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Management of travellers’ diarrhoea

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• Peer review
• David R Hill , director, honorary professor 1 ,
• Edward T Ryan , director, associate professor 2
• 1 National Travel Health Network and Centre, and London School of Hygiene and Tropical Medicine, Hospital for Tropical Diseases, London WC1E 6JB
• 2 Travelers’ Advice and Immunization Center, and Tropical and Geographic Medicine Center, Massachusetts General Hospital, Boston, USA
• Correspondence to: D R Hill david.hill{at}uclh.org

Travellers’ diarrhoea is one of the most common illnesses in people who travel internationally, and depending on destination affects 20-60% of the more than 800 million travellers each year. In most cases the diarrhoea occurs in people who travel to areas with poor food and water hygiene. 1 This review examines the approach to the prevention and treatment of diarrhoea in travellers. Much of the evidence base for travellers’ diarrhoea has been established over the past 30 years, with a strong body of randomised trials and consensus opinion in support of recommendations. The use of antibiotics for self treatment or chemoprophylaxis, however, remains debatable.

Sources and selection criteria

We identified articles through an electronic search of PubMed and the Cochrane library using the term “travelers’ diarrhea” alone and in combination with “treatment”, “etiology”, and “prevention”. Additional studies were sourced from the retrieved articles. We also reviewed our extensive collection of articles on the subject, as well as current national guidelines in travel medicine.

Summary points

Travellers’ diarrhoea affects 20-60% of people travelling primarily to low income regions

Classic travellers’ diarrhoea is defined as three or more loose stools in 24 hours with or without at least one symptom of cramps, nausea, fever, or vomiting

Bacteria cause most identified cases; however, viruses and protozoan parasites are also causative

The objectives of self treatment are to avoid dehydration, reduce the symptoms and duration of illness, and prevent disruption to planned activities

Travellers should maintain hydration, and can use bismuth subsalicylate to treat mild diarrhoea, loperamide to control symptoms when necessary, and a short course of an antibiotic to treat moderate to severe cases

Evaluation and management of returned travellers with diarrhoea includes maintaining hydration during mild illness, bacterial culture of stools and empirical treatment during moderate to severe illness, and, in protracted cases, examination of stools for ova and parasites

What is travellers’ diarrhoea?

Classic travellers’ diarrhoea is defined as at least three loose to watery stools in 24 hours with or without one or more symptoms of abdominal cramps, fever, nausea, vomiting, or blood in the stool. Mild to moderate diarrhoea is one or two loose stools in 24 hours with or without another enteric symptom. The median time to onset is six or seven days after arrival. Although the diarrhoea often resolves spontaneously over three or four days, up to a quarter of affected travellers need to alter their plans, interrupting their holiday or business activities. 2

What causes travellers’ diarrhoea?

The causes of travellers’ diarrhoea depend on the destination, setting, and season, although studies have been done in only a limited number of countries (table 1 ⇓ ). 3 4 Enteric bacteria are documented as the most common causes: several types of Escherichia coli and Campylobacter , Salmonella , and Shigella spp; Vibrio cholerae is rare in travellers. Enterotoxigenic E coli that produce a heat labile or heat stable toxin are the most common species of E coli implicated, with enteroaggregative E coli increasingly recognised. 5 Enterohaemorrhagic E coli (producing shiga toxin or vero cytotoxin) are not typically described in travellers. Enterotoxigenic E coli predominates in travellers to Latin America but is also seen globally. Rates of Campylobacter infection per traveller are highest in those visiting South Asia and South East Asia, 6 exceeding those of enterotoxigenic E coli in some studies.

 Causes of travellers’ diarrhoea

• View inline

Norovirus and rotavirus are the most commonly identified viral causes of travellers’ diarrhoea, although these agents have not been uniformly examined. 7 Norovirus is often associated with outbreaks of diarrhoea in holiday resorts or on cruise ships. Parasites are less common causes of travellers’ diarrhoea; of these, the protozoa Giardia intestinalis and Cryptosporidium are most commonly identified. 8 Cyclospora and Entamoeba histolytica are less common causes, and typically associated with long term travel. In 10-15% of cases more than one pathogen is identified, and in up to 50% of studies no pathogen is described. 4 9 Acute food poisoning—the sudden onset of nausea, vomiting, and diarrhoea after ingestion of a toxin (usually produced by Staphylococcus aureus , Bacillus cereus , or Clostridium perfringens ) in food that has not been properly cooked or stored, accounts for up to 5% of cases.

What are the consequences of having travellers’ diarrhoea?

As the causes of travellers’ diarrhoea are multiple the clinical features vary: from the typical watery stools with cramping and nausea associated with enterotoxigenic E coli , to dysentery with Shigella , to short lived nausea, vomiting, and diarrhoea associated with acute food poisoning or norovirus. Although most cases resolve without treatment over several days, in about 10% the symptoms persist for more than a week, and in about 2% for more than a month. 2 About one quarter of travellers alter their plans because of diarrhoea, and about 5% seek medical care. 2 Illness tends to be more severe in infants and young children, and precautions should be taken to deal with a potentially dehydrating diarrhoeal illness in children when travelling. Serious complications include haemolytic uraemic syndrome with bacteria that produce shiga toxin, Guillain Barré syndrome with Campylobacter , and post-infectious arthropathies with any invasive bacteria. Prolonged illness (>10 days), illness that begins after return, and illness associated with weight loss are more likely to be caused by protozoan parasites such as Giardia .

