Traveler's diarrhea - Revision history

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2026-01-05T00:01:28Z

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Rossdonaldson1: /* Disposition */

2025-01-29T16:42:07Z

Disposition

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	[[Category:Tropical Medicine]]		[[Category:Tropical Medicine]]


	~~==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==		==See Also==

Rossdonaldson1: /* Management */

2025-01-29T16:40:33Z

Management

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	==Management==		==Management==
	===Supportive Care===		===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)<ref>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</ref>		*[[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)<ref>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</ref>
	*Consider [[IVF]] if dehydrated		*Consider [[IVF]] if dehydrated

Rossdonaldson1: /* Management */

2025-01-29T16:36:40Z

Management

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	[[Category:Tropical Medicine]]		[[Category:Tropical Medicine]]


	~~==Management==~~
	~~Most bacterial and viral cases are self-limited and typically resolve in 2-7 days, though parasitic infection may persist for longer if untreated.~~
	~~The severity of illness determines treatment approach.~~
	~~Mild diarrhea is tolerable, not distressing, and does not interfere with planned activities.~~
	~~Moderate diarrhea is distressing or interferes with planned activities.~~
	~~Severe diarrhea is incapacitating or completely prevents planned activities. All dysentery (grossly bloody stools) is considered severe.~~
	~~Self-treatment is the preferred treatment strategy for many travelers as diarrhea often arises during travel.~~
	~~Provide medications to patients prior to travel.~~
	~~Educate patients about preventive measures.~~
	~~Management strategies:~~
	~~All patients with traveler's diarrhea should maintain hydration by drinking clear fluids (fruit juice, soups, tea) and gradually reintroduce regular foods to their diet.~~
	~~The risk of dehydration is higher in very young children or in adults with chronic medical illness.~~
	~~Oral rehydration may help travelers feel better more quickly.~~
	~~Antimotility therapy can be used when rapid control of symptoms is needed (for example, on a long bus ride without a toilet).~~
	~~Loperamide:~~
	~~Consider as monotherapy in patients with mild (ISTM Strong recommendation, Moderate-level evidence) or moderate (ISTM Strong recommendation, High-level evidence) traveler's diarrhea.~~
	~~Loperamide ay be used as adjunctive therapy with antibiotics in patients with moderate-to-severe traveler's diarrhea (ISTM Strong recommendation, High-level evidence).~~
	~~Dosing by age:~~
	~~For patients ≥ 12 years old, dosing is 4 mg orally after the first loose stool, then 2 mg orally after each subsequent loose stool (maximum 16 mg/24 hours; nonprescription maximum of 8 mg/24 hours).~~
	~~For patients 9-11 years old (27 kg-43 kg [60-95 lbs]), dosing is 2 mg orally after the first loose stool, then 1 mg orally after each subsequent loose stool (maximum 6 mg/24 hours).~~
	~~For patients 6-8 years old (21 kg-26 kg [48-59 lbs]), dosing is 2 mg orally after the first loose stool, then 1 mg orally after each subsequent loose stool (maximum 4 mg/24 hours).~~
	~~Do not use loperamide as monotherapy in patients with bloody diarrhea and fever.~~
	~~Bismuth subsalicylate:~~
	~~Consider bismuth subsalicylate in patients with mild traveler's diarrhea (ISTM Strong recommendation, Moderate-level evidence).~~
	~~It may reduce nausea.~~
	~~Dosing in adults and children ≥ 12 years old:~~
	~~Regular strength dosing is 525 mg orally every 0.5 to 1 hour as needed, up to a maximum of 8 doses/day (4200 mg/day).~~
	~~Extra strength dosing is 1050 mg orally every 1 hour as needed, up to a maximum of 4 doses in 24 hours (4200 mg/day).~~
	~~Bismuth subsalicylate is not recommended in children < 3 years old and typically not used in children < 12 years old.~~
	~~Antibiotics are recommended for patients with moderate-to-severe diarrhea.~~
	~~Antibiotics may reduce the duration of illness, but may carry an increased risk of adverse events.~~
	~~International Society of Travel Medicine recommendations for antibiotic use in traveler's diarrhea:~~
	~~Antibiotics are not recommended for mild traveler's diarrhea (ISTM Strong recommendation, Moderate-level evidence).~~
	~~Consider antibiotic therapy for moderate traveler's diarrhea (ISTM Weak recommendation, Moderate-level evidence). Options include:~~
	~~Azithromycin (ISTM Strong recommendation, High-level evidence)~~
	~~Fluoroquinolones (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~~
	~~Rifaximin (ISTM Weak recommendation, Moderate-level evidence), but caution is suggested when considering rifaximin in regions with a high risk of invasive pathogens~~
	~~Antibiotics are recommended for severe traveler's diarrhea (ISTM Strong recommendation, High-level evidence). Options include:~~
	~~Azithromycin (preferred) (ISTM Strong recommendation, Moderate-level evidence)~~
	~~Fluoroquinolones or rifaximin for severe, nondysenteric traveler's diarrhea (ISTM Weak recommendation, Moderate-level evidence)~~
	~~Single-dose regimens are recommended for moderate or severe traveler's diarrhea (ISTM Strong recommendation, High-level evidence).~~
	~~Antibiotics and antimotility agents should be avoided in cases of known or suspected infection with Shiga toxin-producing organisms.~~
	~~While most cases of traveler's diarrhea are caused by bacteria, in cases of known parasitic infection treatment options are based on the causative organism.~~
	~~Preferred options for giardiasis include:~~
	~~5-nitroimidazoles, such as:~~
	~~Tinidazole 2 g orally single dose (50 mg/kg single dose in children)~~
	~~Metronidazole 250 mg orally 3 times daily (15 mg/kg/day in 3 divided doses for children) for 5-7 days~~
	~~Nitazoxanide 500 mg orally twice daily taken with food for 3 days in adults and children ≥ 12 years old (7.5 mg/kg twice daily for 3 days in children < 12 years old)~~
	~~See Giardiasis for additional information.~~
	~~Cryptosporidiosis may be treated with nitazoxanide.~~
	~~Cyclosporiasis may be treated with trimethoprim-sulfamethoxazole.~~
	~~Amebiasis may be treated with metronidazole or tinidazole, followed by luminal agent such as paromomycin or iodoquinol.~~

