Summary of the Committee to Advise on Tropical Medicine and Travel (CATMAT) Statement on Travellers' Diarrhea

Management of Chronic Diarrhea in Primary Care: The Gastroenterologists' Advice

BACKGROUND

Chronic diarrhea is defined as more than 3 bowel movements per day, or loose stools, or stool weight >200 g/day for at least 4 weeks. Accompanying symptoms may include urgency, abdominal pain, or cramps.

SUMMARY

A number of causes have to be considered, including inflammatory, neoplastic, malabsorptive, infective, vascular, and functional gastrointestinal diseases. Other causes include food intolerances, side effects of drugs, or postsurgical conditions. Diarrhea may also be symptom of a systemic disease, like diabetes or hyperthyroidism. Special patient groups, like the very elderly and immunocompromised patients, pose special challenges. This review follows a question-answer style and addresses questions raised on the intersection of primary and secondary care. What do you mean by diarrhea? Why is it important to distinguish between acute or chronic diarrhea? How shall the patient with chronic diarrhea be approached? How can history and physical exam help? How can routine laboratory tests help in categorizing diarrhea? Which additional laboratory tests may be helpful? How to proceed in undiagnosed or intractable diarrhea? What are the treatment options in patients with chronic diarrhea? Key Messages: Acute diarrhea is usually of infectious origin with the main treatment goal of preventing water and electrolyte disturbances. Chronic diarrhea is usually not of infectious origin and may be the symptom of a large number of gastrointestinal and general diseases or drug side effects. In undiagnosed or intractable diarrhea, the question shall be raised whether the appropriate tests have been performed and interpreted correctly.

Travelers' Diarrhea: A Clinical Review

Background:

Travelers’ diarrhea is the most common travel-related malady. It affects millions of international travelers to developing countries annually and can significantly disrupt travel plans.

Objective:

To provide an update on the evaluation, diagnosis, treatment, and prevention of traveler’s diar-rhea.

Methods:

A PubMed search was completed in Clinical Queries using the key term “traveler’s diarrhea”. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature. Patents were searched using the key term “traveler’s diarrhea” from www.freepatentsonline.com.

Results:

Between 10% and 40% of travelers develop diarrhea. The attack rate is highest for travelers from a developed country who visit a developing country. Children are at particular risk. Travelers’ diarrhea is usually acquired through ingestion of food and water contaminated by feces. Most cases are due to a bac-terial pathogen, commonly, Escherichia coli, and occur within the first few days after arrival in a foreign country. Dehydration is the most common complication. Pretravel education on hygiene and on the safe selection of food items is important in minimizing episodes. For mild travelers’ diarrhea, the use of antibi-otic is not recommended. The use of bismuth subsalicylate or loperamide may be considered. For moder-ate travelers’ diarrhea, antibiotics such as fluoroquinolones, azithromycin, and rifaximin may be used. Loperamide may be considered as monotherapy or adjunctive therapy. For severe travelers’ diarrhea, antibiotics such as azithromycin, fluoroquinolones, and rifaximin should be used. Azithromycin can be used even for the treatment of dysentery whereas fluoroquinolones and rifaximin cannot be used for such purpose. Recent patents related to the management of travelers’ diarrhea are discussed.

Conclusion:

Although travelers’ diarrhea is usually self-limited, many travelers prefer expedient relief of diarrhea, especially when they are traveling for extended periods by air or ground. Judicious use of an antimotility agent and antimicrobial therapy reduces the duration and severity of diarrhea.

New Tools to Test Stool: Managing Travelers' Diarrhea in the Era of Molecular Diagnostics

Travelers' diarrhea affects up to 60% of visitors to tropical and subtropical regions. Although symptoms are generally self-limited, some infections are associated with significant morbidity and occasional mortality. Newer molecular diagnostic techniques allow for highly sensitive, specific, and expeditious testing of a wide range of potential pathogens. Identification of the causative pathogen of travelers' diarrhea allows for targeted therapy and management and a reduction in empiric broad-spectrum coverage.

A Review of Guidelines/Guidance from Various Countries Around the World for the Prevention and Management of Travellers' Diarrhoea: A Pharmacist's Perspective

International travel is growing and pharmacists are well placed to provide travel health services for the prevention and management of travellers’ diarrhoea (TD). Legislation changes in many countries has enabled pharmacists to access prescription only medicines and vaccinations to provide advice and over the counter medicines for the prevention and management for travel health services; this makes sense since pharmacies are easily accessible to the public and are the patient’s first port of call in the event of any illness. Currently, whilst many guidelines/guidance exist worldwide for the prevention and management of TD, there is no review that focuses on similarities and differences between these and between guidelines on TD and travel related and non-travel related acute diarrhoea. There is also a lack of publication on legislation and the need for evidence based training for all prescribers to provide travel health services. The aims of this work were to review guidelines/guidance for the prevention and management of TD from across the world which were compared with each other as were the TD guidelines compared to that for travel related and non-travel related acute diarrhoea for similarities and differences, with a focus on any relevant pharmacy legislation, needs assessments and training that may impact upon provision of travel health services by pharmacists focusing mainly on TD in adults. The PubMed, Google Scholar and Cochrane database were used to carry out an online search for publications on TD, acute diarrhoea and the guidance pharmacists have in the prevention and management of diarrhoea. The literature reviewed in this article indicates that where no specific guidelines/guidance existed, some pharmacists used the WHO guidelines (WHO), highlighting a need for local, regional and national evidence based guidelines in these countries.

Guideline for the Antibiotic Use in Acute Gastroenteritis

Acute gastroenteritis is common infectious disease in community in adults. This work represents an update of 'Clinical guideline for the diagnosis and treatment of gastrointestinal infections' that was developed domestically in 2010. The recommendation of this guideline was developed regarding the following; epidemiological factors, test for diagnosis, the indications of empirical antibiotics, and modification of antibiotics after confirming pathogen. Ultimately, it is expected to decrease antibiotic misuse and prevent antibiotic resistance.