travellers diarrhoea

• Patient Care & Health Information
• Diseases & Conditions
• Traveler's diarrhea

Traveler's diarrhea may get better without any treatment. But while you're waiting, it's important to try to stay hydrated with safe liquids, such as bottled water or water with electrolytes such as an oral rehydration solution (see below). If you don't seem to be improving quickly, several medicines are available to help relieve symptoms.

Anti-motility agents. These medicines — which include loperamide and drugs containing diphenoxylate — provide prompt but temporary relief by:

• Reducing muscle spasms in your gastrointestinal tract.
• Slowing the transit time through your digestive system.
• Allowing more time for absorption.

Anti-motility medicines aren't recommended for infants or people with a fever or bloody diarrhea. This is because they can delay clearance of the infectious organisms and make the illness worse.

Also, stop using anti-motility agents after 48 hours if you have stomach pain or if your symptoms worsen and your diarrhea continues. In such cases, see a doctor. You may need blood or stool tests and treatment with an antibiotic.

• Bismuth subsalicylate. This nonprescription medicine can decrease the frequency of your stools and shorten the length of your illness. However, it isn't recommended for children, pregnant women or people who are allergic to aspirin.
• Antibiotics. If you have more than four loose stools a day or severe symptoms, including a fever or blood, pus or mucus in your stools, a doctor may prescribe a course of antibiotics.

Before you leave for your trip, talk to your doctor about taking a prescription with you in case you get a serious bout of traveler's diarrhea.

Avoiding dehydration

Dehydration is the most likely complication of traveler's diarrhea, so it's important to try to stay well hydrated.

An oral rehydration salts (ORS) solution is the best way to replace lost fluids. These solutions contain water and salts in specific proportions to replenish both fluids and electrolytes. They also contain glucose to enhance absorption in the intestinal tract.

Bottled oral rehydration products are available in drugstores in developed areas, and many pharmacies carry their own brands. You can find packets of powdered oral rehydration salts, labeled World Health Organization (WHO)- ORS , at stores, pharmacies and health agencies in most countries. Reconstitute the powder in bottled or boiled water according to the directions on the package.

If these products are unavailable, you can prepare your own rehydrating solution in an emergency by mixing together:

• 3/4 teaspoon table salt.
• 2 tablespoons sugar.
• 1 quart uncontaminated bottled or boiled water.
• Sugar-free flavor powder, such as Crystal Light (optional).

You or your child can drink the solution in small amounts throughout the day as a supplement to solid foods or formula, as long as dehydration persists. Small amounts reduce the likelihood of vomiting. Breastfed infants also can drink the solution but should continue nursing on demand.

If dehydration symptoms — such as dry mouth, intense thirst, little or no urination, dizziness, or extreme weakness — don't improve, seek medical care right away. Oral rehydration solutions are intended only for urgent short-term use.

Lifestyle and home remedies

If you do get traveler's diarrhea, avoid caffeine, alcohol and dairy products, which may worsen symptoms or increase fluid loss. But keep drinking fluids.

Drink canned fruit juices, weak tea, clear soup, decaffeinated soda or sports drinks to replace lost fluids and minerals. Later, as your diarrhea improves, try a diet of easy-to-eat complex carbohydrates, such as salted crackers, bland cereals, bananas, applesauce, dry toast or bread, rice, potatoes, and plain noodles.

You may return to your normal diet as you feel you can tolerate it. Add dairy products, caffeinated beverages and high-fiber foods cautiously.

Preparing for your appointment

Call a doctor if you have diarrhea that is severe, lasts more than a few days or is bloody. If you are traveling, call an embassy or consulate for help locating a doctor. Other signs that you should seek medical attention include:

• A fever of 102 F (39 C) or higher.
• Ongoing vomiting.
• Signs of severe dehydration, including a dry mouth, muscle cramps, decreased urine output, dizziness or fatigue.

If you have diarrhea and you've just returned home from a trip abroad, share that trip information with your doctor when you call to make an appointment.

Here's some information to help you get ready, and what to expect.

Information to gather in advance

• Pre-appointment instructions. At the time you make your appointment, ask whether there are immediate self-care steps you can take to help recover more quickly.
• Symptom history. Write down any symptoms you've been experiencing and for how long.
• Medical history. Make a list of your key medical information, including other conditions for which you're being treated and any medicines, vitamins or supplements you're currently taking.
• Questions to ask your health care professional. Write down your questions in advance so that you can make the most of your time.

The list below suggests questions to ask about traveler's diarrhea.

• What's causing my symptoms?
• Are there any other possible causes for my symptoms?
• What kinds of tests do I need?
• What treatment approach do you recommend?
• Are there any possible side effects from the medicines I'll be taking?
• Will my diarrhea or its treatment affect the other health conditions I have? How can I best manage these conditions together?
• What is the safest way for me to rehydrate?
• Do I need to follow any dietary restrictions and for how long?
• How soon after I begin treatment will I start to feel better?
• How long do you expect a full recovery to take?
• Am I contagious? How can I reduce my risk of passing my illness to others?
• What can I do to reduce my risk of this condition in the future?

In addition to the questions that you've prepared, don't hesitate to ask questions as they occur to you during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to talk about in-depth. Your doctor may ask:

• What are your symptoms?
• When did you first begin experiencing symptoms?
• Have you traveled recently?
• Where did you travel?
• Have you taken any antibiotics recently?
• Have your symptoms been getting better or worse?
• Have you noticed any blood in your stools?
• Have you experienced symptoms of dehydration, such as muscle cramps or fatigue?
• What treatments have you tried so far, if any?
• Have you been able to keep down any food or liquid?
• Are you pregnant?
• Are you being treated for any other medical conditions?
• 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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• Section 2 - Yellow Fever Vaccine & Malaria Prevention Information, by Country
• Section 2 - Perspectives : Antibiotics in Travelers' Diarrhea - Balancing Benefit & Risk

Travelers’ Diarrhea

Cdc yellow book 2024.

Author(s): Bradley Connor

Infectious Agents

Risk for travelers, clinical presentation.

Travelers’ diarrhea (TD) is the most predictable travel-related illness. Attack rates range from 30%–70% of travelers during a 2-week period, depending on the destination and season of travel. Traditionally, TD was thought to be prevented by following simple dietary recommendations (e.g., “boil it, cook it, peel it, or forget it”), but studies have found that people who follow these rules can still become ill. Poor hygiene practices in local restaurants and underlying hygiene and sanitation infrastructure deficiencies are likely the largest contributors to the risk for TD.

TD is a clinical syndrome that can result from a variety of intestinal pathogens. Bacteria are the predominant enteropathogens and are thought to account for ≥80%–90% of cases. Intestinal viruses account for at least 5%–15% of illnesses, although the use of multiplex molecular diagnostic assays demonstrates that their contribution to the overall burden of TD disease is probably greater than previously estimated. Infections with protozoal pathogens are slower to manifest symptoms and collectively account for ≈10% of diagnoses in longer-term travelers (see Sec. 11, Ch. 7, Persistent Diarrhea in Returned Travelers ).

What is commonly known as “food poisoning” involves the ingestion of infectious agents that release toxins (e.g., Clostridium perfringens ) or consumption of preformed toxins (e.g., Staphylococcal food poisoning). In toxin-mediated illness, both vomiting and diarrhea can be present; symptoms usually resolve spontaneously within 12–24 hours.

Bacteria are the most common cause of TD. Overall, the most common pathogen identified is enterotoxigenic Escherichia coli , followed by Campylobacter jejuni , Shigella spp., and Salmonella spp. Enteroaggregative and other E. coli pathotypes also are commonly found in cases of TD. Surveillance also points to Aeromonas spp., Plesiomonas spp., and newly recognized pathogens ( Acrobacter , enterotoxigenic Bacteroides fragilis, Larobacter ) as potential causes of TD.

Viral diarrhea can be caused by several pathogens, including astrovirus, norovirus, and rotavirus.

Protozoal Parasites

Giardia is the main protozoal pathogen found in TD. Entamoeba histolytica and Cryptosporidium are relatively uncommon causes of TD. The risk for Cyclospora is highly geographic and seasonal: the most well-known risks are in Guatemala, Haiti, Nepal, and Peru. Dientamoeba fragilis is a flagellate occasionally associated with diarrhea in travelers. Several pathogens are discussed in their own chapters in Section 5.

TD occurs equally in male and female travelers; it is more common in young adult travelers than in older travelers. In short-term travelers, bouts of TD do not appear to protect against future attacks, and >1 episode of TD can occur during a single trip. A cohort of expatriates residing in Kathmandu, Nepal, experienced an average of 3.2 episodes of TD per person during their first year. In more temperate regions, seasonal variations in diarrhea risk can occur. In South Asia, for example, much higher TD attack rates are reported during the hot months preceding the monsoon.

Particularly in locations where large numbers of people lack plumbing or latrine access, stool contamination in the environment will be greater and more accessible to disease-transmitting vectors (e.g., flies). Inadequate electrical capacity leading to frequent blackouts or poorly functioning refrigeration can result in unsafe food storage and an additional increased risk for disease. Lack of safe, potable water contributes to food and drink contamination, as do unhealthful shortcuts in cleaning hands, countertops, cutting boards, utensils, and foods (e.g., fruits and vegetables). In some places, handwashing might not be a social norm and could represent an extra expense; thus, adequately equipped handwashing stations might not be available in food preparation areas.

Where provided, effective food handling courses have been shown to decrease the risk for TD. However, even in high-income countries, food handling and preparation in restaurants has been linked to TD caused by pathogens such as Shigella sonnei .

The incubation period between exposure and clinical presentation can provide clues to etiology. Toxin-mediated illness, for example, generally causes symptoms within a few hours. By contrast, bacterial and viral pathogens have an incubation period of 6–72 hours. In general, protozoal pathogens have longer incubation periods (1–2 weeks), rarely presenting in the first few days of travel. An exception is Cyclospora cayetanensis , which can present quickly in areas of high risk.

Bacterial and viral TD present with the sudden onset of bothersome symptoms that can range from mild cramps and urgent loose stools to severe abdominal pain, bloody diarrhea, fever, and vomiting; with norovirus, vomiting can be more prominent. Diarrhea caused by protozoa (e.g., E. histolytica , Giardia duodenalis ) generally has a more gradual onset of low-grade symptoms, with 2–5 loose stools per day.

Untreated, bacterial diarrhea usually lasts 3–7 days. Viral diarrhea generally lasts 2–3 days. Protozoal diarrhea can persist for weeks to months without treatment. An acute bout of TD can lead to persistent enteric symptoms, even in the absence of continued infection. This presentation is commonly referred to as postinfectious irritable bowel syndrome (see Sec. 11, Ch. 7, Persistent Diarrhea in Returned Travelers ). Other postinfectious sequelae can include reactive arthritis and Guillain-Barré syndrome.

Vaccines are not available in the United States for pathogens that commonly cause TD. Traveler adherence to recommended approaches can, however, help reduce, although never fully eliminate, the risk for illness. These recommendations include making careful food and beverage choices, using agents other than antimicrobial medications for prophylaxis, and carefully washing hands with soap whenever available. When handwashing is not possible, small containers of hand sanitizer containing ≥60% alcohol can make it easier for travelers to clean their hands before eating. Refer to the relevant chapters in Section 5 ( Cholera , Hepatitis A , and Typhoid & Paratyphoid Fever ) for details regarding vaccines to prevent other foodborne and waterborne infections to which travelers are susceptible.

Food & Beverage Selection

Care in selecting food and beverages can help minimize the risk for acquiring TD. See Sec. 2, Ch. 8, Food & Water Precautions , for detailed food and beverage recommendations. Although food and water precautions are recommended, travelers are not always able to adhere to the advice. Furthermore, food safety factors (e.g., restaurant hygiene) are out of the traveler’s control.

Non-Antimicrobial Drugs for Prophylaxis

Bismuth subsalicylate.

The primary agent studied for prevention of TD, other than antibiotics, is bismuth subsalicylate (BSS). Studies from Mexico have shown that this agent reduces the incidence of TD by approximately 50%. BSS commonly causes blackening of the tongue and stool and can cause constipation, nausea, and rarely tinnitus.

Contraindications & Safety

Travelers with aspirin allergy, gout, or renal insufficiency, and those taking anticoagulants, methotrexate, or probenecid should not take BSS. In travelers taking aspirin or salicylates for other reasons, concomitant use of BSS can increase the risk of developing salicylate toxicity.

BSS is not generally recommended for children aged <12 years; some clinicians use it off-label, however, with caution to avoid administering BSS to children aged ≤18 years with viral infections (e.g., influenza, varicella), because of the risk for Reye’s syndrome. BSS is not recommended for children aged <3 years or pregnant people.

Studies have not established the safety of BSS use for >3 weeks. Because of the number of tablets required and the inconvenient dosing, BSS is not commonly used as TD prophylaxis.

Probiotics (e.g., Lactobacillus GG, Saccharomyces boulardii ) have been studied in small numbers of people as TD prevention, but results are inconclusive, partly because standardized preparations of these bacteria are not reliably available. Studies of probiotics to prevent TD are ongoing, but data are insufficient to recommend their use (see the Sec. 2, Ch. 14, Complementary & Integrative Health Approaches to Travel Wellness ).

Anecdotal reports claim beneficial outcomes after using bovine colostrum as a daily prophylaxis agent for TD. However, commercially sold preparations of bovine colostrum marketed as dietary supplements are not approved by the US Food and Drug Administration (FDA). Because no data from rigorous clinical trials demonstrate efficacy, insufficient information is available to recommend the use of bovine colostrum to prevent TD.

Prophylactic Antibiotics

Older controlled studies showed that use of antibiotics reduced diarrhea attack rates by 90%. For most travelers, though, the risks associated with the use of prophylactic antibiotics (see below) do not outweigh the benefits. Prophylactic antibiotics might rarely be considered for short-term travelers who are high-risk hosts (e.g., immunocompromised people or people who have significant medical comorbidities).