	==Disposition==		==Disposition==

Rossdonaldson1: /* Evaluation */

2025-01-29T16:36:22Z

Evaluation

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	{{Diarrhea DDX}}		{{Diarrhea DDX}}

	==Evaluation~~<ref name="Steffen"></ref>~~==		==Evaluation==
			''Diagnosis is typically made clinically''
	===Uncomplicated Diarrhea===		===Uncomplicated Diarrhea===
	*No workup		*No workup<ref name="Steffen"></ref>

	===Fever, Bloody Stools, or Ill Appearing===		===Fever, Bloody Stools, or Ill Appearing===
	*Stool culture		*Stool culture <ref name="Steffen"></ref>
	*Systemic toxicity		*Systemic toxicity
	**Extended workup including blood cultures		**Extended workup including blood cultures
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	*Typically not done in the ER (at follow-up)		*Typically not done in the ER (at follow-up)
	**Stool culture (including [[Salmonella]], [[Shigella]], and [[Campylobacter]])		**Stool culture (including [[Salmonella]], [[Shigella]], and [[Campylobacter]])
	**Stool O&P (including testing for protozoal parasites, [[Giardia]], [[Cryptosporidium]])		**Stool O&P (including testing for protozoal parasites, [[Giardia]], [[Cryptosporidium]])<ref name="Steffen"></ref>
	**Fecal leukocytes, giardia antigen, C. difficile PCR		**Fecal leukocytes, giardia antigen, C. difficile PCR

