Cefixime in Diarrhea: Limited Role in Specific Clinical Scenarios
Cefixime is NOT recommended for routine treatment of acute diarrhea in adults or children, but has a narrow role as empiric therapy for infants <3 months with suspected bacterial bloody diarrhea or children with neurologic involvement when azithromycin is not appropriate. 1
When Cefixime May Be Considered
Bloody Diarrhea in Specific Populations
Third-generation cephalosporins (including cefixime) are recommended only for:
- Infants <3 months of age with suspected bacterial etiology and bloody diarrhea 1
- Children with neurologic involvement when local susceptibility patterns or travel history make azithromycin less appropriate 1
The 2017 IDSA guidelines explicitly state that empiric antimicrobial therapy for bloody diarrhea is NOT recommended in immunocompetent children and adults while awaiting diagnostic results, with these narrow exceptions 1
Documented Shigellosis (After Culture Results)
Once Shigella is identified, cefixime has demonstrated efficacy, though it is not first-line:
- A pediatric study showed 2-day cefixime (8 mg/kg/day) achieved clinical improvement in all patients by day 3, though bacteriologic failure was higher (55%) compared to 5-day therapy (14%) 2
- Fluoroquinolones or azithromycin remain preferred for documented shigellosis based on current resistance patterns 1
When Cefixime Should NOT Be Used
Watery Diarrhea
Empiric antimicrobial therapy is NOT recommended for acute watery diarrhea in most patients without recent international travel 1. The cornerstone of treatment is:
- Oral rehydration solution (ORS) for mild to moderate dehydration (strong recommendation) 1
- Early resumption of age-appropriate diet 1
- Probiotics may reduce symptom duration (weak recommendation) 1
STEC Infections
Antimicrobial therapy, including cefixime, should be AVOIDED in infections with STEC O157 and other Shiga toxin 2-producing strains due to risk of hemolytic uremic syndrome 1
Preferred Empiric Regimens When Antibiotics Are Indicated
When empiric therapy is warranted for bloody diarrhea:
Adults:
- Fluoroquinolone (ciprofloxacin) OR azithromycin based on local susceptibility and travel history 1
Children:
- Azithromycin is generally preferred given rising fluoroquinolone resistance 1
- Third-generation cephalosporin reserved for infants <3 months or neurologic involvement 1
Critical Pitfalls to Avoid
- Do not use antimotility agents (loperamide) in children <18 years with acute diarrhea 1
- Do not give loperamide with bloody diarrhea or fever at any age due to toxic megacolon risk 1
- Do not prescribe antibiotics empirically for most acute diarrhea cases—this promotes resistance without improving outcomes 1
- Do not continue cefixime for >5 days in shigellosis, as 2-day courses show similar clinical outcomes with higher bacteriologic failure 2
Alternative Uses of Cefixime (Not for Diarrhea)
While not relevant to diarrhea treatment, cefixime has established efficacy in:
The primary role of cefixime in diarrheal illness is extremely limited and should be reserved for the specific populations outlined above, with hydration remaining the cornerstone of management for the vast majority of cases.