What is the treatment approach for infectious diarrhea?

Treatment Approach for Infectious Diarrhea

The primary treatment for infectious diarrhea is oral rehydration therapy with reduced osmolarity oral rehydration solution (ORS), while antimicrobial therapy should be reserved for specific indications only. 1, 2

Initial Assessment and Management

Rehydration (First Priority)

• Oral Rehydration Therapy:

  • Use reduced osmolarity ORS as first-line therapy for mild to moderate dehydration 2
  • ORS composition: 65-70 mEq/L sodium and 75-90 mmol/L glucose 2
  • Preparation: 3.5g NaCl, 2.5g NaHCO₃, 1.5g KCl, and 20g glucose per liter of clean water 2

• Alternative Administration Methods:

  • Nasogastric administration of ORS for those who cannot tolerate oral intake 1
  • Intravenous fluids (isotonic solutions like lactated Ringer's or normal saline) for severe dehydration, shock, altered mental status, or when ORS fails 2

Diet Recommendations

• Continue age-appropriate diet during or immediately after rehydration 2
• For children, breastfeeding should be continued throughout rehydration 2
• A bland/BRAT diet (Bananas, Rice, Applesauce, Toast) may be followed 2
• Avoid spicy foods, coffee, alcohol, and foods high in simple sugars and fats 2

Antimicrobial Therapy

When to Avoid Empiric Antimicrobial Therapy

• In most people with acute watery diarrhea without recent international travel 1
• In patients with persistent watery diarrhea lasting 14 days or more 1
• For STEC O157 and other Shiga toxin 2-producing organisms (can worsen outcomes) 1

When to Consider Empiric Antimicrobial Therapy

1. Bloody diarrhea in specific situations:

   • Infants <3 months with suspected bacterial etiology 1
   • Ill immunocompetent people with fever, abdominal pain, bloody diarrhea, and bacillary dysentery presumptively due to Shigella 1
   • Recent international travelers with fever ≥38.5°C and/or signs of sepsis 1
   • Immunocompromised people with severe illness 1

2. Suspected enteric fever with clinical features of sepsis 1

Choice of Antimicrobial Agent

• For adults: Fluoroquinolone (e.g., ciprofloxacin) or azithromycin, depending on local susceptibility patterns and travel history 1

• For children:

  • Third-generation cephalosporin for infants <3 months or those with neurologic involvement 1
  • Azithromycin for other children, depending on local susceptibility patterns 1

• For confirmed infectious diarrhea: Ciprofloxacin is FDA-approved for infectious diarrhea caused by specific pathogens including E. coli (enterotoxigenic strains), Campylobacter jejuni, Shigella species, and Salmonella typhi 3

Adjunctive Therapies

Probiotics

• May be offered to reduce symptom severity and duration (weak recommendation) 2
• Evidence is stronger for viral gastroenteritis than bacterial or parasitic infections 4
• Effective strains include Lactobacillus casei GG, Lactobacillus reuteri, and Saccharomyces boulardii 4

Zinc Supplementation

• Beneficial for children 6 months to 5 years with signs of malnutrition or in areas with high prevalence of zinc deficiency 2

Monitoring and Follow-up

• Reassess hydration status regularly until corrected 2
• Reassess patients after 48-72 hours of treatment 2
• Consider alternative diagnoses or treatment failure if no improvement occurs 2
• For persistent symptoms, reassess fluid and electrolyte balance, nutritional status, and antimicrobial therapy 1
• Consider noninfectious conditions (IBD, IBS, lactose intolerance) for symptoms lasting ≥14 days 1

Prevention and Infection Control

• Implement proper hand hygiene practices 2
• Educate patients and caregivers about food and water safety 2
• Asymptomatic contacts should not receive preventive therapy but should follow appropriate infection prevention measures 1

Warning Signs Requiring Immediate Attention

• Severe abdominal pain, distension, ileus, toxic megacolon, or sepsis 2
• Worsening dehydration despite appropriate rehydration therapy 2