travellers diarrhoea thailand

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Travelers' Diarrhea

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Travelers' diarrhea is the most common travel-related illness. It can occur anywhere, but the highest-risk destinations are in Asia (except for Japan and South Korea) as well as the Middle East, Africa, Mexico, and Central and South America.

In otherwise healthy adults, diarrhea is rarely serious or life-threatening, but it can make a trip very unpleasant.

You can take steps to avoid travelers’ diarrhea

Choose food and drinks carefully Eat only foods that are cooked and served hot. Avoid food that has been sitting on a buffet. Eat raw fruits and vegetables only if you have washed them in clean water or peeled them. Only drink beverages from factory-sealed containers, and avoid ice because it may have been made from unclean water.
Wash your hands Wash your hands often with soap and water, especially after using the bathroom and before eating. If soap and water aren’t available, use an alcohol-based hand sanitizer. In general, it’s a good idea to keep your hands away from your mouth.

Learn some ways to treat travelers’ diarrhea

Drink lots of fluids If you get diarrhea, drink lots of fluids to stay hydrated. In serious cases of travelers’ diarrhea, oral rehydration solution—available online or in pharmacies in developing countries—can be used for fluid replacements.
Take over-the-counter drugs Several drugs, such as loperamide, can be bought over-the-counter to treat the symptoms of diarrhea. These drugs decrease the frequency and urgency of needing to use the bathroom, and may make it easier for you to ride on a bus or airplane while waiting for an antibiotic to take effect.
Only take antibiotics if needed Your doctor may give you antibiotics to treat travelers’ diarrhea, but consider using them only for severe cases. If you take antibiotics, take them exactly as your doctor instructs. If severe diarrhea develops soon after you return from your trip, see a doctor and ask for stool tests so you can find out which antibiotic will work for you.

More Information

Travelers’ Diarrhea- CDC Yellow Book

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Thailand Travellers' Diarrhea

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Description.

The term Travellers' Diarrhea is used to describe gastrointestinal infections affecting travellers caused by ingesting bacteria, viruses, and protozoa. These microorganisms are found worldwide and are typically transmitted from person to person via the fecal-oral route – an infected person who does not practice proper hand or body hygiene passes on the infection to another person when handling food and water. Travellers' Diarrhea is one of the most common illness among travellers.

Travellers' Diarrhea can happen when:

Eating raw, under cooked, unwashed, or improperly handled meat, poultry products, dairy products, fruits, vegetables, shellfish, and seafood.
Drinking contaminated water or beverages.
Inadvertently ingesting fecal matter, protozoa eggs, or viruses by touching the mouth with dirty or improperly washed hands.
Eating in restaurants, from buffets, or from street vendors where food handling and hygienic practices are not followed properly.

The golden rule to prevent gastrointestinal infections is: Boil it, Cook it, Peel it, or Forget it! However, it’s not just about what you eat, it’s also important to consider where you eat. It’s not always easy to know if a restaurant or food vendor follows proper food handling and hygienic practices (such as separating raw from cooked ingredients, properly cleaning cutting boards and utensils, washing their hands, and correctly refrigerating food). Avoid restaurants and food vendors that appear unclean or that don’t have many customers. Be cautious of food that has been stored uncovered, has been improperly refrigerated, or has been standing out for a long time such as buffets.

If you are unsure about the tap water quality, bring the water to a rolling boil. Boiling water destroys pathogens that can cause Travellers’ Diarrhea and other gastrointestinal infections. If you cannot boil your water, opt for treated or bottled water instead.

The risk of Travellers’ Diarrhea can also be minimized by following good hygiene practices. Make sure to wash your hands for at least 20 seconds with warm water and soap, especially before preparing or eating food and after using the bathroom. If water and soap are unavailable, use an alcohol-based hand sanitizer that contains at least 60% alcohol.

Managing Travellers’ Diarrhea

At the first sign of diarrhea, drink an oral rehydration solution (ORS), a mixture of salt and sugar designed to replenish electrolytes and treat dehydration. Antimotility agents like loperamide can also be used to reduce symptoms, but they do not treat the gastrointestinal infection. Traveller’s diarrhea is usually a self-limiting infection (it resolves itself), but if it persists and becomes worse after 2 or 3 days, you may want to consider taking an antibiotic for treatment.

If you are on high blood pressure medication watch for signs of dehydration since it can become an emergency very quickly.

Before you go, consult your doctor for the best diarrhea treatment options. Travellers who have pre-existing health conditions and are more susceptible to gastrointestinal infections may consider taking preventive medication.

For more information on preventing Travellers' Diarrhea, check out these resources from IAMAT:

Food and water safety
How to prevent Travellers' Diarrhea
How to prevent illness by washing your hands

Information last updated: February 23, 2021.

Velarde JJ, Levine MM, Nataro JP,Escherichia coli Diarrhea. In: McGill, A; Ryan, E; Hill, D; Solomon, T, eds. Hunter's Tropical Medicine and Emerging Infectious Diseases. 9 th ed. New York: Saunders Elsevier; 2013: 442-447.
Wolfe MS. Traveler’s Diarrhea. In: Jong, E; Stevens, D, eds. Netter’s Infectious Diseases. New York: Saunders Elsevier; 2012: 390-393.
Virk A. Amebiasis, Giardiasis, and Other Intestinal Protozoan Infections. In: Jong, E; Sanford, C. eds. The Travel and Tropical Medicine Manual, 4 th ed. Waltham, Elsevier; 2008: 448-466.
Centers for Disease Control and Prevention: Yellow Book, Traveler’s Diarrhea
Committee to Advice on Tropical Medicine and Travel, PHAC: Statement on Travellers' Diarrhea

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(English) I have traveler’s diarrhea in Thailand, what should I do? Should I see a doctor?

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2 comments to (English) I have traveler’s diarrhea in Thailand, what should I do? Should I see a doctor?

I HAVED A HIGH FEVER SINCE COMING OFF THE BOAT AND SICKENS DIARRHEA .. I JUST DONT SEEM TO BE GETTING ANY BETTER I STILL HAVE HAVE HIGH FEVER

That’s not good. Please visit the nearby hospital.

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Diseases & Conditions
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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Traveller's diarrhoea

Peer reviewed by Dr Colin Tidy, MRCGP Last updated by Dr Toni Hazell Last updated 10 Feb 2023

Meets Patient’s editorial guidelines

In this series: Amoebiasis Giardia

Traveller's diarrhoea is diarrhoea that develops during, or shortly after, travel abroad. It is caused by consuming food and water, contaminated by germs (microbes) including bacteria, viruses and parasites. Other symptoms can include high temperature (fever), being sick (vomiting) and tummy (abdominal) pain. In most cases it causes a mild illness and symptoms clear within 3 to 4 days. Specific treatment is not usually needed but it is important to drink plenty of fluids to avoid lack of fluid in the body (dehydration). Always make sure that you get any advice that you need in plenty of time before your journey - some GPs offer travel advice but if yours doesn't then you may need to go to a private travel clinic.

What is traveller's diarrhoea, what causes traveller's diarrhoea, are all travellers at risk, what are the symptoms of traveller's diarrhoea, how is traveller's diarrhoea diagnosed, when should i seek medical advice for traveller's diarrhoea, how is traveller's diarrhoea in adults treated, how is traveller's diarrhoea in children treated, side-effects of traveller's diarrhoea, how long does traveller's diarrhoea last, how can i avoid traveller's diarrhoea.

Continue reading below

Traveller's diarrhoea is diarrhoea that develops during, or shortly after, travel abroad. Diarrhoea is defined as: 'loose or watery stools (faeces), usually at least three times in 24 hours.'

Traveller's diarrhoea is caused by eating food, or drinking water, containing certain germs (microbes) or their poisons (toxins). The types of germs which may be the cause include:

Bacteria: these are the most common microbes that cause traveller's diarrhoea. Common types of bacteria involved are:

Escherichia coli

Campylobacter

Viruses: these are the next most common, particularly norovirus and rotavirus.

Parasites: these are less common causes. Giardia, cryptosporidium and Entamoeba histolytica are examples of parasites that may cause traveller's diarrhoea.

Often the exact cause of traveller's diarrhoea is not found and studies have shown that in many people no specific microbe is identified despite testing (for example, of a stool (faeces) specimen).

See the separate leaflets called E. Coli (VTEC O157) , Campylobacter, Salmonella, Cryptosporidium , Amoebiasis (dysentery information), Shigella and Giardia for more specific details on each of the microbes mentioned above.

Note : this leaflet is about traveller's diarrhoea in general and how to help prevent it.

Traveller's diarrhoea most commonly affects people who are travelling from a developed country, such as the UK, to a developing country where sanitation and hygiene measures may not meet the same standards. It can affect as many as 2 to 6 in 10 travellers.

There is a different risk depending on whether you travel to high-risk areas or not:

High-risk areas : South and Southeast Asia, Central America, West and North Africa, South America, East Africa.

Medium-risk areas : Russia, China, Caribbean, South Africa.

Low-risk areas : North America, Western Europe, Australia and New Zealand.

Sometimes outbreaks of diarrhoea can occur in travellers staying in one hotel or, for example, those staying on a cruise ship. People travelling in more remote areas (for example, trekkers and campers) may also have limited access to medical care if they do become unwell.

By definition, diarrhoea is the main symptom. This can be watery and can sometimes contain blood. Other symptoms may include:

Crampy tummy (abdominal) pains.

Feeling sick (nausea).

Being sick (vomiting).

A high temperature (fever).

Symptoms are usually mild in most people and last for 3 to 4 days but they may last longer. Symptoms may be more severe in the very young, the elderly, and those with other health problems. Those whose immune systems are not working as well as normal are particularly likely to be more unwell. For example, people with untreated HIV infection, those on chemotherapy, those on long-term steroid treatment or those who are taking drugs which suppress their immune system, for example after a transplant or to treat an autoimmune condition

Despite the fact that symptoms are usually fairly mild, they can often mean that your travel itinerary is interrupted or may need to be altered.

Traveller's diarrhoea is usually diagnosed by the typical symptoms. As mentioned above, most people have mild symptoms and do not need to seek medical advice. However, in some cases medical advice is needed (see below).

If you do see a doctor, they may suggest that a sample of your stool (faeces) be tested. This will be sent to the laboratory to look for any microbes that may be causing your symptoms. Sometimes blood tests or other tests may be needed if you have more severe symptoms or develop any complications.

As mentioned above, most people with traveller's diarrhoea have relatively mild symptoms and can manage these themselves by resting and making sure that they drink plenty of fluids. However, you should seek medical advice in any of the following cases, or if any other symptoms occur that you are concerned about:

If you have a high temperature (fever).

If you have blood in your stools (faeces).

If it is difficult to get enough fluid because of severe symptoms: frequent or very watery stools or repeatedly being sick (vomiting).

If the diarrhoea lasts for more than 5-7 days.

If you are elderly or have an underlying health problem such as diabetes, inflammatory bowel disease, or kidney disease.

If you have a weakened immune system because of, for example, chemotherapy treatment, long-term steroid treatment, or HIV infection.

If you are pregnant.

If an affected child is under the age of 6 months.

If you develop any of the symptoms listed below that suggest you might have lack of fluid in your body (dehydration). If it is your child who is affected, there is a separate list for children.

Symptoms of dehydration in adults

Dizziness or light-headedness.

Muscle cramps.

Sunken eyes.

Passing less urine.

A dry mouth and tongue.

Becoming irritable.

Symptoms of severe dehydration in adults

Profound loss of energy or enthusiasm (apathy).

A fast heart rate

Producing very little urine.

Coma, which may occur.

Note : severe dehydration is a medical emergency and immediate medical attention is needed.

Symptoms of dehydration in children

Passing little urine.

A dry mouth.

A dry tongue and lips.

Fewer tears when crying.

Being irritable.

Having a lack of energy (being lethargic).

Symptoms of severe dehydration in children

Drowsiness.

Pale or mottled skin.

Cold hands or feet.

Very few wet nappies.

Fast (but often shallow) breathing.

Dehydration is more likely to occur in:

Babies under the age of 1 year (and particularly those under 6 months old). This is because babies don't need to lose much fluid to lose a significant proportion of their total body fluid.

Babies under the age of 1 year who were a low birth weight and who have not caught up with their weight.

A breastfed baby who has stopped being breastfed during their illness.

Any baby or child who does not drink much when they have a gut infection (gastroenteritis).

Any baby or child with severe diarrhoea and vomiting. (For example, if they have passed five or more diarrhoeal stools and/or vomited two or more times in the previous 24 hours.)

In most cases, specific treatment of traveller's diarrhoea is not needed. The most important thing is to make sure that you drink plenty of fluids to avoid lack of fluid in your body (dehydration).

Fluid replacement

As a rough guide, drink at least 200 mls after each watery stool (bout of diarrhoea).

This extra fluid is in addition to what you would normally drink. For example, an adult will normally drink about two litres a day but more in hot countries. The above '200 mls after each watery stool' is in addition to this usual amount that you would drink.

If you are sick (vomit), wait 5-10 minutes and then start drinking again but more slowly. For example, a sip every 2-3 minutes but making sure that your total intake is as described above.

You will need to drink even more if you are dehydrated. A doctor will advise on how much to drink if you are dehydrated.

Note : if you suspect that you are becoming dehydrated, you should seek medical advice.

For most adults, fluids drunk to keep hydrated should mainly be water. However, this needs to be safe drinking water - for example, bottled, or boiled and treated water. It is best not to have drinks that contain a lot of sugar, such as fizzy drinks, as they can sometimes make diarrhoea worse. Alcohol should also be avoided.

Rehydration drinks

Rehydration drinks may also be used. They are made from sachets that you can buy from pharmacies and may be a sensible thing to pack in your first aid kit when you travel. You add the contents of the sachet to water.

Home-made salt/sugar mixtures are used in developing countries if rehydration drinks are not available; however, they have to be made carefully, as too much salt can be dangerous. Rehydration drinks are cheap and readily available in the UK, and are the best treatment. Note that safe drinking water should be used to reconstitute oral rehydration salt sachets.

Antidiarrhoeal medication

Antidiarrhoeal medicines are not usually necessary or wise to take when you have traveller's diarrhoea. However you may want to use them if absolutely necessary - for example, if you will be unable to make regular trips to the toilet due to travelling.You can buy antidiarrhoeal medicines from pharmacies before you travel. The safest and most effective is loperamide.

The adult dose of this is two capsules at first. This is followed by one capsule after each time you pass some diarrhoea up to a maximum of eight capsules in 24 hours. It works by slowing down your gut's activity.

You should not take loperamide for longer than two days. You should also not use antidiarrhoeal medicines if you have a high temperature (fever) or bloody diarrhoea.

Eat as normally as possible

It used to be advised to 'starve' for a while if you had diarrhoea. However, now it is advised to eat small, light meals if you can. Be guided by your appetite. You may not feel like food and most adults can do without food for a few days. Eat as soon as you are able but don't stop drinking. If you do feel like eating, avoid fatty, spicy or heavy food. Plain foods such as bread and rice are good foods to try eating.

Antibiotic medicines

Most people with traveller's diarrhoea do not need treatment with antibiotic medicines. However, sometimes antibiotic treatment is advised. This may be because a specific germ (microbe) has been identified after testing of your stool (faeces) sample.

