How To Be an Expert Medical Traveler

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It is recognized that this is a departure from conventional definitions and will bring challenges to the interpretation and design of future trials related to TD which have relied on stool frequency-based outcomes; however this classification system will likely lead to more tailored therapy for the individual. Further research on defining valid patient-reported and non-frequency based outcomes in the setting of TD is needed. Table 1 Summary of recommendations and statements.

The definition of dysentery should be discussed with future travelers and is defined as passage of stools that contain gross blood admixed with stool in the commode and is often accompanied by more severe constitutional symptoms including fever. It should be emphasized that normal appearing stools in the commode with streaks of blood on the toilet paper may well represent bleeding haemorrhoids and not dysentery.

As most travelers are unlikely to carry a thermometer to take their temperatures, providers should discuss symptomatology associated with fever and how fever may alter the assessment of disease severity. The traveler should be instructed that if their diarrhea lasts longer than 14 days it is considered persistent diarrhea, and may be associated with a higher frequency of certain bacterial and protozoal pathogens therefore may justifying evaluation see specific recommendations. When antibiotic prophylaxis is indicated, rifaximin is recommended Strong recommendation, moderate level of evidence.

Moreover, this cannot be readily inferred from efficacy data against clinical TD, as subclinical pathogen contact may suffice to trigger the presumed patho-etiology involved in post-TD chronic disease morbidity. Similarly, the rationale of preventing TD-related complications in chronically ill travelers by prophylactic antimicrobials has not been subject to rigorous research, but is supported by clinical reasoning on the vulnerability of certain patient groups to dehydration and bacteremia. Against this background, and based on opinion and clinical expertize, the expert panel gives a strong recommendation in favor of considering antimicrobials for the prevention of TD in travelers at high risk of health-related complications.

This recommendation applies to individuals with a desire to travel and a history of clinically significant long-term morbidity following an enteric infection e. Antimicrobial resistance has been recognized as a major threat to health globally and is known to be fostered by antimicrobial overuse. One cohort study in travelers showed that the use of antimicrobials at destinations with high-prevalence of multi-drug resistant organisms MDROs in the environment doubled the risk of intestinal colonization with these bacteria upon return.

Further research is needed to clarify the clinical significance of MDRO colonization in returning travelers who use antimicrobial chemoprophylaxis. Other traveler populations which may benefit from antimicrobials for the prevention of TD but are not explicitly included in the current panel recommendation have been described.

These include individuals who because of occupation or itinerary e. Given the rapid effectiveness of antibiotics with or without loperamide in combination and the increasing threat of antimicrobial resistance, the rationale supporting the aforementioned sub-group as populations who might benefit from antimicrobial chemoprophylaxis may not be as strong anymore. Therefore, the panel recommends that, when assessing travelers of this sub-group, travel medicine practitioners take clear public health responsibility by conducting an individual risk benefit analysis of antimicrobial chemoprophylaxis vs self-treatment with self-treatment of moderate to severe TD representing the standard approach, and chemoprophylaxis the rare exception.

There is strong evidence to recommend the option of using bismuth subsalicylate BSS for prophylaxis of TD in travelers. A lower dose of 1. BSS is well tolerated; adverse effects are mild in adults and consist of black tongue, black stools, tinnitus, potential for constipation, and potential interference with other medications. The panel is aware of the fact that BSS is not available in many countries.

There is strong evidence to opt for rifaximin in those travelers that require antibiotic prophylaxis. This has been confirmed in trials in traveler 58—62 and non-traveler populations. There is also increasing evidence from non-traveler populations that, in situations where FQs are not essential, the potential for harm to the peripheral and central nervous system, tendons, muscles and joints may outweigh the benefit of their use.

This has led to a recent change of the safety labeling for FQs by the U. Food and Drug administration. Therefore, based on expert opinion, the expert panel does not recommend FQs for the prophylaxis of TD. Increasing concerns on MDRO and the implications on individual, community and global health, requires the conservation of antibiotics used in the self-treatment of TD.

