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Current Infectious Disease Reports

, Volume 4, Issue 1, pp 70–77 | Cite as

Update on traveler’s diarrhea

  • Allen C. Cheng
  • Nathan M. Thielman
Article

Abstract

Diarrhea is one of the most common health problems among travelers. Although enterotoxigenic Escherichia coli is implicated most commonly, enteroaggregative E. coli has recently been described as a major pathogen. Shigella, Campylobacter, and Salmonella organisms are less common causes of acute diarrhea, and intestinal protozoa are typical causes of protracted diarrhea. Although education is the mainstay of prevention measures, behavior modification has been shown to be difficult. Chemoprevention is rarely required with the availability of effective treatment, but there has been some interest in the use of vaccines. Maintenance of hydration is most important in children. In addition to bismuth preparations and loperamide, newer agents being developed for symptomatic relief include zaldaride maleate and racecadotril. Fluoroquinolones effectively treat severe traveler’s diarrhea, and even a single dose may be sufficient. However, with the emergence of resistance, particularly in Campylobacter infection, other agents are required; interest has focused on azithromycin and rifaximin.

Keywords

Azithromycin Norfloxacin Loperamide Rifaximin Fleroxacin 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References and Recommended Reading

  1. 1.
    Steffen R, Collard F, Tornieporth N, et al.: Epidemiology, etiology, and impact of traveler’s diarrhea in Jamaica. JAMA 1999, 281:811–817. A large epidemiologic investigation based on questionnaire results from over 30,000 short-term visitors and over 300 ill hotel guests.PubMedCrossRefGoogle Scholar
  2. 2.
    Hill DR: Occurrence and self-treatment of diarrhea in a large cohort of Americans traveling to developing countries. Am J Trop Med Hyg 2000, 62:585–589.PubMedGoogle Scholar
  3. 3.
    DuPont HL, Ericsson CD: Prevention and treatment of traveler’s diarrhea. N Engl J Med 1993, 328:1821–1827.PubMedCrossRefGoogle Scholar
  4. 4.
    Steffen R, van der Linde F, Gyr K, Schar M: Epidemiology of diarrhea in travelers. JAMA 1983, 249:1176–1180.PubMedCrossRefGoogle Scholar
  5. 5.
    Thielman NM, Guerrant RL: Persistent diarrhea in the returned traveler. Infect Dis Clin North Am 1998, 12:489–501.PubMedCrossRefGoogle Scholar
  6. 6.
    Okhuysen PC: Traveler’s diarrhea due to intestinal protozoa. Clin Infect Dis 2001, 33:110–114.PubMedCrossRefGoogle Scholar
  7. 7.
    Gorbach SL: Travellers’ diarrhea. N Engl J Med 1982, 307:881–883.PubMedCrossRefGoogle Scholar
  8. 8.
    Hoge CW, Shlim DR, Echeverria P, Rajah R, et al.: Epidemiology of diarrhea among expatriate residents living in a highly endemic environment. JAMA 1996, 275:533–538.PubMedCrossRefGoogle Scholar
  9. 9.
    Herwaldt BL, de Arroyave KR, Roberts JM, Juranek DD: A multiyear prospective study of the risk factors for and incidence of diarrheal illness in a cohort of Peace Corps volunteers in Guatemala. Ann Intern Med 2000, 132:982–988. Includes detailed anaylsis of prospectively collected dietary data over 2 years.PubMedGoogle Scholar
  10. 10.
    Shlim DR, Hoge CW, Rajah R, et al.: Persistent high risk of diarrhea among foreigners in Nepal during the first 2 years of residence. Clin Infect Dis 1999, 29:613–616.PubMedGoogle Scholar
  11. 11.
    Ansdell VE, Ericsson CD: Prevention and empiric treatment of traveler’s diarrhea. Med Clin North Am 1999, 83:945–973. Updated review by an authority in the field, including extensive section on preventive measures and risk reduction.PubMedGoogle Scholar
