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Delta flight returns after passenger has diarrhea ‘all the way through’ plane

Passengers re-board flight to Spain after eight-hour delay while social media posts describe flight crew mopping up mess

Footage has emerged of the “onboard medical emergency” that forced a US airliner back to Atlanta only two hours into its flight to Spain: a messy trail of diarrhea left by a struggling passenger.

Maintenance crews spent five hours cleaning the Delta Airlines Airbus A350 after its enforced early landing, including replacing an aisle carpet ruined in the incident.

Passengers, reportedly including the one suffering diarrhea, were allowed to re-board after an eight-hour delay, making it to Barcelona on Saturday afternoon with no further incident.

Accounts from some onboard posted to social media described flight crew doing their best to mop up the mess with paper towels and scented disinfectant. But that only had the effect of making the plane “smell of vanilla shit”, one passenger said.

Another described cabin crew placing an absorbent paper “runner” over the aisle, and passengers having to climb over seats to avoid it as they left the plane at Atlanta .

An audio recording of a conversation between the pilot and air traffic control revealed the reason for the jet’s sudden turnaround over central Virginia.

“It’s just a biohazard issue,” the pilot said. “We had a passenger who had diarrhea all the way through the airplane so they want us to come back to Atlanta.”

The audio was posted to X , formerly Twitter, along with an image of the Federal Aviation Authority (FAA) flight strip confirming the reason for the U-turn.

Delta Airlines blamed an “onboard medical issue”.

“Our teams worked as quickly and safely as possible to get our customers to their final destination. We sincerely apologize to our customers for the delay and inconvenience to their travel plans,” it said.

The incident came a week after Air Canada apologized to two passengers who were booted from a flight from Seattle to Montreal because they complained about being made to sit in seats covered in vomit.

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Best Traveler's Diarrhea Treatments for Symptom Relief

Sources of Bacteria, Prevention, and Medication Types

Complications

Frequently asked questions.

Traveler's diarrhea can turn a trip into a nightmare. Food and water contaminated by germs, also known as pathogens , is not uncommon in certain areas of the world that are popular travel destinations. Consuming even small amounts of these germs can cause loose, watery stool, the main sign of diarrhea , Luckily, treatment options are available.

This article explains the symptoms of traveler's diarrhea, how to treat it, and the best ways to prevent getting infected in the first place.

Luis Alvarez / Getty Images

Symptoms of traveler's diarrhea caused by bacteria or a virus usually appear six to 72 hours after eating or drinking something contaminated. With some types of pathogens, it may take a week or longer for stool to be affected.

Changes in your bowel habits it the main symptoms of diarrhea. At its mildest, diarrhea involves passing loose, watery stool three times a day. You may pass unformed stool 10 or more times a day in severe cases.

Other symptoms vary depending on the type of bacterial or virus you've been exposed to but may include:

• Stomach cramps
• Tenesmus , feeling you need to have a bowel movement even when your bowels are empty
• Mucous in stool

More severe cases of traveler's diarrhea may cause bloody stools .

Should You Go to a Doctor for Traveler's Diarrhea?

See a healthcare provider if your symptoms are accompanied by fever or bloody stools, or they last longer than 48 hours.

Traveler's Diarrhea Causes

The most common cause of traveler's diarrhea is probably poor hygiene (lack of cleanliness) in restaurants. You're most at risk when dining out in areas of Asia, the Middle East, Mexico, Africa, and South and Central America.

Pathogens are usually spread via the fecal-oral route . This means someone with the bacteria or virus excretes the germs in their feces. The feces may not be safely disposed of in a sanitary setting, or the infected person may not properly wash their hands before handling food and beverages. This allows germs to be transmitted to something you put into your mouth.

This cycle of contamination is most common in areas of the world that have specific conditions:

• Warmer climates that promote germ growth
• Poor sanitation (such as open sewage areas)
• Unreliable refrigeration
• Little education on safe food handling.

Common Bacterial Pathogens

The most common cause of traveler's diarrhea is bacteria, which are thought to lead to 80% to 90% of cases. These include:

• Escherichia coli or E-coli
• Campylobacter jejuni

Ingesting these bacterium causes gastroenteritis , which means the stomach and small intestines become inflamed. This leads to diarrhea.

Common Viral Pathogens

Viruses can also be transported via the fecal-oral route. The most common types of viruses that cause diarrhea include:

Viral infections of the digestive system are often referred to as stomach flu . The illness has no connection to respiratory influenza, but like the "flu," it usually lasts a short period.

Other Causes of Diarrhea

In addition to germs in your food and water, you could develop diarrhea from toxins, which cause the common symptoms of food poisoning .

Parasites , or protozoal pathogens, can also cause diarrhea. In these instances, you're more likely to develop symptoms one to two weeks after exposure to the pathogen.

Dehydration is one of the most common complications related to any form of diarrhea. Multiple bowel movements that release a lot of fluid can cause you to have too little water in your body.

Severe dehydration can lead to problems such as:

• Fatigue and muscle weakness or pain
• Dizziness or lightheadedness
• Increased heart rate and breathing
• Kidney Failure

Dysentery is a serious condition that can develop from exposure to Shigella or parasites. It usually causes bloody stool, fever, and extreme dehydration. It can be fatal if it's left untreated. In addition to being picked up from contaminated food or water, the bacteria or parasites that cause dysentery can be passed from person to person in close contact, or you can get it by swimming in unclean water.

Treatment for Traveler's Diarrhea

Getting sick while far from home is more than just inconvenient. The sudden onset and severity of symptoms can be frightening. Often, symptoms will last a few days and resolve on their own, but you may need to manage the condition and take medication.

Fluid Replacement

To manage dehydration, you want to concentrate on getting enough liquids even if you feel like you don't want to put anything in your stomach.

Drinking any safe fluids can manage mild cases of traveler's diarrhea. Since tap water may be a source of infection, you need to boil non-bottled water and let it cool before you drink it. You can also drink boiled broth or prepackaged (non-citrus) fruit juice. Sports drinks like Gatorade are good, too, but not essential.

For severe dehydration, an oral rehydration solution may be needed. These are mixes or packaged beverages that contain glucose and electrolytes such as potassium and sodium. Pedialyte is an example of an oral rehydration solution for kids.

Sweating can cause dehydration as well. Try to find a cool place out of the sun to rest while you rehydrate.

Antibiotics

Antibiotics may be used for traveler's diarrhea caused by bacterial infections. A stool test should be done to identify which antibiotic might work best.

