Travelers' diarrhea
Acute bacterial diarrhea in travelers from developed countries to regions with low sanitary standards. Most often caused by enterotoxigenic E. coli, less often Shigella, Campylobacter, or Salmonella.
ICD-10 A096 drugs
Also known as: Acute travelers' diarrhea
Drugs used for this condition
- ALoperamideFirst line · AntipropulsivesIn traveler's diarrhea in adults, loperamide cuts symptom duration by about 50%. In mild disease it is appropriate as start-of-illness monotherapy; in moderate-to-severe disease the antibiotic (azithromycin or a fluoroquinolone) is the primary agent and loperamide is added to it. Loperamide must not be taken in dysentery (bloody stool, high fever, or suspected invasive infection): slowing gut motility prolongs the illness and risks toxic megacolon. Not used in children under 12 in this setting.
- BCiprofloxacinFirst line · Fluoroquinolone antibacterialsUsed for severe traveler's diarrhea. For the febrile or dysenteric form, ISTM 2017 prefers azithromycin, since Campylobacter fluoroquinolone resistance is rising beyond Southeast Asia. Ciprofloxacin remains an option for non-dysenteric moderate-to-severe disease where resistance is low. Mild cases need only rehydration and loperamide. Short course of 1–3 days.
- CNorfloxacinCase-by-case decision · Second-generation fluoroquinoloneFor travelers' diarrhea, norfloxacin 400 mg twice daily for 1–3 days was formerly part of standard regimens. With FDA 2018 and EMA 2019 restrictions, fluoroquinolones are not used for self-limited gastrointestinal infections. First-line agents for severe diarrhea are azithromycin 1000 mg as a single dose or rifaximin in the absence of fever and bloody stools. Norfloxacin is considered individually when alternatives are unavailable in patients without risk factors for adverse effects.
- CSaccharomyces boulardii CNCM I-745Add-on therapy · Yeast probiotic. AEMPS registered Enterol (Biocodex) as a medicinal product for AAD, travellers diarrhoea and adjunct therapy for C. difficileAEMPS registered Enterol with the indication of travellers diarrhoea prevention in adults. McFarland 2010 meta-analysis included several travellers diarrhoea RCTs with moderate episode frequency reductions on prophylactic S. boulardii 500–1000 mg/day 5 days before and during travel to endemic regions. Effect is modest and incomplete – does not replace basic food and water safety practices. ISTM 2017 states: probiotics are an option for low/medium risk; for high risk – discussion of ciprofloxacin or rifaximin where indicated. For established travellers diarrhoea, primary therapy is oral rehydration; for bacterial aetiology – azithromycin or ciprofloxacin. S. boulardii may be used as adjunct, not as substitute.
Marketing claims without evidence base
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
- DLactobacillus rhamnosus GG (LGG)Not recommended · Probiotic, Lacticaseibacillus rhamnosus GG strain. Supplement in Russia and Spain; in the EU and US available as food supplement or medical food; AEMPS does not register it as a medicineLGG is offered for travellers diarrhoea prevention. Several RCTs showed moderate episode frequency reductions in tourists to endemic regions (Hilton 1997, Oksanen 1990), but the effect is modest and not consistently reproduced across geographies. ISTM (International Society of Travel Medicine) 2017 for travellers diarrhoea prevention lists food safety, hand hygiene and in risk groups – ciprofloxacin or rifaximin when indicated; probiotics are mentioned as an option with limited evidence base. For established travellers diarrhoea, primary therapy is oral rehydration; for bacterial aetiology – azithromycin or ciprofloxacin. If LGG was recommended as a substitute for oral rehydration or empirical antibiotic in a severe episode with fever and bloody stool, consider seeking a second opinion.
- FNifuroxazideNot recommended · Intestinal antimicrobialFor mild-to-moderate travelers' diarrhea, nifuroxazide is not prescribed. The drug is absent from international recommendations (IDSA 2017, ISTM 2017, NICE 2023) for this indication. First-line options for moderate disease are azithromycin 1000 mg as a single dose or rifaximin 200 mg three times daily for 3 days in the absence of fever and bloody stools. There is no evidence base for prescribing nifuroxazide to travelers.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit