Travellers' Diarrhea
Clinical Snapshot
Travellers' diarrhea (TD) is the sudden onset of abnormally loose or frequent stools occurring during or shortly after international travel, most often within the first 2 weeks at a destination given its short incubation period.[1] It is one of the most common travel-related health problems and one of the most frequent travel-health consultations a community pharmacist provides — both before departure, where destination-risk-stratified counselling and self-treatment-kit preparation are core pharmacist tasks, and at the point of need, where the traveller is often self-managing without reliable access to medical care. Most TD is bacterial, predominantly enterotoxigenic and enteroaggregative Escherichia coli, with Campylobacter, Salmonella and Shigella also common; norovirus, astrovirus and rotavirus cause most viral TD, and Giardia and Cryptosporidium are the leading protozoal causes.[1] TD is generally self-limited, but its clinical course cannot be reliably predicted at onset, and an episode does not protect against a second episode on the same trip. This chapter covers the traveller-specific angle of acute diarrhea — destination risk stratification, prevention counselling, and severity-matched self-treatment; general acute-diarrhea principles (non-traveller etiology, testing thresholds, Clostridioides difficile) are covered separately in Acute Diarrhea in Adults and become relevant again once a traveller has returned home.
Recognize the Condition
Typical presentation
Abrupt onset of loose or watery stools, typically within the first 2 weeks at a higher-risk destination, often with abdominal cramping, urgency, nausea and malaise. Severity is classified by functional impact on the traveller's planned activities, not by stool frequency, since this is what actually drives the self-treatment decision.[1]
| Severity | Definition |
|---|---|
| Mild | Diarrhea is tolerable, not distressing, and does not interfere with planned activities. |
| Moderate | Diarrhea is distressing or interferes with planned activities. |
| Severe | Diarrhea is incapacitating or completely prevents planned activities. |
| Dysentery | Passage of grossly bloody stools; dysentery is always classified as severe and is often accompanied by fever and more pronounced systemic symptoms. |
| Persistent | Diarrhea lasting 2 weeks or more. |
Causative pathogens
Knowing the dominant pathogen categories explains why empiric antibiotic choice differs by destination and by presentation.[1]
| Bacteria | Virus | Protozoa |
|---|---|---|
| Enterotoxigenic Escherichia coli (ETEC) and enteroaggregative E. coli (EAEC) — the predominant bacterial causes in adults Campylobacter Salmonella Shigella | Norovirus Astrovirus Rotavirus | Giardia Cryptosporidium |
Risk Factors
- Travel to an intermediate- or high-risk destination — most of Asia, the Middle East, Africa and Latin America are high-risk (attack rate over 20% in the first 2 weeks); parts of Southern/Eastern Europe, Israel, South Africa, and some Caribbean and Pacific islands are intermediate-risk (8% to 20%); Western Europe, the United States, Canada, Australia, New Zealand and Japan are low-risk (under 8%).[1][2]
- Travel during the hot or rainy season, which raises TD attack rates at many destinations, particularly in South Asia.
- Itinerary and accommodation type — backpacking, rural travel, and travel with less-controlled food preparation carry higher risk than resort- or cruise-based travel with more reliable food-safety standards.
- Reduced gastric acidity — proton pump inhibitor or H2-receptor antagonist use increases susceptibility to enteric infection; reassess the ongoing need for these agents before travel to a high-risk destination.
- Prior gastric surgery or another cause of achlorhydria.
- Underlying gastrointestinal disease — inflammatory bowel disease or a history of irritable bowel syndrome.
- Immunocompromise or significant comorbidity — heart failure, insulin-dependent diabetes, inflammatory bowel disease and chronic kidney disease all raise the risk of TD complications and are specifically relevant to pre-travel prophylaxis and vaccine decisions.
- Food and beverage choices at the destination — raw or undercooked food, unpasteurized dairy, tap water or ice, and food from street vendors.
