From the Guidelines
As a hospitalist treating enteritis, the most effective approach is to start with supportive care and empiric antibiotic therapy, with the choice of antibiotics guided by the severity and suspected cause of the infection, as well as local resistance patterns, as recommended by the Infectious Diseases Society of America 1.
Assessment and Supportive Care
When treating enteritis, it's crucial to first assess the severity and cause of the inflammation. For mild to moderate cases, provide supportive care with intravenous fluids, typically normal saline or lactated Ringer's, to correct dehydration and electrolyte imbalances. Antiemetics such as ondansetron 4-8 mg IV every 8 hours can help manage nausea and vomiting.
Empiric Antibiotic Therapy
For bacterial enteritis, empiric antibiotic therapy may include ciprofloxacin 500 mg PO twice daily or azithromycin 500 mg PO daily for 3-5 days, adjusting based on culture results. However, the choice of antibiotics should be guided by the most recent and highest quality evidence, which suggests that for adult patients with mild-to-moderate community-acquired infection, the use of ticarcillin-clavulanate, cefoxitin, ertapenem, moxifloxacin, or tigecycline as single-agent therapy or combinations of metronidazole with cefazolin, cefuroxime, ceftriaxone, cefotaxime, levofloxacin, or ciprofloxacin are preferable to regimens with substantial anti-Pseudomonal activity 1.
Special Considerations
For patients with neutropenic enteritis or typhlitis, treatment should be non-operative with broad-spectrum antibiotics and bowel rest, reserving surgery for those presenting with signs of perforation or ischemia, as suggested by recent guidelines 1. The use of broad-spectrum antibiotics should be based on the IDSA guidelines for “fever with neutropenia,” which suggest monotherapy with an anti-pseudomonas B-lactam agent or a carbapenem or piperacillin-tazobactam as the first choice.
Monitoring and Adjunctive Therapy
Monitor patients for signs of clinical improvement, including decreased diarrhea frequency, improved oral intake, and hemodynamic stability. Ensure gradual reintroduction of oral intake, starting with clear liquids and advancing as tolerated. Consider probiotics like Lactobacillus or Saccharomyces boulardii to help restore gut flora. For severe cases with significant inflammation or complications, consult gastroenterology for possible endoscopic evaluation.
Key Recommendations
- Assess severity and cause of enteritis to guide treatment approach.
- Use supportive care with IV fluids and antiemetics as needed.
- Choose empiric antibiotics based on severity, suspected cause, and local resistance patterns, considering guidelines from reputable sources like the Infectious Diseases Society of America 1.
- Consider special patient populations, such as those with neutropenic enteritis, and adjust treatment accordingly, focusing on non-operative management with broad-spectrum antibiotics and bowel rest 1.
From the Research
Treatment Approach
- The primary goal in treating enteritis is to manage symptoms and prevent complications, with a focus on fluid and electrolyte repletion and symptomatic care 2.
- Antibiotics are not always necessary and should only be prescribed based on clinical or epidemiologic features that suggest a treatable bacterial origin or a high-risk host 2, 3.
- Loperamide can be an effective therapy for managing diarrhea in patients with enteritis, particularly for those with acute, nonspecific diarrhea or diarrhea-predominant irritable bowel syndrome 4.
Antibiotic Use
- The decision to prescribe empiric antibiotic therapy should be based on clinical or epidemiologic features of the illness, such as the presence of leukocytes or blood in the stool 2.
- A quinolone is generally the best initial choice for empiric antibiotic therapy 2.
- Antibiotic use should be guided by epidemiological factors, diagnostic tests, and the indications for empirical antibiotics, with the goal of decreasing antibiotic misuse and preventing antibiotic resistance 3.
Management and Prevention
- The physician's primary task is to assess the severity of illness and tailor fluid and electrolyte replacement and symptomatic therapy accordingly 5.
- Narrowing the considerations in differential diagnosis can help guide decision making about the need for diagnostic tests, specific therapy, and public health intervention 5.
- A stepwise approach to management and prevention can help ensure that patients receive appropriate care and reduce the risk of complications 5.