Do I have travellers' diarrhoea?

If you are in (or have very recently returned from) a developing/resource-poor country, and have developed diarrhoea (runny poo) more than 3 times a day, then this is probably travellers' diarrhoea. You may also have abdominal pain and cramps, nausea, vomiting, fever, and possibly blood in the stools.

What is the difference between diarrhoea and travellers' diarrhoea?

Travellers' diarrhoea is most often caused by a bacteria, e.g. E.coli or campylobacter, whereas most diarrhoea at home is caused by viruses - e.g. rotavirus, norovirus. Diarrhoea can also be caused by other micro-organisms, both home and abroad, and also other things like medications, lactose, and fructose intolerance, artificial sweeteners, and medical and surgical conditions.

Why do travellers get diarrhoea?

Travellers are more prone to developing diarrhoea if the hygiene conditions are worse than they are used to at home. Food and drink prepared in less hygienic conditions may easily have been contaminated, and so cause diarrhoea.

Diarrhoea-causing bacteria can also be picked up on hands and without frequent hand washing or use of hand gel, that can also lead to diarrhoea.

Local people have a tolerance to the local bacteria and, as their bodies have become used to them, they don't get diarrhoea.

Where am I at most risk of getting travellers' diarrhoea?

The risk of travellers' diarrhoea is more in some countries than others:

• Low risk - Western European countries, USA, Canada, Japan, Australia, New Zealand.
• Intermediate risk - Southern European countries, Israel, South Africa, some Caribbean and Pacific Islands.
• High risk - Africa, Latin America, Middle East, most of Asia.

What causes travellers' diarrhoea?

The most common cause is a bacteria- either E. coli or campylobacter. However, it can also be caused by other bacteria, viruses, protozoa, parasites, and toxins (bad chemicals) in foods.

How did I get travellers' diarrhoea?

It is most likely that you have developed diarrhoea due to eating or drinking contaminated food or water, that was prepared in a less hygienic environment. Sometimes the bug will come from your own hands, so good hand hygiene is essential when travelling.

How can I stop myself getting travellers' diarrhoea?

As the bugs causing travellers' diarrhoea tend to be in food and drink, be careful with what you eat and drink.

• Stick to freshly prepared food that is thoroughly cooked and served piping hot.
• Drink only bottled (with intact seal) or 'clean' drinks.
• Don't have ice in your drinks.
• Don't use local tap water to clean teeth.
• Avoid street food or eating at places that appear dirty.
• Avoid ice cream, shellfish, salads, and cold foods in buffets.
• Avoid unpasteurized milk and cheese.
• Only eat fruit that you have peeled yourself.
• Take care when swimming and showering not to drink the water.
• Make sure you wash your hands or use hand gel frequently.

Does Pepto-Bismol, Cola, or Whisky prevent travellers' diarrhoea?

There is no evidence that taking Pepto-Bismol, coke, or whisky reduces the chance of getting travellers' diarrhoea.

Is there a vaccine for travellers' diarrhoea?

There is no vaccine to prevent travellers' diarrhoea. Some travel vaccines prevent illnesses where there may also be diarrhoea, but they cannot prevent travellers’ diarrhoea itself.

How can I treat travellers' diarrhoea?

Sometimes the diarrhoea will settle on its own, with no specific treatment beyond fluid replacement and a light diet (small amounts of foods such as rice or bananas which can be digested easily).

• It is important to keep well hydrated as you can lose a lot of fluid - either use sachets of rehydration salts or take a rehydration spoon with you and make your own rehydration drink with salt, sugar, and clean drinking water. Try and drink 3-4 litres (6 pints) of fluid per day. Don't drink alcohol as this can cause further dehydration.
• Loperamide will usually settle the frequency of the diarrhoea.
• An antibiotic can shorten the time and intensity of travellers' diarrhoea, but only if the diarrhoea is caused by bacteria - see causes of diarrhoea. Dr Fox prescribes azithromycin to take with you as a stand by medication.

I took ciprofloxacin in the past for travellers' diarrhoea - can I use that again?

Ciprofloxacin is not now recommended as an antibiotic for travellers' diarrhoea. It has become less efficient due to increased antibiotic resistance, and there are also reports of occasional severe side effects.

I have a long journey - what can I do to stop the diarrhoea?

If you have a long journey, or an important meeting then taking loperamide will usually reduce the diarrhoea.

How do you get rid of diarrhoea from abroad?

If you have returned home and the diarrhoea is persistent after trying the suggestions above (How can I treat travellers' diarrhoea?) then contact your GP who may want you to send a sample of the diarrhoea for testing. Some diarrhoea is caused by other bugs which will require different treatments.

