ACUTE GASTROENTERITIS

● Acute gastroenteritis is a common infectious disease syndrome, causing a combination of

nausea, vomiting, diarrhea, and abdominal pain.
● Viral infections are the most common cause of acute diarrhea.
● Bacterial infections are usually associated with foodborne illnesses and traveling.
● Diagnostic investigation and antibiotics should be reserved for patients with severe dehydration
or illness, persistent fever, bloody stool, or immunosuppression, and for cases of suspected
nosocomial infection or outbreak. However, for severe cases, electrolytes should be checked if
available.
● Acute gastroenteritis usually lasts fewer than 14 days, persistent gastroenteritis lasts between
14-30 days and chronic gastroenteritis lasts beyond 30 days.1 If symptoms do not resolve on
antibiotic treatment in 24-48 hours consider giving Metronidazole for Entamoeba histolytica and
Giardia intestinalis.
● Rehydration is the main treatment for acute diarrhea disease (oral or intravenous).
● In children, use a low-osmolarity oral rehydration solution to prevent dehydration. In addition,
zinc tablets (10–20 mg/day) for 10–14 days are usually recommended.
● Antidiarrheal and antiemetic medicines are not routinely needed because they do not prevent
dehydration and do not improve nutritional status.
● Antimotility agents should be avoided in patients with bloody diarrhea, but
Loperamide/simethicone may improve symptoms in patients with watery diarrhea. 4
● Probiotics are not routinely recommended for acute infectious diarrhea. 4,7

CLINICAL PRESENTATION:

● Vomiting is more suggestive of viral infection1

● Three or more unformed stools a day, with or without fever1
● Nausea, vomiting, bloating, abdominal pain and cramping may also be present.1
 Classification of dehydration2

Severe dehydration Some dehydration No dehydration

At least two signs from following list: At least two signs from Too few signs to classify as
•Lethargy and/or unconsciousness following list: some or severe dehydration
• Sunken ••eyes • Restlessness, irritability
• Inability to drink • Sunken eyes
CONFIRM SOURCE OF INFECTION:
• Skin pinch goes back very slowly (≥2 secs) • Drinks eagerly, is thirsty

Classification of Diarrhea3

Mild Diarrhea Moderate Diarrhea Severe Diarrhea

•1-2 unformed stools per day •3-5 unformed stools per day •>6 unformed stools per day
• Minimal associated symptomology •With or without systemic symptoms, • +/- temperature >101 ®F, tenesmus,
••
with minimal interference with activities interferes with planned activities blood or fecal leucocytes
Severe afebrile bloody diarrhea should
increase suspicion of [Link]

TYPE OF DIARRHEA MANAGEMENT

MILD  Hydration: ORS + lactose-free diet (For children KYB diet, child <2 years
encourage breastfeeding + Zinc supplementation)
 Avoid caffeine
MODERATE For Adults:
Fluids + antimotility agents*
 Loperamide (Imodium) 4 mg po, then 2 mg after each loose stool to
max. of 16 mg per day
 Bismuth subsalicylate (Pepto-Bismol) 2 tablets (262 mg) po qid
For children:
Hydration with ORS + Zinc supplementation  follow up in 5 days if not
improving8 and Counsel mother when to return.

*Do not use antimotility agents if hemolytic uremic syndrome (HUS) is suspected.
SEVERE Supportive therapy with ORS and Zinc supplementation (in children) PLUS
empirical antibiotic therapy. Rule out the other sources of infection.
 (Ciprofloxacin 500 mg po q12h or Levofloxacin 500 mg q24h) x 3–5 days
 Azithromycin 1000 mg po once or 500 mg q 24h x 3 days
  If C. difficile is suspected (e.g., recent antibiotic use) add Vancomycin
125 mg po qid x 10–14 days. Metronidazole 500 mg po tid can be used
for mild C. difficile cases.
ALTERNATIVE REGIMENS: TMP-SMX-DS po bid x 3–5 days.
EMPIRICAL THERAPY: 3
 CLINICAL PATHWAY: 1
Acute Diarrhea

↓ Stool consistency and/or > 3 stools/24hrs, <7days

Oral rehydration therapy, IV when

oral not feasible or severe diarrhea

Evaluate history, risk factors and

assess for source

Community Nosocomial diarrhea Immunocompromi Food poisoning Viral Suspicion

Acquired/ Travelers’ (>3days in hospital) sed esp. with HIV suspicion
diarrhea OR antibiotic use
within 3 months
Stool DR + Stool Generally self- Usually non-
Stool DR and Stool CS Test for [Link] for modified AFB limiting bloody, watery
toxins A+/- B supportive stool and afebrile
(Culture test for
Salmonella, Shigella, therapy supportive
Campylobacter, [Link]) therapy; may
Discontinue include
antimicrobial Loperamide
therapy if possible If signs of infectious
diarrhea consider
suspected pathogen Follow up to
specific therapy confirm resolution
Suspected organisms:
Bacillus cereus, Clostridium
perfringens, Vibrio,
Consider empirical antibiotic therapy Clostridium botulinum,
Staphlococcus aureus
See Table 1

