Management strategies in the treatment of neonatal and pediatric gastroenteritis

Figures & data

Table 1A Clinical and epidemiological characteristics of the main bacterial enteropathogens

Pathogen	Typical age at presentation	Type of diarrhea	Duration of symptoms	Clinical features	Transmission	Seasonality
Campylobacter spp	C jejuni: highest rate among young children and young adults. In rich countries, highest rate in early childhood. In poor countries, highest rate in children < 2 years old.C fetus: highest rates at the extremes of age	Acute diarrhea with or without blood or mucus in stool	>1 week in only 10%–20%	Malaise Abdominal pain Abdominal tenderness Fever Nausea Vomiting Headache Myalgia Arthralgia	Contact with farm animals (age 2–11 years). Drank raw milk. Drank untreated water from lake, river, stream. Eat chicken and other meat prepared in a restaurant. Consumption of undercooked poultry.	Incidence peaks during summer and early autumn
Clostridium difficile  Clostridium difficile-associated disease (CDAD)	1–4 years of age	Stools are almost never grossly bloody and range from soft and unformed to watery or mucoid in consistency, with a characteristic odor	The diarrhea ranges from a few days of intestinal fluid loss to life-threatening pseudomembranous colitis (PMC)	Abdominal pain Fever Leukocytosis	CDAD occurs most frequently in hospitals and nursing homes where the antimicrobial use is high and the environment is contaminated by C difficile spores. C. difficile has been hypothesized as a possible source for community-associated infections through food ready for consumption, such as raw meat and salad.	Winter months
Escherichia coli: Five pathotypes dominate the clinical spectrum: – Enterotoxigenic E. coli (ETEC) – Enteropathogenic E. coli (EPEC) – Enteroinvasive E. coli (EIEC) – Enteroaggregative E. coli (EAEC) (EAEC serotype OI04:H4 Shiga toxin-producing STEC) – Enterohemorrhagic E. coli (EHEC) (EHEC OI57 Shiga toxin-producing – STEC)	ETEC children < 5 years old. In infants, age 0–6 months, more dehydrating diarrhea in resource-constrained countries. EPEC most common in children < 1 year of age. EIEC can cause systemic infection. EAEC predominant in children < 2 years EAEC OI04:H4 infection: higher risk of hemolytic uremic syndrome (HUS) EHEC bloody diarrhea EHECOI57:H7 infection especially in children < 5 years, higher risk of HUS.	Watery (ETEC, EPEC, EAEC) or bloody diarrhea and dysentery (ETEC, STEC, EHEC)	Variable, depending on the pathotype and the age: from mild self-limiting (1–2 days) to severe bloody disease (4-20 days). Life-threatening complication, such as hemolytic uremic syndrome, often needs hospitalization	ETEC: the most common cause of traveler’s diarrhea. EPEC: severe and protracted diarrhea in neonates and infants. EIEC: bloody, mucoid diarrhea with fever, crampy abdominal pain EHEC: bloody diarrhea with low or no fever at all. EAEC: bloody, mucoid diarrhea, abdominal cramps, malaise EHEC serotype 0157:H7: 10% develop HUS, a triad of acute renal failure, hemolytic anemia and thrombocytopenia. Mortality for HUS is approximately 5%. Only EIEC and EHEC can cause systemic infection or complication.	Contaminated food and water. Person-to-person transmission can occur if infected people do not wash their hands after using the toilet or changing diapers. E. coli 0157:H7 is transmitted by ingestion of beef and other foods contaminated with cattle feces	ETEC infections in areas of endemic infection tend to be clustered in warm, wet months, when multiplication of ETEC in food and water is most efficient. EPEC, EAEC identified in the same proportions during winter and summer seasons. EHEC infections most sporadic cases reported in the summer in rich countries of the Northern Hemisphere
Salmonella spp	<20–24 months in resource-constrained nations (S. typhimurium is predominant, followed by S. typhi and S. paratyphi). Children < 5 years old in rich countries.	Usually loose, nonbloody, moderate volume. Large volume, bloody stools, or symptoms of dysentery do not rule out the diagnosis	Usually self-limited – Diarrhea (3–7 days) – Fever (72 hours)	Nausea, vomiting, abdominal cramping Fever usually 38°C–39°C Rare: pseudoappendicitis, illness that mimics inflammatory bowel disease	Most commonly transmitted through eggs and poultry. Also transmitted through undercooked ground meat, unpasteurized dairy products, seafood, and fresh produce.	Tropical climates: highest during rainy season. Temperate climates: highest during warmer months
Shigella spp	Worldwide 69% of all cases among children < 5 years old	Many patients have only self-limited watery diarrhea (watery diarrhea may progress to bloody diarrhea and dysentery). Bacillary dysentery with blood, mucus, and pus	Mild disease usually lasts from a few days to a week. Severe disease can progress to toxic dilatation and colonic perforation	Fever (in children, frequently 40°C–41°C. Abdominal cramps, tenesmus, dehydration from mild (common) to severe (rare) and vomiting.	From feces to mouth, from person-to-person contact, although intermediate vectors, such as food, water, flies, and fomites, can be involved. Also transmitted during participation in water sports in poorly chlorinated pools or contaminated lakes.	July–October
Vibrio cholerae	Affects adults and children equally when newly introduced. Predominantly a pediatric disease in endemic areas	Watery diarrheal disease, acutely dehydrating	4–5 days	Vomiting. Severe dehydration (thirst, muscle cramps, painful contractions, hypothermic skin with normal rectal temperature, tachycardia, hypotension, decreased dieresis) and electrolyte disorders (hypokalemia, and hypocalcemia). Complications: renal failure, pulmonary edema, profound hypoglycemia, and seizures in children.	Drinking of contaminated water or consumption of contaminated seafood, particularly undercooked shellfish	Endemic areas: more common in summer and fall months
Yersinia enterocolitica	Children < 5 years of age	Mucoid diarrhea, containing leukocytes, with or without blood	1–3 weeks	Fever, Abdominal cramps	Most commonly transmitted through undercooked pork meat. Also caused by infected water, milk and other foods stored at refrigerator temperatures	Winter months

