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Clinical Update
Multidrug-Resistant Travelers’ Diarrhea: Counseling Travelers on Responsible Self-Treatment

Travelers’ diarrhea is the most predictable travel-related illness, occurring in up to 70% of travelers to developing countries. The development of antibiotic resistance to commonly encountered enteric pathogens, illustrated by an ongoing outbreak of quinolone-resistant Shigella sonnei, is an emerging problem in travel health.

2014–2015 Quinolone-Resistant Shigella Outbreak

From May 2014 through March 2015, CDC detected 157 cases of illness caused by genetically similar Shigella sonnei strains in 32 US states and Puerto Rico. Public health officials in California identified 86 additional cases that have not been genotyped but have epidemiologic connections to the other cluster, for a total of 243 cases. Antimicrobial susceptibility was reported for 126 isolates, and 108 (86%) were resistant to ciprofloxacin. One person was infected with a strain that was resistant to all commonly used oral antibiotics and remained symptomatic for 7 weeks.

Excluding the California outbreak, travel history was available for 75 of the 157 cases, and 40 traveled shortly before they became sick. The most common destination was the island of Hispaniola—Haiti and the Dominican Republic—followed by India. The California outbreak, which is believed to have started with an imported case because of epidemiologic connections to the cluster of 157, predominantly affected the homeless population before spreading to the larger community.

The Role of Antibiotics in Promoting Resistance

Clinicians frequently prescribe antibiotics for travelers to carry with them while traveling so that they can self-treat diarrhea if it develops. Antibiotics, however, can disrupt the normal lower intestinal microbiota and allow resistant bacteria to outcompete beneficial as well as susceptible pathogenic bacteria. Recent findings suggest that travelers who take antibiotics to treat diarrhea are at increased risk of becoming colonized with resistant bacteria, specifically with extended-spectrum β-lactamase–producing Enterobacteriaceae. The risk is highest in South Asia, where 80% of travelers who had diarrhea and self-treated with antibiotics became colonized with these organisms. As shown in the current Shigella outbreak, travelers who are infected in other countries may continue to shed organisms after they return to the United States, producing local foci of infection.

Counseling Travelers

First and foremost, emphasize prevention:

  • Travelers to developing countries should rigidly adhere to food and water precautions. CDC has resources for travelers on safe food and water and water disinfection, including a mobile app called “Can I Eat This?” that guides travelers in making safer food and beverage choices.
  • Travelers should frequently wash their hands with soap and water or use hand sanitizer, especially after going to the bathroom and before eating.
  • Bismuth subsalicylate (Pepto-Bismol, Kaopectate) reduces the incidence of travelers’ diarrhea by approximately 50% when taken daily (2 ounces of liquid or 2 chewable tablets, taken 4 times per day).
  • The use of probiotics (such as Lactobacillus GG and Saccharomyces boulardii) or bovine colostrum to prevent travelers’ diarrhea has not been studied in depth, and they are not approved for this indication by the Food and Drug Administration.

For many travelers who have only mild or moderate diarrhea, symptom management may be an acceptable way to keep them going so they don’t miss out on vacation activities or business commitments. Several nonantimicrobial drugs are available to manage symptoms:

  • Bismuth subsalicylate (if not used for prophylaxis)
  • Loperamide (Imodium)
  • Diphenoxylate-atropine (Lomotil, prescription only)

Encourage travelers to reserve antibiotic self-treatment for severe diarrhea. What constitutes “severe” diarrhea is subjective and will vary by the traveler and specific context, but knowing that antibiotic use contributes to acquiring an infection with a resistant strain may encourage many travelers to adhere to preventive measures and symptom management.

Diarrhea After Travel

If you see a patient with diarrhea that does not respond to antibiotic treatment, ask about travel history and order stool culture and sensitivity testing and consider testing for intestinal parasites. Counsel patients with diarrhea, particularly those with multidrug-resistant cases, about the need to practice good hygiene to avoid transmitting it to others.

Additional Resources

 

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