Antidiarrheal Compound Research Articles

Ethnobotany, phytochemistry, and biological activities of Psidium guajava in the treatment of diarrhea: a review.

Psidium guajava: is a tropical tree that is widely used in traditional medicine, especially for treating diarrhea. While P. guajava has been the subject of numerous reviews, none have specifically examined its ethnobotany, pharmacology, and phytochemistry in relation to its antidiarrheal activity. This review aims to summarize the evidence of effectiveness and safety of P. guajava in the treatment of diarrhea. Literature searches were conducted through Web of Science, PubMed, and ScienceDirect by using keywords "Psidium guajava" and "diarrhea" in October 2022. A total of 189 studies were included in this review. P. guajava is widely used in traditional medicine in 44 countries. Decoction and oral were the most represented method of preparation and administration, respectively, while leaves represented the most frequently cited part of the plant. Around 27 antidiarrheal or antibacterial compounds have been isolated and identified, including benzophenone glycosides, terpenes, polysaccharides, phenols, and flavonoids. This article presents ethnobotanical and pharmacological evidence for the efficacy of P. guajava leaves in the treatment of diarrhea and provides reference information for further investigation of this plant. However, despite the large number of publications on the topic, there are still some questions to answer: are quercetin and its glycosides the only ones to act as antidiarrheal agents? What is the mechanism of action of P. guajava antidiarrheal compounds? are the use of guava leaves safe in all types of populations including children, and at what dosage? To answer these questions, more complete phytochemical studies and systematic clinical trials are needed.

UJI AKTIVITAS ANTIDIARE TABLET EKSTRAK ETANOL DAUN KATUK (Sauropus androgynus L.) Merr. PADA MENCIT PUTIH (Mus musculus)

Diarrhea is a condition in which a person experiences excretion of feces more than 3 times a day accompanied by an increase in volume and dilu­­tion which results in dehydration and even causes death. The aim this study was to determine the antidiarrheal activity of ethanol extract tablets of katuk leaves (Sauropus androgynus L.) Merr. which contains tannins, flavonoids and alkaloids as anti-diarrheal compounds because they can inhibit intestinal motility. This test uses the intestinal transit method which measures the length of the intestine through which the marker passes. The number of mice used was 25 which were divided into 5 groups. The positive control group 1 used loperamide HCl at a dose of 4 mg/kgBW. Group 2 was negative control with tablets without extract, Group 3 with tablet extract 80 mg/kgBW, group 4 tablets with extract dose 160 mg/kgBW and group 4 with tablet extract 320 mg/kgBW. The results of this test show that in formulation 1 it has an activity value of 40.32%, in formulation 2 it is 43.21% and in formulation 3 it is 45.2%. Tablet preparations with the best results were in formulation 3 with an extract dose of 320 mg/kgBW which showed the best results

UJI EFEKTIVITAS ANTIDIARE EKSTRAK ETANOL DAUN GELUGUR (Garcinia atroviridis Griff ex. T Anderson)TERHADAP TIKUS JANTAN PUTIH (Rattus norvegicus) DENGAN LOPERAMIDE SEBAGAI PEMBANDING

Gelugur leaf (Garcinia atroviridis Griff ex T. Anderson) is a kind of nadir is believed to origanate from the wild forest of Peninsular Malaysia. Gelugur leaves have antidiarrheal compounds in the shapes of tannins and flavonoids to reduce diarrhea. The purpose of this study was to find out the antidiarrheal activity of the ethanolic extract of gelugur leaf in white male rats. The antidiarrheal effect was tested on 15 white male rats with 5 treatment groups, namely, a negative control group of 1% CMC Na, a positive control group of loperamidee hcl, and a treatment group of ethanol extract of gelugur leaves at a dose of 150 miligrams/kgBW, a dose of 300 miligrams/kgBW, and 600 miligrams/kg body weight. Each group was given oral treatment and observations were made on the onset of diarrhea, frequency of diarrhea, and stool consistency. Tests were carried out using an experimental method. The ethanol extract of gelugur leaves was made by maceration method using 96% ethanol. The results of the study on the onset of diarrhea were EEDG 600 miligrams/kgBB (60 minutes), a good decrease in diarrhea frequency was indicated by EEDG 600 miligrams/kgBB (4 times), a good decrease in stool weight was shown by EEDG 600 miligrams/ kgBB (0,7757 grams), good consistency was also shown in the EEDG 600 miligrams/kgBB (soft stools. The data were statistically analyzed using One Way Anova. The results of data analysis from the three EEDG groups affected the decrease in diarrhea because the sig value <0.05 Based on One Way Anova analysis, the five most effective treatments were loperamidee, 600 miligrams/kgBB, EEDG at 300 miligrams/kgBB, EEDG at 150 miligrams/kgBB, and CMC Na 1%. The conclusion in this study is that EEDG 600 miligrams/kgBB has antidiarrheal activity induced by oleum recini when compared with EEDG concentrations of 150 miligrams/kgBB and 300 miligrams/kgBB.