Irritable bowel syndrome can occur after travellers’ diarrhoea. In two prospective observational studies, travellers who had diarrhoea were more likely to have a new diagnosis of irritable bowel syndrome at six months after return. 10 11

How can travellers’ diarrhoea be prevented?

Food, water, and personal hygiene.

Travellers’ diarrhoea is acquired through the ingestion of contaminated food and water, therefore strict food, water, and personal hygiene precautions should decrease the risk (see box). Despite an increased understanding of the causes and pathogenesis of travellers’ diarrhoea, its incidence has not substantially decreased over the past few decades, and travellers who practise preventive measures do not always have a lower incidence of the condition. The risk of travellers’ diarrhoea increasingly seems related to the sanitation level at the destination rather than the ability to adhere to avoidance measures. 12 13 14 15

Diet and personal hygiene measures to prevent travellers’ diarrhoea

Foods and beverages to be avoided.

Raw or undercooked meats, fish, and seafood

Unpasteurised milk, cheese, ice cream, and other dairy products

Tap water and ice cubes

Cold sauces and toppings

Ground grown leafy greens, vegetables, and fruit

Cooked foods that have stood at room temperature in warm environments

Food from street vendors, unless freshly prepared and served piping hot

Hygiene measures

Render water potable by either bringing it to a boil or treating it with chlorine or iodine preparations* and filtering with a filter of 1 µm or less

Wash hands before eating

*Protozoan parasites are relatively resistant to chlorine and iodine. Contact time should be extended for cold or turbid water

No single vaccine prevents travellers’ diarrhoea, because of the multiple potential causes. Enteric vaccines prevent rotavirus (being introduced into childhood immunisation programmes), hepatitis A, typhoid, and cholera and such vaccines can be given when indicated after a careful risk assessment based on destination and itinerary.

Some enterotoxigenic E coli strains express a heat labile enterotoxin that is similar to cholera toxin produced by V cholerae . Consideration has therefore been given to using the oral killed cholera vaccine (Dukoral; Crucell, Leiden), which contains a non-toxic portion of cholera vaccine, to induce cross protective immunity against enterotoxigenic E coli . Up to 50% of enterotoxigenic E coli strains do not, however, express heat labile enterotoxin, and an analysis of studies suggests that using oral killed cholera vaccine would prevent only 1-7% of people from developing travellers’ diarrhoea, depending on destination and frequency of heat labile producing entertoxigenic E coli . 16 In a phase II trial, vaccination of travellers with heat labile enterotoxin using a transcutaneous delivery system showed 75% protective efficacy against all cause moderate to severe diarrhoea (defined as ≥4 stools in 24 hours). 17 Although no difference was found in the overall incidence of diarrhoea between the recipients of the vaccine and those of placebo, vaccine recipients had fewer stools and a shorter duration of illness.

Chemoprophylaxis

Chemoprophylaxis comprises two approaches: the use of non-antibiotic products (bismuth subsalicylate and probiotics) and the use of antibiotics. Bismuth subsalicylate (preferably in tablet form) provides about 60% protection against travellers’ diarrhoea; however, adverse events may be common at the most effective doses. 18 A meta-analysis suggests that probiotics can lessen the likelihood of travellers’ diarrhoea by about 15%. 19

Although several randomised placebo controlled studies in the 1970s and ‘80s showed antibiotic prophylaxis to be effective in preventing travellers’ diarrhoea, it is not currently recommended for most travellers for several reasons: the potential adverse events associated with prophylactic antibiotics, predisposition to other infections such as vaginal candidiasis or Clostridium difficile associated disease, development of bacterial resistance, cost, and lack of data on the safety and efficacy of antibiotics given for more than two or three weeks. 20 In addition, the highly efficacious nature of early self treatment of travellers’ diarrhoea further dampens enthusiasm for chemoprophylaxis with antibiotics.

Expert opinion supports the use of prophylactic antibiotics when a trip is vitally important or the consequences of watery diarrhoea would be difficult to manage (for example, after colostomy or ileostomy). Sulfonamides and tetracyclines should not be used because of widespread resistance. A fluoroquinolone is the drug of choice when travelling to most areas of the world, and several randomised trials support its efficacy. 20 Campylobacter spp are often resistant to fluoroquinolones, and when the relative risk is higher, such as in South Asia and South East Asia, azithromycin can be considered. No trials have been published on this agent when used for prophylaxis. Rifaximin, a poorly absorbed derivative of rifamycin, is an alternative choice in regions where E coli predominates, such as Latin America and Africa. 21 Because of decreased efficacy, it should not be used when potentially invasive pathogens such as Salmonella , Campylobacter , and Shigella are likely.

How can travellers’ diarrhoea be treated?

Since behavioural modifications, vaccines, and chemoprophylaxis have limited efficacy on travellers’ diarrhoea or may be associated with adverse events, consensus opinion based on randomised placebo controlled and comparative trials supports self treatment (table 2 ⇓ ). The goals of treatment are to avoid dehydration, reduce the severity and duration of symptoms, and prevent interruption to planned activities.

