Treatment Options for Diarrhea
The cornerstone of treatment for diarrhea is rehydration therapy, with oral rehydration solution (ORS) as the first-line treatment for mild to moderate dehydration and intravenous fluids for severe dehydration. 1
Assessment and Classification
- Evaluate the degree of dehydration by assessing mental status, pulse, skin turgor, and mucous membranes 2
- Determine if warning signs are present: high fever, bloody stools, severe vomiting, obvious dehydration, or worsening symptoms 3, 2
- Classify diarrhea as "uncomplicated" (mild symptoms without complicating factors) or "complicated" (presence of fever, bloody stools, severe dehydration, or immunocompromised state) 1
Rehydration Therapy
Mild to Moderate Dehydration
- Administer reduced osmolarity oral rehydration solution (ORS) containing 50-90 mEq/L of sodium 1
- For children: Give 50-100 mL/kg of ORS over 3-4 hours 1
- For adults: Administer 2-4 L of ORS, with additional fluid intake as indicated by thirst 1, 2
- Replace ongoing losses with 10 mL/kg of ORS for each watery stool in children or 120-240 mL for each diarrheal stool in adults 1
Severe Dehydration
- Administer isotonic intravenous fluids such as lactated Ringer's or normal saline solution immediately 1
- Give intravenous boluses (20 mL/kg) until pulse, perfusion, and mental status normalize 1
- Once stabilized, transition to oral rehydration to replace the remaining deficit 1
- Nasogastric administration of ORS may be considered in patients who cannot tolerate oral intake but do not require IV fluids 1
Dietary Management
- Continue breastfeeding in infants throughout the diarrheal episode 1
- Resume age-appropriate usual diet during or immediately after rehydration 1, 2
- For adults, maintain food intake guided by appetite; small, light meals are recommended 3, 2
- Avoid fatty, heavy, spicy foods and caffeine-containing drinks 3, 2
Pharmacological Treatment
Antimotility Agents
- Loperamide may be given to immunocompetent adults with acute watery diarrhea (initial dose 4 mg followed by 2 mg every 4 hours or after each unformed stool, not exceeding 16 mg/day) 1, 2, 4
- Antimotility drugs should NOT be given to children <18 years of age with acute diarrhea 1
- Avoid loperamide in patients with bloody diarrhea, fever, or suspected inflammatory diarrhea 2, 4
- Loperamide should be used with caution due to risk of cardiac adverse reactions, including QT prolongation, with higher than recommended doses 4
Antibiotics
- Empiric antimicrobial therapy is not recommended in most people with acute watery diarrhea 1
- Consider antibiotics for:
Special Populations
Children
- Antimotility drugs (loperamide) are contraindicated in children <18 years of age 1
- Loperamide is specifically contraindicated in children <2 years due to risks of respiratory depression and cardiac adverse reactions 4
- Maintain breastfeeding throughout illness for infants 1
- Consider lactose-free formulas for bottle-fed infants with persistent diarrhea 1
Cancer Patients
- For mild to moderate chemotherapy-induced diarrhea: loperamide (4 mg initially, then 2 mg every 4 hours) 1
- For severe chemotherapy-induced diarrhea: consider octreotide (100-150 μg SC TID) and IV fluids 1
When to Seek Medical Attention
- No improvement within 48 hours of self-treatment 3, 2
- Development of warning signs: severe vomiting, dehydration, persistent fever, abdominal distension, or blood in stools 3, 2
- Immunocompromised patients with any degree of diarrhea 1, 6
Common Pitfalls and Caveats
- Do not substitute sports drinks, apple juice, or commercial soft drinks for proper ORS, as they have inappropriate electrolyte content 1
- Antimotility agents should not be used as a substitute for proper rehydration therapy 1
- Empiric antibiotics should be avoided unless specifically indicated, as they may worsen certain conditions like STEC infections 1
- Loperamide should be discontinued if constipation, abdominal distention, or ileus develop 4