From the Guidelines
The first line treatment for traveler's diarrhea is azithromycin (1000mg single dose or 500mg daily for 3 days) due to its efficacy in treating moderate to severe cases and its ability to cover a broad range of pathogens, including those resistant to fluoroquinolones 1.
Key Considerations
- The decision to treat traveler's diarrhea with antibiotics is based on the severity of illness and its impact on the traveler's activities and plans.
- Azithromycin is recommended as the first-line agent for dysentery and acute watery diarrhea with greater than mild fever due to its effectiveness against FQ-resistant Campylobacter and other bacterial causes.
- The use of fluoroquinolones, such as ciprofloxacin, is still an option, but their efficacy is limited by increasing resistance rates, particularly in Southeast Asia 1.
Treatment Approach
- For mild cases, focus on maintaining hydration with oral rehydration solutions or clear fluids while continuing to eat as tolerated.
- For symptomatic relief, loperamide (Imodium) 4mg initially followed by 2mg after each loose stool (maximum 16mg/day) can be used to reduce frequency of bowel movements.
- In moderate to severe cases, add an antibiotic such as azithromycin (1000mg single dose or 500mg daily for 3 days) to eliminate the bacterial cause of diarrhea.
Important Notes
- Antimotility agents, such as loperamide, should not be used by patients with high fever or with blood in the stool, and their use should be discontinued if symptoms persist beyond 48 hours 1.
- It is crucial to maintain adequate fluid and electrolyte intake to prevent dehydration, which is the primary risk of traveler's diarrhea.
- The choice of antibiotic should be guided by the severity of illness, the likelihood of treatment efficacy, and regional patterns of antimicrobial resistance.
From the Research
First Line Treatment for Traveler's Diarrhea
- The first line treatment for traveler's diarrhea is antibiotic therapy, which significantly reduces symptom severity and duration of illness 2.
- Azithromycin is the preferred first-line antibiotic for the treatment of acute watery diarrhea, as well as for febrile diarrhea and dysentery 2.
- The recommended dosage for azithromycin is a single dose of 500 mg for acute watery diarrhea and 1,000 mg for febrile diarrhea and dysentery 2.
- Other options for acute watery diarrhea include levofloxacin and ciprofloxacin, but their use is becoming less effective due to increasing fluoroquinolone resistance 2.
- Rifaximin is another alternative for acute watery diarrhea, but it should not be used with invasive illness 2.
- The use of loperamide in combination with antibiotic treatment is also beneficial, as it has been shown to further reduce gastrointestinal symptoms and duration of illness 2, 3, 4.
Combination Therapy
- Combination therapy with azithromycin and loperamide has been shown to be as effective as combination therapy with levofloxacin and loperamide for the treatment of traveler's diarrhea 3.
- Loperamide plus azithromycin has been found to be more effective than azithromycin alone in treating traveler's diarrhea in Mexico 4.
- The combination of loperamide and azithromycin has been shown to reduce the duration of diarrhea and the number of unformed stools passed in the first 24 hours after treatment 4.