Traveler's Diarrhea Treatments

Preventive Measures for Travelers

bulletFor travelers to high-risk areas, several approaches may be recommended that can reduce but never completely eliminate the risk for TD. These include—
bulletInstruction regarding food and beverage selection
bulletUse of agents other than antimicrobial drugs for prophylaxis
bulletUse of prophylactic antibiotics
bulletCarrying small containers of hand-sanitizing solutions or gels (containing at least 60% alcohol) may make it easier for travelers to clean their hands before eating.

Treatment of TD Caused by Protozoa

The most common parasitic cause of TD is Giardia intestinalis, and treatment options include metronidazole, tinidazole, and nitazoxanide. Although cryptosporidiosis is usually a self-limited illness in immunocompetent persons, nitazoxanide can be considered as a treatment option. Cyclosporiasis is treated with trimethoprim–sulfamethoxazole. Treatment of amebiasis is with metronidazole or tinidazole, followed by treatment with a luminal agent such as paromomycin.

Treatment for Children

Children who accompany their parents on trips to high-risk destinations may be expected to have TD as well. There is no reason to withhold antibiotics from children who contract TD. In older children and teenagers, treatment recommendations for TD follow those for adults, with possible adjustments in the dose of medication. Macrolides such as azithromycin are considered first-line antibiotic therapy in children, although some experts now use short-course fluoroquinolone therapy for travelers <18 years of age. Rifaximin is approved for use starting at 12 years of age.
Infants and younger children are at higher risk for developing dehydration from TD, which is best prevented by the early use of ORS solutions. Breastfed infants should continue to nurse on demand, and bottle-fed infants can continue to drink their formula. Older infants and children may eat a regular diet, depending on the level of their appetite while they are ill. Infants in diapers are at risk for developing a painful, ecxematous rash on their buttocks in response to the liquid stool. Hydrocortisone cream will quickly improve this rash. More information about diarrhea and dehydration are discussed in the Traveling Safely with Infants and Children section in Chapter 7.

Nonantimicrobial Drugs for Prophylaxis

The primary agent studied for prevention of TD, other than antimicrobial drugs, is bismuth subsalicylate (BSS), which is the active ingredient in Pepto-Bismol. Studies from Mexico have shown this agent (taken daily as either 2 oz of liquid or two chewable tablets four times per day) reduces the incidence of TD from 40% to 14%. BSS commonly causes blackening of the tongue and stool and may cause nausea, constipation, and rarely tinnitus. BSS should be avoided by travelers with aspirin allergy, renal insufficiency, and gout, and by those taking anticoagulants, probenecid, or methotrexate. In travelers taking aspirin or salicylates for other reasons, the use of BSS may result in salicylate toxicity. Caution should be used in administering BSS to children with viral infections, such as varicella or influenza, because of the risk for Reye syndrome. BSS is not recommended for children <3 years of age. Studies have not established the safety of BSS use for periods >3 weeks.
The use of probiotics, such as Lactobacillus GG and Saccharomyces boulardii, has been studied in the prevention of TD in limited numbers of subjects. Results are inconclusive, partially because standardized preparations of these bacteria are not reliably available.

Oral Rehydration Therapy

Fluids and electrolytes are lost in cases of TD, and replenishment is important, especially in young children or adults with chronic medical illness. In adult travelers who are otherwise healthy, severe dehydration resulting from TD is unusual unless prolonged vomiting is present. Nonetheless, replacement of fluid losses remains an important adjunct to other therapy and helps the traveler feel better more quickly. Travelers should remember to use only beverages that are sealed or carbonated, or otherwise known to be purified. For more severe fluid loss, replacement is best accomplished with oral rehydration solutions (ORS), such as the WHO ORS solutions, which are widely available at stores and pharmacies in most developing countries (see Table 2-25 for details). ORS is prepared by adding one packet to the appropriate volume of boiled or treated water. Travelers may find most ORS formulations to be relatively unpalatable, due to their saltiness. In most cases, rehydration can be maintained with any palatable liquid.

Table 2-25. Composition of WHO oral rehydration salts (ORS) for diarrheal illness

Ingredient Amount
Sodium chloride 2.6 g/L
Potassium chloride 1.5 g/L
Glucose, anhydrous 13.5 g/L
Trisodium citrate, dihydrate 2.9 g/L (or 2.5 g/L)
Water 1.0 L
1World Health Organization. Oral Rehydration Salts (ORS): Production of the new ORS. Geneva: WHO; 2006: p. 2–4.