What is the recommended treatment for Campylobacter infections?

Campylobacter Treatment Guidelines

Azithromycin is the first-line treatment for Campylobacter infections due to its superior efficacy and lower resistance rates compared to fluoroquinolones. 1

First-Line Treatment Options

Azithromycin Regimens:

• Preferred regimen: 500 mg once daily for 3 days 1
• Alternative regimen: Single 1-gram dose 1, 2
• For children: 20-30 mg/kg as a single dose (30 mg/kg showing superior efficacy) 3

Azithromycin demonstrates several advantages:

• Effective against Campylobacter with minimal resistance 4, 1
• Clinical cure rates of 96% with single-dose therapy 4, 2
• Most effective when started within 72 hours of symptom onset 1
• Significantly shorter time to last unformed stool (TLUS) compared to fluoroquinolones for resistant strains 4

Alternative Treatment Options

Fluoroquinolones (in areas with low resistance):

• Ciprofloxacin 500 mg twice daily for 3 days 1, 5
• Levofloxacin 500 mg once daily for 3 days 1

Important caveat: Fluoroquinolone resistance in Campylobacter is widespread, particularly in Southeast and South Asia (>85% resistance) 4, 6, 2. In these regions, fluoroquinolones should be avoided for empiric treatment.

Treatment Considerations

When to Treat:

• Severe symptoms (profuse diarrhea, significant dehydration)
• Immunocompromised patients
• Persistent symptoms
• Bloody diarrhea (dysentery)
• Systemic spread of infection 1

When to Avoid Antibiotics:

• Mild, self-limiting cases in immunocompetent hosts 6
• Empiric therapy is not recommended for most cases of acute watery diarrhea 1

Special Considerations

Route of Administration:

• Oral azithromycin is preferred when patients can tolerate oral intake 1
• IV azithromycin is appropriate for patients who cannot tolerate oral medications due to:
  • Severe vomiting
  • Ileus
  • Altered mental status
  • Severe dehydration requiring IV fluids 1

Contraindications and Cautions:

• Rifaximin should not be used for Campylobacter infections due to high resistance rates and documented treatment failures 4
• Antimotility agents should be avoided in children under 18 years and in cases of inflammatory diarrhea 1
• Azithromycin may cause nausea and vomiting, particularly with the 1-gram single dose 2

Supportive Care

Hydration:

• Oral rehydration solution for mild to moderate dehydration 1
• IV fluids (isotonic solutions) for severe dehydration, shock, altered mental status, or ileus 1

Nutrition:

• Continue normal feeding throughout the illness 1
• For infants, continue breastfeeding 1

Monitoring and Follow-up

• Monitor for worsening symptoms and signs of dehydration 1
• Consider blood cultures in patients with fever, particularly immunocompromised hosts 1
• If symptoms persist beyond 14 days, consider non-infectious conditions 1

Antibiotic Resistance Concerns

• Fluoroquinolone resistance is increasing globally, particularly in Southeast Asia 4, 6, 2
• Azithromycin resistance is emerging but still limited 1, 7
• Heteroresistant C. jejuni strains (with varying susceptibility to azithromycin) have been identified and may lead to treatment failures 7

Prevention

• Practice proper hand hygiene after using the toilet and before preparing or eating food 1
• Avoid raw or undercooked poultry, meat, and unpasteurized dairy products 1
• Asymptomatic contacts should not receive preventive therapy but should follow appropriate infection prevention measures 1

By following these guidelines, clinicians can effectively manage Campylobacter infections while minimizing the risk of treatment failure and antibiotic resistance.