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Traveller's Diarrhoea

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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?

What is traveller's diarrhoea?

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.'

What causes traveller's diarrhoea?

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.

Book a pharmacy appointment today

Arrange a consultation with your local pharmacist to discuss your travel plans and medication for traveller's diarrhoea.

What are the symptoms of traveller's diarrhoea?

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.

How is traveller's diarrhoea diagnosed?

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.

When should I seek medical advice for traveller's diarrhoea?

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.)

How is traveller's diarrhoea in adults treated?

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.

How is traveller's diarrhoea in children treated?

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.

Side-effects of traveller's diarrhoea

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

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.

How long does traveller's diarrhoea last?

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.

How can I avoid traveller's diarrhoea?

• 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.

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Further reading and references

Travellers' diarrhoea ; Fitfortravel

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.

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 124(suppl_1):S57-S74. doi: 10.1093/jtm/tax026.

Giddings SL, Stevens AM, Leung DT ; Traveler's Diarrhea. Med Clin North Am. 2016 Mar100(2):317-30. doi: 10.1016/j.mcna.2015.08.017.

Diarrhoea - prevention and advice for travellers ; NICE CKS, February 2019 (UK access only)

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Diarrhoea - prevention and advice for travellers: Have I got the right topic?

Last revised in September 2023

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From age 1 month onwards.

This CKS topic covers the prevention of travellers' diarrhoea, and includes the use of antibiotics for the prophylaxis and empirical treatment of travellers' diarrhoea.

This CKS topic does not cover the assessment of diarrhoea, the management of acute gastroenteritis (including presumed infectious gastroenteritis) in adults and children, diarrhoea due to food poisoning, or antibiotic-associated diarrhoea. These are covered in the CKS topics on  Diarrhoea - adult's assessment ,  Diarrhoea - antibiotic associated , and  Gastroenteritis . 

There are separate CKS topics on  Gastrointestinal tract (lower) cancers - recognition and referral ,  Gastrointestinal tract (upper) cancers - recognition and referral ,  Irritable bowel syndrome  and  Palliative care - nausea and vomiting .

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Travellers’ diarrhoea

Chinese translation.

• Related content
• Peer review
• Jessica Barrett , infectious diseases registrar 1 ,
• Mike Brown , consultant in infectious diseases and tropical medicine 1 2
• 1 Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London WC1E 6AU, UK
• 2 Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
• Correspondence to: J Barrett jessica.barrett{at}gstt.nhs.uk

What you need to know

Enterotoxic Escherichia coli (ETEC) is the most common cause of acute travellers’ diarrhoea globally

Chronic (>14 days) diarrhoea is less likely to be caused by bacterial pathogens

Prophylactic antibiotic use is only recommended for patients vulnerable to severe sequelae after a short period of diarrhoea, such as those with ileostomies or immune suppression

A short course (1-3 days) of antibiotics taken at the onset of travellers’ diarrhoea reduces the duration of the illness from 3 days to 1.5 days

Refer patients with chronic diarrhoea and associated symptoms such as weight loss for assessment by either an infectious diseases specialist or gastroenterologist

Diarrhoea is a common problem affecting between 20% and 60% of travellers, 1 particularly those visiting low and middle income countries. Travellers’ diarrhoea is defined as an increase in frequency of bowel movements to three or more loose stools per day during a trip abroad, usually to a less economically developed region. This is usually an acute, self limiting condition and is rarely life threatening. In mild cases it can affect the enjoyment of a holiday, and in severe cases it can cause dehydration and sepsis. We review the current epidemiology of travellers’ diarrhoea, evidence for different management strategies, and the investigation and treatment of persistent diarrhoea after travel.

We searched PubMed and Cochrane Library databases for “travellers’ diarrhoea,” and “travel-associated diarrhoea,” to identify relevant articles, which were added to personal reference collections and clinical experience. Where available, systematic reviews and randomised controlled trials were preferentially selected.

Who is at risk?

Variation in incidence 1 2 may reflect the degree of risk for different travel destinations and dietary habits while abroad. Destinations can be divided into low, medium, and high risk (see box 1). Rates of diarrhoea are likely to correlate closely with the quality of local sanitation.

Box 1: Risk of travellers’ diarrhoea according to destination 1 3

High risk destinations.

South and South East Asia*

Central America*

West and North Africa*

South America

East Africa

Medium risk

South Africa

North America

Western Europe

Australia and New Zealand

*Regions with particularly high risk of travellers’ diarrhoea

Backpackers have roughly double the incidence of diarrhoea compared with business travellers. 4 Travel in cruise ships is associated with large outbreaks of viral and bacterial gastroenteritis. 5 General advice is to avoid eating salads, shellfish, and uncooked meats. There is no strong evidence that specific dietary measures reduce incidence of diarrhoea, but studies examining this are likely to be biased by imperfect recall of what was eaten. 6 Risk factors for travellers’ diarrhoea are listed in box 2.

Box 2: Factors increasing risk of travellers’ diarrhoea 4 7 8 9

By increased dietary exposure.

Backpacking

Visiting friends and family

All-inclusive holidays (such as in cruise ships)

By increased susceptibility to an infectious load

Age <6 years

Use of H 2 receptor antagonists and proton pump inhibitors

Altered upper gastrointestinal anatomy

Genetic factors (blood group O predisposes to shigellosis and severe cholera infection)

What are the most important causes of travellers’ diarrhoea?

Most studies report a failure to identify the causative pathogen in between 40% and 70% of cases. 10 This includes multicentre studies based in high prevalence settings (that is, during travel). 3 10 11 12 This low diagnostic yield is partly due to delay in obtaining samples and partly due to the insensitivity of laboratory investigations. Older studies did not consistently attempt to identify enteroaggregative Escherichia coli (EAEC), and surveillance studies vary in reporting of other E coli species. 3 Where a pathogen is identified, bacteria are the commonest cause of acute travellers’ diarrhoea, with the remainder being caused by norovirus, rotavirus, or similar viruses (see table 1 ⇓ ). Protozoa such as Giardia lamblia can also cause acute diarrhoea, but they are more often associated with persistent diarrhoea, lasting more than two weeks. Cyclospora catayensis , another protozoan cause of diarrhoea, was identified in an increased number of symptomatic travellers returning from Mexico to the UK and Canada in 2015. 13

Frequency of pathogens causing travellers’ diarrhoea 2 3 10 11 12

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Table 1 ⇑ illustrates overall prevalence of causative agents in returning travellers with diarrhoea. However relative importance varies with country of exposure. Rates of enterotoxigenic E coli (ETEC) are lower in travellers returning from South East Asia than in those returning from South Asia, sub-Saharan Africa, and Latin America, whereas rates of Campylobacter jejuni are higher. Norovirus is a more common cause in travellers to Latin America and sub-Saharan Africa, and Giardia lamblia and Entamoeba histolytica are more common in travellers to South and South East Asia. 10

The importance of enterotoxigenic E coli as a cause for diarrhoea in travellers returning from Latin America has been decreasing over the past four decades. 10 A large scale analysis of EuroTravNet surveillance data shows increasing incidence of Campylobacter jejuni infection in travellers returning from India, Thailand, and Pakistan. 2

How does travellers’ diarrhoea present?

Most episodes of travellers’ diarrhoea start during the first week of travel, with the peak incidence on the second or third day after arrival. 8 14

Typically diarrhoea caused by enterotoxigenic E coli (“turista”) is watery and profuse, and preceded by abdominal cramps, nausea, and malaise. Symptoms are not a reliable guide to aetiology, but upper gastrointestinal manifestations such as bloating and belching tend to predominate with Giardia lamblia , while colitic symptoms such as urgency, bloody diarrhoea, and cramps are seen more often with Campylobacter jejuni and Shigella spp.

Most episodes will last between one and seven days, with approximately 10% lasting for longer than one week, 5% lasting more than two weeks, and 1% lasting more than 30 days. 8 During the illness, few patients will be severely incapacitated (in one large prospective cohort about 10% of 2800 participants were confined to bed or consulted a physician), but planned activities are often cancelled or postponed. 8

How can travellers’ diarrhoea be prevented?

Several controlled trials have failed to demonstrate an impact of food and drink hygiene advice on rates of diarrhoea. 15 However, the clear food-related source of most diarrhoeal pathogens means that general consensus among travel physicians is to continue to recommend boiling water, cooking food thoroughly, and peeling fruit and vegetables. 6 Other basic advice includes avoiding ice, shellfish, and condiments on restaurant tables, using a straw to drink from bottles, and avoiding salads and buffets where food may have been unrefrigerated for several hours. Travellers should be advised to drink bottled water where available, including in alcoholic drinks, as alcohol does not sterilise non-bottled water. If bottled water is not available, water can be purified by boiling, filtering, or use of chlorine based tablets. 16 There is some weak evidence that use of alcohol hand gel may reduce diarrhoea rates in travellers, 17 but, based on studies in non-travellers, it is reasonable to strongly encourage travellers to adhere to good hand hygiene measures. Two recent systematic reviews estimated hand washing with soap reduces the risk of diarrhoeal illness by 30-40%. 18 19

When is antibiotic prophylaxis recommended?

For most travellers antibiotic chemoprophylaxis (that is, daily antibiotics for the duration of the trip) is not recommended. While diarrhoea is annoying and distressing, severe or long term consequences from a short period of diarrhoea are rare, and routine use of chemoprophylaxis would create a large tablet burden and expose users to possible adverse effects of antibiotic therapy such as candidiasis and diarrhoea associated with Clostridium difficile .

Chemoprophylaxis should be offered to those with severe immune suppression (such as from chemotherapy for malignancy or after a tissue transplant, or advanced HIV infection), underlying intestinal pathology (inflammatory bowel disease, ileostomies, short bowel syndrome), and other conditions such as sickle cell disease or diabetes where reduced oral intake may be particularly dangerous (table 2 ⇓ ). 22 These patient groups may be unable to tolerate the clinical effects and dehydration associated with even mild diarrhoea, or the consequences of more invasive complications such as bacteraemia. For such patients, it is important to discuss the benefits of treatment aimed at preventing diarrhoea and its complications against the risks of antibiotic associated diarrhoea and other side effects. If antibiotics are prescribed then consideration should be given to any possible interactions with other medications that the patient is taking.

Antibiotic chemoprophylaxis options for immunosuppressed or other high risk travellers

A small comparative study in US soldiers showed that malaria prophylaxis with daily doxycycline has the added benefit of reducing rates of travellers’ diarrhoea caused by enterotoxigenic E coli and Campylobacter jejuni . 23

Do vaccines have a role in prevention of travellers’ diarrhoea?

Vaccines have been developed and licensed against Salmonella typhi , Vibrio cholerae , and rotavirus—all with reasonable efficacy. However, unlike enterotoxigenic E coli , none of these is a major cause of travellers’ diarrhoea, and only vaccines against S typhi are recommended for most travellers to endemic settings. Phase 3 trials of enterotoxigenic E coli toxin vaccines have been undertaken but have failed to demonstrate efficacy. 24 Studies suggest vaccines against enterotoxigenic E coli would have a major public health impact in high burden countries, and further candidate vaccines are in development. 25

What are the options for self administered treatment?

Table 3 ⇓ summarises the options for self treatment.

Summary of self treatment choices

Anti-motility agents and oral rehydration therapy

For most cases of travellers’ diarrhoea, oral rehydration is the mainstay of treatment. This can be achieved with clear fluids such as diluted fruit juice or soups. Young children, elderly people, and those at greater risk from dehydration (that is, those with medical comorbidities) are recommended to use oral rehydration salts (or a mixture of six level teaspoons of sugar and half a teaspoon of salt in a litre of clean water if rehydration salts are unavailable) (see http://rehydrate.org/rehydration/index.html ).

Anti-motility agents such as loperamide may be appropriate for mild symptoms, or where rapid cessation of diarrhoea is essential. Case reports of adverse outcomes such as intestinal perforation suggest anti-motility agents should be avoided in the presence of severe abdominal pain or bloody diarrhoea, which can signify invasive colitis. 26 Systematic review of several randomised controlled trials have demonstrated a small benefit from taking bismuth subsalicylate, but this has less efficacy in reducing diarrhoea frequency and severity than loperamide. 27

Antibiotics

Symptomatic treatment is usually adequate and reduces antibiotic use. However, some travellers will benefit from rapid cessation of diarrhoea, particularly if they are in a remote area with limited access to sanitation facilities or healthcare. Several systematic reviews of studies comparing antibiotics (including quinolones, azithromycin, and rifaximin) against placebo have shown consistent shortening of the duration of diarrhoea to about one and a half days from around three days. 28 29 30 Short courses (one to three days) of antibiotics are usually sufficient to effect a cure. 30

For some people travelling to high and moderate risk areas (see box 1) it will be appropriate to provide a short course of a suitable antibiotic, with advice to start treatment as soon as they develop diarrhoea and to keep well hydrated. Choice of antibiotic will depend on allergy history, comorbidities, concomitant medications, and destination. Avoid quinolones for both prophylaxis and treatment of travellers to South East and South Asia as levels of quinolone resistance are high. 31 Azithromycin remains effective in these areas, but resistance rates are likely to increase.

A meta-analysis of nine randomised trials showed that the addition of loperamide to antibiotic treatment (including azithromycin, ciprofloxacin, and rifamixin) resulted in statistically significantly higher rates of cure at 24 and 48 hours compared with antibiotic alone. 32 Travellers can be advised to add loperamide to their antibiotic treatment to reduce the time to symptomatic improvement as long as there are no features of invasive colitis such as severe pain, high fever, or blood visible in the diarrhoea. 30 If any of these symptoms develop, travellers are advised to seek medical advice immediately.

Returned travellers with persistent diarrhoea

Most bacterial causes mentioned do not cause persistent diarrhoea in immune competent adults. Travellers with diarrhoea persisting beyond 14 days may present in primary or secondary care on their return and require assessment for other underlying causes of persistent diarrhoea.

Table 4 ⇓ lists the important clinical history and symptoms that can point to the underlying cause.

Assessment of chronic diarrhoea

What investigations should be sent?

For diarrhoeal symptoms that persist beyond 14 days following travel (or sooner if there are other concerning features such as fever or dysentery), offer patients blood tests for full blood count, liver and renal function, and inflammatory markers; stool samples for microscopy and culture; and examination for ova, cysts, and parasites. Historically, advice has been to send three stool samples for bacterial culture, but this is unlikely to increase the diagnostic yield. Instead, stool microscopy can be used to distinguish inflammatory from non-inflammatory causes: a small observational study found presence of faecal leucocytes was predictive of a positive bacterial stool culture. 33 Yield from stool culture may be increased by dilution of the faecal sample, and the introduction of molecular tests such as polymerase chain reaction (PCR) for common gastrointestinal pathogens such as Campylobacter spp may decrease turnaround times and increase yield. 34

Additional tests should be offered according to symptoms and risk (table 4 ⇑ ). If the patient has eosinophilia and an appropriate travel history, the possibility of schistosomiasis, strongyloides, and other helminthic infections should be considered. While schistosomiasis can rarely cause diarrhoea in the context of acute infection, serology may be negative in the first few months of the illness.

Imaging is required only if the patient has signs of severe colitis or local tenderness, in which instances toxic megacolon, inflammatory phlegmon, and hepatic collections should be excluded. Patients with severe colitis or proctitis may need joint assessment with gastroenterology and consideration of endoscopy, or laparotomy if perforation has occurred.

Where infectious and non-infectious causes have been appropriately excluded, the most likely diagnosis is post-infectious irritable bowel syndrome, although diarrhoea can also herald underlying bowel pathology and anyone with red flags for malignancy should be referred by the appropriate pathway for assessment. Post-infectious irritable bowel syndrome has an incidence of around 30% after an acute episode of travel associated gastroenteritis. 35 36 It is more commonly a sequela of prolonged episodes of diarrhoea or diarrhoea associated with fever and bloody stools. 36 There is weak evidence from small randomised trials suggesting that exclusion of foods high in fermentable carbohydrates (FODMAP) may be helpful. 37 Exclusion of dietary lactose and use of loperamide, bile acid sequestrants, and probiotics can also be tried, but there is limited evidence for long term benefit. 35 37 38

How should giardiasis be managed?

The most common pathogen identified in returning travellers with chronic diarrhoea is Giardia lamblia, particularly among people returning from South Asia. 39 Use of G lamblia PCR testing has increased detection, 40 which potentially will identify infection in some patients previously labelled as having post-infectious irritable bowel syndrome and in those whose diarrhoea may have been attributed to non-pathogenic protozoa. Most patients respond to 5-nitroimidazoles (a systematic review of a large number of trials has shown similar cure rates with tinidazole 2 g once only or metronidazole 400 mg three times daily for five days 41 ), but refractory cases are increasingly common and require investigation, identification of underlying risk factors, and repeated treatment (various antimicrobials have been shown to be effective but may have challenging risk profiles). .

Questions for future research

What is the justification for using antibiotics to treat a usually self limiting illness, in the wider context of rising levels of global antimicrobial resistance rates? What is the clinical impact of resistant enterobacteriaciae found in stool samples from returning travellers? 42 43

To what extent do host genetic factors increase susceptibility to gastrointestinal pathogens, and can this help to identify at risk populations and tailor treatments to individual patients?

What is the long term efficacy of new pharmacological treatments such as selective serotonin reuptake inhibitors and rifaximin in post-infectious irritable bowel syndrome?

Tips for non-specialists

Include consideration of chemoprophylaxis for high risk individuals in pre-travel assessment

Advise all travellers on hygiene measures (such as hand washing and food consumption) and symptom management of diarrhoea

Avoid quinolones for prophylaxis or treatment in travellers to South East and South Asia

Where diarrhoea persists beyond 14 days, consider investigations to rule out parasitic and non-infectious causes. The presence of white blood cells on stool microscopy indicates an inflammatory cause

Additional educational resources

Resources for patients.

National Travel Health Network and Centre (NaTHNaC): http://travelhealthpro.org.uk/travellers-diarrhoea/

Provides pre-travel advice, as well as links to country-specific advice

Fit for Travel: www.fitfortravel.nhs.uk/advice/disease-prevention-advice/travellers-diarrhoea.aspx

Provides similar pre-travel advice on hygiene and disease prevention

Patient.co.uk: http://patient.info/doctor/travellers-diarrhoea-pro

Has patient leaflets and more detailed information about investigation and management of travellers’ diarrhoea

Resources for healthcare professionals

Centers for Disease Control and Prevention yellow book: http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/travelers-diarrhea

Provides a guide to pre-travel couselling

Rehydration Project website: http://rehydrate.org/rehydration/index.html

Has additional information about non-pharmacological management of diarrhoea

How patients were involved in the creation of the article

No patients were involved in the creation of this review.

Contributors: Both authors contributed equally to the preparation of this manuscript. MB is guarantor. We thank Dr Ron Behrens for sharing his extensive expertise on this subject.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: Commissioned; externally peer reviewed.

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Diarrhoea (acute)

Description of condition.

Diarrhoea is the abnormal passing of loose or liquid stools, with increased frequency, increased volume, or both. Acute diarrhoea is that which lasts less than 14 days, but symptoms usually improve within 2–4 days. It can result from infection, as a side-effect of a drug, or as an acute symptom of a chronic gastro-intestinal disorder (such as Crohn's disease , Irritable bowel syndrome , or Ulcerative colitis ). It may also result from the accumulation of non-absorbed osmotically active solutes in the gastro-intestinal lumen (e.g. in lactase deficiency) or from the gastro-intestinal effects of secretory stimuli (other than the enterotoxins from an infection). It may also occur when intestinal motility or morphology is altered.

Prompt investigation is required to identify or exclude any serious underlying cause if the patient has any red flag symptoms such as unexplained weight loss, rectal bleeding, persistent diarrhoea, a systemic illness, has received recent hospital treatment or antibiotic treatment, or following foreign travel (other than to Western Europe, North America, Australia or New Zealand).

Aims of treatment

The priority of acute diarrhoea treatment, as in gastro-enteritis, is the prevention or reversal of fluid and electrolyte depletion and the management of dehydration when it is present. This is particularly important in infants, frail and elderly patients, when excessive water and electrolyte loss and dehydration can be life-threatening.

Most episodes of acute diarrhoea will settle spontaneously without the need for any medical treatment. Oral rehydration therapy (ORT, such as disodium hydrogen citrate with glucose, potassium chloride and sodium chloride ; potassium chloride with sodium chloride ; potassium chloride with rice powder, sodium chloride and sodium citrate ) is the mainstay of treatment for acute diarrhoea to prevent or correct diarrhoea dehydration and to maintain the appropriate fluid intake once rehydration is achieved—see Fluids and electrolytes . A Strength of recommendation: High

However, in patients with severe dehydration and in those unable to drink, immediate admission to hospital and urgent replacement treatment with an intravenous rehydration fluid is recommended—see Fluids and electrolytes . A Strength of recommendation: High

The antimotility drug loperamide hydrochloride is usually considered to be the standard treatment when rapid control of symptoms is required. It can also be used for mild-to-moderate travellers' diarrhoea (e.g. where toilet amenities are limited or unavailable) but should be avoided in bloody or suspected inflammatory diarrhoea (febrile patients) and in cases of significant abdominal pain (which also suggests inflammatory diarrhoea). A Strength of recommendation: High

Loperamide hydrochloride is also the first-line treatment for patients with faecal incontinence [unlicensed indication] after the underlying cause of incontinence has been addressed. A Strength of recommendation: High

Racecadotril is licensed as an adjunct to rehydration for the symptomatic treatment of uncomplicated acute diarrhoea in adults and children over 3 months.

There is insufficient evidence to recommend adsorbent preparations (such as kaolin) in acute diarrhoea.

Antibacterial drugs for acute diarrhoea

Ciprofloxacin is occasionally used for prophylaxis against travellers' diarrhoea, but routine use is not recommended. A Strength of recommendation: High For guidance on antibacterial treatment for infections that cause acute diarrhoea, see Gastro-intestinal system infections, antibacterial therapy .

Related drugs

Other drugs used for diarrhoea: codeine phosphate , co-phenotrope , methylcellulose, rifaximin .

• Ciprofloxacin
• Co-phenotrope
• Codeine phosphate
• Disodium hydrogen citrate with glucose, potassium chloride and sodium chloride
• Loperamide hydrochloride
• Potassium chloride with rice powder, sodium chloride and sodium citrate
• Potassium chloride with sodium chloride

Related treatment summaries

• Crohn's disease
• Fluids and electrolytes
• Gastro-intestinal system infections, antibacterial therapy
• Irritable bowel syndrome
• Ulcerative colitis

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Traveller's Diarrhoea

Travellers’ diarrhoea (TD) is the most common health problem affecting travellers. It is defined as the passage of 3 or more unformed stools per day while travelling, associated with at least 1 symptom such as fever, nausea, vomiting, cramps, or faecal urgency. Its consequences can range from lost time and opportunity to hospitalisation. Read the JTM collection for access to more research and updates.

What causes TD?

Traveller’s diarrhoea can be caused by a wide range of pathogens, including bacteria, parasites and viruses: multiplex PCR technologies can be useful in determining aetiologic agents. As addressed in our collection , culture independent-testing has also led to increased detection of norovirus: this supports recommendations to limit antibiotic use for the treatment of TD.

When to use antibiotics for TD?

A cluster of articles looks into the efficacy and safety of Rifamycin SV-MMX® in treating TD; more broadly, several papers examine the scenarios for the appropriate use of antibiotics. Widespread antibiotic use predisposes travellers to acquire and import multidrug-resistant intestinal bacteria: cutting back on unnecessary antibiotics is fundamental to help mitigate the global threat of antimicrobial resistance (AMR).

What else can be done to avoid TD?

Finally, the collection reviews current non-pharmacotherapeutic interventions – including pre- and probiotics, water purification and sanitary advice – investigating their effectiveness and consistency.

THE COLLECTION

What’s new in travellers’ diarrhoea: updates on epidemiology, diagnostics, treatment and long-term consequences  Audrey V Adler, Hailee R Ciccotti,  Spencer J H Trivitt, et al. Journal of Travel Medicine , taab099, https://doi.org/10.1093/jtm/taab099 . Published: 06 July 2021

Guidelines for the prevention and treatment of travelers’ diarrhea: a graded expert panel report  Mark S. Riddle, Bradley A. Connor, Nicholas J. Beeching, et al. Journal of Travel Medicine , Volume 24, Issue suppl_1, April 2017, Pages S63–S80, https://doi.org/10.1093/jtm/tax026

TaqMan Array Card testing of participant-collected stool smears to determine the pathogen-specific epidemiology of travellers’ diarrhoea Michele D Tisdale,  David R Tribble, Indrani Mitra, et al. Journal of Travel Medicine , taab138, https://doi.org/10.1093/jtm/taab138 . Published: 07 September 2021

Use of a multiplex DNA extraction PCR in the identification of pathogens in travelers’ diarrhea  Bradley A Connor,  Marina Rogova, Olga Whyte, Journal of Travel Medicine , Volume 25, Issue 1, 2018, tax087, https://doi.org/10.1093/jtm/tax087 . 

Etiology of travellers’ diarrhea  Z.D. Jiang, H.L. DuPont Journal of Travel Medicine , Volume 24, Issue suppl_1, April 2017, Pages S13–S16,  https://doi.org/10.1093/jtm/tax003

Norovirus as a frequent cause of traveller’s diarrhoea  Eyal Leshem Journal of Travel Medicine , Volume 26, Issue 8, 2019, tay159, https://doi.org/10.1093/jtm/tay159

Treatment strategies for nitroimidazole-refractory giardiasis: a systematic review  Daniel L Bourque, Andreas Neumayr, Michael Libman, Lin H Chen Journal of Travel Medicine, taab120, https://doi.org/10.1093/jtm/taab120 . Published: 05 August 2021

Traveler’s diarrhea in Nepal—changes in etiology and antimicrobial resistance  Holly Murphy,  Ladaporn Bodhidatta, Siriporn Sornsakrin, et al. Journal of Travel Medicine , Volume 26, Issue 8, 2019, taz054, https://doi.org/10.1093/jtm/taz054

Travel-associated multidrug-resistant organism acquisition and risk factors among US military personnel  Gregory Buchek, Katrin Mende, Kalyani Telu, et al. Journal of Travel Medicine , Volume 28, Issue 3, April 2021, taab028, https://doi.org/10.1093/jtm/taab028

Risk factors for acquisition of multidrug-resistant Enterobacterales among international travellers: a synthesis of cumulative evidence  Luis Furuya-Kanamori, Jennifer Stone, Laith Yakob, et al. Journal of Travel Medicine , Volume 27, Issue 1, January 2020, taz083, https://doi.org/10.1093/jtm/taz083

Rifamycin SV-MMX® for treatment of travellers’ diarrhea: equally effective as ciprofloxacin and not associated with the acquisition of multi-drug resistant bacteria  Robert Steffen, Zhi-Dong Jiang, Mónica L Gracias Garcia, et al. Journal of Travel Medicine , Volume 25, Issue 1, 2018, tay116, https://doi.org/10.1093/jtm/tay116

Antibiotics for Travellers’ Diarrhoea on Trial—is there a potential role for Rifamycin SV?  Mark S Riddle, Patrick Connor, David R Tribble Journal of Travel Medicine , Volume 26, Issue 1, 2019, tay137, https://doi.org/10.1093/jtm/tay137

When should travel medicine practitioners prescribe Rifamycin SV-MXX for self-treatment of travellers’ diarrhoea?  Charles D Ericsson, Bradley A Connor,  Mark S Riddle Journal of Travel Medicine , Volume 26, Issue 3, 2019, taz013, https://doi.org/10.1093/jtm/taz013

Rifamycin SV-MMX® as the recommended self-treatment for moderate to severe travellers’ diarrhoea: reply  Robert Steffen, Herbert L DuPont Journal of Travel Medicine , Volume 26, Issue 3, 2019, taz014, https://doi.org/10.1093/jtm/taz014

Revisiting travellers’ diarrhoea justifying antibiotic treatment: prospective study  K A Turunen, A Kantele Journal of Travel Medicine , Volume 28, Issue 3, April 2021, taaa237, https://doi.org/10.1093/jtm/taaa237

Extended-spectrum beta-lactamase-producing strains among diarrhoeagenic Escherichia coli—prospective traveller study with literature review  Anu Kantele, MD PhD, Tinja Lääveri, MD PhD Journal of Travel Medicine , taab042, https://doi.org/10.1093/jtm/taab042

Non-pharmacotherapeutic interventions in travellers diarrhoea (TD)  Derek P Evans Journal of Travel Medicine , Volume 25, Issue suppl_1, May 2018, Pages S38–S45, https://doi.org/10.1093/jtm/tay013  

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• Patient Care & Health Information
• Diseases & Conditions
• 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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• Pharmacy (Basel)

A Review of Guidelines/Guidance from Various Countries Around the World for the Prevention and Management of Travellers’ Diarrhoea: A Pharmacist’s Perspective

International travel is growing and pharmacists are well placed to provide travel health services for the prevention and management of travellers’ diarrhoea (TD). Legislation changes in many countries has enabled pharmacists to access prescription only medicines and vaccinations to provide advice and over the counter medicines for the prevention and management for travel health services; this makes sense since pharmacies are easily accessible to the public and are the patient’s first port of call in the event of any illness. Currently, whilst many guidelines/guidance exist worldwide for the prevention and management of TD, there is no review that focuses on similarities and differences between these and between guidelines on TD and travel related and non-travel related acute diarrhoea. There is also a lack of publication on legislation and the need for evidence based training for all prescribers to provide travel health services. The aims of this work were to review guidelines/guidance for the prevention and management of TD from across the world which were compared with each other as were the TD guidelines compared to that for travel related and non-travel related acute diarrhoea for similarities and differences, with a focus on any relevant pharmacy legislation, needs assessments and training that may impact upon provision of travel health services by pharmacists focusing mainly on TD in adults. The PubMed, Google Scholar and Cochrane database were used to carry out an online search for publications on TD, acute diarrhoea and the guidance pharmacists have in the prevention and management of diarrhoea. The literature reviewed in this article indicates that where no specific guidelines/guidance existed, some pharmacists used the WHO guidelines (WHO), highlighting a need for local, regional and national evidence based guidelines in these countries.

1. Introduction

International travel has increased due to cheaper air fares making some of most seemingly inaccessible countries in the world to be reached relatively easily. In 2016, there were estimated to have been 58.2 million international tourists to Africa, 53.6 million to The Middle East, 302.9 million to Asia and Pacific, 200.9 million to the Americas and 619.7 million to Europe. Around 820.6 million tourists in total were estimated to have visited Europe and the Americas, and 414.7 million estimated tourists visited Africa and the Middle East [ 1 ]. According to the WorldAtlas website [ 2 ], the United States, China, Mexico and Thailand are the 3rd, 4th, 6th and 10 th respectively, most frequently visited countries by tourists all over the world outside of Europe. A survey by Geo-Sentinel data from 2007–2011 [ 3 ] from its 53 clinical sites in 24 countries (North America, Europe, Australasia, Latin America, Southern Africa and the Middle East) showed that the most frequent health hazards encountered by travellers included gastrointestinal and febrile systemic illness, and dermatologic diseases. Respiratory and ear–nose–throat was also identified amongst common infections acquired in a surveillance analysis undertaken in returning travellers in France from 2003 to 2015 [ 4 ]. In a study by Hill on factors that may affect the onset of TD in 784 American travellers who were provided with pre-travel advice, 46% reported having some form of diarrhoea of which 34% had TD [ 5 ]. TD is usually an acute, normally self-limiting condition which is rarely life threatening; however, it does affect the enjoyment of a holiday. According to the most recent guidelines by Riddle et al. [ 6 ] the stages of TD are defined as follows:

• “Mild (acute): Diarrhoea that is tolerable, is not distressing, and does not interfere with planned activities.
• Moderate (acute): Diarrhoea that is distressing or interferes with planned activities.
• Severe (acute): Diarrhoea that is incapacitating or completely prevents planned activities; all dysentery (passage of grossly bloody stools) is considered severe; persistent: close space diarrhoea lasting two weeks”.

