Traveler's Diarrhea Prophylaxis
The Centers for Disease Control and Prevention (CDC) recommends non-pharmacological prophylaxis through careful food and water precautions as the primary prevention strategy for traveler's diarrhea, with antibiotic prophylaxis reserved only for high-risk travelers due to concerns about antimicrobial resistance. 1
Non-Pharmacological Prophylaxis (First-Line)
Food and Water Precautions
- Consume only steaming-hot foods that are thoroughly cooked
- Eat fruits that you peel yourself
- Avoid:
- Raw fruits and vegetables
- Raw or undercooked seafood or meat
- Items sold by street vendors 1
Safe Beverages
- Drink only:
- Bottled beverages
- Hot coffee and tea
- Beer and wine
- If using tap water, bring it to a rolling boil for 1 minute
- Water treatment with iodine or chlorine is a less effective alternative 1
Hygiene Measures
- Practice frequent handwashing with soap and water
- Supervise handwashing for children, especially after handling pets and before eating 1
Pharmacological Prophylaxis (Reserved for High-Risk Travelers)
Indications for Antibiotic Prophylaxis
- HIV-infected travelers
- Immunocompromised individuals
- Travelers with inflammatory bowel disease or other conditions where diarrhea would be particularly problematic
- Travelers on critical short-term missions where even brief illness would compromise objectives 1, 2
Recommended Prophylactic Regimen
- For those who qualify for prophylaxis, the CDC recommends providing a prescription for ciprofloxacin 500 mg twice daily for 3-7 days to be taken only if diarrhea develops 1
- Fluoroquinolones taken once daily while in the risk area provide up to 95% protection 3
Cautions with Antibiotic Prophylaxis
- Rising resistance to fluoroquinolones necessitates ongoing surveillance
- Resistance rates to ceftriaxone reached 14.2% in Asia-Africa after 2007
- Resistance to nalidixic acid and ciprofloxacin in Asia-Africa is progressively increasing 1
- Most authorities do not recommend routine prophylaxis for all travelers due to concerns about antimicrobial resistance 3, 2
Management if Diarrhea Develops Despite Prophylaxis
Mild Cases
- Provide salt (crackers or soup) and mineral water to prevent dehydration
- Symptomatic relief with loperamide (contraindicated in children under 2 years) 1, 4, 3
- Adults: Initial dose 4 mg followed by 2 mg after each unformed stool (maximum 16 mg/day)
- Children 2-12 years: Age-appropriate dosing per FDA guidelines 4
Moderate to Severe Cases
- For moderate diarrhea (requiring change in itinerary): Combination of fluoroquinolone with loperamide 3
- For severe diarrhea (fever >38°C, bloody stools): Azithromycin is preferred
- Dosage: 1000 mg single dose or 500 mg daily for 3 days 1
- If diarrhea persists after 3 days of ciprofloxacin, consider adding metronidazole 500 mg three times daily for 7-10 days 1
Special Considerations
Pediatric Patients
- Loperamide is contraindicated in children under 2 years due to risks of respiratory depression and cardiac adverse reactions 4
- Azithromycin is preferred over fluoroquinolones in children due to its safety profile 1
Elderly Patients
- No dose adjustment required for elderly patients taking loperamide
- Avoid loperamide in elderly patients taking drugs that can prolong QT interval 4
Pregnant Women
- Azithromycin has a better safety profile compared to fluoroquinolones 1
The evidence strongly supports prioritizing non-pharmacological prevention strategies for most travelers, with pharmacological prophylaxis reserved for specific high-risk individuals. This approach balances the benefits of prevention against the risks of contributing to antimicrobial resistance.