Review of Traveler's Diarrhea

Selected by Pietro Cazzola

diarreaWhat is new in traveler’s diarrhea?

The incidence of traveler’s diarrhea is falling, likely related to improved global sanitation. Current incidence is 10% to 40% compared with 65% 20 years ago. Because traveler’s diarrhea is caused by ingesting fecally contaminated (most commonly by Escherichia coli) food and beverages, the incidence is highest in low-income countries where sanitation is suboptimal. Without treatment, the diarrhea generally lasts 4 to 5 days. Treatment with loperamide and an antibiotic reduces duration by 1.5 days.

If traveling to South and Southeast Asia, azithromycin is recommended instead of ciprofloxacin due to the higher incidence of invasive bacteria such as the Campylobacter species, which are resistant to fluoroquinolones. Rifaximin is another antibiotic that may be safer than ciprofloxacin because it is not systemically absorbed; however, it does not cover invasive bacterial pathogens such as Shigella, Salmonella, or Campylobacter species.

Who is at greatest risk?

Adventure travelers going to warm climates with more rain fall are at high risk. Infants and those taking proton pump inhibitors, as acid helps kill pathogens, are also at risk. The quality of sanitation at the travel destination is the main predictor of incidence.

What should be in the travel kit?

Prophylaxis medications should be avoided unless the traveler is at high risk for complications from infection.

Ingredient

Prophylaxis

Treatment

Advice

“Boil it, cook it, peel it, or forget it.” Avoid ice cubes, street vendors, and food buffets. Drink bottled beverages.

Take your medicine: bismuth for mild infections; antibiotics and loperamide for more severe symptoms.

Bismuth subsalicylate (takes longer than loperamide to slow diarrhea but helps with nausea)

2 tablets chewed four times daily (65% reduction in infection)

2 tablets chewed four times daily

Loperamide (diarrhea)

NA

4 mg initially, then 2 mg after each unformed stool; max = 8 mg/day

Choose ONE of the following antibiotics

Ciprofloxacin (not for children)

500 mg once or twice daily

500–750 mg once daily for 1–3 days

Rifaximin

200 mg once or twice daily with meals

200 mg three times daily for 3 days

Azithromycin (easiest to dose for children)

(South and SE Asia)

NA

500 mg daily for 3 days or 1000 mg for 1 day

2 months–12 years: 10 mg/kg daily for 3 days

There is inadequate evidence to promote probiotics for traveler’s diarrhea; however, evidence from treating other conditions along with the low associated risk would encourage one to use a probiotic containing Lactobacillus and Bifidobacteria for 5 days post infection to help restore a healthy gut microbiome.

What if diarrhea persists?

Check stool for culture, ova, and parasites including Giardia and Cryptosporidium. You should also check for Clostridium difficile if your patient self-medicated with antibiotics.