What is the best approach for treating diarrhea with fever?

Treatment of Diarrhea with Fever

For diarrhea with fever, the cornerstone of treatment is oral rehydration therapy with appropriate fluid and electrolyte replacement, while antibiotics should only be considered when there is evidence of bacterial infection, with azithromycin being the preferred first-line agent. 1

Initial Assessment and Management

Rehydration (First Priority)

• Oral Rehydration Solution (ORS) is the mainstay treatment for mild to moderate dehydration 1, 2
  • Use reduced osmolarity ORS containing 75-90 mEq/L sodium, 20 mEq/L potassium, 65-80 mEq/L chloride, 10 mEq/L citrate, and 75-111 mmol/L glucose 1
  • For severe dehydration, begin with intravenous fluids (60-100 ml/kg of 0.9% saline) to restore circulation before transitioning to ORS 1, 3

Dietary Modifications

• Resume age-appropriate diet during or immediately after rehydration 1
• Follow BRAT diet (bread, rice, applesauce, toast) 1
• Avoid:
  • Lactose-containing products
  • Alcohol
  • High-osmolar supplements
  • Foods high in simple sugars and fats 1

Pharmacological Management

Antimotility Agents

• Loperamide should be avoided in cases of diarrhea with fever due to risk of complications 1, 4
• Contraindications for loperamide:
  • Children under 2 years (absolute contraindication due to risk of respiratory depression and cardiac adverse reactions) 4
  • Bloody diarrhea
  • Fever
  • Suspected inflammatory diarrhea 1, 4

Antibiotic Therapy

• Only consider antibiotics when there is:

  • Evidence of bacterial infection
  • Immunocompromised status
  • Severe illness with systemic symptoms 1

• First-line antibiotic recommendations for bacterial gastroenteritis with fever:

  Suspected Pathogen	First-line Treatment	Alternative Treatment
  Shigella	Azithromycin	TMP-SMX (if susceptible)
  Campylobacter	Azithromycin	Erythromycin
  ETEC	Azithromycin or TMP-SMX (if susceptible)	-
  Bacterial gastroenteritis (unspecified)	Azithromycin or third-generation cephalosporin	-

Monitoring and Red Flags

Signs of Dehydration to Monitor

• General appearance
• Eyes (sunken)
• Mucous membranes (dry)
• Tears (decreased)
• Capillary refill time (prolonged)
• Urine output (decreased)
• Vital signs (tachycardia, hypotension) 1

Warning Signs Requiring Immediate Medical Attention

• No improvement within 48 hours
• Worsening symptoms
• Severe vomiting
• Persistent fever
• Abdominal distension
• Blood in stool 1

Special Considerations

Cardiac Risk with Loperamide

• Cases of QT prolongation, Torsades de Pointes, and sudden death have been reported with loperamide, particularly at higher doses 4
• Avoid loperamide in combination with other QT-prolonging medications 4

Pediatric Patients

• Children show greater variability in response to treatments, particularly those under 6 years 4
• Loperamide is contraindicated in children under 2 years 4
• ORS is particularly important in pediatric patients to prevent mortality 2

Prevention

• Proper hand hygiene is essential to prevent spread of infection 1
• Consider rotavirus vaccination for prevention of rotavirus gastroenteritis 1