travellers diarrhoea spain

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• Traveler's diarrhea

Gastrointestinal tract

Your digestive tract stretches from your mouth to your anus. It includes the organs necessary to digest food, absorb nutrients and process waste.

Traveler's diarrhea is a digestive tract disorder that commonly causes loose stools and stomach cramps. It's caused by eating contaminated food or drinking contaminated water. Fortunately, traveler's diarrhea usually isn't serious in most people — it's just unpleasant.

When you visit a place where the climate or sanitary practices are different from yours at home, you have an increased risk of developing traveler's diarrhea.

To reduce your risk of traveler's diarrhea, be careful about what you eat and drink while traveling. If you do develop traveler's diarrhea, chances are it will go away without treatment. However, it's a good idea to have doctor-approved medicines with you when you travel to high-risk areas. This way, you'll be prepared in case diarrhea gets severe or won't go away.

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Traveler's diarrhea may begin suddenly during your trip or shortly after you return home. Most people improve within 1 to 2 days without treatment and recover completely within a week. However, you can have multiple episodes of traveler's diarrhea during one trip.

The most common symptoms of traveler's diarrhea are:

• Suddenly passing three or more looser watery stools a day.
• An urgent need to pass stool.
• Stomach cramps.

Sometimes, people experience moderate to severe dehydration, ongoing vomiting, a high fever, bloody stools, or severe pain in the belly or rectum. If you or your child experiences any of these symptoms or if the diarrhea lasts longer than a few days, it's time to see a health care professional.

When to see a doctor

Traveler's diarrhea usually goes away on its own within several days. Symptoms may last longer and be more severe if it's caused by certain bacteria or parasites. In such cases, you may need prescription medicines to help you get better.

If you're an adult, see your doctor if:

• Your diarrhea lasts beyond two days.
• You become dehydrated.
• You have severe stomach or rectal pain.
• You have bloody or black stools.
• You have a fever above 102 F (39 C).

While traveling internationally, a local embassy or consulate may be able to help you find a well-regarded medical professional who speaks your language.

Be especially cautious with children because traveler's diarrhea can cause severe dehydration in a short time. Call a doctor if your child is sick and has any of the following symptoms:

• Ongoing vomiting.
• A fever of 102 F (39 C) or more.
• Bloody stools or severe diarrhea.
• Dry mouth or crying without tears.
• Signs of being unusually sleepy, drowsy or unresponsive.
• Decreased volume of urine, including fewer wet diapers in infants.

It's possible that traveler's diarrhea may stem from the stress of traveling or a change in diet. But usually infectious agents — such as bacteria, viruses or parasites — are to blame. You typically develop traveler's diarrhea after ingesting food or water contaminated with organisms from feces.

So why aren't natives of high-risk countries affected in the same way? Often their bodies have become used to the bacteria and have developed immunity to them.

Risk factors

Each year millions of international travelers experience traveler's diarrhea. High-risk destinations for traveler's diarrhea include areas of:

• Central America.
• South America.
• South Asia and Southeast Asia.

Traveling to Eastern Europe, South Africa, Central and East Asia, the Middle East, and a few Caribbean islands also poses some risk. However, your risk of traveler's diarrhea is generally low in Northern and Western Europe, Japan, Canada, Singapore, Australia, New Zealand, and the United States.

Your chances of getting traveler's diarrhea are mostly determined by your destination. But certain groups of people have a greater risk of developing the condition. These include:

• Young adults. The condition is slightly more common in young adult tourists. Though the reasons why aren't clear, it's possible that young adults lack acquired immunity. They may also be more adventurous than older people in their travels and dietary choices, or they may be less careful about avoiding contaminated foods.
• People with weakened immune systems. A weakened immune system due to an underlying illness or immune-suppressing medicines such as corticosteroids increases risk of infections.
• People with diabetes, inflammatory bowel disease, or severe kidney, liver or heart disease. These conditions can leave you more prone to infection or increase your risk of a more-severe infection.
• People who take acid blockers or antacids. Acid in the stomach tends to destroy organisms, so a reduction in stomach acid may leave more opportunity for bacterial survival.
• People who travel during certain seasons. The risk of traveler's diarrhea varies by season in certain parts of the world. For example, risk is highest in South Asia during the hot months just before the monsoons.

Complications

Because you lose vital fluids, salts and minerals during a bout with traveler's diarrhea, you may become dehydrated, especially during the summer months. Dehydration is especially dangerous for children, older adults and people with weakened immune systems.

Dehydration caused by diarrhea can cause serious complications, including organ damage, shock or coma. Symptoms of dehydration include a very dry mouth, intense thirst, little or no urination, dizziness, or extreme weakness.

Watch what you eat

The general rule of thumb when traveling to another country is this: Boil it, cook it, peel it or forget it. But it's still possible to get sick even if you follow these rules.

Other tips that may help decrease your risk of getting sick include:

• Don't consume food from street vendors.
• Don't consume unpasteurized milk and dairy products, including ice cream.
• Don't eat raw or undercooked meat, fish and shellfish.
• Don't eat moist food at room temperature, such as sauces and buffet offerings.
• Eat foods that are well cooked and served hot.
• Stick to fruits and vegetables that you can peel yourself, such as bananas, oranges and avocados. Stay away from salads and from fruits you can't peel, such as grapes and berries.
• Be aware that alcohol in a drink won't keep you safe from contaminated water or ice.

Don't drink the water

When visiting high-risk areas, keep the following tips in mind:

• Don't drink unsterilized water — from tap, well or stream. If you need to consume local water, boil it for three minutes. Let the water cool naturally and store it in a clean covered container.
• Don't use locally made ice cubes or drink mixed fruit juices made with tap water.
• Beware of sliced fruit that may have been washed in contaminated water.
• Use bottled or boiled water to mix baby formula.
• Order hot beverages, such as coffee or tea, and make sure they're steaming hot.
• Feel free to drink canned or bottled drinks in their original containers — including water, carbonated beverages, beer or wine — as long as you break the seals on the containers yourself. Wipe off any can or bottle before drinking or pouring.
• Use bottled water to brush your teeth.
• Don't swim in water that may be contaminated.
• Keep your mouth closed while showering.

If it's not possible to buy bottled water or boil your water, bring some means to purify water. Consider a water-filter pump with a microstrainer filter that can filter out small microorganisms.

You also can chemically disinfect water with iodine or chlorine. Iodine tends to be more effective, but is best reserved for short trips, as too much iodine can be harmful to your system. You can purchase water-disinfecting tablets containing chlorine, iodine tablets or crystals, or other disinfecting agents at camping stores and pharmacies. Be sure to follow the directions on the package.

Follow additional tips

Here are other ways to reduce your risk of traveler's diarrhea:

• Make sure dishes and utensils are clean and dry before using them.
• Wash your hands often and always before eating. If washing isn't possible, use an alcohol-based hand sanitizer with at least 60% alcohol to clean your hands before eating.
• Seek out food items that require little handling in preparation.
• Keep children from putting things — including their dirty hands — in their mouths. If possible, keep infants from crawling on dirty floors.
• Tie a colored ribbon around the bathroom faucet to remind you not to drink — or brush your teeth with — tap water.

Other preventive measures

Public health experts generally don't recommend taking antibiotics to prevent traveler's diarrhea, because doing so can contribute to the development of antibiotic-resistant bacteria.

Antibiotics provide no protection against viruses and parasites, but they can give travelers a false sense of security about the risks of consuming local foods and beverages. They also can cause unpleasant side effects, such as skin rashes, skin reactions to the sun and vaginal yeast infections.

As a preventive measure, some doctors suggest taking bismuth subsalicylate, which has been shown to decrease the likelihood of diarrhea. However, don't take this medicine for longer than three weeks, and don't take it at all if you're pregnant or allergic to aspirin. Talk to your doctor before taking bismuth subsalicylate if you're taking certain medicines, such as anticoagulants.

Common harmless side effects of bismuth subsalicylate include a black-colored tongue and dark stools. In some cases, it can cause constipation, nausea and, rarely, ringing in your ears, called tinnitus.

• Feldman M, et al., eds. Infectious enteritis and proctocolitis. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 11th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 25, 2021.
• LaRocque R, et al. Travelers' diarrhea: Microbiology, epidemiology, and prevention. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
• Ferri FF. Traveler diarrhea. In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed April 28, 2023.
• Diarrhea. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/diarrhea. Accessed April 27, 2023.
• Travelers' diarrhea. Centers for Disease Control and Prevention. https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/travelers-diarrhea. Accessed April 28, 2023.
• LaRocque R, et al. Travelers' diarrhea: Clinical manifestations, diagnosis, and treatment. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
• Khanna S (expert opinion). Mayo Clinic. May 29, 2021.
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Traveller's diarrhoea

Peer reviewed by Dr Colin Tidy, MRCGP Last updated by Dr Toni Hazell Last updated 10 Feb 2023

Meets Patient’s editorial guidelines

In this series: Amoebiasis Giardia

Traveller's diarrhoea is diarrhoea that develops during, or shortly after, travel abroad. It is caused by consuming food and water, contaminated by germs (microbes) including bacteria, viruses and parasites. Other symptoms can include high temperature (fever), being sick (vomiting) and tummy (abdominal) pain. In most cases it causes a mild illness and symptoms clear within 3 to 4 days. Specific treatment is not usually needed but it is important to drink plenty of fluids to avoid lack of fluid in the body (dehydration). Always make sure that you get any advice that you need in plenty of time before your journey - some GPs offer travel advice but if yours doesn't then you may need to go to a private travel clinic.

In this article :

What is traveller's diarrhoea, what causes traveller's diarrhoea, are all travellers at risk, what are the symptoms of traveller's diarrhoea, how is traveller's diarrhoea diagnosed, when should i seek medical advice for traveller's diarrhoea, how is traveller's diarrhoea in adults treated, how is traveller's diarrhoea in children treated, side-effects of traveller's diarrhoea, how long does traveller's diarrhoea last, how can i avoid traveller's diarrhoea.

Continue reading below

Traveller's diarrhoea is diarrhoea that develops during, or shortly after, travel abroad. Diarrhoea is defined as: 'loose or watery stools (faeces), usually at least three times in 24 hours.'

Traveller's diarrhoea is caused by eating food, or drinking water, containing certain germs (microbes) or their poisons (toxins). The types of germs which may be the cause include:

Bacteria: these are the most common microbes that cause traveller's diarrhoea. Common types of bacteria involved are:

Escherichia coli

Campylobacter

Viruses: these are the next most common, particularly norovirus and rotavirus.

Parasites: these are less common causes. Giardia, cryptosporidium and Entamoeba histolytica are examples of parasites that may cause traveller's diarrhoea.

Often the exact cause of traveller's diarrhoea is not found and studies have shown that in many people no specific microbe is identified despite testing (for example, of a stool (faeces) specimen).

