Treatment for Infective Diarrhea

Rehydration Therapy

The Infectious Diseases Society of America recommends reduced osmolarity oral rehydration solution (ORS) as first-line therapy for mild to moderate dehydration in all age groups 1
Nasogastric administration of ORS may be considered in patients with moderate dehydration who cannot tolerate oral intake, as suggested by the Clinical Infectious Diseases guidelines 2
Isotonic intravenous fluids should be administered for severe dehydration, shock, altered mental status, or when ORS therapy fails, according to the Clinical Infectious Diseases recommendations 3
IV rehydration should continue until pulse, perfusion, and mental status normalize, after which remaining deficit can be replaced using ORS, as stated in the Clinical Infectious Diseases guidelines 3
Once rehydrated, maintenance fluids should be administered, with ongoing stool losses replaced with ORS until diarrhea resolves, as recommended by the Clinical Infectious Diseases society 4

The American Academy of Pediatrics suggests that human milk feeding should be continued in infants and children throughout the diarrheal episode 5
Age-appropriate usual diet should be resumed during or immediately after rehydration, as recommended by the Clinical Infectious Diseases guidelines 5
Oral zinc supplementation reduces diarrhea duration in children 6 months to 5 years of age in countries with high zinc deficiency prevalence or in children with signs of malnutrition, according to the World Health Organization 6

The Infectious Diseases Society of America recommends that empiric antimicrobial therapy is not recommended in most people with acute watery diarrhea without recent international travel 7
Exceptions for empiric antimicrobial therapy include immunocompromised patients, ill-appearing young infants, infants <3 months with suspected bacterial etiology, patients with fever, abdominal pain, bloody diarrhea with presumptive shigellosis, and recent international travelers with fever ≥38.5°C or signs of sepsis, as stated in the Clinical Infectious Diseases guidelines 7, 8
Antimicrobial treatment should be modified or discontinued when a specific pathogen is identified, as recommended by the Clinical Infectious Diseases society 1
Antimicrobial therapy should be avoided in infections with STEC O157 and other Shiga toxin 2-producing E. coli, according to the Clinical Infectious Diseases guidelines 9

Antimotility drugs should not be given to children <18 years with acute diarrhea, as recommended by the American Academy of Pediatrics 6
Loperamide may be given to immunocompetent adults with acute watery diarrhea but should be avoided in inflammatory or febrile diarrhea due to risk of toxic megacolon, as stated in the Clinical Infectious Diseases guidelines 6
Antinausea/antiemetic agents may be given to children >4 years and adolescents to facilitate oral rehydration when vomiting is present, as recommended by the Clinical Infectious Diseases society 6
Probiotic preparations may be offered to reduce symptom severity and duration in immunocompetent patients, according to the World Health Organization 6

Asymptomatic carriers generally don't need treatment except those with Salmonella Typhi who may be treated to reduce transmission, as recommended by the Clinical Infectious Diseases guidelines 6
Persistent diarrhea requires consideration of non-infectious causes including IBD and IBS, as stated in the Clinical Infectious Diseases guidelines 9
Hand hygiene is crucial for prevention, especially after using the toilet, changing diapers, before/after food preparation, and after handling animals, as recommended by the Centers for Disease Control and Prevention 4

Assess hydration status and severity of illness, as recommended by the Clinical Infectious Diseases guidelines 3
For mild-moderate dehydration: Administer ORS, as suggested by the Clinical Infectious Diseases society 5
For severe dehydration: Start IV fluids until stabilized, then transition to ORS, as stated in the Clinical Infectious Diseases guidelines 5
Continue appropriate diet during illness, as recommended by the Clinical Infectious Diseases society 1
Consider antimicrobials only if necessary, as stated in the Clinical Infectious Diseases guidelines 8, 9

Administering antimotility agents to children or in cases of bloody/inflammatory diarrhea, as warned by the American Academy of Pediatrics 6
Using antimicrobials for routine acute watery diarrhea, as cautioned by the Infectious Diseases Society of America 7
Neglecting rehydration while focusing on antimicrobial therapy, as warned by the Clinical Infectious Diseases guidelines 1
Withholding food during diarrheal episodes, as cautioned by the Clinical Infectious Diseases society 5
Using antimicrobials in STEC infections, which may increase risk of hemolytic uremic syndrome, as warned by the Clinical Infectious Diseases guidelines 9

The Infectious Diseases Society of America recommends IV antibiotics for patients with suspected enteric fever and sepsis, as they should receive broad-spectrum IV antimicrobial therapy immediately after obtaining blood, stool, and urine cultures 10, 11
The Infectious Diseases Society of America suggests that patients with severe dehydration requiring IV fluids should be considered for concurrent IV antibiotics if bacterial etiology is suspected 12, 11
The Infectious Diseases Society of America recommends empiric antibacterial treatment for immunocompromised patients with severe illness and bloody diarrhea, which may need to be administered IV depending on severity 10, 11

The Infectious Diseases Society of America recommends transitioning to oral antibiotics once the patient is rehydrated with pulse, perfusion, and mental status normalized 12, 11
The Infectious Diseases Society of America suggests modifying or discontinuing antimicrobials when a specific pathogen is identified 10, 11

The Infectious Diseases Society of America recommends assessing severity, initiating IV fluids first, obtaining cultures, and starting IV antibiotics only if sepsis, enteric fever, severe immunocompromise, or inability to tolerate oral route are present 10, 11, 12

The Infectious Diseases Society of America recommends avoiding IV antibiotics in patients with STEC O157 or Shiga toxin 2-producing E. coli infections due to the risk of hemolytic uremic syndrome 10, 11
The Infectious Diseases Society of America suggests considering local resistance patterns when choosing empiric IV therapy, such as using azithromycin based on travel history and local patterns 10, 11