- Local sanitation and food-handling infrastructure at the destination — a larger overall driver of risk than an individual traveller's own precautions.
Red Flags & Refer
Escalate to medical care — rather than continuing self-treatment — for any of the following:
- Bloody diarrhea or dysentery — suggests an invasive/inflammatory pathogen; antimotility agents should be avoided or used only with real caution in this setting.
- High fever with systemic toxicity (chills, marked malaise), not simply a low-grade temperature.
- Signs of severe dehydration — marked thirst, decreased urination, dizziness or confusion, or an inability to keep fluids down — especially in young children, pregnant travellers and frail older adults.
- Diarrhea persisting beyond the expected short, self-limited course of TD, or lasting 2 weeks or more (persistent diarrhea) — this needs medical evaluation and stool studies rather than continued empiric self-treatment, since it may reflect a parasitic infection or another specific cause.
- An immunocompromised traveller, or one with significant comorbidity, who develops more than mild symptoms.
- Symptoms that have not improved within 48 hours despite appropriate severity-matched self-treatment.[1]
- Severe or worsening abdominal pain.
- New fever in a traveller with diarrhea who has visited a malaria-endemic region — malaria must be excluded promptly regardless of the diarrhea, since it is a medical emergency in its own right.
Assessment & Diagnosis
History
- Exact itinerary — destinations visited, urban versus rural, and dates — since this determines the applicable risk tier and the most likely resistant pathogens for empiric antibiotic selection.
- Timing of onset relative to travel — TD typically begins within the first 2 weeks at a destination; new diarrhea starting well into a long trip, or well after return, needs the general acute/persistent diarrhea approach rather than assumptions specific to arrival-related TD.
- Whether a pre-travel self-treatment kit (loperamide, bismuth subsalicylate and/or an antibiotic) was prescribed, and whether it has already been used, and at what dose.
- Functional severity — whether symptoms are tolerable, distressing, or incapacitating — this is what actually drives the treatment decision, not stool count.
- Presence of blood or mucus in the stool, and fever.
- Hydration status — thirst, urine output, dizziness, ability to tolerate oral fluids.
- Vaccination status (Dukoral) and any antibiotic prophylaxis taken.
- Comorbidities and immunosuppression, and current medications (including proton pump inhibitors/H2-receptor antagonists and anticoagulants, both relevant to treatment choice).
- For a returning traveller: exact date of return, and whether diarrhea has persisted 2 weeks or more.
When to test, and when not to
A traveller with mild-to-moderate TD during travel does not need stool testing — severity-matched self-treatment is started empirically, without waiting for or requiring a specific microbiologic diagnosis.
Send stool culture (and consider a multiplex molecular panel where available) in a returning traveller with severe symptoms, dysentery, symptoms that failed empiric self-treatment, or symptoms persisting 2 weeks or more.
Add stool ova and parasite testing specifically for persistent diarrhea (2 weeks or more) after return, since protozoal causes (Giardia, Cryptosporidium) become proportionally more likely the longer symptoms persist.
Persistent post-travel diarrhea — what else to consider
Diarrhea persisting after return is frequently post-infectious irritable bowel syndrome, which is common following TD. Also consider a specific parasitic infection, antibiotic-associated colitis (particularly if an antibiotic was used for TD itself), disaccharidase (lactose) deficiency, and bowel malignancy in an older traveller with a new bowel-habit change. An episode of TD can also unmask previously undiagnosed inflammatory bowel disease or celiac disease.[1]
Treatment Targets
- Reduce the risk of acquiring TD through pre-travel counselling and destination-appropriate prevention measures.
- Maintain hydration throughout the illness, regardless of severity or cause.
- Limit the duration and severity of symptoms, minimizing disruption to the itinerary.
- Match treatment intensity to functional severity — avoid unnecessary antibiotic exposure in mild disease, and avoid under-treating severe or dysenteric disease.
