Diarrhea

Stefano Guandalini, MD, Director, University of Chicago Celiac Disease Program, Section Chief of
Gastroenterology, Hepatology and Nutrition; Professor, Department of Pediatrics, University of Chicago
Comer Children's Hospital
Richard E Frye, MD, PhD, Assistant Professor, Departments of Pediatrics and Neurology, University of
Texas Health Science Center at Houston; M Akram Tamer, MD, Program Director, Professor,
Department of Pediatrics, University of Miami
Updated: Jan 5, 2009
Introduction
Background
Acute diarrhea is defined as the abrupt onset of abnormally high fluid content in the stool (more than
the normal value of approximately 10 mL/kg/d). This situation typically implies an increased frequency
of bowel movements, which can range from 4-5 to more than 20 times per day. The augmented water
content in the stools is due to an imbalance in the physiology of the small and large intestinal
processes involved in the absorption of ions, organic substrates, and thus water. A common disorder in
its acute form, diarrhea has many causes and may be mild to severe. Childhood acute diarrhea is
usually caused by infection; however, numerous disorders may cause this condition, including a
malabsorption syndrome and various enteropathies. Acute-onset diarrhea is usually self-limited;
however, an acute infection can have a protracted course. By far, the most common complication of
acute diarrhea is dehydration.
Although the term "acute gastroenteritis" is commonly used synonymously with "acute diarrhea," the
former term is a misnomer. The term gastroenteritis implies inflammation of both the stomach and the
small intestine, whereas, in reality, gastric involvement is rarely if ever seen in acute diarrhea
(including diarrhea with an infectious origin); enteritis is also not consistently present. Examples of
infectious acute diarrhea syndromes that do not cause enteritis include Vibrio cholerae– induced
diarrhea and Shigella -induced diarrhea. Thus, the term acute diarrhea is preferable to acute
gastroenteritis.
Diarrheal episodes are classically distinguished into acute and chronic (or persistent) based on their
duration. Acute diarrhea is thus defined as an episode that has an acute onset and lasts no longer than
14 days; chronic or persistent diarrhea is defined as an episode that lasts longer than 14 days. The
distinction, supported by the World Health Organization (WHO), has implications not only for
classification and epidemiological studies but also from a practical standpoint because protracted
diarrhea often has a different set of causes, poses different problems of management, and has a
different prognosis.
Pathophysiology
Diarrhea is the reversal of the normal net absorptive status of water and electrolyte absorption to
secretion. Such a derangement can be the result of either an osmotic force that acts in the lumen to
drive water into the gut or the result of an active secretory state induced in the enterocytes. In the
former case, diarrhea is osmolar in nature, as is observed after the ingestion of nonabsorbable sugars
such as lactulose or lactose in lactose malabsorbers. Instead, in the typical active secretory
state, enhanced anion secretion (mostly by the crypt cell compartment) is best exemplified by
enterotoxin-induced diarrhea.
In osmotic diarrhea, stool output is proportional to the intake of the unabsorbable substrate and is
usually not massive; diarrheal stools promptly regress with discontinuation of the offending nutrient,
and the stool ion gap is high, exceeding 100 mOsm/kg. In fact, the fecal osmolality in this circumstance
is accounted for not only by the electrolytes but also by the unabsorbed nutrient(s) and their
degradation products. The ion gap is obtained by subtracting the concentration of the electrolytes from
total osmolality, according to the formula: ion gap = osmolality – [(Na + K) × 2].
In secretory diarrhea, the epithelial cells’ ion transport processes are turned into a state of active
secretion. The most common cause of acute-onset secretory diarrhea is a bacterial infection of the gut.
Several mechanisms may be at work. After colonization, enteric pathogens may adhere to or invade the
epithelium; they may produce enterotoxins (exotoxins that elicit secretion by increasing an intracellular
second messenger) or cytotoxins. They may also trigger release of cytokines attracting inflammatory
cells, which, in turn, contribute to the activated secretion by inducing the release of agents such as
prostaglandins or platelet-activating factor. Features of secretory diarrhea include a high purging rate,
a lack of response to fasting, and a normal stool ion gap (ie, 100 mOsm/kg or less), indicating that
nutrient absorption is intact.
Frequency
United States
In the United States, one estimate assumes a cumulative incidence of 1 hospitalization for diarrhea per
23-27 children by age 5 years, with more than 50,000 hospitalizations in 2000. By these estimates,
rotavirus is associated with 4-5% of all childhood hospitalizations, and 1 in 67 to 1 in 85 children are
hospitalized due to rotavirus by age 5 years. Furthermore, acute diarrhea is responsible for 20% of
physician referrals in children younger than 2 years and for 10% in children younger than 3 years.
International
In developing countries, an average of 3 episodes per child per year in children younger than 5 years is
reported; however, some areas report 6-8 episodes per year per child. In these settings, malnutrition is
an important additional risk factor for diarrhea, and recurrent episodes of diarrhea lead to growth
faltering. Childhood mortality associated with diarrhea has constantly but slowly declined during the
past 2 decades, mostly because of the widespread use of oral rehydration solutions; however, it still
remains high.
Because the single most common cause of infectious diarrhea worldwide is rotavirus, and because a
vaccine has been in use for over 2 years now, a reduction in the overall frequency of diarrheal episodes
is hoped for in the near future.
Mortality/Morbidity
Mortality from acute diarrhea is overall globally declining but remains high. Most estimates have
diarrhea as the second cause of childhood mortality, with 18% of the 10.6 million yearly deaths in
children younger than age 5 years.
Despite a progressive reduction in global diarrheal disease mortality over the past 2 decades, diarrhea
morbidity in published reports from 1990-2000 slightly increased worldwide compared with previous
reports.
Furthermore, in countries where the toll of diarrhea is highest, poverty also adds an enormous
additional burden, and long-term consequences of the vicious cycle of enteric infections, diarrhea, and
malnutrition are devastating.
Sex
Most cases of infectious diarrhea are not sex specific. Females have a higher incidence of
Campylobacter species infections and hemolytic uremic syndrome (HUS).
Age
Viral diarrhea is most common in young children. Rotavirus and adenovirus are particularly prevalent in
children younger than 2 years. Astrovirus and norovirus usually infect children younger than 5 years.
Yersinia enterocolitis typically infects children younger than 1 year, and the Aeromonas organism is a
significant cause of diarrhea in young children.
Very young children are particularly susceptible to secondary dehydration and secondary nutrient
malabsorption. Age and nutritional status appear to be the most important host factors in determining
the severity and the duration of diarrhea. In fact, the younger the child, the higher is the risk for severe,
life-threatening dehydration as a result of the high body-water turnover and limited renal compensatory
capacity of very young children. Whether younger age also means a risk of running a prolonged course
is an unsettled issue. In developing countries, persistent postenteritis diarrhea has a strong inverse
correlation with age.
Clinical
History
• Acute diarrhea in developed countries is almost invariably a benign, self-limited condition,
subsiding within a few days. The clinical presentation and course of illness depend on the
etiology of the diarrhea and on the host. For example, rotavirus is more commonly associated
with vomiting, fever, and a greater number of work days lost than nonrotavirus gastroenteritis.
• A prospective study conducted in the United States in 604 children aged 3-36 months in
community settings found that the highest incidence of acute diarrhea was in January and
August, with an overall incidence of 2.21 episodes per person-year.[1 ]Close to 90% of episodes
were acute (ie, lasting <14 d, with a median duration of 2 d and a median of 6 stools per day).
• Diarrhea implies an increase in stool volume and diminished stool consistency.
o In children younger than 2 years, diarrhea is defined as daily stools with a volume
greater than 10 mL/kg.
o In children older than 2 years, diarrhea is defined as daily stools with a weight greater
than 200 g. In practice, this typically means loose-to-watery stools passed 4 or more
times per day.
o Individual stool patterns widely vary; for example, breastfed children may normally have
5-6 stools per day.
• Flatulence associated with foul-smelling stools that float suggests fat malabsorption, which can
be observed with infection with Giardia lamblia.
• Knowledge of the characteristics of consistency, color, volume, and frequency can be helpful in
determining whether the source is from the small or large bowel. Table 1 outlines these
characteristics and demonstrates that an index of suspicion can be easily generated for a
specific set of organisms.

