What is the management protocol for gastroenteritis?

Management Protocol for Gastroenteritis

The cornerstone of gastroenteritis management is appropriate rehydration therapy, with reduced osmolarity oral rehydration solution (ORS) as first-line treatment for mild to moderate dehydration, and isotonic intravenous fluids for severe dehydration. 1, 2

Assessment of Dehydration

• Mild dehydration: Normal mental status, decreased oral intake, normal or slightly increased heart rate
• Moderate dehydration: Irritability, decreased urine output, increased thirst, sunken eyes, decreased skin turgor
• Severe dehydration: Altered mental status, tachycardia, hypotension, severely decreased skin turgor, serum osmolality >300 mOsm/kg 2, 3

Rehydration Protocol

Mild to Moderate Dehydration

1. Oral Rehydration Therapy (ORT):

   • Use reduced osmolarity ORS (first-line therapy) 1
   • Preparation: Mix 3.5g NaCl, 2.5g NaHCO₃, 1.5g KCl, and 20g glucose per liter of clean water 2
   • For children: Half-strength apple juice followed by preferred liquids can be effective 3
   • Continue breastfeeding throughout rehydration if applicable 2

2. If vomiting persists:

   • Consider ondansetron to improve ORS tolerance 3, 4
   • Nasogastric administration of ORS may be used for those unable to tolerate oral intake 1

Severe Dehydration

1. Intravenous Rehydration:
   • Use isotonic fluids (lactated Ringer's or normal saline) 1, 2
   • Continue until pulse, perfusion, and mental status normalize 1
   • Transition to oral rehydration once patient is stable 2, 5

Nutritional Management

• Resume age-appropriate diet during or immediately after rehydration 2
• Consider BRAT diet (Bananas, Rice, Applesauce, Toast) initially 2
• Avoid spicy foods, coffee, alcohol, and foods high in simple sugars and fats 2
• Consider zinc supplementation for children 6 months to 5 years with malnutrition 2

Antimicrobial Therapy

When to Consider Antimicrobial Treatment

Empiric antimicrobial therapy is NOT recommended for most cases of acute watery diarrhea 1, except for:

1. Infants <3 months with suspected bacterial etiology
2. Immunocompetent patients with fever, abdominal pain, and bloody diarrhea (suspected Shigella)
3. Recent international travelers with fever ≥38.5°C or signs of sepsis
4. Immunocompromised patients with severe illness and bloody diarrhea
5. Persistent watery diarrhea lasting ≥14 days 1, 2

Choice of Antimicrobials

• Adults: Fluoroquinolone (e.g., ciprofloxacin) or azithromycin based on local susceptibility patterns 1, 2
• Children: Third-generation cephalosporin for infants <3 months or those with neurologic involvement; azithromycin for other children 1, 2
• STEC O157 and other Shiga toxin 2-producing E. coli: Avoid antimicrobial therapy 1

Special Considerations

• Asymptomatic contacts: Do not offer empiric treatment; advise on infection prevention measures 1
• Suspected enteric fever: Treat empirically with broad-spectrum antimicrobials after obtaining cultures 1
• C. difficile infection: Requires specific antimicrobial treatment 6
• Persistent symptoms: Reassess fluid and electrolyte balance, nutritional status, and antimicrobial therapy; consider non-infectious causes (IBD, IBS, lactose intolerance) 1, 2

Prevention

• Implement proper hand hygiene practices 2
• Promote breastfeeding and rotavirus vaccination in children 3
• Educate about food and water safety 2

Monitoring and Follow-up

• Reassess hydration status regularly until corrected 2
• Evaluate patients after 48-72 hours of treatment 2
• Consider alternative diagnoses if no improvement occurs 2

Common Pitfalls to Avoid

• Delaying IV fluids when indicated in severe dehydration
• Using hypotonic fluids which may worsen electrolyte imbalances
• Administering antimotility agents in inflammatory diarrhea
• Overlooking underlying disease exacerbation (e.g., IBD flare vs. infectious diarrhea)
• Failing to recognize warning signs requiring immediate attention (severe abdominal pain, distension, ileus, toxic megacolon, sepsis) 2