From the Guidelines
Travelers' diarrhea is best treated with oral rehydration therapy as the primary intervention, focusing on replacing lost fluids and electrolytes, and for moderate to severe cases, azithromycin 1000mg as a single dose or 500mg daily for three days is commonly prescribed, as supported by the highest quality evidence 1.
Treatment Options
- For mild cases, continue eating and drinking while monitoring symptoms.
- For moderate to severe cases, over-the-counter medications like loperamide (Imodium) can help reduce frequency of bowel movements; take 4mg initially followed by 2mg after each loose stool, not exceeding 16mg daily, as recommended by the guidelines 1.
- Bismuth subsalicylate (Pepto-Bismol) is another option, taking two tablets or 30ml four times daily.
- For severe cases or those with fever and bloody stools, antibiotics may be necessary, with azithromycin being the preferred choice due to its high efficacy and low resistance rates 1.
- Fluoroquinolones like ciprofloxacin 500mg twice daily for 1-3 days are alternatives, though resistance is increasing, and their use should be cautious, especially in areas with high resistance rates 1.
- Rifaximin 200mg three times daily for three days works for non-invasive diarrhea, but its use should be cautious in areas where invasive pathogens are likely to be encountered 1.
Important Considerations
- Rehydration is crucial because diarrhea causes significant fluid and electrolyte losses that can lead to dehydration.
- Most cases resolve within 3-5 days with proper treatment, but seek medical attention if symptoms persist beyond a week, if there's severe dehydration, high fever, or bloody stools.
- The choice of antibiotic should be based on the severity of the disease, the likelihood of treatment efficacy, and regional patterns of probable target pathogens and their antimicrobial resistance, as well as the patient's preferences and medical history 1.
From the FDA Drug Label
XIFAXAN is indicated for the treatment of travelers’ diarrhea (TD) caused by noninvasive strains of Escherichia coli in adults and pediatric patients 12 years of age and older The recommended dose of XIFAXAN is one 200 mg tablet taken orally three times a day for 3 days. XIFAXAN should not be used in patients with diarrhea complicated by fever or blood in the stool or diarrhea due to pathogens other than Escherichia coli
The treatment of travelers' diarrhea with rifaximin (PO) is indicated for patients with noninvasive strains of Escherichia coli. The recommended dosage is 200 mg taken orally three times a day for 3 days. However, it should not be used in patients with:
- Diarrhea complicated by fever or blood in the stool
- Diarrhea due to pathogens other than Escherichia coli 2 2 2
From the Research
Treatment Options for Travelers' Diarrhea
- Antibiotics such as rifaximin 3, azithromycin 4, 5, and fluoroquinolones 6, 4, 5 are effective in treating travelers' diarrhea
- Rifaximin is a minimally absorbed oral antibiotic that has been shown to be superior to placebo or loperamide in reducing the duration of illness and restoring wellbeing in patients with travelers' diarrhea 3
- Azithromycin is the drug of choice for treating travelers' diarrhea, especially in Asia where Campylobacter is common 4
- Fluoroquinolone antibiotics are effective in Latin America and Africa where ETEC is predominant 4
- Bismuth subsalicylate (BSS) and loperamide (LOP) are also effective as standalone treatments for travelers' diarrhea 6, 4, 5
Prevention of Travelers' Diarrhea
- Pretravel education on hygiene and safe selection of food items is important in minimizing episodes of travelers' diarrhea 5
- Antibiotics such as doxycycline, trimethoprim-sulfamethoxazole, and rifaximin have been used for prevention, but their use is limited due to increasing resistance 4
- Bismuth subsalicylate (BSS) is an option for prophylaxis 4
Management of Travelers' Diarrhea
- For mild travelers' diarrhea, the use of antibiotic is not recommended, and bismuth subsalicylate or loperamide may be considered 5
- For moderate travelers' diarrhea, antibiotics such as fluoroquinolones, azithromycin, and rifaximin may be used, and loperamide may be considered as monotherapy or adjunctive therapy 5
- For severe travelers' diarrhea, antibiotics such as azithromycin, fluoroquinolones, and rifaximin should be used 5