 Approach to prophylaxis and treatment of travellers’ diarrhoea in adults

Hydration and diet

Hydration is a key intervention that should be done for all forms of diarrhoea and is often all that is necessary in mild illness. Infants and young children, elderly people, and those with chronic debilitating medical conditions can maintain hydration by drinking oral rehydration formulations that combine electrolytes, sugar, and buffer. A randomised trial on healthy adolescents and adults who were taking loperamide for symptomatic treatment of travellers’ diarrhoea, however, showed no additional benefit from specific oral rehydration compared with drinking potable fluids ad libitum. 22 It is a sensible recommendation during recovery from travellers’ diarrhoea to gradually advance the diet from liquids to more complex solids, although this recommendation may not provide additional benefit if the diarrhoea is also being treated with an antibiotic. 23

Symptomatic treatment

The two most common symptomatic treatments for travellers’ diarrhoea are bismuth subsalicylate or an antimotility agent. Symptomatic treatment alone can be considered for mild to moderate diarrhoea. In a randomised placebo controlled trial, bismuth subsalicylate reduced the number of loose stools by about 50% and was helpful in reducing nausea. 24 Bismuth subsalicylate can be recommended for people with mild diarrhoea, but more effective agents are available for those with moderate or severe diarrhoea. Loperamide has become an antimotility agent of choice because of supporting trials in travellers and its favourable adverse event profile. In a randomised comparative trial with bismuth subsalicylate, loperamide was more effective in controlling diarrhoea and cramping and had a more rapid onset of action, usually within the first four hours. 25 Loperamide should not be given to young children, those with diarrhoea and fever (>38.5°C), or when there is gross blood in the stools. Information on probiotics in the treatment of travellers’ diarrhoea is insufficient.

Antibiotic treatment

Many randomised placebo controlled and comparative trials done over the past 25 years have shown the efficacy of antibiotics in the treatment of travellers’ diarrhoea. 26 Most trials indicate that an antibiotic taken as a single dose or for up to three days will improve the condition within 20 to 36 hours. This shortens the duration of diarrhoea by one or two days when compared with controls taking placebo. Adverse events associated with short course therapy are usually mild. The application of this evidence base to clinical practice has differed among clinicians: some advocate prompt self treatment with antibiotics for moderate to severe travellers’ diarrhoea, whereas others urge a more cautious approach to what is usually a self limited illness. Clinicians will need to decide in discussion with the traveller they are advising, the most appropriate approach, taking into account the traveller’s ability and willingness to tolerate a diarrhoeal illness during his or her trip.

Fluoroquinolones are effective for travellers’ diarrhoea acquired in most areas of the world, except when potentially resistant Campylobacter is common, such as in South Asia and South East Asia. 27 A growing body of evidence documents the effectiveness of azithromycin in treating fluoroquinolone resistant Campylobacter , 28 as well as other enterics. 27 Azithromycin can also be used in the treatment of pregnant women and young children with travellers’ diarrhoea; however, the empirical antibiotic treatment of young children should only be used after careful consideration. Rifaximin was not inferior to a fluoroquinolone in a randomised, double blind trial of treatment in Mexico and Jamaica 29 where E coli associated travellers’ diarrhoea was common, but rifaximin is less effective and not recommended when invasive agents, such as Campylobacter and Shigella , are causative. 30

Combination treatment

Combining an antibiotic with loperamide should be considered for people with classic travellers’ diarrhoea who need prompt resolution of symptoms. Six randomised controlled trials examined combination treatment (single dose or short course antibiotics plus loperamide) compared with an antibiotic or loperamide alone. 31 32 The weight of evidence favoured combination treatment when the predominate organisms were sensitive to the antibiotic. 31 32

How should returned travellers with diarrhoea be evaluated?

Diarrhoea is one of the most common syndromes in travellers who return ill. In a US cohort of returned travellers, diarrhoea affected 13%, 2 and in a large multicentre study (travel clinics and tropical disease units) acute or chronic diarrhoea was diagnosed at a rate of 335 cases per 1000 ill returned travellers. 33 Regions associated with the highest relative rates of gastrointestinal infection, as determined by numbers of clinical visits in returned travellers, were South Asia, South America, and sub-Saharan Africa. 1

Travellers’ diarrhoea can be evaluated in a general practice setting with referral to a specialist as needed. If fever, tenesmus, or gross blood in the stool are not present (that is, non-inflammatory diarrhoea) patients can be treated symptomatically and observed. If the patient seems unwell and there are additional symptoms, however, a stool should be cultured for enteropathogens and empirical antibiotic treatment considered using a fluoroquinolone or azithromycin. Unusually, C difficile associated disease presents after antibiotic treatment for travellers’ diarrhoea. 34 In travellers with diarrhoea that has lasted for 10 days to two weeks or longer, stool samples should be evaluated for Giardia , Cryptosporidium , and other parasites.

Tips for non-specialists

Discuss the likelihood of travellers’ diarrhoea with someone who is planning to travel and advise about avoidance measures to decrease the risk of illness: safe foods, beverages, and eating establishments

Avoidance measures are not always sufficient in preventing travellers’ diarrhoea, therefore review self management options, including when to use symptomatic measures or take antibiotics, and when to seek medical care

Consider referring travellers who have special health needs (for example, HIV infection, immunocompromised, pregnant) to a specialist travel clinic for advice

Send a stool sample for microscopy and culture in returned travellers who are febrile and have complicated diarrhoea; empirical antibiotic treatment can be considered while awaiting the results of stool cultures

Treat afebrile patients who do not have tenesmus or gross blood in the stool symptomatically and observe. Give empirical antibiotic therapy—a fluoroquinolone or azithromycin—to patients who do present with such symptoms, after obtaining a stool sample

Questions for future research

What is the cause of travellers’ diarrhoea when a pathogen cannot be identified?

