Treatment for acute gastroenteritis in ward admission
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Treatment of Acute Gastroenteritis (Ward Admission)
Acute gastroenteritis (AGE) admitted to the ward requires a structured approach covering fluid resuscitation, symptom management, dietary guidance, targeted antibiotic therapy, and infection control. The cornerstone of treatment remains rehydration - everything else is adjunctive.
1. Criteria for Ward Admission
Admission is warranted when any of the following are present:
- Severe dehydration (>9% body weight loss)
- Hemodynamic compromise or altered mental status
- Persistent/protracted vomiting preventing oral intake
- Stool losses exceeding fluid input
- Electrolyte abnormalities requiring IV correction
- Infants <3 months, very low birth weight, immunocompromised
- Chronic medical conditions complicating therapy
- Dysentery with systemic signs
- Failure of outpatient oral rehydration therapy (ORT)
2. Fluid Resuscitation
Oral Rehydration Therapy (ORT) - First Line
ORT exploits the sodium-glucose co-transport mechanism, which remains intact even in severe diarrhea. It is equivalent to IV therapy for mild-moderate dehydration and is associated with shorter hospital stays.
| Solution | Na (mmol/L) | Glucose (mmol/L) | Osmolarity (mOsm/L) |
|---|---|---|---|
| WHO ORS (reduced osmolarity, 2002) | 75 | 75 | 245 |
| Pedialyte | 45 | 139 | 250 |
| Sports drinks / juice | <2 | 600+ | 730+ - NOT suitable |
- Mild dehydration: 50 mL/kg ORS over 3-4 hours
- Moderate dehydration: 100 mL/kg ORS over 3-4 hours
- Replace ongoing losses: ~10 mL/kg per stool, ~2 mL/kg per vomit episode
- In adults, preferred fluids (water, dilute juices) are acceptable once moderate deficit is corrected
IV Rehydration - Reserved For
- Severe dehydration (>9%)
- Hemodynamic compromise or shock
- Altered mental status / inability to drink safely
- Failure of ORT after 4-6 hours
- Persistent vomiting
IV fluid of choice: Normal saline (0.9% NaCl) or Ringer's lactate. Give 20 mL/kg bolus for shock; correct remaining deficit over 24-48 hours. Monitor electrolytes - hyponatremia and hypokalemia are common complications.
3. Antiemetics
Antiemetics reduce vomiting, shorten ED/ward stay, and decrease need for IV fluids.
| Drug | Dose (Adults) | Notes |
|---|---|---|
| Ondansetron (first-line) | 4-8 mg IV/oral q6-8h | Single oral dose highly effective; minimal side effects |
| Metoclopramide | 10 mg IV/oral q8h | Extrapyramidal risk; use cautiously |
| Domperidone | 10 mg oral q8h | Preferred over metoclopramide for children |
| Promethazine | 25 mg IM/IV | Avoid in children <2 years - risk of fatal respiratory depression (FDA black box) |
In children: Ondansetron (0.15 mg/kg) is the antiemetic of choice. Dopamine antagonists (promethazine, prochlorperazine, metoclopramide, droperidol) should NOT be used in children due to respiratory depression and extrapyramidal effects with no proven benefit.
- Tintinalli's Emergency Medicine, p. 889-890
4. Antimotility Agents
| Agent | Adult Use | Pediatric Use |
|---|---|---|
| Loperamide | Acceptable for mild-moderate non-bloody diarrhea without fever | Contraindicated <2 years; avoid in bloody stools/bacterial GE |
| Diphenoxylate/atropine (Lomotil) | Limited use in adults | No role in children |
| Bismuth subsalicylate | Modest effect; do not exceed dosing limits | Caution <12 years (salicylate toxicity) |
Do NOT use antimotility agents in: dysentery (fever + bloody diarrhea), suspected STEC O157:H7, Salmonella/Shigella/Campylobacter, children with any suspected bacterial cause. These can cause paralytic ileus, toxic megacolon, lethargy, and death.
- Rosen's Emergency Medicine, p. 3256; Tintinalli's, p. 890
5. Antibiotic Therapy
Empiric antibiotics are NOT indicated for most cases - viral and self-limited bacterial infections account for the majority of AGE.