Table 1B Clinical and epidemiological characteristics of the main viral enteropathogens

Pathogen	Typical age at presentation	Type of diarrhea	Duration of symptoms	Clinical features	Transmission	Seasonality
Adenovirus (enteric serotypes 40, 41)	Primarily affects children younger than 2 years	Watery diarrhea	Adenovirus infections are most communicable during the first few days of an acute illness, but persistent and intermittent shedding for longer periods (mean 10 days) is common.	Vomiting. High fever (over 39°C) is uncommon. Asymptomatic infections are common, and reinfections can occur	Transmitted by direct contact, fecal-oral transmission, and occasionally waterborne transmission	The adenovirus activity peak is in winter and spring seasons (December–March)
Astrovirus (Astroviridae family)	Children < 4 years	Copious, watery diarrhea	5–6 days	Abdominal pain, vomiting, nausea, fever, malaise	Astrovirus is most frequently transmitted through a fecal-oral route. Contaminated food, water, or fomites have been suspected in several outbreaks	Winter
Caliciviridae family (genus Calicivirus)
Norovirus (species called Norwalk virus)	Children < 5 years of age (predominant between 12 and 24 months)	Watery diarrheal disease	Symptoms usually last for 24–60 hours	Fever(over 38°C) Vomiting more common in children Headaches Stomach cramps Aching limbs Pediatric patients are more liable to have dehydration requiring hospitalization.	Often implicated in norovirus outbreaks are shellfish and salad ingredients. Water is the most common source of outbreaks and may include water from municipal supplies, wells, recreational lakes, swimming pools, and water stored aboard cruise ships.	Norovirus disease is also called “winter vomiting disease”
Sapovirus	Children < 5 years of age	Mild, self-limiting, nonbloody diarrhea	2–3 days	Occasionally fever and vomiting	Mainly transmitted via fecal-oral route and consumption of contaminated food (oysters, clams, salads). Outbreaks often occur in closed populations, and attack rates are high in hospitalized children, orphanages, kindergartens, schools, and in children in child-care centers.	Most cases occur during winter in temperate climates and during the rainy season in tropical climates
Rotavirus (Reoviridae family)	Children < 5 years of age. Neonatal infections are common but often mild or asymptomatic, presumably because of protection from maternal antibody or breastfeeding. First infections after 3 months of age are likely to be symptomatic; incidence peaks among children 4–23 months of age	Watery diarrheal disease	Most of the infections resolve spontaneously (4–6 days)	Fever Stomach cramps Vomiting Dehydration due to severe diarrhea is one of the major complications	The virus is usually spread by the fecal-oral route, after touching toys or things that have been contaminated by the stool of another infected child. This usually happens when children do not wash their hands after using the toilet or before eating food. The viruses can also spread by way of contaminated food and drinking water. Infected food handlers who prepare salads, sandwiches, and other foods that require no cooking can spread the disease	Winter disease in the temperate zones: incidence peaks in winter primarily in the Americas, and peaks in the autumn or spring are common in other parts of the world. In the tropics, the seasonality of such infections is less distinct. Throughout most of the world, rotavirus is present all year round

