How should I treat a child with dysentery presenting with bloody stool, fever, and abdominal pain?

Treatment of Dysentery in Children

For a child presenting with bloody stools, fever, and abdominal pain, initiate oral rehydration therapy immediately while obtaining stool culture, then start empiric antibiotic therapy with either azithromycin or a third-generation cephalosporin (ceftriaxone) based on local resistance patterns and travel history. 1

Immediate Assessment & Red Flags

Dysentery (bloody diarrhea) requires urgent medical evaluation and is not adequately treated with oral rehydration alone. 1 The presence of bloody stools with fever strongly suggests bacterial infection—most commonly Shigella, Salmonella, or Campylobacter—and carries risk of complications including hemolytic uremic syndrome with enterohemorrhagic E. coli. 1, 2

Critical Warning Signs Requiring Hospitalization:

• Severe dehydration (≥10% fluid deficit): altered consciousness, prolonged skin tenting >2 seconds, cool extremities, poor capillary refill, rapid deep breathing 2, 3
• Signs of sepsis or shock: persistent tachycardia, hypotension despite initial fluid resuscitation 1
• Altered mental status or severe lethargy 2
• Infants <3 months of age with suspected bacterial etiology 1
• Intractable vomiting preventing oral intake 2

Rehydration Protocol (First Priority)

Mild-to-Moderate Dehydration (3-9% deficit):

• Administer oral rehydration solution (ORS) 50-100 mL/kg over 2-4 hours 2, 3
• Give small volumes (5-10 mL) every 1-2 minutes via spoon or syringe to prevent triggering vomiting 1, 2
• Replace ongoing losses: 10 mL/kg ORS for each bloody stool, 2 mL/kg for each vomiting episode 2
• Reassess hydration status after 2-4 hours; if still dehydrated, recalculate deficit and restart 2

Severe Dehydration (≥10% deficit):

• Immediate IV bolus: 20 mL/kg lactated Ringer's or normal saline over 30 minutes 2, 3
• Repeat boluses until pulse, perfusion, and mental status normalize 2
• Transition to ORS once mental status improves to replace remaining deficit 2
• Hospital admission mandatory 2

Antibiotic Therapy (Second Priority)

Empiric Treatment Indications:

Start empiric antibiotics immediately in children with bloody diarrhea who have:

• Fever documented in medical setting 1
• Abdominal pain and systemic toxicity 1
• Bacillary dysentery syndrome (frequent scant bloody stools, fever, abdominal cramps, tenesmus) presumptively due to Shigella 1
• Infants <3 months of age with suspicion of bacterial etiology 1
• Recent international travel with fever ≥38.5°C 1

Recommended Empiric Regimens:

For children:

• Azithromycin (first-line in most settings due to rising fluoroquinolone resistance) 1
• Third-generation cephalosporin (ceftriaxone 50-75 mg/kg/day IV/IM every 12-24 hours) for infants <3 months or those with neurologic involvement 1
• Dosing depends on local susceptibility patterns and travel history 1

Ciprofloxacin, ceftriaxone, and pivmecillinam achieve >99% cure rates for dysentery when bacterial pathogens are susceptible 4, but local resistance patterns must guide selection 1.

Obtain Stool Culture Before Starting Antibiotics:

• Blood in stool with fever warrants immediate stool culture 2, 3
• Modify or discontinue antibiotics once organism identified 1

Critical Exception—STEC Infection:

Avoid antibiotics if Shiga-toxin-producing E. coli O157 or other Shiga toxin 2-producing STEC is suspected, as antimicrobials increase risk of hemolytic uremic syndrome 1. This is a common pitfall—always consider STEC in bloody diarrhea, especially without high fever.

Nutritional Management

• Resume age-appropriate normal diet immediately during or after rehydration; do not withhold food 2, 3
• Continue breastfeeding on demand throughout illness 2
• Offer starches (rice, potatoes, noodles), cereals, yogurt, fruits, vegetables 2
• Avoid high-sugar drinks (soft drinks, undiluted juice), high-fat foods, and caffeine 2, 3

Medications to Avoid

Never use loperamide or any antimotility agents in children with dysentery. 5 The FDA explicitly contraindicates loperamide in:

• Pediatric patients <2 years of age (risk of respiratory depression, cardiac events) 5
• Acute dysentery characterized by blood in stools and high fever 5
• Bacterial enterocolitis caused by invasive organisms including Salmonella, Shigella, and Campylobacter 5

Serious adverse events including ileus and death have been reported in children given antimotility agents 1, 2.

Monitoring & Follow-Up

• Monitor vital signs, mental status, urine output, and hydration status every 2-4 hours 2
• Seek immediate re-evaluation if:
  • Bloody stools persist or worsen despite treatment 2
  • Fever persists >5 days (consider Kawasaki disease in infants) 2
  • Decreased urine output, severe lethargy, or altered mental status develops 2, 3
  • Signs of hemolytic uremic syndrome appear (oliguria, pallor, petechiae) 1

Common Pitfalls

• Delaying rehydration while awaiting stool culture results—always start ORS immediately 2
• Using sports drinks or juice instead of proper ORS—these lack appropriate electrolyte balance 2
• Allowing rapid, large-volume drinking from a cup—this triggers vomiting and falsely suggests ORT failure 1, 2
• Giving antibiotics for all bloody diarrhea without considering STEC—this can precipitate HUS 1
• Withholding food during or after rehydration—early refeeding shortens illness duration 2