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Gastrointestinal Infections and infestations Preventative medicine

Diarrhoea - prevention and advice for travellers

Last revised in September 2023

Travellers' diarrhoea is a clinical syndrome associated with contaminated food or water, that occurs during or shortly after travel

Diarrhoea - prevention and advice for travellers: Summary

  • Travellers' diarrhoea is defined as passing three or more unformed stools in a 24-hour period with at least one additional symptom, such as abdominal pain or cramps, nausea, vomiting, fever, or blood in the stools.
  • Bacterial infection is the most common cause and is thought to account for 80–90% of cases of travellers' diarrhoea. The clinical picture may vary depending on the infecting pathogen. 
    • Enteric bacteria are the most commonly documented (for example, Escherichia coli, Campylobacter spp., Salmonella spp., and Shigella spp.).
    • Viruses and parasites can also cause travellers' diarrhoea.
  • The risk of travellers' diarrhoea can be classed as follows:
    • Low for people travelling to western European countries, the USA and Canada, Japan, Australia, and New Zealand.
    • Intermediate for people travelling to southern European countries, Israel, South Africa, and some Caribbean and Pacific Islands.
    • High for people travelling to Africa, Latin America, the Middle East, and most parts of Asia.
  • People at risk of travellers' diarrhoea should be assessed. For low or intermediate risk, advice should be offered regarding:
    • Food hygiene and safe drinking water.
    • Self-management and when to seek medical advice if diarrhoea develops during travel.
  • For people at high risk of travellers' diarrhoea:
    • The importance of personal hygiene, food hygiene, and safe drinking water should be emphasized.
    • Advice regarding the risk of waterborne infection and avoiding contaminated recreational water should be offered.
    • Antibiotic prophylaxis or 'stand-by' antibiotic treatment can be considered for certain high-risk travellers. Specialist advice should be sought.
  • Advice should be offered about managing diarrhoea while travelling, including the following:
    • Most episodes are short-lived and self-limiting, lasting a few days.
    • The person could consider purchasing sachets of oral rehydration salt before travelling.
    • During an episode of diarrhoea, it is important to prevent dehydration — particularly for young children, pregnant women, elderly people, and those with pre-existing illnesses.
    • Both loperamide and bismuth subsalicylate (for example, Pepto-Bismol®) may be considered in adults for the relief of mild-to-moderate diarrhoea. They should be used for a maximum of 2 days.
    • When to seek medical assistance.

Have I got the right topic?

From age 1 month onwards.

This CKS topic covers the prevention of travellers' diarrhoea, and includes the use of antibiotics for the prophylaxis and empirical treatment of travellers' diarrhoea.

This CKS topic does not cover the assessment of diarrhoea, the management of acute gastroenteritis (including presumed infectious gastroenteritis) in adults and children, diarrhoea due to food poisoning, or antibiotic-associated diarrhoea. These are covered in the CKS topics on Diarrhoea - adult's assessment, Diarrhoea - antibiotic associated, and Gastroenteritis. 

There are separate CKS topics on Gastrointestinal tract (lower) cancers - recognition and referral, Gastrointestinal tract (upper) cancers - recognition and referral, Irritable bowel syndrome and Palliative care - nausea and vomiting.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

September 2023 — reviewed. A literature search was conducted in August 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to the recommendations have been made.

Previous changes

February 2019 — reviewed. A literature search was conducted in January 2019 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. There have been minor changes to the definition and new sections added on risk factors and complications. The recommendations on prophylactic and stand-by antibiotics have been changed.

June 2018 — minor update. Prescribing information updated with information regarding azithromycin interacting with colchicine.  

September 2017 — minor update. SPC update on quinolones to align all CKS topics prescribing advice. Prostatitis – chronic, Gonorrhoea, Pyelonephritis, Diarrhoea – prevention and advice for travellers, Dyspepsia – unidentified cause, Dyspepsia – proven functional, Dyspepsia – proven peptic ulcer, Diverticular disease, Gastroenteritis and Scrotal pain swellings. 

March 2013 — reviewed. A literature search was conducted in February 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. There are no changes to the recommendations.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

June 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic. 

January 2010 — minor technical update. 

July to September 2009 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence. Together with the updated CKS topics on Diarrhoea - antibiotic associated and Gastroenteritis, this CKS topic replaces the former topic on Gastroenteritis.

December 2008 — minor update to the text to amend advice regarding the assessment and investigation of pregnant women with gastroenteritis.

July to September 2006 — reviewed. Validated in December 2006 and issued in January 2007.

July 2007 — minor update to the text to include advice regarding the assessment and investigation of pregnant women with gastroenteritis.

February 2006 — minor update. Nalidixic acid tablets discontinued and prescriptions have been removed. 

June 2003 — reviewed. Validated in September 2003 and issued in October 2003.

January 2000 — rewritten. Validated in March 2000 and issued in May 2000.

October 1998 — written.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 August 2023.

HTAs (Health Technology Assessments)

No new HTAs since 1 August 2023.

Economic appraisals

No new economic appraisals relevant to England since 1 August 2023.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 August 2023.

Primary evidence

No new primary evidence since 1 August 2023.

New policies

No new national policies or guidelines since 1 August 2023.

New safety alerts

No new safety alerts since 1 August 2023.

