Guidelines on Managing Traveller's Diarrhea

If you’re a snowbird you might want to pay close attention attention to the article below. Thousands of Canadians head south during winter months and are susceptible to traveller’s diarrhea (TD). Below are guidelines on managing TD.

Updated Canadian guidelines on managing of traveller’s diarrhea | Canadian Healthcare Network

CATMAT outlines recommendations for prevention and treatment.

From the Canadian Healthcare Network
Published on December 4, 2015 by Lu-Ann Murdoch


Traveller’s diarrhea (TD) is acquired primarily through the ingestion of food and beverages contaminated with diarrhea-producing pathogens. The most common causes are Escherichia coli (particularly, enterotoxigenic and enteroaggregative E. coli) and Campylobacter, although this varies by region of travel.

Incidence rates for TD range from 20%–90% for people travelling up to two weeks in high-risk regions (low- and middle-income countries). TD is usually mild and self-limiting, but up to half of travellers with TD will experience some limitation of activities and up to 10% experience persistent diarrhea or other complications.

The Committee to Advise on Tropical Medicine and Travel (CATMAT) has issued the following recommendations for the prevention and treatment of TD.

Prevention

  • Oral TD and cholera vaccine (Dukoral) is not routinely recommended for preventing TD because it has no demonstrated benefit. Moderate quality data show the vaccine is not effective in preventing TD compared to vaccination with placebo. About 35% of vaccinated subjects and 37% of non-vaccinated subjects develop diarrhea.
  • Bismuth subsalicylate should be considered an option for preventing TD for adults at significant risk, and who are willing to accept multiple doses per day (2.1–4.2 g/day, in four divided doses per day).
  • A lower dosage of bismuth subsalicylate (1.05 g/day) could be used to prevent TD in situations where a higher dosage is not feasible. High quality data shows that bismuth subsalicylate is more effective than placebo in preventing TD in travellers, with 250 fewer cases of TD per 1000 travellers treated. The high and low doses show no difference in efficacy.
  • Fluoroquinolones can be considered for the prevention of TD in select high-risk short-term travellers when chemoprophylaxis is considered essential. High quality data show that fluoroquinolones are effective in preventing TD compared with placebo, resulting in 293 fewer cases of TD per 1000 travellers treated.
  • Rifaximin (Zaxine) can be considered for prevention of TD, resulting in 213 fewer cases of TD per 1000 travellers treated. (This is a non-approved indication in Canada.) The recommended dosage is 600 mg once daily. Only a 550 mg tablet is available in Canada; CATMAT does not consider the 600 mg and 550 mg once daily dosages to be significantly different.


Treatment

  • Loperamide can be considered for the treatment of TD. It reduces the duration and intensity of TD compared to placebo, resulting in 145 more cases of rapid first relief per 1000 travellers treated.
  • Fluoroquinolones (in single-dose or 3-day regimens) can be considered for the treatment of TD; moderate quality data show that they reduce the duration of TD compared to placebo, with 322 more cases of cure after 72 hours per 1000 travellers treated.
  • Loperamide in conjunction with antibiotic therapy may be considered for the treatment of TD; the addition of loperamide to antibiotic therapy is more effective in reducing the duration of TD compared with antibiotic use alone, resulting in 200 more cases of complete relief after 24 hours per 1000 travellers treated with adjunct loperamide.
  • Azithromycin can be considered as an option in the treatment of TD; it is comparable to or more effective than fluoroquinolones in reducing the duration of TD, resulting in 134 more cases of recovery after 48 hours per 1000 travellers treated with azithromycin over fluoroquinolones.
  • Rifaximin can be considered for the treatment of TD. It is associated with a higher percentage of TD cures compared to placebo, with 177 more travellers cured of TD at the end of follow-up per 1000 treated. No significant difference in cure rates has been seen between rifaximin and fluoroquinolones. However, treatment of TD would be considered an off-label use in Canada and may not be practical. The usual dosage for treatment of TD is rifaximin 200 mg three times daily and only a 550 mg tablet (Zaxine) is available in Canada; the manufacturer does not recommend that the tablets be cut.
  • Hand washing or use of hand sanitizer, and prudent choice and preparation of food and beverages are best practices for preventing TD.
  • Probiotics and prebiotics have insufficient available evidence for prevention of TD.


The TD guidelines are published in two formats—the full 79-page document(1) and an abbreviated version.(2) The full version of the guidelines includes a table of prophylactic and treatment drug doses for adults and children (see Table 2, pg 44-6), including comments and contraindications. It also contains a table outlining how to prepare an oral rehydration solution at home (Table 3, pg 47).(1)


References
Committee to Advise on Tropical Medicine and Travel. Statement on travellers’ diarrhea. www.phac-aspc.gc.ca/tmp-pmv/catmat-ccmtmv/assets/pdfs/diarrhea-diarrhee-eng.pdf (accessed December 3, 2015).

Libman M; Committee to Advise on Tropical Medicine and Travel. Summary of the Committee to Advise on Tropical Medicine and Travel (CATMAT) statement on travellers’ diarrhea. CCDR 2015; 41(11). www.phac-aspc.gc.ca/publicat/ccdr-rmtc/15vol41/dr-rm41-11/ar-03-eng.php (accessed December 3, 2015).
 



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