Treatment Of Travelers Research Articles

Treatment of Travelers’ Diarrhea: Randomized Trial Comparing Rifaximin, Rifaximin Plus Loperamide, and Loperamide Alone

Antimotility agents provide rapid temporary relief of acute diarrhea, whereas antibiotics slowly cure the illness. Thus, the combination of an antimotility agent and an antibiotic may provide greater therapeutic benefit than either drug alone. This study evaluated the efficacy and safety of rifaximin-loperamide in the treatment of travelers' diarrhea. Consenting adults with acute diarrhea (> or =3 unformed stools in 24 hours with > or =1 symptom of enteric infection) were randomized to receive rifaximin 200 mg 3 times daily for 3 days; loperamide 4 mg initially followed by 2 mg after each unformed stool; or a combination of both drugs using the same dosing regimen. The primary end point was the median time from beginning therapy until passing the last unformed stool. A total of 310 patients completed treatment with rifaximin (n = 102), loperamide (n = 104), or rifaximin-loperamide combination therapy (n = 104). The groups showed demographic similarity. Rifaximin and rifaximin-loperamide significantly reduced the median time until passage of the last unformed stool (32.5 +/- 4.14 h and 27.3 +/- 4.13 h, respectively) vs loperamide (69 +/- 4.11 h; P = .0019). The mean number of unformed stools passed during illness was lower with rifaximin-loperamide (3.99 +/- 4.28) compared with rifaximin (6.23 +/- 6.90; P = .004) or loperamide alone (6.72 +/- 6.93; P = .002). All treatments were well tolerated with a low incidence of adverse events. Rifaximin-loperamide therapy provided rapid symptomatic improvement and greater overall wellness compared with either agent alone.

Travelers’ Knowledge of Prevention and Treatment of Travelers’ Diarrhea

Information regarding the prevention and treatment of travelers' diarrhea (TD) is available to the public from various sources, such as medical personnel, travel clinics, personal contacts, and the Internet. This type of information may help travelers avoid this illness or help those afflicted minimize its duration. We collected questionnaire data from 104 travelers at departure gates for flights to Mexico from Calgary, Alberta on their knowledge of symptoms and treatment of TD and food risks associated with this illness and sources of information used. Almost half reported they received some information on travel-related diseases and on TD prior to the flight. When education level was controlled for, the mean score for people who had obtained information on TD was significantly higher than that for those who did not have such information. College or university-educated travelers scored better than did other travelers. A high proportion of travelers correctly identified risk levels associated with specific foods consumed during travel, and many recognize that they are at an increased risk of acquiring diarrheal illness while traveling in a developing country. Information on TD appears to improve the level of knowledge on its prevention and treatment among travelers from southern Alberta.

Novel Use of Rifaximin for Treatment of Secretory Diarrhea in a Pediatric Patient with Biliary Diversion

Patients with ostomies are at high risk of bacterial overgrowth. We report a case of a patient with PFIC-1 who had partial biliary diversion and secretory diarrhea. HISTORY: 3yo male with PFIC-1 diagnosed by biopsy and genetic testing. Biliary diversion done at age 18mo. Last winter after an acute “viral” illness he developed worsening jaundice and severe diarrhea. Treatment consisted of IV antibiotics for presumed cholangitis without significant improvement of his jaundice. Loss of large quantities of fluid and solid food from the stoma required IV normal saline supplementation of 1L/d. Attempt at endoscopic stomal cholangiogram was complicated by perforation. Exploratory laparotomy and intraoperative cholangiogram did not identify any obtruction. He was treated empirically with IV antibiotics, probiotics, and oral ciprofloxacin without improvement in the stool output (800 to >1000cc/day). Jaundice gradually resolved. Due to persistent foul smelling excessive drainage, pt was treated with rifaximin 200 mg TID for 2 weeks. Ostomy drainage decreased from averaging more than 1000cc/night to 400cc/night. His drainage became greener with no further visible food particles. Impression: this patient demonstrates secretory diarrhea likely due to bacterial overgrowth. Previous antibiotic therapy with ciprofloxacin was not broad enough to cover possible anerobic contamination. Rifaximin is an oral, non-systemic, gut-selective antibiotic with minimal absorption by the GI tract. Its in vitro activity is against both gram-positive, gram-negative, aerobic and anaerobic isolates. Its use in pediatrics has been limited to infectious diarrhea but it has been approved for use in the treatment of traveler's diarrhea in adults but not approved for use in children. It has been shown to be useful in gut decontamination for treatment of hepatic encephalopathy, and anecdotally in IBD and bacterial overgrowth in adults. Due to the disruption of his quality of life secondary to daily normal saline infusions, use of this non-approved agent was tried. Ciprofloxacin, which is not approved for use in children, was already tried without success. Metronidazole was not attempted due to its poor palatability as a suspension and also due to side effect profile. Rifaximin was well tolerated in our patient and had no side effects. Treatment was short term with long term results significantly improving our patient's quality of life.

Experience of corporate medical assistance clinics during the Centennial Olympic Games, Atlanta, 1996.

The health of travelers returning home from developing countries has received increased attention in recent years. Much of this attention has centered on immunizations, malaria chemoprophylaxis and treatment of traveler's diarrhea. In contrast, there are very few data on the health problems of international travelers to developed countries such as the United States. We studied the experience of two corporate medical assistance clinics established for both national and international travelers to Atlanta, Georgia during the Centennial Summer Olympic Games in 1996.

Influenza: Changing Approaches to Prevention and Treatment in Travelers

Influenza: Changing Approaches to Prevention and Treatment in Travelers

Self‐Reported Description of Diarrhea Among Military Populations in Operations Iraqi Freedom and Enduring Freedom

Infectious diarrhea is among the most common medical problems associated with military deployments and has been reported as a frequent problem for troops currently deployed to Iraq and Afghanistan. Lacking is information describing clinical presentation, risk behaviors, and treatment of travelers' diarrhea in this population. An anonymous cross-sectional survey was conducted among 15,459 US military personnel deployed to Southwest Asia during 2003 to 2004. Overall, diarrhea was commonly reported (76.8% in Iraq and 54.4% in Afghanistan) and was frequently severe (more than six stools/d) (20.8% in Iraq and 14.0% in Afghanistan) or associated with fever (25.8%), vomiting (18% with diarrhea and 16.5% without), persistent symptoms (>14 d, 9.8%), or chronic symptoms (>30 d, 3.3%). Diarrhea was associated with time spent off military compounds and eating local food. Over 80% of respondents sought care for their symptoms, usually at the lowest echelon of care (field medic), and were most often treated with either loperamide or an antibiotic. Self-treatment with loperamide or Pepto-Bismol was also common and successful with only 9% of self-treated individuals reporting seeking further medical care. Infectious diarrhea is a common problem for US military personnel, and associated fevers and vomiting are more common than in past conflicts in the region. As with past studies, time spent off base and local food consumption, both more common in Iraq than Afghanistan, continue to be the most important risk factors for acquiring diarrhea. The majority of soldiers reported seeking care for diarrhea, but appropriate treatment, including self-treatment with over-the-counter medicines, was generally successful. Further studies should be conducted to evaluate appropriate treatment algorithms, including the use of self-treatment, for deployed military personnel.

Safety and Tolerability of the Antibacterial Rifaximin in the Treatment of Travellers??? Diarrhoea

Although travellers' diarrhoea can sometimes be associated with postinfectious complications, the condition is typically self-limiting. The infectious-diarrhoea guidelines subcommittees of the Infectious Disease Society of America and the American College of Gastroenterology recommend empirical antibacterial therapy for travellers' diarrhoea. Because therapy is directed largely at relieving symptoms and minimising inconvenience, the chosen antibacterial should ideally be both efficacious and pose a low risk of adverse effects. This review discusses the safety and tolerability of rifaximin in the treatment of travellers' diarrhoea, with a focus on data from controlled clinical trials. Data were obtained from a MEDLINE search using the key word 'rifaximin' with no date limits and from the rifaximin New Drug Application submitted to the US FDA for approval to market rifaximin in the US.Currently, the antibacterials considered as standard treatment for travellers' diarrhoea are systemically absorbed, carry defined risks of adverse effects, and have many uses other than the treatment of enteric disease. The minimally absorbed (<0.4%) oral antibacterial rifaximin constitutes a non-systemic approach to antidiarrhoeal therapy that should overcome some of the limitations of current antibacterials used for travellers' diarrhoea. Rifaximin is differentiated from these, and most other antibacterials, by having a tolerability profile comparable with that of placebo and minimal potential for drug interactions. To date, clinically relevant resistance to rifaximin has not been observed. As the first nonabsorbable antibacterial to be marketed for travellers' diarrhoea, rifaximin should help to change the management paradigm for travellers' diarrhoea and other gastrointestinal illnesses from a systemic approach to a predictably safer, non-systemic approach.

Current concepts in travelersʼ diarrhea: epidemiology, antimicrobial resistance and treatment

The aim of this article is to review recent advances in travelers' diarrhea, which remains one of the most common health problems afflicting individuals from developed countries visiting less affluent regions of the world. A large epidemiologic study done at the point of departure provided insights into regional risk factors for travelers' diarrhea and demonstrated that visitors rarely exercised dietary precautions aimed at disease prevention. A preventive program implemented with the close interaction between public health agencies, hotel industry and academia can result in effective reduction of cases. A polymorphism in the IL-8 gene promoter is associated with susceptibility to diarrhea due to enteroaggregative Escherichia coli. New diagnostic tools assist in better understanding the role of norovirus and emerging bacterial enteric pathogens such as enteroaggregative E. coli. Rifaximin, a non-absorbable antibiotic, is a safe and effective alternative for the prevention and treatment of travelers' diarrhea due to non-invasive organisms. Traditional public health and new antimicrobial agents can decrease the risk of travel related diarrhea.

Nonantimicrobial Agents in the Prevention and Treatment of Traveler' Diarrhea

Among the nonantimicrobial agents that are available and useful for the prevention of traveler's diarrhea are bismuth subsalicylate-containing preparations, which can provide a rate of protection of up to 65% when taken 4 times daily. In one study, the probiotic Lactobacillus GG was found to provide 49% protection against traveler's diarrhea, but results with this agent and other probiotics have been highly variable and geographically inconsistent. Tannin albuminate plus ethacridine lactate provided 36% protection, but it is not widely available. Among the nonantimicrobial agents that are available and useful for the treatment of traveler's diarrhea are bismuth subsalicylate-containing preparations, which reduce the passage of loose stools by 16%-18%. The antisecretory and antimotility agent loperamide reduces the passage of loose stools by approximately 50% and has been especially useful, in combination with antimicrobial agents, in reducing the total duration of posttreatment diarrhea to a matter of hours.

What's new in enteric infectious diseases at home and abroad

This review was designed to focus on the important research in the area of acute infectious diarrhea published within the past year. PubMed was reviewed for articles published in 2004 and 2005 relating to pathogen-specific diarrhea and for travelers' diarrhea to identify the newly published articles. New studies continue to show the importance of the diarrheagenic Escherichia coli as causes of acute and persistent diarrhea. Enteroaggregative E. coli has recently been shown to be an unrecognized cause of community-acquired diarrhea in infants in the USA. Genetic factors explain an increased susceptibility to travelers' diarrhea among international travelers. Also, poorly non-absorbed rifaximin (< 0.4%) was shown to be an effective drug when used prophylactically to prevent bacterial diarrhea during high risk travel. Studies will continue to define the etiology of diarrhea and to better understand the epidemiology and prevention of infectious diarrhea. Antibacterial resistance among enteric bacterial pathogens is a growing problem, leading to the search for newer antibacterial drugs. Diarrhea due to bacterial agents in international travelers can be prevented and treated successfully by antibacterial drugs. The nonabsorbed rifamycin drug, rifaximin, appears to be ideally suited to become the important new drug in prevention and treatment of travelers' diarrhea. Studies are underway to determine the value of the drug in preventing invasive forms of diarrhea during travel to Asia and in the prevention of the commonly occurring post-infectious irritable bowel syndrome.