Fluids to prevent dehydration

You should encourage your child to drink plenty of fluids. The aim is to prevent lack of fluid in the body (dehydration). The fluid lost in their sick (vomit) and/or diarrhoea needs to be replaced. Your child should continue with their normal diet and usual drinks. In addition, they should also be encouraged to drink extra fluids. However, avoid fruit juices or fizzy drinks, as these can make diarrhoea worse.

Babies under 6 months old are at increased risk of dehydration. You should seek medical advice if they develop acute diarrhoea. Breast feeds or bottle feeds should be encouraged as normal. You may find that your baby's demand for feeds increases. You may also be advised to give extra fluids (either water or rehydration drinks) in between feeds.

If you are travelling to a destination at high risk for traveller's diarrhoea, you might want to consider buying oral rehydration sachets for children before you travel. These can provide a perfect balance of water, salts and sugar for them and can be used for fluid replacement. Remember that, as mentioned above, safe water is needed to reconstitute the sachets.

If your child vomits, wait 5-10 minutes and then start giving drinks again but more slowly (for example, a spoonful every 2-3 minutes). Use of a syringe can help in younger children who may not be able to take sips.

Note : if you suspect that your child is dehydrated, or is becoming dehydrated, you should seek medical advice urgently.

Fluids to treat dehydration

If your child is mildly dehydrated, this may be treated by giving them rehydration drinks. A doctor will advise about how much to give. This can depend on the age and the weight of your child. If you are breastfeeding, you should continue with this during this time. It is important that your child be rehydrated before they have any solid food.

Sometimes a child may need to be admitted to hospital for treatment if they are dehydrated. Treatment in hospital usually involves giving rehydration solution via a special tube called a 'nasogastric tube'. This tube passes through your child's nose, down their throat and directly into their stomach. An alternative treatment is with fluids given directly into a vein (intravenous fluids).

Eat as normally as possible once any dehydration has been treated

Correcting any dehydration is the first priority. However, if your child is not dehydrated (most cases), or once any dehydration has been corrected, then encourage your child to have their normal diet. Do not 'starve' a child with infectious diarrhoea. This used to be advised but is now known to be wrong. So:

Breastfed babies should continue to be breastfed if they will take it. This will usually be in addition to extra rehydration drinks (described above).

Bottle-fed babies should be fed with their normal full-strength feeds if they will take it. Again, this will usually be in addition to extra rehydration drinks (described above). Do not water down the formula, or make it up with less water than usual. This can make a baby very ill.

Older children - offer them some food every now and then. However, if he or she does not want to eat, that is fine. Drinks are the most important consideration and food can wait until the appetite returns.

Loperamide is not recommended for children with diarrhoea. There are concerns that it may cause a blockage of the gut (intestinal obstruction) in children with diarrhoea.

Most children with traveller's diarrhoea do not need treatment with antibiotics. However, for the same reasons as discussed for adults above, antibiotic treatment may sometimes be advised in certain cases.

Most people have mild illness and complications of traveller's diarrhoea are rare. However, if complications do occur, they can include the following:

Salt (electrolyte) imbalance and dehydration .

This is the most common complication. It occurs if the salts and water that are lost in your stools (faeces), or when you are sick (vomit), are not replaced by you drinking adequate fluids. If you can manage to drink plenty of fluids then dehydration is unlikely to occur, or is only likely to be mild and will soon recover as you drink.

Severe dehydration can lead to a drop in your blood pressure. This can cause reduced blood flow to your vital organs. If dehydration is not treated, your kidneys may be damaged . Some people who become severely dehydrated need a 'drip' of fluid directly into a vein. This requires admission to hospital. People who are elderly or pregnant are more at risk of dehydration.

Reactive complications

Rarely, other parts of your body can 'react' to an infection that occurs in your gut. This can cause symptoms such as joint inflammation (arthritis), skin inflammation and eye inflammation (either conjunctivitis or uveitis). Reactive complications are uncommon if you have a virus causing traveller's diarrhoea.

Spread of infection

The infection can spread to other parts of your body such as your bones, joints, or the meninges that surround your brain and spinal cord. This is rare. If it does occur, it is more likely if diarrhoea is caused by salmonella infection.

Irritable bowel syndrome is sometimes triggered by a bout of traveller's diarrhoea.

Lactose intolerance

Lactose intolerance can sometimes occur for a period of time after traveller's diarrhoea. It is known as 'secondary' or 'acquired' lactose intolerance. Your gut (intestinal) lining can be damaged by the episode of diarrhoea. This leads to lack of a substance (enzyme) called lactase that is needed to help your body digest the milk sugar lactose.

Lactose intolerance leads to bloating, tummy (abdominal) pain, wind and watery stools after drinking milk. The condition gets better when the infection is over and the intestinal lining heals. It is more common in children.

Haemolytic uraemic syndrome

Usually associated with traveller's diarrhoea caused by a certain type of E. coli infection, haemolytic uraemic syndrome is a serious condition where there is anaemia, a low platelet count in the blood and kidney damage. It is more common in children. If recognised and treated, most people recover well.

Guillain-Barré syndrome

This condition may rarely be triggered by campylobacter infection, one of the causes of traveller's diarrhoea. It affects the nerves throughout your body and limbs, causing weakness and sensory problems. See the separate leaflet called Guillain-Barré syndrome for more details.

Reduced effectiveness of some medicines

During an episode of traveller's diarrhoea, certain medicines that you may be taking for other conditions or reasons may not be as effective. This is because the diarrhoea and/or being sick (vomiting) mean that reduced amounts of the medicines are taken up (absorbed) into your body.

Examples of such medicines are those for epilepsy, diabetes and contraception . Speak with your doctor or practice nurse before you travel if you are unsure of what to do if you are taking other medicines and develop diarrhoea.

As mentioned above, symptoms are usually short-lived and the illness is usually mild with most people making a full recovery within in few days. However, a few people with traveller's diarrhoea develop persistent (chronic) diarrhoea that can last for one month or more. It is also possible to have a second 'bout' of traveller's diarrhoea during the same trip. Having it once does not seem to protect you against future infection.

Avoid uncooked meat, shellfish or eggs. Avoid peeled fruit and vegetables (including salads).

Be careful about what you drink. Don't drink tap water, even as ice cubes.

Wash your hands regularly, especially before preparing food or eating.

Be careful where you swim. Contaminated water can cause traveller's diarrhoea.

Regular hand washing

You should ensure that you always wash your hands and dry them thoroughly; teach children to wash and dry theirs:

After going to the toilet (and after changing nappies or helping an older child to go to the toilet).

Before preparing or touching food or drinks.

Before eating.

Some antibacterial hand gel may be a good thing to take with you when you travel in case soap and hot water are not available.

Be careful about what you eat and drink

When travelling to areas with poor sanitation, you should avoid food or drinking water that may contain germs (microbes) or their poisons (toxins). Avoid:

Fruit juices sold by street vendors.

Ice cream (unless it has been made from safe water).

Shellfish (for example, mussels, oysters, clams) and uncooked seafood.

Raw or undercooked meat.

Fruit that has already been peeled or has a damaged skin.

Food that contains raw or uncooked eggs, such as mayonnaise or sauces.

Unpasteurised milk.

Drinking bottled water and fizzy drinks that are in sealed bottles or cans, tea, coffee and alcohol is thought to be safe. However, avoid ice cubes and non-bottled water in alcoholic drinks. Food should be cooked through thoroughly and be piping hot when served.

You should also be careful when eating food from markets, street vendors or buffets if you are uncertain about whether it has been kept hot or kept refrigerated. Fresh bread is usually safe, as is canned food or food in sealed packs.

Be careful where you swim

Swimming in contaminated water can also lead to traveller's diarrhoea. Try to avoid swallowing any water as you swim; teach children to do the same.

Obtain travel health advice before you travel

Always make sure that you visit your GP surgery or private travel clinic for health advice in plenty of time before your journey. Alternatively, the Fit for Travel website (see under Further Reading and References, below) provides travel health information for the public and gives specific information for different countries and high-risk destinations. This includes information about any vaccinations required, advice about food, water and personal hygiene precautions, etc.

There are no vaccines that prevent traveller's diarrhoea as a whole. However, there are some other vaccines that you may need for your travel, such as hepatitis A, typhoid, etc. You may also need to take malaria tablets depending on where you are travelling.

Antibiotics

Taking antibiotic medicines to prevent traveller's diarrhoea (antibiotic prophylaxis) is not generally recommended. This is because for most people, traveller's diarrhoea is mild and self-limiting. Also, antibiotics do not protect against nonbacterial causes of traveller's diarrhoea, such as viruses and parasites. Antibiotics may have side-effects and their unnecessary use may lead to problems with resistance to medicines.

Probiotics have some effect on traveller's diarrhoea and can shorten an attack by about one day. It is not known yet which type of probiotic or which dose, so there are no recommendations about using probiotics to prevent traveller's diarrhoea.

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Patient Information: Seen related handout on traveler’s diarrhea , written by the author of this article.

Acute diarrhea affects millions of persons who travel to developing countries each year. Food and water contaminated with fecal matter are the main sources of infection. Bacteria such as enterotoxigenic Escherichia coli , enteroaggregative E. coli , Campylobacter, Salmonella, and Shigella are common causes of traveler’s diarrhea. Parasites and viruses are less common etiologies. Travel destination is the most significant risk factor for traveler’s diarrhea. The efficacy of pretravel counseling and dietary precautions in reducing the incidence of diarrhea is unproven. Empiric treatment of traveler’s diarrhea with antibiotics and loperamide is effective and often limits symptoms to one day. Rifaximin, a recently approved antibiotic, can be used for the treatment of traveler’s diarrhea in regions where noninvasive E. coli is the predominant pathogen. In areas where invasive organisms such as Campylobacter and Shigella are common, fluoroquinolones remain the drug of choice. Azithromycin is recommended in areas with quinolone-resistant Campylobacter and for the treatment of children and pregnant women.

Acute diarrhea is the most common illness among travelers. Up to 55 percent of persons who travel from developed countries to developing countries are affected. 1 , 2 A study 3 of Americans visiting developing countries found that 46 percent acquired diarrhea. The classic definition of traveler’s diarrhea is three or more unformed stools in 24 hours with at least one of the following symptoms: fever, nausea, vomiting, abdominal cramps, tenesmus, or bloody stools. Milder forms can present with fewer than three stools (e.g., an abrupt bout of watery diarrhea with abdominal cramps). Most cases occur within the first two weeks of travel and last about four days without treatment. 1 , 3 Although traveler’s diarrhea rarely is life threatening, it can result in significant morbidity; one in five travelers with diarrhea is bedridden for a day and more than one third have to alter their activities. 1 , 3

Destination is the most significant risk factor for developing traveler’s diarrhea. 1 – 4 Regions with the highest risk are Africa, South Asia, Latin America, and the Middle East. Travelers who are immunocompromised and those with lowered gastric acidity (e.g., patients taking histamineH 2 blockers or proton pump inhibitors) are more susceptible to traveler’s diarrhea. Recently, a genetic susceptibility has been demonstrated. 5 Younger age and adventurous travel increase the risk of developing traveler’s diarrhea, 3 , 6 but persons staying at luxury resorts or on cruise ships also are at risk. 7 , 8

Food and water contaminated with fecal matter are the main reservoirs for the pathogens that cause traveler’s diarrhea. Unsafe foods and beverages include salads, unpeeled fruits, raw or poorly cooked meats and seafood, unpasteurized dairy products, and tap water. Eating in restaurants increases the probability of contracting traveler’s diarrhea 6 and food from street vendors is particularly risky. 9 , 10 Cold sauces, salsas, and foods that are cooked and then reheated also are risky. 6 , 11

In contrast to the largely viral etiology of gastroenteritis in the United States, diarrhea acquired in developing countries is caused mainly by bacteria 1 , 4 , 6 , 12 ( Table 1 ) . Enterotoxigenic Escherichia coli is the pathogen most frequently isolated, but other types of E. coli such as enteroaggregative E. coli have been recognized as common causes of traveler’s diarrhea. 13 Invasive pathogens such as Campylobacter, Shigella, and non-typhoid Salmonella are relatively common depending on the region, while Aeromonas and non-cholera Vibrio species are encountered less frequently.

Protozoal parasites such as Giardia lamblia , Entamoeba histolytica , and Cyclospora cayetanensis are uncommon causes of traveler’s diarrhea, but increase in importance when diarrhea lasts for more than two weeks. 14 Parasites are diagnosed more frequently in returning travelers because of longer incubation periods (often one to two weeks) and because bacterial pathogens may have been treated with antibiotics. Rotavirus and noroviruses are infrequent causes of traveler’s diarrhea, although noroviruses have been responsible for outbreaks on cruise ships.

The prevalence of specific organisms varies with travel destination. 1 , 4 , 12 , 13 , 15 Available data suggest that E. coli is the predominant cause of traveler’s diarrhea in Latin America, the Caribbean, and Africa, while invasive pathogens are relatively uncommon. Enterotoxigenic E. coli and enteroaggregative E. coli may be responsible for up to 71 percent of cases of traveler’s diarrhea in Mexico. 13 In contrast, Campylobacter is a leading cause of traveler’s diarrhea in Thailand 15 – 17 and also is common in Nepal. 6 Regional variation also exists with parasitic causes of traveler’s diarrhea ( Table 2 ) . 12 , 13 For example, Cyclospora is endemic in Nepal, Peru, and Haiti.

Food poisoning is part of the differential diagnosis of traveler’s diarrhea. Gastroenteritis from preformed toxins (e.g., Staphylococcus aureus , Bacillus cereus ) is characterized by a short incubation period (one to six hours), and symptoms typically resolve within 24 hours. 18 Seafood ingestion syndromes such as diarrhetic shellfish poisoning, ciguatera poisoning, and scombroid poisoning also can cause diarrhea in travelers. These syndromes can be distinguished from traveler’s diarrhea by symptoms such as perioral numbness and reversal of temperature sensation (ciguatera poisoning) or flushing and warmth (scombroid poisoning). 19

Although travelers often are advised to “Boil it, cook it, peel it, or forget it,” data on the effectiveness of dietary precautions in preventing traveler’s diarrhea are inconclusive. 3 , 6 , 20 Many travelers find it difficult to adhere to dietary recommendations. 21 In a study 3 of American travelers, nearly one half developed diarrhea despite pretravel advice on avoidance measures; even persons who strictly followed dietary recommendations developed diarrhea. Avoiding high-risk foods and adventuresome eating behaviors may reduce the inoculum of ingested pathogens or prevent the development of other enteric diseases such as typhoid and hepatitis A and E.

Boiling is the best way to purify water. Iodination or chlorination is acceptable but does not kill Cryptosporidium or Cyclospora, and increased contact time is required to kill Giardia in cold or turbid water. 22 Filters with iodine resins generally are effective in purifying water, although it is uncertain whether the contact time with the resin is sufficient to kill viruses. Bottled water generally is safe if the cap and seal are intact.

DRUG PROPHYLAXIS

Antibiotic prophylaxis is not recommended by the Centers for Disease Control and Prevention (CDC) even for high-risk travelers because it can lead to drug-resistant organisms and may give travelers a false sense of security. Although antibiotic prophylaxis does not prevent viral or parasitic infection, some health care professionals believe that it may be an option for travelers who are at high risk of developing traveler’s diarrhea and related complications (e.g., immunocompromised persons). Prophylaxis with fluoroquinolones is up to 90 percent effective. 23 Rifaximin (Xifaxan) may prove to be the preferred antibiotic because it is not absorbed and is well tolerated, although data on its effectiveness for prophylaxis have not yet been published.

