Traveler's Diarrhea

Diarrhea occurs in a significant number of people who travel to foreign countries. Travelers to developing countries of the world become ill from eating or drinking food or water contaminated by infected human bowel waste.

Traveler’s diarrhea can be defined as 3 or more unformed stools in a 24-hour period.

• Travelers at risk: Those going from industrialized countries to developing countries. The condition is more common in young adults. About 30-50% of travelers to the high-risk areas will develop diarrhea.

• High-risk areas
  
  
  • Mexico
    
    
  • Latin America
    
    
  • Africa
    
    
  • Middle East
    
    
  • Asia

• Moderate-risk areas
  
  
  • Caribbean islands
    
    
  • Southern Europe
    
    
  • Israel

• Low-risk areas
  
  
  • United States
    
    
  • Canada
    
    
  • Northern Europe
    
    
  • New Zealand
    
    
  • Australia

You can become infected by eating or drinking food or water that has come in contact with feces. Food and water become contaminated when they are handled by people with fecal content on their hands—not in direct contact with feces. Restaurants are common sites for exposure to this type of food poisoning. Food from street vendors is even more risky. Eating in a private home is the safest food source.

• High-risk food and drink: Certain items are considered high risk for transmission and include the following:
  
  
  • Raw or undercooked meats
    
    
  • Raw leafy vegetables
    
    
  • Seafood
    
    
  • Unpeeled fruits
    
    
  • Unpasteurized dairy products
    
    
  • Tap water (A common mistake travelers make is to avoid tap water but to place ice cubes in a beverage. Contaminated ice is still able to transmit disease. Do not use ice cubes.)
    
    

• Safe products to eat and drink
  
  
  • Bottled carbonated beverages
    
    
  • Hot coffee or tea
    
    
  • Water boiled or treated appropriately with chlorine

• Specific bacterial causes: Up to 85% of traveler's diarrhea is caused by bacteria. The remaining cases are caused by viruses and protozoa. The most common organism causing traveler’s diarrhea is Escherichia coli accounting for up to 72% of cases in some regions.

• Other bacterial causes
  
  
  • Subtypes of E coli
    
    
  • Shigella species
    
    
  • Salmonella species
    
    
  • Campylobacter jejuni
    
    
  • Vibrio species

• Protozoa causing traveler's diarrhea
  
  
  • Giardia duodenalis, known as giardiasis
    
    
  • Entamoeba histolytica
    
    
  • Cryptosporidium parvum

• Viral causes
  
  
  • Norwalk virus
    
    
  • Rotavirus virus
    
    
  • Enteroviruses

Traveler’s diarrhea usually does not begin immediately on arrival in a foreign country but starts 2-3 days into the stay. Diarrhea can also occur after you return home from the trip.

• Common signs and symptoms
  
  
  • Loose or watery stools
    
    
  • Abdominal cramping
    
    
  • Bloating
    
    
  • Nausea
    
    
  • Urgency to have a bowel movement
    
    
  • Fever
    
    
  • Vomiting
    
    
  • Headache
    
    
  • Painful defecation
    
    
  • Bloody stools

When to call the doctor

• If diarrhea lasts longer than 3 days
  
  
• If blood, mucus, or worms are seen in stool
  
  
• If you have pain in the abdomen or rectum
  
  
• If your temperature is greater than 102°F
  
  
• If severe headache develops
  
  
• If you have signs of water loss including dry mouth, excessive thirst, little or no urination, or feel lightheaded
  
  
• If your immune system is weakened by another condition such as HIV or cancer
  
  
• If your symptoms do not improve when you drink fluids or use nonprescription medications for diarrhea

When to go to the hospital

• Continuing bloody diarrhea
  
  
• Severe weakness
  
  
• Passing out 

Diagnosis of traveler's diarrhea is made solely on the signs and symptoms. Laboratory testing is not necessary. If signs and symptoms last longer than a week or bloody diarrhea occurs, the doctor may order stool cultures for microscopic examination for parasites.

|Self-Care at Home|

• Drink 2-3 quarts of fluid per day. In the first 24 hours the best fluids to drink are bottled fruit juices and beverages, caffeine-free soft drinks, hot tea, and broth.
  
  
• During the next 24 hours, eat bland foods such as rice, soup, bread, crackers, eggs, and cereals. Advance to regular foods after 2-3 days.
  
  
• With more severe cases, over-the-counter medications may help reduce symptoms and shorten the time they last.
  
  
  • Antimotility agents, such as loperamide (Imodium), give the stools more consistency and provide some relief from your symptoms.
    
    
  • Bismuth subsalicylate (Pepto-Bismol) is also moderately effective. Use according to package directions or upon direction of your doctor.

|Medications|

• For mild cases, the doctor may recommend the nonprescription medications bismuth subsalicylate and loperamide.

• The use of an antibiotic can reduce the duration of illness from days to hours. For moderate to severe diarrhea, the doctor may prescribe one of these antibiotics:
  
  
  • Trimethoprim-sulfamethoxazole (Bactrim DS)
    
    
  • Ciprofloxacin (Cipro)
    
    
  • Norfloxacin (Noroxin)
    
    
  • Ofloxacin (Floxin)
    
    
  • Doxycycline (Vibramycin)

|Prevention|

• Avoid these foods when traveling:
  
  
  • Raw vegetables
    
    
  • Raw fish, meat, and dairy products
    
    
  • Raw leafy vegetables
    
    
  • Unpeeled fruits
    
    
  • Tap water
    
    
  • Ice
    
    
  • Any food from street vendors

• You may safely eat or drink these items:
  
  
  • Well-cooked fish, meats, and vegetables served hot
    
    
  • Carbonated beverages
    
    
  • Boiled water (3-5 minutes)
    
    
    • If boiling water is not possible, other options include putting tincture of iodine drops in water (5 drops per quart of water), use of tetracycline drops in water, or chlorine bleach to treat water (2 drops per quart of water). These preparations can be obtained from camping and sporting goods stores.
      
      
  • It is best to see your physician prior to foreign travel and to bring the necessary medications with you to prevent any unnecessary trips to doctors or hospitals in foreign countries.

• The use of a single daily dose of an antibiotic is up to 90% effective in preventing traveler’s diarrhea. Preventive use of antibiotics is not routinely recommended except in special circumstances such as travelers with weakened immune systems, those with significant other medical illnesses, or for people traveling to very high-risk areas.

|Outlook|

Although it can ruin a vacation, traveler’s diarrhea rarely requires hospitalization and usually is not life threatening.

• Untreated, the diarrhea typically lasts 3-5 days.

• 20% of people have symptoms severe enough to keep them in bed.

• In 10% of people, the illness will last more than a week.

• Traveler’s diarrhea is not life threatening to an otherwise healthy person. In the very young, very old, and people with weakened immune systems, it can be dangerous.

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Author: Anthony L Buscaglia, DO, Staff Physician, Department of Emergency Medicine, State University of New York at Buffalo.

Coauthor(s): Ronald M Moscati, MD, Director of Research, Assistant Professor, Department of Emergency Medicine, Erie County Medical Center, State University of New York at Buffalo.

Editors: Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; James Ungar, MD, Medical Director, Chair Department of Emergency Medicine Santa Rosa Memorial Hospital.