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• Traveler's diarrhea

Traveler's diarrhea may get better without any treatment. But while you're waiting, it's important to try to stay hydrated with safe liquids, such as bottled water or water with electrolytes such as an oral rehydration solution (see below). If you don't seem to be improving quickly, several medicines are available to help relieve symptoms.

Anti-motility agents. These medicines — which include loperamide and drugs containing diphenoxylate — provide prompt but temporary relief by:

• Reducing muscle spasms in your gastrointestinal tract.
• Slowing the transit time through your digestive system.
• Allowing more time for absorption.

Anti-motility medicines aren't recommended for infants or people with a fever or bloody diarrhea. This is because they can delay clearance of the infectious organisms and make the illness worse.

Also, stop using anti-motility agents after 48 hours if you have stomach pain or if your symptoms worsen and your diarrhea continues. In such cases, see a doctor. You may need blood or stool tests and treatment with an antibiotic.

• Bismuth subsalicylate. This nonprescription medicine can decrease the frequency of your stools and shorten the length of your illness. However, it isn't recommended for children, pregnant women or people who are allergic to aspirin.
• Antibiotics. If you have more than four loose stools a day or severe symptoms, including a fever or blood, pus or mucus in your stools, a doctor may prescribe a course of antibiotics.

Before you leave for your trip, talk to your doctor about taking a prescription with you in case you get a serious bout of traveler's diarrhea.

Avoiding dehydration

Dehydration is the most likely complication of traveler's diarrhea, so it's important to try to stay well hydrated.

An oral rehydration salts (ORS) solution is the best way to replace lost fluids. These solutions contain water and salts in specific proportions to replenish both fluids and electrolytes. They also contain glucose to enhance absorption in the intestinal tract.

Bottled oral rehydration products are available in drugstores in developed areas, and many pharmacies carry their own brands. You can find packets of powdered oral rehydration salts, labeled World Health Organization (WHO)- ORS , at stores, pharmacies and health agencies in most countries. Reconstitute the powder in bottled or boiled water according to the directions on the package.

If these products are unavailable, you can prepare your own rehydrating solution in an emergency by mixing together:

• 3/4 teaspoon table salt.
• 2 tablespoons sugar.
• 1 quart uncontaminated bottled or boiled water.
• Sugar-free flavor powder, such as Crystal Light (optional).

You or your child can drink the solution in small amounts throughout the day as a supplement to solid foods or formula, as long as dehydration persists. Small amounts reduce the likelihood of vomiting. Breastfed infants also can drink the solution but should continue nursing on demand.

If dehydration symptoms — such as dry mouth, intense thirst, little or no urination, dizziness, or extreme weakness — don't improve, seek medical care right away. Oral rehydration solutions are intended only for urgent short-term use.

Lifestyle and home remedies

If you do get traveler's diarrhea, avoid caffeine, alcohol and dairy products, which may worsen symptoms or increase fluid loss. But keep drinking fluids.

Drink canned fruit juices, weak tea, clear soup, decaffeinated soda or sports drinks to replace lost fluids and minerals. Later, as your diarrhea improves, try a diet of easy-to-eat complex carbohydrates, such as salted crackers, bland cereals, bananas, applesauce, dry toast or bread, rice, potatoes, and plain noodles.

You may return to your normal diet as you feel you can tolerate it. Add dairy products, caffeinated beverages and high-fiber foods cautiously.

Preparing for your appointment

Call a doctor if you have diarrhea that is severe, lasts more than a few days or is bloody. If you are traveling, call an embassy or consulate for help locating a doctor. Other signs that you should seek medical attention include:

• A fever of 102 F (39 C) or higher.
• Ongoing vomiting.
• Signs of severe dehydration, including a dry mouth, muscle cramps, decreased urine output, dizziness or fatigue.

If you have diarrhea and you've just returned home from a trip abroad, share that trip information with your doctor when you call to make an appointment.

Here's some information to help you get ready, and what to expect.

Information to gather in advance

• Pre-appointment instructions. At the time you make your appointment, ask whether there are immediate self-care steps you can take to help recover more quickly.
• Symptom history. Write down any symptoms you've been experiencing and for how long.
• Medical history. Make a list of your key medical information, including other conditions for which you're being treated and any medicines, vitamins or supplements you're currently taking.
• Questions to ask your health care professional. Write down your questions in advance so that you can make the most of your time.

The list below suggests questions to ask about traveler's diarrhea.

• What's causing my symptoms?
• Are there any other possible causes for my symptoms?
• What kinds of tests do I need?
• What treatment approach do you recommend?
• Are there any possible side effects from the medicines I'll be taking?
• Will my diarrhea or its treatment affect the other health conditions I have? How can I best manage these conditions together?
• What is the safest way for me to rehydrate?
• Do I need to follow any dietary restrictions and for how long?
• How soon after I begin treatment will I start to feel better?
• How long do you expect a full recovery to take?
• Am I contagious? How can I reduce my risk of passing my illness to others?
• What can I do to reduce my risk of this condition in the future?

In addition to the questions that you've prepared, don't hesitate to ask questions as they occur to you during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to talk about in-depth. Your doctor may ask:

• What are your symptoms?
• When did you first begin experiencing symptoms?
• Have you traveled recently?
• Where did you travel?
• Have you taken any antibiotics recently?
• Have your symptoms been getting better or worse?
• Have you noticed any blood in your stools?
• Have you experienced symptoms of dehydration, such as muscle cramps or fatigue?
• What treatments have you tried so far, if any?
• Have you been able to keep down any food or liquid?
• Are you pregnant?
• Are you being treated for any other medical conditions?
• Feldman M, et al., eds. Infectious enteritis and proctocolitis. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 11th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 25, 2021.
• LaRocque R, et al. Travelers' diarrhea: Microbiology, epidemiology, and prevention. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
• Ferri FF. Traveler diarrhea. In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed April 28, 2023.
• Diarrhea. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/diarrhea. Accessed April 27, 2023.
• Travelers' diarrhea. Centers for Disease Control and Prevention. https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/travelers-diarrhea. Accessed April 28, 2023.
• LaRocque R, et al. Travelers' diarrhea: Clinical manifestations, diagnosis, and treatment. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
• Khanna S (expert opinion). Mayo Clinic. May 29, 2021.

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INTRODUCTION

The treatment and prevention of travelers' diarrhea are discussed here. The epidemiology, microbiology, clinical manifestations, and diagnosis of travelers' diarrhea are discussed separately. (See "Travelers' diarrhea: Epidemiology, microbiology, clinical manifestations, and diagnosis" .)

Clinical approach  —  Management of travelers’ diarrhea depends on the severity of illness. Fluid replacement is an essential component of treatment for all cases of travelers’ diarrhea. Most cases are self-limited and resolve on their own within three to five days of treatment with fluid replacement only. Antimotility agents can provide symptomatic relief but should not be used when bloody diarrhea is present. Antimicrobial therapy shortens the disease duration, but the benefit of antibiotics must be weighed against potential risks, including adverse effects and selection for resistant bacteria. These issues are discussed in the sections that follow.

When to seek care  —  Travelers from resource-rich settings who develop diarrhea while traveling to resource-limited settings generally can treat themselves rather than seek medical advice while traveling. However, medical evaluation may be warranted in patients who develop high fever, abdominal pain, bloody diarrhea, or vomiting. Otherwise, for most patients while traveling or after returning home, medical consultation is generally not warranted unless symptoms persist for 10 to 14 days.

Fluid replacement  —  The primary and most important treatment of travelers' (or any other) diarrhea is fluid replacement, since the most significant complication of diarrhea is volume depletion [ 11,12 ]. The approach to fluid replacement depends on the severity of the diarrhea and volume depletion. Travelers can use the amount of urine passed as a general guide to their level of volume depletion. If they are urinating regularly, even if the color is dark yellow, the diarrhea and volume depletion are likely mild. If there is a paucity of urine and that small amount is dark yellow, the diarrhea and volume depletion are likely more severe.

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Traveler's Diarrhea

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Traveler's Diarrhea

• Conditions Basics

What is traveler's diarrhea?

Traveler's diarrhea is a common medical problem for people traveling from developed, industrialized countries to developing areas of the world.

High-risk areas for traveler's diarrhea include developing countries in Africa, Asia, the Middle East, and Latin America. Low-risk areas include the developed countries of North America, Central Europe, Australia, and Japan.

What causes it?

Traveler's diarrhea is usually caused by a bacterial infection. Bacteria such as Escherichia coli (E. coli) , Campylobacter , Shigella , or Salmonella are the most common causes. These bacteria are in water contaminated by human or animal stools. Drinking water, water used to wash food, or irrigation water may be affected. When the traveler drinks this water or eats contaminated food, he or she is likely to get diarrhea.