Do avoidance measures prevent illness?

How often do vero cytotoxin or shiga toxin producing E coli and C difficile associated disease occur in patients with travellers’ diarrhoea?

What is the frequency of irritable bowel syndrome after an episode of travellers’ diarrhoea, and what are the predisposing factors?

What is the role of rifaximin in the prevention and treatment of travellers’ diarrhoea?

How should vaccines be used in the prevention of travellers’ diarrhoea?

Additional educational resources

Ericsson CD, DuPont HL, Steffen, R, eds. Travelers’ diarrhea . 2nd ed. Hamilton, Ontario: BC Decker, 2008—reviews all aspects of travellers’ diarrhoea

World Health Organization. International Travel and Health 2008 ( www.who.int/ith/en/index.html )—authoritative guidance on travel medicine

Centers for Disease Control and Prevention. Health Information for International Travel 2008 ( wwwn.cdc.gov/travel/default.aspx )—authoritative guidance on travel medicine

Al-Abri SS, Beeching NJ, Nye FJ. Traveller’s diarrhoea. Lancet Infect Dis 2005;5:349-60

Diemert DJ. Prevention and self-treatment of traveler’s diarrhea. Clin Microbiol Rev 2006;19:583-94

Cite this as: BMJ 2008;337:a1746

Contributors: DRH planned the paper, wrote the first draft, and is the guarantor. ETR contributed to the content, helped to revise the paper, and agreed to the final submission.

Competing interests: None declared.

Provenance and peer review: commissioned; externally peer reviewed.

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Traveller's diarrhoea

• Overview  
• Theory  
• Diagnosis  
• Management  
• Follow up  
• Resources  

Traveller's diarrhoea is a common problem among travellers to destinations with deficiencies in water, sanitation, and hygiene (WASH) infrastructure, typically caused by the consumption of contaminated food or water. Predominantly caused by bacteria.

Prevention strategies include careful selection of food and beverages, though these are not fail-safe. Prophylactic antibiotics are not recommended for most travellers.

Management is self-diagnosis while still travelling, followed by hydration, medicine for symptom relief, and possibly, antibiotics. Antibiotic therapy is generally reserved for moderate to severe infections.

In healthy patients, resolution is typically within 3-5 days even without antibiotic treatment.

Traveller's diarrhoea (TD) is defined as ≥3 unformed stools in 24 hours accompanied by at least one of the following: fever, nausea, vomiting, cramps, tenesmus, or bloody stools (dysentery) during a trip abroad, typically to a destination with deficiencies in water, sanitation, and hygiene (WASH) infrastructure. It is usually a benign, self-limited illness lasting 3-5 days.

History and exam

Key diagnostic factors.

• presence of risk factors
• diarrhoea (with or without tenesmus), cramping, nausea, and vomiting
• dysentery (blood and fever)
• persistent diarrhoea >14 days

Other diagnostic factors

• diarrhoea without illness

Risk factors

• travel to a high-risk destination
• age <30 years
• proton-pump inhibitor use
• travellers with prior residence in higher-risk destination visiting friends and relatives
• travel during hot and wet seasons
• deployed military populations
• lack of caution in food and water selection

Diagnostic investigations

1st investigations to order.

• stool culture and sensitivity
• multi-pathogen molecular diagnostic (polymerase chain reaction)
• protozoal stool antigens

Investigations to consider

• stool ova and parasite examination
• Clostridioides difficile stool toxin
• colonoscopy, endoscopy, and biopsy
• haematology, blood chemistries, serology

Treatment algorithm

Pre-travel prophylaxis, non-pregnant adults: mild diarrhoea, non-pregnant adults: moderate diarrhoea, non-pregnant adults: severe diarrhoea, contributors, daniel t. leung, md, msc.

Associate Professor

Division of Infectious Diseases

University of Utah School of Medicine

Salt Lake City

Disclosures

DTL receives authorship royalties from UpToDate, Inc, for a chapter on travel medicine. DTL is an author of upcoming chapters on traveller's diarrhoea for the US CDC Yellow Book. DTL is the president-elect of the American Committee on Clinical Tropical Medicine and Travelers' Health - Clinical Group within the American Society of Tropical Medicine and Hygiene. DTL is an author of some of the references cited in this topic.

Jakrapun Pupaibool, MD, MS

JP declares that he has no competing interests.

Acknowledgements

Dr Daniel T. Leung and Dr Jakrapun Pupaibool would like to gratefully acknowledge Dr Mark Riddle and Professor Gregory Juckett, the previous contributor to this topic.

MR has given talks on the management of traveller's diarrhoea for the International Society of Travel Medicine (ISTM), the CDC Foundation, the American College of Gastroenterology (ACG), and the American College of Preventive Medicine. MR has led the development of guidelines for traveller's diarrhea for the ISTM, the ACG, and the Department of Defense. This work has been unpaid but support for travel has been accepted. MR is employed with Pfizer Inc., and is working on their Lyme disease vaccine programme. While this is not in conflict with traveller’s diarrhoea, Pfizer also makes azithromycin, which is an antibiotic recommended for the treatment of traveller’s diarrhoea. MR does not work in the area of Pfizer that develops, markets, or distributes azithromycin. MR is an author of several references cited in this topic. GJ declares that he has no competing interests.

Peer reviewers

Andrea summer, md.

Assistant Professor of Pediatrics

Medical University of South Carolina

AS declares that she has no competing interests.