The prophylactic antibiotic of choice has changed over the past few decades as resistance patterns have evolved. Historically, fluoroquinolones have been the most effective antibiotics for prophylaxis and treatment of bacterial TD pathogens, but resistance among Campylobacter and Shigella species globally now limits their use. In addition, fluoroquinolones are associated with tendinitis, concerns for QT interval prolongation, and an increased risk for Clostridioides difficile infection. Current guidelines discourage their use for prophylaxis. Alternative considerations include rifaximin and rifamycin SV.

Antimicrobial Resistance & Other Adverse Consequences

Prophylactic antibiotics are not recommended for most travelers. Prophylactic antibiotics afford no protection against nonbacterial pathogens and can remove normally protective microflora from the bowel, increasing the risk for infection with resistant bacterial pathogens. Travelers can become colonized with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE), a risk that is increased by exposure to antibiotics while abroad (see Sec 2, Ch. 17, . . . perspectives: Antibiotics in Travelers’ Diarrhea—Balancing Benefit & Risk , and Sec. 11, Ch. 5, Antimicrobial Resistance ).

Use of prophylactic antibiotics limits therapeutic options if TD occurs; a traveler relying on prophylactic antibiotics will need to carry an alternative antibiotic to use if severe diarrhea develops. Additionally, use of antibiotics has been associated with allergic and other adverse reactions.

Antibiotics

The effectiveness of a particular antimicrobial drug depends on the etiologic agent and its antibiotic sensitivity ( Table 2-09 ). If tolerated, single-dose regimens are equivalent to multidose regimens and might be more convenient for the traveler.

Azithromycin

Azithromycin is an alternative to fluoroquinolones (see below), although enteropathogens with decreased azithromycin susceptibility have been documented in several countries. The simplest azithromycin treatment regimen is a single dose of 1,000 mg, but side effects (mainly nausea) can limit the acceptability of this large dose; taking the medication as 2 divided doses on the same day can help.

Fluoroquinolones

Fluoroquinolones (e.g., ciprofloxacin, levofloxacin) have traditionally been the first-line antibiotics for empiric therapy of TD or to treat specific bacterial pathogens. Increasing microbial resistance to fluoroquinolones, however, especially among Campylobacter isolates, limits their usefulness in many destinations, particularly South and Southeast Asia, where both Campylobacter infection and fluoroquinolone resistance are prevalent. Increasing fluoroquinolone resistance has been reported from other destinations and in other bacterial pathogens, including in Salmonella and Shigella . Furthermore, fluoroquinolones now carry a black box warning from the FDA regarding multiple adverse reactions including aortic tears, hypoglycemia, mental health side effects, and tendinitis and tendon rupture.

Rifamycin SV

A new therapeutic option is rifamycin SV, approved by the FDA in November 2018 to treat TD caused by noninvasive strains of E. coli in adults. Rifamycin SV is a nonabsorbable antibiotic in the ansamycin class of antibacterial drugs formulated with an enteric coating that targets delivery of the drug to the distal small bowel and colon. Two randomized clinical trials showed that rifamycin SV was superior to placebo and non-inferior to ciprofloxacin in the treatment of TD. As with rifaximin (see below), travelers would need to carry a separate antibiotic (e.g., azithromycin) in case of infection due to an invasive pathogen.

Rifaximin has been approved to treat TD caused by noninvasive strains of E. coli . Since travelers likely cannot distinguish between invasive and noninvasive diarrhea, however, and since they would have to carry a backup drug in the event of invasive diarrhea, the overall usefulness of rifaximin as empiric self-treatment remains undetermined.

Table 2-09 Acute diarrhea antibiotic treatment recommendations 1

ANTIBIOTIC 1

Azithromycin 2,3

Single or divided dose 4

Ciprofloxacin

Single dose 4

Levofloxacin

1–3 days 4

Rifamycin SV 5

Rifaximin 5

Abbreviations: BID, twice daily; QD, once daily; TID, three times a day

1 Antibiotic regimens can be combined with loperamide 4 mg, initially, followed by 2 mg after each loose stool, not to exceed 16 mg in a 24- hour period.

2 Use empirically as first-line treatment for travelers’ diarrhea in Southeast Asia or other areas if fluoroquinolone- resistant bacteria are suspected.

3 Preferred treatment for dysentery or febrile diarrhea.

4 If symptoms are not resolved after 24 hours, continue daily dosing for up to 3 days.

5 Do not use if clinical suspicion for Campylobacter , Salmonella , Shigella , or other causes of invasive diarrhea. Use may be reserved for patients unable to receive azithromycin or fluoroquinolones.

Antibiotics are effective in reducing the duration of diarrhea by ≈1–2 days in cases caused by bacterial pathogens susceptible to the antibiotic prescribed. However, concerns about the adverse consequences of using antibiotics to treat TD remain. Travelers who take antibiotics are at risk of becoming colonized by drug-resistant organisms (e.g., ESBL-PE), resulting in potential harm to travelers—particularly immunocompromised people and people prone to urinary tract infections—and the possibility of introducing resistant bacteria into the community.

In addition, antibiotic use can affect the travelers’ own microbiota and increase the potential for C. difficile infection. These concerns must be weighed against the consequences of TD and the role of antibiotics in shortening the acute illness and possibly preventing postinfectious sequelae. Primarily because of these concerns, an expert advisory panel was convened in 2016 to prepare consensus guidelines on the prevention and treatment of TD. The advisory panel suggested a classification of TD using functional impact for defining severity ( Box 2-03 ) rather than the frequency-based algorithm used traditionally. The guidelines suggest an approach that matches therapeutic intervention with severity of illness, in terms of both safety and effectiveness ( Box 2-04 ).

Box 2-03 Acute travelers’ diarrhea: functional definitions

Mild diarrhea.

Tolerable, not distressing, does not interfere with planned activities

MODERATE DIARRHEA

Distressing or interferes with planned activities

SEVERE DIARRHEA

Incapacitating or completely prevents planned activities

All dysentery is considered severe

Box 2-04 Acute travelers’ diarrhea: treatment recommendations

Antibiotic treatment not recommended

Consider treatment with bismuth subsalicylate or loperamide

Antibiotics can be used for treatment

• Azithromycin

• Fluoroquinolones

• Rifaximin (for moderate, noninvasive diarrhea)

Antimotility drugs

• Consider loperamide for use as monotherapy or as adjunctive therapy

Antibiotic treatment is advised (single-dose regimens may be used)

• Azithromycin is preferred

• Fluoroquinolones or rifaximin1 can be used for severe, non-dysenteric diarrhea

• Consider loperamide for use as adjunctive therapy

• Not recommended as monotherapy for patients with bloody diarrhea or diarrhea and fever

Antimotility Agents

Antimotility agents provide symptomatic relief and are useful therapy in TD. Synthetic opiates (e.g., diphenoxylate, loperamide) can reduce frequency of bowel movements and therefore enable travelers to ride on an airplane or bus. Loperamide appears to have antisecretory properties as well. The safety of loperamide when used along with an antibiotic has been well established, even in cases of invasive pathogens; however, acquisition of ESBL-PE might be more common when loperamide and antibiotics are coadministered.

Antimotility agents alone are not recommended for patients with bloody diarrhea or those who have diarrhea and fever. Loperamide can be used in children, and liquid formulations are available. In practice, however, these drugs are rarely given to children aged <6 years.

Oral Rehydration Therapy

Fluids and electrolytes are lost during TD, and replenishment is important, especially in young children, older adults, and adults with chronic medical illness. In otherwise healthy adult travelers, severe dehydration from TD is unusual unless vomiting is prolonged. Nonetheless, replacement of fluid losses is key to diarrhea therapy and helps the traveler feel better more quickly. Travelers should remember to use only beverages that are sealed, treated with chlorine, boiled, or are otherwise known to be purified (see Sec. 2, Ch. 9, Water Disinfection ).

For severe fluid loss, replacement is best accomplished with oral rehydration solution (ORS) prepared from packaged oral rehydration salts (e.g., those provided by the World Health Organization). ORS is widely available at stores and pharmacies in most low- and middle-income countries. ORS is prepared by adding 1 packet to the indicated volume of boiled or treated water—generally 1 liter. Due to their saltiness, travelers might find most ORS formulations relatively unpalatable. In mild cases, rehydration can be maintained with any preferred liquid (including sports drinks), although overly sweet drinks (e.g., sodas) can cause osmotic diarrhea if consumed in quantity.

Travelers’ Diarrhea Caused by Protozoa

The most common parasitic cause of TD is Giardia duodenalis , and treatment options include metronidazole, nitazoxanide, and tinidazole (see Sec. 5, Part 3, Ch.12, Giardiasis ). Amebiasis (see Sec. 5, Part 3, Ch. 1, Amebiasis ) should be treated with metronidazole or tinidazole, then treated with a luminal agent (e.g., iodoquinol or paromomycin). Although cryptosporidiosis is usually a self-limited illness in immunocompetent people, clinicians can consider nitazoxanide as a treatment option (see Sec. 5, Part 3, Ch. 3, Cryptosporidiosis ). Cyclosporiasis should be treated with trimethoprim-sulfamethoxazole but not trimethoprim alone (see Sec. 5, Part 3, Ch. 5, Cyclosporiasis ).

Travelers’ Diarrhea in Children

Children who accompany their parents on trips to high-risk destinations can contract TD, and their risk is elevated if they are visiting friends and family. Causative organisms include bacteria responsible for TD in adults, as well as viruses (e.g., norovirus, rotavirus). The main treatment for TD in children is ORS. Infants and younger children with TD are at greater risk for dehydration, which is best prevented by the early initiation of oral rehydration.

Consider recommending empiric antibiotic therapy for bloody or severe watery diarrhea or evidence of systemic infection. In older children and teenagers, treatment guidelines follow those for adults, with possible adjustments in the dose of medication. Among younger children, macrolides (e.g., azithromycin) are considered first-line antibiotic therapy. Rifaximin is approved for use in children aged ≥12 years. Rifamycin SV is approved for use only in adults.

Breastfed infants should continue to nurse on demand, and bottle-fed infants can continue to drink formula. Older infants and children should be encouraged to eat and should consume a regular diet. Children in diapers are at risk for developing diaper rash on their buttocks in response to liquid stool. Barrier creams (e.g., zinc oxide, petrolatum) could be applied at the onset of diarrhea to help prevent and treat rash; hydrocortisone cream is the best treatment for an established rash. More information about diarrhea and dehydration is discussed in Sec. 7, Ch. 3, Traveling Safely with Infants & Children .

The following authors contributed to the previous version of this chapter: Bradley A. Connor

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Eckbo EJ, Yansouni CP, Pernica JM, Goldfarb DM. New tools to test stool: managing travelers’ diarrhea in the era of molecular diagnostics. Infect Dis Clin N Am. 2019;33(1):197–212.

Kantele A, Lääveri T, Mero S, Vilkman K, Pakkanen S, Ollgren J, et al. Antimicrobials increase travelers’ risk of colonization by extended-spectrum beta lactamase producing Enterobacteriaceae. Clin Infect Dis. 2015;60(6):837–46.

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What Is Travelers' Diarrhea?

A bout of diarrhea after traveling can increase the risk of dehydration and other complications.

Kasandra Brabaw is a writer who focuses on health, sex/relationships, and stories for and about her communities including the LGBTQ+ and fat communities. Other than at Health, her work can be found at SELF, Women’s Health, VICE, and Refinery29.

• Travelers' Diarrhea Symptoms
• What Causes Travelers' Diarrhea?
• Is Travelers' Diarrhea Contagious?
• How Is Travelers' Diarrhea Diagnosed?
• Treatments for Travelers' Diarrhea
• How To Prevent Travelers' Diarrhea

Complications

• Coping With Travelers' Diarrhea

A Quick Review

Vacation is supposed to be a time of rest, but a case of travelers'  diarrhea  can make your trip a nightmare.

Travelers' diarrhea causes loose, watery stools, usually brought about by bacteria, viruses, or fungi. Generally, mild cases of travelers' diarrhea resolve with hydration, rest, and a bland diet. Still, travelers' diarrhea may lead to complications, such as dehydration and malabsorption.

Travelers' diarrhea is one of the most common travel-related illnesses, affecting anywhere from 30% to 70% of travelers. Though travelers' diarrhea can occur anywhere in the world, it is more common when traveling to parts of Asia, the Middle East, Africa, Mexico, and Central and South America.

Here, gastroenterologists explain what causes travelers' diarrhea, the symptoms, and how best to treat it so you can enjoy your vacation as much as possible.

Travelers' Diarrhea Symptoms

Travelers' diarrhea is a form of acute diarrhea that comes on while traveling. Acute diarrhea is sudden loose and watery stools . 

There are different levels of travelers' diarrhea (i.e., mild, acute, and severe). At varying severities, those levels can include symptoms like:

• Mild cramps
• Urgent loose stools
• Severe abdominal pain
• Bloody diarrhea

Symptoms can occur within a few hours to as long as a few weeks depending on the cause of the travelers' diarrhea. Bacterial travelers' diarrhea can last up to seven days. In contrast, viral travelers' diarrhea lasts about three days.

What Causes Travelers' Diarrhea?

Travelers' diarrhea spreads through fecal matter through contaminated food and water. Bacteria, viruses, and parasites cause travelers' diarrhea.

Bacteria account for about 80% to 90% of cases, while viruses make up about 5% to 15%. Less commonly, parasites, also known as protozoal pathogens, can cause travelers' diarrhea. Usually, those parasites are slower to manifest than bacteria and viruses.

Depending on the culprit, travelers' diarrhea may occur through non-inflammatory or inflammatory pathways. Non-inflammatory pathways reduce the ability of your intestines to absorb nutrients. As a result, your waste products increase. In contrast, inflammatory pathways damage your intestines, which increases bowel movements.

Risk Factors

Travelers' diarrhea is more likely to occur if you travel outside the country to a place with poor sanitation . A lack of clean water makes practicing proper hygiene and food preparation hard.