Common sources of bacteria that cause diarrhea are undercooked or raw foods, contaminated food, or contaminated water (including ice cubes).

What are the symptoms?

Traveler's diarrhea can be mild to severe. Most people who develop traveler's diarrhea experience symptoms within the first 2 weeks, and often within 2 to 3 days, of arriving in a developing area. Symptoms include:

• Abdominal cramps.
• Mild to severe dehydration .
• General lack of energy, nausea, and vomiting.
• Fever, vomiting, and stools with blood or mucus. These symptoms mean you have serious diarrhea, which is more likely to lead to problems with dehydration. Dehydration may alter the effect of any medicines being taken, such as oral contraceptives or antimalarials.

How is traveler's diarrhea treated?

Treatment for traveler's diarrhea includes drinking fluids to avoid dehydration, taking nonprescription medicines, and in some cases, antibiotics and intravenous (I.V.) fluids.

• Take frequent, small sips of bottled or boiled water or a rehydration drink .
• If possible, drink a solution made with World Health Organization (WHO) oral rehydration salts. Packets of the salts are available at stores and pharmacies in most developing countries. Add one packet to boiled or treated water, making sure to read the instructions regarding the proper amounts of salts and water. Drink the solution within 12 hours if kept at room temperature, or within 24 hours if refrigerated.
• Let your stomach rest. Start to eat small amounts of mild foods if you feel like it. After your diarrhea is gone, you may eat a regular diet again.

Children 2 years old or younger are at high risk of dehydration from diarrhea. If your child has diarrhea:

• Give your child a solution of WHO rehydration salts in addition to your child's regular food as long as diarrhea continues. If your baby has trouble keeping the liquids down, try giving frequent sips by spoon.
• Continue breastfeeding normally. Bottle-fed babies should continue their usual formula.
• Feed your child starches, cereals, yogurt, fruits, and vegetables.
• Seek medical help immediately if you or your child has bloody diarrhea, fever, or persistent vomiting, and give rehydration fluids in the meantime.
• Your doctor may recommend an over-the-counter medicine. These may include bismuth subsalicylate (Pepto-Bismol) or loperamide (Imodium). Read and follow all instructions on the label. Do not use these medicines if your doctor does not recommend them.
• Be safe with medicines. If your doctor recommends prescription medicine, take it as prescribed. Call your doctor if you think you are having a problem with your medicine. You will get more details on the specific medicines your doctor prescribes.
• If your doctor prescribes antibiotics, take them as directed. Do not stop taking them just because you feel better. You need to take the full course of antibiotics.

How can you help prevent it?

The best way to prevent traveler's diarrhea is to avoid food or water that may be contaminated. Eating raw or uncooked seafood and meat puts you at higher risk for getting sick. Also avoid foods like salads, uncooked vegetables, and raw fruits that don't have a peel. Dry foods, such as breads, or fruits that you can peel are safe to eat.

Avoid drinking local water where you are traveling. Beverages that are usually safe to drink include:

• Tea and coffee if made with boiled water.
• Carbonated bottled water or soda pop.
• Bottled beer and wine.

Water also can be filtered or treated with iodine to make it safe to drink.

Also, be aware that contaminated water may be used to wash fruits and vegetables, clean utensils and plates, and make ice cubes. Brushing your teeth with untreated water also may increase your risk of infection.

Avoid eating food from street vendors where flies can transmit bacteria and poor hygiene practices are more likely to contaminate foods. If you purchase food at an outdoor market, make sure you boil it, cook it thoroughly, or peel it before you eat it.

Good hand-washing is important in preventing the spread of infectious diseases. Washing with treated water or using alcohol wipes or antibacterial gels to disinfect your hands are good ways to reduce your risk of getting an infectious disease.

Talk with your doctor about antibiotics you can carry with you on your trip and instructions on when to use them just in case you should develop diarrhea.

Other information sources

In the United States, the Centers for Disease Control and Prevention (CDC) maintains current information on infectious diseases around the world. Local health departments can access this information to help you determine what prevention measures-such as vaccines, antimalarial medicine, or supplies to treat water-are appropriate for the area of the world you are traveling to. The CDC website (www.cdc.gov/travel/default.aspx) also updates information for travelers.

Resources for medical care in a foreign country include embassies or consulates and major hotels. For English-speaking travelers, multinational corporations or credit card companies also may have referrals for local medical care in the foreign country.

• Related Information
• Diarrhea, Age 11 and Younger
• Diarrhea, Age 12 and Older
• Travel Health

Current as of: June 12, 2023

Author: Healthwise Staff Clinical Review Board All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.

Author: Healthwise Staff

Clinical Review Board All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.

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Travelers’ Diarrhea

Travelers’ diarrhea (TD) is the most predictable travel-related illness. Attack rates range from 30% to 70% of travelers, depending on the destination and season of travel. Traditionally, it was thought that TD could be prevented by following simple recommendations such as “boil it, cook it, peel it, or forget it,” but studies have found that people who follow these rules may still become ill. Poor hygiene practice in local restaurants is likely the largest contributor to the risk for TD.

TD is a clinical syndrome that can result from a variety of intestinal pathogens. Bacterial pathogens are the predominant risk, thought to account for up to 80%–90% of TD. Intestinal viruses may account for at least 5%–15% of illnesses, although multiplex molecular diagnostic assays increase their detection. Infections with protozoal pathogens are slower to manifest symptoms and collectively account for approximately 10% of diagnoses in longer-term travelers. What is commonly known as “food poisoning” involves the ingestion of preformed toxins in food. In this syndrome, vomiting and diarrhea may both be present, but symptoms usually resolve spontaneously within 12 hours.

Infectious Agents

Bacteria are the most common cause of TD. Overall, the most common pathogen identified is enterotoxigenic Escherichia coli , followed by Campylobacter jejuni, Shigella spp., and Salmonella spp. Enteroaggregative and other E. coli pathotypes are also commonly found in cases of TD. There is increasing discussion of Aeromonas spp., Plesiomonas spp., and newly recognized pathogens ( Acrobacter, Larobacter , enterotoxigenic Bacteroides fragilis ) as potential causes of TD as well. Viral diarrhea can be caused by a number of pathogens, including norovirus, rotavirus, and astrovirus.

Giardia is the main protozoal pathogen found in TD. Entamoeba histolytica is a relatively uncommon cause of TD, and Cryptosporidium is also relatively uncommon. The risk for Cyclospora is highly geographic and seasonal: the most well-known risks are in Nepal, Peru, Haiti, and Guatemala. Dientamoeba fragilis is a flagellate occasionally associated with diarrhea in travelers. Most of the individual pathogens are discussed in their own sections in Chapter 4, and diarrhea in returned travelers is discussed in Chapter 11.

Risk for Travelers

TD occurs equally in male and female travelers and is more common in young adult travelers than in older travelers. In short-term travelers, bouts of TD do not appear to protect against future attacks, and >1 episode of TD may occur during a single trip. A cohort of expatriates residing in Kathmandu, Nepal, experienced an average of 3.2 episodes of TD per person in their first year. In more temperate regions, there may be seasonal variations in diarrhea risk. In south Asia, for example, much higher TD attack rates are reported during the hot months preceding the monsoon.

In environments in warmer climates where large numbers of people do not have access to plumbing or latrines, the amount of stool contamination in the environment will be higher and more accessible to flies. Inadequate electrical capacity may lead to frequent blackouts or poorly functioning refrigeration, which can result in unsafe food storage and an increased risk for disease. Lack of safe water may lead to contaminated foods and drinks prepared with such water; inadequate water supply may lead to shortcuts in cleaning hands, surfaces, utensils, and foods such as fruits and vegetables. In addition, handwashing may not be a social norm and could be an extra expense; thus there may be no handwashing stations in food preparation areas. In destinations in which effective food handling courses have been provided, the risk for TD has been demonstrated to decrease. However, even in developed countries, pathogens such as Shigella sonnei have caused TD linked to handling and preparation of food in restaurants.

Clinical Presentation

Bacterial and viral TD presents with the sudden onset of bothersome symptoms that can range from mild cramps and urgent loose stools to severe abdominal pain, fever, vomiting, and bloody diarrhea, although with norovirus vomiting may be more prominent. Protozoal diarrhea, such as that caused by Giardia intestinalis or E. histolytica , generally has a more gradual onset of low-grade symptoms, with 2–5 loose stools per day. The incubation period between exposure and clinical presentation can be a clue to the etiology:

• Bacterial toxins generally cause symptoms within a few hours.
• Bacterial and viral pathogens have an incubation period of 6–72 hours.
• Protozoal pathogens generally have an incubation period of 1–2 weeks and rarely present in the first few days of travel. An exception can be Cyclospora cayetanensis , which can present quickly in areas of high risk.