Bismuth subsalicylate (Pepto-Bismol) provides a rate of protection of about 60 percent against traveler’s diarrhea. 24 However, it is not recommended for persons taking anticoagulants or other salicylates. Because bismuth subsalicylate interferes with the absorption of doxycycline (Vibramycin), it should not be taken by travelers using doxycycline for malaria prophylaxis. Travelers should be warned about possible reversible side effects of bismuth subsalicylate, such as a black tongue, dark stools, and tinnitus.

Probiotics are a more natural approach to prophylaxis of traveler’s diarrhea. Probiotics colonize the gastrointestinal tract and theoretically prevent pathogenic organisms from infecting the gut. Studies 25 , 26 of Lactobacillus GG (Culturelle) have suggested protection rates of up to 47 percent. More studies are needed to confirm the efficacy of probiotic prophylaxis. Agents for the prophylaxis of traveler’s diarrhea are summarized in Table 3 .

Empiric Treatment

Counseling travelers about food precautions does not eliminate the risk of traveler’s diarrhea, and nonantibiotic prophylaxis requires frequent dosing to achieve only a modest reduction in risk. In addition, the traveler with diarrhea may have difficulty accessing medical care, the quality of care may be poor, and the quality of medications purchased abroad may be substandard. 27 However, because antibiotics reduce the duration and severity of traveler’s diarrhea and generally are well tolerated, 28 providing the traveler with the means for empiric self-treatment can effectively reduce morbidity from traveler’s diarrhea.

Waiting 24 hours to confirm the diagnosis of traveler’s diarrhea results in unnecessary discomfort and time away from activities. Therapy can be initiated after the first episode of “distressing” diarrhea (i.e., diarrhea that is uncomfortable or interferes with activities). 29 , 30 If symptoms resolve within 24 hours, no further treatment is necessary. 31 , 32 If diarrhea persists after one day, treatment should be continued for one or two more days. An algorithm for the treatment of traveler’s diarrhea is presented in Figure 1 . 33 , 34

Antibiotic selection is based on the likelihood that an invasive organism is present and on antibiotic resistance patterns. These factors are determined largely by travel destination. Although blood in the stool suggests invasive disease, fever is not a sensitive indicator of dysentery. Fluoroquinolones have been the drug of choice for traveler’s diarrhea in most parts of the world because of their efficacy against most enteropathogens. Rifaximin recently became available for the treatment of noninvasive diarrhea caused by E. coli . For persons traveling to destinations where noninvasive E. coli is the predominant pathogen (e.g., Mexico), rifaximin is a good choice. 35 , 36

In regions where invasive pathogens are responsible for a significant proportion of traveler’s diarrhea, quinolones should be used. Azithromycin (Zithromax) is recommended in places where quinoloneresistant Campylobacter is prevalent (e.g., Thailand). 15 , 16 Antibiotics used for the treatment of traveler’s diarrhea are listed in Table 4 . 16 , 32 , 37 Trimethoprim-sulfamethoxazole (Bactrim, Septra) and doxycycline are no longer recommended because of the development of widespread resistance. 12

Therapy that involves an antibiotic with loperamide (Imodium) often limits symptoms to one day. 38 , 39 Loperamide has antimotility and antisecretory effects and is taken as two 2–mg tablets after the first loose stool, followed by one tablet after each subsequent loose stool (maximum of 8 mg in 24 hours for two days). The use of loperamide in dysentery has been controversial because of concerns about prolonging illness, but it is now considered safe when combined with an antibiotic. 29 , 34 , 38 A conservative approach would be to use loperamide for dysentery only if combined with an antibiotic and if the traveler has a long trip or will have no toilet access.

Oral rehydration solutions generally are unnecessary in adults younger than 65 years. 40 However, all travelers with diarrhea should be encouraged to drink plenty of fluids and to replace lost electrolytes using foods such as salt crackers or broth.

Traveler’s Diarrhea in Infants, Children, and Pregnant Women

Traveler’s diarrhea is more common in young children than in adults, and they have a higher risk of dehydration and severe illness. 41 Parents should seek immediate medical attention if their child shows signs of moderate to severe dehydration, bloody diarrhea, a temperature higher than 39°C (102°F), or persistent vomiting. Few data exist on the treatment of diarrhea in children. The use of oral rehydration solutions is essential, and parents should include prepackaged packets (to be mixed with safe water) in their travel kits. These packets are available in camping stores in the United States or in pharmacies in other countries.

Because infants and toddlers normally can have three or more loose stools, an alternate definition of diarrhea in this age group is a twofold increase in the frequency of unformed stool. 37 Nursing infants should continue to breastfeed on demand, and infants and older children should be offered their usual food.

Fluoroquinolones are not approved by the U.S. Food and Drug Administration (FDA) for use in children, and rifaximin is approved only for children 12 years and older. Therefore, azithromycin is the drug of choice for most children with traveler’s diarrhea. 37 Another option is nalidixic acid (Neggram) in a dosage of 55 mg per kg per day divided into four doses, not to exceed 1 g in 24 hours. 37 Loperamide is approved for children older than two years, but should not be used in children with dysentery. Bismuth subsalicylate should be avoided for prophylaxis in children because of the possible risk of Reye’s syndrome.

Pregnant women may be at higher risk of traveler’s diarrhea than nonpregnant women because of lowered gastric acidity and increased gastrointestinal transit time. 42 Quinolones (FDA pregnancy category C) generally are not advised during pregnancy, but azithromycin (FDA pregnancy category B) is safe. Oral rehydration should be emphasized. Although rifaximin is not absorbed, the safety of this medication in pregnant women has not been established. Loperamide (FDA pregnancy category B) may be used, but bismuth subsalicylate (FDA pregnancy category D) should be avoided. Being careful with food and water is particularly important during pregnancy because infections such as listeriosis can cause miscarriage, and hepatitis E can result in maternal mortality.

Complications

Dehydration is the main complication of traveler’s diarrhea, especially in children and older adults. Because E. coli O157:H7 is a rare cause of traveler’s diarrhea, there is little risk of hemolyticuremic syndrome. Other complications include Guillain-Barré syndrome after Campylobacter enteritis, Reiter’s syndrome (especially in persons who are HLA-B27 positive), Clostridium difficile colitis after antibiotic use, and postinfectious irritable bowel. These conditions may appear after the traveler has returned home.

If diarrhea persists despite antibiotic treatment, medical attention should be sought. Parasitic causes should be suspected in travelers who return with prolonged diarrhea or who do not respond to antibiotics. For those traveling to remote areas for extended periods, it is reasonable to discuss empiric treatment of protozoal infections (e.g., metronidazole [Flagyl] 250 mg three times a day for five days or tinidazole [Fasigyn] in a single 2–g dose for Giardia). 43

Resources such as the Travelers’ Health section of the CDC Web site ( http://www.cdc.gov/travel/diarrhea.htm ) or commercial sites such as Travel Health Online ( http://www.tripprep.com ) can keep physicians up to date on the epidemiology and resistance patterns of traveler’s diarrhea. Better preventive and prophylactic strategies will be needed until newer antibiotics become available and the sanitation and hygiene in developing countries improve.

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Travelers’ Diarrhea in Thailand: A Quantitative Analysis Using TaqMan® Array Card

Paphavee lertsethtakarn.

1 Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand

Sasikorn Silapong

Pimmada sakpaisal, oralak serichantalergs, nattaya ruamsap, woradee lurchachaiwong, sinn anuras.

2 Bumrungrad International Hospital, Bangkok, Thailand

James A Platts-Mills

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

Eric R Houpt

Ladaporn bodhidatta, brett e swierczewski, carl j mason.

The TaqMan® array card (TAC) was used to detect enteropathogens in stool samples from travelers’ diarrhea cases and asymptomatic controls in a hospital-based surveillance in Thailand. Analyses were performed to determine pathogen–disease association to compare TAC and conventional results.

Travelers’ diarrhea (TD) is a common illness experienced by travelers from developed countries who visit developing countries. Recent questionnaire-based surveillance studies showed that approximately 6%–16% of travelers experienced TD while visiting Thailand; however, a majority of TD information was limited mainly to US military populations.

A TD surveillance study was conducted at Bumrungrad International Hospital in 2012–2014 in Bangkok, Thailand. Enteropathogens were identified using conventional methods and the TaqMan® array card (TAC), which uses real-time polymerase chain reaction for the simultaneous detection of multiple pathogens. Analyses to determine pathogen–disease and symptoms association were performed to elucidate the clinical relevance of each enteropathogen.

TAC identified more pathogens per sample than conventional methods. Campylobacter spp. were the most prevalent, followed by the diarrheagenic Escherichia coli and norovirus GII. These agents had significant pathogen–disease associations as well as high attributable fractions among diarrheal cases. A wide range of pathogen loads for Campylobacter spp. was associated with TD, while heat-labile toxin enterotoxigenic Escherichia coli was associated with an increased pathogen load. Most cases were associated with inflammatory diarrhea, while Campylobacter spp. and Shigella spp. were associated with dysentery.

Conclusions

A pan-molecular diagnostic method such as TAC produces quantifiable and comparable results of all tested pathogens, thereby reducing the variability associated with multiple conventional methods. This allows better determination of the clinical relevance of each diarrhea etiologic agent, as well as their geographical relevance in Thailand.

Travelers’ diarrhea (TD) is one of the most common travel-related illnesses experienced by travelers from developed countries who visit developing countries [ 1 ]. Destination plays a major role in developing TD. Africa and South Asia are high-risk regions [ 1–3 ], and South America, Southeast Asia, and East Asia have reduced risks due to improved sanitation [ 3 ]. However, additional elements contribute to TD, including environmental and host factors [ 3 ].

Thailand, located in Southeast Asia, was the top regional tourist destination in 2015 [ 4 ]. In recent questionnaire-based surveillance studies, approximately 6%–16% of foreign visitors reported experiencing TD while visiting Thailand [ 5–7 ]. Information on the TD etiologic agents was limited to regional- or geographical-based reports [ 8 , 9 ]; however, specific reports from Thailand were focused on Campylobacter spp. [ 10 , 11 ]. To account for this limited data, a hospital-based TD case-control surveillance study of travelers to Thailand was conducted in Bangkok from 2012 through 2014. Stool samples were collected for routine laboratory diagnostics to identify potential enteric pathogens.

Conventional diagnostic approaches require multiple sample assessments for all suspected agents. This introduces variability between methods, is limited to the pathogens assessed, is labor intensive, and requires excess time and excess samples. Numerous studies have demonstrated that molecular diagnostic methods to determine diarrhea etiologic agents are sensitive, enable quantification, and estimate pathogen copy numbers required to better ascribe clinical relevance [ 12–15 ]. Here, stool samples were retrospectively tested with an enteric pathogen panel TaqMan® array card (TAC), which is a customizable microfluidic card for real-time polymerase chain reaction (PCR) [ 12 , 16–18 ].

TD etiology results generated from both conventional diagnostic methods and TAC were compared, and TAC was assessed as a potential diagnostic tool for the epidemiological study of TD. Additional evaluation and quantitative analyses were performed to determine pathogen–disease associations applicable to TD in Thailand.

Study Enrollment

Foreign travelers who visited Thailand were enrolled in a TD surveillance study from January 2012 through December 2014. Travelers were limited to citizens who originated from North America, Europe, Australia, New Zealand, Japan, Taiwan, and South Korea, were aged ≥18 years, and solicited the inpatient department or outpatient department services of Bumrungrad International Hospital located in Bangkok, Thailand. Diarrhea cases were defined as having 3 or more unformed stools per 24 hours; having 1 additional clinical symptom such as abdominal cramps, fecal urgency, nausea, vomiting, tenesmus, and fever; and waiting 7 days or less before soliciting treatment at the hospital. Controls were participants who visited the hospital for routine health examinations and had no history of diarrhea 2 weeks prior. Controls were matched to cases by age group, for example, 18–29, 30–39, 40–49, etc. Individuals who had resided outside of their home countries for more than 1 year were not eligible for the study. After obtaining written informed consent, a stool sample was provided by the study volunteer. Study participants were asked to complete a questionnaire that captured demographic, clinical, and medical history data. No follow-up was scheduled. The study was approved by the institutional review boards for both Bumrungrad International Hospital in Thailand and the Walter Reed Army Institute of Research, Silver Spring, Maryland.

Conventional Methodology

Stool samples were initially examined for fecal red blood cells (RBCs), white blood cells (WBCs), and ova and parasites by direct microscopic examination. Stool samples were then resuspended and inoculated onto the following selective media and enrichment broth: MacConkey, Hektoen, thiosulfate citrate bile salts sucrose, modified semisolid Rappaport Vassiliadis, modified charcoal cefoperazone deoxycholate agar, buffered peptone water, alkali peptone water, and Preston selective enrichment broth in order to culture Aeromonas , Arcobacter , Campylobacter , Escherichia coli , Plesiomonas , Salmonella , Shigella , and Vibrio spp. as previously described [ 19 ]. Subsequently, isolated colonies were identified by standard biochemical and serotype testing. Five lactose-fermenting and 5 nonlactose-fermenting E. coli were identified and selected for identification of the diarrheagenic E. coli by multiplex PCR assays as previously described [ 20–26 ]. Norovirus and sapovirus were detected by real-time reverse transcription (RT) PCR [ 27 , 28 ]. Commercial enzyme-linked immunosorbent assay kits were used to detect parasites ( Cryptosporidium , Entamoeba histolytica , and Giardia ; TECHLAB, Blacksburg, Virginia) and enteric viruses (adenovirus, astrovirus, and rotavirus; RIDASCREENR, R-Biopharm AG, Darmstadt, Germany) following the manufacturers’ instructions.

Testing With TaqMan® Array Card

Total nucleic acid was extracted using the QiaAmp Fast Stool DNA kit via the QIAcube extraction platform (Qiagen, Valencia, California) [ 29 ]. The testing using TAC was performed as previously described [ 18 , 29 ]. Briefly, 40 µL of extracted nucleic acid from each sample was mixed with 60 µL of reagents from Ag-Path-ID One-Step RT-PCR kit (Applied Biosystems, Foster City, California). This was loaded into each of the 8 ports of the TAC. The card was then sealed and loaded into the ViiA7 instrument (Applied Biosystems) [ 29 ]. Each TAC card contained a previously developed enteric pathogen panel [ 18 , 30 ] that included 12 bacteria ( Aeromonas , Bacteroides fragilis , Campylobacter spp. [ C. coli and C. jejuni ], Clostridium difficile , enteroaggregative Escherichia coli [EAEC], enteropathogenic E. coli [EPEC], enterotoxigenic E. coli [ETEC; heat-labile toxin (LT) and heat-stable toxin (ST)], Helicobacter pylori , Salmonella , Shigella /enteroinvasive E. coli [EIEC], Shiga toxin–producing E. coli [STEC], and Vibrio cholerae ); 2 fungi ( Encephalitozoon intestinalis and Enterocytozoon bieneusi ); 5 nematodes ( Ancylostoma duodenale , Ascaris lumbricoides , Necator americanus , Strongyloides stercoralis , and Trichuris trichiuria ); 5 protozoan parasites ( Cryptosporidium , Cyclospora cayetanensis , E. histolytica , Giardia lamblia , and Cystoisospora belli ); and 5 viruses (adenovirus, astrovirus, norovirus GI/GII, rotavirus, and sapovirus). Raw data files were processed using ViiA7 software, version 1.2.2 (Applied Biosystems), and analysis was performed as previously described [ 17 ]. An analytical cutoff (lower limit of detection) was applied at a threshold cycle (Ct) >35.

