CLINICAL

CASE
CSU JUNIOR INTERNS
Mangabat, Allison Mae
Mapalo, Karen Ruth
Marquez, Ricky Dann
Martinez, Pia Louise
Masa, Elton Dominic
Monzon, Mark Anthony
 GENERAL DATA CHIEF
COMPLAINT
PATIENT J.A.
Age: 3 years old FEVER
Gender: Female
Nationality: Filipino
Date of Birth: January 23, 2019
Place of Birth: Tuguegarao City
Religion: Jehovah’s witness
Admission: 1st Residence: Annafunan West, Tuguegarao City
Date of Admission:
March 09, 2022
Informant: Mother
Reliability: 95%
HISTORY OF PRESENT ILLNESS

3 days PTA
● on and off fever Tmax of 38.3C.
● Paracetamol 10mkd every 4 h
● No associated signs or symptoms
● No consult done

2 days PTA
● fever Tmax of 39C and still taking Paracetamol 10mkd every 4 h
● There is loss of appetite
● no consult was done
HISTORY OF PRESENT ILLNESS
1 day PTA

● Still with febrile episodes. Unrecalled Tmax

● Now with 3x episodes of loose watery stools
● Did not seek consult.

Few hours PTA

● still with on and off fever Tmax of 38.9C
● 1 episode of loose watery stools
● no vomiting episodes
● sought consult and was subsequently admitted.
 REVIEW OF SYSTEMS

CONSTITUTIONAL (+) fever, (+) weight loss, (-) chills, (-) fatigue

SKIN (-) itching, (-) pallor, (-) rashes, (-) lumps, (-) dryness, (-) color change, (-)
changes in nails

HAIR (-) baldness, (-) excess hair

HEAD (-) headache, (-) dizziness, (-) lightheadedness, (-) trauma, (-) syncope

EYES (-) pain, (-) lacrimation, (-) blurred vision

EARS (-) hearing problems, (-) earache, (-) tinnitus

NOSE & SINUSES (-) epistaxis, (-) nasal stuffiness, (-) itching

MOUTH/THROAT (-) dysphagia, (-) odynophagia, (-) sore throat, (-) mouth sores, (-)
toothache, (-) hoarseness
 REVIEW OF SYSTEMS

NECK (-) pain, (-) stiffness

RESPIRATORY (-) cough, (-) colds, (-) hemoptysis, (-) dyspnea

CARDIOVASCULAR (-) easy fatigability, (-) chest pain, (-) palpitations

GASTROINTESTINAL (+) loss of appetite, (+) diarrhea, (-) abdominal pain, (-)
vomiting, (-) nausea, (-) hematemesis, (-) hematochezia,
(-) constipation

RENAL (-) oliguria, (-) nocturia, (-) polyuria, (-) dysuria, (-) gross
hematuria

GENITALIA (-) pain, (-) itching, (-) swelling

REVIEW OF SYSTEMS
REVIEW OF SYSTEMS

MUSCULOSKELETAL (-) muscle pain, (-) joint pain, (-) muscle weakness,
(-) stiffness

NEUROLOGIC (-) numbness, (-) loss of consciousness, (-) tremors, (-)

seizures, (-) memory loss

HEMATOLOGIC (-) easy bruising

ENDOCRINE (-) excessive sweating, (-) polydipsia, (-) polyphagia,

(-) heat/cold intolerance

PSYCHIATRIC (-) hallucinations, (-) anxiety

 PAST MEDICAL HISTORY

Previous Hospitalizations -

Surgical Procedures Done -

Trauma -

Other Childhood Illnesses (asthma, -

heart disease, seizure)

Allergies -
 PRENATAL AND BIRTH HISTORY

Prenatal checkup 10x

Medications Iron, Folic Acid

Maternal illnesses -

Exposure (radiation, -
cigarette smoke,
alcoholic beverage)

