Traveler's Diarrhea (Montezuma’s Revenge)

What is traveler's diarrhea?

I know, I know…disgusting…but almost everyone (including me) that’s ever been out of their own country has, at one time or another, been struck down by Traveler's diarrhea, commonly referred to as Montezuma’s Revenge. In fact, each year 20%–50% of international travelers or more than 10 million people, suffer from traveler's diarrhea. Just when you thought you were going to be enjoying all kinds of different foods and exotic delicacies, BAM!, you get hit with a stomach flu from hell that can ruin your entire vacation. Traveler's diarrhea, or TD, is a term used to describe the infection and resulting diarrhea caused by bacteria, protozoa, or viruses ingested by consuming food or water that has been contaminated. About 80-90% of cases are caused by bacteria such as E-Coli (Escherichia coli) Camje (Campylobacter jejuni), Shigella and Salmonella. About 10-20% of all TD cases in long-term travelers are caused by the protozoal pathogen Giardia (Giardia intestinalis), a very nasty bug that caused me to be seriously sick for six weeks two years ago. Always willing to try something new, I ate some strange seafood in Lima, Peru the second night there and was sick the entire rest of the time I was there. So, instead of enjoying Anticuchos, Ceviche and Aji de Gallina, I ate boiled chicken for 5 weeks! It wasn’t until I returned home to the states that I finally got the proper diagnosis and antibiotic that killed it..and then it took 5 days...which brings up another topic altogether...medical treatment in other countries, especially Latin American countries. While their overall bedside manner and general medical practice is second to none and American doctors could learn a hell of a lot about real medical caring from them, their medical treatment in the form of antibiotics is strictly third world. I could go on and on about the total lack of pharmaceutical education and practice but suffice it to say that if you get really sick in Latin America (or anywhere else) or if you mention a specific drug by name and they give you that dumb puppy-dog look, come home! How I do digress, sorry.

What are the causes of traveler's diarrhea?

Traveler's diarrhea describes a specific condition that most often occurs when traveling to countries that have poor public sanitation and hygiene. It is that poor hygiene practice in local restaurants that has been specifically identified as the main contributor to TD. High-risk areas are often located in developing countries, such as Africa, Asia, Mexico, Central and South American, and the Middle East.

One of the major reasons for travelers diarrhea, and why it hits everyone of all nations, is that there are different bacteria in different parts of the world, especially in the oceans of the world, which can cause even the most prepared traveler to catch TD. For example, the bacterium in the water off Miami is totally different than the bacteria off the coast of Peru. This is why when we travel to Peru and eat “fresh-caught” seafood, we can still get sick! The converse is also true…when foreign travelers come to the states they can get sick as well, because they are eating different bacteria than their guts are accustomed to processing. In other words, we build up an immunity or tolerance to our specific bacteria in our specific region of the world…this is why locals in another country can eat the exact same fish that will make you or I vomit for days  (or weeks) and not get sick at all.

Traveler's diarrhea is also caused by drinking water or eating foods contaminated with fecal material (yeh I know, gross…but true!), unsafe storage of food, improper food handling and preparation, and inadequate sterilization of surfaces and utensils used in food preparation.

What are the symptoms of traveler's diarrhea?

I think you all know what to look out for, like running to the bathroom every 10 minutes or throwing up everything you ever ate in your entire life, but here are the not-so-pleasant highlights:

• Bloating (Oh yeh, like someone shoved a football down your throat and it’s lodged in your intestines bloating)

·         Nausea (see Bloating)

• Urgency to evacuate (that’s a pleasant phrase for if you don’t get to a bathroom in the next 60 seconds you're going to be wearing it)
• Fatigue (from dehydration, from all the ‘Urgency to evacuate’ occasions)
• Loose, watery stools (There’ll be plenty of this for sure)
• Fever (From the raging infection that has completely taken over your bowels)

*Keep in mind that a ‘normal’ course of traveler's diarrhea lasts anywhere from 3 to 7 days and that my 6 week excursion into hell was not the ‘norm’.

Can traveler's diarrhea be prevented?

While common sense is the best prevention, the best preventives for traveler's diarrhea are:

• Only use water that has been boiled or chemically disinfected for:
• Drinking, or preparing beverages such as tea or coffee (only with bottled water, even if you’re going to boil it)
• Brushing teeth (only with bottled water)
• Washing face and hands (alcohol-based gel can also be used to wash hands)
• Washing fruits and vegetables (With bottled water. It wouldn’t make sense to wash of feces-laden veggies with feces-laden tap water now would it?)
• Washing eating utensils and food preparation equipment (with, you guessed it, bottled water)
• Washing the surfaces of tins, cans, and bottles that contain food or beverages (again, with bottled water)
• Do not eat food or drink beverages from unknown sources, and only drink beverages that have been bottled and sealed. (‘sealed’ is the key word here)
• Do not put ice in drinks (unless it came from bottled water)
• Any raw food could be contaminated, including:
• Fruits, vegetables, salad greens (especially difficult when trying to maintain a heart-healthy diet when traveling)
• Unpasteurized milk and milk products
• Raw meat
• Shellfish
• Any fish caught in tropical reefs rather than the open ocean

Although antibiotics, antimicrobial drugs, antidiarrheals, as well as other over-the-counter medications are sometimes used as preventives, the Centers for Disease Control and Prevention does not recommend their use without the specific advice and supervision of a doctor. Taking any medication without medical supervision can be dangerous. In addition to side effects or allergic reactions, long-term use of medications can mask symptoms that may need medical attention…as well as build a tolerance for the antibiotics, which renders their usefulness moot.

Although the above is advisable, I wanted to share the results of a recent study by Johns Hopkins:

"A prophylactic program was designed to prevent traveler's diarrhea comparing the efficacy of doxycycline and trimethoprim-sulfamethoxazole. A total of 99 volunteers received either medication. No cases of traveler's diarrhea were reported in either group or in a control group not taking prophylactic antibiotics. The 42 volunteers taking doxycycline showed neither of its main two side effects, photosensitivity or gastrointestinal discomfort. Three of 57 volunteers taking trimethoprim-sulfamethoxazole had side affects from it--two with some gastric discomfort and one with a skin rash. Another common side effect, which did not occur, is diarrhea."

Treatment for traveler's diarrhea

Traveler's diarrhea, although uncomfortable and unpleasant, usually lasts only a few days. Dehydration (loss of fluids) can be a serious side effect, especially for children and babies. Drinking plenty of non-contaminated fluids is important, like (yes, again) bottled water!

For diarrhea that is worse than normal or lasts more than three days, it is best to consult a doctor, especially for pregnant women and children. Seek medical help when diarrhea is:

• Severe
• Bloody
• Does not get better within a few days (If you’re in a foreign place and have diarrhea I’d see a doctor after two days at the max, why put off delaying the cure?)
• Accompanied by fever and chills
• Causes dehydration

Also, antibiotics are typically given for three to five days,but a single doses of azithromycin or levofloxacin have been used

My advice for all you world travelers (and eaters) out there: Be careful out there my friends, even in so-called ‘good’ hotels and never, ever eat food from street vendors. As quaint and gastronomically experimental as it may seem this practice can ruin the rest of your hard earned vacation! 

Be healthy people!