What is the management for a patient presenting with fever and diarrhea?

Management of Fever with Loose Stool

The cornerstone of management is immediate oral rehydration therapy with reduced osmolarity ORS, while empiric antibiotics should be reserved only for patients with documented dysentery (high fever >38.5°C with frank blood in stool) or specific high-risk conditions. 1, 2

Immediate Assessment Priorities

Evaluate hydration status first by checking for:

• Thirst, dry mucous membranes, and decreased skin turgor 2
• Capillary refill time and orthostatic vital signs 2, 3
• Abnormal respiratory pattern (predictor of ≥5% dehydration) 3
• Mental status changes or decreased urination 2

Determine stool characteristics:

• Watery vs. bloody/mucoid appearance 2
• Frequency and volume of stools 2
• Presence of frank blood (not just occult) 1

Assess fever severity:

• Temperature >38.5°C suggests invasive/inflammatory bacterial process 1, 2
• Fever with bloody diarrhea and severe cramping suggests Shigella dysentery 1

Identify red flags requiring immediate intervention:

• Severe vomiting preventing oral intake 2
• Altered mental status or signs of shock 1
• Immunocompromised status 1
• Recent international travel with high fever or sepsis signs 1
• Infants <3 months of age 1

Rehydration Protocol (First-Line Treatment)

For mild to moderate dehydration:

• Administer reduced osmolarity ORS as first-line therapy 1, 2
• Give 50 mL/kg over 2-4 hours for mild dehydration 2
• Give 100 mL/kg over 2-4 hours for moderate dehydration 2
• Replace ongoing losses with 10 mL/kg ORS for each watery stool 4

For patients with vomiting:

• Administer small volumes (5-10 mL) every 1-2 minutes via spoon or syringe 2
• Consider ondansetron to facilitate oral rehydration tolerance in adults and children >4 years 1, 4
• Nasogastric ORS administration may be considered if oral intake fails 1

For severe dehydration:

• Immediate IV boluses of 20 mL/kg lactated Ringer's or normal saline until perfusion normalizes 1, 2
• Continue IV rehydration until pulse, perfusion, and mental status normalize 1
• Transition to ORS once patient can tolerate oral intake 1

Antimicrobial Therapy Decision Algorithm

DO NOT give empiric antibiotics for:

• Simple acute watery diarrhea with fever (promotes resistance without benefit) 1, 2
• Asymptomatic contacts of patients with bloody diarrhea 1

GIVE empiric antibiotics ONLY for:

1. Documented dysentery (high fever >38.5°C + frank blood in stool + severe cramping/tenesmus presumed Shigella) 1, 2

   • Adults: Ciprofloxacin 500 mg PO twice daily OR azithromycin based on local resistance patterns 1
   • Children: Azithromycin based on local resistance patterns 1

2. Infants <3 months with suspected bacterial etiology 1

   • Third-generation cephalosporin 1

3. Recent international travelers with:

   • Temperature ≥38.5°C and/or signs of sepsis 1
   • Fluoroquinolone or azithromycin depending on travel history 1

4. Immunocompromised patients with severe illness and bloody diarrhea 1

5. Suspected enteric fever with sepsis features 1

   • Obtain blood, stool, and urine cultures first 1
   • Start broad-spectrum therapy, narrow when susceptibilities available 1

AVOID antibiotics in:

• STEC O157 or Shiga toxin 2-producing strains (increases HUS risk) 1
• Use of loperamide with bloody diarrhea or high fever 1, 5

Dietary Management

Resume feeding immediately after rehydration:

• Continue normal age-appropriate diet during or immediately after rehydration 1, 2
• Continue breastfeeding throughout illness 1
• Avoid fatty, heavy, spicy foods and caffeine initially 2
• Eliminate lactose-containing products temporarily 1, 4
• Drink 8-10 large glasses of clear liquids daily 1

Antimotility and Adjunctive Agents

Loperamide is CONTRAINDICATED in: 1, 5

• Children <18 years of age 1
• Bloody diarrhea or suspected inflammatory diarrhea 1, 5
• Fever or signs of sepsis 1, 5
• Suspected C. difficile infection 4

May consider loperamide ONLY in:

• Immunocompetent adults with acute watery diarrhea (no fever, no blood) 1
• After adequate rehydration is achieved 1

Probiotics may be offered:

• To reduce symptom severity and duration in immunocompetent patients 1

Hospitalization Criteria

Admit patients with:

• Severe dehydration despite oral rehydration attempts 4
• Hemodynamic instability or signs of sepsis 1, 4
• Altered mental status 1
• Inability to tolerate oral fluids after ondansetron trial 4
• Immunocompromised status with persistent symptoms 4
• Infants <3 months with suspected bacterial infection 1

Critical Pitfalls to Avoid

Do not routinely order stool cultures unless patient has severe dehydration, persistent high fever, bloody stool, immunosuppression, or suspected outbreak 6

Do not withhold food during rehydration—this delays recovery 1, 2

Do not use antimotility agents in children or in any patient with bloody diarrhea or high fever, as this can precipitate toxic megacolon 1, 5

Do not give antibiotics for suspected STEC as this increases risk of hemolytic uremic syndrome 1

Warn laboratory staff if enteric fever, brucella, Q fever, or melioidosis suspected due to laboratory hazard risk 1