Kalamaoo County

Health and Community Services Department

INTERNATIONAL TRAVEL CLINIC

Travelers' Diarrhea

Etiology
This can be caused many different organisms such as E.Coli, Shigella, and Entamoeba histolytica, Salmonella, Campylobacter, Giardia, Cryptosporidia, Cyclospora and Vibrio cholera. All these organisms are spread through the fecal/oral route.

Remember loose motions can also result from a change in diet including, for example, spicy or oily foods.

Prevention
This depends upon effective drinking water sterilization and ensuring food is uncontaminated or cooked thoroughly. Personal hygiene when eating and drinking is also important including hand washing prior to eating and using sterile plates, cups and utensils.

What to avoid
  • Water should only be drunk when you are sure of its purity. Don't drink it without boiling, chemical disinfection or using a reliable filter. This also applies to water used for making ice cubes and cleaning teeth. Bottled water is usually safe, as are hot tea and coffee, beer and wine.
  • Milk should be boiled unless you are sure it has been pasteurized.
  • Cheeses and ice cream are often made from unpasteurized milk and when in doubt these should only be bought from larger well-established companies when quality can usually be assured.
  • Meat should be thoroughly cooked and eaten hot whenever possible. Avoid leftovers.
  • Fish and shellfish can be hazardous at certain times of year, even if well cooked. Take local advice about seafood, but when in doubt it is best to avoid them.
  • Vegetables should only be eaten when thoroughly cooked.
  • Green salads should be avoided.
  • Fruit should be peeled, including tomatoes.
  • Wash hands thoroughly before eating or handling food, and always after using the toilet.
Vaccination
  • No licensed vaccines are available in the UK against travelers' diarrhea
  • Dukoral (the oral cholera vaccine) may give some protection against travelers' diarrhea specifically due to enterotoxaemia E.Coli (ETEC). Widespread use of this vaccine is however not advised for travelers' diarrhea - chemoprophylaxis (see below) is generally preferred for those going to high risk countries when a few days disruption to activities is unacceptable

Tablets to prevent travelers' diarrhea

A number of broad-spectrum antibiotics have been show to reduce the incidence of travelers' diarrhea by 70% to 90%. This is called chemoprophylaxis.

The normal antibiotic dose used for preventing travelers diarrhea
Half that used for treatment. e.g. ciprofloxacin 250mg daily; doxycycline 100 mg daily; trimethoprim 100mg daily. Bismuth subsalicylate is an effective, non-antibiotic approach to prevent traveler's diarrhea with an overall efficacy of about 60%. A tablet formulation is now available - two tablets are taken 4 times daily at meal times and on retiring. (Two weeks supply of the liquid form adds 5kg to the weight of a traveler's luggage!)

Recommendations for travelers
Chemoprophylaxis should not be used routinely. However it might be offered, for example, to a traveler who makes a very short tour (3-5 days) when loss of even 12-24 hours would seriously impact on the success of the visit. Prophylaxis may also be helpful in those with pre-existing bowel problems such as colitis or irritable bowel syndrome where an attack of diarrhea could seriously aggravate symptoms or cause relapse.

Remember antimicrobials may cause adverse drug reactions, which are occasionally severe and include diarrhea. Ciprofloxacin occasionally causes confusion and hallucinations; doxycycline is contra-indicated in pregnancy and young children.

Treatment
The priority in treatment is preventing dehydration especially in young children. Clear fluids such as diluted fruit juices or ideally specially prepared oral rehydrating solutions such as dioralyte (bought at the chemist) should be drunk liberally. All these preparations must be prepared with sterile water. Anti-diarrhea agents such as loperamide ( Imodium) or diphenoxylate plus atropine ( lomotil) should be used sparingly - they can help particularly with associated colicky pains. Overuse can cause 'rebound' constipation and occasionally encourage other complications such as septicemia.

Blood and mucous suggests campylobacter, shigella or amoebic infection. Marked vomiting, fever, pain, bleeding or dehydration usually requires hospital referral so the intravenous fluids can be administered.

While not necessary in most instances of travelers' diarrhea, if the diarrhea is very frequent and continues for more than a few hours, use of the same antibiotics that are sometimes used for prevention can shorten the illness. They are effective against E.coli, shigella, salmonella and campylobacter. Amoebic dysentery requires the use of metronidazole.

The normal antibiotic dose used for treatment
Ciprofloxacin 250mg, doxycycline 100 mg or trimethoprim 100mg (all taken twice a day). If used without medical supervision, prolonged courses are not normally necessary or desirable - treatment for 1 or 2 days is usually all that is required - and if the illness continues medical help should be sought.




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