See the separate leaflets called E. Coli (VTEC O157) , Campylobacter, Salmonella, Cryptosporidium , Amoebiasis (dysentery information), Shigella and Giardia for more specific details on each of the microbes mentioned above.

Note : this leaflet is about traveller's diarrhoea in general and how to help prevent it.

Traveller's diarrhoea most commonly affects people who are travelling from a developed country, such as the UK, to a developing country where sanitation and hygiene measures may not meet the same standards. It can affect as many as 2 to 6 in 10 travellers.

There is a different risk depending on whether you travel to high-risk areas or not:

High-risk areas : South and Southeast Asia, Central America, West and North Africa, South America, East Africa.

Medium-risk areas : Russia, China, Caribbean, South Africa.

Low-risk areas : North America, Western Europe, Australia and New Zealand.

Sometimes outbreaks of diarrhoea can occur in travellers staying in one hotel or, for example, those staying on a cruise ship. People travelling in more remote areas (for example, trekkers and campers) may also have limited access to medical care if they do become unwell.

By definition, diarrhoea is the main symptom. This can be watery and can sometimes contain blood. Other symptoms may include:

Crampy tummy (abdominal) pains.

Feeling sick (nausea).

Being sick (vomiting).

A high temperature (fever).

Symptoms are usually mild in most people and last for 3 to 4 days but they may last longer. Symptoms may be more severe in the very young, the elderly, and those with other health problems. Those whose immune systems are not working as well as normal are particularly likely to be more unwell. For example, people with untreated HIV infection, those on chemotherapy, those on long-term steroid treatment or those who are taking drugs which suppress their immune system, for example after a transplant or to treat an autoimmune condition

Despite the fact that symptoms are usually fairly mild, they can often mean that your travel itinerary is interrupted or may need to be altered.

Traveller's diarrhoea is usually diagnosed by the typical symptoms. As mentioned above, most people have mild symptoms and do not need to seek medical advice. However, in some cases medical advice is needed (see below).

If you do see a doctor, they may suggest that a sample of your stool (faeces) be tested. This will be sent to the laboratory to look for any microbes that may be causing your symptoms. Sometimes blood tests or other tests may be needed if you have more severe symptoms or develop any complications.

As mentioned above, most people with traveller's diarrhoea have relatively mild symptoms and can manage these themselves by resting and making sure that they drink plenty of fluids. However, you should seek medical advice in any of the following cases, or if any other symptoms occur that you are concerned about:

If you have a high temperature (fever).

If you have blood in your stools (faeces).

If it is difficult to get enough fluid because of severe symptoms: frequent or very watery stools or repeatedly being sick (vomiting).

If the diarrhoea lasts for more than 5-7 days.

If you are elderly or have an underlying health problem such as diabetes, inflammatory bowel disease, or kidney disease.

If you have a weakened immune system because of, for example, chemotherapy treatment, long-term steroid treatment, or HIV infection.

If you are pregnant.

If an affected child is under the age of 6 months.

If you develop any of the symptoms listed below that suggest you might have lack of fluid in your body (dehydration). If it is your child who is affected, there is a separate list for children.

Symptoms of dehydration in adults

Dizziness or light-headedness.

Muscle cramps.

Sunken eyes.

Passing less urine.

A dry mouth and tongue.

Becoming irritable.

Symptoms of severe dehydration in adults

Profound loss of energy or enthusiasm (apathy).

A fast heart rate

Producing very little urine.

Coma, which may occur.

Note : severe dehydration is a medical emergency and immediate medical attention is needed.

Symptoms of dehydration in children

Passing little urine.

A dry mouth.

A dry tongue and lips.

Fewer tears when crying.

Being irritable.

Having a lack of energy (being lethargic).

Symptoms of severe dehydration in children

Drowsiness.

Pale or mottled skin.

Cold hands or feet.

Very few wet nappies.

Fast (but often shallow) breathing.

Dehydration is more likely to occur in:

Babies under the age of 1 year (and particularly those under 6 months old). This is because babies don't need to lose much fluid to lose a significant proportion of their total body fluid.

Babies under the age of 1 year who were a low birth weight and who have not caught up with their weight.

A breastfed baby who has stopped being breastfed during their illness.

Any baby or child who does not drink much when they have a gut infection (gastroenteritis).

Any baby or child with severe diarrhoea and vomiting. (For example, if they have passed five or more diarrhoeal stools and/or vomited two or more times in the previous 24 hours.)

In most cases, specific treatment of traveller's diarrhoea is not needed. The most important thing is to make sure that you drink plenty of fluids to avoid lack of fluid in your body (dehydration).

Fluid replacement

As a rough guide, drink at least 200 mls after each watery stool (bout of diarrhoea).

This extra fluid is in addition to what you would normally drink. For example, an adult will normally drink about two litres a day but more in hot countries. The above '200 mls after each watery stool' is in addition to this usual amount that you would drink.

If you are sick (vomit), wait 5-10 minutes and then start drinking again but more slowly. For example, a sip every 2-3 minutes but making sure that your total intake is as described above.

You will need to drink even more if you are dehydrated. A doctor will advise on how much to drink if you are dehydrated.

Note : if you suspect that you are becoming dehydrated, you should seek medical advice.

For most adults, fluids drunk to keep hydrated should mainly be water. However, this needs to be safe drinking water - for example, bottled, or boiled and treated water. It is best not to have drinks that contain a lot of sugar, such as fizzy drinks, as they can sometimes make diarrhoea worse. Alcohol should also be avoided.

Rehydration drinks

Rehydration drinks may also be used. They are made from sachets that you can buy from pharmacies and may be a sensible thing to pack in your first aid kit when you travel. You add the contents of the sachet to water.

Home-made salt/sugar mixtures are used in developing countries if rehydration drinks are not available; however, they have to be made carefully, as too much salt can be dangerous. Rehydration drinks are cheap and readily available in the UK, and are the best treatment. Note that safe drinking water should be used to reconstitute oral rehydration salt sachets.

Antidiarrhoeal medication

Antidiarrhoeal medicines are not usually necessary or wise to take when you have traveller's diarrhoea. However you may want to use them if absolutely necessary - for example, if you will be unable to make regular trips to the toilet due to travelling.You can buy antidiarrhoeal medicines from pharmacies before you travel. The safest and most effective is loperamide.

The adult dose of this is two capsules at first. This is followed by one capsule after each time you pass some diarrhoea up to a maximum of eight capsules in 24 hours. It works by slowing down your gut's activity.

You should not take loperamide for longer than two days. You should also not use antidiarrhoeal medicines if you have a high temperature (fever) or bloody diarrhoea.

Eat as normally as possible

It used to be advised to 'starve' for a while if you had diarrhoea. However, now it is advised to eat small, light meals if you can. Be guided by your appetite. You may not feel like food and most adults can do without food for a few days. Eat as soon as you are able but don't stop drinking. If you do feel like eating, avoid fatty, spicy or heavy food. Plain foods such as bread and rice are good foods to try eating.

Antibiotic medicines

Most people with traveller's diarrhoea do not need treatment with antibiotic medicines. However, sometimes antibiotic treatment is advised. This may be because a specific germ (microbe) has been identified after testing of your stool (faeces) sample.

Fluids to prevent dehydration

You should encourage your child to drink plenty of fluids. The aim is to prevent lack of fluid in the body (dehydration). The fluid lost in their sick (vomit) and/or diarrhoea needs to be replaced. Your child should continue with their normal diet and usual drinks. In addition, they should also be encouraged to drink extra fluids. However, avoid fruit juices or fizzy drinks, as these can make diarrhoea worse.

Babies under 6 months old are at increased risk of dehydration. You should seek medical advice if they develop acute diarrhoea. Breast feeds or bottle feeds should be encouraged as normal. You may find that your baby's demand for feeds increases. You may also be advised to give extra fluids (either water or rehydration drinks) in between feeds.

If you are travelling to a destination at high risk for traveller's diarrhoea, you might want to consider buying oral rehydration sachets for children before you travel. These can provide a perfect balance of water, salts and sugar for them and can be used for fluid replacement. Remember that, as mentioned above, safe water is needed to reconstitute the sachets.

If your child vomits, wait 5-10 minutes and then start giving drinks again but more slowly (for example, a spoonful every 2-3 minutes). Use of a syringe can help in younger children who may not be able to take sips.

Note : if you suspect that your child is dehydrated, or is becoming dehydrated, you should seek medical advice urgently.

Fluids to treat dehydration

If your child is mildly dehydrated, this may be treated by giving them rehydration drinks. A doctor will advise about how much to give. This can depend on the age and the weight of your child. If you are breastfeeding, you should continue with this during this time. It is important that your child be rehydrated before they have any solid food.

Sometimes a child may need to be admitted to hospital for treatment if they are dehydrated. Treatment in hospital usually involves giving rehydration solution via a special tube called a 'nasogastric tube'. This tube passes through your child's nose, down their throat and directly into their stomach. An alternative treatment is with fluids given directly into a vein (intravenous fluids).

Eat as normally as possible once any dehydration has been treated

Correcting any dehydration is the first priority. However, if your child is not dehydrated (most cases), or once any dehydration has been corrected, then encourage your child to have their normal diet. Do not 'starve' a child with infectious diarrhoea. This used to be advised but is now known to be wrong. So:

Breastfed babies should continue to be breastfed if they will take it. This will usually be in addition to extra rehydration drinks (described above).

Bottle-fed babies should be fed with their normal full-strength feeds if they will take it. Again, this will usually be in addition to extra rehydration drinks (described above). Do not water down the formula, or make it up with less water than usual. This can make a baby very ill.

Older children - offer them some food every now and then. However, if he or she does not want to eat, that is fine. Drinks are the most important consideration and food can wait until the appetite returns.

Loperamide is not recommended for children with diarrhoea. There are concerns that it may cause a blockage of the gut (intestinal obstruction) in children with diarrhoea.

Most children with traveller's diarrhoea do not need treatment with antibiotics. However, for the same reasons as discussed for adults above, antibiotic treatment may sometimes be advised in certain cases.

Most people have mild illness and complications of traveller's diarrhoea are rare. However, if complications do occur, they can include the following:

Salt (electrolyte) imbalance and dehydration .

This is the most common complication. It occurs if the salts and water that are lost in your stools (faeces), or when you are sick (vomit), are not replaced by you drinking adequate fluids. If you can manage to drink plenty of fluids then dehydration is unlikely to occur, or is only likely to be mild and will soon recover as you drink.

Severe dehydration can lead to a drop in your blood pressure. This can cause reduced blood flow to your vital organs. If dehydration is not treated, your kidneys may be damaged . Some people who become severely dehydrated need a 'drip' of fluid directly into a vein. This requires admission to hospital. People who are elderly or pregnant are more at risk of dehydration.

