What is the management for multiple family members presenting with nausea, vomiting, diarrhea, fever, and itching for 5 days after exposure to each other?

Management of Acute Gastroenteritis with Fever in Multiple Family Members

For this cluster of family members presenting with nausea, vomiting, diarrhea, fever, and itching for 5 days, the priority is aggressive oral rehydration therapy with reduced osmolarity ORS, strict infection control measures including vigorous handwashing (not just alcohol sanitizers), and empiric antibiotics should be avoided unless specific high-risk features develop. 1

Immediate Assessment and Hydration Strategy

Assess hydration status immediately by evaluating capillary refill, skin turgor, and respiratory pattern—these three findings are the most reliable predictors of ≥5% dehydration. 2 Check for abnormal pulse, perfusion, and mental status changes that would indicate severe dehydration requiring IV fluids. 1

Rehydration Protocol

• For mild to moderate dehydration: Administer reduced osmolarity oral rehydration solution (ORS) as first-line therapy 1
• For vomiting patients: Start with small, frequent volumes (5 mL every minute) using a spoon or syringe under supervision 1. Correction of dehydration often reduces vomiting frequency 1
• For severe dehydration or shock: Use isotonic IV fluids (lactated Ringer's or normal saline) until pulse, perfusion, and mental status normalize, then transition to ORS 1
• Nasogastric ORS can be considered for moderate dehydration when oral intake is refused or not tolerated 1
• Continue ORS to replace ongoing stool and vomit losses until symptoms resolve 1

Antiemetic Consideration

Ondansetron may be administered to control vomiting and facilitate oral rehydration—studies show it decreases vomiting rates, improves oral intake success, and reduces need for IV hydration with minimal serious side effects. 2

Empiric Antibiotic Therapy: When NOT to Treat

Do NOT prescribe empiric antibiotics for this presentation. 1 The IDSA guidelines strongly recommend against empiric antimicrobial therapy in acute watery diarrhea without recent international travel. 1 Key reasons:

• Most acute gastroenteritis is viral (likely norovirus given the family cluster pattern) 1
• Antibiotics may prolong shedding of non-typhi Salmonella species 1
• Growing quinolone resistance in Campylobacter may worsen outcomes 1
• Antibiotics do not reduce secondary transmission—handwashing does 1

Exceptions Requiring Empiric Antibiotics

Consider empiric treatment ONLY if: 1

• Severe illness with high fever AND bloody diarrhea (dysentery)
• Immunocompromised patients
• Young infants (<6 months) who appear ill
• Watery diarrhea persisting >5 days 1

If empiric therapy is warranted: Use fluoroquinolone (adults) or TMP-SMX (children) after obtaining stool specimen for culture. 1 Modify or discontinue when organism identified. 1

Critical Infection Control Measures

This family cluster strongly suggests norovirus, which is highly contagious and requires specific precautions: 1

• Vigorous handwashing with soap, friction, and running water is mandatory—alcohol hand sanitizers do NOT inactivate norovirus or C. difficile spores 1
• Isolate symptomatic family members when possible 1
• Disinfect contaminated surfaces and fomites 1
• Do NOT treat asymptomatic contacts with antibiotics or preventive therapy 1

Nutritional Management

Resume age-appropriate diet immediately once rehydration begins—do not withhold food: 1

• Continue breastfeeding in infants throughout the illness 1
• Older children and adults: starches, cereals, yogurt, fruits, vegetables 1
• Avoid foods high in simple sugars and fats 1
• Full-strength, lactose-containing formulas are acceptable for infants unless true lactose intolerance develops (worsening diarrhea with reintroduction) 1

Medications to AVOID

Do NOT use antimotility agents (loperamide) in children <18 years with acute diarrhea. 1 In adults, loperamide may be considered ONLY after adequate hydration and ONLY if no bloody stools, high fever, or suspected invasive pathogens. 1

The Itching Component

The itching raises concern for scabies, especially in a family cluster. 1 Scabies outbreaks in households present with pruritus and can occur alongside viral gastroenteritis. Consider skin examination for burrows, papules, or vesicles in intertrigenous areas. 1 However, itching may also represent urticaria from viral infection or food-related allergen.

When to Escalate Care

Instruct family members to return immediately if: 1

• Decreased urine output develops
• Patient becomes irritable, lethargic, or has altered mental status
• Intractable vomiting prevents any oral intake
• Bloody stools appear
• Symptoms persist beyond 5-7 days

Diagnostic Testing: Usually Not Needed

Stool cultures are NOT routinely indicated for acute watery diarrhea without high-risk features. 1 Consider testing only if:

• Bloody diarrhea or dysentery present 1
• Severe illness requiring hospitalization 1
• Symptoms persist >7 days 1
• Outbreak investigation needed 1

Laboratory testing (BUN, electrolytes, bicarbonate) is not routinely recommended but may help assess dehydration severity in select cases. 2

Common Pitfalls to Avoid

• Prescribing antibiotics "just in case"—this increases resistance, prolongs pathogen shedding, and provides no benefit in viral gastroenteritis 1
• Using only alcohol-based hand sanitizers—these do not eliminate norovirus or C. difficile spores 1
• Withholding food during rehydration—early refeeding prevents nutritional deterioration 1
• Giving antimotility agents to children or patients with bloody diarrhea—risk of toxic megacolon and worsened outcomes 1
• Treating asymptomatic household contacts prophylactically—no evidence of benefit 1