Treatment of acute diarrhea flowchart.

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Treatment of Acute Diarrhea

Source: Goldman-Cecil Medicine, International Edition - Fig. 126-1: Approach to the diagnosis and treatment of acute diarrhea.

Step 1 - Assess for Dehydration (ALL patients)

Severity	Action
Mild to moderate	Oral rehydration solution (ORS)
Severe	IV hydration (lactated Ringer's or saline); admit to hospital, especially if elderly

Step 2 - Branch by Clinical Context

A. High-risk exposure (traveler, food outside home, daycare worker, water park, peripartum, sexually active):

Afebrile, watery diarrhea: Antimotility agent (e.g., loperamide 2 mg QID). If no improvement → workup (below)
Fever, bloody diarrhea, severe abdominal pain:
- Multiplex PCR for stool pathogens; culture if positive
- EIA for GDH antigen or toxin (if C. difficile suspected)
- Ova & parasites exam
- Then: Antibiotic + antimotility agent
- Report to public health; save blood/stool samples

B. Medications

Stop offending drug if possible
If currently on antibiotics: stool PCR for C. difficile
700 drugs cause diarrhea (metformin, SSRIs, PPIs, checkpoint inhibitors, laxatives, etc.)

C. Other causes

D. Immunosuppressed patients

Mild-moderate dehydration: ORS (Na⁺ 75 mmol/L, osmolarity 245 mmol/L reduced-osmolarity preferred in non-cholera). Infants/children: 50-100 mL/kg over 4-6 hrs. Adults: up to 1000 mL/hr.
Severe dehydration: IV lactated Ringer's or saline ± potassium + bicarbonate.
Continue ORS at a rate equaling stool loss + insensible losses until diarrhea ceases.

Drug	Dose	Notes
Loperamide	2 mg PO QID (max 16 mg/day)	Safe in acute/traveler's diarrhea; avoid in dysentery (bloody stool + high fever)
Bismuth subsalicylate	525 mg PO q30-60 min x 5 doses; repeat day 2	Safe, effective in bacterial diarrhea
Racecadotril	100 mg PO TID (adults); 1.5 mg/kg TID (children)	Enkephalinase inhibitor; antisecretory without paralyzing motility
Loperamide + simethicone	2 mg + 125 mg QID	Reduces cramps and duration of traveler's diarrhea

Opiates and anticholinergics are not recommended for invasive bacterial diarrhea.

Empiric (while awaiting cultures):

1st line: Fluoroquinolones - Ciprofloxacin 500 mg PO BID x 1-3 days, or Levofloxacin 500 mg PO daily x 1-3 days
2nd line: Trimethoprim-sulfamethoxazole 1 DS tablet PO BID x 5 days
If Campylobacter suspected: add Azithromycin 500 mg/day x 3 days
Traveler's diarrhea (Mexico): Rifaximin 200 mg TID or 400 mg BID x 3 days (not effective vs. Campylobacter/Shigella)
Resistant strains (Shigella, Campylobacter): Azithromycin 500 mg day 1, then 250 mg/day x 4 days

Specific indications:

Pathogen/Situation	Drug
Shigellosis	Fluoroquinolone or azithromycin
Cholera	Fluoroquinolone or doxycycline
C. difficile	Fidaxomicin 200 mg PO BID x 10 days (preferred over vancomycin to prevent recurrence); Vancomycin 125 mg PO QID x 10 days
Recurrent C. difficile	Fecal microbiota transplantation (90% resolution) > vancomycin (30%); or bezlotoxumab 10 mg/kg IV x 1 dose
Parasites (Giardia, Cryptosporidium)	Metronidazole or specific antiparasitic
E. coli O157:H7	No antibiotics (increases risk of HUS)
Viral diarrhea	No antibiotics

Mandatory antibiotic indications (regardless of pathogen):

Zinc 20 mg elemental PO daily: reduces recurrences in malnourished children
Probiotics: not beneficial in children with acute diarrhea; insufficient RCT data in adults
Anxiolytics (diazepam 2 mg PO BID-QID) and antiemetics (promethazine 12.5-25 mg PO) for symptom relief
Chemotherapy/radiation diarrhea: loperamide + NSAIDs (naproxen 250-500 mg BID); severe cases: octreotide up to 700 mcg/day SQ
Checkpoint inhibitor diarrhea: stop agent + glucocorticoids (0.5-2 mg/kg prednisone with 4-6 week taper)

Management by Patient Appearance (Sleisenger & Fordtran):

Patient Appearance	Action
Nontoxic	Symptomatic therapy + rehydration only
Toxic	Fluid/electrolyte repletion + CBC + metabolic panel + stool cultures/PCR/O&P/C. diff testing ± sigmoidoscopy/colonoscopy

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