eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Gastroenteritis: Treatment & Medication
Updated: Jan 5, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
The American Academy of Pediatrics (AAP) states, "oral rehydration therapy is the preferred treatment of fluid and electrolytes lost by diarrhea in children with mild-to-moderate dehydration."2 In addition, both the AAP and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recommend rapid rehydration over 3-4 hours.2,3 A useful method is to administer 100 mL/kg/d for the first 10 kg of body weight (BW), 50 mL/kg for the next 10 kg BW, and 20 mL/kg for each additional kg BW.
The latest CDC recommendations for managing acute gastroenteritis in children can be viewed online at Managing Acute Gastroenteritis Among Children.4
- Oral rehydration therapy in the home environment
- Several oral rehydration solutions (ORSs) and pediatric maintenance solutions are available commercially (eg, Pedialyte, Rehydralyte, Kaolectrolyte, CeraLyte, Infalyte, Equalyte).
- A general guideline is to provide 4-8 oz for every episode of loose or watery stools until the diarrhea resolves.
- These fluids are not recommended for rehydration: tea, juices, pop, Kool-Aid, Gatorade (or similar sport drinks), boiled rice water, or boiled skim milk.
- Rehydration therapy in healthcare settings
- Oral rehydration is possible in a doctor's office with available space for at least 4 hours monitoring, adequately trained staff, and adequate mechanisms for billing this service. Intravenous rehydration also is feasible in these settings for mildly dehydrated patients who do not tolerate oral rehydration.
- Provide rapid intravenous rehydration for patients with the following conditions:
- Severe dehydration with cardiovascular involvement (ie, hypotension or shock)
- Failure of oral rehydration because of persistent vomiting
- High stool output (ie, usually >10 mL/kg BW/h)
- Monosaccharide malabsorption, evidenced by the presence of glucose or reducing substances in the stool and a significant increase in the stool volume following administration of the ORS
- Cerebral edema is the most serious potential consequence of rapidly infusing hypotonic fluids in a patient with hypernatremic dehydration.
- Medications
- Loperamide, opiates, opiate-and-atropine combination drugs, anticholinergic drugs, and absorbents are not recommended to treat diarrhea in children. No evidence exists that these are effective, and use may lead to possible adverse events.
- Similarly, routine use of bismuth subsalicylate and lactobacillus-containing compounds is not recommended.
- Most authorities do not recommend routine antiemetic use for children. Clinical evidence is currently insufficient to justify the use of ondansetron or metoclopramide in children with acute viral gastroenteritis.
- Although antibiotic treatment clearly shortens the clinical illness and duration of pathogen excretion in dysentery caused by Shigella species, routine antibiotic use provides no clear advantage to treat gastroenteritis caused by Campylobacter jejuni, Yersinia enterocolitica, E coli, and Salmonella species.
- Antibiotic administration may be considered for very young patients with Salmonella- caused gastroenteritis, for patients who are immunocompromised, and for patients who are systemically ill.
- Evidence suggests that antibiotic treatment of enterohemorrhagic E coli infection may increase the risk for developing hemolytic uremic syndrome.
- Rifaximin has excellent antibacterial activity and was approved in 2004 for the treatment for traveler's diarrhea caused by noninvasive strains of E coli.
Diet
- Rapidly reintroducing normal feeding is the optimal rehydration method for children who are mildly to moderately dehydrated.
- For infants, the AAP, ESPGHAN, and other groups currently recommend full-strength formula. The recommended rehydration method for breastfed infants is to continue to receive mother's milk.
- For older children, the usual advice is to eat bananas, rice cereals, applesauce, and toast (ie, BRAT diet). Also on the recommended list are complex carbohydrates (eg, rice, wheat, bread, cereals), lean meats, yogurt, fruits, and vegetables.
Medication
Antibiotics
In cases of Shigella enteritis, antibiotic treatment provides more rapid resolution of symptoms and faster fecal shedding of the organism. Trimethoprim-sulfamethoxazole (TMP-SMZ) is the drug of choice. In uncomplicated enteritis caused by nontyphoidal Salmonella species, antibiotics have no beneficial effect and may prolong the carrier state. The role of antimicrobials to treat enteritis caused by Campylobacter species, Y enterocolitica, and E coli remains controversial. Metronidazole is the recommended medication for G lamblia.
Sulfamethoxazole and Trimethoprim (Bactrim, Cotrim, Septra)
An antibacterial combination that may be used to treat enteritis caused by susceptible strains of Shigella flexneri and Shigella sonnei when antibacterial therapy is indicated.
Adult
160 mg (based on trimethoprim component)/800 mg (based on sulfamethoxazole component) PO bid for 5 d (ie, 1 double-strength tab bid)
Pediatric
8 mg/kg/d (based on trimethoprim component) PO divided bid for 5 d
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; 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
Documented hypersensitivity; documented megaloblastic anemia from folate deficiency; pregnant and nursing mothers; infants <2 mo; marked hepatic damage and renal insufficiency
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; obtain CBC counts regularly when used for more than 5 d; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; caution in folate deficiency (eg, patients with chronic alcoholism, older patients, patients receiving anticonvulsant therapy, patients with malabsorption syndrome); hemolysis may occur in patients with G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in patients with renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation
Metronidazole (Flagyl)
Appears to be absorbed into cells where intermediate-metabolized compounds are formed that bind DNA and inhibit protein synthesis.
