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Key Features

Essentials of Diagnosis

  • Usually a benign, self-limited disease occurring about a week into travel

  • Prophylaxis not recommended unless there is a comorbid disease (inflammatory bowel syndrome, HIV, immunosuppressive medication)

  • Single-dose therapy with a fluoroquinolone usually effective if symptoms develop

General Considerations

  • Whenever a person travels from one country to another—particularly if the change involves a marked difference in climate, social conditions, or sanitation standards and facilities—diarrhea may develop within 2–10 days

  • Bacteria cause 80% of cases

  • Contributory causes include

    • Unusual food and drink

    • Change in living habits

    • Occasional viral infections (adenoviruses or rotaviruses)

    • Change in bowel flora

  • Traveler's diarrhea is a risk factor for development of irritable bowel syndrome

Etiology

  • Most common

    • Enterotoxigenic E coli

    • Shigella

    • Campylobacter

  • Less common

    • Aeromonas

    • Salmonella

    • Noncholera vibrios

    • E histolytica

    • G lamblia

    • Adenoviruses

    • Rotavirus

  • Chronic watery diarrhea

    • E histolytica

    • G lamblia

    • Tropical sprue (rare)

Clinical Findings

Symptoms and Signs

  • There may be up to 10 or more loose stools per day

  • Abdominal cramps, nausea, occasionally vomiting

  • Fever is rare

  • When cause is enterotoxigenic E coli

    • Stools are usually watery

    • Fever is not usually present

  • When cause is invasive bacterial pathogens (eg, Shigella, Campylobacter, Salmonella)

    • Stools may be bloody

    • Fever may be present

  • Course of illness

    • It usually subsides spontaneously within 1–5 days

    • However, 10% remain symptomatic for a week or longer

    • In 2%, symptoms persist for longer than a month

Diagnosis

Laboratory Tests

  • In patients with fever and bloody diarrhea, stool culture is indicated, but in most cases cultures are reserved for those who do not respond to antibiotics

Treatment

Medications

  • For most patients, symptomatic therapy with loperamide is all that is required provided there is no systemic illness (fever ≥ 39°C) or dysentery (bloody stools), in which case antimotility agents should be avoided

  • Packages of oral rehydration salts to treat dehydration are available over the counter in the United States (Infalyte, Pedialyte, others) and in many foreign countries

  • Loperamide (4 mg loading dose, then 2 mg after each loose stool to a maximum of 16 mg/day) with a single oral dose of ciprofloxacin (750 mg), levofloxacin (500 mg), or ofloxacin (200 mg) cures most cases

  • If diarrhea is severe, associated with fever or bloody stools, or persists despite single-dose of a fluoroquinolone, then 1000 mg of azithromycin should be given

  • Azithromycin is drug of choice for pregnant women and for cases due to invasive bacteria

  • Rifaximin, a nonabsorbable rifampin-like drug, is effective at 200 mg orally three times daily or 400 mg orally twice daily for 3 days. Because the drug is not systemically absorbed, it should not be used in situations where there is a high likelihood of invasive disease ...

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