gastroenteritis case study nursing

Gastroenteritis Nursing Diagnosis and Nursing Care Plan

Gastroenteritis nursing care plans diagnosis and interventions.

Gastroenteritis NCLEX Review and Nursing Care Plans

The most prevalent symptom of gastroenteritis is diarrhea. Moreover, symptom alleviation and fluid therapy are the cornerstones of treatment.

Pathophysiology of Gastroenteritis

Types of gastroenteritis.

Viral Gastroenteritis. Viral gastroenteritis is an infection of the intestines induced by most notable viruses such as norovirus or rotavirus. This condition is sometimes referred to as the stomach flu. Furthermore, close interaction with individuals who have the virus or are exposed to contaminated food or water transmits this extremely contagious infection.

These parasites have strong exterior shells that permit them to withstand certain circumstances for extended periods.

Risks Factors to Gastroenteritis

Signs and symptoms of gastroenteritis.

Symptoms may emerge one to three days after infection, depending on the cause, and range from mild to severe gastroenteritis. Symptoms typically last a few days, although they might last up to ten days.

Diagnosis of Gastroenteritis

Sigmoidoscopy. Healthcare professionals may perform some tests to rule out other disorders. As a result, the doctor may recommend that the patient with gastroenteritis undergo sigmoidoscopy. To look for symptoms of inflammatory bowel illness, a thin, flexible tube with a tiny camera is inserted from the anus into the lower large intestine. The sigmoidoscopy is a 15-minute procedure that typically does not require sedation.

Complications of Gastroenteritis

Crohn’s disease and colitis. Some individuals with gastroenteritis may develop ulcerative colitis or Crohn’s disease, which are inflammatory diseases of the digestive tract.

Treatment for Gastroenteritis

Prevention of gastroenteritis, gastroenteritis nursing diagnosis, nursing care plan for gastroenteritis 1.

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to vomiting and nausea secondary to gastroenteritis as evidenced by anorexia, insufficient food consumption, a reported inability to eat, and growling in the abdominal area.

Nursing Care Plan for Gastroenteritis 2

Nursing Diagnosis: Diarrhea related to infections caused by bacteria, viruses, or parasites secondary to gastroenteritis as evidenced by abdominal pain and cramps, more than three stools per day, overactive bowel movements, watery stool, and urgency

Nursing Care Plan for Gastroenteritis 3

Nursing Diagnosis: Deficient Knowledge related to an inability to recollect previously learned information, ignorance about a new disorder and treatment, and lack of familiarity with information resources secondary to gastroenteritis as evidenced by asking frequent inquiries, a lack of information, and verbalizing misconceptions or erroneous information.

Nursing Care Plan for Gastroenteritis 4

Nursing Diagnosis: Hyperthermia related to dehydration secondary to gastroenteritis as evidenced by a body temperature that is higher than usual, warm, flushed skin, elevated heart rate and respiratory rate, decreased appetite, lethargy or fatigue , and convulsions.

Nursing Care Plan for Gastroenteritis 5

Nursing Diagnosis: Risk for Fluid Volume Deficit related to diarrhea, insufficient fluid intake, nausea, and vomiting secondary to gastroenteritis.

As a risk nursing diagnosis, the Risk for Deficient Volume is entirely unrelated to any signs and symptoms since it has not yet developed in the patient, and safety precautions will be initiated instead.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020).  Nursing diagnoses handbook: An evidence-based guide to planning care . St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020).  Saunders comprehensive review for the NCLEX-RN examination . St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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7 Gastroenteritis Nursing Care Plans

Use this nursing care plan and management guide to help care for patients with gastroenteritis . Enhance your understanding of nursing assessment , interventions, goals, and nursing diagnosis , all specifically tailored to address the unique needs of individuals facing gastroenteritis. This guide equips you with the necessary information to provide effective and specialized care to patients dealing with gastroenteritis.

Table of Contents

What is gastroenteritis, nursing problem priorities, nursing diagnosis, nursing goals, 1. managing diarrhea and restoring normal function, 2. preventing dehydration, 3. promoting adequate nutritional balance, 4. initiating patient education and health teachings, 5. administering medications and providing pharmacologic support, 6. monitoring diagnostic and laboratory procedures, 7. assessing and monitoring for potential complications, recommended resources.

Gastroenteritis (also known as Food Poisoning; Stomach Flu ; Traveler’s Diarrhea ) is the inflammation of the lining of the stomach and small and large intestines. The most common cause of this disease is infection obtained from consuming food or water. A variety of bacteria, viruses, and parasites are associated with gastroenteritis. Viral gastroenteritis also called stomach flu is a very contagious form of this disease. Food-borne gastroenteritis or food poisoning is associated with bacteria strains such as Escherichia coli, Clostridium, Campylobacter, and salmonella. The ingestion of foods contaminated with chemicals (lead, mercury, arsenic) or the ingestion of poisonous species of mushrooms or plants or contaminated fish or shellfish can also result in gastroenteritis. Symptoms of this disease include fever , anorexia , nausea , vomiting , diarrhea , and abdominal discomfort. The treatment is symptomatic, although cases of bacterial and parasitic infections require antibiotic therapy.

Nursing Care Plans and Management

The nursing care plan goals for patients with gastroenteritis include preventing dehydration by promoting adequate fluid and electrolyte intake, managing symptoms such as nausea and diarrhea , and preventing the spread of infection to others. In addition, the nursing care plan should focus on educating the patient on proper hygiene and food handling practices to prevent future episodes of gastroenteritis. This care plan for gastroenteritis focuses on the initial management in a non-acute care setting.

The following are the nursing priorities for patients with gastroenteritis:

• Manage dehydration and electrolyte imbalances.
• Alleviate symptoms of nausea, vomiting , and diarrhea.
• Prevent further spread of infection and transmission to others.
• Provide dietary recommendations and guidance for fluid intake.
• Monitor for complications, such as severe dehydration or bacterial infection.
• Educate patients on proper hygiene practices and handwashing .
• Offer supportive care to aid in recovery and symptom relief.
• Administer appropriate medications, if necessary.
• Schedule follow-up appointments for monitoring and assessment of progress.
• Collaborate with healthcare professionals for coordinated care and management.

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with gastroenteritis based on the nurse ’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.

Goals and expected outcomes may include:

• The client will have a negative stool culture.
• The client will pass soft, formed stool no more than 3 x a day.
• The client will verbalize understanding of the causes of gastroenteritis, mode of transmission, and management of symptoms.
• The client will have an increased nutritional intake and an absence of nausea and vomiting .

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with gastroenteritis may include:

Diarrhea is a common symptom of acute gastroenteritis caused by bacterial, viral, or parasitic infections because these microorganisms can damage the lining of the digestive tract and lead to inflammation, which can cause fluid and electrolytes to leak from the body. This results in loose, watery stools that can lead to dehydration if not treated promptly.

Ask the client about a recent history of drinking contaminated water, eating food inadequately cooked, and ingestion of unpasteurized dairy products: Eating contaminated foods or drinking contaminated water may predispose the client to intestinal infection.

Evaluate the pattern of defecation. The defecation pattern will promote immediate treatment.

Assess for abdominal pain , abdominal cramping, hyperactive bowel sounds, frequency, urgency, and loose stools . These assessment findings are commonly connected with diarrhea. If gastroenteritis involves the large intestine , the colon is not able to absorb water and the client’s stool is very watery.

Submit the client’s stool for culture. A culture is a test to detect which causative organisms cause an infection.

Teach the client about the importance of hand washing after each bowel movement and before preparing food for others. Hands that are contaminated may easily spread the bacteria to utensils and surfaces used in food preparation hence hand washing after each bowel movement is the most efficient way to prevent the transmission of infection to others.

Educate the client about perianal care after each bowel movement . The anal area should be gently cleaned properly after a bowel movement to prevent skin irritation and transmission of microorganisms.

Encourage increase fluid intake of 1.5 to 2.5 liters/24 hours plus 200 ml for each loose stool in adults unless contraindicated. Increased fluid intake replaces fluid lost in liquid stools .

Encourage the client to restrict the intake of caffeine, milk, and dairy products. These food items can irritate the lining of the stomach, hence may worsen diarrhea.

Encourage the client to eat foods rich in potassium . When a client experience diarrhea, the stomach contents which are high in potassium get flushed out of the gastrointestinal tract into the stool and out of the body, resulting in hypokalemia .

Administer antidiarrheal medications as prescribed. Bismuth salts, kaolin, and pectin which are adsorbent antidiarrheals are commonly used for treating the diarrhea of gastroenteritis. These drugs coat the intestinal wall and absorb bacterial toxins.

One of the primary concerns in managing gastroenteritis is preventing dehydration , as excessive fluid loss from vomiting and diarrhea can quickly lead to a dangerous imbalance in the body’s fluid levels. Dehydration can be especially problematic for certain populations, such as young children, older adults, and individuals with weakened immune systems. Therefore, it is crucial to take proactive measures to prevent dehydration in patients with gastroenteritis.

Assess the client’s skin turgor and mucous membranes for signs of dehydration . A loss of interstitial fluid causes the loss of skin turgor. Assessment of skin turgor in adults is less accurate since their skin normally loses its elasticity. Therefore the skin turgor assessed over the sternum in the forehead is best. Several longitudinal furrows and coating may be noted along the tongue.

Assess the volume and frequency of vomiting. Vomiting is associated with fluid loss.

Assess the consistency and number of bowel movements. Gastroenteritis is associated with an increased frequency of very loose or watery bowel movements. The inflammation in the large intestine limits the colon ‘s ability to absorb water, leading to fluid volume deficit .

Assess the color and amount of urine . A decrease in urine volume and concentrated urine, as evidenced by darker urine color, denotes fluid volume deficit.

Assess the client’s PR and BP . A reduction in circulating blood volume can cause hypotension and tachycardia. The change in HR is a compensatory mechanism to maintain cardiac output. Usually, the pulse is weak and may be irregular if electrolyte imbalance also occurs. Hypotension is evident in fluid volume deficit.

Assess the client’s temperature. Fever that occurs with gastroenteritis increases fluid loss through perspiration and increased respiration.

Monitor BP for orthostatic changes (changes seen when changing from a supine to a standing position). Postural hypotension is a common manifestation of fluid loss. The incidence increase with age. Note the following orthostatic hypotension significances:

• Greater than 10 mm Hg: circulating blood volume decreases by 20%.
• Greater than 20 to 30 mm Hg drop: circulating blood volume is decreased by 40%.

Instruct the client to monitor weight daily and consistently with the same scale, preferably at the same time of the day, and wearing the same amount of clothing. The client with gastroenteritis may experience weight loss from fluid loss with diarrhea and vomiting. Instruction facilitates accurate measurement and assessment provides useful data for comparisons and helps in following trends.

Encourage regular oral hygiene . A fluid volume deficit can cause a dry, sticky mouth . Attention to mouth care promotes interest in drinking and reduces the discomfort of dry mucous membranes.

Encourage increase fluid intake of 1.5 to 2.5 liters/24 hours plus 200 ml for each loose stool in adults unless contraindicated. Increased fluid intake replaces fluid lost in the liquid stool. Being creative in selecting fluid sources (e.g., flavored gelatin, frozen juice bars, sports drink) can facilitate fluid replacement. Oral hydrating solutions (e.g., Rehydrate) can be considered as needed.

For the client who is unable to take sufficient oral fluids, consider the need for hospitalization and the administration of parental fluids as ordered. Fluids are needed to maintain hydration status. Determining the type and amount of fluid to be replaced and the infusion rates will vary depending on the client’s clinical status.

Administer antiemetic medications as ordered These drugs will reduce vomiting and the risk of fluid volume deficit.

Patients with acute gastroenteritis may experience imbalanced nutrition due to decreased appetite, nausea, vomiting, and diarrhea. These symptoms can cause reduced food intake and nutrient absorption, leading to a negative balance of energy and nutrients that the body needs for normal function and repair. Additionally, if the symptoms persist, patients may not be able to maintain their usual food intake, leading to further nutrient deficiencies.

Measure client weight. This will accurately monitor the response to therapy.

Monitor and record the number of vomiting, amount, and frequency. These data will help in initiating nursing actions and subsequent treatment.

Monitor the client’s food intake. To determine the amount of food that is consumed.

Provide a diverse diet according to his needs. This will stimulate the appetite of the client.

Provide parenteral fluids, as ordered. To ensure adequate fluid and electrolyte levels.

Refer to a dietitian if indicated. Collaboration with the dietician in order to guide the client about proper nutrition .

There may be a lack of knowledge among patients with acute gastroenteritis due to several reasons, including limited access to healthcare information, a lack of understanding about the causes and symptoms of the condition, and the perception that diarrhea is a common and self-limiting ailment that does not require medical attention. Additionally, different pathogens can cause acute gastroenteritis, and their symptoms can vary, making it difficult for patients to identify the specific cause of their illness. While medical treatment is crucial in managing gastroenteritis, patient education and health teachings play a vital role in improving outcomes and preventing further complications.

Assess the client’s knowledge of gastroenteritis, its mode of transmission, and its treatment. Clients who experience diarrhea and vomiting may not correlate the symptoms with an acquired intestinal infection. The client may not realize the risk of transmitting the infection to others.

Assess the client’s knowledge of safe food preparation and storage. The client may not understand the relationship of gastroenteritis to the consumption of inadequately cooked food, food contaminated with bacteria during preparation, and foods that are not maintained at appropriate temperatures.

Determine the client’s usual methods of managing diarrhea or vomiting. An effective teaching plan will include methods of symptom management that the client has found helpful in the past.

Teach the client about symptoms that must be reported immediately to the healthcare provider such as black tarry stools, blood or pus in the feces , fever greater than 38.3° C (101° F), increased dizziness, lightheadedness, or thirst, and vomiting or diarrhea that gets worse or continues for more than five days (3 days for the older adult or immunocompromised client: The client needs to understand that changes in the stool, high fever, persistent vomiting, and diarrhea may indicate intestinal bleeding and worsen the infection. Signs of fluid volume deficit and the inability to replace fluids by the oral route may require hospitalization for fluid replacement.

Educate the client and the family about the causes and treatments for gastroenteritis. Knowledge about the possible cause of this episode of gastroenteritis will help the client initiate to prevent future episodes. The client needs to recognize that the use of antibiotics is controversial in managing diarrhea. The client needs to understand the importance of fluid replacement.

Educate the client about the importance of hand washing after toileting and perianal hygiene and before preparing food for others. Good hand washing will prevent the spread of infectious agents.

