Travelers' diarrhea (TD) is a stomach and intestinal infection. TD is defined as the passage of unformed
stool (one or more by some definitions, three or more by others) while traveling.
[ It may be accompanied by abdominal cramps, nausea, fever, headache and bloating.][ Occasionally ]dysentery
Dysentery ( , ), historically known as the bloody flux, is a type of gastroenteritis that results in bloody diarrhea. Other symptoms may include fever, abdominal pain, and a feeling of incomplete defecation. Complications may include dehyd ...
may occur. Most travelers recover within three to four days with little or no treatment.[ About 12% of people may have symptoms for a week.]
Bacteria
Bacteria (; : bacterium) are ubiquitous, mostly free-living organisms often consisting of one Cell (biology), biological cell. They constitute a large domain (biology), domain of Prokaryote, prokaryotic microorganisms. Typically a few micr ...
are responsible for more than half of cases,[ typically via ]foodborne illness
Foodborne illness (also known as foodborne disease and food poisoning) is any illness resulting from the contamination of food by pathogenic bacteria, viruses, or parasites,
as well as prions (the agents of mad cow disease), and toxins such ...
and waterborne diseases
Waterborne diseases are conditions (meaning adverse effects on human health, such as death, disability, illness or disorders) caused by pathogenic micro-organisms that are transmitted by water. These diseases can be spread while bathing, washing ...
. The bacteria enterotoxigenic ''Escherichia coli'' (ETEC) are typically the most common except in Southeast Asia
Southeast Asia is the geographical United Nations geoscheme for Asia#South-eastern Asia, southeastern region of Asia, consisting of the regions that are situated south of China, east of the Indian subcontinent, and northwest of the Mainland Au ...
, where ''Campylobacter
''Campylobacter'' is a type of bacteria that can cause a diarrheal disease in people. Its name means "curved bacteria", as the germ typically appears in a comma or "s" shape. According to its scientific classification, it is a genus of gram-negat ...
'' is more prominent.[ About 10 to 20 percent of cases are due to ]norovirus
Norovirus, also known as Norwalk virus and sometimes referred to as the winter vomiting disease, is the most common cause of gastroenteritis. Infection is characterized by non-bloody diarrhea, vomiting, and stomach pain. Fever or headaches may ...
.[ ]Protozoa
Protozoa (: protozoan or protozoon; alternative plural: protozoans) are a polyphyletic group of single-celled eukaryotes, either free-living or parasitic, that feed on organic matter such as other microorganisms or organic debris. Historically ...
such as ''Giardia
''Giardia'' ( or ) is a genus of anaerobic flagellated protozoan parasites of the phylum Metamonada that colonise and reproduce in the small intestines of several vertebrates, causing the disease giardiasis. Their life cycle alternates be ...
'' may cause longer term disease.[ The risk is greatest in the first two weeks of travel and among young adults.][ People affected are more often from the ]developed world
A developed country, or advanced country, is a sovereign state that has a high quality of life, developed economy, and advanced technological infrastructure relative to other less industrialized nations. Most commonly, the criteria for eval ...
.[
Recommendations for prevention include eating only properly cleaned and cooked food, drinking ]bottled water
Bottled water is drinking water (e.g., Water well, well water, distilled water, Reverse osmosis, reverse osmosis water, mineral water, or Spring (hydrology), spring water) packaged in Plastic bottle, plastic or Glass bottle, glass water bott ...
, and frequent hand washing
Hand washing (or handwashing), also known as hand hygiene, is the act of cleaning one's hands with soap, soap or handwash and water to remove viruses, bacteria, microorganisms, dirt, grease, and other harmful or unwanted substances stuck to th ...
.[ The oral cholera vaccine, while effective for ]cholera
Cholera () is an infection of the small intestine by some Strain (biology), strains of the Bacteria, bacterium ''Vibrio cholerae''. Symptoms may range from none, to mild, to severe. The classic symptom is large amounts of watery diarrhea last ...
, is of questionable use for travelers' diarrhea
Diarrhea (American English), also spelled diarrhoea or diarrhœa (British English), is the condition of having at least three loose, liquid, or watery bowel movements in a day. It often lasts for a few days and can result in dehydration d ...
