II. Precautions

  1. Antibiotic Resistance: Overall
    1. Avoid trimethoprim-sulfamethoxazole (Bactrim, Septra) and Doxycycline due to high resistance rates
    2. Most Traveler's Diarrhea is self-limited and spontaneously resolves WITHOUT antibiotics
      1. Use of antibiotics (esp. self treatment) is associated with multi-drug resistance
      2. Kantele (2015) Clin Infect Dis 60(6): 837-46 +PMID:25613287 [PubMed]
  2. Antibiotic Resistance: Travel to Southeast Asia, Thailand, India or Nepal
    1. Quinolone-resistant Campylobacter is common
    2. Azithromycin as first-line agent is preferred in these cases
  3. Drug Interactions
    1. Antimalarials and Azithromycin both prolong QT Interval (Exercise caution when prescribing both)

III. Management: Preparation for trip to endemic area

  1. See Traveler's Diarrhea Prophylaxis
  2. See Traveler's Diarrhea Prevention
  3. Review CDC Travel recommendations for region
    1. http://www.cdc.gov/travel
    2. Malaria Prophylaxis (endemic regions)
    3. Vaccinations - Start at least 6 weeks before travel
      1. Hepatitis A Vaccine
      2. Hepatitis B Vaccine
      3. Influenza Vaccine
      4. MeningitisVaccine
      5. Yellow Fever Vaccine
      6. Typhoid FeverVaccine
  4. High risk patients should bring medications on trip
    1. Instructions on use as below
    2. Oral rehydration Salts
    3. Antibiotic
      1. Pregnant women or Children or Adults traveling to Southeast Asia/India/Nepal
        1. Azithromycin 500 mg (3 tabs) or 200 mg/5ml (for 1-3 doses at 10 mg/kg)
      2. Adults traveling outside of Southeast Asia/India/Nepal
        1. Ciprofloxacin 500-750 mg (6 tablets)
    4. Loperamide 2 mg (20 tablets)
      1. See Loperamide for description
      2. Alternative: Diphenoxylate
  5. Precautions for seeking medical attention
    1. Dysentary (High fever, bloody stool, stools with mucus present)
    2. Dehydration or Syncope
    3. Diarrhea persists >1 week

IV. Management: Mild Diarrhea - Non-Pregnant Adults

  1. Criteria
    1. Self limited Diarrhea
    2. Stool frequency: 3-5 stools per day for 1-3 days
  2. Medications
    1. Consider bismuth tablets 2-4 tablets four times daily (adults only due to Salicylate content)
    2. Loperamide (Imodium) with one single dose antibiotic
    3. Antibiotic (1 dose): Pregnant women or Children or Adults traveling to Southeast Asia/India/Nepal
      1. Azithromycin 500 mg (single dose)
    4. Antibiotic (1 dose): Non-pregnant adults traveling outside of Southeast Asia/India/Nepal
      1. Ciprofloxacin 750 mg (single dose)
      2. Levofloxacin 500 mg (single dose)
      3. Ofloxacin 300 mg (single dose)
    5. Other options
      1. Rifaximin (Xifaxan)
        1. Well tolerated, non-absorbed, effective agent
        2. Indicated for non-invasive disease
          1. Example: Enterotoxigenic E. coli

V. Management: Moderate or Severe Diarrhea (dysentery) - Non-Pregnant Adults

  1. Criteria
    1. Stool frequency: >6 stools per day for 5 days
    2. High fever
    3. Bloody stools
    4. Stools with mucus present
  2. Medications
    1. Loperamide (Imodium) with one antibiotic below
      1. Do not use Loperamide if fever or bloody stool are present (dysentery)
    2. Antibiotic (3 days): Pregnant women or Children or Adults traveling to Southeast Asia/India/Nepal
      1. Azithromycin 500 mg (or 10 mg/kg in children) once daily for 3 days or
      2. Ceftriaxone 50 mg/kg/day (up to 1 g) IV every 24 hours for 3 days
    3. Antibiotic (3 days): Adults traveling outside of Southeast Asia/India/Nepal
      1. Ciprofloxacin 500 mg orally twice daily for 3 days or
      2. Norfloxacin 400 mg orally twice daily for 3 days or
      3. Ofloxacin 300 mg orally twice daily for 3 days or
      4. Levofloxacin 500 mg orally daily for 3 days
    4. Avoid antibiotics with high resistance rates
      1. Avoid trimethoprim-sulfamethoxazole (Bactrim, Septra)
      2. Avoid Doxycycline

VI. Management: Children with Traveler's Diarrhea

  1. General
    1. See Diarrhea in Children
    2. See Diarrhea Management in Children
    3. See Management of Moderate Diarrhea under age 2 years
    4. See Management of Mild Diarrhea under age 2 years
    5. See Pediatric Diarrhea Fluid Replacement
    6. See Oral Rehydration Solution
  2. Children age 12 years or over
    1. Loperamide (non-dysentary cases only) and
    2. Antibiotic: Rifaximin
  3. Children under age 12 years
    1. Loperamide (only age >2 years old and in non-dysentary cases) and
    2. Antibiotic
      1. Azithromycin (drug of choice) 10 mg/kg/day for 1-3 days OR
      2. Nalidixic Acid 14 mg/kg/dose up to 250 mg orally four times daily OR
      3. Ceftriaxone 50 mg/kg/day (up to 1 g) IV every 24 hours for 1-3 days
  4. Medications contraindicated in children
    1. Fluoroquinolone
    2. Bismuth Subsalicylate

VII. Management: Pregnant women with Traveler's Diarrhea

  1. Medications
    1. Loperamide (non-dysentary cases) and
    2. Antibiotic options
      1. Azithromycin 500 mg once daily for 3 days
      2. Ceftriaxone 1 g IV every 24 hours for 1-3 days
  2. Medications contraindicated in pregnancy and in children
    1. Fluoroquinolone
    2. Bismuth Subsalicylate

VIII. References

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