Phil Fischer, MD

Professor of Pediatrics

Department of Pediatric and Adolescent Medicine

Mayo Clinic

PF is an author of a reference cited in this topic.

Differentials

• Food poisoning
• Irritable bowel syndrome
• Secondary disaccharidase (or other dietary) deficiency
• CDC Yellow Book 2024: travelers' diarrhea
• 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea

Patient information

Diarrhoea in adults

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Diarrhoea - prevention and advice for travellers

Last revised in September 2023

Travellers' diarrhoea is a clinical syndrome associated with contaminated food or water, that occurs during or shortly after travel

• Scenario: Diarrhoea - prevention and advice for travellers

Background information

• Risk factors
• Complications

Diarrhoea - prevention and advice for travellers: Summary

• Travellers' diarrhoea is defined as passing three or more unformed stools in a 24-hour period with at least one additional symptom, such as abdominal pain or cramps, nausea, vomiting, fever, or blood in the stools.
• Enteric bacteria are the most commonly documented (for example, Escherichia coli, Campylobacter spp., Salmonella spp., and Shigella spp .).
• Viruses and parasites can also cause travellers' diarrhoea.
• Low for people travelling to western European countries, the USA and Canada, Japan, Australia, and New Zealand.
• Intermediate for people travelling to southern European countries, Israel, South Africa, and some Caribbean and Pacific Islands.
• High for people travelling to Africa, Latin America, the Middle East, and most parts of Asia.
• Food hygiene and safe drinking water.
• Self-management and when to seek medical advice if diarrhoea develops during travel.
• The importance of personal hygiene, food hygiene, and safe drinking water should be emphasized.
• Advice regarding the risk of waterborne infection and avoiding contaminated recreational water should be offered.
• Antibiotic prophylaxis or 'stand-by' antibiotic treatment can be considered for certain high-risk travellers. Specialist advice should be sought.
• Most episodes are short-lived and self-limiting, lasting a few days.
• The person could consider purchasing sachets of oral rehydration salt before travelling.
• During an episode of diarrhoea, it is important to prevent dehydration — particularly for young children, pregnant women, elderly people, and those with pre-existing illnesses.
• Both loperamide and bismuth subsalicylate (for example, Pepto-Bismol ® ) may be considered in adults for the relief of mild-to-moderate diarrhoea. They should be used for a maximum of 2 days.
• When to seek medical assistance.

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Traveller's diarrhoea

Peer reviewed by Dr Colin Tidy, MRCGP Last updated by Dr Toni Hazell Last updated 10 Feb 2023

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In this series: Amoebiasis Giardia

Traveller's diarrhoea is diarrhoea that develops during, or shortly after, travel abroad. It is caused by consuming food and water, contaminated by germs (microbes) including bacteria, viruses and parasites. Other symptoms can include high temperature (fever), being sick (vomiting) and tummy (abdominal) pain. In most cases it causes a mild illness and symptoms clear within 3 to 4 days. Specific treatment is not usually needed but it is important to drink plenty of fluids to avoid lack of fluid in the body (dehydration). Always make sure that you get any advice that you need in plenty of time before your journey - some GPs offer travel advice but if yours doesn't then you may need to go to a private travel clinic.

In this article :

What is traveller's diarrhoea, what causes traveller's diarrhoea, are all travellers at risk, what are the symptoms of traveller's diarrhoea, how is traveller's diarrhoea diagnosed, when should i seek medical advice for traveller's diarrhoea, how is traveller's diarrhoea in adults treated, how is traveller's diarrhoea in children treated, side-effects of traveller's diarrhoea, how long does traveller's diarrhoea last, how can i avoid traveller's diarrhoea.

Traveller's diarrhoea is diarrhoea that develops during, or shortly after, travel abroad. Diarrhoea is defined as: 'loose or watery stools (faeces), usually at least three times in 24 hours.'

Traveller's diarrhoea is caused by eating food, or drinking water, containing certain germs (microbes) or their poisons (toxins). The types of germs which may be the cause include:

Bacteria: these are the most common microbes that cause traveller's diarrhoea. Common types of bacteria involved are:

Escherichia coli

Campylobacter

Viruses: these are the next most common, particularly norovirus and rotavirus.

Parasites: these are less common causes. Giardia, cryptosporidium and Entamoeba histolytica are examples of parasites that may cause traveller's diarrhoea.

Often the exact cause of traveller's diarrhoea is not found and studies have shown that in many people no specific microbe is identified despite testing (for example, of a stool (faeces) specimen).

See the separate leaflets called E. Coli (VTEC O157) , Campylobacter, Salmonella, Cryptosporidium , Amoebiasis (dysentery information), Shigella and Giardia for more specific details on each of the microbes mentioned above.

Note : this leaflet is about traveller's diarrhoea in general and how to help prevent it.

Continue reading below

Traveller's diarrhoea most commonly affects people who are travelling from a developed country, such as the UK, to a developing country where sanitation and hygiene measures may not meet the same standards. It can affect as many as 2 to 6 in 10 travellers.

There is a different risk depending on whether you travel to high-risk areas or not:

High-risk areas : South and Southeast Asia, Central America, West and North Africa, South America, East Africa.

Medium-risk areas : Russia, China, Caribbean, South Africa.

Low-risk areas : North America, Western Europe, Australia and New Zealand.

Sometimes outbreaks of diarrhoea can occur in travellers staying in one hotel or, for example, those staying on a cruise ship. People travelling in more remote areas (for example, trekkers and campers) may also have limited access to medical care if they do become unwell.