. Preventive antibiotic
An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...
s are generally discouraged.[ Primary treatment includes rehydration and replacing lost salts (]oral rehydration therapy
Oral rehydration therapy (ORT) also officially known as Oral Rehydration Solution is a type of fluid replacement used to prevent and treat dehydration, especially due to diarrhea. It involves drinking water with modest amounts of sugar and salt ...
).[ Antibiotics are recommended for significant or persistent symptoms, and can be taken with ]loperamide
Loperamide, sold under the brand name Imodium, among others,Drugs.co Page accessed 4 September 2015 is a medication of the opioid receptor agonist class used to decrease the frequency of diarrhea. It is often used for this purpose in irritable ...
to decrease diarrhea.[ Hospitalization is required in less than 3 percent of cases.][
Estimates of the percentage of people affected range from 20 to 50 percent among travelers to the ]developing world
A developing country is a sovereign state with a less-developed industrial base and a lower Human Development Index (HDI) relative to developed countries. However, this definition is not universally agreed upon. There is also no clear agreeme ...
.[ TD is particularly common among people traveling to Asia (except for Japan and South Korea), the Middle East, Africa, Latin America, and Central and South America.] The risk is moderate in Southern Europe
Southern Europe is also known as Mediterranean Europe, as its geography is marked by the Mediterranean Sea. Definitions of southern Europe include some or all of these countries and regions: Albania, Andorra, Bosnia and Herzegovina, Bulgaria, C ...
, and Russia. TD has been linked to later irritable bowel syndrome
Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by a group of symptoms that commonly include abdominal pain, abdominal bloating, and changes in the consistency of bowel movements. These symptoms may ...
and Guillain–Barré syndrome
Guillain–Barré syndrome (GBS) is a rapid-onset Paralysis, muscle weakness caused by the immune system damaging the peripheral nervous system. Typically, both sides of the body are involved, and the initial symptoms are changes in sensation ...
.[ It has colloquially been known by a number of names, including " Montezuma's revenge", "Turkey trots", and "]Delhi
Delhi, officially the National Capital Territory (NCT) of Delhi, is a city and a union territory of India containing New Delhi, the capital of India. Straddling the Yamuna river, but spread chiefly to the west, or beyond its Bank (geography ...
belly".
Signs and symptoms
The onset of TD usually occurs within the first week of travel, but may occur at any time while traveling, and even after returning home, depending on the incubation period of the infectious agent. Bacterial TD typically begins abruptly, but ''Cryptosporidium
''Cryptosporidium'', sometimes called crypto, is an apicomplexan genus of alveolates which are parasitism, parasites that can cause a respiratory and gastrointestinal illness (cryptosporidiosis) that primarily involves watery diarrhea (inte ...
'' may incubate for seven days, and ''Giardia
''Giardia'' ( or ) is a genus of anaerobic flagellated protozoan parasites of the phylum Metamonada that colonise and reproduce in the small intestines of several vertebrates, causing the disease giardiasis. Their life cycle alternates be ...
'' for 14 days or more, before symptoms develop. Typically, a traveler experiences four to five loose or watery bowel movements each day. Other commonly associated symptoms are abdominal cramping, bloating, fever, and malaise
In medicine, malaise is a feeling of general discomfort, uneasiness or lack of wellbeing and often the first sign of an infection or other disease. It is considered a vague termdescribing the state of simply not feeling well. The word has exist ...
. Appetite may decrease significantly. Though unpleasant, most cases of TD are mild, and resolve in a few days without medical intervention.
Blood or mucus
Mucus (, ) is a slippery aqueous secretion produced by, and covering, mucous membranes. It is typically produced from cells found in mucous glands, although it may also originate from mixed glands, which contain both Serous fluid, serous and muc ...
in the diarrhea, significant abdominal pain, or high fever suggests a more serious cause, such as cholera
Cholera () is an infection of the small intestine by some Strain (biology), strains of the Bacteria, bacterium ''Vibrio cholerae''. Symptoms may range from none, to mild, to severe. The classic symptom is large amounts of watery diarrhea last ...
