What is the treatment for travel diarrhea?

Treatment of Traveler's Diarrhea

For mild traveler's diarrhea, use loperamide alone without antibiotics; for moderate cases, azithromycin (single 1-gram dose or 500 mg daily for 3 days) is the preferred antibiotic with optional loperamide; for severe cases, azithromycin is mandatory with loperamide as adjunctive therapy only if no fever or bloody stools are present. 1, 2

Severity-Based Treatment Algorithm

Mild Traveler's Diarrhea (Tolerable, Not Disrupting Activities)

• Start with loperamide only: 4 mg loading dose, then 2 mg after each loose stool, maximum 16 mg per day 1, 2
• Do not use antibiotics for mild cases to minimize antimicrobial resistance 1, 2
• Ensure adequate hydration with oral rehydration solutions 1
• Escalate immediately to antibiotics if fever, moderate-to-severe abdominal pain, or bloody diarrhea develop 1

Moderate Traveler's Diarrhea (Distressing, Disrupting Activities)

• Azithromycin is the preferred first-line antibiotic: Single 1-gram dose OR 500 mg daily for 3 days 1, 2, 3
• Loperamide can be used as monotherapy or combined with antibiotics for faster symptomatic relief 1, 2
• When combining loperamide with antibiotics, the mean time to last unformed stool decreases to less than half a day 1
• Alternative option: Rifaximin 200 mg three times daily for 3 days, but only for non-invasive watery diarrhea (not for dysentery or febrile illness) 1

Severe Traveler's Diarrhea (Incapacitating, Dysentery, or Febrile)

• Azithromycin is mandatory: Single 1-gram dose OR 500 mg daily for 3 days 1, 2, 3
• Loperamide can be used as adjunctive therapy ONLY if no fever or blood in stool 1, 2
• Do not use loperamide if fever, severe abdominal pain, or bloody diarrhea is present 1, 3
• Single-dose antibiotic regimens are preferred when possible for better compliance 1

Regional Considerations: Southeast Asia and India

Azithromycin is clearly superior to fluoroquinolones in Southeast Asia and India due to fluoroquinolone resistance exceeding 85-90% for Campylobacter. 1, 2, 3

• Always use azithromycin first-line for travel to these regions 1, 2
• Fluoroquinolone resistance is increasing globally, not just in Southeast Asia 1, 3
• Ciprofloxacin 500 mg twice daily for 3-7 days may still be considered for non-dysenteric cases outside Southeast Asia, but azithromycin remains preferred 3

Critical Safety Warnings for Loperamide

Discontinue loperamide immediately if any of the following develop: 1, 3, 4

• Fever
• Severe abdominal pain
• Blood in stool
• Symptoms persist beyond 48 hours

Loperamide is contraindicated in children less than 2 years of age due to risks of respiratory depression and serious cardiac adverse reactions 4

• Avoid loperamide dosages higher than recommended (maximum 16 mg daily) due to risk of serious cardiac adverse reactions including QT prolongation, Torsades de Pointes, and sudden death 4
• Use with special caution in pediatric patients due to greater variability of response and risk of CNS effects 4

Special Populations

Children and Pregnant Women

• Azithromycin is the preferred agent for children and pregnant women 1, 2
• Avoid fluoroquinolones in children less than 6 years of age 1

HIV-Infected Persons

• Consider empiric fluoroquinolones before departure for self-treatment 1, 2
• Consider ciprofloxacin for salmonella gastroenteritis to prevent extraintestinal spread 1
• Stop therapy at earliest signs of abdominal distention due to risk of toxic megacolon 1

When to Seek Medical Attention

Seek medical attention if: 1

• Symptoms do not improve within 24-48 hours despite self-treatment
• Bloody diarrhea develops
• High fever with shaking chills occurs
• Severe dehydration is present

Microbiologic testing is strongly recommended for: 1, 2

• Severe or persistent symptoms (>14 days)
• Bloody diarrhea
• Failure of empiric antibiotic therapy
• Immunocompromised patients

Important Caveats

• Routine antibiotic prophylaxis is not recommended due to promotion of antimicrobial resistance and increasing association with acquisition of multidrug-resistant bacteria 1, 2
• Antibiotic treatment should be reserved for moderate to severe cases to minimize antimicrobial resistance 1, 2
• Loperamide should not be used when inhibition of peristalsis is to be avoided due to possible risk of ileus, megacolon, and toxic megacolon 4
• Avoid loperamide in combination with drugs that prolong the QT interval (Class 1A or III antiarrhythmics, certain antipsychotics, antibiotics like moxifloxacin) 4