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traveler's diarrhea

Etiology: 1) bacterial enteritis a) enterotoxigenic E. coli (most common) b) Campylobacter, Salmonella, Shigella, Aeromonas, Vibrio 2) protozoan infection (< 10%) a) Cyclospora cayetanensis b) Giardia lamblia c) Cryptosporidium d) Isospora e) Microsporidia f) Entamoeba histolytica* 3) viral enteritis - norovirus, rotovirus 4) idiopathic (30%) * see Entamoeba histolytica for differential diagnosis of protozoan infections Epidemiology: 1) 30-35% of travelers 2) risk is greater when traveling from temperate to tropical climates Clinical manifestations: 1) passage of > 2 unformed stools (diarrhea) & at least 1 sign of enteric infection [4] - abdominal pain - fever - generally non-bloody watery stool - may be blood in stool [14] 2) diarrhea is generally mild in healthy adults [4] Laboratory: - indications: a) severe disease b) prolonged symptoms c) failure of empiric antibiotic therapy - complete blood count: absence of leukocytosis - stool culture - stool gram stain Special laboratory: - Differential diagnosis: - consider antibiotic-associated diarrhea in cases lasting > 7 days [1] - consider protozoa if diarrhea despite antibiotic prophylaxis, stool culture negative & antibiotic treatment unsuccessful Management: 1) preventative measures a) avoid contaminated food, water, beverages, unpeeled fruit or salads, ice made with local water b) prophylaxis - prophylaxis generally unnecessary [2,4], only prompt treatment - indications for prophylaxis - immunocompromised patients - patients with inflammatory bowel disease - other patients with chronic disease that could be exacerbated by dehydration & electrolyte imbalance [1] - rifaximin 200 mg QD-TID for < 2 weeks [1] - not absorbed - active against E coli - preferred antibiotic [1,10] - fluoroquinolone + loperamide [1] - fluoroquinolone resistance has emerged [1] - bismuth subsalicylate (Pepto Bismol) - 2 tablets QID for < 3 weeks - risk of adverse effects may exceed benefit [1] - treatment of choice [10] - probiotics may be of some benefit [5]; not recommended [10] c) handwashing & alcohol-based hand sanitizers of limited value in preventing traveler's diarrhea, but may be useful in preventing cruise ship outbreaks of norovirus & institutional outbreaks, or in areas of endemic diarrhea [10] 2) treatment a) oral hydration, normal diet b) bismuth subsalicylate (Pepto-Bismol) anti-secretory - treatment of choice for mild-moderate diarrhea [10] c) antimotility agents - loperamide (Imodium) - do not give for > 48 hours [10] - may even be safe in dysentery presentation provided it is combined with antibiotic therapy [10] - do not use antimotility agent if bloody stool [1] - only as adjunct to antibiotics in treatment of dysentery [1] - concern (but no proof) that antimotility agents may prolong dysentery [1] d) antimicrobial agents for more severe cases (fever, dysentery) - azithromycin 1000 mg (single dose) [3,5,10] - drug of choice due to rising quinolone resistance [14] - quinolone resistant resistant Campylobacter in Southeast Asia - fluoroquinolone for up to 3 days [10] - ciprofloxacin 500 mg BID - ofloxacin 200 mg BID - norfloxacin 400 mg BID - levofloxacin 500 mg (single dose) [3] - pregnant women - rifaximin 200 mg TID for 3 days - Bactrim, doxycycline not recommended due to high rate of resistance - exception: shigellosis requires 5 days of fluoroquinolone [10] e) untreated traveler's diarrhea generally resolves in 3-5 days, but treatment can improve symptoms & shorten the duration by 1-2 days [1]

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diarrhea

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Prescriber's Letter 9(7):40 2002
  3. Journal Watch 23(24):194, 2003 Adachi JA et al Azithromycin found to be comparable to levofloxacin for the treatment of US travelers with acute diarrhea acquired in Mexico. Clin Infect Dis 37:1165, 2003 PMID: 14557959
  4. Journal Watch 25(13):103, 2005 DuPont HL, Jiang ZD, Okhuysen PC, Ericsson CD, de la Cabada FJ, Ke S, DuPont MW, Martinez-Sandoval F. A randomized, double-blind, placebo-controlled trial of rifaximin to prevent travelers' diarrhea. Ann Intern Med. 2005 May 17;142(10):805-12. Summary for patients in: Ann Intern Med. 2005 May 17;142(10):I30. PMID: 15897530
  5. Prescriber's Letter 14(5): 2007 CHART: Medications for Traveler's Diarrhea PATIENT HANDOUT: What You Should Know About Traveler's Diarrhea HEALTHCARE PROFESSIONAL INFORMATION: CDC or Public Health Agency of Canada Travel Recommendations Opportunities to Provide Travel Medication Services Detail-Document#: 230506 (subscription needed) http://www.prescribersletter.com
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  7. DuPont HL, Ericsson CD, Farthing MJ et al Expert review of the evidence base for prevention of travelers' diarrhea. J Travel Med. 2009 May-Jun;16(3):149-60 PMID: 19538575
  8. Steffen R, Hill DR, DuPont HL. Traveler's diarrhea: a clinical review. JAMA. 2015 Jan 6;313(1):71-80. Review. PMID: 25562268
  9. Nair D. Travelers' diarrhea: prevention, treatment, and post-trip evaluation. J Fam Pract. 2013 Jul;62(7):356-61. PMID: 23957028
  10. Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol. 2016 May;111(5):602-22. PMID: 27068718
  11. ARUP Consult: Diarrhea in Returned Traveller or Immigrant Testing Algorithm https://arupconsult.com/algorithm/diarrhea-returned-traveller-or-immigrant-testing-algorithm
  12. DuPont HL. Acute infectious diarrhea in immunocompetent adults. N Engl J Med 2014 Apr 17; 370:1532 PMID: 24738670 https://www.nejm.org/doi/full/10.1056/NEJMra1301069
  13. Shane AL et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis 2017 Nov 29; 65:e45 PMID: 29053792 PMCID: PMC5850553 Free PMC article
  14. NEJM Knowledge+