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Traveler's Diarrhea


General Information

General InformationGeneral Information


  • diarrheal syndrome which may be caused by a variety of intestinal pathogens contracted while traveling, particularly in developing countries1,2,3,4
  • formally defined as ≥ 3 loose stools in 24-hour period with ≥ 1 accompanying systemic or enteric symptom, such as fever, nausea, vomiting, or abdominal cramps1,3
  • bacteria account for majority of cases, but traveler's diarrhea may also be caused by parasites or viruses1,2


General references used

  1. Hill DR, Ericsson CD, Pearson RD, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006 Dec 15;43(12):1499-539OpenInNewfull-textOpenInNew, commentary can be found in Clin Infect Dis 2008 Feb 1;46(3):475OpenInNew
  2. Connor, BA. Chapter 2: Travelers' Diarrhea. In: Brunette GW, Kozarsky PE, Magill AJ, Shlim DR, Whatley AD, eds. CDC Health Information for International Travel: The Yellow BookOpenInNew.New York, NY: Oxford University Press; 2017
  3. Steffen R, Hill DR, DuPont HL. Traveler's diarrhea: a clinical review. JAMA. 2015 Jan 6;313(1):71-80OpenInNew
  4. Barrett J, Brown M. Travellers' diarrhoea. BMJ. 2016 Apr 19;353:i1937OpenInNew
  5. Kollaritsch H, Paulke-Korinek M, Wiedermann U. Traveler's Diarrhea. Infect Dis Clin North Am. 2012 Sep;26(3):691-706OpenInNew
  6. Yates J. Traveler's diarrhea. Am Fam Physician. 2005 Jun 1;71(11):2095-100OpenInNewfull-textOpenInNew
  7. 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-S74OpenInNewfull-textOpenInNew, commentary can be found in J Travel Med 2017 Sep 1;24(6)OpenInNew

Recommendation grading systems used

  • International Society of Travel Medicine (ISTM) grades of recommendation
    • grade of recommendation
      • Strong - desirable effects clearly outweigh undesirable effects, or vice versa
      • Weak - desirable and undesirable effects were more closely balanced and it was plausible that direction or strength of a recommendation could be changed by patient values and preferences, additional research information, or other conditions specific to an individual case
    • levels of evidence
      • High - evidence from > 1 properly randomized controlled trial that met most or all of the criteria in terms of quality study design, precision, directness, consistency and minimized risk of publication bias
      • Moderate - evidence from > 1 well-designed clinical trial, without randomization or from cohort or case-controlled analytic studies, from multiple time-series, or from dramatic results from uncontrolled experiments
      • Low/Very low - evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
    • Reference - ISTM graded expert panel guideline on prevention and treatment of travelers' diarrhea (28521004J Travel Med 2017 Apr 1;24(suppl_1):S57OpenInNewfull-textOpenInNew), commentary can be found in 28922822J Travel Med 2017 Sep 1;24(6)OpenInNew
  • European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases (ESPGHAN/ESPID) grades of recommendation
    • grade of recommendation
      • Strong - desirable effects of intervention clearly outweigh the undesirable effects, or they clearly do not
      • Weak - tradeoffs are less certain (either because of low quality of evidence or because evidence suggests that desirable and undesirable effects are closely balanced)
    • quality of evidence
      • High - further research is unlikely to change confidence in estimate of effect
      • Moderate - further research is likely to have important impact on confidence in estimate of effect and may change estimate
      • Low - further research is extremely likely to have important impact on confidence in estimate of effect and is likely to change estimate
      • Very low - any estimate of effect is extremely uncertain
  • Infectious Diseases Society of America (IDSA) evidence and recommendation ratings
    • quality of evidence ratings
      • I - evidence from ≥ 1 randomized, controlled trial
      • II - evidence from ≥ 1 nonrandomized clinical trial, case-control or cohort study, multiple time-series study, or dramatic results from uncontrolled experiments
      • III - evidence from opinions of respected authorities
    • strength of recommendation ratings
      • A - strongly in favor
      • B - moderately in favor
      • C - optional
      • D - moderately against
      • E - strongly against
    • Reference - IDSA guideline on practice of travel medicine (17109284Clin Infect Dis 2006 Dec 15;43(12):1499OpenInNewfull-textOpenInNew)
  • grades of recommendation from guideline commissioned by United Kingdom (UK) Government Department for Education and Employment and Department of Health
    • grades of recommendation
      • Grade A - derived from Level I evidence of period of infectiousness and/or effectiveness of exclusion
      • Grade B - derived from Level II evidence of period of infectiousness and/or effectiveness of exclusion, or Level I-II evidence of duration of shedding and/or serial interval
      • Grade C - derived from Level III or IV evidence of period of infectiousness, effectiveness of exclusion, duration of shedding, and/or serial interval
    • levels of evidence
      • Level I - systematic review, meta-analysis, or well-designed epidemiologic or experimental study with ≥ 50 persons
      • Level II - well-designed epidemiologic or experimental study with 5-50 persons
      • Level III - case reports with < 5 persons, or poorly substantiated larger study
      • Level IV - opinion or clinical experience of experts (not supported by published data)
    • Reference - 11332662Pediatr Infect Dis J 2001 Apr;20(4):380OpenInNew, commentary can be found in 11740335Pediatr Infect Dis J 2001 Dec;20(12):1184OpenInNew