Other risk factors for travelers' diarrhea include:

• Warm climates
• A lack of refrigeration
• Inadequate food storage practices
• Proton pump inhibitor (PPI) and antibiotic use
• Unprotected sex
• Age (i.e., older adults and young children)
• Health conditions affecting the gastrointestinal (GI) system
• Weak immune system

Is Travelers' Diarrhea Contagious?

Depending on the culprit, travelers' diarrhea can be contagious . For example, cruise ships are a common culprit of travelers' diarrhea. 

"Cruise ships are known for two viruses specifically that spread like wildfire," Rabia De Latour, MD , a gastroenterologist and assistant professor in the department of medicine at the NYU Grossman School of Medicine, told  Health . 

Norovirus is a highly contagious virus that causes diarrhea and vomiting. Cruise ships help the virus spread because so many people stay in such proximity, and many people are not great at washing their hands before touching their faces or eating, noted Dr. De Latour.

In contrast, some cases of travelers' diarrhea are not spread between people. For instance, you may develop acute diarrhea because you are not used to the food or water in the place you are traveling.

"There may be different probiotic bacteria that live on lettuce or other foods there that you're just not accustomed to," explained Dr. De Latour. In that case, the diarrhea is about the change in environment, not an infection, and should clear up in a couple of days, added Dr. De Latour.

Traveling can be stressful, especially traveling internationally. For example, your body might respond with loose, watery stool if you are stressed and physically tired after a 12-hour flight. Diarrhea caused by stress isn't infectious and will get better quickly.

How Is Travelers' Diarrhea Diagnosed?

Healthcare providers can diagnose traveler's diarrhea by asking about your symptoms, recent travels outside the country, and what you ate. For example, having acute diarrhea three or more times within 24 hours or double the amount of regular bowel movements may signal travelers' diarrhea. 

A healthcare provider can palpate the stomach to check whether your abdomen is tender. Abdominal cramps, nausea , vomiting, and fever often accompany acute diarrhea.

Healthcare providers do not usually require laboratory tests or imaging to diagnose travelers' diarrhea. In contrast, a healthcare provider may acquire a stool sample if you have blood in your stool or feel like you need to pass stool even if your bowels are empty. 

In severe cases, a healthcare provider may send for X-rays of the kidneys, ureters, and bladder and an abdominal CT scan.  

Treatments for Travelers' Diarrhea

Treatment for travelers' diarrhea depends on the severity of the case and may include the following:

• Fluid replenishment:  To avoid dehydration , increasing your water intake is essential. Sports drinks and electrolyte mixes can help, too. In contrast, milk and fruit juices can worsen diarrhea, increasing the risk of dehydration. You may require oral rehydration salt or intravenous (IV) fluids to replenish fluids for severe cases. 
• Anti-diarrheal medicines:  A healthcare provider may advise taking an anti-diarrheal like loperamide for mild cases. 
• Antibiotics:  In some cases, a healthcare provider may prescribe a round of antibiotics. Common antibiotics for travelers' diarrhea include ciprofloxacin, azithromycin, and rifaximin. The type of antibiotic may depend on your symptoms and where you are traveling. 

Mainly, mild to moderate cases of travelers' diarrhea involve supportive therapy. For many people with travelers' diarrhea, the illness simply runs its course. 

Try the following to make yourself as comfortable as possible:

• Hydrate to prevent dehydration .
• Get lots of rest.
• Eat small, gentle meals on your stomach , such as salty (e.g., pretzels, crackers, soup, sports drinks) and high-potassium (e.g., bananas, potatoes without the skin, fruit juices) foods.

How To Prevent Travelers' Diarrhea

Preventing travelers' diarrhea can be tricky, especially when traveling abroad. On a cruise ship , one of the best ways to avoid travelers' diarrhea is to watch where you put your hands, wash your hands frequently, and avoid touching your face, advised Dr. De Latour. Steer clear of buffet lines, where someone carrying norovirus could touch the food or serving utensils.

When traveling to underdeveloped countries, be careful what you eat and drink to prevent traveler's diarrhea. In the United States, many people are used to eating pasteurized foods partially sterilized through heat or irradiation. Sometimes, that is different in other countries.

"[G]etting that exposure to a digestive system that has never had an unpasteurized product, we would be very vulnerable," Christine Lee, MD , a gastroenterologist at the Cleveland Clinic, told Health . When traveling, be extra careful to check if something is pasteurized before you eat or drink it. You will want to avoid undercooked meats and seafood, too. 

"If you're traveling to an underdeveloped country, that might not be where you want to eat a rare steak," said Dr. Lee. The same goes for sushi made with raw fish or dishes like ceviche or tartare made with raw seafood and meat. Instead, cooked foods are your safest option while traveling anywhere you are unsure how safe the water is.

Fruit and vegetables are risky since they could have been washed in contaminated water. In that case, the fruit you can peel (e.g., bananas or oranges) may be the safest option.  

Finally, paying attention to what you drink is also vital in preventing travelers' diarrhea. Alcohol is considered safe because it can kill bacteria. Likewise, bottled drinks are safe if they have an unbroken seal. Boiled water is your next safest bet if those options are not available. 

Remember that contaminating water can get into your mouth in other ways, like showering and swimming . Try not to swallow during those times, brush your teeth with bottled water, and avoid ice in drinks, advised Dr. Lee.

Finally, a healthcare provider may advise taking precautions if traveling outside the country. For example, you might take two tabs of bismuth subsalicylate four times daily to decrease the risk of travelers' diarrhea. Usually, healthcare providers do not advise bismuth subsalicylate for pregnant people and children. 

A healthcare provider may recommend a round of antibiotics to prevent travelers' diarrhea if you are traveling to a high-risk area for a short period.

Most people with travelers' diarrhea make full recoveries. In rare, severe cases, complications can occur. For example, dehydration is one of the most common complications of travelers' diarrhea. Dehydration happens if you lose too many fluids through acute diarrhea, requiring immediate medical attention.

Other complications of travelers' diarrhea may include:

• Malabsorption:  This happens if the small intestine cannot absorb enough nutrients.
• Sepsis:  This is an infection that develops secondary to an existing one. Sepsis causes inflammation, which leads to organ damage and failure and, in some cases, death. 
• Hemolytic uremic syndrome:  This occurs if an infection damages the blood vessels in your kidneys.
• Reactive arthritides:  Some infections may cause painful and swollen joints.

Typically, those complications are more common in older adults and children younger than 4 than others.

Coping With Travelers' Diarrhea

To manage travelers' diarrhea, follow a healthcare provider's advice and treatment plan . Other steps to keep comfortable while your symptoms resolve include staying hydrated and practicing proper hygiene, such as handwashing. 

Mostly, people with travelers' diarrhea only require emergency medical attention if they are dehydrated. Consult a healthcare provider if your symptoms do not subside after 10 days.

Travelers' diarrhea causes acute diarrhea that comes on while traveling . You can avoid travelers' diarrhea as much as possible by watching what you eat and drink while traveling outside the country. To treat mild cases, staying hydrated is essential. 

Although you are at risk for diarrhea when traveling, it should not be scary. South America, Central America, Mexico, Africa, the Middle East, and Asia offer unique, enriching experiences worth the risk.

Connor BA. Travelers' diarrhea . In:  Travelers' Health . Centers for Disease Control and Prevention; 2020.

Dunn N, Okafor CN. Travelers diarrhea . In:  StatPearls . StatPearls Publishing; 2023.

MedlinePlus. Traveler's diarrhea diet .

Related Articles

Traveler’s Diarrhea

• Symptoms and Signs |
• Diagnosis |
• Treatment |
• Prevention |
• Key Points |
• More Information |

Traveler’s diarrhea is gastroenteritis that is usually caused by bacteria endemic to local water. Symptoms include vomiting and diarrhea. Diagnosis is mainly clinical. Treatment is with replacement fluids and sometimes antibiotics for moderate to severe diarrhea.

(See also Overview of Gastroenteritis and see the Center for Disease Control and Prevention’s [CDC] information for preparing international travelers for travelers’ diarrhea .)

Etiology of Traveler's Diarrhea

Traveler’s diarrhea may be caused by any of several bacteria, viruses, or, less commonly, parasites.

The most common cause of traveler's diarrhea is

Enterotoxigenic Escherichia coli ( E. coli )

E. coli is common in the water supplies of areas that lack adequate purification. Infection is common among people traveling to low-resource countries.

Norovirus gastroenteritis has been a particular problem on some cruise ships.

Both food and water can be the source of infection. Travelers who avoid drinking local water may still become infected by brushing their teeth with an improperly rinsed toothbrush, drinking bottled drinks with ice made from local water, or eating food that is improperly handled or washed with local water. People taking medications that decrease stomach acid (antacids, H2 blockers, and proton pump inhibitors) are at risk of more severe illness.

Symptoms and Signs of Traveler's Diarrhea

Nausea, vomiting, hyperactive bowel sounds, abdominal cramps, and diarrhea begin 12 to 72 hours after ingesting contaminated food or water. Severity is variable. Some people develop fever and myalgias. Diarrhea is rarely bloody.

Most cases are mild and self-limited, although dehydration can occur, especially in warm climates.

Diagnosis of Traveler's Diarrhea

Clinical evaluation

Specific diagnostic measures are usually not necessary. However, fever, severe abdominal pain, and bloody diarrhea suggest more serious disease and should prompt immediate evaluation.

Treatment of Traveler's Diarrhea

Fluid replacement

Sometimes antidiarrheal (antimotility) medications

Antibiotics (eg, ciprofloxacin , azithromycin ) for moderate to severe diarrhea

The mainstay of treatment of traveler's diarrhea is fluid replacement and an antidiarrheal medication such as loperamide

Antidiarrheal medications should not be used in adults with suspected C. difficile or E. coli O157:H7 infection (eg, with recent antibiotic use, bloody diarrhea, heme-positive stool, or diarrhea with fever) or in children, particularly those < 2 years. Iodochlorhydroxyquin, which may be available in some low- and middle-income countries, should not be used because it may cause neurologic damage.

Pearls & Pitfalls

Generally, antibiotics are not necessary for mild diarrhea. However, in patients with moderate to severe diarrhea ( ≥ Campylobacter 2017 guidelines for the prevention and treatment of travelers' diarrhea .)

Prevention of Traveler's Diarrhea

Travelers should dine at restaurants with a reputation for safety and avoid foods and beverages from street vendors. They should consume only cooked foods that are still steaming hot, fruit that can be peeled, and carbonated beverages without ice served in sealed bottles (bottles of noncarbonated beverages can contain tap water added by unscrupulous vendors); uncooked vegetables (particularly including salsa left out on the table) should be avoided. Buffets and fast food restaurants pose an increased risk.

Traveler's diarrhea is usually caused by enterotoxigenic E. coli , but viruses, parasites, and other bacteria may be involved.

Diagnosis is clinical and testing is not usually needed unless bloody diarrhea, fever, or abdominal pain is present.

Prevention is the best measure and involves careful selection of foods and beverages; prophylactic antibiotics are not routinely used except for patients with immunocompromise.

More Information

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

Centers for Disease Control and Prevention: Preparing international travelers for travelers’ diarrhea

Expert panel: Guidelines for the prevention and treatment of travelers' diarrhea (2017)

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Traveller's diarrhoea

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

Meets Patient’s editorial guidelines

In this series: Amoebiasis Giardia

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

In this article :

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

Continue reading below

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

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

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

Escherichia coli

Campylobacter

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

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

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

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

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

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

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

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

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

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

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

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

Crampy tummy (abdominal) pains.

Feeling sick (nausea).

Being sick (vomiting).

A high temperature (fever).

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

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

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

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

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

If you have a high temperature (fever).

If you have blood in your stools (faeces).

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

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

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

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

If you are pregnant.

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

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

Symptoms of dehydration in adults

Dizziness or light-headedness.

Muscle cramps.

Sunken eyes.

Passing less urine.

A dry mouth and tongue.

Becoming irritable.

Symptoms of severe dehydration in adults

Profound loss of energy or enthusiasm (apathy).

A fast heart rate

Producing very little urine.

Coma, which may occur.

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

Symptoms of dehydration in children

Passing little urine.

A dry mouth.

A dry tongue and lips.

Fewer tears when crying.

Being irritable.

Having a lack of energy (being lethargic).

Symptoms of severe dehydration in children

Drowsiness.

Pale or mottled skin.

Cold hands or feet.

Very few wet nappies.

Fast (but often shallow) breathing.

Dehydration is more likely to occur in:

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

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

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

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

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

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

Fluid replacement

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

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

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

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

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

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

Rehydration drinks

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

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

Antidiarrhoeal medication

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

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

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

Eat as normally as possible

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

Antibiotic medicines

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

Fluids to prevent dehydration

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

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

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

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

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

Fluids to treat dehydration

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

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

Eat as normally as possible once any dehydration has been treated

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

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

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

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

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

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

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

Salt (electrolyte) imbalance and dehydration .

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

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

Reactive complications

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

Spread of infection

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

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

Lactose intolerance

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

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

Haemolytic uraemic syndrome

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

Guillain-Barré syndrome

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

Reduced effectiveness of some medicines

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

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

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

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

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

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

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

Regular hand washing

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

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

Before preparing or touching food or drinks.

Before eating.

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

Be careful about what you eat and drink

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

Fruit juices sold by street vendors.

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

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

Raw or undercooked meat.

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

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

Unpasteurised milk.

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

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

Be careful where you swim

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

Obtain travel health advice before you travel

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

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

Antibiotics

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

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

Further reading and references

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

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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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Diarrhoea - prevention and advice for travellers

Last revised in September 2023

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

• Scenario: Diarrhoea - prevention and advice for travellers

Background information

• Risk factors
• Complications

Diarrhoea - prevention and advice for travellers: Summary

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

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Travelers diarrhea.

Noel Dunn ; Chika N. Okafor .

Affiliations

Last Update: July 4, 2023 .