Table 1C Clinical and epidemiological characteristics of the main fungal and parasitic enteropathogens

Pathogen	Typical age of presentation	Type of diarrhea	Duration of symptoms	Clinical features	Transmission	Seasonality
Candida spp	<12 months of age	Prolonged secretory diarrhea without blood and mucus	Cases of diarrhea that last as long as 3 months are reported	Abdominal pain and cramping	Candida has been identified in high concentrations in the stools of malnourished children. It has also been suggested as a cause of antibiotic-associated diarrhea in infants	Hot and dry summer months
Cryptosporidium parvum	<2 years of age	Acute, watery, nonbloody diarrhea	Diarrhea may last for a few days to 2 weeks	Mild fever, abdominal cramps, malaise, anorexia	Drinking water or food (oysters, clams, and mussels, raw vegetables, salads) contaminated with fecal matter containing the oocysts. Vegetables can be contaminated from fertilizer of animal or human feces, by contaminated water used to irrigate or moisten produce, by soiled hands of farm workers, produce handlers, or food workers, and from contaminated surfaces where vegetables are packed	March–May and October–November in endemic areas
Entamoeba histolytica	2–5 years of age	Fulminating dysentery Bloody diarrhea Nondysenteric diarrhea is a common presentation of amebiasis in children < 2 years of age	The dysentery lasts 3 to 4 weeks	~90% of infections are asymptomatic. ~10% of infections produce a spectrum of clinical syndromes ranging from dysentery to abscesses of the liver or ther organs. Weight loss, fatigue, abdominal pain are seen. Very young children seem to be predisposed to fulminant colitis. Abscesses of the liver or other organs are the most important complications	It is also called the “four F” infection: – flies – food (ingestion of viable cysts from fecally contaminated water, food, or hands) – fingers – fornication	Common in the tropics but rare in temperate climates More common in summer (particularly July–August)
Giardia lamblia	Greater susceptibility in the young (1–4 years of age)	Creamy or watery diarrhea with mucus	Symptoms usually last > 1 week; diarrhea often subsides	Asymptomatic infections are common. Symptomatic patients frequently have malaise, vague abdominal discomfort, and moderate weight loss. Anorexia, nausea, and vomiting are less common	– Person-to-person: poor fecal hygiene, anal-oral contact, common in day-care centers and other institutional settings – Food-borne: food contamination with Giardia cysts after cooking or preparation – Waterborne: ingestion of contaminated water. –Animal reservoirs: importance as a source of infection is unclear. Parasites similar to those in humans are found in many mammals, including beavers from reservoirs implicated in epidemics	Summer

Table 2 Characteristics of stool, intestinal segment-damaged, microorganisms involved

Feature of feces	Small intestine	Colon
Appearance	Liquid	Mucus and/or with blood
Volume	Abundant	Poor
Frequency	Increase	Large increase
Blood	+/−	+++
pH	<5.5	>5.5
Reducing substances	Positive	Negative
Fecal leukocytes	<5 per field	>10 per field
Blood leukocytes	Normal	Possible leukocytosis
Microorganism	Virus	Invasive bacteria
	Adenovirus	Aeromonas spp
	Astrovirus	Campylobacter spp
	Calicivirus	EIEC – EHEC
	Rotavirus	Salmonella spp
		Shigella spp
		Plesiomonas spp
		Yersinia spp
	Enterotoxigenic bacteria	Bacterial toxins
		Clostridium difficile
	Clostridium perfringens
	Cholera spp
	ETEC
	Vibrio spp
	Parasites	Parasites
	Cryptosporidium spp	Entamoeba
	Giardia spp	organism

Note: © 2009 Biomedia. Reproduced with permission from Caramia G, Ruffini E, Salvatori P. Infectious gastroenteritis. Neonatal Infectious Diseases Study Group of the Italian Society of Neonatology. Manual of Neonatal Infectious Diseases. Milan: Biomedia; 2009.⁵⁵