Quinolone antibiotics such as Cipro (ciprofloxacin) are most often used when antibiotics are needed.

A single dose of 750 milligrams (mg) for adults is the typical treatment. Children may be given 20 to 30 mg per kilogram of weight per day.

In some areas, bacteria are resistant to quinolones, which means the medication won't help. This is especially a problem in Southeast Asia. Another antibiotic, azithromycin , may also be used in this case, although some strains are resistant to it.

Upset Stomach Medication

Pepto-Bismol can provide short-term relief of symptoms. However, it may not be effective in small doses, and high doses put you at risk for a health condition called salicylate toxicity. Additionally, Pepto-Bismol is not recommended for people younger than 18 years because there's a risk of a condition called Reye's syndrome .

Antidiarrheal Agents

It might seem logical to reach for an anti-diarrheal product such as Imodium (loperamide) or Lomotil (diphenoxylate). However, these products should not be used if your diarrhea is related to dysentery or if you see any signs of blood in your stools.

An antidiarrheal agent should only be taken with an antibiotic. When using an antidiarrheal for traveler's diarrhea, it is especially important to keep yourself well-hydrated. Discontinue the product if your symptoms worsen or you still have diarrhea after two days.

How Long Traveler's Diarrhea Lasts

Most cases of traveler's diarrhea last from one to five days. However, symptoms may linger for several weeks.

To help prevent traveler's diarrhea:

• Wash your hands with soap and water after going to the bathroom and before eating.
• At restaurants, only eat foods that are cooked and served hot.
• Drink beverages from factory-sealed bottles or containers.
• Don't get ice in your drink since it may be made with contaminated water.

There is evidence that Pepto-Bismol may protect against traveler's diarrhea. Studies have shown a protection rate of about 60%. However, not everyone should take Pepto-Bismol, including those who are pregnant or are 18 years of age and younger.

Don't take antibiotics or antidiarrheal medicine like Pepto-Bismol as prophylaxis—that is, to prevent traveler's diarrhea— unless it's been recommended to you by your healthcare provider.

Bacteria and viruses can live in water and food. These pathogens (germs) are most common in areas where the climate is warm, refrigeration is unreliable, and there isn't proper hand washing or bathroom sanitation. Infection with these pathogens (bacterial or viral) can cause traveler's diarrhea.

Traveler's diarrhea will often resolve on its own once the bacteria or virus is out of your system. However, you may need antibiotics. You may also need to manage symptoms by staying hydrated and using over-the-counter medications. You should contact your healthcare provider if symptoms last more than a few days.

When traveling to regions that have warm climates and relaxed hygiene practices, be sure to take steps to avoid eating or drinking anything that could have pathogens. Drink pre-packed or boiled water and ensure food is handled properly.

It's important to make sure that your child gets enough fluids. Diarrhea can lead to dehydration more quickly in kids than in adults. Check with your healthcare provider if your child has signs of dehydration such as dry mouth, few or no tears when crying, irritability, reduced urination, and drowsiness.

If you're pregnant, the most important thing to do is to drink enough fluids so you don't get dehydrated. Your doctor may suggest using azithromycin if you need an antibiotic. Don't use Pepto-Bismol (bismuth subsalicylate) when pregnant because of risks to the growing fetus.

Connor BA. Preparing international travelers: Travelers’ diarrhea . In: Brunette GW, ed. CDC Yellow Book 2020: Health information for international travel . Oxford University Press; 2017.

Leung AKC, Leung AAM, Wong AHC, Hon KL. Travelers’ diarrhea: a clinical review . Recent Pat Inflamm Allergy Drug Discov . 2019;13(1):38-48. doi:10.2174/1872213X13666190514105054

Shaheen NA, Alqahtani AA, Assiri H, Alkhodair R, Hussein MA.  Public knowledge of dehydration and fluid intake practices: variation by participants' characteristics .  BMC Public Health . 2018;18(1):1346. doi:10.1186/s12889-018-6252-5

Strachan SR, Morris LF. Management of severe dehydration . Pediatr Crit Care Med . 2017;18(3):251-255. doi:10.1177/1751143717693859

Riddle MS, Connor BA, Beeching NJ, et al. Guidelines for the prevention and treatment of travelers’ diarrhea: a graded expert panel report . J Travel Med . 2017;24(suppl_1):S57-S74. doi:10.1093/jtm/tax026

Johns Hopkins Medicine. Traveler's Diarrhea.

Nemours Foundation. KidsHealth. Staying healthy while you travel.

Morof DF, Carroll ID. Family travel: Pregnant travelers . In: Brunette GW, ed. CDC Yellow Book 2020: Health information for international travel . Oxford University Press; 2017.

Wanke, Christine A. " Travelers' Diarrhea ." UpToDate . 

By Barbara Bolen, PhD Barbara Bolen, PhD, is a licensed clinical psychologist and health coach. She has written multiple books focused on living with irritable bowel syndrome.

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What Is Travelers' Diarrhea?

A bout of diarrhea after traveling can increase the risk of dehydration and other complications.

Kasandra Brabaw is a writer who focuses on health, sex/relationships, and stories for and about her communities including the LGBTQ+ and fat communities. Other than at Health, her work can be found at SELF, Women’s Health, VICE, and Refinery29.

• Is It Contagious?

Complications

Vacation is supposed to be a time of rest, but a case of travelers'  diarrhea  can make your trip a nightmare.

Travelers' diarrhea causes loose, watery stools, usually brought about by bacteria, viruses, or fungi. Generally, mild cases of travelers' diarrhea resolve with hydration, rest, and a bland diet. Still, travelers' diarrhea may lead to complications, such as dehydration and malabsorption.

Travelers' diarrhea is one of the most common travel-related illnesses, affecting anywhere from 30% to 70% of travelers. Though travelers' diarrhea can occur anywhere in the world, it is more common when traveling to parts of Asia, the Middle East, Africa, Mexico, and Central and South America.

Here, gastroenterologists explain what causes travelers' diarrhea, the symptoms, and how best to treat it so you can enjoy your vacation as much as possible.

Travelers' diarrhea is a form of acute diarrhea that comes on while traveling. Acute diarrhea is sudden loose and watery stools . 

There are different levels of travelers' diarrhea (i.e., mild, acute, and severe). At varying severities, those levels can include symptoms like:

• Mild cramps
• Urgent loose stools
• Severe abdominal pain
• Bloody diarrhea

Symptoms can occur within a few hours to as long as a few weeks depending on the cause of the travelers' diarrhea. Bacterial travelers' diarrhea can last up to seven days. In contrast, viral travelers' diarrhea lasts about three days.

