Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

pre-travel prophylaxis

1st line – careful selection of food and beverages

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INITIAL
|
pre-travel prophylaxis
1st line – 

careful selection of food and beverages

Selection of safe food and beverages is recommended.[2][22]

Unsafe items include ice, tap water, salads, previously peeled fruits, and raw foods. Unpackaged condiments and sauces, such as guacamole, often pose a significant risk. Food from street vendors and buffets with poor food turnover also pose a notable risk of food poisoning.

Safe items include thoroughly cooked food served while still hot, boiled or bottled (properly sealed) water, commercially packaged foods, fresh breads, and fruits peeled by the traveller.

Consider – rifaximin or rifamycin or bismuth subsalicylate

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INITIAL
|
pre-travel prophylaxis
Consider – 

rifaximin or rifamycin or bismuth subsalicylate

Additional treatment recommended for SOME patients in selected patient group

Prophylactic antibiotics are not recommended for most travellers.[1][2]​​ Occasional exceptions include short-term critical itineraries such as diplomatic missions, professional sports, and critical business/life event engagements; and chronically ill or immunocompromised patients on trips of <3 weeks' duration.

Antibiotic prophylaxis is not usually recommended in children.

Rifaximin is considered the treatment of choice for prophylaxis; it is effective at preventing TD with no increase in adverse effects (compared with placebo).[1][23][24] Rifamycin can also be considered.[2]​​

Bismuth subsalicylate can reduce the incidence of TD by >60%; however, due to the number of tablets required and the inconvenient dosing, it is not commonly used as prophylaxis for TD.[26][27] Studies have not established the safety of this drug when used for >4 weeks.[1] Adverse effects include salicylate toxicity (e.g., tinnitus) and blackening of the tongue or stools.[27][39]​​

Prophylaxis should be started before departure and discontinued after travel.

Primary options

rifaximin: adults: 200 mg orally once to three times daily

OR

rifamycin: adults: 388 mg orally twice daily

Secondary options

bismuth subsalicylate: adults: 524-1048 mg orally four times daily

ACUTE

non-pregnant adults: mild diarrhoea

1st line – rehydration

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ACUTE
|
non-pregnant adults: mild diarrhoea
1st line – 

rehydration

Fluid replacement is important in all patients. It is critical for older patients who are at risk of dehydration-related complications.[2][29]​​ [ Cochrane Clinical Answers logo ] ​ Bowel rest should be avoided.

Adults with mild diarrhoea who find oral rehydration solutions unpalatable may rehydrate with any preferred liquid, although sugar-sweetened beverages can cause osmotic diarrhoea if consumed in large amounts.[2][28]​​​

Consider – loperamide or bismuth subsalicylate

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ACUTE
|
non-pregnant adults: mild diarrhoea
Consider – 

loperamide or bismuth subsalicylate

Additional treatment recommended for SOME patients in selected patient group

Loperamide or bismuth subsalicylate are recommended for symptomatic relief in patients with mild diarrhoea (i.e., diarrhoea that is tolerable, is not distressing, and does not interfere with planned activities).[37]

Loperamide is an anti-motility agent that controls cramping and diarrhoea.[37][38] Patients should be advised that it can take 1-2 hours for loperamide to take effect, and additional dosing should be spaced accordingly to avoid rebound constipation. Loperamide should not be used in patients with visible blood in the stool or high fever (characteristic of dysentery). Loperamide slows gastrointestinal transit time and, theoretically, may delay the expulsion of invasive bacteria.

The continued use of loperamide in patients with worsening symptoms, or the development of dysentery, is not recommended.[37]

Bismuth subsalicylate is an oral anti-diarrhoeal agent. Adverse effects include salicylate toxicity (e.g., tinnitus) and blackening of the tongue or stools.​[27][39]​​

Primary options

loperamide: 4 mg orally initially, followed by 2 mg after each unformed stool, maximum 16 mg/day

OR

bismuth subsalicylate: 524 mg orally four times daily

non-pregnant adults: moderate diarrhoea

1st line – loperamide and/or antibiotic therapy

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ACUTE
|
non-pregnant adults: moderate diarrhoea
1st line – 

loperamide and/or antibiotic therapy

Treatment options for moderate diarrhoea (i.e., diarrhoea that is distressing or interferes with planned activities) include loperamide alone, antibiotic therapy alone, or loperamide plus antibiotic therapy.[1] However, guidelines are not consistent in regards to treatment of patients with moderate infection, and expert opinion on the choice of treatment varies.

Loperamide is an anti-motility agent that controls cramping and diarrhoea.[37][38]​ Patients should be advised that it can take 1-2 hours for loperamide to take effect, and additional dosing should be spaced accordingly to avoid rebound constipation.