Statistical Analyses

Binary logistic regression and χ 2 tests were performed to calculate odds ratios (ORs), and the disease–pathogen load association was calculated using binary logistic regression with IBM SPSS Statistics, version 23. Analyses of symptoms and pathogen association included case data only. The attributable fraction (AF) was calculated using the following equation: prevalence × [1 − (1/OR)], and the 95% confidence interval (CI) was estimated using the “attribrisk” package in R. The disease–pathogen load association was performed by stratifying Ct values of each pathogen into the following groups: Ct <20, Ct = 20–25, Ct = 25–30, Ct = 30–35, and all strata were compared against Ct >35 (negative) as previously described [ 17 ]. Analyses were performed on all pathogens obtained from available positive cases and controls. Calculated P values <.05 were considered statistically significant.

A total of 338 participants (173 cases and 165 controls) were enrolled; 316 samples (154 cases and 162 controls) were available for testing and analysis by both conventional methods and TAC. The majority of cases were from Europe, and travelers from North America constituted most of the controls ( Table 1 ). The average age was 36.8 years for cases and 37.9 years for controls. More than 80% of the travelers had been in Thailand for less than 30 days at the time of enrollment. Clinical information and stool characteristics are summarized in Table 1 . Loose or watery stool was the predominant characteristic among cases, and soft stool was common among controls. All cases experienced at least 1 clinical symptom, with abdominal pain and/or fatigue reported as the primary additional complaint, and 23.4% experienced all clinical symptoms listed ( Table 1 ). Approximately 51% (78/154) of cases administered some form of self-treatment prior to seeking care at the hospital. Of those, 63% (49/78) took antibiotics; however, the percentage difference between antibiotic use and subsequent overall recovery of pathogens was not significantly different (data not shown) from that for cases who did not use antibiotics prior to seeking medical treatment ( Table 1 ).

Demographic and Clinical Information of Cases and Controls of Study Participants in Travelers’ Diarrhea Surveillance Study Who Visited Bumrungrad International Hospital in Bangkok, Thailand, from January 2011 through December 2014

Abbreviation: NA, not applicable.

a Patients treated their symptoms with more than 1 type of medication.

Comparative analyses on the diagnostic results were conducted for pathogens identified by both conventional and TAC methods. The overall detection accuracy by TAC was 95%. The average number of pathogens detected by conventional methods and TAC was 1.4 vs 2.0 for cases and 0.3 vs 0.7 for controls, respectively ( Table 2 ). A total of 143 samples (45.3%) were pathogen negative (25 cases and 118 controls) by routine conventional testing ( Table 2 ). TAC testing resulted in an additional 35 pathogen-positive samples, while 108 samples (16 cases and 92 controls) remained pathogen negative.

Number of Samples Categorized by Number of Pathogens Detected by Conventional Methods and TaqMan® Array Card

Campylobacter spp. was the most common pathogen detected in cases by both conventional and TAC methods (approximately 30% each; Table 3 ). The diarrheagenic E. coli (EAEC, EPEC, and ETEC) and norovirus GI and GII were detected more by TAC than by conventional methods for both cases and controls. The comparison of ORs for each pathogen by both methods revealed that Campylobacter spp., Salmonella , and norovirus GI and GII were significantly associated with TD ( Table 3 ). EAEC by TAC and Plesiomonas by conventional methods were also associated with TD ( Table 3 ). EPEC was coidentified in combination with other pathogens including EAEC, Campylobacter spp., and norovirus GI and GII in cases. The calculated ORs of these combinations were similar to the calculated ORs of each pathogen, indicating that EPEC did not significantly add to the association of each pathogen to TD. The AF is a metric that combines prevalence and OR to indicate a proportion of cases that can be attributed to a particular pathogen. Most of the TD cases were attributable to Campylobacter spp. (28%) and norovirus GII (23%; Table 3 ).

Summary of Detection Percentages in Travelers’ Diarrhea Case and Diarrhea-Free Control Samples, Odds Ratio, and Attributable Fraction of Each Pathogen by Conventional Methods and TaqMan® Array Card

Abbreviations: AF, attributable fraction; CI, confidence interval; EAEC, enteroaggregative Escherichia coli ; EIEC, enteroinvasive E. coli ; EPEC, enteropathogenic E. coli ; ETEC, enterotoxigenic E. coli ; LT, heat-labile toxin; OR, odds ratio; ST, heat-stable toxin; STEC, Shiga toxin-producing E. coli.

a Pathogen was only tested using either TaqMan® array card or conventional method, as indicated.

b The P value of Fisher exact test from χ 2 was significant when the odds ratio was not calculable with SPSS. The pathogens are listed by group in alphabetical order. Bacteria were detected by culture and biochemical methods. Diarrheagenic Escherichia coli were confirmed by polymerase chain reaction (PCR). Protozoan parasites, adenovirus, astrovirus, and rotavirus were detected by enzyme-linked immunosorbent assay. Norovirus and sapovirus were detected by reverse transcription real-time PCR.

In order to determine disease–pathogen load associations, Ct values were evaluated. Campylobacter spp. exhibited a significant disease–pathogen load on all analyzed Ct ranges, with a calculated OR of 9.2 (95% CI, 2.7–31.9), 5.8 (95% CI, 1.2–27.9), and 5.8 (95% CI, 1.6–21.1) for Ct ranges of 20–25, 25–30, and 30–35, respectively. LT-ETEC indicated a significant disease–pathogen load at Ct <20 with a reported OR of 9.5 (95% CI, 1.2–76.9), indicating that a higher pathogen load in combination with lower Ct was significantly associated with TD. Assessments of the remaining identified pathogens did not yield any significant disease–pathogen load association due to a diminished number of samples after stratification of Ct values or the lack of significant disease–pathogen load association ( Figure 1 ).

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Pathogen load and disease association. Positive threshold cycle (Ct) values (<35) were stratified into 4 groups as indicated on the x -axis and analyzed with binary logistic regression using negative results (Ct >35) as the reference group for each pathogen. *A statistically significant odds ratio at respective Ct cycles. Abbreviations: B. fragilis, Bacteroides fragilis ; Ct, threshold cycle; EAEC, enteroaggregative Escherichia coli ; EIEC, enteroinvasive E. coli ; EPEC, enteropathogenic E. coli ; ETEC, enterotoxigenic E. coli ; LT, heat-labile toxin; ST, heat-stable toxin; STEC, Shiga toxin-producing E. coli .

Using data obtained from both TAC and conventional methods to determine the correlation between pathogen and clinical symptoms demonstrated that among cases, norovirus GII was the only pathogen that was associated with vomiting, and Campylobacter spp. was associated with fever ( Figure 2 ). Approximately half of the cases had watery stool, which had a significant association with infection with Campylobacter spp., Salmonella , and norovirus GII ( Table 1 and Figure 2 ). These pathogens, along with other bacteria such as Plesiomonas , were also associated with the presence of mucus and WBCs in the stool, which are indicative of inflammatory diarrhea. In contrast, dysentery, as defined as a patient having a fever and the presence of RBCs in stool, was associated with Campylobacter spp. and Shigella spp. ( Figure 2 ).

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Associations between clinical symptoms, stool characteristics, and pathogen, as determined by conventional and TaqMan® array card methods. *A statistically significant odds ratio of each pathogen with respect to clinical symptoms and stool characteristics. Abbreviations: Conv., conventional; EAEC, enteroaggregative Escherichia coli ; EIEC, enteroinvasive E. coli ; EPEC, enteropathogenic E. coli ; ETEC, enterotoxigenic E. coli ; LT, heat-labile toxin; RBC, red blood cell; ST, heat-stable toxin; STEC, Shiga toxin-producing E. coli ; TAC, TaqMan® array card; WBC, white blood cell.

This is the first report of the use of the TAC enteric pathogen panel to detect diarrhea etiologic agents from an adult TD population in Bangkok, Thailand. Campylobacter spp. was the most prevalent pathogen detected by both TAC and conventional methods, which aligns with previous reports that Campylobacter spp. were the most prevalent cause of TD in Southeast Asia, particularly in Thailand [ 9 , 31 , 32 ]. ETEC, the most common cause of bacterial TD worldwide, was less prevalent than has been seen in studies from Africa, Latin America, and the Caribbean [ 2 , 3 , 33 ] but was still common. In this study, norovirus was one of the top three pathogens detected using both TAC and conventional methods, highlighting its importance related to TD in Thailand. Norovirus has been underreported in TD studies possibly because most TD studies do not include norovirus diagnostic testing [ 34 ].

The clinical features associated with TD in this population were mainly watery stool, as well as the presence of mucus and WBCs in stool, which are characteristics of inflammatory diarrhea. Plesiomonas was also significantly associated with TD with concurrent inflammatory diarrhea, as observed in previous reports [ 35 ]. Campylobacter spp. and Shigella were also associated with dysentery, which is consistent with their reported invasive nature [ 36 ]. Likewise, the association of noroviruses with vomiting aligns with their reported clinical features [ 37 ].

The difference between TAC and conventional methods resulted in different pathogen detection rates. Specifically, the culture-based method is restricted by the enrichment and selection processes; the molecular method focuses on a specific target gene, which limits the number of species being detected. The difference between these two methodologies was apparent with the detection of Salmonella spp. and Vibrio spp. by culture; the detection by TAC was species specific, which could affect the overall detection sensitivity ( Table 3 ). Likewise, the target genes for EAEC and EPEC were similar for conventional PCR and TAC [ 18 , 23 , 24 ]. However, colony selection for downstream molecular characterization of EAEC and EPEC was limited by the initial colony selection with the conventional method. Higher rates of EAEC and EPEC were previously reported with TAC in samples from children in developing countries [ 17 ]. Norovirus GI and GII were detected by real-time PCR but with slightly different primers and probes used by both methods [ 18 , 27 ] and specimens were tested at different times. The pan-molecular diagnostic method by TAC subjects all present pathogens to the same methodology at the same time, resulting in equal analysis and quantitation for each pathogen. While increased TAC detection led to a simultaneous detection of multiple pathogens, clinically relevant detection could be distinguished between high and low quantities, at least for Campylobacter spp. and ETEC ( Figure 1 ) [ 12 ].

The increased detection sensitivity also indicated that stool from travelers from developed countries might not be as pathogen free as previously expected. However, a traveler’s susceptibility to acquire pathogens and develop TD increase while traveling, depending on their general behavior, adaptive immunity, gut microbiome characteristics, and their genetic composition to include different histo-binding group antigens targeted by different norovirus strains [ 33 , 38 , 39 ]. However, for cases to remain negative even after being tested with a highly sensitive method such as TAC highlights the importance of novel causes of TD, including toxins and emerging pathogens.

Study limitations included the small population sizes of cases and controls and inclusion of study participants who experienced TD for up to 7 days and who took antibiotics prior to the hospital visit. The small population size did not allow a complete quantitative analysis of the data. Antibiotic use did not demonstrate a significant association with the overall pathogen recovery in this study, but it may enrich for viruses and/or fluoroquinolone-resistant Campylobacter spp. to predominate over other bacteria due to the high usage of fluoroquinolones for the treatment of TD [ 40 ]. The combination of these factors may bias the diagnostic results, especially with the culture method, and quantitative analyses to establish associations between disease and symptoms for each pathogen. However, comparative analyses demonstrated that TAC produced similar diagnostic results to conventional methods with noted difference in the diarrheagenic E. coli .

The TAC method was an effective tool for detecting TD etiologic agents, with reduced diagnostic variability, and allowed results to be analyzed quantitatively. However, this does not diminish the importance of conventional methods in studying TD, as culture is still needed to better understand evolution and pathogenicity of bacteria, as well as to determine antibiotic resistance profiles. An expanded TD surveillance study in Thailand and other countries using TAC will provide more information and a better understanding for a cross-comparison between different TD populations from different geographical locations.

Acknowledgments. The authors acknowledge the contribution and support from the study participants, enrolling nurses, the biostatistician, and laboratory technicians who performed all of the testing at the Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences.

Disclaimer. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the US government. Trade names are used for identification purposes only and do not imply endorsement. The investigators have adhered to the policies for protection of human participants as prescribed in AR 70-25.

Funding. This work was supported by the US Military Infectious Diseases Research Program (MIDRP) (Frederick, Maryland).

Potential conflicts of interest. All authors: No reported conflicts of interest. 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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Traveler's Diarrhea in Thailand: Randomized, Double-Blind Trial Comparing Single-Dose and 3-Day Azithromycin-Based Regimens with a 3-Day Levofloxacin Regimen

Article contents
Figures & tables
Supplementary Data

David R. Tribble, John W. Sanders, Lorrin W. Pang, Carl Mason, Chittima Pitarangsi, Shahida Baqar, Adam Armstrong, Paul Hshieh, Anne Fox, Elisabeth A. Maley, Carlos Lebron, Dennis J. Faix, James V. Lawler, Gautam Nayak, Michael Lewis, Ladaporn Bodhidatta, Daniel A. Scott, Traveler's Diarrhea in Thailand: Randomized, Double-Blind Trial Comparing Single-Dose and 3-Day Azithromycin-Based Regimens with a 3-Day Levofloxacin Regimen, Clinical Infectious Diseases , Volume 44, Issue 3, 1 February 2007, Pages 338–346, https://doi.org/10.1086/510589

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Background .Traveler's diarrhea in Thailand is frequently caused by Campylobacter jejuni. Rates of fluoroquinolone (FQ) resistance in Campylobacter organisms have exceeded 85% in recent years, and reduced fluoroquinolone efficacy has been observed.

Methods .Azithromycin regimens were evaluated in a randomized, double-blind trial of azithromycin, given as a single 1-g dose or a 3-day regimen (500 mg daily), versus a 3-day regimen of levofloxacin (500 mg daily) in military field clinics in Thailand. Outcomes included clinical end points (time to the last unformed stool [TLUS] and cure rates) and microbiological end points (pathogen eradication).

Results .A total of 156 patients with acute diarrhea were enrolled in the trial. Campylobacter organisms predominated (in 64% of patients), with levofloxacin resistance noted in 50% of Campylobacter organisms and with no azithromycin resistance noted. The cure rate at 72 h after treatment initiation was highest (96%) with single-dose azithromycin, compared with the cure rates of 85% noted with 3-day azithromycin and 71% noted with levofloxacin ( P = .002). Single-dose azithromycin was also associated with the shortest median TLUS (35 h; P = .03, by log-rank test). Levofloxacin's efficacy was inferior to azithromycin's efficacy, except in patients with no pathogen identified during the first 24 h of treatment or in patients with levofloxacin-susceptible Campylobacter isolates, in whom it appeared to be equal to azithromycin. The rate of microbiological eradication was significantly better with azithromycin-based regimens (96%–100%), compared with levofloxacin (38%) ( P = .001); however, this finding was poorly correlated with clinical outcome. A higher rate of posttreatment nausea in the 30 min after receipt of the first dose (14% vs. <6%; P = .06) was observed as a mild, self-limited complaint associated with single-dose azithromycin.

Conclusions .Single-dose azithromycin is recommended for empirical therapy of traveler's diarrhea acquired in Thailand and is a reasonable first-line option for empirical management in general.