What Causes Travelers' Diarrhea?

Travelers' diarrhea spreads through fecal matter through contaminated food and water. Bacteria, viruses, and parasites cause travelers' diarrhea.

Bacteria account for about 80% to 90% of cases, while viruses make up about 5% to 15%. Less commonly, parasites, also known as protozoal pathogens, can cause travelers' diarrhea. Usually, those parasites are slower to manifest than bacteria and viruses.

Depending on the culprit, travelers' diarrhea may occur through non-inflammatory or inflammatory pathways. Non-inflammatory pathways reduce the ability of your intestines to absorb nutrients. As a result, your waste products increase. In contrast, inflammatory pathways damage your intestines, which increases bowel movements.

Risk Factors

Travelers' diarrhea is more likely to occur if you travel outside the country to a place with poor sanitation . A lack of clean water makes practicing proper hygiene and food preparation hard.

Other risk factors for travelers' diarrhea include:

• Warm climates
• A lack of refrigeration
• Inadequate food storage practices
• Proton pump inhibitor (PPI) and antibiotic use
• Unprotected sex
• Age (i.e., older adults and young children)
• Health conditions affecting the gastrointestinal (GI) system
• Weak immune system

Is Travelers' Diarrhea Contagious?

Depending on the culprit, travelers' diarrhea can be contagious . For example, cruise ships are a common culprit of travelers' diarrhea. 

"Cruise ships are known for two viruses specifically that spread like wildfire," Rabia De Latour, MD , a gastroenterologist and assistant professor in the department of medicine at the NYU Grossman School of Medicine, told  Health . 

Norovirus is a highly contagious virus that causes diarrhea and vomiting. Cruise ships help the virus spread because so many people stay in such proximity, and many people are not great at washing their hands before touching their faces or eating, noted Dr. De Latour.

In contrast, some cases of travelers' diarrhea are not spread between people. For instance, you may develop acute diarrhea because you are not used to the food or water in the place you are traveling.

"There may be different probiotic bacteria that live on lettuce or other foods there that you're just not accustomed to," explained Dr. De Latour. In that case, the diarrhea is about the change in environment, not an infection, and should clear up in a couple of days, added Dr. De Latour.

Traveling can be stressful, especially traveling internationally. For example, your body might respond with loose, watery stool if you are stressed and physically tired after a 12-hour flight. Diarrhea caused by stress isn't infectious and will get better quickly.

Healthcare providers can diagnose traveler's diarrhea by asking about your symptoms, recent travels outside the country, and what you ate. For example, having acute diarrhea three or more times within 24 hours or double the amount of regular bowel movements may signal travelers' diarrhea. 

A healthcare provider can palpate the stomach to check whether your abdomen is tender. Abdominal cramps, nausea , vomiting, and fever often accompany acute diarrhea.

Healthcare providers do not usually require laboratory tests or imaging to diagnose travelers' diarrhea. In contrast, a healthcare provider may acquire a stool sample if you have blood in your stool or feel like you need to pass stool even if your bowels are empty. 

In severe cases, a healthcare provider may send for X-rays of the kidneys, ureters, and bladder and an abdominal CT scan.  

Treatment for travelers' diarrhea depends on the severity of the case and may include the following:

• Fluid replenishment:  To avoid dehydration , increasing your water intake is essential. Sports drinks and electrolyte mixes can help, too. In contrast, milk and fruit juices can worsen diarrhea, increasing the risk of dehydration. You may require oral rehydration salt or intravenous (IV) fluids to replenish fluids for severe cases. 
• Anti-diarrheal medicines:  A healthcare provider may advise taking an anti-diarrheal like loperamide for mild cases. 
• Antibiotics:  In some cases, a healthcare provider may prescribe a round of antibiotics. Common antibiotics for travelers' diarrhea include ciprofloxacin, azithromycin, and rifaximin. The type of antibiotic may depend on your symptoms and where you are traveling. 

Mainly, mild to moderate cases of travelers' diarrhea involve supportive therapy. For many people with travelers' diarrhea, the illness simply runs its course. 

Try the following to make yourself as comfortable as possible:

• Hydrate to prevent dehydration .
• Get lots of rest.
• Eat small, gentle meals on your stomach , such as salty (e.g., pretzels, crackers, soup, sports drinks) and high-potassium (e.g., bananas, potatoes without the skin, fruit juices) foods.

How To Prevent Travelers' Diarrhea

Preventing travelers' diarrhea can be tricky, especially when traveling abroad. On a cruise ship , one of the best ways to avoid travelers' diarrhea is to watch where you put your hands, wash your hands frequently, and avoid touching your face, advised Dr. De Latour. Steer clear of buffet lines, where someone carrying norovirus could touch the food or serving utensils.

When traveling to underdeveloped countries, be careful what you eat and drink to prevent traveler's diarrhea. In the United States, many people are used to eating pasteurized foods partially sterilized through heat or irradiation. Sometimes, that is different in other countries.

"[G]etting that exposure to a digestive system that has never had an unpasteurized product, we would be very vulnerable," Christine Lee, MD , a gastroenterologist at the Cleveland Clinic, told Health . When traveling, be extra careful to check if something is pasteurized before you eat or drink it. You will want to avoid undercooked meats and seafood, too. 

"If you're traveling to an underdeveloped country, that might not be where you want to eat a rare steak," said Dr. Lee. The same goes for sushi made with raw fish or dishes like ceviche or tartare made with raw seafood and meat. Instead, cooked foods are your safest option while traveling anywhere you are unsure how safe the water is.

Fruit and vegetables are risky since they could have been washed in contaminated water. In that case, the fruit you can peel (e.g., bananas or oranges) may be the safest option.  

Finally, paying attention to what you drink is also vital in preventing travelers' diarrhea. Alcohol is considered safe because it can kill bacteria. Likewise, bottled drinks are safe if they have an unbroken seal. Boiled water is your next safest bet if those options are not available. 

Remember that contaminating water can get into your mouth in other ways, like showering and swimming . Try not to swallow during those times, brush your teeth with bottled water, and avoid ice in drinks, advised Dr. Lee.

Finally, a healthcare provider may advise taking precautions if traveling outside the country. For example, you might take two tabs of bismuth subsalicylate four times daily to decrease the risk of travelers' diarrhea. Usually, healthcare providers do not advise bismuth subsalicylate for pregnant people and children. 