Changes in product availability

No changes in product availability since 1 August 2023.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Assess the risk of acquiring travellers' diarrhoea.
  • Assess the need for prophylactic or empirical antibiotic treatment for travellers' diarrhoea.
  • Provide appropriate advice on food and drink to reduce the risk of acquiring travellers' diarrhoea.
  • Offer appropriate self-care advice on managing travellers' diarrhoea.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Travellers' diarrhoea is defined as passing three or more unformed stools in a 24-hour period with at least one additional symptom, such as abdominal pain or cramps, nausea, vomiting, fever, or blood in the stools. It occurs during, or within, 10 days of travel.
    • Stool passage in healthy young children can vary, so in this group, diarrhoea may be more appropriately defined as stooling that is more frequent than normal for the individual. 
  • Travellers' diarrhoea can be described as:  
    • Mild (acute) when it is tolerable, not distressing, and does not interfere with planned activities.
    • Moderate (acute) when it is distressing or interferes with planned activities.
    • Severe (acute) when it is incapacitating or completely prevents planned activities. Note that all dysentery (passage of bloody stools) is considered severe.

[Riddle, 2017; Steffen, 2017; Barrett, 2018; Ashkenazi, 2020; CDC, 2023a; NaTHNaC, 2023]

What causes it?

  • Travellers' diarrhoea is caused by an infection with one or more bacteria, viruses, or parasites.
    • Bacterial infection is thought to be responsible for 80% to 90% of cases.
      • Escherichia coli is the most common bacterial pathogen (associated with acute watery diarrhoea), followed by Campylobacter (more severe symptoms including fever and abdominal pain), Shigella, and Salmonella. Other potential bacterial causes include Vibrio cholerae, Aeromonas spp, Plesiomonas spp, and the newly recognised Acrobacter, Larobacter, and enterotoxigenic Bacteroides fragilis.  
      • Enterotoxigenic E. coli (ETEC) is responsible for the majority of cases of travellers' diarrhoea worldwide and is predominant in Central and South America. Enteroaggregative E. coli (EAEC) and enteropathogenic E. coli (EPEC) are also significant causes of travellers' diarrhoea.  
      • Campylobacter infection is more prevalent in people visiting South East Asia, and a high number of these cases are resistant to fluoroquinolones. It is less common in East and West Africa, South America and the Caribbean.  
    • Intestinal viruses are thought to contribute 5% to 15% of cases.  
      • Astrovirus, norovirus, and rotavirus are most commonly implicated, with norovirus often associated with outbreaks of diarrhoea on cruise ships.  
    • Protozoal pathogens account for approximately 10% of cases in long-term travellers, with absolute risk dependent on the area of travel.  
      • Giardia intestinalis is the most common protozoal cause of travellers' diarrhoea, with both Entamoeba histolytica, and Cryptosporidium being relatively uncommon. 
      • Other causes include Cyclospora (which is seasonal and geographical with the most well-documented risk in Nepal, Peru, Haiti, and Guatemala) and Dientamoeba fragilis.
      • Protozoal pathogens tend to cause more prolonged symptoms. 
    • Helminth infection is an uncommon cause of travellers' diarrhoea, although it may be caused by acute heavy hookworm infection or schistosomiasis. 

[Giddings, 2016; Jiang, 2017; Laaveri, 2018; BMJ Best Practice, 2021; CDC, 2023a]

What are the risk factors for travellers' diarrhoea?

  • The risk of travellers' diarrhoea is influenced by a number of factors, including:
    • Destination:
      • Low-risk areas (fewer than 7% of travellers experience travellers' diarrhoea) include Western Europe, the USA, Canada, Japan, Australia, and New Zealand. 
      • Intermediate risk areas (8–20% of travellers experience travellers' diarrhoea) include southern Europe, Israel, South Africa, and some Caribbean and Pacific islands.
      • High-risk areas (more than 20% of travellers experience travellers' diarrhoea) include Africa, Latin America, the Middle East, and most parts of Asia. 
    • Risk of dietary exposure: 
      • Choice of eating establishment is an important factor in avoidance. Backpackers have around double the risk of travellers' diarrhoea compared with business travellers.
      • Visiting family and friends — immunity tends to be short-lived but people who have previously acquired resistance to travellers' diarrhoea in a developing country may be less discriminating about the safety of food and water.
      • All-inclusive holidays such as cruise ship travel have been associated with outbreaks of viral and bacterial gastroenteritis.
    • Increased susceptibility:
      • Age less than 6 years — infants and toddlers are more likely to acquire severe travellers' diarrhoea and require hospitalisation.
      • Older or frail people.
      • Use of proton pump inhibitors or H2 receptor antagonists.
      • Altered upper gastrointestinal anatomy.
      • People with inflammatory bowel disease — incidence is higher in this group and episodes may last for longer.
      • Genetic factors (for example, blood group O predisposes to Shigellosis and severe cholera infection).
      • Immunosuppression or HIV infection with low CD4 cell counts.
      • Travellers originating from a low-risk area. 

[Barrett, 2018; Ashkenazi, 2020; BMJ Best Practice, 2021; CDC, 2023a; NaTHNaC, 2023]

How common is it?

  • Travellers' diarrhoea is the most common health problem encountered by travellers.
    • It most frequently affects people travelling from areas with high standards of hygiene and sanitation to less developed destinations. 
    • It is thought that travellers' diarrhoea affects up to 70% of people travelling for up to two weeks in low- or middle-income countries. The prevalence is influenced by the destination and season of travel. 
    • Incidence of travellers' diarrhoea is age-dependent. Infants and toddlers have the highest incidence rates and it is more common in young adults than older people. 
    • Travellers' diarrhoea is equally prevalent in men and women.
    • There is a seasonal variation, with higher rates during hot and wet seasons. 

[Giddings, 2016; Jiang, 2017; Steffen, 2017; Laaveri, 2018; BMJ Best Practice, 2021; CDC, 2023a]

What are the complications of travellers' diarrhoea?