Reactive complications

Rarely, other parts of your body can 'react' to an infection that occurs in your gut. This can cause symptoms such as joint inflammation (arthritis), skin inflammation and eye inflammation (either conjunctivitis or uveitis). Reactive complications are uncommon if you have a virus causing traveller's diarrhoea.

Spread of infection

The infection can spread to other parts of your body such as your bones, joints, or the meninges that surround your brain and spinal cord. This is rare. If it does occur, it is more likely if diarrhoea is caused by salmonella infection.

Irritable bowel syndrome is sometimes triggered by a bout of traveller's diarrhoea.

Lactose intolerance

Lactose intolerance can sometimes occur for a period of time after traveller's diarrhoea. It is known as 'secondary' or 'acquired' lactose intolerance. Your gut (intestinal) lining can be damaged by the episode of diarrhoea. This leads to lack of a substance (enzyme) called lactase that is needed to help your body digest the milk sugar lactose.

Lactose intolerance leads to bloating, tummy (abdominal) pain, wind and watery stools after drinking milk. The condition gets better when the infection is over and the intestinal lining heals. It is more common in children.

Haemolytic uraemic syndrome

Usually associated with traveller's diarrhoea caused by a certain type of E. coli infection, haemolytic uraemic syndrome is a serious condition where there is anaemia, a low platelet count in the blood and kidney damage. It is more common in children. If recognised and treated, most people recover well.

Guillain-Barré syndrome

This condition may rarely be triggered by campylobacter infection, one of the causes of traveller's diarrhoea. It affects the nerves throughout your body and limbs, causing weakness and sensory problems. See the separate leaflet called Guillain-Barré syndrome for more details.

Reduced effectiveness of some medicines

During an episode of traveller's diarrhoea, certain medicines that you may be taking for other conditions or reasons may not be as effective. This is because the diarrhoea and/or being sick (vomiting) mean that reduced amounts of the medicines are taken up (absorbed) into your body.

Examples of such medicines are those for epilepsy, diabetes and contraception . Speak with your doctor or practice nurse before you travel if you are unsure of what to do if you are taking other medicines and develop diarrhoea.

As mentioned above, symptoms are usually short-lived and the illness is usually mild with most people making a full recovery within in few days. However, a few people with traveller's diarrhoea develop persistent (chronic) diarrhoea that can last for one month or more. It is also possible to have a second 'bout' of traveller's diarrhoea during the same trip. Having it once does not seem to protect you against future infection.

Avoid uncooked meat, shellfish or eggs. Avoid peeled fruit and vegetables (including salads).

Be careful about what you drink. Don't drink tap water, even as ice cubes.

Wash your hands regularly, especially before preparing food or eating.

Be careful where you swim. Contaminated water can cause traveller's diarrhoea.

Regular hand washing

You should ensure that you always wash your hands and dry them thoroughly; teach children to wash and dry theirs:

After going to the toilet (and after changing nappies or helping an older child to go to the toilet).

Before preparing or touching food or drinks.

Before eating.

Some antibacterial hand gel may be a good thing to take with you when you travel in case soap and hot water are not available.

Be careful about what you eat and drink

When travelling to areas with poor sanitation, you should avoid food or drinking water that may contain germs (microbes) or their poisons (toxins). Avoid:

Fruit juices sold by street vendors.

Ice cream (unless it has been made from safe water).

Shellfish (for example, mussels, oysters, clams) and uncooked seafood.

Raw or undercooked meat.

Fruit that has already been peeled or has a damaged skin.

Food that contains raw or uncooked eggs, such as mayonnaise or sauces.

Unpasteurised milk.

Drinking bottled water and fizzy drinks that are in sealed bottles or cans, tea, coffee and alcohol is thought to be safe. However, avoid ice cubes and non-bottled water in alcoholic drinks. Food should be cooked through thoroughly and be piping hot when served.

You should also be careful when eating food from markets, street vendors or buffets if you are uncertain about whether it has been kept hot or kept refrigerated. Fresh bread is usually safe, as is canned food or food in sealed packs.

Be careful where you swim

Swimming in contaminated water can also lead to traveller's diarrhoea. Try to avoid swallowing any water as you swim; teach children to do the same.

Obtain travel health advice before you travel

Always make sure that you visit your GP surgery or private travel clinic for health advice in plenty of time before your journey. Alternatively, the Fit for Travel website (see under Further Reading and References, below) provides travel health information for the public and gives specific information for different countries and high-risk destinations. This includes information about any vaccinations required, advice about food, water and personal hygiene precautions, etc.

There are no vaccines that prevent traveller's diarrhoea as a whole. However, there are some other vaccines that you may need for your travel, such as hepatitis A, typhoid, etc. You may also need to take malaria tablets depending on where you are travelling.

Antibiotics

Taking antibiotic medicines to prevent traveller's diarrhoea (antibiotic prophylaxis) is not generally recommended. This is because for most people, traveller's diarrhoea is mild and self-limiting. Also, antibiotics do not protect against nonbacterial causes of traveller's diarrhoea, such as viruses and parasites. Antibiotics may have side-effects and their unnecessary use may lead to problems with resistance to medicines.

Probiotics have some effect on traveller's diarrhoea and can shorten an attack by about one day. It is not known yet which type of probiotic or which dose, so there are no recommendations about using probiotics to prevent traveller's diarrhoea.

Further reading and references

• Bourgeois AL, Wierzba TF, Walker RI ; Status of vaccine research and development for enterotoxigenic Escherichia coli. Vaccine. 2016 Mar 15. pii: S0264-410X(16)00287-5. doi: 10.1016/j.vaccine.2016.02.076.
• Travellers' diarrhoea ; Fitfortravel
• Riddle MS, Connor BA, Beeching NJ, et al ; Guidelines for the prevention and treatment of travelers' diarrhea: a graded expert panel report. J Travel Med. 2017 Apr 1;24(suppl_1):S57-S74. doi: 10.1093/jtm/tax026.
• Giddings SL, Stevens AM, Leung DT ; Traveler's Diarrhea. Med Clin North Am. 2016 Mar;100(2):317-30. doi: 10.1016/j.mcna.2015.08.017.
• Diarrhoea - prevention and advice for travellers ; NICE CKS, February 2019 (UK access only)

Article history

The information on this page is written and peer reviewed by qualified clinicians.

Next review due: 9 Feb 2028

10 feb 2023 | latest version.

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How to avoid traveller's diarrhoea (and what to do if it strikes)

Dec 17, 2019 • 9 min read

Traveller's diarrhoea can stop you in your tracks, so it's best to try and avoid it © ViewApart / Getty Images

Although it’s not inevitable that you will get diarrhoea while you are away, it is pretty likely in some destinations. Digestive upsets are the most common travel-related illnesses, affecting about 30-50% of travellers to tropical destinations, so you may as well be prepared.

What causes diarrhoea?

Your risk of getting ill mainly depends on how likely it is that the food and drink you are consuming is contaminated with disease-causing microorganisms. That said, roughly one third of cases are due to non-specific causes such as stress, jet lag and changes in eating habits. If you’re roughing it, and eating from small stalls and restaurants where hygiene is more likely to be a problem, you’re more likely to catch something. If you are away on a long trip, there’s a higher chance you will get ill at some stage.

Read more: 8  tips to stay healthy on vacation from celebrity trainer Harley Pasternak

Fact vs fiction

Not surprisingly, you’ll find diarrhoea a hot topic of conversation among travellers, and it can be hard to separate fact from fiction at times. Just remember: - Travellers diarrhoea is generally a short, mild illness lasting on average about three to five days - Replacing lost fluids and salts is the most important part of treating any watery diarrhoea, whatever the cause - You don’t usually need to get medical advice or antibiotic treatment for mild to moderate diarrhoea - There are certain situations when antibiotics need to be used – in these situations it’s best to get medical advice

Avoiding diarrhoea

Although we don’t want to deprive you of a fascinating talking point during your travels, it’s obviously best to avoid getting diarrhoea in the first place. Unhygienic food preparation practices and contaminated water are common causes of travellers diarrhoea. It sounds gross, but basically you get diarrhoea by eating other people’s faeces through contaminated food, water and eating utensils. Hands used to prepare food may not have been washed thoroughly after toilet duty. Flies carry dirt and microorganisms on their feet. In dusty, urban areas, tonnes of dry faecal matter floats around in the atmosphere, and this can land on food left sitting around.

You can also get diarrhoea from direct contact with an infected person (if you touch hands etc that haven’t been washed adequately) or from swimming in contaminated water (by swallowing small amounts). Some infective agents such as Giardia can survive even in chlorinated water, and rivers and oceans may be contaminated with sewage.

Types of diarrhoea

Different microorganisms cause different types of diarrhoeal illnesses, which may need to be treated in different ways. The most important things to look out for are: a high body temperature, blood in your faeces and how severe the diarrhoea is (ie how often you have to go to the toilet).

Watery diarrhoea This is the type of diarrhoea you’re most likely to get when you are away. The cause varies with your destination, but it’s usually bacterial, often a strain of a bacteria called Escherichia coli . Relatives of this microbe are normal residents of your gut, but this is a strain that has turned nasty.

The usual scenario is that the illness starts a few days after you arrive, and involves up to six episodes of loose faeces a day. You may feel sorry for yourself, but it doesn’t usually make you feel particularly unwell. If you get a fever with it, it’s usually low (less than 38°C). Nausea and vomiting are common, especially at the start, but it’s not a major feature of the illness (compare this with food poisoning). Stomach cramps, bloating and frequent gas are also common.

The illness generally resolves itself in a few days (on average three to five). It rarely causes severe dehydration, although the potential is always there and is more of a risk in children and older travellers. Don’t panic and start stuffing yourself with medications. The most important treatment measure is to avoid dehydration by replacing lost fluids and salts, which you should start doing straight away.

Read more : How the airport security lane could be bad for your health

Bloody diarrhoea (dysentery) Dysentery is any diarrhoea with blood in it. It can be more severe and protracted than the more common watery diarrhoea described earlier, and usually needs antibiotic treatment. Out of every 10 travellers who get diarrhoea, only about one will have dysentery. The most common cause is one of a number of bacteria, including various shigella and salmonella species.

Dysentery usually begins with nonspecific flu-like symptoms, and you often feel really rough, with headache, high fever (38°C and above), and aches and pains all over. To start with, the diarrhoea is often watery and in large quantities; later it gets less and you start to notice blood and mucus (slime) mixed in your faeces. Painful stomach cramps are often a feature of the illness, usually heralding a dash to the little room.

Get medical advice if you have dysentery, as you’ll need a laboratory test and a course of antibiotics. In the meantime, rest and make sure you drink plenty of fluids.

Read more: Want to stay healthy for the holidays? Avoid these airport and airplane surfaces

Vomiting & diarrhoea If you suddenly get an attack of nausea and profuse vomiting soon after eating, it’s probably due to food poisoning. This is a worldwide problem that is more likely when you’re eating food not prepared by yourself, especially where food preparation and storage procedures may be suspect.

