TRAVELERS' DIARRHEA: Epidemiology, Prevention, and Self-Treatment
Section snippets
DEFINITIONS
Most studies require that enrollees meet certain criteria before they begin therapy. Travelers' diarrhea is usually defined as the passage of three to four unformed stools in a 24-hour period plus at least one symptom of enteric disease, such as abdominal pain or cramps, nausea, vomiting, fever, or tenesmus.3, 5 Some definitions of diarrhea consider the volume of unformed stool passed in a period of time. This criterion breaks down in the face of full-blown dysentery during which many
CLINICAL DISEASE
Acute travelers' diarrhea is a clinical syndrome. Considerable overlap exists in the clinical manifestations of the various microbiologic causes of travelers' diarrhea10, 18; however, the average frequency of symptoms can be described: cramps, 40% to 60%; nausea, 10% to 70%; vomiting, 5% to 10%; and fever 10% to 30%.23 Classic categories of diarrhea like “secretory” or “invasive” do not help much in differentiating the specific etiologic agent of diarrhea in an individual because of
CAUSES OF TRAVELERS' DIARRHEA
Table 1 lists causes of travelers' diarrhea. The frequency with which specific microorganisms cause disease varies somewhat around the world, but most of the identified causal organisms are bacterial.23 Invasive bacterial pathogens, such as Shigella or Salmonella, tend to cause more severe, and longer-lasting disease than that caused by the most common cause of travelers' diarrhea in most series, enterotoxigenic Escherichia coli (ETEC). In many regions of the world Campylobacter jejuni is a
EPIDEMIOLOGY
The incidence of travelers' diarrhea is highest among persons moving from developed to developing countries, and there is even some variation in risk among developing countries.14, 15, 22, 23, 30 The world can roughly be divided into three zones based on the risk for travelers' diarrhea.23 Risk averages about 7% in developed countries, such as the United States, Canada, Europe, Australia, New Zealand, and other industrialized areas. Risk averages about 20% in southern Europe, Israel, Japan,
APPROACH TO PREVENTION
Options for the prevention of travelers' diarrhea include education and chemoprophylaxis with either bismuth subsalicylate–containing compounds or antibiotics.11 Vaccination is a promising option; however, vaccines against all enteropathogens that cause travelers' diarrhea might never be possible or cost-effective because of the large number of strains that cause disease, and promising vaccines against ETEC and Shigella are not available for routine use.11
The maxim “boil it, cook it, peel it—or
TREATMENT
Arguably, oral rehydration is the most significant medical advance during this century in terms of a cost-effective, simple but elegant intervention to save countless lives otherwise lost to dehydrating diarrhea. The addition of glucose to electrolyte-containing solutions facilitates absorption of electrolytes, which are not otherwise absorbed in the face of diarrhea. Although death is averted by treatment of such life-threatening dehydration that accompanies diseases like cholera, the actual
ALGORITHMIC APPROACH TO TREATMENT
Among all patients with travelers' diarrhea, approximately 40% have mild disease that is self-limiting within 1 or 2 days with passage of no more than two unformed stools per day.5 Once the third stool has been passed within a 24-hour period, diarrhea can be predicted to become more severe or last many days. At the author's clinic, clinicians advise long-term travelers, like expatriates, to withhold antibiotic treatment for mild travelers' diarrhea until after the third loose stool has been
VACCINATION
Passive protection against enterotoxigenic Escherichia coli (ETEC) using immunoglobulins in milk was successful against the specific strain studied. Further development of this approach seems to have been abandoned, perhaps caused by excessive development costs.
Cholera vaccination is not necessary for most tourists because they are simply not at risk unless they insist on eating raw seafood or are forced to live under deplorable conditions (e.g., some Peace Corps volunteers). Currently there is
SUMMARY
Risk factors for travelers' diarrhea include adventurous behavior, consumption of unclean water or food, and special hosts like those taking long acting H2 blockers. Approaches to prevention include education about risk factors, which often fails to lead to modification of risky behavior, and chemoprophylaxis with bismuth subsalicylate–containing compounds or antimicrobial agents. Chemoprophylaxis is generally discouraged except in special circumstances and in high-risk hosts. Self-treatment of
References (31)
- et al.