In Thailand, surveys conducted among deployed US military personnel have shown that Campylobacter jejuni and Campylobacter coli account for 20%–60% of cases of diarrhea [ 1–3 ]. In recent years, fluoroquinolone (FQ) resistance has been noted in >85% of Campylobacter isolates from Thailand [ 4 ]. Increasing FQ resistance led US Department of Defense researchers to investigate azithromycin as an alternative therapy for traveler's diarrhea in Thailand in 1993 [ 2 ]. The efficacy of azithromycin, 500 mg daily, was comparable to that of ciprofloxacin, 500 mg daily, administered in a 3-day regimen. Limited statistical power prevented detection of differences in effects. There were only 2 clinical failures, both of which occurred in patients with Campylobacter -associated diarrhea treated with ciprofloxacin ( n = 37). Improved eradication of Campylobacter organisms by use of azithromycin therapy did not translate into clinical differences. A reduced duration of illness was noted in association with the use of ciprofloxacin in as many as 40% of cases of non- Campylobacter -associated diarrhea, and this finding led experts to cautiously recommend continued first-line therapy with FQs at that time [ 5 ].

The rate of FQ resistance among Campylobacter organisms in the previous trial was ∼65%. This rate increased to ⩾80% by 1998, with observational data suggesting decreasing effectiveness of FQs [ 3 ]. The objective of the present study was to compare a 3-day FQ regimen with 2 azithromycin-based regimens (a 3-day multidose regimen and a single-dose regimen).

Participants and subject eligibility .The trial was conducted during May 2000 in Nakhon Sri Thammarat. Thailand, and during May 2001 in Phitsanulok, Thailand. US military personnel who presented with acute diarrhea at a field clinic were enrolled in the trial after they provided written informed consent. Diarrhea was defined as the occurrence of either ⩾3 loose stools or ⩾2 loose stools with ⩾1 associated complaint (e.g., abdominal cramps, nausea, vomiting, or fever) during a 24-h period. Additional inclusion criteria included symptoms with a duration of ≤96 h and ambulatory management. Exclusion criteria included pregnancy, an allergy to macrolides or FQs, and receipt of antibiotics (excluding malaria prophylaxis) in the 72 h before enrollment. The use of antidiarrheal medications (e.g., loperamide) after enrollment was not allowed.

Dose selection, treatment assignment, randomization, and blinding procedures .The rationale for use of the 1000-mg single dose of azithromycin was the efficacy noted when a total of 1.5 g was administered over 3 days [ 2 ], as well as more recent experience demonstrating the efficacy of a single 1000-mg dose in the treatment of Shigella dysentery [ 6 ]. Adverse gastrointestinal effects associated with the use of azithromycin administered in single doses of >1 g, particularly for patients who had diarrheal illness with frequent nausea and vomiting at baseline, were also a consideration. The Clinical Research Division of Pfizer Pharmaceuticals supplied the study medications—azithromycin (500 mg daily for 3 days or a single 1000-mg dose) and levofloxacin (500 mg daily for 3 days)—and identical-appearing placebos at no cost. Medicines were dispensed in a 3-day package, with a separate bottle provided for each treatment day. The Pfizer pharmacy supplied computer-generated random-number codes with a block size of 6, which were sequentially assigned at presentation. The blinding procedure was maintained during the laboratory and analysis phases of the trial.

Clinical monitoring .A standardized medical evaluation was used with rehydration therapy, as necessary. The first antibiotic dose was administered under direct observation, with volunteers observed for 30 min. A diary card was provided to record the number of loose stools (per 6-h period), symptoms, functional ability, and medication compliance. Clinical follow-up at 24 h and 72 h monitored for outcomes and drug toxicity. A stool specimen was collected at 5–7 days after treatment initiation, to evaluate pathogen eradication.

Stool microbiological analysis .Primary stool microbiological analysis was undertaken at a field laboratory, as described elsewhere [ 3 ]. Campylobacter species were isolated using a membrane filter method on nonselective blood agar [ 7 ]. Isolates were transported to the Armed Forces Research Institute of Medical Sciences in Bangkok, Thailand, for species identification performed as described elsewhere [ 8 , 9 ]. Stool specimens were examined for the presence of rotavirus and calicivirus antigens by use of a commercially available ELISA (Rotazyme; Abbott Laboratories) and a noncommercial antigen-capture Calicivirus ELISA [ 10 ].

Campylobacter antibiotic susceptibility testing was performed using the E test strip methods (AB Biodisk) for azithromycin, levofloxacin, and ciprofloxacin [ 11 ], with incubation conducted at 37°C in microaerobic conditions. Established interpretative criteria for Enterobacteriaceae were used [ 12 ]. Resistance criteria for Campylobacter species, according to the drug received, were as follows: for ciprofloxacin, an MIC ⩾4 µg/mL; for levofloxacin, an MIC ⩾8 µg/mL; and for azithromycin, an MIC ⩾8 µg/mL [ 13 ]. The upper limit of the FQ MIC was 64 µg/mL (this value was coded for calculation purposes). Antibiotic susceptibility testing of non- Campylobacter isolates was performed using the disk diffusion method [ 4 ].

Outcome measures .The primary outcomes were abatement of diarrhea and the duration of illness. Clinical cure was defined as resolution of diarrhea and associated symptoms within 72 h. The time to the last unformed stool (TLUS) was defined as the time to the last loose/liquid stool occurring in a 24-h period and meeting the definition of diarrhea. A microbiological cure was defined as eradication of isolates 48–72 h (inclusive period, days 5–9) after the last treatment day. Isolate eradication was evaluated for an association with clinical outcomes.

Statistical analysis .The outcome used to estimate study size (60 participants per group) was the clinical cure rate determined using a 20% effect size (80% power), given previously observed FQ cure rates of 75% at 72 h (D.R.T., unpublished data). Lower rates of diarrhea in year 2 led to lower-than-expected enrollment. Intention-to-treat analysis is presented with the subject outcome coded as treatment failure if follow-up is lacking. The majority of the results presented are based on data for evaluable subjects. An evaluable subject was defined as a patient completing a regimen and 72 h of follow-up or a patient requiring treatment modification because of illness progression during the monitoring period.

Characteristics at baseline and summary findings were compared using analysis of variance, Kruskal-Wallis tests, and χ 2 tests, as appropriate [ 14 ]. Confidence intervals were generated using a normal approximation to the binomial distribution. Differences in recovery times were evaluated using Kaplan-Meier analyses, log-rank tests, and generalized Wilcoxon tests [ 14 ]. All tests were 2-tailed, and P < .05 was considered to be statistically significant. Data were entered into EpiInfo software, version 6.04 (Centers for Disease Control and Prevention). Statistical analyses were performed using SPSS software for Windows, version 10.1 (SPSS).

Study approval .This study was approved by the ethics review committees of the Naval Medical Research Center (protocol #31528), the Walter Reed Army Institute of Research (protocol #792), and Uniformed Services University of the Health Sciences (protocol G187MT), in compliance with all federal regulations governing the protection of human subjects.

Patient enrollment and characteristics .A total of 156 (70%) of 222 military personnel met the criteria for entry into the trial (63% of patients were enrolled in 2000). The median patient age was 26 years; the participants were predominantly male (89%) and of junior enlisted rank (71%). Previous travel in Thailand was reported by 27% of patients. A previous episode of traveler's diarrhea was relatively uncommon (16% of patients). Malaria prophylaxis was used for 87% of patients overall, with doxycycline used for 97% of these patients and mefloquine used for the remainder. There were no differences in these characteristics between groups. Observed differences between groups included a slightly higher percentage of women among recipients of single-dose azithromycin (19% vs. 4%–9%), as well as a history of less frequent traveler's diarrhea (6% vs. 22%–26%) and travel to Thailand (17% vs. 31%–33%) among levofloxacin recipients. table 1 shows group comparisons of clinical manifestations.

Clinical manifestations, laboratory findings, and management at presentation, by treatment group.

A total of 8 volunteers were disenrolled from the trial for the following reasons: treatment modification ( n = 4), being lost to follow-up ( n = 3), and noncompliance ( n = 1). Treatment modification occurred as a result of persistent diarrhea without improvement in 1 patient (at day 3) and progression to dysenteric illness in 2 patients (at days 3 and 6). The other patient who had treatment modification sought care for worsening symptoms on the night after enrollment and was prescribed azithromycin by a nonstudy provider. The decision to provide azithromycin to these 3 patients was based on preliminary culture results (patients were Campylobacter positive) and the known high rates of FQ resistance. These 3 patients were later confirmed to have received levofloxacin and were infected with levofloxacin-resistant C. jejuni. All 4 patients experienced symptom resolution within 3 days and were censored for time-to-event analyses. Patients that met the criteria for clinical failure were most commonly provided symptomatic support (79%) and were monitored until symptom resolution.

Distribution of enteric pathogens .An enteric pathogen, typically bacterial, was identified in 81% of patients, with multiple isolates identified in 18% ( table 2 ). Campylobacter species was the most commonly isolated pathogen (recovered from 64% of patients; C. jejuni was isolated from 95% of these patients, and C. coli was isolated from the remainder of the patients), followed by nontyphoidal Salmonella species (recovered from 17% of patients). According to the E test, no Campylobacter species demonstrated azithromycin resistance (MIC 50 , 0.047 µg/mL; MIC 90 , 0.094 µg/mL), whereas 50% of isolates were levofloxacin resistant (MIC 50 , 6.0 µg/mL; MIC 90 >64.0 µg/mL) and 93% were ciprofloxacin resistant (MIC 50 , 16.0 µg/mL; MIC 90 , >64.0 µg/mL). The rates of antibiotic resistance among non- Campylobacter bacterial isolates were as follows: for Escherichia coli ( n = 18), the rate of levofloxacin resistance was 3.8% and that of azithromycin resistance was 5.6%; for Salmonella organisms ( n = 28), there was no levofloxacin resistance, but the rate of azithromycin resistance was 14%; and for Plesiomonas species ( n = 11), there was no levofloxacin resistance or azithromycin resistance.

Distribution of enteric pathogens at presentation, by treatment group.

Clinical outcomes .Clinical resolution was uncommon by 24 h, irrespective of the regimen followed, with levofloxacin associated with the highest cure rate (25%), primarily among patients with no pathogen identified ( table 3 ). Azithromycin regimens had significantly improved cure rates, compared with levofloxacin regimens, as early as 48 h after treatment initiation (53%–65% vs. 38%; P = .02) and, also, at 72 h (85%–96% vs. 71%; P = .001). Intent-to-treat analysis demonstrates similar clinical cure outcomes. The 72-h cure rate for single-dose azithromycin was 94%, compared with 80% for a 3-day regimen of azithromycin and 70% for levofloxacin ( P = .006). A direct comparison of azithromycin-based regimens, by use of intent-to-treat analysis, demonstrated the superior cure rate of the 1-g single-dose regimen ( P = .04). A trend toward improved cure in evaluable patients was observed for the single-dose azithromycin group, compared with group following the 3-day regimen ( P = .09). No notable differences were noted for other measures of clinical outcome, including the mean number of loose stools, the median time to the last loose stool or first formed stool, and the duration of non-diarrhea-associated symptoms.

Clinical and microbiological outcomes, by treatment group.

TLUS indicated prolongation of illness in the levofloxacin group ( figure 1 ) ( P = .03, by log-rank test). The mean TLUS was 39 h (95% CI, 31–47 h) for patients receiving single-dose azithromycin, compared with 43 h (95% CI, 34–51 h) for those receiving the 3-day azithromycin regimen and 56 h (95% CI, 42–71 h) for those receiving levofloxacin. figure 2 stratifies TLUS by isolation of Campylobacter species, demonstrating no differences among patients with non- Campylobacter diarrhea by treatment received. A prominent difference was observed in Campylobacter -associated diarrhea between patients receiving levofloxacin with levofloxacin-resistant isolates, compared with other patients (the mean TLUS was 41 h for patients receiving single-dose azithromycin, 41.2 h for patients with levofloxacin-susceptible pathogens, 47 h for patients receiving the 3-day azithromycin regimen, and 76.4 h for patients with levofloxacin-resistant pathogens).

Time to cure (after receipt of the first antibiotic dose), by treatment group.

Time to cure (after receipt of the first antibiotic dose), by treatment group, as stratified by diagnosis of Campylobacter infection. Azithro, azithromycin; Levo, levofloxacin.

Two patients in the group receiving the 3-day azithromycin regimen experienced relapse of illness. One patient had initial cure at 54 h, followed by a 48-h symptom-free period and then by a 24-h episode in which 7 loose stools were noted without associated complaints. The second subject had initial cure at 72 h, followed by a 72-h symptom-free period and then by a 24-h episode in which 2–3 loose stools, mild nausea, and vomiting were noted. Neither subject required additional treatment. Follow-up microbiological analysis of stool specimens detected no pathogens. Both patients had pretreatment C. jejuni isolates, with eradication occurring by day 3 of treatment.

Microbiological outcome .Microbiological cure rates were much higher for azithromycin-based regimens, primarily as a result of Campylobacter -associated diarrhea ( table 3 ). An eradication rate of ∼100% was observed with azithromycin, compared with the 21% rate noted for levofloxacin ( P < .001). Of patients receiving levofloxacin who had Campylobacter -susceptible strains before treatment ( n = 8), 63% had in vivo resistance develop, with a posttreatment MIC >32 µg/mL; however, in vivo resistance was not associated with therapeutic failure or relapse. A single patient who had azithromycin-susceptible (MIC, 0.064 µg/mL) C. coli (Lior 55) treated with the 1-g dose had a Lior nontypeable, highly resistant (MIC, >256 µg/mL) isolate recovered on days 3 and 7. The patient reported a last diarrheal stool at 71 h after treatment without experiencing relapse. One patient in the group receiving the 3-day azithromycin regimen also had a highly susceptible (MIC, 0.064 µg/mL) C. jejuni (Lior 36) isolate before treatment, with recovery of a Lior nontypeable highly resistant (MIC, >256 µg/mL) isolate occurring on day 3 of treatment. This subject had resolution of diarrhea 4.5 h after receipt of the first dose and did not attend a follow-up visit for posttreatment stool culture.

Eradication of the pretreatment isolate did not correlate with clinical cure at the 72-h end point. In the azithromycin treatment groups, 6 patients experienced clinical failures at 72 h, and all had microbiological cure. In the levofloxacin treatment group, 7 clinical failures occurred, with only 2 patients (29%) having a microbiological cure. A similar rate of microbiological cure was observed in the 14 levofloxacin-treated patients who met the clinical cure outcome (36%). Overall, microbiological cure was observed in 84% and 62% of patients with or without clinical cure, respectively.

Adverse events .Surveillance demonstrated no severe side effects. Single-dose azithromycin was associated with an increased rate of mild to moderate nausea not associated with vomiting and lasting ∼1 day ( table 4 ). The complaint was uncommon, with 14% of patients reporting nausea 30 min after receipt of the first dose and with 1 episode associated with vomiting (without pill contents), and with 17% of patients reporting nausea as a new symptom occurring over the next 3 days. Self-limited vaginal pruritus not requiring medication was reported in 2 patients receiving levofloxacin. Transient rash that was most consistent with heat rash was observed in 1 patient in each of the azithromycin treatment groups. Headache was reported in 22%–35% of patients, and transient dizziness was reported in 8%–12% of patients, without group differences.

Surveillance for posttreatment nausea and vomiting, by treatment group.

