Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Travelers' diarrhea: antimicrobial therapy and chemoprevention

Nature Clinical Practice Gastroenterology & Hepatology volume 2, pages 191–198 (2005)Cite this article

Abstract

The use of preventive measures and self-treatment for travelers' diarrhea is routine in regions where the occurrence of diarrhea is predictably high. People traveling to these areas who do not exercise care in their selection of consumed foods and beverages will suffer high rates of illness. Such diarrhea normally affects the traveler for a day, although it can result in chronic postinfectious irritable bowel syndrome. Although systemic antibacterial drugs are effective in preventing diarrhea, their use is not routinely recommended because of side effects and their importance as a therapy for extra-intestinal infections. This review focuses on current and future uses of antibacterial drugs in the prevention and therapy of travelers' diarrhea. Minimally absorbed (<0.4%) rifaximin can effectively reduce the occurrence of travelers' diarrhea without side effects. Bismuth subsalicylate is a useful alternative, although it is less effective than rifaximin for the prevention of travelers' diarrhea and the required doses are less convenient. All people who travel to high-risk areas should take curative antimicrobial agents with them for self-treatment of illness: rifaximin 200 mg three times a day for 3 days, or an absorbable agent such as a fluoroquinolone or azithromycin taken in a single dose initially, with the need for a second or third dose determined by clinical response. Loperamide (up to 8 mg per day for ≤2 days) can be given with the antibiotic to offer rapid symptomatic improvement. In the future, the ability to evaluate the genetic risk of illness acquisition might allow person-specific recommendations to be made.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1

Similar content being viewed by others

References

  1. Kean BH, Waters SR (1959) The diarrhea of travelers. III. Drug prophylaxis in Mexico. N Engl J Med 261: 71–74

    Article  CAS  Google Scholar 

  2. Ericsson CD et al. (1983) Bicozamycin, a poorly absorbable antibiotic, effectively treats travelers' diarrhea. Ann Intern Med 98: 20–25

    Article  CAS  Google Scholar 

  3. DuPont HL et al. (1982) Treatment of travelers' diarrhea with trimethoprim/sulfamethoxazole and with trimethoprim alone. N Engl J Med 307: 841–844

    Article  CAS  Google Scholar 

  4. Jiang ZD et al. (2002) Prevalence of enteric pathogens among international travelers with diarrhea acquired in Kenya (Mombasa), India (Goa), or Jamaica (Montego Bay). J Infect Dis 185: 497–502

    Article  Google Scholar 

  5. Hoge CW et al. (1998) Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years. Clin Infect Dis 26: 341–345

    Article  CAS  Google Scholar 

  6. Caeiro JP et al. (1999) Improved detection of enterotoxigenic Escherichia coli among patients with travelers' diarrhea, by use of the polymerase chain reaction technique. J Infect Dis 180: 2053–2055

    Article  CAS  Google Scholar 

  7. Scott DA et al. (1990) Norfloxacin for the prophylaxis of travelers' diarrhea in U.S. military personnel. Am J Trop Med Hyg 42: 160–164

    Article  CAS  Google Scholar 

  8. DuPont HL et al. (1992) Five versus three days of ofloxacin therapy for traveler's diarrhea: a placebo-controlled study. Antimicrob Agents Chemother 36: 87–91

    Article  CAS  Google Scholar 

  9. DuPont HL et al. (1992) Oral aztreonam, a poorly absorbed yet effective therapy for bacterial diarrhea in US travelers to Mexico. JAMA 267: 1932–1935

    Article  CAS  Google Scholar 

  10. Mattila L (1994) Clinical features and duration of traveler's diarrhea in relation to its etiology. Clin Infect Dis 19: 728–734

    Article  CAS  Google Scholar 

  11. Haberberger RL Jr et al. (1991) Travelers' diarrhea among United States military personnel during joint American-Egyptian armed forces exercises in Cairo, Egypt. Mil Med 156: 27–30

    Article  Google Scholar 

  12. Ericsson CD et al. (1987) Clinical presentation as a guide to therapy for travelers' diarrhea. Am J Med Sci 294: 91–96

    Article  CAS  Google Scholar 

  13. von Sonnenburg F et al. (2000) Risk and aetiology of diarrhoea at various tourist destinations. Lancet 356: 133–134

    Article  CAS  Google Scholar 

  14. DuPont HL and Capsuto EG (1996) Persistent diarrhea in travelers. Clin Infect Dis 22: 124–128

    Article  CAS  Google Scholar 

  15. Okhuysen PC et al. (2004) Post-diarrhea chronic intestinal symptoms and irritable bowel syndrome in North American travelers to Mexico. Am J Gastroenterol 99: 1774–1778

    Article  Google Scholar 

  16. Kozicki M et al. (1985) 'Boil it, cook it, peel it or forget it': does this rule prevent travellers' diarrhoea? Int J Epidemiol 14: 169–172

    Article  CAS  Google Scholar 

  17. DuPont HL and Steffen R (Eds; 2001) Textbook of Travel Medicine and Health. Second Edition Hamilton: B.C. Decker, Inc