By definition, diarrhoea is the main symptom. This can be watery and can sometimes contain blood. Other symptoms may include:

Crampy tummy (abdominal) pains.

Feeling sick (nausea).

Being sick (vomiting).

A high temperature (fever).

Symptoms are usually mild in most people and last for 3 to 4 days but they may last longer. Symptoms may be more severe in the very young, the elderly, and those with other health problems. Those whose immune systems are not working as well as normal are particularly likely to be more unwell. For example, people with untreated HIV infection, those on chemotherapy, those on long-term steroid treatment or those who are taking drugs which suppress their immune system, for example after a transplant or to treat an autoimmune condition

Despite the fact that symptoms are usually fairly mild, they can often mean that your travel itinerary is interrupted or may need to be altered.

Traveller's diarrhoea is usually diagnosed by the typical symptoms. As mentioned above, most people have mild symptoms and do not need to seek medical advice. However, in some cases medical advice is needed (see below).

If you do see a doctor, they may suggest that a sample of your stool (faeces) be tested. This will be sent to the laboratory to look for any microbes that may be causing your symptoms. Sometimes blood tests or other tests may be needed if you have more severe symptoms or develop any complications.

As mentioned above, most people with traveller's diarrhoea have relatively mild symptoms and can manage these themselves by resting and making sure that they drink plenty of fluids. However, you should seek medical advice in any of the following cases, or if any other symptoms occur that you are concerned about:

If you have a high temperature (fever).

If you have blood in your stools (faeces).

If it is difficult to get enough fluid because of severe symptoms: frequent or very watery stools or repeatedly being sick (vomiting).

If the diarrhoea lasts for more than 5-7 days.

If you are elderly or have an underlying health problem such as diabetes, inflammatory bowel disease, or kidney disease.

If you have a weakened immune system because of, for example, chemotherapy treatment, long-term steroid treatment, or HIV infection.

If you are pregnant.

If an affected child is under the age of 6 months.

If you develop any of the symptoms listed below that suggest you might have lack of fluid in your body (dehydration). If it is your child who is affected, there is a separate list for children.

Symptoms of dehydration in adults

Dizziness or light-headedness.

Muscle cramps.

Sunken eyes.

Passing less urine.

A dry mouth and tongue.

Becoming irritable.

Symptoms of severe dehydration in adults

Profound loss of energy or enthusiasm (apathy).

A fast heart rate

Producing very little urine.

Coma, which may occur.

Note : severe dehydration is a medical emergency and immediate medical attention is needed.

Symptoms of dehydration in children

Passing little urine.

A dry mouth.

A dry tongue and lips.

Fewer tears when crying.

Being irritable.

Having a lack of energy (being lethargic).

Symptoms of severe dehydration in children

Drowsiness.

Pale or mottled skin.

Cold hands or feet.

Very few wet nappies.

Fast (but often shallow) breathing.

Dehydration is more likely to occur in:

Babies under the age of 1 year (and particularly those under 6 months old). This is because babies don't need to lose much fluid to lose a significant proportion of their total body fluid.

Babies under the age of 1 year who were a low birth weight and who have not caught up with their weight.

A breastfed baby who has stopped being breastfed during their illness.

Any baby or child who does not drink much when they have a gut infection (gastroenteritis).

Any baby or child with severe diarrhoea and vomiting. (For example, if they have passed five or more diarrhoeal stools and/or vomited two or more times in the previous 24 hours.)

In most cases, specific treatment of traveller's diarrhoea is not needed. The most important thing is to make sure that you drink plenty of fluids to avoid lack of fluid in your body (dehydration).

Fluid replacement

As a rough guide, drink at least 200 mls after each watery stool (bout of diarrhoea).

This extra fluid is in addition to what you would normally drink. For example, an adult will normally drink about two litres a day but more in hot countries. The above '200 mls after each watery stool' is in addition to this usual amount that you would drink.

If you are sick (vomit), wait 5-10 minutes and then start drinking again but more slowly. For example, a sip every 2-3 minutes but making sure that your total intake is as described above.

You will need to drink even more if you are dehydrated. A doctor will advise on how much to drink if you are dehydrated.

Note : if you suspect that you are becoming dehydrated, you should seek medical advice.

For most adults, fluids drunk to keep hydrated should mainly be water. However, this needs to be safe drinking water - for example, bottled, or boiled and treated water. It is best not to have drinks that contain a lot of sugar, such as fizzy drinks, as they can sometimes make diarrhoea worse. Alcohol should also be avoided.

Rehydration drinks

Rehydration drinks may also be used. They are made from sachets that you can buy from pharmacies and may be a sensible thing to pack in your first aid kit when you travel. You add the contents of the sachet to water.

Home-made salt/sugar mixtures are used in developing countries if rehydration drinks are not available; however, they have to be made carefully, as too much salt can be dangerous. Rehydration drinks are cheap and readily available in the UK, and are the best treatment. Note that safe drinking water should be used to reconstitute oral rehydration salt sachets.

Antidiarrhoeal medication

Antidiarrhoeal medicines are not usually necessary or wise to take when you have traveller's diarrhoea. However you may want to use them if absolutely necessary - for example, if you will be unable to make regular trips to the toilet due to travelling.You can buy antidiarrhoeal medicines from pharmacies before you travel. The safest and most effective is loperamide.

The adult dose of this is two capsules at first. This is followed by one capsule after each time you pass some diarrhoea up to a maximum of eight capsules in 24 hours. It works by slowing down your gut's activity.

