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خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : -2 مورد

Travelers' diarrhea: Treatment and prevention

Travelers' diarrhea: Treatment and prevention
Authors:
Regina LaRocque, MD, MPH
Jason B Harris, MD, MPH
Section Editor:
Stephen B Calderwood, MD
Deputy Editor:
Elinor L Baron, MD, DTMH
Literature review current through: Apr 2025. | This topic last updated: Feb 12, 2025.

INTRODUCTION — 

Travelers' diarrhea refers to development of unformed stools associated with travel to a region where sanitation and hygienic practices are poor and there is limited access to safe drinking water [1,2]. It is the most common travel-associated illness; among travelers to such regions, 30 to 70 percent develop diarrhea [3].

The treatment and prevention of travelers' diarrhea are discussed here. The epidemiology, microbiology, clinical manifestations, and diagnosis of travelers' diarrhea are discussed separately. (See "Travelers' diarrhea: Epidemiology, microbiology, clinical manifestations, and diagnosis".)

MANAGEMENT — 

Most cases of travelers' diarrhea resolve on their own within three to five days of treatment with oral fluid replacement. Antimotility agents can provide symptomatic relief but should not be used for travelers with diarrhea associated with fever or bloody stools.

The benefit of antibiotics must be weighed against potential risks, including adverse effects and selection for resistant bacteria. These issues are discussed further below.

Guidance for self-management — Management of travelers' diarrhea depends on the severity of illness, which can be categorized based on functional impact according to a scheme outlined by the International Society of Travel Medicine [2]:

Mild illness

●Definition

•Diarrhea – Mild illness refers to diarrhea that is tolerable, is not distressing, and does not interfere with planned activities [2].

•Dehydration – For patients who are urinating every 4 to 6 hours (even if the color is dark yellow), volume depletion is likely mild.

●Management – Management of mild illness includes (table 1):

•Rehydration – Fluid replacement is discussed below. (See 'Fluid replacement' below.)

•Role of antimotility agent – Patients may use an antimotility agent such as loperamide, if desired. Antimotility agents should be discontinued if abdominal pain or other symptoms worsen, or if diarrhea remains intractable after two days. (See 'Antimotility agents' below.)

Moderate illness

●Definition

•Diarrhea – Moderate illness refers to diarrhea that is distressing or interferes with planned activities [2].

•Dehydration – For patients who are urinating every four to six hours (even if the color is dark yellow), volume depletion is likely mild. For patients with a paucity of urine (ie, less than two cups of urine in a 24-hour period), volume depletion is likely severe.

●Management – Management of moderate illness includes (table 1):

•Supportive care

-Rehydration – Fluid replacement is discussed below. (See 'Fluid replacement' below.)

-Role of antimotility agent – Loperamide may be used for moderate illness, but should not be used for travelers with diarrhea associated with fever stools. Antimotility agents should be discontinued if abdominal pain or other symptoms worsen, or if diarrhea remains intractable after two days. (See 'Antimotility agents' below.)

•Role of antibiotic therapy – For patients with fever or abdominal pain that is moderate to severe, treatment with antibiotic therapy is appropriate.

Severe illness

●Definition

•Diarrhea – Severe illness refers to diarrhea that is incapacitating or completely prevents planned activities; all dysentery (passage of grossly bloody stools) is considered severe [2].

•Dehydration – For patients with a paucity of urine (ie, less than two cups of urine in a 24-hour period), volume depletion is likely severe.

●Management – Management of severe illness includes (table 1):

•Rehydration – Fluid replacement is discussed below. (See 'Fluid replacement' below.)

•Role of antibiotic therapy – Travelers with severe diarrhea should be treated with antibiotic therapy. However, antibiotics should be avoided in the setting of bloody diarrhea without fever (given the possibility of Shiga toxin-producing Escherichia coli infection, with increased risk for hemolytic uremic syndrome [HUS]).