Table 1. Stool Characteristics and Determining Their Source

Stool Small Bowel Large Bowel
Characteristics
Appearance Watery Mucoid and/or bloody
Volume Large Small
Frequency Increased Highly increased
Blood Possibly positive but never Commonly grossly bloody
gross blood
pH Possibly <5.5 >5.5
Reducing Possibly positive Negative
substances
WBCs <5/high power field Commonly >10/high power field
Serum WBCs Normal Possible leukocytosis, bandemia
Organisms Viral Invasive bacteria
• Rotavirus • Escherichia Coli (enteroinvasive,
• Adenovirus enterohemorrhagic)
• Calicivirus • Shigella species
• Astrovirus • Salmonella species
• Norovirus • Campylobacter species
• Yersinia species
• Aeromonas species
• Plesiomonas species
Enterotoxigenic bacteria Toxic bacteria
• E coli • Clostridium difficile
• Klebsiella
• Clostridium
perfringens
• Cholera species
• Vibrio species
Parasites Parasites
• Giardia species • Entamoeba organisms
• Cryptosporidium
species

• Associated systemic symptoms include the following:

o Some enteric infections commonly have systemic symptoms, whereas others less
commonly are associated with systemic features.
o Table 2 outlines the frequency of some of these symptoms with particular organisms. It
also outlines incubation periods and usual duration of symptoms of common organisms.
Certain organisms (eg, C difficile, Giardia, Entamoeba species) may be associated with a
protracted course.

