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Traveler’s Diarrhea

(Turista)

by Thomas G. Boyce, MD, MPH

Traveler’s diarrhea is gastroenteritis that is usually caused by bacteria endemic to local water. Symptoms include vomiting and diarrhea. Diagnosis is mainly clinical. Treatment is with ciprofloxacin or azithromycin, loperamide, and replacement fluids.

(See also the Center for Disease Control and Prevention’s health information for travelers’ diarrhea .)

Etiology

Traveler’s diarrhea may be caused by any of several bacteria, viruses, or, less commonly, parasites. However, enterotoxigenic Escherichia coli is most common. E. coli is common in the water supplies of areas that lack adequate purification. Infection is common among people traveling to developing countries. Norovirus infection has been a particular problem on some cruise ships.

Both food and water can be the source of infection. Travelers who avoid drinking local water may still become infected by brushing their teeth with an improperly rinsed toothbrush, drinking bottled drinks with ice made from local water, or eating food that is improperly handled or washed with local water. People taking drugs that decrease stomach acid (antacids, H 2 blockers, and proton pump inhibitors) are at risk of more severe illness.

Symptoms and Signs

Nausea, vomiting, hyperactive bowel sounds (borborygmi), abdominal cramps, and diarrhea begin 12 to 72 h after ingesting contaminated food or water. Severity is variable. Some people develop fever and myalgias. Most cases are mild and self-limited, although dehydration can occur, especially in warm climates.

Diagnosis

  • Clinical evaluation

Specific diagnostic measures are usually not necessary. However, fever, severe abdominal pain, and bloody diarrhea suggest more serious disease and should prompt immediate evaluation.

Treatment

  • Fluid replacement

  • Sometimes antimotility drugs

  • Antibiotics (eg, ciprofloxacin, azithromycin) for moderate to severe diarrhea

The mainstay of treatment is fluid replacement and an antimotility drug such as loperamide 4 mg po initially, followed by 2 mg po for each subsequent episode of diarrhea (maximum of 6 doses/day or 16 mg/day), or diphenoxylate 2.5 to 5 mg po tid or qid in tablet or liquid form. For drug treatment in children, see Treatment.For children, loperamide is used. The dose for children 13 to 20 kg is 1 mg po tid; for children 20 to 30 kg, 2 mg po bid; and for children > 30 kg, up to age 12, 2 mg po tid. Adults and children ≥ 12 yr may receive 4 mg po after the first loose stool and then 2 mg after each subsequent loose stool, not to exceed 16 mg in any 24-h period. Antimotility drugs are contraindicated in patients with fever or bloody stools and in children < 2 yr. Iodochlorhydroxyquin, which may be available in some developing countries, should not be used because it may cause neurologic damage.

Generally, antibiotics are not necessary for mild diarrhea. In patients with moderate to severe diarrhea ( 3 loose stools over 8 h), antibiotics are given, especially if vomiting, abdominal cramps, fever, or bloody stools are present. For adults, ciprofloxacin 500 mg po bid for 3 days or levofloxacin 500 mg po once/day for 3 days is recommended. Azithromycin 250 mg po once/day for 3 days or rifaximin 200 mg po tid for 3 days may also be used. For children, azithromycin 5 to 10 mg/kg po once/day for 3 days is preferred.

Prevention

Travelers should dine at restaurants with a reputation for safety and avoid foods and beverages from street vendors. They should consume only cooked foods that are still steaming hot, fruit that can be peeled, and carbonated beverages without ice served in sealed bottles (bottles of noncarbonated beverages can contain tap water added by unscrupulous vendors); uncooked vegetables (particularly including salsa left out on the table) should be avoided. Buffets and fast food restaurants pose an increased risk.

Prophylactic antibiotics are effective in preventing diarrhea, but because of concerns about adverse effects and development of resistance, they should probably be reserved for immunocompromised patients.

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • ZITHROMAX
  • CILOXAN, CIPRO
  • IMODIUM
  • IQUIX, LEVAQUIN, QUIXIN
  • XIFAXAN

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