Educate the client about food preparation and storage methods to reduce contamination by microorganisms. Ground meats are the most common source of foodborne pathogens. These meats should be cooked to an internal temperature of 160°F and should have no evidence of pink color. Raw meats should be kept separate from other ready-to-eat foods. All utensils and surfaces that have been in contact with the raw meat need to be washed with hot, soapy water. Raw fruits and vegetables must be washed before eating if they will not be cooked. Only pasteurized milk, fruit juices, and ciders should be consumed. Bacteria contamination or growth is more likely to occur in foods that are not maintained at appropriate temperatures until eaten.

It is important for healthcare professionals to carefully assess each patient with gastroenteritis, considering the severity of symptoms, the presence of complications, and the individual’s overall health status. Based on this evaluation , appropriate medications and pharmacologic support can be provided to optimize patient care and facilitate a swift recovery. The primary goals of pharmacologic intervention in these patients are to alleviate symptoms, control the infection if present, and prevent complications.

1. Antiemetics . Used to control nausea and vomiting.

• Ondansetron. Helps alleviate nausea and vomiting by blocking certain receptors in the brain and gastrointestinal tract.
• Promethazine . Works as an antihistamine and helps relieve nausea and vomiting symptoms.
• Metoclopramide. Helps reduce nausea and vomiting by increasing the movement of the stomach and intestines.

2. Antidiarrheals . Used to reduce the frequency and severity of diarrhea.

• Loperamide. Slows down bowel movements and helps control diarrhea.
• Bismuth subsalicylate. Helps relieve diarrhea and may also have some antimicrobial effects.

3. Antibiotics. Prescribed in cases of bacterial gastroenteritis to treat the underlying infection.

• Ciprofloxacin . A fluoroquinolone antibiotic effective against many bacterial pathogens.
• Azithromycin . A macrolide antibiotic that targets certain bacterial species causing gastroenteritis.

4. Probiotics. Used to restore the natural balance of gut bacteria.

• Lactobacillus acidophilus. Helps promote the growth of beneficial bacteria in the gut.

5. Electrolyte solutions . Used to rehydrate and restore electrolyte balance.

• Oral rehydration solutions (ORS). Contain electrolytes and glucose to replace lost fluids and prevent dehydration.
• Intravenous fluids . Administered in severe cases of dehydration when oral intake is not possible.

Monitoring the results of diagnostic and laboratory procedures is crucial in patients with gastroenteritis to guide appropriate treatment and ensure optimal patient care . It’s important to note that the specific tests and procedures ordered may vary depending on the patient’s symptoms, medical history , and the suspected cause of gastroenteritis. The healthcare provider will determine the most appropriate diagnostic approach for each individual case.

1. Stool Culture and Examination If a stool culture or examination reveals the presence of bacterial pathogens or parasites, the specific organism identified helps guide targeted therapy. Monitoring subsequent cultures or examinations can assess the effectiveness of treatment and determine if the infection has been cleared.

2. Viral Testing For patients with viral gastroenteritis, monitoring viral test results can confirm the presence of a specific virus, such as norovirus or rotavirus. This information can guide infection control measures in healthcare settings and help manage outbreaks.

3. Complete Blood Count (CBC) Monitoring the CBC helps evaluate the patient’s response to treatment. Decreasing white blood cell (WBC) counts may indicate resolution of infection, while persistently elevated WBC counts could suggest ongoing inflammation or the need for further investigation.

4. Electrolyte Panel Regular monitoring of electrolyte levels is essential, especially in patients with severe gastroenteritis or dehydration. Abnormal electrolyte levels, such as low sodium or potassium , may require correction through fluid replacement or targeted interventions.

5. Kidney Function Tests Continued monitoring of kidney function tests, such as BUN and creatinine , can assess the impact of dehydration on renal function. Improvements in kidney function values indicate rehydration and effective management of gastroenteritis.

6. Liver Function Tests Monitoring liver function tests is crucial if liver inflammation or injury is suspected. Serial measurements of liver enzymes, such as ALT and AST, can help evaluate the resolution of liver involvement and guide further management if necessary.

7. Clinical Assessment Alongside laboratory and diagnostic results, ongoing clinical assessment plays a vital role in monitoring patients with gastroenteritis. Monitoring symptoms such as diarrhea frequency, vomiting, abdominal pain , and general well-being helps gauge the patient’s response to treatment and identify any signs of complications.

Assessing and monitoring for potential complications is an important aspect of managing patients with gastroenteritis. While most cases of gastroenteritis resolve without complications, certain individuals may be at higher risk or develop complications. Early recognition of potential complications allows for prompt intervention and appropriate management. It’s essential for healthcare providers to maintain regular follow-up visits or consultations to assess the patient’s progress, reevaluate symptoms, and address any emerging concerns or complications.

1. Assess for signs and symptoms of dehydration. One of the primary complications of gastroenteritis is dehydration, which can occur due to excessive fluid loss from vomiting and diarrhea. Monitoring hydration status through clinical assessment, such as evaluating skin turgor, mucous membranes, and urine output, is essential. Laboratory tests, including electrolyte levels and kidney function tests, can help identify electrolyte imbalances and assess renal function.

2. Monitor patient’s electrolyte Imbalances. Severe and prolonged diarrhea and vomiting can disrupt the balance of electrolytes in the body, leading to imbalances such as hyponatremia (low sodium ) or hypokalemia (low potassium). Regular monitoring of electrolyte levels through laboratory tests can guide appropriate interventions and prevent complications associated with electrolyte disturbances.

3. Monitor patient’s weight daily. In cases of prolonged or severe gastroenteritis, malnutrition can occur due to inadequate nutrient absorption and decreased oral intake. Monitoring weight loss, assessing dietary intake, and considering nutritional supplementation or support may be necessary, especially in vulnerable populations such as children and older adults.

4. Monitor signs of secondary infections. Gastroenteritis can weaken the immune system, making individuals more susceptible to secondary infections. Monitoring for signs of bacterial superinfection, such as worsening abdominal pain , high fever, or the persistence of symptoms despite appropriate treatment, is important. Additional diagnostic tests or cultures may be needed to identify secondary infections.

5. Monitor patient’s hemodynamic stability. Severe cases of gastroenteritis can lead to hemodynamic instability, particularly in young children or those with compromised health. Monitoring vital signs, including blood pressure , heart rate , and perfusion indicators, can help identify signs of circulatory compromise or shock.

6. Monitor organ dysfunction. Although rare, certain infections associated with gastroenteritis, such as certain strains of E. coli or certain viral infections, can lead to organ dysfunction. Monitoring liver function tests, renal function, and other organ-specific markers may be necessary to identify any signs of organ involvement or complications.

7. Monitor patient’s neurological status. Some viral gastroenteritis infections, such as rotavirus, may cause neurological complications, including seizures or encephalopathy. Monitoring for any neurological symptoms or changes in mental status is crucial, especially in young children.

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care  Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health   Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ! Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

More nursing care plans related to gastrointestinal disorders:

• Appendectomy
• Bowel Incontinence (Fecal Incontinence)
• Cholecystectomy
• Constipation
• Diarrhea Nursing Care Plan and Management
• Cholecystitis and Cholelithiasis
• Gastroenteritis
• Gastroesophageal Reflux Disease (GERD)
• Hemorrhoids
• Ileostomy & Colostomy
• Inflammatory Bowel Disease (IBD)
• Intussusception
• Liver Cirrhosis
• Nausea & Vomiting
• Pancreatitis
• Peritonitis
• Peptic Ulcer Disease
• Subtotal Gastrectomy

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The following is a scenario of a patient with toxic megacolon:

Mary Cole, a 50-year-old female with a known history of ulcerative colitis (UC) and anemia, was driven to the emergency department (ED) by her daughter, Cindy, on April 11, 2019, just after 1000. The reason for her visit was due to complaints of severe abdominal pain/swelling and bloody diarrhea over the past four days.

Vital signs were taken in the ED showing a blood pressure (BP) of 96/50, heart rate (HR) 113 bpm, respiratory rate (RR) of 29, tympanic temperature of 38.9°C, oxygen saturation (O2 sat.) of 97% on room air, and a pain of 9/10 (using the verbal numeric pain scale) located in her left lower abdominal quadrant that is sharp, constant, and aggravated by movement. Mary states, “my stomach hurts so much I can barely take the pain”. She claims that she has been taking extra-strength Advil (ibuprofen 400mg) for the pain. Her vitals were reassessed after 20 minutes showing a decrease in BP to 85/47, HR 130, RR 29, tympanic temperature of 38.9°C, O2 sat. 96%, and pain still at 9/10.

Upon further assessment, Mrs. Cole appeared uncomfortable and was quietly crying and lying on her left side with her knees flexed and arms holding her abdomen. She was alert and oriented to person, place, time, and situation and was demonstrating appropriate responses and PERRLA. Her face was flushed and her skin felt warm and dry to touch. There was slight skin tenting at her clavicle and she admitted to not being able to “eat or drink very much over the past few days” due to her abdominal pain and discomfort. She claims to have been having diarrhea that “looks kind of bloody” and hasn’t been voiding as often as she “normally does”, approximately twice a day over these past few days. Her abdomen is visibly distended and tender/firm upon palpation. Upon auscultation, she has hypoactive bowel sounds in all four quadrants and her pain is noted to be in the left lower quadrant. She is tachycardic and has a clear S1S2 heartbeat with diminished pedal pulses;  tachypnea is noted, lung sounds are clear in all lobes. Her strengths in both upper and lower extremities are slightly weak and her daughter states that her mother has been “dizzy when getting up and has difficulty walking at times”.

While in the ED, the nurse inserted an 18-gauge intravenous (IV) to the left antecubital fossa (AC) and administered a 1 L normal saline (NS) bolus. Mary’s labs (CBC, CMP, cultures) were drawn, an x-ray and abdominal CT scan were performed, and a stool sample was ordered. She was administered 1 mg of morphine sulfate IV push at 1115 for her pain. In 15 minutes, her pain was reassessed and was reported as 8/10 using the numeric pain scale. She received an additional dose of 2 mg morphine sulfate IV push and reassessed after 15 minutes, stating a pain of 6/10; continuous pain assessment and management were performed. She was ordered NPO for bowel rest. The ED nurse administered 500 mg of metronidazole IV to prevent septic complications.

Mary’s labs revealed the following: elevated C-reactive protein of 16, positive antineutrophil cytoplasmic antibodies (ANCA), Hgb: 7.8, Hct: 23%, Platelets: 100,000, WBC: 13000, potassium: 3.3, sodium: 128, pH: 7.26, HCO3: 18, CO2: 31 (metabolic acidosis), lactic acid of 3.8, and the stool showed presence of blood and WBCs. Mary’s abdominal CT revealed colonic dilation of more than 6 cm in the transverse colon. Once results were in from the labs, x-ray, and CT scan, Mary was diagnosed with toxic megacolon resulting from a flare-up of UC and sent to the intensive care unit (ICU) for close observation and monitoring.

Once in the ICU, an NG tube was placed for gastric decompression due to the CT result of a 6 cm dilation of the colon. Her labs were closely monitored for electrolyte imbalance and further decline due to possible perforation of the colon (i.e. Hgb, Hct). Nursing priorities included focused assessments, monitoring for signs/symptoms of shock (perforation) such as rigid abdomen, severe abdominal pain, nausea/vomiting (N/V), fever, chills, and rectal bleeding. Mary was prescribed 400 mg of hydrocortisone IV to decrease inflammation and her pain was being monitored and managed with scheduled IV infusion of acetaminophen (Ofirmev) 1000 mg every 6 hours and 1 mg morphine sulfate IV push for breakthrough pain. Lactic acid was monitored every two hours until the levels fell below 2; she received Zosyn IV running at 25 mL/hr every four hours. Medical treatment was continued in cooperation with the gastroenterologist, intensivist, and surgeons to monitor for sepsis and the need for surgical intervention.

When Mary was stable, she was transferred to the direct observation unit (DOU) floor for observation and case management. On the floor, the patient was educated regarding toxic megacolon and taught about the need to continue her UC medication—Vedolizumab (Entyvio)—which, if taken correctly, should decrease the chance of  recurrence of UC flare-up and risk of toxic megacolon. Lastly, she met with case management and was educated on ulcerative colitis support groups and an appointment was schedule in May with her primary healthcare provider for follow-up.

Open-Ended Questions:

• Which areas of our nursing assessment should we closely monitor and what are we looking for?
• What are the major concerns with toxic megacolon related to bowel perforation?
• What other possible diagnoses should be considered and ruled out?
• What are the primary nursing diagnosis for Mrs. Cole?
• Areas of nursing assessment we want to closely monitor include a focused GI assessment, signs and symptoms of shock, and pain (related to dilation of colon).We would also monitor our lab values for any further indications that may show infection, fluid/electrolyte imbalances, and decrease in Hct/Hgb. It is important to remain cognizant of further deviations from the norm in order to prevent bowel perforation and/or treat the patient in a timely manner to reduce the chance of further complications (i.e. shock from perforation, sepsis).
• Biggest concern related to bowel perforation from toxic megacolon is infection from bacteria being released into abdomen; this places the patient at risk for septic shock.
• Other possible diagnosis that needed to be ruled out include: bowel obstruction peritonitis, pancreatitis, peptic ulcer, and kidney stones.
• Risk for infection
• Deficient fluid volume
• Risk for decreased cardiac tissue perfusion
• Dysfunctional gastrointestinal motility

Basson, M. D. (2018). Ulcerative colitis workup: approach considerations, serologic markers, other laboratory studies. Medscape . Retrieved from https://emedicine.medscape.com/article/183084-workup#showall Feuerstein, J. D., & Cheifetz, A. S. (2014). Ulcerative colitis: Epidemiology, diagnosis, and management. Mayo Clinic Proceedings, 89 (11), 1553-1563. http:dx.doi.org/10.1016/j.mayocp.2014.07.002

Hinkle, J. L., Brunner, L. S., Cheever, K. H., & Suddarth, D. S. (2014). Brunner & suddarth’s textbook of medical-surgical nursing. Philadelphia, PA: Lippincott Williams & Wilkins.

Unbound Medicine, Inc. (2014). Nursing Central (1.22) [Mobile application software]. Retrieved from <http://itunes.apple.com> Woodhouse, E. (2016). Toxic megacolon: A review for emergency department clinicians. Journal of Emergency Nursing, 42 (6), 481-486. https://doi.org/10.1016/j.jen2016.04.007

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Incidence, Etiology, and Severity of Acute Gastroenteritis Among Prospectively Enrolled Patients in 4 Veterans Affairs Hospitals and Outpatient Centers, 2016–2018

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Cristina V Cardemil, Neha Balachandran, Anita Kambhampati, Scott Grytdal, Rebecca M Dahl, Maria C Rodriguez-Barradas, Blanca Vargas, David O Beenhouwer, Karen V Evangelista, Vincent C Marconi, Kathryn L Meagley, Sheldon T Brown, Adrienne Perea, Cynthia Lucero-Obusan, Mark Holodniy, Hannah Browne, Rashi Gautam, Michael D Bowen, Jan Vinjé, Umesh D Parashar, Aron J Hall, Incidence, Etiology, and Severity of Acute Gastroenteritis Among Prospectively Enrolled Patients in 4 Veterans Affairs Hospitals and Outpatient Centers, 2016–2018, Clinical Infectious Diseases , Volume 73, Issue 9, 1 November 2021, Pages e2729–e2738, https://doi.org/10.1093/cid/ciaa806

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Acute gastroenteritis (AGE) burden, etiology, and severity in adults is not well characterized. We implemented a multisite AGE surveillance platform in 4 Veterans Affairs Medical Centers (Atlanta, Georgia; Bronx, New York; Houston, Texas; and Los Angeles, California), collectively serving >320 000 patients annually.

