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JOHNNIE YATES, M.D., CIWEC Clinic Travel Medicine Center, Kathmandu, Nepal
A
Patient Information: cute diarrhea is the most com- mised and those with lowered gastric acidity
▲
A handout on traveler’s mon illness among travelers. Up (e.g., patients taking histamine H2 block-
diarrhea, written by the
author of this article, is to 55 percent of persons who ers or proton pump inhibitors) are more
provided on page 2107. travel from developed countries susceptible to traveler’s diarrhea. Recently,
See page 2029 for
to developing countries are affected.1,2 A a genetic susceptibility has been demon-
strength-of-recommen- study3 of Americans visiting developing strated.5 Younger age and adventurous travel
dation labels. countries found that 46 percent acquired increase the risk of developing traveler’s
diarrhea. The classic definition of traveler’s diarrhea,3,6 but persons staying at luxury
diarrhea is three or more unformed stools resorts or on cruise ships also are at risk.7,8
in 24 hours with at least one of the following Food and water contaminated with fecal
symptoms: fever, nausea, vomiting, abdomi- matter are the main reservoirs for the patho-
nal cramps, tenesmus, or bloody stools. gens that cause traveler’s diarrhea. Unsafe
Milder forms can present with fewer than foods and beverages include salads, unpeeled
three stools (e.g., an abrupt bout of watery fruits, raw or poorly cooked meats and sea-
diarrhea with abdominal cramps). Most food, unpasteurized dairy products, and tap
cases occur within the first two weeks of water. Eating in restaurants increases the
travel and last about four days without treat- probability of contracting traveler’s diar-
ment.1,3 Although traveler’s diarrhea rarely rhea6 and food from street vendors is par-
is life threatening, it can result in significant ticularly risky.9,10 Cold sauces, salsas, and
morbidity; one in five travelers with diar- foods that are cooked and then reheated also
rhea is bedridden for a day and more than are risky.6,11
one third have to alter their activities.1,3 In contrast to the largely viral etiology of
Destination is the most significant risk gastroenteritis in the United States, diarrhea
factor for developing traveler’s diarrhea.1-4 acquired in developing countries is caused
Regions with the highest risk are Africa, mainly by bacteria1,4,6,12 (Table 1). Entero-
South Asia, Latin America, and the Middle toxigenic Escherichia coli is the pathogen
East. Travelers who are immunocompro- most frequently isolated, but other types of
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Strength of Recommendations
2096 American Family Physician www.aafp.org/afp Volume 71, Number 11 ◆ June 1, 2005
Traveler’s Diarrhea
Empiric Treatment
water, although it is uncertain whether the contact time Counseling travelers about food precautions does not
with the resin is sufficient to kill viruses. Bottled water eliminate the risk of traveler’s diarrhea, and nonantibio-
generally is safe if the cap and seal are intact. tic prophylaxis requires frequent dosing to achieve only
a modest reduction in risk. In addition, the traveler with
DRUG PROPHYLAXIS diarrhea may have difficulty accessing medical care, the
Antibiotic prophylaxis is not recommended by the quality of care may be poor, and the quality of medica-
Centers for Disease Control and Prevention (CDC) tions purchased abroad may be substandard.27 However,
even for high-risk travelers because it can lead to drug- because antibiotics reduce the duration and severity of
resistant organisms and may give travelers a false sense traveler’s diarrhea and generally are well tolerated,28 pro-
of security. Although antibiotic prophylaxis does not viding the traveler with the means for empiric self-treat-
prevent viral or parasitic infection, some health care ment can effectively reduce morbidity from traveler’s
professionals believe that it may be an option for travel- diarrhea.
TABLE 3
Agents for the Prophylaxis of Traveler’s Diarrhea
Bismuth subsalicylate Two 262-mg tablets or 2 fluid oz Avoid if allergic to aspirin, pregnant, or on anticoagulants,
(Pepto-Bismol) (60 mL) four times daily for up to probenecid (Benemid), or methotrexate (Rheumatrex).
three weeks Avoid in patients taking doxycycline (Vibramycin) for
malaria prophylaxis.
