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traveler’s diarrhea

two travelers holding hands. Text on photo: Don't Let Traveler's Diarrhea Slow You Down

Don’t Let Traveler’s Diarrhea Slow You Down!

With the COVID-19 lockdowns coming to an end — no more work or school from home (unless you need or want to), and we would be very, very surprised if you haven’t already made travel plans to catch up with friends and family in faraway places this summer. However, before you hit the road, this is a good time to remind you not to let traveler’s diarrhea slow you down, especially if your plans take you long distances and out of the country, even on a cruise.

As exciting as traveling can be, getting there is stressful and can throw your circadian clock and sleep schedule for a loop when you jump into different time zones.

Then, throw in a Western-style diet full of fatty, sugary foods — something very easy to do when you’re away from your healthier routines at home — and you’re creating opportunities for traveler’s diarrhea to occur.

What Is Traveler’s Diarrhea?

Traveler’s diarrhea is a disorder in the digestive tract that causes abdominal cramping and loose stools, according to the Mayo Clinic.

Eating or drinking contaminated foods or liquids are the main causes of traveler’s diarrhea, the most predictable travel-related illness with estimated rates of “attack” as high as 70 percent, depending on when and where you travel, according to the CDC.

Typically, travelers come into contact with the most common bacterial pathogens (E. coli, Salmonella and Campylobacter jejuni) due to poor hygiene practices in local restaurants.

Traveler’s diarrhea usually occurs abruptly, and can happen during or after your trip. What’s more, you may experience it multiple times.

Although it isn’t considered serious in many cases, recent research from The Rockefeller University showed how some people can develop irritable bowel syndrome due to an unfortunate encounter with traveler’s diarrhea.

How Do You Prevent Traveler’s Diarrhea?

If you and your family are heading out on the road any time this summer, here’s some easy steps you can take to reduce your risk for traveler’s diarrhea.

  1. Know where your water comes from, and avoid drinking unsterilized water. Bottled water is your best friend while traveling.
  2. Wash your hands with plain soap and water early and often, especially before eating.
  3. Don’t ask your doctor to prescribe an antibiotic specifically to prevent traveler’s diarrhea, as it can contribute greatly to your risks of antibiotic resistance.
  4. A recently updated meta-analysis of studies published in Epidemiology and Health concluded taking a probiotic may significantly improve your odds of avoiding traveler’s diarrhea altogether.

In fact, among the beneficial bacteria cited in this analysis are two of the 10 building block strains from the Lactobacillus family contained in EndoMune Advanced Probiotic.

More over, older studies have also found that taking a probiotic like EndoMune at least two days before leaving on your trip and during it can help you and yours avoid traveler’s diarrhea and enjoy that long deserved vacation you’ve been waiting for a very long time to enjoy!



Graphic with lists of good bacteria and bad bacteria in your gut.

The IBS/Traveler’s Diarrhea Connection

The holiday travel season may be long over, but the memories of that special trip, maybe to a warmer destination many time zones and thousands of miles away, still resonates.

Your only sour memory of that trip is a bad case of traveler’s diarrhea, the most common ailment vacationers face when they journey long distances, particularly to international destinations like South America, Africa, Mexico and Asia.

That run-in with traveler’s diarrhea could leave you vulnerable to irritable bowel syndrome (IBS), the most common gut health problem that affects up to 15 percent of all Americans, according to the American College of Gastroenterology.

A weakened immune system

Although researchers are still trying to figure out all of the answers, a recent study may have found an important connection between IBS and traveler’s diarrhea, according to a recent study appearing in the journal Cell.

To support a healthy gut, our body’s immune system must be equipped to maintain a balanced response to problems as they come without overdoing it.

For example, inflammation can help the gut fight an infection, but too much of a response “can cause lasting harm,” says Dr. Daniel Mucida, head of The Rockefeller University’s Laboratory of Mucosal Immunology.

After Dr. Mucida and his team treated mice with a weak form of Salmonella (a very common bacterium that causes food poisoning), they discovered a lingering drop of neurons in the gut that could create an inflammatory response.

Previous work by Dr. Mucida determined these neurons could also be triggering the death of a specialized set of gut immune cells that can lead to constipation, a key IBS symptom.

A gut bacteria imbalance

Not surprisingly, this research team also discovered treating mice with Salmonella tipped the balance of beneficial gut bacteria in their tiny bodies in a bad way.

However, those neurons recovered when scientists restored the healthy balance of bacteria in those very same mice.

