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Gastrointestinal tract

Gastrointestinal tract

Your digestive tract stretches from your mouth to your anus. It includes the organs necessary to digest food, absorb nutrients and process waste.

Traveler's diarrhea is a digestive tract disorder that commonly causes loose stools and stomach cramps. It's caused by eating contaminated food or drinking contaminated water. Fortunately, traveler's diarrhea usually isn't serious in most people — it's just unpleasant.

When you visit a place where the climate or sanitary practices are different from yours at home, you have an increased risk of developing traveler's diarrhea.

To reduce your risk of traveler's diarrhea, be careful about what you eat and drink while traveling. If you do develop traveler's diarrhea, chances are it will go away without treatment. However, it's a good idea to have doctor-approved medicines with you when you travel to high-risk areas. This way, you'll be prepared in case diarrhea gets severe or won't go away.

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Traveler's diarrhea may begin suddenly during your trip or shortly after you return home. Most people improve within 1 to 2 days without treatment and recover completely within a week. However, you can have multiple episodes of traveler's diarrhea during one trip.

The most common symptoms of traveler's diarrhea are:

  • Suddenly passing three or more looser watery stools a day.
  • An urgent need to pass stool.
  • Stomach cramps.

Sometimes, people experience moderate to severe dehydration, ongoing vomiting, a high fever, bloody stools, or severe pain in the belly or rectum. If you or your child experiences any of these symptoms or if the diarrhea lasts longer than a few days, it's time to see a health care professional.

When to see a doctor

Traveler's diarrhea usually goes away on its own within several days. Symptoms may last longer and be more severe if it's caused by certain bacteria or parasites. In such cases, you may need prescription medicines to help you get better.

If you're an adult, see your doctor if:

  • Your diarrhea lasts beyond two days.
  • You become dehydrated.
  • You have severe stomach or rectal pain.
  • You have bloody or black stools.
  • You have a fever above 102 F (39 C).

While traveling internationally, a local embassy or consulate may be able to help you find a well-regarded medical professional who speaks your language.

Be especially cautious with children because traveler's diarrhea can cause severe dehydration in a short time. Call a doctor if your child is sick and has any of the following symptoms:

  • Ongoing vomiting.
  • A fever of 102 F (39 C) or more.
  • Bloody stools or severe diarrhea.
  • Dry mouth or crying without tears.
  • Signs of being unusually sleepy, drowsy or unresponsive.
  • Decreased volume of urine, including fewer wet diapers in infants.

It's possible that traveler's diarrhea may stem from the stress of traveling or a change in diet. But usually infectious agents — such as bacteria, viruses or parasites — are to blame. You typically develop traveler's diarrhea after ingesting food or water contaminated with organisms from feces.

So why aren't natives of high-risk countries affected in the same way? Often their bodies have become used to the bacteria and have developed immunity to them.

Risk factors

Each year millions of international travelers experience traveler's diarrhea. High-risk destinations for traveler's diarrhea include areas of:

  • Central America.
  • South America.
  • South Asia and Southeast Asia.

Traveling to Eastern Europe, South Africa, Central and East Asia, the Middle East, and a few Caribbean islands also poses some risk. However, your risk of traveler's diarrhea is generally low in Northern and Western Europe, Japan, Canada, Singapore, Australia, New Zealand, and the United States.

Your chances of getting traveler's diarrhea are mostly determined by your destination. But certain groups of people have a greater risk of developing the condition. These include:

  • Young adults. The condition is slightly more common in young adult tourists. Though the reasons why aren't clear, it's possible that young adults lack acquired immunity. They may also be more adventurous than older people in their travels and dietary choices, or they may be less careful about avoiding contaminated foods.
  • People with weakened immune systems. A weakened immune system due to an underlying illness or immune-suppressing medicines such as corticosteroids increases risk of infections.
  • People with diabetes, inflammatory bowel disease, or severe kidney, liver or heart disease. These conditions can leave you more prone to infection or increase your risk of a more-severe infection.
  • People who take acid blockers or antacids. Acid in the stomach tends to destroy organisms, so a reduction in stomach acid may leave more opportunity for bacterial survival.
  • People who travel during certain seasons. The risk of traveler's diarrhea varies by season in certain parts of the world. For example, risk is highest in South Asia during the hot months just before the monsoons.

Complications

Because you lose vital fluids, salts and minerals during a bout with traveler's diarrhea, you may become dehydrated, especially during the summer months. Dehydration is especially dangerous for children, older adults and people with weakened immune systems.

Dehydration caused by diarrhea can cause serious complications, including organ damage, shock or coma. Symptoms of dehydration include a very dry mouth, intense thirst, little or no urination, dizziness, or extreme weakness.

Watch what you eat

The general rule of thumb when traveling to another country is this: Boil it, cook it, peel it or forget it. But it's still possible to get sick even if you follow these rules.

Other tips that may help decrease your risk of getting sick include:

  • Don't consume food from street vendors.
  • Don't consume unpasteurized milk and dairy products, including ice cream.
  • Don't eat raw or undercooked meat, fish and shellfish.
  • Don't eat moist food at room temperature, such as sauces and buffet offerings.
  • Eat foods that are well cooked and served hot.
  • Stick to fruits and vegetables that you can peel yourself, such as bananas, oranges and avocados. Stay away from salads and from fruits you can't peel, such as grapes and berries.
  • Be aware that alcohol in a drink won't keep you safe from contaminated water or ice.

Don't drink the water

When visiting high-risk areas, keep the following tips in mind:

  • Don't drink unsterilized water — from tap, well or stream. If you need to consume local water, boil it for three minutes. Let the water cool naturally and store it in a clean covered container.
  • Don't use locally made ice cubes or drink mixed fruit juices made with tap water.
  • Beware of sliced fruit that may have been washed in contaminated water.
  • Use bottled or boiled water to mix baby formula.
  • Order hot beverages, such as coffee or tea, and make sure they're steaming hot.
  • Feel free to drink canned or bottled drinks in their original containers — including water, carbonated beverages, beer or wine — as long as you break the seals on the containers yourself. Wipe off any can or bottle before drinking or pouring.
  • Use bottled water to brush your teeth.
  • Don't swim in water that may be contaminated.
  • Keep your mouth closed while showering.

If it's not possible to buy bottled water or boil your water, bring some means to purify water. Consider a water-filter pump with a microstrainer filter that can filter out small microorganisms.

You also can chemically disinfect water with iodine or chlorine. Iodine tends to be more effective, but is best reserved for short trips, as too much iodine can be harmful to your system. You can purchase water-disinfecting tablets containing chlorine, iodine tablets or crystals, or other disinfecting agents at camping stores and pharmacies. Be sure to follow the directions on the package.

Follow additional tips

Here are other ways to reduce your risk of traveler's diarrhea:

  • Make sure dishes and utensils are clean and dry before using them.
  • Wash your hands often and always before eating. If washing isn't possible, use an alcohol-based hand sanitizer with at least 60% alcohol to clean your hands before eating.
  • Seek out food items that require little handling in preparation.
  • Keep children from putting things — including their dirty hands — in their mouths. If possible, keep infants from crawling on dirty floors.
  • Tie a colored ribbon around the bathroom faucet to remind you not to drink — or brush your teeth with — tap water.

Other preventive measures

Public health experts generally don't recommend taking antibiotics to prevent traveler's diarrhea, because doing so can contribute to the development of antibiotic-resistant bacteria.

Antibiotics provide no protection against viruses and parasites, but they can give travelers a false sense of security about the risks of consuming local foods and beverages. They also can cause unpleasant side effects, such as skin rashes, skin reactions to the sun and vaginal yeast infections.

As a preventive measure, some doctors suggest taking bismuth subsalicylate, which has been shown to decrease the likelihood of diarrhea. However, don't take this medicine for longer than three weeks, and don't take it at all if you're pregnant or allergic to aspirin. Talk to your doctor before taking bismuth subsalicylate if you're taking certain medicines, such as anticoagulants.

Common harmless side effects of bismuth subsalicylate include a black-colored tongue and dark stools. In some cases, it can cause constipation, nausea and, rarely, ringing in your ears, called tinnitus.

  • Feldman M, et al., eds. Infectious enteritis and proctocolitis. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 11th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 25, 2021.
  • LaRocque R, et al. Travelers' diarrhea: Microbiology, epidemiology, and prevention. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
  • Ferri FF. Traveler diarrhea. In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed April 28, 2023.
  • Diarrhea. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/diarrhea. Accessed April 27, 2023.
  • Travelers' diarrhea. Centers for Disease Control and Prevention. https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/travelers-diarrhea. Accessed April 28, 2023.
  • LaRocque R, et al. Travelers' diarrhea: Clinical manifestations, diagnosis, and treatment. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
  • Khanna S (expert opinion). Mayo Clinic. May 29, 2021.
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Travellers’ diarrhoea

Chinese translation.

  • Related content
  • Peer review
  • Jessica Barrett , infectious diseases registrar 1 ,
  • Mike Brown , consultant in infectious diseases and tropical medicine 1 2
  • 1 Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London WC1E 6AU, UK
  • 2 Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
  • Correspondence to: J Barrett jessica.barrett{at}gstt.nhs.uk

What you need to know

Enterotoxic Escherichia coli (ETEC) is the most common cause of acute travellers’ diarrhoea globally

Chronic (>14 days) diarrhoea is less likely to be caused by bacterial pathogens

Prophylactic antibiotic use is only recommended for patients vulnerable to severe sequelae after a short period of diarrhoea, such as those with ileostomies or immune suppression

A short course (1-3 days) of antibiotics taken at the onset of travellers’ diarrhoea reduces the duration of the illness from 3 days to 1.5 days

Refer patients with chronic diarrhoea and associated symptoms such as weight loss for assessment by either an infectious diseases specialist or gastroenterologist

Diarrhoea is a common problem affecting between 20% and 60% of travellers, 1 particularly those visiting low and middle income countries. Travellers’ diarrhoea is defined as an increase in frequency of bowel movements to three or more loose stools per day during a trip abroad, usually to a less economically developed region. This is usually an acute, self limiting condition and is rarely life threatening. In mild cases it can affect the enjoyment of a holiday, and in severe cases it can cause dehydration and sepsis. We review the current epidemiology of travellers’ diarrhoea, evidence for different management strategies, and the investigation and treatment of persistent diarrhoea after travel.

We searched PubMed and Cochrane Library databases for “travellers’ diarrhoea,” and “travel-associated diarrhoea,” to identify relevant articles, which were added to personal reference collections and clinical experience. Where available, systematic reviews and randomised controlled trials were preferentially selected.

Who is at risk?

Variation in incidence 1 2 may reflect the degree of risk for different travel destinations and dietary habits while abroad. Destinations can be divided into low, medium, and high risk (see box 1). Rates of diarrhoea are likely to correlate closely with the quality of local sanitation.

Box 1: Risk of travellers’ diarrhoea according to destination 1 3

High risk destinations.

South and South East Asia*

Central America*

West and North Africa*

South America

East Africa

Medium risk

South Africa

North America

Western Europe

Australia and New Zealand

*Regions with particularly high risk of travellers’ diarrhoea

Backpackers have roughly double the incidence of diarrhoea compared with business travellers. 4 Travel in cruise ships is associated with large outbreaks of viral and bacterial gastroenteritis. 5 General advice is to avoid eating salads, shellfish, and uncooked meats. There is no strong evidence that specific dietary measures reduce incidence of diarrhoea, but studies examining this are likely to be biased by imperfect recall of what was eaten. 6 Risk factors for travellers’ diarrhoea are listed in box 2.

Box 2: Factors increasing risk of travellers’ diarrhoea 4 7 8 9

By increased dietary exposure.

Backpacking

Visiting friends and family

All-inclusive holidays (such as in cruise ships)

By increased susceptibility to an infectious load

Age <6 years

Use of H 2 receptor antagonists and proton pump inhibitors

Altered upper gastrointestinal anatomy

Genetic factors (blood group O predisposes to shigellosis and severe cholera infection)

What are the most important causes of travellers’ diarrhoea?

Most studies report a failure to identify the causative pathogen in between 40% and 70% of cases. 10 This includes multicentre studies based in high prevalence settings (that is, during travel). 3 10 11 12 This low diagnostic yield is partly due to delay in obtaining samples and partly due to the insensitivity of laboratory investigations. Older studies did not consistently attempt to identify enteroaggregative Escherichia coli (EAEC), and surveillance studies vary in reporting of other E coli species. 3 Where a pathogen is identified, bacteria are the commonest cause of acute travellers’ diarrhoea, with the remainder being caused by norovirus, rotavirus, or similar viruses (see table 1 ⇓ ). Protozoa such as Giardia lamblia can also cause acute diarrhoea, but they are more often associated with persistent diarrhoea, lasting more than two weeks. Cyclospora catayensis , another protozoan cause of diarrhoea, was identified in an increased number of symptomatic travellers returning from Mexico to the UK and Canada in 2015. 13

Frequency of pathogens causing travellers’ diarrhoea 2 3 10 11 12

  • View inline

Table 1 ⇑ illustrates overall prevalence of causative agents in returning travellers with diarrhoea. However relative importance varies with country of exposure. Rates of enterotoxigenic E coli (ETEC) are lower in travellers returning from South East Asia than in those returning from South Asia, sub-Saharan Africa, and Latin America, whereas rates of Campylobacter jejuni are higher. Norovirus is a more common cause in travellers to Latin America and sub-Saharan Africa, and Giardia lamblia and Entamoeba histolytica are more common in travellers to South and South East Asia. 10

The importance of enterotoxigenic E coli as a cause for diarrhoea in travellers returning from Latin America has been decreasing over the past four decades. 10 A large scale analysis of EuroTravNet surveillance data shows increasing incidence of Campylobacter jejuni infection in travellers returning from India, Thailand, and Pakistan. 2

How does travellers’ diarrhoea present?

Most episodes of travellers’ diarrhoea start during the first week of travel, with the peak incidence on the second or third day after arrival. 8 14

Typically diarrhoea caused by enterotoxigenic E coli (“turista”) is watery and profuse, and preceded by abdominal cramps, nausea, and malaise. Symptoms are not a reliable guide to aetiology, but upper gastrointestinal manifestations such as bloating and belching tend to predominate with Giardia lamblia , while colitic symptoms such as urgency, bloody diarrhoea, and cramps are seen more often with Campylobacter jejuni and Shigella spp.

Most episodes will last between one and seven days, with approximately 10% lasting for longer than one week, 5% lasting more than two weeks, and 1% lasting more than 30 days. 8 During the illness, few patients will be severely incapacitated (in one large prospective cohort about 10% of 2800 participants were confined to bed or consulted a physician), but planned activities are often cancelled or postponed. 8

How can travellers’ diarrhoea be prevented?

Several controlled trials have failed to demonstrate an impact of food and drink hygiene advice on rates of diarrhoea. 15 However, the clear food-related source of most diarrhoeal pathogens means that general consensus among travel physicians is to continue to recommend boiling water, cooking food thoroughly, and peeling fruit and vegetables. 6 Other basic advice includes avoiding ice, shellfish, and condiments on restaurant tables, using a straw to drink from bottles, and avoiding salads and buffets where food may have been unrefrigerated for several hours. Travellers should be advised to drink bottled water where available, including in alcoholic drinks, as alcohol does not sterilise non-bottled water. If bottled water is not available, water can be purified by boiling, filtering, or use of chlorine based tablets. 16 There is some weak evidence that use of alcohol hand gel may reduce diarrhoea rates in travellers, 17 but, based on studies in non-travellers, it is reasonable to strongly encourage travellers to adhere to good hand hygiene measures. Two recent systematic reviews estimated hand washing with soap reduces the risk of diarrhoeal illness by 30-40%. 18 19

When is antibiotic prophylaxis recommended?

For most travellers antibiotic chemoprophylaxis (that is, daily antibiotics for the duration of the trip) is not recommended. While diarrhoea is annoying and distressing, severe or long term consequences from a short period of diarrhoea are rare, and routine use of chemoprophylaxis would create a large tablet burden and expose users to possible adverse effects of antibiotic therapy such as candidiasis and diarrhoea associated with Clostridium difficile .

Chemoprophylaxis should be offered to those with severe immune suppression (such as from chemotherapy for malignancy or after a tissue transplant, or advanced HIV infection), underlying intestinal pathology (inflammatory bowel disease, ileostomies, short bowel syndrome), and other conditions such as sickle cell disease or diabetes where reduced oral intake may be particularly dangerous (table 2 ⇓ ). 22 These patient groups may be unable to tolerate the clinical effects and dehydration associated with even mild diarrhoea, or the consequences of more invasive complications such as bacteraemia. For such patients, it is important to discuss the benefits of treatment aimed at preventing diarrhoea and its complications against the risks of antibiotic associated diarrhoea and other side effects. If antibiotics are prescribed then consideration should be given to any possible interactions with other medications that the patient is taking.

Antibiotic chemoprophylaxis options for immunosuppressed or other high risk travellers

A small comparative study in US soldiers showed that malaria prophylaxis with daily doxycycline has the added benefit of reducing rates of travellers’ diarrhoea caused by enterotoxigenic E coli and Campylobacter jejuni . 23

Do vaccines have a role in prevention of travellers’ diarrhoea?