When to Give Antibiotics (IDSA 2017 Guidelines):
- Infants <3 months with bloody diarrhea
- Immunocompromised patients with severe illness
- Documented fever, abdominal pain, bloody diarrhea, and presumptive Shigella (bacillary dysentery)
- Recent international travelers with fever ≥38.5°C or sepsis signs
Empiric Regimen (Adults):
- Ciprofloxacin 500 mg oral BD x 3-5 days, OR
- Levofloxacin 500 mg oral OD x 3-5 days
- Azithromycin 500 mg OD x 3 days - preferred in areas with fluoroquinolone resistance (SE Asia, South Asia) and in children
Pathogen-Specific Therapy:
| Organism | Treatment |
|---|---|
| C. difficile | Oral vancomycin 125 mg QID x 10 days (first-line for moderate-severe); metronidazole 500 mg TDS (mild, non-severe) |
| Giardia intestinalis | Metronidazole 400 mg TDS x 5-7 days, or tinidazole 2g single dose |
| E. histolytica | Metronidazole 750 mg TDS x 5-10 days + luminal agent (paromomycin or diloxanide) |
| Shigella | Ciprofloxacin 500 mg BD x 3 days (or azithromycin if resistant) |
| Campylobacter | Azithromycin 500 mg OD x 3 days (first-line; fluoroquinolone resistance common) |
| Salmonella (non-typhoidal) | Usually no antibiotics needed; ciprofloxacin for immunocompromised/severe disease |
| Cryptosporidium | Nitazoxanide 500 mg BD x 3 days (immunocompetent); immune reconstitution in HIV |
CRITICAL: Avoid antibiotics if STEC O157:H7 is suspected (non-bloody or bloody diarrhea with HUS signs) - antibiotics increase risk of hemolytic-uremic syndrome (HUS).
- Tintinalli's Emergency Medicine, p. 891; Rosen's Emergency Medicine, p. 3255
6. Diet and Nutrition
- Do NOT withhold feeds for >4 hours in a dehydrated child, or at all in a non-dehydrated child. Early refeeding improves outcomes.
- Resume age-appropriate, nutritionally complete diet as soon as rehydration is achieved.
- The BRAT diet (banana, rice, applesauce, toast) is no longer recommended - unnecessarily restrictive and inadequate in fat and calories.
- Most children can continue lactose-containing milk/formula; consider lactose-free for inpatients (slight reduction in diarrhea duration).
- Breastfed infants should continue breastfeeding throughout illness.
7. Adjunctive Therapies
Zinc Supplementation
- WHO recommendation: 10-20 mg/day x 10-14 days for children <5 years in endemic areas
- Reduces duration and severity of diarrhea in areas with zinc deficiency/malnutrition
- Evidence limited in developed countries
Probiotics
- Lactobacillus rhamnosus GG (LGG) and Saccharomyces boulardii - recommended by ESPGHAN and Asia-Pacific guidelines as adjuncts to ORS
- Modest reduction (~1 day) in diarrhea duration and frequency
- Note: A large PECARN RCT found no benefit of LGG on duration/frequency of vomiting or diarrhea
- Caution: Not recommended for premature infants, immunocompromised, central line patients, cardiac valve disease, short gut syndrome
Ondansetron (ODT) - Facilitating ORT
- A single oral dissolving dose significantly improves ORT success and reduces IV fluid requirement
- Tintinalli's, p. 389
8. Monitoring in Ward
- Fluid balance (input/output) every 4-8 hours
- Body weight daily
- Stool frequency and character (chart bloody stools)
- Electrolytes (Na, K, Cl, HCO3) - especially on admission and after 24h of rehydration
- Blood glucose in infants and young children
- Renal function if severe dehydration
- Watch for HUS signs: pallor, decreased urine output, petechiae (esp. post-bloody diarrhea)
9. Investigations for Ward Patients
| Test | Indication |
|---|---|
| Stool culture/PCR panel | Systemic involvement, bloody stool, dysentery, >2 weeks, immunocompromised, outbreak |
| Stool for C. difficile toxin | Recent antibiotic use, hospitalized patients |
| Stool ova & parasites | Travel history, >2 weeks symptoms, MSM, immunocompromised |
| Stool for STEC O157 / Shiga toxin | Bloody diarrhea, HUS suspicion |
| Serum electrolytes, BUN, Cr | All ward admissions |
| CBC | Systemic features, suspected bacteremia |
| Blood culture | Infants <3 months, immunocompromised, sepsis features |
10. Infection Control
- Contact precautions for all admitted patients with infectious GE
- Strict handwashing with soap and water (alcohol hand rubs are inadequate for norovirus and C. difficile)
- Cohort patients with same pathogen
- Environmental decontamination with 1:10 bleach solution for norovirus
11. Discharge Criteria
- Tolerating oral fluids without persistent vomiting
- No signs of dehydration
- Electrolytes normalized
- Caregiver able to continue ORT at home
- Appropriate follow-up arranged
Provide parents/carers with written instructions on signs of clinical deterioration and return-to-ED criteria.
Key References:
- Tintinalli's Emergency Medicine: A Comprehensive Study Guide, pp. 888-891
- Rosen's Emergency Medicine: Concepts and Clinical Practice, pp. 3254-3256
- Goldman-Cecil Medicine, p. 690
- IDSA 2017 guidelines on infectious diarrhea (Guerrant RL et al.)
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