Table 1 shows the current guidelines/guidance that exist globally for the prevention and management of TD and acute diarrhoea [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ].

Guidelines or guidance from various countries for the prevention and management of TD.

Causes of TD can be bacterial, viral or parasitic. Bacterial TD is caused by Escherichia coli including strains of enterotoxigenic (ETEC) and enteroaggregative (EAEC) E. coli . [ 3 , 4 , 29 , 30 , 31 , 32 ] Campylobacter, Salmonella and Shigella , norovirus, astrovirus, Giardia and Cryptosporidium can all also cause TD with the former three microorganisms being the usual causes for TD along with EAEC [ 3 , 4 , 29 , 30 , 31 , 32 ]. Less common causes of TD include non-cholerae vibrios, Aeromonas species, and Plesiomonas species [ 8 ]. Travellers visiting Latin America also can have norovirus induced TD. Other TD causing viruses include astrovirus, rotavirus and adenovirus. Common parasitic infections that cause TD in travellers to Latin America and SouthEast Asia may be caused by Giardia , Cryptosporidium and Entamoeba species [ 3 , 8 ]. Chronic diarrhoea is usually caused by parasites in travellers on long term visits to developing countries. Cryptosporidium parvum with reported cryptosporidiosis TD has been reported in travellers to Russia [ 33 ]. A less common cause of TD is Cyclospora cayetanensis in travellers from Peru and Nepal [ 34 ].

Risk factors include destination, dietary habits, quality of local sanitation, age with younger adults and children who tend to be at higher risk [ 35 ] and the traveller’s susceptibility to infection [ 36 ] as well as patient factors such as altered upper gastrointestinal anatomy and the use of proton pump inhibitors or H 2 receptor antagonists [ 9 ]. It was also interesting to observe that a study carried out on gender differences in travel-associated disease on data from the GeoSentinel network’s 44 sites which included 58,908 travellers, of which 50.3% were female and 49.7% were male, showed that female travellers were more likely to suffer from acute and chronic diarrhoea compared to men [ 37 ].

The risk and the causative organism of TD is highly associated with the travel destination as follows:

• (a) low risk (North America, Western Europe, Japan, Australia and New Zealand);
• (b) intermediate risk destinations include Russia, China, Eastern Europe, The Caribbean and South Africa;
• (c) high risk destinations which include South and SouthEast Asia, Central America, most African countries, South America, Eastern Europe, and some Caribbean islands [ 10 ]. South and SouthEast Asia, Central America and West and North Africa are regions with particularly high risk of TD [ 8 , 10 ].

Haemolytic uraemic syndrome is a complication of TD caused by shiga toxin. Other complications of TD include Campylobacter induced Guillain Barré syndrome and in severe cases of TD, there is the potential for post-infectious arthropathies [ 38 , 39 , 40 , 41 , 42 , 43 ]. Protozoal infections caused by Giardia can also result in associated weight loss [ 43 ]. Another complication of post TD is irritable bowel syndrome (IBS) where studies have shown that up to 30% of the travellers experience IBS following TD [ 42 , 43 ].

2. Literature Review

The search terms used were travellers’ diarrhoea (UK and USA spelling); guidelines; pharmacists; acute diarrhoea (UK and USA spelling); treatment; prevention; management; travel health; services; ( Figure 1 on Flow chart). The PubMed, Google Scholar and Cochrane database were searched for articles relating to the terms above from 1980 to 2019. Any article which did not include the term TD was excluded from the search as were the formal guidelines from the National Institute of Health and Care Excellence, Public Health England, The British National Formulary and the Health Protection Agency which the author was already aware of and included in this review. Any article which included the term ‘acute diarrhoea’ in the context of TD, only, was included, and this meant articles on diarrhoea caused by conditions such as ulcerative colitis, Crohn’s disease, irritable bowel syndrome (IBS), lactose intolerance, diabetes and pancreatitis were excluded. Articles relating to age-specific disorder causing chronic diarrhoea in children, or malnourishment related diarrhoea, mental health issues such as stress or anxiety and side effects of medicines such as cancer chemotherapy related causes of diarrhoea were all excluded from this review. Additionally, excluded from this search was any article not published in English but if a corresponding abstract was available in English this was included.

Flowchart showing search methodology.

3. Review and Comparison of Guidelines/Guidance on Prevention and Management of TD Worldwide

Table 1 shows the guidelines/guidance for the prevention and management of TD. The most recent guideline for the prevention and management of TD is set by The International Society of Travel Medicine (ISTM) [ 6 ].

Table 1 also shows the Australian [ 11 , 12 ] and Canadian guidelines [ 13 ] for the prevention and management of TD. The differences between various guidelines lie in recommendations on the use of prophylactic antibiotics. For example, The Public Health England Antibiotic Guidance for Primary Care states that stand-by antimicrobials are indicated only for patients at risk of developing severe illness on a visit to high risk areas with a rare need for prophylactic antibiotics [ 14 ]. The American College of Gastroenterology (ACG) and the ISTM evidence based guidelines state that empirical use of antibiotics should be limited in the event of TD being of bacterial origin and the use of antibiotics should be dependent upon travel region and signs and symptoms of diarrhoea [ 7 ]. The National Institute for Health and Clinical Excellence’s (NICE) Clinical Knowledge Summaries ( CKS ) guidelines argue that travellers are not able to distinguish between bloody or non-bloody (non-invasive) diarrhoea, and as such, do not recommend the use of rifaximin but advocate the use of a fluoroquinolone such as ciprofloxacin to treat invasive diarrhoea [ 15 ]. Pharmacists also need to be aware of changes in antibiotic resistance patterns locally and look for evidence-based information when referring to any local or national guidelines.

The Australian evidence-based guidelines prepared by the Royal Australian College of General Practitioners (RACGP) recommend using oral rehydration salts to prevent dehydration followed by an antimotility agent, such as loperamide, which is preferred over the diphenoxylate/atropine (Lomotil ® ) combination due to its potential adverse effects profile [ 11 ]. These guidelines also recommend ciprofloxacin 500 mg or norfloxacin 400 mg as a single dose therapy or azithromycin 500 mg or 1000 mg as a single dose for the treatment of TD. An alternative treatment regimen includes a three day treatment of ciprofloxacin 500 mg or norfloxacin 400 mg every 12 h and azithromycin 500 mg once daily for three days in the event of infection with Campylobacter and Shigella dysenteriae where a single dose may not prove adequate. These guidelines also advise to stop taking any further antibiotics should TD resolve. It is interesting to note that this advice differs from the usual advice to complete a course of antibiotics and advises to keep the rest of the antibiotics for further treatment should TD reoccur. The RAGCP guidelines [ 11 ] do not advocate the use of routine antibiotic prophylaxis, but recommends the use of short courses of antibiotics for travellers at very high risk of developing infection and does not advocate the prophylactic use of rifaximin. Whilst this review has focused mainly on adults, it would be prudent for all healthcare professionals to be aware that the guidance for the use of antimotility agents differs for children in different countries. In the UK, children under 12 years [ 16 ] and in the USA children under two years [ 10 ] should not be treated with loperamide. Whilst the Australian guidelines indicate children under 12 years should not be given loperamide, many Australian doctors prescribe loperamide for children aged six years or older if required [ 11 ]. It is important to bear in mind that loperamide doses are different and vary according to the country’s licensing requirements. Pharmacists should consult latest online and/or reliable resources to verify the exact dose and frequency.

The Australian guidelines also recommend empirical self-treatment with tinidazole dose of 2 g (4 × 500 mg tablets) stat against Giardia intestinalis in travellers going on longer trips of 2–3 weeks. The directions for taking tinidazole are to take it after following a three day course of either fluoroquinolone or azithromycin antibiotic therapy, indicating a possible infection by the Giardia parasite if the duration of TD has been longer than 72 h. In the event of bloody diarrhoea and fever for 48 h, seeking medical guidance is recommended [ 12 ]. However, not all countries have specific guidelines on TD. Added to this, there is not much literature published on the management of TD or acute diarrhoea by pharmacists as stated previously in the literature review section.

4. A Review of Guidelines for the Prevention and Management Between Travellers’ Diarrhoea (TD) and Non-Travel Related and Travel Related Acute Diarrhoea

The authors who developed the guidelines for the prevention and management of TD have also developed the American College of Gastroenterology (ACG) clinical guideline on diagnosis, treatment, and prevention of non-travel related and travel related acute diarrheal infections in adults. Both guidelines bear some similarities in the management of travel related diarrhoea; however, they also indicate some therapeutic differences. The definition of TD [ 6 ] departs from the more traditional definition of TD as the authors feel that this system of definition is suitable towards a more tailored therapy for the prevention and management TD; whereas the definition for AD whether it is travel related or non-travel related describes it as a ‘passage of ≥3 unformed stools in 24 h plus an enteric symptom (nausea, vomiting, abdominal pain/cramps, tenesmus, fecal urgency, moderate to severe flatulence)” [ 7 ] p. 603. For the management of mild watery AD the ACG [ 7 ] recommends hydration through fluid and salt intake for all types of diarrhoea; the guidelines state that loperamide dose of 4 mg may be used initially to control stooling (maximum dose of 8 mg over 24 h period) whereas the ISTM [ 6 ] recommends use of rehydration with use of loperamide for the treatment of mild TD of 4 mg po then 2 mg after each loose stool not to exceed 16 mg daily alongside with hydration. (This dose and frequency is also similar to that recommended in other guidelines [ 12 , 16 ]. The ACG [ 7 ] also recommends loperamide (but not to be taken for more than 48 h) for the management of moderate to severe watery non-travel related diarrhoea, with low or no grade fever of <100°F (37.78 °C) diarrhoea. For moderate to severe watery non-travel related diarrhoea where fever is present for <3 days duration at >101°F (38.3 °C), loperamide is recommended but not to be taken for more than 48 h [ 7 ]. The ACG [ 7 ] also recommends that in moderate to severe watery non-travel related diarrhoea where fever is present for >3 days duration at >101°F (38.3 °C), microbiological assessment, and empirical therapy of azithromycin should be to be taken as 1 g in a single dose OR 500 mg once daily for three days. For the management of moderate to severe watery TD: ACG guidelines recommend a course of antibiotics. The ISTM guidelines recommend the use of loperamide as a monotherapy for moderate TD [ 6 ]. Both guidelines [ 6 , 7 ] recommend the use of bismuth subsalicylate (BSS) with the ACG guidelines stating the following dose for BSS in the treatment of mild to moderate AD: 30 mL (525 mg) of liquid formulation or two tablets (263 mg per tablet) chewed each 30–60 min maximum of eight doses in 24 h for prophylaxis, the ACG states that BSS can be given for a maximum of up to three weeks with a dose of two tablets four times a day at mealtimes and at bedtime for TD prevention according to ref by DuPont et al. [ 44 , 45 ]. ACG guidelines do not recommend empiric antimicrobial therapy for non-travel related AD and discourages the use of antibiotics in community acquired diarrhoea. Likewise, the ISTM guidelines do not recommend the routine use of antimicrobial prophylaxis and advocates antimicrobial prophylaxis only in high risk of groups at health-related complications of TD; rifaximin is recommended as a prophylactic agent and fluoroquinolones are not recommended for prophylaxis due to concerns over antibiotic resistance and associated adverse effects. ISTM [ 6 ] states caution against the use of fluoroquinolones in regions with high quinolone resistance and in SouthEast Asia, India or regions where fluoroquinolone-resistant Campylobacter or resistant ETEC has been identified; it also advises against the use of rifaximin in the event of invasive TD or in regions where this may be anticipated. Both guidelines recommend the use of antibiotics combined with loperamide for the management of moderate to severe diarrhoea. Whilst the ACG recommends a balanced ORS and medical evaluation in TD for the elderly in severe TD, the ISTM guidelines recommend the use of azithromycin to treat severe TD; fluoroquinolones to treat severe, non-dysenteric travelers’ diarrhoea and rifaximin to treat severe, non-dysenteric TD for the managment of dysenteric diarrhoea, both guidelines recommend the use of azithromycin 1 g in a single dose OR 500 mg once daily for three days [ 6 , 7 ]. Additionally, both guidelines advocate in cases of persistent diarrhoea (14–30 days), culture and/or culture-independent microbiologic assessment followed by treatment with antimicrobial agent directed to causal microorganism.

5. Antibiotics, Vaccines, and OTC Medicines for Prevention and Management of TD

Antibiotics and vaccines.

Antimicrobial resistance is a worldwide problem. A recent study found that prescribing of stand by antibiotics led to travellers taking these even when TD was not severe [ 46 ]. This has the potential for travellers to become colonized by multidrug-resistant (MDR) intestinal extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) [ 47 ] as well as shedding these bacteria on their return, and encouraging the spread of MDR bacteria in the community [ 47 , 48 , 49 , 50 ]. Enterotoxigenic E. coli that produce a heat labile (LT) or heat stable (STa) toxin are the most common species of E. coli implicated and the most prevalent cause of TD [ 51 ]. Either one or both strains of toxins have been isolated from patients with TD, depending upon which country they have visited [ 52 ]. Contaminated food and beverages are common sources of ETEC associated TD and currently the oral cholera vaccine, Dukoral ® [ 53 ] for protecting travellers against ETEC diarrhoea is available in the UK and Canada [ 13 ] for travellers if required. Although in the UK, whilst Dukoral is indicated for active immunisation in adults and children from two years of age travelling to or in cholera endemic areas against Vibrio cholerae serogroup O1, the indication does not specifically state it has a routine use in prevention of TD [ 53 ]. Research has shown that more data is needed to show its protective role in TD prophylaxis [ 54 ]. Similarly, a Cochrane review showed similar results of insufficient evidence from RCTs on the prophylaxis use of Dukoral for ETEC diarhhoea [ 51 ]. In the US, for adults aged 18–64 years who are travelling to an area of active toxigenic Vibrio cholerae O1 transmission the Vaxchora™ [ 55 ] single-dose oral cholera vaccine is recommended. This vaccine is approved by the US Food and Drug Administration.

Other MDR bacteria include Enterotoxigenic Bacteroides fragilis (ETBF) [ 56 , 57 , 58 , 59 ] and Campylobacter jejuni [ 60 , 61 , 62 , 63 ] are both enteric pathogen associated with TD. The reader is directed to a review by Hitch and Fleming [ 64 ] for an overview on antimicrobial resistance in TD.

The guidelines discussed in this paper, and listed in Table 1 , recommend the use of azithromycin for the treatment of dysentery or bloody diarrhoea or against other bacterial infections, for regions where fluoroquinolone resistance to Campylobacter has been documented. The Public Health England Antimicrobial Prescribing Guidance [ 14 ] and NICE’s CKS [ 15 ] guidelines recommend the use of azithromycin in countries such as South and SouthEast Asia and in regions where there is known resistance to fluoroquinolones for preventative measures, and either ciprofloxacin (in regions other than where resistance to the drug is noted) or azithromycin only for the treatment of severe TD. All the guidelines recommend the use of azithromycin, which has a documented evidence base in areas where resistance to fluoroquinolones is prevalent and there is a high risk of invasive pathogens. Azithromycin is considered safe for use in pregnant women and young children for the treatment of severe TD. If during pregnancy or breast-feeding, treatment is required for acute diarrhoea, azithromycin or the less effective clarithromycin are recommended and for the treatment of TD caused by giardiasis, or amoebiasis, and metronidazole is recommended in preference to tinidazole [ 9 ].

