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Travel health information for people travelling abroad from the UK

Travellers' Diarrhoea

The Illness

Travellers’ diarrhoea is defined as the passage of 3 or more loose/watery stools in 24 hours, accompanied by any of; fever, abdominal cramps, faecal urgency, nausea or vomiting.

  • Mild travellers’ diarrhoea usually has no accompanying symptoms and does not disrupt normal activities
    • most cases are mild and do not significantly alter travel activities.
  • Moderate to severe travellers’ diarrhoea is associated with additional symptoms and leads to an interruption of normal activities
    • ~ 3% have 10 or more stools daily
  • Most cases occur in the first week of travel.
  • On average, symptoms last for 3-5 days and the majority of cases self resolve without any specific treatment.

Travellers’ diarrhoea can be caused by many different organisms including bacteria, such as E. coli and Salmonella, parasites such as Giardia, and viruses such as norovirus. All these organisms are spread through the faecal/oral route (eating/drinking contaminated food/water or contact between the mouth and contaminated hands, cups, plates etc).

Loose bowel movements can also result from a change in diet including, for example, spicy or oily foods.

Prevention

This depends upon taking effective food and water precautions including water purification. Personal hygiene when eating and drinking is very important including hand washing prior to eating and using clean plates, cups and utensils. Hand washing after using the toilet is essential but may not always be available; carry alcohol rub and wipes for emergencies.

Additional preventive measures may be considered in specific situations, see below. 

Treatment

Most cases of travellers’ diarrhoea will self resolve in 3–5 days without specific treatment. Antibiotics are unnecessary in most cases. Preventing dehydration during an episode of travellers’ diarrhoea is important. 

Travellers with severe or blood/mucous stained diarrhoea, high fever or severe abdominal pain should seek medical attention.

Rehydration

The priority in treatment is preventing dehydration, especially in young children.

Clear fluids such as diluted fruit juices or oral rehydration solutions (purchased as packeted oral rehydration salts in pharmacies) should be drunk liberally. All rehydrating drinks must be prepared with safe water.

Antidiarrhoeal Agents

For mild/moderate diarrhoea only.

Loperamide (Imodium®) or diphenoxylate plus atropine (Lomotil®) can help, particularly with associated colicky pains.

They are not recommended for use in children under 12 years of age.

Please note:

  • Overuse can cause rebound constipation.
  • Do not use if there is blood/mucous in stool and/or high fever or severe abdominal pain. These symptoms suggest invasive diarrhoea (dysentery): antidiarrhoeal agents increase the risk of complications such as septicaemia.  Medical attention must be sought!

Antibiotics - Self Treatment

If diarrhoea is severe or associated with blood and mucous in the stool, medical attention must be sought. If no medical treatment is readily available antibiotic self-treatment may be used. Antibiotics should improve diarrhoea within 1–2 days.

Antibiotics are effective against bacteria, the cause of most cases of travellers’ diarrhoea. They will not improve diarrhoea due to other causes.

Marked vomiting, fever, pain, bleeding or dehydration requires hospital referral so that intravenous fluids can be administered.

Travellers suitable for self-treatment may include:

  • Travellers to remote rural areas, who are distant from medical help.
  • Travellers with pre-existing bowel problems such as inflammatory bowel disease where infection may trigger a relapse.
  • Travellers with pre-existing medical conditions which may be worsened by severe infection or dehydration, i.e. poorly controlled diabetes, renal impairment etc.
  • Travellers with a tendency to severe travellers’ diarrhoea (on the basis of previous travel experience).

Antibiotic dose for self-treatment (adults only)

The choice of which antibiotic to use will be influenced by history of antibiotic allergy, other medications being taken including antibiotic prophylaxis and travel destination.

Ciprofloxacin

  • 500mg twice daily for 1 day.
  • If no improvement can be used for 3 days.

Azithromycin

  • 500-1000mg for 1 day or 500mg once daily for 3 days.

Rifaximin

  • 200mg three times daily for 3 days.
  • Do not use if symptoms of invasive diarrhoea are present (blood/mucous in stool).

Please note: all antibiotics have side effects and may affect/be affected by other medications taken at the same time. Always read the patient information leaflet that accompanies the antibiotic or discuss with your doctor/nurse before taking the medication.

If symptoms persist without improvement after 72 hours medical help should be sought.

Additional Preventive Measures

In certain situations additional measures may be considered to reduce the likelihood of diarrhoea developing. This is not a substitute to practicing good food and water hygiene.

Measures include:

  • Tablets to prevent diarrhoea (chemoprophylaxis) – antibiotics and non-antibiotics.
  • Vaccination.

Tablets to Prevent Travellers' Diarrhoea

Tablets to prevent diarrhoea are not routinely recommended as their side effects may be worse than the diarrhoea. Widespread use of antibiotics also causes drug resistance to develop in bacteria. However prophylaxis might be offered in selected circumstances, for example:

  • Travellers making a very short tour (3-5 days) when loss of even 12-24 hours would seriously impact on the success of the visit.
  • Travellers with pre-existing bowel problems such as inflammatory bowel disease, or severe medical problems, such as diabetes, where an attack of diarrhoea/dehydration could seriously aggravate symptoms or cause relapse.

Non-antibiotic Prophylaxis

Bismuth subsalicylate

  • An effective, non-antibiotic approach to prevent travellers' diarrhoea with an overall efficacy of about 60%.
  • Available in tablet (Pepto-bismol tablets ) or liquid formulation (Pepto-bismol liquid or Boots Pepti-calm).
  • To prevent travellers diarrhoea - two tablets or 30 ml are taken 4 times daily (max of 16 tablets or 240 ml) at meal times and on retiring.
  • Causes blackening of the stool and tongue.
  • Should not be used for more than 3 weeks.
  • Should be avoided in those on salicylate (aspirin) preparations or warfarin, those with hypersensitivity to salicylates and children under 16 years of age.
  • May interfere with the absorption of doxycycline used for malaria prophylaxis.

Antibiotic Prophylaxis

The choice of which antibiotic to use will be influenced by history of antibiotic allergy, other medications and travel destination.

Ciprofloxacin

  • 500mg daily.

Rifaximin

  • 200mg twice daily or 600mg once daily.

Please note: all antibiotics have side effects and may affect/be affected by other medications taken at the same time. Always read the patient information leaflet that accompanies the antibiotic or discuss with your doctor/nurse before taking the medication.

Pre/Probiotics

Pre and probiotics have been suggested as both treatment and prevention of travellers’ diarrhoea. There is not yet any convincing evidence that they are effective and thus they are not recommend for either prevention or treatment.

Vaccination

  • No licensed vaccines are available in the UK against travellers' diarrhoea
  • Dukoral® (the oral cholera vaccine) may give some protection against diarrhoea caused by one strain of E. coli (ETEC) but not other bacterial, parasitic or viral causes. It is not licensed for this use and is not routinely advised for travellers.

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