, characterized by a rapid onset of weakness and torrents of watery diarrhea with flecks of mucus (described as "rice water" stools). Medical care should be sought in such cases; dehydration is a serious consequence of cholera, and may trigger serious sequela
A sequela (, ; usually used in the plural, sequelae ) is a pathological condition resulting from a disease, injury, therapy, or other trauma. Derived from the Latin word meaning "sequel", it is used in the medical field to mean a complication or ...
e—including, in rare instances, death—as rapidly as 24 hours after onset if not addressed promptly.[
]
Causes
Infectious agent
In biology, a pathogen (, "suffering", "passion" and , "producer of"), in the oldest and broadest sense, is any organism or agent that can produce disease. A pathogen may also be referred to as an infectious agent, or simply a germ.
The term ...
s are the primary cause of travelers' diarrhea. Bacterial enteropathogens cause about 80% of cases. Viruses
A virus is a submicroscopic infectious agent that replicates only inside the living cells of an organism. Viruses infect all life forms, from animals and plants to microorganisms, including bacteria and archaea. Viruses are found in almo ...
and protozoans
Protozoa (: protozoan or protozoon; alternative plural: protozoans) are a polyphyletic group of single-celled eukaryotes, either free-living or parasitic, that feed on organic matter such as other microorganisms or organic debris. Historically ...
account for most of the rest.
The most common causative agent isolated in countries surveyed has been enterotoxigenic ''Escherichia coli'' (ETEC). Enteroaggregative ''E. coli
''Escherichia coli'' ( )Wells, J. C. (2000) Longman Pronunciation Dictionary. Harlow ngland Pearson Education Ltd. is a gram-negative, facultative anaerobic, rod-shaped, coliform bacterium of the genus ''Escherichia'' that is commonly foun ...
'' is increasingly recognized.[ '']Shigella
''Shigella'' is a genus of bacteria that is Gram negative, facultatively anaerobic, non–spore-forming, nonmotile, rod shaped, and is genetically nested within ''Escherichia''. The genus is named after Kiyoshi Shiga, who discovered it in 1 ...
'' spp. and ''Salmonella
''Salmonella'' is a genus of bacillus (shape), rod-shaped, (bacillus) Gram-negative bacteria of the family Enterobacteriaceae. The two known species of ''Salmonella'' are ''Salmonella enterica'' and ''Salmonella bongori''. ''S. enterica'' ...
'' spp. are other common bacterial pathogens. ''Campylobacter
''Campylobacter'' is a type of bacteria that can cause a diarrheal disease in people. Its name means "curved bacteria", as the germ typically appears in a comma or "s" shape. According to its scientific classification, it is a genus of gram-negat ...
'', ''Yersinia
''Yersinia'' is a genus of bacteria in the family Yersiniaceae. ''Yersinia'' species are Gram-negative, coccobacilli bacteria, a few micrometers long and fractions of a micrometer in diameter, and are facultative anaerobes. Some members of '' ...
'', ''Aeromonas
''Aeromonas'' is a genus of Gram-negative, Facultative anaerobic organism, facultative anaerobic, rod-shaped, bacteria that morphologically resemble members of the family Enterobacteriaceae. Most of the 14 described species have been associated w ...
'', and '' Plesiomonas'' spp. are less frequently found. Mechanisms of action vary: some bacteria release toxin
A toxin is a naturally occurring poison produced by metabolic activities of living cells or organisms. They occur especially as proteins, often conjugated. The term was first used by organic chemist Ludwig Brieger (1849–1919), derived ...
s which bind to the intestinal wall and cause diarrhea; others damage the intestines themselves by their direct presence.
Brachyspira pilosicoli pathogen also appears to be responsible for many chronic intermittent watery diarrhea and is only diagnosed through colonic biopsies and microscopic discovery of a false brush border on H&E or Warthin silver stain: its brush-border is stronger and longer that Brachyspira aalborgi's brush-border. It is unfortunately often not diagnosed as coproculture does not allow growth and 16S PCR panel primers do not match Brachyspira sequences.
While viruses are associated with less than 20% of adult cases of travelers' diarrhea, they may be responsible for nearly 70% of cases in infants and children. Diarrhea due to viral agents is unaffected by antibiotic therapy, but is usually self-limited.[ Protozoans such as '']Giardia lamblia
''Giardia duodenalis'', also known as ''Giardia intestinalis'' and ''Giardia lamblia'', is a flagellated Parasitism, parasitic protozoan microorganism of the genus ''Giardia'' that colonizes the small intestine, causing a diarrheal condition kn ...
