What is the recommended treatment for food poisoning with antibiotics?

Antibiotics for Food Poisoning

Most cases of food poisoning do not require antibiotics and should be managed with rehydration alone, as antibiotics are generally not indicated for uncomplicated infectious diarrhea and may cause harm in certain pathogens like enterohemorrhagic E. coli. 1

When Antibiotics Are NOT Recommended

Avoid antibiotics in the following situations:

• Uncomplicated watery diarrhea without fever or blood - The vast majority of food poisoning cases are self-limited and resolve with supportive care alone 1, 2

• Enterohemorrhagic E. coli (EHEC/STEC) infections - Antibiotics increase the risk of hemolytic uremic syndrome and should be strictly avoided 1, 3

• Non-typhoidal Salmonella gastroenteritis in healthy adults - Antibiotics do not shorten illness duration and may prolong bacterial shedding 1

• Suspected viral gastroenteritis (norovirus, rotavirus) - These account for two-thirds of foodborne illness and do not respond to antibiotics 1, 4

When Antibiotics ARE Indicated

Consider empiric antibiotic therapy in these specific scenarios:

High-Risk Patient Populations Requiring Treatment

• Neonates (<3 months old) with any bacterial gastroenteritis 1
• Adults >50 years with suspected atherosclerosis and Salmonella infection 1
• Immunocompromised patients (HIV, transplant recipients, chemotherapy patients) 1
• Patients with prosthetic devices (heart valves, joint prostheses) 1
• Severe underlying conditions (cardiac disease, malignancy, uremia, diabetes, liver cirrhosis) 1, 5

Clinical Presentations Requiring Antibiotics

Dysentery (bloody diarrhea with fever):

• First-line: Azithromycin 500 mg daily for 3 days or 1000 mg single dose 3
• This covers Shigella, Campylobacter, enteroinvasive E. coli, and other invasive pathogens 1, 3
• Alternative: Ciprofloxacin 500 mg twice daily for 3 days (if susceptible, though resistance is increasingly common) 1

Confirmed Shigella infection:

• Azithromycin 500 mg daily for 3 days (preferred due to fluoroquinolone resistance) 1, 3
• Alternative: Ceftriaxone if azithromycin unavailable 1
• Avoid fluoroquinolones if ciprofloxacin MIC ≥0.12 μg/mL 1

Campylobacter infection:

• Azithromycin 500 mg daily for 5 days (first-line due to widespread fluoroquinolone resistance) 1, 3
• Alternative: Ciprofloxacin only if susceptibility confirmed 1

Vibrio cholerae (cholera):

• Azithromycin 1000 mg single dose (most effective) 1
• Alternative: Doxycycline 300 mg single dose 1
• Antibiotics reduce duration and volume of diarrhea but rehydration remains the priority 1, 6

Salmonella Typhi/Paratyphi (enteric fever):

• Ceftriaxone 2 g daily or ciprofloxacin 500 mg twice daily for 7-14 days 1

Yersinia enterocolitica (severe cases):

• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 5-7 days 1
• Alternative: Ciprofloxacin or cefotaxime 1

Critical Management Principles

Rehydration is always the cornerstone of treatment:

• Oral rehydration solution (ORS) for mild-moderate dehydration 2, 3
• Intravenous isotonic fluids for severe dehydration or shock 2, 3
• This takes absolute priority over antimicrobial therapy 3

Avoid antimotility agents (loperamide):

• Never use in children <18 years with dysentery 3
• Never use in adults with bloody diarrhea or fever 3
• May worsen outcomes in invasive infections 1

Empiric therapy considerations:

• If pathogen unknown and patient has fever, bloody stools, or severe systemic symptoms, azithromycin 500 mg daily for 3 days is reasonable 3
• The benefit is modest and carries risk of treating EHEC inadvertently 4
• Always obtain stool cultures before starting antibiotics when possible 1, 3

Common Pitfalls to Avoid

• Do not prescribe antibiotics reflexively for all diarrheal illness - Most cases are viral or self-limited bacterial infections that do not benefit 1, 2
• Do not use fluoroquinolones as first-line for dysentery - Resistance rates are high, particularly for Campylobacter and Shigella 1, 3
• Do not treat suspected EHEC with antibiotics - This can precipitate life-threatening hemolytic uremic syndrome 1, 3
• Do not forget that rehydration saves lives, not antibiotics - Mortality in food poisoning is primarily from dehydration 1, 3