Vomiting is the main symptom, often with stomach cramps and some watery diarrhoea later. You may have a suspicion that you’ve eaten something that wasn’t fresh (such as sea food); another clue is if everyone who ate the same thing comes down with the same illness.

No specific treatment is needed as a rule. You should rest, sip fluids if possible, and wait for it to settle down, which it should start doing in about 12 to 24 hours. Generally, it’s best to avoid anti-vomiting medication, as vomiting is your body’s way of getting rid of the bad stuff. You should seek medical help urgently if the illness doesn’t settle down within 24 hours, if it gets much worse, if there’s any blood in the vomit or diarrhoea, if you have a high fever or if you have very severe stomach pains or a severe headache.

How to deal with diarrhoea

If diarrhoea strikes, you don’t necessarily need to reach for your medical kit for "stoppers" (see 'Antidiarrhoeal remedies' below) which paralyses the gut and stops the flow, or for antibiotics; there are some simple measures it’s worth taking: - Rest, which gives your body the best chance to fight whatever is making you ill; in any case, being on the move with diarrhoea presents a few logistical problems - Drink plenty of fluids - Take your temperature and note what it is; repeat this to see how the illness is progressing - Examine what’s coming out of your guts to check for blood or mucus (slime) - Be aware of how often you’re passing urine and what colour it is, so you can check you’re not getting dehydrated - Note any other symptoms you may have: diarrhoea can occur in many other illnesses, including malaria and hepatitis - Remember that diarrhoea is contagious so be scrupulous about washing your hands after you use the toilet

Read more: Airline staff share their tips on how to keep healthy while flying

What to drink when you have diarrhoea

You need to replace what’s being lost through the diarrhoea and any vomiting: mainly salts (sodium, potassium and chloride) and water. Sachets of oral rehydration salts (ORS) are readily available worldwide and contain optimum amounts of glucose and salts. There’s no magic ingredient in ORS, but the relative quantities of salt and sugar are important. You can make up your own solution if necessary by adding six teaspoons of sugar (or honey) and half a teaspoon of table salt to 1L of boiled water. Make it more palatable by adding any flavour you like, for example lemon, ginger or orange juice.

Alcohol, strong tea, coffee and other caffeine-containing drinks (such as colas) are all best avoided because they can irritate the gut and promote fluid loss. It’s best to steer clear of dairy products while you have diarrhoea – you can get an intolerance to the sugar in milk when you have diarrhoea, which then exacerbates the problem.

Read more: 10 best fitness retreats for a healthier life

Antidiarrhoeal remedies

There are remedies you can take to stop the flow if you get diarrhoea, but as a general rule, you’re better off allowing the illness to run its course. Antimotility drugs (ie "stoppers") like loperamide (often sold as Imodium), diphen­oxylate (with atropine) and codeine phosphate slow down your guts, reducing the number of times you have to visit the little room. These are sold under a wide variety of brand names and are usually available without prescription. Stoppers can be useful if you have to travel on a toilet-less mode of transport or attend an important meeting, but you should treat them with a bit of respect. If you do need to take them, be careful not to take more than the recommended dose.

Bismuth subsalicylate (Pepto-Bismol) can be useful in treating diarrhoea, although it is less effective than the antimotility drugs. Bismuth shouldn’t be taken if you have asthma or if you are taking aspirin, are sensitive to aspirin or have been told to avoid aspirin for any reason. Alternatively, peppermint oil is an antispasmodic that may be helpful if you’re experiencing abdominal cramps. It has no serious side effects. Some herbal teas available locally may be helpful for soothing stomach cramps.

Antibiotics

If you are seriously ill or the diarrhoea just won’t go away, you’ll probably need antibiotic treatment. In this situation, you should seek medical advice on the most appropriate treatment and you may need a laboratory test to determine the cause of your illness. Remember that most cases of travellers diarrhoea do not need treatment with antibiotics, and will clear up on their own in a few days.

Whether or not to treat simple watery diarrhoea with antibiotics is much less clear-cut, and it’s an issue the experts can’t agree on. There’s plenty of evidence to show that taking a dose of an antibiotic (such as ciprofloxacin 500mg, single dose) with loperamide (an antimotility drug) can reduce the length of a diarrhoeal illness quite dramatically. Because of this, some doctors will advise you to carry a treatment dose of an antibiotic to take as soon as you develop diarrhoea. Others, however, argue that the benefits are not offset by the risks (including possible side effects of the antibiotic and the emergence of bacterial resistance) and that in any case diarrhoea in travellers is usually a mild illness that will clear up quickly enough on its own. On balance, it’s probably worth having a course of antibiotics with you, but keep it for a bad attack of watery diarrhoea (dashing to the toilet more than about six times a day).

Travel safely and diarrhoea-free!

This article was first published Jun 7, 2012 and updated Dec 17, 2019.

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Management of travellers’ diarrhoea

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• Peer review
• David R Hill , director, honorary professor 1 ,
• Edward T Ryan , director, associate professor 2
• 1 National Travel Health Network and Centre, and London School of Hygiene and Tropical Medicine, Hospital for Tropical Diseases, London WC1E 6JB
• 2 Travelers’ Advice and Immunization Center, and Tropical and Geographic Medicine Center, Massachusetts General Hospital, Boston, USA
• Correspondence to: D R Hill david.hill{at}uclh.org

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 and parasites

What is travellers’ diarrhoea?

Classic travellers’ diarrhoea is defined as at least three loose to watery stools in 24 hours with or without one or more symptoms of abdominal cramps, fever, nausea, vomiting, or blood in the stool. Mild to moderate diarrhoea is one or two loose stools in 24 hours with or without another enteric symptom. The median time to onset is six or seven days after arrival. Although the diarrhoea often resolves spontaneously over three or four days, up to a quarter of affected travellers need to alter their plans, interrupting their holiday or business activities. 2

What causes travellers’ diarrhoea?

The causes of travellers’ diarrhoea depend on the destination, setting, and season, although studies have been done in only a limited number of countries (table 1 ⇓ ). 3 4 Enteric bacteria are documented as the most common causes: several types of Escherichia coli and Campylobacter , Salmonella , and Shigella spp; Vibrio cholerae is rare in travellers. Enterotoxigenic E coli that produce a heat labile or heat stable toxin are the most common species of E coli implicated, with enteroaggregative E coli increasingly recognised. 5 Enterohaemorrhagic E coli (producing shiga toxin or vero cytotoxin) are not typically described in travellers. Enterotoxigenic E coli predominates in travellers to Latin America but is also seen globally. Rates of Campylobacter infection per traveller are highest in those visiting South Asia and South East Asia, 6 exceeding those of enterotoxigenic E coli in some studies.

 Causes of travellers’ diarrhoea

• View inline

Norovirus and rotavirus are the most commonly identified viral causes of travellers’ diarrhoea, although these agents have not been uniformly examined. 7 Norovirus is often associated with outbreaks of diarrhoea in holiday resorts or on cruise ships. Parasites are less common causes of travellers’ diarrhoea; of these, the protozoa Giardia intestinalis and Cryptosporidium are most commonly identified. 8 Cyclospora and Entamoeba histolytica are less common causes, and typically associated with long term travel. In 10-15% of cases more than one pathogen is identified, and in up to 50% of studies no pathogen is described. 4 9 Acute food poisoning—the sudden onset of nausea, vomiting, and diarrhoea after ingestion of a toxin (usually produced by Staphylococcus aureus , Bacillus cereus , or Clostridium perfringens ) in food that has not been properly cooked or stored, accounts for up to 5% of cases.

What are the consequences of having travellers’ diarrhoea?

As the causes of travellers’ diarrhoea are multiple the clinical features vary: from the typical watery stools with cramping and nausea associated with enterotoxigenic E coli , to dysentery with Shigella , to short lived nausea, vomiting, and diarrhoea associated with acute food poisoning or norovirus. Although most cases resolve without treatment over several days, in about 10% the symptoms persist for more than a week, and in about 2% for more than a month. 2 About one quarter of travellers alter their plans because of diarrhoea, and about 5% seek medical care. 2 Illness tends to be more severe in infants and young children, and precautions should be taken to deal with a potentially dehydrating diarrhoeal illness in children when travelling. Serious complications include haemolytic uraemic syndrome with bacteria that produce shiga toxin, Guillain Barré syndrome with Campylobacter , and post-infectious arthropathies with any invasive bacteria. Prolonged illness (>10 days), illness that begins after return, and illness associated with weight loss are more likely to be caused by protozoan parasites such as Giardia .

Irritable bowel syndrome can occur after travellers’ diarrhoea. In two prospective observational studies, travellers who had diarrhoea were more likely to have a new diagnosis of irritable bowel syndrome at six months after return. 10 11

How can travellers’ diarrhoea be prevented?

Food, water, and personal hygiene.

Travellers’ diarrhoea is acquired through the ingestion of contaminated food and water, therefore strict food, water, and personal hygiene precautions should decrease the risk (see box). Despite an increased understanding of the causes and pathogenesis of travellers’ diarrhoea, its incidence has not substantially decreased over the past few decades, and travellers who practise preventive measures do not always have a lower incidence of the condition. The risk of travellers’ diarrhoea increasingly seems related to the sanitation level at the destination rather than the ability to adhere to avoidance measures. 12 13 14 15

Diet and personal hygiene measures to prevent travellers’ diarrhoea

Foods and beverages to be avoided.

Raw or undercooked meats, fish, and seafood

Unpasteurised milk, cheese, ice cream, and other dairy products

Tap water and ice cubes

Cold sauces and toppings

Ground grown leafy greens, vegetables, and fruit

Cooked foods that have stood at room temperature in warm environments

Food from street vendors, unless freshly prepared and served piping hot

Hygiene measures

Render water potable by either bringing it to a boil or treating it with chlorine or iodine preparations* and filtering with a filter of 1 µm or less

Wash hands before eating

*Protozoan parasites are relatively resistant to chlorine and iodine. Contact time should be extended for cold or turbid water

No single vaccine prevents travellers’ diarrhoea, because of the multiple potential causes. Enteric vaccines prevent rotavirus (being introduced into childhood immunisation programmes), hepatitis A, typhoid, and cholera and such vaccines can be given when indicated after a careful risk assessment based on destination and itinerary.

Some enterotoxigenic E coli strains express a heat labile enterotoxin that is similar to cholera toxin produced by V cholerae . Consideration has therefore been given to using the oral killed cholera vaccine (Dukoral; Crucell, Leiden), which contains a non-toxic portion of cholera vaccine, to induce cross protective immunity against enterotoxigenic E coli . Up to 50% of enterotoxigenic E coli strains do not, however, express heat labile enterotoxin, and an analysis of studies suggests that using oral killed cholera vaccine would prevent only 1-7% of people from developing travellers’ diarrhoea, depending on destination and frequency of heat labile producing entertoxigenic E coli . 16 In a phase II trial, vaccination of travellers with heat labile enterotoxin using a transcutaneous delivery system showed 75% protective efficacy against all cause moderate to severe diarrhoea (defined as ≥4 stools in 24 hours). 17 Although no difference was found in the overall incidence of diarrhoea between the recipients of the vaccine and those of placebo, vaccine recipients had fewer stools and a shorter duration of illness.

