Traveler's diarrhea: Difference between revisions

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==Background==
==Background==
*Most respond to antibiotics
*A diarrheal syndrome which may be caused by a variety of intestinal pathogens contracted while traveling, particularly in low-income countries
*as duration of diarrhea increases, higher chance of parasitic cause
Bacteria account for a majority of cases, but traveler's diarrhea may also be caused by parasites or viruses.
*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<ref>Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006</ref>
**Is the most common [[travel-associated disease]]
**Greatest contributor to illness poor hygiene in restaurants <ref> http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/travelers-diarrhea</ref>
*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<ref name="Steffen">Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006</ref>
**Most cases respond to antibiotics (as opposed to non-traveler's [[acute gastroenteritis]], which is most commonly caused by viruses)
**As duration of diarrhea increases, higher chance of parasitic cause
*At risk populations- Immunosuppressed, diabetes, taking meds to suppress acid production


===Etiology===
===Etiology<ref name="Steffen"></ref>===
{| {{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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| align="center" style="background:#f0f0f0;"|'''Southeast Asia'''
| align="center" style="background:#f0f0f0;"|'''Southeast Asia'''
|-
|-
| Enterotoxigenic Escherichia coli|| ≥35|| 25-35 ||15-25|| 5-15
| Enterotoxigenic [[Escherichia coli]]|| ≥35|| 25-35 ||15-25|| 5-15
|-
|-
| Enteroaggregative E coli ||25-35 ||<5 ||15-25 ||No data
| Enteroaggregative [[E coli]] ||25-35 ||<5 ||15-25 ||No data
|-
|-
| Campylobacter ||<5 ||<5 ||15-25 ||25-35
| [[Campylobacter]] ||<5 ||<5 ||15-25 ||25-35
|-
|-
| Salmonella|| <5 ||5-15 ||<5|| 5-15
| [[Salmonella]]|| <5 ||5-15 ||<5|| 5-15
|-
|-
| Shigella||5-15 ||5-15|| 5-15 ||<5
| [[Shigella]]||5-15 ||5-15|| 5-15 ||<5
|-
|-
| Norovirus ||15-25||15-25 ||5-15 ||<5
| [[Norovirus]] ||15-25||15-25 ||5-15 ||<5
|-
|-
| Rotavirus ||15-25 ||5-15||5-15 ||<5
| [[Rotavirus]] ||15-25 ||5-15||5-15 ||<5
|-
|-
| Giardia ||<5 ||<5 ||5-15 ||5-15
| [[Giardia]] ||<5 ||<5 ||5-15 ||5-15
|}
|}
==Clinical Features==
Characterized by the following:<ref name="Steffen"></ref>
*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<ref name="Steffen"></ref>


==Differential Diagnosis==
==Differential Diagnosis==
{{Template:Diarrhea DDX}}
{{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>==
==Evaluation==
*Travel
''Diagnosis is typically made clinically''
*3 or more unformed stools per 24 hours
===Uncomplicated Diarrhea===
*plus (at least 1 of the following):
*No workup<ref name="Steffen"></ref>
**abdominal cramps
 
**tenesmus
===Fever, Bloody Stools, or Ill Appearing===
**nausea
*Stool culture <ref name="Steffen"></ref>
**vomiting
*Systemic toxicity
**fever
**Extended workup including blood cultures
**fecal urgency
 
===Persistent or Refractory Diarrhea (>14 days)===
*Typically not done in the ER (at follow-up)
**Stool culture (including [[Salmonella]], [[Shigella]], and [[Campylobacter]])
**Stool O&P (including testing for protozoal parasites, [[Giardia]], [[Cryptosporidium]])<ref name="Steffen"></ref>
**Fecal leukocytes, giardia antigen, C. difficile PCR


;The average duration of untreated traveler’s diarrhea is 4 to 5 days
==Management==
===Supportive Care===
*PO hydration and consider [[oral rehydration fluids]]
*Consider [[ondansetron]] if concurrent nausea/vomiting
*[[Bismuth subsalicylate]] (Pepto Bismol) ~524 mg every 30 to 60 minutes or 1,050 mg every 60 minutes as needed (maximum: ~4,200 mg/24 hours)<ref>Brum, et al. Systematic Review and Meta-Analyses Assessment of the Clinical Efficacy of Bismuth Subsalicylate for Prevention and Treatment of Infectious Diarrhea. Dig Dis Sci. 2021; 66(7): 2323–2335. doi: 10.1007/s10620-020-06509-7</ref>
*Consider [[IVF]] if dehydrated
*Consider [[loperamide]] 4mg PO followed by 2mg after each loose stool (Max: 16mg/day)<ref name="Steffen"></ref>
**If very frequent stools and no contra-indication:
***Not pregnant
***>2 years old
***[[Fever]] or bloody stools without concomitant antibiotics (do not use as sole therapy)


==Treatment==
===[[Antibiotics]]<ref name="Steffen"></ref>===
===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
*Consider admission if systemic toxicity


===Complications===
==Complications==
*[[Postinfectious irritable bowel syndrome]]
*[[Postinfectious irritable bowel syndrome]]
**Occurs in 3-17% of patients
*[[Reactive arthritis]]
**Risk factors
*[[Guillain-Barre syndrome]]
***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==
==See Also==
*[[Diarrhea]]
*[[Diarrhea]]
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*[[Travel Medicine]]
*[[Travel Medicine]]


==Source==
==External Links==
<references/>  
*[http://wwwnc.cdc.gov/travel/page/travelers-diarrhea CDC - Travelers Diarrhea]
 
==References==
<references/>  


[[Category:GI]]
[[Category:GI]]
[[Category:ID]]
[[Category:ID]]
[[Category:TropMed]]
[[Category:Tropical Medicine]]
 
 
==See Also==
 
 
==External Links==
 
 
==References==
<references/>

Latest revision as of 16:42, 29 January 2025

Background

  • A diarrheal syndrome which may be caused by a variety of intestinal pathogens contracted while traveling, particularly in low-income countries

Bacteria account for a majority of cases, but traveler's diarrhea may also be caused by parasites or viruses.

  • 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[2]
    • Most cases respond to antibiotics (as opposed to non-traveler's acute gastroenteritis, which is most commonly caused by viruses)
    • As duration of diarrhea increases, higher chance of parasitic cause
  • At risk populations- Immunosuppressed, diabetes, taking meds to suppress acid production

Etiology[2]

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

Clinical Features

Characterized by the following:[2]

  • Travel
  • 3 or more unformed stools per 24 hours
  • Plus (at least 1 of the following):
The average duration of untreated traveler’s diarrhea is 4 to 5 days[2]

Differential Diagnosis

Acute diarrhea

Infectious

Noninfectious

Watery Diarrhea

Traveler's Diarrhea

Evaluation

Diagnosis is typically made clinically

Uncomplicated Diarrhea

Fever, Bloody Stools, or Ill Appearing

  • Stool culture [2]
  • Systemic toxicity
    • Extended workup including blood cultures

Persistent or Refractory Diarrhea (>14 days)

Management

Supportive Care

  • PO hydration and consider oral rehydration fluids
  • Consider ondansetron if concurrent nausea/vomiting
  • Bismuth subsalicylate (Pepto Bismol) ~524 mg every 30 to 60 minutes or 1,050 mg every 60 minutes as needed (maximum: ~4,200 mg/24 hours)[4]
  • Consider IVF if dehydrated
  • Consider loperamide 4mg PO followed by 2mg after each loose stool (Max: 16mg/day)[2]
    • If very frequent stools and no contra-indication:
      • Not pregnant
      • >2 years old
      • Fever or bloody stools without concomitant antibiotics (do not use as sole therapy)

Antibiotics[2]

Pediatrics

Antibiotic Options:

Avoid fluroquinolones

Disposition

  • Outpatient for the vast majority
  • Consider admission if systemic toxicity

Complications

See Also

External Links

References

  1. ↑ http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/travelers-diarrhea
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  3. ↑ Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
  4. ↑ Brum, et al. Systematic Review and Meta-Analyses Assessment of the Clinical Efficacy of Bismuth Subsalicylate for Prevention and Treatment of Infectious Diarrhea. Dig Dis Sci. 2021; 66(7): 2323–2335. doi: 10.1007/s10620-020-06509-7
  5. ↑ Hoge CW. et al. Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years. Clin Infect Dis. 1998;26:341–5
  6. ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  7. ↑ 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
  8. ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  9. ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  10. ↑ 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
  11. ↑ Stauffer WM, Konop RJ, Kamat D. Traveling with infants and young children. Part III: travelers’ diarrhea. J Travel Med. 2002;9:141–50


See Also

External Links

References

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