What is the treatment for bacterial diarrhea in children?

Treatment of Bacterial Diarrhea in Children

The cornerstone of treating bacterial diarrhea in children is oral rehydration therapy (ORS) for all cases, with antimicrobial therapy reserved only for specific bacterial pathogens (Shigella, suspected cholera, or enteric fever) or high-risk children (immunocompromised, ill-appearing young infants), while avoiding antibiotics in most acute watery diarrhea and never using them for STEC infections. 1

Initial Assessment and Risk Stratification

Determine Degree of Dehydration

• 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 (acidosis) 1

Identify High-Risk Features Requiring Antimicrobials

• Bloody diarrhea (dysentery) suggesting Shigella or invasive pathogens 1, 2
• Suspected enteric fever (typhoid) based on clinical presentation 1
• Immunocompromised status or ill-appearing young infants 1
• Suspected cholera in appropriate epidemiologic context 1, 2

Rehydration Therapy: The Primary Treatment

For Mild Dehydration (3-5% deficit)

• Administer 50 mL/kg of ORS containing 50-90 mEq/L sodium over 2-4 hours 1
• Use teaspoon, syringe, or medicine dropper to provide small volumes initially (e.g., one teaspoon), gradually increasing as tolerated 1
• Reassess hydration status after 2-4 hours 1

For Moderate Dehydration (6-9% deficit)

• Administer 100 mL/kg of ORS over 2-4 hours using same technique as mild dehydration 1
• Children who tolerate ≥25 mL/kg of ORS during observation are likely to succeed with home oral rehydration 3

For Severe Dehydration (≥10% deficit)

• Medical emergency requiring immediate IV rehydration 1
• Administer 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize 1
• Once consciousness returns, switch to ORS for remaining deficit replacement 1

Replace Ongoing Losses

• Administer 10 mL/kg ORS for each watery/loose stool 1
• Administer 2 mL/kg ORS for each vomiting episode 1

Antimicrobial Therapy: When and What to Use

DO NOT Use Antibiotics For:

• Most acute watery diarrhea without recent international travel 1
• STEC O157 or any STEC producing Shiga toxin 2 (antibiotics increase risk of hemolytic uremic syndrome) 1
• Asymptomatic contacts of children with diarrhea 1

USE Antibiotics For:

Shigella (Dysentery with Blood/Mucus)

• Antimicrobial therapy is beneficial and indicated 1, 2
• Azithromycin is preferred given emerging resistance patterns 4
• Recent evidence shows azithromycin reduces day 3 diarrhea by 11.6% and 90-day hospitalization/death by 3.1% in bacterial watery diarrhea 4

Suspected Cholera

• Antimicrobial therapy beneficial 2
• Tailor choice to local susceptibility patterns 1

Enteric Fever (Typhoid)

• Begin broad-spectrum antimicrobials after blood, stool, and urine cultures 1
• Narrow therapy when susceptibility results available 1

High-Risk Children with Watery Diarrhea

• Consider empiric treatment in immunocompromised children or ill-appearing young infants 1
• Azithromycin shows benefit when bacterial etiology confirmed or presumed (risk difference -11.6% for day 3 diarrhea) 4

Nutritional Management

Continue Feeding Throughout Illness

• Never implement "gut rest" - fasting reduces enterocyte renewal and increases intestinal permeability 1
• Continue breastfeeding on demand throughout the diarrheal episode 1
• Resume age-appropriate diet immediately after rehydration is completed 1

For Bottle-Fed Infants

• Administer full-strength, lactose-free or lactose-reduced formulas immediately upon rehydration 1
• If lactose-containing formula used, monitor for worsening diarrhea indicating true lactose intolerance 1
• Presence of reducing substances in stool alone (without clinical worsening) does NOT indicate lactose intolerance 1

Medications to AVOID

Antimotility Agents

• Never give loperamide or other antimotility drugs to children <18 years with acute diarrhea 1
• These agents do not substitute for proper fluid/electrolyte therapy 1

Routine Antiemetics

• Not recommended as primary therapy 1
• May be considered once adequately hydrated, but not a substitute for rehydration 1

Common Pitfalls to Avoid

• Do not use "clear liquids" instead of ORS - they cause osmotic diarrhea, electrolyte imbalance, contain inadequate sodium and excess sugar 1
• Do not withhold food - early refeeding prevents nutritional consequences and promotes intestinal recovery 1
• Do not give antibiotics for vomiting alone - use small frequent volumes of ORS (5 mL every minute) with close supervision 1
• Do not culture stool routinely - only indicated for dysentery or when specific pathogen identification changes management 1
• Do not treat based solely on stool reducing substances - clinical worsening with lactose reintroduction is required for diagnosis 1

Monitoring and Follow-Up

• Reassess hydration status every 2-4 hours during rehydration phase 1
• Instruct parents to return if child becomes irritable/lethargic, has decreased urine output, develops intractable vomiting, or has persistent diarrhea 1
• Modify or discontinue antimicrobials when clinically plausible organism identified 1