Patient was born full term at 38 weeks AOG to a 39 year-old G2P2 (2002) mother,
cephalic, delivered via NSD at CVMC, assisted by a doctor.
Patient has a birth weight of 3.1kg, with good suck and cry and no fetomaternal
illnesses.
The patient was given Crede’s prophylaxis, vitamin K, and was vaccinated with
BCG and Hepa B.
 IMMUNIZATION HISTORY
VACCINE AT BIRTH 6 WKS 10 WKS 14 WKS 9 MOS 12 MOS

BCG ✔

Hep B ✔ ✔ ✔ ✔

DPT ✔ ✔ ✔

OPV ✔ ✔ ✔

Hib ✔ ✔ ✔

PCV ✔ ✔ ✔

Measles ✔

MMR ✔
 NUTRITIONAL HISTORY

Breastfeeding: Birth to 2 years old

Formula milk (Bear brand): 2 years old up to present

Complementary feeding (Cerelac): Started at 6 months

Table food: Started at 9 months

Present diet: fried chicken, fish with soup, tortang talong, soft drinks
 DEVELOPMENTAL HISTORY

GROSS MOTOR FINE MOTOR LANGUAGE PERSONAL-SOCIAL

1 MONTH Startled to sound

1.5 MONTHS Social smile

5 MONTHS Rolled over

6 MONTHS Held bottle

6 ½ MONTHS Babbles

7 ½ MONTHS Responds to name

11 MONTHS First words: “dada”

12 MONTHS Follows 1-step commands with

gestures

14 MONTHS Scribbled

16 MONTHS Walked independently

24 MONTHS Ran well

36 MONTHS Identifies action in pictures

Can say 3-word phrases and
responds to instructions
 FAMILY HISTORY

FATHER MOTHER
(46, tricycle driver) (42, housewife)
+ Hypertension -
- Diabetes -
- Tuberculosis -
- Cancer -
- Asthma -
- Heart disease -
 PERSONAL, SOCIAL & ENVIRONMENTAL HISTORY

● Youngest among 2 children

● Concrete bungalow house with 2 bedrooms and 1 comfort room with
toilet bowl
● Drinking water - water station
● Kitchen and bathroom water - faucet
● Garbage collected by garbage truck
● Sleeps 9 hours at night and with 1 hour afternoon nap
● COVID-19 history: no exposure to positive cases, no recent travel, never
had COVID
● COVID-19 vaccine: mother, father, elder sister with 2 doses of Pfizer
vaccine
 PHYSICAL EXAMINATION

General Patient is awake and conscious with an ongoing IVF on her

Survey right hand. She is irritable but obeys commands.

BP: 90/60 mmHg

Heart Rate: 118 bpm (increased)
Vital Signs
Temperature: 36.8oC, right axillary
Respiratory Rate: 23 cpm
SPO2: 98%

Height 80 cm (stunted)
Anthropometric
Weight 10 kg (underweight)
Measurements
BMI 15.63 kg/m2 (normal)
X stunted
X underweight
X normal
X normal
 PHYSICAL EXAMINATION

Fair complexion with no discoloration, scars, rashes and lesions. No

Skin
cyanosis, no jaundice, no pallor. Warm to touch, smooth, moist.

Normocephalic, atraumatic. With symmetrical facial features and

Head
movements noted. No tenderness and lumps noted.

Symmetrical. Conjunctiva is pink and sclera is white. Pupils are equally

Eyes
round and reactive to light.

Equal in size and appearance. No periauricular tag/pits, swelling,

Ears
redness, tenderness, discharge and hearing impairments.

Symmetric with no signs of deformity. Midline nasal septum. No sinus

Nose
tenderness, discharge, and lesion.

