What is the recommended antibiotic treatment for bacterial gastroenteritis in children?

Antibiotic Treatment for Bacterial Gastroenteritis in Children

Most children with bacterial gastroenteritis do not require antibiotics, as the majority of cases are viral and self-limited; however, when antibiotics are indicated—specifically for severe cases, high-risk patients, or specific pathogens like Shigella, severe Salmonella, or Campylobacter—azithromycin is the preferred first-line agent for Shigella and Campylobacter infections, while ceftriaxone is recommended for severe Salmonella infections. 1, 2, 3

When Antibiotics Are NOT Indicated

• Routine antibiotic use is not recommended for most children with acute gastroenteritis, as viral etiologies (Rotavirus, Norovirus) predominate and bacterial causes rarely require treatment 3, 4
• Avoid empiric treatment in immunocompetent children with watery diarrhea without specific risk factors 1, 4
• STEC O157 and Shiga toxin-producing E. coli infections should NOT receive antibiotics due to increased risk of hemolytic uremic syndrome 1

When Antibiotics ARE Indicated

Specific clinical scenarios requiring antibiotic treatment include: 1, 2

• Infants < 3 months of age with suspected bacterial etiology 1
• Severe dysentery syndrome (frequent bloody stools, fever, abdominal cramps, tenesmus) presumptively due to Shigella 1
• Recent international travel with fever ≥38.5°C and/or signs of sepsis 1
• Immunocompromised patients with severe illness and bloody diarrhea 1
• High-risk patients with Salmonella (infants <3 months, immunocompromised, sickle cell disease, or severe systemic illness) 2, 3

Pathogen-Specific Antibiotic Recommendations

Shigellosis

• First-line: Azithromycin (preferred due to rising resistance to fluoroquinolones and trimethoprim-sulfamethoxazole) 1, 2, 3, 4
• Azithromycin demonstrates shorter duration of diarrhea compared to ciprofloxacin (32.4 hours less) and erythromycin (12.1 hours less) 1

Severe Salmonellosis

• First-line: Ceftriaxone 50-75 mg/kg/day divided every 12-24 hours 2, 3, 4
• Alternative: Ciprofloxacin 20-30 mg/kg/day divided every 12 hours (avoid if possible in children <18 years) 2, 4
• Only treat severe cases or high-risk patients; uncomplicated Salmonella gastroenteritis does not require antibiotics 3, 4

Campylobacter Infections

• First-line: Azithromycin (most effective when given early in illness) 2, 3, 4
• Treatment primarily indicated for severe cases or early in the disease course 3, 4

Cholera (Vibrio cholerae)

• First-line: Azithromycin (single-dose particularly useful in epidemic situations) 1
• Alternatives: Doxycycline or ciprofloxacin 1
• Antibiotics only for patients with severe dehydration; fluid resuscitation remains the cornerstone of treatment 1

Empiric Treatment Regimens (When Pathogen Unknown)

For severe cases requiring empiric therapy before identification: 1, 2

Children ≥3 months with severe illness:

• Azithromycin (preferred, based on local susceptibility and travel history) 1
• Alternative: Ciprofloxacin 20-30 mg/kg/day divided every 12 hours (avoid in children <18 years if alternatives available) 2

Infants <3 months:

• Third-generation cephalosporin (e.g., ceftriaxone or cefotaxime) 1

Severe sepsis or high-risk patients:

• Ciprofloxacin plus metronidazole (20-30 mg/kg/day every 12 hours + 30-40 mg/kg/day every 8 hours) 2
• Alternative: Aminoglycoside-based regimen 2

Critical Caveats and Pitfalls

• Fluoroquinolones should be avoided in children <18 years and pregnant women when alternatives exist due to musculoskeletal concerns 2
• Antibiotic resistance is a major global concern in Salmonella, Shigella, and Campylobacter, limiting therapeutic options 2, 3
• Multiplex PCR detection does not equal causation—presence of potential pathogens may represent colonization rather than active infection and does not automatically justify treatment 3
• Modify or discontinue antibiotics when a clinically plausible organism is identified and treatment is not indicated 1
• Azithromycin is well-tolerated in children with only 8.7% experiencing adverse events (mostly mild gastrointestinal symptoms), and treatment discontinuation due to adverse events occurs in only 1.3% 5, 6