Fortunately, one of critical steps you should take to prevent traveler’s diarrhea — taking a probiotic — works very well when treating IBS too.

That being said, not just any kind of probiotic will do the trick.

Many probiotics are formulated with a single strain of bacteria to treat a specific problem, but not the kinds that patients encounter with IBS.

Based on a very recent review in the journal Nutrients, patients experienced greater benefits when taking probiotics with multiple strains of beneficial bacteria for at least eight weeks.

The human gut is populated by more than 1,000 species of bacteria. A probiotic made with multiple strains of beneficial bacteria is formulated to boost your immune system and treat IBS more effectively.

Taking a product like EndoMune Advanced Probiotic made from 10 strains of beneficial bacteria from the Lactobacillus and Bifidobacterium families plus a prebiotic (FOS) that feeds the good bugs in your gut may be the safer and more effective choice for treating IBS and traveler’s diarrhea too.


Cell, Vol. 180, Issue 1

The Rockefeller University

Nutrients, Volume 11, Issue 9

Gut Microbiota For Health

You may be spreading antibiotic resistance while traveling

The health problems associated with taking antibiotics too often have grown beyond the risk of having them not work when you really need them. Recent studies have found exposure to antibiotics can increase your odds of colon cancer and reprogram your baby’s gut microbiota for the worst.

Unfortunately, antibiotics like ciprofloxacin (Cipro) have been the go-to drugs for people traveling overseas to avoid traveler’s diarrhea, a very popular topic we’ve discussed often in this space. A recent study published in Clinical Infectious Diseases underscores the health risks associated with taking too many antibiotics, leading to the spread of superbugs.

Finnish researchers collected stool samples and surveys from 430 travelers before and after their trips abroad in hopes of finding traces of extended-spectrum beta-lactamase (EBSL), an enzyme generated by the Enterobacteriaceae group of bacteria that produces resistance to many common antibiotics.

The numbers alone signal grave problems from antibiotics. Overall, 21 percent of travelers to tropical and subtropical areas (90 patients) contracted EBSL-producing bacteria during their trips.

The group most affected by antibiotic-resistant bacteria was the 80 percent of Finnish travelers who visited Southern Asia, followed by Southeast Asia, East Asia, North Africa and the Middle East.

According to scientists, the huge health problem was that although those 90 travelers didn’t develop infections while on vacation, they could have spread superbugs when they returned home. Had the number of infected patients been a little larger, detectable symptoms would’ve been found.

“More than 300 million people visit these high-risk regions every year, “says lead study author Dr. Anu Kantele in a press release. “If approximately 20 percent of them are colonized with the bugs, these are really huge numbers. This is a serious thing. The only positive thing is that the colonization is usually transient, lasting for around half a year.”

Should travelers face diarrhea on the road, Dr. Kantele suggests drinking plenty of fluids, using over-the-counter medications to relieve mild symptoms and only seeking medical attention for severe problems.

Interestingly, an accompanying editorial cited prebiotics and probiotics as non-antimicrobial measures to beat traveler’s diarrhea. Taking a multi-strain probiotic, like EndoMune Advanced Probiotic or EndoMune Advanced Junior (for kids), at least two days before going on a long-distance trip can boost your immune system and maintain the natural balance of bacteria in your gut.

Should you need an antibiotic for any reason, please take a probiotic as well. Follow a two-hour gap between taking an antibiotic and probiotic, as this will reduce the likelihood that the drug will deplete the live, beneficial bacteria before they’ve had a chance to do their work.

Traveling this holiday season? 6 ways to avoid traveler’s diarrhea


With the Christmas/New Year’s holidays nearly upon us, the “trendy” gifts aren’t big-screen TVs or tablets waiting under a tree to be opened. Material things are taking a back seat to something new: Large families taking long-distance trips to far away places across the ocean, according to travel experts.

Traveling with a large contingent of your family, for instance, on a jungle expedition to the other side of the world conjures thoughts of once-in-a-lifetime memories. One of those recollections that will stay with you forever, however, should not be the days you spent sick with traveler’s diarrhea.

Unfortunately, traveler’s diarrhea is the most common ailment travelers face, affecting as many as half of all Americans traveling to international destinations. Although traveler’s diarrhea may happen any time — even after returning home — the CDC warns the onset usually starts during the first week of your trip.

