Intended for healthcare professionals

Clinical Review

Management of travellers’ diarrhoea

BMJ 2008; 337 doi: (Published 06 October 2008) Cite this as: BMJ 2008;337:a1746
  1. David R Hill, director, honorary professor1,
  2. Edward T Ryan, director, associate professor2
  1. 1National Travel Health Network and Centre, and London School of Hygiene and Tropical Medicine, Hospital for Tropical Diseases, London WC1E 6JB
  2. 2Travelers’ Advice and Immunization Center, and Tropical and Geographic Medicine Center, Massachusetts General Hospital, Boston, USA
  1. Correspondence to: D R Hill david.hill{at}

    Travellers’ diarrhoea is one of the most common illnesses in people who travel internationally, and depending on destination affects 20-60% of the more than 800 million travellers each year. In most cases the diarrhoea occurs in people who travel to areas with poor food and water hygiene.1 This review examines the approach to the prevention and treatment of diarrhoea in travellers. Much of the evidence base for travellers’ diarrhoea has been established over the past 30 years, with a strong body of randomised trials and consensus opinion in support of recommendations. The use of antibiotics for self treatment or chemoprophylaxis, however, remains debatable.

    Sources and selection criteria

    We identified articles through an electronic search of PubMed and the Cochrane library using the term “travelers’ diarrhea” alone and in combination with “treatment”, “etiology”, and “prevention”. Additional studies were sourced from the retrieved articles. We also reviewed our extensive collection of articles on the subject, as well as current national guidelines in travel medicine.

    Summary points

    • Travellers’ diarrhoea affects 20-60% of people travelling primarily to low income regions

    • Classic travellers’ diarrhoea is defined as three or more loose stools in 24 hours with or without at least one symptom of cramps, nausea, fever, or vomiting

    • Bacteria cause most identified cases; however, viruses and protozoan parasites are also causative

    • The objectives of self treatment are to avoid dehydration, reduce the symptoms and duration of illness, and prevent disruption to planned activities

    • Travellers should maintain hydration, and can use bismuth subsalicylate to treat mild diarrhoea, loperamide to control symptoms when necessary, and a short course of an antibiotic to treat moderate to severe cases

    • Evaluation and management of returned travellers with diarrhoea includes maintaining hydration during mild illness, bacterial culture of stools and empirical treatment during moderate to severe illness, and, in protracted cases, examination of stools for ova …

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