Loperamide should not be used in patients with visible blood in the stool or high fever (characteristic of dysentery). Loperamide slows gastrointestinal transit time and, theoretically, may delay the expulsion of invasive bacteria.

The continued use of loperamide in patients with worsening symptoms, or the development of dysentery, is not recommended.[37]

Antibiotic options for the treatment of TD include azithromycin, fluoroquinolones, rifaximin, or rifamycin.[1][2]​​

Azithromycin is usually considered first-line because it is well tolerated with minimal adverse effects.

Fluoroquinolones (e.g., ciprofloxacin, ofloxacin, levofloxacin) are considered a second-line option. Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. These include, but are not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[35] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.​ Increased resistance against fluoroquinolones in Southeast Asia and other regions should be considered.

Rifaximin is a second-line agent; it may be the most suitable option for patients taking other medicines as it is less likely to undergo drug-to-drug interactions. However, it may be less effective in Asia, where invasive pathogens (e.g., Campylobacter, Salmonella, Shigella) are more likely.[1] Rifamycin is an alternative to rifaximin.[2] It can be used in adults with TD caused by non-invasive strains of Escherichia coli, not complicated by fever or blood in the stool.[2] Both rifaximin and rifamycin can be used for treating patients with severe, non-dysenteric diarrhoea.​​​[2]

Antibiotic treatment, with adjunctive loperamide, consistently demonstrates the most rapid time to clinical cure (median 12-14 hours) compared with antibiotics alone (24-30 hours); however, antibiotic therapy (with or without adjunctive therapy) can be associated with a higher incidence of adverse effects, although these are often minor and self-limited.[32]

Many experts recommend taking antibiotics only until the patient feels better, usually 1-3 days (with the exception of rifaximin and rifamycin, which should be taken for the full 3-day course). If symptoms have not resolved after 24 hours, the regimen should be taken for up to 3 days.[1]

Primary options

loperamide: 4 mg orally initially, followed by 2 mg after each unformed stool, maximum 16 mg/day

-- AND / OR --

azithromycin: 1000 mg orally as a single dose, continue once daily dosing for up to 3 days if symptoms do not resolve within 24 hours; or 500 mg orally once daily for 3 days

Secondary options

loperamide: 4 mg orally initially, followed by 2 mg after each unformed stool, maximum 16 mg/day

-- AND / OR --

ciprofloxacin: 750 mg orally as a single dose, continue once daily dosing for up to 3 days if symptoms do not resolve within 24 hours; or 500 mg orally once daily for 3 days

or

ofloxacin: 400 mg orally once daily for 1-3 days

or

levofloxacin: 500 mg orally once daily for 1-3 days

OR

loperamide: 4 mg orally initially, followed by 2 mg after each unformed stool, maximum 16 mg/day

-- AND / OR --

rifaximin: 200 mg orally three times daily for 3 days

or

rifamycin: 388 mg orally twice daily for 3 days

Consider – rehydration

Back
ACUTE
|
non-pregnant adults: moderate diarrhoea
Consider – 

rehydration

Additional treatment recommended for SOME patients in selected patient group

Fluid replacement is important in all patients. It is critical for older patients who are at risk of dehydration-related complications.[2][29] [ Cochrane Clinical Answers logo ] ​ Bowel rest should be avoided.

Plus – further work-up

Back
ACUTE
|
non-pregnant adults: moderate diarrhoea
|
persistent diarrhoea not responsive to first-line antibiotic
Plus – 

further work-up

Treatment recommended for ALL patients in selected patient group

A medical evaluation is recommended for persistent diarrhoea, but this is often unavailable or difficult for overseas travellers.

Failure to respond to antibiotic therapy suggests a parasitic or post-infectious aetiology. Viral diarrhoea usually resolves quickly.

Order stool antigen testing, polymerase chain reaction test, or ova and parasite examination to test for protozoal pathogens in patients with persistent diarrhoea (>14 days).[7]​ Treatment for the identified pathogen should be started once results are back. See Giardiasis (Management) and Amoebiasis (Management).

If Clostridioides difficile-associated disease is suspected, the patient should be managed according to current guidelines. See Clostridiodes difficile-associated disease (Management).

non-pregnant adults: severe diarrhoea

1st line – antibiotic therapy

Back
ACUTE
|
non-pregnant adults: severe diarrhoea
1st line – 

antibiotic therapy

Antibiotics are always recommended in severe infection (i.e., diarrhoea that is incapacitating or completely prevents planned activities; dysentery and febrile diarrhoea are considered severe).[1]

Azithromycin is considered the first-line option in severe infection.

Fluoroquinolones (e.g., ciprofloxacin, ofloxacin, levofloxacin) are considered a second-line option. Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[35]​ Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions. Increased resistance against fluoroquinolones in Southeast Asia and other regions should be considered.

