What is the recommended management for norovirus inpatients?

Norovirus Inpatient Management

Primary Management Approach

The cornerstone of norovirus inpatient management is aggressive hydration therapy (oral or intravenous) combined with strict isolation precautions until 24-48 hours after symptom resolution. 1, 2

Immediate Clinical Assessment

Hydration Status Evaluation

• Assess for severe dehydration requiring IV therapy: Look for decreased skin turgor, dry mucous membranes, altered mental status, decreased urine output, and hemodynamic instability 2, 3
• Approximately 10% of norovirus patients require hospitalization specifically for dehydration management 1, 2
• High-risk populations (elderly, young children, hospitalized patients, immunocompromised) warrant lower threshold for IV hydration as they experience prolonged illness courses lasting 4-6 days versus the typical 1-3 days 1, 2, 3

Hydration Management Algorithm

Step 1: Initial Rehydration

• Initiate oral rehydration therapy (ORT) with glucose-electrolyte solutions if patient can tolerate oral intake 2, 4
• Escalate immediately to IV fluid therapy if: 2, 4
  • Patient cannot tolerate oral intake due to persistent vomiting
  • Signs of severe dehydration present
  • Elderly patient in long-term care setting (higher mortality risk) 1, 2

Step 2: Adjunctive Antiemetic Therapy

• Consider ondansetron to facilitate oral rehydration success and reduce need for IV therapy, particularly in pediatric patients 4

Infection Control Measures (Critical for Inpatient Settings)

Patient Isolation

• Isolate patient until 24-48 hours after complete symptom resolution 1, 2
• Cohort infected patients together in a dedicated unit with assigned nursing staff to prevent transmission to uninfected patients 5
• Do not transfer patients to unaffected areas for 48 hours after exposure, even if asymptomatic, as 30% of infections are asymptomatic yet still shed virus 1, 5

Hand Hygiene Protocol

• Mandate soap and water handwashing for minimum 20 seconds - this is non-negotiable 1, 5
• Alcohol-based sanitizers (≥70% ethanol) are inadequate as primary hand hygiene and should only serve as adjunct between proper handwashings 1, 5
• This is a critical pitfall: alcohol sanitizers have limited efficacy against norovirus's non-enveloped structure 5

Environmental Disinfection

• After removing visible soiling, disinfect all surfaces with chlorine bleach solution at 1,000-5,000 ppm concentration (1:50 to 1:10 dilution of 5.25% household bleach) 1, 5
• Prioritize high-touch surfaces: door handles, bed rails, bathroom fixtures, call buttons 5
• Standard hospital disinfectants are often insufficient; EPA-approved norovirus-specific agents are required 1

Special Population Considerations

Elderly and Long-Term Care Patients

• Maintain heightened vigilance for mortality risk - norovirus-associated deaths occur predominantly in elderly persons and long-term care outbreaks 1, 2
• Lower threshold for hospitalization and IV therapy given prolonged illness courses 1, 2

Immunocompromised Patients

• Anticipate prolonged viral shedding lasting weeks to years with potential for chronic diarrhea 3, 6
• Consider experimental therapies (nitazoxanide, ribavirin, immunoglobulin) in severe refractory cases, though evidence remains limited to case reports 6

Pediatric Patients

• Oral rehydration therapy is as effective as IV therapy for mild-to-moderate dehydration 4
• Ondansetron increases ORT success rates and should be considered early 4

Healthcare Worker Management

• Exclude ill healthcare workers until 48-72 hours after symptom resolution 1, 5
• Implement sick leave policies that don't penalize ill workers to facilitate compliance with exclusion 5
• Asymptomatic exposed staff should not work in unaffected areas for 48 hours post-exposure 5

Critical Pitfalls to Avoid

• Never rely on alcohol-based hand sanitizers as primary hand hygiene - they are ineffective against norovirus 5
• Never require negative stool testing before ending isolation - viral shedding continues for average of 4 weeks but doesn't indicate ongoing contagiousness 1, 2, 5
• Never use standard hospital disinfectants without verifying norovirus efficacy - chlorine bleach concentration is critical 1, 5
• Never discharge elderly or immunocompromised patients without ensuring adequate oral intake given their higher complication rates 1, 2, 7

Monitoring and Discharge Criteria

• Patient must be symptom-free for 24-48 hours before ending isolation 1, 2
• Ensure adequate oral intake and stable hydration status before discharge 2, 3
• Provide discharge education on continued hand hygiene for 48 hours post-symptoms to prevent household transmission 5