Traveler's diarrhea

Background

  • A diarrheal syndrome which may be caused by a variety of intestinal pathogens contracted while traveling, particularly in low-income countries

Bacteria account for a majority of cases, but traveler's diarrhea may also be caused by parasites or viruses.

  • Most cases of traveler’s diarrhea are caused by bacterial enteropathogens, whereas bacterial pathogens cause less than 15% of endemic diarrhea cases in adults living in their home country[2]
    • Most cases respond to antibiotics (as opposed to non-traveler's acute gastroenteritis, which is most commonly caused by viruses)
    • As duration of diarrhea increases, higher chance of parasitic cause
  • At risk populations- Immunosuppressed, diabetes, taking meds to suppress acid production

Etiology[2]

Organism Latin America and Caribbean Africa South Asia Southeast Asia
Enterotoxigenic Escherichia coli ≥35 25-35 15-25 5-15
Enteroaggregative E coli 25-35 <5 15-25 No data
Campylobacter <5 <5 15-25 25-35
Salmonella <5 5-15 <5 5-15
Shigella 5-15 5-15 5-15 <5
Norovirus 15-25 15-25 5-15 <5
Rotavirus 15-25 5-15 5-15 <5
Giardia <5 <5 5-15 5-15

Clinical Features

Characterized by the following:[2]

  • Travel
  • 3 or more unformed stools per 24 hours
  • Plus (at least 1 of the following):
The average duration of untreated traveler’s diarrhea is 4 to 5 days[2]

Differential Diagnosis

Acute diarrhea

Infectious

Noninfectious

Watery Diarrhea

Traveler's Diarrhea

Evaluation

Diagnosis is typically made clinically

Uncomplicated Diarrhea

Fever, Bloody Stools, or Ill Appearing

  • Stool culture [2]
  • Systemic toxicity
    • Extended workup including blood cultures

Persistent or Refractory Diarrhea (>14 days)

Management

Supportive Care

  • PO hydration and consider oral rehydration fluids
  • Consider ondansetron if concurrent nausea/vomiting
  • Bismuth subsalicylate (Pepto Bismol) ~524 mg every 30 to 60 minutes or 1,050 mg every 60 minutes as needed (maximum: ~4,200 mg/24 hours)[4]
  • Consider IVF if dehydrated
  • Consider loperamide 4mg PO followed by 2mg after each loose stool (Max: 16mg/day)[2]
    • If very frequent stools and no contra-indication:
      • Not pregnant
      • >2 years old
      • Fever or bloody stools without concomitant antibiotics (do not use as sole therapy)

Antibiotics[2]

Pediatrics

Antibiotic Options:

Avoid fluroquinolones

Disposition

  • Outpatient for the vast majority
  • Consider admission if systemic toxicity

Complications

See Also

External Links

References

  1. ↑ http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/travelers-diarrhea
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  3. ↑ Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
  4. ↑ Brum, et al. Systematic Review and Meta-Analyses Assessment of the Clinical Efficacy of Bismuth Subsalicylate for Prevention and Treatment of Infectious Diarrhea. Dig Dis Sci. 2021; 66(7): 2323–2335. doi: 10.1007/s10620-020-06509-7
  5. ↑ Hoge CW. et al. Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years. Clin Infect Dis. 1998;26:341–5
  6. ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  7. ↑ Sanders JW. et al. An observational clinic-based study of diarrheal illness in deployed United States military personnel in Thailand: presentation and outcome of Campylobacter infection. Am J Trop Med Hyg. 2002;67:533–8
  8. ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  9. ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  10. ↑ DuPont HL. et al. Rifaximin versus ciprofloxacin for the treatment of traveler’s diarrhea: a randomized, double-blind clinical trial. Clin Infect Dis. 2001;33:1807–15
  11. ↑ Stauffer WM, Konop RJ, Kamat D. Traveling with infants and young children. Part III: travelers’ diarrhea. J Travel Med. 2002;9:141–50


Disposition

Fluoroquinolones International Society of Travel Medicine (ISTM) recommendations suggest fluoroquinolones may be used to treat:5 Moderate traveler's diarrhea (ISTM Strong recommendation, Moderate-level evidence), with qualifications due to the: Emergence of resistance to this drug class, especially in Southeast Asia Potential for adverse dysbiotic and musculoskeletal events Severe, nondysenteric traveler's diarrhea (ISTM Weak recommendation, Moderate-level evidence) Avoid fluoroquinolones in cases of suspected Shiga toxin-producing Escherichia coli (STEC), due to the potential for increased risk of complications.4 Dosing:1,2,3,5 Levofloxacin 500 mg orally once daily for 1-3 days (single dose can be continued daily for up to 3 days if symptoms do not resolve after 24 hours) Ciprofloxacin: 750 mg orally as single dose (continue daily dosing for up to 3 days if symptoms do not resolve after 24 hours) OR 500 mg orally twice daily for 3 days Ofloxacin 400 mg/day orally for 1-3 days (single dose can be continued daily for up to 3 days if symptoms do not resolve after 24 hours) Norfloxacin 400 mg orally once daily (not available in the United States) Fluoroquinolones may be associated with abdominal discomfort, nausea, insomnia, or irritability.4 Considerations in special populations:4 There have been concerns about transient musculoskeletal effects in children, but ciprofloxacin is considered safe for pediatric patients, particularly for short-course treatment. Use is not routinely advised during pregnancy. STUDY SUMMARY fluoroquinolones appear to be effective in patients with traveler's diarrhea DynaMed Level 2 RANDOMIZED TRIAL: Antimicrob Agents Chemother 1992 Jan;36(1):87

