From the Guidelines
Antibiotic prophylaxis for traveler's diarrhea is not recommended for travel to Bhutan, except for individuals at high risk of health-related complications. When considering prophylaxis, the most recent guidelines suggest that Bismuth subsalicylate (BSS) may be considered for any traveler to prevent travelers’ diarrhea 1. However, this should be weighed against the potential risks and benefits.
For most travelers, the focus should be on preventive measures, including:
- Drinking only bottled, boiled, or treated water
- Eating thoroughly cooked foods
- Avoiding raw vegetables, unpeeled fruits, and street food
- Washing hands frequently with soap and water or using alcohol-based sanitizer
If diarrhea occurs, treatment options include:
- Loperamide (Imodium) for symptom relief
- Antibiotics like rifaximin (when indicated) for moderate to severe cases
- Oral rehydration salts to prevent dehydration
It's essential to note that fluoroquinolones are not recommended for prophylaxis of travelers’ diarrhea 1, and antimicrobial prophylaxis should not be used routinely in travelers 1. The potential risks of prophylactic antibiotics, including disruption of normal gut flora, antibiotic resistance, and side effects, outweigh the benefits for most travelers. Rifaximin is recommended when antibiotic prophylaxis is indicated 1, but this should be reserved for high-risk individuals.
From the Research
Traveller's Diarrhea Prophylaxis
- Traveller's diarrhea is a common illness encountered by travellers to less developed areas of the world, including Bhutan 2, 3, 4, 5.
- The most frequent causes of traveller's diarrhea are bacterial pathogens such as enterotoxigenic Escherichia coli (ETEC), enteroaggregative E. coli, Campylobacter spp., and Shigella spp. 2, 3.
- Prevention of traveller's diarrhea with antibiotics has been recommended only under special circumstances, such as when a traveller with an underlying illness cannot tolerate diarrhoea 2, 4, 5.
- Antibiotics such as doxycycline, trimethoprim-sulfamethoxazole, fluoroquinolones, and rifaximin have been used for prevention, but their use is limited due to increasing resistance 2, 5.
- Bismuth subsalicylate (BSS) is also an option for prophylaxis, although it provides only moderate protection 5, 6.
- Pretravel education on hygiene and safe selection of food items is important in minimizing episodes of traveller's diarrhea 3.
Recommendations for Bhutan
- There is no specific recommendation for traveller's diarrhea prophylaxis when traveling to Bhutan, as the risk of diarrhoea is generally high in developing countries 2, 3, 4, 5.
- Travellers to Bhutan should take precautions to avoid ingesting contaminated food and water, and consider taking prophylactic medications only if they have an underlying illness or are at high risk of complications 2, 4, 5.
- Bismuth subsalicylate or loperamide may be considered for mild traveller's diarrhea, while antibiotics such as azithromycin, fluoroquinolones, and rifaximin may be used for moderate to severe cases 2, 3.