Lactobacillus GG (Culturelle) Optimal dosing not yet determined Safe; more studies needed to confirm efficacy
June 1, 2005 ◆ Volume 71, Number 11 www.aafp.org/afp American Family Physician 2097
Approach to the Treatment
of Traveler’s Diarrhea
Acute diarrhea in a traveler is
moderate to severe or “distressing”
(i.e., forces a change in itinerary)? invasive organism is present and on antibiotic resistance
patterns. These factors are determined largely by travel
destination. Although blood in the stool suggests inva-
Yes No sive disease, fever is not a sensitive indicator of dysen-
Has patient No therapy, or loperamide tery. Fluoroquinolones have been the drug of choice for
been traveling (Imodium) or bismuth traveler’s diarrhea in most parts of the world because of
in Thailand? subsalicylate (Pepto-Bismol) their efficacy against most enteropathogens. Rifaximin
recently became available for the treatment of noninva-
sive diarrhea caused by E. coli. For persons traveling to
Yes No
destinations where noninvasive E. coli is the predominant
Azithromycin Dysentery pathogen (e.g., Mexico), rifaximin is a good choice.35,36
(Zithromax) for (bloody stool)? In regions where invasive pathogens are responsible
one to three days*†
for a significant proportion of traveler’s diarrhea, qui-
nolones should be used. Azithromycin (Zithromax)
Yes No
is recommended in places where quinolone-resistant
Treat with Fail to respond? Fluoroquinolone Campylobacter is prevalent (e.g., Thailand).15,16 Anti-
fluoroquinolone for one to three biotics used for the treatment of traveler’s diarrhea are
for three days days or rifaximin
listed in Table 4.16,32,37 Trimethoprim-sulfamethoxazole
(Xifaxan) for
Use azithromycin (Bactrim, Septra) and doxycycline are no longer rec-
three days
for three days†
ommended because of the development of widespread
*—Children, older adults, and pregnant women also should con- resistance.12
sume oral rehydration solutions.
Therapy that involves an antibiotic with loperamide
†—If diarrhea fails to respond to azithromycin, stool examination
and culture should be sought. (Imodium) often limits symptoms to one day.38,39 Lopera-
mide has antimotility and antisecretory effects and
Figure 1. Algorithmic approach to the treatment of travel- is taken as two 2-mg tablets after the first loose stool,
er’s diarrhea. followed by one tablet after each subsequent loose stool
Information from references 33 and 34.
(maximum of 8 mg in 24 hours for two days). The use of
loperamide in dysentery has been controversial because
Waiting 24 hours to confirm the diagnosis of traveler’s of concerns about prolonging illness, but it is now con-
diarrhea results in unnecessary discomfort and time sidered safe when combined with an antibiotic.29,34,38
away from activities. Therapy can be initiated after the A conservative approach would be to use loperamide for
first episode of “distressing” diarrhea (i.e., diarrhea dysentery only if combined with an antibiotic and if the
that is uncomfortable or interferes with activities).29,30 traveler has a long trip or will have no toilet access.
If symptoms resolve within 24 hours, no further treat- Oral rehydration solutions generally are unnecessary
ment is necessary.31,32 If diarrhea persists after one day, in adults younger than 65 years.40 However, all travelers
treatment should be continued for one or two more days. with diarrhea should be encouraged to drink plenty of
An algorithm for the treatment of traveler’s diarrhea is fluids and to replace lost electrolytes using foods such as
presented in Figure 1.33,34 salt crackers or broth.
Antibiotic selection is based on the likelihood that an
Traveler’s Diarrhea in Infants, Children,
and Pregnant Women
The Author
Traveler’s diarrhea is more common in young children
JOHNNIE YATES, M.D., is on staff at the CIWEC Clinic Travel than in adults, and they have a higher risk of dehydra-
Medicine Center in Kathmandu, Nepal. He received his medi-
tion and severe illness.41 Parents should seek immediate
cal degree from Yale University School of Medicine, New Haven,
Conn., completed an internship in family medicine at Ventura (Calif.) medical attention if their child shows signs of moderate
County Medical Center, and served a residency in family medicine at to severe dehydration, bloody diarrhea, a temperature
Middlesex Hospital, Middletown, Conn. Dr. Yates has a diploma in higher than 39°C (102°F), or persistent vomiting. Few
tropical medicine and hygiene and a certificate in travel health. data exist on the treatment of diarrhea in children. The
Address correspondence to Johnnie Yates, M.D., CIWEC Clinic
use of oral rehydration solutions is essential, and parents
Travel Medicine Center, P.O. Box 12895, Kathmandu, Nepal. should include prepackaged packets (to be mixed with
Reprints are not available from the author. safe water) in their travel kits. These packets are available
2098 American Family Physician www.aafp.org/afp Volume 71, Number 11 ◆ June 1, 2005
Traveler’s Diarrhea
TABLE 4
Antibiotics Used for the Treatment of Traveler’s Diarrhea
Ciprofloxacin (Cipro) 500 mg twice daily for one to three days Other quinolones (e.g., ofloxacin [Floxin], norfloxacin
[Noroxin], and levofloxacin [Levaquin]) are presumed
to be effective as well.
Rifaximin (Xifaxan) 200 mg three times daily for three days Not effective in persons with dysentery
Azithromycin In adults: 500 mg daily for one to three days Antibiotic of choice in children and pregnant women,
(Zithromax) or 1,000 mg in a single dose32 and for quinolone-resistant Campylobacter16
In children: 10 mg per kg daily for three days37
June 1, 2005 ◆ Volume 71, Number 11 www.aafp.org/afp American Family Physician 2099
Traveler’s Diarrhea
2100 American Family Physician www.aafp.org/afp Volume 71, Number 11 ◆ June 1, 2005