Enjoy your vacation to the fullest with these tips on how to prevent and treat Traveler’s Diarrhea.

We’re here to help keep you healthy (and your stomach happy) on your next vacation! Not only do we keep up with the latest advice from respected sources, but we have decades of international travel experience and professional healthcare background, as well.

We have good reason to follow our own advice; since 2013 we have lived on the road and eaten every meal almost exclusively in restaurants and food carts. From a tour standpoint, our priority is to keep our guests healthy and feeling their best while trying out the local cuisine. 

Before we start, though, we’d like to share some wise words from our friends over at CIWEC clinic in Kathmandu, Nepal:

“Remember, you cannot completely control what you eat, and no matter how careful you are, you can still get ill. Take reasonable precautions, as suggested, then relax and enjoy your food.”

What are the symptoms of Traveler’s Diarrhea?

It might sound self-explanatory, but it’s important to know the range of symptoms. They include:

  • Sudden onset of loose stools, three or more times in once day
  • Nausea or Vomiting
  • Bloating
  • Abdominal pain or cramps
  • Urgency (trouble waiting to have a bowel movement)
  • Feeling tired
  • Loss of appetite

It’s time to seek medical attention if you experience:

  • Blood in your stool (note: the blood may look black, not red)
  • High fever (greater than 101.3°F / 38.5°C)
  • Signs of dehydration
  • You experience diarrhea for more than 5-7 days
drinking airag in a mongolian monastery

Perhaps the best compliment we’ve ever gotten was from our Mongolian hosts, impressed at how we dove right into drinking a seasonal classic, fermented horse’s milk (airag). Apparently it’s not always the easiest thing for a tourist stomach to handle; in fact, even Mongolians struggle with it a bit the first one or two times they have it in the beginning of the summer!

drinking airag in a mongolian monastery

Perhaps the best compliment we’ve ever gotten was from our Mongolian hosts, impressed at how we dove right into drinking a seasonal classic, fermented horse’s milk (airag). Apparently it’s not always the easiest thing for a tourist stomach to handle; in fact, even Mongolians struggle with it a bit the first one or two times they have it in the beginning of the summer!

What are the symptoms of Traveler’s Diarrhea?

It might sound self-explanatory, but it’s important to know the range of symptoms. They include:

  • Sudden onset of loose stools, three or more times in once day
  • Nausea or Vomiting
  • Bloating
  • Abdominal pain or cramps
  • Urgency (trouble waiting to have a bowel movement)
  • Feeling tired
  • Loss of appetite

It’s time to seek medical attention if you experience:

  • Blood in your stool (note: it may look black, not red)
  • Black, tarry stools
  • High fever (greater than 101.3°F / 38.5°C)
  • Signs of dehydration
  • You experience diarrhea for more than 5-7 days

What causes Traveler’s Diarrhea?

Traveler’s diarrhea is due to different bacteria, viruses, or parasites, depending on where you are in the world, although it is most typically caused by bacteria. At the end of the day, it’s about contaminated water or someone with poor hygiene handling your food (and it could be you! More on washing your hands later). “Traveler’s diarrhea” can happen at home, as well—anywhere that you encounter tainted food or drink.

If you feel sick while traveling, you may be quick to blame a food cart or street vendor, but remember that this contamination can happen anywhere. One of the only occasions where both BJ and I fell ill was an American-owned 5-star hotel and restaurant where Michelle Obama and her daughters had recently dined. We couldn’t resist the temptation of a patty melt on the menu (which you never, ever, ever see abroad) and we both paid the price that afternoon and evening. Bonus: it was a very modern, open-concept hotel room so there was no door to the toilet!

No matter how frustrating it is, you might never know exactly what made you sick because different bacteria, viruses, and parasites incubate for different periods of time, so it could have been something you ate 3 hours ago or 3 days ago.

We won’t discuss amoebic dysentery and giardia here because those cases are very infrequent, although you can give them a Google. However, if you’re very, very lucky, you’ll get to hear BJ’s story about his 1995 bout of amoebic dysentery in person!

 

Why don’t locals get sick like tourists do?

This is a great question that NPR has a great answer to:

“They did — when they were kids. Young children in developing countries are frequently exposed to diarrhea-causing E. coli and thus build up immunity to these strains during the first few years of life. These types of E. coli are much rarer in the U.S., so kids here never become immune to them.”

Practical Tips to Prevent Traveler’s Diarrhea

Please take these tips with a grain of salt and always do what you think is best in your current situation. And remember: When in doubt, don’t!