What if the diarrhoea doesn't settle?

If the diarrhoea has not improved after 2-3 days of trying the suggestions above (How can I treat travellers' diarrhoea?) then get medical help. A doctor may test a sample of the diarrhoea to see if it is caused by other bugs (e.g. giardia), needing a different treatment. Occasionally after the original cause has gone, the intestine can take a long time to recover and so there is ongoing diarrhoea. This can happen if there was already a problem in the bowel or it could be because the cells which digest sugars have been damaged leaving an intolerance to lactose or fructose, or sometimes irritable bowel syndrome can be triggered by travellers' diarrhoea. If you are having prolonged symptoms of diarrhoea, even if triggered by an episode of travellers' diarrhoea, see your GP to discuss if further investigation is needed.

What is the best medicine for travellers' diarrhoea?

Dr Fox offers loperamide and azithromycin to treat travellers' diarrhoea. They work in different ways - the loperamide calms the gut and the azithromycin kills any bacteria causing the problem.

Is Pepto Bismol good for travellers' diarrhoea?

Pepto Bismol can be used in mild diarrhoea, but cannot be taken by some people e.g. those with aspirin allergy, kidney problems, gout, bowel disease, HIV, if taking an anticoagulant such as warfarin, pregnant or breastfeeding women, or under 12 year olds. It can help if there is associated nausea, but shouldn't be taken if you have blood or mucous in the stool or high fever or severe abdominal pain. Loperamide is quicker and more effective at controlling the diarrhoea and cramping. Dr Fox does not supply Pepto Bismol.

What can stop diarrhoea fast?

Loperamide is usually very effective at reducing the frequency of diarrhoea. Take two capsules immediately. Then take one capsule after each episode of diarrhoea for up to 48 hours. Maximum of 6 capsules per 24 hours.

What antibiotic can I use for travellers' diarrhoea?

Azithromycin is the antibiotic of choice if you need to self-treat travellers' diarrhoea. The course is 500mg a day for 3 days. This is now the internationally recognised preference and has replaced the one-off dose of 1000mg of azithromycin or the use of ciprofloxacin for travellers' diarrhoea.

I am vomiting as well - what else can I do?

If you are vomiting then Avomine, which is prescribed by Dr Fox for travel sickness, could also be taken to help to reduce fluid loss. Avomine cannot be used if also taking azithromycin. You are at more risk of developing dehydration if you are vomiting as well as having diarrhoea. Consider getting medical help sooner.

Diarrhoea ruined my last holiday - what can I do next time?

Consider where you want to take your holiday (Where am I at most risk of getting travellers' diarrhoea?).

Consider being prepared by taking stand-by medication with you - Dr Fox can supply loperamide to treat the symptoms and azithromycin antibiotic to treat bacteria which are often the cause.

Consider taking rehydration sachets or a rehydration spoon to make up your own rehydration solution, if you become unwell.

Follow the advice about preventing travellers' diarrhoea.

Can I take antibiotics to stop me getting travellers' diarrhoea?

Antibiotic preventative treatment is not normally recommended for travellers' diarrhoea as it may make you vulnerable to much more severe infections. In a very few 'high risk' travellers it may be offered. If you think you are in this group, then you should discuss your travel plans with your specialist or GP.

How do I use loperamide?

Take two loperamide capsules straight away. Then take one capsule after each episode of diarrhoea for up to 48 hours. Maximum 6 capsules per day. For further information read the loperamide patient leaflet.

When should you not take loperamide?

Loperamide should not be taken:

• Where the diarrhoea contains blood and there is a high fever.
• If you have liver disease.
• If you are pregnant or breastfeeding.
• Not suitable for children.
• If you are allergic to lactose.
• When diarrhoea starts after a course of antibiotic.
• If diarrhoea is related to an inflammatory bowel condition (e.g Crohn's disease, ulcerative colitis).
• Where there has been prolonged constipation before diarrhoea starts.
• If taking any of these other medications they may slightly increase the dose of loperamide in your system - ritonavir, quinidine, itraconazole or ketoconazole, gemfibrozil. See also loperamide patient leaflet.

Does loperamide contain lactose?

Yes.

How do I take azithromycin?

Treatment with azithromycin is 500mg daily for three days. Start as soon as you get diarrhoea, not before. It is not a preventative. For further information read the azithromycin page.

Does azithromycin contain lactose?

Yes.

How long can travellers' diarrhoea last?

A mild travellers' diarrhoea will often improve within 2-3 days, with only fluid replacement and a light diet. More severe episodes can last longer and can cause ongoing gut issues for several days or weeks. Also see What if the diarrhoea doesn't settle?

