traveler's diarrhea
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Etiology
- bacterial enteritis
- enterotoxigenic E. coli (most common)
- Campylobacter, Salmonella, Shigella, Aeromonas, Vibrio
- protozoan infection (< 10%)
- viral enteritis - norovirus, rotovirus
- idiopathic (30%)
* see Entamoeba histolytica for differential diagnosis of protozoan infections
Epidemiology
- 30-35% of travelers
- risk is greater when traveling from temperate to tropical climates
Clinical manifestations
- 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]
- diarrhea is generally mild in healthy adults[4]
Laboratory
- indications:
- severe disease
- prolonged symptoms
- failure of empiric antibiotic therapy
- complete blood count: absence of leukocytosis
- stool culture
- stool gram stain
Diagnostic procedures
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
- preventative measures
- avoid contaminated food, water, beverages, unpeeled fruit or salads, ice made with local water
- 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)
- probiotics may be of some benefit[5]; not recommended[10]
- 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]
- treatment
- oral hydration, normal diet
- bismuth subsalicylate (Pepto-Bismol) anti-secretory
- 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]
- loperamide (Imodium)
- 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]
- azithromycin 1000 mg (single dose)[3][5][10]
- untreated traveler's diarrhea generally resolves in 3-5 days, but treatment can improve symptoms & shorten the duration by 1-2 days[1]
More general terms
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 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 - ↑ 2.0 2.1 Prescriber's Letter 9(7):40 2002
- ↑ 3.0 3.1 3.2 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: https://www.ncbi.nlm.nih.gov/pubmed/14557959
- ↑ 4.0 4.1 4.2 4.3 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: https://www.ncbi.nlm.nih.gov/pubmed/15897530
- ↑ 5.0 5.1 5.2 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#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=230506&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ Hill DR, Ericsson CD, Pearson RD et al The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006 Dec 15;43(12):1499-539 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17109284
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/19538575
- ↑ Steffen R, Hill DR, DuPont HL. Traveler's diarrhea: a clinical review. JAMA. 2015 Jan 6;313(1):71-80. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25562268
- ↑ Nair D. Travelers' diarrhea: prevention, treatment, and post-trip evaluation. J Fam Pract. 2013 Jul;62(7):356-61. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23957028
- ↑ 10.00 10.01 10.02 10.03 10.04 10.05 10.06 10.07 10.08 10.09 10.10 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: https://www.ncbi.nlm.nih.gov/pubmed/27068718
- ↑ ARUP Consult: Diarrhea in Returned Traveller or Immigrant Testing Algorithm https://arupconsult.com/algorithm/diarrhea-returned-traveller-or-immigrant-testing-algorithm
- ↑ DuPont HL. Acute infectious diarrhea in immunocompetent adults. N Engl J Med 2014 Apr 17; 370:1532 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24738670 https://www.nejm.org/doi/full/10.1056/NEJMra1301069
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/29053792 PMCID: PMC5850553 Free PMC article
- ↑ 14.0 14.1 14.2 NEJM Knowledge+