General tips

  • Keep your mouth shut in the shower. This is our #1 tip! You may not realize how much water you typically allow into your mouth, knowingly or not, at home, but don’t do it abroad! The same goes for when you’re washing your face in the sink—keep your mouth closed.
  • Brush your teeth with bottled water, particularly if you do a final rinse after you brush your teeth.
  • Wash your hands often (and use hand sanitizer when water and soap are not readily available)
  • Don’t bite your nails. You know what? Best just not to touch your face!

Tips for eating out

Note: on any tour with us, you are in good hands! We have vetted all restaurants and food tours, and we’ll remind you about all of these tips in person.

  • Make sure your plates, utensil, and cups are dry before using them.
  • When possible, check out restaurants on local review sites–TripAdvisor, Google reviews, Facebook reviews, etc. On tours, your tour guides should have done the vetting for you.
  • When you’re deciding where to eat on the go, head for the popular restaurants–ideally, popular with locals, too! Go to the food cart with the longest line; not only does that mean it’s more popular and likely delicious, but there’s a higher turnover of food so nothing has been sitting around all day long.
  • Raw foods (salads, etc) used to be verboten in the past. Nowadays, lots of restaurants are using purified water to wash their uncooked vegetables. If it’s a busy restaurant that caters to tourists, you’re most likely safe; as always, though, when in doubt, don’t!
  • In many parts of the world, smoothies and lassis are a huge part of the local cuisine. CIWEC Clinic in Nepal writes, “Blended fruit and yoghurt drinks (‘Lassis’) were found to be highly associated with diarrhea in our research and should be avoided.” Use your common sense. If it’s a food stand with no purified water around (for the drinks, or more importantly, to wash the blender jar out) then avoid it. If it’s in a reputable tourist restaurant, you’re probably good to go.

If you’re still nervous about trying street foods but you don’t want to miss out, find a trustworthy street food tour company on TripAdvisor with great reviews. They’ll know the safest, most-tourist friendly street vendors in town, and tours like this are always a lot of fun—delicious and educational.

Regarding Water and Ice

Always drink purified water (that is, not out of the tap). Unless you’ve done the research for your destination and you feel confident the tap water is safe, stick to bottled water or purify it yourself out of the tap with a tool such as this wonderful Katadyn filter or a SteriPen. Plastic water bottle waste is a huge problem, particularly in developing countries, so please consider filtering as much water as you can. At the very least, if you must buy plastic bottled water, buy the largest bottle you can and then refill your own smaller drinking containers. Please don’t buy small plastic bottles unnecessarily.

You’ll read in many older guides to be extra cautious and make sure the plastic seal around your water bottle’s cap is intact. This was because when the phenomenon of bottled water was new and prices relatively expensive, some unscrupulous folks might refill a bottle with tap water, put the cap back on, and try to re-sell it. However, bottled water is beyond ubiquitous these days and cheap. No one is making their fortune scamming you on bottled water (well, except Nestle). We have never witnessed this particular scam in our decades of travel. Certainly, though, listen to your Spidey Sense if you think something is off.

Ice used to be a huge travel no-no back in the day; in fact, most blogs you’ll read will still advise you away from it. Certainly, do what feels comfortable for you and what you think is right in the moment. However, since so many restaurants use purified water in the kitchen now, it’s typically fine in most tourist destinations. As a matter of fact, the only regions you’d really want to avoid ice are places that typically would never have it. Ice is just not a “thing” in many places (such as India, Nepal, etc). If you need a bit more guidance, consider this: if it’s a hotel or restaurant that obviously caters to tourists, it’s probably fine. Plus, you can always ask the waitstaff. 

Diarrhea Preventatives

Bismuth (Pepto Bismol)

Studies have shown that 1-2 chewable tablets of bismuth subsalicylate (which you may know as Pepto Bismol) taken with meals was an effective protection against traveler’s diarrhea. Although the liquid has the same properties, we recommend opting for tablets due to their ease of handling while traveling.

You can also use this as a treatment in case you actually get traveler’s diarrhea, 2 tablets, four times a day.

Important: Pepto Bismol may interact with doxycycline, an antibiotic you may using for a malaria preventative. Please ingest them several hours apart. Here’s a mere complete list of potential drug interactions with bismuth subsalicylate.

Probiotics

Probiotics are live yeasts and bacteria that your body needs to function properly. Probiotics are currently used in hospitals to prevent and treat diarrhea due to chemotherapy, to treat Clostridium Difficile (C. diff), IBS, and more. There are many different types of probiotics and they each have unique properties. Although lactobacilli and Saccharomyces boulardii have been studied with traveler’s diarrhea, a good quality blend is a great solution.

