): Severe lethargy, altered consciousness 2

Rehydration Protocol

Mild to Moderate Dehydration

• Use reduced osmolarity ORS with sodium 65-70 mEq/L, glucose 75-90 mmol/L, potassium 20 mEq/L 2
• Replace ongoing losses with approximately 10 mL/kg ORS for each watery stool and 2 mL/kg for each episode of vomiting 2
• Continue until clinical dehydration is corrected 1

Severe Dehydration

• Administer isotonic IV fluids (lactated Ringer's or normal saline) 1
• Continue IV rehydration until pulse, perfusion, and mental status normalize 1
• Once stabilized, transition to ORS to replace remaining deficit 1
• For patients with ketonemia, initial IV hydration may be needed before oral rehydration 1

Alternative Administration

• Nasogastric ORS administration may be considered for those who cannot tolerate oral intake or refuse to drink adequately 1

Nutrition Management

• Continue breastfeeding throughout the diarrheal episode in infants and children 1, 2
• Resume age-appropriate diet during or immediately after rehydration 1, 2
• Avoid foods high in simple sugars and fats 2
• Include starches, cereals, yogurt, fruits, and vegetables 2

Pharmacological Management

Antimicrobial Therapy

• In most cases of acute watery diarrhea without recent international travel, empiric antimicrobial therapy is not recommended 1
• Exceptions for empiric antibiotics:
  • Immunocompromised patients with severe illness and bloody diarrhea 1
  • Ill-appearing young infants 1
  • Patients with clinical features of sepsis or suspected enteric fever 1
• Avoid antibiotics in cases of STEC O157 and other Shiga toxin 2-producing organisms 1
• Modify or discontinue antimicrobial treatment when a clinically plausible organism is identified 1

Symptomatic Treatment

• Antimotility agents (e.g., loperamide):

  • Should NOT be given to children <18 years with acute diarrhea 1, 2, 3
  • May be given to immunocompetent adults with acute watery diarrhea 1
  • Avoid in inflammatory diarrhea, diarrhea with fever, or when toxic megacolon may result 1

• Antiemetics:

  • Ondansetron (4 mg single dose) may be considered for children >4 years and adolescents with vomiting to facilitate oral rehydration 1, 2

• Probiotics:

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

• Zinc supplementation:

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

Special Considerations

Asymptomatic Contacts

• Asymptomatic contacts of people with acute diarrhea should not receive empiric or preventive therapy 1
• They should follow appropriate infection prevention and control measures 1

High-Risk Settings

• Asymptomatic people who work in high-risk settings (healthcare, childcare, elderly care, food service) should be treated according to local public health guidance 1

Prevention Measures

• Hand hygiene: Perform after using toilet, changing diapers, before/after food preparation, before eating, after handling garbage or soiled items 1
• Infection control: Use gloves, gowns, and proper hand hygiene when caring for people with diarrhea 1

Warning Signs Requiring Immediate Medical Attention

• Bloody diarrhea
• Persistent vomiting
• Signs of severe dehydration
• Altered mental status
• High fever 2

Common Pitfalls to Avoid

• Delaying rehydration
• Using inappropriate fluids
• Withholding food
• Overuse of antibiotics
• Inappropriate use of antidiarrheal medications in children 2