Gastroenteritis

Suspect potential gastroenteritis if the resident has one or more of the following:

• Diarrhoea (loose stools and/or three or more bowel motions over an individual’s baseline in a 24 hour period)
• Vomiting (2 or more episodes in a 24 hour period)
• Nausea
• Cramping abdominal pain

Gastroenteritis should also be considered in assessment of residents with:

• Functional decline
• Dehydration
• Systemic symptoms such as fever, headache, myalgia and malaise

Refer to Gastro-info kit and Norovirus and suspected viral gastroenteritis – CDNA National Guidelines for Public Health Units and Australian Guidelines for Prevention and Control of Infection in Healthcare for detailed infection control advice

• Isolate resident and place under standard and transmission-based precautions including contact and droplet precautions - where possible, place resident in a single room with an unshared bathroom. Suspected cases are isolated until alternative, non-infectious cause is confirmed to have caused the symptoms or until 48 hours after resolution of symptoms (or as guided by the HHS Public Health Unit)
• Staff apply appropriate personal protective equipment (PPE) as guided by Norovirus and suspected viral gastroenteritis – CDNA National Guidelines for Public Health Units
• Reinforce hand hygiene with staff & visitors - ensure adequate supplies of liquid soap and running water (note: non-enveloped viruses, such as norovirus are less susceptible to alcohol-based hand rub). Effective hand-washing can reduce staff absenteeism and outbreak size
• Cohort staff and restrict movement between affected and unaffected areas
• Screen and monitor residents and staff for symptoms. Where staff develop symptoms, they should isolate at home for at least 48 hours after resolution of symptoms
• Restrict visitors and place appropriate signage at all entrances and exits - timely institution of visitor restrictions are associated with shorter duration of outbreaks and reduced duration of closure
• Refer to Australian Guidelines for Prevention and Control of Infection in Healthcare for detailed advice on environmental cleaning
• Reinforce food hygiene standards including:
  • attention to hand hygiene
  • prevention of gross contamination during food preparation
  • provision of adequate hand washing facilities for food handlers
  • ensuring that food handlers do not work while they have symptoms of gastroenteritis

Assessment of a resident with symptoms of gastroenteritis involves assessment to:

1. Identify the underlying cause of the symptoms / exclude differential diagnoses

Examples of considerations include:

2. Identify and institute management plans to prevent complications of gastroenteritis including:

• Dehydration - review Dehydration and subcutaneous fluids
• Electrolyte imbalance and / or hypoglycaemia - replace electrolytes and glucose as required
• Skin injury due to perineal excoriation or pressure injury - prevent through institution of a structured skin care procedure for cleansing, moisturising and protecting skin
• Increased falls risk - particularly in residents with evidence of a postural drop in blood pressure or in mobile residents with diarrhoea and new incontinence
• Functional decline
• Destabilisation of comorbidities
• Aspiration pneumonia, particularly in residents with altered level of consciousness or impaired cough reflex

Red flags for deterioration or an underlying life-threatening cause/ complication in residents with gastroenteritis should prompt review of Management of residents with unstable vital signs pathway. Red flags include:

• Unstable vital signs including altered consciousness
• Severe dehydration - review Dehydration and subcutaneous fluids pathway
• Concurrent pulmonary oedema or aspiration pneumonia or new oxygen requirement
• Resident receiving terminal care or nearing end of life
• Severe abdominal pain
• Rigors (uncontrollable shivering / shaking)
• Haematemesis (vomiting of blood or coffee ground vomitus) or melaena (black, tarry stools)

1. Unstable vital signs (refer to Recognition of the deteriorating resident and Management of residents with unstable vital signs)
2. Worsening confusion or delirium
3. Syncope or concurrent falls
4. Progressive worsening of dehydration rather than improvement
5. Development of any of:
   • Sepsis
   • Chest pain
6. Comorbidities that require stabilisation
7. Acute on chronic renal impairment
8. Electrolyte disturbance requiring replacement therapy
9. Persistence of symptoms of gastroenteritis for more than 1 week

Investigations should be individualised to the residents presentation and goals of care but may include:

• SARS-CoV-2 PCR
• Stool bacterial and viral PCR is indicated in this population, predominantly for public health reasons and particularly for index case/s in a gastroenteritis outbreak
• Clostridium difficile if recent hospitalisation or recent antibiotics
• Full blood count and urea and electrolytes should be performed in residents with immune suppression and in those with moderate to severe dehydration or premorbid renal impairment
• Where symptoms persist for more than 7 days, add stool examination for Giardia and Cryptosporidium
• In residents with clinical features of sepsis, perform blood cultures

1. Axelrad JE, Freedberg DE, Whittier S, Greendyke W, Lebwohl B, Green DA. Impact of Gastrointestinal Panel Implementation on Health Care Utilization and Outcomes. J Clin Microbiol. 2019;57(3).
2. White AE, Ciampa N, Chen Y, Kirk M, Nesbitt A, Bruce BB, et al. Characteristics of Campylobacter and Salmonella Infections and Acute Gastroenteritis in Older Adults in Australia, Canada, and the United States. Clin Infect Dis. 2019;69(9):1545-52.
3. Cardemil CV, Balachandran N, Kambhampati A, Grytdal S, Dahl RM, Rodriguez-Barradas MC, et al. Incidence, Etiology, and Severity of Acute Gastroenteritis Among Prospectively Enrolled Patients in 4 Veterans Affairs Hospitals and Outpatient Centers, 2016-2018. Clin Infect Dis. 2021;73(9):e2729-e38.
4. Beeckman D, Van Damme N, Schoonhoven L, Van Lancker A, Kottner J, Beele H, et al. Interventions for preventing and treating incontinence-associated dermatitis in adults. Cochrane Database Syst Rev. 2016;11:CD011627.
5. Shane AL, Mody RK, Crump JA, Tarr PI, Steiner TS, Kotloff K, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis. 2017;65(12):e45-e80.
6. Rehydration in adults. 2016. In: Gastrointestinal Expert Groups, Therapeutic Guidelines: Gastrointestinal [Internet]. Melbourne: Therapeutic Guidelines limited.
7. Communicable Diseases Network of Australia. Guidelines for the public health management of gastroenteritis outbreaks due to norovirus or suspected viral agents in Australia 2020. Available from: https://www.health.gov.au/resources/publications/norovirus-and-suspected-viral-gastroenteritis-cdna-national-guidelines-for-public-health-units?utm_source=health.gov.au&utm_medium=callout-auto-custom&utm_campaign=digital_transformation
8. Supportive management of acute gastroenteritis. 2016. In: Gastrointestinal Expert Groups, Therapeutic Guidelines: Gastrointestinal [Internet]. Melbourne: Therapeutic Guidelines limited.
9. Inns T, Keenan A, Huyton R, Harris J, Iturriza-Gomara M, O’Brien SJ, et al. How timely closure can reduce outbreak duration: gastroenteritis in care homes in North West England, 2012–2016. BMC Public Health. 2018;18(1).
10. Gallelli L, Colosimo M, Tolotta GA, Falcone D, Luberto L, Curto LS, et al. Prospective randomized double-blind trial of racecadotril compared with loperamide in elderly people with gastroenteritis living in nursing homes. Eur J Clin Pharmacol. 2010;66(2):137-44.
11. Gastro-Info: outbreak co-ordinators handbook. In: Department of Health and Ageing, editor. https://www.health.gov.au/sites/default/files/documents/2020/01/outbreak-coordinator-s-handbook-gastroenteritis-kit-for-aged-care.pdf Accessed 25042022.