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Prevention of this common disease is the key to better
enjoyment of your travels. Prevention involves careful
attention to the food you eat and the beverages you
drink. Understandably, most travelers have difficulty
adhering to all of these principles. Currently, no drugs
are routinely recommended for the prevention
of travelers' diarrhea in healthy travelers. This includes
the use of Pepto-Bismol®, Lomotil®, Imodium®
AD, Bactrim® DS, Septra DS, Doxycycline,
Noroxin® or
Cipro.® At times,
however, some travelers with special medical conditions
may require preventive medication.
In situations where the traveler cannot risk the chance
of getting diarrhea, cannot control what they eat or
drink, or when the immune response is depressed, an
antibiotic (e.g., Noroxin® or Cipro®) may be prescribed
at one half the usual daily dose to prevent travelers'
diarrhea. In such a situation, the traveler must closely
follow the recommendations of their health care provider.
To date, there is no immunization available to prevent
travelers' diarrhea. Typhoid vaccines and cholera vaccine
may be useful to prevent these specific diseases but
are of no value to the much more common travelers' diarrhea.
Treatment for Mild to Moderate Travelers' Diarrhea
Replenishing fluids using oral replacement therapy (ORT)
is the cornerstone of treatment. ORT packets are available
at stores or pharmacies in almost all developing countries,
although it is always a good idea to carry your own
supply. If ORT is not available, drink water accompanied
by pretzels or salty crackers. A generic formula for
ORT is 1 liter of water with 6 level teaspoons of sugar
and 1 level teaspoon of salt. For adults, a combination
of ORT and medication (anti-motility agents and/or antibiotics)
may be appropriate.
Pepto-Bismol® may be effective for mild diarrhea.
Do not take it with large doses of aspirin or with coumadin.
It is not uncommon to have black stools or a black tongue
when taking Pepto-Bismol. This product is not recommended
for pregnant women or nursing mothers.
Lomotil® and Imodium® AD are commonly used anti-motility
agents that may be effective for mild diarrhea. They
should not be used for more than 48 hours. These medications
may be used with an antibiotic for moderate to severe
diarrhea (see below). Do not use these products if you
have bloody stools or fever; seek medical advice in
such instances.
Never use Enterovioform, Mexaform, Clioquinol,
Iodoquinol or Intestopan (anti-diarrheal agents banned
in the USA but still sold over-the-counter in foreign
countries) for prevention or treatment of traveler's
diarrhea.
Treatment for Severe Travelers' Diarrhea
Severe travelers' diarrhea is defined as three
or more loose stools in an 8-hour period and is associated
with some combination of cramping, nausea and vomiting,
bloody stools, or fever. At this level, travelers are
SICK! This degree of travelers' diarrhea should be treated
with ORT and a fluoroquinolone antibiotic, (e.g., Noroxin®
or Cipro®). Imodium® AD or Lomotil® may be used in conjunction
with the antibiotic as described below if fever or bloody
stools are not present. If possible, seek physician
advice for severe travelers' diarrhea rather than attempt
self-medication.
Treatment Plan 1
Noroxin®
(norfloxacin) 400 mg tablet or Cipro®
(ciprofloxacin) 500 mg tablet - take one tablet
twice a day for 3 days. Pregnant women, nursing mothers,
or adolescents (under 18 years of age) should not use
these antibiotics. These antibiotics should not be taken
with antacids. They are specifically used for severe
travelers' diarrhea accompanied by abdominal pain, fever,
or bloody stools. As a single-dose alternative, some
authorities suggest two tablets of either Noroxin® or
Cipro® accompanied by Imodium® AD or Lomotil®, if
there is no fever and there are no bloody stools.
Do not use Noroxin® or Cipro® with Bactrim® DS (or Septra®
DS) or other antibiotics. Before taking any medication,
dosage recommendations, contraindications, length of
treatment, and possible side effects must be determined
by a health care provider on an individual basis.
Treatment Plan 2
Bactrim™ DS (double strength) or Septra® DS -
take two tablets immediately, then one tablet twice
a day for 5 days. Pregnant women or nursing mothers
should not use these antibiotics. They both contain
sulfa; do not use if you are allergic to sulfa.
These medications should be discontinued at the first
sign of any rash. They may be used with Imodium® AD
or Lomotil® for moderate diarrhea, but these anti-motility
drugs should not be used if your temperature is over
100 degrees or you have bloody stools. Do not take at
the same time as Noroxin® or Cipro.® Before taking any
medication, dosage recommendations, contraindications,
length of treatment, and possible side effects must
be determined by a healthcare provider on an individual
basis.
Keep a 24-hour supply of ORT packets and/or supplemental
liquids in your possession in case traveler's diarrhea
becomes severe. In the USA, ORT packets are available
from Jianas Brothers Packaging Company, telephone (816-421-2880),
and REI (web site: www.rei.com),
a camping and outdoor equipment store. CeraLyte®
is a rice-based oral electrolyte product that comes
in 3 sodium strengths and several flavors and 2 packet
sizes (call 800-237-2588 to order).
While using ORT and/or an antibiotic, you may supplement
as desired with carbonated beverages, water that has
been purified, or tea made with boiled or carbonated
water. Avoid solid foods and milk until you are recovered.
Despite the above recommendations, if any of the following
occurs, consult a physician on an urgent basis:
- Diarrhea does not resolve within a few days.
- Bloody stools persist.
- Condition is worsening.
- There is fever with shaking chills.
- There is dehydration.
- There is progressive weakness.
Based
on CDC,
Health Information for International Travel 2000-2001,
DHHS, Atlanta, GA, 2001; WHO,
International Travel and Health, 2002, Geneva;
and Dr. Richard Thompson's book
Well on the Road - A
Practical Guide for the International Traveler, 2002.
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