eMedicine Specialties > Gastroenterology > Systemic Disease

Food Poisoning: Treatment & Medication

Author: Roberto M Gamarra, MD, Fellow, Department of Internal Medicine, Section of Gastroenterology and Hepatology, Providence Hospital and Medical Center
Coauthor(s): David M Manuel, MD, Fellow, Department of Internal Medicine, Section of Gastroenterology, Providence Hospital and Medical Center; Michael H Piper, MD, FACG, FACP, Clinical Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Wayne State University School of Medicine; Consulting Staff, Digestive Health Associates PLC; Senthil Nachimuthu, MD, FACP, Fellow, Department of Internal Medicine, Heart and Vascular Institute, Tulane University School of Medicine; Priyankha Balasundaram, MD, Director, Kovai Heart Foundation, India; Resident, Department of Surgery, Tulane University School of Medicine
Contributor Information and Disclosures

Updated: Nov 18, 2009

Treatment

Medical Care

Because most cases of acute gastroenteritis are self-limited, specific treatment is not necessary. Some studies have quantified that only 10% of cases require antibiotic therapy.

• The main objective is adequate rehydration and electrolyte supplementation. This can be achieved with either an oral rehydration solution (ORS) or intravenous solutions (eg, isotonic sodium chloride solution, lactated Ringer solution). Strict personal hygiene should be practiced during the illness. 
• Oral rehydration is achieved by administering clear liquids and sodium-containing and glucose-containing solutions. A simple ORS may be composed of 1 level teaspoon of salt and 4 heaping teaspoons of sugar added to 1 liter of water.
• The use of ORS has reduced the mortality rate associated with cholera from higher than 50% to less than 1%.
• ORS also is indicated in other dehydrating diarrheal diseases.
• ORS promotes cotransport of glucose, sodium, and water across the gut epithelium, a mechanism unaffected in cholera.
• The World Health Organization (WHO) recommends a solution containing 3.5 g of sodium chloride, 2.5 g of sodium bicarbonate, 1.5 g of potassium chloride, and 20 g of glucose per liter of water.
• Intravenous solutions are indicated in patients who are severely dehydrated or who have intractable vomiting.
• Absorbents (eg, Kaopectate, aluminum hydroxide) help patients have more control over the timing of defecation. However, they do not alter the course of the disease or reduce fluid loss. 
• An interval of at least 1-2 hours should elapse when using other medications with absorbents.
• Antisecretory agents, such as bismuth subsalicylate (Pepto-Bismol), may be useful. The dose is 30 mL every 30 minutes, not to exceed 8-10 doses.
• Antiperistaltics (opiate derivatives) should not be used in patients with fever, systemic toxicity, or bloody diarrhea or in patients whose condition either shows no improvement or deteriorates.
• Diphenoxylate with atropine (Lomotil) is available in tablets (2.5 mg of diphenoxylate) and liquid (2.5 mg of diphenoxylate/5 mL). The initial dose for adults is 2 tablets 4 times a day (ie, 20 mg/d). The dose is tapered as diarrhea improves.
• Loperamide (Imodium) is available over the counter as 2-mg capsules and as a liquid (1 mg/5 mL). It increases the intestinal absorption of electrolytes and water and decreases intestinal motility and secretion. The dose in adults is 4 mg initially, followed by 2 mg after each diarrhea stool, not to exceed 16 mg in a 24-hour period.
• If symptoms persist beyond 3-4 days, the specific etiology should be determined by performing stool cultures.
• If symptoms persist and the pathogen is isolated, specific treatment should be initiated.
• Empiric treatment should be initiated in patients with suspected traveler's diarrhea or dysenteric or systemic symptoms. Treatment with an agent that covers Shigella and Campylobacter organisms is reasonable in patients with diarrhea (>4 stools/d) for more than 3 days and with fever, abdominal pain, vomiting, headache, or myalgias. A 5-day course of a fluoroquinolone (eg, ciprofloxacin 500 mg PO bid, norfloxacin 400 mg PO bid) is the first-line therapy.
• TMP/SMX (Bactrim DS 1 tab qd) is an alternative therapy, but resistant organisms are common in the tropics. Infection with either V cholerae or V parahaemolyticus can be treated either with a fluoroquinolone or with doxycycline (100 mg PO bid).
• In the absence of dysentery, do not administer antibiotics until a microbiologic diagnosis is confirmed and E coli O157:H7 is ruled out.

