IDSA Clinical Practice Guidelines for Infectious Diarrhea
This pediatric-focused quick reference summarizes the 2017 IDSA Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. It highlights when stool testing is indicated, how to evaluate suspected Shiga toxin–producing E. coli and other enteric pathogens, when antimicrobial therapy should be avoided or targeted, and the role of oral rehydration, nutrition, infection control, and outbreak reporting. The underlying IDSA guideline covers infants, children, adolescents, and adults; this page emphasizes recommendations most relevant to pediatric practice. Clinicians should consult the complete guideline, current organism-specific recommendations, local susceptibility data, and public-health requirements before making treatment decisions.
Source: Infectious Diseases Society of America (2017 guideline panel)
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Infectious Diarrhea: Pediatric Clinical Quick Reference
A pediatric-focused quick reference summarizing the 2017 IDSA guidelines for the diagnosis and management of infectious diarrhea — including stool testing, Shiga toxin detection, antimicrobial use, rehydration, supportive care, and prevention.
1 Overview & U.S. Burden
This pediatric-focused reference summarizes the 2017 IDSA Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. The underlying guideline applies to infants, children, adolescents, and adults; this page emphasizes recommendations most relevant to pediatric practice. The guideline uses GRADE methodology to rate evidence quality and recommendation strength.
Diarrheal illness can be classified by duration: acute (0–13 days), persistent (14–29 days), and chronic (≥30 days). The figures below are historical U.S. burden estimates cited in the original 2018 presentation and should not be interpreted as current surveillance data.
2 Evaluating the Patient
Several host and exposure factors shape the differential diagnosis and the decision to test or treat. Consider each of the following when assessing a patient with diarrhea:
- Foodborne or waterborne exposure — outbreaks, untreated water, raw products
- International travel — to resource-limited regions
- Antimicrobial use — recent therapy raising concern for C. difficile
- Immunocompromised host — broadens differential and severity
- Animal exposure — reptiles, amphibians, young poultry, farm/petting-zoo contact
- Care settings — child care, long-term care, hospitalization
- Certain sexual practices — anal-genital, oral-anal, digital-anal contact
When to pursue laboratory investigation
- Bloody diarrhea or suspicion of Shiga toxin–producing Escherichia coli (STEC), which may increase the risk of hemolytic uremic syndrome (HUS)
- Immunocompromised host or extraintestinal manifestations
- Epidemiologic concern (child care, nursing home, suspected outbreak)
- Recent travel, or any scenario where results would change management
3 Exposures & Associated Pathogens
Specific exposures point toward particular organisms. The table below condenses the guideline's exposure-to-pathogen associations.
| Exposure or condition | Likely pathogen(s) |
|---|---|
| Foodborne | |
| Outbreaks (hotels, cruise ships, resorts, catered events) | Norovirus, nontyphoidal Salmonella, C. perfringens, B. cereus, S. aureus, Campylobacter, enterotoxigenic E. coli (ETEC), STEC, Listeria, Shigella, Cyclospora, Cryptosporidium |
| Unpasteurized milk / dairy | Salmonella, Campylobacter, Yersinia enterocolitica, S. aureus toxin, Cryptosporidium, STEC; Brucella (goat-milk cheese) |
| Raw / undercooked meat or poultry | STEC (beef), C. perfringens, Salmonella, Campylobacter, Yersinia (pork), Trichinella (pork, wild game) |
| Raw shellfish | Vibrio species, norovirus, hepatitis A, Plesiomonas |
| Exposure or contact | |
| Untreated fresh water (swimming/drinking) | Campylobacter, Cryptosporidium, Giardia, Shigella, Salmonella, STEC, Plesiomonas shigelloides |
| Child care attendance / employment | Rotavirus, Cryptosporidium, Giardia, Shigella, STEC |
| Recent antimicrobial therapy | C. difficile, multidrug-resistant Salmonella |