We recommend an approach to provide antibiotics for judicious self-treatment to travelers at risk for TD and counsel them on use according to the functional impact of symptoms on their travel-related activities. The rates of mild illness may vary widely depending on such factors as the geographic area, type of trip, age of traveler, and previous exposure; however, a sizeable proportion of illnesses will fall into the mild category defined as causing little or no interference in normal daily activities. It is important to counsel the traveler that if diarrhea worsens or is accompanied by moderate-severe or invasive symptoms e.

While dated, the evidence supporting loperamide in treatment of mild TD is strong, and loperamide has an FDA labeled indication for treatment of mild TD. Finally, loperamide was compared to the non-absorbable antibiotic, rifaximin, and to the combination of rifaximin plus loperamide for the treatment of TD in a large study of travelers to Mexico. The mean number of diarrheal stools in the entire illness was 6. None of the subjects treated with loperamide required treatment with antibiotics.

Finally, a number of observational studies also support treatment of mild diarrhea with antimotility agents. No RCTs have been conducted to compare loperamide with azithromycin or fluoroquinolones alone or in combination. Evidence in support of the efficacy of loperamide is stronger than that for BSS. Other OTC products, such as activated charcoal or dimenhydrinate, are not recommended. Emergence of resistance to this class of drug though without strong evidence of clinical failure outside of SE Asia, combined with the potential for adverse dysbiotic reduction in diversity of intestinal microbiota and musculoskeletal consequences, contribute important uncertainties to the risk-benefit assessment and underlie a non-unanimous GRADE of this recommendation.

Caution should be exercised in provision of rifaximin as empirical therapy of moderate diarrhea in regions or itineraries in which high risk of invasive pathogens are anticipated. On the other hand, antibiotic treatment is not without potential adverse consequences. While adverse events for the commonly used antibiotics are rare, they do occur. Most recently, the FDA released a statement on avoidance of FQ use for non-complicated bacterial infections due to emerging and accumulating concerns of peripheral neuropathy, central nervous system, cardiac, dermatologic effects and hypersensitivity reactions.

Particularly in the older traveler, such musculoskeletal and cardiotoxic risks need to be balanced with the adverse consequences of TD in this population who may also be more susceptible to significant dehydration. In addition, the absolute risk of these rare complications associated with a single dose regimen is uncertain, but are likely much lower.

Of growing concern is the demonstration that antibiotic use in the context of travel more than travel alone and untreated TD alone is associated with increased rates of acquisition of ESBL-PE.


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There are also concerns on negative effects of antibiotics use e. One potential value of early and effective treatment of TD relates to its potential of mitigating the well-described chronic health consequences of TD, including IBS. The rationale behind this theoretical benefit relates to the results of a number of epidemiological studies, which have identified increased risk of PI-IBS following longer duration and more severe acute enteric infections.

Thus, taking into consideration all of the real and theoretical risks and benefits of therapy for moderate TD, we recommend that antibiotics may be used for self-treatment for moderate TD. Counselling and traveler preferences should also be taken into consideration. With respect to antibiotic choice in moderate TD, we have made a number of class- and regimen-specific recommendations Table 2.

Table 2 Acute diarrhea antibiotic treatment recommendations. Use empirically as first line in Southeast Asia and India to cover fluoroquinolone resistant Campylobacter or in other geographical areas if Campylobacter or resistant ETEC are suspected. Do not use if clinical suspicion for Campylobacter, Salmonella, Shigella or other causes of invasive diarrhea. Studies support that there are no significant differences in efficacy between FQs and azithromycin.

This represents a potential risk for certain patient populations who might have pre-existing conditions or are taking concomitant medications. In two RCTs rifaximin has been found to be a more effective agent, as compared to placebo, in treating TD associated with non-invasive pathogens, and in another two RCTs, it has been shown to be non-inferior to ciprofloxacin. So far there is a lack of documentation as to whether rifaximin therapy is associated with acquisition of ESBL-PE, but it has been demonstrated to alter the microbiome, possibly in a beneficial way.

