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