Treatment of Traveler’s Diarrhea

Traveler’s who suffer from traveler’s diarrhea, approximately 20% of them become bedridden and need proper treatment (should not do self treatment if diarrhea becomes severe).

In many cases a specific diagnosis is available to guide treatment and is also not necessary. The treatment should be started based on history, stool examination and severity of dehydration. The empirical treatment regimens for traveler’s diarrhea are based on certain clinical syndromes:

(1) Clinical syndrome, watery diarrhea without fever or blood in stool and 1 or 2 unformed stools per day without distressing enteric symptoms:- the treatment is with oral fluid (preferably with ORS or oral re-hydration salt or flavored mineral water).

(2) Clinical syndrome, watery diarrhea without fever or blood in stool and 1 or 2 unformed stools per day with distressing enteric symptoms:- treatment for adults bismuth subsalicylate 30 ml or 2 tablets (262 mg/tablet) every 30 min for a maximum of 8 doses or loperamide 4 mg initially followed by 2 mg after passage of each unformed stool, not to exceed 16 mg per day or 8 tablets and loperamide can be taken for 2 days.

(3) Clinical syndrome, watery diarrhea without fever or blood in stool, but more than 2 unformed stools per day without distressing enteric symptoms:- treatment is antibiotics plus loperamide 4 mg initially followed by 2 mg after passage of each unformed stool, not to exceed 16 mg per day. Antibiotics that are used in traveler’s diarrhea are fluoroquinolones like ciprofloxacin 750 mg single dose or 500 mg twice a day for 3 days (levofloxacin, 500 mg as a single dose or norfloxacin, 800 mg as a single dose or 400 mg two times a day for 3 days are also used effectively), azithromycin, 1000 mg as a single dose or 500 mg twice a day for 3 days, Rifaximin, 200 mg 3 times a day or 400 mg 2 times a day for 3 days (this is not recommended if case of dysentery). All the above regimens are for adults. For children azithromycin, 10 mg/kg on day 1, 5 mg/kg on days 2 and 3 if diarrhea persists (furazolidone, 7.5 mg/kg per day in four divided doses for 5 days is an effective alternative to azithromycin).

In Thailand organisms (mainly Campylobacter) causing traveler’s diarrhea are resistant to fluoroquinolones and the antibiotic of choice in Thailand is azithromycin at the same dose as given above.

(4) Clinical syndrome, passing of blood in stool (dysentery) or fever of more than 37.8° C:- Antibiotic therapy as given above.

(5) Clinical syndrome, vomiting with minimal diarrhea:- treatment for adults bismuth subsalicylate 30 ml or 2 tablets (262 mg/tablet) every 30 min for a maximum of 8 doses.

(6) Clinical syndrome, in infants less than 2 years old:- fluid and electrolyte replacement with ORS (intravenous fluid may also be required), continue feeding (continue breast feeding if infant is breast fed). If diarrhea is with dysentery or fever, antibiotics like azithromycin will be required and dose is as given above.

(7) Clinical syndrome, diarrhea in pregnant women:- Fluids and electrolytes should be given. Consider giving attapulgite, 3 gm initially, repeat after passage of each unformed stool or every 2 hour, whichever is earlier, for a total dosage of 9 gm per day.

(8) Clinical syndrome, diarrhea despite prophylaxis with trimethoprim-sulfamethoxazole:- Fluoroquinolone (ciprofloxacin) with loperamide if no fever and no blood in stool, ciprofloxacin alone if fever or dysentery is present.

(9) Clinical syndrome, diarrhea despite prophylaxis with fluoroquinolone (ciprofloxacin):- For adults bismuth subsalicylate 30 ml or 2 tablets (262 mg/tablet) every 30 min for a maximum of 8 doses for mild to moderate diarrhea. If severe diarrhea persists consult doctor for proper antibiotic therapy like azithromycin.

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