In an adult with confirmed or strongly suspected Campylobacter-associated diarrhoea requiring antibiotics, how many days should ciprofloxacin be given?

Treatment Duration for Campylobacter Diarrhea with Ciprofloxacin

Ciprofloxacin should be given for 5-7 days when treating Campylobacter-associated diarrhea, but azithromycin is strongly preferred over ciprofloxacin due to widespread fluoroquinolone resistance and superior clinical outcomes. 1

Critical Resistance Considerations

Ciprofloxacin is no longer recommended as first-line therapy for Campylobacter infections due to:

• Fluoroquinolone resistance now exceeds 90% in Southeast Asia and is rising globally, with clinical failure occurring in approximately 33% of patients when the isolate is resistant 2
• Patients with ciprofloxacin-resistant Campylobacter infection experience significantly longer duration of diarrhea (12 days vs. 6 days) compared to those with susceptible strains 3
• Antimicrobial treatment of proven Campylobacter infection provides only modest benefit, and the risks of fluoroquinolone treatment often outweigh benefits given high resistance rates 4

Recommended Treatment Algorithm

First-Line: Azithromycin (Preferred)

• Dosing: 1000 mg single dose OR 500 mg daily for 3 days 2, 5
• Clinical cure rate: 96% with azithromycin vs. 70% with fluoroquinolones in high-resistance areas 2
• Timing: Maximum benefit when initiated within 72 hours of symptom onset, reducing illness duration from 50-93 hours to 16-30 hours 2

Second-Line: Ciprofloxacin (Only if Susceptibility Confirmed)

• Dosing: 500 mg every 12 hours for 5-7 days 1
• Use only when: Local resistance patterns show low fluoroquinolone resistance AND susceptibility testing confirms sensitivity 2
• Alternative fluoroquinolone: Levofloxacin 500 mg daily for 3 days 5

When Antibiotics Are Indicated

Treat in these specific scenarios:

• Severe illness with high fever, bloody diarrhea, or signs of systemic toxicity 4
• Immunocompromised patients (even with mild symptoms) due to risk of bacteremia and systemic spread 4, 2
• Patients with prolonged symptoms (>7 days) 4
• Infants <6 months or adults >50 years with moderate-to-severe disease 2
• Pregnant women (azithromycin preferred for safety) 2

Do NOT treat empirically when:

• Most cases of acute watery diarrhea without fever or bloody stools, as the vast majority are self-limited 4
• STEC infection is suspected (avoid all antibiotics including fluoroquinolones due to evidence of harm) 4

Common Pitfalls to Avoid

Using fluoroquinolones without considering resistance patterns leads to treatment failure and prolonged illness, particularly in patients with recent international travel to high-resistance regions 2, 3

Delaying treatment beyond 72 hours significantly reduces antibiotic effectiveness for Campylobacter infections 2

Prescribing antimotility agents (loperamide, opiates) in suspected invasive diarrhea can worsen outcomes and should be avoided 4, 2

Stopping antibiotics prematurely before completing the full 5-7 day course with ciprofloxacin (or 3-day course with azithromycin) can lead to treatment failure 2

Special Population Considerations

Immunocompromised Patients

• Always treat regardless of symptom severity 4, 2
• Consider extended duration (14-21 days) due to higher risk of relapse and systemic complications 2
• Monitor for bacteremia, which occurs more frequently in this population 2

Severe Disease Requiring Hospitalization

• Obtain stool culture before initiating therapy 6
• Administer IV fluids and electrolytes as needed 2
• Consider octreotide (up to 500 μg subcutaneously three times daily) for severe, refractory cases 2

Post-Treatment Monitoring

• No routine follow-up stool cultures needed if symptoms resolve 2
• Monitor for post-infectious complications including Guillain-Barré syndrome, reactive arthritis, and hemolytic-uremic syndrome (rare) 2
• Reassess diagnosis if no improvement after 48 hours of appropriate therapy 2