From the Guidelines
Treatment of enterotoxigenic infections should prioritize fluid replacement and supportive care, with antimicrobial therapy reserved for severe cases or immunocompromised hosts, due to the risk of prolonged bacterial shedding and antimicrobial resistance. When considering antimicrobial therapy, the choice of agent is crucial, and fluoroquinolones, such as ciprofloxacin, are generally recommended for the treatment of enterotoxigenic infections, including those caused by Salmonella and Campylobacter, due to their efficacy and relatively low resistance rates 1. However, it is essential to note that antimicrobial therapy may not be beneficial for all types of enterotoxigenic infections, such as STEC O157 infections, where treatment with fluoroquinolones, β-lactams, TMP-SMX, and metronidazole should be avoided due to evidence of harm 1. Key considerations in the treatment of enterotoxigenic infections include:
- Fluid replacement with oral rehydration solution (ORS) to prevent dehydration and electrolyte imbalances
- Antimicrobial therapy with fluoroquinolones, such as ciprofloxacin, for severe cases or immunocompromised hosts
- Avoidance of antimotility agents, such as loperamide, in patients with fever or bloody diarrhea
- Consideration of alternative antimicrobial agents, such as azithromycin or trimethoprim-sulfamethoxazole, in cases of fluoroquinolone resistance or intolerance 1. The treatment approach should be individualized based on the severity of the infection, the presence of underlying medical conditions, and the risk of antimicrobial resistance, with the goal of minimizing morbidity, mortality, and promoting optimal quality of life 1.
From the FDA Drug Label
Infectious Diarrhea caused by Escherichia coli (enterotoxigenic strains), Campylobacter jejuni, Shigella boydii†, Shigella dysenteriae, Shigella flexneri or Shigella sonnei† when antibacterial therapy is indicated. The efficacy of XIFAXAN given as 200 mg orally taken three times a day for 3 days was evaluated in 2 randomized, multi‑center, double-blind, placebo-controlled studies in adult subjects with travelers’ diarrhea.
Treatment of Enterotoxigenic Infections:
- Ciprofloxacin is indicated for the treatment of infectious diarrhea caused by Escherichia coli (enterotoxigenic strains) 2.
- Rifaximin is effective in treating travelers’ diarrhea caused by Escherichia coli 3.
- Key points:
- Ciprofloxacin can be used to treat enterotoxigenic E. coli infections.
- Rifaximin is effective in reducing the duration of diarrhea and achieving clinical cure in patients with travelers’ diarrhea caused by E. coli.
From the Research
Treatment of Enterotoxigenic Diarrhea
- The treatment of enterotoxigenic diarrhea is primarily supportive, with symptomatic therapy being the most important component 4.
- Empirical antibiotic therapy should be considered for severely ill patients with a high frequency of stools, fever, bloody diarrhea, underlying immune deficiency, advanced age, or significant comorbidities 4.
- The use of antibiotic therapy for mild travelers' diarrhea is not recommended, while for moderate travelers' diarrhea, antibiotics such as fluoroquinolones, azithromycin, and rifaximin may be used 5.
- For severe travelers' diarrhea, antibiotics such as azithromycin, fluoroquinolones, and rifaximin should be used, with azithromycin being suitable for the treatment of dysentery 5.
Antibiotic Resistance
- There is increasing resistance to traditional antibiotics, such as ampicillin, trimethoprim-sulfamethoxazole, and doxycycline, as well as to current first-line antibiotic agents, including fluoroquinolones and azithromycin 6.
- Geographical differences in resistance patterns have been observed, with significant differences between Central America and India 6.
- The use of rifaximin has been shown to be effective, with no significant changes in MICs over time 6.
Alternative Therapies
- Oral rehydration therapy is an effective treatment for acute gastroenteritis, and can prevent or reverse dehydration 7.
- Bovine immunoglobulin milk concentrate from hyperimmunized cows has been tested as a therapeutic agent for enterotoxigenic Escherichia coli-induced diarrhea, but has shown no significant therapeutic benefit 8.
- Loperamide may be considered as monotherapy or adjunctive therapy for mild to moderate travelers' diarrhea 5.