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 azithromycin.
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), and trimethoprim. My current recommendation is azithromycin
(Zithromax) in the doses listed below. For ordinary TD, antibiotics may be stopped when normal stools resume.
|watery stool without
|fever, abdominal pain, vomiting,
blood mixed with diarrhea, failure of initial antibiotic treatment or
appears systemically ill
||azithromycin 250 mg, 2 on the
first day; if diarrhea stops completely, stop azithromycin
||if diarrhea continues (even if a
bit less), continue azithromycin 250 mg one daily for 4 more days
(5 days total)
for possible dysentery
after first liquid stool, take 2 tablets at onset; if diarrhea continues,
take 1 tablet daily for 4 more days
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
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