  12. 12.
    Jiang ZD, Mathewson JJ, Ericsson CD, et al.: Characterization of enterotoxigenic Escherichia coli strains in patients with travelers’ diarrhea acquired in Guadalajara, Mexico, 1992–1997. J Infect Dis 2000, 181:779–782.PubMedCrossRefGoogle Scholar
  13. 13.
    Mathewson JJ, Johnson PC, DuPont HL, et al.: A newly recognized cause of travelers’ diarrhea: enteroadherent Escherichia coli. J Infect Dis 1985, 151:471–475.PubMedGoogle Scholar
  14. 14.
    Adachi JA, Jiang ZD, Mathewson JJ, et al.: Enteroaggregative Escherichia coli as a major etiologic agent in traveler’s diarrhea in 3 regions of the world. Clin Infect Dis 2001, 32:1706–1709. Large series describing the prevelance of EAEC in travelers with diarrhea from three geographically distinct regions.PubMedCrossRefGoogle Scholar
  15. 15.
    Glandt M, Adachi JA, Mathewson JJ, et al.: Enteroaggregative Escherichia coli as a cause of traveler’s diarrhea: clinical response to ciprofloxacin. Clin Infect Dis 1999, 29:335–338.PubMedGoogle Scholar
  16. 16.
    Gascon J, Vargas M, Quinto L, et al.: Enteroaggregative Escherichia coli strains as a cause of traveler’s diarrhea: a case-control study. J Infect Dis 1998, 177:1409–1412.PubMedGoogle Scholar
  17. 17.
    Steiner TS, Nataro JP, Poteet-Smith CE, et al.: Enteroaggregative Escherichia coli expresses a novel flagellin that causes IL-8 release from intestinal epithelial cells. J Clin Invest 2000, 105:1769–1777.PubMedCrossRefGoogle Scholar
  18. 18.
    Walz SE, Baqar S, Beecham HJ, et al.: Pre-exposure anti-Campylobacter jejuni immunoglobulin a levels associated with reduced risk of Campylobacter diarrhea in adults traveling to Thailand. Am J Trop Med Hyg 2001, 65:652–656.PubMedGoogle Scholar
  19. 19.
    Muller A, Bialek R, Kamper A, et al.: Detection of microsporidia in travelers with diarrhea. J Clin Microbiol 2001, 39:1630–1632.PubMedCrossRefGoogle Scholar
  20. 20.
    Kozicki M, Steffen R, Schar M: ’Boil it, cook it, peel it or forget it’: does this rule prevent travellers’ diarrhoea? Int J Epidemiol 1985, 14:169–172.PubMedCrossRefGoogle Scholar
  21. 21.
    Blaser MJ: Environmental interventions for the prevention travelers’ diarrhea. Rev Infect Dis 1986, 8(Suppl 2):S142-S150.PubMedGoogle Scholar
  22. 22.
    DuPont HL, Sullivan P, Evans DG, et al.: Prevention of traveler’s diarrhea (emporiatric enteritis). Prophylactic administration of subsalicylate bismuth). JAMA 1980, 243:237–241.PubMedCrossRefGoogle Scholar
  23. 23.
    Steffen R, DuPont HL, Heusser R, Helminger A, et al.: Prevention of traveler’s diarrhea by the tablet form of bismuth subsalicylate. Antimicrob Agents Chemother 1986, 29:625–627.PubMedGoogle Scholar
  24. 24.
    DuPont HL, Ericsson CD, Johnson PC, et al.: Prevention of travelers’ diarrhea by the tablet formulation of bismuth subsalicylate. JAMA 1987, 257:1347–1350.PubMedCrossRefGoogle Scholar
  25. 25.
    de dios Pozo-Olano J, Warram JH Jr, Gomez RG, Cavazos MG: Effect of a lactobacilli preparation on traveler’s diarrhea. A randomized, double blind clinical trial. Gastroenterology 1978, 74:829–830.Google Scholar
  26. 26.
    Hilton E, Kolakowski P, Singer C, Smith M: Efficacy of Lactobacillus GG as a diarrheal preventive in travelers. J Travel Med 1997, 4:41–43.PubMedCrossRefGoogle Scholar
  27. 27.
    Oksanen PJ, Salminen S, Saxelin M, et al.: Prevention of travellers’ diarrhoea by Lactobacillus GG. Ann Med 1990, 22:53–56.PubMedGoogle Scholar
  28. 28.
