From the Guidelines
Traveler's Diarrhea (TD) treatment should start with supportive measures such as rehydration and non-antibiotic, anti-motility drugs like loperamide for mild cases.
Treatment Approach
- For mild diarrhea, loperamide is recommended as the first-line treatment, with a starting dose of 2 tablets (4 mg), followed by 2 mg after each additional loose or liquid stool, up to a total dose of 16 mg per day 1.
- Antibiotics should be reserved for moderate to severe cases, or when symptoms worsen or are accompanied by fever, abdominal pain, or bloody diarrhea.
- Azithromycin is recommended as the first-line antibiotic for dysentery and acute watery diarrhea with fever, due to its efficacy against FQ-resistant Campylobacter and other bacterial causes 1.
- Rifaximin, a nonabsorbable antibiotic, is an alternative for non-invasive TD caused by diarrheagenic E. coli, but is less effective for invasive pathogens 1.
Considerations
- The decision to treat TD with antibiotics should balance the benefits of symptom reduction against the risks of antibiotic resistance, side effects, and impact on the individual's microbiota 1.
- Single-dose regimens may minimize the risk of adverse consequences, but more research is needed to confirm this 1.
- Fluoroquinolones (FQs) are effective but may have concerns regarding resistance, side effects, and potential for C. difficile infection 1.
From the Research
Treatment Options for Traveler's Diarrhea
The treatment for Traveler's Diarrhea (TD) depends on the severity of the symptoms. According to 2, 3, 4, 5, 6, the mainstay of treatment includes:
- Antibacterial therapy with one of three drugs: a fluoroquinolone, rifaximin, or azithromycin
- Probiotics have been used in preliminary studies for both treatment and prevention of TD, but more studies are needed with these biologic agents
Mild Traveler's Diarrhea
For mild cases, the use of antibiotics is not recommended 5. Instead:
- Bismuth subsalicylate or loperamide may be considered for treatment
- Loperamide may be used alone for treatment of mild TD
Moderate Traveler's Diarrhea
For moderate cases, antibiotics such as:
- Fluoroquinolones
- Azithromycin
- Rifaximin may be used 3, 5. Loperamide may be considered as monotherapy or adjunctive therapy.
Severe Traveler's Diarrhea
For severe cases, antibiotics such as:
- Azithromycin
- Fluoroquinolones
- Rifaximin should be used 5. Azithromycin can be used even for the treatment of dysentery, whereas fluoroquinolones and rifaximin cannot be used for such purpose.
Single-Dose Antibiotic Regimens
A randomized controlled trial compared 3 single-dose antibiotic regimens with loperamide for the treatment of TD 4. The results showed that:
- Single-dose azithromycin, levofloxacin, and rifaximin with loperamide were comparable for treatment of acute watery diarrhea
- Clinical cure at 24 hours occurred in 81.4%, 78.3%, and 74.8% of the levofloxacin, azithromycin, and rifaximin arms, respectively