Review
Traveller's diarrhoea

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Summary

Traveller's diarrhoea affects over 50% of travellers to some destinations and can disrupt holidays and business trips. This review examines the main causes and epidemiology of the syndrome, which is associated with poor public health infrastructure and hygiene practices, particularly in warmer climates. Although travellers may be given common sense advice on avoidance of high-risk foods and other measures to prevent traveller's diarrhoea, adherence to such advice is sometimes difficult and the evidence for its effectiveness is contradictory. However, non-antimicrobial means for prevention of traveller's diarrhoea are favoured in most settings. A simple stepwise approach to the management of traveller's diarrhoea includes single doses or 3-day courses of antimicrobials, often self administered. The antibiotics of choice are currently fluoroquinolones or azithromycin, with an emerging role for rifaximin. In the long term, there will be greater benefit and effect on the health of local inhabitants and travellers from improving public health and hygiene standards at tourist destinations.

Introduction

Traveller's diarrhoea is a common problem that may be defined as the passage of three or more unformed stools over 24 h, with symptoms starting during or shortly after a period of foreign travel. The diarrhoea is often accompanied by other clinical features such as nausea, vomiting, abdominal pain, fever, faecal urgency, tenesmus, and blood or mucus in the stools. Although known gut pathogens are usually responsible for the illness, the predominant organisms may vary from time to time and from country to country.

The population at risk from traveller's diarrhoea is steadily increasing: UK residents currently take over 59 million holiday visits overseas each year.1 Exotic destinations are also increasingly popular: every year nearly 18 million Europeans travel to tropical regions or low-income areas of the world.2, 3 Traveller's diarrhoea has an attack rate of 20–50%,4 and it has been estimated that the illness affects at least 11 million people annually. Although essentially benign, traveller's diarrhoea causes substantial disruption by interfering with travel itineraries, business opportunities, and tourist industry revenues. Furthermore, traveller's diarrhoea also leads to decreased combat effectiveness among the military.5

This review examines the causes and epidemiology of traveller's diarrhoea, and the current evidence for best practice in treatment and prevention.

Section snippets

Epidemiology

Epidemiological surveys have documented several factors that apparently influence the risk and prevalence of traveller's diarrhoea. Many of these surveys have relied on univariate statistical analysis, and since many likely risk factors are interdependent, the results of such studies must be interpreted with caution. Nevertheless, the likelihood of illness depends on who you are, where you go, when you travel, how you travel, where you stay, and what you do.

Clinical features

Symptoms usually begin within 2–3 days of arrival, and more than 90% of illnesses start within the first 2 weeks.25 Approximately 20% of patients are confined to bed for 1 or 2 days, 40% have to change their itinerary, and 1% are admitted to hospital.26 Although symptoms are usually short-lived (3–5 days), 5–10% of those affected have diarrhoea that lasts for 2 weeks or longer.27 Those who travel for long periods may also have repeated attacks.

Within the overall description of traveller's

Microbiology

The causal pathogen is identifiable in only 40–60% of patients with traveller's diarrhoea, and of these, about 85% are bacteria. The relative importance of different pathogens varies according to the region visited (table 1) and the season.29, 30 Worldwide, enterotoxigenic E coli (ETEC) are the most common bacterial pathogens isolated in individuals with traveller's diarrhoea.31 These organisms produce a heat-stable enterotoxin and a heat-labile enterotoxin; two-thirds of ETEC produce a

Chronic diarrhoea

In the 1980s, Steffen and colleagues42 found that 1·1% of travellers with acute diarrhoea went on to have chronic diarrhoea, which had an overall prevalence of 0·9%. Protozoa such as amoebae or Giardia spp accounted for 20 (27%) of 73 cases, but in the remainder no pathogens were identified. More recently, other protozoa—eg, cryptosporidia, cyclospora, isospora, and microsporidia—have been increasingly recognised in association with chronic traveller's diarrhoea, in both immunocompromised and

Treatment

Symptomatic or specific treatment of traveller's diarrhoea is often unnecessary because the disease is self limiting. However, empirical self-therapy of more severe diarrhoea or uncomfortable diarrhoea of severe onset, regardless of the cause, may be a valid approach to the treatment of traveller's diarrhoea.48 The clinical symptoms and signs alone are not reliable predictors of whether an invasive pathogen is the cause of the disease.

The main objectives of successful treatment of traveller's

Modifying risk behaviour

Strategies for prevention include the counselling of patients at high risk so that they can make choices about their travel plans, and education about ingestion of safe food and beverages, and in special circumstances, the option of chemoprophylaxis. If travellers visit a specialised travel clinic, they should receive advice about how to select food, the importance of fluid replacement if diarrhoea does occur, and when to seek medical care.103 In addition, the importance of frequent

Conclusions

Traveller's diarrhoea remains a very common problem, the incidence of which can be reduced, but not completely prevented, by taking simple precautions. However, even these measures are not supported by good evidence. The emergence of bacterial resistance has limited the usefulness of some antibacterial agents, although several alternate options exist for treatment. The use of antibacterials for prevention has a limited role, and fluoroquinolones remain the agent of choice, pending results of

Search strategy and selection criteria

Data for this review were identified by an English language literature search from 1966 to April 2005 of Medline and PubMed for articles using the search terms “traveller's diarrhoea”, “travel”, “diarrhoea”, “enterotoxigenic Escherichia coli”, “enteroaggregative E coli”, “enteroinvasive Escherichia coli”, “Campylobacter jejuni”, “salmonella”, “shigellae”, “aeromonas”, “Plesiomonas shigelloides”, “empirical therapy”, “rifamycin”, “azithromycin”, “travel health advice”, “vaccine”, and

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