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Travellers' Diarrhoea

The Illness

Diarrhoea is one of the most common symptoms experienced during travel. Travellers’ diarrhoea is defined as passing 3 or more loose/watery bowel motions in 24 hours. It may be accompanied by any of the following symptoms; fever, tummy cramps, urgent need to pass bowel motion, nausea or vomiting.

Most cases occur in the first week of travel and are mild; i.e. diarrhoea is the only symptom and it does not disrupt normal activities. On average, symptoms last for 3-5 days and most cases resolve without any specific treatment. When travellers’ diarrhoea is associated with additional symptoms and this leads to an interruption of normal activities, it is classed as moderate to severe.

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 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 mainly upon practising good hand hygiene and effective food and water precautions.

  • Hands should be washed thoroughly before eating or handling food, and always after using the toilet.
    • Sanitising alcohol hand gel is an alternative when washing facilities are not available.

Diarrhoea may occur even in travellers who stick strictly to food and water precautions; in many destinations the risk is determined by local food hygiene and sanitation practices.

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

Treatment

Preventing dehydration during an episode of travellers’ diarrhoea is important. Antibiotics are unnecessary in most cases. Inappropriate antibiotic use can lead to drug resistant bowel organisms; these are unlikely to cause illness in a healthy individual, but  if spread, for example to a household contact with an underlying medical condition may lead to severe/untreatable infections.

Mild/Moderate Travellers Diarrhoea

Most cases are mild or moderate; < 6 diarrhoea stools are passed in 24 hours, there are few additional symptoms and although diarrhoea may disrupt activities, it is not incapacitating.

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

Please note:

  • They are not recommended for use in children under 12 years of age.
  • The effect of loperamide is not instantaneous and may take 1 - 2 hrs to reach its maximal effect.
  • Overuse can cause constipation.

Severe Travellers’ Diarrhoea

If > 6 diarrhoea stools are passed in 24 hours and cause incapacitation, or there is blood or mucous in the stool, or marked vomiting, fever, pain, bleeding,  medical attention must be sought.  Intravenous fluids may be needed to prevent dehydration. Antibiotics may be prescribed depending on the cause. Antibiotics are effective against bacteria, the cause of most cases of travellers’ diarrhoea. They will not improve diarrhoea due to other causes.

If no medical treatment is readily available, rehydration is essential and antibiotic self-treatment may be considered. Antibiotics should improve diarrhoea within 1–2 days.

Consider taking self-treatment if you:

  • Have pre-existing bowel problems such as inflammatory bowel disease where infection may trigger a relapse.
  • Have pre-existing medical conditions which may be worsened by severe infection or dehydration; i.e. poorly controlled diabetes, renal impairment etc.
  • Are travelling to remote rural areas, distant from medical help.

Antibiotic dose for self-treatment of severe diarrhoea (adults only)

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

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.

Additional Preventive Measures

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 and this is an increasing global problem. However prophylaxis might be offered in selected circumstances, for example:

  • 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 240ml) at meal times and on retiring.
    • Causes blackening of the stool and tongue.
    • Should not be used for more than 3 weeks.
    • There may be interactions with other medications – check with your doctor or nurse.

Pre/Probiotics

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

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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