Management of Antibiotic-Associated Diarrhea

Initial Assessment and General Management

The American College of Emergency Physicians and the Infectious Diseases Society of America recommend that the management of antibiotic-associated diarrhea should begin with discontinuation of the causative antibiotic agent when possible, followed by appropriate rehydration therapy, and specific treatment based on severity and etiology, with oral vancomycin or fidaxomicin being the treatments of choice for confirmed Clostridioides difficile infection 1, 2
Evaluate the onset, duration, frequency, and characteristics of diarrhea, as well as associated symptoms such as fever, dizziness, abdominal pain/cramping that might indicate complications 3
Discontinue the causative antibiotic agent if possible, as this is often sufficient to resolve mild cases 1
Implement dietary modifications including elimination of lactose-containing products, alcohol, and high-osmolar dietary supplements 3
Encourage adequate hydration with clear liquids, such as oral rehydration solution, which is the first-line therapy for mild to moderate dehydration 2, 4
For severe dehydration, shock, altered mental status, or ileus, administer isotonic intravenous fluids until clinical improvement occurs 2, 4

For mild to moderate diarrhea, loperamide may be given to immunocompetent adults at an initial dose of 4 mg followed by 2 mg every 4 hours or after every unformed stool 2, 3
Avoid antimotility drugs in children under 18 years of age and in cases of inflammatory diarrhea or diarrhea with fever 2, 4
Gradually reintroduce solid foods as symptoms improve 3
Consider probiotic preparations to reduce symptom severity and duration in immunocompetent patients 2, 4
If diarrhea persists for more than 24 hours on standard-dose loperamide, increase to 2 mg every 2 hours and consider oral antibiotics as prophylaxis for infection 5
If diarrhea persists for more than 48 hours total on loperamide, discontinue it and consider second-line agents such as subcutaneous octreotide 5, 3

Metronidazole is an alternative for mild to moderate cases of CDAD, though it has more gastrointestinal side effects than vancomycin 1
For severe CDAD with complications, higher doses of oral vancomycin may be used 1
For recurrent cases, consider fecal microbiota transplantation or adjunctive treatment with monoclonal antibodies 1

Implement hand hygiene with soap and water rather than alcohol-based sanitizers when caring for patients with suspected or confirmed C. difficile infection 1
Use gloves and gowns when caring for patients with diarrhea 2, 4
Consider isolation or cohort nursing for patients with confirmed C. difficile infection 1
Discontinue unnecessary proton pump inhibitors, as they may be associated with increased risk of CDAD 1

Avoid antimotility agents in children under 18 years and in patients with bloody diarrhea or fever due to risk of complications 2, 4
Do not use antibiotics for STEC O157 infections as they may increase the risk of hemolytic uremic syndrome 6, 4