Despite standard TD treatment, travellers on longer trips of more than two weeks, would benefit from metronidazole or tinidazole for treating noninvasive TD suspected to be caused by Giardia intestinalis or E. histolytica infection [ 65 ]. It would be prudent to seek medical confirmation of the cause of the TD only to rule out diarrhoea of non-infectious aetiology.

The FitforTravel, Health Protection Scotland’s guidelines, recommend rifaximin as a prophylactic antibiotic for at risk group of patients and either azithromycin, ciprofloxacin or rifaximin as a stand by treatment for severe diarrhoea [ 20 ]. Rifaximin is a non-systemic structural analogue of rifampin which inhibits the synthesis of bacterial RNA by binding to the b subunit of bacterial DNA dependent RNA polymerase. NICE’s CKS does not advocate the use of rifaximin for the treatment of severe TD [ 15 ]. The rationale behind this is that their guidelines are evidence based on several references [ 8 , 9 , 13 ]. Dupont’s study [ 66 ] states that as a chemoprophylactic for TD for trips ≤14 d, whilst rifaximin is safe as it is not absorbed, it is only moderately effective and literature review and research articles have shown that the efficacy of rifaximin is uncertain on invasive forms of TD caused by Campylobacter or Salmonella . In addition, some studies have shown that as a chemotherapy for TD, rifaximin is ineffective against mucosal invasive pathogens ( Shigella, Salmonella and Campylobacter ) [ 67 , 68 , 69 , 70 ]. However, rifaximin is approved for the treatment of TD caused by noninvasive enteric pathogens or E. coli infections in many countries worldwide [ 71 ]. Rifaximin is also not recommended as a prophylactic agent by the Australian guidelines [ 11 , 12 ]. The ISTM guidelines also present a weak recommendation with a moderate level of evidence, on the use of rifaximin for the treatment and prevention of TD [ 6 ]. A fluoroquinolone, azithromycin or rifaximin should be used for all other regions, and azithromycin should also be prescribed in the case of bloody diarrhoea. Prescribing of fluoroquinolones is recommended by all the guidelines in Table 1 for prophylactic measures for TD, except FitforTravel [ 20 ] (recommends rifaximin), Public Health England Antimicrobial Prescribing Guidance [ 14 ] (recommends azithromycin) and ISTM guidelines [ 6 ] (recommends rifaximin and azithromycin). The Sanford Guide recommends azithromycin 1 g once with loperamide on the onset of the first loose stool. For those with HIV and CD4 <200, going on short trips, it recommends ciprofloxacin 500 mg once daily or rifaximin 200 mg taken orally twice daily [ 28 ]. Articles reviewed here also show that pharmacists tended to refer to the International Travel and Health from the World Health Organization (WHO) website for Travel and Health guidelines [ 72 ] for the management of acute diarrhoea. For example, a study carried out in Trinidad using a simulated case study presentation of a patient with acute diarrhoea in community pharmacy with 92 pharmacists, showed 70% (n = 64) of pharmacists recommended ORS as a first choice therapy in children [ 73 ]. Over 60% recommended antimotility agents as a first choice of therapy or with ORS for adults and over 59% recommended co-trimoxazole for adults. Whilst the majority of pharmacists would provide information on constitution, preparation, storage and treatment schedule on ORS, few provided information on the discontinuation of ORS. Only 23 pharmacists adhered to the WHO guidelines [ 72 ] although the majority were aware of the existence of these guidelines. Another study aimed to assess travel health practices among community pharmacists in Malaysia and the relation to the quality of travel health services offered showed that out of the 111 respondents from 143 pharmacists to whom questionnaires were sent, 46% answered the only question on TD: “Ciprofloxacin can be used as self-treatment for travellers’ diarrhoea in Thailand” correctly as false, (p. 329) [ 74 ]. This study explored other broader topics on travel health services and so does not give a true picture of knowledge that Malaysian pharmacists may have in the field of TD. Their most widely used resource for travel health information however, was the WHO guidelines. South African pharmacists also have access to a wide variety of resources and guidelines such as Travax and the Centers for Disease Control and Prevention (CDC) website and WHO guidelines if they are a member of South African Society of Travel Medicine [ 75 , 76 , 77 , 78 ]. In another study in the USA, pre-travel services provided by pharmacists were compared to that provided by primary care physicians not trained in travel health medicine initially used the CDC guidelines and where these were unclear, referred to the WHO guidelines and Travax Encompass as secondary sources [ 79 ].

6. Updated Guidance on Use of Fluoroquinolone and Quinolone Antibiotics

Fluoroquinolones and quinolones are broad-spectrum antibiotics used to treat various infections. Ciprofloxacin is widely recommended by many guidelines ( Table 1 for guidelines) for regions where resistance to fluoroquinolones is not documented. However, in terms of side effects and adverse drug reactions, it should be borne in mind by the pharmacist on how and what to counsel the traveller on, if a fluoroquinolone is prescribed, especially if it is someone in a high-risk group such as immunocompromised, pregnant, children, elderly or ongoing chronic diseases such as diabetes where glucose homeostasis can be adversely affected especially in patients on oral hypoglycemic agents [ 80 ].

The European Medicines Agency (EMA) has updated its advice on the use of fluoroquinolones [ 81 ]. The EMA’s human medicines Committee for Medicinal Products for Human Use (CHMP), recently endorsed the review of EMA’s safety committee Pharmacovigilance Risk Assessment Committee (PRAC) on restricting the use of these medicines for preventing TD. The review covered medicines containing the following fluoroquinolone and quinolone antibiotics such as ciprofloxacin, levofloxacin, moxifloxacin, nalidixic acid, norfloxacin and ofloxacin amongst others.

The CHMP has advised special caution in the elderly, patients with renal disease and organ transplantation due to being at higher risk of tendon injury. They also advise against the combined use of fluoroquinolones with corticosteroids as this increases risk tendon injury. Additionally, the British National Formulary (BNF) states that some common side effects can include a decrease in appetite, arthralgia, constipation, diarrhoea, eye disorders, gastrointestinal discomfort and QT interval prolongation to name a few. Other adverse effects can include Achilles tendon damage or Clostridium difficile infection.

There is also an increased risk of aortic aneurysm and aortic dissection in the elderly or in those at-risk and ligament rupture peripheral neuropathy, rhabdomyolysis and self-endangering behaviour [ 82 , 83 ]. The incidence or frequency of these side effects is unknown. However, the BNF [ 31 ] also recommends discontinuation in the event of psychiatric, neurological, or hypersensitivity reactions as well as if a severe rash occurs. Fluoroquinolones tends to upregulate cell matrix metalloproteinases and this causes types I and III collagen fibrils to be reduced. These collagen types are major components of the majority of collagen in both Achilles tendons and the aorta. This maybe a possible way by which the ruptures may be occurring [ 84 ]. Collagen also serves as a critical component of the vitreous body of the eye and in maintaining retinal attachment, but whether fluoroquinolones mediate retinal detachment is controversial even though eye disorders are listed as a side effect in the BNF [ 16 ].

OTC Medicines

Severe dehydration with loss of fluids and electrolytes are lost during TD. This may also be accompanied by vomiting and its vital to replace the lost fluids. Pharmacists should advise travellers to drink lots of clear fluids, fruit juice or thin soups to maintain water and electrolyte balance. For at risk groups, in the children and the elderly, Oral Rehydration Therapy or Solution (ORT or ORS) is recommended to prevent complications from dehydration. Pharmacists should advise travellers on how to make their own ORS should none be available, by mixing six teaspoons of sugar and half a teaspoon of salt to one litre of clean water or lightly salted rice water, the recipe for which can be obtained from the WHO position paper on ORS [ 85 ] to reduce mortality from cholera. In the UK, ORS is available from pharmacies without a prescription as Dioralyte™ and Dioralyte Relief™ which contains pre-cooked rice powder, sodium citrate, sodium chloride, potassium chloride and the rice element helps the watery stools to return to normal and is used for rehydration and restoring electrolytes in TD [ 86 ]. Pharmacists should also make travellers aware of some ORS preparations that may contain a source of phenylalanine (aspartame) which may be harmful to people phenylketonuria. Some preparations contain ethanol (alcohol) which may be harmful to people with a drink problem, in pregnancy, breast-feeding or to children, or in conditions such as liver disease or epilepsy [ 86 ]. Pharmacists should also advise fully on the preparation of ORS and emphasize where drinking water is not available, the water should be freshly boiled and cooled and the solution should be made up immediately before use.

Loperamide has an antisecretory effect in low doses, that reduces the volume of watery stool. At higher doses, there is an additional antimotility effect. Evidence base for using loperamide suggests that it can reduce the duration and severity of TD [ 87 ]. Loperamide may be used if no red flag symptoms are identified in uncomplicated cases of TD ( Table 2 ). It takes up to 1–2 h to work and cannot be given to children under four years old [ 16 ]. As stated previously, the doses for loperamide vary according to the licensing requirements for different countries. Pharmacists should be aware of this and make the traveller aware of this too depending upon the region of travel. Loperamide combined with simethicone is also available as Imodium Plus Caplets ® and Imodium Plus Comfort Tablets ® in the UK for painful wind and bloating with diarrhoea. A maximum dose of eight tablets or capsules can be taken over a 24 h period according to the UK licensing requirements. There are products one can buy from a pharmacy to help with wind, such as charcoal tablets or simethicone. A product that contains both loperamide and simethicone is available (Imodium Multi-Symptom Relief ® ) for added relief of wind. Loperamide can also be taken with antibiotics in the event of treatment of severe diarrhoea [ 88 , 89 , 90 ].

‘Red flag’ symptoms for doctor’s referral.

Other antimotility or antidiarrhoeal agents include diphenoxylate plus atropine (Lomotil ® ), and bismuth subsalicylate (BSS) (Kaopectate ® available in the USA, Pepto-Bismol ® available both in the UK and USA). BSS may cause darkening or blackening of the faeces and tongue along with constipation and possibly tinnitus. It should be avoided in people with allergy to aspirin, and in patients with renal insufficiency, gout, and by those on anticoagulants, probenecid, and methotrexate. BSS may enhance the effect of coumarin anticoagulants and oral hypoglycaemics of the sulphonylurea type. Salicylates also diminish the action of uricosurics [ 13 , 45 , 91 ]. Overdosing with aspirin or salicylates concomitant with the use of BSS may result in salicylate toxicity. BSS is not generally recommended for children aged <12 years in the USA and under 16 years in the UK [ 9 , 45 , 91 ].

The NICE-BNF guidance for children over three months and adults in the UK has listed racecadotril, which is an antisecretory drug licensed for the treatment of acute diarrhoea [ 92 ]. As no rigorous evidence-based clinical trials have emerged for the use of this drug in TD, it has been excluded from most guidelines on the prevention and management of TD. It is available on prescription only in the UK, and has been licensed for use in Europe, mainly in France for over 20 years and is recommended in the Consensus paper for the treatment of acute traveler’s diarrhoea and for the management of acute uncomplicated TD in children [ 19 ].

7. Aims of a Pre-Travel Consultation

The World Tourism Organization (UNWTO) is a specialized agency of the United Nations and data for 2018 showed that the number of tourists worldwide had risen by 6% in 2018 to 1.4 billion [ 93 ]. Using this data and given that the incidence for TD varies by destination, ranging between 10% and 40% [ 93 ], for travellers going to risk regions, between 140 million to 560 million cases of TD are likely to have occurred in 2018. Hence, it is vital for travellers to seek some form of travel health advice before travelling. The aims of the pre-travel consultation as stated by Hatz and Chen [ 94 ] should be based upon (1) the client’s fitness assessment for travel, and the type of travel (2) anticipated and real health risks and (3) subsequent prophylaxis measures to be taken. Historically, doctors and nurses have provided pre-travel consultation services as it was only these professions that were allowed to administer vaccinations [ 95 ]. However, over the last two decades, pharmacists have begun to provide these services as observed in many published articles on travel health services [ 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 ].

Many pharmacists also have access to guidelines as listed in Table 1 from various sources on the management of TD and acute diarrhoea. Whilst the aims of the treatment for AD is to prevent or reversal fluid and electrolyte depletion with the management of dehydration [ 16 ], in any patient group, the treatment should be tailored according to the severity of the symptoms.

8. Pharmacists’ Role in Prevention and Management of TD

Pharmacists are well placed and trained to provide advice, counselling and information on the side effects on taking antibiotics for the prophylaxis and treatment of TD. One of the most basic but extremely vital factors to consider is the extent in which travel risk assessment is carried out by the pharmacist, the current knowledge on the over the counter (OTC) medicines available for prevention and management of TD, as well as updates on guidelines as to where the traveller may be going. In terms of drug interactions, pharmacists should advise travellers if taking loperamide with or without simeticone, high doses of loperamide may cause serious cardiac adverse reactions such as QT prolongation, torsades de pointes, and cardiac arrest [ 12 ]. Pharmacists should be aware of the above drug interactions and the potential for constipation if used in conjunction with anticholinergics antispasmodics potent narcotic pain medicines, antihistamines, tricyclic antidepressants, cholestyramine, and antivirals [ 16 ].

Pharmacists should be vigilant about all OTC or POM products offered to the traveller since some may contain antacids or digestive medications and some combination products may also contain simethicone. Simethicone can also decrease the absorption of thyroid medications e.g., levothyroxine and pharmacists should advise travellers to leave at least 4 h between taking products that contain simethicone when taking thyroid medication [ 16 ].

Pharmacists should be aware and educate the traveller on any current medications they may be taking which can cause diarrhoea may also be a side effect of that medicine. For example, some antibiotics, any antacids that contain magnesium, some chemotherapy medicines, and non-steroidal anti-inflammatory drugs, statins and laxatives can all cause diarrhoea [ 16 ].

The main goal is to prevent dehydration via the adequate rehydration and supply of appropriate OTC medicines for symptomatic relief. Therefore, it is important for the pharmacist to be aware of signs and symptoms of TD and a good knowledge of what OTC products are available and how to use these along with raising awareness and providing appropriate counselling for the prevention and management of TD. In the case of the immunocompromised, pregnant, elderly or children who are regarded as ‘at risk’, the pharmacist should provide information ‘tailored’ to the traveller’s needs. If antibiotics are prescribed, counselling should be provided on potential drug interactions, taking adequate amounts of medication in order not to run out at the destination, educate the traveller on signs and symptoms of invasive diarrhoea and when to refer for medical care. Pharmacists should also educate the traveller on the awareness of ‘Red Flag’ symptoms in the event of being affected by TD ( Table 2 ).

9. Advice on Best Practice

Pharmacists should educate travellers on using soap and water to cleanse hands after using the toilet and before and after preparing and eating meals. If there is lack of soap and water, then evidence has shown that alcohol-based hand sanitizers are also effective to reduce contamination on the hands. Pharmacists should advise on the use of hand rubbing gel sanitizers under the circumstances [ 105 , 106 ]. Advice on food and beverage consumption, storage, preparation and foods to avoid should also be provided. Whilst purified water is considered safe to drink, ice cubes made from local water is not safe to have in drinks. Ice cream and dairy products are also best avoided if there is no information on whether the milk has been pasteurised. Any fruits, vegetables or salads which are unclean or difficult to clean should also be avoided. Regarding the use of prebiotics and probiotics in the prevention or treatment of TD, lack of robust evidence has prevented these from being included in any of the mentioned guidelines [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ]. Advice on best practice is best delivered if pharmacists have the proper communication and consultation skills in order to extract the history of travel, current medical conditions and medications, allergies, and appropriate qualification for prescribing, and clinical training in prescribing, supplying and administration of medicines and vaccinations. During the pre-travel assessment, pharmacists should ask probing questions around the destination, duration of travel, standards of hygiene and sanitation at the place of stay. They should also explore how travellers intend to take practice and take precautions against local food, water, and personal hygiene, traveller’s own risk and assessment of TD and risk of complications, access to local medical facility and planned journeys and necessity of travel to high risk areas. There are many publications and guidelines that highlight the possibilities of acquiring TD whilst travelling from developed countries to developing countries, but a recent study on travellers who travelled to developed countries in North America, Australia, Europe and New Zealand, found that 24 out of 99 travellers (24%) had gastrointestinal related diarrhoea conditions of which 62% were Australian residents, 24% were residents of other ‘developed’ countries, and the remaining 14% were residents of other countries [ 107 ]. Travellers generally do not seek advice prior to visiting developed countries. It is therefore important that when travellers come to the pharmacist adequate advice regarding the destination or region of travel should be provided.

