CASE

A.G.E. is a 14 month old female who was brought in

at the ER with her mother because of watery stool.
History started 2 days prior to consult when px
developed intermittent fever (Tmax 38.9c) associated with
watery diarrhea and vomiting for >5 episodes. Medication
given was Paracetamol and no consult done.
1 day PTC when fever, LBM and vomiting persisted
but px was also noted to have decreasing appetite. Still no
consult done.
On day of consult, symptoms persisted and she was
now unable to tolerate oral intake hence brought to ER.
WHAT WAS THE
CLINICAL
PRESENTATION?
 DIARRHEA
 Passage of 3 or more loose or liquid stools per day;
 Or more frequently than is normal for individual.

3 CLINICAL TYPES OF DIARRHEA:

 1) ACUTE WATERY DIARRHEA – lasts several hours to days

 2) ACUTE BLOODY DIARRHEA – also called dysentery

 3) Persistent diarrhea – lasts 14 days or longer

 PATIENT WITH ACUTE DIARRHEA

HISTORY

PE

Risk Factors Present

Bloody Diarrhea
Severe Diarrhea (>5/24hrs)
Age <6months
Immunocompromised
Exposure To Bloody Or Bacterial Diarrhea

YES NO
 PATIENT WITH ACUTE DIARRHEA

LABS:
- Stool Culture (E. coli
O157:H7, C. dificile
assay, Giardia,
Assess degree of
Cryptosporidia)
dehydration
- Fecal WBC

CONSIDER:
-Fecal Occult Blood
- Blood Culture
- Urine Culture
- AXR

Treatment options based

on identified organisms
 LABORATORY WORK-UP
Complete Blood Count
Stool Examination Not necessary for appropriate management
Indication:
-Laboratory confirmation of amoebiasis and
giardiasis
-Bloody diarrhea
Stool Culture Recommended if:
-Unresponsive to conventional fluid and
nutritional therapy
-Cholera is suspected
-Presents with bloody diarrhea
-Outbreak is suspected
-Sepsis is suspected
Blood Culture Do blood culture when sepsis is suspected
Electrolyte -If with evidence of dehydration
-If renal insufficiency is suspected
-If electrolyte imbalance is suspected
-If purging rate is high
 PATIENT WITH ACUTE DIARRHEA

Assess degree of dehydration

SEVERE SOME NO

Two of the ff signs and

symptoms: Two of the ff signs and
- Abnormally sleepy symptoms:
or difficult to - Restless or irritable
Not enough signs to
awaken - Sunken eyes
classify as moderate or
- Sunken eyes - Drinks eagerly,
severe
- Not able to drink or thirsty
drink poorly - Skin pinch goes back
- Skin pinch goes slowly
back very slowly
 PATIENT WITH ACUTE DIARRHEA

Treatment options based on identified

organisms

Shigella Cholera Amebiasis Giardiasis

FIRST LINE:
FIRST LINE:
TETRACYCLINE/ FIRST LINE: FIRST LINE:
CIPROFLOXACI
DOXYCYCLINE METRONIDAZOLE METRONIDAZOLE
N
Pediatric Dose: Pediatric Dose: Pediatric Dose:
Pediatric Dose:
12.5mg/kg/dose 30mg/kg/day (5- 15mg/kg/day (5-
25mkday BID (3-5
QID; 10 days) 10 days);
days);
Adult Dose: Adult Dose: Adult Dose:
Adult Dose:
Tetra: 500mg cap 750mg TID x 5-10 250mg TID x 5
500mg BID x 3
QID days days
days
Doxy: 300mg OD
WHAT WOULD YOU
LOOK FOR?
 PATIENT WITH ACUTE DIARRHEA

Assess degree of dehydration

SEVERE SOME NO

If with NO other
Two of the ff signs and
SEVERE CLASS’N then
symptoms:
give FLUID
- Restless or irritable
MANAGEMENT; Not enough signs to
- Sunken eyes
If WITH classify as moderate or
- Drinks eagerly,
PNEUMONIA, severe
thirsty
MALARIA, DENGUE
- Skin pinch goes back
& MALNUTRITION
slowly
then ------
 ANTIBACTERIAL THERAPY FOR
PATIENTS WITH SHIGELLA
ADULTS CHILDREN
AGENT DOSAGE AGENT DOSAGE
CIPROFLOXACIN 500 mg BID x 3 25 mkd Q12 x 3-5 days
days

AZITHROMYCIN 500mg OD x 3 10mkd single dose x 3 days

days

LEVOFLOXACIN 500mg OD x 3 CEFTRIAXONE 50mg/kg IV OD

days (max 2gm/day) x
5 days

CEFIXIME 8mkd PO BID x 5

days
 ANTIBACTERIAL THERAPY FOR
PATIENTS WITH CHOLERA
ADULTS CHILDREN
TETRACYCLINE 500mg QID for 3 days 50mkd QID x 3 days
DOXYCYCLINE 300mg single dose Not evaluated

FURAZOLIDONE 100mg QID x 3 days 5mkd QID for 3 days;

7mg/kg as OD
COTRIMOXAZOLE 160mg of 8mg of Trimethoprim/40mg of
Trimethoprim/800mg of Sulfamethoxazole BID for 3
Sulfamethoxazole BID for 3 days
days
NORFLOXACIN 400mg BID for 3 days 20mg/kg OD

CIPROFLOXACIN 1gm as single dose 20mg/kg OD

AZITHROMYCIN 1gm as single dose 20mg/kg as single dose

 TREATMENT FOR
AMOEBIASIS
DRUG PEDIATRIC DOSE ADULT DOSE
METRONIDAZOLE 30mkd TID x 5-10 days 750mg TID x 5-10 days
DILOXANIDE 20mkd TID x 10 days 500mg TID x 10 days
FUROATE
DEHYDROEMETINE 1-1.5mkd IM OD (max 90mg/day for 5 days
of 90mg/day) for 5 days
if severe
 TREATMENT FOR
GIARDIASIS
DRUG PEDIATRIC DOSE ADULT DOSE
METRONIDAZOLE 15mkd TID x 5-10 days 250mg TID x 5 days
TINIDAZOLE 50mg/kg/day OD 2gm as single dose