Traveler’s Diarrhea


What Is It?
Traveler’s Diarrhea (TD) is defined as three to four loose stools in a 24-hour period. Diarrhea when traveling to a foreign country is common, with a reported 40 percent of travelers affected who stay at least one week in Mexico. This rises to 60 percent if tourists stay for more than five weeks.

Recent studies have shown that 5–10 percent of travelers who experience a bout of TD do not improve with treatment and develop a chronic condition known as “irritable bowel syndrome” (IBS). Because of the increased risk of developing IBS after TD, there is even more reason to prevent TD.

Many environmental or infectious factors can contribute to or cause diarrhea. The body’s immune system responds to disease-causing bacteria by increasing fluid production, resulting in diarrhea. In most persons in high-risk areas, the illness rapidly resolves, offering short-term immunity from the most common causes of TD. Keep up your fluid and salt intake by drinking soups, broth, and soft drinks and eating saltine crackers. Most cases of simple TD resolve in about 48 hours.

Associated Symptoms
Symptoms of TD are three or four loose stools daily, nausea, vomiting, abdominal pain and cramps, low-grade fever, and exhaustion. These symptoms are generally benign—dehydration is our main concern.

Should you see bloody stools and experience fever and abdominal cramps, you probably have a more serious and invasive bacterial diarrhea known as “dysentery.” If some bacteria or their toxins enter the bloodstream, you may experience chills, sweats, and/or fever greater than 101.5° F.

Infections with shigella, salmonella, or campylobacter may result in forms of more serious diarrhea, or dysentery, that call for specific treatments and precautions. If you have blood in the stool, fever, chills or sweats associated with TD you will need to receive absorbable antibiotics for three days. Any such diarrhea that does not respond to treatment within 48 hours should be considered reason to seek medical attention.

Also, see a doctor if TD persists for longer than one month.

What Causes It?
Contaminated food and water are the sources of bacterial, viral, and even parasitic infections. Although many Mexican communities tout clean public water systems, bacteria can be found in them during the rainy season. Food is an even more important source of the bacteria that cause diarrhea in international visitors. A small percentage of Mexicans who travel to the United States get traveler’s diarrhea which they call “Washington’s Revenge.”

The most dangerous foods are those containing moisture that are served at room temperature, such as salads, and uncooked vegetables. Others include usually “safe” foods that are steaming hot, dry items like bread, jelly, jam, honey and syrups (with high sugar content), and any fruit or vegetable that has been peeled.

Non-infectious factors may influence the gastrointestinal tract and cause loose stools.
These include:
  • Alcohol consumption
  • Tobacco use
  • Dietary indiscretions
  • Dairy foods for lactose-intolerant individuals
  • Jet lag 
  • Fatigue
  • Stress and anxiety
  • Certain medications

Prevention
Since contaminated foods and water are the primary source of intestinal illness while traveling, we recommend taking certain steps to avoid exposure:
  • First, never eat anything raw that you have not peeled yourself. All types of raw food, including salads and uncooked vegetables and fruits are often contaminated. Raw shellfish or sushi can be infected with parasites if not inspected properly. Do not eat food from street vendors.
  • Second, don’t use tabletop salsa as your condiment. Studies have shown that up to 75 percent of tabletop salsas left out in restaurants are contaminated with infectious e.coli. 
  • Third, drink only bottled, purified water that has a sealed cap. If purified water is not available, boil it for at least one minute or treat it with iodine or chlorine tablets or liquid that can be purchased at most stateside pharmacies or sporting goods stores. 
  • Fourth, breast feed infants less than six months of age or give them pre-packaged, commercial formula products reconstituted with boiled or purified water. 
  • Finally, studies have shown that you can prevent TD by taking daily rifaximin (Xifaxan) or bismuth subsalicylate (see Pepto-Bismol). We do not recommend that you take other common antibiotics (Ciprofloxin, Bactrim DS, or Ampicillin) for prevention, as antibiotic overuse has led to unwanted side effects and bacterial resistance, making many common antibiotics useless in diarrhea treatment.

Treatment
If you don’t have fever, chills, or blood in the stool, your main concern with diarrhea treatment is to avoid dehydration. This is especially true with very small children, especially infants, or with the elderly and/or debilitated. Dehydration is poorly tolerated in adults with heart conditions or on multiple medications used to treat the kidneys or the heart. If your diarrhea is significant and you are in a higher risk category, seek medical attention as a precaution.

For infants and children, prepackaged oral rehydration solution (ORS) is available in most Mexican pharmacies. A common North American equivalent of ORS would be Pedialyte™. ORS is a mixture of purified water, salt, and sugar in amounts that the body needs to absorb the water from the intestinal tract. The general rule is to give 2–4 ounces of ORS for any loose stool or episode of vomiting in children under the age of two.

For adults or larger children (over two years of age), ORS may be used, but it may be more cost-effective to use a soup broth or water and saltine crackers. Homemade ORS can be made with a liter of cooled, boiled water mixed with 6 teaspoons of sugar and one teaspoon of salt. If nausea and vomiting are present and the individual cannot hold down the solution, see a doctor.

If you have fever or bloody diarrhea, you need antibiotics such as ciprofloxin, levofloxin or azithromycin, which are effective in most of these cases, although antibiotic resistance is on the rise. Xifaxan is effective in treating the more common form of TD not associated with fever or passage of bloody stools, but should not be used if you developed diarrhea while taking Xifaxan for prevention. For medication use and guidelines see MedToGo’s Pharmaceutical Guide.