Travelers' diarrhea
Travelers' diarrhea | |
---|---|
Other names | Travellers' diarrhoea, tourist diarrhea, developing world[3] |
Travelers' diarrhea (TD) is a stomach and intestinal infection. TD is defined as the passage of unformed stool (one or more by some definitions, three or more by others) while traveling.[2][3] It may be accompanied by abdominal cramps, nausea, fever, headache and bloating.[3] Occasionally bloody diarrhea may occur.[5] Most travelers recover within three to four days with little or no treatment.[3] About 12% of people may have symptoms for a week.[3]
Recommendations for prevention include eating only properly cleaned and cooked food, drinking
Estimates of the percentage of people affected range from 20 to 50 percent among travelers to the
Signs and symptoms
The onset of TD usually occurs within the first week of travel, but may occur at any time while traveling, and even after returning home, depending on the incubation period of the infectious agent.[10] Bacterial TD typically begins abruptly, but Cryptosporidium may incubate for seven days, and Giardia for 14 days or more, before symptoms develop. Typically, a traveler experiences four to five loose or watery bowel movements each day. Other commonly associated symptoms are abdominal cramping, bloating, fever, and malaise. Appetite may decrease significantly.[11] Though unpleasant, most cases of TD are mild, and resolve in a few days without medical intervention.[12]
Blood or mucus in the diarrhea, significant abdominal pain, or high fever suggests a more serious cause, such as cholera, characterized by a rapid onset of weakness and torrents of watery diarrhea with flecks of mucus (described as "rice water" stools). Medical care should be sought in such cases; dehydration is a serious consequence of cholera, and may trigger serious sequelae—including, in rare instances, death—as rapidly as 24 hours after onset if not addressed promptly.[12]
Causes
E. coli , enterotoxigenic
|
20–75% |
E. coli, enteroaggregative | 0–20% |
E. coli, enteroinvasive | 0–6% |
Shigella spp. | 2–30% |
Salmonella spp. | 0–33% |
Campylobacter jejuni | 3–17% |
Vibrio parahaemolyticus | 0–31% |
Aeromonas hydrophila | 0–30% |
Giardia lamblia
|
0–20% |
Entamoeba histolytica | 0–5% |
Cryptosporidium spp. | 0–20% |
Cyclospora cayetanensis | ? |
Rotavirus | 0–36% |
Norovirus | 0–10% |
The most common causative agent isolated in countries surveyed has been
Brachyspira pilosicoli pathogen also appears to be responsible for many chronic intermittent watery diarrhea and is only diagnosed through colonic biopsies and microscopic discovery of a false brush border [13] on H&E or Warthin silver stain: its brush-border is stronger and longer that Brachyspira aalborgi's brush-border. It is unfortunately often not diagnosed as coproculture does not allow growth and 16S PCR panel primers do not match Brachyspira sequences.[14]
While viruses are associated with less than 20% of adult cases of travelers' diarrhea, they may be responsible for nearly 70% of cases in infants and children. Diarrhea due to viral agents is unaffected by antibiotic therapy, but is usually self-limited.
A subtype of travelers' diarrhea afflicting hikers and campers, sometimes known as
Risk factors
The primary source of infection is ingestion of
The most important determinant of risk is the traveler's destination. High-risk destinations include developing countries in Latin America, Africa, the Middle East, and Asia.[11] Among backpackers, additional risk factors include drinking untreated surface water and failure to maintain personal hygiene practices and clean cookware.[17] Campsites often have very primitive (if any) sanitation facilities, making them potentially as dangerous as any developing country.[citation needed]
Although travelers' diarrhea usually resolves within three to five days (mean duration: 3.6 days), in about 20% of cases, the illness is severe enough to require bedrest, and in 10%, the illness duration exceeds one week.
