What is the treatment for fever with diarrhea?

Treatment of Fever with Diarrhea

The primary treatment for fever with diarrhea is immediate oral rehydration therapy with reduced osmolarity ORS (50-90 mEq/L sodium), while empiric antibiotics should be reserved only for specific high-risk situations including infants under 3 months, patients with documented fever ≥38.5°C plus bloody diarrhea and signs of bacillary dysentery, or recent international travelers with fever ≥38.5°C or sepsis. 1

Initial Assessment and Rehydration Strategy

Assess Dehydration Severity

• Mild dehydration (3-5% fluid deficit): Increased thirst, slightly dry mucous membranes 1
• Moderate dehydration (6-9% fluid deficit): Loss of skin turgor, skin tenting when pinched, dry mucous membranes 1
• Severe dehydration (≥10% fluid deficit): Severe lethargy or altered consciousness, prolonged skin tenting (>2 seconds), cool poorly perfused extremities, decreased capillary refill, rapid deep breathing indicating acidosis 1

Rehydration Protocol Based on Severity

For mild dehydration (3-5% deficit):

• Administer ORS containing 50-90 mEq/L sodium at 50 mL/kg over 2-4 hours 1, 2
• Start with small volumes (one teaspoon) using syringe or medicine dropper, gradually increasing as tolerated 1, 2
• Reassess hydration status after 2-4 hours 1, 2

For moderate dehydration (6-9% deficit):

• Administer ORS at 100 mL/kg over 2-4 hours using the same gradual approach 1, 2
• Consider nasogastric ORS administration if patient cannot tolerate oral intake but has normal mental status 1

For severe dehydration (≥10% deficit, shock, or altered mental status):

• This is a medical emergency requiring immediate IV rehydration 1
• Administer isotonic IV fluids (lactated Ringer's or normal saline) in 20 mL/kg boluses until pulse, perfusion, and mental status normalize 1
• Once circulation is restored, transition to ORS for remaining deficit replacement 1

When to Use Empiric Antibiotics

DO NOT Give Empiric Antibiotics For:

• Most cases of acute watery diarrhea with fever in immunocompetent patients 1, 2
• Persistent watery diarrhea lasting ≥14 days 1

DO Give Empiric Antibiotics For:

High-risk situations requiring immediate treatment: 1

• Infants <3 months of age with suspected bacterial etiology
• Patients with documented fever (≥38.5°C in medical setting) PLUS bloody diarrhea PLUS bacillary dysentery (frequent scant bloody stools, fever, abdominal cramps, tenesmus)
• Recent international travelers with fever ≥38.5°C and/or signs of sepsis
• Immunocompromised patients with severe illness and bloody diarrhea

Antibiotic Selection

For adults: 1, 3

• Fluoroquinolone (ciprofloxacin 500 mg twice daily) OR azithromycin, based on local susceptibility patterns and travel history
• Ciprofloxacin is FDA-approved for infectious diarrhea caused by E. coli (enterotoxigenic), Campylobacter jejuni, Shigella species, and Salmonella typhi 4

For children: 1, 3

• Third-generation cephalosporin for infants <3 months or those with neurologic involvement
• Azithromycin for older children, based on local susceptibility patterns and travel history

Critical Contraindications for Antimotility Agents

NEVER give loperamide or other antimotility drugs in the following situations: 1, 3, 2

• Children <18 years of age with acute diarrhea (absolute contraindication)
• ANY patient with fever and diarrhea (risk of toxic megacolon)
• ANY patient with bloody diarrhea or suspected inflammatory diarrhea
• Suspected or confirmed STEC O157 infection (increases hemolytic uremic syndrome risk) 1, 3

Loperamide may be considered ONLY in: 1

• Immunocompetent adults with acute watery diarrhea WITHOUT fever, after adequate rehydration is achieved

Nutritional Management

Resume feeding immediately or during rehydration: 1, 3, 2

• Continue breastfeeding throughout the illness in infants 1, 2
• Resume age-appropriate diet during or immediately after rehydration is completed 1
• Avoid fatty, heavy, spicy foods and caffeine 1
• Consider avoiding lactose-containing foods if diarrhea is prolonged 1

Adjunctive Therapies

Antiemetics (ondansetron): 1, 3, 2

• May be given to children >4 years and adolescents with vomiting to facilitate oral rehydration
• Use only AFTER adequate hydration begins, not as substitute for fluid therapy

Probiotics: 1, 3

• May be offered to reduce symptom severity and duration in immunocompetent patients
• Not recommended for early empiric treatment 1

Zinc supplementation: 1, 3

• Reduces diarrhea duration in children 6 months to 5 years in countries with high zinc deficiency prevalence or signs of malnutrition

Infection Control Measures

Mandatory hand hygiene: 1, 3, 2

• After toilet use, diaper changes, before and after food preparation, before eating, after handling garbage or animals
• Use soap and water or alcohol-based sanitizers when caring for patients with diarrhea

Isolation precautions: 1, 3

• Use gloves and gowns when caring for patients with diarrhea
• Asymptomatic contacts do NOT require treatment but must follow strict hand hygiene 1, 2

Common Pitfalls to Avoid

• Do not delay rehydration while waiting for diagnostic test results 3
• Do not use antimotility agents in children or patients with fever/bloody diarrhea - this is the most dangerous error and can lead to toxic megacolon 1, 3
• Do not withhold antibiotics in high-risk groups (infants <3 months, immunocompromised, travelers with high fever) 1
• Do not give antibiotics for suspected STEC O157 infection - increases HUS risk 1, 3
• Do not use IV fluids when oral rehydration is feasible - ORS is equally effective for mild-moderate dehydration and reduces healthcare costs 1, 5

Monitoring and Follow-up

• Continue ORS to replace ongoing stool losses until diarrhea and vomiting resolve 1
• Seek medical attention if no improvement in 48 hours, symptoms worsen, or warning signs develop (persistent high fever, severe vomiting, dehydration, abdominal distension, frank blood in stools) 1
• Modify or discontinue antibiotics when specific pathogen is identified from cultures 1, 3