TREATMENT OF TRAVELERS' DIARRHEA AND DYSENTERY

the short version

If you have diarrhea despite your best efforts at prevention, try to distinguish between ordinary Travelers’ Diarrhea and dysentery (dysentery signs are: blood mixed with diarrhea, fever, abdominal pain, vomiting or non-response to a course of antibiotics for mild diarrhea). Starting an antibiotic will shorten your illness irrespective of which one you have.

the long version

TRAVELERS' (mild) DIARRHEA (TD) causes sudden liquid stools, nausea, bloating, a sense of urgency to have a bowel movement, and perhaps mild abdominal cramps or mild nausea. TD usually occurs during travel or soon after returning home, is self-limited and is usually more an inconvenience rather than a serious disease. The chance that a traveler on an average trip is going to come down with TD is in the range of 20 to 40 percent. Most of the diarrhea experienced by travelers is ordinary TD. The most important determinant of risk is the destination of the traveler. High risk destinations include most of Latin America, Africa, the Middle East and Asia. Intermediate risk destinations include Southern European countries and a few Caribbean islands. Low risk destinations include Canada, Northern Europe, Japan, Australia, New Zealand, the United States and other Caribbean islands. There is no information to support any noninfectious cause of TD such as changes in diet, jet lag, altitude, fatigue, etc.

DYSENTERY (more severe diarrhea) is usually more severe than TD and may be associated with fever, blood mixed with diarrhea, more significant abdominal pain, vomiting or non-response to a course of antibiotics for mild diarrhea. TD and dysentery may cause similar symptoms at the onset of diarrhea. Dysentery may be due to other bacteria and generally responds to a longer course of ciprofloxacin or azithromycin. Ciprofloxacin should not be used in pregnancy. Travelers with signs of dysentery generally should not self-administer antimotility agents, rather should generally seek prompt medical care and possibly have a stool exam. A good strategy for those without easy access to medical care during their travels might be to use one dose of cipro or azithromycin for milder “Montezuma’s Revenge”, but treat for a longer time for dysentery or more severe or prolonged diarrhea. Self-treatment for dysentery should probably be restricted to those who will not have ready access to medical care or the means to arrive at an exact diagnosis.

TREATMENT of TD Once diarrhea has begun, relief is needed. Many agents have been proposed to control these symptoms, but few have been demonstrated to be effective by rigorous clinical trials.

Nonspecific Agents: A variety of "adsorbents" have been tried in treating diarrhea. Activated charcoal has been found to be ineffective in the treatment of diarrhea. Kaolin and pectin have been widely used for diarrhea. The combination appears to give the stools more consistency but has not been shown to decrease cramps and frequency of stools nor to shorten the course of diarrhea. Lactobacillus preparations and yogurt have also been advocated; there is one study which suggests benefit. Bismuth subsalicylate preparations (1 oz of liquid or one tablet every 30 minutes for eight doses) have been shown to decrease (but not necessarily abolish) diarrhea and shorten the duration of illness in several placebo controlled studies. There is concern about taking, without medical supervision, large amounts of bismuth and salicylate, especially in individuals who may be intolerant to aspirin or aspirin-like medicines, who have kidney disease or who take salicylates for other reasons.

Oral fluids: Most cases of diarrhea are self limited and require only oral replacement of fluids and salts which have been lost in diarrheal stools. Fluid and electrolyte balance can be maintained by (safe) fruit juices, soft drinks (preferably caffeine-free and alcohol-free) and salted crackers. Iced drinks and noncarbonated bottled fluids made from water of uncertain quality should be avoided. Dairy products aggravate diarrhea in some people and should be avoided. Travelers may prepare their own fruit juice from fresh fruit. Individuals with dehydrations may require fluid and salt replacement in the form of Oral Rehydration Solution (ORS) recommended by the World Health Organization (see article in “Health Information for International Travel” – The Yellow Book). Each ORS packet, available at stores or pharmacies in almost all developing countries, should be added to a liter of boiled or treated water, and consumed or discarded within 12 hours if held at room temperature, or within 24 hours if held refrigerated.

Antimotility Agents which act directly on the bowel may slow diarrhea of any cause and should only be used if significant abdominal pain, significant vomiting, fever (over 100.5 degrees F) and bloody diarrhea are absent. Natural opiates (codeine and others) have long been used to control diarrhea and cramps. Synthetic agents such as loperamide (available as 2 mg pills without prescription both generically and as brand name Imodium) usually provides prompt, temporary symptomatic relief of uncomplicated TD. The usual dose is 2 tablets at onset   Loperamide can worsen bacterial dysentery and can mask worsening infection, therefore its use is discouraged. Using one dose of loperamide under extreme unusual, circumstances might be reasonable, but if used, antibiotic treatment should be given for a full 5 days. Diphenoxylate (brand name Lomotil) is less effective, available by prescription only and is not recommended. Neither diphenoxylate nor loperamide should be used in children under the age of 2 years.

Antibiotic Treatment: Travelers who develop diarrhea (any watery stool) may benefit from antibiotic treatment. A typical three day illness can often be shortened to one day with early self treatment with an antibiotic. Those with the following should be evaluated by a local physician promptly: fever, more than mild vomiting or mild abdominal pain, blood mixed with diarrhea, or diarrhea which is severe or which does not resolve within 48 hours. Nausea and vomiting without diarrhea should not be treated with antibiotics.

Options for antibiotic treatment include ciprofloxacin (Cipro), norfloxacin, TMP/SMX (Bactrim, Septra), trimethoprim and azithromycin (Zithromax); doses of two of these antibiotics are listed below. For ordinary TD, antibiotics and antimotility agents may be stopped when normal stools resume.

This plan should be 97% effective. It will not treat giardia or amebic dysentery. Travelers who are very ill, or in whom this plan is not effective, should be seen by a physician.

Children under the age of 2 years should have individualized management by their physician.

For management of infants with diarrhea, see the section in the CDC’s Yellow Book “Health Information for International Travel”.

(Adapted from Health Information for International Travel, Centers for Disease Control)