TRAVELLERS DIARRHEA

CAUSES
Mostly enterotocigenic E coli (ETEC)
Capylobacter, salmonella, shigella
Norovirus, rotavirus, protozoa
Usually self limiting (<7 days) can occur up to 2 week after arriving
back from vacay
PREVENTION
Nonpharm
Boil water, drink only bottled stuff thats sealed, watch out for ice
cubes
Can sterilize water with Na hypochlorite or iodine
Eat fruit washed and peeled only, no salad/raw veggies
No leftovers, street vendors
Try to minimize PPIs and H2RAs --- because the bacteria might
live easier
Wash hands
BISMUTH SUBSALICYLATE
Good for prophylax and tx BUT YOU DONT use it OFTEN for
prophylaxis
Contra in pts taking anticoags or salicylates or allergic to
salicylates
Black stools can be confused with melemia
Not for kids as prophylaxis high doses encephalopathy
ABX
Prevention cons (resistance, cost, AEs) dont usually outweigh
the pros
Should generally use to treat, not prevent
If they are needed (chronically ill, immunocomp pts, critical
travel, pts who get diarrhea every time) then do the shortest
course possible
FQs are good but theres resistance is some places
SMX/TMP and DOXY and NO LONGER RECOMMENDED too much
resistance
Watch out for c diff
VACCINE

INACTIVATED CHOLERA helps against ETEC

o Insufficient evidence dont use it unless high risk
(aid/relief workers etc)

PROBIOITCS dont help

TREATMENT
Oral rehydration salts
Always a good idea esp in infants, preg, elderly
ANTImotility agents
LOPERAMIDE helps mild-mod diarrhea (up to 5 stools per day,
mild pain)
Diphenoxylate plus atropine isnt as effective
Dont use under 3 toxic megacolon and masking dehydration
Dont use if bloody diarrhea, high fever because RETENTION
ileus, megacolon, toxic megacolon
LOPERAMIDE plus ABX is safe and more effective than either
agent alone
Abx
Initiate at onset of SX ESPECIALLY IF sev diarrhea with blood,
cramps, high fever
If its mild you can prob just manage it with fluid and antimotility
agents
FQs are really good
o Except in places like Thailand cos resistance (AZITHRO
instead)
o SMX/TMP is an alternative for people who cant take FQs but
lots of resistance
o One dose may be enough esp when combined with
loperamide
CHILDREN
ORT
No loperamide <3, no Bismuth <3
o BISMUTH WATCH OUT FOR REYES
ABX of choice: amox then AMX/TMP
o Cipro has the cartilage problems but 1-3 days might be ok?
PREG

 Prophylaxis no recommended
ORT
ABx: azithro is the DOC
Loperamide can be used safely
BFING
Keep on BFing
Azithro, loperamide can be used
Dont use IODINE (sterilization), bismuth, or FQs
QTIPS
Mild usually resolves withing 24 hours of fluid and antimots
If you have fever or desentry seek med attention if sx havent
improved withing 48 hours