Azithromycin was definitively demonstrated to be the preferred antibiotic for empirical treatment of traveler's diarrhea in Thailand. An equivalent time to recovery for patients infected with susceptible Campylobacter strains was observed for levofloxacin and azithromycin. Levofloxacin resistance measured in vitro was shown to correlate with a significantly prolonged time to recovery. The single 1-g dose had superior efficacy. Azithromycin has favorable pharmacokinetics for single-dose treatment of bacterial diarrhea, with an 11–14-h half-life, 46% of active drug passed in the feces, and high levels in the gut lumen (>200 µg/mL) [ 16 , 17 ]. A single lower dose would be desirable, given dose-related nausea and vomiting. Rates of new-onset nausea (8%–17%) higher than those reported in association with nongastrointestinal infections (<1%–3%) are likely caused by exacerbating effects of the primary illness [ 18 ]. Given the superior efficacy, improved compliance, and ease of dosing, the mild transient side effects would seem to be outweighed toward selection of the single-dose regimen.

A single 1-g dose of azithromycin was efficacious in travelers to Mexico [ 19 ]. Among azithromycin recipients, 52% of patients had enterotoxigenic E. coli (ETEC) recovered, 5% had Shigella strains recovered, and no patients had Campylobacter strains recovered; in addition, azithromycin recipients also had a TLUS <24 h and no increase in nausea/vomiting, 58% had microbiological eradication, and 9.5% experienced treatment failure. More rapid abatement of diarrhea, compared with that noted in our study, is consistent with therapeutic responses observed in trials conducted in regions where ETEC is the predominant pathogen, even without the use of antimotility agents [ 1 , 2 , 20 , 21 ]. Lower 24-h cure rates (36%–38%) noted in an FQ-based trial in Thailand, where Campylobacter -associated diarrhea accounted for 41% of cases, are more comparable, although cure rates of >20% are still observed [ 1 ]. The current trial enrolled patients with a broader spectrum of illness, whereas the earlier study excluded patients with dysentery and fever (temperature, >38.3°C), likely accounting for the higher 24-h cure rates [ 1 ]. The rapid cures (those occurring in <24 h) noted in patients with “no pathogen isolated” who were receiving levofloxacin may represent unrecognized enteroaggregative E. coli or other pathogenic E. coli diarrhea [ 22 ].

Acquired in vivo ciprofloxacin resistance is well described in persons with Campylobacter infection [ 23 ]. Frequently, the acquired resistance occurs with the patient experiencing no adverse clinical effects, although it also occurs in the context of clinical relapse [ 1 ]. In some studies surveying for acquired resistance, such resistance has either not been observed [ 2 , 24 ] or has occurred in as many as 6 of 9 patients [ 25 ]. Our study documented a 63% rate of acquired resistance without clinical relapse. The clinical relevance of the difference in rates of resistance between ciprofloxacin and levofloxacin among the Campylobacter isolates is unknown. Levofloxacin was reported to be 2-fold more potent than ciprofloxacin against C. jejuni in vitro [ 26 ]. MIC thresholds using clinical correlation for diarrheal illness remain to be defined [ 27 ].

The concurrent use of doxycycline for malaria prophylaxis in a majority of patients complicates the interpretation of results. Stratified analysis did not demonstrate a confounding effect. Doxycycline prophylaxis for traveler's diarrhea has been extensively studied in travel destinations or regions where ETEC is the predominant pathogen, with prophylactic efficacy ranging from 44% to 90% [ 28 , 29 ]. Doxycycline had no effect on resistant ETEC or on rates of diarrhea or distribution of pathogens among deployed military personnel in Thailand [ 28–30 ]. Campylobacter isolates had high rates of tetracycline resistance (86%), as was also observed for E. coli isolates (83%) and Salmonella isolates (89%), compatible with selective pressure.

Campylobacter eradication secondary to azithromycin was near 100% as early as 3 days after treatment initiation, consistent with the reported time to clearance (mean, 1.1 days) of C. jejuni after erythromycin treatment [ 31 ]. Of concern, was the occurrence, although uncommon, of high-level azithromycin-resistant Campylobacter species in 2 azithromycin-treated patients. These patients possibly had coinfection with susceptible and resistant Campylobacter strains. Mixed infections with multiple Campylobacter species or strains have been reported at rates of 7.5% [ 32 ] and were observed in this study in pretreatment cultures (rate, 5.1%). Azithromycin is an antibiotic that is widely used, particularly for the treatment of acute respiratory infections. A concern regarding broadening azithromycin indications to include acute bacterial enteritis is the development of resistance, as has been observed with treatment with FQs. Macrolide resistance in C. jejuni has been relatively stable worldwide (rate of resistance, 0%–11% [with higher rates noted for C. coli ]) [ 33 ]. Azithromycin resistance among Campylobacter strains has been observed in past surveys of military personnel (rate, 7%–15%) [ 34 ] and in Thai children with diarrhea (rate, 6% [with dual resistance to ciprofloxacin]) [ 35 ]. The current report demonstrated no azithromycin resistance among Campylobacter strains.

A recent multisite survey of azithromycin susceptibility (predominantly among ETEC, enteroaggregative E. coli and Salmonella and Shigella strains) demonstrated an MIC 90 of 0.0625 µg/mL providing greater confidence for broader clinical use [ 36 ]. Nontyphoidal Salmonella isolates with reduced nalidixic acid and FQ susceptibility have been documented in travelers returning from Southeast Asia (most commonly, Thailand) [ 4 , 37 ]. FQ-resistant Salmonella isolates were not observed in this trial, although ∼4% of the E. coli isolates were levofloxacin resistant, with rates of azithromycin resistance of 6%–14% noted for non- Campylobacter bacterial pathogens. Also of concern are nalidixic acid resistance rates of 43%, 17%, and 18% in Salmonella, E. coli and Plesiomonas isolates, respectively.

Alternative antibiotics for traveler's diarrhea continue to be needed, given progressive emergence of resistance. FQ-resistant travel-associated and domestic Campylobacter -associated diarrhea in industrialized countries have increasingly been reported and are not restricted to such countries as Thailand and Spain [ 38 , 39 ]. An alternative agent is the nonabsorbable antibiotic rifaximin, which has documented efficacy equal to that of ciprofloxacin in regions where ETEC is predominant [ 40 ]. Rifaximin was ineffective in the treatment of Campylobacter -associated diarrhea, with a clinical cure rate of only 23.5% (as detailed in the package insert), making this a poor choice for an area such as Thailand.

Antibiotic therapy for acute diarrhea should be restricted to patients with moderate to severe illness, individuals at risk for poor clinical outcomes based on comorbid illnesses, or high-tempo settings with complicating issues, such as the risk of heat-associated illness (which frequently is the case in deployed military personnel). In addition, given current azithromycin use in children and during pregnancy, these data for acute bacterial enteritis can likely be extrapolated for clinical application where concerns exist for FQ use and alternative antibiotics are lacking. In conclusion, single-dose (1-g) azithromycin is recommended for empirical therapy of travelers' diarrhea acquired in Thailand and, on the basis of a synthesis of the clinical studies, is a reasonable first-line option for empirical management of traveler's diarrhea.

We thank the technicians and staff of the Naval Medical Research Center (Silver Spring, MD) and the Armed Forces Research Institute of Medical Sciences (Bangkok, Thailand) for their microbiology expertise and assistance with study conduct. We also thank the medical staff during the Cobra Gold exercises and the voluntary participation of US military personnel.

Potential conflicts of interest .All authors: no conflicts. Pfizer Pharmaceuticals Clinical Research Division (Groton, CT) supplied study medications and placebo formulations at no cost.

Financial support .This work was supported by Work Unit Number 643807A.849.D.A0002 and is in partial support of a doctoral thesis in public health at the Uniformed Services University (Bethesda, MD).

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Presented in part: 8th Conference of the International Society of Travel Medicine, 7–11 May 2003, New York City, New York (abstract FC10.02).

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of Navy, Department of Defense, or the US Government. The corresponding author is an employee of the US Government. This work was prepared as part of my official duties. Title 17 US Code 101 defines a US Government work as a work prepared by a military service member or employee of the US Government as part of that person's official duties.

azithromycin
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levofloxacin
traveler's diarrhea
pathogenic organism
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Published: 07 June 2019

Epidemiology and etiology of Traveler’s diarrhea in Bangkok, Thailand, a case-control study

Ladaporn Bodhidatta ORCID: orcid.org/0000-0002-6965-9183 1 ,
Sinn Anuras 2 ,
Siriporn Sornsakrin 1 ,
Umaporn Suksawad 1 ,
Oralak Serichantalergs 1 ,
Apichai Srijan 1 ,
Orntipa Sethabutr 1 &
Carl J. Mason 1 , 3

Tropical Diseases, Travel Medicine and Vaccines volume 5 , Article number: 9 ( 2019 ) Cite this article

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Traveler’s diarrhea (TD) is a common health problem among visitors from developed to developing countries. Although global and regional estimates of pathogen distribution are available, the etiology of diarrhea among non-military travelers to Thailand is largely unknown.

A prospective TD case-control study was conducted among adult travelers from developed countries at a prominent hospital in Bangkok, Thailand during 2001–2003. Stool samples were collected from acute TD cases and non-diarrheal controls and analyzed for bacterial, viral, and protozoan pathogens by microbiology, ELISA or PCR methods. Calculation of adjusted odd ratios for risk factors was performed by logistic regression using STATA statistical software.

Stool samples were collected and analyzed from 389 TD cases and 400 non-diarrhea controls. At least one pathogen was detected in 227 (58%) cases and 124 (31%) controls. Plesiomonas (14%), Vibrio (14%), Campylobacter (14%), and norovirus (12%) were the most frequently isolated pathogens among cases and significantly associated with diarrhea at p = 0.006, p < 0.001, p < 0.001, p < 0.001, respectively. Shigella (3%) and ETEC (8%), detected in lower prevalence, also showed significant association with TD at p < 0.001 and p = 0.002, respectively. Travelers from East Asian countries had an increased risk of Vibrio infection (Crude odds ratio: 3.1, p -value = 0.001); travelers from the United States, Canada, and Europe had an increased risk of Campylobacter infection (Crude odds ratio: 2.6, p -value = 0.001); and travelers from Australia and New Zealand had an increased risk of Salmonella infection (Crude odds ratio: 3.2, p -value = 0.009).

Conclusions

Etiology of TD in Thailand is mainly of bacterial origin. Plesiomonas, Vibrio, and norovirus are underappreciated diarrheagenic pathogens. In our study, the origin of the traveler plays an important role in diarrhea etiology. Understanding variations in TD severity and etiology among travelers from different regions warrants further study.

Traveler’s diarrhea (TD) is the most common health problem facing residents of developed countries who visit developing regions. Travelers most frequently develop TD within their first week(s) abroad [ 1 , 2 , 3 ]. Although TD in most cases resolves spontaneously within a few days without treatment and is unlikely to be fatal, it has a significant impact on quality of life and economics of healthcare service use, travel change expenses, loss of man-hours, and changes of vacation or business plans [ 4 , 5 ]. As many as 40% of TD cases modify their activities, 23% seek medical treatment, and 1% require hospitalization [ 5 , 6 , 7 , 8 ].

A systematic review of global TD etiology reported Enterotoxigenic Escherichia coli (ETEC) and Enteroaggregative E. coli (EAEC) as the most common diarrhea-causing pathogens isolated in 30.4 and 19.0% of TD cases respectively [ 9 ]. However, significant regional variations in pathogen distributions have been reported. In Southeast Asia, Campylobacter (32.4%) and Enteropathogenic E. coli (EPEC) (18.0%) have been isolated most frequently, and multiple pathogen infections are apparently more common than in other regions [ 8 , 9 ]. More detailed knowledge of regional pathogen distribution may enable more accurate predictions of vaccine-preventable disease and may also have implications for empiric treatment and pre-travel health advice.

The etiology of TD in adult travelers to Bangkok is largely unknown. Previous reports from Thailand on the etiology of TD largely focused on military populations whose unique risk profile, activities and travel history may differ from ordinary travelers and affect the TD epidemiology [ 5 , 10 , 11 , 12 , 13 ]. Moreover, military deployments may not be ideal for surveillance of TD etiology in Thailand due to the limited numbers of subjects, short duration of travel, and restricted activities and locations. Studies of non-military TD in Thailand have focused on epidemiology or tested for a limited number of pathogens [ 14 , 15 , 16 , 17 , 18 , 19 ].

We conducted a prospective case-control study of patients presenting with TD to Bumrungrad International Hospital in Bangkok, Thailand during 2001–2003 in order to describe both TD etiology and epidemiology among adult residents of developed countries visiting Thailand.

Study population

Between January 2001 and January 2003, cases were recruited from adult residents of developed countries (Australia, Canada, Europe, Japan, South Korea, Taiwan, New Zealand and the United States) presenting with acute diarrhea of no more than 72 h duration to the Bumrungrad International Hospital in Bangkok, Thailand. Diarrhea was defined as three or more loose stools in the preceding 24 h with at least one additional symptom, such as nausea, vomiting, abdominal pain, fatigue, fecal urgency, or fever. Controls were recruited from adult residents of the countries mentioned above with no history of diarrhea in the preceding two weeks presenting to the Bumrungrad International Hospital for health screening or immunizations. Cases and controls were at least 20 years of age and were travelers or expatriates to Thailand.

Data regarding demographic, symptoms, antibiotic usage and travel history from both cases and controls were collected by study nurses. Each subject’s travel history was categorized by the highest risk destination visited during the seven days prior to diarrhea onset according to the country risk levels assigned by Greenwood et al. [ 20 ]. Subjects with missing or discrepant data were excluded from analysis.

Written informed consent was obtained from each participant prior to enrollment. This study was approved by the Institutional Review Board of the Walter Reed Army Institute of Research and the Ethical Review Committee for Research in Human Subjects, Ministry of Public Health, Thailand.

Sample collection

Approximately 5 g of stool specimen were collected from each case and control. If a stool specimen was unobtainable, three rectal swabs were collected. Stool samples were transported to the nearby AFRIMS for processing within 4 h of collection. Three aliquots of one gram each were taken and stored at −70 °C for further testing.

Microscopy and parasitology

Briefly, direct microscopic stool examination for red blood cells, white blood cells and parasites and a formalin-ether concentration technique for parasites was performed on each stool sample.

The microbiology techniques used in this study have been previously described elsewhere [ 21 ]. Briefly, stool was inoculated onto MacConkey (MC), Hektoen Enteric (HE), Thiosulfate Citrate Bile Salts Sucrose (TCBS), Modified Semisolid Rappaport Vassiliadis (MSRV) agar and enrichment media [Selenite F (SF), Alkaline Peptone Water (APW), Buffer Peptone Water (BPW), and Doyle]. Subsequently, subcultures from APW were plated on TCBS and subcultures from SF and BPW were plated onto MC, HE and MSRV. Subculture plates were incubated as previously described [ 21 ]. Culture for Campylobacter was performed both by inoculation of millipore filtered stool and by subculture of Doyle enrichment media after millipore filtration on Brucella agar (BA) with sheep blood and incubation under microaerobic conditions. Campylobacter isolates were identified at species level by using conventional phenotypic tests for Campylobacter [ 22 ]. Shigella and Vibrio isolates were subsequently serotyped using Denka-Seiken antisera (Denka-Seiken, Tokyo, Japan). Salmonella isolates were serogrouped using Serotest antisera (S&A Reagents Lab, Bangkok, Thailand).

