Chapter 5.4 Dysentery

Dysentery is diarrhoea presenting with frequent loose stools mixed with blood (not just a few smears on the surface). Most episodes are due to Shigella, and nearly all require antibiotic treatment. Shigellosis can lead to life-threatening complications, including intestinal perforation, toxic megacolon and haemolytic uraemic syndrome.

Diagnosis

The diagnostic signs of dysentery are frequent loose stools with visible red blood.  Other findings on examination may include:

  • abdominal pain
  • fever
  • convulsions
  • lethargy
  • dehydration
  • rectal prolapse.

Treatment

Most children can be treated at home.

Admit to hospital:

  • young infants (< 2 months old)
  • severely ill children, who look lethargic, have abdominal distension and tenderness or convulsions
  • children with any another condition requiring hospital treatment.

Give an oral antibiotic (for 5 days) to which most local strains of Shigella are sensitive.

  • Give ciprofloxacin at 15 mg/kg twice a day for 3 days if antibiotic sensitivity is unknown. If local antimicrobial sensitivity is known, follow local guidelines.
  • Give ceftriaxone IV or IM at 50–80 mg/kg per day for 3 days to severely ill children or as second-line treatment.

Give zinc supplements as for children with watery diarrhoea.


Note: There is widespread Shigella resistance to ampicillin, co-trimoxazole, chloramphenicol, nalidixic acid, tetracycline, gentamicin and first- and second-generation cephalosporin, which are no longer effective. There is also already reported resistance to ciprofloxacin in some countries.

  •  If there is no improvement after 2 full days of treatment:

check for other conditions (see Chapter 2),
stop the first antibiotic, and give a second-line antibiotic or a known effective against Shigella in the area (see Annex 2 for dosages).

  • If the two antibiotics that are usually effective against Shigella in the area have each been given for 2 days, with no sign of clinical improvement, check for other conditions (consult a standard paediatric textbook).
  • If amoebiasis is possible, give metronidazole at 10 mg/kg three times a day for 5 days.

Admit the child if there is an indication requiring hospital treatment.

Infants and young children

  • Consider surgical causes of blood in the stools (for example, intussusception; see section 9.4), and refer to a surgeon, if appropriate. Dysentery is unusual in neonates and young infants; therefore, consider life-threatening bacterial sepsis
  • For suspected sepsis give IM or IV ceftriaxone at 100 mg/kg once daily for 5 days.

Severely malnourished children

  • See Chapter 7 for the general management of severely malnourished children.
  • Treat for Shigella first and then for amoebiasis on clinical grounds if laboratory examination is not possible.
  • If microscopic examination of fresh stools in a reliable laboratory is possible, check for trophozoites of Entamoeba histolytica in red blood cells and treat for amoebiasis, if present. Also examine stools for trophozoites of Giardia lamblia and treat if present.

Supportive care

  • Supportive care includes the prevention or correction of dehydration and contin- ued feeding. For guidelines on supportive care of severe acutely malnourished children with bloody diarrhoea, see also Chapter 7.
  • Never give drugs for symptomatic relief of abdominal or rectal pain or to reduce the frequency of stools, as these drugs can increase the severity of the illness.
  • Treatment of dehydration
    Assess the child for signs of dehydration and give fluids according to treatment plan A, B or C, as appropriate.

Nutritional management

  • Ensuring a good diet is important, as dysentery has a marked adverse effect on nutritional status. Feeding is often difficult because of lack of appetite; return of appetite is an important sign of improvement.
  • Breastfeeding should be continued throughout the course of the illness, more frequently than normal, if possible, because the infant may not take the usual amount per feed.
  • Children aged 6 months or more should receive their normal foods. Encour- age the child to eat, and allow the child to select preferred foods.

Complications

  • Dehydration. Dehydration is the most common complication of dysentery, and children should be assessed and managed for dehydration irrespective of any other complication. Give fluids according to treatment plan AB or C, as appropriate.
  • Potassium depletion. Potassium depletion can be prevented by giving ORS (when indicated) or potassium-rich foods such as bananas, coconut water or dark-green leafy vegetables.
  • High fever. If the child has high fever (≥ 39 °C or ≥ 102.2 °F) that appears to be causing distress, give paracetamol and consider severe bacterial infection.
  • Rectal prolapse. Gently push back the rectal prolapse using a surgical glove or a wet cloth. Alternatively, prepare a warm solution of saturated magnesium sulfate, and apply compresses with this solution to reduce the prolapse by decreasing oedema.
  • Convulsions. A single convulsion occurs most commonly. If they are pro- longed or repeated, give diazepam (see chart 9). Avoid giving rectal diazepam. Always check for hypoglycaemia.
  • Haemolytic uraemic syndrome. Where laboratory tests are not possible, suspect haemolytic uraemic syndrome in patients with easy bruising, pallor, altered consciousness and low or no urine output.
  • Toxic megacolon. Toxic megacolon usually presents with fever, abdominal distension, pain and tenderness with loss of bowel sounds, tachycardia and dehydration. Give IV fluids for dehydration, pass a nasogastric tube, and start antibiotics.

Further details of treatment can be found in standard paediatric textbooks.