  • In addition to changes to plans, incapacitation due to illness, cost of overseas medical treatment, and/or hospitalisation, complications of travellers' diarrhoea include: 
    • Dehydration.
    • Intestinal perforation and bacteraemia as a result of infection with invasive bacterial pathogens (for example Shigella, Salmonella and Campylobacter).
    • Sepsis (in severe cases).
  • Longer-term consequences of travellers' diarrhoea can include:  
    • Post-infectious irritable bowel syndrome (occurs in 3–17% of people after travellers' diarrhoea) – this refers to the new onset of irritable bowel syndrome symptoms following an episode of gastroenteritis or travellers' diarrhoea where investigations do not show chronic enteric infection and there is no underlying organic gastrointestinal disease. 
    • Reactive arthritis — linked with several pathogens, for example, E. Coli, Campylobacter, Salmonella, and Shigella. Joint symptoms typically appear 1–4 weeks after the episode of travellers' diarrhoea and are commonly polyarticular and affect the lower extremities, with presentation varying from transient arthralgia to debilitating arthritis. Extra-articular features (affecting the mucosa, urethra, skin, or eyes) may occur.
    • Guillain-Barre syndrome — this is a rare complication of Campylobacter infection with around 1 in 1000 people affected. An autoimmune response against peripheral nerves results in peripheral neuropathy and acute neuromuscular failure. Guillain-Barre syndrome presents with global weakness of proximal and distal limbs, and the cranial nerves and respiratory function may be affected. Symptoms usually become evident 1–3 weeks post-infection and progress quickly. Most people will make a full recovery, but a small number will remain disabled or die as a result of the disease. 
    • Haemolytic-uremic syndrome — a rare complication following infection with Shigella dysenteriae type 1.

[Connor, 2013; Barrett, 2016; Giddings, 2016; Riddle, 2017; Steffen, 2017; Ashkenazi, 2020; BMJ Best Practice, 2021; CDC, 2023a; CDC, 2023b]

What is the prognosis?

  • Travellers' diarrhoea is, for most people, a short-lived, self-limiting illness with recovery in a few days. It is rarely life-threatening. 
    • The severity of travellers' diarrhoea depends on the cause and the individual person. Most people do not have severe enough symptoms to be confined to bed or need medical attention. 
    • The effects of travellers' diarrhoea are greater in very young children, elderly people and people living with frailty.
    • Most cases of travellers' diarrhoea are self-limiting, but children are more likely to experience dehydration and electrolyte disturbance as a consequence of fluid loss.
  • In terms of duration:
    • Most episodes last up to seven days, with 8 out of 10 episodes resolving within a week. 
    • It is thought that: 
      • Untreated bacterial diarrhoea lasts around 3–7 days.
      • Viral diarrhoea lasts around 2–3 days.
    • About 10% of episodes last for longer than 1 week, 5% persist for longer than 2 weeks, and 1% have a duration of more than 30 days. 
      • Prolonged diarrhoeal symptoms are more likely if the person is immunocompromised or has a protozoal infection. Protozoal diarrhoea can persist for weeks to months without treatment.  

[Barrett, 2016; Barrett, 2018; CDC, 2023a; NaTHNaC, 2023]

Management

Scenario: Diarrhoea - prevention and advice for travellers

From age 1 month onwards.

How should I assess the risk of acquiring travellers' diarrhoea before travelling?

  • Ask which country the person is going to visit.
    • Low-risk areas (fewer than 7% of travellers experience travellers' diarrhoea) include Western Europe, the USA, Canada, Japan, Australia, and New Zealand. 
    • Intermediate risk areas (8–20% of travellers experience travellers' diarrhoea) include southern Europe, Israel, South Africa, and some Caribbean and Pacific islands.
    • High-risk areas (more than 20% of travellers experience travellers' diarrhoea) include Africa, Latin America, the Middle East, and most parts of Asia. 
  • For up-to-date risk assessment of individual countries and the requirement for strict food, water, and personal hygiene precautions, see the National Travel Health Network and Centre (NaTHNaC) website (www.nathnac.org). 
  • Assess for other risk factors known to further increase the risk of travellers' diarrhoea such as: 
    • Local amenities and sanitation — in areas with low standards of hygiene and sanitation and poor control over the safety of food, drink, and drinking water, the risk of acquiring travellers' diarrhoea is high. 
    • How the person will be travelling — backpackers, campers, adventurers, and passengers on cruise ships are at increased risk.
    • When the person will be travelling — the peak incidence of travellers' diarrhoea is in the warmer months. Lower rates occur in winter.
    • What the person eats — for example, risks are associated with food from buffets, restaurants, and street vendors, and certain types of food such as raw fish and seafood, salads, and meat and poultry that have been inadequately cooked. For more information, see Advice on food and drink. 
  • Review the person's susceptibility to traveller's diarrhoea and their risk of complications. For more information on which groups of people are considered to be at higher risk, see the section on Risk factors. 
  • Enquire about access to medical amenities — this is particularly important for those travelling to remote areas with few or no medical amenities (especially trekking and camping).
  • Discuss whether visits to high-risk areas are essential (particularly if the person is at increased risk of complications) and whether they are suitably prepared (for example, if backpacking through remote areas).

Basis for recommendation

The recommendations about how to assess a person's risk of acquiring travellers' diarrhoea are largely based on expert opinion in a World Health Organisation (WHO) publication International Travel and Health [WHO, 2012], the BMJ Best Practice guideline Traveller's Diarrhoea [BMJ Best Practice, 2021], the Centres for Disease Control (CDC) guidance Travelers' diarrhea -  Preparing International Travelers [CDC, 2023a], and the guidance on Travellers' diarrhoea from the National Travel Health Network and Centre (NaTHNaC) [NaTHNaC, 2023].

How should I manage someone at low or intermediate risk of travellers' diarrhoea?

  • For people at low or intermediate risk of travellers' diarrhoea:
    • Advise the person that most travellers' diarrhoea is caused by the consumption of contaminated food or water.
    • Reassure the person that no special precautions (other than basic hygiene measures) are required when travelling to locations with a high standard of hygiene.
    • Provide information on food hygiene and safe drinking water if the person is travelling to locations with lower standards of hygiene and sanitation.
    • Offer advice regarding self-management and when to seek medical advice if the person develops diarrhoea during their trip.

