eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Escherichia Coli Infections: Treatment & Medication
Updated: Jan 8, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Treatment of bacterial gastroenteritis is primarily supportive and directed toward maintaining hydration and electrolyte balance. Antibiotic therapy is rarely indicated and should be deferred until culture results are available.
Oral rehydration therapy (ORT) is the preferred treatment for fluid and electrolyte losses caused by diarrhea in children with mild-to-moderate dehydration. Intravenous hydration is often administered for severe dehydration or when vomiting prevents ORT. In most cases, even children who are vomiting can tolerate oral fluids if administered frequently in small amounts.22
- Do not use antimotility agents to treat acute diarrhea in pediatric patients. Antimotility agents may prolong the clinical and bacteriologic course of the disease and may be associated with other unacceptable morbidities such as excessive sedation. A retrospective study reported hemolytic-uremic syndrome (HUS) was more likely to develop in patients with E coli 0157:H7 infection who received antimotility agents.23
- Antibiotic treatment of E coli 0157:H7 colitis is controversial. Early data indicated antimicrobials offer no substantial benefit and may increase the risk of developing HUS.23 In vitro studies have shown subinhibitory antibiotic concentrations can increase toxin production.24 However, a subsequent meta-analysis reported no association between the use of antimicrobials and higher risk of HUS.25 In the absence of conclusive evidence, empiric antibiotics should not be administered due to the potential risk of HUS.2
- Administer intravenous antibiotics to children who have evidence of systemic infection (eg, bacteremia, sepsis). Include a combination of ampicillin and an aminoglycoside in the initial empiric treatment of a neonate with suspected sepsis. Alternative regimens of ampicillin and a cephalosporin, such as cefotaxime, are also acceptable. Coverage may be narrowed when the etiologic agent and its antimicrobial susceptibilities have been determined. Base therapy duration on the patient's response and established treatment guidelines (usually 10-14 d for uncomplicated sepsis, >21 d for meningitis).2
- Urinary tract infections (UTIs) may be treated with oral antibiotics if the child can tolerate oral medication without vomiting. Antibiotic regimens of 3 days are inadequate; continue treatment for 10 days.
- Treatment of HUS is supportive and includes management of fluid and electrolyte status and dialysis, if necessary. Ake et al (2005) propose that early volume expansion with parenteral isotonic fluids during the pre-HUS interval is essential to attenuate renal injury associated with HUS.26 Leukocytosis has been identified as an early predictor of the development of HUS following an E coli O157:H7 infection.27,28
Consultations
- In cases of hemorrhagic colitis, consultation with a pediatric infectious disease specialist is recommended, especially if considering antibiotic therapy.
- When HUS is suspected or confirmed, a pediatric nephrologist should assist with patient management because dialysis may be necessary. Early dialysis is associated with improved outcome.
- Ongoing research protocols investigating the benefit of a toxin-adsorbing preparation appear promising.24 Enrollment in such a treatment study may be an option at selected tertiary care settings.
Diet
- Children who have diarrhea should continue to receive age-appropriate diets.
- Feed dehydrated children as soon as they have been rehydrated.
- Feeding may be withheld briefly for children who are vomiting, but prolonged periods of fasting or specialized diets are unnecessary once vomiting ceases.
Activity
- Increase allowable activities, as tolerated, for all affected children. In general, children eagerly resume vigorous activity as their illness resolves and restrictions are unnecessary.
- Children with E coli 0157:H7 infection should not return to group childcare settings until the diarrhea has resolved and 2 stool culture results are negative.
Medication
Antibiotic therapy is not indicated in most cases of Escherichia coli enteritis; guidelines for specific circumstances are outlined below.
Antimotility agents are contraindicated for all cases of pediatric gastroenteritis.
Urinary tract infections (UTIs) may be treated with various oral antibiotics, most commonly trimethoprim and sulfamethoxazole, amoxicillin, or cefixime. Duration of therapy is 10 days.
Neonatal sepsis and meningitis are treated based on identified organism susceptibility and clinical response.
Antibiotics
Treatment of traveler's diarrhea is rarely necessary. Prophylaxis for traveler's diarrhea with medications (eg, bismuth subsalicylate, trimethoprim and sulfamethoxazole) is not recommended for children because of potential salicylate accumulation and allergic reactions. Efficacy of antibiotic treatment of enteroinvasive E coli (EIEC) and enterohemorrhagic E coli (EHEC) is not established. Data suggest treating EHEC does not alter the course of infection and increases risk of subsequent hemolytic-uremic syndrome (HUS). UTI in infants and children is treated for 10 days because of the difficulty distinguishing between uncomplicated cystitis and pyelonephritis.
Sulfamethoxazole and Trimethoprim (Bactrim, Cotrim, Septra)
First-line therapy for UTI and most E coli diarrheal illness; resistant organisms are fairly common.
