What are the indications for antibiotics in acute diarrhea?

From the Guidelines

Antibiotics should not be used as a first-line treatment for acute diarrhea, except in specific situations where the benefits outweigh the risks, such as severe symptoms, high fever, bloody diarrhea, or immunocompromise, as supported by the most recent guidelines 1. When considering antibiotic treatment, the following factors should be taken into account:

• The likelihood of bacterial infection, such as traveler's diarrhea, Shigella, Campylobacter, or non-typhoidal Salmonella
• The severity of symptoms, including high fever, bloody diarrhea, or severe abdominal pain
• The presence of immunocompromise or other underlying health conditions
• The potential risks of antibiotic treatment, including disruption of gut flora, antibiotic resistance, and side effects

In general, the following antibiotic regimens may be considered:

• Azithromycin 500mg daily for 3 days for suspected Shigella, Campylobacter, or non-typhoidal Salmonella with severe symptoms
• Ciprofloxacin 500mg twice daily for 1-3 days for traveler's diarrhea
• Oral vancomycin 125mg four times daily for 10 days for C. difficile infection

However, it is essential to note that antibiotics should be used judiciously and only when necessary, as overuse can contribute to antibiotic resistance and disrupt the balance of gut flora, potentially worsening or prolonging diarrhea, as highlighted in recent studies 1.

Key considerations for antibiotic selection include:

• Regional patterns of antimicrobial resistance
• Safety and tolerance profile of the antibiotic
• Simplicity of treatment regimen and patient adherence
• Cost and potential for drug interactions

Ultimately, the decision to use antibiotics for acute diarrhea should be based on a careful assessment of the individual patient's clinical presentation, medical history, and potential risks and benefits, as emphasized in the latest guidelines 1.

From the Research

Acute Diarrhea and Antibiotics

• Acute diarrhea in adults is a common problem, with the most common etiology being viral gastroenteritis, a self-limited disease 2.
• Antibiotics are effective in the treatment of shigellosis, campylobacteriosis, Clostridium difficile, traveler's diarrhea, and protozoal infections when used appropriately 2.
• The use of antibiotics in acute diarrhea should be reserved for patients with severe dehydration or illness, persistent fever, bloody stool, or immunosuppression, and for cases of suspected nosocomial infection or outbreak 2.

Antibiotic Treatment for Clostridium Difficile-Associated Diarrhea

• Vancomycin was found to be more effective than metronidazole for achieving symptomatic cure in patients with Clostridium difficile-associated diarrhea (CDAD) 3.
• Fidaxomicin was found to be more effective than vancomycin for achieving symptomatic cure in patients with CDAD 3.
• Teicoplanin may be more effective than vancomycin for achieving a symptomatic cure, but the quality of evidence is very low 3.

Prevention of Antibiotic-Associated Diarrhea and Clostridium Difficile Infection

• Metronidazole prophylaxis did not result in a reduction in antibiotic-associated diarrhea, but it could be an effective measure for preventing C. difficile infection in selected high-risk patients 4.
• Chemoprophylaxis with antibiotics in selected patients could be a cost-effective tool for prevention of in-hospital diarrhea and C. difficile infection 4.

Clinical Guidelines for Acute Diarrheal Infections

• The American College of Gastroenterology (ACG) Clinical Guideline presents an evidence-based approach to diagnosis, prevention, and treatment of acute diarrhea infection in both US-based and travel settings 5.
• The guideline provides information on treatment, prevention, diagnostics, and the consequences of acute diarrhea infection to inform clinical management 5.