REVIEW

Therapy of acute gastroenteritis: role of antibiotics

I. Zollner-Schwetz and R. Krause

Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria

Abstract

Acute infectious diarrhoea remains a very common health problem, even in the industrialized world. One of the dilemmas in assessing
patients with acute diarrhoea is deciding when to test for aetiological agents and when to initiate antimicrobial therapy. The management
and therapy of acute gastroenteritis is discussed in two epidemiological settings: community-acquired diarrhoea and travellers’ diarrhoea.
Antibiotic therapy is not required in most patients with acute gastroenteritis, because the illness is usually self-limiting. Antimicrobial
therapy can also lead to adverse events, and unnecessary treatments add to resistance development. Nevertheless, empirical antimicrobial
therapy can be necessary in certain situations, such as patients with febrile diarrhoeal illness, with fever and bloody diarrhoea, symptoms
persisting for >1 week, or immunocompromised status.
Clinical Microbiology and Infection © 2015 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All
rights reserved.

Keywords: Antibiotics, community-acquired diarrhoea, diarrhoea, gastroenteritis, travellers’ diarrhoea

Article published online: 11 March 2015

Diarrhoea is usually defined as the passage of three or more

Corresponding author: R. Krause, Section of Infectious Diseases
and Tropical Medicine, Department of Internal Medicine, Medical
University of Graz, Auenbruggerplatz 15, A-8036 Graz, Austria
E-mail: robert.krause@medunigraz.at
Introduction
Acute infectious diarrhoea remains a very common health
problem, even in the industrialized world. Recent data from
Germany indicate that 0.95 episodes of acute gastrointestinal
illness occur per person per year in adults [1]. A similar rate
was reported in the USA [2]. One of the dilemmas in assessing
patients with acute diarrhoea is deciding when to test for
aetiological agents and when to initiate antimicrobial therapy.
The aim of this article is to review the management of acute
gastroenteritis in adults in industrialized countries, with a spe-
cial focus on the role of antibiotics. The management of
persistent and chronic diarrhoea, nosocomial diarrhoea and
acute gastroenteritis in children in resource-restricted coun-
tries is beyond the scope of this article. The management and
therapy of acute gastroenteritis will be discussed in two
epidemiological settings: community-acquired diarrhoea, and
travellers’ diarrhoea.
unformed stools per day or the passage of >250 g of unformed
stool per day, often accompanied by symptoms of nausea,
vomiting, or abdominal cramps [3]. On the basis of duration,
diarrhoea can be divided into acute (<14 days), persistent
(14–29 days), or chronic (30 days) [4].
Epidemiology
Community-acquired diarrhoea
In Europe, the leading causes of bacterial diarrhoeal illness
include Campylobacter, enteropathogenic Escherichia coli, and
enteroaggregative E. coli (EAEC) [5,6]. In 2012, Campylobacter
infections were reported more frequently than infections
caused by non-typhoidal Salmonella (68 per 100 000 vs. 22 per
100 000) [5]. Furthermore, the number of salmonellosis cases
has decreased over the past 5 years, most likely because of the
implementation of veterinary control programmes against Sal-
monella species, especially in poultry [5]. EAEC has also been
recognized as an important agent for community-acquired
diarrhoea in industrialized countries [7]. In addition, Clos-
tridium difficile has emerged as a cause of community-acquired
diarrhoeal illness, with many patients lacking typical risk fac-
tors [8,9]. Foodborne transmission of C. difficile has been