  18. DuPont HL and Ericsson CD (1993) Prevention and treatment of traveler's diarrhea. N Engl J Med 328: 1821–1827.

    Article  CAS  Google Scholar 

  19. DuPont HL et al. (1987) Prevention of travelers' diarrhea by the tablet formulation of bismuth subsalicylate. JAMA 257: 1347–1350

    Article  CAS  Google Scholar 

  20. Hilton E et al. (1997) Efficacy of Lactobacillus GG as a Diarrheal Preventive in Travelers. J Travel Med 4: 41–43

    Article  CAS  Google Scholar 

  21. Gorbach SL et al. (1975) Travelers' diarrhea and toxigenic Escherichia coli. N Engl J Med 292: 933–936

    Article  CAS  Google Scholar 

  22. Sack DA et al. (1978) Prophylactic doxycycline for travelers' diarrhea. Results of a prospective double-blind study of Peace Corps volunteers in Kenya. N Engl J Med 298: 758–763

    Article  CAS  Google Scholar 

  23. DuPont HL et al. (1983) Prevention of travelers' diarrhea with trimethoprim-sulfamethoxazole and trimethoprim alone. Gastroenterology 84: 75–80

    CAS  PubMed  Google Scholar 

  24. Gomi H et al. (2001) In vitro antimicrobial susceptibility testing of bacterial enteropathogens causing traveler's diarrhea in four geographic regions. Antimicrob Agents Chemother 45: 212–216

    Article  CAS  Google Scholar 

  25. Wistrom J et al. (1987) Norfloxacin versus placebo for prophylaxis against travellers' diarrhoea. J Antimicrob Chemother 20: 563–574

    Article  CAS  Google Scholar 

  26. Rademaker CM et al. (1989) Results of a double-blind placebo-controlled study using ciprofloxacin for prevention of travelers' diarrhea. Eur J Clin Microbiol Infect Dis 8: 690–694

    Article  CAS  Google Scholar 

  27. Johnson PC et al. (1986) Lack of emergence of resistant fecal flora during successful prophylaxis of traveler's diarrhea with norfloxacin. Antimicrob Agents Chemother 30: 671–674

    Article  CAS  Google Scholar 

  28. Gorbach S and Edelman R (Eds; 1986) Travelers' diarrhea: National Institutes of Health Consensus Development Conference Bethesda, Maryland, January 28–30, 1985. Rev Infect Dis 8 (Suppl 2): S109–S233

  29. Farthing MJG et al. (1992) Treatment and prevention of travellers' diarrhoea. Gastroenterology International 5: 162–175

    Google Scholar 

  30. Ericsson CD et al. (1985) Efficacy of bicozamycin in preventing traveler's diarrhea. Gastroenterology 88: 473–477

    Article  CAS  Google Scholar 

  31. DuPont H et al.: Randomized placebo controlled trial of rifaximin prevention of travelers' diarrhea in Mexico where diarrheagenic E. coli are major causes of illness. Ann Intern Med, in press

  32. Taylor D et al. (2004) Double-blind, placebo-controlled trial to evaluate the use of rifaximin (200 mg TID) to prevent diarrhea in volunteers challenged with Shigella flexneri 2a (2457T). Amer Soc Trop Med Hyg, Miami, Poster number 2079

  33. Reves RR et al. (1988) A cost-effectiveness comparison of the use of antimicrobial agents for treatment or prophylaxis of travelers' diarrhea. Arch Intern Med 148: 2421–2427

    Article  CAS  Google Scholar 

  34. Banwell JG (1986) Treatment of travelers' diarrhea: fluid and dietary management. Rev Infect Dis 8 (Suppl 2): S182–S187

    Article  Google Scholar 

  35. DuPont HL et al. (1992) Evaluation of new anti-infective drugs for the treatment of acute infectious diarrhea. Infectious Diseases Society of America and the Food and Drug Administration. Clin Infect Dis 15 (Suppl 1): S228–S235

    Article  Google Scholar 

  36. DuPont HL et al. (2001) Rifaximin versus ciprofloxacin for the treatment of traveler's diarrhea: a randomized, double-blind clinical trial. Clin Infect Dis 33: 1807–1815

    Article  CAS  Google Scholar 

  37. Steffen R et al. (2003) Therapy of travelers' diarrhea with rifaximin on various continents. Am J Gastroenterol 98: 1073–1078

    Article  CAS  Google Scholar 

  38. Jiang ZD et al. (2000) In vitro activity and fecal concentration of rifaximin after oral administration. Antimicrob Agents Chemother 44: 2205–2206

    Article  CAS  Google Scholar 

  39. Vila J et al. (2000) Quinolone resistance in enterotoxigenic Escherichia coli causing diarrhea in travelers to India in comparison with other geographical areas. Antimicrob Agents Chemother 44: 1731–1733

    Article  CAS  Google Scholar 

  40. DuPont HL et al.: Rifaximin prevention of travelers' diarrhea in Mexico. A randomized placebo controlled trial. Ann Intern Med, in press

  41. DuPont HL and Jiang ZD (2004) Influence of rifaximin treatment on the susceptibility of intestinal Gram-negative flora and enterococci. Clin Microbiol Infect 10: 1009–1011

