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| Traveler's Diarrhea by C. Leigh Culver Copyright © 2001- 2007. All rights reserved. If you travel often, the odds are that you have suffered from this condition at least once, especially, those of you in the oil/gas and mining industries. Typically, these industries tend to take their workers off the beaten path where the risks for traveler’s diarrhea are greater. It should be noted, however, that traveler’s diarrhea isn’t a condition that occurs only off the beaten path. It can happen anywhere in the world--even in your hometown. What is Traveler’s Diarrhea? So what is traveler’s diarrhea and how is caused? Traveler’s diarrhea is not a disease, but a symptom of a gastrointestinal infection caused by bacteria, viruses or parasites. You get traveler’s diarrhea by ingesting contaminated food (most often) or water (less often). Classification Types of Diarrhea Typically traveler’s diarrhea manifests as one of three classifications, (1) Watery Diarrhea, (2) Dysentery (Bloody Diarrhea), and (3) Chronic Diarrhea. Watery Diarrhea Watery Diarrhea is the most common type of diarrhea that most people get. When occurring, watery diarrhea may present itself as several watery, non-bloody stools, or it may be very profuse and "explosive." Additional symptoms might include abdominal cramping, nausea and vomiting. Watery diarrhea is most often caused by such organisms as E. Coli, Salmonella, and Shigella. If left untreated, symptoms may last for three to five days. The primary danger of watery diarrhea is dehydration. Watery diarrhea is usually easily treated with antibiotics and fluids (which will be discussed below). Dysentery Dysentery is usually characterized by loose, bloody or mucous containing stools, and is a considerably more serious matter. Other accompanying symptoms are similar to that of watery diarrhea, such as, nausea, vomiting and cramping; however, fever, abdominal pain and prostration may present as well. The most common cause for dysentery is Shigella, however, other organisms, such as, Salmonella, C. Jejuni, E. Coli and E. Histolytica may cause the disorder. Dysentery is usually treated with fluids and antibiotics. Should you acquire dysentery-like symptoms, you should seek medical attention, especially, if antibiotic treatment has failed to remedy the situation. Chronic Diarrhea Chronic Diarrhea is the third type (and thankfully the least common) of diarrhea, and is characterized by symptoms that may last for several weeks. Additional symptoms might include, abdominal pain, bloating, nausea, loss of appetite, weight loss, fatigue, and/or a low-grade fever. The primary cause of chronic diarrhea is Giardiasis, a parasite. There are, however, several other organisms that may cause chronic diarrhea. Should you manifest symptoms of chronic diarrhea you should consult with a physician, especially, one who specializes in travel medicine or infectious disease. To determine a correct diagnosis and treatment for chronic diarrhea, laboratory analysis is usually necessary. If you find yourself in a remote are where medical attention is not readily available, then starting self-treatment with Metronidazole (Flagyl) or Tinidazole (Fasigyn) might be the best option until competent medical attention is available. Treatment options will be discussed below. Before traveling you should discuss such options with your physician. Your physician, knowing your health history, will better be able to assist you with these choices. Precautions and Prevention Almost everyone has heard the maxim of "boil it, cook it, peel it or forget it." Of course, most people do not very strictly follow this advice, hence the need for an article such as this. So let’s cover a few basics. Eat your meats well done, peel fruit, drink bottled, treated or filtered water* (avoid tap water), avoid ice cubes in your drinks, wash the surfaces of tins, cans, and bottles that contain food or beverages, and avoid salads. Many times foods sold by street vendors may cause you problems. And let’s not forget--handwashing. Think about how many things you touch, or how many hands you might shake in a day. Simple handwashing with plain soap and water can go a long way to preventing traveler’s diarrhea, not to mention, such things as the common cold. (*Water treatment options will be covered in a separate article.) Medication Prophylaxis Another approach to prevention lies in medication prophylaxis. Prophylaxis is a very good idea if you will be away for several weeks, be in a remote area where medical follow-up is difficult, or will be in a situation where having traveler’s diarrhea would seriously interrupt your agenda. Prophylaxis may be accomplished by taking Bismuth Subsalicylate or antibiotics. Bismuth Subsalicylate Bismuth Subsalicylate is an over-the-counter medication (called Pepto-Bismol in the United States) and it offers a very good option for prophylaxis. The bismuth component of Bismuth Subsalicylate actually helps remove harmful bacteria and the salicylate component has antisecretory and anti-inflammatory effects, which diminishes diarrheal fluid. Bismuth Subsalicylate typically comes in the form of tablets or liquid. The tablet form, of course, is much easier to carry when traveling. Dosage (adult): 2 tablets (or 1 oz/30 ml) four times a day (at mealtimes and bedtime). As with all medications, Bismuth Subsalicylate has the usual precautions and side effects. You should read the insert and/or label to see if any of these apply to you and act accordingly. Antibiotic Prophylaxis Some authorities are advocates of antibiotic prohylaxis for the prevention of traveler’s diarrhea. I tend to lean the other way. My view is that antibiotics often have unwanted side effects, especially, on a sustained use of several weeks. Most physicians are reluctant to prescribe antibiotics for prophylaxis for this same reason. One such effect of extended antibiotic use is that it diminishes the "friendly" microflora that are necessary for a healthy gastrointestinal tract, which can cause it’s own problems. As stated previously, obtaining your physician's advice prior to your traveling will help you in determining what options are best for you. Treatment