•Role of antimotility agent – 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. There is concern that antimotility agents may prolong some types of dysenteric illnesses (eg, Shigella) [4]; however, some studies suggest that antimotility drugs may be used in dysenteric illnesses as long as they are combined with antibiotic therapy [5].

Antimotility agents should be discontinued if abdominal pain or other symptoms worsen or if diarrhea remains intractable after two days.

When to seek medical attention — Indications for seeking care include [2]:

●Persistent symptoms despite 24 to 36 hours of self-treatment

●Progressive dehydration, high fever, abdominal pain, bloody diarrhea, or dehydration unresponsive to oral rehydration solution (ORS)

Available tools

Fluid replacement — The most significant complication of diarrhea is volume depletion [6,7]. Travelers can use the amount of urine passed as a general guide to their level of volume depletion.

Fluid replacement is the cornerstone of treatment for patients with travelers' diarrhea. The approach to fluid replacement depends on the severity of volume depletion:

●Mild dehydration – For patients with diarrhea who are urinating every four to six hours (even if the color is dark yellow), volume depletion is likely mild. Patients may alternate sipping fluids containing salt with fluids containing sugar, to replete and maintain hydration. Broth, diluted fruit juice, or similar fluids may be used. ORS, such as Pedialyte, is useful in children and adults with mild dehydration.

●Severe dehydration – For patients with diarrhea who are urinating less than two cups of urine in a 24-hour period, volume depletion is likely severe.

Severe diarrhea should be treated with ORS (such as Pedialyte), which replaces needed electrolytes in the appropriate concentrations. The electrolyte concentrations of sports beverages are not equivalent to ORS (table 2).

Packets of ORS are available in the pharmacies of most countries and can be mixed with clean drinking water. An alternative approach consists of adding 0.5 teaspoon of salt and 6 teaspoons of sugar to one liter of water. Travelers may benefit from carrying packets of ORS with them while traveling.

ORS should be used until the individual is urinating regularly (every four to six hours).

Issues related to rehydration are discussed further separately. (See "Approach to the adult with acute diarrhea in resource-abundant settings", section on 'Fluid repletion' and "Oral rehydration therapy", section on 'Clinical management'.)

The optimal dietary intake during diarrheal illness is uncertain. In general, patients may eat or not as they choose. Often patients with diarrhea do not feel hungry; if they do choose to eat, a bland diet such as rice or toast may be preferable.

Antimotility agents — An antimotility agent such as loperamide may be used cautiously for ≤2 days to reduce the rate of stooling; it does not treat the cause of diarrhea. The approach depends on the severity of diarrhea. (See 'Guidance for self-management' above.)

Antimotility agents should be discontinued if abdominal pain or other symptoms worsen, or if diarrhea remains intractable after two days.

●Loperamide – Dosing for loperamide consists of a starting dose of 4 mg; with ongoing diarrhea, an additional 2 mg may be taken after each additional loose or liquid stool, with a total dose of up to 16 mg per day. It takes one to two hours for loperamide to reach its therapeutic effect, so additional dosing should be spaced accordingly to avoid rebound constipation.

●Bismuth – Bismuth subsalicylate may ameliorate symptoms; however, large doses are required (four tablets [60 mL] every 30 minutes, up to eight doses per day). Its use is also associated with salicylate toxicity, especially in pregnant women, children, and those who take aspirin.

Limited role for antibiotic treatment — For most individuals with travelers' diarrhea, we suggest not treating with antibiotics; the potential risks of adverse drug effects, adverse effects on intestinal microbiota, and selection of highly drug-resistant organisms generally outweigh the modest reduction in diarrhea duration (by a day or two, compared with placebo) [8-14].