Diet

During episodes of acute diarrhea, patients often develop an acquired disaccharidase deficiency due to washout of the brush-border enzymes. For this reason, avoiding milk, dairy products, and other lactose-containing foods is advisable.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Rehydration solutions

The main objective is adequate rehydration and electrolyte supplementation. This can be achieved with ORS or intravenous solutions (eg, isotonic sodium chloride solution, lactated Ringer solution).

Lactated Ringer solution with NS

Both fluids are essentially isotonic and have equivalent volume-restorative properties. While some differences exist between metabolic changes observed with administration of large quantities of either fluid, for practical purposes and in most situations, differences are clinically irrelevant. No demonstrable difference exists in hemodynamic effect, morbidity, or mortality between resuscitation using either NS or LR.

Oral electrolyte mixtures (Rehydralyte, Pedialyte)

Acts by glucose-facilitated absorption of sodium and water, which is unaffected in diseases such as cholera. Oral rehydration is achieved using clear liquids and sodium-containing and glucose-containing solutions. WHO recommends a solution containing 3.5 g of sodium chloride, 2.5 g sodium bicarbonate, 1.5 g potassium chloride, and 20 g glucose per liter of water.
A simple solution may be made using 1 level tsp salt and 4 heaping tsp sugar added to 1 L water.

Antidiarrheals

Adsorbents (eg, attapulgite, aluminum hydroxide) help patients have more control over the timing of defecation but do not alter the course of the disease or reduce fluid loss. Antisecretory agents (eg, bismuth subsalicylate) may be useful. Antiperistaltics (opiate derivatives) should not be used in patients with fever, systemic toxicity, bloody diarrhea, or in patients whose condition either shows no improvement or deteriorates.

Attapulgite (Kaopectate, Diasorb)

Adsorbent and protectant that controls diarrhea.

Aluminum hydroxide (Amphojel, Dialume, ALternaGEL)

Commonly used as an antacid. Adsorbent and protectant that controls diarrhea.

Bismuth subsalicylate (Pepto-Bismol)

Antisecretory agent that also may have antimicrobial and anti-inflammatory effects.

Diphenoxylate and atropine (Lomotil, Lonox)

Drug combination that consists of diphenoxylate, which is a constipating meperidine congener, and atropine to discourage abuse. Inhibits excessive GI propulsion and motility.
Available in tabs (2.5 mg diphenoxylate) and liquid (2.5 mg diphenoxylate/5 mL).

Loperamide (Imodium)

Acts on intestinal muscles to inhibit peristalsis and slow intestinal motility. Prolongs movement of electrolytes and fluid through bowel and increases viscosity and loss of fluids and electrolytes.
Available over the counter in 2-mg capsules and liquid (1 mg/5 mL).

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Antibiotic selection should be guided by blood culture sensitivity.

Ciprofloxacin (Cipro)

First-line therapy. Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis, and, consequently, growth.

Norfloxacin (Noroxin)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis, and, consequently, growth.

Trimethoprim and sulfamethoxazole (Bactrim DS, Septra DS)

Alternative therapy, but resistant organisms are common in the tropics. Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

Doxycycline (Doryx, Vibramycin, Vibra-Tabs)

For V cholerae or V parahaemolyticus infections. Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Rifaximin (Xifaxan, RedActiv, Flonorm)

Nonabsorbed (<0.4%), broad-spectrum antibiotic specific for enteric pathogens of the gastrointestinal tract (ie, gram-positive, gram-negative, aerobic, anaerobic). Rifampin structural analog. Binds to beta-subunit of bacterial DNA-dependent RNA polymerase, thereby inhibiting RNA synthesis. Indicated for E coli (enterotoxigenic and enteroaggregative strains) associated with travelers' diarrhea.

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