What is the diagnosis and management for a patient with an episode of diarrhea and intermittent fever?

Diagnosis and Management of Single Episode of Loose Bowel Movement with Intermittent Fever

For a patient with one episode of loose bowel movement and intermittent fever, empiric antimicrobial therapy is NOT recommended—focus on assessing hydration status and providing oral rehydration solution if dehydration is present. 1, 2

Initial Assessment

Evaluate hydration status immediately by checking for:

• Thirst, dry mucous membranes, decreased urination 3
• Orthostatic hypotension, altered mental status 3
• Skin turgor (though unreliable in malnourished patients) 4
• Weakness and diminished performance status 3

Assess stool characteristics:

• Presence of blood in stool 1, 5
• Frequency and consistency 3
• Recent consistency change is more important than frequency alone 4

Check for fever documentation in a medical setting and measure body temperature 1

When to Consider Empiric Antimicrobials

Empiric antimicrobial therapy should be avoided in most cases of acute watery diarrhea. 1, 2 However, consider antimicrobials ONLY in these specific circumstances:

• Infants <3 months of age with suspected bacterial etiology 1
• Bloody diarrhea with fever, abdominal pain, and bacillary dysentery (frequent scant bloody stools, fever, cramps, tenesmus) presumptively due to Shigella 1
• Recent international travelers with body temperature ≥38.5°C and/or signs of sepsis 1
• Immunocompromised patients with severe illness and bloody diarrhea 1
• Clinical features of sepsis with suspected enteric fever 1

If empiric therapy is indicated: Use ciprofloxacin or azithromycin in adults, depending on local susceptibility patterns and travel history; use third-generation cephalosporin for infants <3 months or azithromycin for older children based on local patterns. 1

Rehydration Strategy

For mild to moderate dehydration:

• Administer reduced osmolarity oral rehydration solution (ORS) as first-line therapy 1, 2, 6
• ORS is superior to IV fluids when tolerated—safer, less painful, less costly, and equally effective 2
• Give frequent small amounts over 3-4 hours 7
• Nasogastric administration may be considered if oral intake cannot be tolerated 1, 6

For severe dehydration:

• Start isotonic IV fluids (lactated Ringer's or normal saline) immediately 1, 6
• Continue until pulse, perfusion, and mental status normalize 1, 6
• Transition to ORS once stabilized 6

Nutritional Management

Resume age-appropriate diet immediately during or after rehydration—do not withhold food 2, 6

Continue breastfeeding throughout the episode in infants and children 2, 6

Critical Pitfalls to Avoid

Never give antimotility drugs (loperamide) to children <18 years with acute diarrhea 2, 6

Avoid loperamide in ANY patient with:

• Bloody diarrhea 2
• Fever or suspected inflammatory diarrhea 2
• Risk of toxic megacolon 2, 8

Avoid antimicrobials in STEC O157 and Shiga toxin 2-producing E. coli infections—they increase risk of hemolytic uremic syndrome 1, 2, 6

Do not routinely order stool studies for a single episode without severe symptoms, blood in stool, or failure to improve within 48 hours 5, 4

When to Refer or Hospitalize

Hospitalize if:

• Infant <3 months of age 4
• Severe dehydration or shock 1, 4
• Persistent vomiting preventing oral intake 4
• Severe malnutrition 4
• Toxic appearance or suspected surgical abdomen 4

Refer to gastroenterology if:

• Blood in stool with weight loss or anemia 5
• Symptoms persist beyond 48 hours despite treatment 3
• Red flag symptoms present (weight loss, anemia, palpable abdominal mass) 5