Rifaximin is a second-line agent; it may be the most suitable option for patients taking other medicines as it is less likely to undergo drug-to-drug interactions. However, it may be less effective in Asia, where invasive pathogens (e.g., Campylobacter, Salmonella, Shigella) are more likely.[1] Rifamycin is an alternative to rifaximin.[2] It can be used in adults with TD caused by non-invasive strains of Escherichia coli, not complicated by fever or blood in the stool.​​[2] Both rifaximin and rifamycin can be used for treating patients with severe, non-dysenteric diarrhoea.[2]​​

Many experts recommend taking antibiotics only until the patient feels better, usually 1-3 days (with the exception of rifaximin and rifamycin, which should be taken for the full 3-day course). If symptoms have not resolved after 24 hours, the regimen should be taken for up to 3 days.[1]

Primary options

azithromycin: 1000 mg orally as a single dose, continue once daily dosing for up to 3 days if symptoms do not resolve within 24 hours; or 500 mg orally once daily for 3 days

Secondary options

ciprofloxacin: 750 mg orally as a single dose, continue once daily dosing for up to 3 days if symptoms do not resolve within 24 hours; or 500 mg orally once daily for 3 days

OR

ofloxacin: 400 mg orally once daily for 1-3 days

OR

levofloxacin: 500 mg orally once daily for 1-3 days

OR

rifaximin: 200 mg orally three times daily for 3 days

OR

rifamycin: 388 mg orally twice daily for 3 days

Consider – rehydration

Back
ACUTE
|
non-pregnant adults: severe diarrhoea
Consider – 

rehydration

Additional treatment recommended for SOME patients in selected patient group

Fluid replacement is important in all patients. It is critical for older patients who are at risk of dehydration-related complications.[2][29] [ Cochrane Clinical Answers logo ] ​ Bowel rest should be avoided.

Consider – loperamide

Back
ACUTE
|
non-pregnant adults: severe diarrhoea
Consider – 

loperamide

Additional treatment recommended for SOME patients in selected patient group

Loperamide controls cramping and diarrhoea.[37][38]

Patients should be advised that it can take 1-2 hours for loperamide to take effect, and additional dosing should be spaced accordingly to avoid rebound constipation. Loperamide should not be used in patients with visible blood in the stool or high fever (characteristic of dysentery). Loperamide slows gastrointestinal transit time and, theoretically, may delay the expulsion of invasive bacteria.

The continued use of loperamide in patients with worsening symptoms, or the development of dysentery, is not recommended.[37]

Antibiotic treatment, with adjunctive loperamide, consistently demonstrates the most rapid time to clinical cure (median 12-14 hours) compared with antibiotics alone (24-30 hours).[32]

Primary options

loperamide: 4 mg orally initially, followed by 2 mg after each unformed stool, maximum 16 mg/day

Plus – further work-up

Back
ACUTE
|
non-pregnant adults: severe diarrhoea
|
persistent diarrhoea not responsive to first-line antibiotic
Plus – 

further work-up

Treatment recommended for ALL patients in selected patient group

A medical evaluation is recommended for persistent diarrhoea, but this is often unavailable or difficult for overseas travellers.

Failure to respond to antibiotic therapy suggests a parasitic or post-infectious aetiology. Viral diarrhoea usually resolves quickly.

Order stool antigen testing, polymerase chain reaction test, or ova and parasite examination to test for protozoal pathogens in patients with persistent diarrhoea (>14 days).[7]​ Treatment for the identified pathogen should be started once results are back. See Giardiasis (Management) and Amoebiasis (Management).

If Clostridioides difficile-associated disease is suspected, the patient should be managed according to current guidelines. See Clostridiodes difficile-associated disease (Management).

pregnant

1st line – rehydration

Back
ACUTE
|
pregnant
1st line – 

rehydration

Fluid replacement is an important part of treatment in all pregnant patients.[2][29] [ Cochrane Clinical Answers logo ] ​ Bowel rest should be avoided.

Consider – antibiotic therapy

Back
ACUTE
|
pregnant
Consider – 

antibiotic therapy

Additional treatment recommended for SOME patients in selected patient group

Antibiotics are recommended in pregnant women with moderate to severe infection. Azithromycin is the treatment of choice. It is well tolerated with minimal adverse effects.

Many experts recommend taking antibiotics only until the patient feels better, usually 1-3 days. If symptoms have not resolved after 24 hours, the regimen should be taken for up to 3 days.[1]

Primary options

azithromycin: 1000 mg orally as a single dose, continue once daily dosing for up to 3 days if symptoms do not resolve within 24 hours; or 500 mg orally once daily for 3 days

Plus – further work-up

Back
ACUTE
|
pregnant
|
persistent diarrhoea not responsive to first-line antibiotic
Plus – 

further work-up

Treatment recommended for ALL patients in selected patient group

A medical evaluation is recommended for persistent diarrhoea, but this is often unavailable or difficult for overseas travellers.