Table 2. Organisms and Frequency of Symptoms

Organism Incubat Durat Vomit Fev Abdominal
ion ion ing er Pain
Rotavirus 1-7 d 4-8 d Yes Low No
Adenovirus 8-10 d 5-12 d Delaye Low No
d
Norovirus 1-2 d 2d Yes No No
Astrovirus 1-2 d 4-8 d +/- +/- No
Calicivirus 1-4 d 4-8 d Yes +/- No
Aeromonas None 0-2 wk +/- +/- No
species
Campylobacter 2-4 d 5-7 d No Yes Yes
species
C difficile Variable Variabl No Few Few
e
C perfringens Minimal 1 d Mild No Yes
Enterohemorrhag 1-8 d 3-6 d No +/- Yes
ic E coli
Enterotoxigenic E 1-3 d 3-5 d Yes Low Yes
coli
Plesiomonas None 0-2 wk +/- +/- +/-
species
Salmonella 0-3 d 2-7 d Yes Yes Yes
species
Shigella species 0-2 d 2-5 d No High Yes
Vibrio species 0-1 d 5-7 d Yes No Yes
Y enterocolitica None 1-46 d Yes Yes Yes
Giardia species 2 wk 1+ wk No No Yes
Cryptosporidium 5-21 d Month No Low Yes
species s
Entamoeba 5-7 d 1-2+ No Yes No
species wk
• Daycare considerations are as follows:
o Certain organisms are spread quickly in daycare. These organisms include rotavirus;
astrovirus; calicivirus; and Campylobacter, Shigella, Giardia, and Cryptosporidium
species.
o Increase in daycare usage has raised the incidence of rotavirus and Cryptosporidium
species.
• Food history can be helpful.
o Ingestion of raw or contaminated food is a common cause.
o Organisms that cause food poisoning include the following:
 Dairy food -Campylobacter and Salmonella species
 Eggs -Salmonella species
 Meats -C perfringens and Aeromonas, Campylobacter, and Salmonella species
 Ground beef - Enterohemorrhagic E coli
 Poultry -Campylobacter species
 Pork -C perfringens, Y enterocolitica
 Seafood - Astrovirus and Aeromonas, Plesiomonas, and Vibrio species
 Oysters - Calicivirus and Plesiomonas and Vibrio species
 Vegetables -Aeromonas species and C perfringens
• Water exposure can contribute to diarrhea.
o Water is a major reservoir for many organisms that cause diarrhea.
o Swimming pools have been associated with outbreaks of infection with Shigella species;
Aeromonas organisms are associated with exposure to the marine environment.
o Giardia, Cryptosporidium, and Entamoeba organisms are resistant to water chlorination;
therefore, exposure to contaminated water should raise index of suspicion for these
parasites.
• A history of camping suggests exposure to water sources contaminated with Giardia organisms.
• Travel history may indicate a cause for diarrhea.
o Enterotoxigenic E coli is the leading cause of traveler's diarrhea.
o Rotavirus and Shigella, Salmonella, and Campylobacter organisms are prevalent
worldwide and need to be considered regardless of specific travel history.
o Risk of contracting diarrhea while traveling is, by far, highest for persons traveling to
Africa.
o Travel to Central and South America and Eastern European countries is also associated
with a relatively high risk of contracting diarrhea.
o Other organisms that are prevalent in particular parts of the world include the following:
 Nonspecific foreign travel history - Enterotoxigenic E coli and Aeromonas,
Giardia, Plesiomonas, Salmonella, and Shigella species
 Underdeveloped tropical visit -C perfringens
 Travel to Africa -Entamoeba species, Vibrio cholerae
 Travel to South America and Central America -Entamoeba species, V cholerae,
enterotoxigenic E coli
 Travel to Asia -V cholerae
 Travel to Australia -Yersinia species
 Travel to Canada -Yersinia species
 Travel to Europe -Yersinia species
 Travel to India -Entamoeba species, V cholerae
 Travel to Japan -Vibrio parahaemolyticus
 Travel to Mexico -Aeromonas, Entamoeba, Plesiomonas, and Yersinia species
 New Guinea -Clostridium species
• Animal exposure can contribute to diarrhea.
o Exposure to young dogs or cats is associated with Campylobacter organisms.
o Exposure to turtles is associated with Salmonella organisms.
• Certain medical conditions predispose patients to infection, including the following:
 o C difficile - Hospitalization, antibiotic administration
o Plesiomonas species - Liver diseases or malignancy
o Salmonella species - Intestinal dysmotility, malnutrition, achlorhydria, hemolytic anemia
(especially sickle cell disease), immunosuppression, malaria
o Rotavirus - Hospitalization
o Giardia species -Agammaglobulinemia, chronic pancreatitis, achlorhydria, cystic fibrosis
o Cryptosporidia species - Immunocompromised or immunosuppressed state
Physical
• Dehydration
o Dehydration is the principal cause of morbidity and mortality.
o Assess every patient with diarrhea for signs, symptoms, and severity.
o Lethargy, depressed consciousness, sunken anterior fontanel, dry mucous membranes,
sunken eyes, lack of tears, poor skin turgor, and delayed capillary refill are obvious and
important signs of dehydration.
• Failure to thrive and malnutrition
o Reduced muscle and fat mass or peripheral edema may be clues to the presence of
carbohydrate, fat, and/or protein malabsorption.
o Giardia organisms can cause intermittent diarrhea and fat malabsorption.
• Abdominal pain
o Nonspecific nonfocal abdominal pain and cramping are common with some organisms.
o Pain usually does not increase with palpation.
o With focal abdominal pain worsened by palpation, rebound tenderness, or guarding, be
alert for possible complications or for another noninfectious diagnosis.
• Borborygmi: Significant increases in peristaltic activity can cause an audible and/or palpable
increase in bowel activity.
• Perianal erythema
o Frequent stools can cause perianal skin breakdown, particularly in young children.
o Secondary carbohydrate malabsorption often results in acidic stools.
o Secondary bile acid malabsorption can result in a severe diaper dermatitis that is often
characterized as a "burn."
Causes
Although infectious agents are by far the most common cause for sporadic or endemic episodes of
acute diarrhea, one should not dismiss other causes that can lead to the same presentation.
• Causes of acute diarrhea include the following:
o Infections
 Enteric infections (including food poisoning
 Extraintestinal infections
o Drug-induced
 Antibiotic-associated
 Laxatives
 Antacids that contain magnesium
 Opiate withdrawal
 Other drugs
o Food allergies or intolerances
 Cow's milk protein allergy
 Soy protein allergy
 Multiple food allergies
 Olestra
 Methylxanthines (caffeine, theobromine, theophylline)
o Disorders of digestive/absorptive processes
 Sucrase-isomaltase deficiency
 Late-onset (adult-type) hypolactasia, resulting in lactose intolerance
o Chemotherapy or radiation-induced enteritis
o Surgical conditions
 Acute appendicitis
 Intussusception
o Vitamin deficiencies
 Niacin deficiency
 Folate deficiency
o Vitamin toxicity
 Vitamin C
 Niacin, vitamin B3
 o Ingestion of heavy metals or toxins (eg, copper, tin, zinc)
o Ingestion of plants (eg, hyacinths, daffodils, azalea, mistletoe, Amanita species
mushrooms
• Infectious causes of acute diarrhea in developed countries
o Viruses
 Rotavirus - 25-40% of cases
 Calicivirus - 1-20% of cases
 Norovirus - 10% of cases
 Astrovirus - 4-9% of cases
 Enteric-type adenovirus - 2-4% of cases
o Bacteria
 Campylobacter jejuni - 6-8% of cases
 Salmonella - 3-7% of cases
 E Coli - 3-5% of cases
 Shigella - 0-3% of cases
 Y enterocolitica - 1-2% of cases
 C difficile - 0-2% of cases
 Vibrio parahaemolyticus - 0-1% of cases
 V cholerae - Unknown
 Aeromonas hydrophila - 0-2% of cases
o Parasites
 Cryptosporidium - 1-3% of cases
 G lamblia - 1-3% of cases
Differential Diagnoses
Appendicitis Intussusception
Carcinoid Tumor Irritable Bowel Syndrome
Congenital Microvillus Atrophy Malabsorption Syndromes
Crohn Disease Meckel Diverticulum
Cystic Fibrosis Protein Intolerance
Giardiasis Shigella Infection
Hyperthyroidism Short Bowel Syndrome
Intestinal Enterokinase Deficiency Ulcerative Colitis
Intestinal Protozoal Diseases
Workup
Laboratory Studies
• In patients with diarrhea, a stool pH level of 5.5 or less or presence of reducing substances
indicates carbohydrate intolerance, which is usually secondary to viral illness and transient in
nature.
• Enteroinvasive infections of the large bowel cause leukocytes, predominantly neutrophils, to be
shed into stool. Absence of fecal leukocytes does not eliminate the possibility of enteroinvasive
organisms. However, presence of fecal leukocytes eliminates consideration of enterotoxigenic E
coli, Vibrio species, and viruses.
• Examine any exudates found in stool for leukocytes. Such exudates highly suggest colitis (80%
positive predictive value). Colitis can be infectious, allergic, or part of inflammatory bowel
disease (Crohn disease, ulcerative colitis).
• Many different culture mediums are used to isolate bacteria. Table 3 lists common bacteria and
optimum culture mediums for their growth. A high index of suspicion is needed to choose the
appropriate medium.
• With stool not cultured within 2 hours of collection, refrigerate at 4°C or place in a transport
medium. Although stool cultures are useful when positive, yield is low.
• Always culture stool for Salmonella, Shigella, and Campylobacter organisms and Y enterocolitica
in the presence of clinical signs of colitis or if fecal leucocytes are found.
• Look for C difficile in persons with episodes of diarrhea characterized by colitis and/or blood in
the stools. Remember that acute-onset diarrheal episodes associated with C difficile may also
occur without a history of antibiotic use.
• Bloody diarrhea with a history of ground beef ingestion must raise suspicion for
enterohemorrhagic E coli. If E coli is found in the stool, determine if the type of E coli is
O157:H7. This type of E coli is the most common, but not only, cause of HUS.
• History of raw seafood ingestion or foreign travel should prompt additional screening for Vibrio
and Plesiomonas species.
Table 3. Common Bacteria and Optimum Culture Mediums
Organism Detection Method Microbiologic Characteristics
Aeromonas Blood agar Oxidase-positive flagellated gram-negative
species bacillus (GNB)
Campylobact Skirrow agar Rapidly motile curved gram-negative rod
er species (GNR); Campylobacter jejuni 90% and
Campylobacter coli 5% of infections
C difficile Cycloserine-cefoxitin-fructose-egg (CCFE) Anaerobic spore-forming gram-positive rod
agar; enzyme immunoassay (EIA) for toxin; (GPR); toxin-mediated diarrhea; produces
latex agglutination (LA) for protein pseudomembranous colitis
C perfringens None available Anaerobic spore-forming GPR; toxin-
mediated diarrhea
E coli MacConkey eosin-methylene blue (EMB) or Lactose-producing GNR
Sorbitol-MacConkey (SM) agar
Plesiomonas Blood agar Oxidase-positive GNR
species
Salmonella Blood, MacConkey EMB, xylose-lysine- Nonlactose non–H2S-producing GNR
species deoxycholate (XLD), or Hektoen enteric
(HE) agar
• Culture mediums used to isolate bacteria include the following:
o Blood agar - All aerobic bacteria and yeast; detects cytochrome oxidase production
o MacConkey EMB agar - Inhibits gram-positive organisms; permits lactose fermentation
o XLD agar; HE agar - Inhibits gram-positive organisms and nonpathogenic GNB; permits
lactose fermentation H2S production
o Skirrow agar - Selective for Campylobacter species
o SM agar - Selective for enterohemorrhagic E coli
o CIN agar - Selective for Y enterocolitica
o TCBS agar - Selective for Vibrio species
o CCFE agar - Selective for C difficile
• Rotavirus antigen can be identified by enzyme immunoassay and latex agglutination assay of
the stool. The false-negative rate is approximately 50%, and false-positive results occur,
particularly in the presence of blood in the stools.
• Adenovirus antigens can be detected by enzyme immunoassay. Only serotypes 40 and 41 are
able to induce diarrhea.
• Examination of stools for ova and parasites is best for finding parasites. Perform stool
examination every 3 days or every other day.
• The leukocyte count is usually not elevated in viral-mediated and toxin-mediated diarrhea.
Leukocytosis is often but not constantly observed with enteroinvasive bacteria. Shigella
organisms cause a marked bandemia with a variable total white blood cell count.
• At times, a protein-losing enteropathy can be found in patients with extensive inflammation in
the course of enteroinvasive intestinal infections (eg, Salmonella species, enteroinvasive E coli).
In these circumstances, low serum albumin levels and high fecal alpha1-antitrypsin levels can
be found.
Procedures
• Intestinal biopsy: This procedure may be indicated in the presence of chronic or protracted
diarrhea, as well as in cases in which a search for a cause is believed to be mandatory (eg, in
patients with acquired immunodeficiency syndrome [AIDS] or patients who are otherwise
severely immunocompromised).
Treatment
Medical Care
In 2003 the Center for Disease Control (CDC) put forth new recommendations for the management of
acute pediatric diarrhea in both the outpatient and inpatient settings including indication for referral.[2 ]