- Avoid worsening an invasive/dysenteric infection through inappropriate antimotility-agent use.
- Recognize when self-treatment has failed and medical care is needed, whether abroad or after return.
- Minimize the traveller's contribution to antimicrobial resistance and multidrug-resistant organism (MDRO) acquisition/transmission.
Choose Initial Treatment
Pre-travel: assess destination risk and prepare accordingly
For every traveller to an intermediate- or high-risk destination counsel on food/water precautions, discuss oral rehydration solution, and prescribe a self-treatment kit (loperamide plus bismuth subsalicylate, and an itinerary-appropriate antibiotic) so the traveller can begin severity-matched self-treatment immediately rather than waiting for medical care that may be unreliable at the destination.
Rehydration, at every severity
1st line, every traveller with TD, any severity begin oral rehydration therapy alongside any other treatment — this is the foundation of TD management regardless of cause or severity, and matters most for infants, pregnant travellers and frail older adults.
Mild TD
Mild TD (tolerable, not distressing, does not interfere with planned activities) loperamide and/or bismuth subsalicylate for symptomatic relief; no antibiotic is needed.
Moderate TD
Moderate TD (distressing or interferes with planned activities) loperamide (with or without bismuth subsalicylate) remains appropriate, and an itinerary-appropriate antibiotic may be added — the combination of loperamide and a single-dose antibiotic clears symptoms faster than either alone and is preferred when the traveller wants to preserve travel time.
Severe TD, including dysentery
Severe TD, including dysentery or TD with high fever start an antibiotic — azithromycin is preferred, given reliable activity against the invasive/dysenteric pathogens (Shigella, Campylobacter) most likely to cause this presentation.
Avoid loperamide, or use it only with real caution, in bloody diarrhea/dysentery or in TD with high fever — slowing gastrointestinal transit in a likely invasive infection could theoretically worsen toxin/organism retention; loperamide is not the initial priority in this presentation, and if used at all, it is only ever as an adjunct to antibiotic therapy, never as monotherapy for dysentery.[1]
Choosing the antibiotic by destination
South and Southeast Asia (including Thailand, India, Nepal and Indonesia) azithromycin is preferred first-line empiric therapy — Campylobacter is a common cause in this region and is frequently fluoroquinolone-resistant.
Latin America and Africa a fluoroquinolone (ciprofloxacin or levofloxacin) is a reasonable alternative where ETEC predominates, though azithromycin is increasingly preferred everywhere given its broader reliable coverage and fewer stewardship/adverse-effect concerns.
Single-dose versus multi-day regimens a single dose of azithromycin or a fluoroquinolone is as effective as a 3-day course for most travellers and is preferred for its simplicity — extend to the full 3-day course of the same agent if symptoms have not resolved after the single dose.
Do not select trimethoprim/sulfamethoxazole for TD treatment or prophylaxis — resistance is now too widespread for reliable empiric use.
Pre-exposure antibiotic prophylaxis
Reserve for narrow, specific situations — an immunocompromised traveller or one with significant comorbidity, critical short-term travel where any illness cannot be tolerated (for example, a diplomatic mission or an athletic competition), or a traveller who reports TD on every previous trip; it is not routine for the average traveller, given the adverse-effect burden and the antimicrobial-resistance/MDRO-acquisition risk that antibiotic use during travel carries.[2][3]
Rifaximin is the preferred agent when prophylaxis is genuinely indicated, despite prevention not being an approved Canadian indication for it — it stays largely non-absorbed in the gut, limiting systemic adverse effects.[1]
Do not use a fluoroquinolone for prophylaxis — evolving resistance has reduced its reliability, and fluoroquinolones carry class adverse effects (tendon, peripheral nerve and central nervous system effects) that are avoidable when prophylaxis is even genuinely warranted.
