Travelers' Diarrhea: New Guidelines for Prevention and Treatment

Douglas H. Esposito, MD, MPH


October 30, 2017

Editorial Collaboration

Medscape &

Summary for Clinicians

The management of travelers' diarrhea is an unusual clinical scenario in which the traveler is expected to diagnose and treat his or her own illness. Conveying complicated guidelines to travelers is a challenge in the context of an already complex pretravel consultation. The following take-home points can guide the provider and be discussed with the traveler:

  • Most, if not all, travelers to destinations in developing countries should be provided with loperamide and an antibiotic for self-treatment.

  • If the traveler is going to Southeast Asia, the antibiotic should be azithromycin. A fluoroquinolone, azithromycin, or rifaximin can be used in other regions. If rifaximin is given as a first-line agent, a second prescription for azithromycin should be given in case of dysentery or febrile diarrhea.

  • The traveler should be advised that if the illness does not affect his or her travel, to stay hydrated and consider managing symptoms with loperamide.

  • If the illness has some effect on travel but is tolerable, the traveler should take loperamide and consider taking an antibiotic; however, the traveler should understand the risks and benefits of taking antibiotics for moderate disease.

  • If the illness is disruptive (for example, keeps the traveler confined to a hotel room), the traveler should start antibiotics and add loperamide if expeditious symptom relief is desired.

  • If symptoms do not improve (or if they worsen) within 24-36 hours of beginning antibiotic therapy, the traveler may need to seek medical attention.

  • Prophylaxis should be considered only for high-risk groups (underlying health condition or performance-critical occupation or itinerary). Rifaximin is the first choice, and BSS is a second option.

  • If rifaximin is used as prophylaxis, azithromycin should be provided to treat breakthrough travelers' diarrhea.

Web Resources

Travelers' Diarrhea

Antibiotics in Travelers' Diarrhea