Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

all patients

1st line – rehydration and supportive therapy

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INITIAL
|
all patients
1st line – 

rehydration and supportive therapy

Most patients can be treated with oral rehydration.[35][43] Glucose-containing fluids are preferable as glucose promotes the absorption of sodium, and, subsequently, water within the intestinal lumen. In patients unable to tolerate oral fluids, have worsening volume depletion, or have signs of escalating sepsis, intravenous rehydration therapy is recommended.

Young children (<5 years) and older people (>60 years) are treated similarly to younger adults, but they should be observed more closely with a lower threshold for hospital admission and intravenous fluid rehydration.

At the height of illness, patients should consume a bland diet containing glucose and sodium to aid in rehydration. Caffeine and milk should be avoided. Severe gastroenteritis may cause transient lactose intolerance.

Measures to prevent spread of the infection should be implemented.

Consider – bismuth subsalicylate

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INITIAL
|
all patients
Consider – 

bismuth subsalicylate

Treatment recommended for SOME patients in selected patient group

Bismuth subsalicylate may reduce diarrhea and may be considered as an adjunctive treatment.[46][47] It is not generally recommended in children ages <12 years due to the risk of Reye syndrome; however, some physicians use it with caution. It is not recommended in children ages <3 years and in pregnant women.

Primary options

bismuth subsalicylate: children ≥12 years of age and adults: 524 mg orally four times daily

Plus – antibiotic therapy

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INITIAL
|
all patients
|
suspected enterotoxigenic positive
Plus – 

antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Escherichia coli diarrheal infections generally respond to supportive therapy. Patients with severe suspected enterotoxigenic E coli (ETEC) infection (traveler's diarrhea) can be offered antibiotics to possibly shorten the duration of illness.[49]

Some antibiotic regimens can be given as a single dose.

Fluoroquinolones are only recommended when it is considered inappropriate to use other antibiotics for this infection due to the risk of serious, disabling, and potentially irreversible adverse effects (e.g., tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects).[50][54] The Food and Drug Administration (FDA) has also issued warnings about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects in patients taking fluoroquinolones.[55][56][57] Increased resistance against fluoroquinolones in South East Asia and other regions should be considered.

Primary options

ciprofloxacin: children: 20-30 mg/kg/day orally given in 1-2 divided doses for 1-3 days; adults: 750 mg orally as a single dose, continue once daily dosing for up to 3 days if symptoms do not resolve within 24 hours, or 500 mg orally once daily for 3 days

OR

ofloxacin: adults: 400 mg orally once daily for 1-3 days

OR

rifaximin: children ≥12 years of age and adults: 200 mg orally three times daily for 3 days

OR

azithromycin: children: 10 mg/kg orally once daily for 1-3 days, maximum 500 mg/day; adults: 1000 mg orally as a single dose, continue once daily dosing for up to 3 days if symptoms do not resolve within 24 hours, or 500 mg orally once daily for 3 days

OR

rifamycin: adults: 388 mg orally twice daily for 3 days

Consider – antimotility agent

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INITIAL
|
all patients
|
suspected enterotoxigenic positive
Consider – 

antimotility agent

Treatment recommended for SOME patients in selected patient group

A short course of an antimotility agent (e.g., loperamide) can be considered in conjunction with antibiotics in order to provide symptomatic relief and shorten duration of diarrhea, however, antimotility agents in general should not be used in bacterial gastroenteritis as they decrease the rate of fecal bacterial elimination and can lead to an increased risk of toxic colonic dilation.[53]

Primary options

loperamide: children ≥6 years of age: consult specialist for guidance on dose; adults: 4 mg orally initially, followed by 2 mg after each unformed stool, maximum 16 mg/day

ACUTE

confirmed enterotoxigenic positive

1st line – continue rehydration and supportive therapy

Back
ACUTE
|
confirmed enterotoxigenic positive
1st line – 

continue rehydration and supportive therapy

Most patients can be treated with oral rehydration.[35][43] Glucose-containing fluids are preferable as glucose promotes the absorption of sodium, and, subsequently, water within the intestinal lumen. In patients unable to tolerate oral fluids, those with worsening volume depletion, and in cases of escalating sepsis, intravenous rehydration therapy is recommended.

Young children (<5 years) and older people (>60 years) are treated similar to younger adults, but they should be observed more closely with a lower threshold for hospital admission and intravenous fluid rehydration.

At the height of illness, patients should consume a bland diet containing glucose and sodium to aid in rehydration. Caffeine and milk should be avoided. Severe gastroenteritis may cause transient lactose intolerance.

Measures to prevent spread of the infection should be implemented.

Consider – antibiotic therapy

Back
ACUTE
|
confirmed enterotoxigenic positive
Consider – 

antibiotic therapy

Treatment recommended for SOME patients in selected patient group

Generally, Escherichia coli diarrheal infections will respond to supportive therapy.[49]​​

Antibiotics may be used for moderate to severe cases.[49] Fluoroquinolones are only recommended when it is considered inappropriate to use other antibiotics for this infection due to the risk of serious, disabling, and potentially irreversible adverse effects (e.g., tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects).[50][54] The FDA has also issued warnings about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects in patients taking fluoroquinolones.[55][56][57] Increased resistance against fluoroquinolones in South East Asia and other regions should be considered.