Non-Pharmacologic Treatment
Food and water precautions
"Boil it, cook it, peel it, or forget it" is a useful mnemonic, but counsel honestly: following these precautions reduces but does not eliminate risk — a traveller who follows the rules carefully can still become unwell, since local restaurant hygiene and destination sanitation infrastructure are the larger drivers of risk. Still worth practicing consistently:
- Drink only boiled, bottled (cap sealed and intact) or carbonated beverages; alcohol does not sterilize water or ice.
- Use ice only if made from safe water.
- Eat fruit (including tomatoes) only if washed in safe water and peeled; avoid salads and raw vegetables.
- Eat only thoroughly and recently cooked meat and fish; avoid leftovers and condiments left in open containers.
- Avoid food from street vendors.
- Wash hands with soap and water before eating; an alcohol-based hand sanitizer is an effective substitute when hands are not visibly dirty.
Water disinfection, when a safe supply is not otherwise available
- Heat — organisms are killed within seconds at boiling temperature, but boil for 1 minute to be safe.
- Filtration — effectiveness depends on filter pore size; follow filtration with chemical disinfection when possible.
- Chemical disinfection — chlorine (sodium hypochlorite or chlorine dioxide) or iodine (2% tincture, 5 drops per litre of clear water) as tablets or liquid. Limit iodine to a few weeks of emergency use given its physiologic effects, and use iodine resin filters (which transfer iodine to the organisms rather than leaving it in the water) where iodine exposure needs to be minimized.
- Ultraviolet (UV) light — kills bacteria, viruses and other parasites, but does not work in cloudy water; portable battery-operated units are available.
Reassess acid-suppressing therapy before high-risk travel
Reassess the ongoing need for a proton pump inhibitor or H2-receptor antagonist before travel to a destination with a high TD rate, since reduced gastric acidity increases the risk of acquiring an enteric pathogen.
Diet during an active episode
A simple diet that maintains hydration, contains a modest amount of sugar and electrolytes, and avoids fatty/oily foods and natural laxatives (caffeine, alcohol, excess fruit) is best tolerated. Bananas help replace mild potassium losses; dietary fibre can aggravate bloating and cramping during active symptoms.
Special Populations
Pregnancy
Pregnant travellers may be at increased risk of TD and its complications, since significant volume depletion can precipitate premature labour, placental insufficiency or shock — early fluid, energy and electrolyte replacement is the cornerstone of management.[1]
Avoid chemoprophylaxis in pregnancy — it is not recommended regardless of destination risk.
Loperamide is considered safe and can be used when needed.
Azithromycin is considered safe in pregnancy and is the antibiotic of choice if treatment is needed.
Avoid bismuth subsalicylate (bismuth encephalopathy risk) and fluoroquinolones (contraindicated in pregnancy, though the short courses used for TD have not been shown to increase teratogenicity).
Iodine is not recommended as a water disinfectant in pregnancy given a potential risk of fetal thyroid disease — recommend boiling, filtration or chlorine-based disinfection instead.
Breastfeeding
Continue breastfeeding during travel — it reduces the infant's own risk of acquiring a food/water-borne infection. Meticulous handwashing and breast hygiene limit transmission of infecting organisms to the infant.
Azithromycin and loperamide may be used for TD during breastfeeding. Avoid iodine water disinfection, bismuth subsalicylate and fluoroquinolones while breastfeeding.
Pediatrics
Children are at increased risk of rapid, severe dehydration — start oral rehydration therapy early and travel with a commercial oral rehydration product. Rotavirus is a more prominent cause in children under 3 than in adults.
Do not use loperamide in children under 2 years, or in a child who is malnourished, moderately-to-severely dehydrated, systemically unwell, febrile, or has bloody diarrhea — adverse effects outweigh benefit in these situations.
Loperamide may be used with caution in travelling children over 2 years old, limited to 2 days of treatment; see Drug Tables for weight-based pediatric dosing.
Bismuth subsalicylate is contraindicated in children under 2 years, and should be used cautiously in older children given the Reye syndrome risk associated with its salicylate component.
