From the Guidelines
Empiric antibiotics are generally not recommended for most cases of acute diarrhea, and should only be used in specific situations where the benefits outweigh the risks, as indicated by the most recent guidelines from the Infectious Diseases Society of America 1. The indications for empiric antibiotics in diarrhea include:
- Severe traveler's diarrhea: Use azithromycin 1000 mg single dose or 500 mg daily for 3 days, as recommended by the guidelines for the prevention and treatment of travelers' diarrhea 1.
- Suspected cholera: Use doxycycline 300 mg single dose or azithromycin 1 gram single dose, as recommended by the guidelines for the diagnosis and management of infectious diarrhea 1.
- Moderate to severe Clostridium difficile infection: Use oral vancomycin 125 mg four times daily for 10 days, as recommended by the guidelines for the diagnosis and management of infectious diarrhea 1.
- Suspected shigellosis with high fever or bloody diarrhea: Use ciprofloxacin 500 mg twice daily for 3 days, as recommended by the guidelines for the diagnosis and management of infectious diarrhea 1.
- Immunocompromised patients with severe symptoms: Consider empiric treatment based on likely pathogens, as recommended by the guidelines for the diagnosis and management of infectious diarrhea 1. It is essential to note that antibiotics should be avoided in most cases of acute diarrhea because they can prolong bacterial shedding, alter gut flora, and increase the risk of antibiotic resistance, as highlighted by the guidelines for the prevention and treatment of travelers' diarrhea 1 and the guidelines for the diagnosis and management of infectious diarrhea 1. Some key points to consider when deciding on empiric antibiotic treatment for diarrhea include:
- The severity of the illness and the impact on the patient's daily activities
- 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 patient adherence
- Cost of treatment As recommended by the guidelines for the prevention and treatment of travelers' diarrhea 1 and the guidelines for the diagnosis and management of infectious diarrhea 1, it is crucial to always obtain stool cultures before starting antibiotics when possible and to consider the potential risks and benefits of treatment in each individual case.
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.
The indications for empiric antibiotics in diarrhea are for the treatment of infectious diarrhea caused by specific 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
Indications for Empiric Antibiotics in Diarrhea
The following are indications for empiric antibiotics in diarrhea:
- Fever and/or bloody diarrhea 3, 4, 5
- Patients at risk, such as those with severe comorbidities, immunodeficiency, or a history of antibiotic exposure within the last 3 months 3, 4, 6
- Traveler's diarrhea with fever, bloody diarrhea, prolonged course of disease (more than 5 days), severe clinical course with hypotension or dehydration, or during outbreaks 3, 7
- Severe invasive or prolonged diarrhea 6
- High-risk individuals, such as the elderly, diabetics, cirrhotics, and immunocompromised patients 6
Specific Patient Populations
- Immunocompetent patients do not require specific antibiotic therapy, except in cases of Shigella or C. difficile infection 3
- Patients with Shigella or C. difficile infection should receive empirical antibiotic treatment 3, 4
- Patients with traveler's diarrhea may require microbiological diagnosis and empirical antibiotic treatment, depending on the severity of symptoms and risk factors 3, 7
Antibiotic Choices
- Azithromycin or ciprofloxacin are recommended for empiric treatment of diarrhea, taking into account local antimicrobial resistance and possible side effects 3
- Fluoroquinolones, such as ciprofloxacin, may be considered as first-line therapy for traveler's diarrhea 7
- Metronidazole is indicated for C. difficile colitis 6