A healthcare provider may recommend a round of antibiotics to prevent travelers' diarrhea if you are traveling to a high-risk area for a short period.

Most people with travelers' diarrhea make full recoveries. In rare, severe cases, complications can occur. For example, dehydration is one of the most common complications of travelers' diarrhea. Dehydration happens if you lose too many fluids through acute diarrhea, requiring immediate medical attention.

Other complications of travelers' diarrhea may include:

• Malabsorption:  This happens if the small intestine cannot absorb enough nutrients.
• Sepsis:  This is an infection that develops secondary to an existing one. Sepsis causes inflammation, which leads to organ damage and failure and, in some cases, death. 
• Hemolytic uremic syndrome:  This occurs if an infection damages the blood vessels in your kidneys.
• Reactive arthritides:  Some infections may cause painful and swollen joints.

Typically, those complications are more common in older adults and children younger than 4 than others.

To manage travelers' diarrhea, follow a healthcare provider's advice and treatment plan . Other steps to keep comfortable while your symptoms resolve include staying hydrated and practicing proper hygiene, such as handwashing. 

Mostly, people with travelers' diarrhea only require emergency medical attention if they are dehydrated. Consult a healthcare provider if your symptoms do not subside after 10 days.

A Quick Review

Travelers' diarrhea causes acute diarrhea that comes on while traveling . You can avoid travelers' diarrhea as much as possible by watching what you eat and drink while traveling outside the country. To treat mild cases, staying hydrated is essential. 

Although you are at risk for diarrhea when traveling, it should not be scary. South America, Central America, Mexico, Africa, the Middle East, and Asia offer unique, enriching experiences worth the risk.

Connor BA. Travelers' diarrhea . In:  Travelers' Health . Centers for Disease Control and Prevention; 2020.

Dunn N, Okafor CN. Travelers diarrhea . In:  StatPearls . StatPearls Publishing; 2023.

MedlinePlus. Traveler's diarrhea diet .

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• Section 11 - Respiratory Infections
• Section 11 - Dermatologic Conditions

Persistent Diarrhea in Returned Travelers

Cdc yellow book 2024.

Author(s): Bradley Connor

Although most cases of travelers’ diarrhea (TD) are acute and self-limited, a certain percentage of people afflicted will develop persistent (>14 days) gastrointestinal (GI) symptoms. Details on the management of acute TD are available in Sec. 2, Ch. 6, Travelers’ Diarrhea .

Pathogenesis

The pathogenesis of persistent diarrhea in returned travelers generally falls into one of the following broad categories: ongoing infection or co-infection with a second organism not targeted by initial therapy; previously undiagnosed GI disease unmasked by the enteric infection; or a postinfectious phenomenon.

Ongoing Infection

Most cases of TD are the result of bacterial infection and are short-lived and self-limited. In addition to immunosuppression and sequential infection with diarrheal pathogens, ongoing infection with protozoan parasites can cause prolonged diarrheal symptoms.

Individual bacterial infections rarely cause persistent symptoms, but travelers infected with Clostridioides difficile or enteroaggregative or enteropathogenic Escherichia coli (see Sec. 5, Part 1, Ch. 7, Diarrheagenic Escherichia coli ) can experience ongoing diarrhea. C. difficile –associated diarrhea can occur after treatment of a bacterial pathogen with a fluoroquinolone or other antibiotic, or after malaria chemoprophylaxis. The association between C. difficile and antimicrobial treatment is especially important to consider in patients with persistent TD that seems refractory to multiple courses of empiric antibiotic therapy. The initial work-up of persistent TD should always include a C. difficile stool toxin assay. Clinicians can prescribe oral vancomycin, fidaxomicin, or, less optimally, metronidazole to treat C. difficile .

As a group, parasites are the pathogens most likely to be isolated from patients with persistent diarrhea. The probability of a traveler having a protozoal infection, relative to a bacterial one, increases with increasing duration of symptoms. Parasites might also be the cause of persistent diarrhea in patients already treated for a bacterial pathogen.

Giardia (see Sec. 5, Part 3, Ch. 12, Giardiasis ) is the most likely parasitic pathogen to cause persistent diarrhea. Suspect giardiasis particularly in patients with upper GI–predominant symptoms. Untreated, symptoms can last for months, even in immunocompetent hosts.

PCR-based diagnostics, particularly the multiplex DNA extraction PCR, are becoming the diagnostic methods of choice to identify Giardia and other protozoal pathogens, including Cryptosporidium , Cyclospora , and Entamoeba histolytica . Diagnosis also can be made by stool microscopy, antigen detection, or immunofluorescence. In the absence of diagnostics (given the high prevalence of Giardia as a cause for persistent TD), empiric therapy is a reasonable option in the clinical setting. Rare causes of persistent symptoms include the intestinal parasites Cystoisospora , Dientamoeba fragilis , and Microsporidia .

Tropical Sprue & Brainerd Diarrhea

Persistent TD also has been associated with tropical sprue and Brainerd diarrhea. Tropical sprue is associated with deficiencies of vitamins absorbed in the proximal and distal small bowel and most commonly affects long-term travelers to tropical areas, as the name implies. The incidence of tropical sprue appears to have declined dramatically over the past 2 decades. Diagnosed only rarely in travelers, its cause is unknown.

Brainerd diarrhea is a syndrome of acute onset of watery diarrhea lasting ≥4 weeks. Symptoms include 10–20 episodes of explosive, watery diarrhea per day, fecal incontinence, abdominal cramping, gas, and fatigue. Nausea, vomiting, and fever are rare. Although the cause is believed to be infectious, a culprit pathogen has yet to be identified, and antimicrobial therapy is ineffective as treatment. Investigation of an outbreak of Brainerd diarrhea among passengers on a cruise ship to the Galápagos Islands in 1992 identified that individuals with persistent diarrhea (range: 7 to >42 months) were more likely to have consumed contaminated water or eaten raw fruits or vegetables washed with contaminated water.

Underlying Gastrointestinal Disease

Celiac disease.

In some cases, persistent symptoms relate to chronic underlying GI disease or to a susceptibility unmasked by the enteric infection. Most prominent among these is celiac disease, a systemic disease manifesting primarily with small bowel changes. In genetically susceptible people, exposure to antigens found in wheat causes villous atrophy, crypt hyperplasia, and malabsorption. Serologic tests, including tissue transglutaminase antibody testing, support the diagnosis; a small bowel biopsy showing villous atrophy confirms the diagnosis. Patients can be treated with a gluten-free diet.

