A 5-year-old girl is brought to the clinic due to abdominal cramping and diarrhea. The diarrhea started 3 days ago and was initially watery but now contains visible mucus. The patient attends a small day care, where several other children have recently developed similar diarrhea. Temperature is 38 C (100.4 F), blood pressure is 100/62 mm Hg, and pulse is 98/min. On examination, the patient appears uncomfortable but appropriately answers questions and is interactive. The mouth is slightly dry. Heart and lung examinations are normal. The abdomen is diffusely tender to palpation without hepatosplenomegaly. A stool sample is positive for occult blood, and a stool culture is also obtained. The patient tolerates fluids that she receives in the office. In addition to encouraging increased fluid intake, which of the following is the most appropriate management of this patient?
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This patient with fever, abdominal cramping, and diarrhea most likely has acute gastroenteritis. The most common cause is viruses, but bacterial infection (eg, Salmonella, Shiga toxin–producing Escherichia coli [STEC]) should be suspected when the stool contains mucus and blood.
All patients with suspected bacterial gastroenteritis warrant stool studies (eg, multiplex PCR testing, culture) to confirm the pathogen in case treatment is required. However, well-appearing children with acute diarrhea, as in this patient, are managed with supportive care (eg, oral rehydration) and close follow-up only. Empiric antibiotics are not recommended for bloody diarrhea in children because they increase the risk for hemolytic uremic syndrome (HUS) if the causative pathogen is high-risk STEC (ie, E coli O157:H7); no or only low-grade fever (<38.5 C [101.3 F]) is typical with this infection, and the diagnosis should be considered in this patient (Choice C). In addition, those with mild disease (eg, mild dehydration) have limited benefit from antibiotic administration, and resistance can occur with unnecessary use.
Disease progression and culture results can help guide further management. Severe illness (eg, prolonged symptoms, hemodynamic instability) due to bacterial gastroenteritis caused by certain pathogens (eg, Salmonella) may require antibiotic therapy to decrease illness duration and severity. In addition, those with high-risk STEC often warrant hospitalization with aggressive fluid administration to decrease the risk of HUS.
(Choices A and B) Abdominal ultrasound and air contrast enema can diagnose and treat intussusception, which presents in children age 6 months to 3 years with episodic abdominal pain and bloody (currant jelly) stools; watery diarrhea is not typical. In addition, patients typically have no or only focal abdominal tenderness, not persistent cramping and diffuse tenderness, between painful episodes. This patient's history of sick contacts also makes an infectious cause more likely.
(Choice D) Bismuth subsalicylate is not generally recommended in children due to limited benefit and the risk of Reye syndrome and salicylate toxicity.
(Choice F) Loperamide, an antimotility drug, is not recommended in children due to its potential adverse effects (eg, paralytic ileus, toxic megacolon). Decreased intestinal motility can also prolong fecal shedding of some bacteria, and the risk of HUS is increased with its use in patients with STEC.
Educational objective:
Bacterial gastroenteritis should be suspected in a patient with bloody or mucoid diarrhea. Treatment is supportive, with close follow-up in well-appearing children. Empiric antibiotics are not recommended primarily due to the increased risk of hemolytic uremic syndrome associated with Shiga toxin–producing Escherichia coli.