Failure to respond to antibiotic therapy suggests a parasitic or post-infectious aetiology. Viral diarrhoea usually resolves quickly.

Order stool antigen testing, polymerase chain reaction test, or ova and parasite examination to test for protozoal pathogens in patients with persistent diarrhoea (>14 days).[7]​ Treatment for the identified pathogen should be started once results are back. A specialist should be consulted for choice of drug and treatment course in pregnant women.

If Clostridioides difficile-associated disease is suspected, the patient should be managed according to current guidelines. See Clostridiodes difficile-associated disease (Management).

children

1st line – rehydration

Back
ACUTE
|
children
1st line – 

rehydration

Rehydration is a key intervention for infants and younger children. [ Cochrane Clinical Answers logo ] ​ ​​Oral rehydration solutions, available as oral rehydration salt solution or rice-based solutions from pharmacies in many high-risk countries, are very effective for the management of dehydration associated with diarrhoea in infants. Spoon-feeding oral rehydration salts is recommended if a child is vomiting. Infants and children who are breastfed should continue in spite of diarrhoea. Bowel rest should be avoided.

Consider – loperamide or bismuth subsalicylate

Back
ACUTE
|
children
Consider – 

loperamide or bismuth subsalicylate

Additional treatment recommended for SOME patients in selected patient group

Loperamide or bismuth subsalicylate are recommended for symptomatic relief in children, with some caveats. Loperamide is not generally recommended in children aged <6 years. Bismuth subsalicylate (an oral anti-diarrhoeal agent) is not generally recommended in children aged <12 years, due to the risk of Reye's syndrome; however, some physicians still use it with caution.[2]​ It is not recommended in children aged <3 years.[2]​ Adverse effects include salicylate toxicity (e.g., tinnitus) and blackening of the tongue or stools.​[27][39]​​

Loperamide is an anti-motility agent that controls cramping and diarrhoea.[37][38] Patients should be advised that it can take 1-2 hours for loperamide to take effect, and additional dosing should be spaced accordingly to avoid rebound constipation.

Loperamide should not be used in patients with visible blood in the stool or high fever (characteristic of dysentery). Loperamide slows gastrointestinal transit time and, theoretically, may delay the expulsion of invasive bacteria.

The continued use of loperamide in patients with worsening symptoms, or the development of dysentery, is not recommended.[37]

Primary options

loperamide: children ≥6 years of age: consult specialist for guidance on dose

OR

bismuth subsalicylate: children ≥12 years of age: consult specialist for guidance on dose

Consider – antibiotic therapy

Back
ACUTE
|
children
Consider – 

antibiotic therapy

Additional treatment recommended for SOME patients in selected patient group

Antibiotics are recommended in children with moderate to severe infection, especially when there is bloody or severe watery diarrhoea, or evidence of systemic infection. Azithromycin is the treatment of choice in children. It is well tolerated with minimal adverse effects. A fluoroquinolone (e.g., ciprofloxacin) or rifaximin may be used as an alternative in children; however, rifaximin is not approved for children aged <12 years, and fluoroquinolones should be used with caution in children as they may increase the risk of joint and tendon disorders.[2]​​[36]

Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[35] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.​

Many experts recommend taking antibiotics only until the patient feels better, usually 1-3 days (with the exception of rifaximin, which should be taken for the full 3-day course). If symptoms have not resolved after 24 hours, the regimen should be taken for up to 3 days.[1]

Primary options

azithromycin: 10 mg/kg orally once daily for 1-3 days, maximum 500 mg/day

Secondary options

ciprofloxacin: 20-30 mg/kg/day orally given in 1-2 divided doses for 1-3 days

OR

rifaximin: children ≥12 years of age: 200 mg orally three times daily for 3 days

Plus – further work-up

Back
ACUTE
|
children
|
persistent diarrhoea not responsive to first-line antibiotic
Plus – 

further work-up

Treatment recommended for ALL patients in selected patient group

A medical evaluation is recommended for persistent diarrhoea, but this is often unavailable or difficult for overseas travellers.

Failure to respond to antibiotic therapy suggests a parasitic or post-infectious aetiology. Viral diarrhoea usually resolves quickly.

Order stool antigen testing, polymerase chain reaction test, or ova and parasite examination to test for protozoal pathogens in patients with persistent diarrhoea (>14 days).[7]​ Treatment for the identified pathogen should be started once results are back. A specialist should be consulted for choice of drug and treatment course in children.

If Clostridioides difficile-associated disease is suspected, the patient should be managed according to current guidelines. See Clostridiodes difficile-associated disease (Management).

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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