Stuart R. Gallant, MD, PhD
Twenty to fifty percent of international travelers develop travelers’ diarrhea—sudden onset of loose stools while traveling. While some of these cases resolve quickly, others may have serious health effects, particularly if medical care is not near at hand.
One of the challenges to travelers and to those leading international travel groups is that optimal treatment may require consultation of a health care provider and recourse to laboratory testing, but that may be inconvenient or even impossible during travel. So, broad spectrum coverage is needed, together with appropriate monitoring and support.
Today’s post discusses what is known about travelers’ diarrhea and how medical providers approach this condition. (Caveat: discuss any of the points presented in this post with your health provider prior to taking action.)
Causes and Prevention
Many diarrheal illnesses present similarly with only subtle symptomatic differences between causative microorganisms. The following table focuses on the most common causes of travelers’ diarrhea [1]:
As seen in the table, the major route of infection with diarrheal illnesses is fecal-oral contamination. Prevention strategy is based on this common route of infection [2]:
- Hygiene: Wash hands frequently with soap or hand sanitizer.
- Food: Eat only cooked food which is still hot.
- Water: Drink and brush teeth with bottled water or purified water (filtered or treated with tablets).
- Avoid Untreated Water: Avoid ice cubes, salads, and uncooked food. Eat only fruit you can peel yourself (because hand hygiene of kitchen staff is a risk factor).
- Bismuth Subsalicylate: Bismuth subsalicylate taken 4 times a day while travelling can reduce the incidence of travelers’ diarrhea due to bactericidal contamination.
Treatment
Treatment depends on the causative organism. However, given the potential rapid onset and severe effects of diarrheal illnesses, presumptive pharmaceutical treatment is often warranted. Treatments include:
- Oral Rehydration: Depends on the availability of a clean water source or the ability to purify surface or ground water. Add rehydration salts such as “Liquid IV Hydration Multiplier” to the water.
- Loperamide: Slows water loss by decreasing gut motility. There are a range of contraindications (fever, bloody stool, or presence of intestinal wall penetrating organisms such as E. coli O157:H7 or Salmonella spp.). If you will be far from medical care, discuss this medication with your doctor before departing to be sure you understand its risks.
- Antibiotics: Ciprofloxacin and azithromycin are both good options, with azithromycin preferred for severe diarrheal illness [3]. Ciprofloxacin resistance is increasing in Asia, so 3 doses of 500 mg of azithromycin is a good treatment to pack in your travel first aid kit. Discuss with your doctor.
The specific treatment depends on the severity of the symptoms [2, 3, 4]:
| Diarrhea | Severity/Symptoms | Treatment* |
| Mild | Tolerable. Not interfere with daily plans. | Loperamide or bismuth subsalicylate. |
| Moderate | Distressing. Interferes with daily plans. | Loperamide and/or antibiotic. |
| Severe | Incapacitating. Prevents activities. | Antibiotic. May also use loperamide. |
| Dysentery | Blood visible in toilette. | Antibiotic. No loperamide |
* In all cases, include oral rehydration in treatment.
There is a substantially more detailed flow chart for management of diarrhea [4] that can be printed out and included in your traveling first aid kit.
Conclusions
The real lesson of this post is or should be: Get out there! There’s a world to discover, and there is no reason not to see all of it. At the same time, prudence dictates packing a first aid kit. And, it is worth discussing with your physician a three-day prescription of azithromycin to be placed in your first aid kit.
[1] Barrett, J. and Brown, M. “Travellers’ diarrhoea,” BMJ, 353, i1937 (2016).
[2] Grindrod, K.A., Houle, S.K.D., and Fernandes, H. “Traveler’s diarrhea,” Canadian Family Physician, 65 483-486 (2019).
[3] wwwnc.cdc.gov/travel/yellowbook/2024/preparing/travelers-diarrhea
[4] campushealth.unc.edu/wp-content/uploads/2017/09/Travelers-diarrhea-Treatment-flowchart-Aug-2017.pdf
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