What is the treatment for infective diarrhea?

Treatment for Infective Diarrhea

The cornerstone of treatment for infective diarrhea is rehydration therapy, with reduced osmolarity oral rehydration solution (ORS) recommended as first-line therapy for mild to moderate dehydration in all age groups. 1

Rehydration Therapy

• Reduced osmolarity ORS should be used for mild to moderate dehydration from any cause of diarrhea 1
• Nasogastric administration of ORS may be considered in patients with moderate dehydration who cannot tolerate oral intake 1
• Isotonic intravenous fluids (lactated Ringer's or normal saline) should be administered for severe dehydration, shock, altered mental status, or when ORS therapy fails 1
• IV rehydration should continue until pulse, perfusion, and mental status normalize, after which remaining deficit can be replaced using ORS 1
• Once rehydrated, maintenance fluids should be administered, with ongoing stool losses replaced with ORS until diarrhea resolves 1

Nutritional Management

• Human milk feeding should be continued in infants and children throughout the diarrheal episode 1
• Age-appropriate usual diet should be resumed during or immediately after rehydration 1
• Oral zinc supplementation reduces diarrhea duration in children 6 months to 5 years of age in countries with high zinc deficiency prevalence or in children with signs of malnutrition 1

Antimicrobial Therapy

• In most people with acute watery diarrhea without recent international travel, empiric antimicrobial therapy is not recommended 1
• Exceptions for empiric antimicrobial therapy include:
  • Immunocompromised patients 1
  • Ill-appearing young infants 1
  • Infants <3 months with suspected bacterial etiology 1
  • Patients with fever, abdominal pain, bloody diarrhea with presumptive shigellosis 1
  • Recent international travelers with fever ≥38.5°C or signs of sepsis 1
• Antimicrobial treatment should be modified or discontinued when a specific pathogen is identified 1
• Antimicrobial therapy should be avoided in infections with STEC O157 and other Shiga toxin 2-producing E. coli 1

Adjunctive Therapies

• Antimotility drugs (e.g., loperamide) should not be given to children <18 years with acute diarrhea 1
• Loperamide may be given to immunocompetent adults with acute watery diarrhea but should be avoided in inflammatory or febrile diarrhea due to risk of toxic megacolon 1, 2
• Antinausea/antiemetic agents (e.g., ondansetron) may be given to children >4 years and adolescents to facilitate oral rehydration when vomiting is present 1
• Probiotic preparations may be offered to reduce symptom severity and duration in immunocompetent patients 1

Special Considerations

• Asymptomatic carriers generally don't need treatment except those with Salmonella Typhi who may be treated to reduce transmission 1
• Persistent diarrhea (≥14 days) requires consideration of non-infectious causes including IBD and IBS 1
• Hand hygiene is crucial for prevention, especially after using the toilet, changing diapers, before/after food preparation, and after handling animals 1

Treatment Algorithm

1. Assess hydration status and severity of illness
2. For mild-moderate dehydration: Administer ORS
3. For severe dehydration: Start IV fluids until stabilized, then transition to ORS
4. Continue appropriate diet during illness
5. Consider antimicrobials only if:
   • Bloody diarrhea with fever (suspected shigellosis)
   • Immunocompromised host
   • Infant <3 months with suspected bacterial infection
   • Traveler with fever or sepsis
6. Consider adjunctive therapy only after adequate hydration:
   • Probiotics for all ages
   • Loperamide for adults only with non-bloody, non-febrile diarrhea
   • Ondansetron for children >4 years with significant vomiting

Common Pitfalls to Avoid

• Administering antimotility agents to children or in cases of bloody/inflammatory diarrhea 1
• Using antimicrobials for routine acute watery diarrhea 1
• Neglecting rehydration while focusing on antimicrobial therapy 1
• Withholding food during diarrheal episodes 1
• Using antimicrobials in STEC infections, which may increase risk of hemolytic uremic syndrome 1