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
*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>
*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.
*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>
*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>===
===Etiology<ref name="Steffen"></ref>===
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*Travel
*Travel
*3 or more unformed stools per 24 hours
*3 or more unformed stools per 24 hours
*plus (at least 1 of the following):
*Plus (at least 1 of the following):
**abdominal cramps
**Abdominal cramps
**tenesmus
**Tenesmus
**[[nausea]]
**[[Nausea]]
**[[vomiting]]
**[[Vomiting]]
**[[fever]]
**[[Fever]]
**fecal urgency
**Fecal urgency


;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
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{{Template:Diarrhea DDX}}
{{Template:Diarrhea DDX}}


==Diagnosis<ref name="Steffen"></ref>==
==Evaluation<ref name="Steffen"></ref>==
===Uncomplicated Diarrhea===
===Uncomplicated Diarrhea===
*No workup
*No workup
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===Persistent or Refractory Diarrhea (>14 days)===
===Persistent or Refractory Diarrhea (>14 days)===
*Typically not done in the ER (at followup)
*Typically not done in the ER (at follow-up)
**Stool culture (including [[Salmonella]], [[Shigella]], and [[Campylobacter]])
**Stool culture (including [[Salmonella]], [[Shigella]], and [[Campylobacter]])
**Stool O&P (including testing for protozoal parasites, [[Giardia]], [[Cryptosporidium]])
**Stool O&P (including testing for protozoal parasites, [[Giardia]], [[Cryptosporidium]])
**Fecal leukocytes, giardia antigen, C. difficile PCR


==Treatment==
==Management==
*Consider [[ondansteron]] if [[nausea]]
*Consider [[ondansteron]] if [[nausea]]
*Consider [[IVF]] if dehydrated
*Consider [[IVF]] if dehydrated
*Consider [[loperamide]] 4mg PO after each loose stool (Max: 16mg/day)<ref name="Steffen"></ref>
*Consider [[loperamide]] 4mg PO after each loose stool (Max: 16mg/day)<ref name="Steffen"></ref>
**if very frequent stools and no contra-indication:
**If very frequent stools and no contra-indication:
***Not pregnant
***Not pregnant
***>2 years old
***>2 years old
***[[fever]] or bloody stools without concomitant antibiotics (don't use as sole therapy)
***[[Fever]] or bloody stools without concomitant antibiotics (do not use as sole therapy)


===[[Antibiotics]]<ref name="Steffen"></ref>===
===[[Antibiotics]]<ref name="Steffen"></ref>===
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==Disposition==
==Disposition==
*Outpatient, for the vast majority
*Outpatient for the vast majority
*If systemic toxicity, consider admission
*Consider admission if systemic toxicity


==Complications==
==Complications==
*[[Postinfectious irritable bowel syndrome]]
*[[Postinfectious irritable bowel syndrome]]
*[[Reactive arthritis]]
*[[Reactive arthritis]]
*[[Guillain-Barré syndrome]]
*[[Guillain-Barre syndrome]]


==See Also==
==See Also==
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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:Tropical Medicine]]
[[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

Noninfectious

Watery Diarrhea

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)

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)

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]
    • 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
  • Consider admission if systemic toxicity

Complications

See Also

External Links

CDC - Travelers Diarrhea

References

  1. 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
  2. http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/travelers-diarrhea
  3. Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
  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