What is the recommended treatment for uncomplicated Campylobacter jejuni gastroenteritis?

Treatment of Campylobacter jejuni Gastroenteritis

Azithromycin is the first-line treatment for Campylobacter jejuni infections, with a dosing regimen of 500 mg daily for 3 days (or 1000 mg as a single dose), achieving a 96% clinical cure rate and maintaining low resistance rates globally. 1

When to Treat vs. Supportive Care Alone

Most uncomplicated Campylobacter infections are self-limiting and resolve within 3-5 days without antibiotics. 2 However, antibiotic treatment is indicated for:

• Severe disease: bloody diarrhea, high fever (>38.5°C), or severe abdominal pain 1, 2
• Prolonged symptoms: diarrhea lasting >7 days or >10-14 days 1, 2
• Immunocompromised patients: even with mild symptoms, due to risk of bacteremia and systemic spread 1, 2
• High-risk populations: age <6 months or >50 years, pregnant women 1
• Systemic toxicity or dehydration 1

For immunocompetent patients with mild watery diarrhea, no fever, and no blood in stool, supportive care alone is appropriate. 1

Timing of Treatment

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 72 hours significantly reduces antibiotic effectiveness. 1, 2

First-Line Antibiotic: Azithromycin

Dosing regimens:

• 500 mg orally daily for 3 days (preferred) 1
• 1000 mg orally as a single dose (alternative) 1

Why azithromycin is superior:

• Clinical cure rate of 96% vs. 70% with fluoroquinolones in high-resistance areas 1
• Macrolide resistance remains low at ~4% globally 1, 2
• Fluoroquinolone resistance now exceeds 90% in Southeast Asia and is rising worldwide, with clinical failure in 33% of patients when the isolate is resistant 1, 2

Alternative Antibiotics (When Azithromycin Unavailable)

Erythromycin: 500 mg orally four times daily for 5 days 1, 2

• Less effective than azithromycin but acceptable alternative 2
• For infants: 50 mg/kg/day divided every 6-8 hours for 5 days 1

Fluoroquinolones (ciprofloxacin, levofloxacin): Only in areas with documented low fluoroquinolone resistance 1

• Ciprofloxacin: 500 mg twice daily for 3 days 1
• Given widespread resistance, fluoroquinolones should not be used empirically 1, 2

Special Population Considerations

Immunocompromised patients (HIV, cancer, transplant):

• Always treat, even for mild infections 1, 2
• May require extended treatment duration of 14-21 days due to higher relapse risk 1
• Higher risk of bacteremia and systemic complications 1, 2

Pregnant women:

• Azithromycin is the preferred antibiotic due to safety profile 1

Infants <6 months:

• Higher risk for severe disease; prompt treatment with azithromycin warranted 1

Supportive Care (Essential for All Patients)

Rehydration:

• Oral rehydration solutions (e.g., Pedialyte, Ceralyte) for most patients 1, 2
• IV fluids for severe dehydration or inability to tolerate oral intake 1

Dietary management:

• Continue age-appropriate feeding as tolerated 1, 2
• Avoid lactose-containing products during acute illness 3

Critical Pitfalls to Avoid

Never use antimotility agents (loperamide, opioids) in suspected or confirmed Campylobacter infection, especially with bloody diarrhea or fever, as they prolong bacterial shedding and worsen outcomes. 1, 2, 4

Do not use rifaximin for Campylobacter—it exhibits high-level resistance and documented treatment failure. 1

Avoid fluoroquinolones empirically without knowing local resistance patterns, as this leads to treatment failure in one-third of resistant cases. 1, 2

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

Monitoring and Follow-Up

Reassess at 48 hours: If no improvement or worsening symptoms, consider alternative diagnosis or antibiotic resistance; obtain susceptibility testing if available. 1, 2

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

Persistent diarrhea beyond 10-14 days warrants further evaluation for complications, alternative pathogens, or post-infectious sequelae. 2, 5

Post-Infectious Complications to Monitor

Be aware of rare but serious complications that may develop weeks after acute illness:

• Guillain-Barré syndrome (incidence <1 per 1000 infections) 1, 6
• Reactive arthritis and Reiter's syndrome 1, 2
• Hemolytic-uremic syndrome (rare) 1

When to Escalate Care

Immediate surgical consultation indicated for:

• Toxic megacolon 1
• Suspected perforation or peritoneal signs 1
• Severe abdominal distension or ileus 1