What is the management plan for a patient presenting with acute diarrhea (loose stools) and fever?

Management of Acute Diarrhea with Fever

For a patient with 5 episodes of loose stools and fever, immediately assess hydration status and begin oral rehydration therapy with reduced osmolarity ORS solution while maintaining normal diet, reserving antibiotics only for documented dysentery (high fever >38.5°C with frank blood in stool). 1

Initial Assessment

Evaluate the following critical features to guide management:

• Hydration status: Check for thirst, dry mucous membranes, skin turgor, capillary refill time, orthostatic changes, and decreased urination 2
• Stool characteristics: Determine if watery versus bloody/mucoid, frequency, and volume 2
• Fever severity: Temperature >38.5°C suggests invasive/inflammatory process 2
• Warning signs: Frank blood in stool, severe vomiting preventing oral intake, altered mental status, or signs of severe dehydration 2, 1

Degree of dehydration classification 2:

• Mild (3-5% deficit): Increased thirst, slightly dry mucous membranes
• Moderate (6-9% deficit): Loss of skin turgor, prolonged capillary refill, dry mucous membranes
• Severe (≥10% deficit): Lethargy, prolonged skin tenting >2 seconds, cool extremities, shock

Rehydration Protocol

Oral rehydration is first-line therapy for all patients who can tolerate oral intake 2, 1:

• For mild dehydration: Administer 50 mL/kg of ORS over 2-4 hours 2
• For moderate dehydration: Administer 100 mL/kg of ORS over 2-4 hours 2
• For severe dehydration: This is a medical emergency requiring immediate IV boluses of 20 mL/kg Ringer's lactate or normal saline until perfusion normalizes 2

If vomiting is present: Give small frequent volumes (5-10 mL) every 1-2 minutes, gradually increasing as tolerated 1. Nasogastric administration may be considered if oral intake fails but mental status is normal 1.

Replace ongoing losses: Administer 10 mL/kg of ORS for each watery stool and 2 mL/kg for each vomiting episode 2

Dietary Management

Continue normal feeding immediately after rehydration is achieved 1:

• Do NOT withhold food or enforce fasting 2, 1
• Breast-fed infants should continue nursing on demand throughout the illness 2, 1
• Resume age-appropriate normal diet during or immediately after rehydration 1
• Small, light meals are acceptable; avoid fatty, heavy, spicy foods and caffeine 2

The evidence strongly supports early refeeding rather than dietary restriction, as solid food does not hasten or retard recovery in adults and speeds recovery in children 2.

Antimicrobial Therapy Decision

Antibiotics are indicated ONLY for documented dysentery 2:

• Dysentery definition: High fever (>38.5°C) AND frank blood in stool 2
• First-line: Fluoroquinolones for empirical treatment of invasive diarrhea 2
• Do NOT use empirical antibiotics for simple acute watery diarrhea with fever, as this promotes resistance without clear benefit 2

The guidelines explicitly state that empirical antimicrobials for all acute diarrheal episodes is not in the best interest of public health due to increasing drug resistance 2.

Antimotility Agents

Loperamide may be used in immunocompetent adults ONLY after adequate rehydration is achieved 1, 3:

• Absolute contraindications: Children <18 years, bloody diarrhea, high fever, suspected dysentery 1, 3, 4
• Risk: Can cause toxic megacolon in inflammatory diarrhea 3
• Antimotility agents are NOT a substitute for rehydration therapy 3

Red Flags Requiring Medical Evaluation

Seek immediate medical attention for 1:

• Inability to tolerate oral fluids despite small frequent volumes
• Worsening dehydration signs
• Development of bloody diarrhea
• Significant increase in fever
• Altered mental status or severe lethargy 2

Adjunctive Therapies

Probiotics may be considered to reduce symptom severity and duration 1. However, the primary focus must remain on rehydration and nutritional support, which have the strongest evidence base 2, 1.

Common Pitfalls to Avoid

• Do not delay rehydration while pursuing diagnostic workup in non-toxic patients 2
• Do not use antimotility agents in children or when fever/blood are present 1, 3
• Do not withhold food after rehydration is achieved 2, 1
• Do not give antibiotics empirically without evidence of invasive disease 2
• Stool cultures are rarely needed for typical acute watery diarrhea and should be reserved for dysentery or toxic-appearing patients 2, 5