What is the best course of action for a patient with persistent fever and watery stools despite initial treatment with IV paracetamol (acetaminophen) and volume-for-volume replacement with Plasma-Lyte (PLR)?

Management of Persistent Fever and Watery Diarrhea Despite Initial Treatment

Continue aggressive volume replacement with isotonic IV fluids at a rate exceeding ongoing losses, obtain stool studies and blood work to rule out infectious complications, and initiate empiric antibiotics if the patient shows signs of sepsis (fever with tachycardia) or severe dehydration. 1

Immediate Assessment Priorities

Evaluate for sepsis and severe dehydration:

• Check for tachycardia, hypotension, altered mental status, and signs of poor perfusion 1
• Assess urine output (target >0.5 mL/kg/h) and consider central venous pressure monitoring if available 1
• Obtain complete blood count, electrolyte panel, and renal function tests 1
• Send stool studies for blood, fecal leukocytes, C. difficile, Salmonella, E. coli, Campylobacter, and infectious colitis 1

The presence of fever (38.8°C) with persistent watery diarrhea despite volume replacement raises concern for infectious complications or sepsis, which requires more aggressive intervention than simple rehydration. 1

Fluid Management Escalation

Administer IV fluids more aggressively:

• If tachycardic and potentially septic, give an initial fluid bolus of 20 mL/kg 1
• Continue fluid replacement at a rate greater than ongoing losses (urine output + 30-50 mL/h insensible losses + gastrointestinal losses) 1
• Continue rapid fluid administration until clinical signs of hypovolemia improve 1
• Monitor for adequate central venous pressure and maintain urine output >0.5 mL/kg/h 1

Critical pitfall: Patients who develop oliguric acute kidney injury (<0.5 mL/kg/h) despite adequate volume resuscitation are at risk for pulmonary edema and require urgent intensive care or nephrology consultation 1

Antibiotic Consideration

For this febrile patient with persistent diarrhea, empiric antibiotics are indicated if:

• The patient shows signs of sepsis (fever with tachycardia, hypotension, or altered mental status) 1, 2
• The patient is immunocompromised 2
• There is clinical deterioration despite aggressive supportive measures 1

If antibiotics are warranted, use fluoroquinolone therapy (e.g., ciprofloxacin) as first-line for severe cases 1

However, if this is uncomplicated watery diarrhea without bloody stools or severe systemic illness, antibiotics should be avoided as they promote resistance without benefit 2

Adjunctive Pharmacologic Management

Consider octreotide if diarrhea persists despite adequate hydration:

• Start at 100-150 mcg subcutaneously three times daily or 25-50 mcg/hour IV if severely dehydrated 1
• Escalate dose up to 500 mcg three times daily until diarrhea is controlled 1

Loperamide may be considered in immunocompetent adults with watery diarrhea without fever or blood:

• Initial dose 4 mg followed by 2 mg every 2-4 hours or after each unformed stool (maximum 16 mg/day) 1, 2
• However, given this patient has fever, loperamide should be avoided until infection is ruled out 2, 3

Nutritional Support

Resume feeding as soon as clinically appropriate:

• Do not delay feeding until diarrhea stops—early feeding improves outcomes 2, 3
• Offer frequent small meals with easily digestible, energy-rich foods 1
• Continue breastfeeding if applicable 2, 3

Disposition Decision

This patient requires hospitalization or intensive monitoring if:

• Signs of severe dehydration persist despite IV fluids 1
• Fever persists suggesting infectious complications 1
• Oliguria develops (<0.5 mL/kg/h) 1
• Clinical deterioration occurs despite aggressive supportive measures 1

The combination of persistent fever and ongoing diarrhea despite initial treatment represents a complicated case requiring escalation beyond simple volume replacement. 1