What is the treatment for viral enterocolitis?

Treatment of Viral Enterocolitis

For most cases of viral enterocolitis, supportive care with oral rehydration therapy is the primary treatment, as these infections are typically self-limiting; however, specific antiviral therapy is indicated for CMV enterocolitis and may be considered for rotavirus and adenovirus in immunocompromised patients. 1

General Approach to Viral Enterocolitis

Supportive Care (First-Line for Most Viral Causes)

• Oral rehydration therapy (ORT) is as effective as intravenous fluid therapy for mild-to-moderate dehydration and should be the initial approach for most patients with viral gastroenteritis. 1, 2

• Hypotonic oral rehydration solutions are safe and effective across all forms of acute viral diarrhea in childhood, with improved efficacy compared to standard WHO formulations. 3

• For adults, maintenance of adequate hydration is critical, particularly in elderly patients and those on diuretic medications. 1

• Bismuth subsalicylate may reduce symptom duration (from 27 to 20 hours in Norwalk virus infection), though evidence is limited. 1

Important Caveats

• Anticholinergic, antidiarrheal, and opioid agents should be avoided as they may aggravate ileus. 4, 5

• Most infants can be "fed through" an episode, and breast milk may provide protective effects against viral enteric infections. 1

• Intravenous fluids are reserved for severe dehydration or when oral rehydration fails. 1, 2

Specific Antiviral Therapy by Pathogen

CMV Enterocolitis (Requires Treatment)

Ganciclovir is the first-line treatment for CMV enterocolitis, particularly in immunocompromised patients where this infection poses significant morbidity risk. 1

• Standard regimen: Ganciclovir 5 mg/kg IV twice daily for 2-3 weeks, followed by maintenance therapy with 5 mg/kg once daily IV on 5 days per week for several weeks. 1

• Alternative agents include:

  • Foscarnet 90 mg/kg IV twice daily over 2 hours, followed by 60 mg/kg three times daily over 1 hour 1
  • Cidofovir 5 mg/kg IV once weekly for 2 weeks, then once every other week (requires prehydration with at least 2 liters IV fluids and probenecid 2 g orally 3 hours prior, then 1 g at 2 and 8 hours following cidofovir to reduce toxicity) 1

• Combination therapy with foscarnet plus ganciclovir may be used for refractory cases. 1

• Addition of intravenous immunoglobulin may be considered, though evidence for optimal dosing is insufficient. 1

• Oral valganciclovir has shown success in case reports for congenitally infected infants with CMV enterocolitis. 6

Rotavirus Enterocolitis

• Nitazoxanide 7.5 mg/kg orally twice daily may be considered, though this has only been assessed in immunocompetent pediatric patients with limited evidence. 1

• Oral immunoglobulin has been suggested but lacks sufficient evidence for specific dosing recommendations. 1

• In neonatal nursery outbreaks, oral administration of immunoglobulin may protect against disease and shorten symptom duration. 1

Adenovirus Enterocolitis

• Cidofovir 5 mg/kg IV once weekly for 2 weeks, then once every other week is recommended for adenovirus enterocolitis, primarily in immunocompromised patients. 1

• Requires prehydration with at least 2 liters of IV fluids and probenecid administration (2 g orally 3 hours prior, then 1 g at 2 and 8 hours following cidofovir) to reduce nephrotoxicity. 1

Special Populations

Immunocompromised Patients (Including Cancer/Transplant)

• Viral enterocolitis in immunocompromised hosts requires more aggressive evaluation and treatment, as these patients may develop chronic infection. 1

• In AIDS patients, rotavirus was detected in 37% and adenovirus in 24% of specimens from those with diarrhea, associated with higher degrees of immunocompromise. 1

• Specific antiviral therapy is more strongly indicated in this population, particularly for CMV, adenovirus, and rotavirus. 1

Neonates

• Term infants typically have mild or asymptomatic rotavirus infection during the first month due to maternal antibody transfer. 1

• Preterm infants lack adequate maternal antibody and are at increased risk for early symptomatic rotavirus infection. 1

• Oral immunoglobulin may protect against disease during nursery outbreaks. 1

Elderly Patients

• Antibody levels wane with age, placing elderly patients at higher risk for infections and adverse outcomes. 1

• Diuretic medications and debility increase the risk of complications from what might otherwise be mild diarrheal episodes. 1

When Viral Enterocolitis is Part of Neutropenic Enterocolitis

If viral enterocolitis occurs in the context of neutropenic enterocolitis (common in chemotherapy patients), the management differs significantly:

• Broad-spectrum antibiotics covering gram-negative, gram-positive, and anaerobic organisms are essential, with regimens including piperacillin-tazobactam or imipenem-cilastatin monotherapy, or combination therapy with cefepime/ceftazidime plus metronidazole. 7, 4

• Add granulocyte colony-stimulating factors (G-CSFs), nasogastric decompression, IV fluids, and bowel rest. 7, 4

• Antifungal therapy should be considered if no response to antibacterial agents. 4

• Surgical intervention is indicated for bowel perforation, abscess formation, persistent bleeding, or clinical deterioration despite medical management. 7, 4

Monitoring and Follow-Up

• Serial clinical assessments for signs of dehydration, including decreased urine output, altered mental status, and hemodynamic instability. 2

• Laboratory monitoring is generally not necessary for mild-to-moderate cases but should be considered in severe dehydration requiring hospitalization. 2

• Watch for post-infectious lactose intolerance, which may persist for 10-14 days after rotavirus infection. 1