Adult
160 mg (trimethoprim component)/800 mg (sulfamethoxazole component) PO q12h for 3 d (ie, 1 double-strength tab PO q12h)
Pediatric
ETEC (traveler's diarrhea): 10 mg/kg/d PO divided bid for 3 d
UTI: 10 mg/kg/d PO divided bid for 10 d
EIEC (dysentery): 10 mg/kg/d PO divided bid for 5 d
Note: Doses based on trimethoprim component
May increase PT 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 thrombocytopenic purpura in elderly; 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; megaloblastic anemia due to folate deficiency; age <2 mo
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
Do not use near term in pregnancy (risk of kernicterus in newborn); discontinue at first appearance of skin rash or sign of adverse reaction; frequently obtain CBC counts; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; caution in folate deficiency; hemolysis may occur in G-6-PD deficiency; patients with AIDS may not tolerate or respond; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation
Amoxicillin (Amoxil, Biomox, Trimox)
Reasonable choice to treat pediatric UTI. Liquid preparation is palatable and well tolerated. It is concentrated in the urine and active against most gram-positive and some gram-negative organisms.
Adult
250-500 mg PO tid for 3-7 d
Pediatric
30-50 mg/kg/d PO divided tid for 10 d
Reduces efficacy of PO contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Use with caution in patients who are allergic to cephalosporins; adjust dose in renal impairment
Cefixime (Suprax)
Third-generation cephalosporin is a second-line choice to treat UTI or traveler's diarrhea; liquid preparation is pleasant tasting.
Adult
400 mg/d PO divided bid
Pediatric
UTI: 8 mg/kg/d PO divided bid for 10 d
ETEC (traveler's diarrhea): 8 mg/kg/d PO divided bid for 3-5 d
Coadministration of aminoglycosides increase nephrotoxicity; probenecid may increase effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Use with caution in patients with penicillin allergy; adjust dose in renal impairment
Ampicillin (Marcillin, Omnipen, Polycillin, Principen, Totacillin)
Administer parenterally in combination with an aminoglycoside or cephalosporin in cases of neonatal sepsis or meningitis; PO preparation is a second-line therapy for traveler's diarrhea and dysentery.
Adult
250-500 mg PO qid
500 mg to 3 g IV q4-6h; not to exceed 12 g/d
Pediatric
ETEC (traveler's diarrhea), EIEC (dysentery): 100 mg/kg/d PO divided qid for 5 d
Neonatal sepsis and meningitis: 100-200 mg/kg/d IV/IM divided qid for 10-21 d
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of PO contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction; use with caution in patients who are allergic to cephalosporins
Gentamicin
Aminoglycoside antibiotic used in combination with ampicillin to treat neonatal sepsis and meningitis; provides gram-negative coverage and works synergistically against gram-positives.
Adult
3-6 mg/kg/d IV divided tid
Pediatric
<5 years: 2.5 mg/kg/dose IV/IM q8h
>5 years: 1.5-2.5 mg/kg/dose IV/IM q8h or 6-7.5 mg/kg/d divided q8h; not to exceed 300 mg/d; monitor as in adults
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, possibly prolonging respiratory depression; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment; monitor serum levels to minimize risk of toxicity and optimize therapy; nephrotoxicity and ototoxicity may be associated with prolonged elevated trough concentrations
Cefotaxime (Claforan)
Third-generation cephalosporin administered parenterally in combination with ampicillin to treat neonatal sepsis or meningitis.
Adult
1-2 g IV/IM q4-12h
Pediatric
150-250 mg/kg/d IV/IM divided bid/tid for 10-21 d
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in women who are breastfeeding and in patients who are allergic to penicillin
Ciprofloxacin (Cipro, Ciloxan)
Quinolone antibiotics are an alternative therapy for adult UTI or bacterial enteritis. Use is contraindicated in pediatric patients when an acceptable alternative is available.
Adult
ETEC (traveler's diarrhea), EIEC (dysentery): 500 mg PO bid for 3 d
UTI: 250-500 mg PO bid for 3 d
Pediatric
ETEC, EIEC: 20-30 mg/kg/d PO divided bid for 1-3 d
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
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
Use with caution in children <18 y; in prolonged therapy, periodically evaluate organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Rifaximin (Xifaxan, RedActiv, Flonorm)
Nonabsorbed (<0.4%), broad-spectrum antibiotic specific for enteric pathogens of the GI tract (ie, gram-positive, gram-negative, aerobic and 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 traveler's 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 PO 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 more than 24-48 h or worsens; seek immediate medical care if fever and/or bloody stools emerge (tablets not effective); not effective for traveler's diarrhea due to suspected pathogens other than E coli; postmarketing reports include allergic dermatitis, rash, angioneurotic edema, urticaria, and pruritus
More on Escherichia Coli Infections |
| Overview: Escherichia Coli Infections |
| Differential Diagnoses & Workup: Escherichia Coli Infections |
 Treatment & Medication: Escherichia Coli Infections |
| Follow-up: Escherichia Coli Infections |
| References |
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Further Reading
Keywords
Escherichia coli infections, E coli infections, Escherichia coli, E coli, colibacillus, diarrhea, diarrheal illness, hemolytic-uremic syndrome, HUS, urinary tract infection, UTI, neonatal sepsis, meningitis, enterotoxigenic E coli, ETEC, enterohemorrhagic E coli, EHEC, enteropathogenic E coli, EPEC, enteroinvasive E coli, EIEC, enteroaggregative E coli, EAEC, hemolytic anemia, thrombocytopenia, renal insufficiency, diarrhea, oliguria, anuria, traveler's diarrhea, bacteremia, sepsis, respiratory distress, prematurity, low birth weight, hemorrhagic colitis, abdominal cramping, dysentery
