The D-Word (Traveler’s Diarrhea)
… is one you’ll never have to utter on the road – or suffer from – if you read this story: The latest information that medicine has to offer on Traveler’s Diarrhea.
Outside your hotel room is that unspoiled beach, the faint roar of surf on reef, the sigh of trade winds streaming through palm leaves. Sighs and sounds that were the stuff of your dreams back home are now the backdrop to a nightmare. Inside your hotel room, you’re too weak to get up. If you did get up, you’re not sure how far you could stagger. And you’re not convinced a toilet will be instantly available every 100 yards. Now that you’re in paradise, all you can think about is how you’re going to make it to the airplane home.
So goes traveler’s diarrhea, which really we should delicately refer to as “traveler’s complaint,” which was an inevitable misery when I traveled through Belize and Guatemala 30 years ago. I got by on Lomotil (diphenoxylate with atropine) pills to immobilize my intestinal tract; they worked so thoroughly that by the third day of suffering I stopped eating for fear that something might rupture. And I drank a raw egg mixed in orange juice several times a day, on the advice of a local doctor. He might not have been a very good doctor, judging by the way that even some of the locals seemed to struggle with a gag reflex when they saw me drink the stuff.
“A raw egg in orange juice? I can’t figure that one out,” says Dr. Stuart R. Rose, Medical Director and owner of the Travel Medicine Center of Western Massachusetts, Northhampton, Massachusetts [www.travelinghealthy.com]. Dr. Rose is also author of The 2013 International Travel Health Guide. At the home Web page of his company, Travel Medicine, Inc. [www.travmed.com], you can click on “FREE HEALTH GUIDE” for the latest tips.
“A lot of doctors don’t know anything about travel medicine,” Rose says. “It’s one thing to get sick while you’re here, and you can go to the ER or your doctor’s office. But when you’re in a remote area of a foreign country and you get sick, where do you turn?”
- Loperamide (Imodium)
- Oral Rehydration Solution
- …and a big dose of Preventive Behavior.
On a family vacay in Latin American more than a decade ago, we took along a store of the antibiotic ciprofloxacin (Cipro). Since that time two other antibiotics have come into common use against diarrhea (I mean, the Aztec Two-Step, as some Mexico travelers also call it): azithromycin and rifaximin. Dr. Rose summarizes the choices as:
- Azithromycin (Zithromax), 1,000 milligrams (mg) once daily for 1-3 days.
- Ciprofloxacin (Cipro), 750 mg daily for 1-3 days.
- Rifaximin (Xifaxan), 200 mg three times daily for three days.
All are effective, but Dr. Rose says his first choice would be azithromycin (Zithromax). A single, long-acting 1,000-mg dose is usually sufficient for most cases of the Poona Poohs (India) and is also a complete treatment for cholera.
For children, “Liquid forms of azithromycin and ciprofloxacin area available,” according to Dr. Rose. “Although not generally recommended for kids, ciprofloxacin can be safely administered” for Gyppy Tummy (as it’s known to travelers in Egypt). It’s been used extensively in children to treat cystic fibrosis without any adverse side effects, he adds.
Some 80% of diagnosable cases of the Turkey Trots (Turkey) are caused by enterotoxogenic E. coli, or ETEC, transmitted by the oral/fecal contamination of water or food. The Hong Kong Dog (Hong Kong) can be caused by a multitude of other pathogens, but these antibiotics typically provide relief within three days. But “we never prescribe more than three days of treatment,” says Dr. Rose. Beyond three days, according to Rose, Casablanca Crud (Morocco) not responding to these drugs may be due to a parasite such as giardia or cryptosporidia, and that may need treatment with metronidazole (Flagyl) or tinidazole (Fasigyn).
Travelers with symptoms of dysentery (bloody flux, abdominal pain, high fever), “should take the antibiotic but also seek medical consultation as soon as possible,” says Dr. Rose. “An amoebic parasite or a more aggressive bacterium may be the cause, and hospitalization may be needed.”
More than likely, it’s ETEC, but it is still important to start the antibiotics early. At this early stage, the ETEC infection is limited to the lining of the intestines and hasn’t reached deeper tissues.
Also remember that the amount of antibiotic you take along should reflect the possibility that you may experience more than one attack during a single trip. And that includes the use of antibiotics as prevention before a problem starts.
For prevention, “most authorities recommend rifaximin at a dose of 200 mg once or twice a day (with major meals) while the person is in an area of risk…” according to a 2009 article in The New England Journal of Medicine. “In placebo-controlled trials involving U.S. students traveling in Mexico, the risk reduction” in getting Basra Belly (Iraq) “with the use of prophylactic rifaximin treatment was approximately 70%.”
