Traveler's diarrhea

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]
  • At risk populations- Immunosuppressed, diabetes, taking meds to suppress acid production
  • Greatest contributor to illness poor hygiene in restaurants [2]

Etiology[1]

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[1]

  • 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

Differential Diagnosis

Acute diarrhea

Infectious

Noninfectious

Watery Diarrhea

  • Enterotoxigenic E. coli (most common cause of watery diarrhea)[3]
  • Norovirus (often has prominent vomiting)
  • Campylobacter
  • Non-typhoidal Salmonella
  • Enteroaggregative E. coli (EAEC)
  • Enterotoxigenic Bacteroides fragilis

Traveler's Diarrhea

Evaluation[1]

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)

Management

  • Consider ondansteron if nausea
  • Consider IVF if dehydrated
  • Consider loperamide 4mg PO after each loose stool (Max: 16mg/day)[1]
    • 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[1]

  • 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]
    • Nausea is a frequent adverse event[7]
    • First choice for use in South and Southeast Asia[8]
  • Rifaximin 200mg PO TID x 3 days[9]

Pediatrics

Antibiotic Options:

Avoid fluroquinolones

Disposition

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

Complications

See Also

External Links

CDC - Travelers Diarrhea

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  2. http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/travelers-diarrhea
  3. Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
  4. Hoge CW. et al. Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years. Clin Infect Dis. 1998;26:341–5
  5. Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  6. 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
  7. Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  8. Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  9. 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
  10. Stauffer WM, Konop RJ, Kamat D. Traveling with infants and young children. Part III: travelers’ diarrhea. J Travel Med. 2002;9:141–50