eMedicine Specialties > Gastroenterology > Colon
Gastroenteritis, Bacterial: Treatment & Medication
Updated: Feb 19, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Because most infectious diarrhea is self-limited, medical care is primarily supportive in nature. Oral rehydration is the mainstay of treatment. Young infants and neonates are at high risk for secondary complications and require close monitoring, as do older individuals. Consider intravenous rehydration when oral rehydration is unsuccessful. Particular attention must be paid to repletion of potassium as needed.
- Oral rehydration therapy is the cornerstone of diarrhea treatment, especially for small bowel infections that produce a large volume of watery stool output. Studies confirm that early refeeding hastens recovery. Many commercial oral rehydration formulas are available and have been designed to promote optimal absorption of nutrients. Administer maintenance fluids plus replacement of losses to ill children. Administer small amounts of fluid at frequent intervals in order to minimize discomfort and vomiting. A 5- or 10-cc syringe without a needle is a very useful tool. The syringe can be used to place small amounts of fluid in the mouth quickly. Once the patient becomes better hydrated, cooperation improves enough for the patient to take small sips from a cup. This method is time intensive and requires dedication. Encouragement from the physician is necessary to promote compliance.
- Antimicrobial therapy is indicated for some bacterial gastroenteritis infections. However, many conditions are self-limited and do not require therapy. The following is a list of standard therapies:
- Aeromonas species - Use cefixime and most third-generation and fourth-generation cephalosporins.
- Bacillus species - No antibiotics are necessary for self-limited gastroenteritis, but vancomycin and clindamycin are first-line drugs for severe disease.
- Campylobacter species - Erythromycin may shorten illness duration and shedding. Delaying therapy beyond 4 days from onset of symptoms appears to produce no clinical benefit.
- C difficile - Discontinue potential causative antibiotics. If antibiotics cannot be stopped or this does not resolve diarrhea, use oral metronidazole or vancomycin. Vancomycin is reserved for seriously ill patients whose condition does not respond to metronidazole.
- C perfringens - Do not treat with antibiotics.
- E coli - Antibiotic treatment appears to increase the likelihood of HUS developing. Consider antibiotics if diarrhea is moderate or severe. Trimethoprim-sulfamethoxazole is a first-line drug, but use a parenteral second-generation or third-generation cephalosporin for systemic complications.
- Listeria species - No antibiotics are needed unless invasive disease occurs. Ampicillin and Bactrim are first-line drugs for invasive disease.
- Plesiomonas species - Use trimethoprim-sulfamethoxazole or any cephalosporin.
- Salmonella species - Antibiotic treatment prolongs the carrier state and is associated with relapse; thus, treatment is not indicated for nontyphoid, uncomplicated diarrhea. Consider treatment for infants younger than 3 months and for high-risk patients, such as patients who are immunocompromised or who have sickle cell disease. Ampicillin is recommended for drug-sensitive strains. Trimethoprim-sulfamethoxazole, fluoroquinolones, or third-generation cephalosporins (fluoroquinolones are not recommended for use in children) are also acceptable alternatives. S typhimurium T104 is a multidrug-resistant organism. Sensitivities from the cultured specimens are important to guide therapy.
- Shigella species - Antibiotic treatment may shorten illness duration and shedding but does not prevent complications. Most mild infections will recover without antibiotics. Moderate to severe cases should be treated with antibiotics. Ampicillin is preferred for drug-sensitive strains. For ampicillin resistant strains or in cases of penicillin allergy, trimethoprim-sulfamethoxazole is the drug of choice, although resistance does occur. Fluoroquinolones may be considered in patients with highly resistant organisms.
- Vibrio cholerae - Tetracycline is the usual antibiotic of choice, but resistance to it is increasing. Other antibiotics that are effective when V cholerae are sensitive to them include cotrimoxazole, erythromycin, doxycycline, chloramphenicol, and furazolidone.
- Yersinia species - Treatment (ie, trimethoprim-sulfamethoxazole, fluoroquinolones, aminoglycosides) does not shorten the disease duration and should be reserved for complicated cases.
- Antimotility agents are not indicated routinely for infectious diarrhea, (except for refractory cases of Cryptosporidium infection).
- Live Lactobacillus GG and heat-killed Lactobacillus LB reduce the duration of diarrhea in children when they are added to oral rehydration solution.12,13
Consultations
- Certain organisms cause abdominal pain and bloody stools. Symptoms resembling appendicitis, hemorrhagic colitis, intussusception, or toxic megacolon may be appreciated. In such cases, obtain a consultation with a surgeon.
- Consider consultation with an infectious disease specialist, especially for any patient who is immunocompromised due to human immunodeficiency virus (HIV) infection, chemotherapy, or immunosuppressive drugs, because atypical organisms are more likely and complications can be more serious and can fulminate.
Diet
- The BRAT diet (ie, bananas, rice, applesauce, toast) has been recommended for years in cases of gastroenteritis. This diet is adequate during early convalescence, but, as the patient tolerates solid food, advance the diet to provide adequate protein and caloric intake.14,15,16
- Introduce lean meats and clear fluids as soon as possible.14 Dairy products are said to be better absorbed when given with proteins or complex carbohydrates.
- When feeding lactose-containing dairy products, carefully monitor patient for signs of malabsorption.
- Breast milk contains many substances that promote bowel growth and antagonize bacteria; thus, continue breastfeeding throughout the illness for infants.
Medication
The goals of pharmacotherapy in cases of gastroenteritis are to reduce morbidity and to prevent complications.