Immunity
Travelers often get diarrhea from eating and drinking foods and beverages that have no adverse effects on local residents. This is due to
Prevention
Sanitation
Recommendations include avoidance of questionable foods and drinks, on the assumption that TD is fundamentally a sanitation failure, leading to bacterial contamination of drinking water and food.[11] While the effectiveness of this strategy has been questioned, given that travelers have little or no control over sanitation in hotels and restaurants, and little evidence supports the contention that food vigilance reduces the risk of contracting TD,[20] guidelines continue to recommend basic, common-sense precautions when making food and beverage choices:[3]
- Maintain good hygiene and use only safe water for drinking and brushing teeth.[12]
- Safe beverages include bottled water, bottled
- In restaurants, insist that bottled water be unsealed in your presence; reports of locals filling empty bottles with untreated tap water and reselling them as purified water have surfaced.[12] When in doubt, a bottled carbonated beverage is the safest choice, since it is difficult to simulate carbonation when refilling a used bottle.
- Avoid ice, which may not have been made with safe water.[11]
- Avoid green salads, because the lettuce and other uncooked ingredients are unlikely to have been washed with safe water.[11]
- Avoid eating raw fruits and vegetables unless cleaned and peeled personally.[11]
If handled properly, thoroughly cooked fresh and packaged foods are usually safe.[11] Raw or undercooked meat and seafood should be avoided. Unpasteurized milk, dairy products, mayonnaise, and pastry icing are associated with increased risk for TD, as are foods and beverages purchased from street vendors and other establishments where unhygienic conditions may be present.[12]
Water
Although safe bottled water is now widely available in most remote destinations, travelers can treat their own water if necessary, or as an extra precaution.[12] Techniques include boiling, filtering, chemical treatment, and ultraviolet light; boiling is by far the most effective of these methods.[21] Boiling rapidly kills all active bacteria, viruses, and protozoa. Prolonged boiling is usually unnecessary; most microorganisms are killed within seconds at water temperature above 55–70 °C (130–160 °F).[22][23] The second-most effective method is to combine filtration and chemical disinfection.[24] Filters eliminate most bacteria and protozoa, but not viruses. Chemical treatment with halogens—chlorine bleach, tincture of iodine, or commercial tablets—have low-to-moderate effectiveness against protozoa such as Giardia, but work well against bacteria and viruses. UV light is effective against both viruses and cellular organisms, but only works in clear water, and it is ineffective unless manufacturer's instructions are carefully followed for maximum water depth/distance from UV source, and for dose/exposure time. Other claimed advantages include short treatment time, elimination of the need for boiling, no taste alteration, and decreased long-term cost compared with bottled water. The effectiveness of UV devices is reduced when water is muddy or turbid; as UV is a type of light, any suspended particles create shadows that hide microorganisms from UV exposure.[25]
Medications
A hyperimmune bovine colostrum to be taken by mouth is marketed in Australia for prevention of ETEC-induced TD. As yet, no studies show efficacy under actual travel conditions.[3]
Though effective, antibiotics are not recommended for prevention of TD in most situations because of the risk of allergy or adverse reactions to the antibiotics, and because intake of preventive antibiotics may decrease effectiveness of such drugs should a serious infection develop subsequently. Antibiotics can also cause
Antibiotics may be warranted in special situations where benefits outweigh the above risks, such as immunocompromised travelers, chronic intestinal disorders, prior history of repeated disabling bouts of TD, or scenarios in which the onset of diarrhea might prove particularly troublesome. Options for prophylactic treatment include the quinolone antibiotics (such as ciprofloxacin), azithromycin, and trimethoprim/sulfamethoxazole, though the latter has proved less effective in recent years.[28] Rifaximin may also be useful.[26][29] Quinolone antibiotics may bind to metallic cations such as bismuth, and should not be taken concurrently with bismuth subsalicylate. Trimethoprim/sulfamethoxazole should not be taken by anyone with a history of sulfa allergy.[medical citation needed]
Vaccination
The
Probiotics
One 2007 review found that
Treatment
Most cases of TD are mild and resolve in a few days without treatment, but severe or protracted cases may result in significant fluid loss and dangerous
Antibiotics
If diarrhea becomes severe (typically defined as three or more loose stools in an eight-hour period), especially if associated with nausea, vomiting, abdominal cramps, fever, or blood in stools, medical treatment should be sought. Such patients may benefit from antimicrobial therapy.[11] A 2000 literature review found that antibiotic treatment shortens the duration and severity of TD; most reported side effects were minor, or resolved on stopping the antibiotic.[34]
The antibiotic recommended varies based upon the destination of travel.