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T116545, Traveler's Diarrhea; [updated 2018 Nov 30, cited place cited date here]. Available from Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

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    General Information

    • Description

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    • Incidence/Prevalence

    • Risk factors

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    Etiology and Pathogenesis

    • Pathogens

    • Pathogenesis

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    History and Physical

    • KeyboardArrowRight


      • Chief concern (CC)

      • History of present illness (HPI)

      • Social history (SH)

    • Physical

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    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • Blood tests

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      Stool studies

      • Stool studies for invasive infection or bacterial infection

      • Stool studies for parasites

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    • Management overview

    • Fluid and electrolytes

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        • Antibiotics for empiric therapy or known bacterial pathogens

        • Fluoroquinolones

        • Resistance to fluoroquinolones

        • Azithromycin

        • Rifaximin

        • Rifamycin

        • Duration of antibiotics

        • Antibiotics to avoid

        • Comparative efficacy of antibiotics

        • Antibiotics for parasitic pathogens

      • Symptomatic treatment

      • Combination therapy

      • Other medications

    • Self-treatment

    • Diet

    • Follow-up

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • Prognosis

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    Prevention and Screening

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      • Food and beverage selection

      • Chemoprophylaxis

      • Vaccines

      • Probiotics

      • Other preventive measures

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    Quality Improvement

    • Choosing Wisely Canada

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    Guidelines and Resources

    • KeyboardArrowRight


      • International guidelines

      • United States guidelines

      • United Kingdom guidelines

      • European guidelines

    • Review articles

    • Other resources

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight


    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Carlos Seas MSc, MD, FIDSA

Associate Professor of Medicine, Director of Clinical Medicine, Vice Director of Alexander von Humboldt Tropical Medicine Institute and Director of Tuberculosis Research Unit, Cayetano Heredia University; Lima, Peru

Conflicts of Interest

Dr. Seas declares no relevant financial conflicts of interest.

Recommendations Editor
Amir Qaseem MD, PhD, MHA, FACP

Vice President of Clinical Policy, American College of Physicians; Pennsylvania, United States; President Emeritus, Guidelines International Network; Germany

Conflicts of Interest

Dr. Qaseem declares no relevant financial conflicts of interest.

Deputy Editor
Vito Iacoviello MD, FIDSA

Deputy Editor of Infectious Diseases, Immunology and Rheumatology, Dynamed; Massachusetts, United States; Assistant Professor of Medicine, Harvard Medical School; Massachusetts, United States; Chief of the Division of Infectious Diseases, Mount Auburn Hospital; Massachusetts, United States

Conflicts of Interest

Dr. Iacoviello declares no relevant financial conflicts of interest.

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