Indications for medical evaluation of children with acute diarrhea include the following:
• Older than 3 months
• Weight of more than 8 kg
• History of premature birth, chronic medical conditions, or concurrent illness
• Fever of 38ºC or higher in infants younger than 3 months or 39ºC or higher in children aged 3-36
months
• Visible blood in the stool
• High-output diarrhea
• Persistent emesis
• Signs of dehydration as reported by caregiver, including sunken eyes, decreased tears, dry
mucous membranes, and decreased urine output
• Mental status changes
• Inadequate responses to oral rehydration therapy (ORT) or caregiver unable to administer ORT
The report also includes information on assessment of dehydration and what steps should be taken to
adequately treat acute diarrhea.

Treatment of dehydration due to diarrhea includes the following:

• Minimal or no dehydration
o Rehydration therapy - Not applicable
o Replacement of losses
 Less than 10 kg body weight - 60-120 mL oral rehydration solution for each
diarrhea stool or vomiting episode
 More than 10 kg body weight - 120-140 mL oral rehydration solution for each
diarrhea stool or vomiting episode
• Mild-to-moderate dehydration
o Rehydration therapy - Oral rehydration solution (50-100 mL/kg over 3-4 h)
o Replacement of losses
 Less than 10 kg body weight - 60-120 mL oral rehydration solution for each
diarrhea stool or vomiting episode
 More than 10 kg body weight - 120-140 mL oral rehydration solution for each
diarrhea stool or vomiting episode
• Severe dehydration
o Rehydration therapy - Intravenous lactated Ringer solution or normal saline (20 mL/kg
until perfusion and mental status improve), followed by 100 mL/kg oral rehydration
solution over 4 hours or 5% dextrose (half normal saline) intravenously at twice
maintenance fluid rates
o Replacement of losses
 Less than 10 kg body weight - 60-120 mL oral rehydration solution for each
diarrhea stool or vomiting episode
 More than 10 kg body weight - 120-140 mL oral rehydration solution for each
diarrhea stool or vomiting episode
 If unable to drink, administer through nasogastric tube or intravenously
administer 5% dextrose (one fourth normal saline) with 20 mEq/L potassium
chloride
ORT is the cornerstone of treatment, especially for small-bowel infections that produce a large volume
of watery stool output. ORT with a glucose-based ORS must be viewed as by far the safest, most
physiologic, and most effective way to provide rehydration and maintain hydration in children with
acute diarrhea worldwide, as recommended by the WHO; by the ad hoc committee of European Society
for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN); and by the American Academy of
Pediatrics.[3 ]However, the global use of ORT is still insufficient. Developed countries, in particular the
United States, seem to be lagging behind despite studies that demonstrate beyond doubt the efficacy
of ORT in emergency care settings, in which intravenous rehydration unduly continues to be widely
privileged.

Not all commercial ORT formulas promote optimal absorption of electrolytes, water, and nutrients. The
ideal solution has a low osmolarity (210-250) and a sodium content of 50-60 mmol/L. Administer
maintenance fluids plus replacement of losses. Educate caregivers in methods necessary to replace
this amount of fluid. Administer small amounts of fluid at frequent intervals to minimize discomfort and
vomiting. A 5-mL or 10-mL syringe without a needle is a very useful tool. The syringe can be quickly
used to place small amounts of fluid in the mouth of a child who is uncooperative. Once the child
becomes better hydrated, cooperation improves enough to take small sips from a cup. This method is
time intensive and requires a dedicated caregiver. Encouragement from the physician is necessary to
promote compliance. Oral rehydration is now universally recommended to be completed within 4 hours.
The composition of almost all other beverages (carbonated or not) that are commercially available and
frequently used in children with diarrhea is completely inadequate for rehydration or for maintaining
hydration, considering the sodium content, which is invariably extremely low, and osmolarity that is
often dangerously elevated. For instance, Coca-Cola, Pepsi-Cola, and apple juice have an osmolarity of
493, 576, and 694-773, respectively.
At completion of hydration, resumption of feeding is strongly recommended. In fact, many studies
convincingly demonstrate that early refeeding hastens recovery. Also, robust evidence suggests that,
in the vast majority of episodes of acute diarrhea, refeeding can be accomplished without the use of
any special (eg, lactose-free or soy-based) formulas.
Antimotility agents are not indicated for infectious diarrhea, except for refractory cases of
Cryptosporidium infection. Antimicrobial therapy is indicated for some nonviral diarrhea because most
is self-limiting and does not require therapy.

