TRAVELERS' DIARRHEA - "Boil it, peel it, cook it, or forget it!"



ADULT

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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