What is the management of diarrhea according to latest guidelines?

Management of Diarrhea According to Latest Guidelines

Oral rehydration solution (ORS) is the first-line therapy for mild to moderate dehydration in all patients with acute diarrhea, regardless of age, and should be initiated immediately before considering any other interventions. 1, 2

Rehydration Strategy: The Foundation of Treatment

Assess Dehydration Severity First

Evaluate for clinical signs including thirst, decreased urination, dry mucous membranes, tachycardia, orthostasis, and altered mental status to determine severity. 2

Mild to Moderate Dehydration

• Administer reduced osmolarity ORS as first-line therapy (WHO-recommended formulation: Na 90 mM, K 20 mM, Cl 80 mM, HCO₃ 30 mM, glucose 111 mM). 1, 2
• Dosing for infants and children: 50-100 mL/kg over 3-4 hours. 1
• Dosing for adolescents and adults (≥30 kg): 2-4 liters over 3-4 hours. 1
• ORS is superior to IV fluids when oral intake is tolerated—it is safer, less painful, less costly, and equally effective. 2
• For patients unable to tolerate oral intake, consider nasogastric administration of ORS. 1, 3

Severe Dehydration

• Initiate IV isotonic crystalloids immediately (lactated Ringer's or normal saline). 1, 2
• Administer 20 mL/kg boluses until pulse, perfusion, and mental status normalize. 1
• Malnourished infants require smaller-volume, frequent boluses of 10 mL/kg due to reduced cardiac capacity. 1
• Transition to ORS once the patient is stabilized, awake, has no aspiration risk, and no ileus. 1, 3

Replace Ongoing Losses

• For children <10 kg: 60-120 mL ORS for each diarrheal stool (up to ~500 mL/day). 1
• For children >10 kg: 120-240 mL ORS for each diarrheal stool (up to ~1 L/day). 1
• For adolescents and adults: Ad libitum ORS up to ~2 L/day. 1
• Continue replacement until diarrhea and vomiting resolve. 1, 3

Nutritional Management: Feed Early and Continuously

• Resume age-appropriate normal diet immediately during or after rehydration—do not withhold food. 1, 2, 3
• Continue breastfeeding throughout the illness in infants and children. 1, 3
• Early realimentation prevents malnutrition and may reduce stool output. 2
• Avoid the outdated "BRAT diet"—early feeding with regular diet improves outcomes. 4
• Administer oral zinc supplementation (10-20 mg daily) to children 6 months to 5 years of age in zinc-deficient regions or with signs of malnutrition, as it reduces diarrhea duration. 1, 3

Antimicrobial Therapy: Highly Selective Use Only

When NOT to Use Antibiotics (Most Cases)

• Empiric antimicrobial therapy is NOT recommended for most patients with acute watery diarrhea without recent international travel. 2, 3
• Never use antimicrobials in STEC O157 or Shiga toxin 2-producing E. coli infections—they increase the risk of hemolytic uremic syndrome. 2, 3

When to Consider Antimicrobials

Consider antimicrobial therapy ONLY in these specific circumstances: 2, 3

• Immunocompromised patients with severe illness
• Ill-appearing young infants (<3 months with suspected bacterial etiology)
• Bloody diarrhea with presumptive shigellosis
• Recent international travelers with fever ≥38.5°C or signs of sepsis
• Clinical features of sepsis with suspected enteric fever
• Recent antibiotic exposure with suspected C. difficile (wait for testing before starting treatment). 4

Antibiotic Stewardship

• Modify or discontinue antimicrobials when a specific pathogen is identified. 1, 3
• Do not start empiric antibiotics until diagnostic testing returns in healthcare-associated diarrhea. 4

Adjunctive Therapies: Use With Extreme Caution

Antimotility Agents (Loperamide)

• NEVER give loperamide to children <18 years of age with acute diarrhea. 1, 3
• Loperamide may be given to immunocompetent adults with acute watery diarrhea ONLY after adequate hydration. 1, 2
• Absolutely avoid loperamide in bloody diarrhea, fever, suspected inflammatory diarrhea, or until C. difficile is excluded—risk of toxic megacolon. 1, 2, 4
• FDA labeling indicates loperamide is approved for acute nonspecific diarrhea in patients ≥2 years, but guideline recommendations supersede this for safety. 5

Antiemetics

• Ondansetron may be given to children >4 years and adolescents with vomiting to facilitate oral rehydration tolerance. 1, 3

Probiotics

• Probiotics may be offered to reduce symptom severity and duration in immunocompetent adults and children, though evidence quality is moderate. 1, 3

Infection Control and Prevention

• Hand hygiene is critical: Perform after using the toilet, changing diapers, before/after food preparation, before eating, and after handling animals. 1, 3
• Use gloves, gowns, and hand hygiene with soap and water (or alcohol-based sanitizers) in healthcare settings. 1
• Asymptomatic carriers generally do not need treatment except Salmonella Typhi carriers who may be treated to reduce transmission. 1, 3

Critical Pitfalls to Avoid

• Do not delay IV fluids to attempt oral rehydration first when tachycardia or severe dehydration is present. 4
• Do not use antimotility agents in children or in any patient with bloody/inflammatory diarrhea. 1, 2, 3
• Do not use antimicrobials routinely for acute watery diarrhea. 2, 3
• Do not withhold food during diarrheal episodes. 1, 2, 3
• Do not use popular beverages like apple juice, Gatorade, or commercial soft drinks for rehydration—they are not appropriate ORS substitutes. 1