Treatment of Diarrhea in General Practice in India for Beginner Doctors
The primary treatment for diarrhea in general practice is oral rehydration therapy (ORT) with reduced osmolarity oral rehydration solution (ORS), which should be the first-line treatment for all patients with mild to moderate dehydration. 1
Assessment of Dehydration
Assess dehydration level based on these clinical signs:
- Mild dehydration (3-5%): Increased thirst, slightly dry mucous membranes
- Moderate dehydration (6-9%): Loss of skin turgor, dry mucous membranes
- Severe dehydration (≥10%): Lethargy, altered consciousness, tachycardia, hypotension 1
Rehydration Protocol
Mild to Moderate Dehydration
Oral Rehydration Solution (ORS):
- Use reduced osmolarity ORS containing 65-70 mEq/L sodium and 75-90 mmol/L glucose 1
- WHO-recommended ORS can be prepared by mixing:
- 3.5g NaCl (salt)
- 2.5g NaHCO₃ (baking soda) or 2.9g Na citrate
- 1.5g KCl (potassium chloride)
- 20g glucose or 40g sucrose (sugar) or 50-60g cooked cereal flour (rice/wheat)
- Per liter of clean water 2
Administration technique:
- For patients with vomiting: Give small, frequent volumes (5 mL every minute) via spoon or syringe 1
- Continue until clinical dehydration is corrected
Severe Dehydration
Intravenous Rehydration:
Specific IV fluid recommendations based on sodium status:
- Isonatremic dehydration: 5% dextrose in 0.45% saline with 20 mEq/L KCl over 24h
- Hyponatremic dehydration: Alternate 0.9% saline and 0.45% saline in 1:1 ratio with 5% dextrose and 20 mEq/L KCl
- Hypernatremic dehydration: 5% dextrose in 0.2% saline with 20 mEq/L KCl over 2-3 days 3
Nutritional Management
- Continue breastfeeding throughout the diarrheal episode in infants
- Resume age-appropriate diet during or immediately after rehydration
- For older children: Continue regular diet emphasizing starches, cereals, yogurt, fruits, and vegetables
- Avoid foods high in simple sugars and fats 1
Medication Guidelines
Appropriate Use
Antibiotics: Only indicated for:
- Dysentery (bloody diarrhea)
- High fever
- Watery diarrhea lasting >5 days
- Specific identified pathogens requiring treatment
- First-line empiric treatment: Azithromycin 500mg single dose 1
Zinc supplementation: Beneficial for children 6 months to 5 years, especially with malnutrition 1
Probiotics: May reduce symptom severity and duration in immunocompetent patients 1
Ondansetron: May be given to patients >4 years to facilitate oral rehydration, but only after adequate hydration has begun 1
Medications to Avoid
- Antimotility drugs (e.g., loperamide): Contraindicated in children <18 years 1
- Unnecessary antibiotics: Avoid in uncomplicated cases 1, 4
- Antiemetics, antidiarrheals, and spasmolytics: Generally unnecessary and potentially risky 4
Warning Signs Requiring Immediate Attention
- Bloody diarrhea
- Persistent vomiting
- Signs of severe dehydration
- Altered mental status
- High fever
- Symptoms persisting >5 days despite treatment 1
Common Pitfalls in India
- Low prescription rate of ORS (only 22% in one Delhi study) 5
- Overuse of antibiotics and antidiarrheals (64% in same study) 5
- Unnecessary use of IV fluids (40% in same study) 5
- Lack of confidence in ORS effectiveness among healthcare providers 5
Infection Control
- Implement proper hand hygiene and infection control measures
- Educate patients and caregivers about hygiene practices
- Asymptomatic contacts should not receive preventive therapy 1
Remember that dehydration from diarrhea remains a significant cause of morbidity and mortality, especially in children. Appropriate ORT can prevent most of these deaths, making it the cornerstone of diarrhea management in general practice in India.