Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 30-10: Traveler's Diarrhea + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 (eg, fever, systemic toxicity, bloody stools) + Outcome Download Section PDF Listen +++ +++ Prognosis ++ Most illnesses are short-lived and resolve without specific therapy +++ Prevention ++ Recommend avoidance of fresh foods and water sources in developing countries, where infectious diarrheal illnesses are endemic Prophylaxis is recommended for Patients with significant underlying disease (inflammatory bowel disease, HIV/AIDS, diabetes mellitus, heart disease in the elderly, conditions requiring immunosuppressive medications) Patients whose full activity status during the trip is so essential that even short periods of diarrhea would be unacceptable Prophylaxis is started upon entry into the destination country and is continued for 1 or 2 days after leaving For stays of more than 3 weeks, prophylaxis is not recommended because of the cost and increased toxicity Numerous antimicrobial regimens for once-daily oral prophylaxis are effective, such as Ciprofloxacin, 500 mg Rifaximin, 200 mg Bismuth subsalicylate Effective, but rarely used Turns the tongue and the stools black Can interfere with doxycycline absorption, which may be needed for malaria prophylaxis Because not all travelers will have diarrhea and because most episodes are brief and self-limited, an alternative approach currently recommended is to provide the traveler with a supply of antimicrobials +++ When to Refer ++ Cases refractory to treatment Persistent infection Immunocompromised patient +++ When to Admit ++ Severe dehydration Hemodynamically unstable + References Download Section PDF Listen +++ + +Eckbo EJ et al. New tools to test stool: managing travelers' diarrhea in the era of molecular diagnostics. Infect Dis Clin North Am. 2019 Mar;33(1):197–212. [PubMed: 30712762] + +Schweitzer L et al. Emerging concepts in the diagnosis, treatment, and prevention of travelers' diarrhea. Curr Opin Infect Dis. 2019 Oct;32(5):468–74. [PubMed: 31361658] + +Shirley DT et al. A review of the global burden, new diagnostics, and current therapeutics for amebiasis. Open Forum Infect Dis. 2018 Jul 5;5(7):ofy161. [PubMed: 30046644]