What is the treatment for traveler's diarrhea?

Treatment of Traveler's Diarrhea

The treatment of traveler's diarrhea should be tailored according to severity, with mild cases managed with loperamide or bismuth subsalicylate, moderate cases potentially requiring antibiotics plus loperamide, and severe cases requiring prompt antibiotic therapy with azithromycin as the preferred agent. 1

Classification of Traveler's Diarrhea

Traveler's diarrhea is categorized based on severity:

• Mild: Tolerable diarrhea that doesn't interfere with planned activities
• Moderate: Distressing diarrhea that interferes with planned activities
• Severe: Incapacitating diarrhea that completely prevents planned activities; all dysentery (bloody stools) is considered severe
• Persistent: Diarrhea lasting ≥2 weeks

Treatment Algorithm

For Mild Traveler's Diarrhea:

• Antibiotics are NOT recommended (Strong recommendation, moderate evidence) 1
• Treatment options:
  • Loperamide (Strong recommendation, moderate evidence) 1, 2
  • Bismuth subsalicylate (BSS) (Strong recommendation, moderate evidence) 1, 3
  • Maintain adequate hydration

For Moderate Traveler's Diarrhea:

• Antibiotics may be used (Weak recommendation, moderate evidence) 1
• Treatment options:
  • Loperamide as monotherapy (Strong recommendation, high evidence) 1
  • OR Antibiotics:
    • Azithromycin (Strong recommendation, high evidence) 1
    • Fluoroquinolones (Strong recommendation, moderate evidence) - with caution due to resistance concerns and adverse effects 1
    • Rifaximin (Weak recommendation, moderate evidence) - avoid if invasive pathogens suspected 1
  • Loperamide may be used as adjunctive therapy with antibiotics (Strong recommendation, high evidence) 1

For Severe Traveler's Diarrhea:

• Antibiotics should be used (Strong recommendation, high evidence) 1
• Preferred antibiotic: Azithromycin (Strong recommendation, moderate evidence) 1
• Alternative options:
  • Fluoroquinolones for non-dysenteric cases (Weak recommendation, moderate evidence) 1
  • Rifaximin for non-dysenteric cases (Weak recommendation, moderate evidence) 1
• Single-dose antibiotic regimens are effective (Strong recommendation, high evidence) 1
• Loperamide may be used as adjunctive therapy (Strong recommendation, high evidence) 1

Important Considerations and Precautions

When Using Loperamide:

• Cardiac risks: Cases of QT prolongation, Torsades de Pointes, and cardiac arrest have been reported with higher than recommended doses 2
• Contraindications:
  • Children under 2 years
  • When inhibition of peristalsis should be avoided
  • Combined with drugs that prolong QT interval
  • Patients with risk factors for QT prolongation 2
• Discontinue promptly if constipation, abdominal distention, or ileus develop 2

When to Seek Medical Attention:

• Dysentery (bloody stools)
• High fever
• Severe dehydration
• Diarrhea persisting >14 days 1, 4

Diagnostic Testing:

• Microbiologic testing is recommended for:
  • Severe or persistent symptoms
  • Failure to respond to empiric therapy 1
• Molecular testing is preferred when rapid results are needed 1

Special Situations

Persistent Diarrhea (≥14 days):

• Requires evaluation for specific pathogens, particularly protozoal infections 1, 5
• May be associated with post-infectious functional bowel disease 1

Antibiotic Resistance Concerns:

• Increasing resistance to fluoroquinolones, particularly in Southeast Asia 1, 6
• Balance benefits of antibiotic use against risk of acquiring multidrug-resistant bacteria 1

Prophylaxis

• Antimicrobial prophylaxis is not recommended routinely (Strong recommendation) 1
• Consider only for high-risk travelers with health conditions 1
• If prophylaxis is indicated, rifaximin is recommended (Strong recommendation) 1
• Bismuth subsalicylate may be considered for prevention (Strong recommendation) 1, 3

Remember that careful food and beverage selection remains the cornerstone of prevention, and treatment should focus on maintaining hydration while using appropriate symptomatic and antimicrobial therapy based on severity.