Traveler's diarrhea: Difference between revisions

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===Etiology===
===Etiology===
{| {{table}}
{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Organism'''
| align="center" style="background:#f0f0f0;"|'''Organism'''
| align="center" style="background:#f0f0f0;"|'''Latin America and Caribbean'''
| align="center" style="background:#f0f0f0;"|'''Latin America and Caribbean'''
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==Differential Diagnosis==
==Differential Diagnosis==
{{Template:Diarrhea DDX}}
{{Template:Diarrhea DDX}}


==Diagnosis<ref>Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006</ref>==
==Diagnosis<ref>Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006</ref>==
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;The average duration of untreated traveler’s diarrhea is 4 to 5 days
;The average duration of untreated traveler’s diarrhea is 4 to 5 days
==Workup==
===Uncomplicated Diarrhea===
*No workup
===Fever, Bloody Stools, or Ill Appearing===
*Stool culture
*Systemic toxicity
**Extended workup including blood cultures
===Persistent or Refractory Diarrhea (>14 days)===
*Typically not done in the ER (at followup)
**Stool culture (including [[Salmonella]], [[Shigella]], and [[Campylobacter]])
**Stool O&P (including testing for protozoal parasites, [[Giardia]], [[Cryptosporidium]])


==Treatment==
==Treatment==
*Consider [[ondansteron]] if [[nausea]]
*Consider [[IVF]] if dehydrated
*Consider [[loperamide]] 4mg PO after each loose stool (Max: 16mg/day)
**if very frequent stools and no contra-indication:
***Not pregnant
***>2 years old
**[[fever]] or bloody stools without concomitant antibiotics (don't use as sole therapy)
===Antibiotics===
===Antibiotics===
{{Travelers Diarrhea Antibiotics}}
{{Travelers Diarrhea Antibiotics}}
===Antimotility agent===
*Only for nonpregnant adults with no fever or blood in stool
*[[Loperamide]] 4mg PO after each loose stool (Max: 16mg/day)


===Pediatrics===
===Pediatrics===
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==Disposition==
==Disposition==
*Outpatient, for the vast majority
*Outpatient, for the vast majority
*If systemic toxicity, consider admission


===Complications===
===Complications===
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*Reactive arthritis
*Reactive arthritis
*Guillain-Barré syndrome
*Guillain-Barré syndrome
==See Also==
==See Also==
*[[Diarrhea]]
*[[Diarrhea]]

Revision as of 21:03, 6 January 2015

Background

  • Most respond to antibiotics
  • as duration of diarrhea increases, higher chance of parasitic cause
  • Most cases of traveler’s diarrhea are caused by bacterial enteropathogens, whereas bacterial pathogens cause less than 15% of endemic diarrhea cases in adults living in their home country[1]

Etiology

Organism Latin America and Caribbean Africa South Asia Southeast Asia
Enterotoxigenic Escherichia coli ≥35 25-35 15-25 5-15
Enteroaggregative E coli 25-35 <5 15-25 No data
Campylobacter <5 <5 15-25 25-35
Salmonella <5 5-15 <5 5-15
Shigella 5-15 5-15 5-15 <5
Norovirus 15-25 15-25 5-15 <5
Rotavirus 15-25 5-15 5-15 <5
Giardia <5 <5 5-15 5-15

Differential Diagnosis

Acute diarrhea

Infectious

Noninfectious

Watery Diarrhea

Traveler's Diarrhea


Diagnosis[3]

  • Travel
  • 3 or more unformed stools per 24 hours
  • plus (at least 1 of the following):
    • abdominal cramps
    • tenesmus
    • nausea
    • vomiting
    • fever
    • fecal urgency
The average duration of untreated traveler’s diarrhea is 4 to 5 days

Workup

Uncomplicated Diarrhea

  • No workup

Fever, Bloody Stools, or Ill Appearing

  • Stool culture
  • Systemic toxicity
    • Extended workup including blood cultures

Persistent or Refractory Diarrhea (>14 days)

Treatment

  • Consider ondansteron if nausea
  • Consider IVF if dehydrated
  • Consider loperamide 4mg PO after each loose stool (Max: 16mg/day)
    • if very frequent stools and no contra-indication:
      • Not pregnant
      • >2 years old
    • fever or bloody stools without concomitant antibiotics (don't use as sole therapy)

Antibiotics

  • Ciprofloxacin 750mg PO once daily x 1-3 days[4]
    • First choice for use except in South and Southeast Asia[5]
  • Azithromycin 500mg PO q24h x 3 days OR 1000mg PO x 1[6]
    • Nausea is a frequent adverse event[7]
    • First choice for use in South and Southeast Asia[8]
  • Rifaximin 200mg PO TID x 3 days[9]

Pediatrics

Antibiotic Options:

Avoid fluroquinolones

Disposition

  • Outpatient, for the vast majority
  • If systemic toxicity, consider admission

Complications

  • Postinfectious irritable bowel syndrome
    • Occurs in 3-17% of patients
    • Risk factors
      • Severity of traveler’s diarrhea
      • Number of episodes
      • Pretravel diarrhea
      • Pretravel adverse life events
      • Infection with heat-labile toxin–producing ETEC
  • Reactive arthritis
  • Guillain-Barré syndrome


See Also

Source

  1. ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  2. ↑ Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
  3. ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  4. ↑ Hoge CW. et al. Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years. Clin Infect Dis. 1998;26:341–5
  5. ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  6. ↑ Sanders JW. et al. An observational clinic-based study of diarrheal illness in deployed United States military personnel in Thailand: presentation and outcome of Campylobacter infection. Am J Trop Med Hyg. 2002;67:533–8
  7. ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  8. ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  9. ↑ DuPont HL. et al. Rifaximin versus ciprofloxacin for the treatment of traveler’s diarrhea: a randomized, double-blind clinical trial. Clin Infect Dis. 2001;33:1807–15
  10. ↑ Stauffer WM, Konop RJ, Kamat D. Traveling with infants and young children. Part III: travelers’ diarrhea. J Travel Med. 2002;9:141–50
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