What is the treatment for traveler's diarrhea?

From the Guidelines

For treating traveler's diarrhea, start with oral rehydration using water mixed with electrolyte solutions or sports drinks, and take loperamide (Imodium) 4mg initially, then 2mg after each loose stool (maximum 16mg daily) to reduce frequency of bowel movements. For moderate to severe cases, antibiotics are effective: azithromycin 1000mg as a single dose or 500mg daily for 3 days; alternatively, ciprofloxacin 500mg twice daily for 1-3 days (though resistance is increasing in some regions) 1. The use of loperamide is supported by a study that compared loperamide to rifaximin and the combination of rifaximin plus loperamide for the treatment of TD in a large study of travelers to Mexico, which found that loperamide alone was effective in reducing the mean number of diarrheal stools 1. It is also recommended to continue eating simple, bland foods like rice, bananas, and toast while avoiding dairy, caffeine, and alcohol. Seek medical attention if you experience high fever (over 102°F/39°C), bloody stools, severe abdominal pain, or symptoms lasting more than 3-5 days. These treatments work by combating the bacterial infection causing the diarrhea while managing symptoms and preventing dehydration, which is the most dangerous complication of traveler's diarrhea. Key considerations in the selection of an empiric antibiotic include the likelihood of treatment efficacy and rapidity of response, regional patterns of probable target pathogens and their antimicrobial resistance, safety and tolerance profile of the antibiotic, simplicity of treatment regimen, and cost 1. Azithromycin is generally well tolerated with minimal side effects, usually dose-related gastrointestinal complaints, and has demonstrated effective and comparable cure rates with shigellosis, another common agent causing dysentery 1. The use of azithromycin is recommended as the first-line agent in cases of dysentery, as well as acute watery diarrhea with greater than mild fever, given the increased likelihood of FQ-resistant Campylobacter, and other bacterial causes such as Shigella spp., enteroinvasive E. coli, Aeromonas spp., Plesiomonas spp., and Yersinia enterocolitica 1.

Some other points to consider:

• The rates of mild illness may vary widely depending on such factors as the geographic area, type of trip, age of traveler, and previous exposure; however, a sizeable proportion of illnesses will fall into the mild category defined as causing little or no interference in normal daily activities 1.
• Travelers should be counseled that it takes 1 to 2 hours for loperamide to reach its therapeutic effect, so additional dosing should be spaced accordingly so as to avoid rebound constipation 1.
• The decision to treat TD with non-specific anti-diarrheal medications and/or an antimicrobial agent is based on assessment of the severity of illness and the effects it will have on the traveler’s activities and plans 1.
• Rifaximin, a nonabsorbable antibiotic, has demonstrated comparable efficacy to FQs in non-invasive TD caused by diarrheagenic E. coli, but is less effective for the treatment of invasive pathogens, with failure to achieve wellness 1.
• Single-dose antibiotic regimens may be used to treat moderate or severe travelers’ diarrhea 1.
• Loperamide may be used as adjunctive therapy for moderate to severe travelers’ diarrhea, and may be considered for use as monotherapy in moderate travelers’ diarrhea 1.

Overall, the treatment of traveler's diarrhea should be based on the severity of the illness and the impact on the traveler's activities and plans, and should take into account the potential risks and benefits of different treatment options.

From the FDA Drug Label

Dehydration Fluid and electrolyte depletion often occur in patients who have diarrhea In such cases, administration of appropriate fluid and electrolytes is very important. The use of loperamide hydrochloride does not preclude the need for appropriate fluid and electrolyte therapy 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).

Traveling diarrhea treatment with loperamide hydrochloride is symptomatic.

• Administration of appropriate fluid and electrolytes is very important in cases of dehydration.
• Specific treatment should be given when the underlying etiology can be determined. 2

From the Research

Treatment Options for Traveler's Diarrhea

• The combination of an antibiotic and loperamide is a recommended treatment for traveler's diarrhea 3.
• Azithromycin and loperamide are comparable to levofloxacin and loperamide for the treatment of traveler's diarrhea 3.
• Adding loperamide to antibiotic treatment may accelerate resolution of symptoms in traveler's diarrhea with minimal or no adverse effects 4.

Antibiotic Treatment

• Azithromycin is the drug of choice for treatment of traveler's diarrhea, especially in Asia where Campylobacter is common 5.
• Fluoroquinolone antibiotics are effective in Latin America and Africa where ETEC is predominant 5.
• Doxycycline, trimethoprim-sulfamethoxazole, and rifaximin have been used for prevention of traveler's diarrhea, but resistance is a concern 5.

Loperamide Treatment

• Loperamide may be used alone for treatment of mild traveler's diarrhea or in conjunction with antibiotics for treatment of moderate to severe traveler's diarrhea 5.
• The combination of loperamide and ciprofloxacin was not better than treatment with ciprofloxacin alone in a region where enterotoxigenic E. coli was the predominant cause of traveler's diarrhea 6.
• Loperamide appeared to have some benefit in the first 24 hours of treatment in patients infected with enterotoxigenic E. coli 6.

Alternative Treatments

• Racecadotril, a secretion inhibitor, is considered a first-choice treatment for acute uncomplicated traveler's diarrhea in some guidelines 7.
• Bismuth subsalicylate (Pepto-Bismol tablets) is also an option for prophylaxis and treatment of traveler's diarrhea 5.