What is not an indication for antibiotic use in diarrhea?

From the Guidelines

Asymptomatic diarrhea is not an indication for antibiotic use in diarrhea. Antibiotics are generally recommended for diarrhea accompanied by fever, dehydration, or tenesmus, particularly when caused by bacterial pathogens such as Shigella, Salmonella, or Campylobacter, and may be treated with medications like ciprofloxacin 500mg twice daily for 3-5 days or azithromycin 500mg once daily for 3 days 1.

• The use of antibiotics in diarrhea is typically reserved for severe cases or those with specific clinical indicators, such as:
  • Infants < 3 months of age with suspicion of bacterial etiology 1
  • Ill immunocompetent people with fever, abdominal pain, bloody diarrhea, and bacillary dysentery presumptively due to Shigella 1
  • People who have recently traveled internationally with body temperatures ≥ 38.5°C and/or signs of sepsis 1
• Asymptomatic contacts of people with bloody diarrhea should not be offered empiric treatment, but should be advised to follow appropriate infection prevention and control measures 1
• It is also important to note that antimicrobial therapy for people with infections attributed to STEC O157 and other STEC that produce Shiga toxin 2 should be avoided 1

From the Research

Indications for Antibiotic Use in Diarrhea

• Antibiotics are effective against shigellosis, campylobacteriosis, C. difficile colitis, traveler's diarrhea, and protozoal infections 2
• Antibiotic use should be considered in patients who are older than 65 years, immunocompromised, severely ill, or septic 2
• Azithromycin is the preferred first-line antibiotic for the treatment of acute watery diarrhea and febrile diarrhea/dysentery 3
• Antibiotic treatment can be highly effective for Shigella, ETEC, and V. cholerae infections, and metronidazole is indicated for C. difficile colitis 4

Non-Indications for Antibiotic Use in Diarrhea

• Routine antibiotic use is not recommended for most adults with mild, watery diarrhea, as acute diarrhea is most often self-limited and caused by viruses 2
• Antibiotic treatment is not necessary for patients with self-limiting diarrhea, as it can worsen the problem of antibiotic resistance of enteric pathogens 4
• Antibiotics should not be used for patients with non-bloody, watery diarrhea, unless they have a high risk of complications, such as the elderly, diabetics, cirrhotics, and immunocompromised patients 4
• Rifaximin should not be used with invasive illness 3

Specific Considerations

• The choice of antibiotic should take travel destination into consideration, due to regional differences in the predominance of pathogens and resistance levels 3
• Loperamide can be used in combination with antibiotic treatment to further reduce gastrointestinal symptoms and duration of illness 3
• Azithromycin may be beneficial for children with acute watery diarrhea confirmed or presumed to be of bacterial etiology 5