Since loperamide is the fastest acting therapeutic against TD, the rationale of combination therapy with antibiotics is to add symptomatic relief with curative treatment. Five studies have shown that the combination of an antibiotic plus loperamide increases the rate of short term cure, whereas in one study utilizing a FQ in SE Asia where high rates of resistance were known to occur, no benefit was seen.

Loperamide may be used as monotherapy for moderate TD. However, numerous studies have demonstrated the effectiveness of loperamide against TD, among them three travel—related RCTs comparing loperamide to placebo in settings generally limited to 3 days. In children with acute diarrhea between 2 and 11 years of age, loperamide was beneficial without causing severe adverse events.

It is important to consider the syndromes separately since their antibiotic management may differ as detailed in the following summary of evidence. Key considerations in the selection of an empiric antibiotic include the likelihood of treatment efficacy and rapidity of response, regional patterns of probable target pathogens and their antimicrobial resistance, safety and tolerance profile of the antibiotic, simplicity of treatment regimen and hence patient adherence and cost.

Equivalent efficacy for treatment of watery noninvasive diarrhea has been demonstrated between FQs 3-day and single dose , azithromycin 3-day and single dose , and rifaximin three times daily for 3 days. Azithromycin should be considered the first-line agent in cases of dysentery Strong recommendation, high level of evidence as well as acute watery diarrhea with greater than mild fever given the increased likelihood of FQ-resistant Campylobacter , and other bacterial causes such as Shigella spp.

Azithromycin is generally well tolerated with minimal side effects, usually dose-related gastrointestinal complaints. FQs retain efficacy in much of the developing world with the previous caveats regarding resistance in Campylobacter spp. The recommendation is based mainly on concerns about reduced benefit due to the likelihood of FQ-resistant Campylobacter spp. FQs are generally well tolerated, with most adverse effects being mild and transient. Gastrointestinal nausea, vomiting, or diarrhea and central nervous system headache, dizziness, or insomnia side effects are shared by all quinolones.

Recent evidence is accumulating for acquisition of travel-associated gut dysbiosis as well as MDR bacteria during international travel. Rifaximin, a nonabsorbable antibiotic, has demonstrated comparable efficacy to FQs in non-invasive TD caused by diarrheagenic E.

With the above caveats, rifaximin has the best safety profile compared to other first-line antibiotics Weak recommendation, moderate level of evidence. Molecular testing, aimed at a broad range of clinically relevant pathogens, is preferred when rapid results are clinically important or non-molecular tests have failed to establish a diagnosis ungraded.

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No studies have been published as of yet which show that using these tests improves patient outcomes. Detection and identification of specific etiologic agents may be helpful for the management and treatment of patients with TD; however, studies demonstrating the benefit with considerable cost and clinical practicability challenges are lacking.

Therefore, the recommendations made here are based largely on expert opinion and clinical judgement. Specifically, it is recommended that microbiologic diagnosis be attempted in returning travelers with severe or persistent chronic symptoms and if there is bloody diarrhea or mucus present in the stools.

In such cases, knowing an etiology may assist in directing pathogen-specific treatment, or withholding antibiotics in the case of a viral etiology being identified. No clinical trials or well-designed observational studies have been performed to assess the cost-benefit of a test and treatment strategy in such situations, so clinician discretion should be used. While the decision to test is qualified, selection of which diagnostic test to be performed is also complicated. Due to the heterogeneity of etiologies, i.


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However, this method lacks sensitivity, is time consuming, and requires highly trained personnel for detection and interpretation. Specific tests for parasite antigen detection, such as Giardia lamblia , Cryptosporidium spp. However, antigen detection tests can only detect a few specific parasites and therefore cannot completely replace microscopic examination which detects a wider variety of pathogens.