●Indications – Indications for antibiotic treatment include [2]:

•Travelers with fever or abdominal pain (moderate to severe)

•Travelers with severe diarrhea (diarrhea that is incapacitating or completely prevents planned activities)

•Travelers with bloody diarrhea; however, antibiotics should be avoided in the setting of bloody diarrhea without fever (given the possibility of Shiga toxin-producing E. coli infection, with increased risk for HUS)

•Travelers with an underlying medical condition that may increase the risk of complications from diarrhea (such as immunosuppression, inflammatory bowel disease, cardiovascular disease, or renal disease)

Caution should be used for patients with grossly bloody diarrhea, particularly if there is no or minimal fever; this presentation may reflect infection with Shiga toxin-producing E. coli, for which antibiotic treatment may be associated with an increased risk of HUS, especially in children. (See "Shiga toxin-producing Escherichia coli: Treatment and prevention", section on 'Antibiotics'.)

In a systematic review including 15 randomized trials conducted among travelers, antibiotics were not found to be significantly more effective than loperamide in treating mild/moderate travelers' diarrhea [15].

●Antibiotic selection – Antibiotic options for treatment of severe travelers' diarrhea are summarized in the table (table 3).

We suggest azithromycin for empiric treatment of most patients with travelers' diarrhea.

Rifaximin and rifamycin sodium are alternatives for treatment of travelers' diarrhea suspected to be caused by noninvasive strains of E. coli; however, they do not have activity against invasive pathogens, and they should not be used in patients with fever or bloody diarrhea.

•Azithromycin – The most practical adult dose for travelers' diarrhea is a single 1 g dose (table 3); however, it can cause nausea in some individuals. A three-day course of 500 mg daily is also effective [16].

Azithromycin is active against pathogens that cause dysentery (bloody or mucoid diarrhea) and retains activity in some locations where antibiotic-resistant pathogens are prevalent (such as Southeast Asia, where quinolone-resistant Campylobacter jejuni and rifaximin-resistant C. jejuni are common causes of travelers' diarrhea). It can be used safely in pregnant women and children.

In randomized trials, azithromycin was as effective as fluoroquinolones, which had previously been shown to reduce the duration of traveler's diarrhea by about one to two days [16-19].

•Rifaximin and rifamycin sodium – Rifaximin (200 mg three times daily for three days for children ≥12 years of age and adults) and rifamycin sodium (two 194 mg tablets twice daily for three days for adults) are poorly absorbed drugs that are alternatives to azithromycin for travelers' diarrhea likely caused by noninvasive strains of E. coli.

In randomized trials, rifaximin was associated with more rapid cessation of diarrhea than placebo (33 versus 60 hours) [20] and had comparable efficacy with fluoroquinolones [19,21,22]. Rifaximin combined with loperamide may provide more rapid symptomatic improvement than either agent alone [5].

•Impact of antimicrobial resistance – Antimicrobial resistance is increasing among bacterial pathogens that cause travelers' diarrhea. Most of the trials evaluating azithromycin and rifamycin sodium were performed prior to widespread prevalence of multidrug-resistant diarrheagenic bacteria; thus, their contemporary effectiveness is uncertain. In a review of studies evaluating resistance in diarrheagenic E. coli among travelers, rates of resistance to azithromycin and rifaximin ranged from 0 to 61 percent and 0 to 20 percent, respectively, with higher rates in more recent studies; rates of extended-spectrum beta-lactamase production have also increased [14].

•Limited role for fluoroquinolones – Previously, fluoroquinolones were preferred for treatment for travelers' diarrhea; in several randomized trials, fluoroquinolones reduced the duration of travelers' diarrhea by one to two days [23,24].

However, resistance to quinolones among diarrheal pathogens is increasing worldwide, particularly C. jejuni isolates in Southeast Asia [25-28] and diarrheagenic E. coli [29]. In a study including 1726 cases of travel-associated diarrhea reported from 2004 to 2014, 56 percent were quinolone nonsusceptible; most resistant bacteria were Campylobacter species [30].