    Freedman DJ, Tacket CO, Delehanty A, et al.: Milk immunoglobulin with specific activity against purified colonization factor antigens can protect against oral challenge with enterotoxigenic Escherichia coli. J Infect Dis 1998, 177:662–667.PubMedCrossRefGoogle Scholar
  29. 29.
    Peltola H, Siitonen A, Kyronseppa H, et al.: Prevention of travellers’ diarrhoea by oral B-subunit/whole-cell cholera vaccine. Lancet 1991, 338:1285–289.PubMedCrossRefGoogle Scholar
  30. 30.
    Scerpella EG, Sanchez JL, Mathewson IJ, et al.: Safety, immunogenicity, and protective efficacy of the whole-cell/ recombinant B subunit (WC/rBS) oral cholera vaccine against travelers’ diarrhea. J Travel Med 1995, 2:22–27.PubMedCrossRefGoogle Scholar
  31. 31.
    Turner AK, Terry TD, Sack DA, et al.: Construction and characterization of genetically defined aro omp mutants of enterotoxigenic Escherichia coli and preliminary studies of safety and immunogenicity in humans. Infect Immun 2001, 69:4969–4979.PubMedCrossRefGoogle Scholar
  32. 32.
    Ryan ET, Calderwood SB: Cholera vaccines. Clin Infect Dis 2000, 31:561–565.PubMedCrossRefGoogle Scholar
  33. 33.
    Centers for Disease Control and Prevention: Health Information for the International Traveler 2001–2002. Atlanta: US Department of Health and Human Services, Public Health Service; 2001.Google Scholar
  34. 34.
    Guerrant RL, Van Gilder T, Steiner TS, et al.: Practice guidelines for the management of infectious diarrhea. Clin Infect Dis 2001, 32:331–351. Comprehensive guidelines for investigation and management of infectious diarrhea in general.PubMedCrossRefGoogle Scholar
  35. 35.
    Adachi JA, Ostrosky-Zeichner L, DuPont HL, Ericsson CD: Empirical antimicrobial therapy for traveler’s diarrhea. Clin Infect Dis 2000, 31:1079–1083. Most recent guidelines, including a suggested treatment algorithm the managment of traveler’s diarrhea.PubMedCrossRefGoogle Scholar
  36. 36.
    DuPont HL, Hornick RB: Adverse effect of lomotil therapy shigellosis. JAMA 1973, 226:1525–1528.PubMedCrossRefGoogle Scholar
  37. 37.
    Taylor DN, Sanchez JL, Candler W, et al.: Treatment of travelers’ diarrhea: ciprofloxacin plus loperamide compared with ciprofloxacin alone. A placebo-controlled, randomized trial. Ann Intern Med 1991, 114:731–734.PubMedGoogle Scholar
  38. 38.
    Petruccelli BP, Murphy GS, Sanchez JL, et al.: Treatment of traveler’s diarrhea with ciprofloxacin and loperamide. J Infect Dis 1992, 165:557–560.PubMedGoogle Scholar
  39. 39.
    DuPont HL, Ericsson CD, DuPont MW, et al.: A randomized, open-label comparison of nonprescription loperamide and attapulgite in the symptomatic treatment of acute diarrhea. Am J Med 1990, 88:20S-23S.PubMedCrossRefGoogle Scholar
  40. 40.
    DuPont HL, Ericsson CD, Mathewson JJ, et al.: Zaldaride maleate, an intestinal calmodulin inhibitor, in the therapy travelers’ diarrhea. Gastroenterology 1993, 104:709–715.PubMedGoogle Scholar
  41. 41.
    Cezard JP, Duhamel JF, Meyer M, et al.: Efficacy and tolerability of racecadotril in acute diarrhea in children. Gastroenterology 2001, 120:799–805.PubMedCrossRefGoogle Scholar
  42. 42.
    Salazar-Lindo E, Santisteban-Ponce J, Chea-Woo E, Gutierrez M: Racecadotril in the treatment of acute watery diarrhea children. N Engl J Med 2000, 343:463–467.PubMedCrossRefGoogle Scholar
  43. 43.
    Ericsson CD: Travelers’ diarrhea. Epidemiology, prevention, and self-treatment. Infect Dis Clin North Am 1998, 12:285–303. Extensive review of prevention and self treatment.PubMedCrossRefGoogle Scholar
  44. 44.
    De Bruyn G, Hahn S, Borwick A: Antibiotic treatment for travellers’ diarrhoea. Cochrane Database Syst Rev 2000, CD002242. Thorough review of clinical trials evaluating antibiotics for traveler’s diarrhea.Google Scholar
