Travelers' Diarrhea

Travelers to Mexico call it "Montezuma's revenge," while Mexicans call it "turista" (tourist). It undoubtedly goes by other names in Southeast Asia, Africa, the Middle East, and other developing regions all over the world. Whatever you call it, travelers' diarrhea can put a major crimp in your vacation or business trip.

Ten million visitors to developing countries pick up this unwanted souvenir every year, but dealing with a bout of diarrhea doesn't have to be a part of your travel plans. With a few simple precautions, you can spend more time enjoying the sights and less time visiting the bathroom.

What causes travelers' diarrhea?

Most cases of travelers' diarrhea are caused by harmful bacteria lurking in contaminated food and water. The culprits, some familiar and others not so familiar, include: toxic E. coli, salmonella, shigella, campylobacter, and cryptosporidium -- the same germs that occasionally cause food poisoning in the United States. Many other cases are caused by protozoan parasites like giardia and E. histolytica (the cause of amebic dysentery).

Who is at risk for travelers' diarrhea?

The germs that cause travelers' diarrhea thrive in tropical and undeveloped areas throughout the world. Travelers to Mexico, Central America, the Middle East, and most of Africa are likelier to run into these unpleasant bugs. Natives of these areas become relatively immune to these germs by the time they reach adulthood, but visitors from developed countries have few defenses.

Travelers' diarrhea is more common in young adults (partly because they're more likely to venture beyond tourist resorts) than in older people. Men and women are equally affected.

What are the symptoms of travelers' diarrhea?

Travelers' diarrhea is rarely life-threatening, but it's never fun. Most sufferers have diarrhea (three or more loose or watery stools in a 24-hour period) for three to seven days. About one in 100 travelers develops chronic diarrhea that lasts more than 30 days. Chronic diarrhea is especially common in travelers with parasitic infections. While bacterial infections usually cause diarrhea within a few days, a parasitic infection may stay silent for weeks.

Other symptoms that often accompany travelers' diarrhea include nausea, bloating, fatigue, and an urgent need to use the bathroom. More severe cases might cause fever, chills, and bloody stools.

What is the treatment for travelers' diarrhea?

Replenishing fluids with a solution of water, sugar, and mineral salts such as sodium and potassium is the cornerstone of treatment for travelers' diarrhea, especially for children. This combination, which replaces the crucial fluid and nutrients lost to diarrhea, is known as an Oral Rehydration Solution (ORS).

If your symptoms are mild and you're in generally good health, a few extra fluids should be the only treatment you need. But some people need extra help. According to the Centers for Disease Control and Prevention (CDC), infants, children, and pregnant women with travelers' diarrhea should always get prompt medical treatment.

You should also contact a doctor if your diarrhea is severe or bloody, if you have fever or chills, if your symptoms don't clear up within a few days, or if you become dehydrated.

Symptoms of dehydration include dry lips and mouth, sunken eyes, urine that smells strong or is dark, not urinating much or often, dizziness, few or no tears when crying (infants), paying little attention to your surroundings (in children), or being difficult to wake up (a sign of very advanced dehydration).

Because children with diarrhea get dehydrated very easily, they need special care. A sick child or infant should be given an oral rehydration solution, which sometimes comes as a pre-made packet of salt and carbohydrates that you mix with water. These packets are widely available from drugstores and clinics in most areas of the world; many also sell them as liquids such as Pedialyte. If your child is vomiting, try giving her one to two teaspoons of Pedialyte or another rehydration liquid every one to two minutes. (Don't feed her soups, juices, tea, or Gatorade if she has diarrhea and is vomiting; these don't have the right combination of nutrients and can make matters worse, according to the American Family Physician.) When she is feeling better and has stopped vomiting, you can begin giving her clear broths or clear sodas first. If she can hold that down, you can begin to give her regular food and drink again.

Anti-diarrhea medications (such as Imodium AD and Lomotil) usually aren't recommended. Diarrhea is a way for your body to get rid of an infection, if that is what is causing it. If you feel you or your child needs medication, talk to your doctor. A combination of oral rehydration solutions and medication may be appropriate. (Since these anti-diarrhea medications reduce the "motility," or motor activity in the intestines, they're known as "antimotility" medications.) Antimotility agents shouldn't be used if bloody stools or a fever are present. In addition, they should not be used for more than 48 hours or taken by children less than two years of age.

Depending on where you have been traveling and what type of organism you might have picked up, fluoroquinolones (such as Cipro and Noroxin), rifaximim or azithromycin (Zithromax) are the antibiotics of choice for treatment of severe travelers' diarrhea in people older than 18.

How can I avoid travelers' diarrhea?

Antibiotics may be able to kill the germs, but a little caution is the best medicine of all.

The most important tip: Don't drink the water. Simply brushing your teeth with tap water, or tossing a couple of ice cubes into your drink can be enough to make you sick. In many areas, the only safe beverages are bottled water, boiled water, canned or bottled sodas, tea and coffee (made with boiled water), beer, or wine. If it's not possible to boil your water for at least one minute, treat it with chemical disinfectants such as iodine or chlorine. For extra protection, strain the water through an "absolute 1 micron" filter (available at outdoor supply stores) before adding the disinfectant.

In areas with poor sanitation, the food can be as dangerous as the water. You should be especially suspicious of salads, uncooked fruits and vegetables, unpasteurized milk, raw meat, shellfish, and any foods sold by streetside vendors. Some restaurants catering to tourists disinfect vegetables and fruits, but find out before you order a salad. In general, fruits that you peel yourself and hot meals are safer choices.

References

Centers for Disease Control and Prevention. Food and water precautions and travelers' diarrhea prevention.

Centers for Disease Control and Prevention. Travelers' Diarrhea.

Taylor DN et al. Chronic diarrhea in the returned traveler. Medical Clinics of North America. Vol. 83(4):1033-1051.

Adachi JA et al. Empirical antimicrobial therapy for travelers' diarrhea. Clinical Infectious Diseases. Vol. 31:1079-1083.

Yates J. Traveler's Diarrhea. American Family Physician, Vol. 71(11): 2095-2100.

American Academy of Family Physicians. Vomiting and Diarrhea in Children. March 2009.

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