Use of fluoroquinolones is further discouraged by adverse effects including effects on the tendons, muscles, joints, nerves, and central nervous system [31].

Patients with persistent diarrhea

●Microbiology – Potential causes of persistent diarrhea or if diarrhea does not improve with antibiotic therapy include:

•A less common pathogen

•A drug-resistant pathogen

•Clostridioides difficile

In a study of 7442 returning travelers diagnosed with an infectious gastrointestinal disease (not limited to diarrhea), 2092 cases had a pathogen identified on testing [32]. The most commonly isolated pathogens were Giardia spp (28 percent), Campylobacter spp (13 percent), Entamoeba histolytica (13 percent), Shigella spp (6 percent), and Strongyloides (6 percent). Cyclospora, Isospora, Cryptosporidium, and microsporidia are also thought to be important causes but may be underestimated because of difficulty in identification [33].

●Evaluation – Evaluation focuses on identifying the infecting pathogen so that therapy can be targeted. (See "Travelers' diarrhea: Epidemiology, microbiology, clinical manifestations, and diagnosis".)

Diagnosis and treatment of specific organisms are discussed in the dedicated topic reviews.

GUIDANCE FOR PREVENTION — 

The most important strategy for prevent of travelers' diarrhea is prudent selection of food and drink while traveling (table 4). Indications for immunizations should be reviewed carefully. Most travelers should not take antibiotics for prevention of travelers' diarrhea; prophylaxis may be beneficial for certain high-risk travelers.

Food and drink selection — Careful choices in selecting food and drinks may result in a lower incidence of diarrheal disease. Guidance is summarized in the table (table 4). (See "Travel advice".)

●Water and other beverages – Water may be consumed if it has been boiled, treated, or bottled. If safe drinking water is not available, water may be disinfected by boiling, halogenation, or filtering (table 4). Carbonated beverages, beer, wine, and drinks prepared with boiled water are generally considered to be free of pathogens. Drinks should be requested without ice.

●Food – Food should be eaten well-cooked and while still hot (table 4). Fresh produce that is washed in safe water and peeled by the traveler may be eaten. Unpasteurized dairy products and undercooked fish or meat should be avoided, as should food from street vendors given potential risk for contamination.

Following such dietary guidance can reduce the risk of travelers' diarrhea; however, this has been difficult to demonstrate in formal studies, and few travelers are able to abide by all food and beverage restrictions [34].

Vaccination — Immunizations for prevention of typhoid and cholera are discussed separately. (See "Immunizations for travel".)

Limited role for antibiotics

Prophylaxis

●Indications – Most travelers should not take antibiotics for prevention of travelers' diarrhea; downsides include adverse effects on intestinal microbiota [35], selection of highly drug-resistant organisms [11,12], and adverse drug events.

For very select high-risk travelers, prophylaxis may be beneficial; such individuals include short-term (eg, <2 weeks) travelers with an underlying medical condition that may increase the risk of complications from diarrhea [2]. Examples may include individuals with immunosuppression, inflammatory bowel disease, or severe kidney disease. Alternatively, such individuals can be prescribed standby antibiotics for initiation of self-treatment, if needed. (See 'Self-treatment' below.)

●Antibiotic selection and dosing – For travelers who warrant prophylaxis, we suggest rifaximin (200 mg three times daily for the duration of travel). Rifaximin is not absorbed systemically and has a favorable safety profile [2]. The optimal dose is uncertain; various doses have been evaluated and there is no clear evidence that one is superior to the others.

If rifaximin is used for prophylaxis, an alternative antibiotic should be provided for self-treatment in case of moderate to severe illness (table 3).

We do not use fluoroquinolones for prophylaxis given their adverse event profile and increasing antimicrobial resistance [2].