    Article  CAS  Google Scholar 

  42. Krausse R and Ullmann U (2003) In vitro activities of new fluoroquinolones against Campylobacter jejuni and Campylobacter coli isolates obtained from humans in 1980 to 1982 and 1997 to 2001. Antimicrob Agents Chemother 47: 2946–2950

    Article  CAS  Google Scholar 

  43. Ericsson CD et al. (2001) Optimal dosing of ofloxacin with loperamide in the treatment of non-dysenteric travelers' diarrhea. J Travel Med 8: 207–209

    Article  CAS  Google Scholar 

  44. Ashley DV et al. (2004) Interventions to prevent and control food-borne diseases associated with a reduction in traveler's diarrhea in tourists to Jamaica. J Travel Med 11: 364–367

    Article  Google Scholar 

  45. Jiang ZD et al. (2003) Genetic susceptibility to enteroaggregative Escherichia coli diarrhea: polymorphism in the interleukin-8 promotor region. J Infect Dis 188: 506–511

    Article  CAS  Google Scholar 

  46. Ericsson CD et al. (1987) Ciprofloxacin or trimethoprim-sulfamethoxazole as initial therapy for travelers' diarrhea. A placebo-controlled, randomized trial. Ann Intern Med 106: 216–220

    Article  CAS  Google Scholar 

  47. Wistrom J et al. (1989) Short-term self-treatment of travellers' diarrhoea with norfloxacin: a placebo-controlled study. J Antimicrob Chemother 23: 905–913

    Article  CAS  Google Scholar 

  48. Mattila L et al. (1993) Short-term treatment of traveler's diarrhea with norfloxacin: a double-blind, placebo-controlled study during two seasons. Clin Infect Dis 17: 779–782

    Article  CAS  Google Scholar 

  49. Salam I et al. (1994) Randomised trial of single-dose ciprofloxacin for travellers' diarrhoea. Lancet 344: 1537–1539

    Article  CAS  Google Scholar 

  50. Adachi JA et al. (2003) Azithromycin found to be comparable to levofloxacin for the treatment of US travelers with acute diarrhea acquired in Mexico. Clin Infect Dis 37: 1165–1171

    Article  CAS  Google Scholar 

Download references

Acknowledgements

The travelers' diarrhea studies by the author that are reported herein have been supported by active grants from, among others, the US Public Health Service, which funds the Texas Gulf Coast Digestive Diseases Center, the National Institutes of Allergy and Infectious Diseases, and the Clinical Research Center, which funds the University of Texas General Clinical Research Center.

Author information

Authors and Affiliations

  1. Chief of Internal Medicine at and Vice-Chairman of the Department of Medicine, St Luke's Episcopal Hospital, Director of the Center for Infectious Diseases at the University of Texas—Houston School of Public Health, Baylor College of Medicine, Texas, USA

    Herbert L DuPont

Authors
  1. Herbert L DuPont
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Herbert L DuPont.

Ethics declarations

Competing interests

The author would like to acknowledge that over the last 30 years he has received a consultant fee, honoraria for speaking and research grants to his institution from various pharmaceutical companies: A.H. Robins Company; Alfa Wassermann SpA; Bristol-Myers Squibb; Burroughs Wellcome Company; Ciba-Geigy Ltd; Hoffmann-LaRoche Inc; Janssen Pharmaceutica; McNeil Consumer Products; Merck Sharp and Dohme; Merrell Dow Pharmaceuticals Inc; Norwich Pharmacal Company and Norwich-Eaton Pharmaceuticals; Ortho Pharmaceuticals; Otsuka Pharmaceuticals; Procter & Gamble Company; Romark Laboratories; Shaman Pharmaceuticals Inc; Salix Pharmaceuticals (the manufacturer of rifaximin); SmithKline Beecham Biologicals; Upjohn Company; and Zyma SA.

Glossary

POSTINFECTIOUS IRRITABLE BOWEL SYNDROME (IBS)

A common, chronic illness causing abdominal bloating with diarrhea and/or constipation following an initial bout of infectious diarrhea

PROBIOTICS

Live bacteria that can be taken orally, potentially providing protection against subsequently ingested pathogens

DOXYCYCLINE

An oral tetracycline antibacterial drug

TRIMETHOPRIM-SULFAMETHOXAZOLE

A combination antimicrobial drug currently not recommended for the treatment of travel diarrhea because of high rates of resistance worldwide

FLUOROQUINOLONES

Considered by many the optimal drugs for therapy and prevention of travelers' diarrhea; antibacterial resistance to ciprofloxacin is, however, high

WATERY DIARRHEA SYNDROME

Liquid stools that are commonly passed by patients with travelers' diarrhea, particularly in cases caused by diarrheogenic E. coli

Rights and permissions

Reprints and permissions

About this article

Cite this article

DuPont, H. Travelers' diarrhea: antimicrobial therapy and chemoprevention. Nat Rev Gastroenterol Hepatol 2, 191–198 (2005). https://doi.org/10.1038/ncpgasthep0142

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncpgasthep0142

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing