Donald C. Spencer, MD

Recommendations from others

The United States Centers for Disease Control and Prevention (CDC) state that travelers with nausea, vomiting, cramps, fever, or blood in stools may benefit from treatment for travelers’ diarrhea with ciprofloxacin (500 mg twice daily) or trimethoprim-sulfamethoxazole (double-strength tablet twice daily) for 3 days. The CDC also advises use of World Health Organization oral rehydration solution for replacement of lost fluids and salts.¹ The American College of Gastroenterology Practice Parameters Guidelines Committee recommends that travelers bring loperamide and an antimicrobial with them to use in self-therapy of TD.² However, neither the CDC nor the American College of Gastroenterology recommend antibiotic prophylaxis for otherwise healthy travelers.^1,2 Dosage and cost information is shown in the Table 1.

Evidence Summary

Many studies have documented the efficacy of treating TD with antibiotics. Recent studies have emphasized the use of the 4-fluoroquinolones because of the emergence of bacterial resistance against doxycycline and trimethoprim that was found in previous studies of the prophylactic use of antibiotics for TD. Other quinolones besides ciprofloxacin can be expected to be effective; ofloxacin 300 mg twice daily and norfloxacin 400 mg twice daily have been effective in clinical trials.¹ Illness duration can be shortened by 1 to 2.5 days with antibiotic treatment.³ A review of antibiotic use for TD in The Cochrane Library concluded that antibiotic treatment is associated with a shorter duration of illness at the cost of side effects. Antibiotics increased the proportion of those without diarrhea 72 hours after beginning treatment and also reduced the severity of illness.⁴

Antibiotics should be considered only part of the treatment of TD. Fluid and electrolyte therapy is the first and most important step in treatment and can usually be accomplished through oral rehydration therapy.⁵ Nonspecific agents such as bismuth subsalicylate can reduce stool frequency and shorten illness duration as shown in placebo-controlled trials. Antimotility agents such as loperamide (Imodium) and diphenoxylate with atropine (Lomotil) act to slow intraluminal flow of intestinal contents by increasing segmenting contractions in the intestine. Studies show reduced stool frequency and shortened duration of illness. Antimotility drugs should not be used in the setting of febrile dysentery with bloody stools, because such use may prolong or worsen the illness.²

Recommendations from others

The United States Centers for Disease Control and Prevention (CDC) state that travelers with nausea, vomiting, cramps, fever, or blood in stools may benefit from treatment for travelers’ diarrhea with ciprofloxacin (500 mg twice daily) or trimethoprim-sulfamethoxazole (double-strength tablet twice daily) for 3 days. The CDC also advises use of World Health Organization oral rehydration solution for replacement of lost fluids and salts.¹ The American College of Gastroenterology Practice Parameters Guidelines Committee recommends that travelers bring loperamide and an antimicrobial with them to use in self-therapy of TD.² However, neither the CDC nor the American College of Gastroenterology recommend antibiotic prophylaxis for otherwise healthy travelers.^1,2 Dosage and cost information is shown in the Table 1.

Evidence Summary

Many studies have documented the efficacy of treating TD with antibiotics. Recent studies have emphasized the use of the 4-fluoroquinolones because of the emergence of bacterial resistance against doxycycline and trimethoprim that was found in previous studies of the prophylactic use of antibiotics for TD. Other quinolones besides ciprofloxacin can be expected to be effective; ofloxacin 300 mg twice daily and norfloxacin 400 mg twice daily have been effective in clinical trials.¹ Illness duration can be shortened by 1 to 2.5 days with antibiotic treatment.³ A review of antibiotic use for TD in The Cochrane Library concluded that antibiotic treatment is associated with a shorter duration of illness at the cost of side effects. Antibiotics increased the proportion of those without diarrhea 72 hours after beginning treatment and also reduced the severity of illness.⁴

Antibiotics should be considered only part of the treatment of TD. Fluid and electrolyte therapy is the first and most important step in treatment and can usually be accomplished through oral rehydration therapy.⁵ Nonspecific agents such as bismuth subsalicylate can reduce stool frequency and shorten illness duration as shown in placebo-controlled trials. Antimotility agents such as loperamide (Imodium) and diphenoxylate with atropine (Lomotil) act to slow intraluminal flow of intestinal contents by increasing segmenting contractions in the intestine. Studies show reduced stool frequency and shortened duration of illness. Antimotility drugs should not be used in the setting of febrile dysentery with bloody stools, because such use may prolong or worsen the illness.²

Recommendations from others

The United States Centers for Disease Control and Prevention (CDC) state that travelers with nausea, vomiting, cramps, fever, or blood in stools may benefit from treatment for travelers’ diarrhea with ciprofloxacin (500 mg twice daily) or trimethoprim-sulfamethoxazole (double-strength tablet twice daily) for 3 days. The CDC also advises use of World Health Organization oral rehydration solution for replacement of lost fluids and salts.¹ The American College of Gastroenterology Practice Parameters Guidelines Committee recommends that travelers bring loperamide and an antimicrobial with them to use in self-therapy of TD.² However, neither the CDC nor the American College of Gastroenterology recommend antibiotic prophylaxis for otherwise healthy travelers.^1,2 Dosage and cost information is shown in the Table 1.

Evidence Summary

Many studies have documented the efficacy of treating TD with antibiotics. Recent studies have emphasized the use of the 4-fluoroquinolones because of the emergence of bacterial resistance against doxycycline and trimethoprim that was found in previous studies of the prophylactic use of antibiotics for TD. Other quinolones besides ciprofloxacin can be expected to be effective; ofloxacin 300 mg twice daily and norfloxacin 400 mg twice daily have been effective in clinical trials.¹ Illness duration can be shortened by 1 to 2.5 days with antibiotic treatment.³ A review of antibiotic use for TD in The Cochrane Library concluded that antibiotic treatment is associated with a shorter duration of illness at the cost of side effects. Antibiotics increased the proportion of those without diarrhea 72 hours after beginning treatment and also reduced the severity of illness.⁴

Antibiotics should be considered only part of the treatment of TD. Fluid and electrolyte therapy is the first and most important step in treatment and can usually be accomplished through oral rehydration therapy.⁵ Nonspecific agents such as bismuth subsalicylate can reduce stool frequency and shorten illness duration as shown in placebo-controlled trials. Antimotility agents such as loperamide (Imodium) and diphenoxylate with atropine (Lomotil) act to slow intraluminal flow of intestinal contents by increasing segmenting contractions in the intestine. Studies show reduced stool frequency and shortened duration of illness. Antimotility drugs should not be used in the setting of febrile dysentery with bloody stools, because such use may prolong or worsen the illness.²