Adult
250 mg PO tid for 5 d
Pediatric
5 mg/kg PO tid for 5 d
Cimetidine may increase toxicity; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with PO-ingested ethanol
Documented hypersensitivity; first trimester of pregnancy
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Contraindicated in pregnancy during first trimester; adjust dose in patients with hepatic disease; monitor for seizures and development of peripheral neuropathy
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.
Adult
200 mg PO tid
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Induces CYP450 3A4 in vitro; limited data available; no significant interactions shown in single dose studies with midazolam and PO contraceptives
Documented hypersensitivity to rifaximin or rifamycin antimicrobial agents (eg, rifampin)
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 orally administered live-virus vaccine are available.
RotaTeq contains 5 live human-bovine 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 contains an attenuated human strain and is effective against rotavirus G1, G3, G4, and G9 strains and is administered as a 2-dose series in infants aged 6-24 wk.
Adult
Not indicated
Pediatric
RotaTeq:
First dose: 2 mL PO administered between age 6-12 wk
Second and third doses: 2 mL PO administered at 4-10 wk intervals; complete third dose by age 32 wk
Rotarix:
First dose: 1 mL PO administered at age 6 wk
Second dose: 1 mL PO at least 4 wk after the first dose and before age 24 wk
Immunosuppressive therapies (eg, irradiation, antimetabolites, alkylating agents, cytotoxic drugs, high-dose corticosteroids) may decrease the immune response
RotaTeq:
In clinical trials, RotaTeq was administered concomitantly with DTaP, IPV, Hib, hepatitis B vaccine, and pneumococcal conjugate vaccine; no evidence of reduced antibody responses to the vaccines that were concomitantly administered with RotaTeq
Rotarix:
In 484 infants, no evidence of interference in the immune responses to any of the antigens when Pediarix and a US-licensed Hib conjugate vaccine were coadministered with Rotarix as compared with separate administration of Rotarix
RotaTeq: Documented hypersensitivity
Rotarix: History of uncorrected congenital malformation of the GI tract (such as Meckel diverticulum) that would predispose the infant for intussusception
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; do not mix in same syringe with other vaccines or solutions
Intussusception
Previously marketed rotavirus vaccine (RotaShield) was associated with intussusception and removed from the market
RotaTeq did not show an increased risk compared with placebo in clinical trials (monitor for signs of intestinal blockage); in the Rotavirus Efficacy and Safety Trial [REST] (n=69,625), the data did not show an increased risk of intussusception for RotaTeq when compared with placebo; in postmarketing experience, cases of intussusception have been reported in temporal association with RotaTeq
Rotarix did not show an increase in intussusception when evaluated in a safety study (including 63,225 infants) conducted in Latin America and Finland; 31,673 infants received Rotarix compared with 31,552 infants who received placebo; no increased risk of intussusception was observed in this clinical trial
Immunocompromised patients
No safety or efficacy data are available for either vaccine regarding administration to infants who may be immunocompromised because of coexisting disease, neoplasia, or infection, or who have received immunosuppressive drugs or biologicals
History of GI disorders
No safety or efficacy data are available for administration to infants with history of or chronic GI disorders including active acute GI illness, chronic diarrhea resulting in failure to thrive, congenital abdominal disorders, abdominal surgery, or intussusception
Viral shedding and transmission
The live vaccine virus may be transmitted to nonvaccinated contacts; potential for viral transmission following vaccination should be weighed against the possibility of acquiring and transmitting natural rotavirus; caution is advised when considering whether to administer rotavirus vaccine to individuals with immunodeficient close contacts
RotaTeq: Shedding was evaluated among a subset of subjects in REST 4-6 d after each dose and among all subjects who submitted a stool antigen rotavirus positive sample at any time; RotaTeq was shed in the stools of 32 of 360 (8.9%; 95% CI, 6.2%, 12.3%) vaccine recipients tested after dose 1; 0 of 249 (0.0%; 95% CI, 0.0%, 1.5%) vaccine recipients tested after dose 2; and in 1 of 385 (0.3%, 95% CI, <0.1%, 1.4%) vaccine recipients after dose 3; in phase 3 studies, shedding was observed as early as day 1 and as late as day 15 after a dose; transmission was not evaluated
Rotarix: Rotavirus shedding in stool occurs after vaccination with peak excretion occurring around day 7 after dose 1; live rotavirus shedding was evaluated in 2 studies among a subset of infants at day 7 after dose 1; in these studies, estimated percentages of recipients of Rotarix who shed live rotavirus were 25.6% (95% CI, 10.2, 41.1) and 26.5% (95% CI, 15.5, 37.5), respectively; transmission of virus was not evaluated
More on Gastroenteritis |
| Overview: Gastroenteritis |
| Differential Diagnoses & Workup: Gastroenteritis |
 Treatment & Medication: Gastroenteritis |
| Follow-up: Gastroenteritis |
| References |
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References
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US Food and Drug Administration. Rotarix Product Information. FDA.gov. Available at http://www.fda.gov/cber/label/rotarixLB.pdf. Accessed 11/27/2008.
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Further Reading
Keywords
gastroenteritis, enterogastritis, viral diarrhea, prematurity, dehydration, Shigella, enterohemorrhagic Escherichia coli, electrolyte imbalance, hyponatremia, hypernatremia, hypernatremic dehydration, rotavirus, dehydrating diarrhea, Norwalk virus, enteric adenovirus, calicivirus, sickle cell disease, Giardia lamblia, Cryptosporidium parvum, Cyclospora cayetanesis, Entamoeba coli, Endolimax nana, Iodamoeba butschlii, Blastocystis hominis, HIV, AIDS, cytomegalovirus
