COMMENTARY

Travelers' Diarrhea: New Guidelines for Prevention and Treatment

Douglas H. Esposito, MD, MPH

Disclosures

October 30, 2017

Editorial Collaboration

Medscape &

Therapy for Moderate Travelers' Diarrhea

  • Antibiotics may be used to treat moderate travelers' diarrhea (weak recommendation, moderate level of evidence).

  • Fluoroquinolones may be used to treat moderate travelers' diarrhea (strong recommendation, moderate level of evidence). However, emergence of resistance to this class of drug, particularly in Southeast Asia, combined with the potential for reduced diversity of intestinal microbiota (dysbiosis) and adverse musculoskeletal consequences (tendon rupture), contribute uncertainties to the risk-benefit assessment, and the guideline authors did not unanimously grade this recommendation.

  • Azithromycin may be used to treat moderate travelers' diarrhea (strong recommendation, high level of evidence).

  • Rifaximin may be used to treat moderate travelers' diarrhea (weak recommendation, moderate level of evidence). Clinicians should exercise caution when providing rifaximin for empiric therapy for moderate diarrhea in regions or with itineraries in which the risk for invasive pathogens is high.

  • Loperamide may be used as adjunctive therapy for moderate to severe travelers' diarrhea (strong recommendation, high level of evidence).

  • Loperamide may be considered for use as monotherapy in moderate travelers' diarrhea (strong recommendation, high level of evidence)

Therapy for Severe Travelers' Diarrhea

  • Antibiotics should be used to treat severe travelers' diarrhea (strong recommendation, high level of evidence).

  • Azithromycin is preferred to treat severe travelers' diarrhea, including dysentery (strong recommendation, moderate level of evidence).

  • Fluoroquinolones may be used to treat severe, nondysenteric travelers' diarrhea (weak recommendation, moderate level of evidence).

  • Rifaximin may be used to treat severe, nondysenteric travelers' diarrhea (weak recommendation, moderate level of evidence).

  • Single-dose antibiotic regimens may be used to treat moderate or severe travelers' diarrhea (strong recommendation, high level of evidence). If symptoms have not resolved after 24 hours, travelers should be told to continue daily dosing for up to 3 days.

Follow-up and Diagnostic Testing

  • Microbiologic testing is recommended in returning travelers with severe or persistent symptoms or in those who do not respond to empiric therapy (strong recommendation, low/very low level of evidence).

  • Molecular testing, aimed at a broad range of clinically relevant pathogens, is preferred when rapid results are clinically important or nonmolecular tests have failed to establish a diagnosis (ungraded). No published studies show that using these tests improves patient outcomes.

Additional Consensus Statements (Ungraded)

  • The evidence is insufficient to recommend the use of commercially available prebiotics or probiotics to prevent or treat travelers' diarrhea.

  • Studies are needed on changes in the gut microbiome in travelers with and without diarrhea to clarify the benefits and harms of current and novel preventive, diagnostic, and therapeutic approaches.

  • There is an incrementally increasing association of travel, travelers' diarrhea, antibiotic use. and the acquisition of multidrug-resistant bacteria. Pretravel counseling should include information about this risk, balanced against the potential benefits of antibiotic use.

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