Traveler's diarrhea medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The mainstay of therapy for traveler's diarrhea is rehydration and antimicrobial therapy. Since the majority of cases of traveler's diarrhea are caused by bacterial pathogens, empiric antibiotic therapy is usually recommended among both adult and pediatric patients diagnosed with traveler's diarrhea. Travelers who develop three or more loose stools in a 24-hour period — especially if associated with nausea, vomiting, abdominal cramps, fever, or blood in stools — benefit from antimicrobial therapy. Antibiotics usually are given for 3–5 days, but single dose or 1-3 day regimen are also effective among adults and children. Antimicrobial monotherapy typically includes oral administration of either levofloxacin 500 mg qd, norfloxacin 400 mg bid, ciprofloxacin 500 mg bid, Ofloxacin 200 mg bid, or azithromycin 500 mg qd (3-5 days) or 1000 mg (single dose). Symptomatic management of abdominal cramps and vomiting may also be required.

Medical Therapy

• The mainstay of therapy for traveler's diarrhea is rehydration and antimicrobial therapy.

Rehydration

• Oral rehydration fluids are indicated among patients who can tolerate oral intake, otherwise IV rehydration is indicated.
• Over the counter oral rehydration solutions (ORS) are optimal options for oral rehydration and are usually available for both adults and children.
• Oral rehydration solutions may be home-made by mixing the following:

• Drinking water: 1 liter
• Salt: 0.5 teaspoon
• Sugar: 6 teaspoons

• Rehydration must be gradual until signs of dehydration (e.g. dry mouth, oliguria) are resolved. Drinking ORS must be slow (1 sip every 5 minutes).
• Children often require 1 liter of ORS, whereas adults often require 3 liters of ORS.
• Energy drinks with high concentrations of electrolytes (e.g. sports drinks) may be offered to adults, but not children.
• Fluids high in sugar content (e.g. soda) are not recommended because they may worsen the dehydration.

Antimicrobial Therapy

• Since the majority of cases of traveler's diarrhea are caused by bacterial pathogens, empiric antibiotic therapy is usually recommended among both adult and pediatric patients diagnosed with traveler's diarrhea.
• Travelers who develop three or more loose stools in a 24-hour period — especially if associated with nausea, vomiting, abdominal cramps, fever, or blood in stools — benefit from antimicrobial therapy.
• Antibiotics usually are given for 3–5 days, but single dose azithromycin or levofloxacin have been used (for adults and children).
• If diarrhea persists despite therapy, travelers should be evaluated and treated for possible parasitic infection.

• There are different medications needed for bacterial dysentery, for amoebic dysentery, and for giardia
• There is no medication for Cryptosporidium, which typically affects individuals with AIDS.

• Empiric Therapy

• Antibiotic treatment

• Preferred regimen (1): Norfloxacin 400 mg PO bid single dose or 1-3 day therapy
• Preferred regimen (2): Ciprofloxacin 500 mg PO bid single dose or 1-3 day therapy
• Preferred regimen (3): Ofloxacin 200 mg PO bid single dose or 1-3 day therapy
• Preferred regimen (4): Levofloxacin 500 mg PO qd single dose or 1-3 day therapy
• Alternative regimen (1): Azithromycin 1000 mg PO single dose OR Azithromycin 500 mg PO qd for 1-3 days

Symptomatic Management

• Symptomatic management

• Abdominal discomfort

• Preferred regimen (1): Bismuth subsalicylate 1 oz PO every 30 min for 8 doses

• Vomiting

• Preferred regimen (2): Loperamide 4 mg PO THEN 2 mg after each loose stool not to exceed 16 mg daily
• Note (1): Antimotility agents are not generally recommended for patients with bloody diarrhea or those who have diarrhea and fever.
• Note (2): Loperamide can be used in children, and liquid formulations are available. In practice, however, these drugs are rarely given to small children (aged <6 years)