●Supporting evidence – In a meta-analysis of four randomized trials including more than 500 travelers to Mexico or Turkey, administration of rifaximin (total daily dose ranging from 550 to 1100 mg) was associated with a lower rate of travelers' diarrhea compared with placebo (16 versus 40 percent; relative risk 0.41, 95% CI 0.30-0.56) [36]. Use of rifaximin was associated with minimal changes in intestinal flora and no excess adverse events.

One of the randomized trials in Mexico compared several rifaximin doses (200 mg daily, 200 mg twice daily, or 200 mg three times daily) with placebo for two weeks [37]. At all doses, rifaximin was associated with reduced rate of travelers' diarrhea; the highest dose may have been associated with slightly lower rates of travelers' diarrhea warranting antibiotic therapy (only the highest dose was included in the meta-analysis) [37].

In a subsequent randomized trial including 258 German adults who were traveling to South or Southeast Asia for 6 to 28 days, rifaximin also prevented travelers' diarrhea, although to a more moderate degree [38]. During travel and the week following, symptoms consistent with travelers' diarrhea were reported less frequently among travelers who received rifaximin (200 mg twice daily for the duration of the trip) than among those who received placebo (25 versus 41 percent). Of note, there was a trend toward lower effectiveness among travelers to Southeast Asia; this finding may be related to the decreased activity and efficacy of rifaximin for Campylobacter species [39], which predominate in Southeast Asia.

Self-treatment — We prefer to not routinely prescribe standby antibiotics to travelers for self-treatment of travelers' diarrhea, but this can be considered after an individualized discussion of the advantages and benefits. For some higher-risk travelers, we prescribe azithromycin to have on hand for self-treatment in case of moderate to severe illness (table 3); these include older adults or those with multiple medical conditions. We advise that medical care be sought in conjunction with initiation of antibiotics.

Nonantibiotic agents — Bismuth may reduce the risk of travelers' diarrhea, and may be considered for any traveler [40], but logistics for its use are not practical. (See 'Antimotility agents' above.)

Probiotics may reduce antibiotic-associated diarrhea; however, evidence of their effectiveness for prevention of travelers' diarrhea is insufficient [41,42].

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Acute diarrhea in adults" and "Society guideline links: Acute diarrhea in children" and "Society guideline links: Travel medicine".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Travelers' diarrhea (The Basics)")

●Beyond the Basics topics (see "Patient education: General travel advice (Beyond the Basics)" and "Patient education: Foodborne illness (food poisoning) (Beyond the Basics)" and "Patient education: Giardia (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Management of travelers' diarrhea – The approach to management of travelers' diarrhea is guided by the severity of illness (table 1). Mild illness refers to diarrhea that is tolerable, is not distressing, and does not interfere with planned activities. Moderate illness refers to diarrhea that is distressing or interferes with planned activities. Severe illness refers to diarrhea that is incapacitating or completely prevents planned activities; all dysentery (passage of grossly bloody stools) is considered severe. (See 'Guidance for self-management' above.)

●Fluid replacement (see 'Fluid replacement' above)

•For patients who are urinating every four to six hours (even if the color is dark yellow), volume depletion is likely mild. These patients may alternate sipping fluids containing salt with fluids containing sugar to replete and maintain hydration. Broth, diluted fruit juice, or similar fluids may be used.

•For patients with less than two cups of urine in a 24-hour period, volume depletion is likely severe. These patients should be treated with oral rehydration solution (ORS) (table 2): 50 to 100 mL/kg over four hours. Additional ORS should be given to replace ongoing losses (eg, diarrhea or vomiting).

●Role of antimotility agents (see 'Antimotility agents' above)

•For patients with mild or moderate nonbloody diarrhea (in the setting of absent or low-grade fever), the antimotility agent loperamide may be used cautiously for ≤2 days, if desired.

•Antimotility agents should not be used for patients with fever and/or bloody stools. Antimotility agents should be discontinued if abdominal pain or other symptoms worsen, or if diarrhea remains intractable after two days.