Basis for recommendation

The recommendations on managing people at low or intermediate risk of travellers' diarrhoea are largely based on expert opinion regarding general advice to offer travellers in a World Health Organisation (WHO) publication International Travel and Health [WHO, 2012], the American College of Gastroenterologists guideline Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults [Riddle et al, 2016], the BMJ Best Practice guideline Traveller's Diarrhoea [BMJ Best Practice, 2021], the Centres for Disease Control (CDC) guidance Travelers' diarrhea -  Preparing International Travelers [CDC, 2023a] and the guidance on Travellers' diarrhoea from the National Travel Health Network and Centre (NaTHNaC) [NaTHNaC, 2023]. 

How should I manage someone at high risk of travellers' diarrhoea?

  • For people at high risk:
    • Emphasize the importance of personal hygiene, as well as food hygiene and safe drinking water, to reduce the risk of travellers' diarrhoea.
    • Warn travellers about the risk of food- and water-borne infections and how to avoid potentially contaminated recreational water. Contaminated recreational water can be found in inadequately treated pools, water playgrounds, hot tubs, spas, and freshwater or seawater. Potential illness-causing contaminants include human faeces, animal waste, sewage, or wastewater runoff.
    • Do not routinely offer prophylactic treatment for prevention of travellers' diarrhoea, as it is not indicated for most travellers.
      • Antibiotic prophylaxis may be appropriate for certain high-risk travellers. For more information, see the section on prophylactic antibiotics.
      • The use of bismuth subsalicylate and probiotics for prophylaxis is not recommended.
      • Antidiarrhoeal drugs (such as loperamide) should not be taken prophylactically.
    • Consider whether 'stand by' antibiotic treatment (to use if affected) is appropriate. For more information, see the section on 'stand-by' antibiotics.
    • Inform the person that there are no universal vaccines to cover all the infections which may cause travellers' diarrhoea. However, travellers to risky areas must seek advice about appropriate vaccination against other infections that cause gastrointestinal effects, such as cholera, hepatitis A, and typhoid. For further information on vaccines recommended for overseas travel, extended holidays, or working overseas, see the CKS topic on Immunizations - travel.
    • Offer advice regarding self-management and when to seek medical advice if the person develops diarrhoea during their trip.

Basis for recommendation

The recommendations on managing people at high risk of travellers' diarrhoea are largely based on expert opinion in a World Health Organisation (WHO) publication International Travel and Health [WHO, 2012], the American College of Gastroenterologists guideline Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults [Riddle et al, 2016], the BMJ Best Practice guideline Traveller's Diarrhoea [BMJ Best Practice, 2021], the Centres for Disease Control (CDC) guidelines Travelers' diarrhea -  Preparing International Travelers [CDC, 2023a] and Food and water precautions - Preparing International Travelers [CDC, 2023c] and the guidance on Travellers' diarrhoea from the National Travel Health Network and Centre (NaTHNaC) [NaTHNaC, 2023].

  • General hygiene measures
    • Hands should always be washed with soap and water before handling and consuming food (particularly after contact with raw meat and uncooked food), using the toilet, or caring for an ill person.
    • If soap and water are not available, an alcohol-based hand sanitiser can be used as an alternative until it is possible to wash the hands. Note that hand sanitiser is not effective when hands are greasy or visibly dirty and has limited effectiveness against Cryptosporidium and norovirus.
  • Advice on food and drink
    • Food must have been thoroughly cooked and must remain steaming hot prior to serving.
      • Raw fish and seafood should be avoided, as well as shellfish, and any meat or poultry that has not been thoroughly cooked.
      • Risks are associated with food from buffets, restaurants, and street vendors. Food from these sources should be avoided, if it has neither been kept hot, nor refrigerated or kept on ice.
      • Cooked food that has been in contact with raw food, or contains raw or uncooked eggs (such as homemade mayonnaise), should be avoided.
    • If hygiene and sanitation are likely to be inadequate, avoid salads, uncooked vegetables, and unpasteurised fruit juices. Fruits and vegetables that can be peeled by the end-user are suitable choices (fruits and vegetables with damaged skins should be avoided).
    • Ice should be avoided, unless it has been made from safe water.
    • Unpasteurised (raw) milk or cheese should be avoided.
    • Commercially prepared carbonated drinks, pasteurised drinks, fruit juices, and alcoholic beverages are usually safe provided they are in factory-sealed containers. The surface of the container should be wiped clean and dried if the drink is to be consumed directly from the container.
  • Advice on drinking water
    • Tap water should be avoided for drinking, preparing food, making ice, cooking, and brushing teeth, unless there is reasonable certainty it is safe.
    • Bottled water is the safer choice for drinking water. The seal must not have been tampered with.
    • Water should be boiled (for at least 1 minute) if its safety for drinking is in doubt.
    • Other options include micropore filtering and the use of disinfectant preparations. These might be more relevant for people travelling to areas where there is little or no access to safe drinking water.
  • A fact sheet on Food and Water Hygiene is available on the Travel Health Pro website (travelhealthpro.org.uk).

Basis for recommendation

The recommendations on food and drink precautions to reduce the risk of travellers' diarrhoea are based on expert opinion in the Centres for Disease Control (CDC) guidance on Travelers' diarrhea -  Preparing International Travelers [CDC, 2023a] and Travelers' diarrhea -  Food & Water precautions [CDC, 2023c] and the guidance on Travellers' diarrhoea from the National Travel Health Network and Centre (NaTHNaC) [NaTHNaC, 2023].

