What is the management approach for a patient presenting with fever, diarrhea, and epigastric pain?

Management of Fever with Diarrhea and Epigastric Pain

The cornerstone of management is immediate assessment of hydration status and initiation of oral rehydration solution (ORS) for mild-to-moderate dehydration, with empiric antibiotics reserved only for specific high-risk scenarios including documented fever ≥38.5°C with bloody diarrhea, suspected bacillary dysentery, or recent international travel. 1

Initial Assessment and Risk Stratification

Begin by evaluating the following critical features:

• Hydration status: Check for dry mucous membranes, decreased urination, tachycardia, orthostatic hypotension, lethargy, or decreased skin turgor 1
• Stool characteristics: Determine if bloody, mucoid, or watery 1
• Fever documentation: Temperature ≥38.5°C documented in medical setting is a key threshold 1
• Travel history: Recent international travel significantly changes management 1
• Epidemiologic factors: Day-care attendance, antibiotic use, food exposure, immunocompromised status 1

Rehydration Strategy (First Priority)

Mild-to-Moderate Dehydration

Use reduced osmolarity ORS as first-line therapy 1:

• Administer ORS until clinical dehydration is corrected 1
• For patients who cannot tolerate oral intake, consider nasogastric ORS administration 1
• Resume age-appropriate diet immediately after or during rehydration 1

Severe Dehydration

Administer isotonic intravenous fluids (lactated Ringer's or normal saline) when there is 1:

• Severe dehydration with shock
• Altered mental status
• Failure of ORS therapy
• Ileus

Continue IV rehydration until pulse, perfusion, and mental status normalize, then transition to ORS for remaining deficit 1

Empiric Antibiotic Therapy Decision Algorithm

DO NOT Give Empiric Antibiotics If:

• Acute watery diarrhea without recent international travel in immunocompetent patients 1
• Bloody diarrhea without fever or other high-risk features 1

GIVE Empiric Antibiotics For:

Bloody Diarrhea WITH 1:

• Infants <3 months with suspected bacterial etiology
• Fever documented in medical setting + abdominal pain + bacillary dysentery (frequent scant bloody stools, fever, cramps, tenesmus) presumptively due to Shigella
• Recent international travel + temperature ≥38.5°C and/or signs of sepsis

Antibiotic Selection 1:

• Adults: Fluoroquinolone (ciprofloxacin) OR azithromycin based on local susceptibility and travel history
• Children: Third-generation cephalosporin (infants <3 months or neurologic involvement) OR azithromycin based on local susceptibility and travel history
• Immunocompromised: Consider empiric treatment with severe illness and bloody diarrhea 1

Critical Contraindication:

Avoid antibiotics if STEC O157 or Shiga toxin 2-producing STEC is suspected or confirmed due to risk of hemolytic uremic syndrome 1

Diagnostic Testing Indications

Obtain fecal specimen for culture and testing when 1:

• Illness lasting >1 day with fever, bloody stools, or systemic illness
• Recent antibiotic use
• Day-care attendance
• Hospitalization
• Dehydration present

Consider blood cultures if sepsis suspected, particularly with enteric fever presentation 1

Ancillary Symptomatic Management

Antimotility Agents

• Loperamide: May be given to immunocompetent adults with acute watery diarrhea 1
• CONTRAINDICATED 1, 2:
  • Children <18 years of age
  • Any age with fever and diarrhea (risk of toxic megacolon)
  • Suspected inflammatory diarrhea or bloody diarrhea

Antiemetics

• Ondansetron may facilitate oral rehydration in children >4 years with vomiting 1
• Monitor QTc interval when using antiemetics, especially with concurrent medications 1

Common Pitfalls to Avoid

1. Do not withhold ORS in favor of IV fluids for mild-moderate dehydration—ORS is equally effective, safer, less costly, and reduces hospital stay 1, 3
2. Do not give loperamide with fever—this increases risk of toxic megacolon and masks inflammatory processes 1, 2
3. Do not use empiric antibiotics for watery diarrhea without travel history or high-risk features—this promotes resistance and may worsen outcomes 1
4. Do not delay rehydration while awaiting diagnostic results—fluid resuscitation is the priority 1

Ongoing Management

• Replace ongoing stool losses with ORS until diarrhea resolves 1
• Modify or discontinue antibiotics when organism identified 1
• Reassess if no improvement within 48 hours 1
• Consider probiotics to reduce symptom severity and duration 1