10. In Summary

In summary, the key findings of this review include the following:

• Guidelines/guidance were found online for the many developed countries.
• There are some differences in guidelines/guidance between the prevention and management of TD and acute diarrhoea with a single difference of a maximum dose of loperamide of 8 mg for acute diarrhoea and 16 mg for TD.

11. Conclusions

Comparison between the guidelines from various countries on the prevention and management of TD showed many similarities regarding recommendations on the use of quinolones/fluoroquinolones in regions where resistance was /is reportedly high to this class of drugs. There was some variation on the use of antibiotics as a prophylactic and as stand by medicines. There was some difference in the guidelines between the prevention and management between TD and acute diarrhoea in the case of maximum loperamide dose over a 24 h period. There is a dearth of literature specifically directed towards the role of pharmacists in the prevention and management of TD.

This research received no external funding.

Conflicts of Interest

The author declares no conflict of interest.

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.

Traveller's diarrhoea

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

Traveller's diarrhoea is a common problem among travellers, 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 travellers.

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

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

Traveller's diarrhoea (TD) is defined as ≥3 unformed stools in 24 hours accompanied by at least 1 of the following: fever, nausea, vomiting, cramps, tenesmus, or bloody stools (dysentery) during a trip abroad, typically to a low- or middle-income country. It is usually a benign self-limited illness lasting 3 to 5 days.

History and exam

Key diagnostic factors.

• presence of risk factors
• diarrhoea (with or without tenesmus), cramping, nausea, and vomiting
• dysentery (blood and fever)
• persistent diarrhoea >14 days

Other diagnostic factors

• diarrhoea without illness

Risk factors

• travel to a high-risk destination
• age <30 years
• decreased stomach acidity
• prior TD susceptibility
• chronic disease, immunocompromise
• travellers with prior residence in developing country visiting friends and relatives
• travel during hot and wet seasons

Diagnostic investigations

1st investigations to order.

• stool culture and sensitivity
• stool occult blood
• multi-pathogen molecular diagnostic (polymerase chain reaction)
• stool ova and parasite examination

Investigations to consider

• protozoal stool antigens
• Clostridium difficile stool toxin
• colonoscopy, endoscopy, and biopsy
• haematology, blood chemistries, serology

Treatment algorithm

Pre-travel prophylaxis, non-pregnant adults: mild diarrhoea, non-pregnant adults: moderate diarrhoea, non-pregnant adults: severe diarrhoea, contributors, mark riddle, md, mph&tm, drph, c trop med, certificate in travel health.

Professor and Chair

Department of Preventive Medicine & Biostatistics

Uniformed Services University of the Health Sciences

Disclosures

MR has given talks on the management of traveller's diarrhoea for the International Society of Travel Medicine (ISTM), CDC Foundation, American College of Gastroenterology (ACG), and American College of Preventive Medicine. MR has led the development of guidelines for traveller's diarrhoea for the ISTM, ACG, and the US Department of Defense. This work has been unpaid but support for travel has been accepted. MR is an author of several references cited in this topic.

Acknowledgements

Dr Mark Riddle would like to gratefully acknowledge Professor Gregory Juckett, the previous contributor to 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

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

Patient leaflets

Diarrhoea in adults

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• Enter Costa Rica
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Samara and Carrillo

The beautiful curved bay of light grey sand and gentle waters of  Playa Samara  has attracted vacationing Ticos and foreigners for years. Unlike the more hardcore  surf destinations  nearby, Samara has friendly little waves suitable for novice surfers, so a day of lessons taught by one of the locals is a must! Playa Carrillo, located just south of Samara, is one of the prettiest beaches and best kept secrets in Costa Rica. These two  gems  combine for a paradisical   off-the-beaten-path  beach destination, unlike any other in Costa Rica!

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Discover playa samara and playa carrillo: your costa rican paradise.

Welcome to Playa Samara and its enchanting neighbor, Playa Carrillo, two of Costa Rica's best-kept secrets. Nestled on the country's Pacific coast, these idyllic beach towns offer travelers a taste of authentic Costa Rican life, abundant natural beauty, and a relaxed atmosphere that embodies the famous "Pura Vida" lifestyle. Let's explore what makes Playa Samara and Playa Carrillo such exceptional destinations.

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Water Adventures: The calm waters of Samara Beach make it an excellent place for water sports. You can try your hand at kayaking, stand-up paddleboarding, windsurfing, and even snorkeling. The town's numerous operators offer scuba diving excursions and boat tours to nearby islands. Wildlife Encounters: The surrounding area is teeming with wildlife. You might spot howler monkeys, iguanas, and colorful tropical birds. To witness nesting sea turtles, visit nearby Camaronal Wildlife Refuge during the nesting season. Vibrant Local Culture: Playa Samara is a welcoming community where you can immerse yourself in Costa Rican culture. Stroll along the beachfront promenade to discover local art galleries, shops, and restaurants serving authentic cuisine. Eco-Tourism: Explore the natural wonders of the Nicoya Peninsula by taking guided hikes through tropical dry forests or embarking on horseback riding adventures. The nearby Barra Honda National Park also offers opportunities for cave exploration.

Playa Carrillo: A Hidden Paradise:

Secluded Beach Bliss: Playa Carrillo is a tranquil, horseshoe-shaped bay known for its uncrowded shores and natural beauty. With fewer tourists, it's the ideal place to unwind in serenity. Beachfront Serenity: The gentle waves and shallow waters of Carrillo Beach make it suitable for swimming and family outings. Its uncrowded ambiance makes it feel like your own private paradise. Scenic Sunsets: The sunsets at Playa Carrillo are simply breathtaking. As the sun dips below the horizon, the sky transforms into a vibrant canvas of oranges and pinks, creating a magical atmosphere. Marine Adventures: If you're a fishing enthusiast, Carrillo offers excellent opportunities for sportfishing. You can also explore the underwater world through snorkeling or scuba diving excursions.

Traveler's Tips:

Liberia Airport Access: Both Playa Samara and Playa Carrillo are easily accessible from Daniel Oduber Quirós International Airport (LIR) in Liberia. The drive takes approximately 2-2.5 hours, making it a convenient option for travelers. Weather: Costa Rica has a tropical climate with distinct wet and dry seasons. The dry season, from late November to April, is ideal for sunny beach days. The wet season, from May to November, brings occasional rain showers but lush green landscapes. September and October are the rainiest months and at times, it can rain all day. Accommodations: These beach towns offer a range of accommodations, from boutique hotels to beachfront resorts and vacation rentals. Accommodations are typically cozy and reflect the laid-back atmosphere of the region. Explore Nearby: While in the area, consider day trips to explore nearby attractions such as the vibrant town of Nicoya, the wildlife-rich Ostional Wildlife Refuge, and the beautiful Rio Ora. Pura Vida: In Playa Samara and Playa Carrillo, you'll experience the true essence of "Pura Vida." Embrace the unhurried pace, connect with friendly locals, and savor the simple joys of life. Playa Samara and Playa Carrillo invite you to experience the magic of Costa Rica's Pacific coast. Whether you're seeking adventure in the ocean, relaxation on tranquil beaches, or the warmth of local culture, these hidden gems offer a slice of paradise that will leave you enchanted with the spirit of Pura Vida. Explore, unwind, and create unforgettable memories in these coastal havens.

Planning a vacation to Samara

We recommend visiting Samara for 3 – 5 days.  As with most beach destinations, we do not recommend more days as you will likely regret missing out on other parts of the country. A 3 -5 day stay is just right mixed in with another destination or two.

As mentioned above, there are enough interesting activities for a few days stay. However, don’t forget to set aside time to visit nearby Playa Carrillo.  This is one of the most beautiful beaches in Costa Rica and only takes 5 minutes to drive from Samara.

While one can easily get around with the local cab system, it is nice to have a rental car in Samara, and especially in Carrillo. 

The Best Hotels in Samara and Carrillo

Here are some of the best hotels in Samara and Carrillo, each offering a unique experience for travelers: Azura Beach Resort (Samara): Azura Beach Resort is an adults-only, all-inclusive boutique resort located in Samara. This luxurious beachfront property is perfect for couples seeking a romantic getaway. The resort offers elegant suites with ocean, garden, or pool views, fine dining experiences, and a barefoot luxury ambiance. Guests can unwind at the spa or relax by the infinity pool while enjoying the stunning Pacific coastline. Hotel Punta Islita (South of Carrillo): Hotel Punta Islita is a beautiful eco-friendly resort located south of Samara in the remote and serene Punta Islita region. This luxury resort combines sustainability with luxury, offering guests a secluded paradise with breathtaking ocean views, a golf course, an art gallery, and various adventure activities. It's an excellent choice for those looking for a tranquil and upscale retreat. Nammbu Bungalows (Carrillo): Nammbu Bungalows is a delightful hotel in Carrillo, offering easy beach access and comfortable and well-appointed bungalows surrounded by lush tropical gardens. Guests can enjoy the beautiful Carrillo Beach, dine at the hotel's restaurant, and relax by the pool. It's an ideal choice for couples and families alike. Montelaguna Boutique Hotel (Samara): Montelaguna Boutique Hotel in Samara is known for its beautiful architecture and eco-conscious practices. Guests can stay in stylish rooms, walk 10 minutes to either Samara or Carrillo Beach, and explore the nearby attractions. The lush gardens and serene atmosphere make it a peaceful retreat. Samara Pacific Lodge (Samara): Samara Pacific Lodge is a budget-friendly option in Samara, offering comfortable rooms surrounded by nature. It's a great choice for travelers looking to explore the area without splurging on accommodation. The lodge is within walking distance of Samara Beach and the town's amenities. Samara Palm Lodge (Samara): Another budget-friendly option in Samara is Samara Palm Lodge. This cozy lodge offers a range of room types, including private cabins and dormitory-style accommodations. It's a relaxed and welcoming place for budget-conscious travelers. These hotels in Samara and Carrillo cater to a variety of preferences, whether you're seeking a luxurious and romantic escape or a more budget-friendly stay while enjoying the natural beauty and attractions of this region in Costa Rica.

The Best Restaurants in Samara and Carrillo

Gusto Beach Restaurant Pizzeria: Located right on the beach, Gusto Beach Restaurant Pizzeria is known for its relaxed atmosphere and delicious food. They serve a variety of dishes, including Italian, fresh seafood, and international cuisine. Guests can dine with their toes in the sand and enjoy beautiful ocean views.

El Lagarto Steak House & Sea Food: If you're in the mood for a hearty meal, El Lagarto Steak House & Sea Food is a great choice. This restaurant specializes in grilled meats and seafood. The menu features a selection of steaks, ribs, and fresh fish, all prepared to perfection. The rustic ambiance adds to the dining experience.

MamaGui: MamaGui is a charming restaurant in Samara known for its warm hospitality and delicious Italian foods, pasta, and pizza.

Kimbute Restaurant: Kimbute Restaurant is a hidden gem in Punta Islita, offering a unique blend of seafood, and local Costa Rican, and Caribbean flavors. The friendly staff and vibrant atmosphere make it a favorite among locals and visitors alike.

Hotel El Colibri Bar/Restaurante y Steakhouse: Located in Carrillo, Hotel El Colibri's on-site restaurant and steakhouse is a delightful place to enjoy a meal. They are known for their succulent steaks, and the menu also includes a variety of seafood, pasta, and vegetarian options. The cozy ambiance and attentive service make it a great choice for a special evening.

Locanda Playa Samara: A delightful beachfront Italian restaurant and pizzeria located in the heart of Samara and directly on the beach. This charming eatery offers a delicious barefoot dining experience as waves crash in the background.

These restaurants in Samara offer diverse culinary experiences, from beachfront dining to cozy, family-run establishments. Whether you're in the mood for seafood, steak, or international flavors, you'll find something to satisfy your taste buds in this charming beach town.

Reasons to visit

• It is an off the beaten path beach town with local flavor
• Plenty of options for unique dining, including some of the best restaurants in Costa Rica
• Good souvenir shopping
• Unlike several of the other more popular beaches in Guanacaste, Samara has not been Americanized
• Samara is a very scenic beach and nearby Playa Carrillo is unsurpassed in beauty on the Costa Rica Pacific coast
• Despite being a smaller village, there actually is a pretty good nighlife scene

Reasons NOT to visit

• There are no luxury hotels in Samara - edit - The new Azura Beach Hotel is both luxurious and highly recommended!
• As this is an off the beaten path beach, the beaches are not groomed like in areas such as Tamarindo.  This means that there are coconuts, branches and other natural debris on the beach

How to get there

From San Jose: The shortest way to get to Samara is on Autopista del Sol to Caldera and keep driving to Puntarenas. When you pass Puntarenas turn left and follow signs to the Friendship Bridge (Puente de la Amistad in Spanish). Cross the bridge and follow the road signs to Nicoya. Cross straight through town until you see signs for Samara, the paved road there is well marked.

Weather and packing list

Like all the Northwest Pacific beaches of Costa Rica, Samara enjoys a dry, tropical climate, with stable year round temperatures averaging in the upper 80s to lower 90s. Nighttime lows are usually in the upper 70s. With precipitation levels that vary throughout the year, the nicest weather in Samara is usually between the months of November and August . 

When packing for your trip , remember to include a swimsuit, flip flops, a beach towel, shorts, t-shirts, rain gear, insect repellent, sunblock and aloe vera gel to soothe and moisturize your skin after sun exposure. 

Fun Fact: The reef that protects Playa Samara is an excellent place to snorkel on the inside or surf big waves on the outside.

Driving Distance

Attractions in the area.

Latitude: N 9° 52' 58.26" Longitude: W 85° 31' 39.14"

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A Complete Guide To The Hip Beach Town of Samara, Costa Rica

If you are looking for an under the radar town to spend your time in Costa Rica in, do yourself a favour and visit Samara, Costa Rica. It is a hip beach town, the perfect size and there are so many things to do in Samara, Costa Rica that you can easily fill up your time.

I would consider Samara the little sister of Nosara. It is a bit smaller and still retains an authentic Costa Rican culture.

Samara is only 30 minutes from Nosara and it is a lot cheaper. It is also located in the Guanacaste province. It should definitely be added to your Costa Rica Travel plans.

Samara, Costa Rica crime rates are low making it super safe for families and solo travellers as well

CHECK OUT OTHER POSTS ON COSTA RICA:

• Nosara Travel Guide:   The Complete Guide to staying in Nosara
• Unique Hotel In Nicoya  : Add this jungle luxury hotel to your Costa Rica Itinerary
• Things To Do In Playa Pelada Beach: The Best Beach in Nosara
• Costa Rica Travel Agent : We Booked our entire Costa Rica Trip with The Travelogist and it was amazing

How To Get To Playa Samara Beach Costa Rica from Liberia

Samara Costa Rica is located in the province of Guanacaste in the Nicoya region. This little town can be reached by car in about 2.5 hours from Liberia International Airport. This is the easiest way to get there. The roads on this route are pretty paved and well maintained.

If you are coming from San Jose, Costa Rica the drive is about 4.5 hours.

Group or Private Shuttle

There are lots of shuttles that leave on the daily from Liberia Airport to the town of Samara. If you booked a shuttle with a group, the price per person on average is about $50-$60. If you book a private shuttle to Samara, you are looking at about $150 total. Prices are in USD!

Public Transportation

Travelling to Samara Costa Rica on a budget? Lots of people are and taking public transportation there is a great way to keep your Samara budget on track! There are buses twice daily from the Liberia Airport and you can see that schedule here. Routes from Liberia to Samara show 3 hours but expect some delays

How To Get To Samara Beach from Nosara?