Antigen detection tests have also been used to detect some viruses causing gastroenteritis such as rotavirus and adenovirus; these tests are usually quite specific and their sensitivity is variable. In the last decade multi-pathogen molecular-based clinical assays which can detect a variety of relevant bacteria, viruses and parasites have been developed which provide the potential for quick identification and potential impact on treatment decisions.

This panel detects 15 pathogens, including nine bacteria, three parasites and three viruses, and has been evaluated for the diagnosis of diarrhea in different populations, including travelers. While these assays have high sensitivity and specificity, the clinical outcomes advantage and financial impact of these molecular panels has not yet been fully evaluated, and there are some concerns that molecular testing may, in some cases, detect colonization rather than infection.

Interpretation therefore may be difficult and implementation will depend on the economics of each hospital or clinic system, and perhaps cost-effectiveness will vary depending on the type of patients tested pediatric, hospital or community diarrhea, TD, etc. Furthermore, the use of molecular diagnostic methods does not allow for the resistance characterization of etiologies which may be important for directing care. Further studies are needed to evaluate the utility of these assays in a clinical setting of the returning traveler with diarrhea.

Until such studies are conducted, an evidence-based recommendation for their use cannot be made. Studies are needed on changes in the gut microbiome in travelers with and without diarrhea to clarify the benefits and harms of current and novel preventive, diagnostic, and therapeutic approaches ungraded. Pre-travel counseling should include information about this risk, balanced against the benefits of antibiotic use ungraded. The use of probiotics and prebiotics to prevent or treat acute diarrheal infection is an appealing concept because of their ease of use and relative safety.

The concept of host resistance to enteric infection, also commonly referred to as colonization resistance, describes the microbiota's capability to prevent and limit pathogen colonization and growth. Over the past few decades our understanding of the varied colonization resistance mechanisms has expanded to understand key direct and indirect mechanisms. There are also large variations in the dosage of probiotics, frequency of administration and formulations used. Further variation is seen with regard to timing and administration of these preparations relative to a number of factors including travel populations and locations, and concurrent treatment with antimicrobials.

With regards to a potential treatment indication, a Cochrane Collaboration systematic review on probiotics and treatment of intestinal infection identified 63 randomized and quasi-randomized controlled trials comparing specific probiotic agent s vs placebo or no-treatment for acute diarrhea of presumed infectious etiology. Probiotic use for the treatment of antibiotic associated diarrhea has been recommended.

In summary, in considering the totality of evidence, the panel reached a consensus that the data supporting the use of probiotics and prebiotics for either a prevention or treatment indication in TD is not adequate to make a graded recommendation. More research is needed, however a more thorough knowledge of the host microbiome and mechanisms of action might be necessary before appropriate trials can be designed using specific agents for prevention and treatment of TD.

For the last three decades, RCTs have consistently and clearly demonstrated that antibiotics significantly shorten the duration and alleviate the morbidity of TD which if left untreated can last 3 days or more and significantly disrupt travel plans. However, recently the concern over antibiotic induced colonization with MDRO has called into question the role of antibiotics for what is often is a self-limiting, albeit often disruptive experience.

While the impact to the average traveler of this colonization appears limited it has been identified as an important fraction of MDRO urinary tract infections in community and hospital-based settings. The elderly traveler or the traveler with a history of recurrent urinary tract infections present a unique challenge as these individuals may be at higher risk of individual health consequences from ESBL-PE colonization acquisition, but also, in case of the elderly or otherwise vulnerable traveler, the consequences of delayed or untreated illness must be measured.

At a minimum travelers should be made aware of this risk, and should they become ill following travel, they ought to convey their travel exposure history to their treating providers. ESBL-PE infections are clearly an important health threat and addressing this complex problem will likely take a multi-faceted approach. We are then left with considering what equipoise exists in the balance of treatment vs no treatment in the traveler setting.

More evidence is needed. However, in the interim we recommend discussion with the individual about the multi-level individual, community, global risks of travel, TD, and the role of antibiotic treatment take place. Most if not all travelers should be provided with loperamide and an antibiotic for self-treatment. If the traveler is going to SE Asia, azithromycin should be prescribed. A FQ, azithromycin or rifaximin can be used in all other regions. The traveler should be informed that if the illness does not impact his or her travel, he or she should keep up on fluids and consider taking loperamide.

