Travelers' diarrhea: Clinical manifestations, diagnosis, and treatment
- Christine A Wanke, MD
Christine A Wanke, MD
- Professor of Medicine and Public Health
- Tufts University School of Medicine
Travelers' diarrhea is the most common illness in persons traveling from resource-rich to resource-limited regions of the world [1,2]. The fear of developing diarrhea while traveling is common among such travelers. This concern is realistic; 40 to 60 percent of travelers to these countries may develop diarrhea. Episodes of travelers' diarrhea are nearly always benign and self-limited, but the dehydration that can complicate an episode may be severe and pose a greater health hazard than the illness itself.
The clinical features, diagnosis and evaluation, and treatment of travelers' diarrhea are discussed here. The microbiology, epidemiology, and prevention of travelers' diarrhea are discussed elsewhere. (See "Travelers' diarrhea: Microbiology, epidemiology, and prevention".)
Travelers' diarrhea refers to diarrhea that develops in individuals from resource-rich settings during or within 10 days of returning from travel to resource-limited countries or regions. For epidemiological purposes, it is frequently categorized into three forms: classic, moderate, and mild. These forms of travelers' diarrhea are defined as follows :
●Classic — passage of three or more unformed stools in a 24 hour period plus at least one of these other symptoms: nausea, vomiting, abdominal pain or cramps, fever, blood in stools
●Moderate — passage of one or two unformed stools in 24 hours plus at least one of the above symptoms or more than two unformed stools in 24 hours without other symptomsTo continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Greenwood Z, Black J, Weld L, et al. Gastrointestinal infection among international travelers globally. J Travel Med 2008; 15:221.
- Steffen R, Hill DR, DuPont HL. Traveler's diarrhea: a clinical review. JAMA 2015; 313:71.
- von Sonnenburg F, Tornieporth N, Waiyaki P, et al. Risk and aetiology of diarrhoea at various tourist destinations. Lancet 2000; 356:133.
- Soonawala D, Vlot JA, Visser LG. Inconvenience due to travelers' diarrhea: a prospective follow-up study. BMC Infect Dis 2011; 11:322.
- Steffen R, Collard F, Tornieporth N, et al. Epidemiology, etiology, and impact of traveler's diarrhea in Jamaica. JAMA 1999; 281:811.
- Rendi-Wagner P, Kollaritsch H. Drug prophylaxis for travelers' diarrhea. Clin Infect Dis 2002; 34:628.
- Avery ME, Snyder JD. Oral therapy for acute diarrhea. The underused simple solution. N Engl J Med 1990; 323:891.
- Carpenter CC, Greenough WB, Pierce NF. Oral-rehydration therapy--the role of polymeric substrates. N Engl J Med 1988; 319:1346.
- Caeiro JP, DuPont HL, Albrecht H, Ericsson CD. Oral rehydration therapy plus loperamide versus loperamide alone in the treatment of traveler's diarrhea. Clin Infect Dis 1999; 28:1286.
- de Zoysa I, Kirkwood B, Feachem R, Lindsay-Smith E. Preparation of sugar-salt solutions. Trans R Soc Trop Med Hyg 1984; 78:260.
- Huang DB, Awasthi M, Le BM, et al. The role of diet in the treatment of travelers' diarrhea: a pilot study. Clin Infect Dis 2004; 39:468.
- Kuschner RA, Trofa AF, Thomas RJ, et al. Use of azithromycin for the treatment of Campylobacter enteritis in travelers to Thailand, an area where ciprofloxacin resistance is prevalent. Clin Infect Dis 1995; 21:536.
- Murray BE. Resistance of Shigella, Salmonella, and other selected enteric pathogens to antimicrobial agents. Rev Infect Dis 1986; 8 Suppl 2:S172.
- Murray BE, Mathewson JJ, DuPont HL, et al. Emergence of resistant fecal Escherichia coli in travelers not taking prophylactic antimicrobial agents. Antimicrob Agents Chemother 1990; 34:515.
- DuPont HL, Ericsson CD. Prevention and treatment of traveler's diarrhea. N Engl J Med 1993; 328:1821.
- Mattila L, Peltola H, Siitonen A, et al. Short-term treatment of traveler's diarrhea with norfloxacin: a double-blind, placebo-controlled study during two seasons. Clin Infect Dis 1993; 17:779.
- Taylor DN, Sanchez JL, Candler W, et al. Treatment of travelers' diarrhea: ciprofloxacin plus loperamide compared with ciprofloxacin alone. A placebo-controlled, randomized trial. Ann Intern Med 1991; 114:731.
