Traveler's Diarrhea Management

Aka: Traveler's Diarrhea Management

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II. Precautions

  1. Antibiotic Resistance: Overall
    1. Avoid trimethoprim-sulfamethoxazole (Bactrim, Septra) and Doxycycline due to high resistance rates
    2. Most Traveler's Diarrhea is self-limited and spontaneously resolves WITHOUT Antibiotics
      1. Use of Antibiotics (esp. self treatment) is associated with multi-drug resistance, c. diff
      2. Kantele (2015) Clin Infect Dis 60(6): 837-46 +PMID:25613287 [PubMed]
  2. Antibiotic Resistance: Travel to Southeast Asia, Thailand, India or Nepal
    1. Quinolone-resistant Campylobacter is common
    2. Azithromycin as first-line agent is preferred in these cases
  3. Drug Interactions
    1. Antimalarials and Azithromycin both prolong QT Interval (Exercise caution when prescribing both)
  4. Causes of persistent Diarrhea >14 days
    1. Antibiotic resistant Bacteria
      1. Giardia
      2. Cryptosporidium
    2. Parasitic Infection
      1. Salmonella
      2. Shigella
      3. Campylobacter
  5. Consider Diarrhea Differential Diagnosis
    1. Especially for recent Antibiotics predisposing to Clostridium difficile
  6. Stand-By Antibiotics do not alter course and increase Antibiotic Resistance
    1. Riddle (2018) J Travel Med 25(1): 1-3 [PubMed]

III. Management: Preparation for trip to endemic area

  1. See Traveler's Diarrhea Prophylaxis
  2. See Traveler's Diarrhea Prevention
  3. Review CDC Travel recommendations for region
    1. http://www.cdc.gov/travel
    2. Malaria Prophylaxis (endemic regions)
    3. Vaccinations - Start at least 6 weeks before travel
      1. Hepatitis A Vaccine
      2. Hepatitis B Vaccine
      3. Influenza Vaccine
      4. MeningitisVaccine
      5. Yellow Fever Vaccine
      6. Typhoid FeverVaccine
  4. High risk patients should bring medications on trip
    1. Instructions on use as below
    2. Oral rehydration Salts
    3. Antibiotic
      1. Pregnant women or Children or Adults traveling to Southeast Asia/India/Nepal
        1. Azithromycin 500 mg (3 tabs) or 200 mg/5ml (for 1-3 doses at 10 mg/kg)
      2. Adults traveling outside of Southeast Asia/India/Nepal
        1. Ciprofloxacin 500-750 mg (6 tablets)
        2. Precaution: In addition to resistance, adverse effects limit Fluoroquinolone use
          1. Consider Azithromycin in all patients
    4. Loperamide 2 mg (20 tablets)
      1. See Loperamide for description
      2. Alternative: Diphenoxylate
  5. Precautions for seeking medical attention
    1. Dysentery (High fever, bloody stool, stools with mucus present)
    2. Dehydration or Syncope
    3. Diarrhea persists >1 week (esp. >2 weeks)

IV. Management: Mild Diarrhea - Non-Pregnant Adults

  1. Criteria
    1. Self limited Diarrhea
    2. Stool frequency: 3-5 stools per day for 1-3 days
  2. Efficacy
    1. Antibiotics shorten the Diarrhea course from an average of 3 days to 1.5 days
  3. Medications
    1. See Oral Rehydration Solution
    2. Consider bismuth tablets 2-4 tablets four times daily (adults only due to Salicylate content)
    3. Loperamide (Imodium) with one single dose Antibiotic
    4. Antibiotic (1 dose): Pregnant women or Children or Adults traveling to Southeast Asia/India/Nepal
      1. Azithromycin 500-1000 mg (single dose, adult dose listed)
        1. High dose is more effective, but greater Incidence of Nausea and Vomiting
    5. Antibiotic (1 dose): Non-pregnant adults traveling outside of Southeast Asia/India/Nepal
      1. Ciprofloxacin 750 mg (single dose)
      2. Levofloxacin 500 mg (single dose)
      3. Ofloxacin 300 mg (single dose)
      4. Precaution: In addition to resistance, adverse effects limit Fluoroquinolone use
        1. Consider Azithromycin in all patients
    6. Other options
      1. Rifaximin (Xifaxan) 200 mg orally 3 times daily for 3 days
        1. Well tolerated, non-absorbed, effective agent
        2. Indicated for non-invasive disease
          1. Example: Enterotoxigenic E. coli
      2. Rifamycin (Aemcolo)
        1. Released in 2019
        2. Not absorbed, and may be indicated in non-invasive disease (similar to Rifaximin)

