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 antibiotics reserved for moderate to severe cases, while azithromycin is preferred for severe diarrhea, especially dysentery. 1

Classification of Traveler's Diarrhea

Traveler's diarrhea is classified 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 Based on Severity

Mild Traveler's Diarrhea

• Antibiotics are NOT recommended (Strong recommendation, moderate evidence) 1
• Treatment options:
  • Loperamide (2mg after first loose stool, then 2mg after each subsequent loose stool, max 16mg/day) 1, 2
  • Bismuth subsalicylate (BSS) 1
  • Maintain adequate hydration with safe fluids

Moderate Traveler's Diarrhea

• Treatment options:
  • Loperamide alone can be considered (Strong recommendation, high evidence) 1
  • Antibiotics may be used (Weak recommendation, moderate evidence) 1
    • Azithromycin: 1000mg single dose or 500mg daily for 3 days (Strong recommendation, high evidence) 1
    • Fluoroquinolones: Single dose or 3-day course (Strong recommendation, moderate evidence) 1
    • Rifaximin: 200mg three times daily for 3 days (Weak recommendation, moderate evidence) 1
  • Combination therapy: Loperamide plus antibiotic (Strong recommendation, high evidence) 1

Severe Traveler's Diarrhea

• Antibiotics should be used (Strong recommendation, high evidence) 1
• Preferred antibiotic: Azithromycin (Strong recommendation, moderate evidence) 1
  • Particularly for dysentery or febrile diarrhea
  • 1000mg single dose or 500mg daily for 3 days
• For non-dysenteric severe diarrhea:
  • Fluoroquinolones may be used (Weak recommendation, moderate evidence) 1
  • Rifaximin may be used (Weak recommendation, moderate evidence) 1
• Single-dose antibiotic regimens are effective (Strong recommendation, high evidence) 1
• Loperamide can be used as adjunctive therapy (Strong recommendation, high evidence) 1

Persistent Diarrhea (≥2 weeks)

• Microbiologic testing is recommended (Strong recommendation, low/very low evidence) 1
• Molecular testing is preferred when rapid results are needed 1

Important Medication Considerations

Loperamide Safety Precautions

• Cardiac risks: Cases of QT prolongation, Torsades de Pointes, and cardiac arrest have been reported with higher than recommended doses 2
• Avoid loperamide in:
  • Children under 2 years (contraindicated)
  • Patients taking QT-prolonging medications
  • Patients with risk factors for QT prolongation 2
• Discontinue promptly if constipation, abdominal distention, or ileus develop 2
• Do not use when inhibition of peristalsis should be avoided 2

Antibiotic Selection Considerations

• Azithromycin is preferred for:
  • Dysentery (bloody stools)
  • Febrile diarrhea
  • Travel to Southeast Asia or India (high fluoroquinolone resistance) 1
• Rifaximin should be used with caution in regions with high risk of invasive pathogens 1
• Fluoroquinolones have increasing resistance and potential adverse effects 1

Prevention Strategies

• Food and water precautions are the most important preventive measures 3
• Antimicrobial prophylaxis is not recommended for routine use 1
• Bismuth subsalicylate may be considered for prevention 1
• Rifaximin is recommended when antibiotic prophylaxis is indicated 1

Follow-up Care

• If diarrhea persists beyond 14 days, further evaluation is warranted 1, 4
• Patients with severe or persistent symptoms or those who fail empiric therapy should undergo microbiologic testing 1
• Be aware that post-infectious irritable bowel syndrome can develop following traveler's diarrhea 1

Common Pitfalls to Avoid

1. Using antibiotics for mild cases when they're not needed
2. Using fluoroquinolones in regions with high resistance (Southeast Asia)
3. Continuing loperamide despite worsening symptoms or development of dysentery
4. Neglecting hydration and electrolyte replacement
5. Failing to recognize when microbiological testing is needed for persistent symptoms