Traveler's diarrhea
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Background
- Most respond to antibiotics
- as duration of diarrhea increases, higher chance of parasitic cause
- 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[1]
Etiology
| 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 |
Differential Diagnosis
Acute diarrhea
Infectious
- Viral (e.g. rotavirus)
- Bacterial
- Campylobacter
- Shigella
- Salmonella (non-typhi)
- Escherichia coli
- E. coli 0157:H7
- Yersinia enterocolitica
- Vibrio cholerae
- Clostridium difficile
- Parasitic
- Toxin
Noninfectious
- GI Bleed
- Appendicitis
- Mesenteric Ischemia
- Diverticulitis
- Adrenal Crisis
- Thyroid Storm
- Toxicologic exposures
- Antibiotic or drug-associated
- Inflammatory bowel disease
Watery Diarrhea
- Enterotoxigenic E. coli (most common cause of watery diarrhea)[2]
- Norovirus (often has prominent vomiting)
- Campylobacter
- Non-typhoidal Salmonella
- Enteroaggregative E. coli (EAEC)
- Enterotoxigenic Bacteroides fragilis
Traveler's Diarrhea
- Giardia lamblia
- Cryptosporidiosis
- Entamoeba histolytica
- Cyclospora
- Clostridium perfringens
- Listeriosis
- Helminth infections
- Marine toxins
- Ciguatera
- Scombroid poisoning
- Paralytic shellfish poisoning
- Neurotoxic shellfish poisoning
- Diarrheal shellfish poisoning
Diagnosis[3]
- Travel
- 3 or more unformed stools per 24 hours
- plus (at least 1 of the following):
- abdominal cramps
- tenesmus
- nausea
- vomiting
- fever
- fecal urgency
- The average duration of untreated traveler’s diarrhea is 4 to 5 days
Workup
Uncomplicated Diarrhea
- No workup
Fever, Bloody Stools, or Ill Appearing
- Stool culture
- Systemic toxicity
- Extended workup including blood cultures
Persistent or Refractory Diarrhea (>14 days)
- Typically not done in the ER (at followup)
- Stool culture (including Salmonella, Shigella, and Campylobacter)
- Stool O&P (including testing for protozoal parasites, Giardia, Cryptosporidium)
Treatment
- Consider ondansteron if nausea
- Consider IVF if dehydrated
- Consider loperamide 4mg PO after each loose stool (Max: 16mg/day)
- if very frequent stools and no contra-indication:
- Not pregnant
- >2 years old
- fever or bloody stools without concomitant antibiotics (don't use as sole therapy)
- if very frequent stools and no contra-indication:
Antibiotics
- Ciprofloxacin 750mg PO once daily x 1-3 days[4]
- First choice for use except in South and Southeast Asia[5]
- Azithromycin 500mg PO q24h x 3 days OR 1000mg PO x 1[6]
- Rifaximin 200mg PO TID x 3 days[9]
- Ineffective against mucosally invasive pathogens (Shigella, Salmonella, Campylobacter)
- Considered very safe as it is not absorbed
Pediatrics
Antibiotic Options:
- Avoid fluroquinolones
- Azithromycin 10mg/kg/day once daily x 3 days OR[10]
- Ceftriaxone 50mg/kg/day once daily x 3 days
Disposition
- Outpatient, for the vast majority
- If systemic toxicity, consider admission
Complications
- Postinfectious irritable bowel syndrome
- Occurs in 3-17% of patients
- Risk factors
- Severity of traveler’s diarrhea
- Number of episodes
- Pretravel diarrhea
- Pretravel adverse life events
- Infection with heat-labile toxin–producing ETEC
- Reactive arthritis
- Guillain-Barré syndrome
See Also
Source
- ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
- ↑ Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
- ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
- ↑ Hoge CW. et al. Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years. Clin Infect Dis. 1998;26:341–5
- ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
- ↑ 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
- ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
- ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
- ↑ 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
- ↑ Stauffer WM, Konop RJ, Kamat D. Traveling with infants and young children. Part III: travelers’ diarrhea. J Travel Med. 2002;9:141–50