Should Antibiotics Be Prescribed for Acute Infectious Diarrhea?

Aunt Tilly's summer picnic was happy, relaxing, and sunbaked. The chicken salad and cole slaw were sunbaked too, and you wondered how long these items had been unrefrigerated. Questioning your aunt's food sanitation practices was certain to cause a family squabble, so you ate lunch and hoped for the best.

Aunt Tilly's Revenge

Your tact and optimism were not rewarded. A day later you began to have abdominal cramps and diarrhea. You vow zero tolerance on food sanitation in the future.

You have "Montezuma's revenge," "the runs,"  "the squirts" – acute, sudden onset infectious diarrhea, also known as acute gastroenteritis. You call your physician's office and are told to take fluids. You are told that the diarrhea will "run its course." Although on average antibiotics decrease the severity and duration of this illness, you don't get a. prescription for antibiotics. Why not?

Antibiotics Clearly of Benefit for Acute Diarrhea

The answer is not simple or straightforward. Although well-controlled studies show that antibiotics are beneficial for traveler's diarrhea and for domestically acquired diarrhea, experts generally recommend not giving antibiotics to patients with these problems.

Textbooks' Recommendation: No Antibiotics

For example, the Lange 2008 Current Medical Diagnosis and Treatment advises that “antibiotic treatment of all patients with acute diarrhea is not indicated.” The 2005 Mandell's Infectious Diseases states that "Specific antimicrobial therapy for infectious diarrhea is indicated in a limited number of situations."

Clinical Trials Show a Benefit for Antibiotics

Textbooks and journals have lengthy, complicated recommendations for acute diarrhea evaluation and treatment which have never been tested in clinical trials. However, what has been tested in multiple clinical trials is the comparison of antibiotics to inactive placebo. Patients given antibiotics consistently have a duration and severity of illness about half that of the patients given placebo. The suggestion that acute gastroenteritis should be allowed to "run its course" with fluids and no antibiotics (although fluids are important) is at odds with the available medical research results.

Objections to Antibiotics

You may want some good reasons why a doctor isn't going to decrease your suffering when he is capable of doing so, even if it's only by a couple of days. One reason given not to prescribe antibiotics for acute gastroenteritis is that diarrhea can be the initial symptom of other more serious illnesses which require different management. However, this is a meaningless argument, because you have to make a correct diagnosis to treat any disease appropriately.

Another objection to antibiotic use is the possibility that some patients with acute diarrhea may be infected with antibiotic-resistant organisms. However, the patient usually does well if the doctor makes an intelligent initial antibiotic choice, orders lab tests if necessary, and closely monitors the patient.

Drug Side Effects

Drug side effects can be avoided by not prescribing antibiotics, but side effects are usually minor for the antibiotics used to treat acute infectious diarrhea. Of course, any antibiotic can cause potentially severe antibiotic-associated colitis, but the antibiotics used to treat infectious diarrhea rarely cause this problem.

Small Chance of Making Things Worse

The potential for actually causing antibiotic resistance is another reason given to avoid antibiotic use. This is usually a concern for the population as a whole and not for the individual patient, and the physician's main concern is the individual patient. Another concern is that antibiotics can actually make a gastroenteritis patient worse, but the risk of this occurring is small and, at present, only theoretical.

What's Wrong With a Little Suffering?

Finally, here is the least supportable reason given for withholding antibiotics. Many physicians feel that since acute diarrhea usually runs its course in a few days with no permanent ill effects, antibiotics, even though beneficial, are unnecessary and should be withheld. This practice is completely at odds with the physician's duty to minimize suffering if this can be accomplished without doing more harm than good. Do you think most doctors with acute infectious diarrhea would suffer without treatment, or would they grab a few tablets of ciprofloxacin or azithromycin off the shelf? The latter, most likely.

A Balanced Approach

Certainly, every acute diarrhea patient should be evaluated carefully. Treatment should be tailored to the individual patient. However, expert management recommendations usually assume that the patient should not be treated with antibiotics unless there is a very strong reason to give them. It makes more sense to treat most patients with acute diarrhea with antibiotics unless there is a very good reason not to do so.