Clin Microbiol Infect 2015; 21: 744–749

Clinical Microbiology and Infection © 2015 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved
http://dx.doi.org/10.1016/j.cmi.2015.03.002
CMI
hypothesized as a possible source of community-associated
infections; however, the evidence needed to confirm or
refute this hypothesis is incomplete [10,11]. Other less com-
mon pathogens include Yersinia species, non-cholera Vibrio
species and Shiga toxin-producing E. coli (STEC) strains. In 2011,
there was a nationwide outbreak of STEC O104:H4 in Ger-
many, resulting in >4000 infections and >900 cases of haemo-
lytic–uraemic syndrome (HUS) [12,13]. The outbreak was
traced back to contaminated sprouts [12]. In 2012, STEC cases
were reported at a rate of 1.5 cases per 100 000 in the EU [5].
Travellers’ diarrhoea
Between 20% and 50% of travellers from industrialized coun-
tries to resource-restricted nations experience travellers’
diarrhoea, depending on the destination [14,15]. It is most often
acquired in the first 2–3 weeks of travel, through the ingestion
of contaminated foods and, less often, drinks [16]. A meta-
analysis concluded that the incidence of diarrhoea was very
similar in travellers who followed the advice ‘boil it, cook it,
peel it, or forget it’ and those who engaged in more adven-
turous eating habits [17]. The majority of travellers have self-
limiting illnesses; <1% require hospitalization [18]. Bacterial
enteropathogens account for 80% of the cases of travellers’
diarrhoea [16]. Enterotoxigenic E. coli, enteroinvasive E. coli and
EAEC are implicated in the majority of cases, followed by
Campylobacter, Salmonella and Shigella [16]. Parasitic agents are
uncommon causes of acute travellers’ diarrhoea, but should be
suspected in the case of a subacute and chronic illness [19].
Management of acute gastroenteritis
Most patients with acute diarrhoea are able to manage their
illness, and do not seek medical attention. In patients with sig-
nificant diarrhoeal illness, i.e. profuse, dehydrating, febrile or
bloody diarrhoea, the first step for the attending physician con-
sists of obtaining a thorough history, including epidemiological
and clinical information. Relevant clinical features include onset
of illness, the frequency of bowel movements, the presence of
dysenteric symptoms (fever, tenesmus, or blood or mucus in the
stool), symptoms of volume depletion, and associated symptoms
such as nausea, vomiting, or abdominal pain [4]. Important
epidemiological information includes previous international
travel, treatment with antibiotics, chemotherapy, underlying
immunosuppressive conditions, work at a day-care centre, and
consumption of unsafe foods (e.g. raw meats, eggs, and shellfish).
A directed physical examination is aimed at exploring the pa-
tient’s hydration status and abdominal tenderness.
The determination of the precise cause of diarrhoea is not
necessary in most cases of non-severe illnesses [3]. However,
Clinical Microbiology and Infection © 2015 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved, CMI, 21, 744–749
Zollner-Schwetz and Krause Therapy of acute gastroenteritis 745
any diarrhoeal illness lasting for >1 day accompanied by fever,
recent use of antibiotics, duration of symptoms of >1 week,
hospitalization, immunosuppression, diarrhoea in elderly pa-
tients or symptoms of dehydration (defined as dry mucous
membranes, decreased urination, tachycardia, symptoms of
postural hypotension, or lethargy) should prompt evaluation of
faecal specimens for Salmonella, Campylobacter species, and
Shigella species [4]. In cases with bloody stools, testing for STEC
should be added to the panel of stool examinations [4]. Testing
for C. difficile is recommended if the patient has a history of
antibiotic intake, chemotherapy, or hospitalization [4]. It should
be kept in mind that community-acquired cases of C. difficile
infection in the absence of typical risk factors do occur [6,8,20].
In the majority of cases, the bacterial pathogen is detected in
the first or second sample that is submitted [21], so perfor-
mance of multiple cultures is not useful. Although the bacterial
yield of stool cultures is quite low (1.5–3%) [22], the infor-
mation obtained is important for both the individual patient and
public health purposes.
In the past 10 years, PCR-based diagnostic methods have
evolved as novel tools, often detecting multiple enter-
opathogens in a single test [23,24]. These techniques offer the
advantages of high sensitivity and, in the case of automated
multiplex systems, of a very short turnaround time as
compared with conventional culture [6]. However, detection of
a pathogen’s nucleic acid does not automatically implicate this
pathogen as the causative agent of clinical symptoms. The pa-
tient could be an asymptomatic carrier, or the pathogen’s
nucleic acid may be detected although the pathogen is no longer
viable. Combined approaches of PCR-based methods followed
by culture in cases of positive results to detect resistance pat-
terns could be a useful strategy in the future. It should be kept
in mind that the patient’s history and symptoms rather than
laboratory results alone constitute the determining factor
regarding when to initiate antimicrobial therapy.
Additional diagnostic evaluations, such as serum chemistry
analysis, complete blood count, and blood cultures, may be
necessary in patients who have fever or symptoms indicative of
systemic inflammatory response syndrome [3].
Therapy
The initial treatment of acute diarrhoeal illnesses must include
rehydration, which can be achieved with oral electrolyte solu-
tions or intravenous fluids. Antibiotic therapy is not required in
most patients, because the illness is usually self-limiting. Any
consideration of antimicrobial therapy must be carefully
weighed against unintended and potentially harmful conse-
quences [4]. Nevertheless, empirical and specific antimicrobial
746 Clinical Microbiology and Infection, Volume 21 Number 8, August 2015
therapy can be considered in certain situations. Knowledge of
