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Traveler’s Diarrhea A Clinical Review

Robert Steffen, MD1,2; David R. Hill, MD, DTM&H3; Herbert L. DuPont, MD2,4,5
[+] Author Affiliations
1Epidemiology, Biostatistics and Prevention Institute, Division of Communicable Diseases, WHO Collaborating Centre for Travellers’ Health, University of Zurich, Zurich, Switzerland
2Division of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas School of Public Health and School of Medicine, Houston
3Global Public Health Program, Frank H. Netter MD School of Medicine, Quinnipiac University, Hamden, Connecticut
4Baylor St Luke’s Medical Center, Houston, Texas
5Baylor College of Medicine, Houston, Texas
JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006.
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Importance  Acute diarrhea is the most common illness that affects travelers to low-income regions of the world. Although improved hygiene has reduced the risk of traveler’s diarrhea in many destinations, the risk remains high in others.

Objective  To review the current state of knowledge on the etiology, risk factors, prevention, and management of traveler’s diarrhea.

Evidence Review  A search of the PubMed, Google Scholar, and Cochrane Library databases for the period 2012–April 2014 was performed for articles on traveler’s diarrhea. The database search yielded 2976 articles, of which 37 were included in this review. These were added to 85 articles previously identified by the authors.

Findings  Improved hygiene has reduced the risk of traveler’s diarrhea from 20% or more (for a 2-week stay) to between 8% and 20% in some parts of the world. Acquiring traveler’s diarrhea causes 12% to 46% of travelers to change their travel plans. Returning travelers seeking medical care have a diagnosis of gastrointestinal disturbance in approximately one-third of all cases. Postinfectious irritable bowel syndrome may occur in 3% to 17% of patients who have had traveler’s diarrhea. Prevention of traveler’s diarrhea by dietary avoidance measures is often not successful. Chemoprophylaxis should be restricted to travelers who are at risk of severe complications of diarrhea. Ciprofloxacin is the standard treatment in self-therapy of traveler’s diarrhea except when patients are in South or Southeast Asia, where azithromycin is preferred.

Conclusions and Relevance  Diarrhea remains a common problem for international travelers. Persons intending to travel to at-risk countries should be counseled regarding prevention measures and may be given a travel pack that includes medications for self-treatment should they become ill.

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Figure.
Incidence Rates of Traveler’s Diarrhea in the Initial 2 Weeks of Stay in Various Regions of the World Among Visitors Residing in Industrialized Countries, 1996-2008

Adapted from Greenwood et al,15 Pitzurra et al,16 Belderok et al,18 Soonawala et al,19 and Mues et al.21

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