Traveler's diarrhea prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Prophylactic antibiotics should not be recommended for most travelers. Prophylactic antibiotics using fluoroquinolones for 1 to 3 days may be effective in the prevention of some cases of traveler's diarrhea (e.g. for short-term travelers who are high-risk hosts (such as those who are immunosuppressed) or who are taking critical trips (such as engaging in a sporting event) during which even a short bout of diarrhea could affect the trip). A traveler relying on prophylactic antibiotics will need to carry an alternative antibiotic to use in case diarrhea develops despite prophylaxis. Other preventive measures include maintaining good hygiene, drinking safe water, and proper food handling during travel.

Prevention

Antimicrobial Prophylaxis

• Prophylactic antibiotics should not be recommended for most travelers.

• Prophylactic antibiotics afford no protection against nonbacterial pathogens and can remove normally protective microflora from the bowel, which could make a traveler more susceptible to infection with resistant bacterial pathogens.
• A traveler relying on prophylactic antibiotics will need to carry an alternative antibiotic to use in case diarrhea develops despite prophylaxis.
• Additionally, the use of antibiotics may be associated with allergic or adverse reactions in a certain percentage of travelers and may potentially contribute to drug resistance.

• Nonetheless, prophylactic antibiotics are effective in the prevention of some cases of traveler's diarrhea.

The use of prophylactic antibiotics should be weighed against the result of using prompt, early self-treatment with antibiotics when traveler's diarrhea occurs, which can limit the duration of illness to 6–24 hours in most cases.

• Prophylactic antibiotics may be considered for short-term travelers who are high-risk hosts (such as those who are immunosuppressed) or who are taking critical trips (such as engaging in a sporting event) during which even a short bout of diarrhea could affect the trip.
• Fluoroquinolones are considered the most effective prophylactic therapy for traveler's diarrhea.

• Traveler’s diarrhea

• Prophylaxis

• Preferred regimen (1): Norfloxacin 400 mg PO bid for 1 to 3 days
• Preferred regimen (2): Ciprofloxacin 500 mg PO bid for 1 to 3 days
• Alternative regimen (3): Rifaximin 200 mg PO tid for 14 days

• Note: Rifaximin for prophylaxis against traveler's diarrhea is not FDA-approved. It has been evaluated in the prophylaxis of traveler's diarrhea in one randomized phase 3 trial among patients traveling from USA to Mexico

Non-pharmacologic Prevention

• Traveler's diarrhea may be prevented through proper water quality management systems as found in responsible hotels and resorts.

• Maintain good hygiene and make sure that you drink safe water, even for teeth brushing.
• Use only safe bottled water. Reports of locals filling bottles with tap water, then sealing them and then selling the bottled water as purified water have come out of several countries.

• Drink safe beverages include bottled carbonated beverages, hot tea or coffee, beer, wine, and water boiled or appropriately treated by yourself.

• Active intervention involves boiling water for three to five minutes (depending on elevation), filtering water with appropriate filters or using chlorine bleach (2 drops per liter) or tincture of iodine (5 drops per liter) in the water. The wide availability of safe bottled water makes these interventions usually unnecessary for all but the most remote destinations.
• Avoid eating raw fruits and vegetables unless the traveler peels them.
• If handled properly, well-cooked and packaged foods are usually safe. Avoid eating raw or undercooked meat and seafood. Unpasteurized milk, dairy products, mayonnaise and pastry icing are associated with increased risk for TD, as are foods or drinking beverages purchased from street vendors or other establishments where unhygienic conditions are present.