Table 3 Differential diagnosis

Enzymatic and metabolic disorders	Anatomical defects
	Hirschsprung’s disease
Congenital glucose-galactose malabsorption	Intestinal lymphangiectasia
	Short bowel
Congenital disaccharidase defect (lactase, isomaltase-saccaridasi)
	Primary immune disorders
Secondary malabsorption of monosaccharides and disaccharidases (gastrointestinal surgery, infections, intolerance to soy protein)	Wiskott–Aldrich syndrome
	Thymic dysplasia
	Enteropathy associated with HIV-1
Congenital chloridorrea	Inflammatory disorders
Congenital defect of the Na^+/H^+ exchanger	Intolerance to cow’s milk protein
	Intolerance to soy protein
Congenital bile acid malabsorption	Regional enteritis
	Ulcerative colitis
Congenital defect of enterochinasi	Hypoparathyroidism
	Hyperparathyroidism
Cystic fibrosis
Shwachman syndrome	Various
Physiological pancreatic amylase deficiency	Phototherapy for hyperbilirubinemia
Enteropathic acrodermatitis	Familial dysautonomia
Wolman’s disease	Familial enteropathy
Abetalipoproteinemia	Diarrhea from medications (antibiotics, etc)
Adrenal insufficiency
Intestinal hormone hypersecretion	Necrotizing enterocolitis
Transcobalamin II deficiency
Hereditary tyrosinemia
Methionine malabsorption
Congenital microvillous atrophy

Note: © 2009 Biomedia. Reproduced with permission from Caramia G, Ruffini E, Salvatori P. Infectious gastroenteritis. Neonatal Infectious Diseases Study Group of the Italian Society of Neonatology. Manual of Neonatal Infectious Diseases. Milan: Biomedia; 2009.⁵⁵

Table 4 Management of rehydration

Dehydration status	Treatment
Milda (<3% weight loss)	Oral rehydration salts, at home Practical advice: – Liquids should be administered in small amounts frequently (each 15–30 minutes) – For children over 14 years old and adults: ensure at least 2 L per day and add one glass (200 mL) per each bowel movement	Children less than 2 years old: 50–100 mL of oral rehydration solution (ORS), after each evacuation, providing a volume similar to the assessed fluid loss (gastrointestinal and urinary) Children between 1 and 14 years old: 100–200 mL of ORS, after each evacuation, providing a volume similar to the assessed fluid loss (gastrointestinal and urinary) Children over 14 years old and adults: drink the amount of ORS needed, ingesting a volume similar to the assessed fluid loss (gastrointestinal and urinary); up to 2 L daily
Moderatea (3%–8% weight loss)  Sunken eyes with ocular hypotony  Absence of tears  Dryness of the oral mucosa, tongue, and mucous membrane  Intense thirst, drinks eagerly  Skin pinch goes back slowly (1–2 seconds)	Oral rehydration salts and close clinical monitoring, especially in children under 18 months of age Practical advice: – It is recommended that the patient be sitting up during treatment – If the taste of the solution causes nausea: oral rehydration via nasogastric tube	Administer within first 4 hours: Children less than 4 months (less than 5 kg): 200–400 mL Children 4–11 months (5–7.9 kg): 400–600 mL Children 13–23 months (8–10.9 kg): 600–800 mL Children 2–4 years (11–15.9 kg): 800–1200 mL Children 5-years (16–29.9 kg): 1200–2200 mL Children over 15 years and adults (30 kg or more): 2200–4000 mL
Severeb	Rehydrate in two phases: 1. Intravenous rehydration  Practical advice:  – Absence of or weak radial pulse indicates a life-threatening emergency. Two or more lines should be installed in order to reach the necessary perfusion speed. Solutions may be pumped into the patient. As soon as radial pulse is palpable, the perfusion can be adjusted to the guideline  –Lactated Ringer’s solution is the first option. In an emergency situation, if it is not available, isotonic saline solution (CINa 0.9%) can be used  – never use glucose solution 2. Oral rehydration  Practical advice:  – Sit the patient, supporting the arms on a table, at the beginning of the oral rehydration. This keeps the patient alert and improves the oral tolerance Closely monitor fluid balance during this phase in order to guarantee sufficient replenishment of volume. If this is not done, the patient is at risk of developing renal failure	1. Intravenous rehydration (2–4 hours)  Intravenous lactated Ringer’s solution is recommended at the following perfusion rates:  1st hour: 50 mL/kg  2nd hour: 25 mL/kg  3rd hour: 25 mL/kg  Clinical assessment should be used to determine whether to continue intravenous rehydration  Closely monitor radial pulse or capillary nail-refillc time to assess the dehydration. If the pulse is weak or the capillary perfusion is greater than 2 seconds, increase the speed of perfusion 2. Oral rehydration  Start oral rehydration as soon as the patient is able to drink.  Follow the guidelines for moderate dehydration, always adapting to the volume of fluid loss