Up to 5 lactose fermenting and 5 non-lactose fermenting E. coli as identified on MC agar were saved on Dorset egg yolk media slants. E.coli isolates were tested by hybridization with specific Digoxigenin-labeled polynucleotide probes: Heat-labile enterotoxin (LT) and heat-stable enterotoxin (ST) probes for ETEC; EIEC probe for Enteroinvasive E.coli (EIEC); Shiga-like toxin (SLT) I and SLT II probes for Shiga-like toxin producing E.coli ; Effacing and Attaching E.coli (EAE), Entero adherence factor (EAF), and Bundle-forming protein A (BfpA) probes for EPEC [ 23 , 24 , 25 , 26 , 27 ]. ETEC colonization factor antigens (CFAs), coli surface (CS) and putative colonization factor antigens (PCF) antigens were detected by dot-blotting assays using monoclonal antibodies against CFA/I, CFA/III, CS1, CS2, CS3, CS4, CS5, CS6, CS7, CS17, PCFO159, PCFO166 as described previously [ 28 , 29 ].

Detection of norovirus genogroup I and II was performed by a real-time reverse transcriptase PCR technique on available samples at AFRIMS [ 30 ]. All stool samples were tested for intestinal parasites by direct and concentrated microscopic examination. Samples with adequate quantity were further tested by ELISA. Common intestinal parasites, Giardia lamblia and Cryptosporidium were identified using commercial EIA kits (ProSpecT®, Remel, KS, USA). Samples positive on the combination Giardia/Cryptosporidium ELISA test were subsequently tested by Giardia -specific ELISA and Cryptosporidium -specific ELISA.

Data were analyzed using STATA 14 (STATA Corp LP, College Station, TX, USA). Isolation percentages were calculated for cases and controls and compared by chi-square or Fisher exact test with a significance level of p < 0.05. For continuous variables, means were compared by student t-test. Medians and categorical variable distributions were compared by Pearson chi-square statistic. A two-sided Fisher’s exact test was performed when zero cell counts excluded regression analysis. Crude odds ratios for demographic factors and symptoms were calculated using single variable logistic regression. Adjusted odds ratios were calculated by multivariate logistic regression including sex and age (year) and a categorical variable for length of time in Thailand.

Of 417 cases and 417 controls enrolled, 389 cases and 400 controls with complete data and either a stool sample or rectal swabs were included for analysis. Compared to controls, cases were younger, predominantly female, and had been in Thailand for a shorter period of time (Table 1 ). Length of stay in Thailand ranged from 1 day to 40 years for both cases and controls, with 207 (53%) cases and 85 (21%) controls reporting a stay of less than 1 month. Cases were also more likely than controls to report travel to a moderate or high-risk location, however this difference was not significant after adjustment for sex, age, and time in Thailand (Crude odds ratio: 1.62, p -value = 0.003; Adjusted odds ratio: 1.03, p -value = 0.882).

One hundred and seventy-nine (46%) cases reported taking at least one medication for their diarrhea before stool sample collection. One hundred and forty-two (37%) of the cases received an antibiotic, of which majority of them were a quinolone. Seven cases reported taking an anti-parasitic, and six reported taking an anti-motility drug. In contrast to cases, only one control reported taking an antibiotic, of unknown type, in the preceding two weeks.

One hundred and eighty-five (48%) cases reported diarrhea onset of ≤24 h prior to hospital visits. Cases reported a range of bowel movements per 24 h of 3 to 30, with a median of 8.327. In regard to symptoms among TD cases: abdominal pain, nausea, fever, vomiting were reported in 84, 69, 58 and 53%, respectively. In TD cases, 294 (76%) reported watery stool, and 80 (21%) and 16 (4%) reported stool with mucus or blood, respectively.

Pathogen identification

At least one pathogen was detected in 227 (58%) cases and 124 (31%) controls ( p < 0.001). Detection of multiple pathogens was more common in cases (19%) than in controls (5%). Percent detection was significantly higher in cases than controls for Campylobacter ( p < 0.001), Shigella ( p < 0.001), Vibrio ( p < 0.001), Plesiomonas ( p = 0.006), ETEC ( p = 0.002), and norovirus ( p < 0.001) (Table 2 ). The most commonly isolated pathogens in cases were Plesiomonas (14%), Campylobacter (14%), Vibrio (14%) and norovirus (12%). Salmonella (13%) and Plesiomonas (8%) were the most frequently isolated pathogens in controls.

Of the 56 isolates of Vibrio spp. from 54 stool samples, 49 (88%) isolates were V. parahaemolyticus (48 cases and 1 control), 5 (9%) V. cholerae Non O1/O139 (all cases), 1(2%) Vibrio group F (case), and 1(2%) V. cholerae O139 (case). Of the 63 Campylobacter isolates from 61 stool samples, 17% were C. coli , 78% were C. jejuni , 1 was C. upsaliensis , and 2 isolates were unknown type species. Of the 12 Shigella isolates, 9 (75%) were S. sonnei and others were S. boydii (2 cases) and S. flexneri 2a (1 case).

Enterotoxin genes for the 37 ETEC isolates from 36 cases or controls were also classified, with 7 positive for LT, 6 for STIa, 16 for STIb, 2 for LTSTIa, and 6 for LTSTIb. Thirty-six of the 37 ETEC isolates were tested for CFAs. Eighteen (50%) were positive with CS6 (19%), CS2,3 (14%), PCFO159 (5%), and CS1,3, CS17, PCFO166 and CFA/I (3% of each). The distribution of toxin genes was not significantly different between ETEC positive cases and controls.

A total of 20 samples were positive on the combination Giardia/Cryptosporidium ELISA test. Seventeen samples subsequently tested positive for Giardia -specific ELISA and 3 others for Cryptosporidium -specific ELISA. One additional sample of a case was positive for Giardia by direct and concentrated microscopy. These 21 samples were considered positive for presence of protozoa. Of the 32 cases with norovirus detection by PCR, 29 (91%) belonged to GII genogroup and 3 (9%) belonged to GI genogroup. One control was positive for GII norovirus.

Regression analysis

Pathogen detection was more common in cases than in controls (Crude odds ratio: 3.09, p -value < 0.001, Adjusted odds ratio: 2.86, p -value < 0.001). Among cases, pathogen detection was more likely among those with moderate white blood cells (Crude odds ratio: 1.94, p -value = 0.053, Adjusted odds ratio: 1.81, p -value = 0.095), or many white blood cells (Crude odds ratio: 3.48, p -value < 0.001, Adjusted odds ratio: 3.49, p -value < 0.001) or many red blood cells (Crude odds ratio: 4.80, p -value < 0.001, Adjusted odds ratio: 5.06, p -value < 0.001) observed in the stool microscopic examination as compared to those with no blood cells in the stool. Prior antibiotic use decreased the likelihood of pathogen isolation (Crude odds ratio: 0.71, p -value = 0.110, Adjusted odds ratio: 0.68, p -value = 0.077). Compared to younger cases, those 25 and older were less likely to have a pathogen isolated (Crude odds ratio: 0.53, p -value = 0.030; Adjusted odds ratio: 0.55, p -value = 0.049). However, when prior antibiotic use was controlled for, the associations between pathogen isolation and age was no longer significant. Associations between pathogen isolation and sex, nationality, time in Thailand, season, diarrhea duration, mean bowel movement, and other symptoms were not statistically significant (Additional file 1 : Table S1).

Isolation of bacteria was positively associated with the presence of many white blood cells (Crude odds ratio: 3.49, p -value < 0.001, Adjusted odds ratio: 3.48, p -value < 0.001) and many red blood cells (Crude odds ratio: 4.38, p -value < 0.001, Adjusted odds ratio: 4.72, p -value < 0.001). Reports of abdominal pain were also associated with an increased percentage of bacteria isolation (Crude odds ratio: 1.95, p -value = 0.019, Adjusted odds ratio: 1.93, p -value = 0.023). Use of antibiotics was negatively associated with the isolation of bacteria (Crude odds ratio: 0.72, p -value = 0.126, Adjusted odds ratio: 0.70, p -value = 0.091) but was not significant (Additional file 1 : Table S2).

Norovirus detection was positively associated with reports of vomiting (Crude odds ratio: 4.01, p -value = 0.002, Adjusted odds ratio: 4.10, p -value = 0.002). Those presenting with diarrhea 3 days after onset were less likely than those with a diarrhea duration one day or less to have a virus detected (Crude odds ratio: 0.30, p -value = 0.012, Adjusted odds ratio: 0.27, p -value = 0.008) (Additional file 1 : Table S3).

Protozoa detection was associated with travel to high-risk destinations [compare to low-risk/Bangkok destination] (Crude odds ratio: 11.81, p -value = 0.001, Adjusted odds ratio: 11.06, p -value = 0.005) and negatively associated with reports of abdominal pain (Crude odds ratio 0.147, p -value = 0.001, Adjusted odds ratio: 0.14, p -value = 0.001). Those presenting with diarrhea of 3 days duration were more likely to have protozoa detected than those presenting within the first day (Crude odds ratio: 4.59, p -value = 0.024, Adjusted odds ratio: 5.00, p -value = 0.019). After adjustment, protozoa detection was more likely in the rainy season (Crude odds ratio: 9.25, p -value = 0.037, Adjusted odds ratio: 10.06, p -value = 0.032) and the cool season (Crude odds ratio 11.53, p -value = 0.030, Adjusted odds ratio: 14.20, p -value = 0.020) as compared to the hot season (Additional file 1 : Table S4). Gender, time in Thailand, antimotility drug use, antiparasitic drug use, and other diarrhea symptoms were not significantly associated with bacteria, viral or protozoan detection (Additional file 1 ).

Of the six pathogens with significantly higher detection percentages in cases, Campylobacter , ETEC and norovirus were associated with specific symptoms. As compared to other cases, those with Campylobacter isolated were more likely to report loose stool (22 of 53, Crude odds ratio 2.56, p -value = 0.002) or bloody stool (5 of 53, Crude odds ratio: 3.08, Fisher’s exact p -value = 0.052). Cases with ETEC isolated were less likely to report fever (9 of 26, Crude odds ratio: 0.36, p -value = 0.017). When norovirus was the only pathogen detected that compared with no any pathogen identified, cases were more likely to report the symptom of vomiting (18 of 19, crude odds ratio: 19.14, p -value = 0.005) and fatigue (14 of 19, crude odds ratio: 3.05, p -value = 0.040).

Moderate or many white blood cells (as compare with no blood cells) on microscopic stool examination were more often found in cases with Campylobacter (Crude odds ratio: 6.32, p -value < 0.001) and Shigella (Crude odds ratio: 9.56, p -value = 0.032) and found less often in cases where ETEC was the only pathogen isolated (Crude odds ratio: 0.24, p -value = 0.073) (Table 3 ). Moderate or many red blood cells were found more often in cases with Campylobacter (Crude odds ratio: 2.42, p -value = 0.012), Shigella (Crude odds ratio: 19.50, p -value = 0.005), Vibrio (Crude odds ratio: 2.69, p -value = 0.008), and Plesiomonas (Crude odds ratio: 2.29, p -value = 0.017). Moderate or many red blood cells were less often found in cases with ETEC (Crude odds ratio: 0.10, p = 0.023) (Table 3 ).

Compared to Europeans, North Americans, Australians and New Zealanders, Asian nationals were younger (mean age 35.31 years for case vs. 39.03 years for control, student t-test < 0.001), and they had been in Thailand for a shorter period of time (median stay 10 days for Asian case vs. 30 days for non-Asian case, median test: p -value = 0.001). Asian cases were more likely to have Vibrio isolated (Crude odds ratio: 3.10, p -value = 0.001, Adjusted odds ratio: 3.36, p -value < 0.001). Campylobacter was isolated more frequently in North Americans and Europeans (Crude odds ratio: 2.65, p -value = 0.001, Adjusted odds ratio: 2.79, p -value = 0.001). Salmonella was more frequently isolated in Australians and New Zealanders (Crude odds ratio: 3.23, p -value = 0.009, Adjusted odds ratio: 2.99, p -value = 0.018), and Campylobacter was isolated less frequently (none positive) (Fisher’s exact test p -value = 0.021) (Additional file 1 : Table S5).

Our findings suggest that Plesiomonas , Vibrio, Campylobacter , and norovirus are important pathogens causing acute diarrhea among travelers and expatriates to Bangkok. Isolation percentages for Shigella , Salmonella , Aeromonas , ETEC, EIEC, Giardia , Cryptosporidium, and rotavirus were within three percentage points of the Southeast Asian regional estimates from Shah et al. [ 9 ]. Our data also supports Riddle’s finding that TD cases in Southeast Asia have a high risk of co-infection [ 8 ]. Unlike in Nepal, protozoa appear to cause little traveler’s diarrhea in travelers to Thailand [ 31 ], and cases with protozoa detected in this study were mainly associated with travel to a high-risk destination prior to visiting Thailand. However, it is important to note that 46% of TD cases in this study took medications including antibiotics for their diarrhea treatment prior to enrollment. This may have had potential effect on detection of bacterial organisms in stool samples by culture method.

The percent of Campylobacter isolation in our study was lower than an estimate of 32.4% in the review by Shah [ 9 ], possibly due to the large proportion of American military studies in the review. American soldiers may be at increased risk of Campylobacter infection, as was seen in the North American and European travelers in this study. Our study also found a four-fold higher percent detection for norovirus (12% vs. 0.3%). However, the odds of experiencing diarrhea given viral pathogen detection was much greater than for those with bacteria or protozoa isolation in this study, suggesting that norovirus is highly infective in addition to being common among travelers to Bangkok. As sapovirus, adenovirus, astrovirus were not tested in this study; the importance of viral pathogens in TD in Thailand may still be underappreciated.

Our study also suggests that composition of diarrhea etiologic agents varies by the traveler’s nationality. The odds of isolating Vibrio was significantly higher among Asian cases, while the odds of isolating Campylobacter was significantly higher among Europeans and North Americans and the odds of isolating Salmonella was significantly higher among Australians and New Zealanders.

Australians and New Zealanders may also suffer more severely from TD in Thailand than North Americans, Europeans and Asians [ 14 , 19 ]. A previous survey study in Thailand by Chongsuvivatwong et al. of 22,401 travelers departing from Phuket or Chiang Mai including 2268 Australians and New Zealanders found Australians and New Zealanders to be at 2 to 3 times the risk of TD compared to Europeans and North Americans and to report experiencing more severe symptoms [ 14 ]. A subsequent survey by Kittatrakul et al. of 7963 travelers departing from Bangkok including 696 Australians and New Zealanders also found Australians and New Zealanders to be at greater risk of TD [ 19 ]. In our study, travelers from Australia and New Zealand were more likely to report fever, vomiting, and nausea. They were also less likely to have been in Thailand for one year or longer, thereby shortening their opportunity to develop natural immunity. However, in contrast to expectations for a naïve population, the percent isolation of Campylobacter among Australians and New Zealanders was significantly lower than Asians, North Americans and Europeans. An investigation of pathogen distribution by traveler nationality in other destinations and an exploration of risk factors, including dietary preferences and accommodation, may further elucidate the patterns of TD observed in this study.

Recruitment of cases and controls from developed countries in a prominent hospital in Bangkok may have biased our subjects towards well-off travelers with moderate to severe diarrhea. The pathogen distribution may not be representative of TD among all international visitors to Thailand. Other weaknesses of the study included the demographic differences between cases and controls, especially with regards to time in Thailand, the inability to determine the causal agent of co-infected patients, the inability to precisely determine the location of pathogen acquisition, the limited pathogen testing of some samples, samples were not tested for EAEC or the aforementioned viruses. Furthermore, the data were collected over 15 years ago and epidemiology of TD in Thailand may have changed.

