Role of Antibiotics in Childhood Diarrhoea
Antibiotics should NOT be used routinely in childhood diarrhoea, as rehydration with oral rehydration solution (ORS) is the cornerstone of treatment and most cases resolve without antimicrobial therapy. 1, 2
When Antibiotics Are Indicated
Antibiotics are reserved for specific high-risk situations only:
Definite Indications for Empiric Antibiotics
Infants <3 months of age with suspected bacterial etiology require a third-generation cephalosporin (ceftriaxone), NOT azithromycin or fluoroquinolones 1, 2
Bloody diarrhea with fever (bacillary dysentery syndrome) presumptively due to Shigella requires immediate antibiotic treatment with azithromycin as first-line (500 mg daily for 3 days in adults; 10 mg/kg daily for 3 days in children) 1, 2, 3
Recent international travelers with fever ≥38.5°C and/or signs of sepsis should receive empiric antibiotics 2
Immunocompromised children with severe illness and bloody diarrhea require empiric treatment 2
Suspected enteric fever with clinical features of sepsis warrants empiric antibiotics after obtaining cultures 2
Specific Pathogen-Directed Treatment
Shigella: Azithromycin 10 mg/kg daily for 3 days is first-line; ceftriaxone 100 mg/kg/day is an alternative if azithromycin is unavailable 2, 3
Campylobacter: Azithromycin 10 mg/kg daily for 3 days if diagnosed early; fluoroquinolones should be avoided due to >90% resistance in many regions 2, 4
Cholera: Azithromycin single dose is superior to ciprofloxacin, reducing diarrhea duration by >1 day 2
Non-typhoidal Salmonella: Antibiotics are NOT recommended for uncomplicated cases; only treat if severe infection, age <6 months or >50 years, or immunocompromised 2, 4
Critical Contraindications
NEVER give antibiotics for STEC O157:H7 or Shiga toxin 2-producing E. coli, as this significantly increases the risk of hemolytic uremic syndrome (HUS) 1, 2. This is the most important pitfall to avoid.
- Obtain stool culture and Shiga toxin testing BEFORE starting antibiotics in any child with bloody diarrhea 1
- Monitor hemoglobin, platelets, and renal function closely if STEC is confirmed 1
Antibiotics to Avoid
Antimotility agents (loperamide) are contraindicated in children <18 years with acute diarrhea, and at any age with bloody diarrhea or fever due to risk of toxic megacolon 1, 2
Fluoroquinolones should NOT be used as first-line in children due to widespread resistance (>90% for Campylobacter in Southeast Asia) and FDA safety warnings 2, 4
Ampicillin, co-trimoxazole, tetracycline, and chloramphenicol have alarmingly high resistance rates (approaching 90%) for Shigella and E. coli in many regions 5, 4
Treatment Algorithm for Acute Diarrhea
Assess hydration status first: Use ORS for mild-moderate dehydration; IV fluids for severe dehydration, shock, altered mental status, or ileus 2
Determine if antibiotics are needed based on:
If no response within 48-72 hours, reassess for antibiotic resistance, inadequate rehydration, non-infectious causes, or need for hospitalization 2
Why Most Cases Don't Need Antibiotics
Viral gastroenteritis (rotavirus, norovirus) accounts for 51.7% of childhood diarrhea cases and does not respond to antibiotics 4
Watery diarrhea without fever or blood in children >3 months is typically viral and resolves with rehydration alone 6, 7
Empiric antibiotic use promotes antimicrobial resistance without improving outcomes in uncomplicated cases 1, 5
Common Pitfalls to Avoid
Prescribing antibiotics for simple watery diarrhea: This is the most common error; rehydration is sufficient 1, 2
Using fluoroquinolones in children: Resistance exceeds 90% in many regions, and FDA warnings limit their use 2, 4
Treating non-typhoidal Salmonella routinely: This prolongs carriage and increases resistance without clinical benefit 2, 3
Neglecting rehydration while focusing on antibiotics: ORS remains the cornerstone regardless of antibiotic use 6, 2