What is the management bundle for acute gastroenteritis?

Management Bundle for Acute Gastroenteritis

The management of acute gastroenteritis should focus on oral rehydration therapy as first-line treatment, early refeeding, judicious use of antiemetics in specific situations, and avoidance of antimotility agents in children. 1

Rehydration Therapy

Oral Rehydration

• Oral rehydration solution (ORS) is the first-line treatment for mild to moderate dehydration in both children and adults 1
• Evaluate hydration status through clinical signs: skin turgor, mental status, mucous membrane moisture, capillary refill, and vital signs 1
• For mild to moderate dehydration, use ORS until clinical dehydration is corrected 1
• Continue ORS to replace ongoing losses until diarrhea and vomiting resolve 1
• Low-osmolarity ORS formulations are preferred over sports drinks or juices 1
• Nasogastric administration of ORS may be considered for patients who cannot tolerate oral intake 1

Intravenous Rehydration

• Reserve intravenous rehydration for patients with:
  • Severe dehydration
  • Shock
  • Altered mental status
  • Failure of oral rehydration therapy
  • Ileus 1
• Use isotonic fluids such as lactated Ringer's or normal saline 1
• Transition to ORS once patient improves 1

Nutritional Management

• Continue breastfeeding in infants throughout the diarrheal episode 1
• Resume age-appropriate diet during or immediately after rehydration 1, 2
• Early refeeding decreases intestinal permeability, reduces illness duration, and improves nutritional outcomes 2
• Avoid foods high in simple sugars (soft drinks, undiluted apple juice, Jell-O, presweetened cereals) as they can exacerbate diarrhea through osmotic effects 2, 1
• Although commonly recommended, the BRAT (bananas, rice, applesauce, and toast) diet has limited supporting data 2
• Instructing patients to refrain from eating solid food for 24 hours is not useful 2
• In children <5 years of age, a lactose-free diet may reduce the duration of diarrhea by an average of 18 hours 2

Pharmacological Management

Antiemetics

• Ondansetron may be given to children >4 years and adolescents to facilitate oral rehydration when vomiting is significant 2, 1
• Ondansetron reduces the need for hospitalization or intravenous rehydration but may increase stool volume 2, 3
• Antiemetics should only be considered once the patient is adequately hydrated 2

Antimotility Agents

• Loperamide should not be given to children <18 years with acute diarrhea 2, 1
• Loperamide may be given to immunocompetent adults with acute watery diarrhea once adequately hydrated 2, 4
• Avoid loperamide in suspected or proven cases of inflammatory diarrhea or diarrhea with fever at any age 2
• For adults with acute diarrhea, the recommended initial dose of loperamide is 4 mg (two capsules) followed by 2 mg (one capsule) after each unformed stool, with a maximum daily dose of 16 mg 4

Other Agents

• Probiotics may reduce symptom severity and duration in both adults and children 1
• Zinc supplementation reduces diarrhea duration in children 6 months to 5 years of age in areas with high zinc deficiency prevalence 1
• Nonspecific antidiarrheal agents (kaolin-pectin, cholestyramine) have not demonstrated effectiveness in reducing diarrhea volume or duration 2, 1

Infection Control Measures

• Practice proper hand hygiene after using toilet or changing diapers, before and after food preparation, before eating, and after handling soiled items 1
• Use gloves and gowns when caring for people with diarrhea 1
• Clean and disinfect contaminated surfaces promptly 1
• Separate ill persons from well persons until at least 2 days after symptom resolution 1

Common Pitfalls to Avoid

• Delaying rehydration therapy while awaiting diagnostic testing 1
• Using inappropriate fluids like apple juice or sports drinks as primary rehydration solutions 1
• Administering antimotility drugs to children or in cases of bloody diarrhea 2
• Unnecessarily restricting diet during or after rehydration 2, 1
• Reliance on antidiarrheal agents shifts the therapeutic focus away from appropriate fluid, electrolyte, and nutritional therapy 2
• Antimicrobial agents have limited usefulness in the management of acute gastroenteritis since viral agents are the predominant cause 2, 1