The symptoms of traveler’s diarrhea — frequent trips to the bathroom, loose stools, nausea, cramping, bloating and fever — are abrupt, meaning they won’t sneak up on you. Although traveler’s diarrhea is rarely life-threatening, most incidents are resolved in a week, just enough time to ruin your dream trip.

The following precautions should do the trick to help you and your family sidestep traveler’s diarrhea and make your trip a healthy one.

The Six Ways to Avoid Traveler’s Diarrhea

1. Be sure you and your loved ones are current on all of your vaccinations. You may also need to be vaccinated for diseases (Hepatitis A and B and Typhoid) that aren’t found in North America.

2. The popular warning “don’t drink the water” should also include avoiding unpasteurized dairy foods (milk and cheeses), fruit that hasn’t been washed and peeled and cooked foods allowed to cool. Also, don’t chill your drinks with ice that may be produced with unclean water.

3. Keep your hands as clean as possible with simple soap and water, especially before a meal. Travelers should also stay away from touching their mouths, faces or any mucous membranes with their hands as much as possible during their trip, according to the CDC.

(A warning: A proposed rule under consideration by the FDA would raise the burden on manufacturers to prove their antibacterial soaps prevent more infections than simpler soaps.)

Watch For Bugs!

4. Because diseases can be spread due to mosquito bites, consider using insect repellants made with DEET or picaridin.

5. As a preventative measure, some medical experts have suggested prescribing antibiotics in the past. However, those same experts are thinking twice, considering all the problems connected with increased antibiotic resistance and eradicating the balance of beneficial bacteria in your gut.

6. A growing number of studies have found consistently taking a probiotic at least two days before a long-distance trip can boost your immune system naturally, and help you and your family avoid traveler’s diarrhea.

For healthy adults, taking a probiotic formulated with multiple strains of bacteria like EndoMune on an empty stomach about a half-hour before eating your morning meal may boost your immune system and promote optimal gut health.

Also, if you must take an antibiotic on the road, be sure to delay taking a probiotic by two hours. Doing so will reduce the risk of antibiotics destroying the live, beneficial bacteria contained in a probiotic that preserve and protect your gut health.

An Expert’s take on Traveler’s Diarrhea

Now that it is getting close to summer, folks are starting to consider vacation travel plans. This newsletter will discuss options for staying healthy when traveling outside the United States to developing countries.

I would like to review the updated recommendations in preventing and treating Traveler’s diarrhea (TD).

Overview: Among travel-related illnesses, acute diarrhea is the most common disorder. A study of Americans visiting developing countries found that 46% acquired diarrhea (1). Destination is the most significant risk factor for developing diarrhea. Areas with highest risk are developing countries in Latin America, the Middle East, Africa and South Asia.

Definition: Traveler’s diarrhea is defined as three or more unformed stools per 24 hours starting during or shortly after a period of foreign travel with at least one of the following symptoms: fever, nausea, vomiting, or abdominal cramps. Most episodes last 3-4 days without therapy, but some infections can cause severe diarrhea and dehydration requiring hospitalization and IV fluids.

Etiology: The cause of TD is exposure to food and water that has been contaminated with fecal matter due to poor sanitary and public health conditions.

The organisms that cause the diarrhea are bacteria, viruses and parasites. Studies have found that bacteria like E. Coli, Shigella and Campylobacteria account for 80% of the episodes (2). Parasites and viruses are less common causes although there have been a number of outbreaks on cruise ships due to viruses (3).

Prevention: Travelers are advised to ”boil it, cook it, peel it, or forget it.” Unfortunately, despite pre-travel advice, many travelers still develop diarrhea even when avoiding high risk foods. The general recommendations include avoid raw vegetables, fruits that you have not peeled, unpasteurized dairy products, cooked food not served steaming and tap water, including ice. Although it smells and looks great…don’t eat food from street vendors!

Drug prophylaxis: There have been a number of studies evaluating different medications taken on a daily basis in order to prevent the development of diarrhea.

Antibiotics: It is not generally recommended to prescribe antibiotics as a prophylaxis to prevent TD as it can lead to drug resistant organisms (4). In immuno-compromised individuals or those with serious health issues, use of prophylactic antibiotics may be beneficial. Taking daily antibiotics like ciprofloxin (Cipro) 500mg, or levofloxacin (Levaquin) 500mg have been used successfully to prevent bacterial diarrhea in 90% of those treated (5).

Rifaximin (Xifaxan) is a non-absorbable antibiotic that has also been shown to lessen the risk of TD in 75% of those taking a single 200mg dose daily. However, the antibiotic does not protect against invasive bacteria like Samonella.