From 1 July 2016 to 30 June 2018, we actively identified inpatient AGE case patients and non-AGE inpatient controls through prospective screening of admitted patients and passively identified outpatients with AGE through stool samples submitted for clinical diagnostics. We abstracted medical charts and tested stool samples for 22 pathogens by means of multiplex gastrointestinal polymerase chain reaction panel followed by genotyping of norovirus- and rotavirus-positive samples. We determined pathogen-specific prevalence, incidence, and modified Vesikari severity scores.

We enrolled 724 inpatients with AGE, 394 non-AGE inpatient controls, and 506 outpatients with AGE. Clostridioides difficile and norovirus were most frequently detected among inpatients (for AGE case patients vs controls: C. difficile , 18.8% vs 8.4%; norovirus, 5.1% vs 1.5%; P < .01 for both) and outpatients (norovirus, 10.7%; C. difficile , 10.5%). The incidence per 100 000 population was highest among outpatients (AGE, 2715; C. difficile, 285; norovirus, 291) and inpatients ≥65 years old (AGE, 459; C. difficile, 91; norovirus, 26). Clinical severity scores were highest for inpatient norovirus, rotavirus, and Shigella /enteroinvasive Escherichia coli cases. Overall, 12% of inpatients with AGE had intensive care unit stays, and 2% died; 3 deaths were associated with C. difficile and 1 with norovirus. C. difficile and norovirus were detected year-round with a fall/winter predominance.

C. difficile and norovirus were leading AGE pathogens in outpatient and hospitalized US veterans, resulting in severe disease. Clinicians should remain vigilant for bacterial and viral causes of AGE year-round.

Acute gastroenteritis (AGE), characterized by diarrhea, vomiting, fever, and abdominal pain, causes 1.3 million deaths globally every year [ 1 ]. In the United States, AGE causes 179 million cases and 1 million hospitalizations annually [ 2 , 3 ]. Historically, AGE prevention and control efforts have focused on children, but adults experience a substantial proportion of illness; most US deaths are in older adults [ 3 , 4 ]. Both viral and bacterial pathogens play important roles in AGE across all age groups, and norovirus and Clostridioides difficile are important emerging infectious causes of AGE among US adults, including AGE-associated deaths [ 4 ]. In the United States, norovirus causes 20 million AGE illnesses and about 800 deaths every year [ 5 ]. C. difficile, increasingly observed in community and acute care settings, caused an estimated 453 000 infections with 29 000 associated deaths in 2011 [ 6 ]. Other pathogens, such as rotavirus, contribute to AGE in children [ 7 ], but the adult burden is largely unknown.

Despite accumulating evidence on the importance of specific pathogens for AGE, population-based studies of the endemic burden of all-cause AGE in adults are rare. Although some data are available on bacterial pathogens [ 8 ], lack of population-based data on viral pathogens hinders estimations of pathogen-specific prevalence and incidence to inform clinical management and interventions, such as vaccines. Past viral AGE burden studies used indirect methods, such as billing codes without laboratory confirmation of disease; relied on clinician-ordered diagnostic testing results, which can bias detection away from viral pathogens; or focused on groups or populations that limit generalizability [ 3 , 7 , 9–11 ]. Moreover, traditional surveillance methods have been limited by infrequent diagnostic testing, except in severe AGE cases or outbreak settings [ 12 ]. With norovirus and C. difficile vaccines in clinical trials among all age groups [ 13 , 14 ], robust pathogen-specific burden estimates are needed for baseline data that can serve as benchmarks for future impact evaluations.

To address these gaps, SUPERNOVA (Surveillance Platform for Enteric and Respiratory Infectious Organisms in the Veterans Affairs population) was established as a multisite outpatient and inpatient surveillance platform in VA medical centers (VAMCs) in Atlanta, Georgia; Bronx, New York; Houston, Texas; and Los Angeles, California. The project was initially designed to estimate the norovirus burden through passive surveillance [ 15 , 16 ]; in 2015, an active surveillance pilot was launched at 1 site to characterize the AGE etiologic burden [ 17 ]. Subsequently, SUPERNOVA expanded to include active and passive AGE surveillance at all 4 sites, as well as testing for 22 gastrointestinal pathogens.

In the current article, we describe findings from the first 2 years of prospective, inpatient and outpatient multisite surveillance for AGE, with standardized methods and laboratory testing. We sought to estimate prevalence and incidence of outpatient encounters and inpatient hospitalizations for AGE due to norovirus, in the context of other viral, bacterial, and parasitic pathogens. Secondary objectives included describing the severity of illness among hospitalized patients with AGE caused by specific pathogens. Findings will inform clinical AGE management in adults and future treatment and control interventions for AGE pathogens.

Participants and Case Definitions

SUPERNOVA sites served 322 468 unique veterans in outpatient and inpatient settings in fiscal year 2018 (24 485 in the Bronx, 83 477 in Los Angeles, 104 926 in Houston, and 109 580 in Atlanta). For inpatient active surveillance, veterans ≥18 years of age admitted to a participating VAMC were screened for eligibility during 2 surveillance years (from 1 July 2016 to 30 June 2017 and from 1 July 2017 to 30 June 2018). Active cases were defined as the occurrence of ≥3 loose stools, ≥2 episodes of vomiting, or ≥1 episode of both loose stool and vomiting in a 24-hour period and illness ≤10 days in duration. Patients were excluded if symptoms were present for >10 days or attributed to a noninfectious cause; if they were transferred from another hospital after admission of >48 hours; or if they were enrolled within the previous month. Controls were patients without AGE symptoms for ≥2 weeks, and were frequency matched to case patients by age bracket (<65 or ≥65 years) and admission date (±1 week). All inpatients meeting inclusion criteria during core surveillance hours were invited to participate ( Supplementary Methods ). For outpatient passive surveillance, patients with stool specimens collected for clinician-requested diagnostic testing in each site’s catchment area that met the case definition—acute onset of AGE symptoms recorded in the medical chart—were included in outpatient surveillance.

Laboratory Testing

Whole stool specimens were tested at each VAMC using the BioFire FilmArray Gastrointestinal Panel (bioMérieux), a polymerase chain reaction (PCR)–based multidiagnostic assay with targets for 22 viral, bacterial, and parasitic pathogens ( https://www.biomerieux-diagnostics.com/filmarrayr-gi-panel ). Stool samples with norovirus or rotavirus detected using this panel were shipped to the Centers for Disease Control and Prevention for real-time reverse-transcription quantitative PCR testing and genotyped by sequencing [ 18–21 ].

Statistical Analysis

The final analysis included the Houston VAMC from 1 July 2016 through 30 November 2016, and all 4 sites after the Atlanta, Bronx, and Los Angeles VAMCs began surveillance from 1 December 2016 through 30 June 2018. We calculated the prevalence of each pathogen among case patients and controls; examined the severity of illness, including duration of illness, hospital stay, modified Vesikari score ( Supplementary Table 1 ), and intensive care unit (ICU) stay; and identified deaths by follow-up interview for inpatients, stratified by pathogens. We generated confidence intervals by bootstrapping or by assuming Poisson and conducted comparisons with Mann-Whitney, χ  2 , and Fisher exact tests in SAS 9.4 software (SAS Institute). We report in-depth results for case patients where pathogen prevalence significantly differed between case patients and controls.

The incidence per 100 000 person-years among a VA patient population was calculated based on previously published methods [ 15 , 17 ]. To identify only incident episodes of AGE, we counted encounters within 30 days as a single episode. Inpatient incidence estimates were stratified as community onset (illness onset before admission or on the day of or the day after admission) or hospital onset (illness onset ≥2 days after admission).

Enrollment, Demographics, and Risk Factors for AGE Case Patients

Over the 2-year surveillance period, 793 inpatients were enrolled (53% of eligible patients), and 724 (91%) completed all baseline study procedures ( Figure 1 ). For outpatients, 544 stool specimens were available from clinician-ordered diagnostic testing; 506 (93%) met eligibility criteria and were included in analyses ( Figure 1 ). Stool specimens were collected a median of 3 days after symptom onset for inpatients, and 4 days after onset for outpatients.

Screening, enrollment and study completion for inpatients with acute gastroenteritis (AGE), inpatient controls, and outpatients with AGE, from July 2016 to June 2018.

Most participants were male, reflective of the veteran population. Their median ages were 64 years for inpatients with AGE and 63 years for controls ( P = .5) ( Table 1 ). Inpatients with AGE were more likely than controls to have human immunodeficiency virus (HIV) (8.4% vs 2.4%; P = .003), severe renal disease (18.1% vs 4.9%; P < .001), or household contact with a patient with AGE (5.2% vs 2.3%; P = .02) or to be transplant recipients (2.8% vs 0%; P = .01).

Demographic Characteristics and Risk Factors for Inpatients with Acute Gastroenteritis (AGE), Inpatient Controls, and Outpatients With AGE, July 2016 to June 2018

Abbreviations: AGE, acute gastroenteritis; HIV, human immunodeficiency virus; IQR, interquartile range; NA, not applicable; VA, Veterans Affairs.

a Data represent no. (%) of patients and controls unless otherwise specified. Some data were missing for race, ethnicity, residence before admission, previous hospitalization, prior antibiotic use, and household contact, representing <5% for each variable.

b P values based on χ  2 , Fisher exact, or Wilcoxon rank-sum tests used to compare inpatients with AGE and controls.

c “Other” includes American Indian/Alaskan Native, Native Hawaiian/Pacific Islander, multiple races, or other race.

d Non-VA sources of care included a physician’s office, non-VA emergency room, urgent care center, or other non-VA site.

e Data were available for HIV/AIDS, cancer, transplants, and immunosuppressive therapy for case patients (n = 667) from October 2016 to June 2018 and for controls (n = 206) from October 2017 to June 2018. Sensitivity analysis of data from only October 2017 to June 2018 resulted in similar proportions and levels of significance. For severe renal disease (severe kidney disease or kidney failure (stage 4 [glomerular filtration rate 15–29] or 5 [glomerular filtration rate <15, or requirement for dialysis]) and prior hospitalization within 30 days, data were available for case patients (n = 331) and controls (n = 206) from October 2017 to June 2018.

Pathogen Prevalence, Seasonality, and Laboratory Testing

Among inpatients, prevalence of 6 pathogens differed significantly between case patients and controls: C. difficile (18.8% vs 8.4%; P < .001), norovirus (5.1% vs 1.5%; P = .003), Campylobacter (3.9% vs 0.5%; P <.001), Shigella /enteroinvasive Escherichia coli (EIEC) (2.2% vs 0%; P = .003), Salmonella (1.8% vs 0.3%; P = .03), and rotavirus (1.5% vs 0%; P = .01) ( Figure 2A ). In the outpatient setting, norovirus (10.7%) and C. difficile (10.5%) were leading pathogens ( Figure 2B ). Among both inpatients and outpatients, most patients with C. difficile or norovirus (inpatients, 84% and 70%, respectively; outpatients, 75% and 80%) had only a single pathogen detected with FilmArray; the most common codetection was C. difficile and norovirus (in 8 inpatients and 2 outpatients). The highest norovirus prevalence was in adults aged ≥85 years (13%–36% by setting; Supplementary Table 2 ).

Prevalence of pathogens detected by means of the BioFire FilmArray Gastrointestinal Panel, from July 2016 to June 2018. A, Inpatients with acute gastroenteritis (AGE) and non-AGE inpatient controls. *Significant difference ( P < .05; χ  2 test) in prevalence between case patients and controls for the following pathogens: Clostridioides difficile ( P < .001), norovirus ( P = .003), Campylobacter spp. ( P < .001), Shigella /enteroinvasive Escherichia coli (EIEC) ( P = .003), Salmonella ( P = .03), and rotavirus ( P = .01). The following pathogens are on the FilmArray panel but are not included because there were no positive detections: Vibrio cholerae , Escherichia coli O157, Aeromonas , and Cyclospora cayetanensis . Two stool specimens from inpatient controls were excluded owing to inconclusive results. B, Outpatients with AGE. The following pathogens on the FilmArray panel are not included because there were no positive detections: Entamoeba histolytica, Plesiomonas shigelloides, V. cholerae, E. coli O157, and Aeromonas. Two outpatient stool specimens were excluded owing to inconclusive results. Abbreviations: EAEC, enteroaggregative Escherichia coli ; EPEC, enteropathogenic Escherichia coli ; ETEC, enterotoxigenic Escherichia coli ; G. lamblia, Giardia lamblia ; STEC, Shiga-like toxin-producing Escherichia coli ; Y. enterocolitica, Yersinia enterocolitica .

Most AGE cases in inpatients were community onset (80%) rather than hospital onset (20%); 78% of C. difficile cases, and 95% of norovirus cases were community onset ( Supplementary Tables 2 and 3 ). The prevalence of C. difficile in community-onset cases did not differ from that in hospital-onset cases (18% vs 21%, respectively; P = .4), and the prevalence of norovirus was higher in community-onset cases (6% vs 1%; P = .03).

AGE cases were identified year-round ( Figure 3A and 3B ). Norovirus was detected every month, most commonly in November–January, reaching a peak prevalence of 16% in December. Rotavirus showed a distinct peak in April. Among bacterial pathogens, C. difficile was also detected year-round and reached a peak prevalence of 23% in October.

Seasonality of viral and bacterial pathogens among inpatient and outpatient cases, from July 2016 to June 2018. A, Viral pathogens. B, Bacterial pathogens. Abbreviations: C. difficile, Clostridioides difficile ; EIEC, enteroinvasive Escherichia coli .

Norovirus-positive samples were typed into 7 GI and 12 GII types; GII.4 Sydney[P16] (56%) viruses were most common, followed by GII.2[P16] (11%) ( Figure 4 ). The most common rotavirus genotypes were G12P[8] (79%) and G2P[4] (11%). For inpatient AGE cases with clinician-ordered testing data, 83% of C. difficile cases (55 of 66) positive by BioFire assay were also tested with PCR in the respective institution’s clinical laboratory (Cepheid Xpert C. difficile or Xpert C. difficile/Epi; Cepheid); of these cases, 87% (48 of 55) were also positive for C. difficile by clinical laboratory test. Clinical symptoms were similar among C. difficile –positive cases tested by both methods (data not shown).