If rifaximin is used as prophylaxis, azithromycin should be provided for standby break-through therapy. A rational approach of minimizing antibiotic exposure through use of single dose regimens and selection of a first line antibiotic agent with less evidence of microbiome disruption rifaximin and resistance colonization may be advised and needs immediate further study. Additionally, as travel itself and untreated TD also increase the individual risk of ESBL-PE colonization, non-antibiotic chemoprophylactic strategies, including use of bismuth subsalicylate, may decrease both the acute and post-travel risk concerns.

We also recognize that there are differences in the construct, strength and grading of recommendations of this guideline when compared to the recent American College of Gastroenterology guideline and CATMAT statement on the topic of TD treatment, diagnosis and prevention. The expert members involved in this guideline were representative of a broad diversity of country of practice, clinical specialty, and scientific discipline.

Finally, making such calculations and decisions can be a challenge for even the most astute traveler and added to the anxiety provoked by the onset of that first abdominal cramp and disturbing urgency while traveling in sometimes austere and inconvenient settings. We are entirely grateful to leadership and staff from the ISTM for their support and assistance in the conduct of the workshop, coordination of attendance, and other activities. In addition, we appreciate the support of Clifford McDonald, Doug Esposito and Ronnie Henry from the Centers of Disease Control and Prevention CDC who also supported this effort through development of meeting agenda and focus, expert panel participation, reviewing and managing conflict of interest disclosures, and recording minutes.

Supported by an unrestricted grantfrom the International Society of Travel Medicine Foundation including a contribution from the Rudin Foundation. The ISTM Foundation strives to produce clinical guidelines that reflect the best available evidence supplemented with the judgment of expert clinicians. Significant efforts are taken to minimize the potential for conflicts of interest to influence guideline content. Funding of guideline production by medical or pharmaceutical entities is prohibited, full disclosure is obtained and evaluated for all guideline contributors, and recusal is used to manage identified relationships.

Individual conflict of interest statements for each of the panel voting members are summarized. Connor has also participated in the development and drafting of guidelines for the American College of Gastroenterology , and the US Department of Defense Charles Ericsson has received meals from various pharmaceutical companies, and has published research which supports self-treatment and a relatively liberal approach to prevention.

Mark Riddle is a U. David Tribble is a U. Philipp Zanger has published on a randomized controlled trial on the effectiveness of rifaximin in prevention of diarhea in individuals traveling to south and southeast Asia. The views expressed are those of the authors and do not reflect those of their respective institutions, organizations or governments. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.

Sign In or Create an Account. Close mobile search navigation Article navigation. Clinical practice guideline , emporiatrics , evidence-based medicine. Studies are needed on changes in the gut microbiome in travelers with and without diarrhea to clarify the benefits and harms of current and novel preventive, diagnostic, and therapeutic approaches. Pretravel counseling should include information about this risk, balanced against the benefits of antibiotic use. The practice of travel medicine is a unique clinical scenario where we expect the traveler to be the diagnostician, practitioner, and patient when it comes to management of TD.

The translation, conveyance and provision of effective confidence in the traveler to follow complicated guidelines with various alternatives and caveats are an obvious challenge in the already compact interaction in which discussion of other topics such as vaccines, prevention measures of malaria, and other pre-travel counseling occurs. View large Download slide. Global, regional, and national disability-adjusted life years DALYs for diseases and injuries and healthy life expectancy HALE for countries, Effect of adjunctive loperamide in combination with antibiotics on treatment outcomes in traveler's diarrhea: Pre-travel health advice guidelines for humanitarian workers: Preparing children for international travel: ESBL-producing Enterobacteriaceae in travellers: Detection of enteropathogens associated with travelers' diarrhea using a multiplex Luminex-based assay performed on stool samples smeared on Whatman FTA Elute cards.

