Travellers’ Diarrhea

Travellers Diarrhea

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This information has been derived from various authoritative sources, but only a physician
can adequately advise about the best course of treatment for your particular situation.

The Unavoidable Travelling Companion

It’s an unpleasant topic to contemplate or discuss, but Travellers’ Diarrhea (TD) is a major concern of travelers heading to developing countries. Traveller’s Diarrhea is the most common type of illness encountered by travelers worldwide. ¬†Although it is not a pleasant topic, a quick briefing now can help you effectively manage your health and minimize disruptions during your journey.

TD results from ingesting contaminated food or water. The vast majority of TD is caused by bacteria (e.g., E. coli), but can also be caused by protozoa (e.g., Giardia) or a virus (e.g., rotavirus). TD occurs in up to 60% of travelers and is characterized by the passage or 3 or more unformed stools in a 24-hour period. Episodes typically last 3-4 days on average, but some cases can persist for weeks.

Most developing countries in Africa, Central and South America, Asia, and the Middle East are considered high-risk areas for acquiring TD, while southern Europe and a few Caribbean islands are considered intermediate risk. Australia, Canada, northern Europe, New Zealand, the United States and several of the Caribbean Islands are considered low risk.

You can help reduce your chances of acquiring traveler’s diarrhea by strictly following food and water precautions and paying close attention to hygiene. A vaccine (DukoralTM) that has been shown to be effective against some types of diarrhea is available in Canada and elsewhere but not in the U.S.

However, despite prevention strategies TD still occurs. Therefore, it is important to learn how to recognize and manage TD if it occurs.

Symptoms

Bacterial diarrhea has an abrupt onset of uncomfortable diarrhea. Fever, nausea, or vomiting may occur. “Abrupt onset” generally means that you are aware of the exact time of day the illness began, and the symptoms are quite bothersome from the beginning. If you experience an abrupt onset of uncomfortable diarrhea you can be reasonably confident that the cause is bacterial, and you can treat yourself with an appropriate antibiotic (as provided by your travel health physician) to shorten the illness.

In contrast, protozoal diarrhea begins gradually, with looser stools occurring in distinct episodes during the day, gradually becoming more bothersome, and may be associated with gas, bloating, upper abdominal discomfort, and fatigue. Diarrhea might occur after the first few weeks of travel, and persons with protozoal infections often do not seek medical care for 2 weeks or more due to the generally mild nature of the symptoms. Antibiotics such as metronidazole or tinidazole (Tindamax) are usually prescribed for protozoal diarrhea, but in general, you should not carry these drugs for self-treatment. A proper diagnosis should be made and the drugs administered under supervision.

Drug Treatments for Bacterial TD

Travelers are often in areas where prompt, effective medical care is unavailable. Therefore, it is often more practical to self-treat bacterial diarrhea with antibiotics that have been prescribed and purchased prior to leaving for the trip. If you do bring medication with you, make sure that written information on symptoms, precautions, correct dosage and scheduling is included. Many drug treatments for diarrhea should not be used by pregnant women, and some that are recommended for adults can cause complications for children.

Antibiotics

For treatment of suspected bacterial diarrhea, quinolone antibiotics (ciprofloxacin, levofloxacin, ofloxacin, norfloxacin) are preferred. Quinolones may be used with caution in children of all ages, although only ciprofloxacin is FDA-approved for children less than 18 years of age. Safety of quinolone antibiotic use during pregnancy and lactation has not been established.

When quinolones cannot be used, azithromycin may be an effective alternative in treating bacterial TD; azithromycin is also the drug of choice for children and pregnant women. Rifaximin (Xifaxan) is an alternative when neither quinolones nor azithromycin can be used; rifaximin is approved for treatment of TD caused by E. coli in persons 12 years of age and older (only for use in persons who do not have fever or bloody stools). Safety of rifaximin in pregnancy and lactation has not been established.

Non-Antibiotic Methods

Antimotility drugs such as loperamide (Imodium) or diphenoxylate (Lomotil) may be useful on a temporary basis to slow bowel movement and reduce frequency of stools. These drugs are not curative, and they are only recommended in certain situations. Consult your health care provider about the advantages and disadvantages of use.

Some people take bismuth subsalicylate (Pepto-Bismol) preventively to reduce their risk of traveler’s diarrhea. It should be used this way only if recommended by your health care provider and only for less than 3 weeks. Side effects include darkening of the tongue and stools and, occasionally, nausea, constipation, or ringing in the ears. It should not be used by children less than 3 years of age; people who have an aspirin allergy or are taking aspirin, have renal insufficiency, or gout; and any child or teen with a viral infection.

Suggestions for Treatment of Bacterial Diarrhea

  • If you have mild loose stools without other symptoms: An antibiotic is probably not necessary. Try bismuth subsalicylate (Pepto-Bismol) or an antimotility drug such as loperamide (Imodium) if needed for travel, but not for more than 48 hours.
  • If you have moderately loose or frequent stools with cramps or nausea: Take an antibiotic. Take an antimotility drug if needed for travel, but not for more than 48 hours.
  • If you have severe diarrhea with cramps, nausea, bloody stools, dehydration, or high fever and chills: Take an antibiotic. Try to avoid using antimotility drugs. Seek medical help if symptoms do not rapidly improve.

Management of TD Symptoms

If you have diarrhea you will need to take measures to prevent dehydration, especially during prolonged episodes.

  • Adults can replace fluids and electrolytes (body salts) by eating salted crackers and drinking plenty of nonalcoholic, noncaffeinated beverages, and soups. If there is any question about the purity of your water source, make sure all beverages and soups are prepared with purified water.
  • If signs of dehydration appear (dizziness, weakness, dry skin, sunken eyes, deep-yellow urine, reduction or lack of tears and urine), seek medical help immediately. Dehydration can quickly become serious for infants, children, and the elderly.
  • When you begin to pass soft stools, try eating easy-to-digest foods such as bread, potatoes, tortillas, and rice. Eat lightly for a few days, and stay away from dairy products and foods that are spicy or greasy.
  • Infants must be given food and fluids throughout the course of any diarrheal episodes and watched closely for signs of dehydration.
  • Oral rehydration solutions (ORS) may be helpful in replacing lost fluids. They were designed to decrease childhood mortality rates and are absorbed rapidly from the intestine. ORS packets are available in most developing countries. They should be reconstituted with boiled, bottled, or purified water.

See your health care provider or travel medicine specialist if the following problems occur:

  • Diarrhea does not improve after a few days
  • You have fever, shaking chills, severe fluid loss, or blood or mucus in the stools
  • You are taking antibiotics and have a rash or hives that might indicate an allergic reaction.