Advising the traveller

International travel provides many rewards for the traveller, not least of which is the exposure to new cultures and ideas. It is important that the health professional tries to assure travellers’ health by careful pre-travel medical preparation that balances risk assessment of travellers and their trip with attention to health promotion. Health promotion should focus on the areas of safety, responsible personal behaviour, prevention of vaccine-preventable illness, vector avoidance and malaria chemoprophylaxis, and prevention and treatment of travellers’ diarrhoea.

Rifaximin Is an Effective Prophylaxis for Travelers’ Diarrhea

Rifaximin is a recently FDA-approved alternative to quinolones for the treatment of travelers’ diarrhea. In this manufacturer-supported study, 219 U.S.

Rifaximin: A New Treatment for Travelers' Diarrhea

To review the pharmacology, pharmacokinetics, clinical efficacy, adverse effects, drug interactions and precautions, and dosing recommendations of rifaximin, a new nonabsorbed antimicrobial agent for travelers' diarrhea. A MEDLINE search (1966-July 2004) was conducted to extract human and animal research data in the English language on rifaximin. Randomized, double-blind, placebo-controlled trials were reviewed and included to evaluate the efficacy of rifaximin in the treatment of travelers' diarrhea. Rifaximin is approved for the treatment of travelers' diarrhea in patients > or =12 years of age with diarrhea caused by noninvasive strains of Escherichia coli. Rifaximin was superior to placebo and trimethoprim/sulfamethoxazole and equivalent to ciprofloxacin in the primary clinical endpoint of the time to the last unformed stool passed. Rifaximin is a viable alternative to ciprofloxacin for the treatment of travelers' diarrhea. As rifaximin is not systemically absorbed, it offers the advantage of leading to the development of less resistance compared with systemically absorbed antibiotics, in addition to fewer systemic adverse effects and drug interactions. However, the potential for cross-resistance between rifaximin and rifampin, as well as with other classes of antibiotics, is of concern and needs to be elucidated.

Treatment of travelers' diarrhea among Austrian tourists.

either during their stay abroad or shortly following their return.Diarrhea was defined as three or more unformed stools per day, including at least one additional symptom, such as nausea,vomiting, abdominal cramps or pain, fever, and blood in stools. The subjects received a selfadministered questionnaire in which the therapeutic measures for TD were investigated, as prescribed by a physician, in an outpatient department or in a hospital, or as self-medication. Patients were also asked for the brand names of the drugs used. In cases of incomplete or ambiguous answers, travelers were contacted via telephone for clarification.

Review of sangre de drago (Croton lechleri)--a South American tree sap in the treatment of diarrhea, inflammation, insect bites, viral infections, and wounds: traditional uses to clinical research.

The objective of this review is to provide an overview of the pharmacologic evidence that may or may not support clinical and ethnomedical uses of the sap of sangre de drago (dragon's blood; Croton lechleri Müll. Arg.). Data sources used were BIOSIS, EMBASE, PubMed, TOXLIT, International Pharmaceutical Abstracts, manual searches, papers on file from peer-reviewed journals, textbooks available at Armana Research, Inc., and researchers in the field of South American botanical medicine. The results of in vitro and in vivo studies largely support the majority of ethnomedical uses of sangre de drago including the treatment of diarrhea, wounds, tumors, stomach ulcers, herpes infection, the itching, pain and swelling of insect bites, and other conditions. Clinical studies of sangre de drago products have reported positive results in the treatment of traveler's and watery diarrhea and the symptoms of insect bites. Because the sap has shown low toxicity and preparations used in clinical studies were well tolerated, further clinical and pharmacologic studies are anticipated. Acknowledgment of the diversity in the chemical makeup of the sap from one geographic area to another and the recent characterization of alkaloid chemotypes of sangre de drago will require that materials developed for clinical use are standardized.