Spectrum of enteropathogens detected by the FilmArray GI Panel in a multicentre study of community-acquired gastroenteritis. Characterization of the human gut microbiome during travelers' diarrhea. Effect of crofelemer extract on severity and consistency of experimentally induced enterotoxigenic Escherichia coli diarrhea in newborn Holstein calves. A comparative study of racecadotril and single dose octreotide as an anti-secretory agent in acute infective diarrhea.


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Treatment of travellers' diarrhea: Zaldaride maleate a new calmodulin antagonist versus loperamide in the treatment of traveler's diarrhea: High rate of acquisition but short duration of carriage of multidrug-resistant enterobacteriaceae after travel to the tropics.

Colonization with extended-spectrum beta-lactamase-producing and carbapenemase-producing Enterobacteriaceae in international travelers returning to Germany. Antimicrobials increase travelers' risk of colonization by extended-spectrum betalactamase-producing Enterobacteriaceae. Effectiveness of rifaximin and fluoroquinolones in preventing travelers' diarrhea TD: Travel to Asia and traveller's diarrhea with antibiotic treatment are independent risk factors for acquiring ciprofloxacin-resistant and extended spectrum beta-lactamase-producing Enterobacteriaceae-a prospective cohort study.

Fecal carriage rates of extended-spectrum beta-lactamase-producing Escherichia coli among antibiotic naive healthy human volunteers. Trends in human fecal carriage of extended-spectrum beta-lactamases in the community: Aetiology of traveller's diarrhea: Development and assessment of molecular diagnostic tests for 15 enteropathogens causing childhood diarrhea: High number of diarrheal co-infections in travellers to Benin, West Africa. Gastrointestinal pathogens detected by multiplex nucleic acid amplification testing in stools of pediatric patients and patients returning from the tropics.

Post-infectious sequelae of travelers' diarrhea: Chronic gastrointestinal consequences of acute infectious diarrhea: Expatriates ill after travel: Microbial signatures in post-infectious irritable bowel syndrome—toward patient stratification for improved diagnostics and treatment. Meta-analysis of probiotics for the prevention of traveler's diarrhea.

GeoSentinel

Persistent abdominal symptoms in us adults after short-term stay in Mexico. Sequelae of traveler's diarrhea: By the age of 30, I saw more states and countries than most people could dream of seeing in a lifetime. Professional development is also huge.

As a clinician, you may get stuck in a routine working at the same place year in and year out. You see the same type of patients and work next to the same co-workers. Traveling to new buildings or new settings can help you to jump start your learning and professional growth. You can learn new methods from new co-workers and from working with patients with different impairments. Learning through experience in new places has helped turn me from a novice clinician into an experienced, well rounded, expert practitioner. The biggest challenges now are the cuts to Medicare that will impact therapy reimbursements, specifically in Skilled Nursing Facilities SNFs.

Many SNF therapists will likely find their hours cut or jobs lost over the next couple of years. The jobs that may be lost in the SNF setting will likely be booming in the home health setting. Housing is also a considerable concern. The cost of renting apartments continues to rise, while the payment for travel contracts stays relatively the same.

When I started traveling, I lived in plush apartments in the city.

Now, I rent rooms and do what I can to save on rent. In I saw a huge shortage of therapy jobs and decrease in bill rates after the MDS 3.

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At that time, I honestly thought that travel may be dead. Then, slowly but surely, the market improved and now it may be better than ever! The job market, just like the housing or stock market, is cyclical. However, there is an overwhelming trend of high-paying jobs moving to home health and schools for SLPs. Meanwhile, there are less options for SNF jobs and those jobs are paying less. As I mentioned above, home health is definitely a great place to look for a travel job.

As a Speech-Language Pathologist, school contracts are also very lucrative and easy to find. I Google neighborhoods, buildings, and addresses. I also crowd surf for recommendations and thoughts on areas. City-Data also provides a lot of useful neighborhood data.