What is the treatment approach for enteritis?

Treatment Approach for Enteritis

The treatment of enteritis depends critically on the clinical context: uncomplicated infectious enteritis requires primarily oral rehydration and supportive care, while complicated cases (fever, bloody diarrhea, immunocompromise, or severe dehydration) demand aggressive management with IV fluids, empiric antibiotics, and potential hospitalization.

Initial Assessment and Risk Stratification

The first step is determining disease severity and patient risk factors:

• Uncomplicated enteritis presents with watery diarrhea without fever, blood, or signs of dehydration 1
• Complicated enteritis includes fever, bloody stools, severe dehydration, immunocompromise, or systemic illness 1
• Evaluate for orthostatic vital sign changes, dry mucous membranes, decreased skin turgor, altered mental status, and abdominal tenderness 1

Rehydration Therapy (Foundation of Treatment)

Reduced osmolarity oral rehydration solution (ORS) is first-line therapy for mild to moderate dehydration in all age groups 1:

• ORS should be administered for any patient who can tolerate oral intake 1
• Nasogastric ORS may be considered in patients with moderate dehydration who cannot tolerate oral intake 1
• Isotonic IV fluids (lactated Ringer's or normal saline) are mandatory for severe dehydration, shock, altered mental status, or ORS failure 1
• Continue IV rehydration until pulse, perfusion, and mental status normalize 1

Empiric Antibiotic Therapy: When and What

Uncomplicated Cases

Do NOT use empiric antibiotics for uncomplicated watery diarrhea 1. Most cases are self-limited and antibiotics provide no benefit 2, 3.

Indications for Empiric Antibiotics

Empiric therapy is indicated for 1:

• Infants <3 months with suspected bacterial etiology 1
• Febrile patients (≥38.5°C) with bloody diarrhea and bacillary dysentery syndrome (frequent bloody stools, fever, cramps, tenesmus) 1
• Recent international travelers with fever ≥38.5°C or signs of sepsis 1
• Immunocompromised patients with severe illness and bloody diarrhea 1
• Traveler's diarrhea where prompt treatment reduces illness from 3-5 days to <1-2 days 1

Antibiotic Selection

For adults: Fluoroquinolone (ciprofloxacin) OR azithromycin based on local resistance patterns and travel history 1

For children: Third-generation cephalosporin (infants <3 months or neurologic involvement) OR azithromycin based on local patterns 1

Critical caveat: Avoid antibiotics in STEC O157 and Shiga toxin 2-producing E. coli infections, as they may precipitate hemolytic uremic syndrome 1. This is a potentially fatal pitfall.

Special Populations and Contexts

Neutropenic Enterocolitis (High Mortality Risk)

Treatment is non-operative with immediate broad-spectrum antibiotics and bowel rest 1, 4:

• First-line: Monotherapy with anti-pseudomonal β-lactam (piperacillin-tazobactam) OR carbapenem OR imipenem-cilastatin 1
• Alternative: Combination therapy with cefepime or ceftazidime PLUS metronidazole 1
• Add antifungal therapy (amphotericin) if fever persists despite antibacterial treatment 1
• Resolution occurs in 86% with conservative treatment over 6-8 days 1, 4
• Avoid anticholinergics, antidiarrheals, and opioids as they may worsen ileus 1

Surgery is reserved ONLY for perforation, uncontrolled bleeding, or clinical deterioration despite aggressive medical therapy 1. Mortality with emergency surgery in neutropenic patients on recent chemotherapy approaches 57-81% 1.

Cytomegalovirus Enteritis/Colitis

Treatment is non-operative with antiviral therapy, broad-spectrum antibiotics, and bowel rest 4. Emergency surgery only for toxic megacolon, fulminant colitis, perforation, or ischemia 4.

Clostridioides difficile

• Test specifically for C. difficile in nosocomial diarrhea (≥3 days after hospitalization) or recent antibiotic exposure 1, 4
• If detected, administer oral vancomycin and consider fecal microbial transplant 1
• Stop immunosuppression if possible 1

Symptomatic Management

Uncomplicated Diarrhea

• Loperamide: 4 mg initially, then 2 mg after each loose stool (maximum 16 mg/day) 1
• Dietary modification and skin care to prevent irritation 1

Complicated Diarrhea

• IV fluids and electrolyte replacement (potassium supplementation ≥60 mmol/day to prevent toxic dilatation) 1
• Octreotide for severe cases: 100-150 μg subcutaneously three times daily, or IV 25-50 μg/hour if severely dehydrated, escalating to 500 μg three times daily 1
• Antiemetics as needed for nausea/vomiting 1

Diagnostic Testing to Guide Therapy

Selective fecal testing is recommended for 1:

• Diarrhea lasting >1 day with fever, bloody stools, systemic illness, recent antibiotics, daycare attendance, hospitalization, or dehydration 1
• Stool evaluation should include blood, leukocytes, fecal lactoferrin, and culture for Salmonella, Shigella, Campylobacter, E. coli, and C. difficile 1
• Modify or discontinue antibiotics when a specific pathogen is identified 1

Critical Pitfalls to Avoid

• Never delay surgery in critically ill patients with perforation, uncontrolled bleeding, or shock 1
• Do not treat asymptomatic contacts empirically 1
• Immunocompromised patients may not present with typical signs—maintain high suspicion even with subtle findings 1, 4
• Avoid antibiotics in confirmed or suspected STEC infections 1
• Do not use antidiarrheals in neutropenic enterocolitis 1