Despite these limitations, our findings suggest that facility-based surveillance of TD in Thailand is feasible. Logistically, military deployments present several challenges to ongoing surveillance, and our studies suggest that their pathogen distribution may vary considerably from that of Thailand’s traveler population [ 5 , 8 , 9 , 10 , 11 , 12 , 13 ]. Other TD studies have largely focused on the pathogen distribution and risk factors associated with specific travel destinations [ 7 , 9 ]; however results from our study suggest that the origins of the traveler may play an important role in diarrhea etiology. More detailed characterization of the risk factors and pathogen distribution variations among travelers from different regions as well as a larger sample size and data collected from other locations will be required for better understanding of this observation. Understanding TD etiology and epidemiology will improve pre-travel health advice, empiric treatment and estimates of vaccine-preventable disease in this population. However, facility-based studies do not capture milder episodes of diarrhea or episodes that resolve by self-treatment, therefore a full estimate of TD disease burden will require complementary population-based research.

Etiology of TD in Thailand is mainly caused by bacterial origin. Plesiomonas, Vibrio , and norovirus underappreciated as diarrheagenic pathogens. Although TD studies often focus on the pathogen distribution or risk factors associated with specific travel destinations, our study also confirms that the origin of the traveler also plays an important role in diarrhea symptoms and etiology. More detailed characterization of the risk factors and pathogen distribution variations among travelers from different regions warrants further study.

Abbreviations

Colonization Factor Antigens

Enteroaggregative E. coli

Enteroinvasive E.coli

Enzyme-linked immunosorbent assay

Enteropathogenic E.coli

Enterotoxigenic E.coli

heat-labile enterotoxin

Shiga-like toxin

heat-stable enterotoxin

Shiga toxin-producing E. coli

Traveler’s diarrhea

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Acknowledgements

The authors thank the technicians, nurses, and professional staff of the Armed Forces Research Institute of Medical Sciences in Bangkok, Thailand for their devoted microbiology expertise and assistance with collection of specimens and data processing; and the clinical staff of the Bumrungrad International Hospital for their assistance with subject enrollment and study execution.

Financial support for the study was provided by the Armed Forces Health Surveillance Center Global Emerging Infections Surveillance and Response System (AFHSC-GEIS).

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The data that support the finding of this study are available from the corresponding author on reasonable requests.

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LB conceived of the study, participated in the design, coordination and execution, the acquisition of data, analysis of data and preparation of the manuscript. SA conceived of the study, participated in the design, coordination and execution and reviewing the final draft of the manuscript. SS and US were primarily responsible for study coordination and execution, the acquisition of data and data analysis. OS1, AS and OS2 participated in laboratory detection and isolation of enteric pathogen as well as preparation of the manuscript. CM conceived of the study, participated in the design, coordination and execution, statistical analysis, and manuscript review. All authors read and approved the final manuscript.

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Additional file

Additional file 1:.

Regression analyses for pathogen detection, bacterial isolation, norovirus detection, protozoa detection, and traveler origin. Supplementary tables of regression analyses results. (DOCX 44 kb)

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Bodhidatta, L., Anuras, S., Sornsakrin, S. et al. Epidemiology and etiology of Traveler’s diarrhea in Bangkok, Thailand, a case-control study. Trop Dis Travel Med Vaccines 5 , 9 (2019). https://doi.org/10.1186/s40794-019-0085-9

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How To Avoid Getting Sick In Thailand (Goodbye Thai Bangkok Belly)

by Melissa Giroux | Last updated Feb 4, 2023 | Asia , Thailand , Travel Tips

It is no secret that one of the best aspects of traveling to Thailand ; and to any country for that matter; is being able to gorge on the flavourful local cuisine.

The truth is that up to 70% of travelers leave the country with the memory of constantly running to the restroom, and could probably tell you where every toilet is located in and around the Grand Palace.

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Occasional intestinal upset and diarrhea due to travel stress can be uncomfortable, energy-draining, and kind of embarrassing. It often results in a ruined travel experience. Luckily, there are measures you can take to help make your vacation memorable for the right reasons.

What is occasional diarrhea?

You may already be aware of occasional diarrhea by one of its other well-known monikers; Bali Belly, Montezuma’s Revenge, or simply food poisoning. One thing that is for sure is that if the word “diarrhea” is used to describe a symptom, you know that you are not in for a fun time.

Diarrhea can be caused by bacterial pathogens; often foodborne; that infect your gut. This is often a result of the food not being prepared in a clean environment or not being cooked properly. Eating at popular spots; even food stalls; will reduce your risk of falling ill.

Water in Thailand can be contaminated as well which is why even the locals suggest drinking bottled or filtered water. You can find water refill stations near your hotel, hostel, and in residential communities that give you access to filtered water for only 1 baht a litre.

Why travelers have a higher risk of getting sick in Thailand?

While getting occasional diarrhea is not limited to Thailand; it is really common for travelers to become bathroom-bound in the Land of Smiles.

This is due to the tempting food stalls’ lower sanitary conditions. That is not to say that you should NEVER eat at any food stalls as some of the best dishes are only available from a stall.

Think smart; you might not want to have to wait in a long line for food from the popular stall, but you are less likely to get sick from a cart that is constantly cooking food vs. the one with food sitting out and waiting to be eaten.

Ice cubes used to be a large concern around Thailand travelers however, most ice cubes are being made with filtered water in the major cities. If you are worried and would like to take extra precautions, stick with only consuming water from your own water bottles.

Other Digestive Upsets

In addition to experiencing new food and water, travel also brings with it changing timetables, a lack of sleep and various other stresses that can wreak havoc on your digestive system. Abdominal cramps, bloating, uncontrollable gas and loss of appetite are all potential upsets that can make your trip uncomfortable – even if they don’t involve running to the bathroom – and something you want to prepare for, before stepping foot on the plane.

Maintaining a Healthy Digestive System While Traveling

If only there was an affordable, over-the-counter supplement that can help you to support a calm stomach while adventuring. Oh, wait! There is Travelan!

Travelan should be on everyone’s essential packing list when heading to Thailand It can be purchased online through Amazon or from Passport Health Clinics across America.

All you need to do is take one of the small caplets before enjoying your meal and then Travelan’s little antibodies are on the job. They work to promote digestive health by targeting and neutralizing toxic bacteria before it makes you sick.

Travelan isn’t just another cheap sell to travelers that are desperate to avoid the runs and stomach upsets, it is supported by extensive research. One Travelan caplet is packed with naturally occurring antibodies for E. coli that have been shown to not only bind to E.coli but other forms of bacteria that can be found in Thailand.

In layman’s terms, Travelan has got all your bases, gut, and booty covered.

Diarrhea Treatment

I hate to break it to you but if you have fallen victim to diarrhea, your only choice is to wait it out. Take this as a sign from the universe giving you the green light to lay in your room all day and watch Netflix.

Some travelers find taking antidiarrheal medications from the Pharmacy or Drug Store helpful for relief. The most important thing is to take in lots of water.

Since you are losing a lot of fluids and most likely not eating much (due to the loss of appetite) it is important to focus on replacing these electrolytes. Ingesting as much water as you can during this time is crucial but if you can also take electrolyte packets or rehydration salt, it will help your body combat impending dehydration.

If you are keeping hydrated and still experiencing prolonged unusual or painful symptoms, you want to consider visiting a doctor.

Don’t let the fear of getting sick stop you from trying the local cuisine. No one wants to think about their travels and memories that make your stomach churn. Travelan has gotten your back so that you can reminisce about the trip that you planned with no unexpected surprises.

That said, if you’re planning your trip, make sure to bring medicine and prescriptions. If not, do research so that you know exactly how to get medicine overseas.

In Australia, Travelan® is a listed medicine and is specifically indicated to reduce the risk of Travelers’ Diarrhea. It’s available to purchase from Australian pharmacies. In Canada, Travelan® is a licensed natural health product and can be purchased from Canadian pharmacies.

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Epidemiology of travelers' diarrhea in Thailand

Affiliation.

1 Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hatyai, Thailand. [email protected]
PMID: 19538578
DOI: 10.1111/j.1708-8305.2009.00331.x

Background: Current data on risk of travelers' diarrhea (TD) among visitors to Thailand largely comes from US military personnel, Peace Corps volunteers, or expatriates. We performed a 14-month systematic study of the incidence rate and characteristics of TD and a smaller study of etiology of the disease among visitors to Phuket and Chiang Mai.

Methods: One randomly selected day each week from August 2005 until October 2006, data were collected from foreign tourists departing from airports serving Phuket and Chiang Mai. A separate subgroup of subjects with TD acquired in Phuket were invited to submit a stool sample for enteropathogens.

Results: Based on 22,401 completed questionnaires, the attack rate for TD was highest among residents from Australia or New Zealand (16%), while those from the United States and Europe had attack rates of 7% to 8%. Independent risk factors for the development of TD were eating outside the hotel and eating meat. In contrast, a history of drinking tap water and consuming ice cream were protective. In 56 subjects studied for etiology, Aeromonas spp were found in 8 subjects (14%), enterotoxigenic Escherichia coli (ETEC) or Vibrio spp each was found in 7 (13%) with O1 V. cholera (cholera) seen in one, mixed pathogens were found in 3 (5%), with no pathogen being detected in 33 (59%).

Conclusions: Phuket and Chiang Mai should not be considered high-risk destinations for development of TD among US and European travelers to Thailand. In the study, Aeromonas, ETEC, and Vibrio spp were the most frequent enteropathogens identified.

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Travellers diarrhoea

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3 replies to this topic

Go see a doctor

Hello Claudia,

I would have already been on medication.

Have someone from your hotel go to the pharmacy for you.

They will know what to give you.

I had it last July, no vomiting, no cramps thankfully.. I had to see my GP.

She gave me antibiotics so I would ask your hotel to help you with a doctor. So you can get started on something.

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COMMENTS

I have traveler's diarrhea in Thailand, what ...
All hospital in Thailand can take care travelers' diarrhea. Most patients can be treated as outpatients but some patients may need hospitalization. If you're in Bangkok, and you choose to visit us, you may collect your stool before attending our clinic. Use small plastic container with cap, and put some of your stool in it.
Traveler's diarrhea
Traveler's diarrhea is a digestive tract disorder that commonly causes loose stools and stomach cramps. It's caused by eating contaminated food or drinking contaminated water. Fortunately, traveler's diarrhea usually isn't serious in most people — it's just unpleasant. When you visit a place where the climate or sanitary practices are ...
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Treatment. Travelers' diarrhea (TD) is the most predictable travel-related illness. Attack rates range from 30%-70% of travelers during a 2-week period, depending on the destination and season of travel. Traditionally, TD was thought to be prevented by following simple dietary recommendations (e.g., "boil it, cook it, peel it, or forget ...
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The onset of travelers' diarrhea usually occurs within the first week of travel, but it may occur at any time while traveling. It also can occur shortly after you get home. Diarrhea usually occurs abruptly. The illness results in increasing frequency and amount of loose or watery stool. It usually causes 5-10 bowel movements each day.
Travelers' Diarrhea
Travelers' Diarrhea. Travelers' diarrhea is the most common travel-related illness. It can occur anywhere, but the highest-risk destinations are in Asia (except for Japan and South Korea) as well as the Middle East, Africa, Mexico, and Central and South America. In otherwise healthy adults, diarrhea is rarely serious or life-threatening, but it ...
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Travelers Diarrhea: Nobody wants to spend their hard-earned vacation time dealing with traveler's diarrhea. Yet, the unfortunate reality is that it affects a significant percentage of international tourists. When in Thailand, a country renowned for its beautiful beaches and delicious street food, the risk exists.
Travellers' Diarrhea in Thailand
Travellers' Diarrhea can happen when: Eating raw, under cooked, unwashed, or improperly handled meat, poultry products, dairy products, fruits, vegetables, shellfish, and seafood. Drinking contaminated water or beverages. Inadvertently ingesting fecal matter, protozoa eggs, or viruses by touching the mouth with dirty or improperly washed hands.
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Diarrhea is something that no one want during the trip. Unfortunately, it's pretty common among travelers in Asia. According to our research, up to 16% of
Epidemiology and etiology of Traveler's diarrhea in Bangkok, Thailand
Background. Traveler's diarrhea (TD) is the most common health problem facing residents of developed countries who visit developing regions. Travelers most frequently develop TD within their first week(s) abroad [1-3].Although TD in most cases resolves spontaneously within a few days without treatment and is unlikely to be fatal, it has a significant impact on quality of life and economics ...
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INTRODUCTION. Foreign travel may pose medical risks to travelers' health, especially in resource-limited settings. 1 According to the CDC, the attack rate of travelers' diarrhea (TD) ranges from 30% to 70% depending on multiple factors. 2 Thailand has experienced more than a 10 million rise in foreigner's visits from the year 2012. The number of overnight travelers in 2017 was 35.6 ...
Traveller's Diarrhoea
Traveller's diarrhoea. Traveller's diarrhoea is diarrhoea that develops during, or shortly after, travel abroad. It is caused by consuming food and water, contaminated by germs (microbes) including bacteria, viruses and parasites. Other symptoms can include high temperature (fever), being sick (vomiting) and tummy (abdominal) pain.
Traveler's Diarrhea: What It Is, Treatment & Causes
Traveler's diarrhea is the most common travel-related illness. It affects between 30% and 70% of travelers, depending on the destination and the season. It's especially common in hot and/or humid climates, where bacteria breed more easily. Most of Asia, the Middle East, Africa, Mexico and Central and South America have this type of climate ...
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Epidemiology of Travelers' Diarrhea in Thailand
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The TaqMan® array card (TAC) was used to detect enteropathogens in stool samples from travelers' diarrhea cases and asymptomatic controls in a hospital-based surveillance in Thailand. Analyses were performed to determine pathogen-disease association to compare TAC and conventional results. Keywords: travelers' diarrhea, Thailand, TaqMan ...
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Abstract. Background.Traveler's diarrhea in Thailand is frequently caused by Campylobacter jejuni. Rates of fluoroquinolone (FQ) resistance in Campylobacter organisms have exceeded 85% in recent years, and reduced fluoroquinolone efficacy has been observed.. Methods.Azithromycin regimens were evaluated in a randomized, double-blind trial of azithromycin, given as a single 1-g dose or a 3-day ...
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Background Traveler's diarrhea (TD) is a common health problem among visitors from developed to developing countries. Although global and regional estimates of pathogen distribution are available, the etiology of diarrhea among non-military travelers to Thailand is largely unknown. Methods A prospective TD case-control study was conducted among adult travelers from developed countries at a ...
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Health Tips: How to Avoid and Treat Traveler's Diarrhea
If you are experiencing traveler's diarrhea, you will need to drink at least three quarts (3 liters) a day, to replace lost fluids. A sports drink (Gatorade, Powerade, Lucozade, etc) often works well, and several glasses of this should be drunk each day you are experiencing symptoms. If you can't find a sports drink, you can make your own with ...
Epidemiology of travelers' diarrhea in Thailand
Background: Current data on risk of travelers' diarrhea (TD) among visitors to Thailand largely comes from US military personnel, Peace Corps volunteers, or expatriates. We performed a 14-month systematic study of the incidence rate and characteristics of TD and a smaller study of etiology of the disease among visitors to Phuket and Chiang Mai.
Vietnam Forum
Hi guys, i've been travelling Vietnam for about two weeks now and for the past five days I have been suffering really badly with travellers diarrhoea. It's gotten to the point where I've been in bed for a full day and passing diarrhoea every half an hour also and vomiting now as well.