Version July 2025
| Symptoms | Management | |||
| Diarrhea | Dehydration | Rehydration | Role of antimotility agent | Role of antibiotic treatment |
Mild diarrhea
| Mild dehydration – Urinating every four to six hours | Box A | Box B | None |
| Alternate sipping fluids containing salt with fluids containing sugar to replete and maintain hydration. Broth, diluted fruit juice, or similar fluids may be used. | Loperamide may be used if desired. The starting dose is 4 mg orally. An additional 2 mg may be taken after each additional loose stool, with a total dose of up to 16 mg per day*. Antimotility agents should be discontinued if abdominal pain or other symptoms worsen, or if diarrhea remains intractable after two days. | |||
Moderate diarrhea
| Mild dehydration – Urinating every four to six hours | Refer to Box A above | Antimotility agents should not be used for travelers with diarrhea associated with fever. In the absence of these manifestations, loperamide may be used; refer to Box B above. | For patients with fever or abdominal pain that is moderate to severe, treatment with antibiotic therapy is appropriate. |
| Severe dehydration – Less than two cups of urine in a 24-hour period | Box C | |||
| Treat with oral rehydration solution: 50 to 100 mL/kg over four hours. Give additional ORS to replace ongoing losses (eg, diarrhea or vomiting). Continue until urinating every four to six hours, then continue as with Box A above. | ||||
Severe diarrhea
| Severe dehydration – Less than two cups of urine in a 24-hour period¶ | Refer to Box C above | Antimotility agents should not be used for travelers with diarrhea associated with fever or bloody stools. For travelers with severe diarrhea who wish to use antimotility agents for symptomatic therapy, this intervention should be used only in conjunction with antibiotics. Refer to Box B above. | Antibiotic therapy is warranted in the following circumstances:
Bloody diarrhea without fever could represent STEC infection; antibiotic use in such cases should be avoided given increased risk for hemolytic uremic syndrome. |
When to seek medical attention:
| ||||
ORS: oral rehydration solution; STEC: Shiga toxin-producing Escherichia coli.
* It takes one to two hours for loperamide to reach its therapeutic effect, so additional dosing should be spaced accordingly to avoid rebound constipation.
¶ In dysentery, the degree of dehydration may be variable; many patients with dysentery do not have severe dehydration.
