Revista de Medicina Desportiva (English) September 2018 | Page 6

What we are reading
In this heading we intend to give news of
recent articles or that deserve to be reread
and commented. It will be an open page to all
colleagues who wish to collaborate by describing
or commenting on topics of sports medicine.
Rev. Med. Desp. informa, 2018; 9(5):4-6.
Dra. Ana Luísa
Santos, Prof. Doctor
Guilherme Macedo
Porto Medical
School.
Guidelines for the prevention and
treatment of travelers’ diarrhea: a
graded expert panel report 1
The prevention and treatment of
the traveler’s diarrhea: what ‘s
been said by the experts?
Traveler’s diarrhea (TD) is an
increasingly global problem, with
very known repercussions at individ-
ual and public level health. Despite
the numerous publications on the
subject, this paper, based on experts’
opinion, concentrates and renews a
crucial set of practical recommen-
dations for prevention and treat-
ment of TD, which is essential for
all professionals who deal with this
problem daily.
One of the great revolutions pre-
sented in this article is related to the
classification of the severity of TD
according to the functional impact
on the individual, rather than the
classification according to the num-
ber/frequency of the dejections. This
disease may be classified as acute
or persistent (if it lasts more than
two weeks), being classified, accor-
ding to the functional impact, as
slight, when tolerable and without
impact on the activity, moderate,
when causing anguish and with
implication in the plans of the trip,
or severe, when it is incapacitating.
All cases of dysentery (which implies
the presence of bloody diarrhea) are
considered severe.
4 september 2018 www.revdesportiva.pt
Although recent studies have
shown the efficacy of the antibiotic
prophylaxis, there is no enough data
to recommend it on a global scale,
even more when it is known that
the antibiotic resistance, with the
growing appearance of multidrug-
-resistant microbial strains, presents
itself as problem on the current
society. Thus, this group of experts
considers that the antibiotic pro-
phylaxis for TD should be reserved
for individuals at high risk of post-
-disease complications, in particular
those with a prior history of long-
-term morbidity after an episode of
TD or with a chronic pathology that
may predispose to these consequen-
ces. In these cases, rifaximin should
be prescribed, but the fluoroquinolo-
nes are contraindicated. The non-
-antibiotic prophylaxis with subsali-
cylate of bismuth can be considered
for any traveler, although it is no
sold isolated in Portugal.
Regarding the treatment, and at
the onset of symptoms, it is essen-
tial that the traveler, supported by
previous information, has the aware-
ness of the severity of the disease,
in order he can take autonomously
the right therapy. For the slight TD,
symptomatic measures are recom-
mended, with enhanced hydration
(water and/or saline beverages for
oral hydration) the ingestion of anti-
diarrheal drugs, like a loperamide: 2
tablets (4 mg) on the beginning, with
reinforcement of one tablet after
each dejection (maximum of 16 mg/
day). When the TD is moderate, anti-
diarrheal drugs (such as loperamide)
and the antibiotics can be taken,
single or in combination according
to the symptomatology. As far as the
antibiotics are concerned, the evi-
dence indicates three equally valid
options: fluoroquinolones (levo-
floxacin, ciprofloxacin, ofloxacin),
azithromycin and rifaximin. Despite
its proven efficacy, the opinions con-
cerning fluoroquinolone become dis-
cordant, due to the adverse effects
(notably musculoskeletal), the emer-
gence of antibiotic resistances and
the effects on intestinal dysbiosis. A
rifaximin is poorly absorbed and is a
tolerated option. However, its empi-
rical use should be under precau-
tion or even avoided in the areas of
higher prevalence of invasive enteric
microorganisms, such as campylo-
bacter, salmonella and shigella. Due
to its faster action for symptomatic
relief, loperamide is a great adju-
vant to the antibiotic therapy. It can
be taken alone one a moderate TD,
but it is contraindicated in children
under two years of age. The antibio-
tic therapy should always be used
on the Severe TD. Azithromycin
should be considered as the first
option in cases of dysentery, as well
as on acute watery diarrhea with
moderate/high fever, which suggests
a higher probability of an infection
caused by microorganisms resistant
to the fluoroquinolones (Campylo-
bacter) and other enteric bacteria,
like the enteric invasive E. coli,
Aeromonas spp. and Yersinia enteroco-
litis. Additionally, it should also be
the preferred drug for the southeast
Asian travelers, due to the greater
resistance to fluoroquinolones. In
cases of non-invasive aqueous
diarrhea, besides azithromycin, the
fluoroquinolones and the rifaximin
are equally recommended options,
but the patients will disregard rifa-
ximin because more than one daily
intake is needed, unlike the other
drugs that are a single daily dose. In
all situations, the visit to the local
health services should be ce carried
out if the symptomatology does not
improve during the first 24-36 hours
after the impplementation of appro-
priate empirical therapy.
After returning from the trip, all
patients whose diarrhea was consi-
dered persistent or severe, or who
did not respond to empirical therapy,
should undergo stool microbiologi-
cal tests to identifying species for