Traveler's diarrhea: Difference between revisions
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==Background== | ==Background== | ||
*Most respond to antibiotics | *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<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> | |||
*At risk populations- Immunosuppressed, diabetes, taking meds to suppress acid production | |||
*Greatest contributor to illness poor hygiene in restaurants <ref> http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/travelers-diarrhea</ref> | |||
===Etiology<ref name="Steffen"></ref>=== | |||
{| class="wikitable" | |||
| align="center" style="background:#f0f0f0;"|'''Organism''' | |||
| align="center" style="background:#f0f0f0;"|'''Latin America and Caribbean''' | |||
| align="center" style="background:#f0f0f0;"|'''Africa''' | |||
| align="center" style="background:#f0f0f0;"|'''South Asia''' | |||
| align="center" style="background:#f0f0f0;"|'''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<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 | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Template:Diarrhea DDX}} | {{Template:Diarrhea DDX}} | ||
== | ==Evaluation<ref name="Steffen"></ref>== | ||
===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 follow-up) | |||
**Stool culture (including [[Salmonella]], [[Shigella]], and [[Campylobacter]]) | |||
**Stool O&P (including testing for protozoal parasites, [[Giardia]], [[Cryptosporidium]]) | |||
**Fecal leukocytes, giardia antigen, C. difficile PCR | |||
==Management== | |||
*Consider [[ondansteron]] if [[nausea]] | |||
*Consider [[IVF]] if dehydrated | |||
*Consider [[loperamide]] 4mg PO 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) | |||
== | ===[[Antibiotics]]<ref name="Steffen"></ref>=== | ||
{{Travelers Diarrhea Antibiotics}} | {{Travelers Diarrhea Antibiotics}} | ||
===Pediatrics=== | ===Pediatrics=== | ||
'''Antibiotic Options:''' | '''Antibiotic Options:''' | ||
{{Travelers Diarrhea Pediatric Antibiotics}} | {{Travelers Diarrhea Pediatric Antibiotics}} | ||
==Disposition== | |||
*Outpatient for the vast majority | |||
*Consider admission if systemic toxicity | |||
==Complications== | |||
*[[Postinfectious irritable bowel syndrome]] | |||
*[[Reactive arthritis]] | |||
*[[Guillain-Barre syndrome]] | |||
==See Also== | ==See Also== | ||
Line 32: | Line 92: | ||
*[[Travel Medicine]] | *[[Travel Medicine]] | ||
== | ==External Links== | ||
[http://wwwnc.cdc.gov/travel/page/travelers-diarrhea CDC - Travelers Diarrhea] | |||
==References== | |||
<references/> | |||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:ID]] | [[Category:ID]] | ||
[[Category: | [[Category:Tropical Medicine]] |
Revision as of 15:05, 14 April 2019
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]
- At risk populations- Immunosuppressed, diabetes, taking meds to suppress acid production
- Greatest contributor to illness poor hygiene in restaurants [2]
Etiology[1]
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[1]
- 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
Differential Diagnosis
Acute diarrhea
Infectious
- Viral (e.g. rotavirus)
- Bacterial
- Campylobacter
- Shigella
- Salmonella (non-typhi)
- Escherichia coli
- E. coli 0157:H7
- Yersinia enterocolitica
- Vibrio cholerae
- Clostridium difficile
- Parasitic
- Toxin
Noninfectious
- GI Bleed
- Appendicitis
- Mesenteric Ischemia
- Diverticulitis
- Adrenal Crisis
- Thyroid Storm
- Toxicologic exposures
- Antibiotic or drug-associated
Watery Diarrhea
- Enterotoxigenic E. coli (most common cause of watery diarrhea)[3]
- Norovirus (often has prominent vomiting)
- Campylobacter
- Non-typhoidal Salmonella
- Enteroaggregative E. coli (EAEC)
- Enterotoxigenic Bacteroides fragilis
Traveler's Diarrhea
Evaluation[1]
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 follow-up)
- Stool culture (including Salmonella, Shigella, and Campylobacter)
- Stool O&P (including testing for protozoal parasites, Giardia, Cryptosporidium)
- Fecal leukocytes, giardia antigen, C. difficile PCR
Management
- Consider ondansteron if nausea
- Consider IVF if dehydrated
- Consider loperamide 4mg PO after each loose stool (Max: 16mg/day)[1]
- 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)
- If very frequent stools and no contra-indication:
Antibiotics[1]
- 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]
- Rifaximin 200mg PO TID x 3 days[9]
- Ineffective against mucosally invasive pathogens (Shigella, Salmonella, Campylobacter)
- Considered very safe as it is not absorbed
Pediatrics
Antibiotic Options:
- Avoid fluroquinolones
- Azithromycin 10mg/kg/day once daily x 3 days OR[10]
- Ceftriaxone 50mg/kg/day once daily x 3 days
Disposition
- Outpatient for the vast majority
- Consider admission if systemic toxicity
Complications
See Also
External Links
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
- ↑ http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/travelers-diarrhea
- ↑ Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
- ↑ Hoge CW. et al. Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years. Clin Infect Dis. 1998;26:341–5
- ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
- ↑ 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
- ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
- ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
- ↑ 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
- ↑ Stauffer WM, Konop RJ, Kamat D. Traveling with infants and young children. Part III: travelers’ diarrhea. J Travel Med. 2002;9:141–50