Primary options

ciprofloxacin: children: 20-30 mg/kg/day orally given in 1-2 divided doses for 1-3 days; adults: 750 mg orally as a single dose, continue once daily dosing for up to 3 days if symptoms do not resolve within 24 hours, or 500 mg orally once daily for 3 days

OR

ofloxacin: adults: 400 mg orally once daily for 1-3 days

OR

rifaximin: children ≥12 years of age and adults: 200 mg orally three times daily for 3 days

OR

azithromycin: children: 10 mg/kg orally once daily for 1-3 days, maximum 500 mg/day; adults: 1000 mg orally as a single dose, continue once daily dosing for up to 3 days if symptoms do not resolve within 24 hours, or 500 mg orally once daily for 3 days

OR

rifamycin: adults: 388 mg orally twice daily for 3 days

Consider – bismuth subsalicylate

Back
ACUTE
|
confirmed enterotoxigenic positive
Consider – 

bismuth subsalicylate

Treatment recommended for SOME patients in selected patient group

Bismuth subsalicylate may reduce diarrhea and may be considered as an adjunctive treatment. It is not generally recommended in children ages <12 years due to the risk of Reye syndrome; however, some physicians still use it with caution. It is not recommended in children ages <3 years and in pregnant women.

Primary options

bismuth subsalicylate: children ≥12 years of age and adults: 524 mg orally four times daily

Consider – antimotility agent

Back
ACUTE
|
confirmed enterotoxigenic positive
Consider – 

antimotility agent

Treatment recommended for SOME patients in selected patient group

A short course of an antimotility agent (e.g., loperamide) can be considered in conjunction with antibiotics in order to provide symptomatic relief and shorten duration of diarrhea, however, antimotility agents in general should not be used in bacterial gastroenteritis as they decrease the rate of fecal bacterial elimination and can lead to an increased risk of toxic colonic dilation.[53]

Primary options

loperamide: children ≥6 years of age: consult specialist for guidance on dose; adults: 4 mg orally initially, followed by 2 mg after each unformed stool, maximum 16 mg/day

confirmed enterohemorrhagic positive

1st line – continue rehydration and supportive therapy

Back
ACUTE
|
confirmed enterohemorrhagic positive
1st line – 

continue rehydration and supportive therapy

Most patients can be treated with oral rehydration.[35][43] Glucose-containing fluids are preferable as glucose promotes the absorption of sodium, and, subsequently, water within the intestinal lumen. In patients unable to tolerate oral fluids, those with worsening volume depletion, or in cases of escalating sepsis, intravenous rehydration therapy is recommended.

Young children (<5 years) and older people (>60 years) are treated similar to younger adults, but they should be observed more closely with a lower threshold for hospital admission and intravenous fluid rehydration.

At the height of illness, patients should consume a bland diet containing a source of glucose and sodium to aid in rehydration. Caffeine and milk should be avoided. Severe gastroenteritis may cause transient lactose intolerance.

Measures to prevent spread of the infection should be implemented.

Plus – notification of local or state health department

Back
ACUTE
|
confirmed enterohemorrhagic positive
Plus – 

notification of local or state health department

Treatment recommended for ALL patients in selected patient group

Enterohemorrhagic Escherichia coli (EHEC) infection is a notifiable disease, and local or state health authorities should be informed of all cases. Notification helps identify contaminated food sources and remove them from the market, to reduce further spread and curtail a potential outbreak.[31]

Consider – bismuth subsalicylate

Back
ACUTE
|
confirmed enterohemorrhagic positive
Consider – 

bismuth subsalicylate

Treatment recommended for SOME patients in selected patient group

Bismuth subsalicylate may reduce diarrhea and may be considered as an adjunctive treatment.[46][47] It is not generally recommended in children ages <12 years due to the risk of Reye syndrome; however, some physicians still use it with caution. It is not recommended in children ages <3 years and in pregnant women.

Primary options

bismuth subsalicylate: children ≥12 years of age and adults: 524 mg orally four times daily

other Escherichia coli serotypes

1st line – continue rehydration and supportive therapy

Back
ACUTE
|
other Escherichia coli serotypes
1st line – 

continue rehydration and supportive therapy

Most patients can be treated with oral rehydration.[35][43] Glucose-containing fluids are preferable as glucose promotes the absorption of sodium, and, subsequently, water within the intestinal lumen. In patients unable to tolerate oral fluids, those with worsening volume depletion, or in cases of escalating sepsis, intravenous rehydration therapy is recommended.

Young children (<5 years) and older people (>60 years) are treated similar to younger adults, but they should be observed more closely with a lower threshold for hospital admission and intravenous fluid rehydration.

At the height of illness, patients should consume a bland diet containing glucose and sodium to aid in rehydration. Caffeine and milk should be avoided. Severe gastroenteritis may cause transient lactose intolerance.

Measures to prevent spread of the infection should be implemented.

Consider – bismuth subsalicylate

Back
ACUTE
|
other Escherichia coli serotypes
Consider – 

bismuth subsalicylate

Treatment recommended for SOME patients in selected patient group

Bismuth subsalicylate may reduce diarrhea and may be considered as an adjunctive treatment.[46][47] It is not generally recommended in children ages <12 years due to the risk of Reye syndrome; however, some physicians still use it with caution. It is not recommended in children ages <3 years and in pregnant women.

Primary options

bismuth subsalicylate: children ≥12 years of age and adults: 524 mg orally four times daily

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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