Untreated bacterial diarrhea usually lasts 3–7 days. Viral diarrhea generally lasts 2–3 days. Protozoal diarrhea can persist for weeks to months without treatment. An acute bout of gastroenteritis can lead to persistent gastrointestinal symptoms, even in the absence of continued infection (see Chapter 11 , Persistent Diarrhea in Returned Travelers). This presentation is commonly referred to as postinfectious irritable bowel syndrome. Other postinfectious sequelae may include reactive arthritis and Guillain-Barré syndrome.

For travelers to high-risk areas, several approaches may be recommended that can reduce, but never completely eliminate, the risk for TD. These include following instructions regarding food and beverage selection, using agents other than antimicrobial drugs for prophylaxis, using prophylactic antibiotics, and carefully washing hands with soap where available. Carrying small containers of alcohol-based hand sanitizers (containing ≥60% alcohol) may make it easier for travelers to clean their hands before eating when handwashing is not possible. No vaccines are available for most pathogens that cause TD, but travelers should refer to the Cholera, Hepatitis A, and Typhoid & Paratyphoid Fever sections in Chapter 4 regarding vaccines that can prevent other foodborne or waterborne infections to which travelers are susceptible.

Food and Beverage Selection

Care in selecting food and beverages can minimize the risk for acquiring TD. See the Food & Water Precautions section in this chapter for CDC’s detailed food and beverage recommendations. Although food and water precautions continue to be recommended, travelers may not always be able to adhere to the advice. Furthermore, many of the factors that ensure food safety, such as restaurant hygiene, are out of the traveler’s control.

Nonantimicrobial Drugs for Prophylaxis

The primary agent studied for prevention of TD, other than antimicrobial drugs, is bismuth subsalicylate (BSS), which is the active ingredient in adult formulations of Pepto-Bismol and Kaopectate. Studies from Mexico have shown that this agent (taken daily as either 2 oz. of liquid or 2 chewable tablets 4 times per day) reduces the incidence of TD by approximately 50%. BSS commonly causes blackening of the tongue and stool and may cause nausea, constipation, and rarely tinnitus.

Travelers with aspirin allergy, renal insufficiency, and gout, and those taking anticoagulants, probenecid, or methotrexate should not take BSS. In travelers taking aspirin or salicylates for other reasons, the use of BSS may result in salicylate toxicity. BSS is not generally recommended for children aged <12 years; however, some clinicians use it off-label with caution to avoid administering BSS to children aged ≤18 years with viral infections, such as varicella or influenza, because of the risk for Reye syndrome. BSS is not recommended for children aged <3 years or pregnant women. Studies have not established the safety of BSS use for periods >3 weeks. Because of the number of tablets required and the inconvenient dosing, BSS is not commonly used as prophylaxis for TD.

The use of probiotics, such as Lactobacillus GG and Saccharomyces boulardii , has been studied in the prevention of TD in small numbers of people. Results are inconclusive, partially because standardized preparations of these bacteria are not reliably available. Studies are ongoing with prebiotics to prevent TD, but data are insufficient to recommend their use. There have been anecdotal reports of beneficial outcomes after using bovine colostrum as a daily prophylaxis agent for TD. However, commercially sold preparations of bovine colostrum are marketed as dietary supplements that are not Food and Drug Administration (FDA) approved for medical indications. Because no data from rigorous clinical trials demonstrate efficacy, there is insufficient information to recommend the use of bovine colostrum to prevent TD.

Prophylactic Antibiotics

Although prophylactic antibiotics can prevent some TD, the emergence of antimicrobial resistance has made the decision of how and when to use antibiotic prophylaxis for TD difficult. Controlled studies have shown that use of antibiotics reduces diarrhea attack rates by 90% or more. The prophylactic antibiotic of choice has changed over the past few decades as resistance patterns have evolved. Fluoroquinolones have been the most effective antibiotics for the prophylaxis and treatment of bacterial TD pathogens, but increasing resistance to these agents among Campylobacter and Shigella species globally limits their potential use. In addition fluoroquinolones are associated with tendinitis and an increased risk of Clostridioides difficile infection, and current guidelines discourage their use for prophylaxis. Alternative considerations include azithromycin, rifaximin, and rifamycin SV.

At this time, prophylactic antibiotics should not be recommended for most travelers. Prophylactic antibiotics afford no protection against nonbacterial pathogens and can remove normally protective microflora from the bowel, increasing the risk of infection with resistant bacterial pathogens. Travelers may become colonized with extended-spectrum β -lactamase (ESBL)–producing bacteria, and this risk is increased by exposure to antibiotics while abroad. Additionally, the use of antibiotics may be associated with allergic or adverse reactions, and prophylactic antibiotics limit the therapeutic options if TD occurs; a traveler relying on prophylactic antibiotics will need to carry an alternative antibiotic to use if severe diarrhea develops despite prophylaxis.

The risks associated with the use of prophylactic antibiotics should be weighed against the benefit of using prompt, early self-treatment with antibiotics when moderate to severe TD occurs, shortening the duration of illness to 6–24 hours in most cases. Prophylactic antibiotics may be considered for short-term travelers who are high-risk hosts (such as those who are immunosuppressed or with significant medical comorbidities) or those who are taking critical trips (such as engaging in a sporting event) without the opportunity for time off in the event of sickness.

Oral Rehydration Therapy

Fluids and electrolytes are lost during TD, and replenishment is important, especially in young children or adults with chronic medical illness. In adult travelers who are otherwise healthy, severe dehydration resulting from TD is unusual unless vomiting is prolonged. Nonetheless, replacement of fluid losses remains an adjunct to other therapy and helps the traveler feel better more quickly. Travelers should remember to use only beverages that are sealed, treated with chlorine, boiled, or are otherwise known to be purified.

For severe fluid loss, replacement is best accomplished with oral rehydration solution (ORS) prepared from packaged oral rehydration salts, such as those provided by the World Health Organization. ORS is widely available at stores and pharmacies in most developing countries. ORS is prepared by adding 1 packet to the indicated volume of boiled or treated water—generally 1 liter. Travelers may find most ORS formulations to be relatively unpalatable due to their saltiness. In mild cases, rehydration can be maintained with any palatable liquid (including sports drinks), although overly sweet drinks, such as sodas, can cause osmotic diarrhea if consumed in quantity.

Antimotility Agents

Antimotility agents provide symptomatic relief and are useful therapy in TD. Synthetic opiates, such as loperamide and diphenoxylate, can reduce frequency of bowel movements and therefore enable travelers to ride on an airplane or bus. Loperamide appears to have antisecretory properties as well. The safety of loperamide when used along with an antibiotic has been well established, even in cases of invasive pathogens; however, acquisition of ESBL-producing pathogens may be more common when loperamide and antibiotics are coadministered. Antimotility agents alone are not recommended for patients with bloody diarrhea or those who have diarrhea and fever. Loperamide can be used in children, and liquid formulations are available. In practice, however, these drugs are rarely given to small children (aged <6 years).

Antibiotics

Antibiotics are effective in reducing the duration of diarrhea by about a day in cases caused by bacterial pathogens that are susceptible to the particular antibiotic prescribed. However, there are concerns about adverse consequences of using antibiotics to treat TD. Travelers who take antibiotics may acquire resistant organisms such as ESBL-producing organisms, resulting in potential harm to travelers—particularly those who are immunosuppressed or women who may be prone to urinary tract infections—and the possibility of introducing these resistant bacteria into the community. In addition, there is concern about the effects of antibiotic use on travelers’ microbiota and the potential for adverse consequences such as Clostridioides difficile infection as a result. These concerns have to be weighed against the consequences of TD and the role of antibiotics in shortening the acute illness and possibly preventing postinfectious sequelae (see Chapter 11 , Persistent Diarrhea in Returned Travelers).

Primarily because of these concerns, an expert advisory panel was convened in 2016 to prepare consensus guidelines on the prevention and treatment of TD. A classification of TD using functional impact for defining severity (Box 2-3 ) was suggested rather than the frequency-based algorithm that has traditionally been used. The guidelines suggest an approach that matches therapeutic intervention with severity of illness, in terms of both safety and effectiveness (Table 2-10 ).

