Traveler’s diarrhea is gastroenteritis that is usually caused by bacteria endemic to local water. Symptoms include vomiting and diarrhea. Diagnosis is mainly clinical. Treatment is with replacement fluids and sometimes antibiotics for moderate to severe diarrhea.
(See also Overview of Gastroenteritis and see the Center for Disease Control and Prevention’s [CDC] information for preparing international travelers for travelers’ diarrhea.)
Etiology of Traveler's Diarrhea
Traveler’s diarrhea may be caused by any of several bacteria, viruses, or, less commonly, parasites.
The most common cause of traveler's diarrhea is
Enterotoxigenic Escherichia coli (E. coli)
E. coli is common in the water supplies of areas that lack adequate purification. Infection is common among people traveling to low-resource countries.
Norovirus gastroenteritis has been a particular problem on some cruise ships.
Both food and water can be the source of infection. Travelers who avoid drinking local water may still become infected by brushing their teeth with an improperly rinsed toothbrush, drinking bottled drinks with ice made from local water, or eating food that is improperly handled or washed with local water. People taking medications that decrease stomach acid (antacids, H2 blockers, and proton pump inhibitors) are at risk of more severe illness.
Symptoms and Signs of Traveler's Diarrhea
Nausea, vomiting, hyperactive bowel sounds, abdominal cramps, and diarrhea begin 12 to 72 hours after ingesting contaminated food or water. Severity is variable. Some people develop fever and myalgias. Diarrhea is rarely bloody.
Most cases are mild and self-limited, although dehydration can occur, especially in warm climates.
Diagnosis of Traveler's Diarrhea
Clinical evaluation
Specific diagnostic measures are usually not necessary. However, fever, severe abdominal pain, and bloody diarrhea suggest more serious disease and should prompt immediate evaluation.
Treatment of Traveler's Diarrhea
Fluid replacement
Sometimes antidiarrheal (antimotility) medications
Antibiotics (eg, ciprofloxacin, azithromycin) for moderate to severe diarrhea
The mainstay of treatment of traveler's diarrhea is fluid replacement and an antidiarrheal medication such as loperamide
Antidiarrheal medications should not be used in adults with suspected C. difficile or E. coli O157:H7 infection (eg, with recent antibiotic use, bloody diarrhea, heme-positive stool, or diarrhea with fever) or in children, particularly those < 2 years. Iodochlorhydroxyquin, which may be available in some low- and middle-income countries, should not be used because it may cause neurologic damage.
Pearls & Pitfalls
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Generally, antibiotics are not necessary for mild diarrhea. However, in patients with moderate to severe diarrhea (≥Campylobacter2017 guidelines for the prevention and treatment of travelers' diarrhea.)
Prevention of Traveler's Diarrhea
Travelers should dine at restaurants with a reputation for safety and avoid foods and beverages from street vendors. They should consume only cooked foods that are still steaming hot, fruit that can be peeled, and carbonated beverages without ice served in sealed bottles (bottles of noncarbonated beverages can contain tap water added by unscrupulous vendors); uncooked vegetables (particularly including salsa left out on the table) should be avoided. Buffets and fast food restaurants pose an increased risk.
Key Points
Traveler's diarrhea is usually caused by enterotoxigenic E. coli, but viruses, parasites, and other bacteria may be involved.
Diagnosis is clinical and testing is not usually needed unless bloody diarrhea, fever, or abdominal pain is present.
Prevention is the best measure and involves careful selection of foods and beverages; prophylactic antibiotics are not routinely used except for patients with immunocompromise.
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Centers for Disease Control and Prevention: Preparing international travelers for travelers’ diarrhea
Expert panel: Guidelines for the prevention and treatment of travelers' diarrhea (2017)
