Should I give an antidiarrheal to a patient with anemia and bacteremia due to Enterococcus (bacteria causing infection in the blood)?

Should You Give an Antidiarrheal to a Patient with Anemia and Enterococcus Bacteremia?

No, do not give antidiarrheal agents to a patient with enterococcus bacteremia—antiperistaltic agents including opiates are discouraged in the setting of bacterial infections causing diarrhea, and your priority should be treating the bacteremia with appropriate antibiotics and identifying/removing the source of infection. 1

Why Antidiarrheals Are Contraindicated

• Antiperistaltic agents can worsen outcomes in bacterial infections by slowing intestinal transit, potentially increasing bacterial translocation and toxin absorption 1
• The 2013 German Society guidelines explicitly discourage antiperistaltic agents, including opiates, in bacterial diarrhea 1
• In the context of bacteremia, slowing gut motility may facilitate further bacterial invasion from the gastrointestinal tract, which is a common source of enterococcal bacteremia 2

Focus on Treating the Bacteremia

Your immediate priority is appropriate antibiotic therapy for the enterococcus bacteremia:

• Ampicillin is the drug of choice for ampicillin-susceptible enterococci 1, 3
• Vancomycin should be used if the pathogen is resistant to ampicillin 1, 3
• For ampicillin and vancomycin-resistant enterococci, use linezolid or daptomycin based on susceptibility testing 1, 3

Treatment Duration and Source Control

• A 7-14 day course is recommended for uncomplicated enterococcal bacteremia 1, 3
• Identify and remove the source of infection—this is critical for treatment success 1
• If a catheter is present, remove short-term catheters immediately 1, 3
• For long-term catheters, removal is indicated if there is insertion site infection, pocket infection, suppurative thrombophlebitis, sepsis, or persistent bacteremia >72 hours 1, 3

Evaluate for Complications

• Obtain transesophageal echocardiography (TEE) if the patient has signs of endocarditis, prolonged bacteremia/fever >72 hours despite appropriate therapy, or prosthetic valves 1, 3
• The risk of endocarditis with enterococcal bacteremia is relatively low (1.5%), but E. faecalis carries higher risk than E. faecium 1
• Enterococcal bacteremia persisting >4 days is independently associated with increased mortality 1, 3

Address the Diarrhea Appropriately

If diarrhea is present, investigate the cause rather than suppressing it:

• Consider whether the diarrhea is related to the enterococcal infection, antibiotic-associated, or due to C. difficile 1
• Test for C. difficile if the patient has healthcare exposure, especially if there is fever or leukocytosis >20,000 cells/μL 1
• Use oral rehydration solution for fluid replacement rather than antidiarrheals 1

Common Pitfalls to Avoid

• Do not use antidiarrheals in the setting of bacterial infections—this can prolong illness and increase complications 1
• Do not delay catheter removal when indicated—this is a major predictor of treatment failure 1, 3
• Do not fail to obtain follow-up blood cultures to document clearance of bacteremia 1, 3
• Do not overlook the gastrointestinal tract as a potential source—48% of enterococcal bacteremias have no discernible primary focus, suggesting GI translocation 2