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Travel Health advice for travellers interested in Travellers Diarrhoea

Aetiology

This can be caused many different organisms such as E.Coli, Shigella, Entamoeba histolytica, Salmonella, Campylobacter, Giardia, Cryptosporidia, Cyclospora and Vibrio cholerae. All these organisms are spread through the faecal/oral route. 

Remember loose motions can also result from a change in diet including, for example, spicy or oily foods.

Prevention

This depends upon effective drinking water sterilization and ensuring food is uncontaminated or cooked thoroughly. Personal hygiene when eating and drinking is also important including hand washing prior to eating and using sterile plates, cups and utensils.

What to avoid

  • Water should only be drunk when you are sure of its purity. Don't drink it without boiling, chemical disinfection or using a reliable filter. This also applies to water used for making ice cubes and cleaning teeth. Bottled water is usually safe,(watch out for bottled water sitting in iced water), as are hot tea and coffee, beer and wine.
  • Milk should be boiled unless you are sure it has been pasteurised.
  • Cheeses and ice-cream are often made from unpasteurised milk and when in doubt these should only be bought from larger well established companies when quality can usually be assured.
  • Meat should be thoroughly cooked and eaten hot whenever possible. Avoid leftovers.
  • Fish and shellfish can be hazardous at certain times of year, even if well cooked. Take local advice about seafood, but when in doubt it is best to avoid them.
  • Vegetables should only be eaten when thoroughly cooked.
  • Salads should be avoided.
  • Fruit should be peeled, including tomatoes.
  • Wash hands thoroughly before eating or handling food, and always after using the toilet.

Vaccination

No vaccinations are currently available in Britain for any of these infections although an oral cholera vaccine is available in some countries and vaccines for E.Coli are under development.

Tablets to prevent travellers' diarrhoea

A number of broad spectrum antibiotics have been show to reduce the incidence of travellers' diarrhoea by 70% to 90%. This is called chemoprophylaxis.

The normal antibiotic dose used for preventing travellers diarrhoea
Half that used for treatment. e.g. ciprofloxacin 250mg daily; doxycycline 100 mg daily; trimethoprim 100mg daily. Bismuth subsalicylate is an effective, non-antibiotic approach to prevent travellers diarrhoea with an overall efficacy of about 60%. A tablet formulation is now available - two tablets are taken 4 times daily at meal times and on retiring. (Two weeks supply of the liquid form adds 5kg to the weight of a traveller's luggage!)

Recommendations for travellers
Chemoprophylaxis should not be used routinely. However it might be offered, for example, to a traveller who making a very short tour (3-5 days) when loss of even 12-24 hours would seriously impact on the success of the visit. Prophylaxis may also be helpful in those with pre-existing bowel problems such as colitis or irritable bowel syndrome where an attack of diarrhoea could seriously aggravate symptoms or cause relapse.

Remember antimicrobials may cause adverse drug reactions, which are occasionally severe and include diarrhoea. Ciprofloxacin occasionally causes confusion and hallucinations, doxycycline is contra-indicated in pregnancy and young children.

Treatment

The priority in treatment is preventing dehydration especially in young children. Clear fluids such as diluted fruit juices or ideally specially prepared oral rehydrating solutions such as dioralyte (bought at the chemist) should be drunk liberally. All these preparations must be prepared with sterile water. Anti-diarrhoea agents such as loperamide ( ImodiumŪ) or diphenoxylate plus atropine ( lomotilŪ) should be used sparingly - they can help particularly with associated colicky pains. Overuse can cause 'rebound' constipation and occasionally encourage other complications such as septicaemia.

Blood and mucous suggests campylobacter, shigella or amoebic infection. Marked vomiting, fever, pain, bleeding or dehydration usually require hospital referral so the intravenous fluids can be administered. 

While not necessary in most instances of travellers' diarrhoea, if the diarrhoea is very frequent and continues for more than a few hours, use of the same antibiotics that are sometimes used for prevention can shorten the illness. They are effective against E.coli, shigella, salmonella and campylobacter. Amoebic dysentery requires the use of metronidazole.

The normal antibiotic dose used for treatment
Ciprofloxacin 250mg, doxycycline 100 mg or trimethoprim 100mg (all taken twice a day). If used without medical supervision, prolonged courses are not normally necessary or desirable - treatment for 1 or 2 days is usually all that is required - and if the illness continues medical help should be sought.

     
     
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