What is the management for viral gastrointestinal infections?

Management of Viral Gastroenteritis

Oral rehydration therapy (ORT) is the primary treatment for viral gastroenteritis, as it effectively addresses the main risk of dehydration and electrolyte imbalance in this self-limited condition. 1

Assessment of Dehydration

Evaluate for:

• Abnormal capillary refill time (>2 seconds)
• Abnormal skin turgor
• Abnormal respiratory pattern
• Tachycardia (>90 bpm)
• Fever (>37.8°C)
• Altered mental status
• Signs of shock

Severe dehydration may present with:

• Oral rehydration intolerance
• Severe abdominal pain
• Altered mental status
• More than 6 bloody stools per day 1

Treatment Algorithm

1. Rehydration

• Mild to Moderate Dehydration:

  • Oral rehydration therapy with appropriate electrolyte solutions 1, 2
  • Continue breastfeeding in infants (protective effects against viral enteric infections) 1
  • Avoid foods high in simple sugars as they can worsen diarrhea 1

• Severe Dehydration:

  • Intravenous fluid therapy for patients with:
    • Severe dehydration
    • Inability to tolerate oral fluids
    • Altered mental status
    • Signs of shock 1
  • Hospitalization for aggressive treatment 1

2. Antiemetics

• Ondansetron may be given to children >4 years and adolescents to facilitate oral rehydration when vomiting is prominent 1, 2
• This can increase success rate of oral rehydration and reduce need for IV therapy and hospitalization 2

3. Antimotility Agents

• Do not give antimotility drugs (e.g., loperamide) to children <18 years 1
• May be used cautiously in immunocompetent adults 1
• Avoid in all patients with:
  • Inflammatory diarrhea
  • Diarrhea with fever
  • Risk of toxic megacolon 1, 3

4. Nutrition

• Resume normal feeding during illness
• Return to age-appropriate usual diet during or immediately after rehydration
• This approach decreases intestinal permeability, reduces illness duration, and improves nutritional outcomes 1

Special Considerations

Cardiac Risk with Antimotility Agents

Loperamide carries significant warnings:

• Cases of QT prolongation, Torsades de Pointes, ventricular arrhythmias, and cardiac arrest reported
• Avoid in patients taking medications that prolong QT interval
• Avoid in patients with risk factors for QT prolongation 3

Laboratory Testing

For hospitalized patients with severe illness, consider:

• Complete blood count
• CRP
• Electrolytes
• Liver function tests
• Stool studies as indicated 1

Prevention Measures

1. Hand Hygiene:

   • Vigorous handwashing with soap and water for at least 20 seconds
   • Alcohol-based hand sanitizers (≥70% ethanol) as an adjunct 1

2. Environmental Cleaning:

   • Clean soiled surfaces promptly
   • Disinfect bathrooms and rooms occupied by ill persons 4

3. Isolation Precautions:

   • Separate ill persons from well persons until at least 2 days after symptom resolution
   • Staff with symptoms should be excluded from contact with susceptible persons for at least 2 days after resolution 4
   • Food handlers should not prepare food during illness and for 2 days after resolution 4

4. Protective Equipment:

   • Use disposable gloves when in contact with ill persons
   • Consider masks when cleaning areas contaminated by feces or vomitus
   • Handle soiled linens with minimal agitation 4

5. Vaccination:

   • Rotavirus vaccination is strongly recommended for prevention 1

Common Pitfalls to Avoid

1. Overuse of IV fluids: ORT is as effective as IV therapy for mild to moderate dehydration and doesn't necessarily take longer 5

2. Inappropriate use of antimotility agents: Avoid in children and in cases of inflammatory or febrile diarrhea 1, 3

3. Withholding food: Continuing normal feeding during illness improves outcomes 1

4. Neglecting hand hygiene: Proper handwashing is critical to prevent transmission 4, 1

5. Premature return to work/school: Ill individuals should be excluded from food handling and contact with susceptible persons for at least 2 days after symptom resolution 4