What is the treatment for Campylobacter jejuni infection?

Treatment of Campylobacter jejuni Infection

Azithromycin is the preferred 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, due to its superior efficacy (96% clinical cure rate) and low resistance rates in the setting of widespread fluoroquinolone resistance. 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 specifically indicated for:

• Bloody diarrhea 2
• High fever 2
• Severe abdominal pain 2
• Prolonged symptoms exceeding 1 week 2
• Any degree of illness in immunocompromised patients, even mild infections, due to high risk of bacteremia and systemic spread 1, 2, 3
• Infants under 6 months of age, who are at higher risk for severe disease and complications 1

Timing of Treatment

Early treatment within 72 hours of symptom onset is critical—it reduces illness duration from 50-93 hours to 16-30 hours. 1, 2 Delaying treatment beyond 72 hours significantly reduces antibiotic effectiveness. 1, 2

First-Line Treatment: Azithromycin

The Infectious Diseases Society of America recommends azithromycin as first-line therapy, particularly in regions with high fluoroquinolone resistance. 1, 2 Dosing options include:

• 1000 mg single dose, OR
• 500 mg daily for 3 days 1, 2

Erythromycin (50 mg/kg/day divided every 6-8 hours for 5 days in children) may be used as an alternative if azithromycin is unavailable, though it is less effective. 4, 1, 2

Why Not Fluoroquinolones?

Fluoroquinolone resistance among Campylobacter has increased dramatically worldwide, exceeding 90% in Southeast Asia and reaching 10.2% even in regions like Minnesota. 4, 1, 2 Clinical failure occurs in approximately 33% of patients when the isolate is fluoroquinolone-resistant. 1, 2 The FDA label indicates ciprofloxacin is approved for infectious diarrhea caused by C. jejuni, but this approval predates the current resistance crisis. 5

Fluoroquinolones (ciprofloxacin 750 mg single dose or 500 mg twice daily for 3 days; levofloxacin 500 mg single dose or daily for 3 days) should only be considered in areas with documented low fluoroquinolone resistance. 1 Additionally, quinolone resistance can develop during treatment and be accompanied by symptomatic relapse. 4

Essential Supportive Care

Initial rehydration is critical, particularly for patients with severe diarrhea or signs of dehydration. 1, 2, 3 Use oral rehydration solutions (e.g., Ceralyte, Pedialyte) for most patients. 1

Avoid antimotility agents—they may prolong bacterial shedding and worsen symptoms. 4, 2, 3 Continue age-appropriate feeding as tolerated. 1, 2

Special Population Considerations

HIV-infected and immunocompromised patients are at increased risk for:

• Non-jejuni non-coli Campylobacter species (C. fetus, C. upsaliensis, C. lari) requiring specialized testing 3
• More severe and prolonged diarrheal disease 3
• Bacteremia and systemic spread 1, 3
• Relapse after appropriate treatment 3

These patients require antibiotic treatment regardless of symptom severity. 1, 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. 1, 2 Diarrhea persisting beyond 10-14 days warrants further evaluation. 2

No routine follow-up stool cultures are needed if symptoms resolve. 1, 2

Critical Pitfalls to Avoid

• Using fluoroquinolones empirically without considering local resistance patterns leads to treatment failure in one-third of resistant cases 1, 2, 3
• Delaying treatment beyond 72 hours reduces antibiotic effectiveness by more than half 1, 2
• Discontinuing antibiotics prematurely before completing the full 3-5 day course leads to treatment failure 1, 2
• Using antimotility agents can worsen outcomes and prolong bacterial shedding 4, 2, 3
• Standard laboratory protocols may fail to identify non-jejuni Campylobacter species—notify the lab if Campylobacter is suspected in immunocompromised patients 3

Post-Infectious Complications to Monitor

Be aware that C. jejuni is associated with subsequent development of:

• Guillain-Barré syndrome (incidence <1 per 1000 infections) 1, 6, 7
• Reactive arthritis and Reiter's syndrome 1, 7
• Hemolytic-uremic syndrome (rare) 1
• Bacteremia, ileus, toxic megacolon, and perforation (rare severe complications) 1