Vaccines have been developed and licensed against Salmonella typhi , Vibrio cholerae , and rotavirus—all with reasonable efficacy. However, unlike enterotoxigenic E coli , none of these is a major cause of travellers’ diarrhoea, and only vaccines against S typhi are recommended for most travellers to endemic settings. Phase 3 trials of enterotoxigenic E coli toxin vaccines have been undertaken but have failed to demonstrate efficacy. 24 Studies suggest vaccines against enterotoxigenic E coli would have a major public health impact in high burden countries, and further candidate vaccines are in development. 25

What are the options for self administered treatment?

Table 3 ⇓ summarises the options for self treatment.

Summary of self treatment choices

Anti-motility agents and oral rehydration therapy

For most cases of travellers’ diarrhoea, oral rehydration is the mainstay of treatment. This can be achieved with clear fluids such as diluted fruit juice or soups. Young children, elderly people, and those at greater risk from dehydration (that is, those with medical comorbidities) are recommended to use oral rehydration salts (or a mixture of six level teaspoons of sugar and half a teaspoon of salt in a litre of clean water if rehydration salts are unavailable) (see http://rehydrate.org/rehydration/index.html ).

Anti-motility agents such as loperamide may be appropriate for mild symptoms, or where rapid cessation of diarrhoea is essential. Case reports of adverse outcomes such as intestinal perforation suggest anti-motility agents should be avoided in the presence of severe abdominal pain or bloody diarrhoea, which can signify invasive colitis. 26 Systematic review of several randomised controlled trials have demonstrated a small benefit from taking bismuth subsalicylate, but this has less efficacy in reducing diarrhoea frequency and severity than loperamide. 27

Antibiotics

Symptomatic treatment is usually adequate and reduces antibiotic use. However, some travellers will benefit from rapid cessation of diarrhoea, particularly if they are in a remote area with limited access to sanitation facilities or healthcare. Several systematic reviews of studies comparing antibiotics (including quinolones, azithromycin, and rifaximin) against placebo have shown consistent shortening of the duration of diarrhoea to about one and a half days from around three days. 28 29 30 Short courses (one to three days) of antibiotics are usually sufficient to effect a cure. 30

For some people travelling to high and moderate risk areas (see box 1) it will be appropriate to provide a short course of a suitable antibiotic, with advice to start treatment as soon as they develop diarrhoea and to keep well hydrated. Choice of antibiotic will depend on allergy history, comorbidities, concomitant medications, and destination. Avoid quinolones for both prophylaxis and treatment of travellers to South East and South Asia as levels of quinolone resistance are high. 31 Azithromycin remains effective in these areas, but resistance rates are likely to increase.

A meta-analysis of nine randomised trials showed that the addition of loperamide to antibiotic treatment (including azithromycin, ciprofloxacin, and rifamixin) resulted in statistically significantly higher rates of cure at 24 and 48 hours compared with antibiotic alone. 32 Travellers can be advised to add loperamide to their antibiotic treatment to reduce the time to symptomatic improvement as long as there are no features of invasive colitis such as severe pain, high fever, or blood visible in the diarrhoea. 30 If any of these symptoms develop, travellers are advised to seek medical advice immediately.

Returned travellers with persistent diarrhoea

Most bacterial causes mentioned do not cause persistent diarrhoea in immune competent adults. Travellers with diarrhoea persisting beyond 14 days may present in primary or secondary care on their return and require assessment for other underlying causes of persistent diarrhoea.

Table 4 ⇓ lists the important clinical history and symptoms that can point to the underlying cause.

Assessment of chronic diarrhoea

What investigations should be sent?

For diarrhoeal symptoms that persist beyond 14 days following travel (or sooner if there are other concerning features such as fever or dysentery), offer patients blood tests for full blood count, liver and renal function, and inflammatory markers; stool samples for microscopy and culture; and examination for ova, cysts, and parasites. Historically, advice has been to send three stool samples for bacterial culture, but this is unlikely to increase the diagnostic yield. Instead, stool microscopy can be used to distinguish inflammatory from non-inflammatory causes: a small observational study found presence of faecal leucocytes was predictive of a positive bacterial stool culture. 33 Yield from stool culture may be increased by dilution of the faecal sample, and the introduction of molecular tests such as polymerase chain reaction (PCR) for common gastrointestinal pathogens such as Campylobacter spp may decrease turnaround times and increase yield. 34

Additional tests should be offered according to symptoms and risk (table 4 ⇑ ). If the patient has eosinophilia and an appropriate travel history, the possibility of schistosomiasis, strongyloides, and other helminthic infections should be considered. While schistosomiasis can rarely cause diarrhoea in the context of acute infection, serology may be negative in the first few months of the illness.

Imaging is required only if the patient has signs of severe colitis or local tenderness, in which instances toxic megacolon, inflammatory phlegmon, and hepatic collections should be excluded. Patients with severe colitis or proctitis may need joint assessment with gastroenterology and consideration of endoscopy, or laparotomy if perforation has occurred.

Where infectious and non-infectious causes have been appropriately excluded, the most likely diagnosis is post-infectious irritable bowel syndrome, although diarrhoea can also herald underlying bowel pathology and anyone with red flags for malignancy should be referred by the appropriate pathway for assessment. Post-infectious irritable bowel syndrome has an incidence of around 30% after an acute episode of travel associated gastroenteritis. 35 36 It is more commonly a sequela of prolonged episodes of diarrhoea or diarrhoea associated with fever and bloody stools. 36 There is weak evidence from small randomised trials suggesting that exclusion of foods high in fermentable carbohydrates (FODMAP) may be helpful. 37 Exclusion of dietary lactose and use of loperamide, bile acid sequestrants, and probiotics can also be tried, but there is limited evidence for long term benefit. 35 37 38

How should giardiasis be managed?

The most common pathogen identified in returning travellers with chronic diarrhoea is Giardia lamblia, particularly among people returning from South Asia. 39 Use of G lamblia PCR testing has increased detection, 40 which potentially will identify infection in some patients previously labelled as having post-infectious irritable bowel syndrome and in those whose diarrhoea may have been attributed to non-pathogenic protozoa. Most patients respond to 5-nitroimidazoles (a systematic review of a large number of trials has shown similar cure rates with tinidazole 2 g once only or metronidazole 400 mg three times daily for five days 41 ), but refractory cases are increasingly common and require investigation, identification of underlying risk factors, and repeated treatment (various antimicrobials have been shown to be effective but may have challenging risk profiles). .

Questions for future research

What is the justification for using antibiotics to treat a usually self limiting illness, in the wider context of rising levels of global antimicrobial resistance rates? What is the clinical impact of resistant enterobacteriaciae found in stool samples from returning travellers? 42 43

To what extent do host genetic factors increase susceptibility to gastrointestinal pathogens, and can this help to identify at risk populations and tailor treatments to individual patients?

What is the long term efficacy of new pharmacological treatments such as selective serotonin reuptake inhibitors and rifaximin in post-infectious irritable bowel syndrome?

Tips for non-specialists

Include consideration of chemoprophylaxis for high risk individuals in pre-travel assessment

Advise all travellers on hygiene measures (such as hand washing and food consumption) and symptom management of diarrhoea

Avoid quinolones for prophylaxis or treatment in travellers to South East and South Asia

Where diarrhoea persists beyond 14 days, consider investigations to rule out parasitic and non-infectious causes. The presence of white blood cells on stool microscopy indicates an inflammatory cause

Additional educational resources

Resources for patients.

National Travel Health Network and Centre (NaTHNaC): http://travelhealthpro.org.uk/travellers-diarrhoea/

Provides pre-travel advice, as well as links to country-specific advice

Fit for Travel: www.fitfortravel.nhs.uk/advice/disease-prevention-advice/travellers-diarrhoea.aspx

Provides similar pre-travel advice on hygiene and disease prevention

Patient.co.uk: http://patient.info/doctor/travellers-diarrhoea-pro

Has patient leaflets and more detailed information about investigation and management of travellers’ diarrhoea

Resources for healthcare professionals

Centers for Disease Control and Prevention yellow book: http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/travelers-diarrhea

Provides a guide to pre-travel couselling

Rehydration Project website: http://rehydrate.org/rehydration/index.html

Has additional information about non-pharmacological management of diarrhoea

How patients were involved in the creation of the article

No patients were involved in the creation of this review.

Contributors: Both authors contributed equally to the preparation of this manuscript. MB is guarantor. We thank Dr Ron Behrens for sharing his extensive expertise on this subject.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: Commissioned; externally peer reviewed.

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  • ↵ Schlagenhauf P, Weld L, Goorhuis A, et al. EuroTravNet. Travel-associated infection presenting in Europe (2008-12): an analysis of EuroTravNet longitudinal, surveillance data, and evaluation of the effect of the pre-travel consultation. Lancet Infect Dis 2015 ; 15 : 55 - 64 . doi:10.1016/S1473-3099(14)71000-X   pmid:25477022 . OpenUrl CrossRef PubMed
  • ↵ Health Protection Agency. Foreign travel-associated illness: a focus on travellers’ diarrhoea. HPA, 2010. http://webarchive.nationalarchives.gov.uk/20140714084352/http:/www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1287146380314 .
  • ↵ Schindler VM, Jaeger VK, Held L, Hatz C, Bühler S. Travel style is a major risk factor for diarrhoea in India: a prospective cohort study. Clin Microbiol Infect 2015 ; 21 : 676.e1 - 4 . doi:10.1016/j.cmi.2015.03.005   pmid:25882361 . OpenUrl CrossRef
  • ↵ Freeland AL, Vaughan GH Jr, , Banerjee SN. Acute gastroenteritis on cruise ships - United States, 2008-2014. MMWR Morb Mortal Wkly Rep 2016 ; 65 : 1 - 5 . doi:10.15585/mmwr.mm6501a1   pmid:26766396 . OpenUrl PubMed
  • ↵ DuPont HL, Ericsson CD, Farthing MJ, et al. Expert review of the evidence base for prevention of travelers’ diarrhea. J Travel Med 2009 ; 16 : 149 - 60 . doi:10.1111/j.1708-8305.2008.00299.x   pmid:19538575 . OpenUrl Abstract / FREE Full Text
  • ↵ Bavishi C, Dupont HL. Systematic review: the use of proton pump inhibitors and increased susceptibility to enteric infection. Aliment Pharmacol Ther 2011 ; 34 : 1269 - 81 . doi:10.1111/j.1365-2036.2011.04874.x   pmid:21999643 . OpenUrl CrossRef PubMed
  • ↵ Pitzurra R, Steffen R, Tschopp A, Mutsch M. Diarrhoea in a large prospective cohort of European travellers to resource-limited destinations. BMC Infect Dis 2010 ; 10 : 231 . doi:10.1186/1471-2334-10-231   pmid:20684768 . OpenUrl CrossRef PubMed
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Traveller's Diarrhoea

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Traveller's diarrhoea is diarrhoea that develops during, or shortly after, travel abroad. It is caused by consuming food and water, contaminated by germs (microbes) including bacteria, viruses and parasites. Other symptoms can include high temperature (fever), being sick (vomiting) and tummy (abdominal) pain. In most cases it causes a mild illness and symptoms clear within 3 to 4 days. Specific treatment is not usually needed but it is important to drink plenty of fluids to avoid lack of fluid in the body (dehydration). Always make sure that you get any advice that you need in plenty of time before your journey - some GPs offer travel advice but if yours doesn't then you may need to go to a private travel clinic.

In this article

  • What is traveller's diarrhoea?
  • What causes traveller's diarrhoea?

Are all travellers at risk?

  • What are the symptoms of traveller's diarrhoea?
  • How is traveller's diarrhoea diagnosed?
  • When should I seek medical advice for traveller's diarrhoea?
  • How is traveller's diarrhoea in adults treated?
  • How is traveller's diarrhoea in children treated?
  • Side-effects of traveller's diarrhoea
  • How long does traveller's diarrhoea last?
  • How can I avoid traveller's diarrhoea?

What is traveller's diarrhoea?

Traveller's diarrhoea is diarrhoea that develops during, or shortly after, travel abroad. Diarrhoea is defined as: 'loose or watery stools (faeces), usually at least three times in 24 hours.'

What causes traveller's diarrhoea?

Traveller's diarrhoea is caused by eating food, or drinking water, containing certain germs (microbes) or their poisons (toxins). The types of germs which may be the cause include:

  • Bacteria: these are the most common microbes that cause traveller's diarrhoea. Common types of bacteria involved are:
  • Escherichia coli
  • Campylobacter
  • Viruses: these are the next most common, particularly norovirus and rotavirus.
  • Parasites: these are less common causes. Giardia, cryptosporidium and Entamoeba histolytica are examples of parasites that may cause traveller's diarrhoea.

Often the exact cause of traveller's diarrhoea is not found and studies have shown that in many people no specific microbe is identified despite testing (for example, of a stool (faeces) specimen).

See the separate leaflets called E. Coli (VTEC O157) , Campylobacter, Salmonella, Cryptosporidium , Amoebiasis (dysentery information), Shigella and Giardia for more specific details on each of the microbes mentioned above.

Note : this leaflet is about traveller's diarrhoea in general and how to help prevent it.

Traveller's diarrhoea most commonly affects people who are travelling from a developed country, such as the UK, to a developing country where sanitation and hygiene measures may not meet the same standards. It can affect as many as 2 to 6 in 10 travellers.

There is a different risk depending on whether you travel to high-risk areas or not:

High-risk areas : South and Southeast Asia, Central America, West and North Africa, South America, East Africa.

Medium-risk areas : Russia, China, Caribbean, South Africa.

Low-risk areas : North America, Western Europe, Australia and New Zealand.

Sometimes outbreaks of diarrhoea can occur in travellers staying in one hotel or, for example, those staying on a cruise ship. People travelling in more remote areas (for example, trekkers and campers) may also have limited access to medical care if they do become unwell.

Book a pharmacy appointment today

Arrange a consultation with your local pharmacist to discuss your travel plans and medication for traveller's diarrhoea.

What are the symptoms of traveller's diarrhoea?

By definition, diarrhoea is the main symptom. This can be watery and can sometimes contain blood. Other symptoms may include:

  • Crampy tummy (abdominal) pains.
  • Feeling sick (nausea).
  • Being sick (vomiting).
  • A high temperature (fever).

Symptoms are usually mild in most people and last for 3 to 4 days but they may last longer. Symptoms may be more severe in the very young, the elderly, and those with other health problems. Those whose immune systems are not working as well as normal are particularly likely to be more unwell. For example, people with untreated HIV infection, those on chemotherapy, those on long-term steroid treatment or those who are taking drugs which suppress their immune system, for example after a transplant or to treat an autoimmune condition

Despite the fact that symptoms are usually fairly mild, they can often mean that your travel itinerary is interrupted or may need to be altered.

How is traveller's diarrhoea diagnosed?

Traveller's diarrhoea is usually diagnosed by the typical symptoms. As mentioned above, most people have mild symptoms and do not need to seek medical advice. However, in some cases medical advice is needed (see below).

If you do see a doctor, they may suggest that a sample of your stool (faeces) be tested. This will be sent to the laboratory to look for any microbes that may be causing your symptoms. Sometimes blood tests or other tests may be needed if you have more severe symptoms or develop any complications.

When should I seek medical advice for traveller's diarrhoea?

As mentioned above, most people with traveller's diarrhoea have relatively mild symptoms and can manage these themselves by resting and making sure that they drink plenty of fluids. However, you should seek medical advice in any of the following cases, or if any other symptoms occur that you are concerned about:

  • If you have a high temperature (fever).
  • If you have blood in your stools (faeces).
  • If it is difficult to get enough fluid because of severe symptoms: frequent or very watery stools or repeatedly being sick (vomiting).
  • If the diarrhoea lasts for more than 5-7 days.
  • If you are elderly or have an underlying health problem such as diabetes, inflammatory bowel disease, or kidney disease.
  • If you have a weakened immune system because of, for example, chemotherapy treatment, long-term steroid treatment, or HIV infection.
  • If you are pregnant.
  • If an affected child is under the age of 6 months.
  • If you develop any of the symptoms listed below that suggest you might have lack of fluid in your body (dehydration). If it is your child who is affected, there is a separate list for children.

Symptoms of dehydration in adults

  • Dizziness or light-headedness.
  • Muscle cramps.
  • Sunken eyes.
  • Passing less urine.
  • A dry mouth and tongue.
  • Becoming irritable.

Symptoms of severe dehydration in adults

  • Profound loss of energy or enthusiasm (apathy).
  • A fast heart rate
  • Producing very little urine.
  • Coma, which may occur.

Note : severe dehydration is a medical emergency and immediate medical attention is needed.

Symptoms of dehydration in children

  • Passing little urine.
  • A dry mouth.
  • A dry tongue and lips.
  • Fewer tears when crying.
  • Being irritable.
  • Having a lack of energy (being lethargic).

Symptoms of severe dehydration in children

  • Drowsiness.
  • Pale or mottled skin.
  • Cold hands or feet.
  • Very few wet nappies.
  • Fast (but often shallow) breathing.

Dehydration is more likely to occur in:

  • Babies under the age of 1 year (and particularly those under 6 months old). This is because babies don't need to lose much fluid to lose a significant proportion of their total body fluid.
  • Babies under the age of 1 year who were a low birth weight and who have not caught up with their weight.
  • A breastfed baby who has stopped being breastfed during their illness.
  • Any baby or child who does not drink much when they have a gut infection (gastroenteritis).
  • Any baby or child with severe diarrhoea and vomiting. (For example, if they have passed five or more diarrhoeal stools and/or vomited two or more times in the previous 24 hours.)