• Continuing Education Activity

Traveler's diarrhea is a common ailment in individuals traveling to resource-limited destinations overseas. It is estimated to affect nearly 40 to 60 percent of travelers and is the most common travel-associated condition. Bacterial, viral, and parasitic infections can cause symptoms, though bacterial sources represent the most frequent etiology. Although traveler's diarrhea is typically a benign, self-resolving condition, it can lead to dehydration and, in severe cases, significant complications. This activity reviews the evaluation and management of traveler's diarrhea and highlights the role of interprofessional team members in collaborating to provide well-coordinated care and enhance outcomes for affected patients.

• Identify the causes of traveler's diarrhea.
• Identify strategies to prevent traveler's diarrhea.
• Explain the management of traveler's diarrhea.
• Explain the importance of improving coordination amongst the interprofessional team to enhance care for patients affected by traveler's diarrhea.
• Introduction

Travelers’ diarrhea is a common ailment in persons traveling to resource-limited destinations overseas. Estimates indicate that it affects nearly 40% to 60% of travelers depending on the place they travel, and it is the most common travel-associated condition.  Bacterial, viral, and parasitic infections can cause symptoms, though bacterial sources represent the most frequent etiology. While travelers’ diarrhea is typically a benign self-resolving condition, it can lead to dehydration and, in severe cases, significant complications.  [1] [2] [3]

The most common bacterial cause is enterotoxigenic Escherichia coli (ETEC), with estimates that the bacteria is responsible for nearly 30% of cases. Other common bacterial causes of travelers’ diarrhea include Campylobacter jejuni , Shigella , and Salmonella species. Norovirus is the most common viral cause while rotavirus is another source of infection.  Giardia intestinalis is the most common parasitic source while Cryptosporidium and Entamoeba histolytica can also cause travelers’ diarrhea. The most common cause of travelers’ diarrhea varies by region, though the source is rarely identified in less severe cases. [4] [5] [6]

Traveler's diarrhea can occur in both short and long term travelers; in general, there is no immunity against future attacks. Traveler's diarrhea appears to be most common in warmer climates, in areas of poor sanitation and lack of refrigeration. In addition, the lack of safe water and taking short cuts to preparing foods are also major risk factors. In areas where food handling education is provided, rates of traveler's diarrhea are low.

• Epidemiology

Estimates place the incidence of travelers’ diarrhea at 30% to 60% of travelers to resource-limited destinations. Incidence and causal agent vary by destination, with the highest incidence reported in sub-Saharan Africa. Other locations with high incidence include Latin America, the Middle East, and South Asia. Risk factors are typically related to poor hygiene in resource-limited areas. These include poor hygienic practices in food handling and preparation; lack of refrigeration due to inadequate electrical supply; and poor food storage practices. Additional modifiable risk factors include proton pump inhibitor (PPI) use, recent antibiotic use, and unsafe sexual practices. Risk factors for severe complications are pregnancy, young or old age, travelers with underlying chronic gastrointestinal diseases, or people who are immunocompromised.  [7] [8]

• Pathophysiology

Travelers’ diarrhea is most commonly spread by fecal-oral transmission of the causative organism, typically through consumption of contaminated food or water.  The incubation period varies by causal agent, with viruses and bacteria ranging from 6 to 24 hours and intestinal parasites requiring 1 to 3 weeks before the onset of symptoms.  The pathophysiology for travelers’ diarrhea differs by a causative agent but can be split into non-inflammatory or inflammatory pathways. Non-inflammatory agents cause a decrease in the absorptive abilities of the intestinal mucosa, thereby increasing the output of the gastrointestinal (GI) tract. Inflammatory agents on the other hand cause destruction of the intestinal mucosa either through cytotoxin release or direct invasion of the mucosa. The loss of mucosa surface again results in a decrease of absorption with a resultant increase in bowel movements. [9]

• History and Physical

The onset of symptoms will typically occur 1 to 2 weeks after arrival in a resource-limited destination, though travelers can develop symptoms throughout their stay or shortly after arrival. Travelers’ diarrhea is considered as three or more loose stools in 24 hours or a two-fold increase from baseline bowel habits. Diarrhea often occurs precipitously and is accompanied by abdominal cramping, fever, nausea, or vomiting. Patients should be asked about any blood in their stool, fevers, or any associated symptoms. A thorough travel history should be obtained including timeline and itinerary, diet and water consumption at their destination, illnesses in other travelers, and possible sexual exposures.

In most self-limited cases physical examination will show mild diffuse abdominal tender to palpation. Providers should assess for dehydration through skin turgor and capillary refill.  In more severe cases patients may have severe abdominal pain, high fever, and evidence of hypovolemia (tachycardia, hypotension).

Laboratory investigation is typically not required in most cases.  In patients with concerning features, such as with high fever, hematochezia, or tenesmus, stool studies can be obtained. Typical stool studies include stool culture, fecal leukocytes, and lactoferrin. The stool should be assessed for ova and parasites in patients with longer duration of symptoms. New multiplex polymerase chain reaction (PCR) screens are becoming available and provide quick analysis of multiple stool pathogens. These screens, however, are expensive, are not widely available, and may not change the clinical management of patients. [4]

Radiological studies are not required in most cases. Kidneys, ureters, and bladder x-ray can be obtained to assess for acute intra-abdominal pathology or look for evidence of perforation in severe cases. An abdominal CT can also be used to assess for intraabdominal pathology in severe cases.

• Treatment / Management

Travelers should be counseled on risk reduction before travel, including avoiding tap water & ice, frequent hand washing, avoiding leafy vegetables or fruit that isn’t peeled, and avoiding street food. Bismuth subsalicylate (two tabs 4 times a day) can be used for prophylaxis and can reduce the incidence of travelers’ diarrhea by almost half, though it should be avoided in children and pregnant women due salicylate side effects. In short high-stakes travel, it may be reasonable to start antibiotics as prophylaxis but is generally avoided in longer-term travel. Rifaximin is a commonly used chemoprophylaxis due to its minimal absorption and minimal side effects. [10] [11] [12]

The foundation of diarrhea management is fluid repletion. In mild cases, travelers should focus on increasing water intake. Water is usually sufficient though sports drinks and other electrolyte fluids can be used. Pedialyte can be used for pediatric patients. Milk and juices should be avoided as this can worsen diarrhea. In more severe cases, oral rehydration salt can be used to ensure rehydration with adequate electrolyte repletion. In cases of severe dehydration, IV fluids may ultimately be required.

Treatment is supportive in mild-moderate cases. In patients without signs of inflammatory diarrhea, loperamide can be used for symptomatic relief.  The typical dose for adults is 4 mg initially with 2 mg after each subsequent loose stool, not to exceed 16 mg total in a day.

Also, travelers can be given antibiotics to take as needed at the onset of symptoms. Ciprofloxacin is commonly used for treatment, though there are concerns with resistance with Campylobacter species.  For this reason, fluoroquinolones are not often prescribed for travelers to Asia and azithromycin preferable. Also, azithromycin is often prescribed for pregnant travelers and children. A common regimen is 500 mg daily for three days, though evidence suggests that a single dose of 1000 mg may be slightly more effective. Parents can be given azithromycin powder with instructions to mix with water when needed. Rifaximin is a minimally absorbed antibiotic that is also available and is safe for older children and pregnant travelers.

• Differential Diagnosis
• Pseudomembranous colitis
• Ischemic colitis
• Radiation-induced colitis
• Food poisoning

New Guidelines for Traveler's Diarrhea

• Travelers should be advised against the use of prophylactic antibiotics
• In high-risk groups, one may consider antibiotic prophylaxis
• Bismuth subsalicylate can be considered in any traveler.
• The antibiotic of choice is rifaximin
• Fluoroquinolones should not be used as prophylaxis

The outcomes in most patients with traveler's diarrhea are good. However, in severe cases, dehydration can occur requiring admission.

• Complications
• Dehydration
• Malabsorption
• Hemolytic uremic syndrome
• Reactive arthritides
• Postoperative and Rehabilitation Care

The majority of patients are managed as outpatients and need to do the following:

• Maintain hydration
• Hand washing
• Only take antimotility agents if prescribed by the healthcare provider
• Maintain good personal hygiene
• If diarrhea persists for more than 10 days, should follow up with the primary provider
• Deterrence and Patient Education
• Wash hands regularly
• Avoid shellfish from waters that are contaminated
• Wash all foods before consumption
• Drink bottled water when traveling
• Avoid consumption of raw poultry or eggs
• When traveling, consume dry foods and carbonated beverages
• Avoid water and ice from the street
• Avoid drinking water from lakes and rivers
• Pearls and Other Issues

There is a strong correlation with travelers’ diarrhea and the subsequent development of irritable bowel syndrome (IBS), with some studies suggesting up to 50% incidence.

• Enhancing Healthcare Team Outcomes

The key to traveler's diarrhea is preventing it. Today, nurses, the primary care provider and the pharmacists are in the prime position to educate the patient on the importance of hydration and good hygiene. The traveler should be educated on drinking bottled water and washing all fresh fruit and vegetables prior to consumption. Plus, travelers should be warned not to drink from lakes and streams. Carrying small packets of alcohol desansitizer to wash hands can be very helpful when hand washing is not possible.

The pharmacist should educate the traveler on managing the symptoms of diarrhea with over-the-counter medications or loperamide. Travelers should be discouraged from taking prophylactic antibiotics when traveling, as this leads to more harm than good. Finally, the traveler should be educated on the symptoms of dehydration and when to seek medical care. The primary care clinicians should monitor patients until there is a complete resolution of symptoms. Any patient that fails to improve within a few days should be referred to a specialist for further workup. With open communication between the team members, the morbidity of traveler's diarrhea can be reduced. [1] [8] (level V)

The prognosis for most patients with traveler's diarrhea is excellent. However, thousands of patients go to the emergency departments each year looking for a magical cure. Hydration is the key and admission is only required for severe dehydration and orthostatic hypotension. The elderly and children under the age of 4 are at the highest risk for developing complications, which often occur because of self-prescribing of over-the-counter medications. [13] [14] (Level V)

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Disclosure: Noel Dunn declares no relevant financial relationships with ineligible companies.

Disclosure: Chika Okafor declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Dunn N, Okafor CN. Travelers Diarrhea. [Updated 2023 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Disease Prevention Advice

Travellers' Diarrhoea

Introduction.

• Recommendations

Overview of Disease

The illness.

• Additional Preventative Measures

Vaccination

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

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

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

Recommendations for Travellers 

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

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

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

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

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

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

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

Mild travellers’ diarrhoea

Travellers’ diarrhoea is mild if:

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

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

Preventing dehydration

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

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

Anti-diarrhoeal Medicine

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

Please note:

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

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

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

Severe Travellers’ diarrhoea

You should seek medical attention if:

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

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

Additional Preventive Measures

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

Antibiotics are not routinely recommended to prevent travellers’ diarrhoea:

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

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

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

Non-antibiotic medicines

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

Pre/Probiotics

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

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

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• General Travel Health Advice

Issues by year

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Volume 44, Issue 1, January-February 2015

Advising travellers about management of travellers’ diarrhoea

How is td defined.

Classic, severe TD is usually defined as at least three unformed bowel movements occurring within a 24-hour period, often accompanied by cramps, nausea, vomiting, fever and/or blood in the stools. 5–7 Moderate TD is defined as one or two unformed bowel movements and other symptoms occurring every 24 hours or as three or more unformed bowel movements without additional symptoms. Mild TD is defined as one or two unformed bowel movements without any additional symptoms and without interference with daily activities. 8,9 TD generally resolves spontaneously, usually after 3–4 days, 8 but, in the interim, frequently leads to disruption of planned activities.

What are the causes of TD?

Approximately 50–80% of TD is caused by bacterial infections; enterotoxigenic Escherichia coli (ETEC) is the most common cause overall. Other bacterial causes include enteroinvasive E. coli (EIEC), enteroaggregative E. coli (EAEC), Shigella , Campylobacter and Salmonella species. The exact breakdown of organisms varies according to destination, season and other factors. Noroviruses cause 10–20% of TD cases. Protozoal parasites should be considered particularly in those with persistent diarrhoea (illness lasting ≥14 days) or when antibacterial therapy fails to shorten illness. 10

How can TD be prevented?

Methods for preventing TD include avoidance, immunisation, non-antibiotic interventions or antibiotic prophylaxis. 11

What avoidance measures are generally recommended and do they work?

Avoidance of TD has traditionally relied on recommendations regarding careful food and drink choices (avoiding untreated/unboiled tap water, including ice and water used for brushing teeth, and raw foods such as salads, uncooked vegetables or fruits that cannot be peeled). This underpins the saying ‘Boil it, cook it, peel it or forget it…. easy to remember, impossible to do’. Additional standard advice is that undercooked or raw meat, fish and shellfish are high-risk foods. However, whether deliberately or inadvertently, most people find it very difficult to adhere to dietary restrictions 12 and over 95% of people disobey the rules of ‘safe’ eating and drinking within a few days of leaving home. Additionally, there is minimal evidence for a correlation between adherence to dietary precautions and a reduced risk of TD, 13 although common sense nevertheless supports care with food selection. 4

Where people eat may be more important than what people eat. Risks are associated, in descending order, with street vendors, restaurants and private homes. Use of antibacterial handwash before eating is also recommended. 14

Which vaccines can be considered?

Immunisation has little practical role in the prevention of TD and the only potentially relevant vaccines are those against rotavirus (infants only) and the oral cholera vaccine.

The cholera vaccine has >90% efficacy for prevention of Vibrio cholera but travellers are rarely at risk of infection with this pathogen. 1 The vaccine contains a recombinant B subunit of the cholera toxin that is antigenically similar to the heat-labile toxin of ETEC; therefore, the cholera vaccine may also reduce ETEC TD. However, it is not licensed for TD prevention in Australia and, although initially thought to offer a 15–20% short-term (3 months) reduction in TD, a recent Cochrane review showed no statistically significant effects on ETEC diarrhoea or all-cause diarrhoea. 15 Overall, there is, therefore, insufficient evidence to support general use of the cholera vaccine for TD protection, but it may still be considered for individuals with increased risk of severe or complicated TD (eg immunosuppressed or underlying inflammatory bowel disease).

