What is the recommended treatment for a patient with Campylobacter in their stool?

Treatment of Campylobacter in Stool

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

When to Treat vs. Observe

Most immunocompetent patients with mild symptoms do not require antibiotics, as Campylobacter infections are self-limiting and resolve within 3-5 days. 2 However, antibiotic treatment is indicated for:

• Bloody diarrhea 2
• High fever 2
• Severe abdominal pain 2
• Prolonged symptoms (>1 week) 2
• All immunocompromised patients, even with mild infections, due to risk of bacteremia and systemic spread 1, 2

First-Line Treatment: Azithromycin

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

Dosing options:

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

The Infectious Diseases Society of America recommends azithromycin as first-line therapy, particularly given the dramatic rise in fluoroquinolone resistance worldwide. 1, 2

Alternative Treatment: Fluoroquinolones (Use with Extreme Caution)

Ciprofloxacin is FDA-approved for infectious diarrhea caused by Campylobacter jejuni 3, but should only be used in areas with documented low fluoroquinolone resistance. 1

Critical resistance data:

• Fluoroquinolone resistance exceeds 90% in Southeast Asia 1, 2
• Clinical failure occurs in approximately 33% of patients when the isolate is resistant 1, 2
• Resistance increased from 0% to 84% in Thailand between 1990-1995 1

If fluoroquinolones are used (only when local resistance is known to be low):

• Ciprofloxacin 750 mg single dose or 500 mg twice daily for 3 days 1

Second-Line Alternative: Erythromycin

Erythromycin 50 mg/kg/day divided every 6-8 hours for 5 days may be used if azithromycin is unavailable, though it is less effective. 1, 4 Macrolide resistance remains relatively low at around 4% for travel-related infections. 1, 2

Essential Supportive Care

Initial rehydration is critical, particularly for patients with severe diarrhea or dehydration signs. 1, 2

• Use oral rehydration solutions (e.g., Ceralyte, Pedialyte) for most patients 1
• Continue age-appropriate feeding as tolerated 1, 2
• Avoid antimotility agents (e.g., loperamide), as they may prolong bacterial shedding and worsen symptoms, particularly with bloody diarrhea or fever 1, 2

Special Populations

Immunocompromised patients require immediate antibiotic treatment regardless of symptom severity due to high risk of bacteremia (19% in some series) and systemic complications. 1, 2 This includes cancer patients, HIV-infected persons, and those on immunosuppressive therapy. 1

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

Monitoring and Follow-Up

Reassess at 48 hours: If no improvement or worsening symptoms occur, reconsider the diagnosis and obtain susceptibility testing to guide alternative antibiotic selection. 1, 2

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

Diarrhea persisting beyond 10-14 days warrants further evaluation for alternative diagnoses or complications. 2

Post-Infectious Complications to Monitor

Be aware of potential sequelae that may develop weeks after acute infection:

• Guillain-Barré syndrome 1, 2, 5
• Reactive arthritis 1, 2, 5
• Reiter's syndrome 1, 5
• Hemolytic-uremic syndrome (rare) 1
• Toxic megacolon (rare but life-threatening, particularly in cirrhotic patients) 6

Critical Pitfalls to Avoid

Do not use fluoroquinolones empirically without knowing local resistance patterns, as this leads to treatment failure in up to 33% of resistant cases and prolongs illness. 1, 2

Do not delay treatment beyond 72 hours if antibiotics are indicated, as effectiveness drops significantly. 1, 2

Do not discontinue antibiotics prematurely—complete the full 3-5 day course to prevent treatment failure. 1, 2

Do not use antimotility agents when Campylobacter is suspected, especially with bloody diarrhea, as this worsens outcomes. 1, 2