Chase labs and consider antimicrobial

therapy for specific pathogen
History Pathogen First line therapy and Adult dosing First line therapy and
Children dosing
Consumption of contaminated Giardia Metronidazole, 250 to 750 mg 5 mg/kg/dose every 8 hours
water, persistent diarrhea with three times per day for 7 to 10 days for 5 to 7 days7
weight loss, rectal pain or
proctitis, travelling history
Bloody stools, raw milk, fecal-oral Campylobacter Azithromycin (Zithromax), 500 mg Oral: 10 mg/kg/dose once
sexual contact once per day for 3 to 5 days daily for 3 days; patients with
HIV should receive treatment
for 5 days.9
Bloody stool, recent use of Clostridium Metronidazole (Flagyl), 500 mg Metronidazole: Oral : 7.5
antibiotic difficile three times per day for 10 days in mg/kg/dose every 6 hours for
milder cases and Vancomycin 10 days9
125mg PO Q6hrly in severe cases3,5
Travelling history Enteropathogeni Azithromycin 1gm PO for 1 day Azithromycin: 20 mg/kg/dose
c/ enteroinvasive (500mg bid for 2 days to mitigate (maximum dose: 1,000
Escherichia coli/ GI upset) OR 500mg once daily for mg/dose) once daily for 5 to 7
Enterotoxigenic 3 days1,3 days,
E. coli Alternative therapy: Rifaximin: (in children >12
Ciprofloxacin,500mg twice per day years)10 Oral: 200 mg 3 times
for 3 days OR Rifaximin 200mg tid daily for 3 days9
for 3 days1,3
Bloody stools with abdominal Shiga toxin– No treatment1 No treatment1
pain, raw milk, undercooked meat, producing E. coli
travelling history
Bloody stools with abdominal Shigella Ciprofloxacin, 750 mg once or twice Ceftriaxone (preferred) 50
pain, undercooked meat, per day for 3 days, or Levofloxacin mg/kg IV or IM once daily for
travelling history, rectal pain 500mg PO once daily for 3 days OR 5 days OR Ciprofloxacin 20
IV Ceftriaxone 1-2gm once daily for mg/kg per day IV divided in 2
5 days OR.3,5,6 doses for 3 to 5 days
Alternative Therapy: Azithromycin Alternative Therapy:
500mg once daily for 3 days3 Azithromycin
(preferred): 12 mg/kg orally
once daily on day 1; 6 mg/kg
orally once daily for 2 to 4
days (total duration 3 to 5
days)
Rice water stools Vibrio cholerae Doxycycline, 300-mg single dose OR 4 to 6 mg/kg (single dose) OR
Azithromycin 1gm PO single Azithromycin 20 mg/kg (single
dose3,5,6 dose)
Alternative therapy: Alternative therapy:
Ciprofloxacin 1gm PO single dose3 Ciprofloxacin: 15 mg/kg per
OR 500 mg twice daily for 3 days.9 dose, twice daily for 3 days9
HIV/immunosuppression, Cryptosporidium Therapy may not be necessary in Acute diarrhea should be
persistent diarrhea with weight immunocompetent patients with managed the same as in non-
loss. mild disease or in patients with HIV infected children11
AIDS who have a CD4 cell count
 greater than 150 cells per mm31
Bloody stools Entamoeba Metronidazole, 750 mg three times Oral, IV: 35 to 50 mg/kg/day in
histolytica per day for 5 to 10 days1,3 divided doses every 8 hours
Alternative therapy: for 7 to 10 days7
Tinidazole 2gm PO daily for 3 days3
HIV/immunosuppression Microsporida Albendazole, 400 mg twice per day Albendazole , 7.5mg/kg/dose
for 2-4 weeks3 po bid3
PATHOGEN SPECIFIC ANTIBIOTIC THERAPY1:

References:

1-Acute Diarrhea in Adults

2- WHO AWARE BOOK [Link]

Book_WHO_Dez2022.pdf

3- Sanford guide of antimicrobials 2024

4- [Link]

5- AKUH antibiotic guide 2022

6- IDSA Diarrhea guidelines [Link]

7- Harriet Lane, 21ST Edition.

8- [Link]

9- Up-to-date

10- [Link]
%20treatment%20for%20TD,or%20evidence%20of%20systemic%20infection.

11- Manual on Pediatric HIV Care and Treatment for District Hospitals: Addendum to the Pocket Book of
Hospital Care of Children. Geneva: World Health Organization; 2011. 2, Diarrhoea and other
gastrointestinal problems in HIV-infected children. Available from:
[Link]