There is a long route from Nosara to Samara that is recommended if you do not have an SUV. This route is through Nicoya on Route 21. From Route 21, you will then take Route 150 right into the town of Samara. It is very straightforward.

The short route or short cut is through Route 160 which requires you to cross a river. The river is called Rio Buena Vista and during dry season, it is very shallow and easy to cross. One week when we crossed, there was almost no water.

During wet season, I would avoid the short cut from Nosara to Samara.

When to Visit Samara Costa Rica?

In my opinion, the best time to visit Playa Samara is between March-April. Crowds from the holiday season have tampered off a bit and you are still not in rainy season.

The town of Samara gets very busy during high season which runs from December to end of April with the absolute peak time being from December- February. I would avoid it at that time.

Rainy season is from May-November. While there is something special about rainy season in Costa Rica, it also can be very frustrating with flooding and difficulty getting around.

Samara, Costa Rica weather or Costa Rica weather in general can be unpredictable though so there are times when you expect rain and it could turn out to be beautiful!

Samara boasts an active expat community, comprised of mostly North Americans and Europeans.  Around 1,500 people make up Samara and its outskirts year round.  

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How Many Days Do You Need In Sámara beach?

Some people quickly pass through Samara for a day or two and some people come to Playa Samara and never leave!! haha.

If you are staying in Nosara, you can easily do a day trip to Samara.

If you are doing a whole trip through the Nicoya peninsula, I would recommend 2-3 days to really take it all in!!

The Best Hotels in Samara

Playa Samara features a lot of price friendly hotels, bed and breakfasts and Air Bnb options. Accommodations are much cheaper than in Nosara ( almost half the price) so that is worth considering when planning your Costa Rica Trip.

There are some great Samara, Costa Rica Air Bnb options as well!

If you are looking for hotels though, below are the best hotels in Samara based on each pricing level.

Hotel Azura-Top End Option

Hotel Azura is a luxury all inclusive option that is a new spot in the area. It is on the south end of Samara beach and very secluded. The pool is the real eye show stopper of the resort and although Samara beach is beautiful it is very hard not to set up shop there.

Travelling with kids though? Unfortunately this hotel is Adult only!

Price Range: $400 +

Book a Hostel Stay with Hostel World HERE

Mid-range hotel in samara.

Villas Kalimba is a mid range hotel that has a great location, beautiful pool and bigger rooms. A lot of the rooms have mini kitchenettes which is great if you want to cook or store some items! Definitely recommend this place if you are travelling with kids!

Price Range: $200 +

Samara Palm Lodge-Budget Hotel Option in Samara

Samara Lodge is one of the most reasonable places to stay in Playa Samara and is rated one of the best overall places to stay by Trip Advisor.

Samara Lodge is a 5 minute walk from the beach so it’s quieter than some places directly on the beach. The rooms are simple but a great option for the price.

Price Range: $75 +

The Best Restaurants in Samara Costa Rica

You will not have a problem grabbing a bite to eat in Samara. There are plenty of restaurants along the beach and on the main strip. Another great thing about the Samara food scene is that you can find a mix of just about everything! Local Tico places, Fresh Vegetarian Options, Italian, American and they even have a Super Samara supermarket if you want to cook up something yourself.

Here are some of my favourite Samara restaurants!

Gusto Beach Restaurant- The Best Restaurant in Samara

Gusto Beach is the best beachfront restaurant in Samara. This Italian restaurant makes you feel like you have been transported to Italy! It has a killer Aperol Spritz list and really good pizzas

If Italian food isn’t your thing (Are you Ok?), they do have plenty of other options on the menu.

This place is great for breakfast, lunch OR dinner. The Dinner crowd/scene is a bit more rowdy while during the day it is very chill.

This place is a steakhouse and barbeque restaurant. It features a one of a kind wood burning grill which makes the dishes truly unique. It also has prime real estate on the beach! If you are looking for a nice dinner in Samara Beach, this restaurant is a nice option.

Prices are similar to Gusto Beach.

Bohemia Café

This cute little cafe in Playa Samara, just off the main street, is a great spot to grab breakfast or lunch. It serves up juices, crepes, paninis, pastries and some unique coffees. If you are a digital nomad, you can sit here and work too on their outdoor patio.

Prices are very reasonable.

L’Authentique

L’ Authentique  is home away from home. The ambiance, food, and service team welcome you as if you were long-lost family or friends returning after a long trip. Julien and Eva are the charming, ever jovial couple. They are attentive, efficient, and super friendly. 

This tapas restaurant with French inspired cuisine and wine is 10/10. It features imported cheeses, cured meats and unique sharing style dishes. They also have the most amazing French bread. The ambience is also something special.

TIP: Get the Tapas platter. Best bang for your buck!

Marea Surf Shop Cafe

Located on the main strip, this place is all sorts of cool. It is not only a cafe but it is also a surf shop with some nice gear. We both picked up a Marea branded tshirt and felt like we were cool Costa Rican Tico surfers haha.

They serve up coffees, smoothie, pastries and ACAI BOWLS! Yum. Naturally I got one of those and it was very, very yummy.

Malehu Coffee

One of the newer places in town, Malehu Coffee has delicious coffee in a modern and chic setting. This is located just off the main strip. It is open bright and early at 7AM which was nice for us since the kids were up really early!

First class spot all the way! The pastries are fancy and so are the lattes and it was a nice change of pace from some casual breakfasts we were having. Very good! They have Italian and European coffee and also Costa Rican coffee.

Microbar- The Best Place For a Cocktail in Samara

This little bar in Samara was very cute and had craft beers, speciality cocktails and happy hour specials. It is just a tiny little space but has big personality. We loved the decor inside and as the sun went down, the place really got busy. There isn’t a ton of nightlife in Samara so Microbar is a great place to meet friends for drinks

Some other Amazing Restaurants in Samara worth checking out:

• Falafel Cafe – Mediterranean Food
• La Dolce Vita- Another Italian Spot. Kind of similar to Gusto Beach. More lounge-y!
• La Aldrea- Amazing smoothies and juices!
• Casa Esmeralda- The best place for fresh seafood! Loved the Calamari
• Luv Burger- With a spot in Nosara and now Samara, this is a great spot for a Veggie burger…and a vibe!
• Roots Bakery- fresh pastries and great coffee!

The Best Things To Do in Playa Samara

There are lots of things to do in Samara, Costa Rica but you can also just sit at the beach and lounge the entire time. We did a bit of both and loved the balance of it all. Here are some of our favourite things that we got up to in Playa Samara.

Werner Sauter Biological Reserve

Werner Sauter Biological Reserve is a great place to spend a morning or afternoon. You can see a range of animals like birds, monkeys and other types of wildlife!

The Macau reserve is close by so don’t be surprised to find some flying around here too!

There are also hiking trails within and there is a rewarding look out point of the town and beaches!

You can do this with a guide or with a tour or you can do it on your own! Doing it with a guide is about $60 per person.

Visit Nearby Beaches

While Playa Samara is a beautiful and fun beach, if you are staying in town for a few days you should definitely check out some of the neighbouring beaches.

Playa Carillo and Playa Barrigona are about 10-15PM away and are two of the most beautiful beaches in not only the Nicoya but in all of Costa Rica. They are comparable with the beaches on the pacific coast or dare I say Central America in general. Seriously stunning shorelines.

Playa Samara is sandwiched between the two so get in an ATV or car and do a little day trip to either!

You can also go further south down to Santa Teresa!

Visit A Waterfall

 La Roca Waterfall is only about 15-20 minutes away from Samara and is definitely worth checking out if you are in town for a few days. There isn’t a ton of waterfalls in the Nicoya area so it’s a great option to get your Costa Rica waterfall fix. It’s about 20 minutes to get to the waterfall itself and is an easy hike.

Keep in mind this is not like the waterfalls near Manuel Antonio

Take Surf Lessons in Playa Samara

Taking Surfing lessons in the Nicoya area of Costa Rica is a rite of passage and pretty much something that should be mandatory! It really gives you a true feel of what life is like in these areas.

Tico’s Surf School is a great option to book a lesson. Playa Samara is also a great beach to learn to surf as the waves are very small compared to Nosara.

Snorkle at Isla Chorro

Not far from Samara, is the little island called Isla Chorro. There are local boats that can bring you out there to snorkel or you can rent a kayak if you really feel adventurous! You can see some beautiful fish ….and some times there is even dolphin spotting’s!

Helpful Hints for your Visit to Samara Costa Rica

• Samara, Costa Rica has a big expat scene so expect to see a lot of international travellers
• There is a supermarket there if you need groceries. The town of Nicoya is about 25 minutes away if you need to hit a bigger box store
• Most places accept Credit Cards
• There are no public bathrooms on the beach

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[…] Samara Travel Guide: The Complete Guide to staying in SamaraUnique Hotel In Nicoya : Add this jungle luxury hotel to your Costa Rica ItineraryThings To Do In Playa Pelada Beach: The Best Beach in NosaraCosta Rica Travel Agent: We Booked our entire Costa Rica Trip with The Travelogist and it was amazing […]

[…] to look into the different areas of Costa Rica, you can explore Puntarenas, Ojochal, Tamarindo, Samara, or the Santa Teresa areas. In this Costa Rica itinerary 5 days we will be exploring the popular […]

The Nosara vibe is totally different to Samara… which is also larger and more diverse in a number of ways… Nosara being more of a “trust-fund hippy set” from its surf destination inception… Sámara is not Nosara’s lil’ sis’.

At the risk of being ‘nit-picky’, Luv Burger was established in Sámara before heading to Nosara.

As with many Guanacaste beach havens, over-development and commercialization is frequently to the detriment of Tico’s and the road/traffic/transport, water supply/waste management, internet and communications infrastructure simply can’t keep up… put simply its all getting to big and too busy too fast… sorry, but the plethora of blogs posted by short-term transient nomads is not help the communities and neighbouring pueblos & barrios.

Sámara does have ‘quiet days’ even through the December to February’peak’ – something to be grateful for as the once ‘dreamy somnambulant paee’ takes us back to times of real ‘pura vida’ – that being, grateful for each naturally abundant day or night.

Bendiciones y Saludos

Agree absolutely.

[…] https://thedaydreamdiaries.com/guide-to-samara-costa-rica/ […]

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Home » Destinations » Nicoya Peninsula » Samara » Where to stay in Samara, Costa Rica – BEST Areas & Hotels in Samara

Where to stay in Samara, Costa Rica – BEST Areas & Hotels in Samara

By Author Costa Rica Travel Life

Posted on Published: March 29, 2022  - Last updated: March 17, 2024

This blog may contain affiliate links. Read our disclosure policy for more info.

The picturesque beachfront village of Samara may not be as well-known as other destinations like Playa Flamingo and Tamarindo , but it has become an off-the-beaten-path spot for families to visit.

Tucked away in the Guanacaste Province , Samara is bordered by hectares of tropical jungle, and its sheltered harbor means the surf is calmer than in neighboring towns including Nosara . This, along with the town’s secure environment and laid-back character, offers tourists a seaside scene that appeals to almost everyone.

On top of that, Sámara has a multitude of amazing attractions and activities to enjoy. One of its definite pluses is its centrally located downtown, which runs along to the beach. It’s packed with restaurants, stylish boutique stores, tour operators , and a few modest hotels. You can also head out of town to explore mountain waterfalls or take a short trip out to sea for a swim with the marine life.

Samara really is a dream destination. However, it can be quite overwhelming to decide where to stay in Samara and pick just one of the many Samara hotels available. So to help you plan your upcoming trip, I’ve put together a comprehensive list of the best hotels in Samara and what areas might work best for your vacation.

What are the Best Areas to Stay in Samara, Costa Rica

If you’re wondering where to stay in Samara, you’ll be delighted to know that the village, while small, has hotels to suit every budget. You can find them in three locations: right on Samara Beach, in the heart of town, and on the outskirts of town in the jungle. Each of these areas has its own pros and cons, so it’s important to know what each can offer. 

Samara Beach is undoubtedly the most popular area, and for a good reason. The reef just offshore makes the water relatively calm in the cove. This makes it a good location for swimming and water sports. It’s also a good choice for families. Pick a hotel literally right on the beach to enjoy ocean access right from your room!

On the other hand, the heart of Samara town is where you want to be if you want to be close to all the cute shops, restaurants , bars, and cafes. This isn’t as crowded as Samara Beach, but the digital nomad community in the area has been growing in recent years, so you can expect to see a lot of visitors here as well. Plus, you’ll only be a short walk from the beach.

If you’re looking for somewhere more secluded and quiet, the Samara hotels for you are just on the outskirts of town. Some of the accommodations here are still within walking distance to town, but you may need a rental car if your hotel’s a bit far away. 

Read on to find out more about which three areas are the best base for your next vacation.

Staying in a Hotel on Samara Beach 

Samara’s long, sandy beach is home to great snorkeling spots , a beautiful coastline adorned by Chora Island, and gentle and shallow waves suitable for swimming and learning how to surf. There are a few restaurants here, too, so you can indulge in popular Costa Rican dishes while watching the setting sun.  

But apart from its great variety of gastronomic and beach activities, what made Samara Beach really popular is its family-friendly, dynamic, and colorful atmosphere. It’s a good place to stay in to enjoy the beach to its fullest. So, if you’re one of those beach lovers, then the best hotels in Samara for you are right on Samara Beach.

Advantages to staying on Samara Beach: 

• Be treated to the beach, sunsets, and sunrise right from your hotel room
• Easy to indulge in beach activities since you’re just on the beach
• Waves are perfect for newbie surfers

Disadvantages to staying on Samara Beach: 

• More expensive than hotels that aren’t beachside
• Hotels here typically book up first
• Only a few hotels to choose from that are actually beachfront
• Can be a fair distance from town and restaurants/shops

3 BEST Hotels on Samara Beach

$$$ – azura beach resort – all inclusive – adults only .

Azura Beach Resort blends luxury with seclusion to give you a relaxing and kid-free getaway while in Samara. An all-inclusive resort and adults-only property, Azura Beach Resort sits right at the end of Samara Beach, a little bit far from the town center itself. But while it may not be as close to the downtown area as you hope, its location is well worth the visit. 

You see, once you arrive in Azura, you will be treated to the breathtaking view of the golden coast and the blue waters of the Pacific. So head immediately to the shore for a romantic picnic at the hotel’s picnic area or soak in the sun on one of the loungers by the outdoor pool. Feel free to take your relaxation up a notch, too, with a pampering body treatment at the on-site spa suite. 

This is definitely one of the best places to stay if you’re visiting Costa Rica for your honeymoon !

If you’d rather do something more active, there’s also a 24-hour fitness center right on the property to help you get those gains. You can even rent a bicycle on-site, so you can explore the area at your own pace. 

Every mealtime, the hotel’s restaurant will treat you to some of Costa Rica’s finest dishes while you enjoy the panoramic view of the Pacific right in front. Indulge yourself in multiple culinary experiences from breakfast to dinner, complete with unlimited premium beverages. 

At the end of the day, retreat to your luxurious suite, well-appointed with complimentary minibar items, cable TV, coffee machine, and spa-inspired luxury bathroom. You’ll also have access to a private balcony or terrace with a relaxing view of the hotel’s lush garden or the picturesque Pacific Ocean sunset.

For a staycation with a bit more oomph, book the plunge pool suite, where a private plunge pool awaits you. There’s also a swim-up suite up for grabs, where you easily swim up to the hotel’s river pool. 

Azura Beach Resort comes with a total of 75 suites in different lodging categories. A night’s stay can cost you about $598 to $1,098 USD.

You can check availability and book Azura Beach Resort online here on Hotels.com or here on Expedia !

Related Read: Check out our blog on where to stay in Jaco for other great all-inclusive resorts!

$$ – Fenix Hotel -On the Beach

Fenix Hotel is not exactly located in the downtown area of Samara as it’s a casual 15-minute walk away from the town amenities. But while that’s a bit of a hassle, what makes Fenix Hotel worth the trouble is its strategic position on the beach. In fact, it’s so close that the sand is basically at your room’s front door! 

