Travelers’ Diarrhea (Montezuma’s revenge in Mexico)

I am starting with a digression to make an important, subtle, and interesting point.

Clindamycin is an old antibiotic, seldom used anymore because of early experience with its major side effect, pseudomembranous enterocolitis, which results in very persistent diarrhea. Now that we know the mechanism of this syndrome, it is called Clostridium difficile infection. Clindamycin, more than other antibiotics, inhibits the portion of normal bowel flora that prevents overgrowth of C. difficile previously present in small numbers or available from the environment to colonize us—its spores are very long lived. Lesson: if your doctor gives you an antibiotic to take in case of travelers’ diarrhea, wait a few days after symptoms before you take it (unless you have a very important business appointment). You will probably get better before you need the antibiotic, and you will dodge any threat of C. difficile infection. Its like not killing barnyard cats to avoid an infestation of rats. C. difficile now occurs mostly in chronically ill people who need multiple courses of antibiotics (seldom clindamycin).

Here is the second instructive digression. Cholera is a disease with such severe diarrhea that fatal dehydration can occur in an hour or so. We never saw a case of cholera in two years teaching in Afghanistan, but we learned to teach its treatment because we saw frequent cases of what we called “the cholera syndrome” caused by an enormous dose of ordinary staphylococcus food poisoning resulting in the fulminating life-threatening diarrhea, just like cholera itself for the first few hours. The treatment is to replace the lost fluid as fast as it is lost, either intravenously or orally. Trade names for the oral packets include Rehydralyte, Resol, Ricalyte (Gatorade is too dilute).

The diarrhea of food poisoning is a very good example of why you shouldn’t take powerful antidiarrheal medications such as Lomotil and Imodium at the first sign of diarrhea (Kaopectate and Pepto-Bismol are OK) ---you might interfere with nature trying to push the toxin out as promptly as she can. A smaller point, other causes of travelers’ diarrhea such as salmonella may be prolonged by agents such as Lomotil. In other words, save them for the denouement—the winding down after the climax.

If you travel to areas remote from medical attention or if you want to be self-sufficient, ask your physician for a prescription for rifaximin (Xifaxan) to be taken in case of life-threatening diarrhea with dehydration. One tablet (200 mg) three times a day for three days would give you a good chance of prompt cure. For a “belt and suspenders” program: also ask for a prescription for Cipro 500mg two times a day for 7 to 14 days in case of failure with rifaximin. For more self-sufficiency remember that rifaximin is not absorbed from the intestinal tract and therefore is not effective for infections elsewhere in the body.

Summary: when you get travelers’ diarrhea, try to put up with it for a day or so. If it isn’t getting better by then, get a stool culture if you can (maybe it came on after you got home). By the time the culture is reported, you will know whether you are a candidate for antibiotic treatment, and more importantly you will get the most appropriate antibiotic for your bug.

To avoid trouble in problem parts of the world; 1) practice brushing your teeth out of a canteen for a week or so at home; 2) avoid raw food; 3) watch out for salads especially in ritzy digs with cloth napkins and table cloths (a false sense of security). 4) in some countries bottled water is simply filled from the tap—nose around (asking questions may or may not suffice); 5) ice cubes are a subtle threat—you cannot treat them with Halozone and taking them out of your drink is too late.

My credential: I survived two years in Afghanistan with only one attack of dysentery—I saw the host use ordinary water to wipe the knife he was using to cut watermelon. We had been three weeks without fresh food and there was something of a political problem—the latter perhaps why some of our counterpart Afghan physicians only boiled their drinking water when they were sick already.

John A. Frantz, MD, Green County Health Committee, September 27, 2005