The CDC states that [CDC, 2023a]:

  • Poor hygiene practices in local restaurants and underlying hygiene and sanitation infrastructure deficiencies are likely the largest contributors to the risk for travellers' diarrhoea.
  • While measures such as avoiding certain food and food establishment types and ensuring food is thoroughly cooked, can help to reduce the risk of travellers' diarrhoea, it is acknowledged that some of these measures may be difficult to follow while travelling, and that some food safety factors are out of the traveller's control. Risk can therefore never be fully eliminated.

What should I advise about self-management of travellers' diarrhoea?

  • Advise the person: 
    • That most episodes of travellers' diarrhoea are short-lived and self-limiting, and last a few days. 
    • To consider purchasing sachets of oral rehydration salts before travelling as they may not be available at the destination. 
  • Advise that during an episode of diarrhoea:
    • It is important to prevent dehydration — particularly for young children, pregnant women, elderly people, and those with pre-existing illnesses.
      • For infants, breastfeeding should not be interrupted.
      • Hydration must be maintained, for example with boiled, treated, or sealed bottled water. Most otherwise healthy adults can stay hydrated by eating and drinking as normal.
      • Alcohol and other drinks and beverages with a diuretic effect (such as coffee and tea) and overly sweet drinks (in large quantities) should be avoided.
      • For more severe symptoms, or people prone to complications from dehydration, oral rehydration powders diluted into clean drinking water can help to correct electrolyte imbalances.
      • Immediate medical attention is required if children show signs of dehydration such as restlessness or irritability, great thirst, sunken eyes, and dry skin with reduced elasticity.
    • Symptomatic treatment with loperamide or bismuth subsalicylate (for example Pepto-Bismol®) may be considered for adults to relieve mild-to-moderate diarrhoea for a maximum of two days. 
      • Loperamide is usually considered the standard treatment when rapid control of symptoms is required — for example during travelling where toilet amenities are limited or unavailable. 
      • Bismuth subsalicylate is more suitable for mild diarrhoea; loperamide has a faster onset of action and is more effective than bismuth subsalicylate for controlling diarrhoea and cramping.
      • Bismuth subsalicylate is not suitable for people with aspirin allergy, renal insufficiency, gout, severe enteric disease or HIV (risk of bismuth absorption), or people who are taking an anticoagulant such as warfarin, or pregnant or breastfeeding women. Darkened tongue and stools are common adverse effects.
  • Advise the person not to use loperamide or bismuth subsalicylate (for example Pepto-Bismol®) if they have blood or mucous in the stool and/or high fever or severe abdominal pain. 
  • Neither loperamide nor bismuth subsalicylate (for example Pepto-Bismol®) are recommended for children to relieve diarrhoeal symptoms. 
    • Loperamide should not be used in children younger than 12 years of age because of concerns that it may cause intestinal obstruction. 
    • Bismuth subsalicylate must not be used in children younger than 16 years of age because of the possible association between salicylates and Reye's syndrome. 
  • Medical assistance must be sought if:
    • Stools are blood-stained, profuse and watery, or there is high or persistent fever or severe abdominal pain.
    • Severe diarrhoea occurs in infants or elderly people, or a child is unwell with travellers' diarrhoea and symptomatic treatment is needed.
    • The person becomes dehydrated — particularly in infants and children (restlessness or irritability, very thirsty, sunken eyes, and dry skin with reduced elasticity); or it is difficult to maintain adequate hydration.
    • Diarrhoea does not begin to improve within 24–36 hours despite self-treatment. 
    • There is a medical comorbidity (for example immunosuppression or gastrointestinal disorder).
  • Advice for travellers can be found on the following websites:

Basis for recommendation

The recommendations on self-management of travellers' diarrhoea are largely based on expert opinion in a World Health Organisation (WHO) publication International Travel and Health [WHO, 2012], the American College of Gastroenterologists guideline Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults [Riddle et al, 2016],  the US consensus Guidelines for the prevention and treatment of travellers' diarrhea: a graded expert panel report [Riddle, 2017], the BMJ Best Practice guideline Traveller's Diarrhoea [BMJ Best Practice, 2021], the Centres for Disease Control (CDC) guideline Travelers' diarrhea -  Preparing International Travelers [CDC, 2023a], the guidance on Travellers' diarrhoea from the National Travel Health Network and Centre (NaTHNaC) [NaTHNaC, 2023], as well as a review article Traveler's diarrhea in children: New insights and existing gaps [Ashkenazi, 2020].

Symptomatic treatment for adults
  • Expert consensus guidance suggests that, given the concerns regarding potential adverse effects of antibiotics and antimicrobial resistance patterns, increasing fluid intake and treatment with loperamide or bismuth subsalicylate may be sufficient for most people with mild travellers' diarrhoea [Riddle, 2017]. 
Loperamide
  • Loperamide reduces the frequency of bowel movements, taking 1–2 hours to reach its therapeutic effect, and appears to have antisecretory properties. It has a well-established safety profile and is usually well-tolerated [Steffen, 2015; Riddle, 2017; CDC, 2023a].
  • A systematic review found a small amount of data comparing loperamide with antibiotics and found no proof of antibiotics being more effective for the treatment of travellers' diarrhoea. The review authors therefore advised antibiotics only for severe illness and noted the value of loperamide for symptom control, particularly given increasing antimicrobial resistance [Laaveri, 2016]. 
  • Loperamide should be avoided in people with fever or bloody diarrhoea, and/or active inflammatory bowel disease; loperamide can inhibit peristalsis, resulting in complications such as ileus, megacolon, and toxic megacolon [EMC, 2023a; CDC, 2023a; NaTHNaC, 2023]
Bismuth subsalicylate
  • Bismuth subsalicylate is well tolerated, with usually mild adverse effects in adults, although it is slower to act than loperamide; may be less effective; cannot be used in some of groups of people, and has the potential for interactions with other medications [Moore, 2015; Giddings, 2016; Riddle, 2017]. 
  • A meta-analysis of data from 11 studies (including the study by DuPont discussed below, total n=840 participants with acute diarrhoea) found that compared to those receiving placebo, people treated with bismuth subsalicylate were 3.7-fold more likely to self-report symptomatic relief [Brum, 2020].
Symptomatic treatment for children not recommended
  • Rehydration is the mainstay of self-management for travellers' diarrhoea in young children; parents and carers should be aware that medical assistance should be sought if a child becomes unwell with travellers' diarrhoea, particularly if they are not tolerating fluids or are showing signs of dehydration [NaTHNaC, 2023]. 
  • Loperamide is only licensed for use in children older than 12 years and there is limited data on its use in children younger than 12 years old [EMC, 2023a]. 
  • Bismuth salicylate (Pepto-Bismol®) is not licensed for use in children younger than 16 years of age because of the possible association between salicylates and Reye's syndrome [Ashkenazi, 2020; CDC, 2023a]
When to seek medical assistance