Notes:

a Based on World Health Organization;¹¹⁸

b based on Ognio;¹¹⁹

c in the capillary nail-refill test, pressure is applied on the nail bed until this becomes white. Once the tissue has paled, pressure is removed. While the patient sustains the hand above the heart, the health professional measures the time that it takes for the blood to return to the tissue, indicated by the return of the pink color to the nail. This time has to be less than 2 seconds. If it is longer, it indicates severe dehydration or shock. © 2009 Biomedia. Reproduced with permission from Caramia G, Ruffini E, Salvatori P. Infectious gastroenteritis. Neonatal Infectious Diseases Study Group of the Italian Society of Neonatology. Manual of Neonatal Infectious Diseases. Milan: Biomedia; 2009.⁵⁵

Table 5A Content and distribution of body fluids according to age

	Premature	Infant	1 year old	3 years old	9 years old	Adult
Weight (kg)	1.5	3	10	15	30	70
Body surface area (m^2)	0.15	0.2	0.5	0.6	1	1.7
Liquid body weight (%)	80	78	65	60	60	60
Extracellular fluid (%)	50	45	25	20	20	20
Intracellular fluid (%)	30	33	40	40	40	40

Note: © 2009 Biomedia. Reproduced with permission from Caramia G, Ruffini E, Salvatori P. Infectious gastroenteritis. Neonatal Infectious Diseases Study Group of the Italian Society of Neonatology. Manual of Neonatal Infectious Diseases. Milan: Biomedia; 2009.⁵⁵

Table 5B Daily water demand in relation to age

Body weight	Fluid volume/24 hours	Flow rate administration/hour
Children < 10 kg	100 mL/kg	4 mL/kg
Children 11–20 kg	1000 mL + 50 mL/kg for each kg above 10 kg	40 mL/kg/h + 2 mL/kg/h × (body weight − 10 kg)
Children > 20 kg	1500 mL + 20 mL/kg for each kg above 20 kg	60 mL/kg/h + 1 mL/kg/h × (body weight − 20 kg)

Note: © 2009 Biomedia. Reproduced with permission from Caramia G, Ruffini E, Salvatori P. Infectious gastroenteritis. Neonatal Infectious Diseases Study Group of the Italian Society of Neonatology. Manual of Neonatal Infectious Diseases. Milan: Biomedia; 2009.⁵⁵

Table 6 Composition of the main oral rehydration solutions on the market in Europe

	Glucose mmol/L	Na mEq/L	K mEq/L	Cl mEq/L	HCO3/citrate mEq/L	mOsm/L	Kcal/L	Aroma	Probiotics
WHO (1984/2002)	110/75	90/75	20	80	30/8–12	311/245	80	No	No
ESPGHAN (1989/1997)	74–111	60	20	>25	20	200–250	52–80	No	No
Dicodral forte	111	90	20	80	30	331	80	No	No
Dicodral 60	90	60	20	37	14 citrate	211	80	Banana	No
Dicodral	111	30	20	40	10	211	80	No	No
Floridral	83	60	20	37	14 citrate	214	80	Banana	LGG CFU = 5 × 10^9
GES 60	108	60	20	50	14 citrate	270	80	No	No
Idraton 245	75	75	20	65	10 citrate	245	79.1	Orange	No
Idravita	120	60	20	50	10 citrate	230	80	Banana	No
Prereid	77	50	20	40	10	200	79.35	Citrus	No
Prereid, liquid	1.91	50	20	57	66	230	80	Citrus	No
Reidrax	75	60	20	60	10 citrate	225	60.8	No	No
Reuterin idro	83	61	20	46	11	220	60	No	L. reuteri DSM 17938 CFU = 10^8
Reuterin brick	61	58.5	19.2	44.3	–	230	45	Apricot	L. reuteri DSM 17938 CFU = 10^8
Home solution	Water 1 liter, sugar 1 spoon (19 g), salt 1 teaspoon (3 g), a pinch of bicarbonate (0.5 g)

Abbreviations: Na, sodium; K, potassium; Cl, chloride; HCO³, bicarbonate; L, liter; LGG, Lactobacillus rhamnosus GG; L. reuteri, Lactobacillus reuteri; CFU, colony forming units; WHO, world Health Organization; ESPGHAN, European Society of Paediatric Gastroenterology, Hepatology and Nutrition.