Azithromycin is the paediatric antibiotic of choice for TD when treatment is needed. Ciprofloxacin has traditionally been avoided in children over concern for cartilage effects, but the short 1-3 day courses used for TD are considered acceptable when specifically indicated. Trimethoprim/sulfamethoxazole is limited by the same resistance seen in adults.
Older adults
Dehydration develops faster and can present atypically (confusion, falls) rather than with classic thirst — have a lower threshold to start oral rehydration therapy and to seek medical care if oral intake cannot keep pace with losses, particularly for a frail traveller with limited reserve.
Immunocompromised travellers and those with significant comorbidity
These travellers carry a higher risk of TD complications and are the group for whom pre-exposure antibiotic prophylaxis is most often genuinely appropriate (see Choose Initial Treatment). Have a lower threshold to seek medical care rather than continuing self-treatment if symptoms are more than mild.
Renal impairment
Use bismuth subsalicylate with caution given reduced clearance of the salicylate component. Confirm current renal dose adjustment for rifaximin and for any fluoroquinolone before recommending in significant renal impairment.
Monitoring & Follow-Up
During travel, reassess functional severity and hydration status regularly — ask about the number and character of stools, ability to tolerate oral fluids, and whether planned activities are still possible. Escalate to medical care rather than continuing self-treatment if symptoms have not improved within 48 hours of an appropriately severity-matched regimen, or if new red-flag features develop (blood, high fever, signs of dehydration).[1] After return, investigate diarrhea that has persisted 2 weeks or more with stool culture and ova/parasite testing as first-line tests, since post-infectious irritable bowel syndrome, a specific parasitic infection, and (if an antibiotic was used) antibiotic-associated colitis are all more likely the longer symptoms persist. On the next visit, confirm the traveller's self-treatment kit was actually used correctly (right agent, right severity trigger), and counsel that a traveller treated with antibiotics abroad may carry a multidrug-resistant organism for a period after return — this is relevant context for any future prescriber, particularly around subsequent infections or hospitalization.[3]
Common Errors to Avoid
- Using loperamide as monotherapy — or at all without real caution — in bloody diarrhea/dysentery or in TD with high fever.
- Defaulting to a fluoroquinolone as first-line empiric therapy for a South or Southeast Asian itinerary despite well-documented Campylobacter fluoroquinolone resistance there.
- Prescribing routine antibiotic prophylaxis for an average traveller — this is reserved for narrow, specific high-risk situations, not standard pre-travel counselling.
- Recommending bismuth subsalicylate to a traveller on an anticoagulant or another salicylate, or to a pregnant traveller or a child under 12.
- Giving food/water precaution counselling as though it were fully protective, rather than honestly framing it as a real-but-incomplete risk reduction.
- Sending a traveller to an intermediate- or high-risk destination without a self-treatment kit (loperamide, bismuth subsalicylate and an itinerary-appropriate antibiotic) when one is clinically appropriate.
- Recommending iodine-based water disinfection for a pregnant traveller.
- Continuing self-treatment well beyond 48 hours without improvement instead of directing the traveller to seek medical care.
- Missing malaria as a cause of fever in a traveller who also has diarrhea and a malaria-endemic itinerary.
- Treating persistent post-travel diarrhea (2 weeks or more) with continued antimotility/antibiotic self-treatment instead of pursuing stool studies.
- Failing to warn against nonprescription antidiarrheal products purchased abroad, some of which contain chloramphenicol or iodochlorhydroxyquin.
- Reflexively using antibiotics for every case of moderate TD rather than reserving them for when loperamide/bismuth subsalicylate alone is failing or symptoms are more than mild — unnecessary antibiotic use increases MDRO acquisition risk without benefit in truly mild disease.[3]
Clinical Decision Algorithm
Drug Tables
How to use this table: Doses are adult doses unless otherwise labelled and require patient-specific confirmation, including renal adjustment. Levofloxacin is linked below to its oral/IV Drug Database monograph, not the inhaled Quinsair monograph that shares the bare "levofloxacin" name in this database — the inhaled formulation is not relevant to travellers' diarrhea. Select any drug name to open its complete Pharmasist Drug Database page.
