Approach

Treatment is supportive with close attention to rehydration and correcting electrolyte imbalances.

Antibiotic therapy has shown no clear benefit, and should be avoided for patients with Shiga toxin-producing Escherichia coli (STEC) O157 infections and other STEC that produce Shiga toxin 2.[35]

Patients should adhere to strict hygiene practices while infected with pathogenic E coli in order to prevent spread to others. Hospitalised patients should be isolated from other patients and placed on contact isolation precautions to prevent spread.

Enterohaemorrhagic E 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]

Patients at risk of poor outcome

The risk of severe illness and mortality from dehydration is higher among young children (<5 years) and older people (>60 years). These patients should be closely monitored with a lower threshold for hospital admission and intravenous fluid rehydration.

Young children are at a higher risk of intravascular volume depletion secondary to:[40]

  • A higher metabolic rate

  • A higher body surface-volume ratio

  • Dependence on others for feeding.

Immunosuppression can lead to prolonged infections so it is important to closely monitor patients who are immunocompromised.

Rehydration

Most patients can be treated with oral rehydration.[35][41] Glucose-containing fluids are preferable, as glucose promotes the absorption of sodium and, subsequently, water within the intestinal lumen. Caffeine and milk products may worsen diarrhoea and should be avoided.

Intravenous rehydration is indicated in patients who are unable to tolerate oral fluid intake, have worsening volume depletion despite oral hydration attempts, or have evidence of escalating sepsis.

Delay in fluid resuscitation is detrimental, and is the major contributing factor associated with high mortality in malnourished infants and children in the developing world.[42]

Reduction of spread

The World Health Organization has produced guidelines to prevent spread of infection.[43] These include simple measures for people with diarrhoeal illnesses:

  • Avoid preparing food for other people

  • Thoroughly wash hands

  • Use a separate or disposable towel

  • Use separate toilet facilities, and/or thoroughly clean seats, taps, and door handles after use

  • Isolate hospitalised patients and use barrier contact isolation strategies

  • Strict decontamination or disposal of clothing and/or bedding.

Dietary modification

There are no specific recommendations for dietary modification.

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.

Young children should be fed normally, although infection-associated lactose intolerance may necessitate the need for lactose-free formulation.[40]

Bismuth subsalicylate

Bismuth subsalicylate possesses topical mucosal effects, reduces secretions, and binds bacterial toxins. It may reduce diarrhoea and may be considered as an adjunctive treatment in all types of infection.[44][45]

Bismuth salicylate is not generally recommended in children aged <12 years due to the risk of Reye’s syndrome; however, some physicians use it with caution. It is not recommended in children aged <3 years and in pregnant women.

Antibiotic therapy

Generally, E coli diarrhoeal infections will respond to supportive therapy. However, for patients with enterotoxigenic E coli (ETEC) infection (the most common cause of traveller's diarrhoea), antibiotics can be offered in severe cases to shorten the duration of symptoms, although they are usually not required.[8][32][46][47]

Antibiotic options include rifaximin, azithromycin, a fluoroquinolone (e.g., ciprofloxacin, or ofloxacin), and rifamycin.[47]​ In November 2018, the European Medicines Agency (EMA) completed a review of serious, disabling, and potentially irreversible adverse effects associated with systemic and inhaled fluoroquinolone antibiotics. These adverse effects include tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects. The EMA recommends that fluoroquinolone antibiotics be restricted for use in serious, life-threatening bacterial infections only. Furthermore, the EMA recommends that fluoroquinolones should not be used for mild to moderate infections unless other appropriate antibiotics for the specific infection cannot be used, and should not be used in non-severe, non-bacterial, or self-limiting infections. Patients who are older, have renal impairment, or have had a solid organ transplant, and those being treated with a corticosteroid, are at a higher risk of tendon damage.[48] Increased resistance against fluoroquinolones in South East Asia and other regions should be considered.

The use of antibiotics for individuals with E coli O157:H7 is controversial. Studies have suggested antibiotics can increase the incidence of haemolytic uraemic syndrome.[49][50]​ Guidelines from the Infectious Diseases Society of America therefore recommend against the use of antibiotics for patients with STEC O157 infections and other STEC that produce Shiga toxin 2.[35] Antibiotics for patients with other STEC infections that do not produce Shiga toxin 2 is debatable due to insufficient evidence of benefit and harms.[35]

Antimotility agents

While antimotility agents (e.g., loperamide) provide symptomatic relief and shorten duration of diarrhoea, they generally should not be used in bacterial gastroenteritis as they decrease faecal bacterial elimination and, subsequently, increase the risk of toxic colonic dilatation.[51]

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