As an adjunct to my upcoming podcast this Saturday, I am reposting this article from a few months ago. 

In this post I want to expand on what I wrote in prior blog concerning being prepared for an upcoming adventure. While Traveller’s Diarrhea was mentioned there briefly, there is so much more that the truly prepared adventurer needs to know. In the following paragraphs, we will discuss the organisms and regions in which you are most likely to encounter this problem as well as how best to treat and prevent the illness in the first place.

This is a topic that is near and dear to my heart, well maybe closer to my gastrointestinal (GI) tract. Given my propensity to travel to less developed areas and my desire to soak in the local culture, I tend to place myself and, more specifically, my intestines in harm’s way. I am also more at risk as I take a medication (proton pump inhibitor our PPI) to treat gastroesophageal reflux disease (GERD). This, as with all such stomach acid lowering medications, can increase your risk of such infections. So, it is important to know if you are likely to be at higher risk of infection as well. Do you have anything that would compromise your immune system? Such compromise could be anything from routine or daily steroids, HIV infection or many forms of cancer (specifically leukemias and other blood borne or affecting cancers). Talk with your doctor or travel health advisor to see if your health history might put you at greater risk.

The next step in deterring your risks and therefore your need to be prepared, is deciding what the incidence is in the location you plan to travel to. In general, the risk is divided into low (<8%), intermediate (8-20%) and high (>20%). The CDC website (www.cdc.gov) and many other travel health related sites can be queried for the latest information. As examples, the US and most of Western Europe are in the low risk categories. Areas such as Russia and China are intermediate and Mexico and much of Africa are in the high risk category. Knowing if you have a propensity to such infection and a higher likelihood, given the risk category of the country to which you are traveling, can better help you (along with your health care provider) decide on whether to look more towards prophylactic treatment versus treatment only should infection arise.

You now determined that you are higher risk and that you are heading to a country in the intermediate or even high risk category. You and your provider are likely to consider preventative medications, beyond the standard precautions as have been outlined in prior blog posts, such as only utilizing bottled water (see my next post for additional information on dangers even with bottled water) and avoiding raw or undercooked foods. There are, currently, three recommended prophylactic treatments for traveller’s diarrhea. Bismuth, as in Pepto Bismol tablets, a fluoroquinolone or Rifaximin. As the fluoroquinolone and Rifaximin have to be prescribed, I will let you talk more about this with your provider. As for the Pepto Bismol, this is in the form of over the counter (OTC) tablets taken 2 tablets 4 times each day. It should be noted, this is less effective than the antibiotic prophylaxis but does avoid some of the potential side effects of antibiotics such as a bacterial overgrowth of Clostridium Difficile (C. Diff), as well as antibiotic resistance. Anyone allergic to aspirin or already on aspirin therapy should also avoid this as a treatment alternative as well as children as this can lead to Rye’s Syndrome. If used in combination with antibiotics, Pepto Bismol should be separated several hours from the taking of antibiotics as it can also decrease the absorption of (and thus reduce the effectiveness of) many antibiotics. Finally, if you do decide to take Pepto either for prophylaxis or treatment, know that it is likely to turn your stool and your tongue black. You needn’t worry you have caught an exotic disease when you see this.

Even if you have chosen to do prophylactic treatment with antibiotics, you are not 100% safe from this dreaded disease. You will, likely, want to have a conversation with your travel health care provider to discuss having medications on hand should they be needed. For many years, I have travelled with a combination of Lomotil, Cipro, Flagyl and Zofran. Over the years, data has changed that has caused me to change my own trip medical planning. Now days, if I start with symptoms (cramping, nausea, mild diarrhea), I will start treamtent with OTC loperamide (Immodium) and Zofran. This is symptomatic treatment to slow GI motility (Immodium) and for nausea (Zofran). Should I start runnning a fever or continue or have worsening symptoms, I now move to add Azithromycin (you may be familiar with a Z-pack). A single dose of 1g of Azithromycin is likely enough to knock most such infections out. The only caveat is if Campylobacter is a high likelihood as the source of infection. This would be most likely in South East Asian countries. In those instances a three day course of 500 mg of Azithromycin can be given. The fluoroquinolones are not nearly as effective as they once were due to growing resistance and the side effect profiles can be considerably worse, especially with joint pain and the potential for tendon rupture. On top of this treatment, you must continue to hydrate with clean water and such oral rehydration fluids as Gatorade and World Health Organziation (WHO) rehydration fluids available in many stores worldwide. If you continue to get worse, fever does not improve or you begin to have blood in your stool, a trip to a local ER is required.

As you begin your preparations for your next trip, keep this information in mind. Talk with your Primary Care Provider or Travel Health Professional and decide what makes the most sense for you. Only together can you decide what your risks are and how you can ensure you have the greatest chance of avoiding the Traveller’s Scurge. If you have any questions, please feel free to contact me in the comments below.