Genotypes for norovirus (n = 71) and rotavirus (n = 19).

Incidence Estimates

The incidence of AGE hospitalizations was higher in adults ≥65 old (459 per 100 000 population) than in those <65 years old (315 per 100 000) ( Table 2 ). For outpatients, the reverse pattern was observed, with a slightly higher incidence in those aged <65 years (3100 vs 2247 per 100 000 in those aged ≥65 years). These age group and setting trends were also observed for norovirus, Campylobacter , and rotavirus. Of note, C. difficile and Salmonella had higher rates in adults ≥65 years of age for both inpatients and outpatients.

Incidence Rate Estimates Among Acute Gastroenteritis Case Patients (Inpatients and Outpatients), by Pathogen and Overall, July 2016 to June 2018

Abbreviations: AGE, acute gastroenteritis; CI, confidence interval; EIEC, enteroinvasive Escherichia coli.

a CIs for AGE outpatient estimates and inpatient community and hospital-onset inpatient estimates were calculated assuming Poisson distribution. Remaining estimates including pathogen-specific CIs calculated using bootstrapping.

b The attributable fraction (AF) was calculated for inpatient pathogens based on the odds ratio (OR) of that pathogen’s prevalence among case patients and controls, using the following formula: (OR –1)/OR. The AF is an estimate of the percentage of AGE cases that can be attributed to infection with the pathogen of interest. (The AF was not calculated for other inpatient variables, owing to the small sample size for controls after stratification.)

C. difficile and norovirus had the highest inpatient and outpatient incidence rates ( C. difficile, 71.3 and 285 per 100 000, respectively; norovirus, 19.4 and 291 per 100 000). The hospital-onset rate for C. difficile (114 per 100 000) was notably higher than that other pathogens, and higher than the C. difficile community-onset rate (55.6 per 100 000). For norovirus, the community-onset rate (18.3 per 100 000) was more than twice the hospital-onset rate (7.6 per 100 000). Norovirus incidence was twice as high in winter (November–April) as in summer (May–October), among both outpatients (542 vs 253 per 100 000) and inpatients (29 vs 12.5 per 100 000).

Clinical Symptoms and Severity of Illness Among Inpatients

Almost all inpatients with AGE had diarrhea (94%), and half had vomiting; the median duration of illness at follow-up was 7 days ( Table 3 ). By modified Vesikari clinical severity scores, inpatient AGE cases were largely classified as moderate (42%) or severe (52%). Among all pathogens, norovirus, rotavirus, and Shigella /EIEC had higher median severity scores, and the largest proportions of severe scores (73%, 73%, and 80%, respectively).

Clinical Symptoms and Severity of Illness for Inpatient AGE cases, Overall and by Single and Multiple Pathogens a

a Pathogen-specific columns include AGE cases with single pathogen detections, independent of the other 5 pathogens in the table. Any co-detection (≥2) between the six pathogens are included in the multiple co-pathogens column.

b If cases were missing data for certain measurements, a Vesikari score was not assigned, pathogen (% missing): AGE (4%), Norovirus (3%), C. difficile (6%), Salmonella (8%). Modified Vesikari scoring was defined as follows: Mild (0–6), Moderate (7–10), Severe (≥11). See supplementary appendix for scoring components.

c Among these deaths, 14 occurred while hospitalized. Three deaths occurred within 1–12 days following discharge; one died in inpatient hospice, one died within 24 hours of transferring to inpatient palliative care, and one died after discharge. Deaths following discharge were ascertained when attempting the follow-up interview at 3–5 weeks post-enrollment.

Campylobacter spp. includes jejuni, coli, and upsaliensis. EIEC= Enteroinvasive E. coli

d Diarrhea was defined as 3 or more loose stools within a 24 hour period

Overall, 12% of AGE case patients had ICU stays. By pathogen, Shigella /EIEC and C. difficile case patients had the highest proportion of ICU stays (20% and 17%, respectively) ( Table 3 ). By exposure, patients with hospital-onset AGE were twice as likely to have an ICU stay, and their median hospital stay was almost 4 times that of patients with community-onset AGE (22% vs 10% and 15 vs 4 days, respectively; both P < .01). Among the medical conditions examined (HIV, cancer, transplants, immunosuppressive therapy, and renal disease), only severe renal disease or renal failure was associated with more severe disease in patients with AGE; those with renal disease had a longer median hospital stay and a higher death rate than those without renal disease (7 vs 5 days [ P = .005] and 8% vs 2% [ P = .01], respectively).

Seventeen deaths (2%) were captured among inpatients with AGE. These included 1 norovirus-associated and 3 C. difficile –associated deaths. There was 1 other enteric detection among the deaths (enteroaggregative E. coli ), but based on the clinical course of illness and detailed record review, this pathogen was not believed to be a contributing factor. In the remaining 12 deaths, no pathogens were detected.

SUPERNOVA is a novel multisite AGE surveillance platform in the United States using prospective, active and passive, population-based surveillance with standardized case definitions and laboratory confirmation in a medically attended veteran population. We captured mild to severe AGE illness, including hospitalized cases, ICU stays, and deaths, and identified higher risk groups for AGE, including patients with certain medical conditions (HIV, transplants, and renal disease), and older adults. Testing for a wide range of AGE pathogens in a standardized fashion allowed us to identify C. difficile and norovirus as leading AGE pathogens, detected in inpatient and outpatient settings every month of the year, with a fall and winter predominance. These data will aid clinicians in clinical diagnosis and management for adults with AGE seeking medical care.

Norovirus was the leading viral pathogen in inpatients and outpatients with AGE. In our multisite surveillance, it is the second leading pathogen after C. difficile in inpatients with AGE, and the first in outpatients with AGE. Previous single-setting burden estimates for norovirus in US adults suggested that outpatient visits account for a greater proportion of cases than inpatient hospitalizations [ 3 , 9 , 15 , 17 ]. Our findings build on these studies, demonstrating higher norovirus prevalence in outpatients (10.7%) and inpatients with community-onset AGE (6%) than in those with hospital-onset AGE (1%), and norovirus incidence estimates >1 order of magnitude greater in outpatient (291 per 100 000) than in inpatient (19.4 per 100 000) and hospital-onset settings (7.6 per 100 000).

We also demonstrate that sporadic cases of norovirus were more common in the fall and winter months, from October through January, reaching peak prevalence of 1 in 6 AGE cases in December, and genotype GII.4 Sydney[P16] was detected in just more than half of norovirus positives. Although the genotypes are consistent with national outbreak surveillance [ 22 ], our outpatient and hospital surveillance detected an increase in norovirus cases approximately 2 months earlier in the fall. Earlier detection in the norovirus winter season can alert public health professionals to increase prevention and control efforts, and provide clinicians with timely data to inform appropriate testing and clinical decision making. We also demonstrate the heightened risk of older adults infected with norovirus. Every year in the United States, adults ≥65 years old account for almost half of norovirus hospitalizations and are at high risk for severe norovirus disease, including longer duration of symptoms and death [ 23 ]. In our study, norovirus prevalence was significantly higher in adults ≥85 years old, and the incidence of hospitalizations was almost twice as high in adults ≥65 years old as in younger adults.

C. difficile was the leading pathogen among inpatients; hospital-onset incidence was >10 times higher than any other pathogen, and twice the C. difficile community-onset incidence. Substantial C. difficile burden among veterans has been recognized [ 24 , 25 ], and a national longitudinal study of veterans in 2003–2014 found increasing rates for initial and recurrent C. difficile episodes over time [ 25 ]. However, retrospective studies relying on ICD codes and laboratory test results are influenced by changing diagnostics, including increased use of nucleic acid amplification tests, which are more sensitive than toxin assays. More recent data from Centers for Disease Control and Prevention demonstrate that although community-associated C. difficile cases have increased, healthcare-associated cases are decreasing [ 26 , 27 ]. In addition, there is increased recognition that many hospitalized patients with toxigenic C. difficile in their stool, identified either by toxigenic culture or nucleic acid amplification test (as in our surveillance), may be only colonized. This is reflected in clinical practice guidelines that highlight the importance of testing only patients with a high pretest likelihood for C. difficile and using more specific tests when this cannot be reasonably assured, as well as consideration of a multistep algorithm for testing [ 28 ]. Together with the high detection rate of C. difficile in non-AGE controls, this suggests that our C. difficile attributable fraction estimates, which indicate a 40% lower inpatient incidence rate, may provide more realistic estimates. From a clinical standpoint, these findings suggest that clinicians may consider the colonization rate in controls before starting antibiotic treatment in the setting of a positive result. Nonetheless, even with these lower adjusted estimates, C. difficile remained the leading inpatient pathogen, and adults ≥65 years of age with C. difficile had higher incidences than younger adults in both inpatients and outpatients, an important finding because older adults have higher morbidity and mortality rates related to C. difficile infection [ 29 ].

Our platform was also unique in its capture of adult rotavirus AGE cases, which demonstrated a distinct winter-spring peak and higher incidence in the first surveillance year. Rotavirus is a well-known cause of diarrhea in children, yet the epidemiology and burden of rotavirus in adult populations is not well understood, particularly in the postvaccination era. Indeed, we identified only 1 other study in the United States reporting rotavirus incidence rates in adults in the ambulatory setting, using an insurance claim database in the prevaccine era in outpatient and emergency rooms [ 9 ]. The reported incidence in the outpatient setting (8–19 per 100 000) was much lower than in our study (overall, 81 per 100 000; winter peak, 142 per 100 000); this difference could be due in part to infrequent stool diagnostic testing for rotavirus in adults, and it demonstrates the strength of our surveillance. Adult rotavirus prevalence estimates are similarly sparse. Interestingly, our rotavirus prevalence estimates (inpatients, 1.5%; outpatients, 3%) were similar to that reported from a hospital that retrospectively tested adult stool specimens collected for bacterial stool culture February to May each year from 2006 to 2011 (2.8%), as well as outpatient adult stool specimens submitted to a managed care organization in 2012–2013 (1%–3%) [ 30 , 31 ]. Widespread rotavirus vaccination in children has altered the US rotavirus seasonal pattern to biennial peaks from January to April [ 32 ], and G12P[8] has been the predominant strain detected since 2012 [ 21 ]; both the seasonality and genotyping in children are consistent with our findings in the current adult population.

The severity of disease for several pathogens was notable. Shigella /EIEC, norovirus, and rotavirus cases had the highest proportion of severe disease as measured by modified Vesikari score, whereas Shigella /EIEC and C. difficile cases had the highest proportion of ICU stays. Case patients with C. difficile had the longest median hospital stay, and those with norovirus the longest median ICU stay. Among AGE case patients who died, C. difficile and norovirus were the only pathogens detected that were believed to contribute to death. These patients had significant medical histories in addition to AGE, including cardiac, pulmonary, and renal disease that contributed to their hospitalization course and deaths.

In addition to specific pathogens, our case definition and data collection among all AGE case patients allowed for identification of subpopulations with AGE that may be at higher risk for more severe disease. First, inpatients ≥65 years old with AGE had higher disease incidence and longer median hospital stays than younger adults. Second, patients with AGE were more likely than controls to have HIV, be transplant recipients, or have severe or end-stage renal disease. In particular, AGE case patients with severe renal disease or renal failure had a longer median hospital stay and a death rate that was 4 times higher than AGE case patients without renal disease. Although diarrhea is common in patients with end-stage renal disease, its etiology can be challenging to determine and may include both infectious and noninfectious causes [ 33 ]; as such, this finding merits additional investigation as our surveillance continues. A third group of patients, with hospital-onset AGE, while representing only 1 in 5 AGE hospitalizations, were twice as likely to have an ICU stay and were notable for their higher AGE incidence compared with community-onset case patients. Patients with hospital-onset AGE had longer stays, almost 4 times longer than in patients with community-onset AGE.

Our findings are subject to limitations. First, it was challenging to obtain consent and enroll ICU patients with AGE, and some patients with AGE died before enrollment; therefore, our surveillance may underestimate AGE severity. As previously noted, PCR-based assays are sensitive, and bacterial pathogens were not independently confirmed by culture or toxin assay; detection may not indicate causation. However, the significantly higher case detection rates compared with controls, high single-pathogen detection among C. difficile and norovirus cases, and clinical symptoms and severity consistent with expected presentations for these pathogens gives us confidence in our interpretation. Finally, veterans are predominantly male, and results may not be representative of all US adults.

In conclusion, we offer robust assessment of the burden of AGE and specific AGE pathogens, including norovirus and C. difficile , in an adult population before vaccine introduction for these pathogens. Ongoing surveillance will allow further characterization of AGE pathogens, genotyping, burden, and risk factors in adults. Clinicians can use these data to inform clinical diagnosis and management for adults seeking medical care for AGE.

Supplementary materials are available at Clinical Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.

Acknowledgments. The authors thank the study site participants for their time and contributions. They also gratefully acknowledge the following individuals for their contributions to the surveillance system and laboratory testing: Emory University: Ben Lopman, Jessica Ingersoll, and Candace Miller; Baylor College of Medicine: Robert Atmar and Frederick Neill; Houston Veterans Affairs Medical Center (VAMC): Mahwish Mushtaq, David Diaz Voss Varela, Rosalba Gomez, Bashir Lengi, Ernesto Ruiz, and Martha Bilbatua; Atlanta VAMC: Nana Addo Padi-Adjirackor, Elena Morales, Janet Thonkulpitak, Theron Clark-Stuart, Abeer Moanna, and Nora Oliver; Bronx VAMC: Johane Simelane, Sarah Smith, Amelia Tisi, and Guerry (Anabelle) Perez; Los Angeles VAMC: Matthew Goetz, Anthony Matolek, Evan Goldblatt, and Aleksandra (Sasha) Poteshkina; and Palo Alto VAMC: Madhuri Agrawal, Jessica Lopez, and Jude Lopez.

Disclaimer. The views expressed in this manuscript are those of the authors and do not necessarily reflect the position or policy of the Centers for Disease Control and Prevention, the Department of Veterans Affairs, or the United States government.

Financial support. This study was funded by the Centers for Disease Control and Prevention and by the Emory Center for AIDS Research (funding for laboratory personnel at the Atlanta VAMC).

Potential conflicts of interest. V. C. M. reports grants from Gilead, ViiV, and Bayer, and personal fees from Lilly, Gilead, and ViiV, outside the submitted work. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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Grytdal SP , Rimland D , Hannah Shirley S , et al.  Incidence of medically-attended norovirus-associated acute gastroenteritis in four Veteran’s Affairs Medical Center populations in the United States, 2011–2012 . PLoS One 2015 ; 10 : e0126733 .

