What antibiotics are associated with the least amount of diarrhea (gastrointestinal disturbance)?

From the Guidelines

Azithromycin is the antibiotic associated with the least amount of diarrhea due to its unique pharmacokinetic profile and lower impact on normal gut flora. According to the guidelines for the prevention and treatment of travelers' diarrhea, azithromycin has been shown to be effective in treating moderate to severe acute bacterial diarrhea with minimal side effects, including gastrointestinal complaints 1. The study found that azithromycin has a lower rate of nausea and vomiting compared to other antibiotics, with rates of 3% and <1%, respectively.

Key Considerations

• Azithromycin is generally well tolerated with minimal side effects, making it a preferred choice for treating diarrhea-causing infections.
• The antibiotic has a unique pharmacokinetic profile that allows for short-course therapy, reducing the overall exposure of gut bacteria to the antibiotic.
• Azithromycin has been shown to be effective in treating moderate to severe acute bacterial diarrhea, including infections caused by Shigella spp. and Campylobacter spp. 1.

Recommendations

• Azithromycin is recommended as the first-line agent for treating dysentery and acute watery diarrhea with greater than mild fever 1.
• The antibiotic should be taken with food to minimize the risk of gastrointestinal side effects.
• Consider taking a probiotic supplement during and after the course of antibiotics to further minimize the risk of diarrhea.

Important Notes

• The choice of antibiotic should primarily be based on the type of infection being treated, not just the side effect profile.
• Always follow the healthcare provider's specific instructions for dosing and duration.
• If diarrhea does occur, stay hydrated and contact the healthcare provider if symptoms persist or worsen.

From the FDA Drug Label

The incidence of treatment-related adverse events, primarily gastrointestinal, in all patients treated was 18% on azithromycin and 13% on penicillin. The most common side effects were diarrhea/loose stools (6% azithromycin vs. 2% penicillin), vomiting (6% azithromycin vs. 4% penicillin), and abdominal pain (3% azithromycin vs 1% penicillin). In the safety analysis of this study, the incidence of treatment-related adverse events, primarily gastrointestinal, were comparable between treatment arms (25% with azithromycin and 29% with clarithromycin) The overall incidence of treatment-related adverse events, primarily gastrointestinal, was lower in the azithromycin treatment arm (31%) than in the amoxicillin/clavulanate arm (51%). The most common side effects were diarrhea (17% in the azithromycin arm vs 32% in the amoxicillin/clavulanate arm), and nausea (7% in the azithromycin arm vs. 12% in the amoxicillin/clavulanate arm). Clostridium difficile associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including doxycycline, and may range in severity from mild diarrhea to fatal colitis.

Antibiotics with the least amount of diarrhea:

• Penicillin: 2% incidence of diarrhea/loose stools 2
• Azithromycin: 6% incidence of diarrhea/loose stools, but lower incidence of gastrointestinal side effects compared to amoxicillin/clavulanate and clarithromycin in some studies 2
• Doxycycline: may cause CDAD, but no specific incidence of diarrhea is reported in the provided text 3

Note: The comparison is based on the provided drug labels and may not be comprehensive or definitive.

From the Research

Antibiotics Associated with Diarrhea

• The incidence of antibiotic-associated diarrhea (AAD) differs with the antibiotic and varies from 5 to 25% 4
• The major form of intestinal disorders is the pseudomembranous colitis associated with Clostridium difficile which occurs in 10-20% of all AAD 4
• Principally all microbial agents can cause diarrhoea, especially oral agents like cephalosporines, clindamycin, broad-spectrum penicillins, and quinolones of the 3rd and 4th generation 5
• 3rd generation Cephalosporin, Clyndamicin, 2nd and 4th generation Cephalosporines, Sulfamethoxazole-trimethoprim, Quinolones, Penicillin combination show the strongest association with diarrhea 6

Treatment and Prevention of Antibiotic-Associated Diarrhea

• Discontinuation or replacement of the inciting antibiotic by another drug with lower AAD risk can be effective 4
• For more severe cases involving C. difficile, the treatment of diarrhea requires an antibiotic treatment, with glycopeptides (vancomycin) or metronidazole 4
• Teicoplanin may be slightly more effective than vancomycin with a relative risk of 1.21 [95% CI 1.00 to 1.46] and a p-value of 0.06 7
• Metronidazole, bacitracin, teicoplanin, fusidic acid and rifaximine are as effective as vancomycin for initial symptomatic resolution 7

Antibiotics with Lower Risk of Diarrhea

• There is no clear evidence of antibiotics that are associated with the least amount of diarrhea, as the risk varies depending on the specific antibiotic and individual patient factors 5, 4, 6
• However, it is suggested that antibiotics with a narrower spectrum of activity may be associated with a lower risk of diarrhea 4