Traveler’s Diarrhea

Traveler’s diarrhea (TD) is the most common illness affecting international travelers, particularly those visiting low- and middle-income countries. It is typically caused by ingesting contaminated food or water and leads to acute gastrointestinal symptoms such as diarrhea, abdominal cramps, and sometimes fever and vomiting. While most cases are self-limiting, untreated severe episodes can result in dehydration and complications that disrupt travel plans.

Etiology and Pathogens Responsible for Traveler’s Diarrhea

Bacterial Causes

Approximately 80–90% of traveler’s diarrhea cases are bacterial. The most frequent causative agent is Enterotoxigenic Escherichia coli (ETEC). Other bacterial pathogens include:

Enteroaggregative E. coli (EAEC)
Enteroinvasive E. coli (EIEC)
Shigella spp.
Campylobacter jejuni
Salmonella spp.

Viral and Parasitic Causes

Viruses: Norovirus and rotavirus are less common but responsible for outbreaks, especially on cruise ships.
Parasites: Giardia lamblia and Entamoeba histolytica are less common but may cause prolonged or recurrent diarrhea.

Symptoms of Traveler’s Diarrhea

Symptoms typically begin within 1 to 3 days of exposure and may last up to 3–5 days in uncomplicated cases.

Frequent loose or watery stools (≥3 per day)
Abdominal cramps or pain
Urgency to defecate
Nausea and vomiting
Fever (mild to moderate)
Malaise and dehydration

Symptoms are usually mild to moderate, but in 10–20% of cases, they may be severe enough to require medical intervention.

High-Risk Destinations for Traveler’s Diarrhea

Risk correlates with local sanitation standards and hygiene practices. Regions with the highest risk include:

South Asia (India, Nepal, Bangladesh)
Southeast Asia (Thailand, Indonesia)
Sub-Saharan Africa
Central America and Mexico
Parts of South America (Peru, Bolivia)

Travelers visiting these regions should exercise increased caution with food and water consumption.

Risk Factors Contributing to Infection

Consumption of untreated water
Eating raw or undercooked food
Street food consumption in unsanitary environments
Poor hand hygiene
Young age or elderly
Underlying gastrointestinal conditions (e.g., IBS)
Use of acid-reducing medications (PPIs, H2 blockers)

Preventive Measures for Traveler’s Diarrhea

Safe Eating and Drinking Practices

Boil it, peel it, cook it, or forget it: Avoid raw produce unless peeled.
Drink only bottled or treated water
Avoid ice in beverages unless made from purified water
Use bottled water for brushing teeth
Eat food served piping hot
Avoid buffet-style dining in high-risk areas

Hand Hygiene

Wash hands frequently with soap and clean water
Use alcohol-based hand sanitizers (≥60% alcohol) when soap is unavailable

Vaccination and Chemoprophylaxis

Dukoral: Oral vaccine against cholera and ETEC—modest efficacy in high-risk travelers
Bismuth subsalicylate (Pepto-Bismol): Preventive use in select cases, taken multiple times daily
Antibiotic prophylaxis (e.g., rifaximin) is not routinely recommended but may be considered for high-risk individuals with immunosuppression or chronic illness

Diagnosis of Traveler’s Diarrhea

Routine diagnostic tests are often unnecessary unless:

Symptoms persist beyond 14 days
Severe dehydration or systemic infection is suspected
Presence of blood or mucus in stool
High fever

In such cases, the following may be ordered:

Stool culture
PCR-based multiplex assays
Ova and parasite (O&P) examination

Treatment of Traveler’s Diarrhea

Rehydration

The primary treatment is fluid and electrolyte replacement:

Oral Rehydration Salts (ORS): WHO-approved solutions help prevent dehydration
Clear liquids: Broth, fruit juices (avoid caffeine and alcohol)

Antimicrobial Therapy

Prescribed based on severity and region of travel:

Region	First-Line Antibiotic	Alternatives
South Asia	Azithromycin	Rifaximin (mild), Ciprofloxacin
Latin America	Ciprofloxacin	Azithromycin
Africa	Azithromycin	Rifaximin

Azithromycin: 500 mg once daily for 1–3 days
Rifaximin: 200 mg three times daily for 3 days
Ciprofloxacin: 500 mg twice daily for 1–3 days (check for resistance)

Antimotility Agents

Loperamide: Reduces stool frequency; safe for use in adults without fever or bloody stools
Should not be used if dysentery is suspected

When to Seek Medical Attention

Immediate medical evaluation is warranted if:

Diarrhea persists beyond 72 hours
High fever (>102°F)
Presence of blood or mucus in stools
Signs of severe dehydration (dry mouth, reduced urination, confusion)
Travelers with chronic illnesses or immunosuppression

Complications of Traveler’s Diarrhea

Though often self-limiting, complications can occur in vulnerable individuals:

Severe dehydration and electrolyte imbalance
Post-infectious irritable bowel syndrome (PI-IBS)
Reactive arthritis
Prolonged diarrhea due to parasitic infections