Bismuth subsalicylate: Pepto-Bismo provides a protection rate of 60% when given as two tablets 4 times daily (6). It does cause the tongue and stool to turn black and can cause ringing in the ears. It is not recommended to use this regimen for more than 3 weeks.

Probiotics: A statistical analysis of 12 control trials found that 85% of TD cases were prevented by probiotics (6). The dosage of probiotic bacteria given and the type of organisms varied. It is difficult to generalize that all probiotics are effective. The analysis did find that probiotics containing lactobacillus and Bifidobacteria strains were effective. Also, probiotics containing a yeast, Saccharomyces boulardii, lessened the risk of TD (6).

Probiotics are a more natural approach to prophylaxis. The bacteria colonize the intestines and prevent the pathogenic bacteria from successfully producing harmful toxins and invading the mucosa.


Generally, traveler’s diarrhea is a self-limited illness without fever lasting several days. Unfortunately, it is not possible to determine after the first loose stool the length and severity of the illness. Having diarrhea while on vacation or on a business trip can be very disruptive to planned activities. There are several recommendations:

  • Start an antibiotics if the there are 3 or more loose stools in an eight hour period. The drug of choice is still Cipro 500 mg twice daily for 3 days. If there is no fever or blood in the stools, an alternative antibiotic is Rifaximin 200 mg three times daily for 3 days.
  • There are areas (e.g., Thailand) where the bacteria are resistant to Cipro type medication; in these areas, Azithromycin (Zithromax) is recommended 500mg once daily for 3 days.
  • To lessen the diarrhea and cramps, Pepto Bismo 1 oz (2 tbsp) every half hour for a total of 8 doses (16 tbsps) in eight hours. Pepto Bismo eases the cramps, nausea and diarrhea without any serious side effects.
  • Another medication used to lessen diarrhea and cramps is loperamide or Imodium. Take a loading dose (4 mg) after the first loose stool and then 2mg after every loose stool for a total of 8 doses (16 mg) in 24 hours. This will ease the symptoms of diarrhea and help prevent dehydration. A warning though: do not take Imodium if there is fever or blood in the stool. Imodium slows the motility of the colon and can possibly make an invasive infection worse.
  • Rehydration packets like CeraLyte electrolyte packets can be added to water to help maintain hydration. Otherwise, replace fluids with plenty of water and replace lost electrolytes using foods like broth and saltine crackers.

Final Recommendation

  • If traveling to a developing country, access the CDC webpage for information on immunizations and other health questions.
  • Contact your physician regarding prescriptions for the antibiotics to take if you develop TD. It is important to start therapy on a timely basis. Trying to obtain medical care and medicines while traveling delays treatment and medications purchased abroad may be substandard.
  • Take a good probiotic like EndoMune on a daily basis. Start 2-3 days before you travel. In general, good probiotics should be refrigerated. Studies have shown that EndoMune will survive at room temperature for months. It is best not to store probiotics in temperatures greater than 85 degrees for prolonged periods.

Finally, I hope all your travels are joyful, safe, and healthy. Don’t forget to pack your camera…and some EndoMune.

Eat healthy, exercise and live well!!
Dr. Hoberman

(1) Hill DR: Occurrence and self-treatment of diarrhea in a large cohort of Americans traveling to developing countries. Am J Trop Med Hyg 2000;62:585-9.

(2) Steffen R, Sack RB:Epidemiology. In: Ericsson CD, DuPont HL, Steffen R, eds. Travelers’ diarrhea; Hamilton, Ont.: BC Decker, 2003: 112-23

(3) Chapin AR, Carpenter CM, Dudley WC, et al: Prevalence of norovirus among visitors from the United States to Mexico and Guatemala who experienced traveler’s diarrhea. J Clin Microbiol 2005;43:1112-1117.

(4) Centers for Disease Control:

(5) Rendi-Wagner P, Kollaritsch H. Drug prohylaxis for traveler’s diarrhea. Clin Inft. Dis 2002;34:628-33.

(6) Steffen R, Heusser R, DuPont HL: Prevention of travelers’ diarrhea by nonantibiotic drugs. Rev Infect Dis; 1986;8(suppl 2);S151-9.

(7) McFarland LV: Meta-analysis of probiotics for the prevention of traveler’s diarrhea. Travel Med Infect Dis. 2007;2:97-105.

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