Traveler’s diarrhea (TD) is a clinical syndrome of nausea, vomiting and diarrhea that may develop following consumption of food or water contaminated with bacteria, viruses or parasites. Men and women are affected equally and the incidence varies from 20% to 50% of international travelers. The Center for Disease Control (CDC) report that 85% of all cases of traveler’s diarrhea is due to bacteria, generally Escherichia coli. Traveler’s diarrhea is not serious, but can be unpleasant and affect quality of life. If symptoms develop, preventing dehydration is important and symptoms will generally resolve within a few days without treatment.
Traveler’s diarrhea often occurs within the first week of travel and may begin abruptly with four to five loose or watery stools per day, abdominal cramping, nausea, vomiting, fever and bloating. Most symptoms improve within one to two days without treatment and completely resolve within a week.
Certain groups of people are at higher risk, including those with a weakened immune system and other health problems. The World Health Organization (WHO) designates travel destinations as high risk, intermediate risk or low risk for traveler’s diarrhea based on public sanitation and hygiene. High-risk destinations include developing countries in Latin America, Africa and Asia. Intermediate risk destinations include Argentina, the Caribbean, Croatia, Greece, Portugal, Romania and South Africa. Low risk countries are industrialized countries that have reliable sewage treatment and drinking water. These include Australia, Canada, France, Germany, Great Britain, and the United States. Complete information on heath risks for travelers can be found on the WHO website, at www.who.int/ith/en
Some precautions that will help prevent traveler’s diarrhea include: Do not eat food from street vendors; Do not drink tap water, not even when brushing your teeth; Do not drink unpasteurized milk or dairy products; Do not use ice made from tap water; Avoid all raw fruits and vegetables unless they can be peeled and you peel them yourself; Do not eat raw or rare meat or fish and ensure your food is served hot.
You can safely drink bottled water (if you are the one to break the seal), carbonated soft drinks, beer, wine and hot drinks such as coffee or tea. Iodine tablets function to purify water and are added 30 minutes before drinking. Small portable water filters or portable water purification systems, such as SteriPEN are commercially available for travelers.
The primary goal of treatment is to maintain hydration. During the first 24 hours, drink two to three quarts of fluid such as bottled fruit juices, caffeine-free soft drinks, hot tea and clear soups. Oral rehydration solution (ORS) contains water and salts to replenish both fluids and electrolytes. Diet can be advanced to resumption of regular diet when tolerated.
Bismuth subsalicylate, the active ingredient in Pepto-Bismol, has been used to prevent TD. It is taken as either two tablets (or two ounces) four times daily. Adverse effects include dark stools and blackening of the tongue. Bismuth should be avoided in individuals allergic to aspirin, those who have kidney disease, and people who take blood thinners. Caution should also be used if taking daily aspirin to avoid salicylate toxicity.
Antimotility agents such as loperamide, reduce diarrhea by slowing transit time in the gastrointestinal tract. This increases absorption and decreases duration and frequency of loose stools, which is important when traveling by airplane or public transportation.
Although bacteria cause most traveler’s diarrhea, the CDControl does not currently recommend antibiotics to prevent traveler’s diarrhea. Antibiotics are often used once symptoms develop. On occasion, prophylactic antibiotics may be considered for some travelers.
Apart from unexpected alteration in travel plans, most people with traveler’s diarrhea fully recover in three to seven days. If symptoms persist, evaluation is needed to rule out persistent infection. Occasionally, a post-infectious irritable bowel syndrome develops. Travelers may want to discuss upcoming travel plans with their health care provider. To be proactive, keep hydrated and include over the counter medications when you travel.