to the editor: The use of antibiotics was not mentioned in this article. Unfortunately, antimicrobial therapy is often used inappropriately in acute enteric infections. Gastroenteritis in children usually is infectious and often caused by viruses.¹ Despite this, antibiotics are prescribed to 8 percent of outpatients one to 18 years of age with acute gastroenteritis, whereas stool cultures are performed in only 3 percent.² In another study of emergency and urgent care visits in children, 24 percent of visits for acute diarrheal illness resulted in antibiotic prescriptions.³

Antibiotics can be useful in the treatment of Shigella or Campylobacter infection, if started within two days of symptom onset, but are not usually indicated for Salmonella infection, and are not effective against toxin-mediated illnesses or viral infections. Clinically, it is difficult to distinguish between viral and bacterial causes of acute gastroenteritis; hence, initial treatment decisions are largely empiric. Not only are antimicrobials not effective against most causes of diarrhea, they can also worsen the course of illness. Inappropriate antimicrobial use can lead to adverse outcomes, increased costs, and antimicrobial resistance.⁴ Use of antibiotics can substantially increase the risk of hemolytic uremic syndrome following infection with Escherichia coli O157:H7.⁵ Antibiotics do not improve the course of most noninvasive Salmonella infections, but can markedly prolong excretion of the pathogen.⁴ It is imperative that physicians limit the use of antimicrobials without laboratory confirmation of the etiology of an acute episode of diarrhea. Antibiotics are not indicated for most mild or moderate episodes, and if antimicrobial treatment is being contemplated, stool cultures should be performed.