Note: © 2009 Biomedia. Reproduced with permission from Caramia G, Ruffini E, Salvatori P. Infectious gastroenteritis. Neonatal Infectious Diseases Study Group of the Italian Society of Neonatology. Manual of Neonatal Infectious Diseases. Milan: Biomedia; 2009.⁵⁵

Table 7 Treatment algorithm for acute gastroenteritis

Table 8 Bacterial gastroenteritis and antimicrobial active on germs responsible

Pathogen	Sensitive antimicrobial	Indications for therapy
Aeromonas spp	– Ciprofloxacin (250–350 mg, 2 every 12 hours) – Cephalosporins III (cefotaxime 25–80 mg/kg IV every 12 hours) – Meropenem (20 mg/kg IV every 8 hours) – Aminoglycosides (gentamicin 4 mg/kg IV every 24 hours)	In invasive forms
Campylobacter spp	– Azithromycin (5 mg/kg every 12 hours or10 mg/kg every 24 hours) – Erythromycin (10–15 mg/kg IV every 8 hours)	In invasive forms
Clostridium difficile	– Metronidazole (7.5–10 mg/kg OS/IV every 8 hours) – Vancomycin (10 mg/kg OS every 6 hours)	Therapy should be initiated only if diarrhea persists after a suspension of antibiotic therapy
Escherichia coli	– Cephalosporins III (ceftriaxone 50 mg/kg IV every 24 hours) – Aminoglycosides (amikacyn 7.5 mg/kg every 8–12 hours) (EPEC) – Meropenem (20 mg/kg Iv every 8 hours) (EPEC) – Azithromycin (5 mg/kg every 12 hours or or10 mg/kg every 24 hours) (EHEC) – Ciprofloxacin (250–350 mg every 12 hours) (ETEC; EAEC) – Rifaximin (>12 years: 200 mg every 8–12 hours) (EAEC)	If systemic complications. The use of antibiotics increases the risk of hemolytic uremic syndrome
Helicobacter pylori	– Amoxicillin (70 mg/kg every 8–12 hours) + – Clarithromycin (7.7 mg/kg every 12 hours)	Add one of the related drugs: omeprazole 20 mg, lansoprazole 30 mg, pantoprazole 40 mg, rabeprazole 20 mg, esomeprazole 20 mg) every 12 hours
Pleiomonas spp	– Ciprofloxacin (250–350 mg every 12 hours) – Azithromycin (5 mg/kg or10 mg/kg every 12 hours or10 mg/kg every 24 hours) – Trimethoprim-sulfamethoxazole (4–20 mg/kg orally every 12 hours)	In invasive forms
Salmonella spp	– Ampicillin or amoxicillin (100 mg/kg IV every 6 hours) or cephalosporins III (ceftriaxone 50 mg/kg IV every 24 hours)	In invasive forms. Therapy prolongs the carrier state; however, recommended under 3 months of age for the high incidence of bacteremia. 3–5 days if there is bacteremia, or 1–4 weeks if there is involvement of the meninges
Shigella spp	– Ciprofloxacin (250–350 mg every 12 hours) – Cephalosporins III (ceftriaxone 50 mg/kg IV every 24 hours) – Azithromycin (5 mg/kg every 12 hours)	In invasive forms. The treatment reduces duration of illness, but does not prevent complications
Vibrio cholerae	– Cephalosporins III (ceftriaxone 50 mg/kg IV every 24 hours) – Ciprofloxacin (250–350 mg every 12 hours)	The treatment reduces duration of illness and prevents dehydration. The antimicrobial susceptibility patterns are constantly changing
Yersinia spp	– Cephalosporins III (ceftriaxone 50 mg/kg IV every 24 hours) – Aminoglycosides (gentamicin 4 mg/kg IV every 24 hours) – Meropenem (20 mg/kg IV every 8 hours) – Ciprofloxacin (250–350 mg every 12 hours)	Only in complicated cases

Abbreviations: OS, orally; IV, intravenous; ETEC, Enterotoxigenic E. coli; EPEC, Enteropathogenic E. coli; EAEC, Enteroaggregative E. coli; EHEC, Enterohemorrhagic E. coli.

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