What is the treatment for traveler's diarrhea (TD)?

From the Guidelines

Travelers' diarrhea is best treated with oral rehydration as the primary approach, and for moderate to severe cases, azithromycin is the recommended first-line antibiotic treatment, given its strong recommendation and high level of evidence 1. The primary goal of treatment is to prevent dehydration and reduce symptom severity.

• Oral rehydration can be achieved with water mixed with oral rehydration salts or a homemade solution of 1 teaspoon salt and 8 teaspoons sugar in 1 liter of clean water.
• For symptom relief, loperamide (Imodium) can be taken at a dose of 4mg initially, followed by 2mg after each loose stool, not exceeding 16mg daily, as it has a strong recommendation and high level of evidence for use as adjunctive therapy or monotherapy in moderate travelers’ diarrhea 1.
• Azithromycin is the preferred antibiotic for moderate to severe travelers’ diarrhea, with a dosage of 1000mg single dose or 500mg daily for 3 days, due to its strong recommendation and high level of evidence 1.
• Fluoroquinolones like ciprofloxacin (500mg twice daily for 1-3 days) are alternatives but have increasing resistance, and their use is recommended with caution 1.
• Bismuth subsalicylate (Pepto-Bismol) can help with mild cases at a dose of two tablets four times daily, but its use as prophylaxis is not routinely recommended for all travelers, only those at high risk of health-related complications of travelers’ diarrhea 1. It's essential to seek medical attention if symptoms include high fever, bloody stools, severe abdominal pain, or if diarrhea persists beyond a week, as these may indicate a more severe infection requiring prompt medical evaluation and treatment. Antibiotics work by eliminating the bacterial cause of infection, while anti-motility agents like loperamide slow intestinal movement to reduce frequency of bowel movements. Rehydration is crucial because diarrhea causes significant fluid and electrolyte loss that can lead to dehydration. Given the potential for adverse effects and the emergence of resistance, the choice of antibiotic should be guided by the severity of symptoms, the traveler's health status, and the local resistance patterns, with azithromycin being the preferred choice due to its strong recommendation and high level of evidence 1.

From the FDA Drug Label

Treatment of diarrhea with loperamide hydrochloride is only symptomatic. Whenever an underlying etiology can be determined, specific treatment should be given when appropriate (or when indicated).

The treatment for traveler's diarrhea with loperamide hydrochloride is symptomatic.

• Loperamide hydrochloride does not address the underlying cause of the diarrhea.
• Specific treatment should be given when the underlying etiology is determined. No conclusion can be drawn regarding the most effective treatment for traveler's diarrhea from the provided information 2 2.

From the Research

Treatment Options for Traveler's Diarrhea

• The treatment of traveler's diarrhea can be managed through various methods, including the use of antimicrobials, probiotics, and oral rehydration solutions 3.
• For mild cases, the use of bismuth subsalicylate or loperamide may be considered, while for moderate cases, antibiotics such as fluoroquinolones, azithromycin, and rifaximin may be used 4.
• In severe cases, antibiotics such as azithromycin, fluoroquinolones, and rifaximin should be used, with azithromycin being the preferred choice for the treatment of dysentery 4.
• The use of secretion inhibitors like racecadotril is also considered a first-choice treatment for acute uncomplicated traveler's diarrhea 5.

Antibiotic Treatment

• Ciprofloxacin is a standard treatment for traveler's diarrhea, except in cases where the patient is traveling to South or Southeast Asia, where azithromycin is preferred 6.
• The combination of ciprofloxacin and loperamide has been compared to ciprofloxacin alone in a randomized trial, with results showing that the combination may have some benefit in the first 24 hours of treatment, but not significantly better than ciprofloxacin alone 7.
• Antibiotics should only be used in complicated cases of traveler's diarrhea, and travelers should be advised against demanding antibiotic therapy for uncomplicated cases 5.

Prevention and Management

• Pretravel education on hygiene and safe food selection is important in minimizing episodes of traveler's diarrhea 4, 6.
• Oral rehydration solutions are recommended for infants, children, and the elderly, who are at higher risk of dehydration 3.
• Travelers should be advised to bring an antidiarrheal compound or bismuth subsalicylate, and an antibacterial agent, if available, to manage symptoms and prevent complications 3.