Details Resistance to fluoroquinolones Increasing rates of resistance to fluoroquinolones have been found among causative organisms of traveler's diarrhea.1,5 Impacted pathogens include Campylobacter, Shigella and Salmonella species. Fluoroquinolone resistance is particularly widespread in Southeast and South Asia. STUDY SUMMARY resistance of Campylobacter to fluoroquinolones may be increasing COHORT STUDY: N Engl J Med 1999 May 20;340(20):1525 COHORT STUDY: Emerg Infect Dis 2002 Dec;8(12):1501 COHORT STUDY: Emerg Infect Dis 2003 Feb;9(2):267 COHORT STUDY: Clin Infect Dis 1998 Feb;26(2):341 COHORT STUDY: Am J Trop Med Hyg 2002 Nov;67(5):533

Details Only 25% of Campylobacter jejuni and 33% of Campylobacter coli infections were susceptible to ciprofloxacin in a cohort study of 230 adults with acute diarrhea during a visit to Cusco, Peru between 2003 and 2010 (Am J Trop Med Hyg 2017 May;96(5):1097). Azithromycin International Society of Travel Medicine (ISTM) recommendations for azithromycin:5 Azithromycin may be used to treat moderate traveler's diarrhea (ISTM Strong recommendation, High-level evidence). It is the preferred treatment for severe traveler's diarrhea (including dysentery or febrile diarrhea) (ISTM Strong recommendation, Moderate-level evidence). It is the first-line choice for empiric therapy to cover fluoroquinolone-resistant Campylobacter in Southeast Asia and India, or other areas if there is suspicion of Campylobacter or resistant enterotoxigenic Escherichia coli. Azithromycin is effective against a broad range of pathogens that cause traveler's diarrhea, including Campylobacter infection.2,4 Dosage:1,5 Adult dosing: 1,000 mg orally once (if symptoms are not resolved after 24 hours, continue daily dosing for up to 3 days) 500 mg orally once daily for 3 days Dosing in children: 10 mg/kg orally once daily for 3 days Azithromycin is considered safe for children and pregnant persons.4 It may be associated with pruritus or candida vaginitis.4 Efficacy: Azithromycin 500 mg appears to have similar clinical efficacy compared to ciprofloxacin 500 mg in patients with traveler's diarrhea DynaMed Level 2 . Single dose azithromycin appears at least as effective as single dose levofloxacin for traveler's diarrhea DynaMed Level 2 . Azithromycin 1,000 mg appears to have similar efficacy compared to levofloxacin 500 mg in adults with traveler's diarrhea receiving loperamide DynaMed Level 2 . Azithromycin 1,000 mg orally once appears more effective than a 3-day course of azithromycin 500 mg or levofloxacin 500 mg for resolution of traveler's diarrhea DynaMed Level 2 . See Comparative efficacy of antibiotics for the details of each study. Rifaximin International Society of Travel Medicine (ISTM) recommends rifaximin may be used for treatment of:5 Moderate traveler's diarrhea (ISTM Weak recommendation, Moderate-level evidence), but suggest caution when considering rifaximin in regions with high risk of invasive pathogens Severe, nondysenteric traveler's diarrhea (ISTM Weak recommendation, Moderate-level evidence) Rifaximin is a poorly absorbed, gut-selective antibiotic.2,5 Rifaximin (Xifaxan) is FDA approved for treatment of patients ≥ 12 years old with traveler's diarrhea caused by noninvasive E. coli. Dose is 200 mg orally three times daily for 3 days. Adverse effects include headache. Reference - FDA DailyMed 2020 Oct 30 STUDY SUMMARY rifaximin may reduce duration of traveler's diarrhea in adults DynaMed Level 2 RANDOMIZED TRIAL: Am J Gastroenterol 2003 May;98(5):1073

Details Rifamycin Rifamycin (Aemcolo) is FDA approved for treatment of traveler’s diarrhea caused by noninvasive Escherichia coli. It is not approved for use in patients with diarrhea complicated by fever or blood in the stool or due to pathogens other than noninvasive strains of Escherichia coli. Dosing and administration: Dosing is 388 mg orally twice daily (in the morning and evening) for 3 days. Take each dose with 6-8 ounces of liquid. Do not take with alcohol. Adverse effects include headache and constipation. Reference - FDA DailyMed 2020 Feb 14 Rifamycin may be considered as an alternative to rifaximin.1

See Also

External Links

References

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