What is the recommended treatment for a patient with a presumptive positive result for Yersinia enterocolitica infection?

Treatment of Yersinia enterocolitica Infection

For most patients with presumptive Yersinia enterocolitica gastroenteritis, antibiotic treatment is not required as the infection is typically self-limiting; however, antimicrobial therapy with fluoroquinolones or third-generation cephalosporins is warranted for severe symptoms, immunocompromised hosts, or invasive disease including bacteremia. 1, 2

When to Withhold Antibiotics

• Uncomplicated gastroenteritis in immunocompetent patients does not require antibiotic therapy, as the infection is self-limited with symptoms typically resolving within 10 days 1, 3, 4
• The majority of patients (63% in one study) showed clinical improvement without antimicrobial treatment, with no significant difference compared to those treated with oral antibiotics 2
• Supportive care with hydration and symptomatic management is sufficient for most cases 4

Indications for Antimicrobial Therapy

Antibiotics are specifically indicated in the following clinical scenarios:

• Severe or prolonged symptoms (persistent high fever, severe abdominal pain, bloody diarrhea) 1, 4
• Immunocompromised patients, including those with HIV, malignancy, or receiving immunosuppressive therapy 1, 2
• Bacteremia or septicemia, which carries mortality rates up to 50% if untreated 1
• Patients with iron overload conditions (hemochromatosis, chronic transfusions) or those receiving desferrioxamine therapy, who are at increased risk for invasive disease 5
• Infants younger than 3 months, who have increased risk for bacteremia 2
• Extraintestinal manifestations including hepatic or splenic abscesses, mesenteric lymphadenitis requiring intervention 5, 4

Recommended Antibiotic Regimens

First-line antimicrobial options include:

• Fluoroquinolones (preferred for adults with severe disease) 1, 4
• Third-generation cephalosporins (cefotaxime, ceftazidime) - particularly effective for bacteremia, with 100% clinical response in bacteremic pediatric patients 1, 2
• Trimethoprim-sulfamethoxazole - all isolates in recent studies showed susceptibility, though clinical benefit in uncomplicated enteritis remains unclear 2

Susceptibility patterns show:

• Universal susceptibility to trimethoprim-sulfamethoxazole, tobramycin, and gentamicin 2
• High susceptibility to cefotaxime (99%), ceftazidime (89%), and cefuroxime (88%) 2

Critical Pitfalls to Avoid

• Do not perform unnecessary appendectomies: Yersiniosis can mimic appendicitis, particularly in children 5-14 years with right lower quadrant pain (63% of cases); 6% of patients ≥5 years underwent appendectomy 3
• Consider recent Y. enterocolitica infection in patients with unclear arthritis: Reactive arthritis occurs in 12% of yersiniosis patients versus 5% in controls, and erythema nodosum in 3% versus 0.1% 3
• Avoid overuse of antibiotics: 37% of patients received antimicrobials despite guidelines recommending use only in severe cases 3
• Screen for iron overload and desferrioxamine use: These patients require aggressive antimicrobial therapy due to dramatically increased risk of bacteremia and metastatic infection 5

Special Populations

Pediatric considerations:

• Children ≤4 years present predominantly with diarrhea (95%), while older children 5-14 years more commonly have abdominal pain in the right lower quadrant (63%) 3
• Infants <3 months have 9% bacteremia rate and require blood cultures and consideration for empiric cefotaxime 2
• Exposure to chitterlings (raw pork intestines) is a significant risk factor, identified in 83% of cases with known exposure history 2

Duration of illness:

• Symptoms typically last approximately 10 days in acute infections 3
• Hospitalization occurs in 27% of patients, reflecting significant disease burden 3
• Post-infectious sequelae (reactive arthritis, erythema nodosum) may develop weeks after acute infection and should be monitored 3, 4