Azithromycin Found to Be Comparable to Levofloxacin for the Treatment of US Travelers with Acute Diarrhea Acquired in Mexico

Increased drug resistance among enteropathogens is an emergent problem in travelers' diarrhea. This randomized, double-blind trial was conducted in Guadalajara, Mexico, during the summers of 1999-2001 to compare azithromycin with levofloxacin for the treatment of travelers' diarrhea. A total of 217 US adults were randomized to receive a single oral dose of azithromycin (1000 mg; 108 persons) or levofloxacin (500 mg; 109 persons), with a follow-up period of 4 days. Three patients in each group dropped out of the study. The median time between initiation of therapy and passage of the last unformed stool (azithromycin group, 22.3 h; levofloxacin group, 21.5 h) and the number of unformed stools passed during the 4-day follow-up period (azithromycin group, 6.5; levofloxacin group, 5.5) were similar. Treatment failure occurred in 10 patients (9.5%) receiving azithromycin and 8 patients (7.5%) receiving levofloxacin. Possible minor, self-limiting adverse events occurred in 57 patients in each treatment group. Azithromycin was found to be a safe and effective alternative to levofloxacin for the treatment of acute travelers' diarrhea in US adult travelers to Mexico.

Travellers' diarrhoea

Risk of travellers' diarrhoea is about 7% in developed countries and 20–50% in the developing world. Options for prevention include education and chemoprophylaxis. Vaccination is a promising but incomplete option. Achieving behaviour modification of food and water choices among tourists is difficult. Bismuth subsalicylate (BSS)-containing compounds are about 62% effective in the prevention of travellers' diarrhoea. Antibiotics are about 84% effective in preventing travellers' diarrhoea. Routine prophylaxis of travellers' diarrhoea, especially with antibiotics, should be discouraged. Oral rehydration is generally important in the treatment of diarrhoea, but travellers' diarrhoea is only infrequently dehydrating in adults. The addition of oral rehydration solutions confers no additional benefit to loperamide in the treatment of travellers' diarrhoea in adults. Presently, the most active of the antibiotics routinely available for treatment are members of the fluoroquinolone group. Antibiotics that are not absorbed such as aztreonam and a rifampicin-like agent, rifaximin, are both effective. The latter might become a therapy of choice once it is routinely available, due to predictably less adverse reactions with a non-absorbed antibiotic. Preliminary results with azithromycin look very promising. Less severe disease can be treated with a variety of non-antibiotic agents (e.g. BSS-containing compounds, loperamide and a calmodulin inhibitor, zaldaride). The combination of an antibiotic and loperamide is superior to treatment with either agent alone in a several studies and is arguably the treatment of choice for distressing travellers' diarrhoea.

A double blind, randomized, placebo-controlled study of SP-303 (Provir) in the symptomatic treatment of acute diarrhea among travelers to Jamaica and Mexico

OBJECTIVE: The study was designed to evaluate the effectiveness of SP-303 (Provir), a plant-derived product with novel antisecretory properties, in the treatment of travelers’ diarrhea. METHODS: A total of 184 persons from the United States who acquired diarrhea in Jamaica or Mexico were enrolled in a double-blind, placebo-controlled study examining the effectiveness of three doses of SP-303 in reducing illness. Subjects were treated with 125 mg, 250 mg, or 500 mg SP-303 or a matching placebo four times a day for 2 days. Subjects kept daily diaries of symptoms and were seen each day for 3 days. Of the subjects, 169 (92%) were included in the efficacy analysis. RESULTS: The most common etiological agent identified was enterotoxigenic Escherichia coli, found in 19% of subjects. The mean time interval from taking the first dose of medication until passage of the last unformed stool during 48 h therapy (TLUS 48) was 38.7 h for the placebo group. TLUS 48 was shortened by SP-303: 30.6 h for the 125-mg dose group ( p = 0.005); 30.3 h for the 250-mg group; and 32.6 h for the 500-mg group ( p = 0.01). Treatment failures were seen in 29.3% in the placebo group compared with 7.3% ( p = 0.01), 4.3 ( p = 0.002), and 9.8 ( p = 0.026) in the three treatment groups. SP-303 was well tolerated at all doses. CONCLUSIONS: SP-303 was effective in shortening the duration of travelers’ diarrhea by 21%. This antisecretory approach works directly against the pathophysiology of travelers’ diarrhea and is not likely to potentiate invasive forms of diarrhea or to produce posttreatment constipation.

Treatment of travelers' diarrhea.

Treatment of travelers' diarrhea.

Rifaximin: a new approach to the treatment of travelers' diarrhea. Introduction.

Rifaximin: a new approach to the treatment of travelers' diarrhea. Introduction.