Chemoprophylaxis

Chemoprophylaxis comprises two approaches: the use of non-antibiotic products (bismuth subsalicylate and probiotics) and the use of antibiotics. Bismuth subsalicylate (preferably in tablet form) provides about 60% protection against travellers’ diarrhoea; however, adverse events may be common at the most effective doses. 18 A meta-analysis suggests that probiotics can lessen the likelihood of travellers’ diarrhoea by about 15%. 19

Although several randomised placebo controlled studies in the 1970s and ‘80s showed antibiotic prophylaxis to be effective in preventing travellers’ diarrhoea, it is not currently recommended for most travellers for several reasons: the potential adverse events associated with prophylactic antibiotics, predisposition to other infections such as vaginal candidiasis or Clostridium difficile associated disease, development of bacterial resistance, cost, and lack of data on the safety and efficacy of antibiotics given for more than two or three weeks. 20 In addition, the highly efficacious nature of early self treatment of travellers’ diarrhoea further dampens enthusiasm for chemoprophylaxis with antibiotics.

Expert opinion supports the use of prophylactic antibiotics when a trip is vitally important or the consequences of watery diarrhoea would be difficult to manage (for example, after colostomy or ileostomy). Sulfonamides and tetracyclines should not be used because of widespread resistance. A fluoroquinolone is the drug of choice when travelling to most areas of the world, and several randomised trials support its efficacy. 20 Campylobacter spp are often resistant to fluoroquinolones, and when the relative risk is higher, such as in South Asia and South East Asia, azithromycin can be considered. No trials have been published on this agent when used for prophylaxis. Rifaximin, a poorly absorbed derivative of rifamycin, is an alternative choice in regions where E coli predominates, such as Latin America and Africa. 21 Because of decreased efficacy, it should not be used when potentially invasive pathogens such as Salmonella , Campylobacter , and Shigella are likely.

How can travellers’ diarrhoea be treated?

Since behavioural modifications, vaccines, and chemoprophylaxis have limited efficacy on travellers’ diarrhoea or may be associated with adverse events, consensus opinion based on randomised placebo controlled and comparative trials supports self treatment (table 2 ⇓ ). The goals of treatment are to avoid dehydration, reduce the severity and duration of symptoms, and prevent interruption to planned activities.

 Approach to prophylaxis and treatment of travellers’ diarrhoea in adults

Hydration and diet

Hydration is a key intervention that should be done for all forms of diarrhoea and is often all that is necessary in mild illness. Infants and young children, elderly people, and those with chronic debilitating medical conditions can maintain hydration by drinking oral rehydration formulations that combine electrolytes, sugar, and buffer. A randomised trial on healthy adolescents and adults who were taking loperamide for symptomatic treatment of travellers’ diarrhoea, however, showed no additional benefit from specific oral rehydration compared with drinking potable fluids ad libitum. 22 It is a sensible recommendation during recovery from travellers’ diarrhoea to gradually advance the diet from liquids to more complex solids, although this recommendation may not provide additional benefit if the diarrhoea is also being treated with an antibiotic. 23

Symptomatic treatment

The two most common symptomatic treatments for travellers’ diarrhoea are bismuth subsalicylate or an antimotility agent. Symptomatic treatment alone can be considered for mild to moderate diarrhoea. In a randomised placebo controlled trial, bismuth subsalicylate reduced the number of loose stools by about 50% and was helpful in reducing nausea. 24 Bismuth subsalicylate can be recommended for people with mild diarrhoea, but more effective agents are available for those with moderate or severe diarrhoea. Loperamide has become an antimotility agent of choice because of supporting trials in travellers and its favourable adverse event profile. In a randomised comparative trial with bismuth subsalicylate, loperamide was more effective in controlling diarrhoea and cramping and had a more rapid onset of action, usually within the first four hours. 25 Loperamide should not be given to young children, those with diarrhoea and fever (>38.5°C), or when there is gross blood in the stools. Information on probiotics in the treatment of travellers’ diarrhoea is insufficient.

Antibiotic treatment

Many randomised placebo controlled and comparative trials done over the past 25 years have shown the efficacy of antibiotics in the treatment of travellers’ diarrhoea. 26 Most trials indicate that an antibiotic taken as a single dose or for up to three days will improve the condition within 20 to 36 hours. This shortens the duration of diarrhoea by one or two days when compared with controls taking placebo. Adverse events associated with short course therapy are usually mild. The application of this evidence base to clinical practice has differed among clinicians: some advocate prompt self treatment with antibiotics for moderate to severe travellers’ diarrhoea, whereas others urge a more cautious approach to what is usually a self limited illness. Clinicians will need to decide in discussion with the traveller they are advising, the most appropriate approach, taking into account the traveller’s ability and willingness to tolerate a diarrhoeal illness during his or her trip.

Fluoroquinolones are effective for travellers’ diarrhoea acquired in most areas of the world, except when potentially resistant Campylobacter is common, such as in South Asia and South East Asia. 27 A growing body of evidence documents the effectiveness of azithromycin in treating fluoroquinolone resistant Campylobacter , 28 as well as other enterics. 27 Azithromycin can also be used in the treatment of pregnant women and young children with travellers’ diarrhoea; however, the empirical antibiotic treatment of young children should only be used after careful consideration. Rifaximin was not inferior to a fluoroquinolone in a randomised, double blind trial of treatment in Mexico and Jamaica 29 where E coli associated travellers’ diarrhoea was common, but rifaximin is less effective and not recommended when invasive agents, such as Campylobacter and Shigella , are causative. 30

Combination treatment

Combining an antibiotic with loperamide should be considered for people with classic travellers’ diarrhoea who need prompt resolution of symptoms. Six randomised controlled trials examined combination treatment (single dose or short course antibiotics plus loperamide) compared with an antibiotic or loperamide alone. 31 32 The weight of evidence favoured combination treatment when the predominate organisms were sensitive to the antibiotic. 31 32

How should returned travellers with diarrhoea be evaluated?

Diarrhoea is one of the most common syndromes in travellers who return ill. In a US cohort of returned travellers, diarrhoea affected 13%, 2 and in a large multicentre study (travel clinics and tropical disease units) acute or chronic diarrhoea was diagnosed at a rate of 335 cases per 1000 ill returned travellers. 33 Regions associated with the highest relative rates of gastrointestinal infection, as determined by numbers of clinical visits in returned travellers, were South Asia, South America, and sub-Saharan Africa. 1

Travellers’ diarrhoea can be evaluated in a general practice setting with referral to a specialist as needed. If fever, tenesmus, or gross blood in the stool are not present (that is, non-inflammatory diarrhoea) patients can be treated symptomatically and observed. If the patient seems unwell and there are additional symptoms, however, a stool should be cultured for enteropathogens and empirical antibiotic treatment considered using a fluoroquinolone or azithromycin. Unusually, C difficile associated disease presents after antibiotic treatment for travellers’ diarrhoea. 34 In travellers with diarrhoea that has lasted for 10 days to two weeks or longer, stool samples should be evaluated for Giardia , Cryptosporidium , and other parasites.

Tips for non-specialists

Discuss the likelihood of travellers’ diarrhoea with someone who is planning to travel and advise about avoidance measures to decrease the risk of illness: safe foods, beverages, and eating establishments

Avoidance measures are not always sufficient in preventing travellers’ diarrhoea, therefore review self management options, including when to use symptomatic measures or take antibiotics, and when to seek medical care

Consider referring travellers who have special health needs (for example, HIV infection, immunocompromised, pregnant) to a specialist travel clinic for advice

Send a stool sample for microscopy and culture in returned travellers who are febrile and have complicated diarrhoea; empirical antibiotic treatment can be considered while awaiting the results of stool cultures

Treat afebrile patients who do not have tenesmus or gross blood in the stool symptomatically and observe. Give empirical antibiotic therapy—a fluoroquinolone or azithromycin—to patients who do present with such symptoms, after obtaining a stool sample

Questions for future research

What is the cause of travellers’ diarrhoea when a pathogen cannot be identified?

Do avoidance measures prevent illness?

How often do vero cytotoxin or shiga toxin producing E coli and C difficile associated disease occur in patients with travellers’ diarrhoea?

What is the frequency of irritable bowel syndrome after an episode of travellers’ diarrhoea, and what are the predisposing factors?

What is the role of rifaximin in the prevention and treatment of travellers’ diarrhoea?

How should vaccines be used in the prevention of travellers’ diarrhoea?

Additional educational resources

Ericsson CD, DuPont HL, Steffen, R, eds. Travelers’ diarrhea . 2nd ed. Hamilton, Ontario: BC Decker, 2008—reviews all aspects of travellers’ diarrhoea

World Health Organization. International Travel and Health 2008 ( www.who.int/ith/en/index.html )—authoritative guidance on travel medicine

Centers for Disease Control and Prevention. Health Information for International Travel 2008 ( wwwn.cdc.gov/travel/default.aspx )—authoritative guidance on travel medicine

Al-Abri SS, Beeching NJ, Nye FJ. Traveller’s diarrhoea. Lancet Infect Dis 2005;5:349-60

Diemert DJ. Prevention and self-treatment of traveler’s diarrhea. Clin Microbiol Rev 2006;19:583-94

Cite this as: BMJ 2008;337:a1746

Contributors: DRH planned the paper, wrote the first draft, and is the guarantor. ETR contributed to the content, helped to revise the paper, and agreed to the final submission.

Competing interests: None declared.

Provenance and peer review: commissioned; externally peer reviewed.

