What is the treatment for traveler's diarrhea (TD) in Mexico?

From the Guidelines

For travelers' diarrhea in Mexico, the recommended treatment is loperamide (Imodium) for mild cases, taking 2 tablets (4 mg) initially, followed by 2 mg after each loose stool, not exceeding 16 mg daily, as it has been shown to be effective in reducing the duration and frequency of diarrhea 1.

Treatment Approach

The approach to treating travelers' diarrhea should prioritize supportive measures such as rehydration and the use of non-antibiotic, anti-motility drugs like loperamide for mild cases 1.

• Loperamide is recommended due to its efficacy in treating mild diarrhea, with a starting dose of 2 tablets (4 mg), followed by 2 mg after each loose stool, up to a maximum of 16 mg per day 1.
• It is essential to counsel travelers that loperamide takes 1 to 2 hours to reach its therapeutic effect, and additional dosing should be spaced accordingly to avoid rebound constipation 1.
• If diarrhea worsens or is accompanied by moderate to severe symptoms such as fever, abdominal pain, or bloody diarrhea, antibiotics should be considered 1.

Antibiotic Use

The use of antibiotics for travelers' diarrhea should be judicious, considering the increasing concerns about multidrug-resistant organisms (MDROs) and their implications on individual, community, and global health 1.

• The evidence supporting the use of antibiotics like azithromycin or fluoroquinolones is not as strong as that for loperamide in the treatment of mild diarrhea 1.
• However, for moderate to severe diarrhea, antibiotics may be necessary, and azithromycin is often preferred due to increasing resistance to fluoroquinolones in many regions, including Mexico 1.

Prevention and Hydration

Prevention of travelers' diarrhea is crucial, and this includes drinking bottled or purified water, avoiding raw vegetables, unpeeled fruits, street food, and ice cubes, and practicing good hand hygiene 1.

• Staying hydrated is essential, and travelers should drink purified water or oral rehydration solutions like Pedialyte to prevent dehydration 1.
• Most cases of travelers' diarrhea resolve within 3 to 5 days with appropriate treatment, but medical attention should be sought if symptoms persist or worsen 1.

From the FDA Drug Label

Treatment of diarrhea with loperamide hydrochloride is only symptomatic. Whenever an underlying etiology can be determined, specific treatment should be given when appropriate (or when indicated).

The FDA drug label does not answer the question about the treatment for traveler's diarrhea in Mexico.

From the Research

Treatment Options for Travelers Diarrhea in Mexico

• The combination of sulfamethoxazole-trimethoprim plus loperamide can be highly recommended for the treatment of most patients with traveler's diarrhea 2.
• Minimally absorbed rifaximin can effectively reduce the occurrence of travelers' diarrhea without side effects, and bismuth subsalicylate is a useful alternative, although it is less effective than rifaximin for the prevention of travelers' diarrhea 3.
• For mild travelers' diarrhea, the use of antibiotic is not recommended, but the use of bismuth subsalicylate or loperamide may be considered 4.
• For moderate travelers' diarrhea, antibiotics such as fluoroquinolones, azithromycin, and rifaximin may be used, and loperamide may be considered as monotherapy or adjunctive therapy 4.
• For severe travelers' diarrhea, antibiotics such as azithromycin, fluoroquinolones, and rifaximin should be used, and azithromycin can be used even for the treatment of dysentery whereas fluoroquinolones and rifaximin cannot be used for such purpose 4.

Comparison of Treatment Regimens

• A study compared the safety and efficacy of loperamide used in combination with ciprofloxacin or ciprofloxacin alone for the treatment of travelers' diarrhea, and found that loperamide combined with ciprofloxacin was not better than treatment with ciprofloxacin alone, but loperamide appeared to have some benefit in the first 24 hours of treatment in patients infected with enterotoxigenic E. coli 5.
• Another study found that the median time to recovery was 2.4 days with loperamide compared to 3.2 days with nifuroxazide and to 3.4 days for the no-treatment group, suggesting a rank of antidiarrheal potency as follows: loperamide > nifuroxazide > no-drug treatment 6.

Recommendations for Travelers

• Pretravel education on hygiene and on the safe selection of food items is important in minimizing episodes of travelers' diarrhea 4.
• All people who travel to high-risk areas should take curative antimicrobial agents with them for self-treatment of illness, such as rifaximin 200 mg three times a day for 3 days, or an absorbable agent such as a fluoroquinolone or azithromycin taken in a single dose initially, with the need for a second or third dose determined by clinical response 3.
• Loperamide (up to 8 mg per day for < or = 2 days) can be given with the antibiotic to offer rapid symptomatic improvement 3.