When is admission recommended for acute gastroenteritis?

When to Admit Acute Gastroenteritis

Admit patients with acute gastroenteritis who have severe dehydration (≥10% fluid deficit), signs of shock, failure of oral rehydration therapy, altered mental status, intractable vomiting despite antiemetics, or significant comorbidities that increase risk of complications. 1

Specific Admission Criteria

Severity of Dehydration

• Severe dehydration (≥10% fluid deficit) mandates hospitalization and intravenous fluid therapy 1
• Clinical signs indicating severe dehydration include: markedly abnormal capillary refill (>3 seconds), poor skin turgor, abnormal respiratory pattern, altered mental status, absent tears, sunken eyes, and minimal or no urine output 2, 3
• Patients with moderate dehydration (6-9% deficit) who fail oral rehydration therapy after 2-4 hours require admission 4

Hemodynamic Instability

• Any signs of shock (hypotension, tachycardia, poor perfusion, altered mental status) require immediate hospitalization and intravenous resuscitation 4
• Patients with persistent tachycardia or hypotension despite initial fluid resuscitation need admission 1

Failure of Outpatient Management

• Intractable vomiting that prevents adequate oral intake despite antiemetic therapy (such as ondansetron) necessitates admission 2, 3
• Inability to tolerate oral rehydration solution after appropriate trial with small, frequent volumes requires intravenous therapy and hospitalization 4
• Patients who refuse to drink adequately may require nasogastric ORS administration or admission for IV fluids 4

High-Risk Patient Populations

• Age extremes: The highest percentages of hospitalization and death occur in persons ≥65 years, making lower thresholds for admission appropriate in elderly patients 1
• Immunocompromised patients (including those on immunosuppressive therapy, HIV-infected, transplant recipients, or with malignancy) require aggressive management and lower threshold for admission due to risk of severe or prolonged illness 1, 5
• Infants <3 months warrant careful consideration for admission given higher risk of severe dehydration and complications 1
• Patients with chronic liver disease or renal insufficiency have complicated disease requiring more aggressive medical management 5

Specific Clinical Presentations Requiring Admission

• Bloody diarrhea with fever and systemic toxicity may indicate dysentery from Salmonella, Shigella, or enterohemorrhagic E. coli, requiring hospitalization for monitoring of complications like hemolytic uremic syndrome 1, 5
• Severe abdominal pain that is disproportionate to examination findings or suggests surgical abdomen 1
• Electrolyte abnormalities (particularly hyponatremia, hypernatremia, or severe hypokalemia) requiring intravenous correction 6
• Hypoglycemia in the setting of prolonged vomiting and diarrhea 7
• Secondary septicemia or signs of systemic bacterial infection 6

Social and Logistical Factors

• Inability of caregivers to provide adequate home monitoring or follow-up 3
• Lack of access to oral rehydration solutions or appropriate fluids at home 4
• Concern for inadequate supervision or ability to recognize deterioration 5

Common Pitfalls to Avoid

• Do not delay admission while attempting prolonged oral rehydration in patients with moderate-to-severe dehydration who are not improving after 2-4 hours 4
• Do not discharge patients with persistent altered mental status, as this indicates severe dehydration or potential complications 4
• Do not underestimate dehydration in elderly patients, who may not manifest classic signs and have higher mortality risk 1
• Do not assume viral etiology in immunocompromised patients with bloody diarrhea and fever—these patients require admission for evaluation and potential antimicrobial therapy 1, 8
• Recognize that most acute gastroenteritis is self-limited and does not require admission—the estimated annual burden includes only 500,000 hospitalizations out of 179 million outpatient visits in the United States, emphasizing that admission should be reserved for truly high-risk cases 1