'', ''Cryptosporidium
''Cryptosporidium'', sometimes called crypto, is an apicomplexan genus of alveolates which are parasitism, parasites that can cause a respiratory and gastrointestinal illness (cryptosporidiosis) that primarily involves watery diarrhea (inte ...
'' and ''Cyclospora cayetanensis
''Cyclospora cayetanensis'' is a coccidian parasite that causes a diarrheal disease called cyclosporiasis in humans and possibly in other primates. Originally reported as a novel pathogen of probable coccidian nature in the 1980s and described i ...
'' can also cause diarrhea. Pathogens commonly implicated in travelers' diarrhea appear in the table in this section.
A subtype of travelers' diarrhea afflicting hikers and campers, sometimes known as wilderness diarrhea, may have a somewhat different frequency of distribution of pathogens.
Risk factors
The primary source of infection is ingestion of fecally contaminated food or water. Attack rates are similar for men and women.
The most important determinant of risk is the traveler's destination. High-risk destinations include developing countries
A developing country is a sovereign state with a less-developed Secondary sector of the economy, industrial base and a lower Human Development Index (HDI) relative to developed countries. However, this definition is not universally agreed upon. ...
in Latin America, Africa, the Middle East, and Asia. Among backpackers, additional risk factors include drinking untreated surface water and failure to maintain personal hygiene practices and clean cookware. Campsites often have very primitive (if any) sanitation facilities, making them potentially as dangerous as any developing country.
Although travelers' diarrhea usually resolves within three to five days (mean duration: 3.6 days), in about 20% of cases, the illness is severe enough to require bedrest, and in 10%, the illness duration exceeds one week.[ For those prone to serious infections, such as ]bacillary dysentery
Bacillary dysentery is a type of dysentery, and is a severe form of shigellosis. It is associated with species of bacteria from the family Enterobacteriaceae. The term is usually restricted to ''Shigella'' infections.
Shigellosis is caused by one ...
, amoebic dysentery
Amoebiasis, or amoebic dysentery, is an infection of the intestines caused by a parasitic amoeba '' Entamoeba histolytica''. Amoebiasis can be present with no, mild, or severe symptoms. Symptoms may include lethargy, loss of weight, coloni ...
, and cholera
Cholera () is an infection of the small intestine by some Strain (biology), strains of the Bacteria, bacterium ''Vibrio cholerae''. Symptoms may range from none, to mild, to severe. The classic symptom is large amounts of watery diarrhea last ...
, TD can occasionally be life-threatening.[ Others at higher-than-average risk include young adults, ]immunosuppressed
Immunosuppression is a reduction of the activation or efficacy of the immune system. Some portions of the immune system itself have immunosuppressive effects on other parts of the immune system, and immunosuppression may occur as an adverse react ...
persons, persons with inflammatory bowel disease
Inflammatory bowel disease (IBD) is a group of inflammatory conditions of the colon and small intestine, with Crohn's disease and ulcerative colitis (UC) being the principal types. Crohn's disease affects the small intestine and large intestine ...
or diabetes
Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or the cells of th ...
, and those taking H2 blockers or antacids
An antacid is a substance which neutralizes stomach acidity and is used to relieve heartburn, indigestion, or an upset stomach. Some antacids have been used in the treatment of constipation and diarrhea. Marketed antacids contain salts o ...
.
Immunity
Travelers often get diarrhea from eating and drinking foods and beverages that have no adverse effects on local residents. This is due to immunity
Immunity may refer to:
Medicine
* Immunity (medical), resistance of an organism to infection or disease
* ''Immunity'' (journal), a scientific journal published by Cell Press
Biology
* Immune system
Engineering
* Radiofrequence immunity ...
that develops with constant, repeated exposure to pathogenic organisms. The extent and duration of exposure necessary to acquire immunity has not been determined; it may vary with each individual organism. A study among expatriates in Nepal suggests that immunity may take up to seven years to develop—presumably in adults who avoid deliberate pathogen exposure.
