Management of Nausea, Diarrhea, and Leukocytosis

Initial Assessment and Risk Stratification

The American College of Physicians recommends assessing for infectious causes, evaluating hydration status, and initiating oral rehydration therapy while avoiding antimotility agents until serious bacterial infection is excluded in patients with nausea, diarrhea, and leukocytosis 1, 2
The Infectious Diseases Society of America suggests obtaining stool studies for bacterial pathogens and C. difficile toxin, especially if WBC >15,000 cells/mm³ in patients with infectious diarrhea 1, 2
The Centers for Disease Control and Prevention recommends assessing for signs of severe dehydration, such as tachycardia, orthostatic hypotension, decreased skin turgor, altered mental status, and decreased urine output 1, 2
The World Health Organization advises evaluating for "red flag" features, such as bloody stools, fever, severe abdominal pain, immunocompromised status, or recent antibiotic use 1, 2

The American Academy of Pediatrics recommends using reduced osmolarity oral rehydration solution (ORS) containing sodium 90 mM, potassium 20 mM, chloride 80 mM, bicarbonate 30 mM, and glucose 111 mM for patients with mild to moderate dehydration 1, 4
The World Health Organization suggests replacing ongoing losses with 10 mL/kg ORS for each watery stool and 2 mL/kg for each vomiting episode 4
The Centers for Disease Control and Prevention recommends reserving intravenous fluids for patients with severe dehydration, shock, altered mental status, or inability to tolerate oral intake 1, 2

The American Society of Clinical Oncology recommends using ondansetron to facilitate oral rehydration tolerance in adults and children >4 years with severe vomiting 2

The Infectious Diseases Society of America advises against initiating loperamide until infectious causes are excluded, particularly in the presence of leukocytosis suggesting inflammatory diarrhea 1, 2
The American College of Gastroenterology recommends avoiding loperamide in patients with bloody diarrhea, fever, suspected C. difficile infection, or children <18 years 2, 5

The Infectious Diseases Society of America recommends against giving empiric antibiotics routinely for acute watery diarrhea 2
The American College of Physicians suggests considering empiric fluoroquinolone therapy if patient has severe inflammatory diarrhea with fever and bloody stools, immunocompromised status with persistent symptoms, signs of sepsis, or neutropenia 3, 2
The Centers for Disease Control and Prevention advises initiating metronidazole or vancomycin immediately if C. difficile infection is suspected based on recent antibiotic exposure, healthcare setting, and leukocytosis 3, 2

The American College of Emergency Physicians recommends admitting patients with severe dehydration despite oral rehydration attempts, hemodynamic instability, WBC >30,000 cells/mm³, signs of sepsis, neutropenia with diarrhea, bloody diarrhea with severe cramping, or inability to tolerate oral fluids 3, 2, 4

The American Gastroenterological Association recommends eliminating lactose-containing products, avoiding high-osmolar dietary supplements, spices, coffee, and alcohol, and resuming normal diet immediately after rehydration is achieved 5, 3, 4, 2
The Academy of Nutrition and Dietetics advises against withholding food during treatment 4

The American Society of Clinical Oncology recommends considering neutropenic enterocolitis if patient has neutropenia with leukocytosis, and initiating broad-spectrum antibiotics covering gram-negative organisms, gram-positive organisms, and anaerobes 3, 2
The Infectious Diseases Society of America advises avoiding all antimotility agents and opioids as they may aggravate ileus, and considering amphotericin if no response to antibacterial agents 3