Therapeutic Targets
- Rehydration (fluid balance) and electrolyte replacement (compensation for a loss of electrolytes/blood salts).
- Elimination of pathogens
- Avoidance of complications
Note: 57% of children with acute gastroenteritis with rotavirus under 15 years of age are hospitalized. An assessment of the severity of dehydration should always be made and, if necessary, be the reason for hospitalization.
Therapy Recommendations
- All forms of gastroenteritis
- Symptomatic therapy including fluid replacement – oral rehydration for signs of dehydration (fluid deficiency; >3% weight loss): administration of oral rehydration solutions (ORL), which should be hypotonic, between meals (“tea breaks”) for mild to moderate dehydration; also inpatient intravenous rehydration therapy if necessary (e.g., for shock, severe dehydration)
- If necessary, balance the electrolytes (blood salts) by means of a glucose-based electrolyte solution (osmolarity 245 mosm/l; glucose 13.5 g/l; sodium chloride 2.6 g/l; potassium chloride 1.5 g/l and sodium citrate 2.9 g/l)
- In uncomplicated disease, if necessary, short-term use of motility inhibitors (drugs that inhibit the motility of the intestine; eg, loperamide (opioid); note contraindications (contraindications), see below).
- Viral gastroenteritis: causal antiviral therapy is not currently available for any of the viral pathogens mentioned.
- Bacterial gastroenteritis: depending on the underlying disorder, antibiotics (see below) may need to be given. Their use should be thoroughly considered, as antibiotics are often themselves the cause of diarrhea. (see below “Empirical Therapy“).
- Mild to moderate enteritis: no antibiosis (antibiotic therapy) required. The same applies to uncomplicated traveler’s diarrhea.
- In the currently spreading infections with EHEC (enterohemorrhagic Escherichia coli; E. coli strains of serotype O157:H7), the use of antibiotics is discussed; see also under: Guideline of DEGAM (German Society for General Practice and Family Medicine e. V.): see under “EHEC/HUS (S1 treatment recommendation)”.
- Severe bacterial enteritis with fever (> 38.5 °C) and bloody diarrhea (diarrhea): antibiotic therapy indicated; fluoroquinolones (eg, ciprofloxacin) are suitable.
- In immunosuppression (drug or underlying disease), systemic antimicrobial therapy is also indicated.
- In gastroenteritic course of salmonellosis (Salmonella enteritis), antimicrobial therapy – suitable are 3rd generation cephalosporins (eg, ceftriaxone), co-trimoxazole, ampicillin, fluoroquinolones (ciprofloxacin) – should be considered only in the following constellations because of possible complications:
- Bacteremia and signs of systemic infection [should].
- Diseases in the first year of life
- Older people
- Congenital (congenital)/acquired immunodeficiencies [should be]
- Known abnormalities of heart valves or vessels.
- Hemodialysis [should]
- Patients with vascular prostheses, vascular aneurysms or implants [can][Annual Conference of the DGVS “Leading symptom diarrhea”, Hamburg, September 22, 2016].
See also under typhoid abdominalis or paratyphoid fever, if applicable.
- Shigellosis: Antibiosis (high infectivity); suitable are: Ciprofloxacin and Levofloxacin (quinolones), trimethoprim-sulfamethoxazole, azithromycin (macrolides), doxycycline (tetracycline) and ampicillin (aminopenicillins); resistance testing required!
- Hemolytic uremic syndrome (HUS): diuretic (diuretic) therapy indicated; plasmapheresis or hemodialysis may be required.
- Pseudomembranous colitis: due toantibiotic therapy see below the disease of the same name.
- Traveler’s diarrhea (traveler’s diarrhea; “curse of Pharaoh”): antibiotic therapy is not required in most cases.
- in acute uncomplicated traveler’s diarrhea (90% of cases), the infection runs self-limiting: symptomatic therapy with
- Substitution of fluid, electrolytes and glucose [most dangerous complication of traveler’s diarrhea is acute renal failure due to fluid deficiency!]
- Secretion inhibitor racecadotril
- If necessary, antiemetic (medication designed to suppress nausea and vomiting) metoclopramide.
- In acute complicated traveler’s diarrhea (e.g., bloody-mucous admixtures in the stool (dysentery) as well as fever) antibiotic therapy; if a specific pathogen is present see empirical therapy if necessary emergency medication with rifaximin (broad-spectrum antibiotic; rifaximin is practically not absorbed, < 1 %).
- Note: In traveler’s diarrhea, opioid derivatives such as loperamide (see below) should not be given to infants and young children under two years of age because of numerous contraindications (contraindications).
- in acute uncomplicated traveler’s diarrhea (90% of cases), the infection runs self-limiting: symptomatic therapy with
- See also under “Other therapy”.
Therapy recommendations for infectious gastroenteritis in infancy and childhood.
- Antiemetics (medications for nausea and vomiting) should not be administered for therapy of acute infectious gastroenteritis because of possible side effects.
- Antibiotic therapy is not recommended in patients with acute watery or bloody diarrhea who are otherwise healthy and at least 3 months of age.
Empiric therapy (for an overview; for details, see the relevant disease).
| Pathogen | Agents |
| Campylobacter jejuni(most common bacterial pathogen) | Antibiotics should usually be avoided!Erythromycin (first-line agent)Levofloxacin (note: increasing development of resistance) |
| E. coli 0157:H7 | As a rule, antibiosis should be avoided! |
| Listeria monocytogenes | Ampicillin, gentamicin |
| Salmonellosis or salmonella enteritis(Salmonella enteritidis, Salmonella typhimurium and others). | 3rd generation cephalosporins (e.g., ceftriaxone), co-trimoxazole, ampicillin, fluoroquinolones (ciprofloxacin), azithromycinBeware: Set indication restrictively (see above for which constellations antibiotic therapy can be considered). |
| S. typhi/S. paratyphi | CiprofloxacinCeftriaxone |
| Shigella | Ciprofloxacin and levofloxacin (quinolones), trimethoprim-sulfamethoxazole, azithromycin (macrolides), doxycycline (tetracycline), and ampicillin (aminopenicillins)Note: resistance testing required! |
| Vibrio cholerae | Ciprofloxacin(alternatively doxycycline) |
| Yersinia enterocolitica | As a rule, antibiotics should be avoided!Ciprofloxacin (first-line agent)Ceftriaxone, doxycycline |
Contraindications to loperamide include (Cave! Occurrence of toxic megacolon/life-threatening complication of colitis (inflammation of the bowel) with dilatation (enlargement) greater than 6 cm and systemic septic-toxic effect):
- Ileus (intestinal obstruction)
- Diarrhea with fever
- Diarrhea with blood
- Acute ulcerative colitis (inflammatory bowel disease).
- Pseudomembranous colitis (Clostridium difficile infection).
- Young children (< 2. LJ)
Further notes
- AkdÄ Drug Safety Mail | 19-2016: The United States Food and Drug Administration (FDA) currently warns of serious cardiac events / cardiac arrhythmias when taking loperamide in higher doses than recommended: FDA Safety Announcement, 07/06/2016In cases of cardiac events not otherwise explained, such as QT prolongation, torsades de pointes, other ventricular arrhythmias, syncope (brief loss of consciousness), or cardiac arrest, loperamide use should be considered as a possible cause. Patients should be advised of proper dosing.
- Detection of Candida in stool samples is not an indication for antifungal therapy (German Society of Infectious Diseases).
Further therapy
- Irritable bowel syndrome after enteritis: probiotics can be tried in children, especially in postenteritis genesis of IBS or predominant diarrhea.[Level of evidence B, strength of recommendation ↑, consensus]
