What is the workup and treatment for traveler's diarrhea?

Workup and Treatment of Traveler's Diarrhea

For most cases of traveler's diarrhea, treatment should be based on severity, with antimicrobial therapy recommended for moderate to severe cases, while mild cases can be managed with hydration and symptomatic treatment. 1

Diagnosis and Workup

Clinical Assessment

• Determine severity based on symptoms:
  • Mild: Tolerable, not distressing, doesn't interfere with planned activities
  • Moderate: Distressing, interferes with planned activities
  • Severe: Incapacitating, prevents planned activities, bloody stools (dysentery) or fever

Laboratory Testing

• Routine testing is not indicated for acute, uncomplicated cases
• Microbiologic testing of stool is indicated for:
  • Persistent symptoms (>1 week)
  • Patients who fail empiric therapy
  • Severe illness with fever or bloody diarrhea

Testing Should Include:

• Stool culture for bacterial pathogens
• Ova and parasite examination
• Giardia and Cryptosporidium antigen testing
• Clostridium difficile testing 1

Treatment Algorithm

1. Mild Diarrhea

• Rehydration: Cornerstone of therapy regardless of severity
  • Oral rehydration solutions or increased fluid intake
• Symptomatic treatment options:
  • Loperamide: 4mg first dose, then 2mg after each loose stool (max 16mg/24 hours)
  • Bismuth subsalicylate: For moderate forms of diarrhea 1
• No antibiotics needed for mild cases

2. Moderate to Severe Diarrhea

• Rehydration plus antimicrobial therapy:

• First-line antibiotic:

  • Azithromycin: 1000mg single dose or 500mg daily for 3 days
  • Preferred for dysentery (bloody diarrhea) and febrile diarrhea
  • Superior cure rates (96%) compared to fluoroquinolones in regions with high resistance 1

• Alternative antibiotics:

  • Fluoroquinolones (e.g., ciprofloxacin): For non-dysenteric cases where resistance is less common
    • Note: Take ciprofloxacin with plenty of fluids, avoid dairy products or antacids within 2 hours before or 6 hours after dosing 2
  • Rifaximin: 200mg three times daily for 3 days for non-dysenteric, non-febrile diarrhea only 1

• Combination therapy:

  • Loperamide + antibiotic: For faster symptomatic relief in non-dysenteric cases 1

3. Special Considerations

• Regional variations:

  • In Southeast Asia and India: Use azithromycin as first-line due to high fluoroquinolone resistance rates 1
  • In other regions: Fluoroquinolones remain effective for non-dysenteric cases 1

• Complete the full course of antibiotics to prevent resistance development 2

Prevention Strategies

Food and Water Precautions

• Avoid:

  • Untreated tap water and ice cubes
  • Unpasteurized dairy products
  • Raw fruits and vegetables (unless self-peeled)
  • Raw or undercooked seafood and meat
  • Food from street vendors 1

• Safe options:

  • Steaming hot foods
  • Bottled beverages
  • Hot coffee and tea
  • Beer and wine
  • Water boiled for 1-2 minutes 1

Prophylaxis

• Not routinely recommended for most travelers
• May be considered for high-risk travelers (immunocompromised, inflammatory bowel disease) 1

Post-Travel Care

• Monitor for fever or persistent gastrointestinal symptoms for up to 2 weeks after return
• Seek medical attention if experiencing:
  • Fever, especially with jaundice or rash
  • Persistent diarrhea (>1 week)
  • Bloody stools or severe abdominal pain
  • Significant dehydration 1

Cautions and Pitfalls

• Avoid fluoroquinolones in areas with high resistance rates (Southeast Asia)
• Complete the full antibiotic course to prevent resistance development 2
• Watch for antibiotic side effects:
  • Ciprofloxacin: Photosensitivity, tendon issues, dizziness 2
  • Azithromycin: GI upset, QT prolongation in susceptible individuals
• Be alert for post-infectious complications like irritable bowel syndrome 3