Acute diarrhea incidence may increase after a disaster due to the limited access to electrical services, clean water and sanitary facilities. In addition, regular hygiene practices may be affected and health preservation conducts may change.

The primary goal for the treatment of any diarrhea (viral, bacterial, parasitic or non-infectious) is preventing dehydration or providing appropriate rehydration on dehydrated people. The following guidelines are directed to medical attention providers for evaluation and treatment of patients with acute diarrhea in these situations. However, treatment of each diarrhea patient must be determined based on clinic observation performed by medical attention providers. All questions should be directed to the local health department.

Babies and young children

Refer babies and young children with acute diarrhea to a medical evaluation if they present any of the following factors:

•    Young age (ex., <6 months old) or a weight <18 pounds (about 8.1 kilograms).
•    Premature birth, chronic medical condition history or concurrent diseases.
•    Fever >38 °C (100.4 °F) in babies <3 months or >39 °C (102.2 °F) in children with ages between 3 and 26 months.
•    Visible blood in stool.
•    Profuse diarrhea, frequent and considerable stool volume.
•    Persistent vomit.
•    People in charge of baby or child care report presence of dehydration signs (ex., sunken eyes or tear decrease, dry mucous membranes or decrease in urine flow).
•    Changes in mental state (ex., irritability, apathy or lethargy).
•     Insufficient response to administered oral hydration treatment or inability to provide oral rehydration treatment from the person in charge of baby or child care.

Appropriate treatment principles for BABIES AND YOUNG CHILDREN with diarrhea and dehydration

•    Oral rehydration solutions (ORS) such as Pedialyte® (Abbott Laboratories)* or Gastrolyte® (Aventis Pharmaceuticals)* or similar commercial solutions with appropriate portions of sodium, potassium and glucose must be administered for rehydration when the patient has good oral tolerance; otherwise, adequate liquids must be administered intravenously.
•    The patient must be rehydrated in small, but frequent amounts (spoonful or small sips for children between 1 and 3 years, small amounts in bottles for babies, provided gradually, as if they were sips); see table for recommended amounts and frequency.
•    For speedy nourishment, an age appropriate and unrestricted diet is recommended as soon as dehydration has been corrected.
•    For lactating babies, breast feeding must be continued.
•    Additional ORS or other rehydrating solutions must be provided to compensate continual loss resulting from diarrhea.
•    Routine lab tests or medication is not recommended.
o    However, if a patient lives with a number of people or in optimal conditions for gastrointestinal disease outbreaks, the providers must consider tests for bacteria, virus or parasite detection. If an outbreak possibility is suspected, testing a group of patients might be enough to confirm it (ex., 10 stool samples to confirm norovirus).
•    Deciding to administer an antibiotic treatment must be based on each individual patient. Even if the diarrhea is believed to be bacterial in outpatient centers, antibiotic treatment is usually not prescribed to children since most acute diarrhea cases are of spontaneous resolution and antibiotics do not decrease the duration of the illness. The exceptions to these rules are:
o    Special needs of each child (ex., premature babies, immunodepressed children or with underlying conditions).
o    Presumed sepsis.
o    In case of a shigellosis, cryptosporidiosis or giardiasis. Although hand hygiene is a fundamental part of prevention, antibiotic treatment may eliminate transmission and help control the outbreak, as long as rigorous hand hygiene measures are enforced.
•    People in charge of patient care must receive recommendations regarding appropriate hand hygiene practices.
•    Antiemetic medication and anti-diarrheal medication (antimolity drugs) must be avoided in general.

Older children and adults

Children > 3 years and adults with acute diarrhea must be referred to medical evaluation if any of the following factors is present:

•    Elderly.
•    Chronic medical condition background or concurrent illness.
•    Fever >39 °C (102.2 °F).
•    Visible blood in stool.
•    High diarrhea flow, frequent and considerable stool volumes.
•    Persistent vomit.
•    Indicative signs of dehydration (ex., sunken eyes or tear decrease, dry mucous membranes, orthostatic hypotension or decrease of urine volume).
•    Mental state changes (e.g. irritability, apathy or lethargy).
•    Insufficient response to administered rehydration oral treatment or inability to administer rehydration oral treatment.
Principles of adequate treatment for CHILDREN>3 YEARS OF AGE AND ADULTS with diarrhea and dehydration
•    Although sports drinks are used maintain hydration in healthy people, they are not appropriate to treat people with diarrhea. In place where diarrhea cases are present, oral rehydration solutions (ORS) such as Pedialyte® (Abbott Laboratories)*, Gastrolyte® (Aventis Pharmaceuticals)* or similar commercial solutions with adequate amounts of sodium, potassium and glucose must be used for rehydration when the patient is able to drink the required volumes; otherwise, appropriate liquids must be administered intravenously.
•    The patient should be rehydrated in small but frequent amounts (spoonful or small sips); see table for recommended amounts and administration frequency.
•    For speedy nourishing, an unrestricted diet is recommended as soon as dehydration has been corrected.
•    Additional ORS or other rehydrating solutions must be administered to compensate continual loss caused by diarrhea.
•    Routine lab tests or medication are not recommended.
o    However, if a patient lives with a large amount of people or in conditions leading to a gastrointestinal disease outbreak, providers must consider performing bacteria, virus or parasite detection. If the possibility of an outbreak is suspected, performing tests in a group of patients could be enough to confirm it (e.g. 10 stool samples to confirm norovirus).
•    Anti-diarrhea medication (antimolity drugs) such as Lomotil® (Pfizer) or Immodium® (McNeil Consumer) should be considered only for adult patients who do NOT present fever or do NOT have mucoid or bloody diarrhea. Anti-diarrhea medication may reduce diarrhea flow and stomach colic but will not expedite cure. This medication is usually contraindicated in children.
•    Deciding to administer an antibiotic treatment should be done based on each particular patient and may vary according to the age group.
o    Treatment in children may be considered based on:
•    Special needs of each child (e.g. immunodepressed organisms or children with underlying conditions).
•    Presumed sepsis.
o    In case of a shigellosis, cryptosporidiosis or giardiasis outbreak. Although hand hygiene is an essential part of prevention, antibiotic treatment may eliminate transmission and help controlling the outbreak, as long as rigorous hand hygiene measures are followed. Nitazoxanide is used to treat cryptosporidiosis or giardiasis in immunoincompetent people.
o    In adults, treatment can be considered based on:
•    Fever.
•    Mucoid or bloody stool.
•    Presumed sepsis.
•    People in charge of patient care should receive recommendations about appropriate hand hygiene.
 

Treatment based on dehydration degree

* In case of serious dehydrating diarrheas, normal saline solutions are less effective for treatment since they do not contain bicarbonate or potassium. Use normal saline solutions only if composite sodium lactate solution (Ringers lactate solution) is not available and administer ORS supplements as soon as the patient is able to take liquids. Glucose in water is not effective and should not be used.

NOTE: Restricting diets should be avoided during acute diarrhea episodes. Lactating babies should continue taking unlimited breast milk, even during acute rehydration. Babies who are too weak to be fed may receive breast milk or formula through nasogastric intubation. Baby formulas containing lactose are usually well tolerated. If lactose tolerance is clinically significant, lactose-free formulas may be used. Complex carbohydrates, fresh fruits, lean meats, yogurts and vegetables are recommended. Sodas or commercial juices with a high concentration of simple carbohydrates should be avoided.