V. Management: Moderate or Severe Diarrhea (Dysentery) - Non-Pregnant Adults

  1. Criteria
    1. Stool frequency: >6 stools per day for 5 days
    2. High fever
    3. Bloody stools
    4. Stools with mucus present
  2. General Measures
    1. Rehydration and Electrolyte replacement is primary concern
    2. See Oral Rehydration Solution
  3. Antibiotics
    1. Loperamide (Imodium) with one Antibiotic below
      1. Do not use Loperamide if fever or bloody stool are present (Dysentery)
    2. Antibiotic (3 days): Pregnant women or Children or Adults traveling to Southeast Asia/India/Nepal
      1. Azithromycin 500 mg (or 10 mg/kg in children) once daily for 3 days or
      2. Ceftriaxone 50 mg/kg/day (up to 1 g) IV every 24 hours for 3 days
    3. Antibiotic (3 days): Adults traveling outside of Southeast Asia/India/Nepal
      1. Ciprofloxacin 500 mg orally twice daily for 3 days or
      2. Norfloxacin 400 mg orally twice daily for 3 days or
      3. Ofloxacin 300 mg orally twice daily for 3 days or
      4. Levofloxacin 500 mg orally daily for 3 days
    4. Avoid Antibiotics with high resistance rates
      1. Avoid trimethoprim-sulfamethoxazole (Bactrim, Septra)
      2. Avoid Doxycycline

VI. Management: Children with Traveler's Diarrhea

  1. General
    1. See Diarrhea in Children
    2. See Diarrhea Management in Children
    3. See Management of Moderate Diarrhea under age 2 years
    4. See Management of Mild Diarrhea under age 2 years
    5. See Pediatric Diarrhea Fluid Replacement
    6. See Oral Rehydration Solution
  2. Children age 12 years or over
    1. Loperamide (non-Dysentery cases only) and
    2. Antibiotic: Rifaximin
  3. Children under age 12 years
    1. Loperamide (only age >3 years old and in non-Dysentery cases) and
    2. Antibiotic
      1. Azithromycin (drug of choice) 10 mg/kg/day for 1-3 days OR
      2. Nalidixic Acid 14 mg/kg/dose up to 250 mg orally four times daily OR
      3. Ceftriaxone 50 mg/kg/day (up to 1 g) IV every 24 hours for 1-3 days OR
      4. Other Third Generation Cephalosporin (Cefdinir, Cefpodoxime)
  4. Medications contraindicated in children
    1. Fluoroquinolone
    2. Bismuth Subsalicylate

VII. Management: Pregnant women with Traveler's Diarrhea

  1. Medications
    1. Loperamide (non-Dysentery cases) and
    2. Antibiotic options
      1. Azithromycin 500 mg once daily for 3 days OR
      2. Ceftriaxone 1 g IV every 24 hours for 1-3 days OR
      3. Other Third Generation Cephalosporin (Cefdinir, Cefpodoxime)
  2. Medications contraindicated in pregnancy and in children
    1. Fluoroquinolone
    2. Bismuth Subsalicylate

VIII. References

  1. Wayman (2017) Crit Dec Emerg Med 31(6): 3-10
  2. (2016) Sanford Guide to Antimicrobial Therapy, accessed 5/6/2016
  3. (2005) Med Lett Drugs Ther 40(1025): 47 [PubMed]
  4. Steffen (2015) JAMA 313(1): 71-80 +PMID:25562268 [PubMed]

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