Other vaccines directed against organisms spread by the faecal–oral route are the vaccines for typhoid, hepatitis A and polio, but infection with these organisms rarely causes TD. 15

Do non-antibiotic interventions work?

Several probiotic agents have been studied for treatment and prevention of TD, including Lactobacillus and Saccharomyces preparations. However, their effectiveness for TD prevention has been limited, 11,16,17 and a consensus group has recommended against their use. 4 Other over-the-counter agents are also available (eg travelan, which contains bovine colostrum harvested from cows immunised with an ETEC vaccine) but data regarding overall efficacy of reducing all-cause TD are currently lacking.

Should antibiotic prophylaxis against TD be given?

Quinolone antibiotics are highly effective (80–95%) in preventing TD, but antibiotic prophylaxis is rarely indicated. 4 It may result in a false sense of security and hence less caution in dietary choices, it poses risks of side effects, diarrhoea associated with Clostridium difficile , and, more importantly, would lead to a vast amount of antibiotic use, thus predisposing to more rapid development of antibiotic resistance globally. 11 Therefore non-antibiotic options for prevention and a focus instead on empirical self-treatment if needed according to symptoms are the mainstay of management, aligning with the antimicrobial stewardship perspective of minimisation of antimicrobial overuse and reducing promotion of antimicrobial resistance.

In rare circumstances, it may be reasonable to consider short courses of antibiotic prophylaxis in individuals at very high risk of infection (eg severely immunocompromised). 11 Globally, one of the most commonly used agents in this regard is rifaximin, a non-absorbed semisynthetic rifamycin derivative, which has been shown to be effective and is approved for use for TD prevention in some countries, but it is not approved for this indication in Australia. Other options include the antibiotics discussed below for TD self-treatment.

How should self-treatment of TD be managed?

Because of the limitations of TD prevention measures, the pre-travel consultation should be viewed as an opportunity to ‘arm’ travellers with the knowledge and medication needed to appropriately self-treat, should TD occur during their trip.

The first goal of therapy is the prevention and treatment of dehydration, which is of particular concern for young children, pregnant women and the elderly. Commercial packets of oral rehydration salts are readily available in pharmacies and should be purchased before travel. The other element of TD self-treatment is to recommend travellers bring an antimotility agent plus an antibiotic with them. Loperamide is preferred over the diphenoxylate/atropine combination, as the latter agent is generally less effective and associated with a greater potential for adverse effects.

When should loperamide alone versus loperamide plus an antibiotic be taken?

For mild symptoms of watery diarrhoea, self-treatment with oral rehydration plus loperamide is recommended. Loperamide therapy alone has no untoward effects in mild TD 18 but if symptoms worsen, or do not improve after 24 hours, antibiotics should be added. If TD is moderate or severe at onset, then combination therapy with loperamide plus antibiotics should be started immediately, as this optimises the clinical benefit of self-treatment by providing more rapid relief and shortening the symptom duration. 10,19

The recommended dose of loperamide is two tablets (4 mg) stat, then one tablet after each bowel motion to a maximum of eight per 24-hour period until the TD has resolved. Despite warnings regarding the safety of antidiarrhoeal agents with bloody diarrhoea or diarrhoea accompanied by fever, the combination with antibiotics is likely to be safe in the setting of mild febrile dysentery, 18 and a number of studies have shown the combination to be more efficacious than use of either agent alone. 7,18–20 Rapid institution of effective treatment shortens symptoms to 30 hours or less in most people. 12 For example, the duration of diarrhoea was significantly ( P = 0.0002) shorter following treatment with azithromycin plus loperamide (11 h) than with azithromycin alone (34 h). 19

Which antibiotic should be recommended for empirical elf-treatment of TD?

The most commonly used antibiotics for empirical TD therapy are fluoroquinolones (either norfloxacin or ciprofloxacin) or azithromycin ( Table 1 ). Cotrimoxazole has been used but is no longer recommended because of widespread resistance. For TD caused by ETEC, the fluoroquinolones and azithromycin have similar efficacy; however, in Asia (particularly South and South-East Asia), Campylobacter is a common cause of TD and strains occurring in this part of the world show a high degree of resistance to fluoroquinolones. 10,21 Therefore, azithromycin is preferred for travellers to this region. Azithromycin remains generally efficacious despite emerging resistance, and is also the preferred treatment for diarrhoea with complications of dysentery or high fever, and for use in pregnant women or children under the age of 8 years, in whom avoidance of quinolones is preferred. Moreover, the 24-hour dosing of azithromycin may be preferable to the 12-hourly dosing schedule required with fluoroquinolones.

What is the optimal dosing schedule?

The fluoroquinolones and azithromycin have been administered as a single dose or for 3 days ( Table 1 ). Usually a single dose is adequate and there is no apparent clinically important difference in efficacy with either dosing schedule for TD. 10 However, for bacteria such as Campylobacter and Shigella dysenteriae , single-dose therapy may be inadequate. 11 It is reasonable, therefore, to give travellers a 3-day supply of antibiotics and tell them to continue taking the therapy (either 12- or 24-hourly, depending on which antibiotic is prescribed) only if their TD symptoms persist. If the TD has resolved, no further antibiotics need to be taken and any remaining antibiotic doses can be kept in case of a second bout of TD. It is prudent to specifically highlight that this advice differs from the usual instructions to take all tablets even if symptoms have resolved.

What is the optimal empirical TD management in children?

There are few data on empirical treatment of TD in children and limited options for therapy. The mainstay of therapy is oral rehydration solution, particularly for children <6 years of age. Antimotility agents are contraindicated for children because of the increased risk of adverse effects, especially paralytic ileus, toxic megacolon and drowsiness (narcotic effect) with loperamide. 1 The lower age limit recommended for avoiding loperamide varies by location; US guidelines state that loperamide should not be given to infants <2 years of age, the UK <4 years and Australian guidelines state <12 years. 14 However, most Australian practitioners are prepared to use loperamide in children aged 6 years or older, if needed to control symptoms.

A paediatric (powder) formulation of azithromycin is available and is the most commonly recommended agent for children. The usual dose is 10–25 mg/kg for up to 3 days. A practical tip is to ensure that the pharmacy does not reconstitute the powder into a solution, as once dissolved, the solution lasts only for 10 days. Instead, sterile water should be provided along with instructions on how to reconstitute the powder if needed. Fluoroquinolones (ciprofloxacin or norfloxacin 10mg/kg bd) are an alternative option if there are reasons for avoiding azithromycin, with previous concerns regarding potential effects on cartilage not substantiated in recent studies. 14,22

Does starting antibiotics early prevent the chances of developing prolonged symptoms?

Although TD symptoms are short-lived in most cases, 8–15% of affected travellers are symptomatic for more than a week and 2% develop chronic diarrhoea lasting a month or more. 11 Episodes of TD have been shown to be associated with a quintuple risk of developing irritable bowel syndrome (IBS), and post-travel IBS occurs in 3–10% of travellers. However, it is unknown whether IBS can be prevented by starting antimicrobial therapy earlier in the course of enteric infection. 4,18,23

Should tinidazole also be prescribed and, if so, for whom?

Tinidazole can be prescribed as a second antibiotic for empirical self‑treatment as it is effective against the protozoan parasitic enteric pathogen Giardia intestinalis . A dose of 2 g (4 x 500 mg tablets) stat is recommended. However, for most short-term travellers, tinidazole may be unnecessary and the complexity of the additional instructions required may be unwarranted. It is optimally recommended, therefore, for travellers departing on trips of significant duration (>2–3 weeks). If prescribed, the instructions should be to take tinidazole if the TD persists following the 3-day course of antibiotic therapy (fluoroquinolone or azithromycin). This will mean that the TD has lasted for at least 72 hours, thus increasing the likelihood of a parasitic cause.

When should medical care for acute symptoms be recommended?

While most episodes of TD are amenable to self-treatment, if there is a risk of dehydration due to intolerance of oral fluids or comorbidities, as well as in the setting of frank blood in the stool or unremitting fevers (>38.5°C for 48 hours), medical therapy should be sought. 18

How should TD be managed after return?

While a full description of TD management is beyond the scope of this article, for returning travellers with diarrhoea, at least one (preferably three) stool sample(s) should be taken, including specific requests for evaluation of parasites. For patients who are unwell, particularly those with fevers or dysentery, initiation of empirical antibiotic treatment with azithromycin or a quinolone may be needed while awaiting results. For those with prolonged symptoms, tinidazole as empirical therapy for protozoan parasites may be considered. Endoscopic evaluation may also be advisable if no infectious cause is found and symptoms do not resolve.

• Travellers’ diarrhoea continues to affect 20–50% of people undertaking trips to areas with under-developed sanitation and there is minimal evidence for beneficial effects of dietary precautions.
• Evidence for the benefit of cholera vaccine in reducing TD is limited, but it can be considered in people at high risk of infection.
• In 50–80% of TD cases, TD is caused by bacterial infection. Mild diarrhoea can be managed with an antimotility agent (loperamide) alone, but for moderate or severe diarrhoea, early self-treatment with loperamide in conjunction with antibiotics is advised.
• Recommended empirical antibiotics are fluoroquinolones (norfloxacin / ciprofloxacin) or azithromycin for up to 3 days, although in the setting of increasing resistance, the latter is preferred for travellers to South and South-East Asia.

Competing interests: Karin Leader received a consultancy fee from Imuron in relation to the C. difficile vaccine. She is also an ISTM board member and received a consultancy from ISTM to join the GeoSentinel leadership team. She received grants from Sanofi to develop a mobile phone app for splenectomised patients and from GSK to research the use of the HBV vaccine. GSK also paid her to lecture on travel risks at the Asia Pacific Travel Health Conference. She has received support from both GSK and Sanofi to attend travel medicine conferences.

Provenance and peer review: Commissioned, externally peer reviewed

• Diemert DJ. Prevention and self-treatment of travelers’ diarrhea. Prim Care 2002;29:843–55. Search PubMed
• Department of Health and Human Services. Centers for Disease Control and Prevention. Travelers’ Diarrhea. Available at www.cdc.gov/ncidod/dbmd/diseaseinfo/travelersdiarrhea_g.htm [Accessed 25 November 2014]. Search PubMed
• Paredes-Paredes M, Flores-Figueroa J, Dupont HL. Advances in the treatment of travelers’ diarrhea. Curr Gastroenterol Rep 2011;13:402–07. Search PubMed
• DuPont HL, Ericsson CD, Farthing MJ, et al. Expert review of the evidence base for prevention of travelers’ diarrhea. J Travel Med 2009;16:149–60. Search PubMed
• Nair D. Travelers’ diarrhea: prevention, treatment, and post-trip evaluation. J Fam Pract 2013;62:356–61. Search PubMed
• De Bruyn G, Hahn S, Borwick A. Antibiotic treatment for travellers’ diarrhoea. The Cochrane Database Syst Rev 2000:CD002242. Search PubMed
• Riddle MS, Arnold S, Tribble DR. Effect of adjunctive loperamide in combination with antibiotics on treatment outcomes in traveler’s diarrhea: a systematic review and meta-analysis. Clin Infect Dis 2008;47:1007–14. Search PubMed
• Steffen R. Epidemiology of traveler’s diarrhea. Clin Infect Dis 2005;41(Suppl 8):S536–40. Search PubMed
• Steffen R, Collard F, Tornieporth N, et al. Epidemiology, etiology, and impact of traveler’s diarrhea in Jamaica. JAMA 1999;281:811–17. Search PubMed
• DuPont HL, Ericsson CD, Farthing MJ, et al. Expert review of the evidence base for self-therapy of travelers’ diarrhea. J Travel Med 2009;16:161–71. Search PubMed
• Diemert DJ. Prevention and self-treatment of traveler’s diarrhea. Clin Microbiol Rev 2006;19:583–94. Search PubMed
• Travelers’ diarrhea. NIH Consensus Development Conference. JAMA 1985;253:2700–04. Search PubMed
• Shlim DR. Looking for evidence that personal hygiene precautions prevent traveler’s diarrhea. Clin Infect Dis 2005;41(Suppl 8):S531–35. Search PubMed
• Plourde PJ. Travellers’ diarrhea in children. Paediatr Child Health 2003;8:99–103. Search PubMed
• Ahmed T, Bhuiyan TR, Zaman K, Sinclair D, Qadri F. Vaccines for preventing enterotoxigenic Escherichia coli (ETEC) diarrhoea. Cochrane Database Syst Rev 2013;7:CD009029. Search PubMed
• Ritchie ML, Romanuk TN. A meta-analysis of probiotic efficacy for gastrointestinal diseases. PloS One 2012;7:e34938. Search PubMed
• Centers for Disease Control Prevention. Yellow Book. Chapter 2. Travelers’ Diarrhea. Available at wwwnc.cdc.gov/travel/yellowbook/2014/chapter-2-the-pre-travel-consultation/travelers-diarrhea [Accessed 25 November 2014]. Search PubMed
• Wingate D, Phillips SF, Lewis SJ, et al. Guidelines for adults on self-medication for the treatment of acute diarrhoea. Aliment Pharmacol Ther 2001;15:773–82. Search PubMed
• Ericsson CD, DuPont HL, Okhuysen PC, Jiang ZD, DuPont MW. Loperamide plus azithromycin more effectively treats travelers’ diarrhea in Mexico than azithromycin alone. J Travel Med 2007;14:312–19. Search PubMed
• Murphy GS, Bodhidatta L, Echeverria P, et al. Ciprofloxacin and loperamide in the treatment of bacillary dysentery. Ann Intern Med 1993;118:582–86. Search PubMed
• Tribble DR, Sanders JW, Pang LW, et al. Traveler’s diarrhea in Thailand: randomized, double-blind trial comparing single-dose and 3-day azithromycin-based regimens with a 3-day levofloxacin regimen. Clin Infect Dis 2007;44:338–46. Search PubMed
• Yung A, Leder K, Torresi J, et al. Manual of Travel Medicine. 3rd edn. Melbourne: IP Communciations, 2011. Search PubMed
• Stermer E, Lubezky A, Potasman I, Paster E, Lavy A. Is traveler’s diarrhea a significant risk factor for the development of irritable bowel syndrome? A prospective study. Clin Infect Dis 2006;43:898–901. Search PubMed
• Expert Group for Antibiotic. Antiobiotic: gastrointestinal tract infections: acute gastroenteritis: acute diarrhoea in special groups: travellers’ diarrhoea. In: eTG Complete [Internet] Melbourne. Therapeutic Guidelines Ltd, 2014. Search PubMed

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Traveller's diarrhoea

Actions for this page.

