What is the treatment for traveler's diarrhea?

Treatment of Traveler's Diarrhea

Antibiotics should be used to treat severe traveler's diarrhea, with azithromycin as the preferred first-line agent, particularly for dysentery or when traveling in Southeast Asia. 1, 2

Classification and Treatment Approach

Treatment of traveler's diarrhea depends on symptom severity:

Mild Traveler's Diarrhea

• Antibiotic treatment is not recommended for mild traveler's diarrhea 1, 2
• Loperamide (4 mg first dose, then 2 mg after each loose stool, maximum 16 mg/day) or bismuth subsalicylate may be used for symptomatic relief 1, 3
• Focus on hydration and electrolyte replacement 2

Moderate Traveler's Diarrhea

• Antibiotics may be used but are not always necessary 1, 2
• Treatment options include:
  • Loperamide as monotherapy or adjunctive therapy 1, 4
  • Azithromycin (500 mg daily for 3 days or single 1-gram dose) 1, 2
  • Fluoroquinolones (e.g., ciprofloxacin 500 mg twice daily for 1-3 days) with caution due to resistance concerns 1, 2
  • Rifaximin (200 mg three times daily for 3 days) for non-invasive diarrhea only 1

Severe Traveler's Diarrhea

• Antibiotics should be used (strong recommendation, high level of evidence) 1
• Azithromycin is the preferred first-line agent (strong recommendation, moderate level of evidence) 1, 2
  • Dosing: 1 gram single dose or 500 mg daily for 3 days 1, 2
• Fluoroquinolones may be used for severe non-dysenteric cases (weak recommendation) 1, 2
• Single-dose antibiotic regimens are effective and improve compliance 1, 2
• Loperamide may be used as adjunctive therapy 1, 4

Regional Considerations

• In Southeast Asia and India, azithromycin is clearly superior due to high fluoroquinolone resistance (>90% for Campylobacter) 1, 2
• Increasing fluoroquinolone resistance is being reported globally 2
• Do not use rifaximin if clinical suspicion for Campylobacter, Salmonella, Shigella, or other causes of invasive diarrhea 1

Important Caveats and Precautions

• Seek medical attention if symptoms do not improve within 24-36 hours despite self-treatment 2
• Microbiological testing is recommended for:
  • Severe or persistent symptoms (>14 days) 1, 2
  • Treatment failures 1
  • Bloody diarrhea 2
• Loperamide carries risks of cardiac adverse reactions at higher than recommended doses 4
• Avoid loperamide in combination with drugs that prolong QT interval 4
• There is an increasing association between travel, traveler's diarrhea, and antibiotic use with the acquisition of multidrug-resistant bacteria 1, 2

Antibiotic Selection and Dosing

• Azithromycin: 1 gram single dose or 500 mg daily for 3 days 1, 2
• Fluoroquinolones (for non-dysenteric cases):
  • Ciprofloxacin: 750 mg single dose or 500 mg twice daily for 1-3 days 1
  • Levofloxacin: 500 mg single dose or 500 mg daily for 1-3 days 1
• Rifaximin: 200 mg three times daily for 3 days (only for non-invasive watery diarrhea) 1

Practical Recommendations

• Provide travelers with loperamide and an appropriate antibiotic for self-treatment 2
• Single-dose antibiotic regimens should be considered when possible for better compliance 1, 2
• Fluid and electrolyte replacement remains essential in all cases 4, 5
• Travelers should be advised that persistent diarrhea (>14 days) requires medical evaluation 1, 2