| Travel to resource-challenged countries | E. coli (enterotoxigenic [ETEC], enteroaggregative [EAEC], and enteroinvasive [EIEC]), Shigella, Salmonella Typhi & nontyphoidal, Campylobacter, V. cholerae, E. histolytica, Giardia, Cyclospora |
| Young poultry or reptile contact | Nontyphoidal Salmonella |
| Farm or petting-zoo visit | STEC, Cryptosporidium, Campylobacter |
4 Clinical Presentations & Likely Etiologies
| Finding | Likely pathogens |
|---|---|
| Persistent or chronic diarrhea | Cryptosporidium, Giardia lamblia, Cyclospora cayetanensis, Cystoisospora belli, Entamoeba histolytica |
| Visible blood in stool | STEC, Shigella, Salmonella, Campylobacter, E. histolytica, noncholera Vibrio, Yersinia, Balantidium coli, Plesiomonas |
| Fever | Not highly discriminatory — viral, bacterial, and parasitic causes all possible. Higher temperatures suggest bacterial etiology or E. histolytica; STEC patients are often afebrile at presentation. |
| Severe abdominal pain, often grossly bloody stools, minimal/no fever | STEC, Salmonella, Shigella, Campylobacter, Yersinia enterocolitica |
| Persistent abdominal pain + fever (may mimic appendicitis) | Y. enterocolitica and Y. pseudotuberculosis |
| Nausea & vomiting ≤24 hours | S. aureus enterotoxin or B. cereus (short-incubation emetic syndrome) |
| Vomiting + nonbloody diarrhea, 2–3 days | Norovirus (low-grade fever in ~40% during first 24h) |
5 Post-Infectious Manifestations
Enteric infections can trigger significant sequelae well after the acute illness resolves.
| Manifestation | Organism(s) |
|---|---|
| Guillain-Barré syndrome | Campylobacter |
| Hemolytic uremic syndrome (HUS) | STEC, Shigella dysenteriae serotype 1 |
| Reactive arthritis (incl. Reiter syndrome) | Salmonella, Shigella, Campylobacter, Yersinia; rarely Giardia, Cyclospora |
| Erythema nodosum | Yersinia, Campylobacter, Salmonella, Shigella |
| Meningitis (infants ≤3 months at high risk) | Listeria, Salmonella |
| Intestinal perforation | Salmonella (incl. Typhi), Shigella, Campylobacter, Yersinia, E. histolytica |
| Ekiri syndrome (lethal toxic encephalopathy / seizure) | Shigella |
| Aortitis, osteomyelitis, extravascular deep-tissue focus | Salmonella, Yersinia |
| Post-infectious irritable bowel syndrome | Campylobacter, Salmonella, Shigella, STEC, Giardia |
6 Laboratory Diagnosis
Diagnosis is matched to the suspected agent and optimal specimen. Culture-independent diagnostic tests (CIDTs), including multiplex gastrointestinal (GI) panels, can rapidly detect a broad range of bacterial, viral, and parasitic organisms. Results should be interpreted in the clinical and epidemiologic context, and reflex culture may still be needed for antimicrobial-susceptibility testing or public-health investigation.
| Etiologic agent | Diagnostic procedure | Optimal specimen |
|---|---|---|
| Clostridioides difficile | Nucleic acid amplification test (NAAT); or glutamate dehydrogenase (GDH) antigen with or without toxin detection, followed by cytotoxin assay or toxigenic culture | Unformed stool from a symptomatic patient |
| Salmonella, Shigella, Campylobacter | Routine stool enteric pathogen culture or NAAT | Stool |
| Salmonella Typhi / Paratyphi (enteric fever) | Routine culture | Stool, blood, bone marrow, duodenal fluid |
| Shiga toxin–producing E. coli | Culture for E. coli O157:H7 plus Shiga toxin immunoassay or NAAT for toxin genes | Stool |
| E. histolytica | Species-specific immunoassay or NAAT | Stool |
| Giardia lamblia | Enzyme immunoassay (EIA) or NAAT | Stool |
| Cryptosporidium spp. | Direct fluorescent immunoassay, enzyme immunoassay (EIA), or NAAT | Stool |
| Norovirus / sapovirus, enteric adenovirus, rotavirus | NAAT | Stool |
Tests generally not recommended
- Fecal leukocytes / stool lactoferrin — not recommended
- Serologic tests — not recommended (exception: post-diarrheal HUS)
- Serial stool specimens — generally only for public-health reasons (e.g., return to child care/work) or culture-dependent susceptibility testing
7 Antimicrobial Therapy by Pathogen
| Pathogen | Guideline-listed first choice (2017) | Guideline-listed alternative (2017) |
|---|---|---|
