Diarrhea in the returned traveller

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Background

Microbiology

Epidemiology

  • Usually defined as diarrhea (3 or more unformed stools per day), plus one of abdominal cramps, tenesmus, nausea, vomiting, fever, or fecal urgency, either while travelling
  • Incidence among travellers from rich countries is 10 to 40%

Risk Factors

  • Beach vacations are protective compared to VFR, adventure tours, or all-inclusive hotels
  • Cruise ships are associated with explosive outbreaks of norovirus
  • Lower rates in winter; higher during rainy seasons
  • Higher rates of diarrhea requiring hospitalization in infants and toddlers

Investigations

  • Blood cultures (if febrile)
  • Stool culture or PCR for bacteria
  • Stool for ova & parasites

Management

  • If mild (1-3 stools daily with mild enteric symptoms), can treat with bismuth subsalicylate or loperamide
    • Avoid loperamide in patients less than 2 years, if they are febrile, or if their stools are bloody
  • May benefit from antibiotics if diarrhea is severe, there are systemic symptoms, or it is interfering with their activities
    • Can decrease duration of diarrhea by about a day and a half
  • Empiric treatment depends on country of origin
    • Ciprofloxacin 500 mg PO bid for 3 days, for countries with lower rates of resistance
    • Azithromycin 500 to 1000 mg PO daily for 3 days

Further Reading

  • Traveler's Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi: 10.1001/jama.2014.17006
  • Statement on Travellers' Diarrhea by the Committee to Advise on Tropical Medicine and Travel (CATMAT) (available online)

References

  1. ^  Nipam Shah, David J. Ramsey, Herbert L. DuPont. Global Etiology of Travelers’ Diarrhea: Systematic Review from 1973 to the Present. The American Journal of Tropical Medicine and Hygiene. 2009;80(4):609-614. doi:10.4269/ajtmh.2009.80.609.