Treatment of Traveller's Diarrhea
Azithromycin is the preferred first-line antibiotic for moderate to severe traveller's diarrhea, given as either a single 1-gram dose or 500 mg daily for 3 days, with loperamide as adjunctive therapy for non-bloody cases. 1, 2
Severity-Based Treatment Algorithm
Mild Traveller's Diarrhea (tolerable, not distressing, doesn't interfere with activities)
- Do not use antibiotics for mild cases 3, 1
- Loperamide is the preferred treatment: 4 mg loading dose, then 2 mg after each loose stool, maximum 16 mg per day 3, 1, 2
- Bismuth subsalicylate may be considered as an alternative 3
- Ensure adequate hydration with oral rehydration solutions 1
Moderate Traveller's Diarrhea (distressing or interferes with planned activities)
- Azithromycin is recommended: single 1-gram dose or 500 mg daily for 3 days 3, 1, 2
- Loperamide can be used as monotherapy OR combined with antibiotics for faster symptom relief 3, 1
- When combining loperamide with antibiotics, mean time to last unformed stool decreases to less than half a day 1
- Alternative options include:
Severe Traveller's Diarrhea (incapacitating or prevents planned activities; ALL dysentery is severe)
- Antibiotics are mandatory 3, 2
- Azithromycin is the preferred agent: 1-gram single dose or 500 mg daily for 3 days 3, 1, 2
- Loperamide may be used as adjunctive therapy for non-bloody diarrhea 3
- Single-dose antibiotic regimens are effective and improve compliance 1
Critical Regional Considerations
Southeast Asia and India
- Azithromycin is clearly superior due to fluoroquinolone resistance exceeding 85-90% for Campylobacter 1, 2
- Avoid fluoroquinolones in this region 1
Mexico and Latin America
- Azithromycin remains the preferred agent for moderate to severe cases 5
- Fluoroquinolone resistance is lower than Southeast Asia but increasing 1
Important Safety Warnings and Contraindications
When to STOP Loperamide Immediately
- Discontinue if fever develops 1
- Discontinue if blood appears in stool 1
- Discontinue if severe abdominal pain occurs 1
- Avoid loperamide beyond 48 hours if symptoms persist 1
When to Avoid Rifaximin
- Do NOT use rifaximin for fever or bloody stools 4
- Do NOT use rifaximin for dysentery 3, 4
- Rifaximin is ineffective against Campylobacter jejuni, Shigella, and Salmonella 4
- Discontinue rifaximin if diarrhea persists more than 24-48 hours or worsens 4
Fluoroquinolone Concerns
- FDA has issued safety warnings regarding disabling peripheral neuropathy, tendon rupture, and CNS effects 1
- Increasing global resistance, particularly in Southeast Asia 3, 1
When to Seek Medical Attention
- Symptoms do not improve within 24-48 hours despite self-treatment 1, 2
- Bloody diarrhea develops 1, 2
- High fever with shaking chills occurs 1
- Severe dehydration is present 1
- Symptoms persist beyond 14 days (may indicate protozoal infections, post-infectious IBS, or inflammatory bowel disease) 2, 5
Microbiologic Testing Indications
- Severe or persistent symptoms (>14 days) 1, 2, 5
- Bloody diarrhea 2, 5
- Failure of empiric antibiotic therapy 1, 2, 5
- Immunocompromised patients 2, 5
Special Populations
Children and Pregnant Women
HIV-Infected Persons
- Consider empiric fluoroquinolones before departure for self-treatment 1, 2
- Consider ciprofloxacin for salmonella gastroenteritis to prevent extraintestinal spread 1
- For severely immunosuppressed children, consider TMP-SMX, ampicillin, cefotaxime, ceftriaxone, or chloramphenicol 1
Prophylaxis (Generally NOT Recommended)
- Antimicrobial prophylaxis should NOT be used routinely 3, 1, 2
- Bismuth subsalicylate may be considered for prevention 3, 2
- Prophylaxis may be considered for travelers at high risk of health complications or severe immunosuppression 3, 1
- If prophylaxis is deemed necessary, rifaximin is recommended over fluoroquinolones 3, 1