The effectiveness of a particular antimicrobial drug depends on the etiologic agent and its antibiotic sensitivity (Table 2-11 ). As empiric therapy or to treat a specific bacterial pathogen, first-line antibiotics have traditionally been the fluoroquinolones, such as ciprofloxacin or levofloxacin. Increasing microbial resistance to the fluoroquinolones, especially among Campylobacter isolates, may limit their usefulness in many destinations, particularly South and Southeast Asia, where both Campylobacter infection and fluoroquinolone resistance is prevalent. Increasing fluoroquinolone resistance has been reported from other destinations and in other bacterial pathogens, including in Shigella and Salmonella . In addition, the use of fluoroquinolones has been associated with tendinopathies and the development of C. difficile infection. FDA warns that the potentially serious side effects of fluoroquinolones may outweigh their benefit in treating uncomplicated respiratory and urinary tract infections; however, because of the short duration of therapy for TD, these side effects are not believed to be a significant risk.

A potential alternative to fluoroquinolones is azithromycin, although enteropathogens with decreased azithromycin susceptibility have been documented in several countries. Rifaximin has been approved to treat TD caused by noninvasive strains of E. coli . However, since it is often difficult for travelers to distinguish between invasive and noninvasive diarrhea, and since they would have to carry a backup drug in the event of invasive diarrhea, the overall usefulness of rifaximin as empiric self-treatment remains to be determined.

Single-dose regimens are equivalent to multidose regimens and may be more convenient for the traveler. Single-dose therapy with a fluoroquinolone is well established, both by clinical trials and clinical experience. The best regimen for azithromycin treatment may also be a single dose of 1,000 mg, but side effects (mainly nausea) may limit the acceptability of this large dose. Giving azithromycin as 2 divided doses on the same day may limit this adverse event.

Box 2-3. Travelers’ diarrhea definitions

Mild (acute): diarrhea that is tolerable, is not distressing, and does not interfere with planned activities.

Moderate (acute): diarrhea that is distressing or interferes with planned activities.

Severe (acute): diarrhea that is incapacitating or completely prevents planned activities; all dysentery is considered severe.

Treatment of TD Caused by Protozoa

The most common parasitic cause of TD is Giardia intestinalis , and treatment options include metronidazole, tinidazole, and nitazoxanide (see Chapter 4 , Giardiasis). Although cryptosporidiosis is usually a self-limited illness in immunocompetent people, nitazoxanide can be considered as a treatment option. Cyclosporiasis is treated with trimethoprim-sulfamethoxazole. Treatment of amebiasis is with metronidazole or tinidazole, followed by treatment with a luminal agent such as iodoquinol or paromomycin.

A new therapeutic option is rifamycin SV, which was approved by FDA in November 2018 to treat TD caused by noninvasive strains of E. coli in adults. Rifamycin SV is a nonabsorbable antibiotic in the ansamycin class of antibacterial drugs formulated with an enteric coating that targets delivery of the drug to the distal small bowel and colon. Two randomized clinical trials showed that rifamycin SV was superior to placebo and noninferior to ciprofloxacin in the treatment of TD.

Treatment for Children

Children who accompany their parents on trips to high-risk destinations can contract TD as well, with elevated risk if they are visiting friends and family. Causative organisms include bacteria responsible for TD in adults, as well as viruses including norovirus and rotavirus. The main treatment for TD in children is ORS. Infants and younger children with TD are at higher risk for dehydration, which is best prevented by the early initiation of oral rehydration. Empiric antibiotic therapy should be considered if there is bloody or severe watery diarrhea or evidence of systemic infection. In older children and teenagers, treatment recommendations for TD follow those for adults, with possible adjustments in the dose of medication. Among younger children, macrolides such as azithromycin are considered first-line antibiotic therapy, although some experts now use short-course fluoroquinolone therapy (despite its not being FDA-approved for this indication in children) for travelers aged <18 years. Rifaximin is approved for use in children aged ≥12 years. Rifamycin SV is approved for use only in adults.

Breastfed infants should continue to nurse on demand, and bottle-fed infants can continue to drink formula. Older infants and children should be encouraged to eat and may consume a regular diet. Children in diapers are at risk for developing diaper rash on their buttocks in response to the liquid stool. Barrier creams, such as zinc oxide or petrolatum, could be applied at the onset of diarrhea to help prevent and treat rash. Hydrocortisone cream is the best treatment for an established rash. More information about diarrhea and dehydration is discussed in Chapter 7 , Traveling Safely with Infants & Children.

Bibliography

• Black RE. Epidemiology of travelers’ diarrhea and relative importance of various pathogens. Rev Infect Dis. 1990 Jan–Feb;12(Suppl 1):S73–9.   [PMID:2406860]
• DeBruyn G, Hahn S, Borwick A. Antibiotic treatment for travelers’ diarrhea. Cochrane Database Syst Rev 2000;3:1–21.
• DuPont HL, Ericsson CD, Farthing MJ, Gorbach S, Pickering LK, Rombo L, et al. Expert review of the evidence base for prevention of travelers’ diarrhea. J Travel Med. 2009 May–Jun;16(3):149–60.   [PMID:19538575]
• Farthing M, Salam MA, Lindberg G, Dite P, Khalif I, Salazar-Lindo E, et al. Acute diarrhea in adults and children: a global perspective. J Clin Gastroenterol. 2013 Jan;47(1):12–20.   [PMID:23222211]
• Kantele A, Lääveri T, Mero S, Vilkman K, Pakkanen S, Ollgren J, et al. Antimicrobials increase travelers’ risk of colonization by extended-spectrum betalactamase producing Enterobacteriaceae. Clin Infect Dis. 2015 Mar 15;60(6):837–46.   [PMID:25613287]
• Kendall ME, Crim S, Fullerton K, Han PV, Cronquist AB, Shiferaw B, et al. Travel-associated enteric infections diagnosed after return to the United States, Foodborne Diseases Active Surveillance Network (FoodNet), 2004–2009. Clin Infect Dis. 2012 Jun;54(Suppl 5):S480–7.   [PMID:22572673]
• Mcfarland LV. Meta-analysis of probiotics for the prevention of travelers’ diarrhea. Cochrane Database Syst Rev 2010;Cd003048.
• Raja MK, Ghosh AR. Laribacter hongkongensis: an emerging pathogen of infectious diarrhea. Folia Microbiol. (Praha) 2014 Jul;59 (4):341–7.   [PMID:24481985]
• Riddle MS, Connor BA, Beeching NJ, DuPont HL, Hamer DH, Kozarsky PE et al. Guidelines for the prevention and treatment of travelers’ diarrhea: a graded expert panel report. J Travel Med. 2017;24(Suppl 1):S2–S19.
• Riddle MS, DuPont HL, Connor BA. ACG clinical guideline: diagnosis, treatment, and prevention of acute diarrheal infections in adults. Am J Gastroenterol. 2016 May;111(5):602–22.   [PMID:27068718]
• Shlim DR. Looking for evidence that personal hygiene precautions prevent travelers’ diarrhea. Clin Infect Dis. 2005 Dec 1;41(Suppl 8):S531–5.   [PMID:16267714]
• Steffen R, Hill DR, DuPont HL. Traveler’s diarrhea: a clinical review. JAMA. 2015 Jan 6;313(1):71–80.   [PMID:25562268]
• Zboromyrska Y, Hurtado JC, Salvador P, Alvarez-Martinez MJ, Valls ME, Marcos MA, et al. Aetiology of travelers’ diarrhea: evaluation of a multiplex PCR tool to detect different enteropathogens. Clin Microbiol Infect. 2014;20:O753–9.

Bradley A. Connor

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2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea

Andi l shane.

1 Division of Infectious Diseases, Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Georgia

Rajal K Mody

2 Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia

John A Crump

3 Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina

4 Centre for International Health, University of Otago, Dunedin, New Zealand

Phillip I Tarr

5 Division of Gastroenterology, Hepatology, and Nutrition, Washington University in St. Louis School of Medicine, Missouri

Theodore S Steiner

6 Division of Infectious Diseases, University of British Columbia, Vancouver, Canada

Karen Kotloff

7 Division of Infectious Disease and Tropical Pediatrics, Department of Pediatrics, and the Center for Vaccine Development, University of Maryland School of Medicine, Baltimore

Joanne M Langley

8 Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada

Christine Wanke

9 Division of Nutrition and Infection, Tufts University, Boston, Massachusetts

Cirle Alcantara Warren

10 Division of Infectious Diseases and International Health, University of Virginia, Charlottesville

Allen C Cheng

11 School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia

Joseph Cantey

12 Division of Infectious Diseases, Department of Medicine, Medical University of South Carolina, Charleston

Larry K Pickering

13 Division of Infectious Diseases, Department of Pediatrics, Emory University, Atlanta, Georgia

These guidelines are intended for use by healthcare professionals who care for children and adults with suspected or confirmed infectious diarrhea. They are not intended to replace physician judgement regarding specific patients or clinical or public health situations. This document does not provide detailed recommendations on infection prevention and control aspects related to infectious diarrhea.

