How to manage traveller's diarrhoea?

If symptoms of traveller’s diarrhoea are severe or prolonged and medical assistance is available, then see a doctor. Mild cases of traveller’s diarrhoea should resolve in a few days. Keep up fluid intake, and salts if at risk of dehydration. Oral rehydration sachets (electrolyte replacement) are useful in some groups. If symptoms are ongoing, anti-motility medications may be needed, and/or antibiotics in some cases. Taking antibiotics as a precautionary measure is only advised for people with certain medical conditions. A travel medicine doctor can advise on medicines to pack for a self-management kit.

Ten-point plan

1. Hygiene

Maintaining basic hygiene is simple and effective but it is not always a practical reality for travellers, therefore:

• wash hands before eating and after using the toilet
• clean eating utensils before using them.

2. Mild traveller's diarrhoea

Most instances of traveller's diarrhoea are mild and of short duration (less than 48 to 72 hours) and will not need specific management.

3. Fluids and salts

Travellers with traveller's diarrhoea should drink lots of fluids and salts, especially if they are at risk of dehydration. Consider:

• soups and sugar-flavoured mineral waters
• 1 teaspoon salt + 8 teaspoons sugar in 1 litre of 'clean' water (World Health Organization recommended formula)
• bottled or canned fluids, teas or 'clean' water
• avoid milk and milk products for 24 to 48 hours.

4. Resume eating

Food should be started as soon as the person can eat. Stopping eating completely while suffering diarrhoea is not recommended. Rice, banana, papaya, stewed apple, dry salty biscuits, and pumpkin are examples of suitable foods.

5. Oral rehydration sachets

Oral rehydration sachets (made up into solution) are important for children and elderly patients with traveller's diarrhoea, and for anyone with cholera-like diarrhoea, because the mixture is sterile and contains electrolytes (vital salt replenishment). However, the solution has no influence on traveller's diarrhoea symptoms in adults, for whom soup, juice and similar fluids are adequate.

6. Postpone medication

Before considering the need for medication, travellers should have ongoing diarrhoeal symptoms that do not improve.

The World Health Organization (WHO) defines traveller's diarrhoea as occurring when there are:

• three loose bowel movements within eight hours; or
• four loose bowel movements within 24 hours, plus at least one sign or symptom of nausea, vomiting, abdominal cramps, faecal urgency, tenesmus (anal spasms and straining without passing a great amount) or mild fever.

7. Anti-motility medication

When treatment is required, anti-motility medication should be used in the initial stages of traveller's diarrhoea, before antibiotics are considered. Anti-motility medications loperamide (eg, Diamide, Imodium) and diphenoxylate (eg, Diastop) slow down the bowel muscle contractions and reduce the number of bowel movements. These should be taken according to the medical advice given.

8. Antibiotics

Antibiotics have an important role in treating traveller's diarrhoea. The right antibiotic should relieve symptoms and shorten the illness, especially if caused by Shigella or Escherichia coli. Antibiotics alone are suggested when the diarrhoea is:

• accompanied by a fever above 38 degrees C
• accompanied by blood in the bowel motion (medical assessment should be sought as this is a serious sign)
• accompanied by 3 to 5 motions in a 24-hour period
• unchanged after 2 days.

9. Self-treatment programme

Would-be travellers may be prescribed drugs for their medical kit for self-treatment in the event they get traveller's diarrhoea. Self-treatment can be considered if all the traveller's diarrhoea parameters are met (see World Health Organization definition under point 6 above).

A combination of loperamide plus an antibiotic will generally resolve the illness in less than 2 hours. A travel medicine specialist will help make sure you are carrying the correct antibiotic.

10. Antimicrobial prophylaxis

Taking antibiotics prophylactically in an attempt to avoid getting traveller's diarrhoea is not recommended unless the traveller has:

• AIDS/HIV or is immune compromised
• inflammatory bowel disease or high susceptibility to diarrhoeal disease
• a history of stomach surgery or is using medications for reducing stomach acid (in reflux, heartburn or ulcers)
• insulin-dependent diabetes
• essential business that cannot be compromised by illness
• heart disease and is taking diuretics.

The maximum duration for prophylaxis in these cases is 3 weeks.

Related topics

Also see: Food and drinks - safety tips for travellers

Original content courtesy of Dr Marc Shaw, Medical Director, WORLDWISE Travellers Health Centres, New Zealand, from the Travel Medicine Guide, 6th edition, 2011. Edited by everybody, November 2011.