Traveler's diarrhea medical therapy

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

Overview

TD usually is a self-limited disorder and often resolves without specific treatment; however, oral rehydration therapy is often beneficial to replace lost fluids and electrolytes. Antibiotics are used in those 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

Medical Therapy

Rehydration

• The mainstay of therapy for traveler's diarrhea is 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-day therapy
• Preferred regimen (2): Ciprofloxacin 500 mg PO bid single dose or 1-day therapy
• Preferred regimen (3): Ofloxacin 200 mg PO bid single dose or 1-day therapy
• Preferred regimen (4): Levofloxacin 500 mg PO qd single dose or 1-day therapy
• Alternative regimen (1): Azithromycin 1000 mg PO single dose OR Azithromycin 500 mg PO 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)