Conversely, immunity acquired by American students while living in Mexico disappeared, in one study, as quickly as eight weeks after cessation of exposure.[Luis Ostrosky-Zeichner, Charles D. Ericsson,
''Travelers' diarrhea''. In Jane N. Zucherman, Ed., ''Principles and Practice of Travel Medicine'', John Wiley and Sons, 2001. p.15]
Google books preview
Prevention
Sanitation
Recommendations include avoidance of questionable foods and drinks, on the assumption that TD is fundamentally a sanitation
Sanitation refers to public health conditions related to clean drinking water and treatment and disposal of human excreta and sewage. Preventing human contact with feces is part of sanitation, as is hand washing with soap. Sanitation systems ...
failure, leading to bacterial contamination of drinking water and food. While the effectiveness of this strategy has been questioned, given that travelers have little or no control over sanitation in hotels and restaurants, and little evidence supports the contention that food vigilance reduces the risk of contracting TD, guidelines continue to recommend basic, common-sense precautions when making food and beverage choices:[
* Maintain good hygiene and use only ]safe water
Drinking water or potable water is water that is safe for ingestion, either when drunk directly in liquid form or consumed indirectly through food preparation. It is often (but not always) supplied through taps, in which case it is also calle ...
for drinking and brushing teeth.[
* Safe beverages include bottled water, bottled ]carbonated
Carbonation is the chemical reaction of carbon dioxide to give carbonates, bicarbonates, and carbonic acid. In chemistry, the term is sometimes used in place of carboxylation, which refers to the formation of carboxylic acids.
In inorganic che ...
beverages, and water boiled or appropriately treated by the traveler (as described below).[ Caution should be exercised with tea, coffee, and other hot beverages that may be only heated, not boiled.]
* In restaurants, insist that bottled water be unsealed in your presence; reports of locals filling empty bottles with untreated tap water and reselling them as purified water have surfaced.[ When in doubt, a bottled carbonated beverage is the safest choice, since it is difficult to simulate carbonation when refilling a used bottle.
* Avoid ice, which may not have been made with safe water.]
* Avoid green salads, because the lettuce and other uncooked ingredients are unlikely to have been washed with safe water.
* Avoid eating raw fruits and vegetables unless cleaned and peeled personally.
If handled properly, thoroughly cooked fresh and packaged foods are usually safe. Raw or undercooked meat and seafood should be avoided. Unpasteurized
In food processing, pasteurization (American and British English spelling differences#-ise, -ize (-isation, -ization), also pasteurisation) is a process of food preservation in which packaged foods (e.g., milk and fruit juices) are treated wi ...
milk, dairy products, mayonnaise, and pastry icing are associated with increased risk for TD, as are foods and beverages purchased from street vendors and other establishments where unhygienic conditions may be present.[
]
Water
Although safe bottled water is now widely available in most remote destinations, travelers can treat their own water if necessary, or as an extra precaution.[
Techniques include boiling, filtering, chemical treatment, and ultraviolet light; boiling is by far the most effective of these methods. Boiling rapidly kills all active bacteria, viruses, and protozoa. Prolonged boiling is usually unnecessary; most microorganisms are killed within seconds at water temperature above . The second-most effective method is to combine filtration and chemical disinfection. Filters eliminate most bacteria and protozoa, but not viruses. Chemical treatment with halogens—chlorine bleach, tincture of iodine, or commercial tablets—have low-to-moderate effectiveness against protozoa such as ''Giardia'', but work well against bacteria and viruses.
UV light is effective against both viruses and cellular organisms, but only works in clear water, and it is ineffective unless manufacturer's instructions are carefully followed for maximum water depth/distance from UV source, and for dose/exposure time. Other claimed advantages include short treatment time, elimination of the need for boiling, no taste alteration, and decreased long-term cost compared with bottled water. The effectiveness of UV devices is reduced when water is muddy or turbid; as UV is a type of light, any suspended particles create shadows that hide microorganisms from UV exposure.