Therapies recommended for some nonviral diarrheas include the following:

 • Aeromonas species: Use cefixime and most third-generation and fourth-generation
cephalosporins.
• Campylobacter species: Erythromycin shortens illness duration and shedding.
• C difficile: Discontinue potential causative antibiotics. If antibiotics cannot be stopped or this
does not result in resolution, use oral metronidazole or vancomycin. Vancomycin is reserved for
the child who is seriously ill.
• C perfringens: Do not treat with antibiotics.
• Cryptosporidium parvum: Administer paromomycin; however, effectiveness is not proven.
Nitazoxanide, a newer anthelmintic, is effective against C parvum.
• Entamoeba histolytica: Metronidazole followed by iodoquinol or paromomycin is administered in
symptomatic patients. Asymptomatic carriers in nonendemic areas should receive iodoquinol or
paromomycin.
• E coli: Trimethoprim-sulfamethoxazole (TMP-SMX) should be administered if moderate or severe
diarrhea is noted; antibiotic treatment may increase likelihood of hemolytic-uremic syndrome
(HUS). Parenteral second-generation or third-generation cephalosporin is indicated for systemic
complications.
• G lamblia: Metronidazole or nitazoxanide can be used.
• Plesiomonas species: Use TMP-SMX or any cephalosporin.
• Salmonella species: Treatment prolongs carrier state, is associated with relapse, and is not
indicated for nontyphoid-uncomplicated diarrhea. Treat infants younger than 3 months and
high-risk patients (eg, immunocompromised, sickle cell disease). TMP-SMX is first-line
medication; however, resistance occurs. Use ceftriaxone and cefotaxime for invasive disease.
• Shigella species: Treatment shortens illness duration and shedding but does not prevent
complications. TMP-SMX is first-line medication; however, resistance occurs. Cefixime,
ceftriaxone, and cefotaxime are recommended for invasive disease.
• V cholerae: Treat infected individuals and contacts. Doxycycline is the first-line antibiotic, and
erythromycin is second-line antibiotic.
• Yersinia species: TMP-SMX, cefixime, ceftriaxone, and cefotaxime are used. Treatment does not
shorten disease duration; reserve for complicated cases.
Consultations
• Surgeon
o Certain organisms cause abdominal pain and bloody stools.
o Symptoms resembling appendicitis, hemorrhagic colitis, intussusception, or toxic
megacolon may be appreciated.
o If the infectious etiology in individuals with such symptoms is not certain, seek
consultation with a surgeon.
• Infectious-disease specialist: Consider consultation with an infectious-disease specialist for any
patient who is immunocompromised because of HIV infection, chemotherapy, or
immunosuppressive drugs because atypical organisms are more likely, and complications can
be more serious and fulminate.
Diet
Breastfed infants with acute diarrhea should be continued on breast milk without any need for
interruption. In fact, breastfeeding not only has a well-known protective effect against the development
of enteritis, it also promotes faster recovery and provides improved nutrition. This is even more
important in developing countries, where withdrawal of breastfeeding during diarrhea has been shown
to have a deleterious effect on the development of dehydration in infants with acute watery diarrhea.
• Bananas, rice, applesauce, and toast diet
o A banana, rice, applesauce, and toast (BRAT) diet was introduced in the United States in
1926 and has enjoyed vast popularity. However, no evidence shows that this diet is
useful, and its poor protein content may be a contraindication; therefore, it is not
recommended.
o A strong body of evidence now suggests that resuming the prediarrhea diet is perfectly
safe and must be encouraged, obviously respecting any (usually temporary) lack of
appetite.
• Lactose ingestion
o Although rotavirus can cause secondary transient lactose intolerance, this finding is
believed to be generally not clinically relevant; use lactose-containing formulas in all
individuals with diarrhea.
o In an incident of worsening of diarrhea proven to be secondary to a clinically important
lactose malabsorption in infants positive for rotavirus, a very transient use of lactose-free
formulas (5-6 d) can be considered.
Medication
Diarrheal diseases have been the object of numerous forms of treatment, both dietetic and
pharmacologic, for centuries. However, the evidence is now clear that, in most cases, the best option
for treatment of acute-onset diarrhea is the early use of oral rehydration therapy (ORT).[2 ]
Pharmacological treatment is rarely of any use, and antidiarrheal drugs are often harmful.
In terms of recommended antimicrobial treatment in the immunocompetent host, enteric bacterial and
protozoan pathogens can be grouped as follows:
• Agents for whom antimicrobial therapy is always indicated: The consensus includes only V
cholerae, Shigella species, and G lamblia.
• Agents for whom antimicrobial therapy is indicated only in selected circumstances, include the
following:
o Infections by enteropathogenic E coli, when running a prolonged course
o Enteroinvasive E coli, based on the serologic, genetic, and pathogenic similarities with
Shigella
o Yersinia infections in subjects with sickle cell disease
o Salmonella infections in very young infants, if febrile or with positive blood culture
findings
Probiotics
Recently, some strains of probiotics (lactic acid bacteria or mycetes thought to benefit the host in some
circumstances when ingested in adequate doses) have been found to be effective as an adjunct when
treating children with acute diarrhea. Data from well-conducted randomized controlled trials on efficacy
of probiotics in children with diarrhea are definitely positive. They consistently show a statistically
significant benefit and moderate clinical benefit of a few, now well-identified probiotic strains (mostly
Lactobacillus GG and Saccharomyces boulardii but also Lactobacillus reuteri) in the treatment of acute
watery diarrhea (primarily rotaviral) in infants and young children in developed countries.
Such a beneficial effect seems to result in a reduction of the duration of diarrhea of little more than one
day and seems to be exerted mostly on rotoviral diarrhea, with lack of evidence of efficacy in invasive
bacterial diarrhea. The effect is not only strain-dependent but also dose-dependent, with doses of at
least 5 billion/d. Shortening the duration of diarrhea by one day may not appear to be hugely beneficial.
However, in consideration of the high morbidity of the infection, even a reduction of this order is indeed
desirable because it affords considerable savings in terms of loss of working days and direct health
costs.
Currently, estimates suggest that rotavirus infections cause over 50,000 hospital admissions
annually in the United States alone. Furthermore, probiotics may reduce the risk of spreading rotavirus
infection by shortening diarrhea duration and volume of watery stool output and by reducing the fecal
shedding of rotavirus.
A recent position paper jointly published by the ESPGHAN and the European Society for Pediatric
Infectious Disease (ESPID) stated, ‘‘Probiotics may be an effective adjunct to the management of
diarrhea. However, because there is no evidence of efficacy for many preparations, we suggest the use
of probiotic strains with proven efficacy and in appropriate doses for the management of children with
acute gastroenteritis as an adjunct to rehydration therapy (II, B). The following probiotics showed
benefit in meta-analyses of randomized controlled trials: Lactobacillus GG (I, A) and S boulardii (II, B).’’[4
]

Antibiotic and antiparasitics agents

Antimicrobial agents, in addition to the immune system, help destroy offending organisms. Their use is
confined to specific etiologies and/or clinical circumstances.

