How to Avoid Traveler’s Diarrhea

(RxWiki News) Traveler’s diarrhea can ruin your travels. Learn how to avoid it, and treat it, if it happens to you.

Traveler’s diarrhea most often occurs for those traveling from industrialized countries to developing ones, where sanitation and water systems are not always adequate.

  • Traveler’s diarrhea is often bacterial. It is caused by organisms such as:
    • E. coli
    • Salmonella
  • A smaller number of cases are viral.
  • One of the most stubborn causes of infection is Giardia lamblia, a parasite.
  • Sometimes it’s hard to identify the culprit. Yet, nearly all traveler’s diarrhea comes from food and water that has been contaminated (usually by fecal matter from unwashed hands).

The symptoms can include:

  • Loose and watery stools
  • Cramps
  • Nausea
  • Vomiting
  • Fever
  • Blood in the stool (rarely)

Symptoms can merely spoil your fun or, in bad cases, require hospitalization.

In general, you do not need to take special precautions if you are traveling in the U.S. or other industrialized countries such as Canada, the European Union, Australia, or Japan. But some travelers do get diarrhea in these places.

That is because any change of locale and eating habits can make you more vulnerable.

You are more likely to become ill from contaminated food or water if you go to certain parts of:

  • Asia
  • Latin America
  • Africa
  • Eastern Europe
  • Less-developed areas

In fact, about half of travelers to developing countries may develop diarrhea, depending on:

  • Destination
  • Season
  • Length of stay
  • Individual susceptibility

Even if you stay at a fancy hotel in a developing country and never eat food outside this presumably protected environment, you can still get sick.

7 tips to stay well

If you travel to underdeveloped locales frequently, you may have built up some immunity. But it’s still wise to try to protect yourself by heeding the following tips.

People with impaired or underdeveloped immunity should be especially diligent when traveling, including:

  • Children
  • Pregnant women
  • Patients undergoing immunosuppressant therapies (including chemotherapy)
  • People with certain infections (such as HIV)

They can get sick from lower exposures to microbes and are at higher risk for dangerous complications.

Don’t drink tap water

  • Drink only bottled water or other beverages from sealed bottles, cartons, or cans.
  • Make sure the bottle has an intact seal before you open it otherwise, it could have been filled with tap water. To be extra safe, don’t sip directly from a can or bottle—use a straw or pour into a clean glass.
  • Avoid ice, since it may have been made with contaminated water, and freezing does not assuredly kill microbes.
  • Some restaurants and hotels, especially those that cater to tourists, use purified water for food preparation and to make ice.
  • Use bottled water for brushing your teeth. Don’t swallow water in the shower.
  • Coffee and tea should be made with boiling water, not just hot water. 
  • Before you travel, it may be worth investing in a portable water purifier.

Watch for hidden sources of microbes

  • Tap water, or ice made from tap water, may be found in some foods and beverages you may not think to worry about, including:
    • Fruit juices diluted with water
    • Smoothies
    • Ice pops
    • Fountain drinks
    • Sodas that don’t come from a sealed bottle
  • Avoid unpasteurized (raw) milk and products made from it, such as ice cream or cheese.

With some exceptions, don’t eat anything raw

  • Raw fruit is okay if it can be peeled (banana or oranges) and you do the peeling. Rinse the fruit first with bottled, not tap, water. Make sure your hands are clean.
  • Avoid salads, and eat vegetables only if they are cooked and piping hot.
  • Skip fresh fruit or vegetable garnishes that may come with your meal.
  • Better yet, ask that they be left off the plate when you order.
  • Skip fresh salsas and chutneys, as well as any sauce or topping made from raw fruit or vegetables.
  • Avoid raw and undercooked eggs, meat, and seafood.

Be a stickler for food served at proper temperatures

  • That means hot foods should be very hot, and cold foods cold.
  • Buffets can be especially risky. To spare your health, best to avoid buffets.

Skip street food

  • This advice may be hard to follow, since eating what the locals eat is tempting and often a big part of the travel experience.
    • Vendors’ hands may not be clean
    • Utensils may be contaminated with microbes
    • Food may not be cooked sufficiently or held at adequate temperatures
  • Even if a food stand looks very clean, it’s safest to avoid it.

Wash your hands carefully—and often

  • After using the bathroom and before eating, wash hands thoroughly with soap and water.
  • If that’s not available, use a hand sanitizer containing at least 60% alcohol.
  • Apply a dime-size amount to one palm and rub your hands together for 30 seconds on until dry.
  • Cover all surfaces, including between your fingers and up around your fingertips and nails.
  • You can also use hand sanitizer (or disinfectant wipes) on utensils if you’re not sure they are clean.

Go to the CDC travelers' health information

  • When on the traveler's health information on the CDC website, select the country you plan to visit in the destination field. Next, scroll down to "Eat and drink safely" to learn how to make safe food and beverage choices when traveling. 

If you still get traveler’s diarrhea

  • Traveler’s diarrhea is rarely life-threatening in otherwise healthy people.
  • Drink plenty of bottled water. The condition will usually clear up on its own within 2 to 10 days. In some cases, mild symptoms may continue for weeks.
  • For people who are frail or immunocompromised, symptoms are likely to be worse.
  • In addition, if a parasite such as Giardiais to blame, symptoms may last for months, even in healthy people unless they are treated. Follow up with your physician when you return.

Here’s what to do if you get traveler’s diarrhea despite precautions you’ve taken:

Replace lost fluids

  • Diarrhea and vomiting can cause dehydration, because your body loses more fluids and electrolytes than it takes in.
  • So, it’s vital to rehydrate yourself as soon as you can keep down fluids. Bottled water, fruit juices, sports drinks, coconut water, or tea will help.
  • Some travelers carry a powdered hydration mix with them and mix it with bottled water.
  • You can also make your own by adding four teaspoons of sugar and ½ teaspoon salt to a quart of bottled water.
  • Children under age 2 who are sick should drink a commercial rehydration solution, which contains the correct amounts of fluid, salt, and carbohydrates to prevent dehydration.

Eat selectively

  • When you feel well enough to eat again, small meals and bland foods are typically advised.
  • Consider eating:
    • Clear soup, salted crackers, dry toast, white rice, pasta, low-fiber cooked cereals, applesauce, bananas, eggs, baked poultry, baked potatoes (without skin), and cooked vegetables (like carrots and green beans)
    • An easy to remember acronym is BRATT diet (bananas, rice, applesauce, tea, toast)
  • Avoid consuming:
    • Alcohol, caffeine, fried and fatty foods, spicy foods, and “gassy” foods such as broccoli, peppers, and beans
  • Some research suggests that a restricted diet is not always necessary, however, and that some people may be able to tolerate a normal diet early on.

Take anti­diarrhea medication, if necessary

  • If you are healthy, it’s generally best to give your body time to eliminate the harmful organisms causing the diarrhea.
  • But if you’re in a situation where diarrhea is particularly inconvenient, over-the-counter medication can decrease symptoms. These include:
    • Loperamide (brand name Imodium, among others and available also by prescription)
    • Bismuth subsalicylate (brand name Pepto-Bismol)
  • Unless you know there will be a drugstore handy, take these drugs with you.
  • If you have a chronic health problem, consult your doctor about the advisability of taking such products or possibly a prescription drug such as diphenoxylate/atropine (brand name Lomotil).
  • Don’t dose yourself with anti-diarrhea drugs if you have a fever or bloody diarrhea—seek medical help.

Bring along antibiotics

  • Bring antibiotics if you are traveling to areas where it would be hard to get medical care.
  • Your doctor can give you directions about when and how to take them.
    • For instance, if you have a fever or bloody stool, which can be signs of a serious infection
  • Most cases of traveler’s diarrhea do not require antibiotics.

When to get medical attention

  • Contact a doctor or other health care provider if you have one or a combination of the following symptoms:
    • Diarrhea that lasts more than a few days without improvement
    • A fever of 101° F or higher that lasts more than 24 hours
    • Blood in stool
  • Also get medical care if severe diarrhea occurs in infants, older people, or people with heart disease or impaired immunity.
  • Depending on the symptoms, the doctor may take a stool sample to test for the organism causing your problem and may prescribe medications to relieve symptoms.

Pepto for prevention

Should you take Pepto-Bismol (or a generic) to prevent traveler’s diarrhea?

  • It’s something worth considering if you are traveling to a developing country, especially if you have a history of traveler’s diarrhea or are at risk from complications due to a medical condition.
  • But talk with your health care provider first, since there are some caveats and some medical conditions or existing medications in which you should not take Pepto-Bismol.

The active ingredient in Pepto-Bismol is bismuth subsalicylate (BSS), which has antimicrobial and anti-inflammatory effects.

The typical recommendation:

  • Take two tablets with each meal and two at bedtime (a total daily dose of eight tablets or the liquid equivalent).
  • Start with the first meal at your destination and end with your last meal. To be extra safe, you can take one more dose after that, which might be on the plane home.

This has been shown to reduce the risk of traveler’s diarrhea by up to 65%. Chewable tablets or caplets (as opposed to liquid versions) are convenient for traveling.

A harmless and temporary side effect of BSS is darkening of stool and the tongue.

  • To keep your tongue from turning black, rinse your mouth thoroughly after chewing the tablets. Better yet, gently brush your tongue, especially after the nighttime dose.
  • A problem with having black stools, though, is that normally this could indicate gastrointestinal bleeding. This is something that a number of travel-related diseases produce, so taking BSS could interfere with its detection.

Other potential side effects include:

  • Constipation (which some people might consider worse than getting diarrhea)
  • Mild and transient tinnitus (ringing in the ears), which can also happen with aspirin (another salicylate drug)

Other things to be aware of before popping these pink pills:

  • People with certain medical conditions, including (but not limited to) inflammatory bowel disease, should not take BSS.
    • Children under age 3 should not take it.
    • Consult your doctor before giving it to children between the ages of 3 and 12.
    • BSS should not be taken by anyone who is allergic or sensitive to aspirin.
  • It’s generally cautioned that BSS not be taken longer than three or four weeks.
    • There have been a few reported cases of bismuth toxicity, characterized by tremors and other neurological symptoms.
    • A study from 1990 found that taking 12 tablets a day for six weeks did not have toxic effects, however.
    • In any case, most people don’t travel long enough for bismuth toxicity to be a concern.
  • Of greater concern is salicylate toxicity in people who take BSS along with aspirin—or take BSS while overusing salicylate-containing liniments, such as Bengay. The amount of salicylates you absorb from eight tablets of BSS is equal to that in three or four adult aspirins.
  • BSS can interact with many drugs, including doxycycline, which, depending on your destination, may be recommended for malaria prevention. If you take both doxycycline and BSS, you should take them a few hours apart.
  • Taking BSS shouldn’t give you a false sense of security. It is not a substitute for being careful about what and where you eat and drink when traveling.


Medication adherence

The World Health Organization defines medication adherence as "the degree to which the person's behavior corresponds with the agreed recommendations from a health care provider." Poor adherence to prescribed regimens can result in serious health impacts including hospitalization and death.

About half of all medications for chronic diseases are not taken correctly. People change or skip doses, stop too soon, don’t take them at all, or never fill their prescriptions.

What to do when you get a new medication:

  • Take notes on what your doctor tells you about the medication.
  • Double check with the pharmacist on how to take the medication.
  • Ask questions to make sure you fully understand the medication. Be clear about when and how to take it.
  • Creating a chart for your daily medication regimen can help you stay on track. So might a pill box with multiple sections. This is helpful if you take more than one medication. This is also helpful if you take medications more than once a day. 
  • If you’re being treated for a chronic condition, check regularly with your doctor about whether you are taking the medication(s) correctly.
  • If you are concerned about or are experiencing side effects, talk to your doctor.
  • Do not take yourself off of medications without the knowledge and guidance of your doctor.
  • If you’re having trouble sticking to your medication, for any reason, talk with your doctor. They may be able to suggest other treatments or refer you to services that can help.