Key Considerations in Treating Presumed Gastroenteritis with Continued Fevers

Critical Diagnoses Not to Miss

The Infectious Diseases Society of America recommends evaluating for Shigella infection in patients with fever, abdominal pain, bloody diarrhea, and bacillary dysentery (frequent scant bloody stools, tenesmus) 1
Consider Salmonella typhi/paratyphi (enteric fever) in patients with clinical features of sepsis, which requires broad-spectrum antimicrobial therapy after appropriate cultures 1, 3
Test for Clostridioides difficile in any patient with recent antibiotic exposure or healthcare contact 4

Assess for dehydration and electrolyte imbalances, which require aggressive rehydration therapy 1, 2
Evaluate for neutropenic enterocolitis in immunocompromised patients, which may require CT imaging 4

Obtain new blood cultures if fever persists >3 days despite empiric antibiotic therapy 4
Collect stool samples for C. difficile toxin testing in hospitalized patients with diarrhea 4, 2

The Infectious Diseases Society of America recommends empiric antibiotics for infants <3 months with suspected bacterial etiology, immunocompetent patients with documented fever, abdominal pain, bloody diarrhea, and suspected Shigella, recent international travelers with fever ≥38.5°C and/or signs of sepsis, immunocompromised patients with severe illness and bloody diarrhea, and patients with clinical features of enteric fever 1, 2
For adults, fluoroquinolones or azithromycin are recommended based on local susceptibility patterns and travel history 1, 2
For children, third-generation cephalosporin is recommended for infants <3 months or those with neurologic involvement; otherwise, azithromycin is recommended 1, 2
Avoid antibiotics for Shiga toxin-producing E. coli (STEC) infections, especially O157 strains 1

Prioritize rehydration therapy with reduced osmolarity oral rehydration solution (ORS) for mild to moderate dehydration 1, 2
Use IV fluids for severe dehydration, shock, or altered mental status 3

Lower threshold for empiric antibacterial treatment in immunocompromised patients with severe illness and bloody diarrhea 1, 4
Consider pneumonia as a source of fever in neutropenic patients, treating as healthcare-acquired infection 4
Thoroughly evaluate for breakthrough infections in neutropenic patients with persistent fever despite empiric therapy 4

Do not add vancomycin empirically for persistent fever without evidence of gram-positive infection 4
Do not treat asymptomatic contacts of patients with bloody diarrhea 1, 2
Do not continue empiric therapy without modification when a specific pathogen is identified 1, 2