TRAVELLER’S DIARRHOEA

 

Many intestinal infections are attributable to infections through food, water, objects or hands. With a little care most of these illnesses can be prevented. Hepatitis A, typhoid fever, polio and cholera still occur in countries with poor hygiene, but these diseases are easily prevented.

However, the chance is rather large that you will still contract a light and/or nondangerous form of traveller's diarrhoea. Traveller's diarrhoea almost always spontaneously clears up after a few days, but can nevertheless be irritating. Persons taking gastric acid inhibitor or having reduced/stopped production of gastric acid due to a surgical operation are more susceptible to serious diarrhoea.

In the first place measures must be taken against dehydration. Likewise, treatment of the symptoms must be considered in order to reduce the number of bowel movements and relieve other symptoms such as fever, vomiting and stomach cramps. Sometimes a more serious form of diarrhoea occurs, for which specific treatment with antibiotics is indicated or where hospitalisation or fluid replacement appears unavoidable.

It takes only a few basic preventive measures to make your trip a success :

Total prevention of traveller's diarrhoea is impossible and it is obvious that preventive measures can seldom be strictly followed at all times. But following preventive measures do significantly reduce the risk of contracting serious diarrhoea:

 

-  Before cooking, eating and after using the lavatory: hand washing with water and soap or disinfectant alcoholic gels (hydro-alcoholic solutions) in special dispensers.

-   "Cook it, boil it, peel it or forget it!' Avoid (if possible) :

      -   uncooked vegetables and cold salads, uncooked or raw food in general;

      -   fruit that cannot be peeled by yourself before eating; damaged fruit;

      -   unpasteurized or unboiled dairy products or food based on unpasteurized

          or unboiled dairy products (pudding, ice cream, coffee cream, etc);

      -   dishes based on raw or insufficient boiled eggs;

      -   raw or insufficiently cooked fish, and especially seafoods such as oysters;

-       raw or unsufficiently cooked meat;

-       boiled dishes that are left for hours on room temperature (only eat food that is

    thoroughly cooked and still warm);

-       “local meals” which do not smell fresh; contaminated food can however look, smell and taste perfectly normal

-   ice-cream from vendors (industrially prepared and factory packed ice-cream from the freezer is probably safe).

-  The place where you eat is also important. A meal taken from a stall presents a greater risk than a meal taken in a restaurant. Avoid restaurants with a lot of flies and other insects.

-   Avoid tap water and ice-cubes. Bottled water and soft drinks are safe. Watch out for bottle caps that have already been used. In some countries it is usual to add unboiled cold water to hot tea or coffee before serving.

 

It is very important to disinfect drinking-water on adventure trips.

Total sterilisation of drinking water is impossible.

The following measures considerably reduce the contamination risk:

 

-   Boiling the water is very effective.

-  A good alternative is chemical disinfection with chlorine drops (e.g. Hadex®, Drinkwell chloor®; available in sport shops specialized in outdoor activities) or chlorine tablets (Micropur Forte® = chlorine and silver tablets; available at the pharmacy). Their effect can be improved by first filtering unclear water (a coffee filter or other clean handkerchief can be used). Silver salts (Micropur Classic®) are not very suitable to disinfect water, but they keep disinfected water germ-free for a long time.

-    For adventurous travellers it is best to buy a portable water-filter.

 

It is however important to be aware that preventive use of antibiotics and other medications is not advisable! A prompt self-treatment is after all an excellent alternative.

 

How to treat diarrhoea?

-    It is extremely important to consume sufficient liquid and salt in order to prevent dehydration. You can do this by taking salt solutions, but tea with lemon, broth, soft drinks and fruit juice, supplemented with salt crackers are tastier.

      Commercial salt products are available on the market (ORS-solution).

-    considerable reduction of the complaints as a result. Loperamide may only be used by adults and older children and only for treating ordinary watery diarrhoea: 1 capsule or instant tablet after every loose movement up to a maximum of 4 per day. One has to stop the administration as soon as the faeces become more solid in order to avoid constipation. Further administration is not useful when there is no clear improvement after 4 capsules; then the administration of antibiotics (see schedule - point 3) may be considered.

-        Antibiotics are indicated (see schedule):

1. If blood, mucus or pus are present in the stools (start immediately)

2.  In persons suffering from primary or secondary immunosuppression and in people who don't produce stomach acid (e.g. patients on proton pump inhibitors or acid antagonists) (start immediately)

3. If after 24 to 48 hours, there is no sign of improvement and the diarrhoea is accompanied by fever (above 38.5 C) or severe abdominal cramps, or if there are more than six stools per 24 hours.

4. Or if because of travel circumstances a quicker solution is desirable.

 

Appropriate antibiotics (only on doctor’s prescription) are :

1)     Fluoroquinolone-antibiotic: ofloxacine 400 generic/Tarivid 400® 1 tablet per day OR ciprofloxacine 500 generic/Ciproxine 500®, ofloxacine 200 generic/Tarivid 200®, norfloxacine generic/Zoroxin® 1 tablet in the morning and 1 tablet at night for 1 to 3 days for uncomplicated watery diarrhoea (in case of pure watery diarrhoea, the treatment may be stopped as soon as the symptoms have disappeared) or 3 to 5 days in case of serious symptoms (see schedule). Avoid sunlight.

2)     Zitromax® (azithromycine): 500 mg per day for 1-3 days, (1 day treatment suffices mostly). Azithromycine is the first choice when travelling to Asia. Allowed for pregnant women.

3)     Children and adolescents under 15 years old: A reliable physician should be consulted, but this is not always possible on a journey. Rehydration is the cornerstone of the treatment. In children Azithromycin is administered at a dose of 10 mg/kg/day for 1-3 days (a syrup form exists). (BactrimÒ and EusaprimÒ are no longer recommended, because they frequently have become ineffective).

 

Schematic:

 

 

 

 

 

 

This scheme is only for emergency use when travelling. Do not use it when you get back home, but always consult your doctor!

Keep the antibiotics safely and use them only as an emergency treatment during your next long journey. Check the expiry date; an expired product must be returned to the pharmacy.