Rotavirus infection

Rotaviruses are a common cause of viral gastroenteritis in infants and young children and are transmitted via the fecal-oral route. After a short incubation period of one to three days, patients present with symptoms of variable severity, which may include vomiting, watery diarrhea, high-grade fever, and malaise. Most patients with rotavirus infection receive a clinical diagnosis of acute viral gastroenteritis; diagnostic studies are usually not necessary, as they do not alter management. For patients with severe disease or in whom the diagnosis is uncertain, rotavirus infection can be confirmed by antigen detection in the stool. Treatment is supportive and mainly involves fluid replacement and managing symptoms as needed. Rotavirus infection can be prevented by vaccination.

• A major cause of severe diarrhea in infants and children in the US (especially during the winter) ^[1]
• Leading cause of severe diarrhea among infants and children worldwide, although all age groups are susceptible to infection.
• Most commonly occurs in daycare centers and kindergartens

Epidemiological data refers to the US, unless otherwise specified.

• Pathogen: Rotavirus is a nonenveloped, segmented, double-stranded RNA reovirus.
• Transmission: fecal-oral route (e.g., by contact with hands, objects, food, water contaminated with the virus)

References:^[2][3]

• Mucosal damage and villous atrophy in the gastrointestinal tract impair absorption of sodium and loss of potassium → nonbloody, watery diarrhea

• Incubation period: 1–3 days
• Fever, malaise
• Abdominal pain
• Vomiting and watery diarrhea
  • Can be severe: > 10 loose, watery stools within 24 hours
  • Usually lasts 3–7 days
• Mild to severe dehydration: See clinical signs of significant dehydration.

References:^[4]

General principles ^[5]

• Diagnosis is usually clinical.
  • Young children: variable presentation, ranging from no symptoms to severe disease ^[1][5]
  • Older children and adults: usually asymptomatic or mild symptoms ^[1][5]
• Consider diagnostic studies for:
  • Patients with red flags for diarrhea
  • Admitted patients if cohorting is being considered
  • Exclusion of alternative diagnoses (e.g., bacterial gastroenteritis) ^[5][6]

Confirmatory stool studies ^[5]

• Antigen detection: via enzyme-linked immunosorbent assay (ELISA) or immunochromatography ^[5]
• PCR

Additional studies ^[5][6]

• Signs of significant dehydration: Order diagnostic studies for dehydration.
• If the diagnosis is uncertain: Order diagnostic studies for infectious gastroenteritis.

Although a stool sample analysis can be used for diagnostic confirmation of rotavirus infection, management remains the same. ^[7]

• Norovirus infection
• Bacterial gastroenteritis
• Food poisoning

The differential diagnoses listed here are not exhaustive.

• Treatment is supportive (e.g., fluid replacement, electrolyte repletion, antiemetics). ^[5][6][8]
  • Children: See “Treatment of infectious gastroenteritis in children.”
  • Adults: See “Supportive therapy for gastroenteritis.”
• Patients with severe gastroenteritis or signs of significant dehydration may require inpatient treatment, including IV fluid resuscitation. ^[6][8][9]
• Nitazoxanide may reduce the duration of illness, but evidence supporting its use is limited. ^[10]
• For outpatients, educate patients and/or caregivers on:
  • The expected duration of illness
  • Return precautions
  • Prevention of rotavirus transmission

Most children with gastroenteritis can be safely managed at home. ^[6][11]

General measures ^[5][6][12]

• Encourage breastfeeding; exclusive breastfeeding reduces the risk of rotavirus infection in young infants. ^[6]
• Offer rotavirus vaccination to eligible infants. ^[6]
• Educate patients and/or caregivers on preventing onward transmission of gastroenteritis.
• Isolate at home until symptoms are resolved; defined in children as frequency within 2 stools/day of normal and: ^[12]
  • If toilet trained: no longer having accidents
  • If in diapers: stool is contained within the diaper

Exclusive breastfeeding during the first months of life reduces the risk of rotavirus infection in young infants. ^[6]

Rotavirus vaccination ^[1][13]

• General characteristics ^[1][13]
  • Live attenuated oral vaccine
  • Two versions are available: RV1 (monovalent) and RV5 (pentavalent)
• Indications: recommended for all infants unless there is a contraindication ^[13][14]
• Contraindications to rotavirus vaccination ^[13][14]
  • Severe combined immunodeficiency (SCID)
  • History of intussusception: Rotavirus vaccine is associated with intussusception.
  • Other general contraindications for vaccination (e.g., allergy)
  • Discuss with a specialist if children: ^[12]
    • Are immunocompromised (excluding HIV) ^[12]
    • Have preexisting chronic intestinal conditions
    • Are otherwise unwell at the recommended time of vaccination
• Schedule: See “ACIP immunization schedule” for details on routine and catch-up schedules.
• Additional considerations
  • The risk of intussusception after vaccination is increased in older infants.
    • Do not start an immunization series in a child aged ≥ 15 weeks. ^[13][15]
    • No doses should be given after 8 months 0 days of age. ^[13][15]
  • Transient viral shedding in the stool occurs for up to 4 weeks after vaccination; advise strict hand hygiene during this period for caregivers. ^[12][16]

Children who are HIV-positive can safely receive the rotavirus vaccination, regardless of CD4 count. ^[12]

Older infants have a higher risk of intussusception following rotavirus vaccination; to reduce this risk, do not start the immunization series in infants > 15 weeks of age and ensure the series is completed by 8 months of age. ^[13][15][17]