General Travel Health

Preventing and Treating Travelers' Diarrhea.
--Frank Gillingham, MD

Avoiding Travelers' Diarrhea is difficult. A study published in the mid-1980's found that among 600 travelers who kept complete dietary journals during travel to developing countries, 98% violated the rules for safe eating at least once within the first three days of their trip! Whether they're in New York or New Guinea, most travelers find it difficult not to eat something that looks appetizing -- especially when they're hungry.

While there are no vaccines to prevent TD, bismuth subsalicylate (brand name: Pepto Bismol) has been shown in well-done studies to reduce the incidence of TD by about 60%. However, you have to take it frequently (2 tablets, 4 times a day; or 2 oz. 4 times a day) and it has side effects including temporary blackening of the tongue and stools, nausea and constipation, and, sometimes, ringing in the ears. This agent contains aspirin so don't take it if you're allergic to aspirin, if you take aspirin for another reason, or if you have kidney insufficiency, gout or a history of ulcers. If you take any medications chronically check with your doctor before using it. It is not recommended for children or for extended use (>3 weeks).

If, like so many others, you fall victim to TD, here's what to do (note: recommendations for children are different--see below):

• Antibiotics are the mainstay of treatment and can shorten a 3-5 day episode of TD by 1 1/2 days or more. Some people feel better within hours after the first dose. The so-called "quinolone" antibiotics are most commonly used, especially ciprofloxacin (one 500 mg tablet, twice a day, 12 hours apart) and norfloxacin (these agents are for adults only!!). Trimethoprim/sulfamethoxazole (brand name: Bactrim) may be effective but antibiotic resistance to it is increasing and it is more apt to cause side effects. Get a prescription from your doctor, fill it at home and carry the medication, in its original container, in your carry-on bag. Bring along a copy of the prescription in case a customs agent gets curious.
  
  Start taking the antibiotic if you have severe diarrhea--especially if accompanied by nausea, vomiting, abdominal cramps, fever or blood in the stool. Many Travel Medicine experts recommend a three day course of a quinolone like Ciprofloxacin.
  
  While antibiotics are a mainstay of treatment, using antibiotics to prevent TD is not a particularly good idea for most travelers. In addition to exposing yourself to the risk of medication side effects, taking antibiotics before you're sick may give you a false sense of security (remember, antibiotics won't help at all against viruses and parasites). You may kill only sensitive bacteria and leave the strong ones behind to cause you problems later. And what will you take if you develop diarrhea while taking these medications to prevent it? If your immune system is compromised or if you can't afford under any circumstance to be sick for a day or two, discuss using antibiotics in this way with your doctor.
  
• Hydration is essential to managing diarrhea regardless of the cause. It may seem as if everything you take in is immediately coming out again, but you must keep drinking. Stick with clear, bottled, flavored fluids (carbonated or boiled--so you don't catch another virus or bacteria). Sports-drinks are helpful if you can get them. Oral rehydration solutions (brand name: Cera-Lyte, which may require a prescription) are the most effective way to stay hydrated, but they're not particularly convenient as they must be mixed up properly and discarded after 12 hours (24 hours if refrigerated). I would recommend bringing them along for severe cases of TD.
  
  There's no reason to eat if you don't feel like it. If you are hungry, eat bland foods such as salted crackers and bread (some people use the BRAT diet--Bananas, Rice, Applesauce or Toast). Avoid dairy products, spicy and greasy food. Remember that eating may trigger diarrhea so make sure there's a bathroom nearby.
  
• Lomotil, Imodium and other similar agents can slow down the intestines and reduce the frequency of the diarrhea. These drugs are most useful for mild cases (as is Pepto Bismol--which, in addition to preventing some cases of TD, can be used like Lomotil to slow down the diarrhea). However, they don't help rid your body of the infection. Don't use these agents if you have fever or blood in your stool. Don't use them for more than 48 hours in a row.
• TD caused by protozoa such as giardia and amoeba develops more slowly than bacterial TD, without nausea, vomiting and fever, and requires different antibiotics. It's less common as well. Discuss with the physician that helps prepare you for your trip whether you should carry additional antibiotics to treat protozoa and how you should use them.
• Management of TD TD in children is quite different than that outlined above. Dehydration must be prevented and treated very aggressively and the antibiotics are different. If you traveling with your children to destinations of with significant TD risk--or places with marginal medical facilities -- be sure to make detailed plans with your pediatrician in advance.