In-vitro examination and isolation of antidiarrheal compounds using five bacterial strains from invasive species Bidens bipinnata L.

Bidens bipinnata is widely utilized medicinal plant for treatment of diseases like malaria, sore throat, acute nephritis and dysentery. However, despite its traditional uses Bidens bipinnata is not widely explored for its antimicrobial effect. Thus, the current study is aimed to form antimicrobial activity report of Bidens bipinnata extracts, along with isolation and evaluation of antibacterial activity of the isolated compounds through bioassay-guided purification. Hexane extract of its leaves has appeared to be most active thus it is exposed to automated column chromatography. Further purification using High-performance liquid chromatography has led to isolation of active peaks, identified by Gas Chromatography-mass spectrometry, as 16-Pregnenolone and 9-Octadecenoic acid (Z)-, methyl ester. Their antimicrobial activity was confirmed via broth dilution procedure on Staphylococcus aureus, 16-Pregnenolone revealed a strong antimicrobial activity with MIC50 of 72 μg/mL whereas 9-Octadecenoic acid (Z)-, methyl ester display an MIC50 of >250 μg/mL. Present study is the first report on isolation of these compounds from Bidens bipinnata.

Evaluation of berberine as a natural compound to inhibit peach brown rot pathogen Monilinia fructicola

Berberine (BBR) is a traditional antidiarrheal compound with excellent safety profiles. Our previous study reported that BBR strongly inhibited brown rot pathogen Monilinia fructicola. In this study we assess its potential commercial performance. We found that the spore germination and mycelial growth of M. fructicola could be totally inhibited in vitro by BBR at 4.10 μg ml−1 and 45.50 μg ml−1, respectively, suggesting the strategy of spraying BBR prior to hyphal growth. Next, we compared the 50% effective concentration (EC50) and minimal inhibitory concentration (MIC) of BBR with those of synthetic chemical fungicides, and results showed that BBR is economically viable to manage brown rot disease. Strikingly, although M. fructicola was successively treated by BBR for sixteen generations, the EC50 and MIC values remained nearly unchanged, and no mutation occurred in the genes that confer resistances to chemical fungicides, indicating that M. fructicola is less likely to develop resistance to BBR. Furthermore, two years of field trials showed that BBR effectively controlled peach brown rot and no visual damage was observed on leaves and fruits. Given its well-known safety, high efficacy and prolonged activity, we believe that BBR is a promising natural fungicide to control brown rot disease.

Effect of zaldaride maleate, an antidiarrheal compound, on intracellular cyclic nucleotide-mediated intestinal ion secretion in rats

The purpose of this study is to clarify the mechanisms of action of zaldaride, a calmodulin inhibitor. 16,16-Dimethyl prostaglandin E 2, forskolin, 8-bromo cAMP, nitroprusside, 8-bromo cGMP and Escherichia coli heat-stable enterotoxin STa increased the short-circuit current in rat colonic mucosa. Zaldaride at ≥10 μM significantly attenuated the 16,16-dimethyl prostaglandin E 2 and Escherichia coli heat-stable enterotoxin STa-induced increase in short-circuit current; whereas it did not affect other secretagogues-induced effects. These results suggest that zaldaride inhibits the activation of Ca 2+/calmodulin-sensitive adenylate cyclase or guanylate cyclase linked to a receptor.

Effects of zaldaride maleate, an antidiarrheal compound, on intracellular Ca2+-mediated short-circuit current response in the rat colonic mucosa.

