II. Prevention: Traveler's Diarrhea
- Rule 1: "Boil it, Cook it, Peel it or Forget it"
- Preparing your own food ensures safety (avoid food prepared by street vendors)
- Dry foods (e.g. breads, chips) are typically safe
- Exposures to avoid
- Avoid raw, unpeeled vegetables, lettucs, tomatoes
- Avoid pre-peeled fruit
- Avoid tap water or ice (Alcohol does not sterilize)
- Avoid uncooked meats and seafood
- Avoid unpasteurized dairy products (cream, milk, cheese)
- Avoid foods that are not steaming hot
- Food should be heated above 65 degrees Celsius
- Food should be too hot to touch
III. Indications: Prophylaxis
- Concomitant serious illness or immuncompromising condition (e.g. Diabetes Mellitus)
-
Diarrhea interferes with important medications
- Examples: Digoxin, Fursosemide
- Decreased gastric acidity
- Immunocompromised patient
- Travelers on critically important business (medical mission, disaster relief, major sporting event)
IV. Protocol
- Patient to start prophylaxis with onset of Diarrhea
- Maximum duration of prophylaxis is 3 weeks
V. Medications
-
Bismuth Subsalicylate (Pepto-Bismol) 2 tabs orally four times daily
- Efficacy: 60% protection
- Avoid in children and those with significant sources of Salicylates (Salicylate Toxicity risk)
- Do not use with Doxycycline (esp. when used for Malaria Prophylaxis)
- Interferes with Doxycycline absorption
-
Rifaximin (Xifaxan)
- Rifaximin 200 mg three times daily for 3 days
- Not absorbed, well tolerated, and effective
- May be new preferred agent
-
Azithromycin
- Azithromycin 1000 mg orally once
-
Fluoroquinolones (typically for 3 day course)
- Ciprofloxacin 500 mg orally daily
- Efficacy: 94% prevention at 1 week
- Ofloxacin (Floxin) 300 mg orally daily
- Norfloxacin 400mg orally daily
- Efficacy: 88% prevention at 2 weeks
- Levofloxacin (Levaquin) 500 mg orally daily
- Ciprofloxacin 500 mg orally daily
- Avoid ineffective agents
- Avoid trimethoprim-sulfamethoxazole, Doxycycline, oral Penicillins due to high resistance
- Avoid Probiotics (e.g. Lactobacillus) due to poor efficacy
VI. References
- Wayman (2017) Crit Dec Emerg Med 31(6): 3-10