You should not take loperamide for longer than two days. You should also not use antidiarrhoeal medicines if you have a high temperature (fever) or bloody diarrhoea.

Eat as normally as possible

It used to be advised to 'starve' for a while if you had diarrhoea. However, now it is advised to eat small, light meals if you can. Be guided by your appetite. You may not feel like food and most adults can do without food for a few days. Eat as soon as you are able but don't stop drinking. If you do feel like eating, avoid fatty, spicy or heavy food. Plain foods such as bread and rice are good foods to try eating.

Antibiotic medicines

Most people with traveller's diarrhoea do not need treatment with antibiotic medicines. However, sometimes antibiotic treatment is advised. This may be because a specific germ (microbe) has been identified after testing of your stool (faeces) sample.

Fluids to prevent dehydration

You should encourage your child to drink plenty of fluids. The aim is to prevent lack of fluid in the body (dehydration). The fluid lost in their sick (vomit) and/or diarrhoea needs to be replaced. Your child should continue with their normal diet and usual drinks. In addition, they should also be encouraged to drink extra fluids. However, avoid fruit juices or fizzy drinks, as these can make diarrhoea worse.

Babies under 6 months old are at increased risk of dehydration. You should seek medical advice if they develop acute diarrhoea. Breast feeds or bottle feeds should be encouraged as normal. You may find that your baby's demand for feeds increases. You may also be advised to give extra fluids (either water or rehydration drinks) in between feeds.

If you are travelling to a destination at high risk for traveller's diarrhoea, you might want to consider buying oral rehydration sachets for children before you travel. These can provide a perfect balance of water, salts and sugar for them and can be used for fluid replacement. Remember that, as mentioned above, safe water is needed to reconstitute the sachets.

If your child vomits, wait 5-10 minutes and then start giving drinks again but more slowly (for example, a spoonful every 2-3 minutes). Use of a syringe can help in younger children who may not be able to take sips.

Note : if you suspect that your child is dehydrated, or is becoming dehydrated, you should seek medical advice urgently.

Fluids to treat dehydration

If your child is mildly dehydrated, this may be treated by giving them rehydration drinks. A doctor will advise about how much to give. This can depend on the age and the weight of your child. If you are breastfeeding, you should continue with this during this time. It is important that your child be rehydrated before they have any solid food.

Sometimes a child may need to be admitted to hospital for treatment if they are dehydrated. Treatment in hospital usually involves giving rehydration solution via a special tube called a 'nasogastric tube'. This tube passes through your child's nose, down their throat and directly into their stomach. An alternative treatment is with fluids given directly into a vein (intravenous fluids).

Eat as normally as possible once any dehydration has been treated

Correcting any dehydration is the first priority. However, if your child is not dehydrated (most cases), or once any dehydration has been corrected, then encourage your child to have their normal diet. Do not 'starve' a child with infectious diarrhoea. This used to be advised but is now known to be wrong. So:

Breastfed babies should continue to be breastfed if they will take it. This will usually be in addition to extra rehydration drinks (described above).

Bottle-fed babies should be fed with their normal full-strength feeds if they will take it. Again, this will usually be in addition to extra rehydration drinks (described above). Do not water down the formula, or make it up with less water than usual. This can make a baby very ill.

Older children - offer them some food every now and then. However, if he or she does not want to eat, that is fine. Drinks are the most important consideration and food can wait until the appetite returns.

Loperamide is not recommended for children with diarrhoea. There are concerns that it may cause a blockage of the gut (intestinal obstruction) in children with diarrhoea.

Most children with traveller's diarrhoea do not need treatment with antibiotics. However, for the same reasons as discussed for adults above, antibiotic treatment may sometimes be advised in certain cases.

Most people have mild illness and complications of traveller's diarrhoea are rare. However, if complications do occur, they can include the following:

Salt (electrolyte) imbalance and dehydration .

This is the most common complication. It occurs if the salts and water that are lost in your stools (faeces), or when you are sick (vomit), are not replaced by you drinking adequate fluids. If you can manage to drink plenty of fluids then dehydration is unlikely to occur, or is only likely to be mild and will soon recover as you drink.

Severe dehydration can lead to a drop in your blood pressure. This can cause reduced blood flow to your vital organs. If dehydration is not treated, your kidneys may be damaged . Some people who become severely dehydrated need a 'drip' of fluid directly into a vein. This requires admission to hospital. People who are elderly or pregnant are more at risk of dehydration.

Reactive complications

Rarely, other parts of your body can 'react' to an infection that occurs in your gut. This can cause symptoms such as joint inflammation (arthritis), skin inflammation and eye inflammation (either conjunctivitis or uveitis). Reactive complications are uncommon if you have a virus causing traveller's diarrhoea.

Spread of infection

The infection can spread to other parts of your body such as your bones, joints, or the meninges that surround your brain and spinal cord. This is rare. If it does occur, it is more likely if diarrhoea is caused by salmonella infection.

Irritable bowel syndrome is sometimes triggered by a bout of traveller's diarrhoea.

Lactose intolerance

Lactose intolerance can sometimes occur for a period of time after traveller's diarrhoea. It is known as 'secondary' or 'acquired' lactose intolerance. Your gut (intestinal) lining can be damaged by the episode of diarrhoea. This leads to lack of a substance (enzyme) called lactase that is needed to help your body digest the milk sugar lactose.

