Management of Fever, Bloody/Mucus Stools, and Failure to Thrive
Immediate Diagnostic Workup
- The Infectious Diseases Society of America recommends obtaining stool culture for Salmonella, Shigella, Campylobacter, Yersinia, C. difficile, and STEC in any patient with fever AND bloody or mucoid stools 1, 2, 3
- For STEC detection, the Infectious Diseases Society of America suggests using methods that detect both Shiga toxin (or genes encoding them) AND distinguish E. coli O157:H7 from other STEC serotypes using sorbitol-MacConkey agar or chromogenic agar 1, 2
- If available, assays that distinguish between Shiga toxin 1 and 2 should be used, as toxin 2 (particularly subtypes 2a, 2c, 2d) is associated with more severe disease and hemolytic uremic syndrome risk 1
Immediate Clinical Assessment
- The Infectious Diseases Society of America indicates that blood cultures are indicated if the patient is <3 months old, shows signs of septicemia, or has systemic manifestations 1, 2
- Consider testing for Yersinia enterocolitica specifically if there is severe abdominal pain or exposure to undercooked pork products 1
- The Infectious Diseases Society of America recommends assessing for signs of volume depletion: dry mucous membranes, decreased skin turgor, tachycardia, orthostatic changes, decreased urination, lethargy 2, 4
Empirical Antibiotic Therapy Considerations
- The Infectious Diseases Society of America suggests considering empirical antibiotics BEFORE culture results in patients with fever AND bloody diarrhea with presumed bacillary dysentery (likely Shigella), infants <3 months with suspected bacterial etiology, severe systemic symptoms or signs of sepsis, or failure to thrive 1, 2, 6
- Obtain stool specimen BEFORE starting antibiotics 4, 7
Pathogen-Specific Management
- The Infectious Diseases Society of America recommends always treating Shigella with antibiotics - reduces duration and shedding 5, 7
- For Salmonella (Non-Typhi), treat if: age <6 months, immunocompromised, signs of systemic spread, or severe disease 5
- For STEC, provide supportive care ONLY - no antibiotics 1, 6
- Monitor closely for hemolytic uremic syndrome development 1
- For C. difficile, use specific anti-C. difficile therapy per IDSA/SHEA guidelines 2