What also makes Fenix Hotel one of my favorite Samara hotels is that it’s away from all the crowds, activity, and traffic but still close enough to walk to the town, perfect for couples and families who really want to unwind and get away from it all.

Fenix Hotel is really all about rest and relaxation. Right on the property, you can find an abundance of towering palm trees, providing the hotel’s front yard with lots of shade for you to lounge in. Lay back on the hammocks or movable sunbeds under the trees as you feel the refreshing sea breeze tickle your barefoot. There is even a BBQ rancho and cabanas here, so you can relax with your entire group.

Since the warm waters of the Pacific are within a few steps away from your room, you’re free to do practically anything here without worrying about packing anything. You can just head to the coast with your bikini on, and in case you forget your sunglasses, you’re always just a quick walk to your room. The best part about the beach at Fenix is that it has coral reefs at both ends that prevent riptides and undertows, so you can enjoy a safe swim.

After a long day of building sandcastles and swimming to your heart’s content, cool down at the hotel’s on-site pool, which is perfect for kids to swim in, too. 

When it comes to the rooms, each one comes complete with full kitchens for your convenience. Wind down on your covered patio overlooking the garden and the ocean as you dig into your dinner and listen to the birds flying over the tree-covered yard. 

You can book an apartment here for around $125 USD to $178 USD a night. Fenix Hotel is easily one of the best value-for-money hotels in Samara!

You can check availability and book Fenix Hotel online here on Booking.com !

$$ – Locanda Samara Beach

Combining simplicity with relaxation, Locanda Samara Beach is where you want to be if you’re thinking about where to stay in Samara with your big group of friends and family. The modest apartments here are more than ready to accommodate large parties as they come complete with spacious living spaces, a large terrace, a private bathroom, and your very own fully equipped kitchen. In case you’re traveling alone or with your partner, there are also double rooms available for booking, too!

While the room amenities may sound pretty basic, what I love about them is their beachy decor and furniture. There’s wooden furniture, floral fabrics, and a rock-adorned accent wall and sink. For a more tropical feel, make sure you book the bungalows that feature a thatched roof, ethnic decor, and plenty of natural light!

Outside of your rooms, Locanda has more in store for you. Drop by the on-site restaurant-pizzeria and bar (one of the best restaurants in Samara ) to get a taste of Italian and Costa Rican cuisine. The homemade pasta here is to die for, but don’t skip out on the sumptuous mixed of grilled meat and fish, too! Of course, there’s a varied selection of cocktails always available at the beach bar as early as 7 am and as late as 11 pm. 

After getting your fill of the food, time to get some laps done at the on-site swimming pool or enjoy a quiet afternoon on one of the sunbeds or in the large gazebo under the shade of palm trees. If you’re up for a more adventurous time in Samara, approach the concierge, and they’ll happily book you a tour of your choice, including the popular dolphin and turtle tour and horseback riding . 

Locanda Samara Beach comes in three different room categories: double/triple room, apartment, and bungalow. Rooms cost $120 USD to $144 USD per night, bungalows at $140 USD to $170 USD per night, and apartments at $185 USD per night. The price already includes breakfast, except for the apartments. 

You can check availability and book Locanda Samara Beach online here on Booking.com , here on Hotels.com , or here on Expedia .

Staying in the heart of Samara Town

For me, the heart of Samara is the ideal base for an idyllic weekend away. It isn’t too busy or loud, but it does provide all of the amenities you would expect when on vacation.

You won’t run out of places to eat, bars, cafés, boutique shops, yoga retreats, and tours in Samara to choose from here. Since it’s a small town, everything is also within quick walking distance, especially the beach. You can get around the town by car, too, thanks to the paved roads. There’s not a lot of parking on the main street, though.

The heart of Samara may be small with no major hotel chains, but it has an inviting atmosphere that makes it a popular destination for families.

Advantages of staying in Samara town: 

• Prices are relatively affordable and within budget
• Central location to activities and attractions
• Close to the beach

Disadvantages of staying in Samara town: 

• Can be loud in certain areas
• The part of the beach close to town can get very busy
• Limited parking on the main street

3 BEST Hotels in Samara Town 

$$$ – villas kalimba.

Strategically built just a minute’s walk away from the beach, Villas Kalimba is right in the center of Samara but offers you a private retreat away from the noise. It’s not as posh and luxurious as the other accommodation providers in town, but the traveler’s choice award for 2018 on Trip Advisor is a testament to the hotel’s stellar reputation.

What makes me a fan of Villas Kalimba is their reasonably priced villa-style rooms. Sure, the rooms lean more into the modest and basic side with standard amenities like a private bathroom, air conditioner, cable TV, and fully-equipped kitchen. But what gives them their charm is the lush garden surrounding each unit for privacy. You also have a large wraparound terrace, where you can enjoy your cup of coffee while listening to the sounds of the birds flying across the lawn.  

Villas Kalimba makes it easier for you to enjoy the Playa Samara’s laid-back surf vibe. Spend the afternoon swimming, boogie boarding, and surfing. Feel free to rent a kayak or stand-up paddleboard, too, if you prefer a more relaxing beachside activity. The hotel staff can also help you plan your holiday as they can book your tours for you. 

Back at the hotel, waste the rest of your day away in the on-site swimming pool and jacuzzi as you soak in the beauty of the hotel’s palm garden. There is no restaurant or bar on the property, but at times, the owner is available to cook some local meals for you. Charming café options are also just across the street in case you want to eat out. 

Rooms here start at $195 USD per night. They also offer more expensive 2-bedroom rooms as well as a villa that sleeps up to 10 people!

You can check availability and book Villas Kalimba online here on Booking.com !

$$ – Hotel Giada

Want to stay somewhere budget-friendly but good quality in Samara? Then look no further than Hotel Giada . Offering you reasonably-priced accommodation options, this charming medium-sized hotel will make your stay more memorable without breaking the bank. 

Upon your arrival at Hotel Giada, what will immediately catch your attention is the vibrant African art and the well-manicured flower garden that makes for the perfect backdrop for your photos. In the middle of the garden are pools, where you can cool off after a long day at the beach. There are also sunbeds by the pool for you to lounge in as you take in the beauty of the surrounding landscape and listen to the wildlife around. 

Apart from the charm that Hotel Giada exudes, its on-site restaurant, Mama Gui, and pizzeria, Di Mare Di Vino, make it a popular spot in Samara. Here, you can enjoy a hearty meal of pizzas and seafood, along with some Italian and NYC cuisine. You also won’t have trouble enjoying the rest of what Samara has to offer since the hotel comes complete with a full-service front desk and tour info center, helping guests find things to do and see in the area.

As for the rooms, they are pretty airy and spacious and have all the necessary amenities, including Wi-Fi, mini-fridge, cable TV, and air conditioning. Feel free to book the ones where you’ll have an awesome view of the pool and garden area. 

One thing I like about the rooms, apart from their tropical vibe, is the double-plated windows. Since Hotel Giada is right in the town center, the windows significantly minimize street noise for a good night’s sleep.  

The Hotel Giada has 24 rooms categorized into single, double, triple, and quadruple. Rates range from $72 USD to $77 USD per night.

You can check availability and book Hotel Giada online here on Booking.com , here on Hotels.com , or here on Expedia .

$ – Tico Adventure Lodge

A tropical oasis in Samara? Tico Adventure Lodge has everything you need and more. Providing accommodations to locals and tourists since December 2004, this jungle-style lodge sits away from the bustling streets of the downtown area, giving you the peace and quiet you crave.

One fascinating thing that made me fall in love with this dreamy lodge is the fact that not a single tree was cut down during its construction. This means that you’ll always wake up feeling refreshed as the exotic Costa Rican jungle sights and sounds surround your room. Sip your morning cup of coffee lounging on the hammock on your private balcony while you soak in the beauty of the lush landscape. Some rooms also come complete with views of the pool. 

Take a quick walk around the property, and you’ll come across a year-round outdoor pool and indoor hot tub. There’s also a garden courtyard, where you can lounge and chitchat with the other guests. 

If you’re up for some relaxing “me” time, head to the hotel’s oasis massage center for some trigger point therapy or join the daily yoga class on the on-site yoga deck. If a day out on the beach is what you prefer, you’ll be happy to know that Tico is only a three-minute walk to the beach. Build a sandcastle by the shore or go fishing. 

Then, back at Tico Adventure Lodge, you can cook your catch of the day at the communal outdoor kitchen and cookout area before heading to the downtown area for some disco fun. 

The private rooms here range from $80 USD to $175 USD per night, but you can also stay at the Budget Single/Twin Rooms and Rancho for $50 USD per night.

You can check availability and book Tico Adventure Lodge online here on Booking.com !

Related Read: Traveling around more? Check out our guide about where to stay in Costa Rica with the best hotels and areas to stay !

Staying on the Outskirts of Samara

If you find the downtown area and Samara Beach too busy and crowded, then the best hotels in Samara for you are on the outskirts of town, an area surrounded by Costa Rica’s beautiful jungle. 

Some of the hotels here treat you to stunning views, while others are enveloped in a lush jungle with a lot of wildlife. This makes it the perfect location for those looking for that peace and quiet that the other two areas lack. 

However, most of the hotels in the outskirts of town are beyond the river. So depending on your hotel’s location, it is probably best that you have your own transport. 

Advantages to staying just outside of Samara town: 

• The location is quiet
• Plenty of wildlife to see
• Budget-friendly hotel prices
• Lots of accommodations to choose from
• Has a relaxing ambiance

Disadvantages of staying just outside of Samra town: 

• May need your own transport if you want to visit the downtown area
• Not many choices for places to eat or things to do nearby
• Without your own transport, walking to the beach or town is super time-consuming and in some cases, impossible

The Best Hotels on the outskirts of Samara

$$$ – samara pacific lodge.

Getting away from it all? Samara Pacific Lodge has your back. Nestled in a secluded location amidst pasture and forest, this budget-friendly hotel puts you just a few minutes by car to the downtown area but only a ten-minute walk from the beach. 

When staying in Samara Pacific Lodge, you won’t have to go far to enjoy the luxuries of life. There’s an in-house spa center here, where you can treat yourself to a relaxing massage, as well as a large salt-water pool with comfy lounge chairs for wasting the afternoon away. If you prefer heading to the great outdoors, the hotel’s tour desk can contact some local tour agencies and arrange the itinerary for you. 

While these amenities and services alone are already a bang for the buck, what really makes me want to keep coming back to Samara Pacific Lodge is its top-notch French restaurant. Serving you a unique menu for dinner every day, the in-house restaurant satisfies your tastebuds in the best way possible. Start your day with the breakfast of your choosing, from Costa Rican dishes to Continental food. Make sure you get a taste of the homemade cocktails too!

For your room, expect all the amenities you’d find in a standard hotel room: wireless internet access, a private bathroom with bathroom, and air conditioning. Wind down in your private furnished balcony or patio as you take in the beauty of the pool area and the view of the Guanacaste groves. 

Four types of rooms are available at Samara Pacific Lodge, some of which can accommodate six guests. The Double Room starts at $80 USD per night, while the Family Room starts at $163 USD per night, inclusive of Continental, American, or local breakfast.

You can check availability and book Samara Pacific Lodge online here on Booking.com , here on Hotels.com , or here on Expedia .

$$ – Samara Palm Lodge

A charming Swiss-owned lodge, Samara Palm Lodge offers you cozy, Instagrammable accommodation on the outskirts of town without busting your budget. You can find it just over the bridge, west of Samara. Despite being a little ways away from the conveniences of the downtown area, Samara Palm Lodge makes it easier for you to enjoy the beach as it’s only five minutes away on foot. 

When you check into your room here, you’ll be greeted by the decor that screams tropical vibes. The furniture is made of stained wood, and you have bold, colorful artwork on the wall. Aside from having a comfy king-size bed, I love that these rooms look out over the inviting pool. That said, make sure to book the room with a terrace, so you can make the most out of the refreshing view from your room. 

Samara Palm Lodge also features a landscaped garden on its property, although it isn’t as grand and spacious as the other Samara hotels. If you like to explore the nearby area, simply approach the staff, and they can organize some activities for you, including fishing, diving, horseback riding, and hiking. 

Back at the lodge, you can spend the afternoon lazing in the communal sitting space while reading a book. Make sure you try the drinks from the “Honesty Bar” too!

Prices for Standard Rooms range from $45 to $75 USD per night, while Family Rooms are available for $65 to $110 USD. Breakfast is available for an additional fee of $9 to $12 USD per person per day.

You can check availability and book Samara Palm Lodge online here on Booking.com !

$ – Hostel Marisol

Maintained by a Costa Rican family, Hostel Marisol is one of the best hotels in Samara if you’re traveling on a budget. It’s only an eight-minute walk from the beach, so you can always have your fill of the sea whenever you want. 

Although Hostel Marisol seems pretty basic at first look, you’ll find that it actually has a homey atmosphere. There’s an outdoor swimming pool on the side of the property, where you can escape the scorching Costa Rican heat. A shared lounge is also just nearby if you feel more like spending the day with a book. 

There is no on-site restaurant here, but you have access to two kitchens to prep your meals in. Don’t worry about bringing your own coffee, though, as it comes complimentary every morning with your booking. Breakfast can be ordered à la carte or continental, as well. 

When it comes to the rooms, the amenities are pretty standard. You have a wardrobe, a small work table, a seating area, free Wi-Fi, and a coffee machine. If you feel like indulging yourself, you can book a room with a patio that overlooks the pool.  

A night’s stay here starts at $55 USD and family rooms that hold up to 5 are available for around $140 USD.

You can check availability and book Hostel Marison on Booking.com here , Hostelworld here , Hotels.com here , or Expedia here .

Related Read: Heading to Nosara? Read about the best places to stay and hotels in Nosara before you go!

Must-do Activities While You’re in Samara

Werner Sauter Biological Reserve – Werner Sauter Biological Reserve is a small private reserve located not far from Sámara. It’s the best place to visit near Sámara if you want to see a huge range of wildlife including monkeys, birds , and reptiles. Tours to Werner Sauter cost around $50 USD per person and are guided.  This specific tour  includes pick-up from town as well as a 2.5 hour guided hike through the reserve.

Go snorkeling at Isla Chora – Isla Chora is a small island that is part of the reef that protects Sámara from heavy ocean swells. It’s a beautiful place to visit for the secluded beaches, but the highlight is without a doubt the snorkeling.  Kayaking tours from Sámara are top-rated and involve a short 30-minute paddle out to Isla Chora before relaxing on the beach and snorkeling the reef.  The tour we did  was excellent and our guide, Luis, was such a fun and knowledgeable person. 

Turtle nesting tour – Turtles are one of the highlights of Costa Rican wildlife. Thousands of turtles visit the Pacific coast every month to lay eggs on the pristine beaches , and visitors can see both adults laying eggs and babies hatching.  This specific tour  visits one of three beaches depending on the time of year to see turtles.

Macaw Recovery Network – The Macaw Recovery Network is a center of volunteers and wildlife experts whose mission is to recover endangered Neotropical parrot populations. Although you can find many macaws in their care, they are focused on the Great Green Macaw – a critically endangered species. You can   do this guided tour with an expert and see the macaws in their natural habitat.

Getting Around Costa Rica

How you choose to get around Costa Rica is one of the biggest decisions you’ll make when planning your holiday here! How you do it depends on your budget, travel style, and comfort level. 

Renting a Car

Without a doubt, the number one way to explore Costa Rica is in a rental car. We book rental cars on the Discover Cars website as we have had good experiences with them in the past.

One of the things you need to watch for when renting a car in Costa Rica is the mandatory insurance that the government requires you to have. There are a lot of very cheap rentals that don’t include this mandatory insurance (TPL) in the original booking price, but there are also ones that do. To avoid additional surprise charges when you pick up your rental car, be sure to rent a car that includes the mandatory insurance when you book.

Thankfully, on Discover Cars it’s easy to tell apart the companies that include the mandatory insurance and those that don’t. The trick is you can’t pick any car on their website. In the picture below, you can see this rental car, with pick up in Jaco, includes the TPL. That means the mandatory insurance is included in the price. Any cover you get above that is extra.

Of course, I still suggest getting the full coverage offered by Discover Cars, which covers you even more.

You can  browse cars on Discover Cars here .

Book Shuttles

If renting a car isn’t in your budget, you don’t feel comfortable driving in Costa Rica , or you just don’t like driving, shuttles are the next best option. There are hundreds of shuttle routes available all over the country, and they are very affordable.

Shuttles in Costa Rica are specifically for tourists and often include pick up and drop off at your selected hotels and airports. The drivers also speak some English, and the vehicles have air conditioning. You’ll also be guaranteed a seat when you book a shuttle (which isn’t the case with the public bus system.)

To get the best price, use the website  Bookaway . They compare all the offers and prices of shuttle companies in Costa Rica so you get the best price! Honestly, we have saved so much money using Bookaway! 

You can search for shuttles online on Bookaway here.

Lastly, you can use the public bus system. On short journeys, such as from San Jose to La Fortuna or Uvita to Manuel Antonio, this system is great. However, the longer the journey the more hassle and time spent on a bus. It’s undoubtedly best to save the public bus in Costa Rica for short and straightforward trips!  

The public buses are definitely the cheapest way to get around Costa Rica, but they are not always very reliable and schedules often change without notice and delays are to be expected. The buses can also be very crowded and hot – so just be prepared!

It’s also good to speak some Spanish if you plan on riding the public bus since most drivers and ticket booth operators don’t speak English.

Samara, a small beach town in Guanacaste, has long been a popular beach getaway for those looking for a touristy but laid-back beach excursion.

While the town is charming, you won’t find plenty of luxury options here. But if you’re looking for a family-friendly option with a modest price tag and plenty of things to do, Samara is the best destination. Hopefully, you won’t have trouble finding the best hotels in Samara with this guide.

If you enjoyed this blog, be sure to check out some of our blogs including:

Is Costa Rica expensive? The cost of traveling

Complete guide to visiting Samara, Costa Rica

BEST restaurants in Nosara

Things to do in Santa Teresa, Costa Rica 

• Visit Liverpool
• Visit The U.K.
• Other Destinations
• Ella In The Media
• Work With Me!

Sámara: A Travel Guide to Costa Rica’s Coolest Beach Town

• February 26, 2021

There is a good chance that this post contains affiliate links. If you make a purchase through them, I may receive a small commission at no extra cost to you! As an Amazon Associate, I earn from qualifying purchases. As ever, all opinions are my own.

Are you considering visiting the surf town of Sámara in Costa Rica? Need some persuasion? Well you’ve come to the right place! This Sámara travel guide is designed to tell you everything you need to know to plan your escape to this stunning area of Costa Rica.

I spent a few days in Sámara at the end of my G Adventures Costa Rica tour, and I fell for it fast!

Unlike many other places in Costa Rica, this small town on the pacific coast is surprisingly authentic, and you’ll never have to deal with crowds of other tourists. Most tourists skip over Samara entirely, which in my opinion is almost criminal!

Even if you’re not into surfing, there’s a whole load of reasons you’ll love Sámara. First of all, obviously, the lack of crowds is a big selling point. There’s also the laid-back, anything goes vibe that makes you want to quit your life and become a full-time beach bum. But Samara is also a fabulous base for a tonne of awesome activities that’ll keep you entertained for days! 

Heading to Costa Rica’s Caribbean coast instead? Check out my travel guide here.

How Much Time Do You Need in Sámara?

In Sámara, it’s easy to do whatever it is you want. Feel like reading a book on the beach for a couple of days? No problem. Feel like packing a bunch of activities into your stay and keeping busy? That’s also cool!

Aside from surfing and being a beach bum, there isn’t much to do in Sámara itself so it’s a good idea to get a balance of beach time and adventure activities. I think 3 days in Sámara is ideal for most visitors, but if you like surfing you’ll want to stay there longer.

I personally could have stayed there for over a week without getting bored! Sprawled out on the beach, drinking out of a coconut, I almost cancelled my flights home to extend my trip!

Alas… Real life responsibilities won in the end, and I caught the bus back to San Jose promising to return one day…

How to Get to Sámara

There are a few options for getting to Sámara depending on how adventurous you are.

Obviously, if you’ve hired a car, you should drive to Sámara. It takes around 4 hours from the capital city of San Jose, or 2 hours from Tamarindo. I’m a big scaredy-cat when it comes to driving, though, so it was never something I considered!

The option I went for, and the easiest option by far, is by joining a Costa Rica guided tour that goes to Sámara. There are a few different tour providers in Costa Rica, but I opted for G Adventures and I highly recommend their tours.

I went on this one , which hits up all the highlights of Costa Rica (including Sámara) over 14-days, and I had the time of my life! Taking a tour was ideal for me, as it meant I didn’t have to think at all about logistics and how to get from A to B. Y ou can read my full review of the tour I went on here.

Your final option is to catch a bus to get to Sámara. From San Jose, the bus takes around 4 hours and costs around $8 one-way. There are also local buses from Sámara to popular nearby destinations such as Tamarindo.

Things to Do in Sámara, Costa Rica

Going surfing.

Sámara is all about surf, and whether you’ve never set foot on a surfboard in your life or you’re a seasoned pro, you’ll have the time of your life surfing here.

The guys over at C&C Surf School have unbeatable enthusiasm for teaching you how to surf and are full of helpful advice. A few people in my tour group took lessons here and had nothing but good things to say about them. Everybody managed to stand up on their first lesson, which is a huge achievement!

If you already know what you’re doing they have a wide range of surfboards to hire, although they don’t have too many more “advanced” boards. They also hire out rash vests. Be sure to hire a long sleeve one if you can to protect yourself from the sun!

Surfing here was unbelievable. I just couldn’t get enough. The waves were so clean and easy to ride along (especially compared to the windswept slop I surf back at home)! Sámara is the perfect place to learn how to surf.

That said, though, the surf is only pumping at certain times of the day. When I was there, it was first thing in the morning and around sunset. During the middle of the day, it was almost flat! That means you’ll have time to either lounge on the beach in between surf sessions, or fit in an activity.

Snorkelling

How better to explore Sámara’s surrounding area than by boat, stopping off to snorkel at all the best spots? 

I love snorkelling and always try to do it at least once per trip. There are quite a few snorkelling tours available in Sámara, so I recommend using Viator to check out your options.

This tour gets rave reviews! Taking in the gorgeous scenery at Barco Quebrado, Sámara and Carrillo, you’ll be able to snorkel to your heart’s content and get to know the area by its best and most beautiful asset – the ocean!

Stand up Paddleboarding

Even if you haven’t tried stand up paddleboarding before, taking a paddleboarding tour is one of the best things to do in Samara. Sámara beach itself can sometime be too ferocious for stand up paddleboarding, but joining a tour will enable you to visit the tranquil nearby waters of Carillo, which is much better suited to paddleboarding.

During a paddleboarding class, your guide will give you a quick introduction to paddleboarding and teach you how to balance on the board before you set off along the coast.

Horseback Riding

Fun fact: the first time I ever went horseback riding was in Costa Rica.

Ever since, I’ve made it my life mission to convince everybody else to go horseback riding in Costa Rica too. Well, maybe that’s a bit dramatic, but the experience was just magic!

Luckily, you can go horseback riding in Sámara – and you can actually ride on the beach (goals)!

This tour takes you riding up a mountain through the jungle to reach amazing viewpoints, and allows you to see a part of Sámara not many others visit which isn’t accessible by vehicle. The final leg of the tour includes galloping along the beach.

I’m always super cautious before recommending animal activities as animal welfare is something I am passionate about. Fortunately, this tour company is consistently praised for the condition of their horses, and they pride themselves on never taking the horses on more than one tour per day. 

Meeting Turtles

Ever wanted to see turtles nesting and hatching on the beach?

Well, from Sámara, you can take a tour to see the baby turtles . From Sámara beach, a guided turtle tour will take you to either Corozalito, Camaronal or Ostional beach where you commence your turtle hunt.

The tour guides have a huge emphasis on the wellbeing of the turtles and give you a full safety briefing before you spot the turtles and, after that, you’ll be able to watch the turtles making their way into the ocean.

The peak turtle hatching time in the area is September and October, so, although you can still spot turtles outside of these months, there’s always a risk that you could miss them.

Mangrove Kayaking 

Sámara isn’t far away from the Ora River, a popular kayaking spot in Costa Rica. Paddling the quiet waters of the river on a guided kayak tour is the best way to explore the mangroves. As you paddle you’ll be able to spot wildlife such as monkeys and birds, as well as an easy way to explore the tropical rainforest. 

Sunset Booze Cruise

I skipped this tour in favour of extra time spent surfing, but judging by the state of the girls on my tour group who went on it when they returned to the hostel, I definitely missed out!

With alcohol, soft drinks and snacks all included in the price of the cruise, this is without doubt the most epic way to catch the sunset in Sámara. There’s an opportunity to snorkel and dolphin-spot on the journey before you settle in to witness the sunset over drinks. The cruise lasts around 3 hours.

The girls on my tour who went on this came back so drunk (in the best way possible). They all said they’d had an amazing time – and it sure looked like they did! Check out prices here .

Quad Biking

This was another tour that I skipped in order to go surfing in Sámara (I’m sensing a theme here…) but the people in my tour group who went quad biking couldn’t sing its praises loud enough!

The quad biking tour includes a safety briefing followed by pure adventure! You’ll get to take in the hills and jungle as you zoom through the rainforest. The tour finishes off at the beach, where you’ll get the opportunity to snorkel and wash away all the dirt from the journey.

Be sure to bring a bandana if you’re going quad biking! The wheels kick up dust and dirt like there’s no tomorrow, and breathing in a bunch of dust is something nobody wants.

Is Sámara Costa Rica Safe?

Yes, Sámara is safe, and I didn’t feel concerned for my safety at all whilst I was here – unlike in a few towns on the Atlantic coast of Costa Rica where harassment was a problem.

I would have felt fine walking alone in the town centre at night by myself, but fortunately I didn’t have to, and I’d always prefer to go out with others after dark.

Obviously, like everywhere else in Costa Rica, stay sensible, keep an eye on your belongings, and don’t go wandering around dark alleyways by yourself at night, and you’ll find that Sámara is a perfectly safe place to visit in Costa Rica.

Where to Stay in Sámara

There are great accommodation options in Sámara for all budgets, but especially if you’re travelling on a low to mid-range budget. Here are my picks for the best places to stay in Sámara.

Hostels in Sámara

Sámara has quite a few hostels, but there are only a couple that have good ratings:

Matilori hostel – Surrounded by Mango trees and just 50 metres away from the beach, you can’t beat the location of this hugely popular hostel. It’s fairly small so it’s easy to get to know other people in the hostel, which is ideal if you’re a solo traveller looking to socialise. It also has all the facilities you’d need, including a kitchen to prepare your own food (and keep costs down) and reliable wifi if you need to get some work done or call home. 

One night in a 6-bed dorm costs around $15 , with a private double room costing $40 . Check out availability and reviews here .

Las Mariposas – Just like Matilori hostel, Las Mariposas is just 50 metres away from the beach (Sámara really is all about beachside living!). This hostel is well known amongst travellers to Sámara for its social atmosphere, and it has a hammock area outdoors where you can chill in the evening and chat with other guests. It also offers free coffee in the morning.

One night in an 8-bed dorm costs around $14 , with a private double room costing $40 . Check out availability and reviews here .

Hotels in Sámara

If you’re travelling as a couple (or just prefer your own space and a few extra luxuries) staying at a hotel or guesthouse in Sámara is the ideal option for you. 

The Good Life Lodge – This is the perfect compromise between a hostel and a hotel – it has a communal kitchen, so you can cook your own food to save costs, but it has the little luxuries you wouldn’t find at a hostel. We’re talking about a hot tub, flat-screen TVs, welcome beers and the all-important AIR CONDITIONING! This place gets rave reviews, which you can check out here . 

Double rooms cost around $79 per night . Check availability for your dates here . 

Hotel Peace & Lodge – For one of the best places to stay in Sámara, check out Hotel Peace & Lodge. This place is one of Booking.com’s most popular stays in Sámara, and looking over the property’s pictures, I’m not surprised. With a restaurant, a swimming pool, a garden and a bar, it isn’t short of facilities, and all the rooms are spacious. The price also includes breakfast!

Double rooms cost around $102 per night . Check availability for your dates here .

Best Restaurants in Sámara

Sámara is a small town, so you’re not going to be overwhelmed by choice of places to eat here. That said, there are enough great restaurants in town serving up both local and international cuisine, so you won’t be disappointed. Here are my top picks:

• Samara Sushi – this sushi place is wildly popular and gets rave reviews. In fact, my Costa Rican tour guide said it was his favourite sushi ever! The decor is unique and makes the restaurant feel super laid back, and their 2 for 1 sushi special (which runs after 5pm) is always a hit. Unfortunately, though, it’s quite pricey.
• Restaurante Sheriff Rustic – for an authentic Costa Rican soda (a local restaurant) you don’t need to look any further than Restaurante Sheriff Rustic. I ate here twice, and it was perfect! The prices were reasonable, the staff offer killer recommendations from the menu, and their ceviche cannot be beaten.
• El Lagarto – Is this the best restaurant in Samara? I think so! And so do all the online reviewers! The specialty at El Lagarto is anything grilled, and boy, I didn’t think grilling could make anything taste this good! The restaurant is down a back street and a bit hard to find, but that only makes it more of a hidden gem.

Don’t forget to check out my post on traditional food and drinks to try in Costa Rica!

Things You Need to Bring to Sámara, Costa Rica

For Sámara, you’ll definitely need some mosquito repellent spray and bands , and a quick-dry travel towel for all those beach days you’ll have. Other than that, you won’t need anything special beyond what I covered in my Costa Rica packing list .

I do want to emphasise how important it is that you purchase travel insurance before you visit Sámara, though. 

A lot of people don’t think it’s necessary to get travel insurance before travelling to Costa Rica – and it makes me wince whenever I hear about it! Costa Rica is fairly safe, but being careful and visiting safe destinations doesn’t prevent plain old bad luck from happening!

Not only is travel insurance very affordable, but it can save you from all manner of nightmarish situations – whether that’s having your flights cancelled, accidentally damaging your laptop, or even getting injured on an activity! I recommend World Nomads for travel insurance and would NEVER travel uninsured . 

Travel insurance is the kind of thing you often don’t think about until you need it. Don’t get caught short!

I hope this post has helped you to plan your visit to Sámara – you’re going to love it! With so many fun activities right on its doorstep, and that incredible beach, I can’t understand why Sámara isn’t swamped with visitors. I’m definitely happy it isn’t, though!

Don’t forget to head over to my other Costa Rica posts for more trip planning tips!

Ella Moore is the founder of Many More Maps. Growing up just 45 minutes away from Liverpool, Ella has spent years exploring the city inside out. In her teenage years, she was introduced to the music of The Beatles, and the rest, they say, is history! Today, she stands as a leading authority on Beatles tourism in Liverpool, helping over 40,000 people a month to plan their dream trip to the city.

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I’m so glad I came across your post. I’m somewhat embarrassed to admit I’d never even heard of Samara. Now I can’t wait to go there.

Thanks Jenn! Samara is so lovely!

Thanks for this. How did you feel about the Hotel Villas Playa Samara. We are an active couple in our late 60’s and early 70’s who want to stay in an all inclusive but still take surfing lessons and do some excursions. Did you see this hotel and what did you think of it.

Hi Steve, I’m glad you found the post helpful! I unfortunately didn’t see Hotel Villas Playa Samara during my time in town, but given your interests I think you’ll have a fabulous time in Samara no matter where you stay! I hope you have a great trip 🙂

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