How is traveller's diarrhoea in adults treated?

In most cases, specific treatment of traveller's diarrhoea is not needed. The most important thing is to make sure that you drink plenty of fluids to avoid lack of fluid in your body (dehydration).

Fluid replacement

  • As a rough guide, drink at least 200 mls after each watery stool (bout of diarrhoea).
  • This extra fluid is in addition to what you would normally drink. For example, an adult will normally drink about two litres a day but more in hot countries. The above '200 mls after each watery stool' is in addition to this usual amount that you would drink.
  • If you are sick (vomit), wait 5-10 minutes and then start drinking again but more slowly. For example, a sip every 2-3 minutes but making sure that your total intake is as described above.
  • You will need to drink even more if you are dehydrated. A doctor will advise on how much to drink if you are dehydrated.

Note : if you suspect that you are becoming dehydrated, you should seek medical advice.

For most adults, fluids drunk to keep hydrated should mainly be water. However, this needs to be safe drinking water - for example, bottled, or boiled and treated water. It is best not to have drinks that contain a lot of sugar, such as fizzy drinks, as they can sometimes make diarrhoea worse. Alcohol should also be avoided.

Rehydration drinks

Rehydration drinks may also be used. They are made from sachets that you can buy from pharmacies and may be a sensible thing to pack in your first aid kit when you travel. You add the contents of the sachet to water.

Home-made salt/sugar mixtures are used in developing countries if rehydration drinks are not available; however, they have to be made carefully, as too much salt can be dangerous. Rehydration drinks are cheap and readily available in the UK, and are the best treatment. Note that safe drinking water should be used to reconstitute oral rehydration salt sachets.

Antidiarrhoeal medication

Antidiarrhoeal medicines are not usually necessary or wise to take when you have traveller's diarrhoea. However you may want to use them if absolutely necessary - for example, if you will be unable to make regular trips to the toilet due to travelling.You can buy antidiarrhoeal medicines from pharmacies before you travel. The safest and most effective is loperamide.

The adult dose of this is two capsules at first. This is followed by one capsule after each time you pass some diarrhoea up to a maximum of eight capsules in 24 hours. It works by slowing down your gut's activity.

You should not take loperamide for longer than two days. You should also not use antidiarrhoeal medicines if you have a high temperature (fever) or bloody diarrhoea.

Eat as normally as possible

It used to be advised to 'starve' for a while if you had diarrhoea. However, now it is advised to eat small, light meals if you can. Be guided by your appetite. You may not feel like food and most adults can do without food for a few days. Eat as soon as you are able but don't stop drinking. If you do feel like eating, avoid fatty, spicy or heavy food. Plain foods such as bread and rice are good foods to try eating.

Antibiotic medicines

Most people with traveller's diarrhoea do not need treatment with antibiotic medicines. However, sometimes antibiotic treatment is advised. This may be because a specific germ (microbe) has been identified after testing of your stool (faeces) sample.

How is traveller's diarrhoea in children treated?

Fluids to prevent dehydration.

You should encourage your child to drink plenty of fluids. The aim is to prevent lack of fluid in the body (dehydration). The fluid lost in their sick (vomit) and/or diarrhoea needs to be replaced. Your child should continue with their normal diet and usual drinks. In addition, they should also be encouraged to drink extra fluids. However, avoid fruit juices or fizzy drinks, as these can make diarrhoea worse.

Babies under 6 months old are at increased risk of dehydration. You should seek medical advice if they develop acute diarrhoea. Breast feeds or bottle feeds should be encouraged as normal. You may find that your baby's demand for feeds increases. You may also be advised to give extra fluids (either water or rehydration drinks) in between feeds.

If you are travelling to a destination at high risk for traveller's diarrhoea, you might want to consider buying oral rehydration sachets for children before you travel. These can provide a perfect balance of water, salts and sugar for them and can be used for fluid replacement. Remember that, as mentioned above, safe water is needed to reconstitute the sachets.

If your child vomits, wait 5-10 minutes and then start giving drinks again but more slowly (for example, a spoonful every 2-3 minutes). Use of a syringe can help in younger children who may not be able to take sips.

Note : if you suspect that your child is dehydrated, or is becoming dehydrated, you should seek medical advice urgently.

Fluids to treat dehydration

If your child is mildly dehydrated, this may be treated by giving them rehydration drinks. A doctor will advise about how much to give. This can depend on the age and the weight of your child. If you are breastfeeding, you should continue with this during this time. It is important that your child be rehydrated before they have any solid food.

Sometimes a child may need to be admitted to hospital for treatment if they are dehydrated. Treatment in hospital usually involves giving rehydration solution via a special tube called a 'nasogastric tube'. This tube passes through your child's nose, down their throat and directly into their stomach. An alternative treatment is with fluids given directly into a vein (intravenous fluids).

Eat as normally as possible once any dehydration has been treated

Correcting any dehydration is the first priority. However, if your child is not dehydrated (most cases), or once any dehydration has been corrected, then encourage your child to have their normal diet. Do not 'starve' a child with infectious diarrhoea. This used to be advised but is now known to be wrong. So:

  • Breastfed babies should continue to be breastfed if they will take it. This will usually be in addition to extra rehydration drinks (described above).
  • Bottle-fed babies should be fed with their normal full-strength feeds if they will take it. Again, this will usually be in addition to extra rehydration drinks (described above). Do not water down the formula, or make it up with less water than usual. This can make a baby very ill.
  • Older children - offer them some food every now and then. However, if he or she does not want to eat, that is fine. Drinks are the most important consideration and food can wait until the appetite returns.

Loperamide is not recommended for children with diarrhoea. There are concerns that it may cause a blockage of the gut (intestinal obstruction) in children with diarrhoea.

Most children with traveller's diarrhoea do not need treatment with antibiotics. However, for the same reasons as discussed for adults above, antibiotic treatment may sometimes be advised in certain cases.

Side-effects of traveller's diarrhoea

Most people have mild illness and complications of traveller's diarrhoea are rare. However, if complications do occur, they can include the following:

Salt (electrolyte) imbalance and dehydration .

This is the most common complication. It occurs if the salts and water that are lost in your stools (faeces), or when you are sick (vomit), are not replaced by you drinking adequate fluids. If you can manage to drink plenty of fluids then dehydration is unlikely to occur, or is only likely to be mild and will soon recover as you drink.

Severe dehydration can lead to a drop in your blood pressure. This can cause reduced blood flow to your vital organs. If dehydration is not treated, your kidneys may be damaged . Some people who become severely dehydrated need a 'drip' of fluid directly into a vein. This requires admission to hospital. People who are elderly or pregnant are more at risk of dehydration.

Reactive complications

Rarely, other parts of your body can 'react' to an infection that occurs in your gut. This can cause symptoms such as joint inflammation (arthritis), skin inflammation and eye inflammation (either conjunctivitis or uveitis). Reactive complications are uncommon if you have a virus causing traveller's diarrhoea.

Spread of infection

The infection can spread to other parts of your body such as your bones, joints, or the meninges that surround your brain and spinal cord. This is rare. If it does occur, it is more likely if diarrhoea is caused by salmonella infection.

Irritable bowel syndrome

Irritable bowel syndrome is sometimes triggered by a bout of traveller's diarrhoea.

Lactose intolerance

Lactose intolerance can sometimes occur for a period of time after traveller's diarrhoea. It is known as 'secondary' or 'acquired' lactose intolerance. Your gut (intestinal) lining can be damaged by the episode of diarrhoea. This leads to lack of a substance (enzyme) called lactase that is needed to help your body digest the milk sugar lactose.

Lactose intolerance leads to bloating, tummy (abdominal) pain, wind and watery stools after drinking milk. The condition gets better when the infection is over and the intestinal lining heals. It is more common in children.

Haemolytic uraemic syndrome

Usually associated with traveller's diarrhoea caused by a certain type of E. coli infection, haemolytic uraemic syndrome is a serious condition where there is anaemia, a low platelet count in the blood and kidney damage. It is more common in children. If recognised and treated, most people recover well.

Guillain-Barré syndrome

This condition may rarely be triggered by campylobacter infection, one of the causes of traveller's diarrhoea. It affects the nerves throughout your body and limbs, causing weakness and sensory problems. See the separate leaflet called Guillain-Barré syndrome for more details.

Reduced effectiveness of some medicines

During an episode of traveller's diarrhoea, certain medicines that you may be taking for other conditions or reasons may not be as effective. This is because the diarrhoea and/or being sick (vomiting) mean that reduced amounts of the medicines are taken up (absorbed) into your body.

Examples of such medicines are those for epilepsy, diabetes and contraception . Speak with your doctor or practice nurse before you travel if you are unsure of what to do if you are taking other medicines and develop diarrhoea.

How long does traveller's diarrhoea last?

As mentioned above, symptoms are usually short-lived and the illness is usually mild with most people making a full recovery within in few days. However, a few people with traveller's diarrhoea develop persistent (chronic) diarrhoea that can last for one month or more. It is also possible to have a second 'bout' of traveller's diarrhoea during the same trip. Having it once does not seem to protect you against future infection.

How can I avoid traveller's diarrhoea?

  • Avoid uncooked meat, shellfish or eggs. Avoid peeled fruit and vegetables (including salads).
  • Be careful about what you drink. Don't drink tap water, even as ice cubes.
  • Wash your hands regularly, especially before preparing food or eating.
  • Be careful where you swim. Contaminated water can cause traveller's diarrhoea.

Regular hand washing

You should ensure that you always wash your hands and dry them thoroughly; teach children to wash and dry theirs:

  • After going to the toilet (and after changing nappies or helping an older child to go to the toilet).
  • Before preparing or touching food or drinks.
  • Before eating.

Some antibacterial hand gel may be a good thing to take with you when you travel in case soap and hot water are not available.

Be careful about what you eat and drink

When travelling to areas with poor sanitation, you should avoid food or drinking water that may contain germs (microbes) or their poisons (toxins). Avoid:

  • Fruit juices sold by street vendors.
  • Ice cream (unless it has been made from safe water).
  • Shellfish (for example, mussels, oysters, clams) and uncooked seafood.
  • Raw or undercooked meat.
  • Fruit that has already been peeled or has a damaged skin.
  • Food that contains raw or uncooked eggs, such as mayonnaise or sauces.
  • Unpasteurised milk.

Drinking bottled water and fizzy drinks that are in sealed bottles or cans, tea, coffee and alcohol is thought to be safe. However, avoid ice cubes and non-bottled water in alcoholic drinks. Food should be cooked through thoroughly and be piping hot when served.

You should also be careful when eating food from markets, street vendors or buffets if you are uncertain about whether it has been kept hot or kept refrigerated. Fresh bread is usually safe, as is canned food or food in sealed packs.

Be careful where you swim

Swimming in contaminated water can also lead to traveller's diarrhoea. Try to avoid swallowing any water as you swim; teach children to do the same.

Obtain travel health advice before you travel

Always make sure that you visit your GP surgery or private travel clinic for health advice in plenty of time before your journey. Alternatively, the Fit for Travel website (see under Further Reading and References, below) provides travel health information for the public and gives specific information for different countries and high-risk destinations. This includes information about any vaccinations required, advice about food, water and personal hygiene precautions, etc.

There are no vaccines that prevent traveller's diarrhoea as a whole. However, there are some other vaccines that you may need for your travel, such as hepatitis A, typhoid, etc. You may also need to take malaria tablets depending on where you are travelling.

Antibiotics

Taking antibiotic medicines to prevent traveller's diarrhoea (antibiotic prophylaxis) is not generally recommended. This is because for most people, traveller's diarrhoea is mild and self-limiting. Also, antibiotics do not protect against nonbacterial causes of traveller's diarrhoea, such as viruses and parasites. Antibiotics may have side-effects and their unnecessary use may lead to problems with resistance to medicines.

Probiotics have some effect on traveller's diarrhoea and can shorten an attack by about one day. It is not known yet which type of probiotic or which dose, so there are no recommendations about using probiotics to prevent traveller's diarrhoea.

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Further reading and references

Travellers' diarrhoea ; Fitfortravel

Bourgeois AL, Wierzba TF, Walker RI ; Status of vaccine research and development for enterotoxigenic Escherichia coli. Vaccine. 2016 Mar 15. pii: S0264-410X(16)00287-5. doi: 10.1016/j.vaccine.2016.02.076.

Riddle MS, Connor BA, Beeching NJ, et al ; Guidelines for the prevention and treatment of travelers' diarrhea: a graded expert panel report. J Travel Med. 2017 Apr 124(suppl_1):S57-S74. doi: 10.1093/jtm/tax026.

Giddings SL, Stevens AM, Leung DT ; Traveler's Diarrhea. Med Clin North Am. 2016 Mar100(2):317-30. doi: 10.1016/j.mcna.2015.08.017.

Diarrhoea - prevention and advice for travellers ; NICE CKS, February 2019 (UK access only)

Related Information

  • How to avoid traveller’s diarrhoea
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Traveler's Diarrhea: Symptoms, Treatment and Prevention

rolls of toilet paper packed in a suitcase, to represent travelers diarrhea

Traveler's diarrhea strikes as many as 60 percent of world travelers, making it the most common travel-related illness, according to the Centers for Disease Control and Prevention (CDC). More common, even, than its subtler cousin, traveler's constipation .

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Like other types of diarrhea, it comes with loose stools and stomach cramps and can make you feel miserable, but it usually isn't life-threatening.

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Sometimes called Montezuma's Revenge (after the last Aztec emperor in what is now Mexico), this type of upset stomach is more widespread in resource-limited regions, says Kalyani Meduri, MD , a gastroenterologist with AdventHealth Medical Group in Zephyrhills, Florida. That includes:

  • Subsaharan Africa
  • Central and South America
  • The Middle East
  • Parts of Asia outside Japan and South Korea

These are areas with warmer climates that often lack refrigeration and may have poor sanitation standards.

Here's what causes this type of diarrhea, and how to recognize, diagnose, prevent and treat it.

Causes of Traveler’s Diarrhea

Most cases of traveler's diarrhea are caused by bacteria, with Escherichia coli (E. coli) accounting for about a third of all cases, according to a StatPearls paper updated in July 2021. Other offending bacteria include Campylobacter jejuni (especially in Southeast Asia), while viruses such as norovirus, rotavirus and COVID-19 as well as parasites can also cause traveler's diarrhea.

The pathogens are typically transmitted through contaminated food and drink, says Niket Sonpal, MD , assistant professor of medicine at Touro College of Osteopathic Medicine in New York City.

Risk Factors

Traveler's diarrhea can affect anyone, but some factors make you more likely to get it:

  • Being pregnant
  • Being very old or very young
  • Having a weakened immune system or chronic condition like diabetes
  • Taking antacid or acid-blockers, as these deplete stomach acid, which would normally help kill the organisms

Symptoms of Traveler’s Diarrhea

Symptoms of traveler's diarrhea are no different from any other kind of diarrhea. They usually appear within four to 14 days of flying or any other type of travel, Dr. Meduri says, although the incubation period can be several weeks long in the case of certain parasites.

Signs of the condition include:

  • Three or more loose or watery stools a day, which come on suddenly
  • An urgent need to use the bathroom
  • Stomach cramps
  • Bloating and gas
  • Loss of appetite
  • Nausea and vomiting
  • Muscle pain

Diarrhea associated with COVID-19 will likely bring other telltale symptoms, like shortness of breath and coughing, Dr. Sonpal says.

Luckily, most people recover from traveler's diarrhea within a week, with the worst part lasting a day or two.

A small percentage of people with traveler's diarrhea go on to develop dehydration, according to the Mayo Clinic , which can lead to sepsis and kidney failure. Signs of dehydration include dark urine, dizziness, lightheadedness, weakness and feeling thirsty.

A few people with traveler's diarrhea go on to develop a form of irritable bowel syndrome with continued diarrhea, stomach cramping and bloating, per Johns Hopkins Medicine.

Diagnosing Traveler’s Diarrhea

Most cases of traveler's diarrhea go away on their own and don't need a diagnosis.

However, doctors can diagnose the condition based on your symptoms and travel history or, in more severe cases, by testing a stool sample, according to Johns Hopkins Medicine .

How to Prevent Traveler’s Diarrhea

woman drinking bottled water while traveling, to prevent traveler's diarrhea

Regardless of the cause or symptoms, preventing traveler's stomach boils down to two key practices: Washing your hands often and being very, very diligent with what you eat and drink, Dr. Sonpal says.

  • Only drink water (and ice) from a bottle or that has been boiled for three minutes or longer. The same goes for water used to brush your teeth.
  • Take care not to ingest any water while you shower.
  • Stick to factory-sealed beer, wine, soda or juice, and steer clear of milk and other dairy products which may be unpasteurized.
  • If you're traveling to an extremely remote region, consider taking a compact water filter, advises Dr. Meduri. Iodine and chlorine tablets will also disinfect water.
  • If there's no way to wash your hands, use a hand sanitizer containing at least 60 percent alcohol.
  • Stick to hot, cooked food as well as fruits and vegetables that you can peel yourself. Avoid raw foods, shellfish from contaminated water and food from street vendors and buffets.
  • Antibiotics aren't recommended to prevent traveler's diarrhea. The best medicines to help ward off the condition include over-the-counter loperamide (Imodium) and bismuth subsalicylate (Pepto-Bismol), as long as you take them for less than three weeks. (Bear in mind that Pepto-Bismol can turn your stool and tongue black and can interact with certain medications.)

Treating Traveler’s Diarrhea

Most cases of traveler's diarrhea are mild and go away on their own, per the Cleveland Clinic .

In the meantime, you can help calm symptoms by drinking lots of fluids, including water, electrolyte solutions and Pedialyte for children. Oral rehydration solutions can be purchased or made with half a teaspoon of salt, six small spoons of sugar and one liter of clean water.

Other natural remedies for diarrhea include: eating plain foods high in soluble fiber (think: oats, apples, citrus fruits), nixing artificial sweeteners and avoiding caffeine and alcohol.

The same anti-diarrheal drugs that may help prevent traveler's diarrhea — Imodium and Pepto-Bismol — may help treat the condition. But keep in mind that you shouldn't use these meds if you have bloody stools; in that case, you should see a doctor ASAP.

Antibiotics such as azithromycin (Zithromax), ciprofloxacin (Cipro), doxycycline (Vibramycin) and rifaximin (Xifaxan) should only be prescribed by a doctor and reserved for more severe cases.

Related Reading

5 Foods That Will Make Diarrhea Worse (and 3 That'll Help)

When to See a Doctor

Make an appointment with a doctor if:

  • Your diarrhea doesn't go away after a week
  • You have a high fever (103 F or higher for adults)
  • You're vomiting so much that you can't keep down any food
  • You have bloody stools
  • You're feeling lightheaded or dizzy, or have dark urine or aren't urinating frequently (these are signs of dehydration, which can be dangerous)
  • Centers for Disease Control and Prevention: “Travelers’ Diarrhea”
  • Johns Hopkins Medicine: “Traveler’s Diarrhea”
  • StatPearls: “Travelers Diarrhea”
  • Mayo Clinic: “Traveler’s Diarrhea”
  • Cleveland Clinic: “Traveler’s Diarrhea”
  • Medical Clinics of North America: “Traveler’s Diarrhea”
  • Merck Manual: “Traveler’s Diarrhea”
  • Penn Medicine: “Travelers Diarrhea”
  • Centers for Disease Control and Prevention: “Choose Safe Food and Drinks When Traveling”

Is this an emergency? If you are experiencing serious medical symptoms, please see the National Library of Medicine’s list of signs you need emergency medical attention or call 911.

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  • Section 2 - Yellow Fever Vaccine & Malaria Prevention Information, by Country
  • Section 2 - Perspectives : Antibiotics in Travelers' Diarrhea - Balancing Benefit & Risk

Travelers’ Diarrhea

Cdc yellow book 2024.

Author(s): Bradley Connor

Infectious Agents

Risk for travelers, clinical presentation.

Travelers’ diarrhea (TD) is the most predictable travel-related illness. Attack rates range from 30%–70% of travelers during a 2-week period, depending on the destination and season of travel. Traditionally, TD was thought to be prevented by following simple dietary recommendations (e.g., “boil it, cook it, peel it, or forget it”), but studies have found that people who follow these rules can still become ill. Poor hygiene practices in local restaurants and underlying hygiene and sanitation infrastructure deficiencies are likely the largest contributors to the risk for TD.

TD is a clinical syndrome that can result from a variety of intestinal pathogens. Bacteria are the predominant enteropathogens and are thought to account for ≥80%–90% of cases. Intestinal viruses account for at least 5%–15% of illnesses, although the use of multiplex molecular diagnostic assays demonstrates that their contribution to the overall burden of TD disease is probably greater than previously estimated. Infections with protozoal pathogens are slower to manifest symptoms and collectively account for ≈10% of diagnoses in longer-term travelers (see Sec. 11, Ch. 7, Persistent Diarrhea in Returned Travelers ).

What is commonly known as “food poisoning” involves the ingestion of infectious agents that release toxins (e.g., Clostridium perfringens ) or consumption of preformed toxins (e.g., Staphylococcal food poisoning). In toxin-mediated illness, both vomiting and diarrhea can be present; symptoms usually resolve spontaneously within 12–24 hours.

Bacteria are the most common cause of TD. Overall, the most common pathogen identified is enterotoxigenic Escherichia coli , followed by Campylobacter jejuni , Shigella spp., and Salmonella spp. Enteroaggregative and other E. coli pathotypes also are commonly found in cases of TD. Surveillance also points to Aeromonas spp., Plesiomonas spp., and newly recognized pathogens ( Acrobacter , enterotoxigenic Bacteroides fragilis, Larobacter ) as potential causes of TD.

Viral diarrhea can be caused by several pathogens, including astrovirus, norovirus, and rotavirus.

Protozoal Parasites

Giardia is the main protozoal pathogen found in TD. Entamoeba histolytica and Cryptosporidium are relatively uncommon causes of TD. The risk for Cyclospora is highly geographic and seasonal: the most well-known risks are in Guatemala, Haiti, Nepal, and Peru. Dientamoeba fragilis is a flagellate occasionally associated with diarrhea in travelers. Several pathogens are discussed in their own chapters in Section 5.

TD occurs equally in male and female travelers; it is more common in young adult travelers than in older travelers. In short-term travelers, bouts of TD do not appear to protect against future attacks, and >1 episode of TD can occur during a single trip. A cohort of expatriates residing in Kathmandu, Nepal, experienced an average of 3.2 episodes of TD per person during their first year. In more temperate regions, seasonal variations in diarrhea risk can occur. In South Asia, for example, much higher TD attack rates are reported during the hot months preceding the monsoon.

Particularly in locations where large numbers of people lack plumbing or latrine access, stool contamination in the environment will be greater and more accessible to disease-transmitting vectors (e.g., flies). Inadequate electrical capacity leading to frequent blackouts or poorly functioning refrigeration can result in unsafe food storage and an additional increased risk for disease. Lack of safe, potable water contributes to food and drink contamination, as do unhealthful shortcuts in cleaning hands, countertops, cutting boards, utensils, and foods (e.g., fruits and vegetables). In some places, handwashing might not be a social norm and could represent an extra expense; thus, adequately equipped handwashing stations might not be available in food preparation areas.

Where provided, effective food handling courses have been shown to decrease the risk for TD. However, even in high-income countries, food handling and preparation in restaurants has been linked to TD caused by pathogens such as Shigella sonnei .

The incubation period between exposure and clinical presentation can provide clues to etiology. Toxin-mediated illness, for example, generally causes symptoms within a few hours. By contrast, bacterial and viral pathogens have an incubation period of 6–72 hours. In general, protozoal pathogens have longer incubation periods (1–2 weeks), rarely presenting in the first few days of travel. An exception is Cyclospora cayetanensis , which can present quickly in areas of high risk.

Bacterial and viral TD present with the sudden onset of bothersome symptoms that can range from mild cramps and urgent loose stools to severe abdominal pain, bloody diarrhea, fever, and vomiting; with norovirus, vomiting can be more prominent. Diarrhea caused by protozoa (e.g., E. histolytica , Giardia duodenalis ) generally has a more gradual onset of low-grade symptoms, with 2–5 loose stools per day.

Untreated, bacterial diarrhea usually lasts 3–7 days. Viral diarrhea generally lasts 2–3 days. Protozoal diarrhea can persist for weeks to months without treatment. An acute bout of TD can lead to persistent enteric symptoms, even in the absence of continued infection. This presentation is commonly referred to as postinfectious irritable bowel syndrome (see Sec. 11, Ch. 7, Persistent Diarrhea in Returned Travelers ). Other postinfectious sequelae can include reactive arthritis and Guillain-Barré syndrome.

Vaccines are not available in the United States for pathogens that commonly cause TD. Traveler adherence to recommended approaches can, however, help reduce, although never fully eliminate, the risk for illness. These recommendations include making careful food and beverage choices, using agents other than antimicrobial medications for prophylaxis, and carefully washing hands with soap whenever available. When handwashing is not possible, small containers of hand sanitizer containing ≥60% alcohol can make it easier for travelers to clean their hands before eating. Refer to the relevant chapters in Section 5 ( Cholera , Hepatitis A , and Typhoid & Paratyphoid Fever ) for details regarding vaccines to prevent other foodborne and waterborne infections to which travelers are susceptible.

Food & Beverage Selection

Care in selecting food and beverages can help minimize the risk for acquiring TD. See Sec. 2, Ch. 8, Food & Water Precautions , for detailed food and beverage recommendations. Although food and water precautions are recommended, travelers are not always able to adhere to the advice. Furthermore, food safety factors (e.g., restaurant hygiene) are out of the traveler’s control.

Non-Antimicrobial Drugs for Prophylaxis

Bismuth subsalicylate.

The primary agent studied for prevention of TD, other than antibiotics, is bismuth subsalicylate (BSS). Studies from Mexico have shown that this agent reduces the incidence of TD by approximately 50%. BSS commonly causes blackening of the tongue and stool and can cause constipation, nausea, and rarely tinnitus.

Contraindications & Safety

Travelers with aspirin allergy, gout, or renal insufficiency, and those taking anticoagulants, methotrexate, or probenecid should not take BSS. In travelers taking aspirin or salicylates for other reasons, concomitant use of BSS can increase the risk of developing salicylate toxicity.

BSS is not generally recommended for children aged <12 years; some clinicians use it off-label, however, with caution to avoid administering BSS to children aged ≤18 years with viral infections (e.g., influenza, varicella), because of the risk for Reye’s syndrome. BSS is not recommended for children aged <3 years or pregnant people.

Studies have not established the safety of BSS use for >3 weeks. Because of the number of tablets required and the inconvenient dosing, BSS is not commonly used as TD prophylaxis.

Probiotics (e.g., Lactobacillus GG, Saccharomyces boulardii ) have been studied in small numbers of people as TD prevention, but results are inconclusive, partly because standardized preparations of these bacteria are not reliably available. Studies of probiotics to prevent TD are ongoing, but data are insufficient to recommend their use (see the Sec. 2, Ch. 14, Complementary & Integrative Health Approaches to Travel Wellness ).

Anecdotal reports claim beneficial outcomes after using bovine colostrum as a daily prophylaxis agent for TD. However, commercially sold preparations of bovine colostrum marketed as dietary supplements are not approved by the US Food and Drug Administration (FDA). Because no data from rigorous clinical trials demonstrate efficacy, insufficient information is available to recommend the use of bovine colostrum to prevent TD.

Prophylactic Antibiotics

Older controlled studies showed that use of antibiotics reduced diarrhea attack rates by 90%. For most travelers, though, the risks associated with the use of prophylactic antibiotics (see below) do not outweigh the benefits. Prophylactic antibiotics might rarely be considered for short-term travelers who are high-risk hosts (e.g., immunocompromised people or people who have significant medical comorbidities).

The prophylactic antibiotic of choice has changed over the past few decades as resistance patterns have evolved. Historically, fluoroquinolones have been the most effective antibiotics for prophylaxis and treatment of bacterial TD pathogens, but resistance among Campylobacter and Shigella species globally now limits their use. In addition, fluoroquinolones are associated with tendinitis, concerns for QT interval prolongation, and an increased risk for Clostridioides difficile infection. Current guidelines discourage their use for prophylaxis. Alternative considerations include rifaximin and rifamycin SV.

Antimicrobial Resistance & Other Adverse Consequences

Prophylactic antibiotics are not recommended for most travelers. Prophylactic antibiotics afford no protection against nonbacterial pathogens and can remove normally protective microflora from the bowel, increasing the risk for infection with resistant bacterial pathogens. Travelers can become colonized with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE), a risk that is increased by exposure to antibiotics while abroad (see Sec 2, Ch. 17, . . . perspectives: Antibiotics in Travelers’ Diarrhea—Balancing Benefit & Risk , and Sec. 11, Ch. 5, Antimicrobial Resistance ).

Use of prophylactic antibiotics limits therapeutic options if TD occurs; a traveler relying on prophylactic antibiotics will need to carry an alternative antibiotic to use if severe diarrhea develops. Additionally, use of antibiotics has been associated with allergic and other adverse reactions.

Antibiotics

The effectiveness of a particular antimicrobial drug depends on the etiologic agent and its antibiotic sensitivity ( Table 2-09 ). If tolerated, single-dose regimens are equivalent to multidose regimens and might be more convenient for the traveler.

Azithromycin

Azithromycin is an alternative to fluoroquinolones (see below), although enteropathogens with decreased azithromycin susceptibility have been documented in several countries. The simplest azithromycin treatment regimen is a single dose of 1,000 mg, but side effects (mainly nausea) can limit the acceptability of this large dose; taking the medication as 2 divided doses on the same day can help.

Fluoroquinolones

Fluoroquinolones (e.g., ciprofloxacin, levofloxacin) have traditionally been the first-line antibiotics for empiric therapy of TD or to treat specific bacterial pathogens. Increasing microbial resistance to fluoroquinolones, however, especially among Campylobacter isolates, limits their usefulness in many destinations, particularly South and Southeast Asia, where both Campylobacter infection and fluoroquinolone resistance are prevalent. Increasing fluoroquinolone resistance has been reported from other destinations and in other bacterial pathogens, including in Salmonella and Shigella . Furthermore, fluoroquinolones now carry a black box warning from the FDA regarding multiple adverse reactions including aortic tears, hypoglycemia, mental health side effects, and tendinitis and tendon rupture.

Rifamycin SV

A new therapeutic option is rifamycin SV, approved by the FDA in November 2018 to treat TD caused by noninvasive strains of E. coli in adults. Rifamycin SV is a nonabsorbable antibiotic in the ansamycin class of antibacterial drugs formulated with an enteric coating that targets delivery of the drug to the distal small bowel and colon. Two randomized clinical trials showed that rifamycin SV was superior to placebo and non-inferior to ciprofloxacin in the treatment of TD. As with rifaximin (see below), travelers would need to carry a separate antibiotic (e.g., azithromycin) in case of infection due to an invasive pathogen.

Rifaximin has been approved to treat TD caused by noninvasive strains of E. coli . Since travelers likely cannot distinguish between invasive and noninvasive diarrhea, however, and since they would have to carry a backup drug in the event of invasive diarrhea, the overall usefulness of rifaximin as empiric self-treatment remains undetermined.

Table 2-09 Acute diarrhea antibiotic treatment recommendations 1

ANTIBIOTIC 1

Azithromycin 2,3

Single or divided dose 4

Ciprofloxacin

Single dose 4

Levofloxacin

1–3 days 4

Rifamycin SV 5

Rifaximin 5

Abbreviations: BID, twice daily; QD, once daily; TID, three times a day

1 Antibiotic regimens can be combined with loperamide 4 mg, initially, followed by 2 mg after each loose stool, not to exceed 16 mg in a 24- hour period.

2 Use empirically as first-line treatment for travelers’ diarrhea in Southeast Asia or other areas if fluoroquinolone- resistant bacteria are suspected.

3 Preferred treatment for dysentery or febrile diarrhea.

4 If symptoms are not resolved after 24 hours, continue daily dosing for up to 3 days.

5 Do not use if clinical suspicion for Campylobacter , Salmonella , Shigella , or other causes of invasive diarrhea. Use may be reserved for patients unable to receive azithromycin or fluoroquinolones.

Antibiotics are effective in reducing the duration of diarrhea by ≈1–2 days in cases caused by bacterial pathogens susceptible to the antibiotic prescribed. However, concerns about the adverse consequences of using antibiotics to treat TD remain. Travelers who take antibiotics are at risk of becoming colonized by drug-resistant organisms (e.g., ESBL-PE), resulting in potential harm to travelers—particularly immunocompromised people and people prone to urinary tract infections—and the possibility of introducing resistant bacteria into the community.

In addition, antibiotic use can affect the travelers’ own microbiota and increase the potential for C. difficile infection. These concerns must be weighed against the consequences of TD and the role of antibiotics in shortening the acute illness and possibly preventing postinfectious sequelae. Primarily because of these concerns, an expert advisory panel was convened in 2016 to prepare consensus guidelines on the prevention and treatment of TD. The advisory panel suggested a classification of TD using functional impact for defining severity ( Box 2-03 ) rather than the frequency-based algorithm used traditionally. The guidelines suggest an approach that matches therapeutic intervention with severity of illness, in terms of both safety and effectiveness ( Box 2-04 ).

Box 2-03 Acute travelers’ diarrhea: functional definitions

Mild diarrhea.

Tolerable, not distressing, does not interfere with planned activities

MODERATE DIARRHEA

Distressing or interferes with planned activities

SEVERE DIARRHEA

Incapacitating or completely prevents planned activities

All dysentery is considered severe

Box 2-04 Acute travelers’ diarrhea: treatment recommendations

Antibiotic treatment not recommended

Consider treatment with bismuth subsalicylate or loperamide

Antibiotics can be used for treatment

• Azithromycin

• Fluoroquinolones

• Rifaximin (for moderate, noninvasive diarrhea)

Antimotility drugs

• Consider loperamide for use as monotherapy or as adjunctive therapy

Antibiotic treatment is advised (single-dose regimens may be used)

• Azithromycin is preferred

• Fluoroquinolones or rifaximin1 can be used for severe, non-dysenteric diarrhea

• Consider loperamide for use as adjunctive therapy

• Not recommended as monotherapy for patients with bloody diarrhea or diarrhea and fever

Antimotility Agents

Antimotility agents provide symptomatic relief and are useful therapy in TD. Synthetic opiates (e.g., diphenoxylate, loperamide) can reduce frequency of bowel movements and therefore enable travelers to ride on an airplane or bus. Loperamide appears to have antisecretory properties as well. The safety of loperamide when used along with an antibiotic has been well established, even in cases of invasive pathogens; however, acquisition of ESBL-PE might be more common when loperamide and antibiotics are coadministered.

Antimotility agents alone are not recommended for patients with bloody diarrhea or those who have diarrhea and fever. Loperamide can be used in children, and liquid formulations are available. In practice, however, these drugs are rarely given to children aged <6 years.

Oral Rehydration Therapy

Fluids and electrolytes are lost during TD, and replenishment is important, especially in young children, older adults, and adults with chronic medical illness. In otherwise healthy adult travelers, severe dehydration from TD is unusual unless vomiting is prolonged. Nonetheless, replacement of fluid losses is key to diarrhea therapy and helps the traveler feel better more quickly. Travelers should remember to use only beverages that are sealed, treated with chlorine, boiled, or are otherwise known to be purified (see Sec. 2, Ch. 9, Water Disinfection ).

For severe fluid loss, replacement is best accomplished with oral rehydration solution (ORS) prepared from packaged oral rehydration salts (e.g., those provided by the World Health Organization). ORS is widely available at stores and pharmacies in most low- and middle-income countries. ORS is prepared by adding 1 packet to the indicated volume of boiled or treated water—generally 1 liter. Due to their saltiness, travelers might find most ORS formulations relatively unpalatable. In mild cases, rehydration can be maintained with any preferred liquid (including sports drinks), although overly sweet drinks (e.g., sodas) can cause osmotic diarrhea if consumed in quantity.

Travelers’ Diarrhea Caused by Protozoa

The most common parasitic cause of TD is Giardia duodenalis , and treatment options include metronidazole, nitazoxanide, and tinidazole (see Sec. 5, Part 3, Ch.12, Giardiasis ). Amebiasis (see Sec. 5, Part 3, Ch. 1, Amebiasis ) should be treated with metronidazole or tinidazole, then treated with a luminal agent (e.g., iodoquinol or paromomycin). Although cryptosporidiosis is usually a self-limited illness in immunocompetent people, clinicians can consider nitazoxanide as a treatment option (see Sec. 5, Part 3, Ch. 3, Cryptosporidiosis ). Cyclosporiasis should be treated with trimethoprim-sulfamethoxazole but not trimethoprim alone (see Sec. 5, Part 3, Ch. 5, Cyclosporiasis ).

Travelers’ Diarrhea in Children

Children who accompany their parents on trips to high-risk destinations can contract TD, and their risk is elevated if they are visiting friends and family. Causative organisms include bacteria responsible for TD in adults, as well as viruses (e.g., norovirus, rotavirus). The main treatment for TD in children is ORS. Infants and younger children with TD are at greater risk for dehydration, which is best prevented by the early initiation of oral rehydration.

Consider recommending empiric antibiotic therapy for bloody or severe watery diarrhea or evidence of systemic infection. In older children and teenagers, treatment guidelines follow those for adults, with possible adjustments in the dose of medication. Among younger children, macrolides (e.g., azithromycin) are considered first-line antibiotic therapy. Rifaximin is approved for use in children aged ≥12 years. Rifamycin SV is approved for use only in adults.

Breastfed infants should continue to nurse on demand, and bottle-fed infants can continue to drink formula. Older infants and children should be encouraged to eat and should consume a regular diet. Children in diapers are at risk for developing diaper rash on their buttocks in response to liquid stool. Barrier creams (e.g., zinc oxide, petrolatum) could be applied at the onset of diarrhea to help prevent and treat rash; hydrocortisone cream is the best treatment for an established rash. More information about diarrhea and dehydration is discussed in Sec. 7, Ch. 3, Traveling Safely with Infants & Children .

The following authors contributed to the previous version of this chapter: Bradley A. Connor

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Zboromyrska Y, Hurtado JC, Salvador P, Alvarez-Martinez MJ, Valls ME, Marcos MA, et al. Aetiology of travelers’ diarrhea: evaluation of a multiplex PCR tool to detect different enteropathogens. Clin Microbiol Infect. 2014;20:O753–9.

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Travelers’ Diarrhea: A Clinical Review

Alexander k.c. leung, amy a.m. leung, alex h.c. wong, background:.

Travelers’ diarrhea is the most common travel-related malady. It affects millions of international travelers to developing countries annually and can significantly disrupt travel plans.

To provide an update on the evaluation, diagnosis, treatment, and prevention of traveler’s diar-rhea.

A PubMed search was completed in Clinical Queries using the key term “traveler’s diarrhea”. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature. Patents were searched using the key term “traveler’s diarrhea” from www.freepatentsonline.com .

Between 10% and 40% of travelers develop diarrhea. The attack rate is highest for travelers from a developed country who visit a developing country. Children are at particular risk. Travelers’ diarrhea is usually acquired through ingestion of food and water contaminated by feces. Most cases are due to a bac-terial pathogen, commonly, Escherichia coli, and occur within the first few days after arrival in a foreign country. Dehydration is the most common complication. Pretravel education on hygiene and on the safe selection of food items is important in minimizing episodes. For mild travelers’ diarrhea, the use of antibi-otic is not recommended. The use of bismuth subsalicylate or loperamide may be considered. For moder-ate travelers’ diarrhea, antibiotics such as fluoroquinolones, azithromycin, and rifaximin may be used. Loperamide may be considered as monotherapy or adjunctive therapy. For severe travelers’ diarrhea, antibiotics such as azithromycin, fluoroquinolones, and rifaximin should be used. Azithromycin can be used even for the treatment of dysentery whereas fluoroquinolones and rifaximin cannot be used for such purpose. Recent patents related to the management of travelers’ diarrhea are discussed.

Conclusion:

Although travelers’ diarrhea is usually self-limited, many travelers prefer expedient relief of diarrhea, especially when they are traveling for extended periods by air or ground. Judicious use of an antimotility agent and antimicrobial therapy reduces the duration and severity of diarrhea.

1. INTRODUCTION

Travelers’ diarrhea is generally defined as the passage of ≥ 3 unformed stools per 24 hours plus at least one additional symptom (such as nausea, vomiting, abdominal cramps, fever, blood/mucus in the stools, or fecal urgency) that develop while abroad or within 10 days of returning from any resource-limited destinations [ 1 - 3 ]. In the pediatric age group,

travelers’ diarrhea is defined as a ≥ 2-fold increase in the frequency of unformed stools rather than ≥ 3 unformed stools per 24 hours, with other aforementioned conditions applied [ 1 , 4 ]. Travelers’ diarrhea is the most common travel-related malady. It affects millions of individuals traveling to developing countries annually and can disrupt travel plans, ruining a holiday not only for the patient but for the entire family. During prolonged ground or air transportation, diarrhea may incapacitate the traveler [ 5 ]. Anticipatory guidance on prudent food and beverages selection and preparation, observance of personal hygiene, pretravel vaccination with appropriate enteric vaccines if indicated, and judicious use of antimicrobial and antimotility agents can reduce the incidence and severity of travelers’ diarrhea. Due to the popularity of international travels, the incidence of travelers’ diarrhea is increasing [ 1 ]. Clinicians have to be knowledgeable in the recognition and management of this condition. This paper provides an update on the epidemiology, etiology, clinical manifestations, complications, diagnosis, management, and prevention of travelers’ diarrhea. Recent patents related to the management of travelers’ diarrhea are also discussed.

3. DEFINITIONS

The expert panel of the International Society of Travel Medicine uses the following functional impact to define the severity of travelers’ diarrhea [ 6 ].

Mild (acute) diarrhea is tolerable, not distressing, and does not interfere with planned activities. Moderate (acute) diarrhea is distressing or interferes with planned activities. Severe (acute) diarrhea is incapacitating or completely prevents planned activities. All dysentery (passage of grossly bloody stools) is considered severe.

The expert panel defines persistent diarrhea as diarrhea that lasts for ≥ 14 days [ 6 ]. Conventionally, chronic diarrhea is defined as diarrhea that lasts for ≥ 1 month [ 4 ].

4. EPIDEMIOLOGY

Overall, travelers’ diarrhea affects 10 to 40% of travelers [ 1 , 2 , 7 , 8 ]. The incidence varies according to the traveler’s destination of travel and country of origin, the duration of exposure, and the season of travel [ 1 , 2 , 7 , 8 ]. The sex ratio is approximately equal [ 9 , 10 ]. There is a genetic predisposition to the development of travelers’ diarrhea [ 11 ]. More than one episode of diarrhea might develop within a single trip.

The incidence is highest in destinations where hygienic practices and sanitation are poor, particularly in those regions with warmer climates [ 2 , 9 ]. High-risk destinations (incidence rate of travelers’ diarrhea ≥ 20%) include Africa (with the exception of South Africa), South and Central America, South and Southeast Asia, Mexico, Haiti, and the Dominican Republic [ 2 , 12 ]. Intermediate-risk destinations (incidence rate of travelers’ diarrhea 8 to < 20%) include Southern and Eastern Europe, Central and East Asia (including China and Russia), the Middle East (including Israel), South Africa, and Caribbean Islands [ 2 ]. Low-risk destinations (incidence rate of travelers’ diarrhea < 8%) include North America, Northern and Western Europe, Australia, New Zealand, Singapore, and Japan. The risk of acquiring travelers’ diarrhea is highest for travelers from a developed country who visit a developing country [ 2 , 4 , 5 , 13 ]. In contrast, the risk is lower for travelers from a developing country who visit another developing country, possibly because of previous exposure and subsequent immunity to the offending pathogens [ 4 ]. The incidence is lower in winter months and higher in summer months in the same tourist destinations [ 2 , 3 , 9 , 14 ].

Travelers’ diarrhea is usually acquired by the fecal-oral transmission of the causative pathogen, typically through ingestion of food or water contaminated by feces. Occasionally, travelers’ diarrhea may be acquired by handling contaminated objects or from accidental swallowing of contaminated water from swimming pools and other recreational water sources [ 5 ]. Insects particularly flies are important vectors for some foodborne enteric pathogens.

Children, especially the young ones, are at higher risk because of their natural curiosity and propensity to indiscriminately touch multiple objects and to put objects into their mouths. Furthermore, they are less selective in the type and source of food they consume, less likely to receive pretravel medical advice, and less likely to constantly adhere to the recommended hygiene measures [ 1 , 4 , 7 ].

Other risk factors include gastric hypochlorhydria, use of antacids (especially proton pump inhibitors), pre-existing medical conditions ( e.g ., inflammatory bowel disease, diabetes mellitus, chronic renal failure, immunodeficiency) and adventurous eating habits [ 3 - 5 , 9 , 15 ]. Generally, campers and backpackers are also at higher risk than those who stay in hotels, possibly reflecting different standards of hygiene [ 3 , 9 ].

5. ETIOLOGY

Generally, pathogens can be identified in approximately 85% of cases [ 4 ]. Bacteria account for up to 90% of identified pathogens for travelers’ diarrhea [ 16 ]. Escherichia coli , especially Enterotoxigenic E. coli (ETEC), is the most common pathogen worldwide. ETEC is responsible for 30 to 60% of all cases of travelers’ diarrhea and is a significant cause of childhood morbidity and mortality in the developing world, especially in Africa and Lain America [ 1 ]. Other bacterial pathogens include Enteroaggregative E. coli (EAEC), Enteroinvasive E. coli (EIEC), Diffusely Adherent E. coli (DAEC), Salmonella spp, Shigella spp, Campylobacter spp, and Yersinia enterocolitica [ 2 , 4 , 17 - 19 ]. Less common bacterial pathogens include Plesiomonas shigelloides , Aeromonas hydrophilia , Bacteroides fragilis , Arcobacter spp, Clostridium difficile , Vibrio cholerae , and Vibrio parahaemolyticus [ 7 , 20 - 22 ]. Travelers taking medications for prophylaxis of malaria or antibiotics might develop diarrhea due to Clostridium difficile [ 2 ]. Infection with Vibrio species is often associated with ingestion of partially cooked or raw seafood [ 4 ].

Viral pathogens such as norovirus, rotavirus, astrovirus, and enteric adenovirus may be responsible for up to 10% of cases of travelers’diarrhea [ 17 , 21 , 23 , 24 ].

Protozoal parasites such as Giardia lamblia (also known as Giardia intestinalis ), Entamoeba histolytica , Cyclospora cayetanensis , Dientamoeba fragilis , Cystoisospora belli (also known as Isospora belli ), Cryptosporidium parvum , and Microsporidium spp are less common causes; however, they are increasing in importance when the diarrhea lasts for ≥ two weeks [ 2 , 4 , 7 , 25 , 26 ]. Recently, Yoshikawa et al . identified Ancylostoma ceylanicum as a novel etiological agent for travelers’ diarrhea [ 27 ]. The authors reported four Japanese patients who visited Southeast Asia and Papua Guinea and developed travelers’ diarrhea secondary to Ancylostoma ceylanicum infection.

6. PATHOPHYSIOLOGY

Travelers’ diarrhea may be caused by increased secretion and/or decreased absorption of fluid and electrolytes across the intestinal epithelium. Pathogens that can lead to secretory diarrhea include, ETEC, Vibrio cholera and rotavirus [ 9 , 23 , 28 ]. Infection by these pathogens leads to the secretion of neurotransmitters ( e.g ., 5-hydroxytryptamine) from enteroendocrine cells and activation of afferent neurons that stimulate submucosal secretomotor neurons resulting in an outpouring of electrolytes and fluid into the intestinal lumen [ 8 ]. Activation of adenylate cyclase and elevation of intracellular cAMP in the enterocytes mediated by the bacterial toxins may account for the pathogenesis of secretory diarrhea [ 29 ]. The majority of cholera is caused by the cholera toxin-producing V. cholerae strains of 01 and 0139 serogroups [ 29 , 30 ]. ETEC can produce a heat-labile enterotoxin (LT), a heat-stable enterotoxin (ST), or both enterotoxins (LT/ST) [ 21 , 31 ]. Approximately two-thirds of ETEC produce LT, which is functionally and structurally similar to cholera toxin. The enterotoxins produced by ETEC are responsible for ETEC’s virulence [ 31 ]. Other virulence factors include adhesion properties and colonization factors [ 31 ].

Impaired absorption of fluid and electrolytes with resultant diarrhea may result from the direct invasion of the intestinal mucosa or the destruction of enterocytes by the cytolytic toxins released by the pathogens [ 15 ]. Examples of these pathogens include Salmonella spp, Shigella spp, Campylobacter spp, Yersinia enterocolitica , and ETEC [ 32 , 33 ].

7. CLINICAL MANIFESTATIONS

The majority of the diarrheal episodes develop during the first few days of exposure after arrival in a foreign country, with > 90% of the diarrheal episodes developing within the first two weeks of exposure [ 25 ]. The majority of bacterial and viral causative pathogens have an incubation period of < 24 hours. The incubation period for Campylobacter jejuni is longer at 3 to 10 days [ 4 ]. On the other hand, the incubation periods of Giardia lamblia and Entamoeba histolytica are 3 to 25 days and 2 to 4 weeks, respectively [ 4 ].

The diarrhea is watery in approximately 86% of cases; however, it can also be loose, mucousy or bloody [ 1 , 34 ]. Approximately 3% of patients have ≥ 10 unformed stools per 24 hours [ 7 , 34 ]. Most patients have 3 to 5 unformed stools per 24 hours [ 34 ]. Other symptoms include fecal urgency in 90 to 100%, tenesmus in 71 to 80%, colicky abdominal pain/abdominal discomfort in 40 to 77%, nausea in 10 to 70%, malaise in 50 to 58%, fever in 10 to 30%, vomiting in 5 to 20%, mucoid stools in 3 to 10%, and bloody stools in 2 to 10% of cases [ 4 , 34 ]. Symptoms vary according to the causative pathogen. Characteristically, ETEC present mainly with watery diarrhea without bloody stools or fever [ 4 ]. Yersinia enterocolitica , C. jejuni , and Shigella dysenteriae , on the other hand, often cause dysentery-like diarrhea, with bloody stools, fever, fecal urgency, and abdominal cramps [ 4 , 25 ]. Vomiting is characteristic of Norwalk virus and Rotavirus infection [ 23 ]. Profuse watery diarrhea is characteristically seen in Vibrio cholerae, Cyclospora cayetanensis , and Cryptosporidium parvum infection [ 34 ]. Upper gastrointestinal symptoms such as nausea, bloating, belching, vomiting, and abdominal pain are typically seen in patients with giardiasis [ 25 , 34 ].

8. DIAGNOSIS AND LABORATORY INVESTIGATIONS

The diagnosis is mainly clinical based on the history of passage of ≥ 3 unformed stools per 24 hours, plus at least one additional symptom (such as nausea, vomiting, abdominal cramps, fever, blood/mucus in the stools, or fecal urgency) that develops while abroad or within 10 days of returning from travel to a resource-limited setting [ 1 , 3 , 34 ]. Laboratory evaluation is generally unnecessary unless the patient appears toxic, has a high fever, is hospitalized, develops bloody, mucoid, or cholera-like diarrhea has severe abdominal cramps, is immunocompromised, has a significant underlying medical condition, or has persistent diarrhea not responding to empiric therapy [ 6 , 7 , 15 ]. If that is the case, a fresh stool sample should be sent for culture. Freshly passed stool samples should be collected on three different days and sent for microscopic examination for ova, cysts, and parasites. The likelihood that protozoal pathogens such as Giardia lamblia, Entamoeba histolytica , or Cryptosporidium parvum rather than a bacterium will be isolated from a stool specimen increases with the duration of diarrhea [ 6 ]. An assay for C. difficile toxin should be ordered if the patient has a history of antimicrobial therapy within the month preceding the onset of diarrhea. A real-time multiplex Polymerase Chain Reaction (PCR) has been developed for rapid identification of a broad array of pathogens in a single assay to define the cause of travelers’ diarrhea with high sensitivity and specificity [ 7 , 21 , 35 , 36 ]. However, multiplex PCR testing is expensive and not widely available. In addition, multiplex PCR testing cannot distinguish between viable and non-viable pathogens, may detect microorganisms that may not be the cause of diarrhea, and does not provide antibacterial susceptibility [ 36 - 38 ]. As such, good clinical judgement must be exercised. The use of multiplex PCR should be considered for patients hospitalized with travelers’ diarrhea when rapid results are desirable and those with persistent diarrhea when non-molecular tests have failed to establish a diagnosis [ 6 , 21 ].

9. COMPLICATIONS

Dehydration with or without electrolyte imbalance is the most common complication, particularly in children. Inappropriate rehydration solutions (excessively high glucose content or excessively low electrolyte content) might compound the problem [ 39 , 40 ]. Other less common complications include sepsis, hemolytic-uremic syndrome, postinfectious irritable bowel syndrome, C. difficile colitis (after antibiotic use), Guillain-Barré syndrome (after infection with C. jejuni ), reactive arthritis (often associated with HLA-B27), acute myocarditis (rarely after infection with C. jejuni ), and permanent short-term memory loss (after shellfish poisoning) [ 41 - 48 ]. Travelers’ diarrhea can disrupt business trips and holidays. The financial loss and economic burden associated with travelers’ diarrhea can be considerable.

10. MANAGEMENT

The goals of management are to maintain optimal hydration, minimize the severity and duration of diarrheal illness, prevent cancellation of planned activities, restore functional status, and eradicate the offending pathogen. Individuals at the extremes of age are particularly susceptible to and less tolerant of fluid and electrolyte loss. For most cases of travelers’ diarrhea, correction of water and electrolyte loss is the mainstay of treatment and this can be accomplished preferably with properly designed oral rehydration solutions that can facilitate glucose and sodium cotransport across the intestinal membrane [ 5 , 39 , 49 , 50 ]. Prepackaged oral rehydration salt should be mixed with clean, boiled, bottled, or filtered water [ 39 ]. Breastfeeding should be encouraged in infants who are breastfed [ 51 ]. These infants should be supplemented with an oral rehydration solution if necessary [ 51 ].

Although antisecretory/antimotility agents do not eradicate the pathogen, they can shorten the duration and reduce the severity of diarrhea. Antisecretory/antimotility agents should be considered for travelers who prefer expedient relief of diarrhea. This is especially so when they have to travel for extended periods by air or ground. The short-term use of loperamide (Imodium) has been approved for the treatment of individuals ≥ 2 years of age with travelers’ diarrhea [ 52 ]. Loperamide is an opioid-like agent that is taken orally [ 53 ]. The medication is relatively nonabsorbable; hence only insignificant amounts reaches the systemic circulation. It has a potent antisecretory effect in addition to its antimotility activity [ 53 ]. The drug has a rapid onset of action [ 54 ]. It is particularly useful in the management of mild and moderate travelers’ diarrhea [ 53 ]. The recommended loading dose for individuals ≥ 12 years is 4mg, followed by 2mg per episode of diarrhea (maximum 16mg per day) [ 53 ]. For children 6 to 11 years, the recommended loading dose is 2mg, followed by 1mg per episode of diarrhea (maximum 6mg per day) and that for children 2 to 5 years old, the recommended loading dose is 1mg, followed by 1mg per episode of diarrhea (maximum 3mg per day). Loperamide has a favorable safety profile but should be avoided if the patient has a high fever, severe abdominal cramps, or dysentery because of the risk of toxic megacolon and intestinal perforation [ 1 , 25 ]. The medication should not be given to children ≤ 2 years of age because of the potential risk of central nervous system depression [ 1 , 7 ]. Two systematic reviews including 28 studies concluded that adding loperamide to antibiotic therapy may hasten resolution of travelers’ diarrhea with no or minimal side effects compared to antibiotic therapy alone [ 55 ]. Diphenoxylate (Lomotil), an antimotility agent, is also effective for the treatment of travelers’ diarrhea by reducing the rate of stool frequency [ 34 ]. It is a centrally active opioid drug of the phenylpiperidine series that is used in combination with a subtherapeutic dose of atropine for the treatment of diarrhea. The recommended dose for individuals ≥ 13 years is 5mg of diphenoxylate/0.5mg of atropine every 6 hours for a maximum of 48 hours. The safety and effectiveness of diphenoxylate have not been established in children < 12 years of age. Bismuth subsalicylate (Pepto Bismol) is also effective for the treatment of travelers’ diarrhea [ 56 ]. The medication possesses antisecretory properties and is capable of neutralizing the toxins of ETEC [ 11 ]. The recommended dose for individuals ≥ 12 years is four tablets (262mg/tablet) or 60ml (regular strength) every 30 to 60 minutes until diarrhea subsides or eight doses have been taken [ 34 ]. The recommended dose for children 10 to 11 years, 6 to 9 years, and 3 to 5 years is 1 tablet or 15ml, 2/3 tablet or 10ml, and 1/3 tablet or 5ml, respectively. The medication, however, is less effective than loperamide [ 25 , 56 ]. Other disadvantages include the large and frequent doses of the liquid preparation of medication needed and the potential for adverse events such as blackening of the tongue, black stools, salicylate toxicity, Reye’s syndrome, and tinnitus. This drug is not recommended for pregnant women and children [ 56 ]. For those patients with coexisting severe nausea and vomiting, ondansetron (Zofran) may be given [ 49 , 57 - 59 ].

Antimicrobial therapy is effective in reducing the duration and severity of traveler’s diarrhea [ 52 , 60 ]. For travelers going to moderate and high-risk areas, it might be appropriate to provide them with a short course of a suitable antibiotic with the advice to start antimicrobial treatment should they develop moderate or severe diarrhea [ 25 ]. The choice of the antibiotic should be guided by resistance surveillance data as well as careful assessment of the benefits and risks associated with its use to both the patient and society [ 61 ]. Differences in effectiveness of antimicrobials between regions are likely due to the local pattern of antimicrobial resistance [ 56 ]. Fluoroquinolones, such as ciprofloxacin (Cipro), levofloxacin (Levaquin, Leva-Pak, Quixin), and ofloxacin (Floxin), are efficacious against a broad spectrum of bacterial enteric pathogens. The recommended dose of ciprofloxacin for adults is 750mg as a single dose (children, 20 to 30mg/kg/day in 1 or 2 divided doses) or 500mg daily for 3 days, that of levofloxacin is 500mg as a single dose (children, 10 to 20mg/kg/day in 1 or 2 divided doses) or for 3 days, and that of ofloxacin is 400mg as a single dose or for 3 days [ 6 ]. The safety and efficacy of ofloxacin have not been established in children < 12 years of age. Fluoroquinolones are drugs of choice for most destinations [ 7 ]. Resistance to fluoroquinolones is increasing, particularly in Southeast Asia where Campylobacter jejuni is a common cause of travelers’ diarrhea. Fluoroquinolones are contraindicated in pregnant women and are not recommended for children under 8 years of age [ 18 ]. Azithromycin (Zithromax, Azithrocin) and fluoroquinolones have similar efficacy [ 18 ]. The recommended dose of azithromycin is 500mg (children, 10mg/kg/day, maximum 500mg) daily for three days or 1000mg as a single dose. The single dose regimen may have to be repeated if symptoms persist for up to three days [ 1 , 6 , 18 , 34 ]. Azithromycin is highly effective against most pathogens that cause travelers’ diarrhea and is effective in the treatment of patients with Campylobacter infection that is resistant to fluoroquinolones. It is the drug of choice for treatment of severe or febrile travelers’ diarrhea, dysentery, and moderate to severe travelers’ diarrhea among travelers to Southeast Asia where fluoroquinolone-resistant pathogens are prevalent [ 6 , 7 , 18 , 34 ]. The medication is safe to use in pregnant women and children. Rifaximin (Xifaxan, Xifaxante, Normix) is a nonabsorbable (< 0.4% absorbed), locally active antimicrobial that can achieve high concentrations in the intestines [ 62 , 63 ]. The medication binds to the beta subunit of the bacterial RNA polymerase and inhibits bacterial RNA synthesis. Rifaximin has a broad spectrum of activity and has been approved for the treatment of individuals ≥ 12 years of age who present with uncomplicated travelers’ diarrhea [ 4 , 64 ]. The recommended dose of rifaximin is 200mg three times a day for three days [ 6 , 34 ]. The medication is poorly absorbed from the gastrointestinal tract, thereby achieving high concentration in the intestines [ 48 ]. The medication has minimal side effects [ 63 ]. Rifaximin is less effective for the treatment of invasive pathogens and should not be used for the treatment of dysentery [ 6 ].

The expert panel of the International Society of Travel Medicine has made the following recommendations for the treatment of travelers’ diarrhea depending on its severity in addition to the conservative treatment such as fluid and electrolyte replenishment [ 6 ]:

For mild travelers’ diarrhea, the use of antibiotic is not recommended (strong recommendation, moderate level of evidence). The use of bismuth subsalicylate or loperamide may be considered (strong recommendation, moderate level of evidence) [ 6 ].

For moderate travelers’ diarrhea, antibiotics such as fluoroquinolones (strong recommendation, moderate level of evidence), azithromycin (strong recommendation, high level of evidence), and rifaximin (weak recommendation, moderate level of evidence) may be used [ 6 ]. Loperamide may be considered as monotherapy (strong recommendation, high level of evidence) for the treatment of moderate travelers’ diarrhea and adjunctive therapy (strong recommendation, high level of evidence) for the treatment of moderate to severe travelers’ diarrhea [ 6 ].

For severe travelers’ diarrhea, antibiotics such as azithromycin (strong recommendation, moderate level of evidence), fluoroquinolones (weak recommendation, moderate level of evidence), and rifaximin (weak recommendation, moderate level of evidence) should be used [ 6 ]. In this regard, azithromycin can be used even for the treatment of dysentery whereas fluoroquinolones and rifaximin cannot be used for such purpose [ 6 ].

The majority of cases of travelers’ diarrhea are mild and self-limited. Most cases do not require treatment with antibiotics or antimotility/antisecretory agents. Medical attention should be sought if there are symptoms/signs of dehydration, bloody diarrhea, intractable vomiting, severe abdominal pain, and high fever, especially in those who did not improve with empiric antibiotic therapy within 36 hours [ 5 , 34 ].

11. ADJUNCTIVE THERAPIES

Probiotics such as Lactobacillus rhamnosus GG , Lactobacillus acidophilus , and Saccharomyces boulardii have been used in the treatment as well as the prevention of travelers’ diarrhea because of their beneficial effects on intestinal flora and resultant suppression of pathogenic bacteria [ 65 , 66 ]. A 2018 meta-analysis of 12 randomized clinical trials with a total of 16 intervention arms (n = 3,736) showed a significant reduction in travellers’ diarrhea with S. boulardii prophylaxis (risk ratio: 0.79; 95% confidence interval: 0.72 to 0.87; p < 0.001) [ 67 ]. There was a trend of reduction in travelers’ diarrhea with L . rhamnosus GG prophylaxis (p = 0.008) while there was no reduction in travelers’ diarrhea with L . acidophilus prophylaxis. It has been suggested that the second generation of bifidobacterial-galacto-oligosaccharides prebiotic has the potential in the prevention of travelers’ diarrhea [ 68 ]. The prebiotic, however, has not been subjected to rigorous clinical trials [ 69 ]. Further studies will be needed to determine if prebiotics and probiotics could be used in the prevention of travelers’ diarrhea.

12. PROPHYLAXIS

The majority of diarrheal diseases can be prevented by implementing Water, Sanitation, and Hygiene (WASH) programs aiming at interrupting fecal-oral route of transmission [ 70 ]. Travelers to high-risk areas should be counseled on self-diagnosis and treatment of travelers’ diarrhea. They should also be counseled on personal hygiene and on prudent food and beverages selection and preparation. Frequent handwashing with soap/alcohol-based detergents/hand sanitizer and with the cleanest water available, especially after defecation and urination and before preparing or eating food, is of utmost importance. The rule “cook it, boil it, peel it, or forget it” is logical but is difficult to closely follow [ 9 ]. High-risk products that can be easily contaminated should be avoided. These items include cream-filled desserts, cold sauces and dressings, salads, raw and leafy vegetables that are difficult to clean, fruits that are difficult to peel, undercooked/raw meat and seafood, cooked food that has been left at room temperature for several hours, food brought from street vendors, unpasteurized dairy products, ice cubes and tap water [ 5 ]. Buffet foods and reheated prepared foods are associated with a higher risk of contamination. Fresh and thoroughly cooked meats and vegetables that are still hot, fruit juice or carbonated soft drinks with intact seals, fruits that are peeled by the traveler just prior to eating, pasteurized dairy products, bottled or canned water, hot tea, and hot coffee are usually safe. Food should be well cooked with the interior of the cooked food measuring ≥ 70 o C to kill the pathogens [ 9 ]. Travelers should be advised to avoid shellfish from water that is contaminated as marine toxins cannot be killed by cooking. Boiled beverages should be served at ≥ 60 o C [ 7 ]. Contact with potentially contaminated recreational waters should be avoided [ 5 ].

Chemoprophylaxis should not be routinely used because of the potential of the alteration of gut flora, development of adverse events, development of antimicrobial resistance, possible drug interactions, the expense of the medication, a false sense of security, and confusion as to how to treat those with diarrhea in spite of chemoprophylaxis [ 2 ]. Antimicrobial prophylaxis should be considered for individuals who cannot afford to become sick, such as politicians or elite athletes. It should also be considered for those individuals who have greater susceptibility to travelers’ diarrhea and who are at high risk of severe complications, such as those who are very old, are immunocompromised, are prone to complications ( e.g ., dehydration) from diarrhea, or have a chronic illness ( e.g ., inflammatory bowel disease, short bowel syndrome, gastric hypochlorhydria, congestive heart failure, diabetes mellitus, chronic renal failure) [ 6 , 25 ]. Chemoprophylaxis, if necessary, should be short-term. It should not exceed 14 days [ 71 ]. Rifaximin is effective and safe. It is the drug of choice for the prevention of travelers’ diarrhea [ 2 , 6 , 48 , 71 ]. A meta-analysis of five randomized controlled trials (n = 879) comparing rifaximin with placebo found significant reduction in risk of travelers’ diarrhea with rifaximin (pooled risk ratio: 0.478; 95% confidence interval: 0.375 to 0.610; p < 0.001), especially in individuals who are at risk for travelers’ diarrhea [ 72 ]. If rifaximin is used for prophylaxis, azithromycin should be used to treat break-through travelers’ diarrhea. Since azithromycin is effective in the treatment of travelers’ diarrhea, including invasive forms of travelers’ diarrhea, it is recommended that azithromycin should not be used for prophylaxis [ 62 ]. The use of fluoroquinolones for prophylaxis of travelers’ diarrhea is not recommended either because of increasing bacterial resistance and adverse effects associated with prolonged use of fluoroquinolones [ 6 ].

Bismuth subsalicylate may also be considered for the prevention of travelers’ diarrhea [ 6 ]. The medication provides a protective rate of 60 to 65% against travelers’ diarrhea [ 6 ]. The dosing schedule (2.1 to 4.2 g per day divided into 4 divided doses to be given with meals and at bedtime) is inconvenient for the traveler because of the large quantities of medication that have to be taken four times a day [ 2 , 71 ]. Also, bismuth subsalicylate has an unpleasant taste, turns the tongue and stool black, and has the potential for salicylate toxicity and encephalopathy [ 2 , 52 ]. The medication is not recommended for children or for individuals with aspirin allergy, renal insufficiency, or gout, or for those who are taking anticoagulants, probenecid, or methotrexate.

WC-rBSCT (Dukoral) vaccine is an oral, killed whole-cell cholera vaccine that consists of V. cholerae 01 organisms and the nontoxic, B subunit of cholera toxin [ 73 ]. The vaccine has overall efficacy of 85% against challenge with V. cholerae O1 but not effective against 0139 serogroups [ 4 , 73 ]. The antigenic similarity between nontoxic, B subunit of cholera toxin and LT of ETEC allows protection against diarrhea caused by LT-ETEC and LT/ST-ETEC [ 2 , 4 ]. The vaccine, primarily designed for the prevention of cholera, has been recommended by some investigators for the prevention of travelers’ diarrhea in people visiting endemic areas [ 74 , 75 ]. The vaccine has been proven to be safe and well tolerated [ 73 ]. Two doses of the Dukoral vaccine are recommended and they should be given at least seven days apart on an empty stomach. Based on randomized controlled trials, a Cochrane review, however, found that there is no significant difference in efficacy between Dukoral vaccine and placebo in the prevention of travelers’ diarrhea [ 74 ]. Although there is insufficient evidence to support the routine use of Dukoral vaccine for the prevention of travelers’ diarrhea caused by ETEC [ 52 ], some investigators suggest that Dukoral vaccine should be considered for travelers ≥ 2 years of age who will be visiting areas where there are high risk of contracting travelers’ diarrhea caused by ETEC. The vaccine may also benefit those individuals who are at high risk of severe complications, such as those who are immunocompromised, are prone to complications from diarrhea, or have a chronic illness [ 52 , 76 ].

