What is the recommended antibiotic for treating dysentery in children?

Antibiotic Treatment for Dysentery in Children

Azithromycin is the first-line antibiotic for treating bacterial dysentery in children, given at 10 mg/kg on day 1, followed by 5 mg/kg daily for 4 days (or a single 1000 mg dose for older children). 1, 2

First-Line Treatment

• Azithromycin should be the preferred agent for all cases of dysentery in children, regardless of geographic region, due to its superior efficacy against common dysentery pathogens, excellent safety profile, and high clinical cure rates 2
• The WHO also recommends ciprofloxacin as first-line treatment at 15 mg/kg per dose orally, despite concerns about potential arthropathy in children 1
• However, azithromycin is now preferred globally over fluoroquinolones due to increasing ciprofloxacin resistance patterns, which exceed 85% for Campylobacter in Southeast Asia and reach 5.0% for Shigella in Asia-Africa 1, 2

When to Treat Empirically

Empiric antibiotic therapy is indicated for children with bloody diarrhea in these specific situations: 3

• Infants < 3 months of age with suspicion of bacterial etiology 3
• Ill children with fever documented in a medical setting, abdominal pain, bloody diarrhea, and bacillary dysentery (frequent scant bloody stools, fever, abdominal cramps, tenesmus) presumptively due to Shigella 3
• Children who have recently traveled internationally with body temperatures ≥38.5°C and/or signs of sepsis 3
• Immunocompromised children with severe illness and bloody diarrhea 3

Alternative Antibiotics

When azithromycin is not available or resistance is documented, use these alternatives in order: 1, 2, 4

• Cefixime (oral) is appropriate when ciprofloxacin resistance is high and is effective against shigellosis in pediatric patients 1
• Ceftriaxone (parenteral) for children with severe illness, those who are immunocompromised, or infants < 3 months with neurologic involvement, with resistance rates of only 2.5% in Asia-Africa 3, 1
• Ciprofloxacin only in regions with documented low fluoroquinolone resistance, but should not be first-line 2

Treatment Duration

• 3-5 days of treatment is typically sufficient for uncomplicated cases 1
• Single-dose regimens (azithromycin 1000 mg) may be considered for mild to moderate cases to improve compliance 1

Critical Diagnostic Considerations

Attempt to distinguish bacterial from amebic dysentery when possible: 2

• Perform microscopic examination of fresh stool to identify Entamoeba histolytica trophozoites 2
• Initiate empirical treatment for bacterial dysentery if microscopy is unavailable or negative for amoeba 2
• Consider amebic treatment only if microscopy shows definite trophozoites or two different antibiotics for shigellosis have failed 2

Important Pitfalls to Avoid

• Do not treat STEC O157 or other STEC that produce Shiga toxin 2 with antibiotics, as this should be avoided due to risk of worsening outcomes 3
• Avoid antimotility agents such as loperamide in children with acute dysentery 1
• Do not use rifaximin for dysentery due to documented treatment failures in up to 50% of cases with invasive pathogens 2
• Switch to an alternative agent if no clinical response is seen within 48 hours rather than continuing ineffective therapy 2
• Do not assume fluoroquinolones are universally effective, as regional resistance patterns must guide therapy 2

Monitoring

• Monitor for potential adverse effects with fluoroquinolones, particularly arthropathy concerns with ciprofloxacin 1
• Azithromycin is generally well tolerated with mostly mild to moderate gastrointestinal adverse events 5