]
Medications
Bismuth subsalicylate
Bismuth subsalicylate, sold generically as pink bismuth and under brand names including Pepto-Bismol, Pepti-Calm, and BisBacter, is a medication used to treat temporary discomfort of the stomach and gastrointestinal tract. This includes an upset ...
four times daily reduces rates of travelers' diarrhea.[ Though many travelers find a four-times-per-day regimen inconvenient, lower doses are not effective.][ Potential side effects include black tongue, black stools, nausea, constipation, and ]ringing in the ears
Tinnitus is a condition when a person hears a ringing sound or a different variety of sound when no corresponding external sound is present and other people cannot hear it. Nearly everyone experiences faint "normal tinnitus" in a completely ...
. Bismuth subsalicylate should not be taken by those with aspirin
Aspirin () is the genericized trademark for acetylsalicylic acid (ASA), a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, fever, and inflammation, and as an antithrombotic. Specific inflammatory conditions that aspirin is ...
allergy, kidney disease, or gout
Gout ( ) is a form of inflammatory arthritis characterized by recurrent attacks of pain in a red, tender, hot, and Joint effusion, swollen joint, caused by the deposition of needle-like crystals of uric acid known as monosodium urate crysta ...
, nor concurrently with certain antibiotics such as the quinolones
Quinolone may refer to:
* 2-Quinolone
* 4-Quinolone
* Quinolone antibiotic
Quinolone antibiotics constitute a large group of broad-spectrum bacteriocidals that share a bicyclic core structure related to the substance 4-quinolone. They ar ...
, and should not be taken continuously for more than three weeks. Some countries do not recommend it due to the risk of rare but serious side effects.[
A hyperimmune bovine colostrum to be taken by mouth is marketed in Australia for prevention of ETEC-induced TD. As yet, no studies show efficacy under actual travel conditions.][
Though effective, antibiotics are not recommended for the prevention of TD in most situations because of the risk of allergy or adverse reactions to the antibiotics, and because intake of preventive antibiotics may decrease the effectiveness of such drugs should a serious infection develop subsequently. Antibiotics can also cause vaginal yeast infections, or overgrowth of the bacterium '']Clostridioides difficile
''Clostridioides difficile'' ( syn. ''Clostridium difficile'') is a bacterium known for causing serious diarrheal infections, and may also cause colon cancer. It is known also as ''C. difficile'', or ''C. diff'' (), and is a Gram-positive spec ...
'', leading to pseudomembranous colitis
Colitis is swelling or inflammation of the large intestine ( colon). Colitis may be acute and self-limited or long-term. It broadly fits into the category of digestive diseases.
In a medical context, the label ''colitis'' (without qualificati ...
and its associated severe, unrelenting diarrhea.
Antibiotics may be warranted in special situations where benefits outweigh the above risks, such as immunocompromised travelers, chronic intestinal disorders, prior history of repeated disabling bouts of TD, or scenarios in which the onset of diarrhea might prove particularly troublesome. Options for prophylactic treatment include the fluoroquinolone
Quinolone antibiotics constitute a large group of broad-spectrum bacteriocidals that share a bicyclic core structure related to the substance 4-quinolone. They are used in human and veterinary medicine to treat bacterial infections, as well ...
antibiotics (such as ciprofloxacin
Ciprofloxacin is a fluoroquinolone antibiotic used to treat a number of bacterial infections. This includes bone and joint infections, intra-abdominal infections, certain types of infectious diarrhea, respiratory tract infections, skin ...
), azithromycin
Azithromycin, sold under the brand names Zithromax (in oral form) and Azasite (as an eye drop), is an antibiotic medication used for the treatment of several bacterial infections. This includes otitis media, middle ear infections, strep throa ...
, and trimethoprim/sulfamethoxazole
Trimethoprim/sulfamethoxazole, sold under the trade names Bactrim, Cotrim (a short form of the British Approved Name, Co-trimoxazole) and Septra, among others, is a fixed-dose combination antibiotic medication used to treat a variety of bacte ...
, though the latter has proved less effective in recent years. Rifaximin
Rifaximin is a non-absorbable, broad-spectrum antibiotic mainly used to treat travelers' diarrhea. It is based on the rifamycin antibiotics family. Since its approval in Italy in 1987, it has been licensed in more than 30 countries for the t ...
may also be useful.[ Quinolone antibiotics may bind to metallic cations such as bismuth, and should not be taken concurrently with bismuth subsalicylate. Trimethoprim/sulfamethoxazole should not be taken by anyone with a history of sulfa allergy.
