Continuing Education Activity

Traveler's diarrhea is a common ailment in individuals traveling to resource-limited destinations overseas. It is estimated to affect nearly 40 to 60 percent of travelers and is the most common travel-associated condition. Bacterial, viral, and parasitic infections can cause symptoms, though bacterial sources represent the most frequent etiology. Although traveler's diarrhea is typically a benign, self-resolving condition, it can lead to dehydration and, in severe cases, significant complications. This activity reviews the evaluation and management of traveler's diarrhea and highlights the role of interprofessional team members in collaborating to provide well-coordinated care and enhance outcomes for affected patients.

Objectives:

• Identify the causes of traveler's diarrhea.
• Identify strategies to prevent traveler's diarrhea.
• Explain the management of traveler's diarrhea.
• Explain the importance of improving coordination amongst the interprofessional team to enhance care for patients affected by traveler's diarrhea.

Introduction

Travelers’ diarrhea is a common ailment in persons traveling to resource-limited destinations overseas. Estimates indicate that it affects nearly 40% to 60% of travelers depending on the place they travel, and it is the most common travel-associated condition.  Bacterial, viral, and parasitic infections can cause symptoms, though bacterial sources represent the most frequent etiology. While travelers’ diarrhea is typically a benign self-resolving condition, it can lead to dehydration and, in severe cases, significant complications. [1][2][3]

Etiology

The most common bacterial cause is enterotoxigenic Escherichia coli (ETEC), with estimates that the bacteria is responsible for nearly 30% of cases. Other common bacterial causes of travelers’ diarrhea include Campylobacter jejuni, Shigella, and Salmonella species. Norovirus is the most common viral cause while rotavirus is another source of infection. Giardia intestinalis is the most common parasitic source while Cryptosporidium and Entamoeba histolytica can also cause travelers’ diarrhea. The most common cause of travelers’ diarrhea varies by region, though the source is rarely identified in less severe cases.[4][5][6]

Traveler's diarrhea can occur in both short and long term travelers; in general, there is no immunity against future attacks. Traveler's diarrhea appears to be most common in warmer climates, in areas of poor sanitation and lack of refrigeration. In addition, the lack of safe water and taking short cuts to preparing foods are also major risk factors. In areas where food handling education is provided, rates of traveler's diarrhea are low.

Epidemiology

Estimates place the incidence of travelers’ diarrhea at 30% to 60% of travelers to resource-limited destinations. Incidence and causal agent vary by destination, with the highest incidence reported in sub-Saharan Africa. Other locations with high incidence include Latin America, the Middle East, and South Asia. Risk factors are typically related to poor hygiene in resource-limited areas. These include poor hygienic practices in food handling and preparation; lack of refrigeration due to inadequate electrical supply; and poor food storage practices. Additional modifiable risk factors include proton pump inhibitor (PPI) use, recent antibiotic use, and unsafe sexual practices. Risk factors for severe complications are pregnancy, young or old age, travelers with underlying chronic gastrointestinal diseases, or people who are immunocompromised. [7][8]

Pathophysiology

Travelers’ diarrhea is most commonly spread by fecal-oral transmission of the causative organism, typically through consumption of contaminated food or water.  The incubation period varies by causal agent, with viruses and bacteria ranging from 6 to 24 hours and intestinal parasites requiring 1 to 3 weeks before the onset of symptoms.  The pathophysiology for travelers’ diarrhea differs by a causative agent but can be split into non-inflammatory or inflammatory pathways. Non-inflammatory agents cause a decrease in the absorptive abilities of the intestinal mucosa, thereby increasing the output of the gastrointestinal (GI) tract. Inflammatory agents on the other hand cause destruction of the intestinal mucosa either through cytotoxin release or direct invasion of the mucosa. The loss of mucosa surface again results in a decrease of absorption with a resultant increase in bowel movements.[9]

History and Physical

The onset of symptoms will typically occur 1 to 2 weeks after arrival in a resource-limited destination, though travelers can develop symptoms throughout their stay or shortly after arrival. Travelers’ diarrhea is considered as three or more loose stools in 24 hours or a two-fold increase from baseline bowel habits. Diarrhea often occurs precipitously and is accompanied by abdominal cramping, fever, nausea, or vomiting. Patients should be asked about any blood in their stool, fevers, or any associated symptoms. A thorough travel history should be obtained including timeline and itinerary, diet and water consumption at their destination, illnesses in other travelers, and possible sexual exposures.

In most self-limited cases physical examination will show mild diffuse abdominal tender to palpation. Providers should assess for dehydration through skin turgor and capillary refill.  In more severe cases patients may have severe abdominal pain, high fever, and evidence of hypovolemia (tachycardia, hypotension).

Evaluation

Laboratory investigation is typically not required in most cases.  In patients with concerning features, such as with high fever, hematochezia, or tenesmus, stool studies can be obtained. Typical stool studies include stool culture, fecal leukocytes, and lactoferrin. The stool should be assessed for ova and parasites in patients with longer duration of symptoms. New multiplex polymerase chain reaction (PCR) screens are becoming available and provide quick analysis of multiple stool pathogens. These screens, however, are expensive, are not widely available, and may not change the clinical management of patients.[4]

Radiological studies are not required in most cases. Kidneys, ureters, and bladder x-ray can be obtained to assess for acute intra-abdominal pathology or look for evidence of perforation in severe cases. An abdominal CT can also be used to assess for intraabdominal pathology in severe cases.