Cefixime (Suprax)
Potent long-acting oral cephalosporin with increased gram-negative coverage. Inhibits bacterial cell
wall synthesis by binding to 1 or more PBPs. Bacteria eventually lyse because of ongoing activity of cell
wall autolytic enzymes while cell wall assembly is arrested.
Dosing
Adult
400 mg/d PO qd for 7-10 d
Pediatric
8 mg/kg/d PO qd for 7-10 d
Interactions
Aminoglycosides increase nephrotoxic potential; probenecid may increase effects by decreasing
clearance
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Documented hypersensitivity to penicillins; reduced renal function; administer with food to minimize
nausea and diarrhea

Ceftriaxone (Rocephin)
A third-generation cephalosporin antibiotic with activity against gram-positive and some gram-negative
bacteria. Binds to PBPs, inhibiting bacterial cell wall growth.
Dosing
Adult
1-2 g IV/IM q24h
Pediatric
50 mg/kg/d IV/IM divided qd/bid for 7-10 d; not to exceed 2 g/d
Interactions
Probenecid increases ceftriaxone serum concentration
Contraindications
Documented hypersensitivity; do not use in neonates who are hyperbilirubinemic
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients with allergies to penicillin antibiotics; may cause skin rashes, diarrhea, and pain at
site of injection

Cefotaxime (Claforan)
Third-generation cephalosporin antibiotic with activity against gram-positive and some gram-negative
bacteria. Binds to PBPs, inhibiting bacterial cell wall growth.
Dosing
Adult
1-2 g IV/IM q6-8h for 7-10 d
Pediatric
50 mg/kg/dose IV/IM tid for 7-10 d
Interactions
Probenecid may increase levels; coadministration with furosemide and aminoglycosides may increase
nephrotoxicity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients with allergies to penicillin antibiotics; may cause rashes, thrombophlebitis, and GI
upset (eg, nausea, vomiting, diarrhea)

Erythromycin (E.E.S., E-Mycin, Eryc, Ery-Tab, Erythrocin)

Bacteriostatic macrolide with activity against most gram-positive organisms and atypical respiratory
organisms. Useful for Campylobacter species and vibrio enteritis.
Dosing
Adult
250-500 mg (base, stearate, or estolate) PO qid
400-800 mg (ethylsuccinate) PO qid
Pediatric
50 mg/kg/d PO/IV divided qid for 7-10 d
Interactions
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may
potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases
risk of rhabdomyolysis
Contraindications
Documented hypersensitivity; hepatic impairment; inhibits CYP3A4, caution with concomitant
administration of CYP3A4 substrates (eg, terfenadine, cisapride, astemizole)
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are
common (administer pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occurs

Furazolidone (Furoxone)
Antiparasitic agent with wide coverage. Nitrofuran with antiprotozoal activity. Alternative drug for
children because availability in liquid suspension. Most common adverse effects are GI upset and brown
discoloration of urine.
Dosing
Adult
100 mg PO qid for 7-10 d
Pediatric
5 mg/kg/d PO divided qid for 7-10 d
Interactions
Increases levodopa blood concentrations and, thus, potential for toxicity; causes disulfiramlike
reactions when taken with alcohol; toxicity of meperidine, paroxetine, fluoxetine, sertraline, trazodone,
MAOIs, sympathomimetic amines, and TCAs increases when taken with furazolidone
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
Caution in G-6-PD deficiency when administering prolonged treatments; inhibits enzyme monoamine
oxidase; may cause rashes, thrombophlebitis, and GI upset (eg, nausea, vomiting, diarrhea)

Iodoquinol (Vytone, Yodoxin)

Antiparasitic agents with wide coverage.
Dosing
Adult
650 mg PO tid pc for 20 d
Pediatric
30-40 mg/kg/d PO divided tid pc for 20 d; not to exceed adult dose
Interactions
None reported
Contraindications
Documented hypersensitivity; preexisting optic neuropathy or hepatic damage
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
Avoid long-term use; commonly causes nausea, vomiting, stomach pain, and diarrhea

Metronidazole (Flagyl)
Very active against Giardia species, gram-negative anaerobes, and Entamoeba species. Imidazole ring-
based antibiotic active against various anaerobic bacteria and protozoa. Often used in combination with
other antimicrobial agents except for C difficile enterocolitis).
Dosing
Adult
250-500 mg PO tid for 10 d
Pediatric
30-50 mg/kg/d PO divided tid for 10 d; not to exceed adult dose
Interactions
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of
metronidazole; disulfiramlike reaction may occur with orally ingested ethanol
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use in pregnancy during first trimester; adjust dose in hepatic disease; monitor for seizures and
development of peripheral neuropathy
Paromomycin (Humatin)
Amebicidal and antibacterial aminoglycoside obtained from a strain of Streptomyces rimosus, active in
intestinal amebiasis. Recommended for treatment of Diphyllobothrium latum, Taenia saginata, T
solium, Dipylidium caninum, and Hymenolepis nana.
Dosing
Adult
25-30 mg/kg/d PO divided tid for 7 d; not to exceed 4 g/d
Pediatric
Administer as in adults
Interactions
Nephrotoxic potential may increase with concurrent administration of other aminoglycosides,
penicillins, cephalosporins, amphotericin B, and loop diuretics
Contraindications
Documented hypersensitivity; intestinal obstruction
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
Because of narrow therapeutic index and toxic hazards associated with extended administration, do not
use for long-term therapy; caution in renal failure, hypocalcemia, myasthenia gravis, and conditions
that depress neuromuscular transmission; adjust dose in renal impairment

Quinacrine (Atabrine)
Very effective antiparasitic against Giardia species.
Dosing
Adult
100 mg PO tid for 5-7 d
Pediatric
6 mg/kg/d PO divided tid for 5 d
Interactions
Can cause disulfiram-type reaction when mixed with alcohol
Contraindications
Documented hypersensitivity; psoriasis
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
Hemolysis (frequently dose-related) may occur in individuals who are G-6-PD deficient; may cause
nausea, vomiting, abdominal pain, anorexia, and diarrhea; eczematous eruptions and discoloration of
skin; poor palatability

