OBJECTIVES: In this review, we present a contemporary look at the management of travellers' diarrhoea (TD), and we discuss the potential role of a microbiome as well as the administration of live microorganisms in order to prevent TD. METHODS: We performed a comprehensive search using the PubMed and Web of Science databases for the period 2014-2021, looking for original and review articles on travellers' diarrhoea. RESULTS: TD belongs among the most frequent illnesses experienced by travellers. For the most part, it is manifested as an acute yet self limiting condition, and only in a few cases proceeds to a prolonged form. Epidemiological analyses have shown that the majority of TD cases are caused by bacterial infections. In practice, pharmacological therapy is often used in the prevention and treatment of TD, since patients naturally seek preventive measures against the development of its severe course and its impact on planned activities. Bismuth salicylate is a strongly recommended TD prophylaxis but is not available on all European Union markets. Although the antibiotic prophylaxis is not generally recommended in guidelines, some antibiotic or chemotherapeutic agents are accessible over-the-counter in certain countries, and travellers are routinely encouraged to use them preventively. This routine can alter the microbiome of the traveller and promote the spread of drug resistant bacteria in their place of residence. Probiotic administration is considered safe, although the quality of evidence in favour of its prophylactic use in TD is currently low. CONCLUSIONS: The challenge for public health authorities is to educate personnel that can directly influence the behaviour of travellers through safe and effective pharmacological alternatives to antibiotics. Manipulation of the gut microbiome using specific probiotic strains can represent a safe and promising intervention.

Institute of Pharmacology and Clinical Pharmacology Faculty of Medicine Comenius University Bratislava Slovak Republic

Zobrazit více v PubMed

Kean BH. The diarrhea of travelers to Mexico: summary of five-year study. Annal Intern Med. 1963;59(5 Part 1):605-14.

Gorbach SL, Kean BH, Evans DG, Evans Jr DJ, Bessudo D. Travelers' diarrhea and toxigenic Escherichia coli. New Engl J Med. 1975;292(18):933-6.

DuPont HL, Reves RR, Galindo E, Sullivan PS, Wood LV, Mendiola JG. Treatment of travelers' diarrhea with trimethoprim/sulfamethoxazole and with trimethoprim alone. New Engl J Med. 1982;307(14):841-4.

Greenwood Z, Black J, Weld L, O'Brien D, Leder K, Von Sonnenburg F, et al. Gastrointestinal infection among international travelers globally. J Travel Med. 2008;15(4):221-8. PubMed

Lääveri T, Vilkman K, Pakkanen SH, Kirveskari J, Kantele A. A prospective study of travellers' diarrhoea: analysis of pathogen findings by destination in various (sub)tropical regions. Clin Microbiol Infect. 2018;24(8):908.e9-908.e16. doi: 10.1016/j.cmi.2017.10.034. PubMed DOI

Torresi J, McGuinness S, Leder K, O'Brien D, Ruff T, Starr M, et al. Manual of travel medicine. Singapore: Springer; 2019.

Steffen R, Hill DR, DuPont HL. Traveler's diarrhea: a clinical review. JAMA. 2015;313(1):71-80. PubMed

Soonawala D, Vlot JA, Visser LG. Inconvenience due to travelers' diarrhea: a prospective follow-up study. BMC Infect Dis. 2011;11:322. doi: 10.1186/1471-2334-11-322. PubMed DOI

Barrett J, Brown M. Travellers' diarrhoea. BMJ. 2016;353:i1937. doi: 10.1136/bmj.i1937. PubMed DOI

Pitzurra R, Fried M, Rogler G, Rammert C, Tschopp A, Hatz C, et al. Irritable bowel syndrome among a cohort of European travelers to resource-limited destinations. J Travel Med. 2011;18(4):250-6. PubMed

Mutsch M, Pitzurra R, Hatz C, Steffen R. Post-infectious sequelae of travelers' diarrhea: irritable bowel syndrome. J Travel Med. 2014;21(2):141-3. PubMed

Fletcher SM, McLaws ML, Ellis JT. Prevalence of gastrointestinal pathogens in developed and developing countries: systematic review and meta-analysis. J Public Health Res. 2013 Apr 28;2(1):42-53. PubMed

Lääveri T, Antikainen J, Pakkanen SH, Kirveskari J, Kantele A. Prospective study of pathogens in asymptomatic travellers and those with diarrhoea: aetiological agents revisited. Clin Microbiol Infect. 2016 Jun;22(6):535-41.

McFarland LV, Goh S. Are probiotics and prebiotics effective in the prevention of travellers' diarrhea: a systematic review and meta-analysis. Travel Med Infect Dis. 2019;27:11-9.

Angst F, Steffen R. Update on the epidemiology of traveler's diarrhea in East Africa. J Travel Med. 1997 Sep 1;4(3):118-20. PubMed

Pitzurra R, Steffen R, Tschopp A, Mutsch M. Diarrhoea in a large prospective cohort of European travellers to resource-limited destinations. BMC Infect Dis. 2010;10:231. doi: 10.1186/1471-2334-10-231. PubMed DOI

Belderok SM, van den Hoek A, Kint JA, van der Loeff MF, Sonder GJ. Incidence, risk factors and treatment of diarrhoea among Dutch travellers: reasons not to routinely prescribe antibiotics. BMC Infect Dis. 2011;11:295. doi: 10.1186/1471-2334-11-295. PubMed DOI

Mues KE, Esposito DH, Han PV, Jentes ES, Sotir MJ, Brown C. Analyzing GeoSentinel surveillance data: a comparison of methods to explore acute gastrointestinal illness among international travelers. Clin Infect Dis. 2014 Feb;58(4):546-54.