Antimotility agents
Antimotility drugs such as loperamide and diphenoxylate reduce the symptoms of diarrhea by slowing transit time in the gut. They may be taken to slow the frequency of stools, but not enough to stop bowel movements completely, which delays expulsion of the causative organisms from the intestines.[11] They should be avoided in patients with fever, bloody diarrhea, and possible inflammatory diarrhea.[39] Adverse reactions may include nausea, vomiting, abdominal pain, hives or rash, and loss of appetite.[40] Antimotility agents should not, as a rule, be taken by children under age two.[41][42]
Epidemiology
An estimated 10 million people—20 to 50% of international travelers—develop TD each year.[11] It is more common in the developing world, where rates exceed 60%, but has been reported in some form in virtually every travel destination in the world.[43]
Society and culture
Moctezuma's revenge is a colloquial term for travelers' diarrhea contracted in Mexico. The name refers to
Wilderness diarrhea
References
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- ^ "Health Information for Travelers to Singapore - Clinician view | Travelers' Health | CDC". wwwnc.cdc.gov. Retrieved 5 February 2019.
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- ^ "Traveler's Diarrhea-Topic Overview". WebMD. 2013-03-27. Archived from the original on 2015-06-30. Retrieved 2015-07-02.
Traveler's diarrhea is sometimes called by its more colorful names: Montezuma's revenge, Delhi belly, and Turkey trots.
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- ^ Luis Ostrosky-Zeichner, Charles D. Ericsson, Travelers' diarrhea. In Jane N. Zucherman, Ed., Principles and Practice of Travel Medicine, John Wiley and Sons, 2001. p.153 Google books preview Archived 2017-09-08 at the Wayback Machine
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- ^ "Water Disinfection for Travelers - Chapter 2 - 2018 Yellow Book | Travelers' Health | CDC".
- ^ National Advisory Committee on Microbiological Criteria for Foods: Requisite Scientific Parameters for Establishing the Equivalence of Alternative Methods of Pasteurization, USDA, 2004
- ^ McGee, Harold (2011-08-23). "Bending the Rules on Bacteria and Food Safety". The New York Times. Archived from the original on 2017-09-08. Retrieved 2014-10-24.
{{cite news}}
: CS1 maint: bot: original URL status unknown (link). Retrieved October 24, 2014. - ^ "Drinking Water Treatment Methods for Backcountry and Travel Use" (PDF). www.cdc.gov.
- ^ Ultraviolet Light Disinfection in the Use of Individual Water Purification Devices. Technical Information Paper # 31-006-0211 U.S. Army Public Health Command Archived 2014-03-08 at the Wayback Machine, retrieved January 5, 2016.
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- ^ Travelers' Diarrhea. The Travel Doctor Archived 2011-02-01 at the Wayback Machine Retrieved March 21, 2011.
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- ^ "Xifaxan label information" (PDF). Food and Drug Administration. Retrieved November 15, 2008.
- ^ "Press Announcements - FDA approves new drug to treat travelers' diarrhea". www.fda.gov. Retrieved 19 November 2018.
- ^ "Disease Management Project - Missing Chapter". Archived from the original on 2016-03-04. Retrieved 2015-07-25.
- ^ Diphenoxylate package insert. Drugs.com. Archived 2011-06-22 at the Wayback Machine Retrieved 2010-10-07.
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- ^ Gunderman, Richard (2019-02-19). "How smallpox devastated the Aztecs – and helped Spain conquer an American civilization 500 years ago". The Conversation. Retrieved 2023-05-29.
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This article incorporates public domain material from websites or documents of the Centers for Disease Control and Prevention.
External links
- "Travelers' Diarrhea". Centers for Disease Control and Prevention.