• Many people experience traveller’s diarrhoea.
• Symptoms of traveller’s diarrhoea include abdominal pain, cramps and the need to urgently and frequently pass watery stools (faeces).
• Generally, the cause is consumption of contaminated food or water. In some cases, the micro-organisms that trigger the illness are quite harmless.
• It is usually a self-limiting condition that clears up after a few days.

On this page

Symptoms of traveller’s diarrhoea, causes of traveller’s diarrhoea, traveller’s diarrhoea contamination risk foods, contaminated water and traveller’s diarrhoea, hygiene practices to prevent traveller’s diarrhoea, preventing traveller’s diarrhoea in children, vaccination against traveller’s diarrhoea, diagnosis of traveller’s diarrhoea, treatment for traveller’s diarrhoea, repeat attacks of traveller’s diarrhoea, where to get help, things to remember.

Many people who travel from developed to developing countries experience traveller’s diarrhoea. This illness can occur at any time during the trip, or even after the person gets home. It is usually a self-limiting condition that clears up after a few days. It is often caused by eating contaminated food or water. The micro-organisms that trigger the illness may appear to be harmless to the local population, presumably because local people have acquired immunity to them. The risk of traveller’s diarrhoea is higher where sanitation and hygiene standards are poor, such as in the developing nations of Latin America, Africa, the Middle East and Asia. Traveller’s diarrhoea is more common in young adults than older adults, probably because younger people tend to choose more adventurous destinations or styles of travel, like backpacking. Other names for traveller’s diarrhoea include Montezuma's revenge, Bali belly and the Rangoon runs.

The symptoms include:

• abdominal bloating, cramps and pain
• urgency to go to the toilet
• loose, watery stools (faeces or poo) passed frequently
• mild temperature
• general malaise (weakness or discomfort).

Micro-organisms that can cause traveller’s diarrhoea include:

• Bacteria – Escherichia coli ( E. coli) , primarily enterotoxigenic strains (ETEC). This is one of the most common bacterial causes of traveller’s diarrhoea. Other bacterial causes of traveller’s diarrhoea include Campylobacter jejuni, Salmonella species and Shigella species. These infections are usually associated with severe abdominal pains and fever
• Parasites – certain parasitic infections are known to cause diarrhoea, including Giardia intestinalis , Entamoeba histolytica and Cryptosporidium parvum . In these cases, the illness lasts longer than a few days and the stools may be bloody
• Viruses – some estimates suggest that around one in three cases of traveller’s diarrhoea is caused by or associated with a viral infection, particularly norovirus and rotavirus
• Unknown causes – a cause can't be found in approximately one-fifth to half of all cases of traveller’s diarrhoea. It is thought that diarrhoea may be the gastrointestinal system's response to unfamiliar micro-organisms.

Consuming contaminated food is a major cause of traveller’s diarrhoea. Some high-risk foods that the wary traveller should avoid include:

• raw and peeled fruits and vegetables
• green leafy vegetables such as spinach and lettuce
• raw, rare or undercooked meats of any kind
• seafood, particularly raw or inadequately cooked shellfish or fish
• sauces and mayonnaises
• unpasteurised dairy foods, including milk
• food from street vendors
• any hot food that has been left long enough to cool
• food buffets.

Water contaminated with infected faeces is another common cause of traveller’s diarrhoea. Tips include:

• If you are not sure of the safety of the water supply, avoid drinking the water or brushing your teeth with it.
• Buy bottled water to drink, preferably carbonated.
• Boil tap water for at least five minutes before drinking it.
• Avoid any drinks that contain ice.
• Avoid using tap water to wash your fruit and vegetables.

You can further reduce your risk of traveller’s diarrhoea by practicing good hygiene. Tips include:

• Wash your hands with soap and water after going to the toilet, and before eating or preparing food.
• After washing your hands, make sure they are completely dry before you touch any food.
• Make sure any dishes, cups or other utensils are completely dry after they are washed.
• Eat at reputable and clean restaurants.

Children with traveller’s diarrhoea are more vulnerable to dehydration and need plenty of suitable drinks. To help prevent infection in children:

• Don't allow small children to crawl around on floors.
• Make sure your child doesn't put their unwashed fingers into their mouth.
• Wash their hands frequently.
• When making up formula milk, either use bottled water or thoroughly boil tap water for at least five minutes.

As well as the precautions above, the use of the oral cholera vaccine has been shown to reduce the overall incidence of traveller’s diarrhoea by half, and is now often recommended by travel physicians. This secondary benefit is due to its suppression of the bacteria E. coli. It can be used in adults and children over the age of two.

Traveller’s diarrhoea is usually diagnosed by considering the person's medical history and a physical examination. However, a stool sample may be required for testing if diarrhoea persists. Different infectious agents respond to different medication, so it is important to find out which germ is causing the illness.

Currently there are no vaccines that can reliably prevent traveller’s diarrhoea. The best defence is prevention. In most cases, traveller’s diarrhoea is self-limiting and tends to clear up in around four days. Treatment aims to ease some of the symptoms and prevent dehydration. Options may include:

• plenty of water to avoid dehydration
• oral rehydration drinks to replace lost salts and minerals
• antibiotics to kill a bacterial infection
• anti-nausea drugs
• dairy foods can worsen diarrhoea in some people, so limit consumption of these foods
• avoiding alcohol and spicy foods
• avoiding anti-diarrhoea drugs if you have a high fever – preventing the passage of stools will only keep a bacterial infection and its poisons inside the body for longer.

Enduring one bout of traveller’s diarrhoea doesn't offer any protection against developing it again. This is because so many different infectious agents are capable of causing the illness.

• Your doctor
• Traveller’s diarrhoea – Travel health fact sheet, The Travel Doctor, Travellers’ Medical and Vaccination Centre, Australia. More information here External Link .

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Travel Itinerary For One Week in Moscow: The Best of Moscow!

I just got back from one week in Moscow. And, as you might have already guessed, it was a mind-boggling experience. It was not my first trip to the Russian capital. But I hardly ever got enough time to explore this sprawling city. Visiting places for business rarely leaves enough time for sightseeing. I think that if you’ve got one week in Russia, you can also consider splitting your time between its largest cities (i.e. Saint Petersburg ) to get the most out of your trip. Seven days will let you see the majority of the main sights and go beyond just scratching the surface. In this post, I’m going to share with you my idea of the perfect travel itinerary for one week in Moscow.

Moscow is perhaps both the business and cultural hub of Russia. There is a lot more to see here than just the Kremlin and Saint Basil’s Cathedral. Centuries-old churches with onion-shaped domes dotted around the city are in stark contrast with newly completed impressive skyscrapers of Moscow City dominating the skyline. I spent a lot of time thinking about my Moscow itinerary before I left. And this city lived up to all of my expectations.

Travel Itinerary For One Week in Moscow

Day 1 – red square and the kremlin.

Metro Station: Okhotny Ryad on Red Line.

No trip to Moscow would be complete without seeing its main attraction. The Red Square is just a stone’s throw away from several metro stations. It is home to some of the most impressive architectural masterpieces in the city. The first thing you’ll probably notice after entering it and passing vendors selling weird fur hats is the fairytale-like looking Saint Basil’s Cathedral. It was built to commemorate one of the major victories of Ivan the Terrible. I once spent 20 minutes gazing at it, trying to find the perfect angle to snap it. It was easier said than done because of the hordes of locals and tourists.

As you continue strolling around Red Square, there’s no way you can miss Gum. It was widely known as the main department store during the Soviet Era. Now this large (yet historic) shopping mall is filled with expensive boutiques, pricey eateries, etc. During my trip to Moscow, I was on a tight budget. So I only took a retro-style stroll in Gum to get a rare glimpse of a place where Soviet leaders used to grocery shop and buy their stuff. In case you want some modern shopping experience, head to the Okhotny Ryad Shopping Center with stores like New Yorker, Zara, and Adidas.

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To continue this Moscow itinerary, next you may want to go inside the Kremlin walls. This is the center of Russian political power and the president’s official residence. If you’re planning to pay Kremlin a visit do your best to visit Ivan the Great Bell Tower as well. Go there as early as possible to avoid crowds and get an incredible bird’s-eye view. There are a couple of museums that are available during designated visiting hours. Make sure to book your ticket online and avoid lines.

Day 2 – Cathedral of Christ the Saviour, the Tretyakov Gallery, and the Arbat Street

Metro Station: Kropotkinskaya on Red Line

As soon as you start creating a Moscow itinerary for your second day, you’ll discover that there are plenty of metro stations that are much closer to certain sites. Depending on your route, take a closer look at the metro map to pick the closest.

The white marble walls of Christ the Saviour Cathedral are awe-inspiring. As you approach this tallest Orthodox Christian church, you may notice the bronze sculptures, magnificent arches, and cupolas that were created to commemorate Russia’s victory against Napoleon.

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Unfortunately, the current Cathedral is a replica, since original was blown to bits in 1931 by the Soviet government. The new cathedral basically follows the original design, but they have added some new elements such as marble high reliefs.

Home to some precious collection of artworks, in Tretyakov Gallery you can find more than 150,000 of works spanning centuries of artistic endeavor. Originally a privately owned gallery, it now has become one of the largest museums in Russia. The Gallery is often considered essential to visit. But I have encountered a lot of locals who have never been there.

Famous for its souvenirs, musicians, and theaters, Arbat street is among the few in Moscow that were turned into pedestrian zones. Arbat street is usually very busy with tourists and locals alike. My local friend once called it the oldest street in Moscow dating back to 1493. It is a kilometer long walking street filled with fancy gift shops, small cozy restaurants, lots of cute cafes, and street artists. It is closed to any vehicular traffic, so you can easily stroll it with kids.

Day 3 – Moscow River Boat Ride, Poklonnaya Hill Victory Park, the Moscow City

Metro Station: Kievskaya and Park Pobedy on Dark Blue Line / Vystavochnaya on Light Blue Line

Voyaging along the Moscow River is definitely one of the best ways to catch a glimpse of the city and see the attractions from a bit different perspective. Depending on your Moscow itinerary, travel budget and the time of the year, there are various types of boats available. In the summer there is no shortage of boats, and you’ll be spoiled for choice.

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If you find yourself in Moscow during the winter months, I’d recommend going with Radisson boat cruise. These are often more expensive (yet comfy). They offer refreshments like tea, coffee, hot chocolate, and, of course, alcoholic drinks. Prices may vary but mostly depend on your food and drink selection. Find their main pier near the opulent Ukraine hotel . The hotel is one of the “Seven Sisters”, so if you’re into the charm of Stalinist architecture don’t miss a chance to stay there.

The area near Poklonnaya Hill has the closest relation to the country’s recent past. The memorial complex was completed in the mid-1990s to commemorate the Victory and WW2 casualties. Also known as the Great Patriotic War Museum, activities here include indoor attractions while the grounds around host an open-air museum with old tanks and other vehicles used on the battlefield.

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The hallmark of the memorial complex and the first thing you see as you exit metro is the statue of Nike mounted to its column. This is a very impressive Obelisk with a statue of Saint George slaying the dragon at its base.

Maybe not as impressive as Shanghai’s Oriental Pearl Tower , the skyscrapers of the Moscow City (otherwise known as Moscow International Business Center) are so drastically different from dull Soviet architecture. With 239 meters and 60 floors, the Empire Tower is the seventh highest building in the business district.

The observation deck occupies 56 floor from where you have some panoramic views of the city. I loved the view in the direction of Moscow State University and Luzhniki stadium as well to the other side with residential quarters. The entrance fee is pricey, but if you’re want to get a bird’s eye view, the skyscraper is one of the best places for doing just that.

Day 4 – VDNKh, Worker and Collective Farm Woman Monument, The Ostankino TV Tower

Metro Station: VDNKh on Orange Line

VDNKh is one of my favorite attractions in Moscow. The weird abbreviation actually stands for Russian vystavka dostizheniy narodnogo khozyaystva (Exhibition of Achievements of the National Economy). With more than 200 buildings and 30 pavilions on the grounds, VDNKh serves as an open-air museum. You can easily spend a full day here since the park occupies a very large area.

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First, there are pavilions that used to showcase different cultures the USSR was made of. Additionally, there is a number of shopping pavilions, as well as Moskvarium (an Oceanarium) that features a variety of marine species. VDNKh is a popular venue for events and fairs. There is always something going on, so I’d recommend checking their website if you want to see some particular exhibition.

A stone’s throw away from VDNKh there is a very distinctive 25-meters high monument. Originally built in 1937 for the world fair in Paris, the hulking figures of men and women holding a hammer and a sickle represent the Soviet idea of united workers and farmers. It doesn’t take much time to see the monument, but visiting it gives some idea of the Soviet Union’s grandiose aspirations.

I have a thing for tall buildings. So to continue my travel itinerary for one week in Moscow I decided to climb the fourth highest TV tower in the world. This iconic 540m tower is a fixture of the skyline. You can see it virtually from everywhere in Moscow, and this is where you can get the best panoramic views (yep, even better than Empire skyscraper).

Parts of the floor are made of tempered glass, so it can be quite scary to exit the elevator. But trust me, as you start observing buildings and cars below, you won’t want to leave. There is only a limited number of tickets per day, so you may want to book online. Insider tip: the first tour is cheaper, you can save up to $10 if go there early.

