History and exam

Key diagnostic factors

common

presence of risk factors

Key risk factors include age <30 years, adventure travel, itineraries with high exposure to food and beverages from unhygienic sources, travelers with prior residence in a higher-risk destination visiting friends and relatives, military personnel deployed to high-risk destinations, and travel during seasons of hot and wet climates.

diarrhoea (with or without tenesmus), cramping, nausea, and vomiting

Typical symptoms of TD include cramping, nausea, vomiting, and diarrhoeal stools, with resolution in 3-5 days.

uncommon

dysentery (blood and fever)

Bloody stools indicate an invasive organism and a serious, potentially systemic infection.

persistent diarrhoea >14 days

Parasitic infections do not respond to antibiotics and usually persist.[29]​ Giardia is characterised by gassy diarrhoea and belching with an odour of hydrogen sulfide. Amoebic dysentery is associated with a mucoid bloody diarrhoea.

Secondary lactose intolerance or bile acid malabsorption can occur, as well as tropical sprue. Symptoms lasting >30 days may indicate new-onset gastrointestinal disorder or unmasking of pre-existing organic or structural disease.

Other diagnostic factors

common

diarrhoea without illness

Often termed 'loose motions in travel'.

Excess gas or an occasional loose stool without feeling ill could be related to new foods, changes in the normal timing of meals, stress, and changing bacterial flora.

Risk factors

strong

travel to a high-risk destination

High-risk destinations include: South and Southeast Asia; Central and South America; and East, West, and North Africa.[4][11]​​

age <30 years

Younger age is associated with increased risk-taking behaviour and greater propensity for adventure travel in areas with high exposure to food and beverages from unhygienic sources.[2][9]​​

travellers with prior residence in higher-risk destination visiting friends and relatives

Travellers visiting friends and relatives are less likely to exercise food and water precautions, and may not recognise that any previously acquired TD immunity is short-lived. These travellers are also much less likely to seek pre-travel counselling.[21]

travel during hot and wet seasons

The risk may vary depending on the time of year. Hot and wet climate conditions are generally believed to support increased transmission risk for many of the common bacterial pathogens.[2][12]​​​

deployed military populations

A higher prevalence of TD has been noted in deployed military populations and can lead to a decline in job performance or loss of duty days.[4][13][14]

lack of caution in food and water selection

Unsafe items include ice, tap water, salads, previously peeled fruits, and raw foods. Unpackaged condiments and sauces, such as guacamole, often pose a potential risk. Food from street vendors and buffets with poor food turnover also pose a significant notable risk. Safe items include thoroughly cooked food served while still hot, boiled or bottled (properly sealed) water, commercially packaged foods, fresh breads, and fruits peeled by the traveller.

weak

proton-pump inhibitor use

Proton-pump inhibitors may facilitate the survival of bacteria contaminating food or water during transit through the stomach. However, few studies are available to directly evaluate this risk in travellers.[9]​ Consideration may be given to discontinuing use of these medications during travel, unless they are necessary for symptom control.

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