From the Guidelines
Travelers' diarrhea is best managed through prevention and prompt treatment, with azithromycin being the preferred antibiotic for severe cases, especially in regions with high fluoroquinolone resistance, as it has been shown to be superior to levofloxacin in achieving clinical cure 1. To prevent travelers' diarrhea, it is essential to drink only bottled or treated water, avoid raw foods, and practice good hand hygiene while traveling. If symptoms develop, oral rehydration is crucial - drink plenty of fluids with electrolytes. For treatment, the following options can be considered:
- For mild cases, bismuth subsalicylate (Pepto-Bismol) can be taken at 2 tablets (262mg each) four times daily, or loperamide (Imodium) 4mg initially followed by 2mg after each loose stool (maximum 16mg daily) can help reduce frequency 1.
- For moderate to severe diarrhea, antibiotics may be necessary, with azithromycin 1000mg as a single dose being a common option, especially in regions with high fluoroquinolone resistance like Southeast Asia 1.
- Ciprofloxacin 500mg twice daily for 1-3 days can also be used, but it is not preferred in regions with high fluoroquinolone resistance. It is essential to seek medical attention if you experience high fever, bloody stools, severe abdominal pain, or symptoms persisting beyond 3-5 days. Travelers' diarrhea occurs when unfamiliar bacteria, particularly enterotoxigenic E. coli, enter the digestive system, causing the intestines to secrete excess fluid and accelerate motility, resulting in frequent loose stools and abdominal discomfort. Some key considerations in the selection of an empiric antibiotic include the likelihood of treatment efficacy and rapidity of response, regional patterns of probable target pathogens and their antimicrobial resistance, safety and tolerance profile of the antibiotic, simplicity of treatment regimen, and cost 1.
From the FDA Drug Label
Infectious Diarrhea caused by Escherichia coli (enterotoxigenic strains), Campylobacter jejuni, Shigella boydii†, Shigella dysenteriae, Shigella flexneri or Shigella sonnei† when antibacterial therapy is indicated.
Ciprofloxacin is indicated for the treatment of infectious diarrhea caused by certain bacteria, including Escherichia coli (enterotoxigenic strains), Campylobacter jejuni, and Shigella species. This suggests that ciprofloxacin may be effective in treating traveler's diarrhea caused by these bacteria. However, it is essential to note that ciprofloxacin should only be used when antibacterial therapy is indicated, and the specific cause of the diarrhea should be identified through culture and susceptibility testing whenever possible 2.
From the Research
Causes and Risk Factors
- Travelers' diarrhea is usually acquired through ingestion of food and water contaminated by feces 3
- The attack rate is highest for travelers from a developed country who visit a developing country 3
- Children are at particular risk of developing travelers' diarrhea 3
- Bacterial pathogens, such as Escherichia coli, are the most common cause of travelers' diarrhea 3, 4
Symptoms and Complications
- Dehydration is the most common complication of travelers' diarrhea 3
- Symptoms of travelers' diarrhea typically occur within the first few days after arrival in a foreign country 3
- Between 10% and 40% of travelers develop diarrhea 3
Treatment and Prevention
- Pretravel education on hygiene and safe food selection is important in minimizing episodes of travelers' diarrhea 3
- For mild travelers' diarrhea, the use of antibiotic is not recommended, but bismuth subsalicylate or loperamide may be considered 3
- For moderate travelers' diarrhea, antibiotics such as fluoroquinolones, azithromycin, and rifaximin may be used, and loperamide may be considered as monotherapy or adjunctive therapy 3, 4
- For severe travelers' diarrhea, antibiotics such as azithromycin, fluoroquinolones, and rifaximin should be used 3
- A study found that loperamide combined with ciprofloxacin was not better than treatment with ciprofloxacin alone in patients infected with enterotoxigenic E. coli 5