•For patients with severe illness (in the absence of fever or bloody stools) who seek symptomatic therapy, we avoid use of antimotility agents unless antibiotics are also given, due to concern for prolonging disease. (See "Approach to the adult with acute diarrhea in resource-abundant settings", section on 'Symptomatic therapy'.)

●Limited role for antibiotics (see 'Limited role for antibiotic treatment' above)

•Indications – For most individuals with travelers' diarrhea, we suggest not treating with antibiotics (Grade 2C). Antibiotics should be avoided in the setting of bloody diarrhea without fever (given the possibility of Shiga toxin-producing Escherichia coli infection, with increased risk for hemolytic uremic syndrome [HUS]). The adverse effects and promotion of bacterial resistance with antibiotics generally outweigh the modest reduction in diarrhea duration.

Antibiotic therapy is appropriate in the following circumstances:

-Patients with moderate illness including fever or abdominal pain that is moderate to severe

-Patients with nonbloody diarrhea that is incapacitating

-Patients with bloody diarrhea and fever

-Patients with an underlying medical condition that may increase the risk of complications from diarrhea

•Selection – For patients who warrant empiric antibiotic therapy for travelers' diarrhea, we suggest azithromycin (table 3) (Grade 2C). Rifaximin and rifamycin sodium are alternative agents but should be avoided in patients with features of invasive diarrhea (eg, bloody or mucoid stool). Fluoroquinolones are a potential alternative but are not preferred given their adverse event profile and increasing antimicrobial resistance.

●Prevention of travelers' diarrhea

•Available tools – Preventive measures include careful food and drink selection (table 4) and vaccination if indicated. (See 'Food and drink selection' above and 'Vaccination' above.)

•Limited role for antibiotic prophylaxis

-Indications – We suggest not routinely administering antibiotic prophylaxis to prevent travelers' diarrhea (Grade 2C), given adverse effects that outweigh the benefit of preventing a self-limited illness. (See 'Prophylaxis' above.)

For very select high-risk travelers, prophylaxis may be beneficial; such individuals include short-term (eg, <2 weeks) travelers with an underlying medical condition that may increase the risk of complications from diarrhea; examples may include individuals with immunosuppression, inflammatory bowel disease, or severe kidney disease.

-Selection – For travelers who warrant prophylaxis, we suggest rifaximin (Grade 2C); this agent is not absorbed systemically and has a favorable safety profile. We do not use fluoroquinolones for prophylaxis given their adverse event profile and increasing antimicrobial resistance.

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Christine A Wanke, MD, who contributed to an earlier version of this topic review.

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Topic 99648 Version 31.0

References

1 : Traveler's diarrhea: a clinical review.

2 : Guidelines for the prevention and treatment of travelers' diarrhea: a graded expert panel report.

3 : Guidelines for the prevention and treatment of travelers' diarrhea: a graded expert panel report.

4 : Adverse effect of lomotil therapy in shigellosis.

5 : Treatment of travelers' diarrhea: randomized trial comparing rifaximin, rifaximin plus loperamide, and loperamide alone.

6 : Oral therapy for acute diarrhea. The underused simple solution.

7 : Oral-rehydration therapy--the role of polymeric substrates.

8 : Import and spread of extended-spectrumβ-lactamase-producing Enterobacteriaceae by international travellers (COMBAT study): a prospective, multicentre cohort study.

9 : Travel to Asia and traveller's diarrhoea with antibiotic treatment are independent risk factors for acquiring ciprofloxacin-resistant and extended spectrumβ-lactamase-producing Enterobacteriaceae-a prospective cohort study.

10 : Colonization with extended-spectrum beta-lactamase-producing and carbapenemase-producing Enterobacteriaceae in international travelers returning to Germany.

11 : Antimicrobials increase travelers' risk of colonization by extended-spectrum betalactamase-producing Enterobacteriaceae.

12 : Acquisition and Long-term Carriage of Multidrug-Resistant Organisms in US International Travelers.