EXECUTIVE SUMMARY

The following evidence-based guidelines for management of infants, children, adolescents, and adults in the United States with acute or persistent infectious diarrhea were prepared by an expert panel assembled by the Infectious Diseases Society of America (IDSA) and replace guidelines published in 2001 [ 1 ]. Public health aspects of diarrhea associated with foodborne and waterborne diarrhea, international travel, antimicrobial agents, immunocompromised hosts, animal exposure, certain sexual practices, healthcare-associated diarrheal infections, and infections acquired in childcare and long-term care facilities will be referred to in these guidelines, but are not covered extensively due to availability of detailed discussions of this information in other publications. For recommendations pertaining to Clostridium difficile , refer to the existing IDSA/Society for Healthcare Epidemiology of America (SHEA) guidelines on C. difficile infections, which are in the process of being updated.

Summarized below are recommendations made in the updated guidelines for diagnosis and management of infectious diarrhea. The Panel followed a process used in development of other IDSA guidelines [ 2 ] which included a systematic weighting of the strength of recommendation and quality of evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) [ 3–7 ]. A detailed description of the methods, background, and evidence summaries that support each of the recommendations can be found online in the full text of the guidelines.

RECOMMENDATIONS FOR THE DIAGNOSIS AND MANAGEMENT OF INFECTIOUS DIARRHEA

Clinical, demographic, and epidemiologic features, i. in people with diarrhea, which clinical, demographic, or epidemiologic features have diagnostic or management implications ( tables 1–3 ).

Modes of Acquisition of Enteric Organisms and Sources of Guidelines

Abbreviations: AAP, American Academy of Pediatrics; APHA, American Public Health Association; APIC, Association for Professionals in Infection Control and Epidemiology; CDC, Centers for Disease Control and Prevention; HIV, human immunodeficiency virus; HIVMA, HIV Medicine Association; IDSA, Infectious Diseases Society of America; NIH, National Institutes of Health; NRC, National Resource Center for Health and Safety in Child Care and Early Education; SHEA, Society for Healthcare Epidemiology of America.

Exposure or Condition Associated With Pathogens Causing Diarrhea

Abbreviations: ETEC, enterotoxigenic Escherichia coli ; STEC, Shiga toxin–producing Escherichia coli .

Clinical Presentations Suggestive of Infectious Diarrhea Etiologies

Abbreviation: STEC, Shiga toxin–producing Escherichia coli .

Recommendations

• 1. A detailed clinical and exposure history should be obtained from people with diarrhea, under any circumstances, including when there is a history of similar illness in others (strong, moderate).
• 2. People with diarrhea who attend or work in child care centers, long-term care facilities, patient care, food service, or recreational water venues (eg, pools and lakes) should follow jurisdictional recommendations for outbreak reporting and infection control (strong, high).

II. In people with fever or bloody diarrhea, which clinical, demographic, or epidemiologic features have diagnostic or management implications? ( Tables 1–3 )

• 3. People with fever or bloody diarrhea should be evaluated for enteropathogens for which antimicrobial agents may confer clinical benefit, including Salmonella enterica subspecies, Shigella , and Campylobacter (strong, low).
• 4. Enteric fever should be considered when a febrile person (with or without diarrhea) has a history of travel to areas in which causative agents are endemic, has had consumed foods prepared by people with recent endemic exposure, or has laboratory exposure to Salmonella enterica subspecies enterica serovar Typhi and Salmonella enterica subspecies enterica serovar Paratyphi (strong, moderate). In this document, Salmonella Typhi represents the more formal and detailed name Salmonella enterica subspecies enterica serovar Typhi, and Salmonella Paratyphi corresponds to the Paratyphi serovar.

III. What clinical, demographic, or epidemiologic features are associated with complications or severe disease? ( Tables 2 and ​ and3 3 )

• 5. People of all ages with acute diarrhea should be evaluated for dehydration, which increases the risk of life-threatening illness and death, especially among the young and older adults (strong, high).
• 6. When the clinical or epidemic history suggests a possible Shiga toxin–producing organism, diagnostic approaches should be applied that detect Shiga toxin (or the genes that encode them) and distinguish Escherichia coli O157:H7 from other Shiga toxin–producing E. coli (STEC) in stool (strong, moderate). If available, diagnostic approaches that can distinguish between Shiga toxin 1 and Shiga toxin 2, which is typically more potent, could be used (weak, moderate). In addition, Shigella dysenteriae type 1, and, rarely, other pathogens may produce Shiga toxin and should be considered as a cause of hemolytic uremic syndrome (HUS), especially in people with suggestive international travel or personal contact with a traveler (strong, moderate).
• 7. Clinicians should evaluate people for postinfectious and extraintestinal manifestations associated with enteric infections (strong, moderate) [ 8 ].

Diagnostics

Iv. which pathogens should be considered in people presenting with diarrheal illnesses, and which diagnostic tests will aid in organism identification or outbreak investigation.

• 8. Stool testing should be performed for Salmonella , Shigella , Campylobacter , Yersinia , C. difficile , and STEC in people with diarrhea accompanied by fever, bloody or mucoid stools, severe abdominal cramping or tenderness, or signs of sepsis (strong, moderate). Bloody stools are not an expected manifestation of infection with C. difficile . STEC O157 should be assessed by culture and non-O157 STEC should be detected by Shiga toxin or genomic assays (strong, low). Sorbitol-MacConkey agar or an appropriate chromogenic agar alternative is recommended to screen for O157:H7 STEC; detection of Shiga toxin is needed to detect other STEC serotype (strong, moderate).
• 9. Blood cultures should be obtained from infants <3 months of age, people of any age with signs of septicemia or when enteric fever is suspected, people with systemic manifestations of infection, people who are immunocompromised, people with certain high-risk conditions such as hemolytic anemia, and people who traveled to or have had contact with travelers from enteric fever–endemic areas with a febrile illness of unknown etiology (strong, moderate).
• a. Test for Yersinia enterocolitica in people with persistent abdominal pain (especially school-aged children with right lower quadrant pain mimicking appendicitis who may have mesenteric adenitis), and in people with fever at epidemiologic risk for yersiniosis, including infants with direct or indirect exposures to raw or undercooked pork products.
• 6. In addition, test stool specimens for Vibrio species in people with large volume rice water stools or either exposure to salty or brackish waters, consumption of raw or undercooked shellfish, or travel to cholera-endemic regions within 3 days prior to onset of diarrhea.
• 11. A broader set of bacterial, viral, and parasitic agents should be considered regardless of the presence of fever, bloody or mucoid stools, or other markers of more severe illness in the context of a possible outbreak of diarrheal illness (eg, multiple people with diarrhea who shared a common meal or a sudden rise in observed diarrheal cases). Selection of agents for testing should be based on a combination of host and epidemiologic risk factors and ideally in coordination with public health authorities (strong, moderate).
• 12. A broad differential diagnosis is recommended in immunocompromised people with diarrhea, especially those with moderate and severe primary or secondary immune deficiencies, for evaluation of stool specimens by culture, viral studies, and examination for parasites (strong, moderate). People with acquired immune deficiency syndrome (AIDS) with persistent diarrhea should undergo additional testing for other organisms including, but not limited to, Cryptosporidium , Cyclospora , Cystoisospora , microsporidia, Mycobacterium avium complex, and cytomegalovirus (strong, moderate).
• 13. Diagnostic testing is not recommended in most cases of uncomplicated traveler’s diarrhea unless treatment is indicated. Travelers with diarrhea lasting 14 days or longer should be evaluated for intestinal parasitic infections (strong, moderate). Testing for C. difficile should be performed in travelers treated with antimicrobial agent(s) within the preceding 8–12 weeks. In addition, gastrointestinal tract disease including inflammatory bowel disease (IBD) and postinfectious irritable bowel syndrome (IBS) should be considered for evaluation (strong, moderate).
• 14. Clinical consideration should be included in the interpretation of results of multiple-pathogen nucleic acid amplification tests because these assays detect DNA and not necessarily viable organisms (strong, low).
• 15. All specimens that test positive for bacterial pathogens by culture-independent diagnostic testing such as antigen-based molecular assays (gastrointestinal tract panels), and for which isolate submission is requested or required under public health reporting rules, should be cultured in the clinical laboratory or at a public health laboratory to ensure that outbreaks of similar organisms are detected and investigated (strong, low). Also, a culture may be required in situations where antimicrobial susceptibility testing results would affect care or public health responses (strong, low).
• 16. Specimens from people involved in an outbreak of enteric disease should be tested for enteric pathogens per public health department guidance (strong, low).

