From the Guidelines
Travelers' diarrhea is best managed with prompt hydration and, if symptoms are severe, antimicrobial therapy, with azithromycin 1000mg as a single dose or 500mg daily for 3 days being the first-line treatment for moderate to severe cases, as recommended by the most recent guidelines 1.
Prevention and Treatment
For prevention, practice careful food and water hygiene by consuming only bottled or treated water, avoiding raw vegetables, unpeeled fruits, and undercooked meats. If diarrhea occurs, focus first on rehydration with oral rehydration solutions like Pedialyte or a homemade mixture of 1 liter of clean water with 6 teaspoons of sugar and 1/2 teaspoon of salt.
Mild Symptoms
For mild symptoms, loperamide (Imodium) 4mg initially followed by 2mg after each loose stool (maximum 16mg/day) can provide relief, as supported by studies 1.
Moderate to Severe Cases
For moderate to severe cases, antibiotics are effective: azithromycin is the first-line treatment, while fluoroquinolones like ciprofloxacin are alternatives except in Southeast Asia where resistance is common, as noted in the guidelines 1.
Seek Medical Attention
Seek medical attention if you experience high fever, bloody stools, severe abdominal pain, or symptoms lasting longer than a week, as these may indicate a more serious infection requiring specialized care. Some key points to consider:
- The decision to treat TD with non-specific anti-diarrheal medications and/or an antimicrobial agent is based on assessment of the severity of illness and the effects it will have on the traveler’s activities and plans 1.
- Azithromycin has demonstrated effective and comparable cure rates with shigellosis, another common agent causing dysentery, and is generally well tolerated with minimal side effects 1.
- Rifaximin, a nonabsorbable antibiotic, has demonstrated comparable efficacy to FQs in non-invasive TD caused by diarrheagenic E. coli, but is less effective for the treatment of invasive pathogens 1.
From the FDA Drug Label
XIFAXAN is a rifamycin antibacterial indicated for: • Treatment of travelers’ diarrhea (TD) caused by noninvasive strains of Escherichia coli in adult and pediatric patients 12 years of age and older (1.1)
Limitations of Use • TD: Do not use in patients with diarrhea complicated by fever or blood in the stool or diarrhea due to pathogens other than Escherichia coli (1.1,5.1)
DOSAGE AND ADMINISTRATION Condition Recommended Dosage Regimen TD (2.1) One 200 mg tablet 3 times a day for 3 days
Rifaximin (XIFAXAN) is indicated for the treatment of travelers’ diarrhea (TD) caused by noninvasive strains of Escherichia coli in adult and pediatric patients 12 years of age and older. The recommended dosage regimen for TD is one 200 mg tablet 3 times a day for 3 days 2. However, it 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.
From the Research
Definition and Treatment of Traveler's Diarrhea
- Traveler's diarrhea is typically defined as experiencing at least three unformed stools per day during a stay abroad or within 10 days of returning from the destination 3.
- The treatment of traveler's diarrhea often involves the use of antibiotics, such as ciprofloxacin, levofloxacin, azithromycin, and rifaximin, in combination with loperamide to manage symptoms 4, 5, 6.
Comparison of Treatment Options
- A study comparing azithromycin and loperamide to levofloxacin and loperamide found that both combinations were effective in treating traveler's diarrhea, with similar median times to last diarrheal stool and resolution of associated symptoms 4.
- Another study found that loperamide plus azithromycin was more effective than azithromycin alone in treating traveler's diarrhea, with a shorter duration of diarrhea and fewer unformed stools passed in the first 24 hours 5.
- A study comparing ciprofloxacin plus loperamide to ciprofloxacin alone found that the combination of ciprofloxacin and loperamide was not significantly better than ciprofloxacin alone in treating traveler's diarrhea, although loperamide appeared to have some benefit in the first 24 hours of treatment 6.
Prevention and Management
- Prevention of traveler's diarrhea involves taking precautions regarding dietary habits, such as avoiding fecally contaminated food and beverages, and considering the use of probiotics or immunoprophylaxis 7.
- Management of acute watery traveler's diarrhea involves restoring water and electrolyte balance, and may require pharmacologic treatment to shorten the duration of diarrhea or relieve symptoms 7.
- Poorly absorbed antimicrobials, such as bicozamycin and furazolidone, may be a safe option for treating traveler's diarrhea, although more research is needed to evaluate their effectiveness 7.