Antibiotics
Along with the immune system, antibiotics help destroy offending organisms.
Cefixime (Suprax)
Potent long-acting oral cephalosporin with increased gram-negative coverage.
Adult
400 mg/d PO qd for 7-10 d
Pediatric
8 mg/kg/dose PO qd for 7-10 d
Aminoglycosides increase nephrotoxic potential; probenecid may increase effects by decreasing clearance
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients with penicillin hypersensitivity; adjust dose in the presence of renal impairment; administer with food to minimize adverse GI effects (eg, nausea, diarrhea)
Ceftriaxone (Rocephin)
Third-generation parenteral antibiotic with wide coverage, including gram-negative bacilli. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Adult
1-2 g IV/IM q24h for 7-10 d
Pediatric
50 mg/kg/dose IV/IM qd/bid for 7-10 d
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity.
Documented hypersensitivity; hyperbilirubinemic neonates
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients with penicillin hypersensitivity; common adverse drug reactions include skin rashes, diarrhea, and pain at the site of injection; adjust dose in the presence of renal impairment; caution in breastfeeding women
Cefotaxime (Claforan)
Third-generation parenteral antibiotic with wide coverage, including gram-negative bacilli. Arrests bacterial cell wall synthesis, which, in, turn inhibits bacterial growth.
Adult
1-2 g IV/IM q6-8h for 7-10 d
Pediatric
50 mg/kg/d IV/IM tid for 7-10 d
Probenecid may increase levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity.
Documented hypersensitivity to cefotaxime or cephalosporin antibiotics.
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients with penicillin hypersensitivity; skin rashes, thrombophlebitis, and GI upset (eg, nausea, vomiting, diarrhea) are the most common adverse drug reactions
Erythromycin (E.E.S., E-Mycin, Eryc, Ery-Tab)
Old bacteriostatic macrolide with activity against most gram-positive organisms and atypical respiratory organisms. Useful for Campylobacter and Vibrio enteritis. Nausea is a common adverse effect and may be tolerated poorly in some patients. Enteric-coated tablets reduce nausea.
Adult
250-500 mg (base, stearate, estolate) PO qid
400-800 mg (ethylsuccinate) PO qid
Pediatric
50 mg/kg/d PO/IV qid for 7-10 d
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment; concomitant administration of cisapride
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Nausea is a common adverse effect and may be tolerated poorly in some patients (enteric-coated tablets reduce nausea); caution in patients with liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Trimethoprim-sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)
Folate synthesis blocker that has wide antibiotic coverage.
Adult
160 mg, based on trimethoprim, PO bid for 7-10 d
Pediatric
10 mg/kg/d (trimethoprim) PO bid for 7-10 d
May increase PT duration when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; do not use in neonates, pregnant or lactating women, or persons with history of megaloblastic anemia; do not administer to infants <2 mo
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in the presence of renal or hepatic impairment; maintain adequate fluid intake to prevent crystalluria and stone formation; rash, sore throat, fever, arthralgia, cough, shortness of breath, pallor, purpura, or jaundice may be early indications of serious reactions; hemolysis occurs in individuals with G6PD deficiency
Vancomycin (Vancocin, Lyphocin)
Powerful treatment of antibiotic-associated colitis. Indicated for patients who cannot receive or whose conditions have not responded to penicillins and cephalosporins or have infections with resistant staphylococci.
To avoid toxicity, current recommendation is to assay trough levels after third dose drawn 0.5 h before next dosing. Use creatinine clearance to adjust the dose in patients diagnosed with renal impairment.
Used in conjunction with gentamicin for prophylaxis in patients allergic to penicillin who are undergoing GI or genitourinary procedures.
Adult
500 mg PO qid for 10-14 d
Pediatric
25-50 mg/kg/d PO qid for 10-14 d
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in the presence of renal failure or neutropenia; red man syndrome is caused by IV infusion that is too rapid (dose given over a few min) but rarely happens when dose given as 2-h administration or PO or IP; red man syndrome is not an allergic reaction
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 analogue. 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.
Adult
200 mg PO tid
Pediatric
<12 years: Not established
>12 years: Administer as in adults.
Induces CYP450 3A4 in vitro; limited data exist; no significant interactions shown in single-dose studies with midazolam and oral contraceptives
Documented hypersensitivity to rifaximin or rifamycin antimicrobial agents (eg, rifampin)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May promote intestinal bacterial overgrowth and cause superinfection; discontinue if diarrhea persists >24-48 h or worsens; seek immediate medical care if fever and/or bloody stools emerge (tablets not effective); not effective for travelers' diarrhea due to suspected pathogens other than E coli; postmarketing reports include allergic dermatitis, rash, angioneurotic edema, urticaria, and pruritus
More on Gastroenteritis, Bacterial |
| Overview: Gastroenteritis, Bacterial |
| Differential Diagnoses & Workup: Gastroenteritis, Bacterial |
 Treatment & Medication: Gastroenteritis, Bacterial |
| Follow-up: Gastroenteritis, Bacterial |
| References |
| Further Reading |
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References
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Further Reading
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Keywords
bacterial gastroenteritis, gastroenteritis, diarrhea, traveler's diarrhea, acute gastroenteritis, viral infection, improper diet, malabsorption syndrome, enteropathy, inflammatory bowel disease, Salmonella, Shigella, Campylobacter, Aeromonas, Escherichia coli, E coli, vomiting