The effect of zaldaride maleate (ZAL) on intracellular Ca2+-mediated short-circuit current (Isc) response in rat colonic mucosa was investigated. The Isc response to acetylcholine was partially reduced by the neuronal blocker tetrodotoxin. The tetrodotoxin-sensitive Isc response to acetylcholine was inhibited by ZAL. The tetrodotoxin-insensitive effect, which indicates direct stimulation of acetylcholine in colonic mucosa, was not affected by ZAL. The Isc response to the Ca2+ ionophore A23187 was reduced by ZAL in the presence of tetrodotoxin. These results suggest that ZAL reduces colonic ion secretion by inhibiting a tetrodotoxin-sensitive neuronal pathway and an intracellular Ca2+ pathway in epithelium.

Effect of Zaldaride Maleate, an Antidiarrheal Compound, on Fecal Pellet Output Induced by Hyperpropulsion in Gastrointestine of Rats

The effect of zaldaride, a calmodulin inhibitor, on fecal pellet output in rats was compared with that of loperamide, an antidiarrheal drug. 5-Hydroxytryptamine (10 mg/kg, s.c.), neostigmine (0.3 mg/kg, s.c.) and nicotine (1.0 mg/kg, s.c.) increased fecal pellet output. Zaldaride (≧30 mg/kg, p.o.) reduced these increases in fecal pellet outputs. Loperamide (10 mg/kg, p.o.) inhibited fecal pellet output induced by 5-hydroxytryptamine and neostigmine but not nicotine. Under normal conditions, zaldaride and loperamide did not affect fecal pellet output at doses used in these studies. In conclusion, zaldaride may inhibit increases in fecal pellet output induced by hyperpropulsion of the gastrointestinal tract without causing constipation as a side effect.

The effect of zaldaride maleate, an antidiarrheal compound, on acetylcholine-induced intestinal electrolyte secretion.

The effect of zaldaride on acetylcholine-induced colonic electrolyte secretion was examined. The short-circuit current response to acetylcholine was partially reduced by tetrodotoxin, a neuronal blocker, and was completely inhibited by atropine, an acetylcholine M receptor antagonist, in the rat colonic preparations. The tetrodotoxin sensitive effect was significantly inhibited by zaldaride, whereas the tetrodotoxin insensitive effect was not affected. Acetylcholine release from synaptosomes of submucosal nerves of guinea-pig colon was significantly reduced by zaldaride. Zaldaride may reduce colonic electrolyte secretion by acetylcholine due to the inhibition of acetylcholine release from synaptosomes of colonic submucosal nerves.

Effect of zaldaride maleate, an antidiarrheal compound, on 16,16-dimethyl prostaglandin E2-induced intestinal ion secretion in rats.

The effect of zaldaride, a calmodulin inhibitor, on 16,16-dimethyl prostaglandin E2 (dmPGE2)-induced intestinal ion secretion was investigated in rats. Zaldaride inhibited the dmPGE2-induced increase in water content in the colon, but not that in the small intestine. In the colonic mucosa, zaldaride attenuated the dmPGE2-induced short-circuit current; however, it did not affect the forskolin or dibutyryl cAMP-induced effect. These results suggest that zaldaride inhibits dmPGE2-induced intestinal ion secretion by reducing the activity of Ca2+/calmodulin-dependent adenylate cyclase linked to a receptor, and the colon may be an important site in the action of zaldaride.

Effect of zaldaride maleate, an antidiarrheal compound, on fecal pellet output induced by hyperpropulsion in gastrointestine of rats.

The effect of zaldaride, a calmodulin inhibitor, on fecal pellet output in rats was compared with that of loperamide, an antidiarrheal drug. 5-Hydroxytryptamine (10 mg/kg, s.c.), neostigmine (0.3 mg/kg, s.c.) and nicotine (1.0 mg/kg, s.c.) increased fecal pellet output. Zaldaride (> or = 30 mg/kg, p.o.) reduced these increases in fecal pellet outputs. Loperamide (10 mg/kg, p.o.) inhibited fecal pellet output induced by 5-hydroxytryptamine and neostigmine but not nicotine. Under normal conditions, zaldaride and loperamide did not affect fecal pellet output at doses used in these studies. In conclusion, zaldaride may inhibit increases in fecal pellet output induced by hyperpropulsion of the gastrointestinal tract without causing constipation as a side effect.