Day 5 – A Tour To Moscow Manor Houses

Metro Station: Kolomenskoye, Tsaritsyno on Dark Green Line / Kuskovo on Purple Line

I love visiting the manor houses and palaces in Moscow. These opulent buildings were generally built to house Russian aristocratic families and monarchs. Houses tend to be rather grand affairs with impressive architecture. And, depending on the whims of the owners, some form of a landscaped garden.

During the early part of the 20th century though, many of Russia’s aristocratic families (including the family of the last emperor) ended up being killed or moving abroad . Their manor houses were nationalized. Some time later (after the fall of the USSR) these were open to the public. It means that today a great many of Moscow’s finest manor houses and palaces are open for touring.

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There are 20 manor houses scattered throughout the city and more than 25 in the area around. But not all of them easily accessible and exploring them often takes a lot of time. I’d recommend focusing on three most popular estates in Moscow that are some 30-minute metro ride away from Kremlin.

Sandwiched between the Moscow River and the Andropov Avenue, Kolomenskoye is a UNESCO site that became a public park in the 1920’s. Once a former royal estate, now it is one of the most tranquil parks in the city with gorgeous views. The Ascension Church, The White Column, and the grounds are a truly grand place to visit.

You could easily spend a full day here, exploring a traditional Russian village (that is, in fact, a market), picnicking by the river, enjoying the Eastern Orthodox church architecture, hiking the grounds as well as and wandering the park and gardens with wildflower meadows, apple orchards, and birch and maple groves. The estate museum showcases Russian nature at its finest year-round.

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If my travel itinerary for one week in Moscow was a family tree, Tsaritsyno Park would probably be the crazy uncle that no-one talks about. It’s a large park in the south of the city of mind-boggling proportions, unbelievable in so many ways, and yet most travelers have never heard of it.

The palace was supposed to be a summer home for Empress Catherine the Great. But since the construction didn’t meet with her approval the palace was abandoned. Since the early 1990’s the palace, the pond, and the grounds have been undergoing renovations. The entire complex is now looking brighter and more elaborately decorated than at possibly any other time during its history. Like most parks in Moscow, you can visit Tsaritsyno free of charge, but there is a small fee if you want to visit the palace.

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Last, but by no means least on my Moscow itinerary is Kuskovo Park . This is definitely an off-the-beaten-path place. While it is not easily accessible, you will be rewarded with a lack of crowds. This 18th-century summer country house of the Sheremetev family was one of the first summer country estates of the Russian nobility. And when you visit you’ll quickly realize why locals love this park.

Like many other estates, Kuskovo has just been renovated. So there are lovely French formal garden, a grotto, and the Dutch house to explore. Make sure to plan your itinerary well because the estate is some way from a metro station.

Day 6 – Explore the Golden Ring

Creating the Moscow itinerary may keep you busy for days with the seemingly endless amount of things to do. Visiting the so-called Golden Ring is like stepping back in time. Golden Ring is a “theme route” devised by promotion-minded journalist and writer Yuri Bychkov.

Having started in Moscow the route will take you through a number of historical cities. It now includes Suzdal, Vladimir, Kostroma, Yaroslavl and Sergiev Posad. All these awe-inspiring towns have their own smaller kremlins and feature dramatic churches with onion-shaped domes, tranquil residential areas, and other architectural landmarks.

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I only visited two out of eight cities included on the route. It is a no-brainer that Sergiev Posad is the nearest and the easiest city to see on a day trip from Moscow. That being said, you can explore its main attractions in just one day. Located some 70 km north-east of the Russian capital, this tiny and overlooked town is home to Trinity Lavra of St. Sergius, UNESCO Site.

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Sergiev Posad is often described as being at the heart of Russian spiritual life. So it is uncommon to see the crowds of Russian pilgrims showing a deep reverence for their religion. If you’re traveling independently and using public transport, you can reach Sergiev Posad by bus (departs from VDNKh) or by suburban commuter train from Yaroslavskaya Railway Station (Bahnhof). It takes about one and a half hours to reach the town.

Trinity Lavra of St. Sergius is a great place to get a glimpse of filling and warming Russian lunch, specifically at the “ Gostevaya Izba ” restaurant. Try the duck breast, hearty potato and vegetables, and the awesome Napoleon cake.

Day 7 – Gorky Park, Izmailovo Kremlin, Patriarch’s Ponds

Metro Station: Park Kultury or Oktyabrskaya on Circle Line / Partizanskaya on Dark Blue Line / Pushkinskaya on Dark Green Line

Gorky Park is in the heart of Moscow. It offers many different types of outdoor activities, such as dancing, cycling, skateboarding, walking, jogging, and anything else you can do in a park. Named after Maxim Gorky, this sprawling and lovely park is where locals go on a picnic, relax and enjoy free yoga classes. It’s a popular place to bike around, and there is a Muzeon Art Park not far from here. A dynamic location with a younger vibe. There is also a pier, so you can take a cruise along the river too.

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The Kremlin in Izmailovo is by no means like the one you can find near the Red Square. Originally built for decorative purposes, it now features the Vernissage flea market and a number of frequent fairs, exhibitions, and conferences. Every weekend, there’s a giant flea market in Izmailovo, where dozens of stalls sell Soviet propaganda crap, Russian nesting dolls, vinyl records, jewelry and just about any object you can imagine. Go early in the morning if you want to beat the crowds.

All the Bulgakov’s fans should pay a visit to Patriarch’s Ponds (yup, that is plural). With a lovely small city park and the only one (!) pond in the middle, the location is where the opening scene of Bulgakov’s novel Master and Margarita was set. The novel is centered around a visit by Devil to the atheistic Soviet Union is considered by many critics to be one of the best novels of the 20th century. I spent great two hours strolling the nearby streets and having lunch in the hipster cafe.

Conclusion and Recommendations

To conclude, Moscow is a safe city to visit. I have never had a problem with getting around and most locals are really friendly once they know you’re a foreigner. Moscow has undergone some serious reconstruction over the last few years. So you can expect some places to be completely different. I hope my one week Moscow itinerary was helpful! If you have less time, say 4 days or 5 days, I would cut out day 6 and day 7. You could save the Golden Ring for a separate trip entirely as there’s lots to see!

What are your thoughts on this one week Moscow itinerary? Are you excited about your first time in the city? Let me know in the comments below!

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24 comments.

Ann Snook-Moreau

Moscow looks so beautiful and historic! Thanks for including public transit information for those of us who don’t like to rent cars.

MindTheTravel

Yup, that is me 🙂 Rarely rent + stick to the metro = Full wallet!

Mariella Blago

Looks like you had loads of fun! Well done. Also great value post for travel lovers.

Thanks, Mariella!

I have always wanted to go to Russia, especially Moscow. These sights look absolutely beautiful to see and there is so much history there!

Agree! Moscow is a thousand-year-old city and there is definitely something for everyone.

Tara Pittman

Those are amazing buildings. Looks like a place that would be amazing to visit.

Adriana Lopez

Never been to Moscow or Russia but my family has. Many great spots and a lot of culture. Your itinerary sounds fantastic and covers a lot despite it is only a short period of time.

What was their favourite thing about Russia?

Gladys Parker

I know very little about Moscow or Russia for the\at matter. I do know I would have to see the Red Square and all of its exquisite architectural masterpieces. Also the CATHEDRAL OF CHRIST THE SAVIOUR. Thanks for shedding some light on visiting Moscow.

Thanks for swinging by! The Red Square is a great starting point, but there way too many places and things to discover aside from it!

Ruthy @ Percolate Kitchen

You are making me so jealous!! I’ve always wanted to see Russia.

Moscow is in my bucket list, I don’t know when I can visit there, your post is really useful. As a culture rich place we need to spend at least week.

DANA GUTKOWSKI

Looks like you had a great trip! Thanks for all the great info! I’ve never been in to Russia, but this post makes me wanna go now!

Wow this is amazing! Moscow is on my bucket list – such an amazing place to visit I can imagine! I can’t wait to go there one day!

The building on the second picture looks familiar. I keep seeing that on TV.

Reesa Lewandowski

What beautiful moments! I always wish I had the personality to travel more like this!

Perfect itinerary for spending a week in Moscow! So many places to visit and it looks like you had a wonderful time. I would love to climb that tower. The views I am sure must have been amazing!

I was lucky enough to see the skyline of Moscow from this TV Tower and it is definitely mind-blowing.

Chelsea Pearl

Moscow is definitely up there on my travel bucket list. So much history and iconic architecture!

Thumbs up! 🙂

Blair Villanueva

OMG I dream to visit Moscow someday! Hope the visa processing would be okay (and become more affordable) so I could pursue my dream trip!

Yup, visa processing is the major downside! Agree! Time and the money consuming process…

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Covid-19 pcr tests in moscow – russia.

If you are traveling to Moscow and must perform a Covid-19 PCR test before your flight, below is a list of Covid-19 PCR test centers in Moscow, Russia.

A little tip for big savings: Download Pruvo´s app, which helps you lower the price of the hotels you have already booked by alerting you when price drops occur after booking the hotel. This way you can save hundreds of dollars effortlessly.

Plan your trip easily with Wiki for travel

Centers for molecular detection of Coronavirus (SARS-CoV-2), more commonly referred to as PCR tests, Antigen Tests, or Rapid Lateral Flow tests, can be found on this page. PCR Tests, (Real-time polymerase chain reaction (RT–PCR) is a nuclear-derived technology for identifying the presence of specific genetic material in any disease, including viruses. It’s one of the most extensively utilized COVID-19 viral detection methods in laboratories. An Antigen test is a rapid diagnostic test suitable for point-of-care testing that directly detects the presence or absence of an antigen. Rapid lateral flow tests are required for UK travelers and involve rubbing a long cotton bud (swab) over your tonsils (or where they would have been) and inside your nose.

All Covid-19 PCR Test / Rapid Antigen Test / Rapid Lateral Flow test centers that appear in this list have been certified by the country´s state health department. If you need your Covid-19 diagnostic test prior to your flight, make sure to provide the exact name that appears in your passport (including middle name) and request a test certificate in English.

If you are on vacation or holiday and have symptoms such as fever, cough, tiredness, loss of taste, loss of smell, difficulty breathing, chills, sore throat, runny nose, headaches, chest discomfort, or diarrhea, it´s highly recommended that you conduct a Covid-19 test and auto-isolate till the results are back.

Prior to going for your PCR, Antigen, or Rapid Lateral Flow test, make sure to contact the laboratory and ask if you need to make an appointment or if they accept walk-ins. Some RT-PCR test laboratories offer expedited results (which may incur an additional fee). Not all Covid-19 diagnostic test centers are open on weekends, so plan accordingly and make sure to consult the lab prior to going for your Coronavirus test.

In case you found a mistake or want us to add more information about Covid-19 PCR Test / Rapid Antigen Test / Rapid Lateral Flow test , please contact us and we will be more than happy to share the additional information. It is important to mention that Pruvo has developed this database of Covid-19 PCR Test / Rapid Antigen Test / Rapid Lateral Flow test in order to help you save time and money when traveling abroad or back home.

Moscow concert attack: More than 60 reported dead; ISIS claims responsibility

This live blog has ended. For the most recent updates, please click here .

What we know about the Moscow concert attack

• Men in camouflage broke into a Moscow concert hall and opened fire, shooting an unknown number of people, Russia’s prosecutor general said.
• The terror group ISIS has claimed responsibility but did not provide proof of the claim, which was made on ISIS-affiliated news agency Amaq on Telegram.
• Russia's Investigative Committee said that more than 60 people are dead after the attack at Crocus City Hall. Officials have said more than 100 others were injured.
• A fire also started inside Crocus City Hall, a large concert venue northwest of central Moscow. Firefighters have evacuated about 100 people from the basement of the building and efforts are underway to rescue people from the roof, Russian emergency officials said.
• Russia officials said they were investigating the attack as a terrorist act.
• A popular rock band was scheduled to play what appeared to be a sold-out show at the venue, which has a maximum capacity of more than 9,000 people.

Three children among those killed, state media reports

Chantal Da Silva

Three children were among the more than 60 people killed in yesterday's attack at Crocus City Hall, Russian news agency RIA Novosti reported, citing the Russian Ministry of Health.

Officials have warned that the death toll connected to the deadly incident may increase as the investigation continues.

Xi sends condolences to Putin

Chinese President Xi Jinping sent condolences to Russian President Vladimir Putin on Saturday after a deadly shooting at a concert hall near Moscow, saying China opposes all forms of terrorism and strongly condemns terrorist attacks.

China firmly supports the Russian government’s efforts to maintain national security and stability, Xi said, according to CCTV state television. 

Moscow bloodshed comes two decades after some of worst attacks in Russia

Phil Helsel

The shooting attacks in Moscow are the latest in a series of deadly terror attacks in the country since the 2000s.

In 2004, militants from Chechnya and elsewhere took hostages at a school in Beslan in southern Russia.

The militants demanded a withdrawal from Chechnya. Hostages were kept in a gymnasium, and 334 died — half of them children — when gunfire and explosions erupted when it was stormed. Hostages’ families were critical of the rescue operation. Russian prosecutors later cleared authorities .

Two years prior, in 2002, Chechen separatists attacked the Dubrovka Theater in Moscow and took more than 700 people hostage. Russian forces used gas, and 129 hostages died. The attackers were killed.

More recently, in 2017 a suicide bomber from Kyrgyzstan killed 15 people as well as himself in an attack on a St. Petersburg subway. In 2013, two bombers killed a combined 34 people in attacks on a railway station and a trolleybus in Volgograd.

The group Islamic State, also known as ISIS, claimed responsibility for the attacks Friday at the Crocus City Hall venue.

Putin wishes victims well, deputy prime minister says

President Vladimir Putin is thinking of those injured in today’s attack and thanked doctors, a Russian government official said according to state media.

State media TASS reported that “Putin wished all those injured in the emergency at Crocus City Hall to recover and conveyed his gratitude to the doctors, Golikova said,” referring to Tatiana Golikova deputy prime minister for social policy, labor, health and pension provision.

More than 60 dead, and death toll could grow, Russian agency says

Russia’s Investigative Committee said Saturday that more than 60 people have died in the attack, and warned the number may increase.