Vaxchora, a live attenuated, single dose, oral cholera vaccine, is the only vaccine approved by the Food and Drug Administration (FDA) for the prevention of cholera [ 70 , 77 ]. Cholera is caused by V. cholerae serogroup 01, which is responsible for the majority of outbreaks (> 99% of global cases) [ 70 , 77 ]. The vaccine is recommended for adults 18 to 64 years of age traveling to areas where cholera is epidemic or endemic and should be considered for those who are at high risk of exposure [ 2 , 77 , 78 ]. Vaxchora is well tolerated with no significant adverse events [ 79 ]. The vaccine, however, has not been shown to be effective against serogroup 0139 or other non-01 serogroups [ 78 ]. Shanchol is an oral vaccine containing killed V. cholerae 01 and 0139 organisms [ 80 ]. The vaccine has been found to be immunogenic, effective, and safe [ 81 ]. Two doses of the Shanchol vaccine are recommended and they should be given at least 14 days apart [ 80 ]. The vaccine was subjected to a large-scale field trial in Kolkata in India where cholera was endemic [ 82 ]. It was found that 69 of 31,932 vaccine recipients and 219 of 34,968 controls developed cholera during a 5-year follow-up. The cumulative protective efficacy of the Shanchol vaccine at 5 years was 65% (95% confidence interval: 52 to 74; p < 0.0001) [ 82 ]. Euvichol is another oral vaccine containing killed V. cholerae 01 and 0139 organisms [ 83 ]. The vaccine still has an efficacy of 65% after 5 years for those children > 5 years of age [ 83 ].

Typhoid fever is caused by Salmonella enterica serotype Typhi [ 84 ]. Typhoid vaccine is recommended for travelers to areas with poor sanitation and hygiene. Two typhoid vaccines are globally available, namely, a parenteral inactivated Vi Capsular Polysaccharide vaccine (ViCPS) and an oral live-attenuated vaccine, Ty21a [ 84 ]. Only a single dose of the inactivated vaccine (ViCPS) given intramuscularly is required and should be administered ≥ 2 weeks prior to travel [ 10 ]. On the other hand, 4 doses of the oral vaccine (Ty21a) are required and should be administered two days apart, with the last dose given ≥ 1 week prior to travel [ 10 ]. The oral vaccine has to be refrigerated and taken on an empty stomach with a glass of cool water [ 10 ]. Both vaccines provide approximately 75% protection that lasts for 2 to 3 years [ 84 ]. The ViCPS vaccine is licensed for use for individuals ≥ 2 years whereas the Ty21a for individuals ≥ 5 years [ 10 , 84 ]. Antibiotics and antimalarials, if taken concurrently, may inhibit the oral typhoid vaccine because these agents may prevent a sufficient immune response from the oral vaccine [ 10 ]. The WHO recommends that oral typhoid vaccine should be given at least one week before or after the ingestion of antibiotics and antimalarials. The newly available Tybar-TCV is a typhoid conjugate vaccine which contains Vi capsular polysaccharide of Salmonella enterica serovar typhi Ty2 conjugated to a tetanus toxoid carrier protein. One single dose of Tybar-TCV injected intramuscularly is necessary and should be administered ≥ 2 weeks prior to travel. The vaccine has been proven to be safe, well tolerated, and efficacious. Recently, the WHO has recommended Tybar-TCV as the preferred vaccine for the prevention of typhoid fever [ 85 ].

Rotavirus is the most common cause of gastroenteritis in children [ 23 ]. Clinical trials showed that three doses of a live pentavalent (G1, G2, G3, G4, and P1), human-bovine reassortant vaccine, (RotaTeq ® ) and two doses of a monovalent human-attenuated rotavirus vaccine RIX4414 (Rotarix ® ) are highly effective in the prevention of severe rotavirus diarrhea and its associated mortality and morbidity [ 86 , 87 ]. More recently, an oral human-bovine natural reassortant vaccine (116E) (Rotavac) produced in India has also been shown to be effective [ 88 ]. Bhandari et al . randomly assigned 4532 and 2267 children ≤ 2 years of age to receive three doses of Rotavac vaccine and placebo, respectively [ 88 ]. The authors found that the efficacy of Rotavac vaccine against severe gastroenteritis in these children was 55.1% (95% confidence interval: 39.9 to 66.4; p < 0.001). Co-infections may lead to an approximately 11% decrease in vaccine efficacy [ 89 ].

13. PROGNOSIS

Travelers’ diarrhea is usually self-limited. If left untreated, approximately 50% of the patients are spontaneously cured in 48 hours and, in the majority of patients, the average duration diarrhea is 4 to 5 days [ 7 , 90 ]. Approximately 5% and 1% of affected individuals have diarrhea that persists for longer than 14 days and 1 month, respectively [ 16 , 25 , 91 ]. Approximately 13% of patients are confined to bed for 1 to 2 days, and about 0.4% of patients require hospital admission while abroad or after returning home [ 7 ]. The clinical course tends to be more severe and prolonged in children, especially those younger than 2 years of age.

Travelers’ diarrhea is the most common cause of disability among international travelers to developing countries. Travelers to the high-risk region should receive pretravel counseling on personal hygiene and anticipatory guidance on food safety and pretravel vaccination with enteric vaccines. They should exercise caution by careful selection of safer food. Judicious use of antimicrobial and antimotility agents can reduce the severity of travelers’ diarrhea. Nevertheless, reduction in the incidence of travelers’ diarrhea depends more on the level of sanitation at the destination site rather than the precautions and intervention implemented by the traveler [ 7 ].

CURRENT & FUTURE DEVELOPMENTS

Currently, there are no vaccines licensed for the prevention of ETEC infection which is the principal cause of travelers’ diarrhea [ 92 , 93 ]. Research is urgently needed for the development of ETEC vaccines [ 93 ]. Colonization Factors (CF) and LT enterotoxin are antigens in the development of major ETEC candidate vaccines [ 31 ]. LT entertoxin exerts its toxic effect by binding to ganglioside 1 (GM 1 ) at the apical surface of intestinal cells [ 31 ]. GM 1 -binding LT is a strong immunogen and adjuvant and can serve as a carrier or platform for multivalent vaccine development against ETEC and other pathogens [ 94 ]. Huang et al . identified LT epitopes and demonstrated that substitution of LT epitopes eliminated LT enterotoxicity without altering GM 1 -binding [ 94 ]. ETEC vaccine development has been hindered by a lack of suitable animal models [ 95 ]. Travelers could serve as ideal candidates for clinical trials for the development of future vaccines.

Borde et al . developed a novel multivalent oral vaccine which contains killed ETEC over-expressing the main ETEC colonization factors and a recombinant enterotoxin B subunit protein given together with a recently developed intestinal-mucosal adjuvant double mutated LT [ 96 ]. The authors produced a dry-powder formulation by freeze-drying the vaccine using insulin as a stabilizer. Oral-intragastric immunization of mice with the vaccine elicited strong intestinal mucosal and serum antibody responses against all vaccine antigens.

It has been shown that CFaE, a subunit of the Colonization Factor Antigen 1 (CFA/1), is required for the adhesion of ETEC to intestinal cells of the host [ 92 ]. As such, human antibodies against CFaE by blocking colonization of ETEC may serve as immunoprophylactic agents for the prevention of ETEC-related diarrhea. Recently, Giuntini et al . identified a panel of anti-CFaE human monoclonal antibodies that are active against ETEC with high potency [ 92 ]. Oral administration of anti-CFaE human monoclonal antibodies in either IgG or secretary IgA form inhibited intestinal colonization in mice challenged with ETEC [ 92 ]. In the absence of an effective vaccine against ETEC infection, these anti-CFaE human monoclonal antibodies have the potential to be oral immunoprophylactic agents against ETEC infection.

Very recently, a live, heat-stable, oral Bovine Rotavirus Pentavalent Vaccine (BRV-PV) has been developed in India. A Phase III randomized controlled trial of the vaccine in 3508 infants in Niger showed an efficacy of 66.7% (95% confidence interval: 49.9 to 77.9) against severe rotavirus gastroenteritis [ 97 ].

Current typhoid vaccine cannot be used in children < 2 years of age due to poor immunogenicity [ 98 ]. Mitra et al . prepared a novel Vi-TT conjugate typhoid vaccine (PedaTyph TM ) by binding Vi to tetanus toxoid [ 98 ]. Two doses of the vaccine are required and should be given 6 weeks apart. Of the 1765 children aged 6 months to 12 years recruited into the study, 905 children received the vaccine intramuscularly and 860 children served as the control. The authors found that the vaccine was highly immunogenic and efficacious with minimal adverse events. GelSite-OAC™ is a novel synthetic typhoid vaccine that is currently being developed [ 84 ]. The vaccine is based on the fact that O-acetylated high molecular weight polygalacturonic acid shares the same backbone as Vi polysaccharide of S. typhi [ 84 ]. Preliminary data showed that the vaccine is safe, highly immunogenic, and effective even in individuals under 2 years of age.

Racecadotril is an anti-secretory agent effective in the treatment of diarrhea. The drug, however, has not been studied in travelers who have diarrhea.

It has been shown that the ST produced by ETEC is poorly immunogenic and potently toxic [ 99 ]. Thus, ST itself cannot induce anti-ST immunity, nor could it be a safe antigen even if it were immunogenic. Therefore, there is an unmet need to produce a vaccine which can elicit an immune response and can also induce protective immunity to multiple CFA antigens, as well as anti-LT and anti-ST immunity that would be broadly protective against ETEC. Sack and Zhang disclosed polypeptides comprising up to 9 antigenic elements of ETEC virulence determinants: 7 CFA adhesins [CFA/I, CFA/II (CS1, CS2, CS3), CFA/IV (CS4, CS5, CS6)] and 2 enterotoxins (LT, ST) that were genetically fused together [ 99 ]. These polypeptides can be used in the development of vaccines effective in the prevention of travelers' diarrhea caused by ETEC.

Savkovic and Roy disclosed an invention for the prevention and/or treatment of enteropathogenic bacterial infection in the gastrointestinal tract by concurrently administering to the subject a low molecular weight polyethylene glycol in combination with other antibiotic and antidiarrheal agents [ 100 ]. According to the authors, the low molecular weight polyethylene glycol has a molecular weight between about 100 daltons and 5000 daltons. The authors claimed that the invention is effective in the prevention and/or treatment of enteropathogenic bacterial pathogens, such as ETEC, EIEC, Salmonella , and Shigella which are important causes of travelers' diarrhea.

Savarino disclosed a method for the induction of immunity and prevention of diarrhea resulting from Escherichia coli [ 101 ]. The method provides for the induction of B-cell mediated immunity and for the induction of antibody capable of inhibiting the adherence and colonization of Escherichia coli , to intestinal cells of the host, thereby travelers' diarrhea can be prevented. An immune response can be induced by administrating a priming dose of an immunogen comprising whole or an antigenic polypeptide fragment of Escherichia coli fimbriae or whole or antigenic polypeptide fragment of Escherichia coli fibrillae with unit dose ranging from 50μg to 1 mg of the immunogen in a buffered aqueous solution. Booster doses should be administered at least 1 week after priming dose with a unit dose ranging from 50μg to 1mg of the immunogen in a buffered aqueous solution.

It is a well-known fact that different polymorphic forms of the same drug may have substantial differences in certain pharmaceutically important properties. Because amorphous solids do not have lattice energy, they usually dissolve in a solvent more rapidly and consequently may provide enhanced bioavailability characteristics such as a higher rate and extent of absorption of the compound from the gastrointestinal tract. Also, amorphous forms of a drug may offer significant advantages over crystalline forms of the same drug in the manufacturing process of solid dosage form such as compressibility. Consequently, it would be a significant contribution to the art to provide an amorphous form of rifaximin having increased solubility. Rao et al . disclosed an invention which can provide amorphous rifaximin in bulk form [ 102 ]. The amorphous rifaximin is substantially pure with polymorphic purity of 99% or more.

As rifaximin is sparingly soluble in water, a formulation chemist often finds it difficult to prepare a consistent formulation using the known polymorphic forms. Hence, there is a need to prepare rifaximin in a form which is suitable for formulation and has increased solubility and stability. Ghagare et al . disclosed a complex comprising rifaximin and a complexing agent, wherein the complexing agent is a polyvinyl pyrrolidone or a cyclodextrin [ 103 ]. The complex of this invention exhibits enhanced solubility and stability of rifaximin.

Driessen disclosed dietary supplements for the prevention or treatment of traveler's diarrhea [ 104 ]. The supplements comprise of approximately 1000mg green tea extract with at least 90% catechins, 4g partially hydrolyzed guar gum, 100mg L-theanine, and 5g non-sugar sweetener not containing a polyol.

Cheng disclosed an invention pertaining to the use of the calcium-sensing receptor-activating nutrients for the prevention and/or treatment of diarrheal diseases [ 105 ]. The anti-diarrheal composition consists of an aqueous solution of calcium, potassium, magnesium, zinc, sodium, chloride, bicarbonate, tryptophan; and, optionally, one or more ingredients selected from vitamins; preservatives; flavorings; buffers; carbohydrates; and the conjugate acid and conjugate base of butyrate and acetic acid, respectively. The invention is formulated for oral administration. The author claimed that the invention is effective in the treatment of diarrhea caused by E. coli , Vibrio cholerae , Vibrio parahaemolyticus , Clostridium perfringens , Clostridium difficile , Staphylococcus aureus , Salmonella spp., parvovirus, rotavirus, adenovirus, calicivirus, astrovirus, Cryptosporidia , Giardia lamblia , and Entamoeba histolytica .

Lefevre et al disclosed an invention comprising lyophylized Saccharomyces boulardii as an active ingredient and as sole probiotic, optionally in association with a pharmaceutically acceptable vehicle, wherein the composition is in a closed vial. The first airtight compartment comprising lyophilized S. boulardii powder and a second compartment comprising a solution, can be brought in airtight communication with one another to yield a suspension of S. boulardii to be administered to an individual upon opening of the vial [ 106 ]. According to the authors, the invention is effective in the prevention or treatment of travelers' diarrhea.

ACKNOWLEDGEMENTS

Professor Alexander K.C. Leung is the principal author. Dr Amy A.M. Leung, Dr Alex H.C. Wong, and Professor Kam L. Hon are the co-authors who contributed and helped with the drafting of this manuscript.

CONSENT FOR PUBLICATION

Not applicable.

This work was not funded, there was no honorarium, grant, or other form of payment received by the authors.

CONFLICT OF INTEREST

Professor Alexander K.C. Leung, Dr. Amy A.M. Leung, Dr. Alex H.C. Wong, and Professor Kam L. Hon confirm that this article has no conflicts of interest.

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What Causes Diarrhea and Loss of Appetite?

Related symptoms, when to seek medical attention, frequently asked questions.

Diarrhea and loss of appetite are two common digestive complaints that can occur separately or together and are often indicative of another underlying health condition.

Diarrhea is characterized as watery, loose stools that are usually accompanied by an increased frequency and urgency in bowel movements.

Loss of appetite , referred to by healthcare providers as anorexia, is defined as a reduced desire to eat.

Illustration by Jake Shi for Verywell Health

This article will explain the potential causes of diarrhea and a loss of appetite, as well as diagnosis and treatment options for these digestive issues.

Both diarrhea and loss of appetite may present along with other symptoms.

Symptoms that may be associated with diarrhea include:

  • Urgency and increased frequency of bowel movements
  • Unintentional weight loss
  • Malnutrition
  • Abdominal pain
  • Blood in stools

Symptoms that may be associated with loss of appetite include:

  • Constipation
  • Changes in the ability to smell or taste

Causes of Diarrhea and Loss of Appetite

Diarrhea and a loss of appetite can be due to a number of causes.

Common causes of diarrhea include:

  • Viruses including norovirus , rotavirus , and influenza (the flu)
  • Bacteria from contaminated food
  • Medicines like antibiotics and chemotherapy
  • Food allergies or intolerances
  • Celiac disease
  • Inflammatory bowel disease , including Crohn's or ulcerative colitis
  • Irritable bowel syndrome (IBS)

There are also numerous reasons for a loss of appetite. In elderly adults, a decrease in appetite can occur with no apparent physical cause.

Possible causes for a loss of appetite include:

  • Use of antibiotics
  • Cancer and cancer treatment
  • Chronic liver disease , such as hepatitis C
  • Chronic kidney disease
  • Hypothyroidism
  • Chronic obstructive pulmonary disease (COPD)
  • Heart failure
  • Depression or grief
  • An eating disorder

Diagnosing the Issue

Diarrhea and a loss of appetite can be due to many causes. Your healthcare provider may use several tests to determine the underlying cause.

