Diarrhea in the returned traveller
From IDWiki
Background
Microbiology
- Bacteria
- Escherichia coli (entero-hemorragic (EHEC), entero-toxigenic (ETEC)): most common cause
- Usually afebrile
- Diffusely adherent E. coli (DAEC) also exists
- Campylobacter jejuni: more common in SE Asia
- Salmonella (non-typhoidal)
- Shigella
- Plesiomonas (unclear if cause of diarrhea)
- Vibrio cholerae
- Aeromonas
- Escherichia coli (entero-hemorragic (EHEC), entero-toxigenic (ETEC)): most common cause
- Viruses
- Norovirus: most common virus
- Rotavirus
- Enterovirus
- Parasites
- And others 1
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
- ^ 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.
