II. Prevention: Traveler's Diarrhea

  1. Rule 1: "Boil it, Cook it, Peel it or Forget it"
  2. Preparing your own food ensures safety (avoid food prepared by street vendors)
  3. Dry foods (e.g. breads, chips) are typically safe
  4. Exposures to avoid
    1. Avoid raw, unpeeled vegetables, lettucs, tomatoes
    2. Avoid pre-peeled fruit
    3. Avoid tap water or ice (Alcohol does not sterilize)
    4. Avoid uncooked meats and seafood
    5. Avoid unpasteurized dairy products (cream, milk, cheese)
    6. Avoid foods that are not steaming hot
      1. Food should be heated above 65 degrees Celsius
      2. Food should be too hot to touch

III. Indications: Prophylaxis

  1. Concomitant serious illness or immuncompromising condition (e.g. Diabetes Mellitus)
  2. Diarrhea interferes with important medications
    1. Examples: Digoxin, Fursosemide
  3. Decreased gastric acidity
  4. Immunocompromised patient
  5. Travelers on critically important business (medical mission, disaster relief, major sporting event)

IV. Protocol

  1. Patient to start prophylaxis with onset of Diarrhea
  2. Maximum duration of prophylaxis is 3 weeks

V. Medications

  1. Bismuth Subsalicylate (Pepto-Bismol) 2 tabs orally four times daily
    1. Efficacy: 60% protection
    2. Avoid in children and those with significant sources of Salicylates (Salicylate Toxicity risk)
    3. Do not use with Doxycycline (esp. when used for Malaria Prophylaxis)
      1. Interferes with Doxycycline absorption
  2. Rifaximin (Xifaxan)
    1. Rifaximin 200 mg three times daily for 3 days
    2. Not absorbed, well tolerated, and effective
    3. May be new preferred agent
  3. Azithromycin
    1. Azithromycin 1000 mg orally once
  4. Fluoroquinolones (typically for 3 day course)
    1. Ciprofloxacin 500 mg orally daily
      1. Efficacy: 94% prevention at 1 week
    2. Ofloxacin (Floxin) 300 mg orally daily
    3. Norfloxacin 400mg orally daily
      1. Efficacy: 88% prevention at 2 weeks
    4. Levofloxacin (Levaquin) 500 mg orally daily
  5. Avoid ineffective agents
    1. Avoid trimethoprim-sulfamethoxazole, Doxycycline, oral Penicillins due to high resistance
    2. Avoid Probiotics (e.g. Lactobacillus) due to poor efficacy
      1. Marteau (2001) Am J Clin Nutr 73(Suppl):430S-36S [PubMed]

VI. References

  1. Wayman (2017) Crit Dec Emerg Med 31(6): 3-10

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