• ↵ Greenwood Z, Black J, Weld L, O’Brien D, Leder K, Von Sonnenburg F, et al. Gastrointestinal infection among international travelers globally. J Travel Med 2008 ; 15 : 195 -202. OpenUrl
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• ↵ Jiang ZD, Butzler JP. The bacterial pathogens. In: Ericsson CD, DuPont HL, Steffen R, eds. Travelers’ diarrhea . 2nd ed. Hamilton, Ontario: BC Decker, 2008 :6-17.
• ↵ Riddle MS, Sanders JW, Putnam SD, Tribble DR. Incidence, etiology, and impact of diarrhea among long-term travelers (US military and similar populations): a systematic review. Am J Trop Med Hyg 2006 ; 74 : 891 -900. OpenUrl Abstract / FREE Full Text
• ↵ Adachi JA, Jiang ZD, Mathewson JJ, Verenkar MP, Thompson S, Martinez-Sandoval F, et al. Enteroaggregative Escherichia coli as a major etiologic agent in traveler’s diarrhea in 3 regions of the world. Clin Infect Dis 2001 ; 32 : 1706 -9. OpenUrl Abstract / FREE Full Text
• ↵ Ekdahl K, Andersson Y. Regional risks and seasonality in travel-associated campylobacteriosis. BMC Infect Dis 2004 ; 4 : 54 . OpenUrl CrossRef PubMed
• ↵ Ko G, Garcia C, Jiang ZD, Okhuysen PC, Belkind-Gerson J, Glass RI, et al. Noroviruses as a cause of traveler’s diarrhea among students from the United States visiting Mexico. J Clin Microbiol 2005 ; 43 : 6126 -9. OpenUrl Abstract / FREE Full Text
• ↵ Nair P, Mohamed JA, DuPont HL, Figueroa JF, Carlin LG, Jiang ZD, et al. Epidemiology of cryptosporidiosis in North American travelers to Mexico. Am J Trop Med Hyg 2008 ; 79 : 210 -4. OpenUrl Abstract / FREE Full Text
• ↵ Jiang ZD, Lowe B, Verenkar MP, Ashley D, Steffen R, Tornieporth N, et al. Prevalence of enteric pathogens among international travelers with diarrhea acquired in Kenya (Mombasa), India (Goa), or Jamaica (Montego Bay). J Infect Dis 2002 ; 185 : 497 -502. OpenUrl Abstract / FREE Full Text
• ↵ Okhuysen PC, Jiang ZD, Carlin L, Forbes C, DuPont HL. Post-diarrhea chronic intestinal symptoms and irritable bowel syndrome in North American travelers to Mexico. Am J Gastroenterol 2004 ; 99 : 1774 -8. OpenUrl CrossRef PubMed Web of Science
• ↵ Stermer E, Lubezky A, Potasman I, Paster E, Lavy A. Is traveler’s diarrhea a significant risk factor for the development of irritable bowel syndrome? A prospective study. Clin Infect Dis 2006 ; 43 : 898 -901. OpenUrl Abstract / FREE Full Text
• ↵ Steffen R, Collard F, Tornieporth N, Campbell-Forrester S, Ashley D, Thompson S, et al. Epidemiology, etiology, and impact of traveler’s diarrhea in Jamaica. JAMA 1999 ; 281 : 811 -7. OpenUrl CrossRef PubMed Web of Science
• ↵ Cartwright RY. Food and waterborne infections associated with package holidays. J Appl Microbiol 2003 ; 94 (suppl): 12 -24S. OpenUrl CrossRef
• ↵ Hill DR, Ryan ET. Diet and education about risks. In: Ericsson CD, DuPont HL, Steffen R, eds. Travelers’ diarrhea . 2nd ed. Hamilton, Ontario: BC Decker, 2008 :180-9.
• ↵ Shlim DR. Looking for evidence that personal hygiene precautions prevent traveler’s diarrhea. Clin Infect Dis 2005 ; 41 (suppl 8): S531 -5. OpenUrl CrossRef PubMed Web of Science
• ↵ Hill DR, Ford L, Lalloo DG. Oral cholera vaccines: use in clinical practice. Lancet Infect Dis 2006 ; 6 : 361 -73. OpenUrl CrossRef PubMed Web of Science
• ↵ Frech SA, Dupont HL, Bourgeois AL, McKenzie R, Belkind-Gerson J, Figueroa JF, et al. Use of a patch containing heat-labile toxin from Escherichia coli against travellers’ diarrhoea: a phase II, randomised, double-blind, placebo-controlled field trial. Lancet 2008 ; 371 : 2019 -25. OpenUrl CrossRef PubMed Web of Science
• ↵ DuPont HL, Ericsson CD, Johnson PC, Bitsura JAM, DuPont MW, de la Cabada FJ. Prevention of travelers’ diarrhea by the tablet formulation of bismuth subsalicylate. JAMA 1987 ; 257 : 1347 -50. OpenUrl CrossRef PubMed Web of Science
• ↵ Sazawal S, Hiremath G, Dhingra U, Malik P, Deb S, Black RE. Efficacy of probiotics in prevention of acute diarrhoea: a meta-analysis of masked, randomised, placebo-controlled trials. Lancet Infect Dis 2006 ; 6 : 374 -82. OpenUrl CrossRef PubMed Web of Science
• ↵ Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006 ; 43 : 1499 -539. OpenUrl FREE Full Text
• ↵ DuPont HL, Jiang ZD, Okhuysen PC, Ericsson CD, de la Cabada FJ, Ke S, et al. A randomized, double-blind, placebo-controlled trial of rifaximin to prevent travelers’ diarrhea. Ann Intern Med 2005 ; 142 : 805 -12. OpenUrl CrossRef PubMed Web of Science
• ↵ Caeiro JP, DuPont HL, Albrecht H, Ericsson CD. Oral rehydration therapy plus loperamide versus loperamide alone in the treatment of traveler’s diarrhea. Clin Infect Dis 1999 ; 28 : 1286 -9. OpenUrl Abstract / FREE Full Text
• ↵ Huang DB, Awasthi M, Le BM, Leve ME, DuPont MW, DuPont HL, et al. The role of diet in the treatment of travelers’ diarrhea: a pilot study. Clin Infect Dis 2004 ; 39 : 468 -71. OpenUrl Abstract / FREE Full Text
• ↵ DuPont HL, Sullivan P, Pickering LK, Haynes G, Ackerman PB. Symptomatic treatment of diarrhea with bismuth subsalicylate among students attending a Mexican university. Gastroenterology 1977 ; 73 : 715 -8. OpenUrl PubMed Web of Science
• ↵ Johnson PC, Ericsson CD, DuPont HL, Morgan DR, Bitsura JM, Wood LV. Comparison of loperamide with bismuth subsalicylate for the treatment of acute travelers’ diarrhea. JAMA 1986 ; 255 : 757 -60. OpenUrl CrossRef PubMed Web of Science
• ↵ De Bruyn G, Hahn S, Borwick A. Antibiotic treatment for travellers’ diarrhoea. Cochrane Database Syst Rev 2000 ;(3):CD002242.
• ↵ Adachi JA, Ericsson CD, Jiang ZD, DuPont MW, Martinez-Sandoval F, Knirsch C, et al. Azithromycin found to be comparable to levofloxacin for the treatment of US travelers with acute diarrhea acquired in Mexico. Clin Infect Dis 2003 ; 37 : 1165 -71. OpenUrl Abstract / FREE Full Text
• ↵ Tribble DR, Sanders JW, Pang LW, Mason C, Pitarangsi C, Baqar S, et al. Traveler’s diarrhea in Thailand: randomized, double-blind trial comparing single-dose and 3-day azithromycin-based regimens with a 3-day levofloxacin regimen. Clin Infect Dis 2007 ; 44 : 338 -46. OpenUrl Abstract / FREE Full Text
• ↵ DuPont HL, Jiang ZD, Ericsson CD, Adachi JA, Mathewson JJ, DuPont MW, et al. Rifaximin versus ciprofloxacin for the treatment of traveler’s diarrhea: a randomized, double-blind clinical trial. Clin Infect Dis 2001 ; 33 : 1807 -15. OpenUrl Abstract / FREE Full Text
• ↵ Taylor DN, Bourgeois AL, Ericsson CD, Steffen R, Jiang ZD, Halpern J, et al. A randomized, double-blind, multicenter study of rifaximin compared with placebo and with ciprofloxacin in the treatment of travelers’ diarrhea. Am J Trop Med Hyg 2006 ; 74 : 1060 -6. OpenUrl Abstract / FREE Full Text
• ↵ Dupont HL, Jiang ZD, Belkind-Gerson J, Okhuysen PC, Ericsson CD, Ke S, et al. Treatment of travelers’ diarrhea: randomized trial comparing rifaximin, rifaximin plus loperamide, and loperamide alone. Clin Gastroenterol Hepatol 2007 ; 5 : 451 -6. OpenUrl CrossRef PubMed Web of Science
• ↵ Ericsson CD, DuPont HL, Okhuysen PC, Jiang ZD, DuPont MW. Loperamide plus azithromycin more effectively treats travelers’ diarrhea in Mexico than azithromycin alone. J Travel Med 2007 ; 14 : 312 -9. OpenUrl CrossRef PubMed Web of Science
• ↵ Freedman DO, Weld LH, Kozarsky PE, Fisk T, Robins R, von Sonnenberg F, et al. Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med 2006 ; 354 : 119 -30. OpenUrl CrossRef PubMed Web of Science
• ↵ Norman FF, Perez-Molina J, Perez de Ayala A, Jimenez BC, Navarro M, Lopez-Velez R. Clostridium difficile-associated diarrhea after antibiotic treatment for traveler’s diarrhea. Clin Infect Dis 2008 ; 46 : 1060 -3. OpenUrl CrossRef PubMed Web of Science

Medical assistance (if available) should always be sought if any of the following occur:-

• There is blood in the faeces
• There is a fever
• The sufferer becomes confused
• The diarrhoea does not settle within 72 hours

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Diarrhoea - prevention and advice for travellers

Last revised in September 2023

Travellers' diarrhoea is a clinical syndrome associated with contaminated food or water, that occurs during or shortly after travel

• Scenario: Diarrhoea - prevention and advice for travellers

Background information

• Risk factors
• Complications

Diarrhoea - prevention and advice for travellers: Summary

• Travellers' diarrhoea is defined as passing three or more unformed stools in a 24-hour period with at least one additional symptom, such as abdominal pain or cramps, nausea, vomiting, fever, or blood in the stools.
• Enteric bacteria are the most commonly documented (for example, Escherichia coli, Campylobacter spp., Salmonella spp., and Shigella spp .).
• Viruses and parasites can also cause travellers' diarrhoea.
• Low for people travelling to western European countries, the USA and Canada, Japan, Australia, and New Zealand.
• Intermediate for people travelling to southern European countries, Israel, South Africa, and some Caribbean and Pacific Islands.
• High for people travelling to Africa, Latin America, the Middle East, and most parts of Asia.
• Food hygiene and safe drinking water.
• Self-management and when to seek medical advice if diarrhoea develops during travel.
• The importance of personal hygiene, food hygiene, and safe drinking water should be emphasized.
• Advice regarding the risk of waterborne infection and avoiding contaminated recreational water should be offered.
• Antibiotic prophylaxis or 'stand-by' antibiotic treatment can be considered for certain high-risk travellers. Specialist advice should be sought.
• Most episodes are short-lived and self-limiting, lasting a few days.
• The person could consider purchasing sachets of oral rehydration salt before travelling.
• During an episode of diarrhoea, it is important to prevent dehydration — particularly for young children, pregnant women, elderly people, and those with pre-existing illnesses.
• Both loperamide and bismuth subsalicylate (for example, Pepto-Bismol ® ) may be considered in adults for the relief of mild-to-moderate diarrhoea. They should be used for a maximum of 2 days.
• When to seek medical assistance.