Kambhampati A , Vargas B , Mushtaq M , et al.  Active surveillance for norovirus in a US Veterans Affairs patient population, Houston, Texas, 2015–2016 . OFID 2019 ; 6 : ofz115 .

Cannon JL , Barclay L , Collins NR , et al.  Genetic and epidemiologic trends of norovirus outbreaks in the United States from 2013 to 2016 demonstrated emergence of novel GII.4 recombinant viruses . J Clin Microbiol 2017 ; 55 : 2208 – 21 .

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• gastroenteritis, acute
• hospitals, veterans
• intensive care unit
• outpatients
• pathogenic organism
• surveillance, medical
• enteroinvasive escherichia coli
• clostridium difficile
• stool specimen

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Case Study: Salmonella Gastroenteritis in a 4-Month Old Infant

Alec A. Rudentein, MS3 Rowan SOM; Raveena K. Midha, MS3 Rowan SOM; Puthenmadam Radhakrishnan MD, MPH, FAAP

INTRODUCTION

Salmonella gastroenteritis is an infection that can result in serious and life-threatening complications in the pediatric population. Infants below the age of 12 months are especially at an increased risk of morbidity and mortality. Our case is a 4-month-old male who presents with gastroenteritis in the ED and evaluated for sepsis. Stool cultures were taken and resulted in a positive salmonella gastroenteritis diagnosis. Gastroenteritis is a common presentation in infants and is often not infectious in etiology.We present this case because it is imperative to acknowledge that salmonella infection is a potential and serious cause of gastroenteritis in infants. A search of literature resulted in many mentions of statistics and epidemiology; there are very scant case reports on Salmonella infections in infants.

CASE DESCRIPTION

This is a case of a 4-month-old male with no significant past medical history, born at full term who presented to the emergency department with reports of a fever and loose stools. Patient’s mother reported that onset of symptoms was 6 hours prior to presentation and temperature at home was 102.2 F.The patient had no sick contacts; no recent travel, no pets at home and all immunizations were up to date. Initial VS were significant for a rectal temperature of 105.9 and a HR of 200 BPM. Physical exam showed yellowish stools with streaks of blood, all other findings were unremarkable. Laboratory findings were significant for an elevated absolute neutrophil count (7.38×10^3/mcl), an elevated absolute lymphocyte count (0.72 x 10^3/mcl), and an elevated CRP (2.0 mg/dL). Urinalysis was normal and the patient was negative for influenza, COVID-19, and RSV. XR of chest/ abdomen showed no acute abnormalities. Patient was admitted to the pediatric in-patient floor for further evaluation and a stool culture was ordered.

On the pediatric floor, the patient was given acetaminophen and IV fluid for hydration. A sepsis evaluation including lumbar puncture with CSF cultures and blood cultures were performed on hospital day 2. Stool culture obtained were positive for Salmonella species. After a discussion with pediatric ID, it was decided that the patient would be placed on IV ceftriaxone. The patient’s diarrhea began decreasing on hospital day 5 and stools remained non-bloody for more than 24 hours. Blood culture and CSF cultures showed no growth after 2 days. Patient’s intake increased to 4 oz of fullstrength formula every 4 hrs. After the patient was afebrile for approximately 36 hours, he was discharged on hospital day 6 and placed on azithromycin PO for a duration of 5 days.

Salmonella is a motile, gram-negative facultative anaerobic bacilli as part of the Enterobacteriaceae family.There are numerous Salmonella serotypes and species; however, this case focuses on non-typhoidal Salmonella species and their particular deleterious effects in infants. Most non-typhoidal Salmonella infections are acquired through food-borne contaminants. Frequent transmission of non-typhoid Salmonella infections occurs due to the consumption of contaminated animal-based food, such as eggs, meat, dairy products, contaminated water, or poor hygiene [3]. The infections can be self-limiting or progress to more advanced states. In addition, formula is also a potential nidus for Salmonella infection. The improper storage of formula is the most likely cause of formula-caused Salmonella infection [3]. Furthermore, Salmonella , unlike many other enteric pathogens, have an asymptomatic carrier state which can help spread the disease. A common way for the pathogen to spread to newborns and children is through maternal asymptomatic carriers [1,3].

In the case presented, it was thought that the patient was exposed to Salmonella via mishandling of poultry or an asymptomatic carrier.As there was no local outbreak of Salmonella from the formula, the Department of Health decided not to pursue the formula avenue. Likewise, the patient had no recent travel, no sick contacts and no pets at home.The patient’s mother cooks meals for the family so it can be speculated that the pathogen spread from the food to the mother to the patient.

Salmonella causes its effects locally within the gastrointestinal site as well as distantly through its ability to invade the intestinal mucosa and replicate within the lamina propria. From there, it can invade the mesenteric lymph nodes and spread to the rest of the body. Salmonella gastroenteritis is commonly associated with diarrhea, first starting with watery diarrhea and possibly progressing to bloody or mucus-containing diarrhea due to its invasive properties [1,3]. In immunocompetent adults, Salmonella gastroenteritis is eliminated through the body’s immune response, the naturally occurring enteric flora, gastric acid, and motility, as well as the intestinal mucus. Each aspect works to remove the pathogen as well as form protective barriers to prevent the organism from acclimating to the host’s internal environment. Infants and children lack or have an immature defense system and are thus at increased risk of developing more serious complications of Salmonella infections [1,4].

Noting Salmonella as the cause of gastroenteritis is imperative due to the systemic effects the organism can have. “Bacteremia may occur in 30-50% of neonates infected with Salmonella , including those with no evidence of gastroenteritis. Focal infections of almost every organ system (for example bone, joint, lung) are reported with Salmonella gastroenteritis, but meningitis is the most feared of these complications and emphasizes the vigilance required to evaluate infants who are infected with Salmonella ” [1].The peak incidence of Salmonella bacteremia and meningitis occur in infants less than 2 months of age [2]. According to the CDC, infants, especially those who are not breastfed or have a weakened immune system, are more likely to get an invasive Salmonella infection and should be treated with antibiotics [3,4].

It is recommended that the use of antibiotics be limited in immunocompetent individuals aged 12 months to 50 years old with acute salmonella gastroenteritis because of the self-limiting course of disease. It is established that patient’s less than 3 months of age are given antibiotics due to a risk of complications such as sepsis and meningitis [9]. However, there is little evidence to support that antibiotics should be given from 3 months to 12 months of age. According to a review of literature in 2017, the current recommended guidelines for a patient between 3 months-12 months of age is no treatment required if the patient appears well and non-toxic. If the patient is unwell or toxic appearing, then blood culture, with or without CSF culture, should be obtained and parenteral antibiotics should be started. If the blood culture shows no growth at 48 hours and the patient appears well, then the patient can be switched to oral antibiotics [6]. Antibiotic therapy duration for immunocompetent children is recommended at 3-14 days [5]. According to these guidelines, it was necessary to place our patient on antibiotic therapy due to multiple bouts of bloody diarrhea and persistently high fever, dehydration and general ill appearance.

The mainstay treatment of Salmonella gastroenteritis for adults and adolescents is an oral dose of fluoroquinolones because of their antimicrobial activity against gram-negative enteric pathogens. Some data has shown that fluoroquinolones could potentially be safe during short courses of antibiotics for children. However, previous data on animal models suggests that fluoroquinolones can cause joint toxicity and cartilage damage. As a result, they are not typically prescribed in children [8]. Alternatives to fluoroquinolones are other oral antibiotics such as TMP-SMX, cefixime and azithromycin. Due to this patient’s poor oral intake and peripheral IV access, IV ceftriaxone was a reasonable choice of antimicrobial therapy. Ceftriaxone has been shown to be as effective as oral ciprofloxacin in children with acute invasive diarrheas [ 7]. In addition, ceftriaxone eliminates the risk of joint toxicity in vulnerable pediatric patients such as this 4-month-old male. In this case, the duration of parenteral antibiotic therapy was 3 days. Following discharge, the patient was prescribed azithromycin for 5 additional days for a total of 7 days which falls in the recommended guidelines discussed above.

Gastroenteritis in infants, particularly children under 12 months of age, is a common condition with a range of causes. In many cases, the illness is self-limited and no antibiotics or treatments are needed. However, it is important to note that Salmonella is also a common cause of gastroenteritis and should always be included in the differential diagnosis. In the case presented, the patient was brought to the ED for a sepsis workup and it was most likely due to the presentation of bloody stools that the stool culture was ordered. However, Salmonella’s presentation can vary from watery stools to asymptomatic infections.Though the clinical presentations differ, Salmonella’s potential systematic effects can prove to be fatal. Therefore, Salmonella gastroenteritis should be considered in the differential diagnosis due to its ability to invade the lymphatic system and spread to cause more systemic infections.

• Kinney JS, Eiden JJ. Enteric infectious disease in neonates. Epidemiology, pathogenesis, and a practical approach to evaluation and therapy. Clin Perinatol. 1994 Jun;21(2):317- 33. doi: 10.1016/S0095-5108(18)30348-8. PMID: 8070229; PMCID: PMC7133246.
• Nelson SJ, Granoff D. Salmonella gastroenteritis in the first three months of life. A review of management and complications. Clin Pediatr (Phila). 1982 Dec;21(12):709-12. doi: 10.1177/000992288202101201. PMID: 7140121.
• Bula-Rudas FJ, Rathore MH, Maraqa NF. Salmonella Infections in Childhood. Adv Pediatr. 2015 Aug;62(1):29-58. doi: 10.1016/j.yapd.2015.04.005. PMID: 26205108.
• “Questions and Answers.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 5 Dec. 2019, www.cdc.gov/salmonella/general/index.html.
• Sirinavin, S, and P Garner. “Antibiotics for Treating Salmonella Gut Infections.” Cochrane database of systematic reviews 2 (2000): CD001167–CD001167. Print.
• Wen, Sophie CH, Emma Best, and Clare Nourse. “Non- Typhoidal Salmonella Infections in Children: Review of Literature and Recommendations for Management: Non- Typhoidal Salmonella Infections.” Journal of paediatrics and child health 53.10 (2017): 936–941.Web.
• LEIBOVITZ, EUGENE et al. “Oral Ciprofloxacin Vs. Intramuscular Ceftriaxone as Empiric Treatment of Acute Invasive Diarrhea in Children.” The Pediatric infectious disease journal 19.11 (2000): 1060–1067.Web.
• GRADY, RICHARD. “Safety Profile of Quinolone Antibiotics in the Pediatric Population.” The Pediatric infectious disease journal 22.12 (2003): 1128–1132.Web.
• ST. GEME, JOSEPH W et al. “Consensus: Management of Salmonella Infection in the FirstYear of Life.”The Pediatric infectious disease journal 7.9 (1988): 615–621.Web.

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Case Study on Acute Gastroenteritis

Gastroenteritis, sometimes referred to as “stomach flu”, is an inflammation of the GI (gastrointestinal) tract, which includes the stomach and intestines. Most cases of gastroenteritis are caused by viruses. Bacterial gastroenteritis (caused by bacteria) often causes severe symptoms. It can even be fatal. It is also the most common digestive disorder among children. Severe gastroenteritis causes dehydration and an imbalance of blood chemicals (electrolytes) because of a loss of body fluids in the vomit and stool. This can be acquired through contaminated food and water that contains harmful bacteria (such as salmonella, Campylobacter, and E. coli). Food can be contaminated when food handlers don’t wash their hands. Or when food isn’t stored, handled, or cooked correctly. This can also be acquired and spread through the fecal-oral route, people with gastroenteritis have harmful bacteria in their stool. When they don’t wash their hands well after using the bathroom, they can spread the germs to objects. If you touch the same objects, you can pick up the germs on your hands and transfer them to your mouth. (Fairview.org, 2021)

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Acute gastroenteritis in three community-based nursing homes

Affiliation.

• 1 Geriatrics Division, Philadelphia VA Medical Center, Pennsylvania, USA.
• PMID: 7671026
• DOI: 10.1093/gerona/50a.5.m252

Background: Acute gastroenteritis is a cause of considerable morbidity and mortality in the elderly population. A prospective assessment of acute diarrhea in three community-based long-stay homes is described.

Methods: A cohort study of acute gastroenteritis was performed in three community-based nursing homes, involving 572 residents over an 8-month period. Diarrhea cases were enrolled on the basis of the acute onset of loose stools of > or = 24 hours, as well as one of the following: a rectal temperature of > or = 100 degrees F, dehydration, positive occult blood, > or = 48 hours duration, or as a part of any outbreak. Stool cultures for Clostridium difficile were performed on all NH 1 patients.

Results: Fifty-three gastroenteritis cases were ascertained, consistent with incidence rates of 14.6, 36.4, and 6.7 cases/100 patient years in NH 1, NH 2, and NH 3, respectively. Requiring a Foley catheter (OR = 2.57; 95% CI, 0.93, 7.09) increased diarrhea risk. Six Clostridium difficile enteritis cases and an episode attributable to Aeromonas/Pleisomonas species were diagnosed. One C. difficile diarrhea case was imported from hospital to NH 1. Ten of 12 fecal excretors resided in close geographic clusters in NH 1, where a majority of the latter were mobile and incontinent of stool.

Conclusions: Acute gastroenteritis was a common disease in the study nursing homes, for which specific risk factors were identified. A predominant role for Clostridium difficile in the taxonomy of nursing home diarrhea was suggested.

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• Variability in Antibiotic Use Across Nursing Homes and the Risk of Antibiotic-Related Adverse Outcomes for Individual Residents. Daneman N, Bronskill SE, Gruneir A, Newman AM, Fischer HD, Rochon PA, Anderson GM, Bell CM. Daneman N, et al. JAMA Intern Med. 2015 Aug;175(8):1331-9. doi: 10.1001/jamainternmed.2015.2770. JAMA Intern Med. 2015. PMID: 26121537
• Burden of Clostridium difficile-associated disease among patients residing in nursing homes: a population-based cohort study. Yu H, Baser O, Wang L. Yu H, et al. BMC Geriatr. 2016 Nov 25;16(1):193. doi: 10.1186/s12877-016-0367-2. BMC Geriatr. 2016. PMID: 27884118 Free PMC article.
• An outbreak of acute nonbacterial gastroenteritis in a nursing home. Pegues DA, Woernle CH. Pegues DA, et al. Infect Control Hosp Epidemiol. 1993 Feb;14(2):87-94. doi: 10.1086/646688. Infect Control Hosp Epidemiol. 1993. PMID: 8440885
• Antibiotic treatment for Clostridium difficile-associated diarrhea in adults. Bricker E, Garg R, Nelson R, Loza A, Novak T, Hansen J. Bricker E, et al. Cochrane Database Syst Rev. 2005 Jan 25;(1):CD004610. doi: 10.1002/14651858.CD004610.pub2. Cochrane Database Syst Rev. 2005. Update in: Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004610. doi: 10.1002/14651858.CD004610.pub3. PMID: 15674956 Updated. Review.
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Acute gastroenteritis in primary care: a longitudinal study in the Swiss Sentinel Surveillance Network, Sentinella

Claudia schmutz.