Sulfamethoxazole and trimethoprim (Bactrim, Septra, Cotrim)

Folate-synthesis blocker with wide antibiotic coverage. Inhibits bacterial growth by inhibiting synthesis
of dihydrofolic acid. Effective in E coli infections. Dosage form contains 5:1 ratio of sulfamethoxazole to
trimethoprim.
Dosing
Adult
160 mg (based on trimethoprim component) PO bid for 7-10 d
Pediatric
10 mg/kg/d (based on trimethoprim component) PO bid for 7-10 d
Interactions
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly);
coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics
increases incidence of thrombocytopenia purpura in elderly individuals; phenytoin levels may increase
with coadministration; may potentiate effects of methotrexate in bone marrow depression;
hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of
zidovudine
Contraindications
Documented hypersensitivity; megaloblastic anemia due to folate deficiency; age <2 mo
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of rash or sign of adverse reaction; frequently obtain CBC counts;
discontinue if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with
sulfonamides; caution in folate deficiency (eg, persons with chronic alcoholism, elderly individuals,
those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in
individuals who are G-6-PD deficient; patients with AIDS may not tolerate or respond; caution in renal or
hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent
crystalluria and stone formation

Vancomycin (Vancocin)
Effective treatment (when PO) for antibiotic-associated colitis due to C difficile. However, reserve for
individuals whose symptoms are not responding to less expensive and almost equally effective
metronidazole.
Dosing
Adult
500 mg PO qid for 10-14 d
Pediatric
40-50 mg/kg/d PO divided qid for 10-14 d; not to exceed 2 g/d
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
IV preparation requires dose adjustment for renal failure, but PO form is poorly absorbed

Tetracycline (Sumycin)
Treats gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial
infections. Good agent in older children who present with severe Yersinia species infection.
Dosing
Adult
250-500 mg PO q6h
Mild-to-moderate infections: 500 mg PO bid or 250 mg PO qid for 7-14 d
Severe infections: 500 mg PO qid for 7-14 d
Pediatric
<8 years: Not recommended
>8 years: 25-50 mg/kg/d (10-20 mg/lb) divided PO qid
Interactions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth
subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and
increased risk of pregnancy; can increase hypoprothrombinemic effects of anticoagulants
Contraindications
Documented hypersensitivity; severe hepatic dysfunction
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in
renal impairment; consider drug serum level determinations in prolonged therapy; use during tooth
development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth;
Fanconilike syndrome may occur with outdated tetracyclines

Nitazoxanide (Alinia)
Inhibits growth of C parvum sporozoites and oocysts and G lamblia trophozoites. Elicits antiprotozoal
activity by interfering with pyruvate-ferredoxin oxidoreductase (PFOR) enzyme-dependent electron
transfer reaction, which is essential to anaerobic energy metabolism. Available as a 20-mg/mL oral
susp.
Dosing
Adult
500 mg PO bid for 3 d
Pediatric
<1 year: Not established
1-3 years: 100 mg (5 mL) PO q12h for 3 d with food
4-11 years: 200 mg (10 mL) PO q12h for 3 d with food
>11 years: Administer as in adults
Interactions
Tizoxanide (nitazoxanide metabolite) is >99.9% bound to plasma protein and may potentially increase
toxicity of other highly plasma protein–bound drugs
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause abdominal pain, diarrhea, vomiting, or headache; administer with food; caution when
coadministered with other highly plasma protein–bound drugs with narrow therapeutic indices

Rifaximin (Xifaxan, RedActiv, Flonorm)

Nonabsorbed (<0.4%), broad-spectrum antibiotic specific for enteric pathogens of the gastrointestinal
tract (ie, Gram-positive, Gram-negative, aerobic and anaerobic). Rifampin structural analog. Binds to
beta-subunit of bacterial DNA-dependent RNA polymerase, thereby inhibiting RNA synthesis. Indicated
for E coli (enterotoxigenic and enteroaggregative strains) associated with travelers' diarrhea.
Dosing
Adult
200 mg PO tid
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Interactions
Induces CYP450 3A4 in vitro; limited data exist; no significant interactions shown in single dose studies
with midazolam and oral contraceptives
Contraindications
Documented hypersensitivity to rifaximin or rifamycin antimicrobial agents (eg, rifampin)
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
May promote intestinal bacterial overgrowth and cause superinfection; discontinue if diarrhea persists
more than 24-48 h or worsens; seek immediate medical care if fever and/or bloody stools emerge
(tablets not effective); not effective for travelers' diarrhea due to suspected pathogens other than E
coli; postmarketing reports include allergic dermatitis, rash, angioneurotic edema, urticaria, and
pruritus
Vaccines
These agents elicit active immunization to increase resistance to infection. Vaccines consist of
microorganisms or cellular components, which act as antigens. Administration of the vaccine stimulates
the production of antibodies with specific protective properties.

Rotavirus vaccine (RotaTeq, Rotarix)