When should I consider prescribing a prophylactic antibiotic for travellers' diarrhoea?

  • Do not routinely prescribe prophylactic antibiotic treatments for travellers' diarrhoea.
  • The decision to prescribe prophylactic antibiotic treatments depends on an assessment of:
    • The risk of the person developing travellers' diarrhoea (see Assessing risk (before travelling)).
    • The potential harm to the person if they were to develop travellers' diarrhoea.
    • The benefits and risks of antibiotic treatment. 
    • Access to medical assistance while travelling.
  • Consider prophylactic antibiotic treatment only for people who are at high risk of travellers' diarrhoea and its consequences — seek specialist advice before prescribing. The National Travel Health Network and Centre (NaTHNaC) provides a telephone advice line for health professionals advising travellers with complex itineraries or specialist health needs. For more information, see the NaTHNaC website (www.nathnac.net). Groups who may benefit from prophylactic treatment include those who:
    • Have increased susceptibility to infection or are immunocompromised.
    • Have a high risk of complications if they were to develop travellers' diarrhoea, for example:
      • People with chronic gastrointestinal disease (such as Crohn's disease, or ulcerative colitis). 
      • People with an ileostomy or colostomy.
      • People with other diseases (such as malignancy, type 1 diabetes mellitus, renal disease, stroke, congestive heart failure, or sickle cell disease) in whom a diarrhoeal illness might severely impact on their health.
    • Have a history of significant long-term morbidity after an enteric infection (for example, reactive arthritis).
    • Are undertaking critical trips in which a short bout of diarrhoea could severely impact the purpose of the trip (for example, athlete, politician, professional musician, lecturer).
    • May not have access to adequate medical treatment if they experience complicated travellers' diarrhoea.

Basis for recommendation

The recommendations on when to consider prophylactic antibiotics for travellers' diarrhoea are largely based on expert opinion in a World Health Organisation (WHO) publication International Travel and Health [WHO, 2012], the American College of Gastroenterologists guideline Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults [Riddle et al, 2016], the US consensus Guidelines for the prevention and treatment of travellers' diarrhea: a graded expert panel report [Riddle, 2017], the BMJ Best Practice guideline Traveller's Diarrhoea [BMJ Best Practice, 2021], the Centres for Disease Control (CDC) guidelines Travelers' diarrhea -  Preparing International Travelers [CDC, 2023a] and Perspectives: Antibiotics in Travelers' Diarrhea - Balancing Benefit & Risk [CDC.2023] as well as the guidance on Travellers' diarrhoea from the National Travel Health Network and Centre (NaTHNaC) [NaTHNaC, 2023].

Avoiding routine prophylaxis
  • Antibiotic prophylaxis has been shown in studies to provide up to 90% protection against developing travellers' diarrhoea. However, for most people the potential risks of prophylaxis with antibiotics outweigh the benefits [CDC, 2023a].
  • Reasons for not routinely prescribing antibiotic prophylaxis include [WHO, 2012; Leder, 2015; Riddle et al, 2016; Riddle, 2017; CDC, 2023a]: 
    • For most people, travellers' diarrhoea is mild and self-limiting.
    • Antibiotic prophylaxis offers no protection against non-bacterial causes of travellers' diarrhoea (such as viruses and parasites).
    • Removal of normally protective microflora from the bowel with prophylactic antibiotics can increase the risk of infection with resistant bacteria.
    • Use of prophylactic antibiotics reduces the choices for treatment if required for travellers' diarrhoea.
    • Taking antibiotic prophylaxis may give the traveller a false sense of security, which might lead to neglect of food and water precautions.
    • The increasing prevalence of antibiotic resistance is of concern (including to fluoroquinolones).
    • No antibiotics are licensed in the UK for the prophylaxis of travellers' diarrhoea.
    • Antibiotic treatment can lead to adverse effects and routine use of antibiotics for prophylaxis could expose the person to risks greater than that of the illness.
When to consider prophylaxis
Seeking specialist advice about prophylaxis
  • Planning prophylactic treatment is complex due to the large number of potential pathogens, their geographical variation and resistance patterns, and case-specific factors including comorbidities [Zaidi and Wine, 2015].
  • Potential prophylactic treatment options all have limitations. For example: 
    • Fluoroquinolones were historically used as the first-line choice for prophylaxis. However, resistance among Campylobacter and Shigella species has been observed globally and fluoroquinolones are associated with cartilage damage, tendon rupture, and C. difficile-associated diarrhoea [CDC, 2023a]. In addition, use of fluoroquinolones for prophylaxis limits therapeutic options if travellers' diarrhoea develops [Taylor, 2017].  
    • Rifaximin is a non-absorbable antibiotic for which there is evidence of efficacy (although it does not prevent all cases of travellers' diarrhoea), with a favourable safety profile. It is not associated with antimicrobial resistance in travellers and does not appear to modify the gut microflora, but Campylobacter is not susceptible, meaning it only offers moderate protection in South and South East Asia [Riddle et al, 2016; Riddle, 2017; Taylor, 2017].
    • Azithromycin is lacking an evidence base to support its use as a prophylactic agent for travellers' diarrhoea. It is also useful as a therapeutic option for travellers' diarrhoea, particularly in South and South East Asia, and in cases of dysentery,  [Leder, 2015; Giddings, 2016; Riddle, 2017; Taylor, 2017; Barrett, 2018].  
  • Taking these factors into account, along with the uncertainty regarding the overall benefit of prophylactic antibiotic treatment, and the inconsistent opinion on which groups of people are eligible for prophylaxis, CKS has recommended seeking specialist advice if considering prescribing antibiotic prophylaxis for the prevention of travellers' diarrhoea.