While the antibiotics get to the “fountainhead” of the problem, Imodium tablets – available over the counter – provide temporary relief. Imodium helps reduce peristalsis (muscle contractions in the lower digestive system) and secretion of water from the bowel. It can be given in appropriate doses to children over the age of two, but only with prescriptions and precautions.
Doctors recommend combining an antibiotic with Imodium, but your response might also be affected by your location. “If you’re in a fixed location, like a hotel with a toilet always available and not traveling every day, it might be reasonable to start with Imodium and see what happens,” Dr. Rose says. If you’re getting on a bus to the boondocks, however, it’s probably a good idea to throw everything at the problem.
Oral Rehydration Solution
When traveler’s diarrhea (I mean the Trotskys, as some call it in Russia) goes on long enough, you get dehydrated. Fatigue, dizziness and pallor are the signs to look for. It is extremely important to replace the fluids that are lost – especially for children, who get dehydrated very rapidly. You can drink a lot of water to replace your fluid loss from Seeping Sickness (Africa), but water may just pass through without being absorbed by the intestinal wall. A better choice is oral rehydration solution, which contains salts and sugar to help your body absorb the water. In many camping stores and drugstores, one can buy prepackaged doses of dry formula to add to potable water.
In addition to drinking water, Dr. Rose adds, don’t stop eating. “The absorption of water in the intestine is linked to the active intestinal absorption of glucose and sodium,” he says. “The resulting trans-membrane concentration gradient (“osmotic gradient”) pulls water across the intestine and into the body; thus, water is absorbed passively. Best sources of carbs are rice, noodles, bread, potatoes, etc. Sugar also contains glucose, but complex carbs are more efficient and provide a satisfying source of energy.” Eating also DECREASES the severity of Zermattitus (Switzerland) due to the enhancement of water absorption.
Using Pepto-Bismol (active ingredient bismuth subsalicylate) preventatively, at least at the beginning of your trip, can, according to a study reported in the New England Journal of Medicine, reduce your chances of getting the Ho Chi Minhs (Viet Nam) by about 65%, because the bismuth in Pepto-Bismol kills bacteria. However, people who can’t tolerate aspirin should avoid Pepto-Bismol, and its use has not been approved for children due to a perceived risk of Reye’s syndrome. It is also cautioned that you shouldn’t take Pepto-Bismol for more than three days when you are taking it at a rate of two tablets per day.
Maybe someday we will be able to take some one medicine before we travel that can obliterate any concerns about the state of our entrails. For now, medical science can offer the existing medicines and some practical advice so we can avoid, treat and purge ourselves of this age-old problem. If you’re well-prepared, you should be able to deal with the Thai-Del Wave (Thailand) every bit as gracefully as I have contrived, in the text of this article, to avoid even once substituting a euphemism for the indelicate term “diarrhea.”
To avoid your own big oops and a case of the poops, here are some doctor-recommended Preventative Behaviors to prevent traveler’s diarrhea:
Most people think that drinking water is the main source of traveler’s diarrhea. Not so. Water can be a problem, but food is more likely to be the culprit. Eat safe food and avoid the dangerous foods.
Street vendors are your riskiest source, followed by restaurants and private homes. In general, avoid:
- Raw vegetables and uncooked meat and seafood.
- Unpasteurized dairy products.
- Moist food that’s been sitting at room temperature.
- Food that is steaming hot is generally safe.
- Food that is dry, like bread, is generally safe, because bacteria need moisture.
- Sugar is antibacterial, so foods with high sugar content, like syrups and jellies, are generally safe.
- Food with high acid content, like citrus fruits, is safe; pretty much any fruit is OK, if you peel it yourself.
Dr. Rose recommends that you avoid traveler’s diarrhea by drinking only water that has been boiled, bottled or chemically treated. Since chemical treatment probably isn’t available, though, and you may not know if water has been boiled long enough, bottled water is the best alternative. You’re not restricted to water only, of course. Other commercially bottled or canned beverages, including beer and wine, are generally safe. But whatever you drink, accept no ice cubes. They can be bacteria bombs. When you’re reeling from the runs, avoid alcohol and coffee, which can aggravate it.
Oh, and about bottled water: Check the capping; you never know. There’s the old joke about the native restaurant owner in the “developing” country standing at the village pump filling glass water bottles and then screwing the caps back on. “What are you doing?’ a friend asks. “The tourists prefer bottled water,” is the reply.
According to Dr. Rose, people have a dangerous misconception that they should stop eating when they get traveler’s diarrhea, the idea being to starve away the disease. Actually, you should keep eating and drinking. You need the fluids, and the food helps absorb water and provides the nutrition and calories you need. Unfortunately, the do’s and don’ts of travel dining are complicated enough that you may not always remember to follow them. And when you’re on vacation, it’s hard to resist the allure of culinary adventure. You should expect that traveler’s diarrhea will move in to have its way with your entrails, and that way you’ll be pleasantly delighted if it doesn’t.