When not to treat infectious diarrhea?

From the Guidelines

Infectious diarrhea is generally not treated with antimicrobial therapy in immunocompetent individuals with mild to moderate disease, as symptoms are typically self-limiting and resolve within 3-7 days 1.

Key Considerations

• Mild to Moderate Disease: Antimicrobial therapy is not recommended for immunocompetent individuals with mild to moderate disease, as the benefits do not outweigh the risks 1.
• Severe Disease or Specific Infections: Antibiotic treatment, such as azithromycin (500 mg orally, single dose) or ciprofloxacin (500 mg orally, twice daily for 3 days), is typically reserved for patients with severe disease, immunocompromised individuals, or those with specific bacterial infections, such as Clostridioides difficile or Shigella 1.
• Antimotility Agents: Antimotility agents such as loperamide (2-4 mg orally, 3-4 times daily) may be used to manage symptoms, but are not recommended for patients with bloody stools, fever, or suspected invasive bacterial infection 1.
• Exceptions: Certain patient populations, such as infants <3 months of age, ill immunocompetent people with fever, abdominal pain, and bloody diarrhea, and people who have recently traveled internationally with high fever and/or signs of sepsis, may require empiric antimicrobial therapy 1.
• Avoiding Treatment: Antimicrobial therapy should be avoided in patients with infections attributed to STEC O157 and other STEC that produce Shiga toxin 2, as it may cause harm 1.

From the FDA Drug Label

Patients should be counseled that antibacterial drugs including azithromycin should only be used to treat bacterial infections. They do not treat viral infections (e.g., the common cold). Ciprofloxacin Tablets USP, 250 mg, 500 mg and 750 mg should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria

Do not treat infectious diarrhea when the cause is likely to be viral, as antibacterial drugs like azithromycin and ciprofloxacin are ineffective against viral infections 2 3.

From the Research

When Not to Treat Infectious Diarrhea

• Routine antibiotic use is not recommended for most adults with mild, watery diarrhea, as acute diarrhea is most often self-limited and caused by viruses 4, 5, 6.
• Immunocompetent patients do not require specific antibiotic therapy, except in cases of severe comorbidities, immunodeficiency, fever/SIRS, and in patients with Shigella or C. difficile infection 7.
• Empirical antibiotic treatment should not be considered for patients with uncomplicated, self-limiting courses of infectious diarrhea 7, 5, 6.
• The use of antibiotics should be avoided in patients with no severe symptoms, no signs of invasive illness, and no risk factors for complications, as the benefits of general empirical antibiotic therapy for acute diarrhea are not evidence-based 5, 6.

Specific Cases Where Treatment May Not Be Necessary

• Patients with traveler's diarrhea do not require microbiological diagnosis unless they have fever, bloody diarrhea, prolonged course of disease, severe clinical course, or are part of an outbreak 7, 8.
• Patients with acute watery diarrhea may not require antibiotic treatment unless they are severely ill, immunocompromised, or have a high risk of complications 4, 8.