Considerations when evaluating people with infectious diarrhea. Modified from Long SS, Pickering LK, Pober CG, eds. Principles and Practice of Pediatric Infectious Diseases, 4th ed. New York: Elsevier Saunders, 2012.

V. Which diagnostic tests should be performed when enteric fever or bacteremia is suspected?

Recommendation.

• 17. Culture-independent, including panel-based multiplex molecular diagnostics from stool and blood specimens, and, when indicated, culture-dependent diagnostic testing should be performed when there is a clinical suspicion of enteric fever (diarrhea uncommon) or diarrhea with bacteremia (strong, moderate). Additionally, cultures of bone marrow (particularly valuable if antimicrobial agents have been administered), stool, duodenal fluid, and urine may be beneficial to detect enteric fever (weak, moderate). Serologic tests should not be used to diagnose enteric fever (strong, moderate).

VI. When should testing be performed for Clostridium difficile?

• 18. Testing may be considered for C. difficile in people >2 years of age who have a history of diarrhea following antimicrobial use and in people with healthcare-associated diarrhea (weak, high). Testing for C. difficile may be considered in people who have persistent diarrhea without an etiology and without recognized risk factors (weak, low). A single diarrheal stool specimen is recommended for detection of toxin or a toxigenic C. difficile strain (eg, nucleic acid amplification testing) (strong, low). Multiple specimens do not increase yield.

VII. What is the optimal specimen (eg, stool, rectal swab, blood) for maximum yield of bacterial, viral, and protozoal organisms (for culture, immunoassay, and molecular testing)? ( Table 4 )

Laboratory Diagnostics for Organisms Associated With Infectious Diarrhea

The field of rapid diagnostic testing is rapidly expanding. We expect that additional diagnostic assays will become available following publication of these guidelines, specifically panel-based molecular diagnostics, including NAAT. Contact the laboratory for instructions regarding container, temperature, and transport guidelines to optimize results.

Abbreviations: CDC, Centers for Disease Control and Prevention; EIA, enzyme immunoassay; GDH, glutamate dehydrogenase; NAAT, nucleic acid amplification test.

a Routine stool culture in most laboratories is designed to detect Salmonella spp, Shigella spp, Campylobacter spp, and E. coli O157 or Shiga toxin–producing E. coli , but this should be confirmed with the testing laboratory.

b It is recommended that laboratories routinely process all stool specimens submitted for bacterial culture for the presence of Shiga toxin–producing strains of E. coli including O157:H7. However, in some laboratories, O157:H7 testing is performed only by specific request.

c Specialized cultures or molecular assays may be required to detect these organisms in stool specimens. The laboratory should be notified whenever there is a suspicion of infection due to one of these pathogens.

d   Bacillus cereus , Clostridium perfringens , and Staphylococcus aureus are associated with diarrheal syndromes that are toxin mediated. An etiologic diagnosis is made by demonstration of toxin in stool for C. perfringens and demonstration of toxin in food for B. cereus and S. aureus .

e Toxin assays are either performed in public health laboratories or referred to laboratories specializing in such assays.

f Testing for Clostridium botulinum toxin is either performed in public health laboratories or referred to laboratories specializing in such testing. The toxin is lethal and special precautions are required for handling. Class A bioterrorism agent and rapid sentinel laboratory reporting schemes must be followed. Immediate notification of a suspected infection to the state health department is mandated.

g Implicated food materials may also be examined for C. botulinum toxin, but most hospital laboratories are not equipped for food analysis.

h The pathogenicity of Blastocystis hominis and Dientamoeba fragilis remains controversial. In the absence of other pathogens, they may be clinically relevant if symptoms persist. Reporting semiquantitative results (rare, few, many) may help determine significance and is a College of American Pathologists accreditation requirement for participating laboratories.

i Detection of Strongyloides in stool may require the use of Baermann technique or agar plate culture.

j   Cryptosporidium and Giardia lamblia testing is often offered and performed together as the primary parasitology examination. Further studies should follow if the epidemiologic setting or clinical manifestations suggest parasitic disease.

k These stains may not be routinely available.

l Enteric adenoviruses may not be recovered in routine viral culture.

• 19. The optimal specimen for laboratory diagnosis of infectious diarrhea is a diarrheal stool sample (ie, a sample that takes the shape of the container). For detection of bacterial infections, if a timely diarrheal stool sample cannot be collected, a rectal swab may be used (weak, low). Molecular techniques generally are more sensitive and less dependent than culture on the quality of specimen. For identification of viral and protozoal agents, and C. difficile toxin, fresh stool is preferred (weak, low).

Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

VIII. What is the clinical relevance of fecal leukocytes or lactoferrin or calprotectin in a person with acute diarrhea?

• 20. Fecal leukocyte examination and stool lactoferrin detection should not be used to establish the cause of acute infectious diarrhea (strong, moderate). There are insufficient data available to make a recommendation on the value of fecal calprotectin measurement in people with acute infectious diarrhea.

IX. In which clinical scenarios should nonmicrobiologic diagnostic tests be performed (eg, imaging, chemistries, complete blood count, and serology)?

• 21. Serologic tests are not recommended to establish an etiology of infectious diarrhea or enteric fever (strong, low), but may be considered for people with postdiarrheal HUS in which a stool culture did not yield a Shiga toxin–producing organism (weak, low).
• 22. A peripheral white blood cell count and differential and serologic assays should not be performed to establish an etiology of diarrhea (strong, low), but may be useful clinically (weak, low).
• 23. Frequent monitoring of hemoglobin and platelet counts, electrolytes, and blood urea nitrogen and creatinine is recommended to detect hematologic and renal function abnormalities that are early manifestations of HUS and precede renal injury for people with diagnosed E. coli O157 or another STEC infection (especially STEC that produce Shiga toxin 2 or are associated with bloody diarrhea) (strong, high). Examining a peripheral blood smear for the presence of red blood cell fragments is necessary when HUS is suspected (strong, high).
• 24. Endoscopy or proctoscopic examination should be considered in people with persistent, unexplained diarrhea who have AIDS, in people with certain underlying medical conditions as well as people with acute diarrhea with clinical colitis or proctitis and in people with persistent diarrhea who engage in anal intercourse (strong, low). Duodenal aspirate may be considered in select people for diagnosis of suspected Giardia , Strongyloides , Cystoisospora , or microsporidia infection (weak, low).
• 25. Imaging (eg, ultrasonography, computed tomography, or magnetic resonance imaging) may be considered to detect aortitis, mycotic aneurysms, signs and symptoms of peritonitis, intra-abdominal free air, toxic megacolon, or extravascular foci of infection in older people with invasive Salmonella enterica or Yersinia infections if there is sustained fever or bacteremia despite adequate antimicrobial therapy or if the patient has underlying atherosclerosis or has recent-onset chest, back, or abdominal pain (weak, low).

X. What follow-up evaluations of stool specimens and nonstool tests should be performed in people with laboratory-confirmed pathogen-specific diarrhea who improve or respond to treatment, and in people who fail to improve or who have persistent diarrhea?

• 26. Follow-up testing is not recommended in most people for case management following resolution of diarrhea (strong, moderate). Collection and analysis of serial stool specimens using culture-dependent methods for Salmonella enterica subspecies enterica serovar Typhi or Salmonella enterica subspecies enterica serovar Paratyphi, STEC, Shigella , nontyphoidal Salmonella , and other bacterial pathogens are recommended in certain situations by local health authorities following cessation of diarrhea to enable return to child care, employment, or group social activities (strong, moderate). Practitioners should collaborate with local public health authorities to adhere to policies regarding return to settings in which transmission is a consideration (strong, high).
• 27. A clinical and laboratory reevaluation may be indicated in people who do not respond to an initial course of therapy and should include consideration of noninfectious conditions including lactose intolerance (weak, low).
• 28. Noninfectious conditions, including IBD and IBS, should be considered as underlying etiologies in people with symptoms lasting 14 or more days and unidentified sources (strong, moderate).
• 29. Reassessment of fluid and electrolyte balance, nutritional status, and optimal dose and duration of antimicrobial therapy is recommended in people with persistent symptoms (strong, high).

Empiric Management of Infectious Diarrhea

Xi. when is empiric antibacterial treatment indicated for children and adults with bloody diarrhea and, if indicated, with what agent.