Oral Rehydration Therapy
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Oral rehydration solution (balanced electrolyte) | Adults and children: Dissolve sachet contents in safe water per product directions; sip frequently to replace ongoing stool losses, in addition to usual fluid intake, until diarrhea resolves Emergency homemade substitute, if no commercial product is available: 1/2 teaspoon (2.5 mL) table salt plus 6 teaspoons (30 mL) sugar dissolved in 1 L of safe water | Rare; nausea or bloating if prepared too concentrated | None significant | Carry enough commercial sachets (Gastrolyte, Pedialyte and generic equivalents) to prepare 2-4 L of solution. If genuinely unavailable, an emergency substitute can be prepared from safe water.[4] |
Intestinal Adsorbents
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Bismuth subsalicylate | Prevention (chemoprophylaxis): 2 tablets (524 mg) or 30 mL suspension PO QID, continued through the risk period Treatment, adults: 2-4 tablets (524-1048 mg) or 30-60 mL suspension PO every 30-60 minutes PRN, maximum 4.2 g (8 doses)/24h | Black tongue/stool (harmless, may mimic melena), mild tinnitus; salicylate toxicity with excess/prolonged use | Decreases absorption of tetracyclines/doxycycline (separate by 2 or more hours); additive bleeding/GI risk with ASA, other salicylates, NSAIDs and anticoagulants | Avoid in travellers taking anticoagulants or therapeutic-dose salicylates, or with salicylate allergy. Avoid in children under 12 and in pregnancy given bismuth encephalopathy risk with prolonged/high-dose use. Limit any course to under 3 weeks. |
Antimotility Agents
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Loperamide | Adults: 4 mg PO initially, then 2 mg PO after each loose stool, maximum 16 mg/day; self-treatment limited to 2 days Children 2-5y (13-20 kg), first 24h: 1 mg PO TID Children 6-8y (20-30 kg), first 24h: 2 mg PO BID Children 8-12y (over 30 kg), first 24h: 2 mg PO TID Children, from 24-48h: 0.1 mg/kg PO after each loose stool, not to exceed the initial dose Children under 2 years: Not recommended — do not use | Constipation, abdominal cramping, dizziness (rare), dry mouth, skin rash | None significant at recommended doses | For treatment only — not effective as prophylaxis. Avoid, or use only with real caution, in bloody diarrhea/dysentery, high fever, or in a malnourished/systemically unwell/dehydrated child.[1] |
Fluoroquinolones
Resistance has increased and geographic patterns have evolved — avoid as the empiric first choice for South/Southeast Asia and the Indian subcontinent, where fluoroquinolone-resistant Campylobacter and Shigella are common.[1]
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Ciprofloxacin | Treatment, adults: 500 mg PO BID x 3 days, or 500-1000 mg PO single dose Prophylaxis (off-label), adults: 500 mg PO once daily, for the risk period plus 1-2 days after return, to a maximum of 3 weeks total Children: Not recommended | Generally well tolerated; rarely nausea, diarrhea, tendinopathy, peripheral neuropathy and CNS effects that can rarely be persistent or disabling | None significant for a short TD course | Reasonable choice where ETEC predominates and local resistance is lower (e.g., Latin America, Africa). Stop and reassess if the traveller develops tendon pain. |
| Levofloxacin | Treatment, adults: 500 mg PO once daily x 3 days, or 1000 mg PO single dose Prophylaxis (off-label), adults: 500 mg PO once daily, for the risk period plus 1-2 days after return, to a maximum of 3 weeks total Children: Not recommended | Generally well tolerated; rarely nausea, diarrhea, tendinopathy, peripheral neuropathy and CNS effects that can rarely be persistent or disabling | None significant for a short TD course | Same regional resistance caution as ciprofloxacin. |
