Traveler's Diarrhea Prophylaxis

1. See Also
   1. Prevention of Waterborne Illness
   2. Prevention of Foodborne Illness
2. Prevention of Traveler's Diarrhea
   1. Rule 1: "Boil it, Cook it, Peel it or Forget it"
   2. Preparing your own food ensures safety
   3. Exposures to avoid
      1. Avoid raw vegetables
      2. Avoid pre-peeled fruit
      3. Avoid tap water or ice (Alcohol does not sterilize)
      4. Avoid foods that are not steaming hot
         1. Food should be heated above 65 degrees Celsius
         2. Food should be too hot to touch
3. Indications for prophylaxis
   1. Concomitant illness (e.g. Diabetes Mellitus)
   2. Diarrhea interferes with important medications
      1. Examples: Digoxin, Lasix
   3. Decreased gastric acidity
   4. Immunocompromised patient
   5. Travelers on critically important business
4. Protocol
   1. Patient to start prophylaxis with onset of Diarrhea
   2. Maximum duration of prophylaxis is 3 weeks
5. Medications
   1. First Choice
      1. Ciprofloxacin 500mg PO qd
         1. Efficacy: 94% prevention at 1 week
      2. Ofloxacin (Floxin) 300 mg PO qd
      3. Norfloxacin 400mg PO qd
         1. Efficacy: 88% prevention at 2 weeks
      4. Levofloxacin (Levaquin) 500 mg PO qd
   2. Other options
      1. Bismuth Subsalicylate (Pepto-Bismol) 2 tabs PO qid
         1. Efficacy: 60% protection
         2. Do not use with Doxycycline
            1. Interferes with absorption
      2. Rifaximin (Xifaxan)
         1. Not absorbed, well tolerated, and effective
         2. May be new preferred agent
      3. Lactobacillus GG (Culturelle)
         1. Probiotics colonizes GI tract
         2. Efficacy: 47% protection
      4. Bactrim DS bid
         1. High resistance now
         2. Efficacy
            1. Two weeks: 95% prevention
            2. Three weeks: 71% prevention