History and Physical Evaluation

During a history and physical exam, your healthcare provider will ask a series of questions, examine your body and take a number of measurements to determine your overall health.

This includes:

  • Checking vital signs like blood pressure, weight, and height
  • Asking about any additional symptoms you may be experiencing
  • Listening to your heart
  • Listening to your lungs
  • Taking your pulse
  • Examining your lymph nodes
  • Looking at your skin
  • Listen to and press on your abdomen

Dietary Recall

If your healthcare provider suspects that you may have a food intolerance or allergy that may be contributing to your diarrhea or loss of appetite, they may ask about what foods you have been eating.

Your healthcare provider may also ask you to exclude certain foods from your diet to see if your symptoms improve, or to keep a food diary for a few weeks to help identify any triggers.

Blood Tests

A blood test can be used to detect a number of underlying conditions like celiac disease, chronic liver disease, or hypothyroid. A blood test can also be useful for detecting low levels of vitamins that could indicate problems with nutrient absorption in the intestines.

Stool Samples

Your healthcare provider may take a sample of stool to be tested in a lab. This helps in detecting the presence of any abnormal bacteria or other infections in the digestive tract that may be causing symptoms like diarrhea or loss of appetite.

Treating Loss of Appetite and Diarrhea

Treatment for loss of appetite or diarrhea will depend on the underlying cause of the symptoms.

Medications like antibiotics may be used to treat infections, and other prescription medications may be used to treat or manage the symptoms of underlying health conditions like Crohn's disease.

There are also home remedies that are known to help with short-term diarrhea and loss of appetite.

To help with diarrhea, consider trying the following tips:

  • Drink at least one cup of clear liquid whenever you have a loose bowel movement
  • Drink eight to 10 glasses of clear fluid a day, ideally water
  • Instead of eating three big meals a day, eat smaller meals throughout the day
  • Eat foods high in potassium like potatoes with no skin, bananas, or fruit juice
  • Try eating salty foods like pretzels or soup
  • Ask your healthcare provider if you should consider taking a multivitamin or drinking sports drinks
  • Avoid eating fried foods
  • Avoid caffeine and alcohol
  • Avoid carbonated drinks
  • Limit dairy intake

To help with a loss of appetite, consider trying:

  • Eating regular meals and snacking throughout the day
  • Buying foods that are easy to prepare
  • Choosing foods that are high in nutrients, like vegetables and fruit
  • Keeping your fluids up, especially your water intake
  • If solid food doesn't appeal, try smoothies or soup with added protein powder
  • Trying eating high-calorie foods like cheese, peanut butter, eggs, granola bars, and nuts
  • Eating your favorite foods any time of day

It's normal to experience diarrhea and/or loss of appetite for a few days, especially if you have or are recovering from a stomach bug or have been traveling. But if these issues persist for more than four days or worsen, consult your healthcare provider. They can help determine the underlying cause and direct you to the appropriate treatment.

Contact your healthcare provider if you have diarrhea that does not improve in five days or occurs with any of the following symptoms:

  • Stools that smell unusual
  • Stools that are an unusual color
  • Bloody stools
  • Stomach pain

If you have a loss of appetite, call your healthcare provider if you also:

  • Feel nauseated
  • Haven't eaten at all for more than a day or longer
  • Haven't had a bowel movement in two days or more
  • Aren't urinating frequently
  • Have pain when eating
  • Have been vomiting for more than 24 hours
  • Are losing a lot of weight unintentionally
  • Think you may have an eating disorder

Diarrhea and loss of appetite can be caused by a number of factors including infections, underlying conditions or mental health concerns. Diarrhea and loss of appetite may be accompanied by other symptoms including nausea and weight loss . Treatment will depend on the underlying cause, but there are steps people can take at home to cope with diarrhea or a loss of appetite.

A loss of appetite and diarrhea can both be caused by stress. These digestive complaints can also be caused by anxiety and depression.

There are a number of things that can cause diarrhea. A sudden change in diet or stress may cause diarrhea as well as a lack of appetite. However, not eating has not been associated with causing diarrhea.

Those with a lack of appetite should try and eat their favorite foods, even if this means eating lots of starchy foods like pasta and bread or eating breakfast foods for every meal.

To get in enough calories, reach for foods that are high in protein and fat like steak, eggs, peanut butter, and cheese.

MedlinePlus. Diarrhea.

MedlinePlus. Appetite - decreased

American College of Gastroenterology.  Diarrheal diseases – acute and chronic .

American Cancer Society. Loss of appetite

Musialik J, Suchecka W, Klimacka-Nawrot E, Petelenz M, Hartman M, Błońska-Fajfrowska B. Taste and appetite disorders of chronic hepatitis C patients .  Eur J Gastroenterol Hepatol . 2012;24(12):1400-1405. doi:10.1097/MEG.0b013e3283589f63

  • Health Direct. Changes to your appetite .

National Institute of Diabetes and Digestive and Kidney Diseases.  Diagnosis of diarrhea .

Johns Hopkins Medicine.  Diarrhea

MedlinePlus. When you have diarrhea

Health Direct.  Underlying causes of diarrhoea

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Diarrhoea - adult's assessment: Scenario: Acute diarrhoea (less than 4 weeks)

Last revised in November 2023

Covers the primary care assessment, investigation, and referral of acute or persistent (less than 4 weeks' duration) diarrhoea in adults.

Scenario: Acute diarrhoea (less than 4 weeks)

From age 18 years onwards.

How should I assess a person with acute diarrhoea?

  • The onset of symptoms within 6 hours of contaminated food suggests a pre-formed toxin of either Bacillus cereus or Staphylococcus aureus as the cause.
  • More frequent stool passage suggests an infectious cause.
  • Watery stools are associated with non-invasive and toxin-producing pathogens.
  • Blood in the stool, which is usually seen with invasive pathogens or severe inflammation, e.g. ulcerative colitis.
  • Recent hospital treatment or antibiotic treatment. For more information, see the CKS topic on  Diarrhoea - antibiotic associated .
  • Weight loss.
  • Evidence of dehydration.
  • Nocturnal symptoms — organic cause more likely.
  • Also ask about sexual history (particularly in men who have sex with men) to exclude sexually transmitted enteric infection. 
  • Quantity and character of stools (watery, fatty, containing blood or mucus).
  • Fever — often seen with invasive pathogens e.g. Salmonella, Shigella, and Campylobacter , enteric viruses or a cytotoxic organism such as Clostridioides difficile .
  • Recent contact with a person with diarrhoea.
  • Exposure to possible sources of enteric infection (for example certain foodstuffs such as meat, shellfish, dairy, and eggs), having eaten meals out, or recent farm or petting zoo visits).
  • Travel abroad — increases the likelihood of infection. Ask about potential exposures such as raw milk or untreated water.
  • Being in a higher risk group such as food handlers, nursing home residents (greater risk of norovirus, Cryptosporidium, and Giardia ), and recently hospitalized people.
  • Any new drugs, especially antibiotics or laxatives. For examples, see the  Causes   section on  Acute diarrhoea .
  • Stress or anxiety.
  • Abdominal pain, which is often present in inflammatory bowel disease, irritable bowel syndrome, and ischaemic colitis.
  • History of recent radiation treatment to the pelvis.
  • Factors increasing the risk of immunosuppression (for example, human immunodeficiency virus infection, long-term steroid use, or chemotherapy).
  • Any surgery or medical conditions (for example, endocrine disease) accounting for the diarrhoea. 
  • Diet and use of alcohol or substances such as sorbitol.
  • Features indicating dehydration include increased pulse rate, reduced skin turgor, dryness of mucous membranes, delayed capillary refill time, decreased urine output, hypotension (check for postural changes), and altered mental status. For more detail, see  Clinical features of dehydration .
  • Also consider underlying conditions that may increase the risk of complications.
  • Perform an abdominal examination to assess for pain or tenderness, distension, mass, increased or decreased bowel sounds, or liver enlargement.
  • Consider a rectal examination  to assess for rectal tenderness, stool consistency, blood, mucus, and possible malignancy.
  • If acute causes have been excluded and the person has features suggestive of an early presentation of a  chronic cause ,  see  Scenario: Chronic diarrhoea (more than 4 weeks) .

Clinical features of dehydration

The following signs are observed in dehydration:

  • Anorexia, nausea.
  • Light-headedness.
  • Postural hypotension.
  • Usually no signs.
  • Apathy/tiredness.
  • Nausea/headache.
  • Muscle cramps.
  • Pinched face.
  • Dry tongue or sunken eyes.
  • Reduced skin elasticity.
  • Tachycardia.
  • Profound apathy.
  • Confusion, leading to coma.
  • Marked peripheral vasoconstriction.
  • Systolic blood pressure less than 90 mmHg.
  • Oliguria or anuria.

However, these signs and symptoms have been shown to have poor diagnostic accuracy (particularly in the elderly). Plasma or serum osmolality measurement is the gold standard for diagnosis, with a 90% sensitivity and 100% specificity for plasma osmolality.

[ Bunn, 2019 ; Lacey, 2019 ]

Basis for recommendation

These recommendations are based on the 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea  [ Shane, 2017 ], the Centers for Disease Control Yellow book Travelers' Diarrhea [ CDC, 2023 ], the BMJ Best Practice guide Assessment of acute diarrhoea [ BMJ Best Practice, 2023a ], and the review articles Diarrhea [ Nemeth, 2022 ] and Bacterial Diarrhea [ Akhondi, 2023 ].  

How should I investigate acute diarrhoea in primary care?

  • The person is systemically unwell; needs hospital admission and/or antibiotics.
  • There is blood or pus in the stool.
  • The person is immunocompromised.
  • The person has recently received antibiotics, a proton pump inhibitor (PPI) or been in hospital — also request specific testing for  Clostridioides difficile . For more information, see the CKS topic on Diarrhoea - antibiotic associated . 
  • Diarrhoea occurs after foreign travel — also request tests for ova, cysts, and parasites and state the countries visited on the form.
  • Amoebae, Giardia , or cryptosporidium are suspected, particularly if diarrhoea is persistent (2 weeks or more) or the person has travelled to an at-risk area.
  • There is a need to exclude infectious diarrhoea (for example, severe abdominal pain, exacerbation of inflammatory bowel disease, or irritable bowel syndrome).
  • Diarrhoea in high-risk people (for example food handlers, healthcare workers, elderly residents in care homes).
  • Suspected food poisoning (for example after a barbeque or restaurant meal or eating eggs, chicken, or shellfish).
  • Outbreaks of diarrhoea in the family or community, when isolating the organism, may help pinpoint the source of the outbreak.
  • Contacts of people infected with certain organisms, for example,  Escherichia coli  O157 or  C. difficile , where there may be serious clinical sequelae to an infection.
  • Close household contacts of a person with a Giardia infection.
  • For more information on how to send a stool sample  (such as what information to include), see  Sending a stool sample .
  • See the section on  Investigations  in the  Scenario: Chronic diarrhoea (more than 4 weeks)  for advice on which blood tests to request.

Sending a stool sample

  • Send a single specimen (a quarter-full specimen pot is the minimum needed for routine microbiology investigation). Only send loose stools, as the laboratory will not examine formed stools. 
  • If diarrhoea occurs after exotic travel abroad, is recurrent, or prolonged, request ova, cysts, and parasites and give details of travel. Send three specimens a minimum of 2 days apart (ova, cysts, and parasites are shed intermittently).
  • Clinical features (for example, fever; bloody stool; severe abdominal pain).
  • History of immunosuppression.
  • Food intake (for example, shellfish).
  • Recent foreign travel (specify countries).
  • Recent antibiotic therapy, proton pump inhibitor therapy, or hospitalization (suggestive of  Clostridioides difficile infection).
  • Exposure to untreated water (suggestive of infection with protozoa).
  • Contact with other affected people or an outbreak.
  • Repeat specimens are usually unnecessary unless advised by a specialist (microbiologist or consultant in public health), or ova, cysts and parasites are suspected.
  • These recommendations are largely based on and extrapolated from UK Health Security Agency (UKHSA) guidance M anaging specific infectious diseases (gastroenteritis chapter) [ UK HSA, 2023 ], the BMJ Best Practice guide  Assessment of acute diarrhoea [ BMJ Best Practice, 2023a ], the review articles  Diarrhea [ Nemeth, 2022 ] and Bacterial Diarrhea [ Akhondi, 2023 ]. 

Considering blood tests

  • This recommendation is pragmatic and is based on what CKS considers to be good clinical practice. 

When should I admit or refer a person with acute diarrhoea?

  • The person is vomiting and unable to retain oral fluids,  or
  • They have features of severe dehydration or shock (for more information, see Clinical features of dehydration ).
  • Older age (people 60 years of age or older are more at risk of complications).
  • Home circumstances and level of support.
  • Bloody diarrhoea.
  • Abdominal pain and tenderness.
  • Coexisting medical conditions — immunodeficiency, lack of stomach acid, inflammatory bowel disease, valvular heart disease, diabetes mellitus, renal impairment, rheumatoid disease, systemic lupus erythematosus.
  • Drugs — immunosuppressants or systemic steroids, proton pump inhibitors, angiotensin-converting enzyme inhibitors, diuretics.
  • They are aged 40 and over with unexplained weight loss and abdominal pain, or
  • They are aged 50 and over with unexplained rectal bleeding, or
  • They are aged 60 and over with iron deficiency anaemia or changes in their bowel habit, or tests show occult blood in their faeces.
  • Adults have a rectal or abdominal mass.
  • Abdominal pain.
  • Change in bowel habits.
  • Iron-deficiency anaemia.
  • Refer if the diagnosis remains uncertain after a primary care assessment  — if infection and the other common causes of acute diarrhoea have been excluded and it is suspected that an episode of acute diarrhoea is due to a  chronic cause . 

These recommendations are extrapolated from an expert consensus guideline The management of infective gastroenteritis in adults. A consensus statement by an expert panel convened by the British Society for the Study of Infection [ Farthing, 1996 ], the BMJ Best Practice guide Assessment of acute diarrhoea  [ BMJ Best Practice, 2023a ] and the National Institute for Health and Care Excellence guideline  Suspected cancer: recognition and referral  [ NICE, 2023 ]. 

Referral if the diagnosis remains uncertain

  • CKS has based this recommendation on what it considers to be good clinical practice.

The content on the NICE Clinical Knowledge Summaries site (CKS) is the copyright of Clarity Informatics Limited (trading as Agilio Software Primary Care) . By using CKS, you agree to the licence set out in the CKS End User Licence Agreement .

Thanks for visiting! GoodRx is not available outside of the United States. If you are trying to access this site from the United States and believe you have received this message in error, please reach out to [email protected] and let us know.

Newsweek

Strange Glow Over Moscow Skies Triggers Panic as Explosions Reported

B right flashes lit up the night sky in southern Moscow in the early hours of Thursday morning, new footage appears to show, following reports of an explosion at an electrical substation on the outskirts of the city.

Video snippets circulating on Russian-language Telegram channels show a series of flashes on the horizon of a cloudy night sky, momentarily turning the sky a number of different colors. In a clip shared by Russian outlet MSK1.ru, smoke can be seen rising from a building during the flashes lighting up the scene.

Newsweek was unable to independently verify the details of the video clips, including when and where it was filmed. The Russian Ministry of Emergency situations has been contacted via email.

Several Russian Telegram accounts said early on Thursday that residents of southern Moscow reported an explosion and a fire breaking out at an electrical substation in the Leninsky district, southeast of central Moscow.

Local authorities in the Leninsky district told Russian outlet RBC that the explosion had happened in the village of Molokovo. "All vital facilities are operating as normal," Leninsky district officials told the outlet.

The incident at the substation in Molokovo took place just before 2 a.m. local time, MSK1.ru reported.

Messages published by the ASTRA Telegram account, run by independent Russian journalists, appear to show residents close to the substation panicking as they question the bright flashes in the sky. One local resident describes seeing the bright light before losing access to electricity, with another calling the incident a "nightmare."

More than 10 villages and towns in the southeast of Moscow lost access to electricity, the ASTRA Telegram account also reported. The town of Lytkarino to the southeast of Moscow, lost electricity, wrote the eastern European-based independent outlet, Meduza.

Outages were reported in the southern Domodedovo area of the city, according to another Russian outlet, as well as power failures in western Moscow. Electricity was then restored to the areas, the Strana.ua outlet reported.

The cause of the reported explosion is not known. A Telegram account aggregating news for the Lytkarino area described the incident as "an ordinary accident at a substation."

The MSK1.ru outlet quoted a local resident who speculated that a drone may have been responsible for the explosion, but no other Russian source reported this as a possible cause.

Ukraine has repeatedly targeted Moscow with long-range aerial drones in recent months, including a dramatic wave of strikes in late May.

On Sunday, Moscow Mayor Sergei Sobyanin said the region's air defense systems had intercepted an aerial drone over the city of Elektrostal, to the east of Moscow. No damage or casualties were reported, he said.

The previous day, Russian air defenses detected and shot down another drone flying over the Bogorodsky district, northeast of central Moscow, Sobyanin said.

There is currently no evidence that an aerial drone was responsible for the reported overnight explosion at the electrical substation in southern Moscow.

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Stills from footage circulating on Telegram early on Thursday morning. Bright flashes lit up the night sky in southern Moscow, new footage appears to show, following reports of an explosion at an electrical substation on the outskirts of the city.

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