1 Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002 Basel, Switzerland

2 University of Basel, Petersplatz 1, 4001 Basel, Switzerland

Philipp Justus Bless

Daniel mäusezahl, marianne jost.

3 Federal Office of Public Health, Schwarzenburgstrasse 157, 3003 Bern, Switzerland

Mirjam Mäusezahl-Feuz

Associated data.

Acute gastroenteritis (AG) leads to considerable burden of disease, health care costs and socio-economic impact worldwide. We assessed the frequency of medical consultations and work absenteeism due to AG at primary care level, and physicians’ case management using the Swiss Sentinel Surveillance Network “Sentinella”.

During the 1-year, longitudinal study in 2014, 172 physicians participating in “Sentinella” reported consultations due to AG including information on clinical presentation, stool diagnostics, treatment, and work absenteeism.

An incidence of 2146 first consultations due to AG at primary care level per 100,000 inhabitants in Switzerland was calculated for 2014 based on reported 3.9 thousand cases. Physicians classified patients’ general condition at first consultation with a median score of 7 (1 = poor, 10 = good). The majority (92%) of patients received dietary recommendations and/or medical prescriptions; antibiotics were prescribed in 8.5%. Stool testing was initiated in 12.3% of cases; more frequently in patients reporting recent travel. Among employees (15–64 years), 86.3% were on sick leave. Median duration of sick leave was 4 days.

Conclusions

The burden of AG in primary care is high and comparable with that of influenza-like illness (ILI) in Switzerland. Work absenteeism is substantial, leading to considerable socio-economic impact. Mandatory infectious disease surveillance underestimates the burden of AG considering that stool testing is not conducted routinely. While a national strategy to reduce the burden of ILI exists, similar comprehensive prevention efforts should be considered for AG.

Electronic supplementary material

The online version of this article (doi:10.1007/s15010-017-1049-5) contains supplementary material, which is available to authorized users.

Acute gastroenteritis (AG) is a common disease in humans worldwide. Case definition varies between studies and countries but mostly includes signs and symptoms of diarrhoea, vomiting, nausea, abdominal cramps or pain, fever, and blood or mucus in the stool [ 1 – 5 ]. AG can be caused by a wide variety of pathogens ranging from viruses and bacteria to protozoa and other parasites [ 5 ]. A study in Austria identified norovirus, Clostridium difficile and rotavirus as the most frequent aetiological agents in patients consulting general practitioners (GPs) due to AG [ 4 ]. Norovirus, rotavirus, sapovirus and Campylobacter spp. were the most common organisms among cases of infectious intestinal disease (IID) presenting to the GP in the UK [ 6 ].

Bacterial pathogens causing AG which have to be reported to the National Notification System for Infectious Diseases (NNSID) include positive laboratory tests for Campylobacter spp., Salmonella spp., and Shigella spp. as well as clinical and laboratory reports of positively tested patients with Listeria monocytogenes and enterohaemorrhagic Escherichia coli (EHEC). None of the above-mentioned viral causes of AG are notifiable in Switzerland [ 7 ]. As a result, the NNSID underestimates the true burden of AG because of non-notifiable pathogens causing AG. Additionally, not every patient suffering from AG presents to a physician (under-ascertainment) and, the physician does not always initiate stool diagnosis to investigate the aetiology of the illness (under-reporting) [ 8 , 9 ]. Hence, what is seen in the Swiss mandatory notification system represents only an incomplete picture of the burden of disease due to AG. The determinants of under-ascertainment or under-reporting have been described for several countries but not for Switzerland: In the UK, it is estimated that every case of IID reported to national surveillance represents 9.5 cases presenting to a GP or 147 cases in the community [ 6 ]. In the Netherlands, 8% of patients with an IID visited a physician [ 10 ]. Van Cauteren et al. [ 11 ] estimated that of 115 community cases of campylobacteriosis and 20 community cases of salmonellosis one case is reported to the surveillance system in France. However, it has to be noted that the French surveillance systems are voluntary for these two pathogens.

Swiss routine surveillance data suggest an increasing frequency of campylobacteriosis and a decreasing frequency of salmonellosis [ 12 ]. More than half of campylobacteriosis patients in a case–control study approached a physician within 3 days after onset of symptoms and 14.5% were hospitalised [ 13 ]. A subsequent qualitative survey among primary care physicians described case management approaches including treatment strategies and stool diagnostic testing behaviours from the physicians’ perspective for patients with AG [ 8 ]. Four main approaches were identified of which only two—the “test & wait” and the “test & treat” approaches—include stool specimen testing and, hence, would result in case registration in the mandatory disease surveillance system in case of a positive test outcome. Healthcare costs for AG in Switzerland were estimated at €29–45 million annually [ 14 ].

In Switzerland, we lack data on under-ascertainment and under-reporting. Under-ascertainment refers to people not seeking healthcare and, hence, not being captured by the surveillance system as defined by Gibbons et al. [ 9 ]. Under-reporting is defined as people seeking healthcare but not being reported because of under-diagnosis—not diagnosing or misdiagnosing the infection or pathogen—or under-notification—failure to report positive diagnoses [ 9 ].

This study within the Swiss Sentinel Surveillance Network, Sentinella, aimed at understanding the lower levels of the burden of illness pyramid and addressing the incidence of AG in a broader context. Specifically, the study aimed at understanding determinants of under-diagnosis by (1) estimating the incidence and burden of AG seen at the primary care level, (2) describing the physicians’ case management (diagnostics, treatment) of AG patients and (3) estimating the work loss due to AG of cases presenting to a physician.

A 1-year, longitudinal study in Sentinella, during the year 2014, was conducted asking physicians to report cases of AG on a weekly basis (later referred to as data from the “weekly questionnaire”). A questionnaire about disease characteristics, stool testing, and treating strategies was completed for a subset of cases (later referred to as “supplementary questionnaire”).

Study setting

Sentinella is a voluntary surveillance system and research network of primary care physicians existing since 1986 which is operated and funded by the Federal Office of Public Health (FOPH). Physicians are organised in six geographical regions, each having its representative within the Sentinella steering committee. The steering committee, consisting of physicians and researchers of academic primary care institutes, meets regularly to set the research priorities and to decide on submitted projects. Our study was accepted to run in 2014.

During the Sentinella-year 2014, 172 physicians (47% general practitioners, 37% internists and 16% paediatricians; thereafter referred to as “Sentinella-physicians”) covering entire Switzerland were active in the network. In Switzerland, 6930 physicians were practicing in the ambulatory sector with the main specialty “general internal medicine” (summarising general practitioners and internists) or “paediatrics” in 2014 according to the Swiss medical association FMH [ 15 ]. Among these, 86% were practicing in general internal medicine and 14% in paediatrics.

Case definition

A case of AG was defined as (a) a patient consulting a Sentinella-physician for the first time during the illness episode and suffering from diarrhoea (at least 3 watery or pasty stools daily; for at least 24 h but 14 days the longest) likely due to an infectious cause or (b) a patient consulting a Sentinella-physician for the first time during the illness episode with vomiting and abdominal cramps without significant diarrhoea, likely due to an infectious cause. Patients were excluded if diarrhoea was due to a known gastrointestinal disease (e.g. Crohn’s disease, ulcerative colitis, coeliac disease), medication intake (e.g. antibiotics) or food intolerance. Also patients with persistent diarrhoea (>14 days), or if vomiting was due to pregnancy, were excluded.

Data collection

Sentinella-physicians reported basic data on patients suffering from AG on a weekly questionnaire, and more detailed data for a subsample of patients through a supplementary questionnaire which were available in German and French. German versions of the weekly (part on AG only) and supplementary questionnaires are available online (see Electronic Supplementary Material 1). The questionnaires were piloted with 10 general practitioners.

The weekly questionnaire included information on sex, date of birth, stool testing and hospitalisation of all AG patients (see case definition) seen in the corresponding week. The supplementary questionnaire contained additional questions on employment status, dates of symptom onset and consultation(s), signs and symptoms until first consultation, general condition, antibiotic and symptomatic treatment, stool testing, sick leave, hospitalisation, sequelae, and selected risk exposures in the 7 days preceding symptom onset.

Weekly questionnaires were available on paper and electronically according to the Sentinella standard procedure (method chosen by physician). More than half of the Sentinella-physicians reported electronically, all others reported on paper. Supplementary questionnaires were available on paper only. While weekly paper questionnaires were sent to the FOPH once a week by postal mail according to routine procedures, Sentinella-physicians were asked to send the supplementary questionnaire as soon as they considered the corresponding case as “completed”. Weekly electronic questionnaires were entered directly into the Sentinella-database by the Sentinella-physician.

Information available on Sentinella-physicians included the physicians’ specialty and location of practice. Sentinella-physicians additionally reported the total number of daily physician–patient contacts (PPCs) on the weekly questionnaire. A PPC is defined as each consultation independent of place (in practice or as domiciliary visit) and time (during or off consultation-hour or on emergency service) and serves as denominator for calculating disease incidence rates.

Subsample for supplementary questionnaire

We expected that each Sentinella-physician would report around two AG cases per week based on the pilot testing and discussions with physicians. Assuming that 150 physicians report during 48 weeks, 14,400 cases were expected during the 1-year-study period. To reduce the anticipated work load for Sentinella-physicians but still reaching an appropriate sample size allowing for estimates with acceptable precision, we decided to apply the supplementary questionnaire to a subsample of cases. The targeted subsample size was set at 4800 cases (one-third of all cases). A sampling scheme was defined whereby every Sentinella-physician had to complete supplementary questionnaires during four consecutive weeks four times a year (=16 weeks per physician per year). We randomly assigned each Sentinella-physician a sampling pattern with sampling periods distributed equally over the year, hence not allowing for two consecutive sampling periods.

Case numbers in the first half of the study period were lower than expected necessitating the sampling scheme to change to full sampling. Starting from week 25 (starting on 14.06.2014), supplementary questionnaires had to be completed for every AG patient until the end of the study.

Data entry and analysis

Weekly questionnaires on paper forms and all supplementary questionnaires were entered into the electronic Sentinella database at the FOPH. Ten percent of supplementary questionnaires was randomly selected for double entry to assess data quality. Double entries of questionnaires were compared and discrepancies were eliminated by re-checking against the original paper forms.

Cases of Sentinella-physicians who reported PPC for less than 75% of the weeks during the study period, i.e. <39 of 52 weeks were excluded from data analysis. This rule and cutoff value for regularly reporting physicians are standard for analyses of Sentinella data. Additionally, cases not fulfilling the case definition or cases where the Sentinella-physician spontaneously indicated a final diagnosis not in agreement with infectious AG were excluded from the analysis of supplementary questionnaire data.

Data of weekly questionnaires were analysed descriptively. We calculated the average number of cases per Sentinella-physician and week and the number of initial consultations due to AG per 1000 PPCs per week. Additionally, we estimated the incidence and total number of first consultations due to AG at the primary care level for 2014 in Switzerland by the standard extrapolation of the Sentinella system which is described elsewhere [ 16 ].

Due to the mid-study change in the sampling scheme of supplementary questionnaires, analyses of the supplementary questionnaire data were weighted according to the sampling probability: information from the supplementary questionnaire of cases reported during the first half of the study period was analysed using a sampling weight of 3.25 (as each physician was required to submit a supplementary questionnaire for each case seen during 16 of 52 weeks; 1/(16/52) = 3.25) while information reported during the second half had a sampling weight of 1 (supplementary questionnaire required for every case). Point-estimates including 95% confidence intervals (CI) and interquartile ranges (IQR) for medians are reported for weighted analyses. Data from supplementary questionnaires were analysed descriptively and differences were assessed for significance by weighted, univariable logistic regression. For all analyses involving employment status, only patients aged 15–64 years were considered. Data were analysed and represented graphically using Stata 13.1 (StataCorp.). Maps were created using ArcGIS 10.2.1 for desktop (Environmental Systems Research Institute, Inc., Esri).

Physician and patient characteristics

In total, 3867 cases of AG were reported on weekly questionnaires by 172 participating Sentinella-physicians. After exclusion of cases reported by not regularly reporting Sentinella-physicians (130 cases) and for other reasons (3 cases), 3734 cases were used for analyses of weekly questionnaires. 2200 cases were retained for the analyses of supplementary questionnaires. The detailed inclusion process is described in Fig.  1 .

Study profile of notified cases and reporting physicians. Acute gastroenteritis study, Swiss Sentinel Surveillance Network, 2014. AG acute gastroenteritis, PPC physician–patient contact

Out of 172 physicians registered in the Sentinella system in 2014, 154 of the regularly reporting physicians reported at least one case of AG on the weekly questionnaire. Over the whole study period, individual physicians reported up to 400 cases (median 17, IQR 7–29). A total of 144 physicians submitted at least one supplementary questionnaire of a case fulfilling the case definition (Fig.  1 ). The subsample of cases with supplementary questionnaires was comparable to cases reported on weekly forms in terms of basic patient characteristics (Table  1 ).

Table 1

Basic characteristics of acute gastroenteritis cases reported on the weekly and supplementary questionnaires by physicians from the Swiss Sentinel Surveillance Network in 2014

Median age of AG cases was 21 years (IQR 5–41 years). Children, adolescents and young adults (age groups <1, 1–4, 5–9, 10–14, 15–19 and 20–29 years) were overrepresented among AG cases consulting a physician compared to the frequency of those age groups in the general Swiss population for both genders (Fig.  2 ). In the age group of 10–14 year olds, males were more frequent than females. In adults, female cases aged 20–29 years were most frequently reported while in males the 30–44 year age group predominated.

Age distribution by sex among acute gastroenteritis cases reported by Sentinella-physicians on weekly and/or supplementary questionnaires. Swiss Sentinel Surveillance Network, 2014; age distribution of Swiss population (official numbers [ 17 ]) added for comparison

Burden of AG at primary care level

Each week, 15–139 cases (median 69, IQR 54–80) were reported (Fig.  3 ). Case numbers were highest during the first weeks of the year (maximum in week 4) and decreased thereafter. A median rate of 5.4 first consultations due to AG per 1000 PPCs per week (IQR 4.6–6.7) was observed. The notifications correspond to 2146 first consultations due to AG at primary care level per 100,000 inhabitants or 174,610 first consultations due to AG in Switzerland in 2014 using the standard extrapolation method of the FOPH for Sentinella data. Incidence (of first consultations) by Sentinella-region is displayed in Fig.  4 .

Acute gastroenteritis cases reported by physicians from the Swiss Sentinel Surveillance Network in 2014 (28.12.2013–26.12.2014): weekly case numbers ( bars ) and number of initial AG consultations per 1000 physician–patient contacts (PPCs, “consultations”) per week ( line ). Vertical , dashed line date of change of sampling scheme (from subsample of cases with supplementary questionnaires to supplementary questionnaire for every reported case)

Calculated incidence of first consultations due to acute gastroenteritis at primary care level in Switzerland by Sentinella-region, based on standard extrapolation. Swiss Sentinel Surveillance Network, 2014. Note: an outlier (one physician reporting 400 cases) was excluded from this extrapolation by region. Source of map shapefile: Swiss Federal Office of Topography

Health care seeking and clinical presentation

The median time from symptom onset to first consultation was 2 days (95% CI 2.0–2.0, IQR 1.0 [95% CI 1.0–1.0]–3.0 [95% CI 2.4–3.6]). The majority of patients (87.9% [95% CI 85.6–89.9]) suffered from diarrhoea (Table  2 ). Loss of appetite was reported for 63.5% (95% CI 58.4–68.4), abdominal pain or cramps for 61.1% (95% CI 57.0–65.1), nausea for 60.4% (95% CI 56.6–64.1) and vomiting for 57.5% (95% CI 54.3–60.7) of patients. Less frequently reported signs and symptoms included flatulence, fever, dehydration and headache.

Table 2

Characteristics of cases with acute gastroenteritis at first consultation and number of consultations as reported by primary care physicians from the Swiss Sentinel Surveillance Network, 2014

a  Multiple answers possible

The majority of patients consulted the Sentinella-physician only once (79.6%, 95% CI 76.5–82.4) (Table  2 ). The median general condition of cases as reported by Sentinella-physicians at the time of first consultation was 7 (95% CI 6.5–7.5, IQR 5.0 [95% CI 4.5–5.5]–9.0 [95% CI 8.5–9.5]) on a rating scale from 1 (poor) to 10 (good). Overall, 86.3% (95% CI 83.1–89.0) of employed patients were unable to work. The odds for a good general condition (7 or above) was lower for employed patients compared to unemployed patients although not significantly (odds ratio [OR] 0.76, 95% CI 0.52–1.11, p  = 0.159). The median duration of sick leave was 4 days (95% CI 3.8–4.2, IQR 3.0 [95% CI 3.0–3.0]–5.0 [95% CI 4.5–5.5]). For all except seven cases, the duration of sick leave was below 15 days.

The hospitalisation rate was 2.7% (95% CI 1.9–3.7). The highest hospitalisation rate was observed for the >74 year age group (11.5%, 95% CI 6.4–19.9) whereas for the remaining age groups the rates were below 4%. For 2.0% (95% CI 1.4–2.9) of patients, Sentinella-physicians reported sequelae, like dehydration, diverticulitis, or colitis. No deaths due to AG were reported.

Stool diagnostics and results

Sentinella-physicians reported the initiation of stool specimen testing in 12.3% (95% CI 10.1–14.8); in 11.6% (95% CI 9.5–14.1) of cases they indicated that the sample was actually sent off (Table  3 ). The odds for stool testing did not differ between sexes ([female vs. male]: OR 1.13, 95% CI 0.84–1.50, p  = 0.423) but differed by age group ( p  < 0.001): The proportion of stool testing was generally higher among older age groups. Paediatricians initiated stool testing less frequently (OR 0.32, 95% CI 0.18–0.55, p  < 0.001) than general practitioners. The odds of initiating stool testing did not differ significantly for internists compared to general practitioners (OR 1.13, 95% CI 0.71–1.78, p  = 0.610).

Table 3

Frequency of and reasons for prescription of stool diagnostics among acute gastroenteritis patients consulting primary care physicians from the Swiss Sentinel Surveillance Network, 2014

a  Two pathogens were identified in 11.5% (95% CI 5.4–22.9) of the 98 cases with a positive stool test result

Even though the questionnaire explicitly asked for the main reason for initiating stool testing, multiple answers were given for 31.0% (95% CI 24.9–37.8) of cases. The three most frequent reasons mentioned were protracted course of disease (29.4%, 95% CI 21.9–38.2), poor general condition (11.5%, 95% CI 6.9–18.4) and due to a specific symptom (9.5%, 95% CI 4.6–18.6) when excluding those with multiple answers. When considering also multiple answers, staying abroad before symptom onset was the third most frequent reason (data not shown).

Travelling within the 7 days preceding symptom onset was reported for 9.0% (95% CI 7.4–10.8) of cases. Patients with recent travel history were significantly more likely to undergo stool testing than patients not reporting any recent travels (OR 3.60, 95% CI 2.47–5.33, p  < 0.001). Among patients with recent travel history, 30.0% (95% CI 22.7–38.6) were tested while for patients without travel to a foreign country in the 7 days preceding the symptom onset this proportion was 10.6% (95% CI 8.6–13.0). “Staying abroad” was indicated as the main reason for testing for 40.8% (95% CI 24.4–59.6) of patients with a travel history. Protracted course of disease was the second most often mentioned reason for stool testing among patients with travel history abroad (17.4%, 95% CI 7.2–36.2).

A positive test result was reported for more than one-third (35.9%, 95% CI 29.2–43.2) of tested patients while for the remaining 64.1% (95% CI 56.8–70.8) of patients test results were negative or not specified. The most frequently identified pathogen was Campylobacter spp. (50.8%, 95% CI 39.2–62.3) followed by norovirus (10.9%, 95% CI 5.0–21.9), and Blastocystis spp. (9.6%, 95% CI 4.0–21.1) (Table  3 ). Other pathogens identified included rotavirus, Clostridium spp., Entamoeba spp., pathogenic E. coli , Candida spp., Salmonella spp., Giardia spp., microsporidia, adenovirus, Aeromonas spp. and hepatitis E virus. Two pathogens were identified in 11.5% (95% CI 5.4–22.9) of the 98 cases with a positive stool test result.

Approaches for symptomatic and antibiotic therapy

In 92.0% (95% CI 89.8–93.8) of cases, Sentinella-physicians gave dietary recommendations, or prescribed symptomatic and/or antibiotic treatment. Most commonly, patients were advised to care for fluid replacement by the intake of sufficient tea, broth etc. (58.3%, 95% CI 53.0–63.3) (Table  4 ). Distinct rehydration therapies such as electrolyte solution (11.4%, 95% CI 7.8–16.4) and infusion therapies (1.7%, 95% CI 1.1–2.6) were less frequently prescribed. Symptomatic treatment included probiotics (45.9%, 95% CI 39.1–52.8), antiemetics (45.4%, 95% CI 40.5–50.4), antidiarrhoeals (28.8%, 95% CI 23.6–34.6), analgesics (16.3%, 95% CI 12.8–20.5), and spasmolytics (15.0%, 95% CI 11.5–19.2). Antibiotics were prescribed in 8.5% (95% CI 6.5–11.0) of cases (Table  4 ).

Table 4

Frequency of prescription of antibiotic and symptomatic treatment, and reasons for prescription of antibiotic therapy among acute gastroenteritis patients consulting primary care physicians from the Swiss Sentinel Surveillance Network, 2014

The Sentinella-physicians initiated stool testing and prescribed antibiotics at the first consultation in 33 cases (unweighted results, Table  5 ). Stool diagnostics revealed the presence of a pathogen susceptible to antibiotics in 20 of these cases. No antibiotics were prescribed in 22 cases even though a pathogen which is theoretically susceptible to antibiotics was identified.

Table 5

Time point of prescription of stool testing and antibiotic treatment among acute gastroenteritis patients consulting primary care physicians, Swiss Sentinel Surveillance Network, 2014

Unweighted results. Cases with missing information on (date of) antibiotic prescription and/or (date of) stool test were excluded

a  Not considering possible antibiotic resistances and treatment recommendations

The majority of patients receiving antibiotics was treated with quinolones (60.2%, 95% CI 48.5–70.9), followed by macrolides, metronidazole, aminopenicillin, trimethoprim/sulfamethoxazole, cephalosporin and tetracycline (Table  4 ). Two or more antibiotic classes were reported to be used for 8.5% (95% CI 4.6–15.2) of cases. No antibiotic class was reported for 1.6% (95% CI 0.6–4.4) of cases treated with antibiotics.

Main reasons for the prescription of antibiotic therapy included (suspicion of) bacterial gastroenteritis (41.1%, 95% CI 25.0–59.5), duration of illness (9.0%, 95% CI 3.4–19.6), a specific symptom (7.2%, 95% CI 3.4–14.8) and others (Table  4 ). Sentinella-physicians mentioned several reasons for 23.9% (95% CI 16.6–32.2) of the patients despite being asked to indicate only the main reason. When considering also multiple answers, “poor general condition” was the third most frequently mentioned reason for antibiotic therapy (data not shown).

Similar to stool testing, antibiotic prescription was associated with age ( p  < 0.001) and with the physicians’ specialty ( p  < 0.001) but not with sex ( p  = 0.511) (data not shown). Again, children and adolescents were less frequently treated with antibiotics compared to adults. Among the >74-year-old age group, one-fifth of cases received antibiotics (20.0%, 95% CI 12.8–29.7). Nearly three-quarter of the antibiotic therapies were prescribed at the first consultation (71.3%, 95% CI 60.5–80.1). These patients had a lower general condition according to physicians’ impression (median 5.0, 95% CI 4.0–6.0, IQR 4.0 [95% CI 3.0–5.0]–7.0 [95% CI 6.0–8.0]) than patients receiving antibiotics later on (median 7.0, 95% CI 6.0–8.0, IQR 5.0 [95% CI 4.0–6.0]–8.0 [95% CI 7.0–9.0]) and also suffered slightly more frequently from fever (44.7%, 95% CI 34.5–55.4 vs. 38.9%, 95% CI 24.0–56.2). However, both differences were not statistically significant. Patients with a recent history of travel had significant higher odds to undergo antibiotic therapy (OR 1.75, 95% CI 1.06–2.88, p  = 0.029).

This study underscored that acute gastroenteritis is common in Swiss primary care: extrapolated annual consultation numbers (175,000 first consultations) are comparable to those of influenza-like illness (ILI) during an influenza season (varying between 107,000 and 276,000 ILI cases in the last three seasons [ 18 – 20 ]). The majority of patients is symptomatically treated and does not require multiple consultations. However, most episodes of AG lead to a sick leave of several days, though the physician-assessed general state of the patients is considered as “fairly good”. Stool specimen testing is not systematically conducted and antibiotic therapy is applied to less than 10% of patients.

Multiple factors influence physicians’ decision making

Sentinella-physicians reported more than one reason for stool testing in a third of cases despite being explicitly asked for the main reason in the questionnaire. This suggests that a combination of factors plays a role in decision making. The same holds true for the prescription of antibiotic treatment where in around a quarter of cases several reasons were mentioned albeit physicians were asked to indicate the main reason. The reasons mentioned most frequently for stool testing—namely protracted course of disease, poor general condition, due to a specific symptom and a history of recent travel—are in line with findings from other studies: three of the aforementioned four factors (all except “specific symptom”) were also mentioned by GPs participating in a qualitative study in Switzerland [ 8 ] and in a study from Northern Ireland and the Republic of Ireland [ 21 ]. The Irish study further reported that stool testing is frequently prescribed if the illness is associated with an outbreak or if the physicians suspect a link with a particular consumed food item or food premises (pub, restaurant, take away). Similarly, a qualitative study among GPs in the UK found that long duration of illness, recent travel, blood in the stool, patient being unwell and exclusion of an infectious cause were the reasons mentioned most frequently for stool testing [ 22 ]. Factors most strongly associated with requesting a stool culture were bloody diarrhoea, diarrhoea lasting more than 3 days, and a diagnosis of AIDS in a postal survey among physicians in the US [ 23 ].

Considering that protracted course of disease and poor general condition were mentioned most frequently as main reasons for stool testing in our study, the difference in reported general condition at the time of first consultation among tested and untested patients seems rather small (median 7.0, 95% CI 6.5–7.5, IQR 5.0 [95% CI 4.5–5.5]–8.0 [95% CI 7.5–8.5] vs. median 8.0, 95% CI 7.5–8.5, IQR 6.0 [95% CI 5.5–6.5]–9.0 [95% CI 8.5–9.5]). One explanation for this is that a “protracted course of disease” does not necessarily equate with a poor general condition but simply reflects the lack of improvement of symptoms with an average or fairly good general condition. Most of the aforementioned studies [ 8 , 21 , 22 ] acknowledge that decisions for testing are subjective and depend on the physicians’ experiences and attitudes.

AG, whether of viral or bacterial origin, is usually self-limiting [ 5 ]. Antibiotics are mainly recommended for severely affected patients and are most effective if given early [ 5 , 24 , 25 ]. “Bacterial gastroenteritis” was most frequently mentioned as main reason for antibiotic therapy in our study. We cannot judge whether this reasoning was based on laboratory results or on physicians’ experience. However, only two cases with positive stool test results for pathogens not susceptible to antibiotics were prescribed antibiotics in our study. The second most common reasoning for antibiotic treatment, namely duration of illness, was also reported by Swiss GPs in an extensive qualitative assessment [ 8 ]. A study from Poland concluded that factors associated with antibacterial drug administration included the work environment of the physician (working in large practices and hospital wards favoured antibiotic prescription compared to small practices), presence of fever, or mucus or blood in stool, age of the patient and (rural/urban) residence [ 26 ]. The presence of fever, or mucus or blood in stool could also be a factor leading to antibiotic therapy in our study as the third most frequent mentioned main reason for antibiotic prescription was suffering from a specific symptom.

Some 62% of all cases with a laboratory-confirmed Campylobacter infection received antibiotic treatment in our study. This finding is important in the context of antibiotic resistance development. More than half of those patients received quinolones and one-third was treated with macrolides—a finding confirming results from an earlier qualitative study among Swiss GPs [ 8 ]. Given antibiotic resistance levels for fluoroquinolones as high as 55.3% for human Campylobacter isolates in Switzerland in 2014 [ 27 ], these studies’ findings underscore the need for changes in prescription practise in Switzerland. A similar level of resistance (60.2%) was observed in Europe in 2014 [ 28 ]. Consequently, the European Food Safety Authority and the European Centre for Disease Prevention and Control do no longer recommend fluoroquinolones for the empirical treatment of human campylobacteriosis.

Physicians’ case management impacts on the mandatory surveillance system

A stool test was performed only for 11.6% of patients consulting a Sentinella-physician due to AG. Of these, 19.8% (95% CI 15.1–25.6) had a positive result for a notifiable pathogen. Hence, a very small proportion of 2.3% (=11.6 × 19.8%) of AG patients consulting a Sentinella-physician were actually reportable to the mandatory reporting system. This is in line with Swiss physicians’ typical treatment pattern for AG of “wait & see”, which can be followed by a “treat & see” approach or a desirable (from the perspective of the NNSID) “test & see” or “test & treat” approach based on illness progression [ 8 ]. Considering the (main) reasons mentioned for stool testing, patients with a prolonged duration of illness and patients reporting recent travel abroad are likely overrepresented among notified cases. The proportion of patients with stool testing varies substantially between countries: it was found to be 4.3 or 9.1% in France [ 29 ], 6% in Italy [ 30 ], 7% in Ireland [ 31 ], 12% in the Netherlands [ 32 ], 19% in the US [ 33 ] and 25% in Denmark [ 34 ].

The pathogen most often identified through stool testing in this study ( Campylobacter spp.) is also the pathogen most frequently reported to Swiss national surveillance. Norovirus, which is not notifiable in Switzerland but in several countries of the European Union, was the second most common identified pathogen.

Mild disease with high socio-economic burden

Physicians rated the general condition of AG patients as relatively good. Nevertheless, a high proportion of 86.3% of employed patients was not able to work due to the illness. Sick leave is considerable with a median of 4 days. The risk of transmission seems to play a subordinate role as a reason for inability to work. Similar findings were reported in a French study where 79% of working patients were on sick leave for a median duration of 3 days [ 35 ]. In a Danish study, only 35% of patients with AG reported having missed work or school as a result of illness [ 34 ]. However, this Danish study was a population-based study in which only 13% of patients were seen by a physician and/or hospitalised. In our study, we did not observe a difference in time from symptom onset to consultation between employed and unemployed patients (data not shown). This indicates that the need of a medical certificate is unlikely to be a main reason for consultation.

It is well known that some pathogens causing AG are easily transmitted from human-to-human, especially viruses, and contact with diarrhoea patients has been described as a risk factor for AG previously [ 35 , 36 ]. In our study, 28.6% (95% CI 24.9–32.6) of the patients had contact to other people suffering from similar signs and symptoms in the 7 days preceding symptom onset. Thus, it is possible that these patients had a common source of infection or transmitted the disease among each other.

In summary, our findings suggest that AG is a common, but generally mild disease which results, however, in a high social and economic burden. The overall financial burden due to AG (including losses in productivity) is likely a multiple of the healthcare costs estimated for Switzerland in the range of €29–45 million annually [ 14 ].

Sentinella is invaluable to investigate current public health issues

All information for this study was derived from physicians in the Swiss Sentinel Surveillance Network. This study was specifically set up by the FOPH to clarify current epidemiological questions about gastroenteritis in Switzerland, using a national primary care sentinel surveillance platform.

We consider it a strength of the study to have obtained information on diagnosis and treatment directly from treating primary care physicians. However, the actual duration of sick leave might have been longer or shorter than reported or certified by the physician. Similarly, we could not record the overall duration of the illness as in this study we could not send out follow-up questionnaires at the end of an AG episode.

A limitation of our study is the change in sampling scheme for supplementary questionnaires for the second half of the study period, especially considering that AG is subject to seasonal variation. However, we believe that changing to full sampling and using weighted analyses to adjust for the change in sampling scheme resulted in more reliable data than continuing without changing the sampling scheme and obtaining far less supplementary questionnaires.

We expected to observe a seasonality of case reports considering the literature [ 4 , 36 ], results of a previous study [ 8 ] and surveillance data [ 12 ], with a peak of AG in winter (December–March) and during summer (June–September). Instead we found a decreasing number of initial consultations per 1000 PPCs over the year which we assume is partially due to reporting fatigue of the Sentinella-physicians partaking in the study. This is supported by a survey conducted among Sentinella-physicians in which they were asked about the time required for participating in the sentinel network—in total and for the different research topics. Physicians indicated that the study on AG was comparatively time-consuming although the majority indicated that the total amount of time required for notifying was acceptable [ 37 ].

Not to our complete surprise, this study has shown that acute gastroenteritis is a common disease in Switzerland with consultation frequencies comparable to influenza-like illnesses. AG presented to physicians lead to substantial sick leave in the employed, resulting in considerable socio-economic costs due to productivity loss.

Furthermore, as suspected, the study confirms that the National Notification System for Infectious Diseases captures—if at all—only a fraction of the scope of the problem (see introduction for currently notifiable diarrhoea-causing pathogens). Hence, the Swiss Sentinel Surveillance Network, Sentinella, represents a very important complementary surveillance instrument to grasp principal dynamics of infectious disease epidemiology at the primary care level.

The FOPH and the Federal Food Safety and Veterinary Office, being responsible to maintain population health and food safety in Switzerland, are currently lacking effective tools for pinpointing and a comprehensive national programme addressing the control of foodborne diseases and AG. While there are efforts to increase food safety and consumer hygiene including campaigns to increase awareness for food and kitchen hygiene among consumers in Switzerland, prevention measures to reduce contamination at food production or retail level are incomplete. Overall, there is an imbalance in national disease prevention and control efforts for AG considering that national strategies to reduce the burden of seasonal influenza—an infection with a disease burden comparable to AG—exist since many years.

Below is the link to the electronic supplementary material.

Acknowledgements

We thank all physicians who contributed and provided feedback to pre-testing the questionnaire, especially Professor Andreas Zeller and Dr. Christoph Merlo. Albeit being formally listed in globo as co-authors, all the physicians constituting the Swiss Sentinel Surveillance Network deserve a special word of thanks for relentlessly contributing to the network and collaborating with us weekly in this 1-year study. The authors gratefully acknowledge the help of the Notification Systems Unit of the Federal Office of Public Health, especially Ms. Diana Guido and Dr. Raphael Rytz, for their help in preparing the study and during data collection. The statistical support of Dr. Jan Hattendorf (Swiss Tropical and Public Health Institute) is gratefully acknowledged. We thank the Federal Office of Public Health, Bern, Switzerland for funding this study.

Compliance with ethical standards

Ethical statement.

This study was conducted under the Swiss Epidemics Act (SR 818.101) and the ordinance on disease notification of humans (SR 818.141.1).

Conflict of interest

This study was funded by the Federal Office of Public Health, Bern, Switzerland (Grant numbers 13.004570, 14.000710 and 15.007090). MJ and MM are on the staff of the Federal Office of Public Health and participated in their capacities as public health specialists and their function as scientific collaborators within the organisation.

Claudia Schmutz and Philipp Justus Bless contributed equally to this paper.

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Acute Gastroenteritis: Evidence-Based Management of Pediatric Patients

*NEW* Quick Search this issue!

For a pediatric patient who presents with acute gastroenteritis, the degree of dehydration can help guide the management and necessary interventions. In this issue, you will learn:

What signs and symptoms indicate a case of acute gastroenteritis and which suggest a more serious illness, how to use various dehydration scales to approximate a patient’s degree of dehydration, when laboratory testing is indicated, and which tests are essential in cases of severe dehydration, how to use antiemetics to increase the chance that oral rehydration will be successful, which solutions are best for oral rehydration of mild-to-moderately dehydrated patients and which are recommended for severely dehydrated patients, alternate methods for rehydration when intravenous access may be difficult, which strains of probiotics should be recommended for reduction of the duration of diarrhea, evidence-based recommendations for diet and fluid intake for patients who are discharged home, case presentations, selected abbreviations, introduction, critical appraisal of the literature.

• Viral Pathogens
• Bacterial Pathogens
• Antibiotics
• Pathophysiology
• Inflammatory Bowel Disease
• Allergic Colitis
• Other Diagnoses
• Prehospital Care
• Physical Examination
• Determining the Degree of Dehydration
• Laboratory Studies
• Stool Studies
• Imaging Studies
• Dosages and Administration Routes for Ondansetron
• Side Effects of Ondansetron
• Oral Rehydration
• Intravenous Fluid Resuscitation
• Dextrose-Containing Fluids
• Rapid Versus Standard Rehydration
• Bismuth Subsalicylate
• Special Populations
• Racecadotril
• Gelatin Tannate
• N-acetylcysteine
• Disposition

Risk Management Pitfalls in Management of Pediatric Patients With Gastroenteritis

• Time- and Cost-Effective Strategies
• Case Conclusions
• Clinical Pathway for Management of Pediatric Patients With Suspected Acute Gastroenteritis
• Table 1. Differential Diagnosis of Conditions That Cause Vomiting and-or Diarrhea
• Table 2. The 4- and 10-Point Gorelick Scale for Dehydration for Children Aged 1 Month to 5 Years
• Table 3. Antibiotic Therapy for Bacterial Gastroenteritis

Although most cases of acute gastroenteritis require minimal medical intervention, severe dehydration and hypoglycemia may develop in cases of prolonged vomiting and diarrhea. The mainstay of treatment for mild-to-moderately dehydrated patients with acute gastroenteritis should be oral rehydration solution. Antiemetics allow for improved tolerance of oral rehydration solution, and, when used appropriately, can decrease the need for intravenous fluids and hospitalization. This issue reviews the common etiologies of acute gastroenteritis, discusses more-severe conditions that should be considered in the differential diagnosis, and provides evidence-based recommendations for management of acute gastroenteritis in patients with mild-to-moderate dehydration, severe dehydration, and hypoglycemia.

An 18-month-old girl who is up-to-date on her immunizations and has no prior medical history presents with vomiting and diarrhea for the last 3 days. She initially had multiple episodes of nonbloody, nonbilious emesis that stopped yesterday. On the second day, watery, voluminous diarrhea started. Her parents estimate she has had approximately 20 episodes of diarrhea since yesterday; they cannot quantify urine output because she has had so many episodes of diarrhea. The girl does not have a fever or other symptoms. On examination, she is lying on the stretcher with her eyes closed. The girl weighs 12 kg, and her vital signs are: rectal temperature, 37.6°C (99.7°F); heart rate, 165 beats/min; blood pressure, 90/65 mm Hg; respiratory rate, 22 breaths/min; oxygen saturation, 100% on room air. Although she is crying during the examination, the girl produces no tears. Her lips are dry and her eyes appear sunken. Her abdomen is soft, with no tenderness elicited on palpation. Her capillary refill is 2 seconds. She has watery, yellow-colored stool in her diaper. Should you give this child a dose of ondansetron and attempt oral hydration or does she need intravenous hydration? Do you need to send the stool for culture? Do any laboratory studies need to be performed?

A 2-year-old boy with no past medical history is brought to the ED by his parents. His mother states that his illness started with vomiting, approximately 4 episodes, that has now resolved. He has had 10 episodes of watery, nonbloody stools in the last 2 days. He is drinking well and has appropriate urine output. The boy attends daycare, and several other children at the daycare center have the same symptoms. On examination, he is playing with his toy cars while sitting on the stretcher. His vital signs are within normal limits. He has moist oral mucosa and normal cardiac and lung examinations. His abdomen is soft, with no tenderness elicited. You diagnose him with acute gastroenteritis and inform his parents that they should continue with aggressive oral hydration. The parents ask you whether there is any medication you could prescribe that might stop his diarrhea. They also want to know if there are specific foods he should avoid. As you consider the parents' questions, you think about whether you should prescribe an antidiarrheal agent for this child? Should you recommend that the parents prescribe the traditional BRAT (bananas, rice, applesauce, toast) diet for the next few days? Are probiotics appropriate in this clinical scenario?

Nausea, vomiting, and diarrhea are some of the most common presenting complaints of pediatric patients presenting to the emergency department (ED); and these symptoms may be associated with abdominal pain. The most common discharge diagnosis for children who present with these symptoms is acute gastroenteritis (AGE). AGE is defined as inflammation of the stomach and intestines, typically resulting from viral infection or bacterial toxins. Both vomiting AND diarrhea must be present for the diagnosis of AGE. Most cases of AGE are due to viral pathogens and are usually mild and self-limited, with no need for major medical intervention. Bacterial and parasitic infections are less common, but should be considered in the appropriate clinical context. Antibiotic-associated diarrhea and Clostridium difficile colitis are also possible etiologies of AGE symptoms.

This issue of Pediatric Emergency Medicine Practice discusses various etiologies of AGE, details how to determine the level of a patient's dehydration, and reviews practice guidelines and high-quality studies that can inform the emergency clinician of the most recent and proven treatments for AGE.

A literature search was performed in PubMed using the search terms gastroenteritis, colitis, cows' milk protein allergy, and allergic colitis. Filters included the English language and ages birth to 18 years. No date limits were imposed. Several thousand articles were found, which were screened by title and then abstract. The Cochrane Database of Systematic Reviews and policy statements by the American Academy of Pediatrics (AAP) were also searched. One hundred-seventy articles were reviewed in full, and 119 were ultimately selected for inclusion.

There are many randomized controlled trials related to pediatric AGE. The most common topics include the use of antiemetics, the ideal intravenous (IV) fluid for resuscitation, and the utility of probiotics. While many of these studies come to similar conclusions about the utility of various treatments, several involve relatively few subjects. The most recent practice guidelines published by the AAP are over 20 years old, 1 but more recent studies exist. The studies by Roslund et al and Ramsook et al are robust randomized trials of oral ondansetron use in AGE. 2,3 Articles evaluating probiotic use were also reviewed, such as Dinleyici et al 4 and Van Niel et al, 5 that evaluate Saccharomyces and Lactobacillus therapy for diarrhea, respectively. There is also a recent guideline for the treatment of AGE in children that was developed and published in 2014 by the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Pediatric Infectious Diseases. 6 These recommendations were also endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.

3. “I didn’t find out that the patient had hypoglycemia  until the electrolyte panel came back.”

If you are starting IV hydration in a child that you suspect has severe dehydration, point-of-care glucose testing should be performed rather than waiting for the formal metabolic panel. Young children have low glucose reserves and can easily develop hypoglycemia when they are dehydrated. Hypoglycemia should be treated promptly.

5. “The child was slightly tachycardic but had no other  signs of dehydration on examination and had only  been sick for a few hours. It was late at night and the  child was sleeping, so we gave IV fluids immediately.”

Almost all children with mild-to-moderate dehydration due to AGE can rehydrate via the enteral route. IV placement is painful, IV fluids are more expensive, and the complication rate is higher than from enteral rehydration.

9. “She had been vomiting for the last 3 days.  I just assumed that she had the AGE that  everyone else was coming in with lately. It  turns out she had acute pancreatitis.”

Most cases of vomiting alone will be early AGE; however, there are many other serious entities that will also cause vomiting. Prolonged vomiting without diarrhea is concerning. Look carefully for signs and symptoms that might suggest other diagnoses, such as severe abdominal pain, jaundice, polyuria/polydipsia, bilious emesis, abdominal distension, etc.

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, are noted by an asterisk (*) next to the number of the reference.

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Publication Information

KeriAnne Brady, MD, FAAP

Peer Reviewed By

Landon A. Jones, MD; Alexander Toledo, DO, PharmD, FAAEM, FAAP

Publication Date

February 2, 2018

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