From the Guidelines
Azithromycin should be considered the first-line agent for the treatment of GI infection diarrhea, particularly in cases of dysentery or acute watery diarrhea with greater than mild fever, due to its high efficacy and safety profile. The decision to treat GI infection diarrhea with antibiotics is based on the assessment of the severity of illness and the effects it will have on the patient's activities and plans 1. Antibiotics have been demonstrated to reduce symptom duration in GI infection diarrhea from an average of 50-93 to 16–30 hours 1.
Key considerations in the selection of an empiric antibiotic include the likelihood of treatment efficacy and rapidity of response, regional patterns of probable target pathogens and their antimicrobial resistance, safety and tolerance profile of the antibiotic, simplicity of treatment regimen, and cost 1. Azithromycin has been shown to be superior to levofloxacin in achieving clinical cure in settings with high rates of FQ-resistant Campylobacter spp. 1.
The use of fluoroquinolones (FQs) is not recommended as a first-line treatment due to the increasing resistance of Campylobacter spp. and other enteric pathogens to FQs 1. Rifaximin, a nonabsorbable antibiotic, has demonstrated comparable efficacy to FQs in non-invasive GI infection diarrhea caused by diarrheagenic E. coli, but is less effective for the treatment of invasive pathogens 1.
In general, antibiotics should be reserved for cases with severe symptoms, immunocompromised patients, or when specific bacterial pathogens are identified through stool testing 1. The primary treatment for most infectious diarrhea remains supportive care with fluid replacement and electrolyte management to prevent dehydration.
Some key points to consider when treating GI infection diarrhea include:
- Azithromycin is generally well tolerated with minimal side effects, usually dose-related gastrointestinal complaints 1
- FQs have several concerns regarding adverse effects, including the potential for Achilles tendon rupture, an increased risk for C. difficile infection, and rarely the prolongation of the QT interval that may lead to fatal dysrhythmias 1
- Rifaximin is less effective for the treatment of invasive pathogens, with failure to achieve wellness 1
- Empiric antibacterial treatment should be considered in immunocompromised people with severe illness and bloody diarrhea 1
From the FDA Drug Label
Infectious Diarrhea caused by Escherichia coli (enterotoxigenic strains), Campylobacter jejuni, Shigella boydii†, Shigella dysenteriae, Shigella flexneri or Shigella sonnei† when antibacterial therapy is indicated.
Ciprofloxacin is indicated for the treatment of infectious diarrhea caused by certain bacteria, including:
- Escherichia coli (enterotoxigenic strains)
- Campylobacter jejuni
- Shigella species (including Shigella boydii, Shigella dysenteriae, Shigella flexneri, and Shigella sonnei) when antibacterial therapy is indicated 2.
From the Research
Antibiotics for GI Infection Diarrhea
- The use of antibiotics for GI infection diarrhea is generally not recommended, except for severely ill patients with a high frequency of stools, fever, bloody diarrhea, underlying immune deficiency, advanced age, or significant comorbidities 3, 4.
- Empirical antibiotic therapy can be considered for patients with severe invasive or prolonged diarrhea, or who are at high risk of complications, such as the elderly, diabetics, cirrhotics, and immunocompromised patients 4.
- Specific antibiotics, such as quinolones, can be effective for certain pathogens, including Shigella, ETEC, and V. cholerae infections, while metronidazole is indicated for C. difficile colitis 4.
- The use of ciprofloxacin, a broad-spectrum fluoroquinolone, has been shown to be effective in the treatment of gastrointestinal infections, with excellent tolerability 5.
- Guidelines for antibiotic use in acute gastroenteritis recommend considering epidemiological factors, diagnostic tests, and indications for empirical antibiotics, as well as modification of antibiotics after confirming the pathogen, to decrease antibiotic misuse and prevent antibiotic resistance 6.
- Increasing resistance to antibiotics, particularly fluoroquinolones, must be taken into consideration when selecting antibiotic therapy for GI infection diarrhea 3, 4.