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Information on how to stay safe and healthy abroad. About us.

• Disease Prevention Advice

Travellers' Diarrhoea

Introduction.

• Recommendations

Overview of Disease

The illness.

• Additional Preventative Measures

Vaccination

Travellers' diarrhoea is spread mainly through food and water but it can also spread from person to person.  It is one of the commonest health problems experienced during travel.

Travellers' diarrhoea usually gets better in 3 to 5 days.  Most cases are mild and do not need specific treatment.

• For further information on self-treatment and when to seek medical help, see treatment section below.

Recommendations for Travellers 

Preventing travellers' diarrhoea depends mainly upon you practising good hand hygiene and food and water precautions .

• before eating and drinking
• before and after preparing food, particularly raw meat
• after using the toilet or changing nappies
• after visiting food markets
• after touching live animals
• If you cannot wash your hands, use alcohol based sanitiser :

It might be necessary for you to use extra preventive measures in certain situations.

Travellers' diarrhoea is one of the most common health issues experienced during travel.

It can be caused by many different germs like bacteria (E.coli, Salmonella), viruses ( norovirus ) and parasites ( Giardia ). All these germs are spread through eating and drinking contaminated food and water, or using contaminated dishes and cutlery.

Loose poo can also be caused by a change in your diet such as eating oily or spicy foods.

• Travellers’ diarrhoea is when you have 3 or more bouts of loose, watery poo in 24 hours.
• Most cases are mild, but for some people it is severe.
• Travellers' diarrhoea tends to happen in the first week of travel.
• Symptoms last on average 3 to 5 days and usually get better without you needing specific treatment.

Mild travellers’ diarrhoea

Travellers’ diarrhoea is mild if:

• episodes of diarrhoea are not that frequent, they don’t disrupt your activities and any other symptoms are mild

You will usually get better with rest and without specific treatment, but you should make sure you don’t become dehydrated .

Preventing dehydration

When you have diarrhoea, you can lose a lot of water from your body and become dehydrated. Young children can dehydrate quickly.

• These can be bought in pharmacies and supermarkets.
• All rehydrating drinks must be prepared using safe water .

Anti-diarrhoeal Medicine

If diarrhoea is disrupting your plans but is not severe, you can take medicines such as Loperamide (Imodium®) or diphenoxylate plus atropine (Lomotil®).  These can help, particularly with tummy pains.

Please note:

• these medicines are not recommended for use in children under 12 years of age
• Imodium® does not work straight away – it might take 1 to 2 hours to help
• taking too much of these medicines might make you constipated

If you develop the following symptoms you should not take anti-diarrhoeal medications and should instead seek medical advice:

• blood or slime (mucous) in your diarrhoea
• a high fever
• severe pain in your stomach

Severe Travellers’ diarrhoea

You should seek medical attention if:

• you cannot continue your normal activities and you have had more than 6 episodes of diarrhoea stools in a 24 hour period, OR
• you have passed blood or mucous (slime) in your diarrhoea, OR
• you keep vomiting, have a fever or severe tummy pain

You might need intravenous fluids to prevent you becoming dehydrated, or antibiotics if an infection is suspected.

Additional Preventive Measures

Tablets to prevent diarrhoea are not routinely recommended as their side effects may be worse than the diarrhoea.

Antibiotics are not routinely recommended to prevent travellers’ diarrhoea:

• widespread use of antibiotics causes resistance to develop in germs, meaning that antibiotics no longer work. This is an increasing problem around the world.

Preventative antibiotics might be offered to some people with severe medical problems that could be made worse by diarrhoea or dehydration. If you feel you may require antibiotics for travel, you should discuss this with your GP or a travel health practitioner.

• All antibiotics have side effects, and can interact with other medicines that you may be taking. You should always read the patient information leaflet that comes with the medicine.

Non-antibiotic medicines

• Bismuth subsalicylate (Pepto-Bismol®, Pepti-calm®)
• Can help to prevent travellers' diarrhoea.
• Available in tablet (Pepto-bismol®) or liquid (Pepto-bismol® or Boots Pepti-calm®).
• Can be bought in pharmacies.
• Can cause blackening of your poo and tongue.
• It may interact with other medicines and is not suitable for everyone.
• You should check with the pharmacist if it is safe for you to take.
• Always follow the dose instructions on the medicine packet.

Pre/Probiotics

Pre- and probiotics are not recommended for either prevention or treatment of travellers' diarrhoea.  There is not yet any convincing evidence that they are effective.

No licensed vaccines are available in the UK against travellers' diarrhoea.

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• General Travel Health Advice

When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.

Traveler's diarrhea

• Overview  
• Theory  
• Diagnosis  
• Management  
• Follow up  
• Resources  

Traveler's diarrhea is a common problem among travelers to destinations with deficiencies in water, sanitation, and hygiene (WASH) infrastructure, typically caused by the consumption of contaminated food or water. Predominantly caused by bacteria.

Prevention strategies include careful selection of food and beverages, though these are not fail-safe. Prophylactic antibiotics are not recommended for most travelers.

Management is self-diagnosis while still traveling, followed by hydration, medications for symptom relief, and possibly, antibiotics. Antibiotic therapy is generally reserved for moderate to severe infections.

In healthy patients, resolution is typically within 3-5 days even without antibiotic treatment.

Traveler's diarrhea (TD) is defined as ≥3 unformed stools in 24 hours accompanied by at least one of the following: fever, nausea, vomiting, cramps, tenesmus, or bloody stools (dysentery) during a trip abroad, typically to a destination with deficiencies in water, sanitation, and hygiene (WASH) infrastructure. It is usually a benign, self-limited illness lasting 3-5 days.

History and exam

Key diagnostic factors.

• diarrhea (with or without tenesmus), cramping, nausea, and vomiting
• dysentery (blood and fever)
• persistent diarrhea >14 days

Other diagnostic factors

• diarrhea without illness

Risk factors

• travel to a high-risk destination
• age <30 years
• proton-pump inhibitor use
• travelers with prior residence in higher-risk destination visiting friends and relatives
• travel during hot and wet seasons
• deployed military populations
• lack of caution in food and water selection

Diagnostic investigations

1st investigations to order.

• stool culture and sensitivity
• multipathogen molecular diagnostic (polymerase chain reaction)
• protozoal stool antigens

Investigations to consider

• stool ova and parasite exam
• Clostridioides difficile stool toxin
• colonoscopy, endoscopy, and biopsy
• hematology, blood chemistries, serology

Treatment algorithm

Pretravel prophylaxis, pre-travel prophylaxis, nonpregnant adults: mild diarrhea, nonpregnant adults: moderate diarrhea, nonpregnant adults: severe diarrhea, contributors, daniel t. leung, md, msc.

Associate Professor

Division of Infectious Diseases

University of Utah School of Medicine

Salt Lake City

Disclosures

DTL receives authorship royalties from UpToDate, Inc, for a chapter on travel medicine. DTL is an author of upcoming chapters on traveler's diarrhea for the US CDC Yellow Book. DTL is the president-elect of the American Committee on Clinical Tropical Medicine and Travelers' Health - Clinical Group within the American Society of Tropical Medicine and Hygiene. DTL is an author of some of the references cited in this topic.

Jakrapun Pupaibool, MD, MS

JP declares that he has no competing interests.

Acknowledgements

Dr Daniel T. Leung and Dr Jakrapun Pupaibool would like to gratefully acknowledge Dr Mark Riddle and Professor Gregory Juckett, the previous contributor to this topic.

MR has given talks on the management of traveler's diarrhea for the International Society of Travel Medicine (ISTM), the CDC Foundation, the American College of Gastroenterology (ACG), and the American College of Preventive Medicine. MR has led the development of guidelines for traveler's diarrhea for the ISTM, the ACG, and the Department of Defense. This work has been unpaid but support for travel has been accepted. MR is employed with Pfizer Inc., and is working on their Lyme disease vaccine program. While this is not in conflict with traveler’s diarrhea, Pfizer also makes azithromycin, which is an antibiotic recommended for the treatment of traveler’s diarrhea. MR does not work in the area of Pfizer that develops, markets, or distributes azithromycin. MR is an author of several references cited in this topic. GJ declares that he has no competing interests.

Peer reviewers

Andrea summer, md.

Assistant Professor of Pediatrics

Medical University of South Carolina

AS declares that she has no competing interests.

Phil Fischer, MD

Professor of Pediatrics

Department of Pediatric and Adolescent Medicine

Mayo Clinic

PF is an author of a reference cited in this topic.

Differentials

• Food poisoning
• Irritable bowel syndrome
• Secondary disaccharidase (or other dietary) deficiency
• CDC Yellow Book 2024: travelers' diarrhea
• 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea​

Patient leaflets

Diarrhea in adults

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Spain Traveler View

Travel health notices, vaccines and medicines, non-vaccine-preventable diseases, stay healthy and safe.

• Packing List

After Your Trip

There are no notices currently in effect for Spain.

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Check the vaccines and medicines list and visit your doctor at least a month before your trip to get vaccines or medicines you may need. If you or your doctor need help finding a location that provides certain vaccines or medicines, visit the Find a Clinic page.

Routine vaccines

Recommendations.

Make sure you are up-to-date on all routine vaccines before every trip. Some of these vaccines include

• Chickenpox (Varicella)
• Diphtheria-Tetanus-Pertussis
• Flu (influenza)
• Measles-Mumps-Rubella (MMR)

Immunization schedules

All eligible travelers should be up to date with their COVID-19 vaccines. Please see  Your COVID-19 Vaccination  for more information. 

COVID-19 vaccine

Hepatitis A

Consider hepatitis A vaccination for most travelers. It is recommended for travelers who will be doing higher risk activities, such as visiting smaller cities, villages, or rural areas where a traveler might get infected through food or water. It is recommended for travelers who plan on eating street food.

Hepatitis A - CDC Yellow Book

Dosing info - Hep A

Hepatitis B

Recommended for unvaccinated travelers younger than 60 years old traveling to Spain. Unvaccinated travelers 60 years and older may get vaccinated before traveling to Spain.

Hepatitis B - CDC Yellow Book

Dosing info - Hep B

Cases of measles are on the rise worldwide. Travelers are at risk of measles if they have not been fully vaccinated at least two weeks prior to departure, or have not had measles in the past, and travel internationally to areas where measles is spreading.

All international travelers should be fully vaccinated against measles with the measles-mumps-rubella (MMR) vaccine, including an early dose for infants 6–11 months, according to  CDC’s measles vaccination recommendations for international travel .

Measles (Rubeola) - CDC Yellow Book

Spain is free of dog rabies. However, rabies may still be present in wildlife species, particularly bats. CDC recommends rabies vaccination before travel only for people working directly with wildlife. These people may include veterinarians, animal handlers, field biologists, or laboratory workers working with specimens from mammalian species.

Rabies - CDC Yellow Book

Avoid contaminated water

Leptospirosis

How most people get sick (most common modes of transmission)

• Touching urine or other body fluids from an animal infected with leptospirosis
• Swimming or wading in urine-contaminated fresh water, or contact with urine-contaminated mud
• Drinking water or eating food contaminated with animal urine
• Avoid contaminated water and soil

Clinical Guidance

Avoid bug bites.

Leishmaniasis

• Sand fly bite
• Avoid Bug Bites

Airborne & droplet

• Breathing in air or accidentally eating food contaminated with the urine, droppings, or saliva of infected rodents
• Bite from an infected rodent
• Less commonly, being around someone sick with hantavirus (only occurs with Andes virus)
• Avoid rodents and areas where they live
• Avoid sick people

Tuberculosis (TB)

• Breathe in TB bacteria that is in the air from an infected and contagious person coughing, speaking, or singing.

Learn actions you can take to stay healthy and safe on your trip. Vaccines cannot protect you from many diseases in Spain, so your behaviors are important.

Eat and drink safely

Food and water standards around the world vary based on the destination. Standards may also differ within a country and risk may change depending on activity type (e.g., hiking versus business trip). You can learn more about safe food and drink choices when traveling by accessing the resources below.

• Choose Safe Food and Drinks When Traveling
• Water Treatment Options When Hiking, Camping or Traveling
• Global Water, Sanitation and Hygiene | Healthy Water
• Avoid Contaminated Water During Travel

You can also visit the  Department of State Country Information Pages  for additional information about food and water safety.

Prevent bug bites

Although Spain is an industrialized country, bug bites here can still spread diseases. Just as you would in the United States, try to avoid bug bites while spending time outside or in wooded areas.

What can I do to prevent bug bites?

• Cover exposed skin by wearing long-sleeved shirts, long pants, and hats.
• Use an appropriate insect repellent (see below).
• Consider using permethrin-treated clothing and gear if spending a lot of time outside. Do not use permethrin directly on skin.

What type of insect repellent should I use?

• FOR PROTECTION AGAINST TICKS AND MOSQUITOES: Use a repellent that contains 20% or more DEET for protection that lasts up to several hours.
• Picaridin (also known as KBR 3023, Bayrepel, and icaridin)
• Oil of lemon eucalyptus (OLE) or para-menthane-diol (PMD)
• 2-undecanone
• Always use insect repellent as directed.

What should I do if I am bitten by bugs?

• Avoid scratching bug bites, and apply hydrocortisone cream or calamine lotion to reduce the itching.
• Check your entire body for ticks after outdoor activity. Be sure to remove ticks properly.

What can I do to avoid bed bugs?

Although bed bugs do not carry disease, they are an annoyance. See our information page about avoiding bug bites for some easy tips to avoid them. For more information on bed bugs, see Bed Bugs .

For more detailed information on avoiding bug bites, see Avoid Bug Bites .

Stay safe outdoors

If your travel plans in Spain include outdoor activities, take these steps to stay safe and healthy during your trip:

• Stay alert to changing weather conditions and adjust your plans if conditions become unsafe.
• Prepare for activities by wearing the right clothes and packing protective items, such as bug spray, sunscreen, and a basic first aid kit.
• Consider learning basic first aid and CPR before travel. Bring a travel health kit with items appropriate for your activities.
• If you are outside for many hours in the heat, eat salty snacks and drink water to stay hydrated and replace salt lost through sweating.
• Protect yourself from UV radiation : use sunscreen with an SPF of at least 15, wear protective clothing, and seek shade during the hottest time of day (10 a.m.–4 p.m.).
• Be especially careful during summer months and at high elevation. Because sunlight reflects off snow, sand, and water, sun exposure may be increased during activities like skiing, swimming, and sailing.
• Very cold temperatures can be dangerous. Dress in layers and cover heads, hands, and feet properly if you are visiting a cold location.

Stay safe around water

• Swim only in designated swimming areas. Obey lifeguards and warning flags on beaches.
• Do not dive into shallow water.
• Avoid swallowing water when swimming. Untreated water can carry germs that make you sick.
• Practice safe boating—follow all boating safety laws, do not drink alcohol if you are driving a boat, and always wear a life jacket.

Keep away from animals

Most animals avoid people, but they may attack if they feel threatened, are protecting their young or territory, or if they are injured or ill. Animal bites and scratches can lead to serious diseases such as rabies.

Follow these tips to protect yourself:

• Do not touch or feed any animals you do not know.
• Do not allow animals to lick open wounds, and do not get animal saliva in your eyes or mouth.
• Avoid rodents and their urine and feces.
• Traveling pets should be supervised closely and not allowed to come in contact with local animals.
• If you wake in a room with a bat, seek medical care immediately.  Bat bites may be hard to see.

All animals can pose a threat, but be extra careful around dogs, bats, monkeys, sea animals such as jellyfish, and snakes. If you are bitten or scratched by an animal, immediately:

• Wash the wound with soap and clean water.
• Go to a doctor right away.
• Tell your doctor about your injury when you get back to the United States.

Reduce your exposure to germs

Follow these tips to avoid getting sick or spreading illness to others while traveling:

• Wash your hands often, especially before eating.
• If soap and water aren’t available, clean hands with hand sanitizer (containing at least 60% alcohol).
• Don’t touch your eyes, nose, or mouth. If you need to touch your face, make sure your hands are clean.
• Cover your mouth and nose with a tissue or your sleeve (not your hands) when coughing or sneezing.
• Try to avoid contact with people who are sick.
• If you are sick, stay home or in your hotel room, unless you need medical care.

Avoid sharing body fluids

Diseases can be spread through body fluids, such as saliva, blood, vomit, and semen.

Protect yourself:

• Use latex condoms correctly.
• Do not inject drugs.
• Limit alcohol consumption. People take more risks when intoxicated.
• Do not share needles or any devices that can break the skin. That includes needles for tattoos, piercings, and acupuncture.
• If you receive medical or dental care, make sure the equipment is disinfected or sanitized.

Know how to get medical care while traveling

Plan for how you will get health care during your trip, should the need arise:

• Carry a list of local doctors and hospitals at your destination.
• Review your health insurance plan to determine what medical services it would cover during your trip. Consider purchasing travel health and medical evacuation insurance for things your regular insurance will not cover.
• Carry a card that identifies, in the local language, your blood type, chronic conditions or serious allergies, and the generic names of any medicines you take.
• Bring copies of your prescriptions for medicine and for eye glasses and contact lenses.
• Some prescription drugs may be illegal in other countries. Call Spain’s embassy to verify that all of your prescription(s) are legal to bring with you.
• Bring all the medicines (including over-the-counter medicines) you think you might need during your trip, including extra in case of travel delays. Ask your doctor to help you get prescriptions filled early if you need to.

Many foreign hospitals and clinics are accredited by the Joint Commission International. A list of accredited facilities is available at their website ( www.jointcommissioninternational.org ).

Select safe transportation

Motor vehicle crashes are the #1 killer of healthy US citizens in foreign countries.

Be smart when you are traveling on foot.

• Use sidewalks and marked crosswalks.
• Pay attention to the traffic around you, especially in crowded areas.
• Remember, people on foot do not always have the right of way in other countries.

Riding/Driving

Choose a safe vehicle.

• Choose official taxis or public transportation, such as trains and buses.
• Make sure there are seatbelts.
• Avoid overcrowded, overloaded, top-heavy buses and minivans.
• Avoid riding on motorcycles or motorbikes, especially motorbike taxis. (Many crashes are caused by inexperienced motorbike drivers.)
• Choose newer vehicles—they may have more safety features, such as airbags, and be more reliable.
• Choose larger vehicles, which may provide more protection in crashes.

Think about the driver.

• Do not drive after drinking alcohol or ride with someone who has been drinking.
• Consider hiring a licensed, trained driver familiar with the area.
• Arrange payment before departing.

Follow basic safety tips.

• Wear a seatbelt at all times.
• Sit in the back seat of cars and taxis.
• When on motorbikes or bicycles, always wear a helmet. (Bring a helmet from home, if needed.)
• Do not use a cell phone or text while driving (illegal in many countries).
• Travel during daylight hours only, especially in rural areas.
• If you choose to drive a vehicle in Spain, learn the local traffic laws and have the proper paperwork.
• Get any driving permits and insurance you may need. Get an International Driving Permit (IDP). Carry the IDP and a US-issued driver's license at all times.
• Check with your auto insurance policy's international coverage, and get more coverage if needed. Make sure you have liability insurance.
• Avoid using local, unscheduled aircraft.
• If possible, fly on larger planes (more than 30 seats); larger airplanes are more likely to have regular safety inspections.
• Try to schedule flights during daylight hours and in good weather.

Helpful Resources

Road Safety Overseas (Information from the US Department of State): Includes tips on driving in other countries, International Driving Permits, auto insurance, and other resources.

The Association for International Road Travel has country-specific Road Travel Reports available for most countries for a minimal fee.

Maintain personal security

Use the same common sense traveling overseas that you would at home, and always stay alert and aware of your surroundings.

Before you leave

• Research your destination(s), including local laws, customs, and culture.
• Monitor travel advisories and alerts and read travel tips from the US Department of State.
• Enroll in the Smart Traveler Enrollment Program (STEP) .
• Leave a copy of your itinerary, contact information, credit cards, and passport with someone at home.
• Pack as light as possible, and leave at home any item you could not replace.

While at your destination(s)

• Carry contact information for the nearest US embassy or consulate .
• Carry a photocopy of your passport and entry stamp; leave the actual passport securely in your hotel.
• Follow all local laws and social customs.
• Do not wear expensive clothing or jewelry.
• Always keep hotel doors locked, and store valuables in secure areas.
• If possible, choose hotel rooms between the 2nd and 6th floors.

Healthy Travel Packing List

Use the Healthy Travel Packing List for Spain for a list of health-related items to consider packing for your trip. Talk to your doctor about which items are most important for you.

Why does CDC recommend packing these health-related items?

It’s best to be prepared to prevent and treat common illnesses and injuries. Some supplies and medicines may be difficult to find at your destination, may have different names, or may have different ingredients than what you normally use.

If you are not feeling well after your trip, you may need to see a doctor. If you need help finding a travel medicine specialist, see Find a Clinic . Be sure to tell your doctor about your travel, including where you went and what you did on your trip. Also tell your doctor if you were bitten or scratched by an animal while traveling.

For more information on what to do if you are sick after your trip, see Getting Sick after Travel .

Map Disclaimer - The boundaries and names shown and the designations used on maps do not imply the expression of any opinion whatsoever on the part of the Centers for Disease Control and Prevention concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Approximate border lines for which there may not yet be full agreement are generally marked.

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