Curr Gastroenterol Rep (2011) 13:402–407 DOI 10.1007/s11894-011-0208-6
Advances in the Treatment of Travelers’ Diarrhea Mercedes Paredes-Paredes & Jose Flores-Figueroa & Herbert L. DuPont
Published online: 20 July 2011 # Springer Science+Business Media, LLC 2011
Abstract Diarrhea is the most common complaint reported by travelers from industrialized countries visiting developing nations. High-risk areas for travelers’ diarrhea (TD) include South Asia, Sub-Saharan Africa, and Latin America, while moderate-risk areas include Southeast Asia, Middle East, Oceania and the Caribbean. Bacterial pathogens are the major cause of TD. Recent advances in the therapy for diarrhea include a better understanding of the potential benefit of symptomatic and antimicrobial therapy. The mainstay of treatment includes antibacterial therapy with one of three drugs, a fluoroquinolone, rifaximin, or azithromycin. Probiotics have been used in preliminary studies for both treatment and prevention of TD, but more studies are needed with these biologic agents. The aim of this review is to identify the recent advances in the therapy of TD and to provide recommendations for treatment during international travel. Keywords Travel medicine . Travelers’ diarrhea . Enterotoxigenic E. coli M. Paredes-Paredes : J. Flores-Figueroa : H. L. DuPont University of Texas School of Public Health, 1200 Hermann Pressler Dr., Houston, TX, USA H. L. DuPont University of Texas Medical School at Houston, Houston, TX, USA H. L. DuPont (*) St. Luke’s Episcopal Hospital, Houston, TX 77030, USA e-mail:
[email protected] H. L. DuPont Baylor College of Medicine, Houston, TX, USA
Introduction The most common medical complaint reported by travelers is diarrhea (TD), defined in most studies as passage of ≥ 3 unformed stools plus a sign or symptom of enteric infection, such as abdominal pain or cramps. There are about 24–40 million travelers worldwide affected by diarrhea, 7.5–12.5 million from Europe, and 9.5 to 15.9 million from United States, based on estimates of travel volume for each region and expected rates of diarrhea during international travel. While TD is a non–life threatening, self-limiting disease in most cases, the majority of patients with TD will suffer approximately 24 h of disability, and a small percentage will have chronic abdominal symptoms for months or years. In one recent study, the mean duration of incapacitation varied between 12 h and 3.5 days in West Africa [1•]. It has been calculated that one incapacitation day in all travelers developing diarrhea will result in 290–490 million U.S. dollars of lost revenue. “Tourism 2020 Vision,” a report issued by The United World Tourism Organization (UNWTO) forecasts that international arrivals are expected to reach 1.6 billion by the year 2020 [2••], which will increase the global impact of TD. The GeoSentinel network has categorized regions of the worlds into low, moderate, and high TD risk areas. South Asia, Sub-Saharan Africa and South America have the highest reporting rate ratios (RRR) for TD (described as the number of ill travelers seeking medical care for a defined medical condition per 1000 travelers), ranging from 890 to 203. Southeast Asia, Middle East, North Africa, Central America, the Caribbean and Oceania are considered of moderated risk for TD (RRR from 142 to 25). Meanwhile Europe, North America, Northeast Asia, and Australasia are considered low TD risk areas (RRR 14 days) or in cases where antibiotic treatment fails to resolve illness. Less frequent etiology pathogens recently described are Klebsiella oxytoca, Laribacter honkogensis, Blastocystis, enterotoxigenic Bacteriodes fragilis, and Acrobacter [4•].
403
children and adults with diarrhea. A recent randomized double-blinded clinical trial showed that elderly patients suffering from gastroenteritis had shorter episodes of diarrhea when treated with racecadotril compared to loperamide; normally formed stools were passed 36 h after initiation of therapy in the racecaditril group versus 63.6 h in the loperamide group (P=