Throat (Mouth Dry lips and oral mucosa, no cyanosis; Uvula and tongue in midline,
And Pharynx) tonsils not enlarged; No noticeable lesions at the roof, floor, and palate.
 PHYSICAL EXAMINATION

Symmetric and no signs of deformity, lesions nor swelling. No

Neck lumps or nodules noted. No bruises, abrasion, vein distention and
palpable lymph nodes.
No obvious spine or chest deformities are noted. Symmetric chest
Chest And
expansion, no retractions, no tenderness upon palpation. No
Lungs
wheezes, rales, stridor, or crackles upon auscultation.
Tachycardic. No noticeable bulges, lesions, heaves by inspection
Heart of the precordium. No palpable thrills and friction rub. PMI is at
4th ICS left MCL. No murmur.
Globular. No discoloration, visible pulsations, mass nor lesions. No
Abdomen irregular contours and no scars noted. Hyperactive bowel
sounds. No tenderness and no hepatosplenomegaly on palpation.
No tremors, gross deformity, edema. Full and equal pulses.
Extremities
Capillary refill time <2 secs.
Genitalia Grossly female. No skin lesions. No discharge.
 PHYSICAL EXAMINATION

Neurologic GCS 15/15. No neurologic deficits.

Mental Patient is awake and irritable but obeys some commands. Speech was
State clear and normal in rate.
(I) Not assessed.
(II) Blinks eyes spontaneously; can see near and far objects both eyes.
(III, IV, VI) Intact EOM movement of both eyes, pupils reactive to light.
(V) Intact facial sensation.
Cranial
(VII) Facial symmetry.
Nerves
(VIII) No hearing difficulty.
(IX, X) Positive gag reflex.
(XI) Neck rotation.
(XII) Tongue is on midline.
Motor Good muscle bulk and tone.
Intact pinprick and light touch sensations on the upper and lower
Sensory
extremities
Meningeal
Negative Brudzinski’s sign. Negative Kernig’s sign.
signs
 SALIENT FEATURES

● 3 y/o, Female
● Fever, intermittent
● Loose watery stool
● Loss of appetite
● Water for cooking from faucet
● Weight loss
● Irritable
● HR: 118 bpm (tachycardic)
● Dry lips and oral mucosa
● Hyperactive bowel sounds
 Salmonellosis

RULE IN RULE OUT

Diarrhea (-) Bloody diarrhea

Fever (-) abdominal pain or cramps
Loss of appetite (-) colds and chill
Appearance of symptoms 12-96 hrs (-) headache
after exposure (-) nausea
(-) vomiting
 BACILLARY DYSENTERY (SHIGELLOSIS)

RULE IN RULE OUT

Diarrhea (-) Diarrhea characteristic: small

Fever volume mucoid diarrhea preceding
Tachycardia bloody diarrhea
Hyperactive bowel sounds (-) abdominal pain
(-) severe diffuse colicky
abdominal pain
(-) tenesmus
(-) abdominal tenderness
 GIARDIASIS

RULE IN RULE OUT

Diarrhea (-) greasy stools

Loss of appetite (-) headache
Weight loss (-) nausea
Water from faucet (-) vomiting
(-) bloating
(-) passing of gas
(-) abdominal pain
Course in
the Ward
 COURSE IN THE WARD
ADMISSION (Day 4 of Illness)

S O A P

(+) febrile episodes Temp: 36.5C (afebrile) Admit to Pedia Isolation Ward
(-) cough, colds HR: 140 bpm (tachycardic) Acute gastroenteritis with IVF: D5LRS 1L x 55 cc/hr
(-) vomiting RR: 23 bpm moderate dehydration Diet for age with SAP
(+) loose watery O2 sat: 97% Coronavirus Disease
stools Weight: 10 kg Suspect
Dx: CBC with PC, Na, K, Cl, ionized Ca,
Height: 80 cm urinalysis, Fecalysis, CXR APL, RT-PCR

Tx: Zinc sulfate syrup, 5ml OD

Paracetamol 100mg IV q4 for fever
Vol-vol replacement with PLRS for each
bout of loose stool

VS Q2 & Record
I & O Q shift and record
WOF untoward signs and symptoms
Refer
 COURSE IN THE WARD