Colorectal Cancer

Depending on the clinical setting and age group, clinicians might need to conduct a comprehensive search for other underlying causes of chronic diarrhea. Consider colorectal cancer in the differential diagnosis of patients passing occult or gross blood rectally or in patients with new-onset iron-deficiency anemia.

Inflammatory Bowel Disease

Idiopathic inflammatory bowel disease, including Crohn’s disease, microscopic colitis, and ulcerative colitis, can occur after acute bouts of TD. One prevailing hypothesis is that in genetically susceptible people, an initiating exogenous pathogen changes the microbiota of the gut, thereby triggering inflammatory bowel disease.

Postinfectious Phenomena

In a certain percentage of patients who present with persistent GI symptoms, clinicians will not find a specific cause. After an acute diarrheal infection, patients might experience a temporary enteropathy characterized by villous atrophy, decreased absorptive surface area, and disaccharidase deficiencies, which can lead to osmotic diarrhea, particularly after consuming large amounts of fructose, lactose, sorbitol, or sucrose. Use of antimicrobial medications during the initial days of diarrhea might also lead to alterations in intestinal flora and diarrhea symptoms.

Occasionally, onset of irritable bowel syndrome (IBS) symptoms occurs after a bout of acute gastroenteritis, known as postinfectious IBS (PI-IBS). PI-IBS symptoms can occur after an episode of gastroenteritis or TD. The clinical work-up for microbial pathogens and underlying GI disease in patients with PI-IBS will be negative. Whether using antibiotics to treat acute TD increases or decreases the likelihood of PI-IBS is unknown.

Traditional methods of microbial diagnosis rely on the use of microscopy. Examine stool specimens collected over 3 or more days for ova and parasites; include acid-fast staining for Cryptosporidium , Cyclospora , and Cystoisospora . Giardia antigen testing and a C. difficile toxin assay are appropriate elements of a work-up. In addition, a D-xylose absorption test can determine whether patients are properly absorbing nutrients. If underlying gastrointestinal disease is suspected, include serologic testing for celiac disease and consider inflammatory bowel disease during initial evaluation. Subsequently, studies to visualize both the upper and lower gastrointestinal tracts, with biopsies, might be indicated.

Diagnostic tests to determine specific microbial etiologies in cases of persistent diarrhea have advanced in the past number of years. One of the most useful tools is high-throughput multiplex DNA extraction PCR. This technology uses a single stool specimen to detect multiple bacterial, parasitic, and viral enteropathogens simultaneously. Except for Cryptosporidium , these assays have high sensitivity and specificity; the clinical ramifications and the economic impact of using these diagnostic molecular panels have not been determined fully, however. In some cases, molecular testing detects colonization rather than infection, making it difficult for clinicians to interpret and apply the results properly.

Specific treatment of identified enteropathogens is usually indicated, and appropriate management of underlying gastrointestinal disease warranted (e.g., a gluten-free diet for celiac disease, medication for inflammatory bowel disease). Dietary modifications might help patients with malabsorption. Symptomatic treatment or the use of nonabsorbable antibiotics offer potential benefit if small intestinal bacterial overgrowth accompanies the symptom complex. Additionally, chronic diarrhea might cause fluid and electrolyte imbalances requiring medical management involving oral or intravenous replacement based on clinical presentation.

The following authors contributed to the previous version of this chapter: Bradley A. Connor

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Mintz ED, Weber JT, Guris D, Puhr N, Wells JG, Yashuk JC, et al. An outbreak of Brainerd diarrhea among travelers to the Galapagos Islands. J Infect Dis. 1998;177(4):1041–5.

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INTRODUCTION

The treatment and prevention of travelers' diarrhea are discussed here. The epidemiology, microbiology, clinical manifestations, and diagnosis of travelers' diarrhea are discussed separately. (See "Travelers' diarrhea: Epidemiology, microbiology, clinical manifestations, and diagnosis" .)

Clinical approach  —  Management of travelers’ diarrhea depends on the severity of illness. Fluid replacement is an essential component of treatment for all cases of travelers’ diarrhea. Most cases are self-limited and resolve on their own within three to five days of treatment with fluid replacement only. Antimotility agents can provide symptomatic relief but should not be used when bloody diarrhea is present. Antimicrobial therapy shortens the disease duration, but the benefit of antibiotics must be weighed against potential risks, including adverse effects and selection for resistant bacteria. These issues are discussed in the sections that follow.

When to seek care  —  Travelers from resource-rich settings who develop diarrhea while traveling to resource-limited settings generally can treat themselves rather than seek medical advice while traveling. However, medical evaluation may be warranted in patients who develop high fever, abdominal pain, bloody diarrhea, or vomiting. Otherwise, for most patients while traveling or after returning home, medical consultation is generally not warranted unless symptoms persist for 10 to 14 days.

Fluid replacement  —  The primary and most important treatment of travelers' (or any other) diarrhea is fluid replacement, since the most significant complication of diarrhea is volume depletion [ 11,12 ]. The approach to fluid replacement depends on the severity of the diarrhea and volume depletion. Travelers can use the amount of urine passed as a general guide to their level of volume depletion. If they are urinating regularly, even if the color is dark yellow, the diarrhea and volume depletion are likely mild. If there is a paucity of urine and that small amount is dark yellow, the diarrhea and volume depletion are likely more severe.

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• Traveler's diarrhea

Traveler's diarrhea may get better without any treatment. But while you're waiting, it's important to try to stay hydrated with safe liquids, such as bottled water or water with electrolytes such as an oral rehydration solution (see below). If you don't seem to be improving quickly, several medicines are available to help relieve symptoms.

Anti-motility agents. These medicines — which include loperamide and drugs containing diphenoxylate — provide prompt but temporary relief by:

• Reducing muscle spasms in your gastrointestinal tract.
• Slowing the transit time through your digestive system.
• Allowing more time for absorption.

Anti-motility medicines aren't recommended for infants or people with a fever or bloody diarrhea. This is because they can delay clearance of the infectious organisms and make the illness worse.

Also, stop using anti-motility agents after 48 hours if you have stomach pain or if your symptoms worsen and your diarrhea continues. In such cases, see a doctor. You may need blood or stool tests and treatment with an antibiotic.

• Bismuth subsalicylate. This nonprescription medicine can decrease the frequency of your stools and shorten the length of your illness. However, it isn't recommended for children, pregnant women or people who are allergic to aspirin.
• Antibiotics. If you have more than four loose stools a day or severe symptoms, including a fever or blood, pus or mucus in your stools, a doctor may prescribe a course of antibiotics.

