What is the treatment for diarrhea?

Treatment of Diarrhea

The mainstay of treatment for acute diarrhea is oral rehydration therapy (ORT) with appropriate fluid and electrolyte replacement, followed by early nutritional support and resumption of feeding. 1

Assessment and Classification

• Evaluate the degree of dehydration to determine appropriate management strategy:
  • Mild dehydration (3-5% fluid deficit): administer 50 mL/kg of ORS over 2-4 hours 2
  • Moderate dehydration (6-9% fluid deficit): administer 100 mL/kg of ORS over 2-4 hours 2
  • Severe dehydration (≥10% fluid deficit): requires immediate IV rehydration 3

Oral Rehydration Therapy (ORT)

• Use reduced osmolarity oral rehydration solution (ORS) containing 45-75 mEq/L of sodium as first-line therapy 2, 3
• Administer ORS in small volumes (5-10 mL) every 1-2 minutes with gradual increase in amount consumed 1
• For vomiting patients, administer ORS via small, frequent volumes (e.g., 5 mL every minute) using a spoon or syringe 1
• Replace ongoing losses by giving 10 mL/kg for each watery stool 4
• Nasogastric administration can be considered for children who cannot tolerate oral intake 2
• Commercial ORS products are effective and convenient; providing ORS at the time of office visits increases utilization and reduces unscheduled follow-up visits 5

Nutritional Management

• Continue feeding during diarrheal episodes rather than fasting ("gut rest") 1
• For infants:
  • Breastfed infants should continue nursing on demand throughout the diarrheal episode 2
  • Bottle-fed infants should receive full-strength, lactose-free, or lactose-reduced formulas immediately upon rehydration 2
• For older children and adults:
  • Resume age-appropriate diet during or immediately after rehydration 2
  • Focus on easily digestible foods such as starches, cereals, yogurt, fruits, and vegetables 2

Pharmacological Management

• Antimicrobial therapy is generally not recommended for most cases of acute watery diarrhea 1
• Consider antimicrobial therapy only in specific situations:
  • Infants <3 months of age with suspected bacterial etiology 1
  • Patients with fever, abdominal pain, and bloody diarrhea presumptively due to Shigella 1
  • Recent international travelers with high fever (≥38.5°C) and/or signs of sepsis 1
  • Immunocompromised patients with severe illness 1
• Avoid antimicrobial therapy for STEC O157 and other Shiga toxin 2-producing E. coli due to increased risk of hemolytic uremic syndrome 2
• Antimotility agents (e.g., loperamide):
  • Should not be given to children <2 years of age due to risks of respiratory depression and serious cardiac adverse reactions 6
  • Use with caution in adults and children ≥2 years, avoiding doses higher than recommended due to risk of serious cardiac adverse reactions 6
  • Contraindicated in patients with bloody diarrhea, high fever, or suspected inflammatory bowel disease 6

Special Considerations

• For persistent diarrhea (>14 days):

  • Consider non-infectious causes including lactose intolerance, inflammatory bowel disease (IBD), and irritable bowel syndrome (IBS) 1
  • Avoid empiric antimicrobial treatment 1
  • Reassess fluid and electrolyte balance and nutritional status 1

• For high-risk populations:

  • Elderly patients require closer monitoring due to higher risk of severe complications 4
  • Immunocompromised patients may benefit from earlier empiric antimicrobial therapy 1

Prevention Measures

• Proper hand hygiene after using the toilet, changing diapers, and before preparing food 2
• Appropriate infection control measures in healthcare settings 2
• Education of parents and caregivers on early management of diarrhea at home 1
• Encourage having ORS available in households with children 1

Common Pitfalls to Avoid

• Allowing dehydrated children to drink large volumes of ORS ad libitum, which can worsen vomiting; instead, administer small amounts frequently 1
• Delaying reintroduction of feeding, which can worsen nutritional status and prolong diarrhea 1
• Using antimotility medications in young children or in cases of bloody diarrhea 6
• Prescribing unnecessary antibiotics for uncomplicated acute watery diarrhea, which can disrupt gut flora and potentially worsen symptoms 1
• Failing to recognize when IV rehydration is necessary in cases of severe dehydration or intractable vomiting 3