• a. What are modifying conditions that would support antimicrobial treatment of children and adults with bloody diarrhea?
• b. In which instances should contacts be treated empirically if the agent is unknown?
• a. Infants <3 months of age with suspicion of a bacterial etiology.
• b. Ill immunocompetent people with fever documented in a medical setting, abdominal pain, bloody diarrhea, and bacillary dysentery (frequent scant bloody stools, fever, abdominal cramps, tenesmus) presumptively due to Shigella .
• c. People who have recently travelled internationally with body temperatures ≥38.5°C and/or signs of sepsis (weak, low). See https://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/travelers-diarrhea .
• 31. The empiric antimicrobial therapy in adults should be either a fluoroquinolone such as ciprofloxacin, or azithromycin, depending on the local susceptibility patterns and travel history (strong, moderate). Empiric therapy for children includes a third-generation cephalosporin for infants <3 months of age and others with neurologic involvement, or azithromycin, depending on local susceptibility patterns and travel history (strong, moderate).
• 32. Empiric antibacterial treatment should be considered in immunocompromised people with severe illness and bloody diarrhea (strong, low).
• 33. Asymptomatic contacts of people with bloody diarrhea should not be offered empiric treatment, but should be advised to follow appropriate infection prevention and control measures (strong, moderate).
• 34. People with clinical features of sepsis who are suspected of having enteric fever should be treated empirically with broad-spectrum antimicrobial therapy after blood, stool, and urine culture collection (strong, low). Antimicrobial therapy should be narrowed when antimicrobial susceptibility testing results become available (strong, high). If an isolate is unavailable and there is a clinical suspicion of enteric fever, antimicrobial choice may be tailored to susceptible patterns from the setting where acquisition occurred (weak, low).
• 35. Antimicrobial therapy for people with infections attributed to STEC O157 and other STEC that produce Shiga toxin 2 (or if the toxin genotype is unknown) should be avoided (strong, moderate). Antimicrobial therapy for people with infections attributed to other STEC that do not produce Shiga toxin 2 (generally non-O157 STEC) is debatable due to insufficient evidence of benefit or the potential harm associated with some classes of antimicrobial agents (strong, low).

XII. When is empiric treatment indicated for children and adults with acute, prolonged, or persistent watery diarrhea and, if indicated, with what agent?

• a. What are modifying conditions that would support empiric antimicrobial treatment of children and adults with watery diarrhea?
• b. In which instances, if any, should contacts be treated empirically if the agent is unknown?
• 36. In most people with acute watery diarrhea and without recent international travel, empiric antimicrobial therapy is not recommended (strong, low). An exception may be made in people who are immunocompromised or young infants who are ill-appearing. Empiric treatment should be avoided in people with persistent watery diarrhea lasting 14 days or more (strong, low).
• 37. Asymptomatic contacts of people with acute or persistent watery diarrhea should not be offered empiric or preventive therapy, but should be advised to follow appropriate infection prevention and control measures (strong, moderate).

Directed Management of Infectious Diarrhea

Xiii. how should treatment be modified when a clinically plausible organism is identified from a diagnostic test.

• 38. Antimicrobial treatment should be modified or discontinued when a clinically plausible organism is identified (strong, high).

Supportive Treatment

Xiv. how should rehydration therapy be administered.

• 39. Reduced osmolarity oral rehydration solution (ORS) is recommended as the first-line therapy of mild to moderate dehydration in infants, children, and adults with acute diarrhea from any cause (strong, moderate), and in people with mild to moderate dehydration associated with vomiting or severe diarrhea.
• 40. Nasogastric administration of ORS may be considered in infants, children, and adults with moderate dehydration, who cannot tolerate oral intake, or in children with normal mental status who are too weak or refuse to drink adequately (weak, low).
• 41. Isotonic intravenous fluids such as lactated Ringer’s and normal saline solution should be administered when there is severe dehydration, shock, or altered mental status and failure of ORS therapy (strong, high) or ileus (strong, moderate). In people with ketonemia, an initial course of intravenous hydration may be needed to enable tolerance of oral rehydration (weak, low).
• 42. In severe dehydration, intravenous rehydration should be continued until pulse, perfusion, and mental status normalize and the patient awakens, has no risk factors for aspiration, and has no evidence of ileus (strong, low). The remaining deficit can be replaced by using ORS (weak, low). Infants, children, and adults with mild to moderate dehydration should receive ORS until clinical dehydration is corrected (strong, low).
• 43. Once the patient is rehydrated, maintenance fluids should be administered. Replace ongoing losses in stools from infants, children, and adults with ORS, until diarrhea and vomiting are resolved (strong, low).

XV. When should feeding be initiated following rehydration?

• 44 Human milk feeding should be continued in infants and children throughout the diarrheal episode (strong, low).
• 45. Resumption of an age-appropriate usual diet is recommended during or immediately after the rehydration process is completed (strong, low).

Ancillary Management

Xvi. what options are available for symptomatic relief, and when should they be offered.

• 46. Ancillary treatment with antimotility, antinausea, or antiemetic agents can be considered once the patient is adequately hydrated, but their use is not a substitute for fluid and electrolyte therapy (weak, low).
• 47. Antimotility drugs (eg, loperamide) should not be given to children <18 years of age with acute diarrhea (strong, moderate). Loperamide may be given to immunocompetent adults with acute watery diarrhea (weak, moderate), but should be avoided at any age in suspected or proven cases where toxic megacolon may result in inflammatory diarrhea or diarrhea with fever (strong, low).
• 48. Antinausea and antiemetic (eg, ondansetron) may be given to facilitate tolerance of oral rehydration in children >4 years of age and in adolescents with acute gastroenteritis associated with vomiting (weak, moderate).

XVII. What is the role of a probiotic or zinc in treatment or prevention of infectious diarrhea in children and adults?

• 49. Probiotic preparations may be offered to reduce the symptom severity and duration in immunocompetent adults and children with infectious or antimicrobial-associated diarrhea (weak, moderate). Specific recommendations regarding selection of probiotic organism(s), route of delivery, and dosage may be found through literature searches of studies and through guidance from manufacturers.
• 50. Oral zinc supplementation reduces the duration of diarrhea in children 6 months to 5 years of age who reside in countries with a high prevalence of zinc deficiency or who have signs of malnutrition (strong, moderate).

XVIII. Which asymptomatic people with an identified bacterial organism from stool culture or molecular testing should be treated with an antimicrobial agent?

• 51. Asymptomatic people who practice hand hygiene and live and work in low-risk settings (do not provide healthcare or child or elderly adult care and are not food service employees) do not need treatment, except asymptomatic people with Salmonella enterica subspecies enterica serovar Typhi in their stool who may be treated empirically to reduce potential for transmission (weak, low). Asymptomatic people who practice hand hygiene and live and work in high-risk settings (provide healthcare or child or elderly adult care and are food service employees) should be treated according to local public health guidance (strong, high).

XIX. What strategies, including public health measures, are beneficial in preventing transmission of pathogens associated with infectious diarrhea?

• 52. Hand hygiene should be performed after using the toilet, changing diapers, before and after preparing food, before eating, after handling garbage or soiled laundry items, and after touching animals or their feces or environments, especially in public settings such as petting zoos (strong, moderate).
• 53. Infection control measures including use of gloves and gowns, hand hygiene with soap and water, or alcohol-based sanitizers should be followed in the care of people with diarrhea (strong, high). The selection of a hand hygiene product should be based upon a known or suspected pathogen and the environment in which the organism may be transmitted (strong, low). See https://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html .
• 54. Appropriate food safety practices are recommended to avoid cross-contamination of other foods or cooking surfaces and utensils during grocery shopping, food preparation, and storage; ensure that foods containing meats and eggs are cooked and maintained at proper temperatures (strong, moderate).
• 55. Healthcare providers should direct educational efforts toward all people with diarrhea, but particularly to people with primary and secondary immune deficiencies, pregnant women, parents of young children, and the elderly as they have increased risk of complications from diarrheal disease (strong, low).
• 56. Ill people with diarrhea should avoid swimming, water-related activities, and sexual contact with other people when symptomatic while adhering to meticulous hand hygiene (strong, low).

XX. What are the relative efficacies and effectiveness of vaccines (rotavirus, typhoid, and cholera) to reduce and prevent transmission of pathogens associated with infectious diarrhea, and when should they be used?

• 57. Rotavirus vaccine should be administered to all infants without a known contraindication (strong, high).
• 58. Two typhoid vaccines (oral and injectable) are licensed in the United States but are not recommended routinely. Typhoid vaccination is recommended as an adjunct to hand hygiene and the avoidance of high-risk foods and beverages, for travelers to areas where there is moderate to high risk for exposure to Salmonella enterica subspecies enterica serovar Typhi, people with intimate exposure (eg, household contact) to a documented Salmonella enterica subspecies enterica serovar Typhi chronic carrier, and microbiologists and other laboratory personnel routinely exposed to cultures of Salmonella enterica subspecies enterica serovar Typhi (strong, high). Booster doses are recommended for people who remain at risk (strong, high).
• 59. A live attenuated cholera vaccine, which is available as a single-dose oral vaccine in the United States, is recommended for adults 18–64 years of age who travel to cholera-affected areas (strong, high). See https://www.cdc.gov/cholera/vaccines.html .

