Acute Traveler’s Diarrhea: Initial Treatment

Abstract

Diarrhea is the most common health issue affecting travelers to destinations across the world. This paper reviews the options for initial treatment of acute traveler’s diarrhea (TD). Its prevention, including but not limited to vaccines and safe travel and eating habits, is an important consideration but is beyond the scope of this paper. Treatment of TD has three arms: volume repletion, antibiotics, and antimotility/antisecretory agents. Patients should be advised to continue a diet that they can tolerate and maintain adequate fluid intake. In most cases, neither oral rehydration therapy nor dietary restrictions are likely to provide significant benefit. As yet, there is no evidence to support probiotic use for treatment of this type of diarrhea. Given that bacteria are the most frequent cause of TD, adult patients with moderate to severe disease should be treated empirically with a short course of antibiotics. In many instances, these will be prescribed pre-travel with instructions for proper usage when typical symptoms occur while abroad. However, such travelers should be advised to see a physician or seek emergency treatment if symptoms are severe or persist beyond 3 days. Antibiotic selection must take into account the epidemiology of resistant enteric pathogens. Fluoroquinolones are usually effective, although resistance of Campylobacter to this class of drugs in South and Southeast Asia warrants azithromycin as first-line empiric therapy in travelers to those regions. One day of therapy is often sufficient but can be extended to 3 days. Rifaximin is an alternative in non-invasive disease only. The antimotility agent loperamide is safe and effective and should be considered as adjunctive therapy in most cases of TD and can similarly be prescribed pre-travel. In non-pregnant adults, bismuth subsalicylate can also provide some symptomatic relief. Where available, racecadotril may be a safe alternative in both adults and children, although never specifically studied in TD. In cases of severe symptoms, or those lasting longer than 3 days, the patient should be evaluated for non-bacterial etiologies as well as possible Clostridium difficile infection. Certain travelers are more vulnerable to severe complications related to TD. Children, particularly infants, may need more aggressive fluid resuscitation with oral rehydration therapy. Several of the antidiarrheal agents must be avoided. Elderly patients and those with impaired cardiovascular reserve or immune-deficient states are more prone to complications as well. Treatment recommendations also differ for pregnant women. We generally advise adult non-pregnant travelers to follow smart eating and drinking practices and to bring a supply of bismuth subsalicylate and loperamide. We also prescribe an empiric antibiotic course (ciprofloxacin or azithromycin for up to 3 days) that is to be used for moderate to severe cases of TD.