Management of Bacterial Gastroenteritis

Rehydration Therapy

• Rehydration is the initial critical intervention for all patients with diarrhea, with approaches including increased intake of clear fluids for mild cases, oral rehydration solutions (ORS) for moderate to severe cases, and intravenous rehydration with isotonic fluids for severe dehydration, as recommended by the Infectious Diseases Society of America and the World Health Organization 1, 2, 3
• Reduced osmolarity oral rehydration solution (ORS) is recommended for mild to moderate dehydration, to be continued until clinical dehydration is corrected and to replace ongoing losses with ORS until diarrhea resolves, according to the Clinical Infectious Diseases guidelines 1
• Isotonic intravenous fluids (lactated Ringer's or normal saline) are recommended for severe dehydration, to be continued until pulse, perfusion, and mental status normalize, and to transition to oral rehydration once patient can tolerate oral intake, as recommended by the Clinical Infectious Diseases guidelines 1
• Maintaining hydration with oral rehydration solutions and continuing normal diet/feeding is recommended for patients with acute diarrhea, according to the American Academy of Pediatrics and the World Health Organization 1, 3

Antibiotic Therapy

• For moderate to severe cases in travelers, fluoroquinolone (e.g., ciprofloxacin 500 mg twice daily for 3 days) or azithromycin (depending on local resistance patterns) may be recommended, as suggested by various authorities 2, 4
• Azithromycin is the first-line antibiotic treatment for diarrhea caused by Campylobacter jejuni, especially in areas with high resistance to fluoroquinolones, according to the American Society of Travel Medicine 4
• First-line therapy for immunocompromised patients with Campylobacter infections is azithromycin 500 mg daily for 7 days or ciprofloxacin 500 mg twice daily for 7 days (if susceptibility confirmed), as recommended by the Centers for Disease Control and Prevention 5
• Antimicrobial therapy for people with infections attributed to STEC O157 and other STEC that produce Shiga toxin 2 should be avoided (strong, moderate recommendation), as recommended by various authorities 1

Supportive Care

• Probiotics may be offered to reduce symptom severity and duration, according to the Clinical Infectious Diseases guidelines 1
• Continue breastfeeding in infants, as recommended by various authorities 6
• Avoid antimotility agents in children under 4 years, according to the Clinical Infectious Diseases guidelines 1
• Loperamide may be considered for symptom relief in uncomplicated cases of travelers' diarrhea, but should be avoided in patients with fever, bloody diarrhea, or suspected inflammatory diarrhea, as recommended by various authorities 4, 1, 7

Monitoring and Evaluation

• Monitor for worsening symptoms, which may indicate a different pathogen or complications, according to the Clinical Infectious Diseases guidelines 1
• Evaluate for potential complications in severe cases, as recommended by the Clinical Infectious Diseases guidelines 1
• Stool testing for specific pathogens including C. difficile, Salmonella, E. coli, and Campylobacter should be considered in patients with persistent symptoms, according to various authorities 1, 7, 3, 8
• Monitoring for dehydration is crucial as it increases the risk of life-threatening illness, and patients should be monitored for worsening symptoms, signs of dehydration, and response to treatment, as recommended by various authorities 9, 1

Prevention

• Scrubbing hands thoroughly after potential contact with human feces, handling pets or other animals can prevent infection, as recommended by the Centers for Disease Control and Prevention 5
• Avoiding unprotected sexual practices that may result in oral exposure to feces can prevent infection, according to the Centers for Disease Control and Prevention 5
• Avoiding high-risk foods such as raw or undercooked eggs, poultry, meat, and seafood, unpasteurized dairy products, and unpasteurized fruit juices can prevent infection, as recommended by the Centers for Disease Control and Prevention 5
• Proper hand hygiene after potential contact with feces, safe food handling practices, and avoiding unpasteurized dairy products are essential to prevent the spread of EPEC and Campylobacter infections, as recommended by various authorities 3, 5

Special Populations

• Immunocompromised patients are at higher risk of more severe and prolonged disease, according to the Centers for Disease Control and Prevention 5
• Patients with advanced HIV should consider blood cultures due to the high rate of bacteremia associated with Campylobacter gastroenteritis, as recommended by the Centers for Disease Control and Prevention 5
• The American College of Physicians recommends observation as the most appropriate management for patients with confirmed Shiga toxin-2-producing E. coli infection, and avoiding antibiotics and antimotility agents due to increased risk of hemolytic uremic syndrome (HUS) 1

Antibiotic Resistance