Guest Post: Prevention & Treatment of Traveler’s Diarrhea

Prevention of traveler’s diarrhea (TD) centers around three methods: dietary safety, immunizations, and chemoprophylaxis (medications taken to prevent diarrhea). Education on safe eating practices should form the basis of protection. Hand washing before meals should become second nature. Avoid eating at locations that look dirty or if the chef has a sore on his or her hand. Ensure that food is properly cooked and drink only from clean and disinfected water sources. Bottled water is usually safe to drink, but pouring clean water over ice made from contaminated water is a sure way to become ill. Disinfecting all water, even from supposedly safe bottles, is a good idea

Here are 10 rules for selection of safe food and water:

1. Drink disinfected water or bottled carbonated water. “Purified” does not necessarily mean “disinfected.”
2. Eat foods that are thoroughly cooked and served piping hot.
3. Eat fruits that have thick skins. These should be washed in disinfected water and then peeled at the table by the traveler.
4. Avoid salads that include raw vegetables, especially green leafy vegetables.
5. Do not use ice cubes in any beverages, including alcoholic beverages.
6. Only eat and drink dairy products made from pasteurized milk.
7. Avoid shellfish and raw or undercooked seafood, even if “preserved” with lime/lemon juice or vinegar.
8. Do not buy and eat food sold by street vendors.
9. If canned beverages are cooled by submersion of the can in a bucket of ice water or stream, be sure to dry off the outside of the can prior to drinking.
10. Use disinfected water for brushing teeth and taking medications.

I have to admit that I do not always follow all of these rules. I am what expedition doctors call an “adventurous eater” and am considered to be at higher risk for acquiring TD because of my actions. From personal experience, I can vouch that sticking to the aforementioned rules can go a long way towards preventing TD.

Immunizations to Prevent Traveler’s Diarrhea

Few vaccines exist to prevent TD. Vaccines to consider include that against hepatitis A and typhoid vaccine, both of which are very effective at preventing specific causes of TD. There is also a vaccine against cholera, but this is not widely considered to be very effective.

Chemoprophylaxis to Prevent Traveler’s Diarrhea

Taking medicine to prevent TD is not necessarily for every traveler. Should you be considering this regime, speak with your personal travel health provider before your trip. Travelers who may benefit from such prophylaxis include those on honeymoon or business, athletes, and travelers with prior chronic medical conditions. Generally, travelers should be encouraged to carry antibiotics to treat TD once the affliction is acquired, rather than taking a daily medication to prevent illness.

Common drug regimens to prevent TD include:

Bismuth subsalicylate (Pepto-Bismol)

• two tablets or 60mL solution taken every six hours
• Studies have shown this to be less effective than antibiotics. It is not for use by those with aspirin allergy, those taking other salicylate-containing medications, pregnant women, or children. Frequent doses and the large numbers of tablets required to be carried may affect compliance.

Trimethoprim160mg/sulfamethoxazole 800mg (Bactrim, Septra)

• one tablet daily
• Not to be used by persons with sulfa allergy, and may be ineffective in parts of the world due to bacterial drug resistance.

Doxycycline 100mg

• one tablet daily
• Not for use by pregnant travelers or children under eight years old. May cause vaginal yeast infections and increase your sensitivity to the sun.

Ciprofloxacin 500mg (Cipro)

• one tablet daily
• Not for use by pregnant travelers, children under age 18 years, or those with allergies to quinolone antibiotics. Drug-drug interactions are possible, especially with caffeine.

Probiotics

• Saccharomyces boulardii and Lactobacillus species have been shown to decrease rates of TD by approximately eight percent. This appeared more effective in children than in adults and also seemed to be more effective in decreasing diarrhea rates in persons already taking antibiotics than those who were not. Further studies need to be done to clearly determine the efficacy of this approach in TD prevention.

Treatment of Traveler’s Diarrhea Symptoms

Treatment of TD typically centers on rehydration, lessening diarrheal symptoms, and administering antibiotic medication. Self-treatment of TD is simple: the traveler just needs to get a prescription for antibiotics to be taken upon the onset of symptoms. When attempting self-treatment, the traveler needs to first ensure that he or she is adequately rehydrating. Rehydration can be achieved with adequate amounts of disinfected water and electrolyte replacement. Lessening diarrheal symptoms can be accomplished by taking medications designed to decrease the frequency of the stools. Common choices for symptomatic relief of TD include:

Bismuth subsalicylate (Pepto-Bismol)

• two tabs or 30mL solution every 30 minutes for eight total doses

Loperamide (Imodium)

• two capsules for first dose then one capsule after each loose stool, not to exceed eight capsules in 24 hours
• Do not use if there is blood present in the stool.

Diphenoxylate-atropine (Lomotil)

• two tabs for first dose then one tab after each loose stool, not to exceed eight tabs in 24 hours
• Do not use if there is blood present in the stool. This drug is falling out of favor with medical professionals because of known side effects.

Antibiotics for Self-Treatment of Traveler’s Diarrhea

Choice of empiric antibiotic treatment is based on several factors, including location of the trip and resistance of local pathogens, age of the traveler, and prior medical conditions. Antibiotic choices should be discussed with a travel health professional prior to the trip.

Trimethoprim160mg/sulfamethoxazole 800mg (Bactrim, Septra)

• one double strength tablet every 12 hours for three days
• Not to be used by persons with sulfa allergy; may be ineffective in some parts of the world due to bacterial drug resistance.

Ciprofloxacin 500mg (Cipro)

• one tablet every 12 hours for three days
• Not for use by pregnant women, children under 18 years old, and those with allergies to quinolone antibiotics. Drug-drug interactions are possible, especially with caffeine. Antibiotic resistance is increasing worldwide.

Azithromycin (Zithromax)

• one gram as a single dose or 500mg daily for three days
• This is the drug of choice for treating TD caused by quinolone-resistant Campylobacter species.

Rifaximin (Xifaxin)

• 200mg tablet every eight hours for three days
• Prescribed for children over the age of 12 years and adults only.

Tetracycline

• 2.5 grams as a single dose or 500mg every six hours, for three to five days
• Not for use by pregnant women or children under eight years old; may cause vaginal yeast infections and increased sun sensitivity.

Doxycycline

• 100mg tablet every eight hours, for three to five days
• Not for use by pregnant women or children under eight years old; may cause vaginal yeast infections and increased sun sensitivity. Drug resistance increasing worldwide.