What is the best management approach for a patient with acute gastroenteritis (inflammation of the stomach and intestines) presenting with fever, chills, and dehydration?

Management of Acute Gastroenteritis with Fever, Chills, and Dehydration

The cornerstone of management is immediate assessment of dehydration severity followed by oral rehydration solution (ORS) for mild-to-moderate dehydration or intravenous fluids for severe dehydration, with early refeeding and avoidance of unnecessary antimicrobials or antimotility agents. 1

Initial Assessment of Dehydration Severity

Rapidly categorize dehydration based on clinical signs to guide treatment intensity 1, 2:

Mild Dehydration (3-5% fluid deficit)

• Slightly decreased skin turgor
• Moist mucous membranes
• Normal mental status 1

Moderate Dehydration (6-9% fluid deficit)

• Loss of skin turgor with tenting when pinched
• Dry mucous membranes
• Decreased urine output 1, 2

Severe Dehydration (≥10% fluid deficit) - Medical Emergency

• Severe lethargy or altered consciousness
• Prolonged skin tenting (>2 seconds)
• Cool, poorly perfused extremities with decreased capillary refill
• Rapid, deep breathing indicating acidosis 1, 2

Note: Prolonged skin retraction time, abnormal capillary refill, and rapid deep breathing are more reliable predictors of significant dehydration than sunken fontanelle or absence of tears 1, 2.

Rehydration Strategy Based on Severity

For Mild-to-Moderate Dehydration (Most Cases)

Oral rehydration solution is first-line therapy and successfully rehydrates >90% of patients 1, 2:

• Mild dehydration: Administer 50 mL/kg ORS over 2-4 hours 1, 2
• Moderate dehydration: Administer 100 mL/kg ORS over 2-4 hours 1, 2
• Use low-osmolarity ORS formulations (50-90 mEq/L sodium), not sports drinks or juices 1, 2
• Start with small volumes (5-10 mL every 1-2 minutes) using a teaspoon, syringe, or medicine dropper, then gradually increase as tolerated 1, 2
• Replace ongoing losses continuously: 10 mL/kg ORS for each watery stool and 2 mL/kg for each vomiting episode 2
• Reassess hydration status after 2-4 hours; if still dehydrated, reestimate deficit and restart rehydration 1, 2

If oral intake fails: Consider nasogastric administration of ORS for patients who cannot tolerate oral intake or refuse to drink adequately 1, 2

For Severe Dehydration (≥10% deficit, shock, altered mental status)

This constitutes a medical emergency requiring immediate intravenous rehydration 1:

• Administer boluses of 20 mL/kg of lactated Ringer's solution or normal saline until pulse, perfusion, and mental status normalize 1
• May require two IV lines or alternate access sites (venous cutdown, femoral vein, intraosseous infusion) 1
• Continue IV rehydration until patient awakens, has no aspiration risk, and has no evidence of ileus 1
• Once mental status normalizes, transition to ORS to replace remaining deficit 1

Addressing Fever and Determining Need for Antimicrobials

In most patients with acute watery diarrhea, fever, and chills, empiric antimicrobial therapy is NOT recommended 1:

• Viruses cause approximately 70% of acute gastroenteritis episodes 3, 4
• Antimicrobials have limited usefulness since viral agents predominate 2

When to Consider Antimicrobials

Consider antimicrobial therapy ONLY in specific circumstances 1:

• Bloody diarrhea (dysentery): Obtain stool cultures and consider empiric treatment for Shigella, Salmonella, or enterohemorrhagic E. coli 1
• Immunocompromised patients or young infants who are ill-appearing: Lower threshold for empiric treatment 1
• Recent international travel with persistent symptoms 1
• Recent antibiotic use: Test for Clostridioides difficile 1, 3

Stool cultures are indicated for dysentery but NOT needed for typical acute watery diarrhea in immunocompetent patients 1

Nutritional Management

Resume age-appropriate diet during or immediately after rehydration is completed 1, 2:

• Continue breastfeeding throughout the diarrheal episode 1, 2
• Early refeeding reduces severity and duration of illness 2
• Avoid foods high in simple sugars (soft drinks, undiluted apple juice) as they exacerbate diarrhea through osmotic effects 2
• Limit or avoid caffeinated beverages as they worsen symptoms through stimulation of intestinal motility 2

Adjunctive Pharmacological Management

Antiemetics (for Vomiting)

Ondansetron may be given to facilitate oral rehydration tolerance when vomiting is significant 1, 2:

• Appropriate for children >4 years and adults with gastroenteritis associated with vomiting 1, 5
• Ondansetron blocks serotonin at chemoreceptor trigger zone, reducing vomiting without antimotility effects 5
• Avoid in inflammatory diarrhea or diarrhea with fever due to risk of toxic megacolon 5
• Use only AFTER adequate hydration is initiated, not as substitute for fluid therapy 1, 2

Antimotility Agents (Generally Avoided)

Loperamide should NOT be given to children <18 years with acute diarrhea 1, 2:

• Serious adverse events including ileus and deaths have been reported 2
• Avoid at any age in suspected inflammatory diarrhea or diarrhea with fever due to risk of toxic megacolon 1
• May be considered in immunocompetent adults with acute watery diarrhea ONLY after adequate hydration 1

Probiotics

Probiotic preparations may reduce symptom severity and duration in immunocompetent patients 1, 2:

• Lactobacillus rhamnosus GG, Lactobacillus reuteri, and Saccharomyces boulardii have documented efficacy 6
• Evidence is moderate quality 1

Maintenance Phase

Once rehydration is achieved 1, 2:

• Administer maintenance fluids
• Replace ongoing losses with ORS until diarrhea and vomiting resolve 1
• Continue age-appropriate diet 1

Infection Control Measures

Implement strict infection control to prevent transmission 1, 2:

• Hand hygiene with soap and water after toilet use, diaper changes, before food preparation, and before eating 1, 2
• Use gloves and gowns when caring for patients with diarrhea 1, 2
• Clean and disinfect contaminated surfaces promptly 2

Common Pitfalls to Avoid

• Do not delay rehydration while awaiting diagnostic testing - initiate ORS immediately 2
• Do not use sports drinks or apple juice as primary rehydration solutions for moderate-to-severe dehydration 2
• Do not administer antimotility drugs to children or in cases of bloody diarrhea/fever 1, 2
• Do not restrict diet unnecessarily - early refeeding improves outcomes 1, 2
• Do not prescribe empiric antimicrobials for typical watery diarrhea - most cases are viral and self-limited 1, 2
• Do not underestimate dehydration in elderly patients who may not manifest classic signs 2