When should I prescribe a 'stand-by' antibiotic for treatment of travellers' diarrhoea?

  • Do not routinely prescribe 'stand-by' (to be used if affected) treatments for travellers' diarrhoea.
  • Consider a 'stand-by' (to be used if affected) antibiotic for people who are:
    • Travelling to high-risk locations (especially where access to medical assistance is poor or not available, or there is doubt about the safety and purity of antibiotics available at their destination). 
    • At high risk of severe illness.
  • Seek specialist advice if considering prescribing a 'stand-by' antibiotic. 
    • The National Travel Health Network and Centre (NaTHNaC) provides a telephone advice line for health professionals advising travellers with complex itineraries or specialist health needs. For more information, see the NaTHNaC website (www.nathnac.net).

Basis for recommendation

The recommendations on when to consider 'stand-by' antibiotic treatment for travellers' diarrhoea are largely based on expert opinion in the American College of Gastroenterologists guideline Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults [Riddle et al, 2016], the US consensus Guidelines for the prevention and treatment of travellers' diarrhea: a graded expert panel report [Riddle, 2017], the BMJ Best Practice guideline Traveller's Diarrhoea [BMJ Best Practice, 2021], the Centres for Disease Control (CDC) guidelines Travelers' diarrhea -  Preparing International Travelers [CDC, 2023a] and Perspectives: Antibiotics in Travelers' Diarrhea - Balancing Benefit & Risk [CDC.2023] as well as the guidance on Travellers' diarrhoea from the National Travel Health Network and Centre (NaTHNaC) [NaTHNaC, 2023].

Not routinely offering a 'stand-by' antibiotic
  • Most cases of travellers' diarrhoea are mild and self-limiting and will resolve without treatment [Giddings, 2016; Riddle, 2017].
  • Risks of antibiotic treatment for travellers' diarrhoea include changes to the host microbiome, and the acquisition of multidrug resistant bacteria. In particular, travellers to South and Southeast Asia who take antibiotics for travellers' diarrhoea are at risk for colonization with extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL-PE), which may be harmful to some, for example older people and those prone to urinary tract infections [CDC.2023]. 
  • NaTHNaC advises that since travellers who take antibiotics may acquire organisms that are resistant to antibiotics such multi-drug resistant (MDR) Enterobacteriaceae or Clostridium difficile, the prescribing of antibiotics for standby treatment of travellers' diarrhoea should be carefully considered. Groups that may be eligible include people at high risk of developing severe illness, or those visiting high-risk areas in remote locations where access to medical care is limited [NaTHNaC, 2023]. 
Seeking specialist advice if considering a 'stand-by' antibiotic
  • CKS recommends seeking specialist advice if considering prescribing a 'stand-by' antibiotic for travellers' diarrhoea because of the complexities surrounding the appropriate choice and the need to take into account a number of factors including efficacy, destination (and associated likely pathogens and resistance patterns), potential for adverse effects, and acceptability of the treatment regimen [Steffen, 2015; Giddings, 2016; Riddle, 2017]. Possible options for 'stand-by' antibiotic treatment (on specialist advice) include:
    • Azithromycin — although it is not licensed for the treatment of travellers' diarrhoea [EMC, 2023b], azithromycin can be useful if there is severe travellers' diarrhoea, dysentery, high fever, travel to south and south East Asia, and if rifaximin has been used as prophylaxis [Leder, 2015; Riddle, 2017; Barrett, 2018; CDC, 2023a]. Azithromycin is well-tolerated by most people, and has a more convenient dosing schedule compared with quinolones [Leder, 2015; Riddle, 2017]. Prescribers should note, however, that enteropathogens with increased azithromycin resistance have been documented in several countries [CDC, 2023a].
    • Rifaximin — this antibiotic is licensed for the treatment of travellers' diarrhoea that is not associated with fever, bloody diarrhoea, blood or leucocytes in the stools [EMC, 2020]. Although there is evidence that rifaximin is effective for treating travellers' diarrhoea compared with placebo and has similar efficacy to fluoroquinolones in non-invasive travellers' diarrhoea [Steffen, 2015; Riddle, 2017], it is not effective for treating diarrhoea caused by invasive enteric pathogens such as Salmonella, Shigella, or Campylobacter [EMC, 2020].
  • Note: although fluoroquinolones were historically first-line therapy for empiric treatment of travellers; diarrhoea, or to treat specific pathogens, there is increasing fluoroquinolone resistance in Campylobacter, Shigella, and Salmonella species, particularly in South and South East Asia, where a significant proportion of travellers' diarrhoea is due to Campylobacter [Leder, 2015; Riddle, 2017; Taylor, 2017; CDC, 2023a]. In addition, the prescribing of fluoroquinolones is now not generally recommended due to risks of multiple adverse reactions including aortic tears, hypoglycaemia, mental health side effects, and tendinitis and tendon rupture [CDC, 2023a; NaTHNaC, 2023].

