What is the recommended treatment for acute enteritis?

Treatment for Acute Enteritis

Oral rehydration solution (ORS) is the cornerstone of treatment for acute enteritis, with antimicrobial therapy reserved only for specific bacterial pathogens in high-risk patients or those with severe dysentery. 1, 2

Immediate Rehydration Strategy

Assessment of Dehydration Severity

• Evaluate hydration status through clinical signs: skin turgor, mental status, mucous membrane moisture, capillary refill, and vital signs 1
• Categorize dehydration severity:
  • Mild (3-5% fluid deficit): Minimal clinical signs 1
  • Moderate (6-9% fluid deficit): Prolonged skin tenting >2 seconds, dry mucous membranes, decreased urine output 1, 3
  • Severe (≥10% fluid deficit): Altered mental status, poor perfusion, cool extremities, rapid deep breathing 1

Oral Rehydration Therapy (First-Line)

• Administer low-osmolarity ORS at 50-100 mL/kg over 2-4 hours for mild to moderate dehydration 1, 2, 3
• Use small, frequent volumes (5-10 mL every 1-2 minutes via spoon or syringe) to prevent triggering vomiting—this technique achieves >90% success rates 1
• Replace ongoing losses continuously: 10 mL/kg ORS for each watery stool and 2 mL/kg for each vomiting episode 1
• Avoid sports drinks, soft drinks, or undiluted fruit juices as they lack appropriate electrolyte balance and contain excess simple sugars that worsen diarrhea through osmotic effects 1, 3

Intravenous Rehydration (Second-Line)

• Reserve IV therapy for severe dehydration (≥10% deficit), shock, altered mental status, failure of oral rehydration, or ileus 1, 2
• Administer isotonic crystalloid boluses (lactated Ringer's or normal saline) at 20 mL/kg until pulse, perfusion, and mental status normalize 1, 2
• Transition to ORS once patient improves to replace remaining deficit 1

Nutritional Management

• Resume age-appropriate diet immediately during or after rehydration—early refeeding reduces severity, duration, and nutritional consequences 1, 3
• Continue breastfeeding throughout the illness in infants 1, 3
• Avoid fasting or restrictive diets, as this impairs intestinal recovery and worsens nutritional status 1, 3
• Limit caffeine and avoid foods high in simple sugars during active illness 1

Antimicrobial Therapy: Highly Selective Use Only

When Antibiotics Are NOT Indicated

• Most acute enteritis is viral and does not require antimicrobials 1, 2
• The CDC emphasizes that antimicrobial agents have limited usefulness since viral agents are the predominant cause 1
• Never use antibiotics for STEC O157 or other Shiga toxin-producing E. coli, as this increases risk of hemolytic uremic syndrome 2, 3

When to Consider Empiric Antibiotics

• Infants <3 months with suspected bacterial etiology 2, 3
• Immunocompromised patients with severe illness and bloody diarrhea 2, 3
• Fever, abdominal pain, bloody diarrhea, and bacillary dysentery (presumptive Shigella) 2, 3
• Recent foreign travel with severe symptoms 1

Antibiotic Selection When Indicated

• Adults: Fluoroquinolone (ciprofloxacin) or azithromycin 2, 3
• Children: Third-generation cephalosporin or azithromycin 2, 3
• Pathogen-specific therapy (when culture available):
  • Campylobacter: Azithromycin 2
  • Shigella: Ciprofloxacin or fluoroquinolone 2
  • Salmonella: Ciprofloxacin, TMP-SMX, or amoxicillin (only if severe or high-risk host) 2

Adjunctive Pharmacotherapy

Antiemetics

• Ondansetron may be given to children >4 years and adolescents to facilitate oral rehydration when vomiting is significant 1, 4
• Ondansetron enhances compliance with ORT and decreases hospitalization rates 4

Antimotility Agents

• Loperamide should NEVER be given to children <18 years with acute diarrhea due to risk of serious adverse events including ileus and deaths 1, 2
• Loperamide may be given to immunocompetent adults with acute watery diarrhea once adequately hydrated (initial 4 mg, then 2 mg after each loose stool, maximum 16 mg/day) 1, 2
• Avoid loperamide in bloody diarrhea, fever, or suspected inflammatory diarrhea 2

Probiotics and Zinc

• Probiotics may reduce symptom severity and duration in both adults and children 1, 2
• Zinc supplementation (10-20 mg daily) reduces diarrhea duration in children 6 months to 5 years in areas with high zinc deficiency or malnutrition 1, 2

Critical Red Flags Requiring Immediate Medical Attention

• Severe dehydration signs: Altered mental status, prolonged skin tenting >2 seconds, poor perfusion, rapid deep breathing 1
• Bloody stools with fever and systemic toxicity—may indicate Salmonella, Shigella, or enterohemorrhagic E. coli requiring immediate evaluation 1
• Bilious (green) vomiting—suggests possible intestinal obstruction 2
• Persistent vomiting despite small-volume ORS administration 1
• Absent bowel sounds (absolute contraindication to oral rehydration) 1
• Failure to improve after 2-4 hours of rehydration 1

Infection Control Measures

• Practice proper hand hygiene after toilet use, diaper changes, before food preparation, and before eating 1, 3
• Use gloves and gowns when caring for patients with diarrhea 1, 3
• Clean and disinfect contaminated surfaces promptly 1
• Separate ill persons from well persons until at least 2 days after symptom resolution 1

Common Pitfalls to Avoid

• Do not delay rehydration while awaiting diagnostic testing—initiate ORS immediately 1
• Do not use inappropriate fluids (apple juice, sports drinks) as primary rehydration solutions for moderate to severe dehydration 1
• Do not administer antimotility drugs to children or in bloody diarrhea 1, 2
• Do not unnecessarily restrict diet during or after rehydration 1
• Do not give antibiotics empirically without specific indications, as most cases are viral 1, 2
• Never use metoclopramide in gastroenteritis—it is counterproductive and has no role in management 1