Before you leave for your trip, talk to your doctor about taking a prescription with you in case you get a serious bout of traveler's diarrhea.

Avoiding dehydration

Dehydration is the most likely complication of traveler's diarrhea, so it's important to try to stay well hydrated.

An oral rehydration salts (ORS) solution is the best way to replace lost fluids. These solutions contain water and salts in specific proportions to replenish both fluids and electrolytes. They also contain glucose to enhance absorption in the intestinal tract.

Bottled oral rehydration products are available in drugstores in developed areas, and many pharmacies carry their own brands. You can find packets of powdered oral rehydration salts, labeled World Health Organization (WHO)- ORS , at stores, pharmacies and health agencies in most countries. Reconstitute the powder in bottled or boiled water according to the directions on the package.

If these products are unavailable, you can prepare your own rehydrating solution in an emergency by mixing together:

• 3/4 teaspoon table salt.
• 2 tablespoons sugar.
• 1 quart uncontaminated bottled or boiled water.
• Sugar-free flavor powder, such as Crystal Light (optional).

You or your child can drink the solution in small amounts throughout the day as a supplement to solid foods or formula, as long as dehydration persists. Small amounts reduce the likelihood of vomiting. Breastfed infants also can drink the solution but should continue nursing on demand.

If dehydration symptoms — such as dry mouth, intense thirst, little or no urination, dizziness, or extreme weakness — don't improve, seek medical care right away. Oral rehydration solutions are intended only for urgent short-term use.

Lifestyle and home remedies

If you do get traveler's diarrhea, avoid caffeine, alcohol and dairy products, which may worsen symptoms or increase fluid loss. But keep drinking fluids.

Drink canned fruit juices, weak tea, clear soup, decaffeinated soda or sports drinks to replace lost fluids and minerals. Later, as your diarrhea improves, try a diet of easy-to-eat complex carbohydrates, such as salted crackers, bland cereals, bananas, applesauce, dry toast or bread, rice, potatoes, and plain noodles.

You may return to your normal diet as you feel you can tolerate it. Add dairy products, caffeinated beverages and high-fiber foods cautiously.

Preparing for your appointment

Call a doctor if you have diarrhea that is severe, lasts more than a few days or is bloody. If you are traveling, call an embassy or consulate for help locating a doctor. Other signs that you should seek medical attention include:

• A fever of 102 F (39 C) or higher.
• Ongoing vomiting.
• Signs of severe dehydration, including a dry mouth, muscle cramps, decreased urine output, dizziness or fatigue.

If you have diarrhea and you've just returned home from a trip abroad, share that trip information with your doctor when you call to make an appointment.

Here's some information to help you get ready, and what to expect.

Information to gather in advance

• Pre-appointment instructions. At the time you make your appointment, ask whether there are immediate self-care steps you can take to help recover more quickly.
• Symptom history. Write down any symptoms you've been experiencing and for how long.
• Medical history. Make a list of your key medical information, including other conditions for which you're being treated and any medicines, vitamins or supplements you're currently taking.
• Questions to ask your health care professional. Write down your questions in advance so that you can make the most of your time.

The list below suggests questions to ask about traveler's diarrhea.

• What's causing my symptoms?
• Are there any other possible causes for my symptoms?
• What kinds of tests do I need?
• What treatment approach do you recommend?
• Are there any possible side effects from the medicines I'll be taking?
• Will my diarrhea or its treatment affect the other health conditions I have? How can I best manage these conditions together?
• What is the safest way for me to rehydrate?
• Do I need to follow any dietary restrictions and for how long?
• How soon after I begin treatment will I start to feel better?
• How long do you expect a full recovery to take?
• Am I contagious? How can I reduce my risk of passing my illness to others?
• What can I do to reduce my risk of this condition in the future?

In addition to the questions that you've prepared, don't hesitate to ask questions as they occur to you during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to talk about in-depth. Your doctor may ask:

• What are your symptoms?
• When did you first begin experiencing symptoms?
• Have you traveled recently?
• Where did you travel?
• Have you taken any antibiotics recently?
• Have your symptoms been getting better or worse?
• Have you noticed any blood in your stools?
• Have you experienced symptoms of dehydration, such as muscle cramps or fatigue?
• What treatments have you tried so far, if any?
• Have you been able to keep down any food or liquid?
• Are you pregnant?
• Are you being treated for any other medical conditions?
• Feldman M, et al., eds. Infectious enteritis and proctocolitis. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 11th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 25, 2021.
• LaRocque R, et al. Travelers' diarrhea: Microbiology, epidemiology, and prevention. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
• Ferri FF. Traveler diarrhea. In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed April 28, 2023.
• Diarrhea. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/diarrhea. Accessed April 27, 2023.
• Travelers' diarrhea. Centers for Disease Control and Prevention. https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/travelers-diarrhea. Accessed April 28, 2023.
• LaRocque R, et al. Travelers' diarrhea: Clinical manifestations, diagnosis, and treatment. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
• Khanna S (expert opinion). Mayo Clinic. May 29, 2021.

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Traveler’s Diarrhea

• Symptoms and Signs |
• Diagnosis |
• Treatment |
• Prevention |
• Key Points |
• More Information |

Traveler’s diarrhea is gastroenteritis that is usually caused by bacteria endemic to local water. Symptoms include vomiting and diarrhea. Diagnosis is mainly clinical. Treatment is with replacement fluids and sometimes antibiotics for moderate to severe diarrhea.

(See also Overview of Gastroenteritis and see the Center for Disease Control and Prevention’s [CDC] information for preparing international travelers for travelers’ diarrhea .)

Etiology of Traveler's Diarrhea

Traveler’s diarrhea may be caused by any of several bacteria, viruses, or, less commonly, parasites.

The most common cause of traveler's diarrhea is

Enterotoxigenic Escherichia coli ( E. coli )

E. coli is common in the water supplies of areas that lack adequate purification. Infection is common among people traveling to low-resource countries.

Norovirus gastroenteritis has been a particular problem on some cruise ships.

Both food and water can be the source of infection. Travelers who avoid drinking local water may still become infected by brushing their teeth with an improperly rinsed toothbrush, drinking bottled drinks with ice made from local water, or eating food that is improperly handled or washed with local water. People taking medications that decrease stomach acid (antacids, H2 blockers, and proton pump inhibitors) are at risk of more severe illness.