  45. 45.
    Ericsson CD, Johnson PC, Dupont HL, et al.: Ciprofloxacin or trimethoprim-sulfamethoxazole as initial therapy for travelers’ diarrhea. A placebo-controlled, randomized trial. Ann Intern Med 1987, 106:216–220.PubMedGoogle Scholar
  46. 46.
    Thornton SA, Wignall SF, Kilpatrick ME, et al.: Norfloxacin compared to trimethoprim/sulfamethoxazole for the treatment of travelers’ diarrhea among U.S. military personnel deployed to South America and West Africa. Mil Med 1992, 157:55–58.PubMedGoogle Scholar
  47. 47.
    Mattila L, Peltola H, Siitonen A, et al.: Short-term treatment of traveler’s diarrhea with norfloxacin: a double-blind, placebocontrolled study during two seasons. Clin Infect Dis 1993, 17:779–782.PubMedGoogle Scholar
  48. 48.
    DuPont HL, Ericsson CD, Mathewson JJ, DuPont MW: Five versus three days of ofloxacin therapy for traveler’s diarrhea: a placebo-controlled study. Antimicrob Agents Chemother 1992, 36:87–91.PubMedGoogle Scholar
  49. 49.
    Ericsson CD, DuPont HL, Mathewson JJ: Single dose ofloxacin plus loperamide compared with single dose or three days of ofloxacin in the treatment of traveler’s diarrhea. J Travel Med 1997, 4:3–7.PubMedCrossRefGoogle Scholar
  50. 50.
    Hoge CW, Gambel JM, Srijan A, et al.: Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years. Clin Infect Dis 1998, 26:341–345. Describes high rates of resistance to many antibiotics in pathogens in Thailand.PubMedGoogle Scholar
  51. 51.
    Gomi H, Jiang ZD, Adachi JA, et al.: In vitro antimicrobial susceptibility testing of bacterial enteropathogens causing traveler’s diarrhea in four geographic regions. Antimicrob Agents Chemother 2001, 45:212–216. Survey of antimicrobial susceptibilities in pathogens in India, Jamaica, Mexico, and Kenya.PubMedCrossRefGoogle Scholar
  52. 52.
    Kuschner RA, Trofa AF, Thomas RJ, et al.: Use of azithromycin for the treatment of Campylobacter enteritis in travelers to Thailand, an area where ciprofloxacin resistance is prevalent. Clin Infect Dis 1995, 21:536–541.PubMedGoogle Scholar
  53. 53.
    Jiang ZD, Ke S, Palazzini E, et al.: In vitro activity and fecal concentration of rifaximin after oral administration. Antimicrob Agents Chemother 2000, 44:2205–2206.PubMedCrossRefGoogle Scholar
  54. 54.
    DuPont HL, Reves RR, Galindo E, et al.: Treatment of travelers’ diarrhea with trimethoprim/sulfamethoxazole and with trimethoprim alone. N Engl J Med 1982, 307:841–844.PubMedCrossRefGoogle Scholar
  55. 55.
    Ericsson CD, DuPont HL, Galindo E, et al.: Efficacy of bicozamycin in preventing traveler’s diarrhea. Gastroenterology 1985, 88:473–477.PubMedGoogle Scholar
  56. 56.
    Salam I, Katelaris P, Leigh-Smith S, Farthing MJ: Randomised trial of single-dose ciprofloxacin for travellers’ diarrhoea. Lancet 1994, 344:1537–1539.PubMedCrossRefGoogle Scholar
  57. 57.
    Steffen R, Jori R, DuPont HL, et al.: Efficacy and toxicity of fleroxacin in the treatment of travelers’ diarrhea. Am J Med 1993, 94:182S-186S.PubMedGoogle Scholar
  58. 58.
    Wistrom J, Jertborn M, Hedstrom SA, et al.: Short-term self-treatment of travellers’ diarrhoea with norfloxacin: a placebo-controlled study. J Antimicrob Chemother 1989, 23:905–913.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2002

Authors and Affiliations

  • Allen C. Cheng
    • 1
  • Nathan M. Thielman
    • 1
  1. 1.Duke South, Division of Infectious DiseasesDuke University Medical CenterDurhamUSA

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