| Bacteria | ||
| Campylobacter | Azithromycin | Ciprofloxacin |
| Clostridioides difficile | Consult the current IDSA/SHEA C. difficile guideline and age-appropriate pediatric guidance. CDI recommendations have been updated separately from the 2017 infectious-diarrhea guideline. | |
| Nontyphoidal Salmonella | Usually not indicated for uncomplicated infection | Consider for groups at increased risk of invasive disease |
| Salmonella Typhi / Paratyphi | Ceftriaxone or ciprofloxacin | Ampicillin, trimethoprim-sulfamethoxazole (TMP-SMX), or azithromycin |
| Shigella | Azithromycin, ciprofloxacin, or ceftriaxone | TMP-SMX or ampicillin (if susceptible) |
| Vibrio cholerae | Doxycycline | Ciprofloxacin, azithromycin, or ceftriaxone |
| Yersinia enterocolitica | TMP-SMX | Cefotaxime or ciprofloxacin |
| Parasites | ||
| Cryptosporidium spp. | Nitazoxanide, with effective combination antiretroviral therapy (cART) when HIV-infected | — |
| Cyclospora cayetanensis | TMP-SMX | Nitazoxanide (limited data) |
| Giardia lamblia | Tinidazole or nitazoxanide | Metronidazole |
| Cystoisospora belli | TMP-SMX | Pyrimethamine; ciprofloxacin or nitazoxanide |
8 Supportive & Ancillary Care
Rehydration is the cornerstone of management. Reduced-osmolarity oral rehydration solution (ORS) is first-line therapy for mild to moderate dehydration in infants, children, adolescents, and adults with acute diarrhea. Severe dehydration, shock, altered mental status, ileus, or failure of ORS requires prompt escalation and intravenous isotonic fluids according to current resuscitation guidance.
| Degree of dehydration | Rehydration therapy | Replacement during maintenance |
|---|---|---|
| Mild to moderate | Infants & children: ORS 50–100 mL/kg over 3–4 h. Adolescents & adults (≥30 kg): ORS 2–4 L. | <10 kg: 60–120 mL ORS per stool/vomit (up to ~500 mL/day). >10 kg: 120–240 mL per episode (up to ~1 L/day). Adults: ad libitum, up to ~2 L/day. |
| Severe | Children, adolescents & adults: IV isotonic crystalloid boluses per current resuscitation guidelines until pulse, perfusion, and mental status normalize (up to 20 mL/kg). | As above; if unable to drink, give via nasogastric tube, or 5% dextrose / 0.25 normal saline with 20 mEq/L potassium chloride IV. |
Directed & ancillary measures
- Human milk — breastfed infants should continue nursing throughout the illness
- Diet — resume an age-appropriate normal diet after rehydration; diluted formula confers no benefit
- Antimotility agents — do not give loperamide or similar agents to children younger than 18 years with acute diarrhea. Avoid them at any age when inflammatory diarrhea, fever, or toxic megacolon is suspected
- Antiemetics — ondansetron may be considered to help children older than 4 years and adolescents tolerate ORS when vomiting is present; it may increase stool volume
- Probiotics — certain preparations may be offered to immunocompetent children and adults to reduce symptom severity or duration, but evidence and dosing are product- and strain-specific
- Oral zinc supplementation — most applicable to children 6 months to 5 years who live in areas with a high prevalence of zinc deficiency or who show signs of malnutrition
9 Prevention & Vaccines
Prevention rests on hand hygiene, infection control, food-safety practices, patient education, and reporting of nationally notifiable diseases.
Vaccines that prevent diarrhea
- Rotavirus — routinely recommended for infants
- Typhoid — oral and injectable vaccines available in the U.S.; not routinely recommended
- Cholera — a single-dose oral vaccine is recommended for travelers ages 2–64 visiting areas with active cholera transmission; it is not routinely recommended for most travelers
This page is an educational summary for healthcare professionals and does not replace the complete guideline, current organism-specific recommendations, local susceptibility data, public-health requirements, product labeling, or individual clinical judgment. Clinical recommendations and vaccine indications may change. Confirm current guidance before using this information for diagnosis, treatment, dosing, or patient counseling.