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Traveler's Diarrhea Management

See Also
Precautions
1. Antibiotics and dosing are listed for adults only
Preparation for trip to endemic area
1. Oral rehydration Salts
2. High risk patients should bring medications on trip
  1. Ciprofloxacin 250 mg (12 tablets)
  2. Loperamide 2 mg (20 tablets)
  3. Instructions on use as below
    1. See also Loperamide for description
Mild Diarrhea
1. Criteria
  1. Self limited Diarrhea
  2. Stool frequency: 3-5 stools per day for 1-3 days
2. Medications
  1. Loperamide (Imodium) with one antibiotic below
  2. Antibiotic for a single dose
    1. Ciprofloxacin 750 mg (single dose)
    2. Levofloxacin 500 mg (single dose)
    3. Ofloxacin 400 mg (single dose)
    4. Rifaximin (Xifaxan)
      1. Well tolerated, non-absorbed, effective agent
      2. Indicated for non-invasive disease
        
        Example: Enterotoxigenic E. coli
  3. Other antibiotics
    1. Bismuth Subsalicylate (not a first line agent)
Moderate or Severe Diarrhea (dysentery)
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
  2. Antibiotic
    1. Ciprofloxacin 500 mg PO bid for 3 days
    2. Norfloxacin 400 mg PO bid for 3 days
    3. Ofloxacin 300 mg PO bid for 3 days
    4. Levofloxacin 500 mg PO qd for 3 days
  3. Other antibiotics
    1. Bactrim is no longer recommended due to resistance
Children with Traveler's Diarrhea
1. General
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 in non-dysentary cases) and
  2. Antibiotic
    1. Azithromycin (drug of choice)
    2. Nalidixic Acid 14 mg/kg/dose up to 250 mg PO qid
4. Medications contraindicated in children
  1. Fluoroquinolone
  2. Bismuth Subsalicylate
Pregnant women with Traveler's Diarrhea
1. Medications
  1. Loperamide (non-dysentary cases) and
  2. Antibiotic: Azithromycin
2. Medications contraindicated in pregnancy
  1. Fluoroquinolone
  2. Bismuth Subsalicylate
Other management
1. Azithromycin (3 day regimen) indications
  1. Travel to Thailand (first-line drug)
    1. Quinolone-resistant Campylobacter is common
  2. Failure to respond to Quinolone above
  3. Moderate to severe Traveler's Diarrhea in age <12
References
1. (2005) Med Lett Drugs Ther 40(1025):47

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This page was written by Scott Moses, MD. This page was last revised before 5/10/08, prior to consistent tracking of revision date. This page was last published on 2/26/2010. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.