Symptoms and Signs of Traveler's Diarrhea

Nausea, vomiting, hyperactive bowel sounds, abdominal cramps, and diarrhea begin 12 to 72 hours after ingesting contaminated food or water. Severity is variable. Some people develop fever and myalgias. Diarrhea is rarely bloody.

Most cases are mild and self-limited, although dehydration can occur, especially in warm climates.

Diagnosis of Traveler's Diarrhea

Clinical evaluation

Specific diagnostic measures are usually not necessary. However, fever, severe abdominal pain, and bloody diarrhea suggest more serious disease and should prompt immediate evaluation.

Treatment of Traveler's Diarrhea

Fluid replacement

Sometimes antidiarrheal (antimotility) medications

Antibiotics (eg, ciprofloxacin , azithromycin ) for moderate to severe diarrhea

The mainstay of treatment of traveler's diarrhea is fluid replacement and an antidiarrheal medication such as loperamide

Antidiarrheal medications should not be used in adults with suspected C. difficile or E. coli O157:H7 infection (eg, with recent antibiotic use, bloody diarrhea, heme-positive stool, or diarrhea with fever) or in children, particularly those < 2 years. Iodochlorhydroxyquin, which may be available in some low- and middle-income countries, should not be used because it may cause neurologic damage.

Pearls & Pitfalls

Generally, antibiotics are not necessary for mild diarrhea. However, in patients with moderate to severe diarrhea ( ≥ Campylobacter 2017 guidelines for the prevention and treatment of travelers' diarrhea .)

Prevention of Traveler's Diarrhea

Travelers should dine at restaurants with a reputation for safety and avoid foods and beverages from street vendors. They should consume only cooked foods that are still steaming hot, fruit that can be peeled, and carbonated beverages without ice served in sealed bottles (bottles of noncarbonated beverages can contain tap water added by unscrupulous vendors); uncooked vegetables (particularly including salsa left out on the table) should be avoided. Buffets and fast food restaurants pose an increased risk.

Traveler's diarrhea is usually caused by enterotoxigenic E. coli , but viruses, parasites, and other bacteria may be involved.

Diagnosis is clinical and testing is not usually needed unless bloody diarrhea, fever, or abdominal pain is present.

Prevention is the best measure and involves careful selection of foods and beverages; prophylactic antibiotics are not routinely used except for patients with immunocompromise.

More Information

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

Centers for Disease Control and Prevention: Preparing international travelers for travelers’ diarrhea

Expert panel: Guidelines for the prevention and treatment of travelers' diarrhea (2017)

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Travelers diarrhea.

Noel Dunn ; Chika N. Okafor .

Affiliations

Last Update: July 4, 2023 .

• Continuing Education Activity

Traveler's diarrhea is a common ailment in individuals traveling to resource-limited destinations overseas. It is estimated to affect nearly 40 to 60 percent of travelers and is the most common travel-associated condition. Bacterial, viral, and parasitic infections can cause symptoms, though bacterial sources represent the most frequent etiology. Although traveler's diarrhea is typically a benign, self-resolving condition, it can lead to dehydration and, in severe cases, significant complications. This activity reviews the evaluation and management of traveler's diarrhea and highlights the role of interprofessional team members in collaborating to provide well-coordinated care and enhance outcomes for affected patients.

• Identify the causes of traveler's diarrhea.
• Identify strategies to prevent traveler's diarrhea.
• Explain the management of traveler's diarrhea.
• Explain the importance of improving coordination amongst the interprofessional team to enhance care for patients affected by traveler's diarrhea.
• Introduction

Travelers’ diarrhea is a common ailment in persons traveling to resource-limited destinations overseas. Estimates indicate that it affects nearly 40% to 60% of travelers depending on the place they travel, and it is the most common travel-associated condition.  Bacterial, viral, and parasitic infections can cause symptoms, though bacterial sources represent the most frequent etiology. While travelers’ diarrhea is typically a benign self-resolving condition, it can lead to dehydration and, in severe cases, significant complications.  [1] [2] [3]

The most common bacterial cause is enterotoxigenic Escherichia coli (ETEC), with estimates that the bacteria is responsible for nearly 30% of cases. Other common bacterial causes of travelers’ diarrhea include Campylobacter jejuni , Shigella , and Salmonella species. Norovirus is the most common viral cause while rotavirus is another source of infection.  Giardia intestinalis is the most common parasitic source while Cryptosporidium and Entamoeba histolytica can also cause travelers’ diarrhea. The most common cause of travelers’ diarrhea varies by region, though the source is rarely identified in less severe cases. [4] [5] [6]

Traveler's diarrhea can occur in both short and long term travelers; in general, there is no immunity against future attacks. Traveler's diarrhea appears to be most common in warmer climates, in areas of poor sanitation and lack of refrigeration. In addition, the lack of safe water and taking short cuts to preparing foods are also major risk factors. In areas where food handling education is provided, rates of traveler's diarrhea are low.

• Epidemiology

Estimates place the incidence of travelers’ diarrhea at 30% to 60% of travelers to resource-limited destinations. Incidence and causal agent vary by destination, with the highest incidence reported in sub-Saharan Africa. Other locations with high incidence include Latin America, the Middle East, and South Asia. Risk factors are typically related to poor hygiene in resource-limited areas. These include poor hygienic practices in food handling and preparation; lack of refrigeration due to inadequate electrical supply; and poor food storage practices. Additional modifiable risk factors include proton pump inhibitor (PPI) use, recent antibiotic use, and unsafe sexual practices. Risk factors for severe complications are pregnancy, young or old age, travelers with underlying chronic gastrointestinal diseases, or people who are immunocompromised.  [7] [8]

• Pathophysiology

Travelers’ diarrhea is most commonly spread by fecal-oral transmission of the causative organism, typically through consumption of contaminated food or water.  The incubation period varies by causal agent, with viruses and bacteria ranging from 6 to 24 hours and intestinal parasites requiring 1 to 3 weeks before the onset of symptoms.  The pathophysiology for travelers’ diarrhea differs by a causative agent but can be split into non-inflammatory or inflammatory pathways. Non-inflammatory agents cause a decrease in the absorptive abilities of the intestinal mucosa, thereby increasing the output of the gastrointestinal (GI) tract. Inflammatory agents on the other hand cause destruction of the intestinal mucosa either through cytotoxin release or direct invasion of the mucosa. The loss of mucosa surface again results in a decrease of absorption with a resultant increase in bowel movements. [9]

• History and Physical

The onset of symptoms will typically occur 1 to 2 weeks after arrival in a resource-limited destination, though travelers can develop symptoms throughout their stay or shortly after arrival. Travelers’ diarrhea is considered as three or more loose stools in 24 hours or a two-fold increase from baseline bowel habits. Diarrhea often occurs precipitously and is accompanied by abdominal cramping, fever, nausea, or vomiting. Patients should be asked about any blood in their stool, fevers, or any associated symptoms. A thorough travel history should be obtained including timeline and itinerary, diet and water consumption at their destination, illnesses in other travelers, and possible sexual exposures.

