Question: I’m 62 and I've had diarrhea for two months now. It started a couple of days before I went to Mexico and got worse there. When I came home, my internist prescribed ciprofloxin but I only took one because it upset my stomach so much.
I've had diarrhea at least four times a day ever since, and I can’t sleep through the night without getting up to go to the bathroom. I have no other symptoms except my scalp broke out in a rash a couple of days ago. I started on probiotics yesterday but haven't noticed any relief yet. Can you help?
Dr. Hibberd's Answer:
You do not have traveler's diarrhea. Be sure your doctor knows your symptoms started before your travel to Mexico.
Your approach to investigation and treatment should be aggressive due to the length of your symptoms. Viral diseases are the most common causes of diarrhea in the United States, but protozoal, bacterial, and parasitic disorders are sometimes seen, especially if contaminated well water has been consumed.
Be sure your doctor confirms this is infectious diarrhea, since antibiotic treatment of non-infectious diarrhea will only destroy your pocketbook and set you up for complications, not to mention the delay in diagnosis and correct treatment.
Bacterial and parasitic diarrhea illnesses are common in travelers returning from Mexico and the Caribbean especially after consuming food washed in local water, which can be contaminated with fecal matter, or from eating with utensils cleaned with local water. There is no vaccine for general traveler's diarrhea.
Routine preventative regimens based on drugs are not usually recommended. When they are, however, they should be considered for use in healthy travelers whose wellness is critical (i.e., some athletes) and in travelers who are at increased risk of severe illness or complications. They should be used for only two to three weeks.
Fruits and vegetables peeled by the traveler, dry foods, and foods that are piping hot and thoroughly cooked are generally safe. Avoid fruits and vegetables washed with local water, all tap water, ice cubes, fruit juice, fresh salads, raw dairy products, cold sauces and toppings, open buffets, and undercooked or reheated foods. Bottled water is safest.
Ciprofloxacin is widely used as a preventive agent (which I have major reservations about) and is the first line recommended drug to treat returning adult (over 18 years of age) travelers.
With protracted symptoms, I recommend you ask for a stool analysis for ova and parasites, smear for WBCs and Giardia, culture and sensitivity exam (to include campylobacter bacterial culture), and C. Diff toxin assay (if you have been on recent antibiotics) on a stool specimen as well as a CBC, ESR (sed rate) and blood chemistry (comprehensive metabolic profile). While awaiting results, ask your doctor to consider an alternative treatment regimen.
Assuming you have infectious diarrhea, azithromycin (Zithromax) and occasionally Xiphaxin( in select circumstances) are commonly used as alternative medications for travelers diarrhea, but they may not be best for your case. Bactrim DS may also be an option, but your doctor should make the decision.
In addition, your doctor may consider empiric treatment for Giardiasis, which will consist of a treatment course with Flagyl. Avoid all alcohol beverages or mouth rinses while on this medication. Testing for Giardiasis is not always as reliable as we wish it should be, and sometimes it is easier to give you coverage for this especially since this has been so protracted.
Loperamide (Imodium) is an effective antimotile agent. While Bismuth subsalycylate (Pepto-Bismol) reduces loose stool episodes by one half, Loperamide is more effective and works quicker. Loperamide is not to be used in children, when blood is noted in the stool, when a temperature is over 101.3 Fahrenheit.
When treating diarrheal illness, it is usually advisable to eliminate dairy products for two weeks since lactose absorption is often disturbed for 7-10 days after diarrheal illness, and may fool you into believing the infection is still present.
Failure to respond to treatment should be followed by imaging studies (direct imaging by colonoscopy or indirect imaging by barium contrast X-rays) if the other studies on blood and stool do not give you a firm diagnosis. Probiotics won’t help you now, but may have some use after your treatment course is complete. Good luck.
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