“The bodies of the dead are being examined. It has been previously established that more than 60 people died as a result of the terrorist attack. Unfortunately, the number of victims may increase,” according to the Investigative Committee, which is a federal state agency.

Russia's Ministry of Internal Affairs and the security agency FSB are continuing to investigate, the committee said in a statement, and weapons and ammunition have been found.

U.S. warned Russia about planned terrorist attack in Moscow, NSC says

Monica Alba

The United States shared information about a potential terrorist attack in Moscow with Russia’s government earlier this month, a spokesperson for the National Security Council said.

The U.S. Embassy in Russia on March 7 warned U.S. citizens to avoid crowds and said it was monitoring reports that extremists might attack large gatherings in Moscow.

“Earlier this month, the U.S. Government had information about a planned terrorist attack in Moscow — potentially targeting large gatherings, to include concerts — which prompted the State Department to issue a public advisory to Americans in Russia,” NSC spokesperson Adrienne Watson said.

“The U.S. Government also shared this information with Russian authorities in accordance with its longstanding ‘duty to warn’ policy,” Watson said.

Putin recently dismissed ‘provocative’ warning about potential attacks

In remarks that aired three days ago, Russian President Vladimir Putin accused the West of “provocative statements” about potential terror attacks in Russia, and dismissed them.

“I’ll remind you of recent, let’s say directly, provocative statements of certain official Western structures about potential terror attacks in Russia,” Putin said.

“All of this looks like obvious blackmail and an attempt to intimidate, destabilize our country,” he said before the state security agency FSB.

Putin in those remarks did not specify a country or warning. The U.S. embassy in Russia on March 7 warned U.S. citizens to avoid crowds .

“The Embassy is monitoring reports that extremists have imminent plans to target large gatherings in Moscow, to include concerts, and U.S. citizens should be advised to avoid large gatherings over the next 48 hours,” the U.S. embassy warned.

Guards at concert hall didn't have guns, state news says

The Associated Press

Guards at the concert hall didn’t have guns, and some could have been killed at the start of the attack, Russian media reported.

Some Russian news outlets suggested the assailants fled before special forces and riot police arrived.

Reports said police patrols were looking for several vehicles the attackers could have used to escape.

U.S. had been gathering intelligence that ISIS could attack Russia

Ken Dilanian

The U.S. had been gathering intelligence for months that ISIS could mount a mass casualty attack in Russia, two U.S. officials confirmed to NBC News.

That information led to a March 7 warning issued by the U.S. embassy in Russia about possible extremist attacks, including at concerts, urging people to stay away from large gatherings, one of the officials said.

That official said the claim of responsibility today by ISIS appears to be genuine, though no final assessment had been made about who was responsible.

Some Moscow concertgoers filmed events as they unfolded Friday night, when gunmen opened fire inside a theater and people ran to take cover in fear for their lives.

Witness says gunfire was first thought to be construction noise

A witness to today’s armed attack on Moscow’s Crocus City Hall told a state news agency that they first mistook the gunfire for sounds of an installation being dismantled.

“First, we started hearing typical loud pops, but it was impossible to understand that they were gunshots. We thought that something was falling, as exhibitions were being dismantled at that moment, and someone seemed to be dropping something large,” Mikhail Semyonov told TASS .

“Then, the bangs were getting more and more frequent. Suddenly, there was a scream, and the bangs started to be heard as bursts. Then it became clear that it was shooting,” he said.

ISIS claims responsibility for attack but does not provide proof

The terror group Islamic State has claimed responsibility for the attack in Moscow.

The group, also known as ISIS, did not provide any proof of its claim, which came from ISIS-affiliated news agency Amaq on Telegram.

The group’s members have carried out a number of terror attacks, including the 2015 attacks in Paris that killed 130 people.

Children among the victims, Russia's children commissioner says

Yuliya Talmazan

Russia’s commissioner for children’s rights, Maria Lvova-Belova, said children were among the victims of tonight's attack.

"Information about their condition is regularly updated," Lvova-Belova said on Telegram. "Any additional assistance will be provided immediately."

She later told Russia 24 TV channel that at least two children had been injured, including one boy with a gunshot wound.

Earlier, Russian officials released a preliminary casualty toll of at least 40 people dead and more than 100 injured.

France, U.K., Germany condemn attack

Officials from France, the U.K. and Germany were among those who expressed their condolences to the victims of the attack at the Crocus concert hall.

"The images of the terrible attack on innocent people in Crocus City Hall near #Moscow are horrific," Germany's Foreign Office said on X . "The background must be investigated quickly. Our deepest condolences with the families of the victims."

"We condemn the terrorist attack in the Crocus City Hall near Moscow," the U.K.'s embassy in Russia said . "This is a terrible tragedy."

Meanwhile, France's foreign ministry called for "full light" to be shed on "these heinous acts."

Public events across Russia called off after attack

Several regional leaders across Russia, including in the annexed Kherson region of Ukraine, have canceled public events this weekend over security considerations after the deadly concert attack in Moscow.

Shortly after the attack, Moscow Mayor Sergey Sobyanin canceled all sports, cultural and other public events in Moscow this weekend. State news agency TASS also quoted Russia's cultural ministry as saying that mass and entertainment events in federal cultural institutions have been canceled in the coming days.

Zelenskyy adviser speaks out about attack

President Volodymyr Zelenskyy’s adviser denied that Ukraine was involved in the deadly Crocus concert hall attack.

“Ukraine certainly has nothing to do with the shooting/explosions in the Crocus City Hall (Moscow Region, Russia),” Mykhailo Podolyak wrote on X. “It makes no sense whatsoever.”

No evidence has emerged to suggest Ukraine may have been involved, but Ukrainian officials may be trying to pre-empt accusations, as some Kremlin hawks have already started pointing at Kyiv. 

Asked whether the shooting was at all tied to the war in Ukraine, U.S. National Security Council spokesperson John Kirby said: “There is no indication at this time that Ukraine, or Ukrainians, were involved in the shooting, but again, this just broke. We’re taking a look at it, but I would disabuse you at this early hour have any connection to Ukraine.”

Videos posted to social media appear to show chaos inside Moscow's Crocus City Hall during and after a terrorist attack.

Some videos include what sound like gunshots and show men with rifles, as concertgoers frantically try to exit the venue.

State Department issues warning to Americans in Moscow

Jason Abbruzzese

The State Department said that the U.S. Embassy in Moscow is aware of the terrorist attack on Crocus City Hall and that U.S. citizens should avoid the area and follow the instructions of local authorities.

"The U.S. government’s ability to provide routine or emergency services to U.S. citizens in Russia is severely limited, particularly in areas far from the U.S. embassy in Moscow, due to Russian government limitations on travel for U.S. embassy personnel and staffing, and the ongoing suspension of operations, including consular services, at U.S. consulates in Russia," the State Department said in a message posted to its website .

'What a nightmare in Crocus,' Widow of opposition leader Alexei Navalny condolences about concert attack

Yulia Navalnaya, the widow of Russian opposition leader Alexei Navalny who died in prison last month, expressed her condolences about the attack Friday.

"What a nightmare in Crocus," Navalnaya wrote on X. "Condolences to the families of the victims and quick recovery to the injured. Everyone involved in this crime must be found and held accountable."

320 firefighters, 3 helicopters working to put out fire

Russia's Ministry of Emergency Situations said the number of rescue crews responding to the attack is growing and now includes more than 320 firefighters, 130 emergency vehicles and three helicopters dumping water on the burning concert venue.

Moscow regional governor says 40 dead, more than 100 injured

Moscow Regional Governor Andrei Vorobyov said on Telegram that at least 40 people are dead and more than 100 injured in the terrorist attack, confirming figures previously reported by Russian state news.

Putin informed about concert venue attack 'in the first minutes,' Kremlin spokesperson says

Kremlin spokesperson Dmitry Peskov said President Vladimir Putin was informed about the shooting at the Crocus concert hall "in the first minutes" of the attack, Russian state news agency RIA reported.

The president is receiving information about what is happening and the measures being taken through all relevant services and is giving necessary instructions, Peskov said according to RIA.

Russian journalist was inside concert venue when gunmen entered

Russian news agency RIA Novosti said on Telegram that one of its reporters was inside the venue when gunmen entered and began shooting concertgoers.

The journalist said that at least three unmasked gunmen in camouflage entered the hall a few minutes before 8 p.m. Moscow time. They shot people point-blank and threw incendiary bombs, according to the journalist.

Russia's foreign ministry spokesperson calls incident 'bloody terrorist attack'

Maria Zakharova, spokesperson for Russia's foreign ministry, called the Friday night incident at the Crocus City Hall in Moscow a "bloody terrorist attack" as she called for "strong condemnation" from the international community.

"Now, as the Russian authorities have stated, all efforts are being devoted to saving people," Zakharova said. "The entire world community is obliged to condemn this monstrous crime!"

U.S. national security spokesperson says embassy has told Americans to avoid large gatherings in Moscow

Kyla Guilfoil

National Security Council Spokesman John Kirby addressed the attack in Moscow at a White House press briefing Friday afternoon, calling it a “terrible, terrible shooting attack.”

“The images are just horrible and just hard to watch and our thoughts obviously are going to be with the the victims,” Kirby said.

Kirby added that the U.S. embassy has notified all Americans in Moscow to avoid large gatherings, concerts, shopping malls, etc., and “stay put where they are” for their safety.

Russian media says 40 dead, more than 100 injured at concert attack

TASS, Russia's state-owned news agency, and RIA Novosti are reporting that Russia's FSB security agency has put the preliminary casualty count at 40 dead and more than 100 injured by a terrorist attack on a Moscow-area concert venue.

NBC News has not confirmed those casualty numbers.

Roof of concert venue at risk of collapse, Russian media says

Russian news agency RIA Novosti said on Telegram that the roof of the building near the concert venue's stage has begun to collapse.

Video posted to Telegram by RIA Novosti showed fire continue to blaze inside the venue.

Moscow area governor says more than 70 ambluances at scene of attack

Andrei Vorobyov, Moscow's regional governor, said on Telegram that more than 70 ambulances have been dispatched to the scene of concert venue attack.

“Everything is being done at the scene to save people," he wrote in the Telegram message. "The Special Rapid Response Unit (SOBR) has been deployed. There are over 70 ambulance carriages near Crocus, doctors provide the necessary assistance to all victims."

Nigel Chiwaya

Russia’s prosecutor general office says number of victims still being determined

Russia's prosecutor general said on Telegram that officials are working to determine how many people have been killed or hurt in the concert attack.

“On behalf of Igor Krasnov, the prosecutor of the Moscow region has gone to the scene of the incident at Crocus City Hall to coordinate the actions of law enforcement agencies," the prosecutor general's Telegram account posted. "Tonight, before the start of the event in the concert hall in Krasnogorsk, unknown men in camouflage clothes broke into the building and started shooting."

"The number of victims is being determined, a fire started in the entertainment center building, and citizens are being evacuated."

Moscow's mayor cancels weekend events

Moscow Mayor Sergei Sobyanin said on Telegram that he was canceling all public events in Moscow this weekend.

"I have taken the decision to cancel all sports, cultural and other public events in Moscow this weekend," he said. "I ask of you to treat this measure with understanding."

Popular rock band was to play sold-out venue that can hold 9,500

Tim Stelloh

A popular rock band was scheduled to play what appeared to be a sold-out show at the Moscow concert hall where there were reports of gunmen in combat fatigues opening fire.

Picnic, formed in 1978, was to play at Crocus City Hall, west of central Moscow.

The multilevel facility in Krasnogorsk has a maximum capacity of 9,527 people. Booking sites show the event was sold out.

Russia's aviation agency says additional security added to Moscow airports

The Russian aviation agency Rosaviatsiya said that additional security measures are being introduced in Moscow airports

"Due to increased security measures, we ask passengers to arrive at Sheremetyevo, Domodedovo, Vnukovo and Zhukovsky airports in advance," the agency said on the Telegram messaging app.

Moscow's emergency ministry says it is working to extinguish fire

Moscow’s emegency ministry said it was working to extinguish a fire that began at the music venue.

The ministry said about 100 people were evacuated from the building, and it was working to rescue people from the roof.

Russian media says state security taking action

Russia's news outlet RIA Novosti said that the country's security agency, the FSB, is taking measures to respond to the shooting at a concert hall near Moscow.

Videos posted by Russian media show men with rifles moving through area

Extended rounds of gunfire could be heard on multiple videos posted by Russian media and Telegram channels. One showed two men with rifles moving through a concert hall. Another one showed a man inside the auditorium, saying the assailants set it on fire, with incessant gunshots ringing out in the background.

Andrei Vorobyov, the governor of the Moscow region, said he was heading to the area and set up a task force to deal with the damage. He didn’t immediately offer any further details.

Russian media reports said that riot police units were being sent to the area as people were being evacuated.

Russian news outlets report gunman opened fire at Moscow concert hall

Several gunmen in combat fatigues burst into a big concert hall in Moscow on Friday and fired automatic weapons at the crowd, injuring an unspecified number of people, Russian media said.

Russian news reports said that the assailants also used explosives, causing a massive blaze at the Crocus City Hall on the western edge of Moscow. Video posted on social media showed huge plumes of black smoke rising over the building.

Russia’s state RIA Novosti news agency reported that at least three people in combat fatigues fired weapons. The state Tass news agency also reported the shooting.

U.S. warned of imminent Moscow attack by ‘extremists,’ urges citizens to avoid crowds

Patrick Smith

U.S. citizens in  Moscow  had been warned to avoid large gatherings earlier this month because of heightened fears of a terrorist attack.

The U.S. Embassy in the Russian capital said it was “monitoring reports that extremists have imminent plans to target large gatherings in Moscow, to include concerts, and U.S. citizens should be advised to avoid large gatherings over the next 48 hours.”

U.S. citizens should avoid crowds, monitor local media for updates and “be aware of your surroundings,” it said in a brief  online update .

Read the full story here.