CBC

Hgb 115 115-155 g/L

Hct 0.34 0.34-0.40

ELECTROLYTES
RBC 4.05 3.90-5.30
Na 135.20 135-145
PLT 225 150-400 mmol/L

WBC 13.3 5.5-15.5 K 3.63 3.5-5.5

mmol/L
Neutro 51.2 23.0-45.0
Cl 97.70 98-108
Lymph 40.2 35.0-65.0 mmol/L

Mono 8.3 2.0-8.0 iCa 1.19 1.10-1.40

mmol/L
 COURSE IN THE WARD

URINALYSIS URINALYSIS

Color Light Yellow Urobilinogen Normal

Transparency Hazy Nitrite Negative

pH 6.0 Leukocyte +

SG 1.025 RBC 7/HPF 0-2/HPF

Protein Negative WBC 5/HPF 0-3/HPF

Glucose Negative Bacteria 196/HPF 0-50/HPF

Ketones + Epit Cells 2/LPF 0-3/LPF

Blood Negative Hyaline Cast 3/LPF 0-3/LPF

Bilirubin Negative
COURSE IN THE WARD

FECALYSIS

Color Brown

Consistency Watery

WBC 1-3/HPF

RBC 1-2/HPF

Bacteria +++

Parasites NO
INTESTINAL
PARASITE
SEEN
 COURSE IN THE WARD
2nd Hospital Stay (5th Day Illness)

S O A P
(+) fever Temp: 37.5C (afebrile) Acute gastroenteritis with IVF: D5LRS 1L x 55 cc/hr
(-) cough, colds HR: 121 bpm (tachycardic) moderate dehydration Diet for age with SAP
(-) vomiting RR: 26 bpm No typhoid fever
(+) 2x loose O2 sat: 99% Dx: Follow up RT-PCR results of patient
watery stools and watcher
Fair appetite AS, PPC,
SCE, (-) retractions Tx: Zinc sulfate syrup, 5ml OD
AP, (-) murmur Paracetamol 100mg IV q4 for fever
Undistended, soft abdomen Vol-vol replacement with PLRS for each
Full and equal pulses both bout of loose stool
extremities
VS Q2 and record
I &O Q shift and record
WOF untoward signs and symptoms
refer
 COURSE IN THE WARD
2nd Hospital Stay at 7:30PM (5th Day Illness)

S O A P
Still febrile SCE, CBS, (-) retractions Acute gastroenteritis with For Transfer to Pedia ward
(-) cough, colds AP, (-) murmur moderate dehydration IVF: D5LRS 1L x 42 cc/hr
(-) vomiting soft abdomen, Normoactive No typhoid fever Diet for age with SAP
(-) loose watery bowel sounds
stools Full and equal pulses both Dx: Blood CS, Salmonella IgG/IgM
Last febrile extremities
episode at 6pm CRT <2 seconds Tx: Zinc sulfate syrup, 5ml OD
Tmax=39.0C Paracetamol 100mg IV q4 for fever >37.8C
No phlebitis Vol-vol replacement with PLRS for each
Np seizure bout of loose stool
Fair appetite
VS Q2 and record
I &O Q shift and record
WOF untoward signs and symptoms
refer
 COURSE IN THE WARD

SEROLOGY

Salmonella IgM/IgG POSITIVE

BLOOD CULTURE AND SENSITIVITY

NO GROWTH AFTER 24 HOURS OF INCUBATION

 COURSE IN THE WARD
3rd Hospital Stay (6th Day of Illness)

S O A P

(+) febrile episode Temp: 37.5C (afebrile) Acute gastroenteritis with IVF: D5LRS 1L x 42 cc/hr
(LFE: 10PM) HR: 121 bpm (tachycardic) moderate dehydration Diet for age with SAP
(-) cough, colds RR: 26 bpm
(-) vomiting O2 sat: 99% Dx: Blood CS, Salmonella IgG/IgM
(-) loose watery
Fair appetite Awake, irritable Tx: Start Ampicillin 300 mg/ IV every 6 hrs
No pallor Zinc sulfate syrup, 5ml OD
No sunken eyeballs Paracetamol 120mg IV q4 for temp 37.8C
Moist lips and mucosa
SCE, CBS VS Q4
AP, No murmur I&O Q shift
No abdominal pain, flat refer
Full pulses
 COURSE IN THE WARD
3rd Hospital Stay at 1PM (6th Day of Illness)