Lactose intolerance leads to bloating, tummy (abdominal) pain, wind and watery stools after drinking milk. The condition gets better when the infection is over and the intestinal lining heals. It is more common in children.

Haemolytic uraemic syndrome

Usually associated with traveller's diarrhoea caused by a certain type of E. coli infection, haemolytic uraemic syndrome is a serious condition where there is anaemia, a low platelet count in the blood and kidney damage. It is more common in children. If recognised and treated, most people recover well.

Guillain-Barré syndrome

This condition may rarely be triggered by campylobacter infection, one of the causes of traveller's diarrhoea. It affects the nerves throughout your body and limbs, causing weakness and sensory problems. See the separate leaflet called Guillain-Barré syndrome for more details.

Reduced effectiveness of some medicines

During an episode of traveller's diarrhoea, certain medicines that you may be taking for other conditions or reasons may not be as effective. This is because the diarrhoea and/or being sick (vomiting) mean that reduced amounts of the medicines are taken up (absorbed) into your body.

Examples of such medicines are those for epilepsy, diabetes and contraception . Speak with your doctor or practice nurse before you travel if you are unsure of what to do if you are taking other medicines and develop diarrhoea.

As mentioned above, symptoms are usually short-lived and the illness is usually mild with most people making a full recovery within in few days. However, a few people with traveller's diarrhoea develop persistent (chronic) diarrhoea that can last for one month or more. It is also possible to have a second 'bout' of traveller's diarrhoea during the same trip. Having it once does not seem to protect you against future infection.

Avoid uncooked meat, shellfish or eggs. Avoid peeled fruit and vegetables (including salads).

Be careful about what you drink. Don't drink tap water, even as ice cubes.

Wash your hands regularly, especially before preparing food or eating.

Be careful where you swim. Contaminated water can cause traveller's diarrhoea.

Regular hand washing

You should ensure that you always wash your hands and dry them thoroughly; teach children to wash and dry theirs:

After going to the toilet (and after changing nappies or helping an older child to go to the toilet).

Before preparing or touching food or drinks.

Before eating.

Some antibacterial hand gel may be a good thing to take with you when you travel in case soap and hot water are not available.

Be careful about what you eat and drink

When travelling to areas with poor sanitation, you should avoid food or drinking water that may contain germs (microbes) or their poisons (toxins). Avoid:

Fruit juices sold by street vendors.

Ice cream (unless it has been made from safe water).

Shellfish (for example, mussels, oysters, clams) and uncooked seafood.

Raw or undercooked meat.

Fruit that has already been peeled or has a damaged skin.

Food that contains raw or uncooked eggs, such as mayonnaise or sauces.

Unpasteurised milk.

Drinking bottled water and fizzy drinks that are in sealed bottles or cans, tea, coffee and alcohol is thought to be safe. However, avoid ice cubes and non-bottled water in alcoholic drinks. Food should be cooked through thoroughly and be piping hot when served.

You should also be careful when eating food from markets, street vendors or buffets if you are uncertain about whether it has been kept hot or kept refrigerated. Fresh bread is usually safe, as is canned food or food in sealed packs.

Be careful where you swim

Swimming in contaminated water can also lead to traveller's diarrhoea. Try to avoid swallowing any water as you swim; teach children to do the same.

Obtain travel health advice before you travel

Always make sure that you visit your GP surgery or private travel clinic for health advice in plenty of time before your journey. Alternatively, the Fit for Travel website (see under Further Reading and References, below) provides travel health information for the public and gives specific information for different countries and high-risk destinations. This includes information about any vaccinations required, advice about food, water and personal hygiene precautions, etc.

There are no vaccines that prevent traveller's diarrhoea as a whole. However, there are some other vaccines that you may need for your travel, such as hepatitis A, typhoid, etc. You may also need to take malaria tablets depending on where you are travelling.

Antibiotics

Taking antibiotic medicines to prevent traveller's diarrhoea (antibiotic prophylaxis) is not generally recommended. This is because for most people, traveller's diarrhoea is mild and self-limiting. Also, antibiotics do not protect against nonbacterial causes of traveller's diarrhoea, such as viruses and parasites. Antibiotics may have side-effects and their unnecessary use may lead to problems with resistance to medicines.

Probiotics have some effect on traveller's diarrhoea and can shorten an attack by about one day. It is not known yet which type of probiotic or which dose, so there are no recommendations about using probiotics to prevent traveller's diarrhoea.

Further reading and references

• Bourgeois AL, Wierzba TF, Walker RI ; Status of vaccine research and development for enterotoxigenic Escherichia coli. Vaccine. 2016 Mar 15. pii: S0264-410X(16)00287-5. doi: 10.1016/j.vaccine.2016.02.076.
• Travellers' diarrhoea ; Fitfortravel
• Riddle MS, Connor BA, Beeching NJ, et al ; Guidelines for the prevention and treatment of travelers' diarrhea: a graded expert panel report. J Travel Med. 2017 Apr 1;24(suppl_1):S57-S74. doi: 10.1093/jtm/tax026.
• Giddings SL, Stevens AM, Leung DT ; Traveler's Diarrhea. Med Clin North Am. 2016 Mar;100(2):317-30. doi: 10.1016/j.mcna.2015.08.017.
• Diarrhoea - prevention and advice for travellers ; NICE CKS, February 2019 (UK access only)

Article history

The information on this page is written and peer reviewed by qualified clinicians.

Next review due: 9 Feb 2028

10 feb 2023 | latest version.

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