XXI. How does reporting of nationally notifiable organisms identified from stool specimens impact the control and prevention of diarrheal disease in the United States?

• 60. All diseases listed in the table of National Notifiable Diseases Surveillance System at the national level, including those that cause diarrhea, should be reported to the appropriate state, territorial, or local health department with submission of isolates of certain pathogens (eg, Salmonella , STEC, Shigella , and Listeria ) to ensure that control and prevention practices may be implemented (strong, high).

Acknowledgments. The expert panel expresses its gratitude for thoughtful reviews of an earlier version by Drs Herbert Dupont, Richard L. Guerrant, and Timothy Jones. The panel thanks the Infectious Diseases Society of America (IDSA) for supporting guideline development, and specifically Vita Washington for her continued support throughout the guideline process. Appreciation is expressed to Dr Nathan Thielman for his contributions to the initial stages of guideline development and Dr Faruque Ahmed for his continued support and guidance regarding the GRADE system. Many thanks to Reed Walton for her assistance at many levels, William Thomas for help with the literature review, and Bethany Sederdahl for her editorial assistance.

Disclaimer. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC).

Financial support. Support for these guidelines was provided by the IDSA.

Potential conflicts of interest. The following list is a reflection of what has been reported to the IDSA. To provide thorough transparency, the IDSA requires full disclosure of all relationships, regardless of relevancy to the guideline topic. Evaluation of such relationships as potential conflicts of interest is determined by a review process which includes assessment by the Standards and Practice Guidelines Committee (SPGC) Chair, the SPGC liaison to the development panel and the Board of Directors liaison to the SPGC and if necessary, the Conflicts of Interest (COI) Task Force of the Board. This assessment of disclosed relationships for possible COI will be based on the relative weight of the financial relationship (ie, monetary amount) and the relevance of the relationship (ie, the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recommendation of consideration). The reader of these guidelines should be mindful of this when the list of disclosures is reviewed. The institution at which A. L. S. is employed has received research grants from the Division of Microbiology and Infectious Diseases of the National Institute of Allergy and Infectious Diseases (NIAID), and the Gerber Foundation, from which she has received salary support, and she has received honoraria from SLACK and travel subsidies from International Scientific Association for Probiotics and Prebiotics ( https://isappscience.org/ ) to attend annual meetings. J. C. has received research grants from the US Army, and stocks and bonds from Ariad and SIS Pharmaceuticals. A. C. has received research grants from CSL Behring and National Health & Medical Research. J. A. C. has received research grants from the CDC, National Institutes of Health (NIH), UK Biotechnology and Biological Sciences Research Council, Bill & Melinda Gates Foundation, and New Zealand Health Research Council. J. M. L.’s institution has received research grants from Merck, GlaxoSmithKline, the Canadian Institutes of Health Research (CIHR), Pfizer, PCIRN, Dynavax, and Afexa. T. S. has received research grants from Merck, Crohn’s and Colitis Canada, and CIHR; has received honoraria from Merck, Bristol-Meyers Squibb, Wyeth, and Pendopharm; and has served as a consultant on research contracts for Merck, Rebiotix, Acetlion, and Sanofi Pasteur. P. I. T. has received research grants from the National Institute of Diabetes and Digestive and Kidney Diseases, the NIAID, and the Bill & Melinda Gates Foundation. C. W. has received research grants from the NIH, GlaxoSmithKline, and Merck, and served as a consultant for Pfizer and Thera Pharmaceuticals. C. A. W. has received research grants from NIH, NIAID and received a patent from the University of Virginia. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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How much do you know about travelers’ diarrhea?

Dr. Meissner is professor of pediatrics at Floating Hospital for Children, Tufts Medical Center. He also is an ex officio member of the AAP Committee on Infectious Diseases and associate editor of the AAP Visual Red Book.

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H. Cody Meissner; How much do you know about travelers’ diarrhea?. AAP News July 2015; 36 (7): 7. 10.1542/aapnews.2015367-7

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Diarrhea, a common travel-related problem for children and adults, generally is benign and self-limited. Treatment includes fluid replacement, antibiotics and anti-motility agents; the greatest concern is volume depletion.

The incidence of travelers’ diarrhea (TD) during a two-week trip is between 10% and 40% depending on the traveler’s destination and activities. The level of sanitation where the traveler purchases meals is the most important determinant of infection. TD occurs when food or water becomes contaminated with fecal material.

Which one of the following statements regarding TD is correct?

Travelers on cruise-based vacations have a higher incidence of TD compared to travelers on a land-based vacation.

The risk of TD varies from location to location and with the season of the year.

Children have a lower risk of acquiring TD compared to adults.

Men are more likely to experience TD than women.

Spices in food may cause TD.

Answer: b) is correct.

The risk of TD varies from location to location and with the season of the year. High-risk regions include the developing countries of Latin America, Asia, Africa and parts of the Middle East. Attack rates of TD are highest during summer months and rainy seasons.

Travelers on cruise-based trips have a lower incidence of TD than travelers on land-based vacations. This is despite the risk of norovirus outbreaks on cruise ships. Children have a greater risk than adults, perhaps because they consume more food and ingest a higher inoculum. The risk of TD is equal for men and women, although women are more likely to seek care once infected. Spices do not cause TD.

Diarrhea is one of the most common travel-related problems affecting children and adults. The classic definition of TD includes passage of three or more watery stools within 24 hours with varying degrees of nausea, vomiting, abdominal pain, fever and bloody stool, depending on the etiology.

Most TD is caused by bacteria, but viruses and parasites also may be transmitted in contaminated food or water. The development of bacterial TD is directly related to the number of viable bacteria that reach the intestine. Any factor that enables bacteria to survive in the intestine (such as proton pump inhibitors) will increase the risk of TD.

Enterotoxigenic Escherichia coli is the most common bacterial cause of TD followed by enteroaggregative E. coli , Salmonella spp., Campylobacter jejuni and Shigella spp. Rotavirus is the most common viral cause of TD followed by norovirus.

Parasites are less likely than bacteria or viruses to cause TD because parasitic contamination of food or water is uncommon in most locations. Sites where parasites are more likely to be acquired include Nepal and St. Petersburg, Russia, where Giardia or Cyclospora may be hyperendemic. Entamoeba histolytica is an uncommon cause of TD. Patients taking malaria prophylaxis may develop antibiotic-associated diarrhea due to Clostridium difficile , although overall this organism is an uncommon cause of TD.

Dr. Meissner

Preventive measures include avoidance of foods or beverages purchased from street vendors or other establishments where unhygienic conditions are present, avoidance of undercooked meat and seafood, and avoidance of raw fruits and vegetables unless peeled by the traveler.

Antibiotic chemoprophylaxis generally is not recommended for children or adults because of expense and side effects such as sun sensitivity, allergic reactions, yeast infections and risk of C. difficile colitis. Prophylaxis sometimes is considered for travelers at increased risk such as those with inflammatory bowel disease or ostomies.

For infants, breastfeeding is the best way to reduce the risk of foodborne and waterborne illness. Water served to young children, including water used to prepare infant formula, should be disinfected. In some parts of the world, even bottled water may be contaminated.

When proper hand-washing facilities are not available, alcohol-based hand sanitizers containing more than 60% alcohol can be used to clean hands, but they should not be relied on if organic material is visible. Alcohol-based hand washes are less effective against norovirus or the spores of C. difficile . Careful attention should be paid to cleaning bottles and pacifiers. Food available on aircraft generally is obtained at the site of departure.

TD generally is benign and self-limited, although dehydration may pose a health hazard to those with co-morbidities. Often, treatment is initiated without documentation of etiology. Routine stool culture is not warranted in most settings because various pathogenic strains of E. coli are not easily identified.

Treatment of TD includes fluid replacement, antibiotics and anti-motility agents. The greatest concern with TD is volume depletion. Patients with severe diarrhea should be treated with oral rehydration solution to replace electrolytes in the appropriate concentrations. For mild diarrhea, use of fluids generally is adequate. Self-medication may be appropriate.

For adults, ciprofloxacin will be active against most bacterial causes of TD. Azithromycin generally is the preferred agent for children. For children 12 years of age and older, rifaximin has similar efficacy as ciprofloxacin. Bismuth subsalicylate has the disadvantage of potential salicylate toxicity, the need to carry large quantities and the concern for Reye syndrome.

Anti-motility agents sometimes are used in combination with antibiotics to reduce the amount of stooling. Particularly with bloody diarrhea, anti-motility agents should be used with caution and only with an antibiotic.

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