Diarrhea in the returned traveller

Background

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%

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

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

^ 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.