Abstract
BackgroundInfectious gastroenteritis is common in the emergency department (ED). Patients infected with either Norovirus or toxigenic Clostridium difficile require special isolation procedures. The aims were to describe the aetiology of infectious gastroenteritis in the ED, evaluate whether current isolation procedures, based on clinical judgement are sufficient, and to identify information that might be used to identify patients requiring isolation.MethodsProspective, observational, multicentre study. We collected information on symptoms, vital signs, travel history, the recent use of antibiotics, and infectious contacts and tested faecal samples for Norovirus, C. difficile, and enteropathogenic bacteria.ResultsThe study enrolled 227 patients, of whom 163 (71%) delivered a faecal sample for Norovirus analysis (13% positive), 171 (74%) for C. difficile (13% positive), and 173 (76%) for enteropathogenic bacteria (16% positive). In total 71% of the patients were isolated using strict precautions, 29% of the isolated patient and 14% of the patients who were not isolated had had a highly contagious GE. Risk factors for Norovirus included frequent vomiting (OR 5.5), recent admission of another patient with Norovirus (OR 2.6), and a short duration of diarrhoea. Risk factors for C. difficile infections included older age (OR 6.0), longer duration of diarrhoea (OR 5.2), mucus in stool (OR 3.5), and previous antibiotic use (OR 23.4).ConclusionHighly contagious GE occurs in ¼ of the GE patients in the EDs, isolation based on clinical judgement is not very efficient. Several risk factors can predict the presence of Norovirus or toxigenic Clostridium difficile. It is uncertain whether this knowledge can improve isolation practices in ED settings.Trial registrationThis study was retrospectively registered in the Clinical Trials Data Base (NCT02685527) and prospectively approved by the Regional Committees on Health Research Ethics for Southern Denmark (project ID S20140200) and Ethics Committee at the Medical Association of Schleswig-Holstein [“Ethikkommission bei der Ärztekammer Schleswig-Holstein”, project ID 120/15(I)] and registered with the Danish Data Protection Agency (project ID nr. 2008-58-0035/ 1608).
Highlights
Infectious gastroenteritis is common in the emergency department (ED)
Difficult to assess whether a patient has a contagious GE, based on clinical judgement and in a previous study we found that only one-quarter of the patients who were isolated had Norovirus or C. difficile infection [2]
This study revealed three major findings: The results of the faecal samples (13% positive for Norovirus, 13% positive for C. difficile, and 16% had another identifiable enteropathogenic bacterium), the ability to decide isolation criteria based on clinical judgement had a reasonable sensitivity of 83%, but a low specificity (33%) and accuracy (45%), and we confirmed well known risk factors for Norovirus and for C. difficile
Summary
The aims were to describe the aetiology of infectious gastroenteritis in the ED, evaluate whether current isolation procedures, based on clinical judgement are sufficient, and to identify information that might be used to identify patients requiring isolation. At the time of admission there is a high degree of uncertainty with respect to GE aetiology, and the decision to initiate isolation is largely dependent on clinical judgement. It is, difficult to assess whether a patient has a contagious GE, based on clinical judgement and in a previous study we found that only one-quarter of the patients who were isolated had Norovirus or C. difficile infection [2]
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