Zaldaride maleate, an intestinal calmodulin inhibitor, in the therapy of travelers' diarrhea
Gastroenterology
(1993) - et al.
Clinical presentation as a guide to therapy for travelers' diarrhea
Am J Med Sci
(1987) Turista in Teheran: Travelers diarrhea at the 8th International Congress of Tropical Medicine and Malaria
Lancet
(1969)- et al.
Development of resistance to quinolones in five patients with campylobacteriosis treated with norfloxacin or ciprofloxacin
Eur J Clin Microbiol
(1991) - et al.
Survival of bacterial enteropathogens in the ice of popular drinks
JAMA
(1985) - et al.
Prevention and treatment of travelers' diarrhea
N Engl J Med
(1993) - et al.
Travelers' diarrhea: Approaches to prevention and treatment
Clin Infect Dis
(1993) - et al.
Epidemiologic observations on diarrhea developing in U.S. and Mexican students living in Guadalajara, Mexico
J Travel Med
(1994) - et al.
Single dose of loxacin plus loperamide compared with single dose or three days of ofloxacin in the treatment of travelers' diarrhea
J Travel Med
(1997) - et al.
Treatment of travelers' diarrhea with sulfamethoxazole and trimethoprim and loperamide
JAMA
(1990)
Optimal dosing of trimethoprim/sulfamethoxazole when used with loperamide to treat travelers' diarrhea
Antimicrob Agents Chemother
Prevention of travelers' diarrhea: Risk avoidance and chemoprophylaxis
The diarrhea of travelers to Mexico: Summary of a five-year study
Ann Intern Med
Travelers' diarrhea among Austrian tourists in warm climate countries: I. Epidemiology
Eur J Epidemiol
Cited by (83)
New Tools to Test Stool: Managing Travelers’ Diarrhea in the Era of Molecular Diagnostics
2019, Infectious Disease Clinics of North AmericaPrevention of travelers’ diarrhea
2018, Travel MedicineHow low an effect of a preventive measure against diarrhoea are travellers willing to pay for?: A survey of Norwegian travellers
2016, Travel Medicine and Infectious DiseaseCitation Excerpt :General precautions have no documented effect [2]. Prophylactic use of antibacterial agents is cost-effective for short-term travel [3], but the use of antibiotics may increase the risk of acquiring multiresistant bacteria: Kantele et al. [4] found an odds ratio of 4.2 for carrying ESBL (Extended Spectrum Beta Lactamase) producing bacteria after having been treated with antibiotics for TD while travelling (P < 0.001). Antibiotic treatment of uncomplicated TD, which is mostly a self-limiting disease, should therefore be discouraged [5].
Prevention of Travelers' Diarrhea
2013, Travel Medicine: Third EditionOutcomes of diarrhea management in operations Iraqi Freedom and Enduring Freedom
2009, Travel Medicine and Infectious DiseaseCitation Excerpt :There is currently no standardized treatment course for TD in the field, though consensus guidelines on recommended management in travel medicine are available. These travel medicine guidelines recommend varied management approaches from pushing oral fluids only, to the addition of antimotility agents and/or antibiotics depending on the type of traveler, location of travels and severity of illness.5–7 To assess the use of these various treatment options, we evaluated post-treatment duration of illness and satisfaction with treatment using a systematic survey given to military personnel during mid- or post-deployment from Iraq or Afghanistan, from January through August of 2004.
Address reprint requests to Charles D. Ericsson, MD, 1.729 John Freeman Building, 6431 Fannin Street, Houston, TX 77030
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Clinical Infectious Diseases and Travel Medicine Clinic, Department of Medicine, Division of Infectious Diseases, University of Texas Houston Medical School, Houston, Texas