Herbinger KH, Drerup L, Alberer M, Nothdurft HD, Sonnenburg FV, Löscher T. Spectrum of imported infectious diseases among children and adolescents returning from the tropics and subtropics. J Travel Med. 2012;19(3):150-7. PubMed

Kuenzli E, Juergensen D, Kling K, Jaeger VK, DeCrom S, Steffen R, et al. Previous exposure in a high-risk area for travellers' diarrhoea within the past year is associated with a significant protective effect for travellers' diarrhoea: a prospective observational cohort study in travellers to South Asia. J Travel Med. 2017;24(5). doi: 10.1093/jtm/tax056. PubMed DOI

Riddle MS, Connor BA, Beeching NJ, DuPont HL, Hamer DH, Kozarsky P, et al. Guidelines for the prevention and treatment of travelers' diarrhea: a graded expert panel report. J Travel Med. 2017;24(Suppl 1):S63-80.

Riddle MS, Connor BA. The traveling microbiome. Curr Infect Dis Rep. 2016;18:29. doi: 10.1007/s11908-016-0536-7. PubMed DOI

Youmans BP, Ajami NJ, Jiang ZD, Campbell F, Wadsworth WD, Petrosino JF, et al. Characterization of the human gut microbiome during travelers' diarrhea. Gut Microbes. 2015;6(2):110-9. PubMed

Stamps BW, Lyon WJ, Irvin AP, Kelley-Loughnane N, Goodson MS. A pilot study of the effect of deployment on the gut microbiome and traveler's diarrhea susceptibility. Front Cell Infect Microbiol. 2020;10:589297. doi: 10.3389/fcimb.2020.589297. PubMed DOI

Rasko DA. Changes in microbiome during and after travellers' diarrhea: what we know and what we do not. J Travel Med. 2017;24(Suppl 1):S52-6. PubMed

Szajewska H, Guarino A, Hojsak I, Indrio F, Kolacek S, Shamir R, et al. Use of probiotics for management of acute gastroenteritis: a position paper by the ESPGHAN Working Group for Probiotics and Prebiotics. J Pediatr Gastroenterol Nutr. 2014;58(4):531-9. PubMed

Guarino A, Guandalini S, Lo Vecchio A. Probiotics for prevention and treatment of diarrhea. J Clin Gastroenterol. 2015;49:S37-45.

McFarland LV. From yaks to yogurt: the history, development, and current use of probiotics. Clin Infect Dis. 2015;60(Suppl 2):S85-90.

Sanders ME, Benson A, Lebeer S, Merenstein DJ, Klaenhammer TR. Shared mechanisms among probiotic taxa: implications for general probiotic claims. Curr Opini Biotechnol. 2018;49:207-16.

McFarland LV, Evans CT, Goldstein EJ. Strain-specificity and disease-specificity of probiotic efficacy: a systematic review and meta-analysis. Front Med (Lausanne). 2018;5:124. doi: 10.3389/fmed.2018.00124. PubMed DOI

Behrens RH, Cramer JP, Jelinek T, Shaw H, von Sonnenburg F, Wilbraham D, et al. Efficacy and safety of a patch vaccine containing heat-labile toxin from Escherichia coli against travellers' diarrhoea: a phase 3, randomised, double-blind, placebo-controlled field trial in travellers from Europe to Mexico and Guatemala. Lancet Infect Dis. 2014;14(3):197-204.

Booth I, Cunha Ferreira R, Desjeux JF, Farthing M, Guandalini S, Hoekstra JH. Recommendations for composition of oral rehydration solutions for the children of Europe. Report of an ESPGAN working group. J Pediatr Gastroenterol Nutr. 1992;14(1):113-5. PubMed

World Health Organization. World Health Organization model list of essential medicines, 21st list, 2019. Geneva: WHO; 2019.

Lääveri T, Vilkman K, Pakkanen S, Kirveskari J, Kantele A. Despite antibiotic treatment of travellers' diarrhoea, pathogens are found in stools from half of travellers at return. Travel Med Infect Dis. 2018;23:49-55.

Kantele A, Lääveri T, Mero S, Vilkman K, Pakkanen SH, Ollgren J, et al. Antimicrobials increase travelers' risk of colonization by extended-spectrum betalactamase-producing Enterobacteriaceae. Clin Infect Dis. 2015;60(6):837-46.

Schweitzer L, Singh B, Rupali P, Libman M. Emerging concepts in the diagnosis, treatment, and prevention of travelers' diarrhea. Curr Opin Infect Dis. 2019;32(5):468-74.

Ericsson CD, Riddle MS. Should travel medicine practitioners prescribe antibiotics for self-treatment of travelers' diarrhea? J Travel Med. 2018;25(1). doi: 10.1093/jtm/tay081. PubMed DOI

Turunen KA, Kantele A. Revisiting travellers' diarrhoea justifying antibiotic treatment: prospective study. J Travel Med. 2021;28(3):taaa237. doi: 10.1093/jtm/taaa237. PubMed DOI

Szajewska H, Guarino A, Hojsak I, Indrio F, Kolacek S, Salvatore S, et al. Use of probiotics for the management of acute gastroenteritis in children: an update. J Pediatr Gastroenterol Nutr. 2020;71(2):261-9. PubMed