S O A P

(+) fever Temp: 39.2C (febrile) Acute gastroenteritis with IVF: D5LRS 1L x 41 cc/hr
(+) colds (runny HR: 156 bpm (tachycardic) moderate dehydration Diet for age with SAP
nose) RR: 20 bpm URTI
(-) cough O2 sat: 99% Tx:
(-) vomiting Zinc sulfate syrup, 5ml OD
(-) loose bowel Awake, irritable Paracetamol 100mg IV q4 for fever >37.9C
movement Moist lips and mucosa Cetirizine 5mg/5mL 2.5mL once a day at
Fair appetite SCE, CBS bedtime
AP, No murmur NaCl Nasal spray, 2 sprays each nostril
Soft abdomen twice a day
Full extremity pulses
VS Q4
I&O Q shift
refer
 COURSE IN THE WARD
4th day of Hospital Stay (7th Day of Illness)

S O A P

(+) febrile episode Temp: 37.7C Acute gastroenteritis with Diet for age with SAP
(-) loose bowel HR: 144 bpm moderate dehydration Heplock
movement RR: 40 bpm URTI
(-) cough O2 sat: 98% Dx:
(-) colds For urine GC/CS
Good appetite Awake
Moist lips and mucosa Tx:
SCE, CBS, (-) retractions Ampicillin D 1+1
AP, No murmur Zinc sulfate syrup, 5ml OD
Soft abdomen Paracetamol PRN
Full extremity pulses Cetirizine 5mg/5mL 2.5mL once a day at
bedtime

VS Q4
I&O Q shift
WOF untoward signs and symptoms
refer
 COURSE IN THE WARD
5th day of Hospital Stay (8th Day of Illness)

S O A P

Still with febrile Temp: 37.7C Acute gastroenteritis with Diet for age with SAP
episode (5PM - 40C; HR: 144 bpm moderate dehydration Heplock
7:30AM - 37.8C) RR: 40 bpm URTI
Good appetite O2 sat: 98% Dx:
No vomiting For CBC
No diarrhea Awake, active
No cough Ambulatory Tx:
No Pallor Ampicillin D 2
SCE, CBS Zinc sulfate syrup, 5ml OD
Ap, no murmur Paracetamol PRN
Globular, soft
No Phlebitis VS Q4
I&O Q shift
WOF untoward signs and symptoms

For CXR ApL

For Procalcitonin
Refer
 COURSE IN THE WARD

CBC

Hgb 116 115-155 g/L

Hct 0.36 0.34-0.40

RBC 4.27 3.90-5.30

PLT 433 150-400

WBC 14.6 5.5-15.5

Neutro 52.1 23.0-45.0

Lymph 36.5 35.0-65.0

Mono 7.9 2.0-8.0

FINAL IMPRESSION:

Acute Gastroenteritis with

Moderate signs of Dehydration
 Case
Discussion
Acute Gastroenteritis

● gastroenteritis - inflammation of the gastrointestinal tract,

most commonly the result of infections with bacterial, viral, or
parasitic pathogens.
● Many of these infections are foodborne illnesses
● diarrhea and vomiting - most common manifestations of
acute gastroenteritis
● can also be associated with systemic features such as
abdominal pain and fever.
Dysentery

● syndrome characterized by frequent small stools

containing visible blood, accompanied by fever,
tenesmus, and abdominal pain.

● distinguished from bloody diarrhea (larger volume bloody

stools with less systemic illness) because the etiologies
may differ.
DIARRHEA
Prolonged Diarrhea
(lasting 7-13 days)
● excessive loss of fluid and electrolyte
in the stool Persistent diarrhea
● Acute diarrhea is defined as sudden (lasting 14 days or
onset of excessively loose stools of longer)
○ >10 mL/kg/day in infants and
○ >200 g/24 hr in older children,
● which lasts <14 days.
● When the episode lasts longer than 14
days, - chronic or persistent diarrhea.
Chronic diarrhea

● stool volume of more than 10 g/kg/day in toddlers/infants and greater

than 200 g/day in older children that lasts for 4 wk or more.
● Persistent diarrhea began acutely but lasts longer than 14 days.