Currently, 2 PO administered live-virus vaccines are marketed in the United States. Both are indicated
to prevent rotavirus gastroenteritis, a major cause of severe diarrhea in infants.
RotaTeq is a pentavalent vaccine that contains 5 live reassortant rotaviruses and is administered as a
3-dose regimen against G1, G2, G3, and G4 serotypes, the 4 most common rotavirus group A
serotypes. It also contains attachment protein P1A (genotype P[8]).
Rotarix protects against rotavirus gastroenteritis caused by G1, G3, G4, and G9 strains and is
administered as a 2-dose series in infants aged 6-24 wk.
Clinical trials found that the vaccines prevented 74-78% of all rotavirus gastroenteritis cases, nearly all
severe rotavirus gastroenteritis cases, and nearly all hospitalizations.
Dosing
Adult
Not indicated
Pediatric
<6 weeks: Not established
RotaTeq
6-12 weeks: 2 mL PO as a single dose, followed by 2 additional doses at 4- to 10-wk intervals; do not
administer after age 32 wk
Rotarix
6 weeks: 1 mL PO as a single dose; administer a second dose after an interval of at least 4 wk and
before 24 wk of age
Interactions
Immunosuppressive therapies (eg, irradiation, antimetabolites, alkylating agents, cytotoxic drugs, high-
dose corticosteroids) may decrease immune response
Contraindications
Documented hypersensitivity; uncorrected congenital GI malformation that would predispose to
intussusception
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions
Common adverse effects include diarrhea, vomiting, otitis media, inflamed nasal passages, and
bronchospasm; refrigerate and protect from light; handle and discard empty tube according to
biological waste procedures; previously marketed rotavirus vaccine (RotaShield) was associated with
intussusception; however, RotaTeq did not show an increased risk compared with placebo in clinical
trials (monitor for signs of intestinal blockage), and Rotarix did not show an increase in intussusception
in 31,673 infants compared with 31,552 infants who received placebo; do not mix in same syringe with
other vaccines or solutions; febrile illness may be reason for delaying use except when, in the opinion
of the physician, withholding the vaccine entails a greater risk; low-grade fever (<100.5°F [38.1°C])
itself and mild upper respiratory infection do not preclude vaccination
Follow-up
Further Inpatient Care
• Admit neonates or young infants with moderate dehydration, suspected infection with
enterohemorrhagic E coli, or bloody diarrhea.
• Oral rehydration therapy (ORT) is the universally recommended form of treatment, proven to be
successful even in children who vomit or have mild-to-moderate dehydration. Admit a child with
severe dehydration. Also, ORT requires vigilance. If the caregiver cannot comply with protocol,
consider admission.
Further Outpatient Care
• Follow-up care depends on the severity of diarrhea and the child's age.
• Uncomplicated diarrhea in a school-aged child may not require follow-up care if the caregiver is
reliable and has quick access to a physician.
• Closely monitor young children to ensure that complications do not occur.
• Closely monitor children who require labor-intensive ORT.
• Neonates require strict follow-up care within a few days of illness to ensure that malabsorption
and dehydration do not occur.
Deterrence/Prevention
• Vaccines are indicated for persons with high risk of exposure to some pathogens.
• In February 2006, the United States Food and Drug Administration (FDA) approved an oral
vaccine for rotavirus (RotaTeq). It is currently the only vaccine approved in the United States for
prevention of rotavirus gastroenteritis as of the date of this publication. On February 21, 2006,
the AAP and the Advisory Committee on Immunization Practices (ACIP) recommended RotaTeq
to be part of regularly scheduled childhood immunizations. RotaTeq is administered in a 3-dose
series starting between age 6-12 weeks and completing before 32 weeks. An older rotavirus
vaccine (RotaShield) was associated with an increased incidence of intussusception and is no
longer on the market, but RotaTeq did not show an increased risk compared with placebo in
clinical trials.
• In April 2008, the FDA approved Rotarix, another oral vaccine, for prevention of rotavirus
gastroenteritis. The current recommendation is to administer 2 separate doses of Rotarix to
patients aged 6-24 weeks. Rotarix was efficacious in a large study, which reported that Rotarix
protected patients with severe rotavirus gastroenteritis and decreased the rate of severe
diarrhea or gastroenteritis of any cause.[5 ]
• A study that involved over 63,000 patients who received Rotarix or placebo at age 2 months and
at age 4 months reported a decreased risk of intussusception in patients who received Rotarix.
[5 ]
The intussusception data was determined over a 31-day observation period (inpatient or
outpatient) after each dose of the Rotarix vaccine; this also included a 100-day surveillance
period for all serious adverse events. Although more patients who received Rotarix were
observed to have seizures or pneumonia-related deaths, this link has not been directly
established to Rotarix. In addition, the FDA is requiring the Rotarix manufacturer to report data
on postmarketing safety in a study that involves over 40,000 patients.
 • The Salmonella typhi vaccine is recommended for travelers to countries with a high risk of this
infection, persons with intimate exposure to a documented typhoid fever carrier, and workers
with frequent exposure to this bacteria. Live-attenuated, killed whole-cell, and capsular
polysaccharide vaccines are available.
• The Vibrio species vaccine is available but only protects 50% of immunized persons for 3-6
months. It is not indicated for use.
Complications
• Common complications include the following:
o Aeromonas caviae - Intussusception, gram-negative sepsis, hemolytic-uremic syndrome
(HUS)
o Campylobacter species -Bacteremia, meningitis, cholecystitis, urinary tract infection,
pancreatitis, Reiter syndrome (RS)
o C difficile - Chronic diarrhea
o C perfringens serotype C - Enteritis necroticans
o Enterohemorrhagic E coli - Hemorrhagic colitis
o Enterohemorrhagic E coli O157:H7 - HUS
o Plesiomonas species - Septicemia
o Salmonella species - Seizures, HUS, perforation, RS
o Vibrio species - Rapid dehydration
o Y enterocolitica - Appendicitis, perforation, intussusception, peritonitis, toxic megacolon,
cholangitis, bacteremia, RS
o Rotavirus - Isotonic dehydration, carbohydrate intolerance
o Giardia species - Chronic fat malabsorption
o Cryptosporidium species - Chronic diarrhea
o Entamoeba species - Colonic perforation, liver abscess
• Enteric fever is caused by S typhi. This syndrome has an insidious onset of malaise, fever,
abdominal pain, and bradycardia. Diarrhea and rash (rose spots) appear after 1 week of
symptoms. Bacteria may have disseminated at that time, and treatment is required to prevent
systemic complications such as hepatitis, myocarditis, cholecystitis, or GI bleeding.
• HUS is caused by damage to vascular endothelial cells by verotoxin (released by
enterohemorrhagic E coli and by Shigella organisms). Thrombocytopenia, microangiopathic
hemolytic anemia, and acute renal failure characterize HUS. Symptoms usually develop one
week after onset of diarrhea, when the organism may be absent.
• RS can complicate acute infections and is characterized by arthritis, urethritis, conjunctivitis,
and mucocutaneous lesions. Individuals with RS usually do not demonstrate all features.
• Carrier states are observed after some bacterial infections.
o After diarrhea caused by Salmonella organisms, 1-4% of individuals with nontyphoid and
enteric fever infections become carriers. The carrier stage for Salmonella organisms is
more likely for females, infants, and individuals with biliary tract disease.
o Asymptomatic C difficile carriage may be observed in as many as 20% of hospitalized
patients receiving antibiotics and in 50% of infants.
o Rotavirus is excreted asymptomatically in feces of children who were previously infected,
typically for as long as 1-2 weeks.
Prognosis
• In developed countries, with proper management, prognosis is very good.
• Death is caused predominantly by dehydration and secondary malnutrition from a protracted
course. Severe dehydration must be managed with parenteral fluids. Once malnutrition from
secondary malabsorption begins, prognosis turns grim unless the patient is hospitalized and
supplemental parenteral nutrition is started. Neonates and young infants are at particular risk of
dehydration, malnutrition, and malabsorption syndromes.
• Even though the mortality rate is low in developed countries, children can die from
complications; however, prognosis for children in countries without modern medical care and
children with comorbid conditions is more guarded.
Patient Education
• Education is most important for prevention and treatment.
• Proper ORT prevents dehydration, and early refeeding speeds recovery of intestinal mucosa.
• With caregiver, emphasize proper hygiene and food preparation practices to prevent future
infections and spread.
• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine
Center. Also, see eMedicine's patient education articles Irritable Bowel Syndrome, Inflammatory
Bowel Disease, and Diarrhea.