local patterns of resistance is crucial to reduce the number of
treatment failures.
There is concern about antibiotic treatment in patients with
suspected or proven infection with STEC, because experimental
models suggest an increase in the production and release of the
toxin during treatment with fluoroquinolones [25]. This may lead
to an increase in the risk of HUS when antibiotics are administered
[26], although some studies have suggested that antibiotic treat-
ment is not associated with an increased risk of HUS [27]. Several
studies have shown a correlation between antibiotic use and the
risk for HUS [26,28], including a large, prospective study among
259 children [29]. STEC infection should be suspected in patients
with bloody diarrhoea, abdominal pain or tenderness in the
absence of fever [26,30]. Therefore, in an outbreak of bloody
diarrhoea, antibiotics are not currently recommended for patients
with little or no fever who may have STEC infection [3]. In general,
single cases of acute febrile bloody diarrhoea are more likely to be
caused by pathogens such as Campylobacter species or Shigella
species, depending on the epidemiological setting. These patients
are likely to benefit from empirical antimicrobial therapy [3].
Community-acquired diarrhoea
A Swedish study demonstrated that empirical treatment with
norfloxacin reduced the intensity and, to some extent, the
duration of diarrhoeal symptoms, although the effect was
restricted to patients who were severely ill [31]. However,
treatment with norfloxacin delayed the elimination of Salmonella
and induced resistance in Campylobacter [31]. A meta-analysis
confirmed that antimicrobial therapy does not reduce the
length of illness in otherwise healthy patients with non-severe
diarrhoea caused by non-typhoidal Salmonella [32]. In addition,
antimicrobial therapy tended to increase the period during which
Salmonella was detected in stools [32]. Therefore, antimicrobial
therapy is not necessary in patients with non-severe non-
typhoidal salmonellosis who are otherwise healthy [3].
In Europe, Campylobacter infections were three times more
frequent than infections caused by non-typhoidal Salmonella in
2012 [5,6]. Resistance to ciprofloxacin was as high as 44% in
Campylobacter isolates from humans in some states of the EU,
whereas resistance to erythromycin was <5% [33]. In contrast,
only 5–13% of non-typhoidal Salmonella isolates were resistant
to ciprofloxacin in Europe in 2011, depending on the serovars
[33]. A recent study estimated that approximately one-fifth of
Campylobacter cases in the USA are associated with interna-
tional travel in the week before onset of symptoms [34].
Among international travel-associated cases, 60% of the
Campylobacter isolates were resistant to fluoroquinolones, as
compared with 13% of the non-travel-associated cases [34].
Although it seems unreasonable to suggest fluoroquinolones as
Clinical Microbiology and Infection © 2015 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved, CMI, 21, 744–749
CMI
first-line empirical therapy for community-acquired diarrhoea
in European countries, this class of antibiotics may be effective
in non-travel-associated cases in the USA. The use of azi-
thromycin seems reasonable in international travel-associated
cases in the USA and in community-acquired cases in Europe.
Empirical antimicrobial therapy is recommended in selected
patient groups: six or more stools per day, with fever and
bloody diarrhoea or fever only, symptoms persisting for >1
week, or immunocompromised status. In Europe, treatment
options include azithromycin, fluoroquinolones, and trimetho-
prim–sulfamethoxazole (Fig. 1). The use of fluoroquinolones
and trimethoprim–sulfamethoxazole should be avoided in
pregnant women. In some patients with an established infec-
tious cause of acute diarrhoea, organism-specific antimicrobial
therapy may be necessary. The treatment options have recently
been summarized [3].
Travellers’ diarrhoea
It is important to remember that the majority of patients with
travellers’ diarrhoea have self-limiting illnesses, and that <1%
require hospitalization [18]. However, antibiotic treatment is
warranted to treat those with moderate to severe diarrhoea
(more than four stools per day, fever, and blood or mucus in the
stool). Traditionally, ampicillin, trimethoprim–sulfamethoxazole
and doxycycline have been used as the drugs of choice [35].
However, high levels and frequencies of resistance were re-
ported for these substances, making them inappropriate as
empirical therapy [36]. Currently, three substances are recom-
mended to travellers as self-medication: ciprofloxacin, azi-
thromycin, and rifaximin [19] (Fig. 2). The increasingly frequent
resistance to fluoroquinolones among enteropathogens world-
wide is of growing concern, particularly concerning Campylo-
bacter isolates from Southeast Asia [37], but also in Europe [33].
Rifaximin, a non-absorbed rifamycin, was shown to be effective in
the treatment of travellers’ diarrhoea caused by non-invasive
pathogens [38]. It has also been used successfully as a prophy-
lactic agent in travellers from the USA visiting Mexico [39].
Although rifaximin is non-absorbed, it has been demonstrated
that rifampin-resistant staphylococci emerge after the intake of
rifaximin [40]. As rifampin resistance is associated with treat-
ment failure in staphylococcal foreign-body infections, rifaximin
should be used prudently, especially in patients at risk for such
infections. Azithromycin, a modern macrolide antibiotic, was
more effective than levofloxacin for the treatment of travellers’
diarrhoea in Thailand [41]. A study performed in Turkey
comparing azithromycin and loperamide with levofloxacin and
loperamide led to similar results [42]. A single oral dose of
1000 mg was more successful than administration of 500 mg once
daily for 3 days, although the single-dose regimen tended to be
more frequently associated with mild nausea after intake [41].
CMI Zollner-Schwetz and Krause Therapy of acute gastroenteritis 747