Effects of Zaldaride Maleate, an Antidiarrheal Compound, on Intracellular Ca2+-Mediated Short-Circuit Current Response in the Rat Colonic Mucosa

ABSTRACT The effect of zaldaride maleate (ZAL) on intracellular Ca2+-mediated short-curcuit current (Isc) response in rat colonic mucosa was investigated. The Isc response to acetylcholine was partially reduced by the neuronal blocker tetrodotoxin. The tetrodotoxin-sensitive Isc response to acetylcholine was inhibited by ZAL. The tetrodotoxin-insensitive effect, which indicates direct stimulation of acetylcholine in colonic mucosa, was not affected by ZAL. The Isc response to the Ca2+ ionophore A23187 was reduced by ZAL in the presence of tetrodotoxin. These results suggest that ZAL reduces colonic ion secretion by inhibiting a tetrodotoxin-sensitive neuronal pathway and an intracellular Ca2+ pathway in epithelium.

Effect of Zaldaride Maleate, an Antidiarrheal Compound, on 16,16-Dimethyl Prostaglandin E2-Induced Intestinal Ion Secretion in Rats

Effect of Zaldaride Maleate, an Antidiarrheal Compound, on 16,16-Dimethyl Prostaglandin E2-Induced Intestinal Ion Secretion in Rats

Effect of Zaldaride Maleate, an Antidiarrheal Compound, on Visceral Pain Reflex Induced by Small Intestinal Distention in Anesthetized Rats

Effect of Zaldaride Maleate, an Antidiarrheal Compound, on Visceral Pain Reflex Induced by Small Intestinal Distention in Anesthetized Rats

Prognostic Factors Related to Recovery from Diarrhea among U.S. Students with Diarrhea in Mexico.

Background: Medical charts of subjects treated with placebo from five double-blinded placebo-controlled clinical trials were reviewed to determine pre-enrollment prognostic factors related to later recovery from diarrhea. Method: Recovery or time from initiation of a placebo until passage of the last unformed stool after being declared well was calculated for each subject. Results: A longer duration of diarrhea was associated with presence of fever (rate ratio = 0.34; 95% CI = 0.2-0.9), presence of an invasive pathogen in the stool (rate ratio = 0.35; 95% CI = 0.2-0.7) or a noninvasive pathogen in stool (rate ratio = 0.7; 95% CI = 0.6-1.0), severe abdominal pain or cramps (rate ratio = 0.5; 95% CI = 0.3-0.9), passage of more than five watery stools per 24 hours (rate ratio = 0.58; 95% CI = 0.4-0.8). Severe vomiting predicted a shorter duration of post-enrollment diarrhea (rate ratio = 2.43; 95% CI = 1.1-5.6). Conclusion: A number of clinical and microbiologic factors found in travelers with diarrhea in the present study predicted duration of untreated diarrhea. The authors suggest the use of antimicrobial therapy in travelers with predictors of a long duration of diarrhea. Data developed in the present study may be used to create a historical control for clinical trials of antidiarrheal compounds using the same study criteria.

Prevention and Treatment of Traveler's Diarrhea: A Clinical Pharmacological Approach (Part 1 of 2)

Diarrhea represents a major health problem for travelers to developing countries. Although the syndrome is usually self-limited and recovery occurs in the majority of cases without any specific form of therapy, there is a need for safe and effective ways of preventing and treating it. Since the syndrome is most often caused by an infection acquired by ingesting fecally contaminated food or beverages, precautions regarding dietary habits remain the cornerstone of prophylaxis, but dietary self-restrictions do not always translate to reduced rates of diarrheal illness. Administration of probiotics (e.g. lactobacilli or Saccharomyces boulardii) and immunoprophylaxis with the newer oral cholera vaccines have been tried with promising results. Antimicrobials remain, however, the most successful form of prophylaxis, being effective in up to 90% of travelers. For those with impaired health who will take prophylaxis, systemic agents with proved efficacy should be recommended. For other otherwise healthy persons, poorly absorbed agents are preferable in order to avoid the serious, albeit rare, toxicity of systemic drugs. The key factor in the management of acute watery traveler's diarrhea, particularly in infants and young children, is the restoration of water and electrolyte balance. This does not reduce the duration of the illness but will limit dehydration and prevent acidosis. Many patients will require no additional therapy, whereas some will need pharmacologic treatment to shorten the duration of diarrhea or to relieve the accompanying symptoms, like abdominal discomfort, nausea and vomiting. A typical 3- to 5-day illness can be reduced to approximately 1 day by trimethoprim-sulfamethoxazole (TMP-SMX) combination. Some other systemic antimicrobials have been successfully used but, during the last few years, the 4-fluoroquinolone drugs have received considerable attention and have been shown to be highly effective in reducing the duration of traveler's diarrhea. These antimicrobials may become the best option for adults. The safest choice remains the use of poorly absorbed antimicrobials. Unfortunately, however, only a few compounds (i.e. bicozamycin and furazolidone) have been specifically tested in the therapy of traveler's diarrhea. Others (e.g. nifuroxazide or rifaximin), which have been found effective in various homeland forms of infective diarrhea deserve to be evaluated in specifically designed clinical trials. Persons visiting developing countries where the risk of traveler's diarrhea is high should be recommended to bring an antidiarrheal compound or bismuth subsalycilate, if available, and an antibacterial agent. For infants, children and the elderly, in whom dehydration may occur rapidly and be particularly dangerous, oral rehydration solutions are indicated.(ABSTRACT TRUNCATED AT 400 WORDS)

