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Traveler's Diarrhea: Getting it, fixing it, and preventing it
Probably the most important thing to remember with a diarrheal illness is the need to rehydrate. Your body is losing large amounts of water in the stools. In addition to the water, valuable electrolytes such as salt, sugar, potassium, and bicarbonate are also being passed out. This is where diarrhea becomes a problem; The person becomes dehydrated and gets an imbalance in their electrolytes, sometimes requiring hospitalization for IV (intravenous) fluids.
Replacing lost water is the most important intervention one can make. But how much water should you drink and replace? A good rule of thumb, for healthy people without prior medical problems, is to determine how much water is needed based on weight.
Here's a quick chart for daily water requirements based on weight:
- 50 lbs or 22kg 1.5 liters/day
- 100 lbs or 45 kg 2 liters/day
- 150 lbs or 68 kg 2.4 liters/day
- 200lbs or 90 kg 2.9 liters/day
- 250lbs or 113 kg 3.3 liters.day
If you are making the effort to rehydrate, make sure you're getting the most out of your efforts. I always say, "work smarter not harder." Simple sugar in your water helps re-hydration, which allows the water molecules to pass through the lining of the intestines easier. This means the water goes from the bowels to the bloodstream (where it is needed) faster! Sports drinks take great advantage of this fact and use a lot of tasty sugar in their drinks. Salt and potassium are the other two important things your water should contain. Most sports drinks contain everything you need, for re-hydration.
You can also make your own "sports drink" if you need too. Make sure your water is clean and drinkable first, then add 2 pinches of salt, 2 pinches of sugar and a squirt of fruit juice. Maybe not as tasty as store-bought, but works just as well! Powdered electrolyte packets are also available and I always carry a few when I travel.
Making it stop
My general rule is to let a case of Montezuma revenge, Delhi belly, or what ever you call it, run its course. Let it flow, keep well hydrated and ride it out. Loperamide (Immodium, Diareze) is a medicine that slows peristalsis, the mechanism that moves feces through the intestines. This medicine can generally "plug up" a person with profuse, watery diarrhea. Sometimes, the nature of the trip may prohibit frequent bathroom breaks. (Think bus travel, business meetings, walking tours, etc.) Loperamide is a wonderful medicine for this, but not in all cases, and should be used sparingly.
Blood in the diarrhea means that the bacteria is actually damaging the lining of the intestines. This is a need for antibiotics. This is also not a time to take a medicine that traps this bacteria in the intestines! You want that damaging bacteria out of your body, as quickly as possible.
A bland diet such as a BRAT (bananas, rice, apples, toast) often helps "cool off" an angry belly. A few days of eating this should help alleviate the frequency of stools. Dairy products should also be avoided if possible. The enzymes that digest lactose are destroyed when diarrhea occurs. The lactose ends up sitting in the intestine and osmotically draws more fluid from the body into the bowel, bringing on more diarrhea. After a few days, the enzymes are re-formed and you can go back to that cheese.
Escherichia Coli is the bacteria name to know or "E. Coli" to his friends. Studies have shown that the vast majority of traveler's diarrhea is due to E. Coli. A few other bacteria such as Campylobacter Jejuni, Salmonella and Shigella can also frequently occur, depending on geographic location. Viruses are another common cause of diarrhea, as well. The Norwalk virus seems to get a lot of attention, especially on cruise ships.
Cholera is a world famous bacteria that as caused several global pandemics.
Most of the deaths due to cholera are from profound dehydration and depletion of electrolytes. This is the source of the WHO ORS (Oral Re-hydration Solution) program.
Some adventure travelers may encounter some parasites such as Giardia or E. Histolytica.
I always use the term "common sense travel." This is basically all the things your mother told you to do as a kid, such as:
Wash your hands before you eat! This little habit can reduce chances of diarrheal infection by more than half.
Don't eat at a place that looks dirty. I know, the road side stands have the best food, and they can often be safer than a normal restaurant. Travel health is all about risk management. You know that eating at this place may make you a little sick, but it is worth the chance? This is an individual choice.
Make sure your food is properly cooked and not raw. Extra caution should be taken with shellfish and sea food.
Lastly, we all know about bottled water. Local water may not be the healthiest stuff. Ice is another thing to think of; chances are it is made with local tap water, too. Fruits and veggies should all be washed, hopefully with clean water or avoided.
The use of antibiotics as prophylaxis (doing something to prevent illness) is a controversial matter. The nature of the trip and medical history are things to be considered when decideing whether or not to use them. Honeymoons, business trips and athletic competitions are instances that can be derailed by a simple case of diarrhea. Also, people who travel with low immune status are candidates for such prophylaxis.
Some studies have shown that bismuth subsalicylate (Pepto Bismol) is effective in prevention of traveler's diarrhea and is a good option as well. Generally, I avoid recommending prophylactic antibiotics for most travelers.
Should you take them? This seems to be the main question when it comes to traveler's diarrhea. I believe that there are certain instances when taking antibiotics for travel-acquired diarrhea makes sense, with the presence of blood in the stool being the most important. Presence of fever is another indication of more severe infection, as is abdominal cramping. Realizing that most people don't have quick access to health care when they travel, I do think it is wise to carry a dose of antibiotics in case of invasive or severe diarrhea. Speak with your health care provider about this working for you. Some choices include a quinolone such as Cipro or TMP/SMX (Bactrim). There are instances of increasing antibiotic resistance and other options may be needed.
Getting sick while traveling is something everybody wants to avoid. The natural adventurous spirit of travel means that more risks are taken, especially when it comes to eating. Hopefully this will help people feel a little more comfortable if they have to deal with this problem.
- CDC Travel Health Yellow Book: Diarrhea
- Trav Med Index
- American Family Physician Traveler's Diarrhea Article
Filed under: Travel Health