What is the treatment for Campylobacter jejuni infections?

Treatment of Campylobacter jejuni Infections

Azithromycin is the first-line treatment for Campylobacter jejuni infections, with a dosing regimen of either 1000 mg as a single dose or 500 mg daily for 3 days, achieving a 96% clinical cure rate. 1, 2

When to Treat vs. Observe

Most C. jejuni infections are self-limiting and resolve without antibiotics within 3-5 days in immunocompetent patients with mild symptoms. 2 However, antibiotic treatment is indicated for:

• Severe disease presentations: bloody diarrhea, high fever (>38.5°C), or severe abdominal pain 2
• Prolonged symptoms: diarrhea lasting more than 1 week 2
• Immunocompromised patients: always treat, even for mild infections, due to risk of systemic spread and recurrent bacteremia 2, 3
• Early presentation: patients presenting within 72 hours of symptom onset benefit most from treatment 1, 2

First-Line Antibiotic Therapy

Azithromycin is recommended by the Infectious Diseases Society of America as the preferred agent, particularly in regions with high fluoroquinolone resistance. 1, 2 The dosing options are:

• 1000 mg single dose, OR
• 500 mg daily for 3 days 1

Early treatment within 72 hours reduces symptom duration from 50-93 hours down to 16-30 hours, making timing critical for optimal efficacy. 1, 2 Delaying treatment beyond this window significantly reduces antibiotic effectiveness. 1, 2

Alternative Antibiotic Options

Erythromycin can be used if azithromycin is unavailable, though it is less effective and requires more frequent dosing (typically 500 mg four times daily for 5 days in adults, or 50 mg/kg/day divided every 6-8 hours for 5 days in children). 1, 2 Historical data shows erythromycin produces "rapid clinical and bacteriologic cure" when given early in moderately to severely ill patients. 4, 5

Fluoroquinolones (ciprofloxacin, levofloxacin) should only be used in areas with documented low fluoroquinolone resistance. 1 Ciprofloxacin is FDA-approved for infectious diarrhea caused by C. jejuni at doses of 750 mg single dose or 500 mg twice daily for 3 days. 6 However, fluoroquinolone resistance now exceeds 90% in Southeast Asia and has increased dramatically worldwide, with clinical failure occurring in approximately 33% of patients when the isolate is resistant. 1, 2

Critical Antimicrobial Resistance Considerations

Using fluoroquinolones empirically without considering local resistance patterns is a major pitfall that leads to treatment failure and prolonged illness. 1, 2 In contrast, macrolide resistance (azithromycin, erythromycin) remains relatively low at around 4% for travel-related infections, making azithromycin the safer empiric choice. 2

Supportive Care Measures

Initial rehydration is critical, particularly for patients with severe diarrhea or signs of dehydration. 2 Oral rehydration solutions (e.g., Ceralyte, Pedialyte) are recommended for most patients. 1, 2

Avoid antimotility agents (loperamide, diphenoxylate) as they may prolong bacterial shedding and worsen symptoms. 2 Historical data shows that 36% of patients treated with antimotility agents required secondary antimicrobial therapy due to static or worsening illness, compared to only 9% of untreated controls. 5

Continue age-appropriate feeding as tolerated during the illness. 2

Special Population Considerations

Immunocompromised patients require mandatory antibiotic treatment regardless of symptom severity, as they are at risk for recurrent bacteremia and chronic infection. 2, 3 Some immunocompromised patients may require prolonged therapy (up to 3 months with doxycycline) to prevent recurrence, though optimal duration is not well-established. 3

Infants under 6 months are at higher risk for severe disease and complications, warranting prompt treatment with azithromycin. 1

HIV-infected persons are at higher risk for infection with non-jejuni non-coli Campylobacter species and may require specialized testing and treatment. 2

Monitoring and Follow-up

If no improvement or worsening symptoms occur after 48 hours of treatment, reassess the diagnosis and consider alternative antibiotics based on susceptibility testing. 2

No routine follow-up stool cultures are needed if symptoms resolve. 2 However, diarrhea persisting beyond 10-14 days warrants further evaluation to rule out complications or alternative diagnoses. 4, 2

Post-Infectious Complications to Monitor

Be aware that C. jejuni infection can be followed by:

• Guillain-Barré syndrome (incidence <1 per 1000 infections) 7, 8
• Reactive arthritis or Reiter's syndrome 4, 2, 7
• These complications can occur even after gastrointestinal symptoms resolve 4

Common Pitfalls to Avoid

• Discontinuing antibiotics prematurely before completing the full 3-5 day course leads to treatment failure 2
• Empiric fluoroquinolone use without knowledge of local resistance patterns results in high failure rates 1, 2
• Delaying treatment beyond 72 hours significantly reduces azithromycin effectiveness 1, 2
• Using antimotility agents impedes resolution of infection and increases need for rescue antibiotics 2, 5