Travellers’ Diarrhea – Still Important and Still Prone to Inappropriate Treatment and Prevention

Author(s):  Dr Sherilyn Houle

Travellers’ diarrhea (TD) is the most common travel-related ailment, with a recent systematic review and meta-analysis of 10 studies with over 8,000 travellers reporting an overall incidence of 36.1% (95% CI 21-41%) among travellers from high-income countries.¹ Five studies examined risk factors for TD, finding statistically significant associations including female sex, longer duration of travel, destination (low- and middle-income countries), backpacking activities, and use of antacid medication prior to travel.¹

E. coli, a common pathogen causing TD, is treated with antimicrobial therapy for those with moderate to severe TD.² With a recent GeoSentinel analysis finding that 37% of E. coli isolates from travellers were multi-drug resistant,³ appropriate selection of antimicrobial drugs is of great importance. Specifically, 50% of isolates were non-susceptible to cotrimoxazole, 38% to fluoroquinolones, 33% to third-generation cephalosporins, and 3% to carbapenems. South-Central Asia and Sub-Saharan Africa had the highest rates of multi-drug resistance.³

Pre-travel counseling is an important strategy to reduce the risk of and ensure proper management of TD, with a study of travellers visiting a clinic in Portugal reporting that prior to their consultation only 35.2% correctly identified that TD is rarely serious or life-threatening, and 57.3% believed that all travellers should take antibiotics for the prevention of TD,⁴ suggesting the potential for inappropriate use of antibiotics by travellers.

Pre-travel advice and care should therefore include patient awareness of risk of TD and non-drug preventive measures, advice on when antimicrobial treatment may be warranted, and the selection of an antibiotic with sufficient susceptibility for the region being visited. Travellers should also be advised that evidence on the use of probiotics for the prevention of TD is limited and that not all probiotics are equal, with a meta-analysis of 10 randomized controlled trials unable to reach definitive conclusions given the small sample size of some studies as well as significant heterogeneity in included strain(s), doses and duration of therapy studied, and destinations.⁵

A multifaceted and evidence-informed approach to prevention and treatment of TD is critical to ensure the wellness of travellers and to ensure antimicrobial sensitivity for those experiencing more severe illness.

References

[1].  Incidence and risk factors for travellers’ diarrhoea among short-term international adult travellers from high-income countries: a systematic review with meta-analysis of cohort studies.  Carroll SC, Castellanos ME, Stevenson RA, Henning L ‐ J Travel Med 2025;32(2):taae008 [Link]
[2].  Guidelines for the prevention and treatment of travelers' diarrhea: a graded expert panel report.  Riddle MS, Connor BA, Beeching NJ, et al ‐ J Travel Med 2017;24(suppl_1):S57-S74 [Link]
[3].  Patient characteristics and antimicrobial susceptibility profiles of Escherichia coli and Klebsiella pneumoniae infections in international travellers: a GeoSentinel analysis.  McGuinness SL, Muhi S, Nadimpalli ML, et al ‐ J Travel Med 2025;32(1):taae090 [Link]
[4].  What do travelers know about traveler’s diarrhea? Impact of a pre-travel consultation in the Lisbon Area, Portugal.  Estrada J, Conceicao C, Augusto GF, Teodosio R ‐ Trop Med Infect Dis 2024;9(10):232 [Link]
[5].  Investigating the influence of probiotics in preventing traveler's diarrhea: Meta-analysis based systematic review.  Alharbi BF, Alateek AA ‐ Travel Med Infect Dis 2024;59:102703 [Link]