FIG. 1. Management of community-acquired diarrhoea. Note that Shiga toxin-producing Escherichia coli (STEC) infection should be suspected in
patients with bloody diarrhoea, abdominal pain or tenderness in the absence of fever. Antimicrobial therapy is not recommended for patients with
suspected or proven STEC infection.

FIG. 2. Management of travellers’ diarrhoea (adapted from [19]). Antibiotic treatment is warranted in cases of moderate to severe diarrhoea (more
than four stools per day, fever, or blood or mucus in the stool). In travellers with severe symptoms accompanied by fever, azithromycin is the
treatment of choice, because of the lack of a systemic effect of rifaximin and increasing resistance to fluoroquinolones, especially in Campylobacter
species.

Conclusion immunocompromised status. In patients with travellers’ diar-

rhoea, antimicrobial therapy is recommended in cases of
moderate and severe disease. Knowledge of local patterns of
Antibiotic therapy is not required in most patients with acute
resistance is crucial to reduce the number of treatment failures.
gastroenteritis, because the illness is usually self-limiting.
Nevertheless, in community-acquired diarrhoea, empirical
Transparency declaration
antimicrobial therapy should be considered in selected patient
groups, such as patients with fever and bloody diarrhoea or
febrile diarrhoeal illness, symptoms persisting for >1 week, or The authors declare that they have no conflicts of interest.
Clinical Microbiology and Infection © 2015 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved, CMI, 21, 744–749
748 Clinical Microbiology and Infection, Volume 21 Number 8, August 2015 CMI

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