Prevention and Treatment of Traveler's Diarrhea: A Clinical Pharmacological Approach (Part 2 of 2)

Diarrhea represents a major health problem for travelers to developing countries. Although the syndrome is usually self-limited and recovery occurs in the majority of cases without any specific form of therapy, there is a need for safe and effective ways of preventing and treating it. Since the syndrome is most often caused by an infection acquired by ingesting fecally contaminated food or beverages, precautions regarding dietary habits remain the cornerstone of prophylaxis, but dietary self-restrictions do not always translate to reduced rates of diarrheal illness. Administration of probiotics (e.g. lactobacilli or Saccharomyces boulardii)and immunoprophylaxis with the newer oral cholera vaccines have been tried with promising results. Antimicrobials remain, however, the most successful form of prophylaxis, being effective in up to 90% of travelers. For those with impaired health who will take prophylaxis, systemic agents with proved efficacy should be recommended. For other otherwise healthy persons, poorly absorbed agents are preferable in order to avoid the serious, albeit rare, toxicity of systemic drugs. The key factor in the management of acute watery traveler’s diarrhea, particularly in infants and young children, is the restoration of water and electrolyte balance. This does not reduce the duration of the illness but will limit dehydration and prevent acidosis. Many patients will require no additional therapy, whereas some will need pharmacologic treatment to shorten the duration of diarrhea or to relieve the accompanying symptoms, like abdominal discomfort, nausea and vomiting. A typical 3- to 5-day illness can be reduced to approximately 1 day by trimethoprim-sulfamethoxazole (TMP-SMX) combination. Some other systemic antimicrobials have been successfully used but, during the last few years, the 4-fluoroquinolone drugs have received considerable attention and have been shown to be highly effective in reducing the duration of traveler’s diarrhea. These antimicrobials may become the best option for adults. The safest choice remains the use of poorly absorbed antimicrobials. Unfortunately, however, only a few compounds (i.e. bicozamycin and furazolidone) have been specifically tested in the therapy of traveler’s diarrhea. Others (e.g. nifuroxazide or rifaximin), which have been found effective in various homeland forms of infective diarrhea deserve to be evaluated in specifically designed clinical trials. Persons visiting developing countries where the risk of traveler’s diarrhea is high should be recommended to bring an antidiarrheal compound or bismuth subsalycilate, if available, and an antibacterial agent. For infants, children and the elderly, in whom dehydration may occur rapidly and be particularly dangerous, oral rehydration solutions are indicated. With these drugs at hand, the traveler can face a trip with more confidence and fully enjoy the stay abroad.

Therapy for acute infectious diarrhea in children

This article reviews current recommendations of therapy with antidiarrheal compounds and antimicrobial agents for acute infectious diarrhea in children. In most infants and children with acute infectious diarrhea, treatment with antidiarrheal compounds is not indicated. Many of these compounds interfere with identification of enteropathogens in stool specimens, and the antimotility class has an overdose potential. Antimicrobial therapy is given to reduce symptoms and to prevent the spread of infection by decreasing fecal shedding of organisms. Although effective therapy is not available for patients with enteric viruses, Cryptosporidium, and Microsporidium, therapy is useful for children with amebiasis, antimicrobial-associated colitis, cholera, giardiasis, various forms of Escherichia coli diarrhea and Salmonella disease, isosporiasis, shigellosis, and strongyloidiasis. For several other conditions, antimicrobial therapy is of questionable benefit (infection with Campylobacter jejuni or Yersinia enterocolitica, intestinal salmonellosis and enterohemorrhagic E. coli infection). Compounds such as the fluoroquinolones, which are effective in the treatment of acute infectious diarrhea in adults, are not approved for use in children because of potential side effects. Many bacterial, viral, and parasitic organisms cause acute infectious diarrhea; appropriate antimicrobial therapy requires the accurate, rapid identification of the offending enteropathogen. In children with an underlying illness such as acquired immunodeficiency syndrome, manifestations may be prolonged, severe, and recurrent despite appropriate therapy.

