Travel to Developing Countries - Traveler's Diarrhea

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Antimotility Drugs. Antimotility drugs provide prompt but temporary symptomatic relief by reducing muscle spasms in the gastrointestinal tract. They include:

• Loperamide (Imodium). Loperamide is the agent of choice, even when used in combination with antibiotics.
• Diphenoxylate (Lomotil).
• Opiates (such as paregoric, tincture of opium, and codeine). Opiates are often poorly tolerated, and can affect the central nervous system.

Antimotility drugs should be discontinued if symptoms persist beyond 48 hours. They should NOT be used at all in patients with high fever, if there is blood in the stool, or in children under age 2. Imodium is approved for children 2 years and up, but its use in children is controversial because of reports of severe side effects. Experts do not recommend it.

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Note: Lomotil and Imodium work well for treating diarrhea, but are not effective for prevention. Both drugs may even prolong the duration of illness.

Antibiotics. Antibiotics are generally effective for treating traveler's diarrhea that develops in an 8-hour period, with three or more loose stools, and especially if associated with nausea, vomiting, abdominal cramps, fever, or blood in the stools. Because antibiotics are prescription drugs, travelers at risk should obtain them before they depart and should receive directions for self-treatment while abroad. Antibiotics should not be used for nausea and vomiting when diarrhea is not present. Although self-treatment is generally safe, a doctor should be sought for any child with diarrhea and for adult patients who develop fever or bloody diarrhea. (Antibiotics are generally not useful for diarrhea in developed nations, since such cases are likely to be caused by viruses.)

In general, patients take one tablet every 12 hours for 5 days. Fluoroquinolones are the preferred antibiotic, unless the person is traveling to SE Asia or India, where bacterial resistance to this class of drugs is high. In these cases, azithromycin (Zithromax) is preferred. Taking a single dose of an antibiotic such as ofloxacin (Floxin), plus an anti-motility drug (usually Imodium), often provides relief within 24 hours for many patients. Other antibiotics used for diarrhea include ciprofloxacin (Cipro) and levofloxacin (Levaquin).

Rifaximin (Xifaxan) is another type of antibiotic that is specifically approved for the treatment of traveler's diarrhea. It is taken by mouth for 3 days. This medication was approved by the FDA in 2004, and there is evidence it may be useful in prevention as well as treatment of the condition.

Parasites do not usually respond to standard antibiotics. Trimethoprim-sulfamethoxazole (Bactrim), for example, has fallen out of favor for routine use because of resistant bacteria, but it may be very effective against the severe diarrhea caused by the parasite Cyclospora. Metronidazole (Flagyl) is the standard drug for Giardia. Erythromycin and similar antibiotics may be useful for Cryptosporidium or Campylobacter. Nitazoxanide is another antibiotic showing promise for treating diarrhea caused by parasites. Antibiotics do not work for diarrhea caused by viruses.

Review Date: 01/30/2011
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org).