My most important tip is to make sure your product says the probiotic count is good until the expiration date. So many companies make staggering claims of billions of live bacteria in each pill until you read the fine print; there is it revealed that the only guarantee is that they were alive at the time of manufacture, with no promise of how they will do in shipping (and sitting on warehouse and store shelves, not to mention your refrigerator or cupboard). That’s like ordering a bouquet of flowers that shows up completely dead and rotting, and the florist says, “Well, they were alive when they left the shop!”

My recommendation: choose shelf-stable probiotics that don’t require refrigeration and guarantee potency through their expiration date. I like Jarrodophilus EPS or either of these two products (here and here) by Renew Life. Take them as recommended on the packaging, starting a week or two before your trip (and continue throughout your trip).

If you do end up taking antibiotics for your diarrhea, you can and should continue taking your probiotics. Simply take them 2 hours before or after your antibiotics to get the most out of them.

 

Diarrhea Treatments

Imodium

Chances are you already know about Imodium (sold by its generic name of Loperamide in most countries). You probably already know it’s effective at stopping diarrhea in an emergency.

The recommended initial dose is 4 mg (two 2 mg caplets) followed by 2 mg (one caplet) after each unformed stool. Do not take for more than 48 hours. Do not take if you also have a fever or bloody stools.

Some people don’t like Imodium because they feel it’s too strong and binds them up for too long. This will all depend on your constitution and your current situation, but you can always take less than the recommended dose if you feel that is appropriate for you. I would purchase the caplets/tablets which are already scored so you can break them in half easily, if need be.

Activated Charcoal

There are no studies to confirm the efficacy of activated charcoal for traveler’s diarrhea, but the anecdotal evidence of using charcoal is too great to ignore. Charcoal has long been used in hospital settings to adsorb toxins in cases of overdose or accidental poisoning; activated charcoal’s enormous surface area allows these harmful substances to bind to the charcoal and be escorted out of the body with the feces. People have taken this principle and applied it to traveler’s diarrhea, thinking that the offending bacteria will be bound up with the charcoal and neutralized.

Taken responsibly and short-term, there’s no harm in trying this. It’s VERY IMPORTANT to remember that everything binds to charcoal, including nutrients, so ingest it a few hours before or after any prescription medicine or other supplements you are taking.

Other good things to know: It will turn your poop black, don’t panic (especially since one of the signs to head to a doctor is black stools). And again, please do not use for extended periods of time, due to this extreme binding action. It can even prevent you from absorbing the nutrients in your food.

Antibiotics

Using antibiotics as a first line of defense–even as a preventative—used to be commonplace. Now, however, doctors don’t recommend you jump to that option too quickly. Dr. David Shlim, past president of the International Society of Travel Medicine, said in an NPR interview  that “Your body will naturally fight off bacterial diarrhea in three to seven days.” He added that if the diarrhea is frequent or bloody, that antibiotics are appropriate. On his own private practice site Dr. Shlim recommends one of the following:

  • Ciprofloxacin 500mg—take one pill to start, and a second pill 8-12 hours later. This is the drug of choice for most destinations.  OR—

     

  • Azithromycin 500mg—take 1 pill per day for 1 to 2 days. This drug is necessary in countries where the bacteria have become resistant to ciprofloxacin.

He adds, “Most people will be cured with one day’s treatment, either two doses of ciprofloxacin or a single dose of azithromycin. The message is you can stop [taking the drug] when it is clear that you are starting to recover.” You do not need to take a full course of antibiotics when using them to combat traveler’s diarrhea. 

It is worth mentioning that in much of the world (besides the U.S), antibiotics are available over the counter, without a prescription at pharmacies. Pharmacists are highly trained professionals and are of great benefit when traveling abroad. Also, continue taking your probiotics, but take them at a different time than your antibiotics to get the most out of them (at least 3 hours before your antibiotics).

Water!

Don’t forget to keep drinking lots of water to replenish what you’ve lost. If you’ve lost a decent amount of fluids through diarrhea, please add some rehydration salts (preferably), something like Emergen-C, or a local sports drink.

 

To treat any accompanying nausea

Please check out our more comprehensive “How to Stay Healthy While Traveling…Naturally!” blog for information on ginger and Sea-Bands.

Do I need Travel Insurance?

We believe the answer is Yes! We require our guests to carry travel insurance, and we think it’s an important safety net for all travelers. It’s a small price to pay for peace of mind should something unexpected happen during your journey. Click here to find out more about where to start your search for travel insurance.

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