What is the management for a young patient with 2 days of low-grade fevers, intermittent nausea, vomiting, and diarrhea, following a recent hospitalization (hospital stay)?

From the Guidelines

Management for a young patient with 2 days of low-grade fevers, intermittent nausea, vomiting, and diarrhea following a recent hospitalization should focus on rehydration, symptom management, and evaluation for hospital-acquired infections, starting with oral rehydration using electrolyte solutions like Pedialyte, as recommended by the 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea 1.

Rehydration Therapy

• The patient should consume small amounts (30-60 ml) of oral rehydration solution every 15-20 minutes, as tolerated.
• If unable to tolerate oral fluids, the patient may need IV fluids at an urgent care or emergency department, with isotonic intravenous fluids such as lactated Ringer’s and normal saline solution administered when there is severe dehydration, shock, or altered mental status and failure of ORS therapy 1.

Symptom Management

• For symptom control, acetaminophen (Tylenol) 650 mg every 6 hours can manage fever and discomfort.
• Anti-emetics such as ondansetron (Zofran) 4-8 mg every 8 hours as needed may help control nausea and vomiting, as supported by evidence from the 2017 IDSA guidelines 1.

Evaluation for Hospital-Acquired Infections

• The recent hospitalization raises concern for Clostridioides difficile infection, particularly if the patient received antibiotics during their stay.
• Stool testing for C. difficile and other pathogens should be performed, as recommended by the 2017 IDSA guidelines 1.
• Blood tests including complete blood count, comprehensive metabolic panel, and blood cultures may be necessary if the patient appears toxic or has persistent symptoms.

Treatment of C. difficile Infection

• If C. difficile is confirmed, treatment with oral vancomycin 125 mg four times daily for 10 days or fidaxomicin 200 mg twice daily for 10 days would be indicated, as recommended by the 2017 IDSA guidelines 1.

Monitoring for Dehydration

• The patient should be monitored closely for signs of dehydration, including decreased urination, dry mouth, dizziness, or confusion, which would necessitate immediate medical attention.

From the Research

Management of Young Patient with Gastroenteritis Symptoms

The patient's symptoms of low-grade fevers, intermittent nausea, vomiting, and diarrhea, especially after recent hospitalization, suggest a possible case of acute gastroenteritis.

• The condition is common among children, with an estimated 500 million cases worldwide each year 2.
• Symptoms of gastroenteritis include fever, nausea, vomiting, and diarrhea, which are consistent with the patient's presentation 2.
• The most common cause of acute gastroenteritis is viruses, with rotavirus being the most frequent agent 2.

Diagnostic and Therapeutic Management

• Dehydration assessment is crucial in determining the severity of acute gastroenteritis and deciding on hospital admission 2.
• The majority of patients can be treated in outpatient settings, with hospitalization reserved for those requiring enteral or parenteral rehydration 2.
• Oral rehydration with hypoosmolar fluids is the standard first-line treatment 2.
• Other effective procedures include administration of probiotics, racecadotril, and diosmectite as antidiarrheals, and ondansetron to reduce nausea and vomiting 2, 3.

Management of Nausea and Vomiting

• Current recommendations for managing acute gastroenteritis focus on supportive care, with limited emphasis on correcting nausea and vomiting 3.
• However, recent evidence suggests that ondansetron, an antagonist of the type 3 serotonin receptor, can reduce the rate of vomiting, improve oral rehydration tolerance, and decrease the need for intravenous rehydration 3, 4.
• A randomized controlled trial found that a single oral dose of ondansetron facilitated successful rehydration in children with acute diarrhea and vomiting, reducing the failure rate of oral rehydration therapy and the number of vomiting episodes 4.