From the Guidelines
Antibiotics should only be used in cases of diarrhea when there is evidence of bacterial infection, and azithromycin is often the first-line choice for bacterial diarrhea. The majority of diarrhea episodes are caused by viruses or will resolve on their own without specific treatment 1. For bacterial diarrhea that requires antibiotics, alternatives to azithromycin include ciprofloxacin, levofloxacin, or rifaximin, but the choice of antibiotic should be based on the severity of illness, local susceptibility patterns, and travel history 1.
Key Considerations for Antibiotic Choice
- 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
Recommended Antibiotic Regimens
- Azithromycin: 500 mg once daily for 3 days or a single 1000 mg dose
- Ciprofloxacin: 500 mg twice daily for 3-5 days
- Levofloxacin: 500 mg once daily for 3 days
- Rifaximin: 200 mg three times daily for 3 days
Special Considerations
- For Clostridioides difficile infections, oral vancomycin or fidaxomicin is recommended 1
- Asymptomatic contacts of people with diarrhea should not be offered empiric treatment, but should be advised to follow appropriate infection prevention and control measures 1
- Antibiotics should be avoided in people with persistent watery diarrhea lasting 14 days or more, except in cases of immunocompromised individuals or young infants who are ill-appearing 1
Importance of Judicious Antibiotic Use
Overuse of antibiotics can disrupt gut flora, potentially worsening or prolonging diarrhea, and contribute to antibiotic resistance 1. Most cases of diarrhea are better managed with hydration, probiotics, and dietary modifications while the body clears the infection naturally.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Antibiotic Choices for Diarrhea
The choice of antibiotic for treating diarrhea depends on various factors, including the type of diarrhea, travel history, and the presence of certain pathogens.
- For acute watery diarrhea, azithromycin is the preferred first-line antibiotic, with a single dose of 500 mg 2.
- Levofloxacin and ciprofloxacin are also options for acute watery diarrhea, with single doses of 500 mg and 750 mg, respectively, but their use is becoming less effective due to increasing fluoroquinolone resistance 2.
- Rifaximin is another alternative for acute watery diarrhea, with a dose of 200 mg three times a day for 3 days, but it should not be used with invasive illness 2.
- For febrile diarrhea and dysentery, azithromycin is also the preferred first-line antibiotic, with a single dose of 1,000 mg 2.
- Antibiotics are not indicated for the majority of enteric infections, and their promiscuous use can contribute to the escalating prevalence of bacterial resistance worldwide 3.
- Antimicrobial agents are indicated for shigellosis, cholera, traveler's diarrhea, amebiasis, and giardiasis 3.
Considerations for Antibiotic Use
When considering antibiotic use for diarrhea, it is essential to take into account the travel destination, as regional differences in the predominance of pathogens and resistance levels can affect the choice of antibiotic 2.
- Empiric antibiotics are rarely warranted, except in sepsis and some cases of travelers' or inflammatory diarrhea 4.
- Targeted antibiotic therapy may be appropriate following microbiologic stool assessment 4.
- Hand hygiene, personal protective equipment, and food and water safety measures are integral to preventing infectious diarrheal illnesses 4.
Special Considerations
In children, rehydration therapy is the key to management of acute watery diarrhea, whereas antimicrobial agents play a vital role in the management of acute invasive diarrhea, particularly shigellosis and amebiasis 5.
- In patients with inflammatory bowel disease, diarrhea requires a wide differential diagnosis to define the pathophysiologic mechanisms in individual patients, and treatment should be tailored according to presumed etiologies 6.
- Antidiarrheal agents are not recommended in extremely ill patients and those with known hypersensitivity or evidence of obstruction or colonic dilation, fever, or abdominal tenderness 6.