Travellers' Diarrhoea

The Illness
Prevention
Treatment
Additional Measures
Vaccination

The Illness

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 dirty hands, cups, plates etc).

Remember loose motions 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.

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

Treatment

Rehydration

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 pharmacy) 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.

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

The majority of cases of travellers’ diarrhoea will resolve within 3-5 days with rehydration only. Antibiotic treatment is unnecessary in most cases.

However, if diarrhoea is severe or associated with blood and mucous in the stool 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 of the developing world 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)

Ciprofloxacin - 750mg once daily or 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).

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

Most cases of travellers’ diarrhoea are mild and will settle after a few days with simple measures such as rehydration. 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

Ciprofloxacin - 500mg daily.

Rifaximin - 200mg twice daily or 600mg once daily.