1
|
Riddle MS, Connor BA, Beeching NJ, DuPont HL, Hamer DH, Kozarsky P, Libman M, Steffen R, Taylor D, Tribble DR, Vila J, Zanger P, Ericsson CD. Guidelines for the prevention and treatment of travelers' diarrhea: a graded expert panel report. J Travel Med 2017; 24:S57-S74. [PMID: 28521004 PMCID: PMC5731448 DOI: 10.1093/jtm/tax026] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND : Travelers' diarrhea causes significant morbidity including some sequelae, lost travel time and opportunity cost to both travelers and countries receiving travelers. Effective prevention and treatment are needed to reduce these negative impacts. METHODS : This critical appraisal of the literature and expert consensus guideline development effort asked several key questions related to antibiotic and non-antibiotic prophylaxis and treatment, utility of available diagnostics, impact of multi-drug resistant (MDR) colonization associated with travel and travelers' diarrhea, and how our understanding of the gastrointestinal microbiome should influence current practice and future research. Studies related to these key clinical areas were assessed for relevance and quality. Based on this critical appraisal, guidelines were developed and voted on using current standards for clinical guideline development methodology. RESULTS : New definitions for severity of travelers' diarrhea were developed. A total of 20 graded recommendations on the topics of prophylaxis, diagnosis, therapy and follow-up were developed. In addition, three non-graded consensus-based statements were adopted. CONCLUSIONS : Prevention and treatment of travelers' diarrhea requires action at the provider, traveler and research community levels. Strong evidence supports the effectiveness of antimicrobial therapy in most cases of moderate to severe travelers' diarrhea, while either increasing intake of fluids only or loperamide or bismuth subsalicylate may suffice for most cases of mild diarrhea. Further studies are needed to address knowledge gaps regarding optimal therapies, the individual, community and global health risks of MDR acquisition, manipulation of the microbiome in prevention and treatment and the utility of laboratory testing in returning travelers with persistent diarrhea.
Collapse
Affiliation(s)
| | - Bradley A. Connor
- Weill Cornell Medical College and The New York Center for Travel and
Tropical Medicine, New York, NY, USA
| | - Nicholas J. Beeching
- Clinical Science Group, Liverpool School of Tropical Medicine, Pembroke
Place, Liverpool, UK and National Institute of Health Research (NIHR) Health Protection Unit
in Gastrointestinal Infections, Farr Institute, University of Liverpool, Liverpool, UK
| | | | - Davidson H. Hamer
- Department of Global Health, Center for Global Health and Development,
Boston University School of Public Health, Section of Infectious Diseases, Department of
Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Michael Libman
- J.D. MacLean Centre for Tropical Diseases, McGill University, Montreal,
Québec, Canada
| | - Robert Steffen
- Epidemiology, Biostatistics and Prevention Institute, World Health
Organization Collaborating Centre for Traveller's Health, University of Zurich, Zurich,
Switzerland
| | | | - David R. Tribble
- Uniformed Services University of the Health Sciences, Bethesda, MD,
USA
| | - Jordi Vila
- ISGlobal, Barcelona Centre for International Health Research, Hospital
Clínic–Universitat de Barcelona, Barcelona, Spain
| | - Philipp Zanger
- Institute of Public Health, University Hospitals,
Ruprecht-Karls-Universität, Heidelberg, Germany
| | - Charles D. Ericsson
- Department of Medicine, Division of Infectious Diseases, University of
Texas Medical School at Houston, Houston, TX, USA
| |
Collapse
|
2
|
Lääveri T, Sterne J, Rombo L, Kantele A. Systematic review of loperamide: No proof of antibiotics being superior to loperamide in treatment of mild/moderate travellers' diarrhoea. Travel Med Infect Dis 2016; 14:299-312. [PMID: 27363327 DOI: 10.1016/j.tmaid.2016.06.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/19/2016] [Accepted: 06/20/2016] [Indexed: 12/18/2022]
Abstract
Looking at the worldwide emergency of antimicrobial resistance, international travellers appear to have a central role in spreading the bacteria across the globe. Travellers' diarrhoea (TD) is the most common disease encountered by visitors to the (sub)tropics. Both TD and its treatment with antibiotics have proved significant independent risk factors of colonization by resistant intestinal bacteria while travelling. Travellers should therefore be given preventive advice regarding TD and cautioned about taking antibiotics: mild or moderate TD does not require antibiotics. Logical alternatives are medications with effects on gastrointestinal function, such as loperamide. The present review explores literature on loperamide in treating TD. Adhering to manufacturer's dosage recommendations, loperamide offers a safe and effective alternative for relieving mild and moderate symptoms. Moreover, loperamide taken singly does no predispose to contracting MDR bacteria. Most importantly, we found no proof that would show antibiotics to be significantly more effective than loperamide in treating mild/moderate TD.
Collapse
Affiliation(s)
- Tinja Lääveri
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, POB 348, FIN-00029 HUS, Finland.
| | - Jesper Sterne
- Centre for Clinical Research, Sörmland County Council, Eskilstuna and University of Uppsala, SE 631 88 Eskilstuna, Sweden.
| | - Lars Rombo
- Centre for Clinical Research, Sörmland County Council, Eskilstuna and University of Uppsala, SE 631 88 Eskilstuna, Sweden; Karolinska Institutet, Department of Medicine/Solna, Unit for Infectious Diseases, SE 17176 Stockholm, Sweden.
| | - Anu Kantele
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, POB 348, FIN-00029 HUS, Finland; Karolinska Institutet, Department of Medicine/Solna, Unit for Infectious Diseases, SE 17176 Stockholm, Sweden; Department of Medicine, University of Helsinki, Finland.
| |
Collapse
|
3
|
Grondin C, Imbert P, Ficko C, Mérens A, Dutasta F, Bigaillon C, Rapp C. Shigella flexneri bacteremia in two immune-competent adult travelers. J Travel Med 2012; 19:258-60. [PMID: 22776390 DOI: 10.1111/j.1708-8305.2012.00627.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Shigella bacteremias are uncommon in immune-competent adults. We report two cases of Shigella flexneri bacteremia that occurred in healthy young travelers, who recovered. Self-medication with loperamide and ibuprofen without antibiotics (case 1) and concomitant falciparum malaria (case 2) were the only co-morbidities found in our two patients.
Collapse
Affiliation(s)
- Cynthia Grondin
- Service des maladies infectieuses et tropicales, Hôpital d'instruction des armées Bégin, Saint-Mandé, France
| | | | | | | | | | | | | |
Collapse
|
5
|
Abstract
Toxic megacolon is a rare consequence of infection with Entamoeba histolytica. We present such a patient in whom the course of disease may have been influenced by heavy loperamide use. Loperamide and other anti-motility agents have been implicated previously in the pathogenesis of toxic megacolon in patients with infectious gastroenteritis.
Collapse
Affiliation(s)
- Alastair McGregor
- Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, UK
| | | | | | | |
Collapse
|