Infectious gastroenteritis

Last updated: January 24, 2022

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Infectious gastroenteritis is an inflammation of the gastrointestinal tract that is most commonly caused by viruses (e.g., norovirus, rotavirus, enteric adenovirus). However, it can also be caused by bacteria (e.g., Campylobacter, Salmonella, Shigella, Yersinia, Vibrio cholerae, diarrheagenic Escherichia coli, Clostridioides difficile), fungi, or parasites, such as protozoans (e.g., giardiasis, or cryptosporidiosis) or helminths (e.g., nematodes, or cestodes). Transmission is commonly fecal-oral, foodborne, or waterborne and therefore education on food and water hygiene is crucial for preventing disease. Clinical features can be mild, manifesting as abdominal pain and diarrhea, nausea, and/or vomiting, or severe, e.g., sepsis, intense abdominal pain, and/or significant dehydration from severe diarrhea and/or vomiting. For mild disease courses, diagnostic studies are not usually required, and since the disease is usually self-limiting, patients often only require supportive therapy (e.g., oral rehydration and antiemetics). Stool cultures followed by empiric antibiotic therapy may be considered in patients with severe gastroenteritis and/or risk factors for complicated disease (e.g., those who are immunocompromised).

See “Clostridioides difficile infection” for details on the management of this condition.

Definitions

Clinical features [1][2][3][4]

Diagnostics [1][5][6]

Approach

Suspect Shiga toxin-producing E. coli (STEC) gastroenteritis in patients with abdominal pain or tenderness and bloody diarrhea in the absence of fever. [2]

Viral gastroenteritis may be asymptomatic or manifest with nonbloody watery diarrhea and vomiting, which is sometimes accompanied by abdominal pain or cramps, and fever. [3]

Laboratory studies [1][4]

Testing for leukocytes and/or lactoferrin in the stool in patients with suspected infectious gastroenteritis is controversial and 2017 IDSA guidelines recommend against these studies in patients with acute infectious diarrhea. [1]

Diagnostic confirmation

Microbiological studies should be reserved for patients with fever, mucoid or bloody stools, signs of sepsis, immunosuppression, or severe abdominal cramping, and cases in which the identification of a causative pathogen would modify management.

Differential diagnosis

See “Overview of bacterial gastroenteritis,”; Overview of viral gastroenteritis,” “Diagnostic workup of diarrhea,” and “Food poisoning.”

Treatment [1]

Supportive therapy for gastroenteritis

Infectious gastroenteritis is usually self-limiting. Supportive therapy may suffice for most patients.

Antimotility drugs (e.g., loperamide) should be avoided in patients with fever or inflammatory diarrhea because of the risk of developing toxic megacolon.

Antibiotic therapy [1]

Antibiotic therapy is not routinely indicated in bacterial gastroenteritis. When indications for empiric antibiotics exist, they should be started after appropriate cultures have been collected.

Antibiotic therapy is contraindicated for enterohemorrhagic E. coli. It may increase the risk of or worsen HUS.

Complications

Prevention

See also “Infection prevention and control” and “HIV-associated enteropathies.”

  • Infection with enteric viruses is the leading cause of gastroenteritis worldwide and may contribute to local outbreaks.
  • Patients often present with acute onset of vomiting and diarrhea but the illness is generally self-limiting.
  • Routine testing is often not required but may be helpful in severe cases.
Overview of viral gastroenteritis
Pathogen Incubation period [12] Transmission Key features
Norovirus [13][14]
  • 1–2 days
  • Fecal-oral
  • Aerosol
  • Fomites
  • Food, water, or environmental contamination
  • Individuals of all ages are affected.
  • Very young and very elderly patients are at risk for complications and mortality.
  • Outbreaks may be seen in semi-closed environments.
  • See “Norovirus infection” for further details.
Rotavirus [15][16]
  • 1–4 days
  • Primarily fecal-oral
  • Primarily occurs in children < 5 years of age (may be fatal)
  • Adult infections may be related to travel or an outbreak.
  • See “Rotavirus infection” for further details.
Enteric adenovirus [17][18]
  • 8–10 days
  • Predominantly fecal-oral
  • Young children are most commonly affected.
  • May cause periodic diarrhea that lasts ≥ 10 days
  • May result in outbreaks
Astrovirus [19]
  • 1–5 days
  • Primarily fecal-oral
  • Primarily affects children < 2 years of age and elderly patients
  • Diarrhea and vomiting are usually milder than with norovirus or rotavirus infections.
Cytomegalovirus (CMV) [20]
  • Not defined [21]
Overview of bacterial gastroenteritis [6]
Pathogen Pathophysiology Associations Stool findings
Secretory diarrhea
Bacillus cereus
  • Rice
  • Manifests as vomiting
  • WBC negative
  • No blood
Enterotoxigenic E. coli (ETEC)
  • Recent travel [5]
Clostridium perfringens
  • Undercooked meat and raw legumes
Staphylococcus aureus
  • Inadequately refrigerated food
  • Poor hand hygiene among food preparers
Vibrio cholerae
Invasive diarrhea
Yersinia
  • WBC positive (fecal mononuclear leukocytes)
  • Blood may be present

Salmonella enterica serotype Typhi or Salmonella enterica serotype Paratyphi

Inflammatory diarrhea
Campylobacter
  • Bacteria or cytotoxins damage the colonic mucosa, which leads to blood in the stool and fever.
  • Most common bacterial pathogen responsible for foodborne gastroenteritis in the US
  • Recent travel to low- or middle-income countries
Enterohemorrhagic E. coli (EHEC)
  • Most common infectious trigger of HUS
  • Undercooked meat
Clostridioides difficile
Shigella
  • Second most common infectious trigger of HUS
  • Recent travel to low- or middle-income countries
Noncholera Vibrio species
  • Shellfish
Salmonella (nontyphoidal)
  • Poultry and eggs

Overview

“There's no camping without a campfire:” Campylobacter jejuni grows best at hot temperatures.

Clinical features

Treatment

Complications

Complications are more common and severe in patients with HIV (see “HIV-associated conditions” for details).

This section covers nontyphoidal Salmonella. For S. enterica serotype Typhi and S. enterica serotype Paratyphi enteric fever, see “Typhoid fever.”

Overview

Clinical features

Treatment [1][4][10]

Antibiotic treatment for salmonellosis prolongs fecal excretion of the pathogen. Therefore, it is only indicated for severe nontyphoidal Salmonella infections (e.g., in patients with systemic manifestations or ≥ 9 episodes of diarrhea per day, and those who require hospitalization).

Complications

Complications are more frequent in immunocompromised patients, e.g., those with HIV; treatment for complicated salmonellosis (e.g., antibiotic therapy) in patients with HIV should be given in consultation with a specialist.

Overview [26]

Clinical features

  • Duration: 2–7 days
  • High fever
  • Tenesmus, abdominal cramps
  • Profuse inflammatory, mucoid-bloody diarrhea

Treatment [1][4][10]

Complications

Overview

  • Pathogen: Vibrio cholerae
  • Transmission
    • Fecal-oral
    • Undercooked seafood or contaminated water (e.g., unseparated drinking water and sewage systems)
  • Incubation period: 0–2 days
  • Infectivity
    • Acid-labile (grows well in an alkaline medium)
    • High infective dose required (over 108 pathogens)
    • Gastric acid provides a natural barrier against V. cholerae infection; therefore, the infective dose in individuals with reduced gastric acidity is lower.

Clinical features

  • Low-grade fever, vomiting
  • Profuse “rice-water” stools

Diagnosis

Treatment [1][10][27]

Complications

Overview

Clinical features

Diagnosis

Treatment [1][29]

Complications

Particularly common in patients with HLA-B27

Overview

Clinical features

Diagnosis

Treatment

Complications

Overview

Clinical features

Treatment [4][32][33]

Infections caused by Vibrio species are often self-limiting and may only require supportive care.

Complications

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