In most self-limited cases physical examination will show mild diffuse abdominal tender to palpation. Providers should assess for dehydration through skin turgor and capillary refill.  In more severe cases patients may have severe abdominal pain, high fever, and evidence of hypovolemia (tachycardia, hypotension).

Laboratory investigation is typically not required in most cases.  In patients with concerning features, such as with high fever, hematochezia, or tenesmus, stool studies can be obtained. Typical stool studies include stool culture, fecal leukocytes, and lactoferrin. The stool should be assessed for ova and parasites in patients with longer duration of symptoms. New multiplex polymerase chain reaction (PCR) screens are becoming available and provide quick analysis of multiple stool pathogens. These screens, however, are expensive, are not widely available, and may not change the clinical management of patients. [4]

Radiological studies are not required in most cases. Kidneys, ureters, and bladder x-ray can be obtained to assess for acute intra-abdominal pathology or look for evidence of perforation in severe cases. An abdominal CT can also be used to assess for intraabdominal pathology in severe cases.

• Treatment / Management

Travelers should be counseled on risk reduction before travel, including avoiding tap water & ice, frequent hand washing, avoiding leafy vegetables or fruit that isn’t peeled, and avoiding street food. Bismuth subsalicylate (two tabs 4 times a day) can be used for prophylaxis and can reduce the incidence of travelers’ diarrhea by almost half, though it should be avoided in children and pregnant women due salicylate side effects. In short high-stakes travel, it may be reasonable to start antibiotics as prophylaxis but is generally avoided in longer-term travel. Rifaximin is a commonly used chemoprophylaxis due to its minimal absorption and minimal side effects. [10] [11] [12]

The foundation of diarrhea management is fluid repletion. In mild cases, travelers should focus on increasing water intake. Water is usually sufficient though sports drinks and other electrolyte fluids can be used. Pedialyte can be used for pediatric patients. Milk and juices should be avoided as this can worsen diarrhea. In more severe cases, oral rehydration salt can be used to ensure rehydration with adequate electrolyte repletion. In cases of severe dehydration, IV fluids may ultimately be required.

Treatment is supportive in mild-moderate cases. In patients without signs of inflammatory diarrhea, loperamide can be used for symptomatic relief.  The typical dose for adults is 4 mg initially with 2 mg after each subsequent loose stool, not to exceed 16 mg total in a day.

Also, travelers can be given antibiotics to take as needed at the onset of symptoms. Ciprofloxacin is commonly used for treatment, though there are concerns with resistance with Campylobacter species.  For this reason, fluoroquinolones are not often prescribed for travelers to Asia and azithromycin preferable. Also, azithromycin is often prescribed for pregnant travelers and children. A common regimen is 500 mg daily for three days, though evidence suggests that a single dose of 1000 mg may be slightly more effective. Parents can be given azithromycin powder with instructions to mix with water when needed. Rifaximin is a minimally absorbed antibiotic that is also available and is safe for older children and pregnant travelers.

• Differential Diagnosis
• Pseudomembranous colitis
• Ischemic colitis
• Radiation-induced colitis
• Food poisoning

New Guidelines for Traveler's Diarrhea

• Travelers should be advised against the use of prophylactic antibiotics
• In high-risk groups, one may consider antibiotic prophylaxis
• Bismuth subsalicylate can be considered in any traveler.
• The antibiotic of choice is rifaximin
• Fluoroquinolones should not be used as prophylaxis

The outcomes in most patients with traveler's diarrhea are good. However, in severe cases, dehydration can occur requiring admission.

• Complications
• Dehydration
• Malabsorption
• Hemolytic uremic syndrome
• Reactive arthritides
• Postoperative and Rehabilitation Care

The majority of patients are managed as outpatients and need to do the following:

• Maintain hydration
• Hand washing
• Only take antimotility agents if prescribed by the healthcare provider
• Maintain good personal hygiene
• If diarrhea persists for more than 10 days, should follow up with the primary provider
• Deterrence and Patient Education
• Wash hands regularly
• Avoid shellfish from waters that are contaminated
• Wash all foods before consumption
• Drink bottled water when traveling
• Avoid consumption of raw poultry or eggs
• When traveling, consume dry foods and carbonated beverages
• Avoid water and ice from the street
• Avoid drinking water from lakes and rivers
• Pearls and Other Issues

There is a strong correlation with travelers’ diarrhea and the subsequent development of irritable bowel syndrome (IBS), with some studies suggesting up to 50% incidence.

• Enhancing Healthcare Team Outcomes

The key to traveler's diarrhea is preventing it. Today, nurses, the primary care provider and the pharmacists are in the prime position to educate the patient on the importance of hydration and good hygiene. The traveler should be educated on drinking bottled water and washing all fresh fruit and vegetables prior to consumption. Plus, travelers should be warned not to drink from lakes and streams. Carrying small packets of alcohol desansitizer to wash hands can be very helpful when hand washing is not possible.

The pharmacist should educate the traveler on managing the symptoms of diarrhea with over-the-counter medications or loperamide. Travelers should be discouraged from taking prophylactic antibiotics when traveling, as this leads to more harm than good. Finally, the traveler should be educated on the symptoms of dehydration and when to seek medical care. The primary care clinicians should monitor patients until there is a complete resolution of symptoms. Any patient that fails to improve within a few days should be referred to a specialist for further workup. With open communication between the team members, the morbidity of traveler's diarrhea can be reduced. [1] [8] (level V)

The prognosis for most patients with traveler's diarrhea is excellent. However, thousands of patients go to the emergency departments each year looking for a magical cure. Hydration is the key and admission is only required for severe dehydration and orthostatic hypotension. The elderly and children under the age of 4 are at the highest risk for developing complications, which often occur because of self-prescribing of over-the-counter medications. [13] [14] (Level V)

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Disclosure: Noel Dunn declares no relevant financial relationships with ineligible companies.

Disclosure: Chika Okafor declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Dunn N, Okafor CN. Travelers Diarrhea. [Updated 2023 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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