- Pichler HE, Diridl G, Stickler K, Wolf D. Clinical efficacy of ciprofloxacin compared with placebo in bacterial diarrhea. Am J Med 1987; 82:329.
- Salam I, Katelaris P, Leigh-Smith S, Farthing MJ. Randomised trial of single-dose ciprofloxacin for travellers' diarrhoea. Lancet 1994; 344:1537.
- Steffen R. Epidemiologic studies of travelers' diarrhea, severe gastrointestinal infections, and cholera. Rev Infect Dis 1986; 8 Suppl 2:S122.
- From the Centers for Disease Control. Cholera--international travel, 1992. JAMA 1992; 268:1648.
- Smith KE, Besser JM, Hedberg CW, et al. Quinolone-resistant Campylobacter jejuni infections in Minnesota, 1992-1998. Investigation Team. N Engl J Med 1999; 340:1525.
- Hakanen A, Jousimies-Somer H, Siitonen A, et al. Fluoroquinolone resistance in Campylobacter jejuni isolates in travelers returning to Finland: association of ciprofloxacin resistance to travel destination. Emerg Infect Dis 2003; 9:267.
- Nachamkin I, Ung H, Li M. Increasing fluoroquinolone resistance in Campylobacter jejuni, Pennsylvania, USA,1982-2001. Emerg Infect Dis 2002; 8:1501.
- Sanders JW, Isenbarger DW, Walz SE, et al. An observational clinic-based study of diarrheal illness in deployed United States military personnel in Thailand: presentation and outcome of Campylobacter infection. Am J Trop Med Hyg 2002; 67:533.
- Campbell PJ, Green AR. The myeloproliferative disorders. N Engl J Med 2006; 355:2452.
- Adachi JA, Ericsson CD, Jiang ZD, et al. Azithromycin found to be comparable to levofloxacin for the treatment of US travelers with acute diarrhea acquired in Mexico. Clin Infect Dis 2003; 37:1165.
- Sanders JW, Frenck RW, Putnam SD, et al. Azithromycin and loperamide are comparable to levofloxacin and loperamide for the treatment of traveler's diarrhea in United States military personnel in Turkey. Clin Infect Dis 2007; 45:294.
- Tribble DR, Sanders JW, Pang LW, et al. Traveler's diarrhea in Thailand: randomized, double-blind trial comparing single-dose and 3-day azithromycin-based regimens with a 3-day levofloxacin regimen. Clin Infect Dis 2007; 44:338.
- Steffen R, Sack DA, Riopel L, et al. Therapy of travelers' diarrhea with rifaximin on various continents. Am J Gastroenterol 2003; 98:1073.
- DuPont HL, Jiang ZD, Ericsson CD, et al. Rifaximin versus ciprofloxacin for the treatment of traveler's diarrhea: a randomized, double-blind clinical trial. Clin Infect Dis 2001; 33:1807.
- Adachi JA, DuPont HL. Rifaximin: a novel nonabsorbed rifamycin for gastrointestinal disorders. Clin Infect Dis 2006; 42:541.
- Dupont HL, Jiang ZD, Belkind-Gerson J, et al. Treatment of travelers' diarrhea: randomized trial comparing rifaximin, rifaximin plus loperamide, and loperamide alone. Clin Gastroenterol Hepatol 2007; 5:451.
- Petruccelli BP, Murphy GS, Sanchez JL, et al. Treatment of traveler's diarrhea with ciprofloxacin and loperamide. J Infect Dis 1992; 165:557.
- Riddle MS, Arnold S, Tribble DR. Effect of adjunctive loperamide in combination with antibiotics on treatment outcomes in traveler's diarrhea: a systematic review and meta-analysis. Clin Infect Dis 2008; 47:1007.
- DuPont HL, Hornick RB. Adverse effect of lomotil therapy in shigellosis. JAMA 1973; 226:1525.
- Swaminathan A, Torresi J, Schlagenhauf P, et al. A global study of pathogens and host risk factors associated with infectious gastrointestinal disease in returned international travellers. J Infect 2009; 59:19.
- Ross AG, Olds GR, Cripps AW, et al. Enteropathogens and chronic illness in returning travelers. N Engl J Med 2013; 368:1817.
- CLINICAL MANIFESTATIONS
- Classic symptoms
- Symptoms associated with specific etiologies
- Long-term sequelae
- DIAGNOSIS AND EVALUATION
- DIFFERENTIAL DIAGNOSIS
- When to seek care
- Fluid replacement
- Dietary guidance
- - Indications
- - Selection
- Symptomatic therapy
- - Antimotility agents
- - Bismuth
- PATIENTS WITH PERSISTENT DIARRHEA
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS