Travellers' diarrhea

Question 1

What is the hallmark symptom of travellers’ diarrhea (TD)?

Answer 1

≥3 loose stools a day (frequency and quality of stool)

Question 2

What is the difference in onset between the different types of diarrhea?

Answer 2

• Bacterial and viral diarrhea: sudden onset
• Protozoal diarrhea: gradual onset of mild symptoms, with 2-5 loose stools a day

Question 3

What is/are the difference(s) in duration between the different type of diarrheas?

Answer 3

• Bacterial: 3-7d
• Viral: 2-3d
• Protozoal: up to a month if untreated

Question 4

What is the difference in terms of symptoms between food poisoning and travellers diarrhea?

Answer 4

• Food: incubation period of 1-6h, and resolves within a day
• TD: Lasts longer and may or may not have incubation period

Question 5

What kind of diarrhea should you NOT use anti-motility agents such as loperamide and diphenoxylate?

Answer 5

Diarrhea associated with fever or blood in stools

Question 6

Antibiotics used in bacterial TD?

Answer 6

1. Ciprofloxacin (FQs)
2. Azithromycin

Question 7

Antibiotic that can be used in protozoal TD?

Answer 7

Metronidazole

Question 8

Are antibiotics necessary in bacterial or protozoal TD?

Answer 8

Not always
- TD self-limiting
- Antibiotic use may promote resistance

However, abx does reduce duration of TD by 2-3 days

Question 9

Forensic classification of loperamide and its usual dosage for TD? What is the minimum age?

Answer 9

• P only
• 4 mg after an episode of loose stool, then 2mg per diarrhea episode, max 16mg/day
• Age ≥ 12yo

Question 10

Purpose of atropine in diphenoxylate?

Answer 10

Discourage abuse

• Atropine is an anti-muscarinic
• Diphenoxylate is an opioid that stimulates mu receptors in the GI tract. It is well absorbed and can cause opioid side effects especially euphoria. Hence it can be abused
• Atropine produces undesirable and uncomfortable effects at higher doses (e.g. dry mouth, dry eyes) which hence discourages patients from taking too much of the combination of diphenoxylate/atropine

Question 11

Forensic classification of diphenoxylate/atropine and its usual dosage for TD? What is the minimum age?

Answer 11

• P only
• Two tablets (2.5 mg/0.025 mg) QDS, max 20mg/day
• ≥12 yo

Question 12

Forensic classification of buscopan and its usual dosage for TD? What is the minimum age?

Answer 12

• P only
• 10 mg tablets. 1-2 tabs 3-5 times a day
• ≥6yo

Question 13

Side effects of buscopan?

Answer 13

Anti-cholinergic side effects (dry mouth, dry eyes, blurred vision, constipation, etc.)

Question 14

Forensic classification of meteospasmyl and its usual dosage for TD? What is meteospasmyl made of? What is the minimum age?

Answer 14

• P only
• Alverine citrate 60mg + simethicone 300 mg
• Dose: 1 cap 2-3 times a day (before food?)
• Minimum age: only for adults

Question 15

Forensic classification of colimix and its usual dosage for TD? What is colimix made of? What is the minimum age?

Answer 15

• P only
• Dicyclomine HCl 5mg/5mL + simethicone 50mg/5mL
• Children 4-12yo: 5-10 mL up to QDS
• Adults: 10 mL up to QDS

Question 16

Common side effects of meteospasmyl?

Answer 16

• Nausea, headache, dizziness
• Skin (pruiritus, rash)

Question 17

Forensic classification of smecta and its usual dosage for TD? What is smecta? What is the minimum age?

Answer 17

• GSL
• Diaoctahedral smectite
• 1-2yo: 1 sachet/day
• > 2yo: 2-3 sachet/day
• Adults: 3-6 sachets a day
• Minimum age 1yo

Question 18

General counselling points to prevent travellers’ diarrhea

Answer 18

1. Hygiene: wash hands before use
2. Food: always heat up food before eating. Try to take fresh food. Avoid raw food
3. Beverage: Avoid ice since they might be made of contaminated water.