]
Vaccination
The oral cholera vaccine, while effective for prevention of cholera, is of questionable use for prevention of TD.[ A 2008 review found tentative evidence of benefit. A 2015 review stated it may be reasonable for those at high risk of complications from TD.][ Several vaccine candidates targeting ETEC or ''Shigella'' are in various stages of development.
]
Probiotics
One 2007 review found that probiotics
Probiotics are live microorganisms that provide health benefits when consumed, generally by improving or restoring the microbiota in the Gut microbiota, gut. Probiotics are considered GRAS, generally safe to consume, but may cause bacteria– ...
may be safe and effective for prevention of TD, while another review found no benefit.[ A 2009 review confirmed that more study is needed, as the evidence to date is mixed.]
Treatment
Most cases of TD are mild and resolve in a few days without treatment, but severe or protracted cases may result in significant fluid loss and dangerous electrolytic imbalance. Dehydration due to diarrhea can also alter the effectiveness of medicinal and contraceptive drugs. Adequate fluid intake (oral rehydration therapy
Oral rehydration therapy (ORT) also officially known as Oral Rehydration Solution is a type of fluid replacement used to prevent and treat dehydration, especially due to diarrhea. It involves drinking water with modest amounts of sugar and salt ...
) is therefore a high priority. Commercial rehydration drinks are widely available; alternatively, purified water or other clear liquids are recommended, along with salty crackers or oral rehydration salts (available in stores and pharmacies in most countries) to replenish lost electrolytes. Carbonated water or soda, left open to allow dissipation of the carbonation, is useful when nothing else is available. In severe or protracted cases, the oversight of a medical professional is advised.
Antibiotics
If diarrhea becomes severe (typically defined as three or more loose stools in an eight-hour period), especially if associated with nausea, vomiting, abdominal cramps, fever, or blood in stools, medical treatment should be sought. Such patients may benefit from antimicrobial therapy. A 2000 literature review found that antibiotic treatment shortens the duration and severity of TD; most reported side effects were minor, or resolved on stopping the antibiotic.
The antibiotic recommended varies based upon the destination of travel. Trimethoprim–sulfamethoxazole
Trimethoprim/sulfamethoxazole, sold under the trade names Bactrim, Cotrim (a short form of the British Approved Name, Co-trimoxazole) and Septra, among others, is a fixed-dose combination antibiotic medication used to treat a variety of bacter ...
and doxycycline
Doxycycline is a Broad-spectrum antibiotic, broad-spectrum antibiotic of the Tetracycline antibiotics, tetracycline class used in the treatment of infections caused by bacteria and certain parasites. It is used to treat pneumonia, bacterial p ...
are no longer recommended because of high levels of resistance to these agents. Antibiotics are typically given for three to five days, but single doses of azithromycin
Azithromycin, sold under the brand names Zithromax (in oral form) and Azasite (as an eye drop), is an antibiotic medication used for the treatment of several bacterial infections. This includes otitis media, middle ear infections, strep throa ...
or levofloxacin
Levofloxacin, sold under the brand name Levaquin among others, is a broad-spectrum antibiotic of the fluoroquinolone drug class. It is the left-handed isomer of the medication ofloxacin. It is used to treat a number of bacterial infections ...
have been used. Rifaximin
Rifaximin is a non-absorbable, broad-spectrum antibiotic mainly used to treat travelers' diarrhea. It is based on the rifamycin antibiotics family. Since its approval in Italy in 1987, it has been licensed in more than 30 countries for the t ...
and rifamycin
The rifamycins are a group of antibiotics that are synthesized either naturally by the bacterium '' Amycolatopsis rifamycinica'' or artificially. They are a subclass of the larger family of ansamycins. Rifamycins are particularly effective aga ...
are approved in the U.S. for treatment of TD caused by ETEC. If diarrhea persists despite therapy, travelers should be evaluated for bacterial strains resistant to the prescribed antibiotic, possible viral or parasitic infections, bacterial or amoebic dysentery, ''Giardia'', helminths, or cholera.
