What is the recommended management of norovirus infection, including fluid replacement, antiemetic use, and infection‑control precautions?

Norovirus Management

Norovirus infection requires supportive care with oral or intravenous rehydration, strict infection control measures including handwashing with soap and water for at least 20 seconds, environmental disinfection with bleach solution (1,000-5,000 ppm), and isolation of infected individuals until 24-48 hours after symptom resolution. 1

Fluid Replacement Strategy

Hydration is the cornerstone of norovirus management, as approximately 10% of infected persons require medical attention for dehydration. 2

• Initiate oral rehydration therapy as first-line treatment if the patient can tolerate oral intake 2
• Escalate to intravenous fluid therapy when oral rehydration is inadequate or not tolerated 2
• Hospitalization is indicated for severe dehydration unresponsive to oral rehydration, particularly in elderly patients or those in long-term care facilities given the association with mortality in these settings 2, 3

High-Risk Populations Requiring Close Monitoring

• Elderly patients (>65 years) are at risk for prolonged diarrhea lasting >2 days and require more intensive monitoring 3
• Patients with cardiovascular disease have a 17-fold increased risk of severe potassium depletion 3
• Renal transplant recipients have a 13-fold increased risk of electrolyte disturbances and may develop acute graft rejection 3
• Immunosuppressed patients have a 5.7-fold increased risk of creatinine elevation 3

Antiemetic Use

The CDC guidelines do not specifically recommend routine antiemetic use for norovirus infection. 1 Treatment remains primarily supportive with focus on hydration rather than pharmacologic symptom control. In clinical practice, antiemetics may be considered for severe vomiting that prevents oral rehydration, but this should not delay appropriate fluid replacement therapy.

Infection Control Precautions

Hand Hygiene (Critical Priority)

Handwashing with soap and running water for at least 20 seconds is the most effective method to reduce norovirus contamination and is non-negotiable. 1, 4

• Alcohol-based hand sanitizers (≥70% ethanol) may serve only as an adjunct between proper handwashings but should never substitute for soap and water 1, 4
• This is because norovirus is a non-enveloped virus with limited susceptibility to alcohol-based products 1

Isolation and Exclusion Protocols

Isolate infected individuals until 24-48 hours after complete symptom resolution in institutional settings such as hospitals, long-term care facilities, and cruise ships 1, 2

Exclude ill healthcare workers, food handlers, and childcare workers until 48-72 hours after symptom resolution to prevent transmission 1, 4

• Do not require negative stool results before returning to work, as viral shedding can continue for an average of 4 weeks without indicating ongoing contagiousness 2, 4
• In healthcare facilities, cohort ill patients together with dedicated nursing staff to minimize transmission 1, 4
• Restrict exposed asymptomatic staff and patients from working in or transferring to unaffected areas for 48 hours after exposure 1, 4

Environmental Disinfection

After initial cleaning to remove soiling, disinfect all potentially contaminated surfaces using chlorine bleach solution at 1,000-5,000 ppm concentration (1:50 to 1:10 dilution of household bleach). 1, 4

• Focus intensive cleaning on bathrooms and high-touch surfaces including door knobs and handrails 4, 5
• Prepare bleach solutions fresh daily for use within 2 hours due to evaporative dilution 5
• Avoid phenolic compounds, triclosan, and quaternary ammonium compounds as they are less effective against norovirus 5
• In healthcare settings, use EPA-registered products with label claims for healthcare use and follow manufacturer's instructions for dilution, application, and contact time 1

Additional Preventive Measures

Eliminate bare-hand contact with ready-to-eat foods as an essential preventive strategy 1, 4

Common Pitfalls to Avoid

• Never rely solely on alcohol-based hand sanitizers as primary hand hygiene—this is the most common error in norovirus control 2, 4, 5
• Do not transfer ill patients to unaffected units except for medical necessity and only after infection control consultation 1, 5
• Do not underestimate illness duration in vulnerable populations—while typical norovirus resolves in 1-3 days, prolonged courses of 4-6 days occur in young children, elderly persons, and hospitalized patients 2
• Recognize that persistent vomiting beyond one week is atypical and warrants evaluation for alternative diagnoses or complications 2

Outbreak Management in Institutional Settings

In long-term care facilities and hospitals, consider isolating both exposed and unexposed well persons to break the transmission cycle during active outbreaks 1, 4, 5

• Close affected units to new admissions to prevent introduction of new susceptible individuals 5
• Screen all visitors for symptoms and exclude symptomatic individuals, or at minimum caution about risks and emphasize hand hygiene 5
• Implement strict contact precautions immediately upon identification of clustered cases, as early detection and prompt action are critical for rapid outbreak termination 6, 7

Expected Outbreak Duration

Expect outbreaks in nursing homes to be prolonged, sometimes lasting weeks to months despite control measures, due to the highly infectious nature of norovirus and vulnerability of residents 5, 8