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

From the Guidelines

Travelers' diarrhea can be effectively treated with azithromycin as the first choice for moderate to severe cases, due to its high efficacy and low resistance rates, as demonstrated in studies such as 1 and 1. The treatment approach depends on the severity of the illness. For mild cases, focus on hydration with oral rehydration solutions (ORS) like Pedialyte or a homemade solution of 1 liter of clean water with 6 teaspoons of sugar and 1/2 teaspoon of salt. Some key points to consider in the treatment of travelers' diarrhea include:

• For moderate to severe diarrhea, antimotility agents like loperamide (Imodium) at 4mg initially followed by 2mg after each loose stool (maximum 16mg daily) can provide symptomatic relief, as supported by studies such as 1 and 1.
• Antibiotics are recommended for moderate to severe cases, with azithromycin being the first choice (1000mg single dose or 500mg daily for 3 days), due to its high efficacy and low resistance rates, as demonstrated in studies such as 1 and 1.
• Fluoroquinolones like ciprofloxacin (500mg twice daily for 1-3 days) are alternatives but have increasing resistance, as noted in studies such as 1 and 1.
• Bismuth subsalicylate (Pepto-Bismol) can help with mild cases at a dose of two tablets (262mg each) four times daily, as supported by studies such as 1.
• Continue eating simple, bland foods and avoid dairy, caffeine, and alcohol during recovery.
• Most cases resolve within 3-5 days with treatment.
• Seek medical attention if you experience high fever, bloody stools, severe abdominal pain, or symptoms persisting beyond 5 days, as advised in studies such as 1. These treatments work by either slowing intestinal motility, killing the infectious organisms (typically bacteria like E. coli), or helping maintain hydration while your body fights the infection.

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 for travelers' diarrhea is rifaximin (XIFAXAN), with a recommended dose of 200 mg orally three times a day for 3 days in adults and pediatric patients 12 years of age and older, but only for cases caused by noninvasive strains of Escherichia coli 2.

• Contraindications: Patients with a hypersensitivity to rifaximin or any of the rifamycin antimicrobial agents.
• Limitations of use: Not effective in cases of travelers’ diarrhea due to Campylobacter jejuni, and its effectiveness has not been proven in cases caused by Shigella spp. or Salmonella spp..

From the Research

Treatment Options for Traveler's Diarrhea

• The recommended treatment for traveler's diarrhea is the combination of an appropriate antibiotic (usually a fluoroquinolone) and loperamide 3.
• Azithromycin compared favorably with fluoroquinolones in trials that did not include the use of loperamide, but combination therapy has not been studied to date 3.
• A study found that single-dose treatment with azithromycin (1000 mg) and loperamide is as effective as single-dose treatment with levofloxacin (500 mg) and loperamide for noninflammatory diarrhea 3.
• Loperamide can be given with the antibiotic to offer rapid symptomatic improvement, with a dosage of up to 8 mg per day for less than or equal to 2 days 4.
• For mild traveler's diarrhea, the use of antibiotic is not recommended, but the use of bismuth subsalicylate or loperamide may be considered 5.
• For moderate traveler's diarrhea, antibiotics such as fluoroquinolones, azithromycin, and rifaximin may be used, with loperamide as monotherapy or adjunctive therapy 5.
• For severe traveler's diarrhea, antibiotics such as azithromycin, fluoroquinolones, and rifaximin should be used, with azithromycin being effective for the treatment of dysentery 5.

Antibiotic Treatment

• Fluoroquinolones, such as ciprofloxacin, are effective in reducing the duration of traveler's diarrhea 6, 7.
• Azithromycin is effective in treating traveler's diarrhea, including dysentery 4, 5.
• Rifaximin is a poorly absorbed antibiotic that can effectively reduce the occurrence of traveler's diarrhea without side effects 4.
• Trimethoprim-sulfamethoxazole (TMP-SMX) combination can reduce the duration of diarrhea to approximately 1 day 7.

Prevention and Management

• Pretravel education on hygiene and safe selection of food items is important in minimizing episodes of traveler's diarrhea 5, 7.
• Restoration of water and electrolyte balance is key in managing acute watery traveler's diarrhea, particularly in infants and young children 7.
• Oral rehydration solutions are indicated for infants, children, and the elderly, in whom dehydration may occur rapidly and be particularly dangerous 7.