What are the alternative treatments for diarrhea?

Alternative Treatments for Diarrhea

For most cases of acute diarrhea, oral rehydration therapy (ORT) using reduced osmolarity oral rehydration solutions (ORS) is the primary treatment of choice, with early refeeding and appropriate dietary management. 1

First-Line Treatments

Oral Rehydration Therapy (ORT)

• Use reduced osmolarity oral rehydration solutions containing 65-70 mEq/L sodium and 75-90 mmol/L glucose 1
• Total fluid intake should be 2200-4000 mL/day, exceeding ongoing losses 1
• ORT remains the cornerstone of treatment for all forms of gastroenteritis 1
• For children, the WHO and American Academy of Pediatrics recommend ORS as the mainstay of treatment 2, 1

Dietary Management

• Resume age-appropriate diet during or immediately after rehydration 1
• Continue breastfeeding throughout the entire illness for infants 1
• Avoid foods high in simple sugars and fats 1
• Early refeeding (within 4-6 hours of initial rehydration) is recommended 1

Pharmacological Alternatives

Antimotility Agents

• Loperamide can be used for adults with watery diarrhea 1, 3
  • Starting dose: 4 mg followed by 2 mg every 2-4 hours or after each unformed stool
  • Maximum daily dose: 16 mg
  • CAUTION: Avoid in patients with bloody diarrhea, suspected inflammatory diarrhea, ileus, and in children under 18 years 1

Probiotics

• May shorten the duration of illness 3
• Can be considered as an adjunctive therapy to ORT 4

For Severe, Refractory Cases

• Octreotide can be used for severe, refractory diarrhea 1
  • Starting dose: 100-150 μg subcutaneous/IV three times daily

When to Consider Antibiotics

Antibiotics should be considered only in specific situations:

• Immunocompromised patients
• Severe bloody diarrhea with fever
• Confirmed bacterial pathogen requiring treatment
• Suspected neutropenic enterocolitis 1

Pathogen-specific antibiotic recommendations:

• Shigella: Azithromycin (first-line) or TMP-SMX if susceptible
• Campylobacter: Azithromycin (first-line) or Erythromycin
• Enterotoxigenic E. coli: TMP-SMX (if susceptible) or Azithromycin 1

IMPORTANT: Antibiotics should NOT be used for E. coli O157:H7 or other Shiga toxin-producing E. coli as they may increase the risk of hemolytic uremic syndrome 1

Special Considerations

Severity Assessment

• Assess dehydration severity to guide treatment:
  • Mild: <3% weight loss
  • Moderate: 3-9% weight loss
  • Severe: >9% weight loss, altered mental status, or poor perfusion 1

When to Use IV Fluids Instead

• For severe dehydration, intravenous fluid replacement is first-line treatment
• Initial fluid bolus of 20 mL/kg using isotonic saline or balanced salt solution 1
• Continue rapid infusion until clinical signs of hypovolemia improve 1

What to Avoid

• Sport drinks, juice, soft drinks, and chicken broth are not recommended for rehydration, though may be considered for patients with no or mild dehydration 5
• Antiemetics, antidiarrhetics (except loperamide in adults), and spasmolytics are generally unnecessary and potentially risky, especially in children 6
• Uncritical use of antibiotics and intestinal antiseptics in bacterial diarrhea should be avoided 6

Monitoring and Prevention

• Monitor for signs of dehydration: urine output (target ≥0.5 ml/kg/h), vital signs, and electrolytes 1
• Hand hygiene is essential after toilet use, diaper changes, before/after food preparation 1
• For persistent diarrhea (>14 days) with unidentified source, evaluate for non-infectious conditions 1

When to Seek Medical Attention

• Persistent vomiting preventing ORS intake
• High stool output (>10 mL/kg/hour)
• Bloody diarrhea
• Worsening dehydration despite treatment
• Lethargy or altered mental status 1