Watery Diarrhea

● Semi-formed to loose-watery stools without the presence of blood

● Often clinical presentation of enterotoxin-induced diarrhea

Bloody Diarrhea

● considered if macroscopic exam of stools contains blood

 Secretory diarrhea Osmotic diarrhea

Caused by: caused by

-inhibition of neutral NaCl absorption in -nonabsorbed nutrients in the intestinal
villous enterocytes lumen
-increase in electrogenic chloride -osmotic force generated by
secretion in secretory crypt cells nonabsorbed solutes drives water into
from(CFTR) chloride channel opening the intestinal lumen.

large volumes of watery stools stool volumes are usually not as

massive

persists when oral feeding is dependent on oral feeding

withdrawn.
Epidemiology

● In 2015, diarrheal disease caused an estimated 499,000, or 8.6% of all

childhood deaths, 4th most common cause of child mortality worldwide.

● Over the same period, a smaller decline (10%) was observed in the
incidence of diarrhea disease among children younger than 5 yr.

● Diarrhoeal disease is the second leading cause of death in children under five
years old, and was responsible for the deaths of 370,000 children in 2019
according to WHO.
In the Philippines

● Morbidity due to diarrhea (both acute bloody diarrhea and acute watery
diarrhea) has decreased by almost two thirds,
○ 288.7/100,000 population in 2010
○ 166.8/100,000 population in 2015.

● The number of acute bloody diarrhea and acute watery diarrhea cases was
lowest in the year 2013, but it increased in 2014 and 2015.
○ The fluctuating values reflect the difficulty in sustaining good control and
prevention of diarrhea in the past 6 years.

● Mortality. The desired zero deaths due to diarrhea was not realized.
Surveillance data in 2015 showed 18 deaths due to diarrhea, which
increased to 44 deaths in 2016.
 ETIOLOGY

BACTERIAL PATHOGENS
VIRAL PARASITIC
Nontyphoidal Salmonella
PATHOGENS PATHOGENS
(NTS)
Shigella
Rotavirus Campylobacter Giardia intestinalis
Norovirus Yersinia Cryptosporidium spp.
Sapovirus Escherichia coli Cyclospora
Adenovirus 40 pathotypes: EHEC, ETEC, cayetanensis
and 41 EPEC, EAEC, EIEC Entamoeba
Astroviruses Bacillus cereus histolytica
Clostridium perfringens
Staphylococcus aureus
PATHOGENESIS
CPG CLINICAL MANIFESTATIONS
GENERAL FINDINGS

● Acute diarrhea: passage of 3 or more

abnormally loose, watery or bloody stools in
24 hours, with a duration <14 days.
● Fever
● Abdominal pain
● Nausea
● Vomiting
● Signs of dehydration

CPG AID
 CLINICAL MANIFESTATIONS

VIRAL BACTERIAL PROTOZOAL

Vomiting Fever >40C Explosive diarrhea

Watery non bloody stools Overt fecal blood
Fever Abdominal pain
No vomiting before diarrhea
onset
Lacks fecal leukocytes High stool frequency (>10/day)
20% with mucus
Nausea
Abdominal cramps
Abdominal bloating
Watery or greasy and foul
smelling diarrhea
Bloody or mucoid diarrhea
(amebic dysentery)

Recovery with complete

resolution: 7 days More prolonged illness: >2
weeks
CLINICAL MANIFESTATIONS

CPG AID
DIAGNOSIS
 DIAGNOSIS

Routine stool not indicated in acute watery diarrhea, except in cases

examination where parasitism is suspected or in the presence of bloody
diarrhea

Stool culture Severe cases

High risk of transmission of enteric pathogens
High risk of complications
Epidemiologic purposes
Within 3 days of symptom onset and before administration
of antibiotics

Routine laboratory Not useful in patients with acute diarrhea

tests (CBC, serum Useful to detect complications
electrolytes, renal
function tests)

Biomarkers (Lactoferrin, CRP, cytokines, calprotectin, ESR, procalcitonin)