Can you lose weight from travellers' diarrhoea?

Any gut infection can cause weight loss if it goes on for long enough. It is important to replace fluid loss by drinking 3-4 litres of clean fluid per day. You can and should continue to eat, but a light diet. You may not feel very hungry or feel sick as well, and so not eat as much as usual. This can also add to weight loss. If the diarrhoea is not settling and you are losing significant weight, consult a doctor. Also see How can I treat travellers' diarrhoea?

How long does it take for travellers' diarrhoea to start?

Travellers' diarrhoea usually starts about 6-7 days into a trip, but can start sooner or even much later, especially if you’re travelling through many countries.

Does travellers' diarrhoea resolve on its own?

Yes, mild cases can settle on their own, with drinking lots and eating a light diet. If it is more severe, persisting beyond 48 hours or worsening, then treatment should be considered.

Is it best to starve yourself when you have diarrhoea?

In the past it was believed that resting the gut by starving would help to improve diarrhoea, but this approach has not been confirmed in studies. Advice now is to eat a light diet, avoid alcohol and caffeine, and drink lots of clean water.

What is a 'light' diet?

A light diet consists of foods which are easily digestible including plain biscuits, white rice, potatoes, white bread and toast, fish, white meat, eggs. Avoid rich fatty foods, spices, sweet foods, and high fibre.

Do probiotics/yoghurt help travellers' diarrhoea?

There is no evidence that probiotics and live yoghurt will affect the course of the illness or prevent travellers' diarrhoea. They may help to replace the natural gut flora. With travellers' diarrhoea, the natural balance of gut microbes is altered, both by the diarrhoea and by any antibiotics taken.

When should I see a doctor for travellers' diarrhoea?

You should see a doctor if:

• The diarrhoea is not improving within 24–36 hours despite self-treatment.
• You have a high fever over 38.5°C for more than 48 hours especially if you are in a malaria zone.
• You have persistent blood and green or yellow slime in the diarrhoea - you may need tests and a different type of antibiotic.
• You have severe abdominal pains - may indicate a more serious condition than straightforward travellers' diarrhoea.
• There is a rash - may indicate other more serious infections.
• You are becoming dehydrated and are unable to take enough fluids - you may need a saline drip if you can't drink enough.

What are the signs of dehydration?

• Feeling very thirsty.
• Not passing urine more than four times a day.
• Urine that is a very dark yellow and smells strongly. Try to drink enough for it to be pale straw coloured during the day.
• Dry wrinkly skin, sunken eyes, dry mouth, lips and eyes.
• Feeling tired, dizzy or lightheaded, restless, irritable.

For further information see NHS - Dehydration.

Is coca-cola good for diarrhoea?

Coke and other fizzy drinks can be good fluids to drink when you are trying to rehydrate with travellers' diarrhoea. They will give you some replacement sugar as well as fluid. Fizzy drinks are usually easy to get hold of all over the world and as long as the seal is intact, they should be 'safe' to drink. It is probably better to let the drink go flat as too much fizz may make you feel worse.

Can anyone take azithromycin?

Do not take azithromycin if you are allergic to it or erythromycin or clarithromycin.

If you have any of these medical conditions you should not take azithromycin:

• A tendency to irregular heart beat or other heart disease.
• Myasthenia gravis.
• Liver disease.
• Kidney disease.
• Lactose intolerance.

Do not take azithromycin if trying to conceive, or during pregnancy and breastfeeding, without first discussing with your own GP.

For further information read the azithromycin page.

I'm taking other medication - can I take azithromycin?

There is possible interaction with some rarely used medications: ciclosporin, digoxin, ergotamine, terfenadine, theophylline, disopyramide, amiodarone, sotalol, any medication for irregular heartbeat, rifabutin, colchicine, medication to prevent blood clots, talazoparib, topotecan, antidepressants, and other mood altering medications, antibiotics from the quinolone class e.g. moxifloxacin, levofloxacin, ciprofloxacin. If in doubt discuss with your GP.

You should NOT take Avomine or other tablets containing promethazine at the same time as azithromycin.

For further information read the azithromycin patient leaflet.

Can I take antacids with azithromycin?

If taking antacids for indigestion, azithromycin can be taken but leave at least 2 hours from the antacid as it will prevent full absorption of the azithromycin.

What is the Bristol stool chart?

The Bristol stool chart is often used by doctors to help assess the level of diarrhoea or constipation.

Travellers' diarrhoea is technically defined as 3 or more type 6 (fluffy pieces with ragged edges, a mushy stool) or 7 (watery, no solid pieces, entirely liquid) stools in 24 hours.

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