Rossdonaldson1: /* Evaluation */

2025-01-29T16:34:29Z

Evaluation

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	~~==Evaluation==~~
	~~The diagnosis is made clinically in patients with new onset diarrhea during travel or shortly afterward (within 1-2 weeks).~~
	~~Laboratory testing is not required in most cases, as the diarrhea is often self-limited.~~
	~~Consider the following tests when signs of invasive infection (such as fever, bloody stool, or cholera-like diarrhea with dehydration) are present, or in patients with diarrhea lasting ≥ 14 days:~~
	~~Stool culture for enteropathogens~~
	~~Shiga toxin assay, to rule out Shiga toxin-producing E. Coli (STEC)~~
	~~Fecal leukocyte or lactoferrin testing~~
	~~Molecular assays targeting common enteropathogens~~
	~~When diarrhea persists for ≥ 14 days, consider testing for parasites with:~~
	~~Stool microscopy for ova, cysts, and parasites (O&P).~~
	~~Stool antigen detection for Giardia spp., Cryptosporidium spp., And Entamoeba histolytica parasites.~~
	~~Modified acid-fast staining of stool for Cyclospora spp.~~
	~~===Workup===~~
	~~Evaluation of returned travelers:~~
	~~Testing is typically not required as mild or uncomplicated disease is often self-limited or can be treated empirically.2,4~~
	~~Indications for laboratory evaluation include:2,3~~
	~~Diarrhea lasting ≥ 14 days~~
	~~Fever > 101.3 degrees F (38.5 degrees C)~~
	~~Dysentery~~
	~~Cholera-like diarrhea with dehydration~~
	ISTM recommends microbiological testing for returning travelers with severe or persistent symptoms, including bloody diarrhea or mucus in stools, or who fail empiric therapy (ISTM Strong recommendation, Low/very low-level evidence).
	~~Identification of the etiology may help direct pathogen-specific treatment.~~
	Molecular testing to identify broad range of clinically-relevant pathogens is preferred when rapid results are clinically important or nonmolecular tests have failed to establish a diagnosis (ISTM Ungraded recommendation).
	~~Testing may include:~~
	~~Stool culture~~
	~~Stool microscopy to examine for ova, cysts, and parasites~~
	~~Blood culture if bacteremia is suspected~~
	~~Fecal leukocytes or fecal lactoferrin test if bacterial infection is suspected~~
	~~Molecular assays targeting multiple pathogens~~
	~~===Diagnosis===~~
	~~Stool culture for enteropathogens~~
	~~Microscopy and antigen detection to test for parasites~~
	~~Blood tests, including blood culture, if bacteremia is suspected~~
	~~Shiga toxin assay to rule out Shiga toxin-producing Escherichia coli (STEC)~~
	~~Fecal leukocyte or lactoferrin testing~~
	~~Molecular assays for detection of common enteropathogens~~
	~~Blood tests~~
	~~Blood tests may be helpful for patients with persistent, systemic, or severe symptoms and include:2,3~~
	~~Complete blood count (eosinophilia may indicate schistosomiasis, strongyloidiasis, or other helminthic infection)~~
	~~Liver function tests~~
	~~Renal function tests~~
	~~Inflammatory markers (such as erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP])~~
	~~Blood culture if bacteremic salmonellosis (including typhoid fever) is suspected~~
	==Management==		==Management==
	Most bacterial and viral cases are self-limited and typically resolve in 2-7 days, though parasitic infection may persist for longer if untreated.		Most bacterial and viral cases are self-limited and typically resolve in 2-7 days, though parasitic infection may persist for longer if untreated.

Rossdonaldson1: /* Differential Diagnosis */

2025-01-29T15:51:51Z

Differential Diagnosis

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	==Differential Diagnosis==		==Differential Diagnosis==
	{{~~Template:~~Diarrhea DDX}}		{{Diarrhea DDX}}

	==Evaluation<ref name="Steffen"></ref>==		==Evaluation<ref name="Steffen"></ref>==

Rossdonaldson1: /* Differential Diagnosis */

2025-01-29T15:51:13Z

Differential Diagnosis

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	[[Category:Tropical Medicine]]		[[Category:Tropical Medicine]]


	~~==Differential Diagnosis==~~
	~~The differential diagnosis includes foodborne illnesses less commonly associated with travel, such as:~~
	~~Bacterial gastroenteritis, including:~~
	~~Bacillus cereus food poisoning, which often presents with nausea and vomiting resolving in 12-24 hours~~
	~~Staphylococcus aureus food poisoning, which often presents with acute onset nausea, vomiting, and abdominal cramping resolving in 24-48 hours~~
	~~Clostridium perfringens food poisoning, which often presents as severe watery diarrhea with abdominal cramps and little or no vomiting~~
	~~Listeriosis~~
	~~Helminth infections acquired from fish, such as anisakiasis, typically presenting with nausea and vomiting~~
	~~Food poisoning from marine toxins, including:~~
	~~Ciguatera fish poisoning, in which gastrointestinal symptoms often occur in first 6-24 hours and may be followed by neurologic symptoms, often perioral numbness and paresthesias~~
	~~Scombroid poisoning, which is typically associated with flushing, palpitation, itching due to histamine release, and scombrotoxins, which may be accompanied by diarrhea and abdominal cramps~~
	~~Paralytic shellfish poisoning, in which neurologic symptoms arise 30-60 minutes after ingestion and may be accompanied by nausea, vomiting, and diarrhea~~
	~~Neurotoxic shellfish poisoning, which presents with gastroenteritis accompanied by minor paresthesias/dysesthesias~~
	~~Diarrheic shellfish poisoning, which typically presents with nausea, vomiting, and abdominal cramps~~
	~~Diarrhea caused by Shiga toxin-producing organisms:~~
	~~Antibiotic treatment may increase the release of Shiga toxins and precipitate hemolytic-uremic syndrome (HUS). Antimotility agents should be similarly avoided.~~
	~~Shiga toxin-producing organisms include:~~
	~~Shiga toxin-producing Escherichia coli (STEC), predominantly O157:H7~~
	~~Shigella dysenteriae serotype 1, a less common cause (see also Bacillary Dysentery)~~
	~~Suspect STEC in patients with:~~
	~~Bloody diarrhea~~
	~~Abdominal pain greater that is typically seen with other forms of bacterial gastroenteritis~~
	~~Painful defecation~~
	~~Fever and leukocytosis are variably present.~~
	~~Reference - Lancet 2005 Mar 19-25;365(9464):1073~~
	~~See also Foodborne Illnesses.~~
	~~The differential diagnosis also includes early presentations of inflammatory bowel disease such as Crohn disease and ulcerative colitis.~~
	~~See also:~~
	~~Acute Diarrhea in Adults~~
	~~Acute Diarrhea in Children - Approach to the Patient~~
	~~Fever in the Returning Traveler~~

	==Evaluation==		==Evaluation==

Rossdonaldson1: /* Clinical Features> */

2025-01-29T15:50:54Z

Clinical Features>

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	\|}		\|}

	==Clinical Features>==		==Clinical Features==
	Characterized by the following:<ref name="Steffen"></ref		Characterized by the following:<ref name="Steffen"></ref>
	*Travel		*Travel
	*3 or more unformed stools per 24 hours		*3 or more unformed stools per 24 hours
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	**Fecal urgency		**Fecal urgency

	;The average duration of untreated traveler’s diarrhea is 4 to 5 days		;The average duration of untreated traveler’s diarrhea is 4 to 5 days<ref name="Steffen"></ref>

	==Differential Diagnosis==		==Differential Diagnosis==

Rossdonaldson1: /* Clinical Features */

2025-01-29T15:50:36Z

Clinical Features

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	==Clinical Features<ref name="Steffen"></ref~~>==~~		==Clinical Features>==
			Characterized by the following:<ref name="Steffen"></ref
	*Travel		*Travel
	*3 or more unformed stools per 24 hours		*3 or more unformed stools per 24 hours