Treatment of Traveler's Diarrhea
For traveler's diarrhea, treatment should be based on symptom severity, with rehydration as the cornerstone of therapy, antimotility agents for symptomatic relief in mild to moderate cases, and appropriate antibiotics for moderate to severe cases. 1
Assessment of Severity
Treatment approach should be tailored based on severity:
- Mild: Tolerable, doesn't interfere with activities
- Moderate: Distressing symptoms that interfere with activities
- Severe: Incapacitating symptoms, fever >38°C, or bloody diarrhea (dysentery)
First-Line Treatment Approach
1. Rehydration (All Cases)
- Maintain fluid and electrolyte balance with oral rehydration solutions
- Consume safe beverages (bottled water, hot coffee/tea, beer/wine)
- Include salt sources (crackers, soup) to prevent electrolyte imbalance
2. Antimotility Agents
- For mild to moderate cases without fever or bloody stools:
3. Antibiotic Therapy
- For moderate to severe cases:
| Severity | Recommended Treatment | Notes |
|---|---|---|
| Moderate (non-dysenteric) | Azithromycin + Loperamide | Combination more effective than antibiotics alone |
| Severe/Dysenteric | Azithromycin 1000mg single dose or 500mg daily for 3 days | Do NOT use loperamide with high fever or bloody stools [1] |
Specific Antibiotic Recommendations
First choice: Azithromycin (1000mg single dose or 500mg daily for 3 days)
- Preferred for dysentery and fever
- Safe in pregnancy
Alternative options:
- Fluoroquinolones (ciprofloxacin, levofloxacin): Use with caution due to increasing resistance and FDA warnings regarding tendon rupture, peripheral neuropathy, and CNS effects
- Rifaximin: For moderate non-dysenteric cases only; NOT for bloody diarrhea or fever
Important Cautions and Contraindications
Loperamide contraindications 2:
- Avoid in bloody diarrhea or high fever
- Contraindicated in children under 2 years
- Use with caution in elderly patients or those taking QT-prolonging medications
- Discontinue if constipation, abdominal distention, or ileus develops
When to seek immediate medical attention:
- Persistent symptoms >48 hours despite treatment
- Severe dehydration
- High fever
- Bloody stools
- Severe abdominal pain
Special Populations
- Children: Adjust antibiotic dosages based on weight; loperamide contraindicated under age 2
- Pregnant women: Azithromycin is preferred due to safety profile
- Immunocompromised patients: May require longer treatment duration
Follow-up Care
- Monitor for persistent symptoms for up to 2 weeks after return
- Microbiologic testing indicated for:
- Symptoms persisting >1 week
- Failure of empiric therapy
- Should include stool culture, ova and parasite examination, and testing for specific pathogens
Prevention Strategies
- Avoid high-risk foods: raw fruits/vegetables, raw/undercooked seafood/meat, tap water, ice, unpasteurized dairy, street vendor foods
- Safe food choices: steaming hot foods, self-peeled fruits, bottled beverages
- Routine antimicrobial prophylaxis is not recommended for most travelers 1