Antimotility agents
Antimotility drugs such as loperamide
Loperamide, sold under the brand name Imodium, among others,Drugs.co Page accessed 4 September 2015 is a medication of the opioid receptor agonist class used to decrease the frequency of diarrhea. It is often used for this purpose in irritable ...
and diphenoxylate
Diphenoxylate is a centrally active opioid drug of the phenylpiperidine series that is used as a combination drug with atropine for the treatment of diarrhea. Diphenoxylate is an opioid and acts by slowing intestinal contractions; the atropine ...
reduce the symptoms of diarrhea by slowing transit time in the gut. They may be taken to slow the frequency of stools, but not enough to stop bowel movements completely, which delays expulsion of the causative organisms from the intestines. They should be avoided in patients with fever, bloody diarrhea, and possible inflammatory diarrhea. Adverse reactions may include nausea, vomiting, abdominal pain, hives or rash, and loss of appetite. Antimotility agents should not, as a rule, be taken by children under age two.
Epidemiology
An estimated 10 million people—20 to 50% of international travelers—develop TD each year. It is more common in the developing world, where rates exceed 60%, but has been reported in some form in virtually every travel destination in the world.
Society and culture
Moctezuma's revenge is a colloquial term for travelers' diarrhea contracted in Mexico. The name refers to Moctezuma II
Moctezuma Xocoyotzin . ( – 29 June 1520), retroactively referred to in European sources as Moctezuma II, and often simply called Montezuma,Other variant spellings include Moctezuma, Motewksomah, Motecuhzomatzin, Moteuczoma, Motecuhzoma, Motē ...
(1466–1520), the Tlatoani
''Tlahtoāni'' ( , "ruler, sovereign"; plural ' ) is a historical title used by the dynastic rulers of (singular ''āltepētl'', often translated into English as "city-state"), autonomous political entities formed by many pre-Columbian Nahuatl- ...
(ruler) of the Aztec
The Aztecs ( ) were a Mesoamerican civilization that flourished in central Mexico in the Post-Classic stage, post-classic period from 1300 to 1521. The Aztec people included different Indigenous peoples of Mexico, ethnic groups of central ...
civilization who was overthrown by the Spanish conquistador Hernán Cortés
Hernán Cortés de Monroy y Pizarro Altamirano, 1st Marquis of the Valley of Oaxaca (December 1485 – December 2, 1547) was a Spanish ''conquistador'' who led an expedition that caused the fall of the Aztec Empire and brought large portions o ...
in the early 16th century, thereby bringing large portions of what is now Mexico and Central America under the rule of the Spanish crown
The monarchy of Spain or Spanish monarchy () is the constitutional form of government of Spain. It consists of a Hereditary monarchy, hereditary monarch who reigns as the head of state, being the highest office of the country.
The Spanish ...
. The relevance being that Cortés and his soldiers carried the smallpox
Smallpox was an infectious disease caused by Variola virus (often called Smallpox virus), which belongs to the genus '' Orthopoxvirus''. The last naturally occurring case was diagnosed in October 1977, and the World Health Organization (W ...
virus, to which Mexicans had never been exposed. The resulting infection reduced the population of Tenochtitlan
, also known as Mexico-Tenochtitlan, was a large Mexican in what is now the historic center of Mexico City. The exact date of the founding of the city is unclear, but the date 13 March 1325 was chosen in 1925 to celebrate the 600th annivers ...
by 40 percent in 1520 alone.
Wilderness diarrhea
Wilderness diarrhea, also called wilderness-acquired diarrhea (WAD) or backcountry diarrhea, refers to diarrhea among backpackers, hikers, campers and other outdoor recreationalists in wilderness or backcountry situations, either at home or abroad. It is caused by the same fecal microorganisms as other forms of travelers' diarrhea, usually bacterial or viral. Since wilderness campsites seldom provide access to sanitation facilities, the infection risk is similar to that of any developing country. Water treatment, good hygiene, and dish washing have all been shown to reduce the incidence of WAD.
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{{DEFAULTSORT:Travelers' Diarrhea
Diarrhea
Foodborne illnesses
Waterborne diseases
Infectious diseases
Tourism
Conditions diagnosed by stool test
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