 COMPLICATIONS
Extraintestinal complications
● Dehydration
● Electrolyte imbalances
○ Hyponatremia
○ Hypernatremia
○ Hypokalemia
COMPLICATIONS
 COMPLICATIONS
Extraintestinal complications
● Acid-base disturbances
○ Metabolic acidosis
○ Lactic acidosis
○ Hyperchloremic metabolic acidosis - typical in cholera
● Poor growth and nutrition
● Bacteremia
● Pseudoappendicitis
○ Secondary to mesenteric adenitis
○ Yersinia, Campylobacter
○ Older children and adolescent - most often affected
 COMPLICATIONS
Extraintestinal complications
● Acute kidney injury
○ Acute diarrhea - important cause of preventable AKI
○ Delayed restoration of GI losses → ↓blood supply to the
kidneys → AKI
 COMPLICATIONS
Intestinal complications
● Chronic diarrhea
● Intussusception
○ Triggered by lymphoid hyperplasia
○ Associated with Viral AGE
○ Rare
● Toxic megacolon, intestinal perforation, rectal prolapse -
Shigella, C. difficile
 COMPLICATIONS
Postinfectious complications
● Hemolytic uremic syndrome
○ Leading cause of acquired renal failure in children
○ Caused by Shiga-toxin producing organisms (Shigella
dystenteriae, E. coli)
○ Risk factors:
■ 6mo to 4 yr
■ Bloody diarrhea
■ Fever
■ Elevated leukocyte count
■ Treatment with antibiotics and antimotility agents
 COMPLICATIONS
Postinfectious complications
● Immune-mediated complications
○ Reactive arthritis
○ Guillain-Barré syndrome - Campylobacter
● Protozoan illnesses
○ Poor weight gain in the young and immunocompromised
individuals, weight loss, malnutrition, or vitamin
deficiencies
○ Entamoeba → severe ulcerating colitis, colonic dilation,
and perforation, liver abscess
COMPLICATIONS
 TREATMENT
1. Management for each Level of Dehydration

No Signs of ● Reduced osmolarity oral rehydration solution

Dehydration (ORS) is recommended to replace ongoing losses

Mild to Moderate ● Reduced osmolarity oral rehydration solution

Dehydration (ORS) is recommended to replace ongoing losses
● If oral rehydration is not feasible, administration
of OR via nasogastric tube is preferred over IV
hydration

Severe Dehydration ● Rapid intravenous rehydration is recommended

with plain Lactated Ringer’s (LR) solution or
0.9% Sodium Chloride
 TREATMENT
2. Monitoring
● Check the child from time to time during rehydration to ensure that ORS
is being taken satisfactorily and that signs of dehydration are not
worsening. Evaluate the child’s hydration status at least hourly.

3. For Breastfed infants, breastfeeding should be continued

in addition to hydration therapy

4. Carbonated, sweetened, caffeinated and sports beverages

are not recommended for fluid replacement
 TREATMENT
Indications for Empiric Antibiotic Treatment

1. Primary management of acute infectious diarrhea in children is

still rehydration therapy. Routine empiric antibiotic therapy is
NOT recommended.
2. Antimicrobials may be recommended for the following conditions:
● Suspected cholera
● Bloody diarrhea
● Diarrhea associated with other acute infections (e.g.
pneumonia, meningitis, etc.)
 TREATMENT
Recommended Antimicrobials for the following etiologies:
1. Cholera ● Azithromycin 10 mg/kg/dose OD for 3 days, or 20 mg/kg single dose (max
dose: 500 mg/24 hrs)
● Doxycycline (only for >8 y/o): 2mg/kg single dose (max dose: 100 mg/dose)

Alternatives (when susceptible) include:

● Cotrimoxazole 8-12 mg/kg/day PO divided into 2 doses for 3-5 days (max
dose: 160 mg/dose)
● Chloramphenicol 50-100 mg/kg/day PO q 6 hrs for 3 days (max dose: 750
mg/dose)
● Erythromycin 12.5 mg/kg/dose PO q 6 hrs for 3 days (max dose: 4g/24 hrs)