Rapid detection of giardia antigen in stool with the use of enzyme immunoassays.

Enzyme-linked immunosorbent assays (ELISAs) using sera from rabbits and goats immunized with Giardia trophozoites were compared for detection of Giardia antigen in 300 stool specimens, 80 of which had positive results for Giardia by microscopic examination. The diagnostic accuracy of the two assays was similar, with sensitivities of 92% and 87% and specificities of 87% and 91% with the use of rabbit and goat antisera, respectively. Both ELISAs detected Giardia antigen in stool samples from asymptomatic as well as symptomatic excretors and from treated patients after organisms were no longer visualized by microscopic examination. The specificity of the assays was confirmed by consistently negative results on stool specimens from 10 neonates and 27 patients with enteric parasitic infections other than Giardia. Negative results also occurred when stool specimens containing 21 bacterial enteropathogens were tested. Potential confounding variables including multiple freezing and thawing episodes, prolonged storage, and stool filtration did not affect test results from clinical specimens. Antidiarrheal compounds did not interfere with assay results. Preservation of specimens in formalin did interfere with the assay, even if formalinized stool specimens were dialyzed before testing. For diagnosis of giardiasis, the ELISA is a sensitive and specific test that is not influenced by many environmental factors or by other enteropathogens. This test provides a practical and reliable method for evaluating large numbers of specimens in a variety of clinical and epidemiologic settings.

Travelers' Diarrhea

Diarrhea is by far the most frequent health problem of travelers to developing countries. Of the estimated 300 million international travelers who will cross the world's frontiers this year, at least 16 million persons from industrialized countries, including more than 8 million US residents, will travel to developing countries. Approximately one third of these travelers to developing countries will get diarrhea. The economic impact of travelers' diarrhea (TD) is substantial, because fear of sickness is one of the major deterrents to tourism. International tourists worldwide spend over $100 billion annually, and the economies of many nations depend on this travel. For educational, recreational, political, and financial reasons, this international exchange should be fostered. The incidence of TD varies markedly by destination and may depend in part on the number of dietary indiscretions made by the traveler and on the style of travel. Travelers' diarrhea is caused by a variety of infectious agents, and the spectrum of clinical illness varies considerably. However, this illness in travelers is usually not severe; high fever, vomiting, or bloody stools occur only in a minority of cases. Dietary prudence and hygienic measures are safe and simple preventive techniques, but they do not eliminate entirely the risk of diarrhea. Prophylactic measures such as antidiarrheal drugs and oral antimicrobial agents have been used. Travelers' diarrhea is treated with a variety of regimens, including oral electrolyte solutions, antidiarrheal compounds, and antimicrobial drugs, prescribed either singly or in combination. There continues to be a debate concerning whether the risk of antimicrobial agents is worth the benefit; whether early treatment of ill travelers is preferable to daily prophylaxis of all travelers; whether all currently employed treatment strategies are useful; and whether given groups of travelers, such as vacationers, students, or business travelers, should be selectively advised to follow special regimens. To resolve some of these questions, the National Institutes of Health Office of Medical Applications of Research and the National Institute of Allergy and Infectious Diseases convened a Consensus Development Conference on Travelers' Diarrhea from Jan 28 to 30, 1985. After 1 1/2 days of expert presentation of the available data, a consensus panel of epidemiologists, biostatisticians, microbiologists, pediatricians, internists, infectious diseases specialists, travel experts, and lay representatives considered the evidence and agreed on answers to the following questions. What is the epidemiology of travelers' diarrhea, and why is it important? What causes travelers' diarrhea? What prevention measures are effective for travelers' diarrhea? What treatment measures are effective for travelers' diarrhea? What should be the direction of future research?