13 : Acquisition of Antibiotic-Resistant Bacteria by U.S. International Travelers.

14 : Extended-spectrum beta-lactamase-producing strains among diarrhoeagenic Escherichia coli-prospective traveller study with literature review.

15 : Systematic review of loperamide: No proof of antibiotics being superior to loperamide in treatment of mild/moderate travellers' diarrhoea.

16 : Traveler's diarrhea in Thailand: randomized, double-blind trial comparing single-dose and 3-day azithromycin-based regimens with a 3-day levofloxacin regimen.

17 : Azithromycin found to be comparable to levofloxacin for the treatment of US travelers with acute diarrhea acquired in Mexico.

18 : Azithromycin and loperamide are comparable to levofloxacin and loperamide for the treatment of traveler's diarrhea in United States military personnel in Turkey.

19 : Trial Evaluating Ambulatory Therapy of Travelers' Diarrhea (TrEAT TD) Study: A Randomized Controlled Trial Comparing 3 Single-Dose Antibiotic Regimens With Loperamide.

20 : Therapy of travelers' diarrhea with rifaximin on various continents.

21 : Rifaximin versus ciprofloxacin for the treatment of traveler's diarrhea: a randomized, double-blind clinical trial.

22 : Rifaximin: a novel nonabsorbed rifamycin for gastrointestinal disorders.

23 : Prevention and treatment of traveler's diarrhea.

24 : Randomised trial of single-dose ciprofloxacin for travellers' diarrhoea.

25 : Quinolone-resistant Campylobacter jejuni infections in Minnesota, 1992-1998. Investigation Team.

26 : Fluoroquinolone resistance in Campylobacter jejuni isolates in travelers returning to Finland: association of ciprofloxacin resistance to travel destination.

27 : Increasing fluoroquinolone resistance in Campylobacter jejuni, Pennsylvania, USA,1982-2001.

28 : An observational clinic-based study of diarrheal illness in deployed United States military personnel in Thailand: presentation and outcome of Campylobacter infection.

29 : Emergence of Resistance to Quinolones andβ-Lactam Antibiotics in Enteroaggregative and Enterotoxigenic Escherichia coli Causing Traveler's Diarrhea.

30 : Quinolone nonsusceptibility among enteric pathogens isolated from international travelers - Foodborne Diseases Active Surveillance Network (FoodNet) and National Antimicrobial Monitoring System (NARMS), 10 United States sites, 2004 - 2014.

31 : Quinolone nonsusceptibility among enteric pathogens isolated from international travelers - Foodborne Diseases Active Surveillance Network (FoodNet) and National Antimicrobial Monitoring System (NARMS), 10 United States sites, 2004 - 2014.

32 : A global study of pathogens and host risk factors associated with infectious gastrointestinal disease in returned international travellers.

33 : Enteropathogens and chronic illness in returning travelers.

34 : Epidemiology, etiology, and impact of traveler's diarrhea in Jamaica.

35 : Clostridium difficile infection in returning travellers.

36 : Efficacy of rifaximin in prevention of travelers' diarrhea: a meta-analysis of randomized, double-blind, placebo-controlled trials.

37 : A randomized, double-blind, placebo-controlled trial of rifaximin to prevent travelers' diarrhea.

38 : Effectiveness of rifaximin in prevention of diarrhoea in individuals travelling to south and southeast Asia: a randomised, double-blind, placebo-controlled, phase 3 trial.

39 : Rifaximin Fails to Prevent Campylobacteriosis in the Human Challenge Model: A Randomized, Double-Blind, Placebo-Controlled Trial.

40 : Prevention of travelers' diarrhea by the tablet formulation of bismuth subsalicylate.

41 : Efficacy of probiotics in prevention of acute diarrhoea: a meta-analysis of masked, randomised, placebo-controlled trials.

42 : A meta-analysis of probiotic efficacy for gastrointestinal diseases.