2. Shigella ● Ceftriaxone IV 75-100 mg/kg/day q 12-24 hrs (max dose: 2g/24 hrs) for 2-5
days
● Ciprofloxacin 30 mg/kg/day PO divided into 2 doses x 3 days max dose: IV
800 mg/24 hrs)
● Azithromycin 10 mg PO OD for 3 days (max dose: 500 mg/dose)
 TREATMENT
Recommended Antimicrobials for the following etiologies:

3. Non-typhoidal ● Antibiotic treatment is NOT recommended for children with

Salmonella non-typhoidal Salmonella EXCEPT in high-risk children to
prevent secondary bacteremia, such as:
● Neonates or young infants <3 months old
● Immunodeficient patients
● Anatomical or functional asplenia, corticosteroid or
immunosuppressive therapy, inflammatory bowel disease,
or achlorhydria

4. Amoebiasis ● Metronidazole 10 mg/kg/dose IV/PO 3 times a day (max dose:

750 mg/dose) for 10-14 days is recommended for confirmed
cases of amoebiasis to avoid relapse.
 TREATMENT
Zinc & Racecadotril for Acute Infectious Diarrhea

1. Zinc supplementation (not in combination with vitamins and minerals) at 20

mg/day for 10-14 days should be given routinely as adjunctive therapy for
acute infectious diarrhea in children >6 mos old to shorten the duration of
diarrhea and reduce frequency of stools.
2. Zinc supplementation is NOT routinely given as adjunctive therapy for acute
infectious diarrhea in children <6 mos old as it may cause diarrhea to persist.
3. Racecadotril (1.5 mg/kg/dose) 3x a day during the first 3 days of watery
diarrhea may be given to infants and children as adjunctive therapy to shorten
duration of diarrhea.
4. Loperamide is NOT recommended for children with acute infectious
gastroenteritis due to serious adverse events.
 TREATMENT
Probiotics for Acute Infectious Diarrhea

1. Probiotics are recommended as an adjunct therapy throughout the duration

of the diarrhea in children. Probiotics have been shown to reduce symptom
severity and duration of diarrhea.
2. Probiotics may be extended for 7 more days after completion of antibiotics.
3. The following probiotics may be used:
a. Saccharomyces boulardii 250-750 mg/day for 5-7 days
b. Lactobacillus rhamnosus GG ≥ 1010 CFU/day for 5-7 days
c. Lactobacillus reuteri DSM 17938 108 to 4x108 CFU/day for 5-7 days
d. There is insufficient evidence to recommend Bacillus clausii.
 PREVENTION
Interventions

1. Hand Hygiene promotion

2. Access to clean and safe water
3. Proper food Handling
4. Proper Excreta disposal
5. Vaccination
6. Supplements
7. Breastfeeding
 PREVENTION
HAND HYGIENE AND HAND HYGIENE PROMOTION
 PREVENTION
WATER SAFETY INTERVENTIONS

1. Drinking water should be clean and safe. Recommended methods to ensure

clean and safe water include Boiling, chemical disinfection, and ultraviolet
radiation
2. Drinking water should comply with the philippine National Standards of
Drinking Water (DENR AO No. 26-A. Series 1994)
 PREVENTION
PROPER FOOD HANDLING
 PREVENTION
PROPER EXCRETA DISPOSAL

1. Safe stool disposal and hand hygiene

2. Use of approved excreta disposal facilities based on the Code on
Sanitation of the Philippines
3. Open defecation threatens public health and safety and is unacceptable
 PREVENTION
VACCINES

1. Cholera Vaccine
2. Rotavirus Vaccine

SUPPLEMENTS

1. Probiotics
2. Zinc Supplementation
3. Vitamin A

BREASFEEDING AND BREASTFEEDING PROMOTION

 PROGNOSIS
Prognosis and complications are directly related to access to
care and treatment

The outcomes of pediatric gastroenteritis depend on the

severity of diarrhea and the time of treatment. Children who
have delayed treatment can develop multiorgan failure,
leading to death.
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