Of Traveler’s Diarrhea The treatment of traveler’s diarrhea usually consists of a regimen that includes, (1) change of diet, (2) rehydration, (3) antidiarrheal agents and (4) antibiotic therapy. Diet It is a good idea to rest the bowel, and it is a good idea to avoid high-fiber foods, fats, milk products, caffeine, and alcohol. Easily digested bland foods, like soups and crackers, are suggested. Rehydration In most instances of traveler’s diarrhea, dehydration doesn’t become a serious issue; however, rehydration is important. In severe and prolonged diarrhea dehydration may occur very quickly—especially in children. When experiencing diarrhea, it is also a good idea to avoid drinks with a high glucose or sugar content such as sodas. A too high a glucose concentration in the stomach will inhibit water absorption and may draw more fluid into the intestine makeing the diarrhea worse. Surprisingly, many commercially available sports drinks, that are regularly used for rehydration, actually have glucose contents that are not optimal. A solution with a percentage of glucose around 2.5% is optimal. Many sports drinks have glucose ranges that are 6% or higher. What you can do in this case is dilute them by adding safe water. A very good option, if available, are the oral electrolyte solutions such as Pedialyte. Pedialyte is typically used for children, however, anyone can use it. The World Health Organization (WHO) has an oral rehydration therapy formula that is sometimes available. It contains:
3.5 gms sodium chloride Dissolve contents of packet in 1 liter (about 4 cups) of safe water Recently the WHO has recommend replacing 2.5 gms of sodium bicarbonate with 2.9 gms of trisodium citrate dihydrate. This new formula is supposed to provide for a longer shelf life and is also designed to correct acidosis and reduce stool volume. Should you find yourself in a situation where oral rehydration is necessary, and your options for finding the above are nil, then you might need to create your own oral rehydration formula. Here are some suggestions:
Oral Rehydration Formula No. 1
Oral Rehydration Formula No. 2
Oral Rehydration Formula No. 3 This formula is the best option of the three if all of the ingredients are available. Antidiarrheal Agents Antidiarrheal agents may be used safely when diarrheal symptoms are mild to moderate. They should not, however, be used when there are accompanying symptoms of high fever, bloody diarrhea or systemic toxicity as they may worsen the situation. They should also be discontinued when diarrhea is worsening despite therapy. Bismuth Subsalicylate is not only useful for prophylaxis, but also as a treatment for traveler’s diarrhea. Dosage (adult): 2 tablets (or 1 oz/30 ml) initially, repeated at ½ to 1 hour intervals as needed. You shouldn’t exceed 16 tablets (or 8 oz) in a 24 hour period. Loperimide (Imodium) is the antidiarrheal medication of choice. Loperamide reduces diarrhea by virtue of its antimotility and antisecretory effects on the bowel. Lopermide is quick acting and has minimal side effects. Dosage (adult): 4 mg (2 tablets) initially, followed by 2 mg (1 tablet) after every each subsequent loose stool. You shouldn’t exceed 16 mg in a 24 hour period. The efficacy of Loperamide may be greatly enhanced by the additional treatment of an antibiotic. Antidiarrheals do work, however, they do not work on the cause of the problem—the diarrhea causing microorganisms. Several studies have been performed to determine the best course of action regarding treatment of diarrhea. Treatment using only Loperamide, treatment using only antibiotics, and treatment involving the use of Loperamide and certain antibiotics have been researched. These studies demonstrated that the use of Loperamide, with the adjunctive use of certain antibiotics, greatly reduced symptom duration time than when either Loperamide or antibiotics were used separately. Antibiotic Therapy There are several antibiotic choices for treating traveler’s diarrhea. The choices range from the once favored sulfa drugs to the now superior quinolones. Being that the quinolone antibiotics are so superior, this article will only describe their use. The following quinolones are recommended for the treatment of traveler's diarrhea:
Ciprofloaxacin (Cipro) is very effective against E. Coli, Shigella, Salmonella, Yersinia and Campylobacter. Ofloxacin (Floxin) is also very effective in the treatment of the above and has a more broad treatment effect against other infective organisms as well. Dosage: 400 mg twice daily for 1-3 days Levofloxacin (Levaquin) is the isolated active component of Ofloxacin. Dosage: 500 mg once daily for 1-3 days The quinolones are also very effective for other types of infections such as Urinary Tract Infections (UTI), Pneumonia, Bronchitis, Chlamydia and Gonorrhea with Levofloaxcin and Ofloxacin being more broadly effective in the treatment of these conditions. Parasites As stated previously, diarrhea that last for two weeks or more should followed up by medical consultation. Such persistent diarrhea is usually due to Giardiasis or Amebiasis. Should medical attention not be readily available, then starting self-treatment with Metronidazole (Flagyl) or Tinidazole (Fasigyn) might be the best option until you can follow-up with a physician. Keep in mind, that laboratory analysis is necessary to determine whether or not you have either of these conditions. Metronidazole (Flaygl) is used for the treatment for Giardiasis or Amebiasis. Dosage for Giardiasis: 250 mg three times a day for 5-7 days For Amebiasis: 750 mg three times a day for 5-10 days
Tinidazole (Fasigyn) is chemically similar to Metronidazole and is used to treat Giardiasis and Ambiasis as well. Final Thoughts Finally, it should be stated that you should always seek the advice of your physician regarding the use of antidiarrheals or antibiotics. Also, when traveling with any medication, it is prudent to carry a letter of authorization from your physician. Medications should also be in prescription vials with your name and your physicians name on it. This will help avoid misunderstandings when going through customs in "drug-conscious" countries.
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