Supporting evidence

This CKS topic is largely based on a World Health Organisation (WHO) publication International Travel and Health [WHO, 2012], the American College of Gastroenterologists guideline Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults [Riddle et al, 2016],  the US consensus Guidelines for the prevention and treatment of travellers' diarrhea: a graded expert panel report [Riddle, 2017], the BMJ Best Practice guideline Traveller's Diarrhoea [BMJ Best Practice, 2021], the Centres for Disease Control (CDC) guideline Travelers' diarrhea -  Preparing International Travelers [CDC, 2023a], and the guidance on Travellers' diarrhoea from the National Travel Health Network and Centre (NaTHNaC) [NaTHNaC, 2023].

The rationale for the primary care advice on prevention and treatment of travellers' diarrhoea is discussed in the relevant basis for recommendation sections. 

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on primary care management of travellers' diarrhoea.

Search dates

January 2019 - August 2023.

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 15th January 2019). The search strategy was adapted to search The Cochrane Library databases. 

S6    AB (travel* N5 diarrh*) OR TI (travel* N5 diarrh*) 
S5    S3 AND S4 
S4    S1 OR S2 
S3    (MH "Travel+") OR (MH "Travel-Related Illness+") OR (MH "Travel Medicine") 
S2    (MH "Antidiarrheals") 
S1    (MH "Diarrhea+") 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Ashkenazi, S. and Schwartz, E. (2020) Traveler's diarrhea in children: New insights and existing gaps. Travel Medicine and Infectious Disease 34, 101503. [Abstract]
  • Barrett, J. and Brown, M. (2016) Travellers' diarrhoea. BMJ 353. [Abstract]
  • Barrett, J. and Brown, M. (2018) Diarrhoea in travellers. Medicine 46(1), 24-29.
  • BMJ Best Practice (2021) Travellers' diarrhoea. London: BMJ Publishing Group.
  • Brum, J.M., Gibb, R.D., Ramsey, D.L., et al. (2020) Systematic Review and Meta-Analyses Assessment of the Clinical Efficacy of Bismuth Subsalicylate for Prevention and Treatment of Infectious Diarrhea. Digestive Diseases and Sciences 66(7), 2323-2335. [Abstract]
  • CDC (2023a) Travelers’ Diarrhea. CDC Yellow Book — Preparing International Travelers. Centres for Disease Control. https://wwwnc.cdc.gov [Free Full-text]
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  • CDC (2023) Perspectives: Antibiotics in Travelers' Diarrhea - Balancing Benefit & Risk. CDC Yellow Book 2024. Centres for Disease Control. https://wwwnc.cdc.gov [Free Full-text]
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  • DuPont, H.L. and Steffen, R. (2017) Use of antimicrobial agents for treatment and prevention of travellers' diarrhoea in the face of enhanced risk of transient fecal carriage of multi-drug resistant enterobacteriaceae: setting the stage for consensus recommendations. Journal of Travel Medicine 24(suppl_1), S57-S62. [Free Full-text]
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  • Giddings, S.L., Stevens, A.M. and Leung, D.T. (2016) Traveler's Diarrhea. Medical clinics of North America 100(2), 317-330. [Abstract] [Free Full-text]
  • Jiang, Z.D. and DuPont, H.L. (2017) Etiology of travellers' diarrhea. Journal of Travel Medicine 24(suppl_1), S13-S16. [Abstract]
  • Laaveri, T., Sterne, J., Rombo, L. and Kantele, A. (2016) Systematic review of loperamide: No proof of antibiotics being superior to loperamide in treatment of mild/moderate travellers' diarrhoea. Travel Medicine and Infectious Disease 14(4), 299-312. [Abstract] [Free Full-text]
  • Laaveri, T., Vilkman, K. and Pakkanen, S.H. (2018) A prospective study of travellers' diarrhoea: analysis of pathogen findings by destination in various (sub)tropical regions. Clinical microbiology and infection 24(8), 908.e9-908.e16. [Abstract]
  • Leder, K. (2015) Advising travellers about management of travellers' diarrhoea. Australian Family physician 44(1-2), 34-37. [Abstract] [Free Full-text]
  • Moore, K.S. (2015) Travelers' diarrhea: Risk reduction and management. Nurse Practitioner 40(11), 1-5. [Abstract]
  • NaTHNaC (2023) Travellers' diarrhoea. National Travel Health Network and Centre. https://travelhealthpro.org.uk [Free Full-text]
  • Riddle, M.S., DuPont, H.L. and Connor, B.A. (2016) ACG Clinical Guideline: Diagnosis, treatment, and prevention of acute diarrheal infections in adults. American journal of gastroenterology 111(5), 602-622. [Abstract] [Free Full-text]
  • Riddle, M.S., Connor, B.A., Beeching, N.J., et al. (2017) Guidelines for the prevention and treatment of travelers' diarrhea: a graded expert panel report. Journal of Travel Medicine 24(suppl_1), S57-S74. [Abstract] [Free Full-text]
  • Steffen, R., Hill, D.R. and DuPont, H.L. (2015) Traveler's diarrhea: a clinical review. JAMA 313(1), 71-80. [Abstract]
  • Steffen, R. (2017) Epidemiology of travellers' diarrhea. Journal of Travel Medicine 24(suppl_1), S2-S5. [Abstract] [Free Full-text]
  • Taylor, D.N., Hamer, D.H. and Shlim, D.R. (2017) Medications for the prevention and treatment of travellers' diarrhea. Journal of Travel Medicine 24(suppl_1), S17-S22. [Abstract] [Free Full-text]
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  • Zaidi, D. and Wine, E. (2015) An update on travelers' diarrhea. Current Opinion in Gastroenterology 31(1), 7-13. [Abstract]
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