What is the treatment for traveler's diarrhea?

From the Guidelines

For traveler's diarrhea treatment, azithromycin 1000mg as a single dose or 500mg daily for 3 days is the most effective antibiotic option, especially in Southeast Asia where resistance to fluoroquinolones is common, as recommended by the most recent and highest quality study 1. This approach prioritizes reducing morbidity, mortality, and improving quality of life.

Treatment Approach

When treating traveler's diarrhea, it's essential to start with oral rehydration using water mixed with electrolyte solutions like Pedialyte or a homemade solution (1 liter water, 6 teaspoons sugar, 1/2 teaspoon salt) 1. Most cases resolve within 3-5 days with hydration alone.

Symptom Relief

For symptom relief, taking loperamide (Imodium) 4mg initially, then 2mg after each loose stool (maximum 16mg daily), is recommended as adjunctive therapy for moderate to severe travelers’ diarrhea, with a strong recommendation and high level of evidence 1. Bismuth subsalicylate (Pepto-Bismol) is an alternative, taken as two tablets (262mg each) every 30-60 minutes up to 8 doses daily.

Antibiotic Treatment

For moderate to severe diarrhea, antibiotics can shorten the duration of the illness. Azithromycin is preferred due to its high level of evidence and strong recommendation 1, especially in regions with high resistance to fluoroquinolones, as highlighted by the study on resistant pathogens as causes of traveler's diarrhea globally 1. Alternatively, ciprofloxacin 500mg twice daily for 1-3 days works well in most regions, but its use is cautioned due to the emergence of resistance 1.

Seeking Medical Attention

It's crucial to seek medical attention if you experience high fever, bloody stools, severe abdominal pain, or symptoms lasting more than 3-5 days.

Key Considerations

• Antibiotics work by killing the bacterial pathogens causing the infection.
• Anti-motility agents like loperamide slow intestinal movement, allowing more water absorption and reducing stool frequency.
• The increasing antibiotic resistance among enteropathogens, as reported in the study on resistant pathogens 1, requires careful consideration in the selection of empiric therapy.

From the FDA Drug Label

that diarrhea is a common problem caused by antibiotics which usually ends when the antibiotic is discontinued. Sometimes after starting treatment with antibiotics, patients can develop watery and bloody stools (with or without stomach cramps and fever) even as late as two or more months after having taken the last dose of the antibiotic If this occurs, patients should contact their physician as soon as possible

• Traveler's diarrhea treatment is not explicitly mentioned in the provided drug labels.
• The labels for ciprofloxacin 2 and azithromycin 3 discuss the common problem of diarrhea caused by antibiotics, but do not provide specific guidance on treating traveler's diarrhea. The FDA drug label does not answer the question.

From the Research

Treatment Options for Traveler's Diarrhea

• Antibiotics such as azithromycin, fluoroquinolones, and rifaximin are recommended for moderate to severe traveler's diarrhea 4, 5, 6
• For mild traveler's diarrhea, the use of antibiotic is not recommended, instead bismuth subsalicylate or loperamide may be considered 5, 7
• Loperamide may be used alone for treatment of mild traveler's diarrhea or in conjunction with antibiotics for treatment of moderate to severe traveler's diarrhea 4, 5
• Racecadotril, a secretion inhibitor, is considered first choice for the treatment of acute uncomplicated traveler's diarrhea in some guidelines 8

Prevention of Traveler's Diarrhea

• Pretravel education on hygiene and on the safe selection of food items is important in minimizing episodes of traveler's diarrhea 5, 6
• Antibiotic prophylaxis has been recommended only under special circumstances, such as when a traveler with an underlying illness cannot tolerate traveler's diarrhea 4
• Rifaximin is the only current option for antibiotic prophylaxis due to increasing resistance to other antibiotics 4
• Bismuth subsalicylate (BSS) is also an option for prophylaxis 4

Management of Traveler's Diarrhea

• The key factor in the management of acute watery traveler's diarrhea is the restoration of water and electrolyte balance 7
• Oral rehydration solutions are indicated for infants, children, and the elderly, in whom dehydration may occur rapidly and be particularly dangerous 7
• Judicious use of an antimotility agent and antimicrobial therapy reduces the duration and severity of diarrhea 5