| Norfloxacin | Treatment, adults: 400 mg PO BID x 3 days, or 800 mg PO single dose Prophylaxis (off-label), adults: 400 mg PO once daily, for the risk period plus 1-2 days after return, to a maximum of 3 weeks total Children: Not recommended | Generally well tolerated; rarely nausea, diarrhea, tendinopathy, peripheral neuropathy and CNS effects that can rarely be persistent or disabling | None significant for a short TD course | Same regional resistance caution as ciprofloxacin. |
Macrolides
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Azithromycin | Treatment, adults: 1000 mg PO single dose, or 500 mg PO once daily x 3 days Treatment, children: 5-10 mg/kg PO (maximum 500 mg) once daily x 3 days | Generally well tolerated; abdominal pain, nausea, vomiting, diarrhea — dose-related with the single 1000 mg dose | None significant for a short TD course | Preferred antibiotic for South/Southeast Asia given fluoroquinolone-resistant Campylobacter, and preferred for dysentery/febrile TD at any destination. Safe in children and in pregnancy. Not recommended for prophylaxis.[2][1] |
Semi-synthetic Rifamycin Antibiotics
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Rifaximin | Treatment, adults and children 12 years and older: 200 mg PO TID x 3 days Prophylaxis (off-label), adults: 200-600 mg PO daily in 1-3 divided doses, for the risk period | Headache; hypersensitivity reactions (rare); otherwise well tolerated given minimal systemic absorption | None significant given minimal systemic absorption | Not an approved treatment or prevention indication in Canada, though CATMAT and ISTM guidance both support its use for TD. Not effective for dysentery — do not use if blood or high fever is present.[4] |
Vaccines
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Cholera and enterotoxigenic E. coli (ETEC) diarrhea vaccine | Primary immunization, adults and children 2 years and older: 2 oral doses, the second given 7-42 days after the first and at least 1 week before arrival at the destination; if more than 42 days have passed since the first dose, restart the primary series Booster: 1 dose if the last dose was under 5 years ago; repeat the full 2-dose primary series if the last dose was 5 or more years ago Administration: Taken on an empty stomach, 1 hour before or after eating or drinking | Abdominal pain, diarrhea, nausea, vomiting | None significant | Approved in Canada for prevention of TD caused by ETEC specifically. Evidence supporting routine TD-prevention use is limited and it is not routinely recommended for all travellers — consider selectively for a traveller with a chronic illness (e.g., heart failure, insulin-dependent diabetes, inflammatory bowel disease, chronic kidney disease) or immune suppression.[4] |
References
- Guidelines for the Prevention and Treatment of Travelers' Diarrhea: A Graded Expert Panel Report — Journal of Travel Medicine, International Society of Travel Medicine (Riddle MS, Connor BA, Beeching NJ, et al.). J Travel Med 2017;24(Suppl 1):S63-S80
- Travelers' Diarrhea — CDC Yellow Book, 2026 Edition: Health Information for International Travel, Centers for Disease Control and Prevention (Connor BA, Leung DT). CDC Yellow Book 2026 edition, published Apr 23, 2025
- Acquisition of Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae (ESBL-PE) Carriage after Exposure to Systemic Antimicrobials during Travel: Systematic Review and Meta-Analysis — Travel Medicine and Infectious Disease (Wuerz TC, Kassim SS, Atkins KE). Travel Med Infect Dis 2020;37:101823
- Summary of the Committee to Advise on Tropical Medicine and Travel (CATMAT) Statement on Travellers' Diarrhea — Canada Communicable Disease Report, Public Health Agency of Canada (Libman M; CATMAT). Can Commun Dis Rep 2015;41(11):272-284
Professional reference only. Apply clinical judgment and verify patient-specific decisions against current authoritative guidance and product information.