Traveler’s diarrhea meds

Travelers’ diarrhea, [1] Travelers’ Diarrhea https://wwwnc.cdc.gov/travel/yellowbook/2024/preparing/travelers-diarrhea or ‘food poisoning”, is the most widespread health condition among tourists. According to the World Health Organization (WHO), this condition affects over 50% of international travelers. It mostly occurs among travelers visiting the developing regions of the world (Central and South America, Africa, Asia).
People mainly get it when they consume contaminated food or water. In the majority of cases, this illness is caused by bacteria. However, in some cases the travelers’ diarrhea may be caused by a viral infection, such as norovirus or rotavirus. The condition often occurs between 4-14 days after a tourist arrives in a foreign country. Usually, the illness disappears within 5 days without any treatment.

People with traveler’s diarrhea experience loose stools with or without abdominal pain, fever, and nausea. However, based on the overall health status and frequency of the bowel movements of a person, travelers’ diarrhea is conditionally categorized into 3 groups of severity, namely mild, moderate, and severe. Disease manifestation varies from group to group.

Imodium (Loperamide) is a famous antimotility medication that helps to deal with symptoms such as frequent and watery stool. However, it is important to know that this medication does not treat the infectious disease. That is why for international travelers with symptoms of severe diarrhea it is suggested to take Imodium alongside antibiotics. Those having mild or moderate diarrhea may take it without antibiotics. Children aged two years old and younger should avoid this medication.
The table below summarizes information on dosage of the medication for travelers of different age groups

This medication is helpful in the treatment of some types of poisoning. However, it is not effective in the prevention or treatment of diarrhea and gas.

Antibiotics should not be taken for the mild and moderate types of travelers’ diarrhea. [2] Travelers’ Diarrhea https://www.aafp.org/pubs/afp/issues/1999/0701/p119.html Mostly, this medications are recommended when:

• Traveler has a severe infectious diarrhea
• Traveler has pus or blood in the stool
• Traveler cannot perform planned activities because of diarrhea

Nowadays, the antibiotics that are indicated for this condition are Azithromycin, Rifaximin or Fluoroquinolones with the following dosages:

• Azithromycin  (1 g) single dose of Azithromycin  (500 mg) once in a day (for 3 days)
• Fluoroquinolones  (400 mg) twice a day (for 3 days)
• Rifaximin  (200 mg) 3 times a day (for 3 days)

In summary, treatment options for travelers’ diarrhea are tailored to the severity of diarrhea. The table below describes the suggested treatment options for each group of the severity of diarrhea.

There are several recommendations that need to be followed to prevent travelers’ diarrhea when traveling to high-risk regions (Middle East, Southeast Asia, Africa, Latin America, Mexico, and the Caribbeans).
The tables below summarize these recommendations.

Fruits are one of those products that are often contaminated, which is why they are a common risk factor for traveler's diarrhea. However, travelers can eat fruits, but only the ones that they can  easily peel themselves, like:

• Bananas
• Oranges

It is recommended to avoid   the consumption of fruits that cannot be peeled, such as:

• Berries
• Grapes
• Plumps
• Also, it is important to know that fruits should be peeled right before eating.

Fruits should always be washed before eating. However, in developing countries, water is often contaminated, thus, may cause diarrhea in travelers. Unsterilized water should always be avoided. It is recommended to use boiled (for 3 minutes) or bottled water when washing hands, fruits, and teeth. Moreover, travelers should avoid sliced fruits, ice cubes and juices since those may be made from tap water.

One of the most commonly used non-antimicrobial prophylactic medications is Bismuth subsalicylate (Pepto-Bismol ). According to the Centers for Disease Control and Prevention (CDC), travelers who take this over-the-counter medication have up to 50% lower incidence of travelers’ diarrhea. Some studies claim that its preventive efficacy is more than 60% higher than placebo. However, Bismuth subsalicylate should not be taken by:

• Children aged 3 years old and younger
• Tourists having aspirin allergy
• Pregnant women
• Tourists having renal insufficiency
• Tourists having gout
• Tourists taking other medications such as anticoagulants, probenecid, and/or methotrexate

Moreover, those who take Bismuth subsalicylate may develop side effects such as nausea, hard stool (infrequent bowel movements), and blackening of the stool and/or tongue.

The next medication that is helpful in both the prevention and treatment of travelers’ diarrhea is Lactobacillus GG (probiotic). This medication helps to prevent diarrhea by increasing the number of good bacteria that help to defeat the pathogenic (bad) bacteria.

Though antibiotics are effective in the prevention of travelers’ diarrhea [3] Traveler's diarrhea https://www.mayoclinic.org/diseases-conditions/travelers-diarrhea/diagnosis-treatment/drc-20352188 development (more than 90%  of cases may be prevented), their routine use is not recommended. The thing is that antibiotics have various disadvantages:

• They are expensive
• They may cause vaginal yeast infection
• They may cause skin rash and allergy
• They disrupt the growth of normal (good) bacteria
• They promote antibiotic resistance

However, health care providers suggest that in some cases, the benefits of taking antibiotics outweigh its disadvantages. These is true for:

• Tourists with health conditions that can lead to diarrhea-related complications such as severe inflammatory bowel disease, kidney diseases, and suppressed immunity (for example HIV).
• Athletes attending tournaments or competitions that cannot afford to become sick

Usually, travelers diagnose the condition by themselves. Yet, some specificities may help to identify the causative agent and come up with an effective treatment strategy. The symptoms and possible pathogens are described below:

Usually, travelers’ diarrhea [4] Prevention and Self-Treatment of Traveler's Diarrhea https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1539099/ will be gone, without any treatment. However, there are some cases when a patient should see a travel medicine provider. Those cases are:

• If a traveler has a high fever
• If a traveler has bloody diarrhea
• If a traveler has bloody vomiting
• If a traveler has severe abdominal pain
• If antibiotics are ineffective (patients have symptoms for more than 2 weeks)

If travers’ diarrhea lasts for more than 2 weeks it is considered persistent diarrhea. Usually, this condition is a result of antibiotic-resistant bacteria. In his case, it is recommended to identify the pathogen and undergo a targeted therapy.