Community Acquired Acute Gastrointestinal Infection ( including Food Poisoning ) in Adults Seen in Accident and Emergency and/or Requiring Hospital Admission

Community Acquired Acute Gastrointestinal Infection ( including Food Poisoning ) in Adults Seen in Accident and Emergency and/or Requiring Hospital Admission - Guideline for the Management of

Publication: 01/01/2008

Next review: 20/01/2025

Clinical Guideline

CURRENT

ID: 1211

Approved By: Improving Antimicrobial Prescribing Group

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

GUIDELINE FOR THE MANAGEMENT OF COMMUNITY ACQUIRED ACUTE GASTROINTESTINAL INFECTION (INCLUDING FOOD POISONING) IN ADULTS SEEN IN ACCIDENT AND EMERGENCY AND/OR REQUIRING HOSPITAL ADMISSION

Diagnostics
Non-antimicrobial management
Empirical treatment
Review by 72
Directed therapy

Acute gastroenteritis is an illness of <14 days duration characterised by the presence of diarrhoea (3 or more loose stools per day or bloody stools).
Accompanying symptoms may include abdominal pain/cramps, nausea, vomiting and fever.
Causes included a wide range of bacterial (e.g. Campylobacter spp., Salmonella spp., certain strains of Escherichia coli), viral and protozoal pathogens.
The history should identify pre-existing medical conditions that increase the risk of an adverse outcome (e.g. immunosuppression).
It is also important to ascertain the potential source of the infection by asking about travel history, contact with a similar illness affecting others and possible food sources.
C.difficile infection should be considered in patients where risk factors are present (click here).
As the symptoms/signs of gastroenteritis are nonspecific, alternative diagnoses should also be considered.
The majority of patients with acute gastroenteritis DO NOT require antimicrobial treatment as the illness will be self-limiting and without sequelae
Certain Shigella and E.coli infections (e.g. E.coli O157) can be complicated by Haemolytic-Uraemic syndrome (HUS). The clinical features are non-specific (unless Thrombotic Thrombocytopenic Purpura (TTP) is present) and can follow resolution of gastroenteritis.

DIAGNOSTICS

For patients with a presumed diagnosis of community acquired acute gastrointestinal infection (including food poisoning) the following diagnostic tests should be taken to confirm diagnosis:
Include pertinent clinical details on the request form, e.g. travel history/possible food source. Note that in the absence of clinical details the sample will not be processed.

All patients	FBC, U&E, LFT, CRP
	Stool sample for bacterial cultures (MC&S) For patients who are being discharged (e.g. from A&E or admissions units) supply a faeces collection container and advise them to deliver a sample to their GP at the earliest opportunity.
	Stool sampling for enteric virus PCR should be performed in patients who are hospitalised, the immunocompromised, and when cases may be part of an outbreak.
If Haemolytic uraemic syndrome (HUS) is suspected	Blood film Urinalysis Haemolysis screen These cases should be discussed with Microbiology/Infectious Diseases.
If abdominal pain/distention	Consider abdominal radiograph. An erect chest radiograph should be performed if there is evidence of peritonism.
If immunocompromised or potentially part of an outbreak	Stool sampling for enteric virus PCR should be performed in patients who are hospitalised, the immunocompromised, and when cases may be part of an outbreak.
If patient is immunocompromised, recent foreign travel or symptoms present >2 weeks, and/or concerns about Enteric fever	3 stool samples may be sent for ova, cyst and parasite (OCP) examination These cases should be discussed with Microbiology/Infectious Diseases.
Risk factors for Clostridium difficle	Request toxin testing if the patient has any risk factors for Clostridium difficile infection (CDI; see history section).
If showing signs of sepsis	Blood cultures - if showing signs of sepsis or enteric fever (typhoid or paratyphoid) suspected Check other electrolytes if indicated.

NON-ANTIMICROBIAL MANAGEMENT

Ensure adequate rehydration using either oral fluids if tolerated, or intravenous fluids.
Do not use anti-diarrhoeals as they may worsen acute gastroenteritis and its complications.

EMPIRICAL TREATMENT

Doses assume normal renal and hepatic function.
The majority of patients with acute gastroenteritis DO NOT require antimicrobial treatment as the illness will be self-limiting and without sequelae

Empirical options for community acquired acute gastrointestinal infection (including food poisoning)
	Treatment
Non-severe	Treatment not recommended
Moderate severity	Treatment not recommended
Where IV antibiotics are indicated blood cultures should be sent before initiating treatment.
Severe (IV required)	Refer to Intra-abdominal Infection guideline

REVIEW BY 72

By 72 hours of antimicrobial treatment, diagnostics should have proven your initial diagnosis or guided to a new diagnosis.

If your patient in on IV treatment this should be reviewed daily.

The review, outcome and future plans (where appropriate) should be documented in the medical notes.

If the diagnosis is still correct your options are now:

IVOS	If your initial diagnosis is correct and the patient is prescribed IV antibiotics, review whether an oral switch is appropriate using the ACED criteria (see below). If they meet all 4 criteria (community acquired acute gastrointestinal infection (including food poisoning) is not a deep seated infection) consider switching using the oral options listed in the table above. A - Afebrile for 24 hours C - Clinically improving E - Eating and drinking D - not Deep seated infection
Stop	If no signs of infection and diagnostics support this decision.
Change	If the patient is not clinically responding, check microbiology results to see if directed therapy is required or you may need to consider an alternative diagnosis.
Continue	If the patient is improving but does not fully meet ACED criteria. Review daily until ready to switch. Document the reason for continuing.

DIRECTED THERAPY

Pathogen	1st line	2nd line	Duration
The choice of step-down antibiotic should be guided by sensitivities. ALWAYS REVIEW FINAL SENSITIVITIES IF NOT AVAILABLE AT THE TIME OF ORAL ANTIBIOTIC STEP-DOWN
*Campylobacter* ¹	Clarithromycin PO 500mg 12-hourly	Ciprofloxacin PO 500mg 12-hourly	5 days
*Clostrium difficile* ¹	Refer to separate guideline
*E coli* O157 (and other verotoxin producing strains) ¹	Discuss with microbiology or infectious diseases
*Salmonella* (except enteric fever) ¹	Ciprofloxacin PO 500mg 12-hourly Duration: 5 days If history of travel to SE Asia/Indian subcontinent or possible/confirmed Salmonella Typhi/Paratyphi discuss urgently with infectious diseases	Discuss with microbiology or infectious diseases	5 days
*Shigella* ¹	Ciprofloxacin PO 500mg 12-hourly Duration: 5 days (NB no antibiotics if associated HUS - discuss with microbiology or infectious diseases)	Azithromycin PO 500mg 12-hourly Duration: 3 days Sensitivities not routinely performed for azithromycin - contact microbiology if prescribing azithromycin
*Yersinia enterocolitica*	Treatment not usually indicated, but contact ID/Microbiology if severe or patient has risk factors.
*Aeromonas*	Treatment not usually recommended.
*Cryptosporidium*	Treatment not usually recommended. If severe/immunocompromised discuss with microbiology or infectious diseases
*Enteric viruses (e.g. Norovirus)*	Treatment not usually recommended.

FOOTNOTES

Organisms associated with bloody stools (dysentery). Entamoeba histolytica also indicated.

Provenance

Record:	1211
Objective:
Clinical condition:	Acute gastroenteritis (including food poisoning) in adult patients
Target patient group:	Adults patients seen in Accident and Emergency and all those admitted to hospital
Target professional group(s):	Pharmacists Secondary Care Doctors
Adapted from:

Evidence base

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Approved By

Improving Antimicrobial Prescribing Group

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