Treatment / Management

Travelers should be counseled on risk reduction before travel, including avoiding tap water & ice, frequent hand washing, avoiding leafy vegetables or fruit that isn’t peeled, and avoiding street food. Bismuth subsalicylate (two tabs 4 times a day) can be used for prophylaxis and can reduce the incidence of travelers’ diarrhea by almost half, though it should be avoided in children and pregnant women due salicylate side effects. In short high-stakes travel, it may be reasonable to start antibiotics as prophylaxis but is generally avoided in longer-term travel. Rifaximin is a commonly used chemoprophylaxis due to its minimal absorption and minimal side effects.[10][11][12]

The foundation of diarrhea management is fluid repletion. In mild cases, travelers should focus on increasing water intake. Water is usually sufficient though sports drinks and other electrolyte fluids can be used. Pedialyte can be used for pediatric patients. Milk and juices should be avoided as this can worsen diarrhea. In more severe cases, oral rehydration salt can be used to ensure rehydration with adequate electrolyte repletion. In cases of severe dehydration, IV fluids may ultimately be required.

Treatment is supportive in mild-moderate cases. In patients without signs of inflammatory diarrhea, loperamide can be used for symptomatic relief.  The typical dose for adults is 4 mg initially with 2 mg after each subsequent loose stool, not to exceed 16 mg total in a day.

Also, travelers can be given antibiotics to take as needed at the onset of symptoms. Ciprofloxacin is commonly used for treatment, though there are concerns with resistance with Campylobacter species.  For this reason, fluoroquinolones are not often prescribed for travelers to Asia and azithromycin preferable. Also, azithromycin is often prescribed for pregnant travelers and children. A common regimen is 500 mg daily for three days, though evidence suggests that a single dose of 1000 mg may be slightly more effective. Parents can be given azithromycin powder with instructions to mix with water when needed. Rifaximin is a minimally absorbed antibiotic that is also available and is safe for older children and pregnant travelers.

Differential Diagnosis

• Pseudomembranous colitis
• Ischemic colitis
• Vipoma
• Radiation-induced colitis
• Food poisoning

Staging

New Guidelines for Traveler's Diarrhea

1. Travelers should be advised against the use of prophylactic antibiotics
2. In high-risk groups, one may consider antibiotic prophylaxis
3. Bismuth subsalicylate can be considered in any traveler.
4. The antibiotic of choice is rifaximin
5. Fluoroquinolones should not be used as prophylaxis

Prognosis

The outcomes in most patients with traveler's diarrhea are good. However, in severe cases, dehydration can occur requiring admission.

Complications

• Dehydration
• Malabsorption
• Sepsis
• Hemolytic uremic syndrome
• Reactive arthritides

Postoperative and Rehabilitation Care

The majority of patients are managed as outpatients and need to do the following:

• Maintain hydration
• Hand washing
• Only take antimotility agents if prescribed by the healthcare provider
• Maintain good personal hygiene
• If diarrhea persists for more than 10 days, should follow up with the primary provider

Deterrence and Patient Education

• Wash hands regularly
• Avoid shellfish from waters that are contaminated
• Wash all foods before consumption
• Drink bottled water when traveling
• Avoid consumption of raw poultry or eggs
• When traveling, consume dry foods and carbonated beverages
• Avoid water and ice from the street
• Avoid drinking water from lakes and rivers

Pearls and Other Issues

There is a strong correlation with travelers’ diarrhea and the subsequent development of irritable bowel syndrome (IBS), with some studies suggesting up to 50% incidence.

Enhancing Healthcare Team Outcomes

The key to traveler's diarrhea is preventing it. Today, nurses, the primary care provider and the pharmacists are in the prime position to educate the patient on the importance of hydration and good hygiene. The traveler should be educated on drinking bottled water and washing all fresh fruit and vegetables prior to consumption. Plus, travelers should be warned not to drink from lakes and streams. Carrying small packets of alcohol desansitizer to wash hands can be very helpful when hand washing is not possible.

The pharmacist should educate the traveler on managing the symptoms of diarrhea with over-the-counter medications or loperamide. Travelers should be discouraged from taking prophylactic antibiotics when traveling, as this leads to more harm than good. Finally, the traveler should be educated on the symptoms of dehydration and when to seek medical care. The primary care clinicians should monitor patients until there is a complete resolution of symptoms. Any patient that fails to improve within a few days should be referred to a specialist for further workup. With open communication between the team members, the morbidity of traveler's diarrhea can be reduced. [1][8](level V)

Outcomes

The prognosis for most patients with traveler's diarrhea is excellent. However, thousands of patients go to the emergency departments each year looking for a magical cure. Hydration is the key and admission is only required for severe dehydration and orthostatic hypotension. The elderly and children under the age of 4 are at the highest risk for developing complications, which often occur because of self-prescribing of over-the-counter medications.[13][14] (Level V)