Treatment of Campylobacter Diarrhea

Azithromycin is the first-line treatment for Campylobacter diarrhea, dosed as either 1000 mg as a single dose or 500 mg daily for 3 days. 1

Why Azithromycin is Preferred

Azithromycin achieves a 96% clinical cure rate and maintains low resistance rates (approximately 4%) globally, making it superior to fluoroquinolones in the current resistance landscape. 1, 2
Fluoroquinolone resistance in Campylobacter has reached catastrophic levels—exceeding 90% in Southeast Asia and Thailand, with increasing resistance worldwide—rendering ciprofloxacin and levofloxacin unreliable as empiric therapy. 1, 3
In head-to-head trials in Thailand, azithromycin demonstrated zero treatment failures compared to ciprofloxacin, which had 2 clinical failures and 6 bacteriologic failures when treating Campylobacter infections. 3

Start antibiotics within 72 hours of symptom onset for maximum benefit—early treatment reduces illness duration from 50-93 hours down to 16-30 hours. 2, 1
Treatment initiated after 72 hours shows diminished effectiveness, though still provides some benefit in severe cases. 2, 1

Azithromycin is strongly recommended as first-line therapy when patients present with bloody diarrhea or fever >38°C, as these features suggest invasive Campylobacter or other resistant pathogens (Shigella, enteroinvasive E. coli). 2

In Southeast Asia and India, use azithromycin empirically as first-line therapy due to near-universal fluoroquinolone resistance. 2
Even in industrialized countries, fluoroquinolone-resistant Campylobacter cases are increasingly reported, supporting azithromycin as first-line regardless of geography. 2

Always treat with antibiotics, even for mild infections, due to high risk of bacteremia and systemic spread. 1
Use azithromycin 500 mg daily for 3-5 days depending on severity and clinical response. 1

For infants under 6 months: azithromycin 10 mg/kg/day for 3 days (infants are at higher risk for severe disease). 1
Alternative if azithromycin unavailable: erythromycin 50 mg/kg/day divided every 6-8 hours for 5 days, though less effective. 1

Ciprofloxacin (500 mg twice daily for 3 days or 750 mg single dose) or levofloxacin (500 mg daily for 3 days) can be considered only in geographic areas with documented low fluoroquinolone resistance rates. 2, 4
The FDA labels ciprofloxacin for infectious diarrhea caused by Campylobacter jejuni, but this indication predates widespread resistance. 4
Clinical failure occurs in approximately 33% of patients when treating fluoroquinolone-resistant Campylobacter with fluoroquinolones. 1

Oral rehydration with solutions like Pedialyte or Ceralyte is critical, particularly for severe diarrhea or dehydration signs. 1
Continue age-appropriate feeding as tolerated—do not withhold nutrition. 1
Avoid antimotility agents (loperamide) in suspected Campylobacter infection, as they may prolong bacterial shedding and worsen outcomes. 1, 2

Reassess at 48 hours: if no improvement or worsening symptoms, consider alternative antibiotics based on susceptibility testing. 1
No routine follow-up stool cultures needed if symptoms resolve. 1
Watch for post-infectious complications: Guillain-Barré syndrome (develops in rare cases 1-3 weeks after infection), reactive arthritis, and Reiter's syndrome. 1, 5

Using fluoroquinolones empirically without considering local resistance patterns leads to treatment failure and prolonged illness. 1
Delaying treatment beyond 72 hours reduces antibiotic effectiveness. 1
Discontinuing antibiotics prematurely before completing the full 3-day course can result in treatment failure. 1
Prescribing antimotility agents in dysentery or suspected invasive diarrhea worsens outcomes. 2

With appropriate azithromycin treatment: symptoms improve within 1-2 days, with complete resolution in 3-5 days. 5
Without treatment: self-limited illness typically resolves in 5-7 days, though symptoms may persist up to 10 days. 5
Seek further evaluation if diarrhea persists beyond 10-14 days to rule out complications or alternative diagnoses. 5