What is the treatment for traveler's diarrhea?

Treatment of Traveler's Diarrhea

For traveler's diarrhea, treatment should be based on symptom severity, with mild cases managed with loperamide alone and moderate to severe cases requiring antibiotics, with azithromycin being the preferred first-line antibiotic treatment. 1, 2

Classification and Treatment Algorithm

Mild Traveler's Diarrhea (little or no interference with daily activities)

• First-line treatment: Supportive care with rehydration and loperamide
  • Loperamide dosing: 4 mg loading dose, then 2 mg after each loose stool (maximum 16 mg/day) 1
  • Allow 1-2 hours between doses to avoid rebound constipation 1
• Avoid antibiotics for mild cases (strong recommendation) 1, 2
• Bismuth subsalicylate may be considered as an alternative 1

Moderate to Severe Traveler's Diarrhea (interferes with daily activities)

• First-line treatment: Antibiotics with or without loperamide
  • Preferred antibiotic: Azithromycin 1000 mg single dose or 500 mg daily for 3 days 2
  • Alternative antibiotics:
    • Rifaximin (not for dysentery or invasive disease)
    • Fluoroquinolones (with caution due to increasing resistance and adverse effects) 1, 2
• Loperamide can be used as adjunctive therapy or monotherapy 1

Dysentery (bloody diarrhea) or Fever

• First-line treatment: Azithromycin (strong recommendation) 2
• Avoid loperamide if high fever or blood in stool is present 2, 3

Important Considerations

Hydration

• Maintain adequate fluid and electrolyte replacement 2, 3
• For mild dehydration: 50 mL/kg of oral rehydration solution over 2-4 hours
• For moderate dehydration: 100 mL/kg of oral rehydration solution over 2-4 hours
• Severe dehydration (≥10% fluid deficit) requires immediate IV fluids 2

Antibiotic Selection Considerations

• Azithromycin is preferred over fluoroquinolones due to:
  • Increasing fluoroquinolone resistance globally 1, 2
  • Better safety profile in children and pregnant women 2
  • Superior efficacy in areas with high fluoroquinolone resistance 2
• Rifaximin should be used with caution in regions where invasive pathogens are common 1

Loperamide Safety

• Contraindications: Pediatric patients less than 2 years of age due to risk of respiratory depression and cardiac adverse reactions 3
• Caution: Risk of cardiac adverse reactions including QT prolongation with higher than recommended doses 3
• Discontinue if symptoms persist >48 hours or if constipation, abdominal distention, or ileus develop 2, 3

When to Seek Medical Attention

• Severe diarrhea not responding to empiric therapy
• Blood in stool
• Fever with shaking chills
• Signs of dehydration
• Symptoms persisting >1 week 2

Prevention Strategies

• Avoid raw fruits and vegetables, raw/undercooked seafood or meat, street vendor food, and unpasteurized dairy 2
• Safe beverages include bottled drinks, hot coffee/tea, beer/wine, and water boiled for >1 minute 2
• Treat tap water with iodine/chlorine or boil for >1 minute 2
• Avoid swallowing water while swimming 2
• Routine antibiotic prophylaxis is not recommended due to risk of promoting drug-resistant organisms 2

The evidence strongly supports a judicious approach to antibiotic use in traveler's diarrhea, reserving antibiotics for moderate to severe cases while managing mild cases with symptomatic treatment and hydration to minimize the development of antibiotic resistance.