Measures to prevent dehydration

• These recommendations are based on guidelines issued by the World Health Organization (WHO) on managing traveller's diarrhoea [WHO, 2007; WHO, 2009].

Symptomatic treatment for children is not recommended.

• CKS found no evidence to support the use of bismuth subsalicylate and loperamide in children with traveller's diarrhoea.
• The recommendation to avoid loperamide in children younger than 13 years of age is in line with guidance from WHO, which advises against the use of loperamide and other antimotility drugs because they may cause intestinal obstruction [WHO, 2007]. Over-the-counter loperamide is only licensed for use in children older than 12 years of age [ABPI Medicines Compendium, 2008].
• Bismuth salicylate (Pepto-Bismol^®) is not licensed for use in children younger than 16 years of age because of the possible association between salicylates and Reye's syndrome [ABPI Medicines Compendium, 2009a; ABPI Medicines Compendium, 2009b].

Symptomatic treatment for adults

• Symptomatic treatment is usually not necessary because traveller's diarrhoea is generally a mild, self-limiting illness.
• CKS found limited evidence to support the use of bismuth subsalicylate and loperamide for traveller's diarrhoea in adults. Trials were generally of poor methodological quality. Although a reduction in stool frequency was reported when compared with placebo, the differences were small.
• Some experts recommended their use for mild-to-moderate traveller's diarrhoea [Ericsson, 2003; Hill and Ryan, 2008].
• Comparison between loperamide and bismuth subsalicylate
• There is weak evidence from two unblinded trials in students with traveller's diarrhoea that loperamide is more effective than bismuth subsalicylate at reducing the number of unformed stools in the initial stage of treatment (generally within the first 24 hours). However, the differences were small and the clinical significance is uncertain.
• Consequently, loperamide (widely available over-the-counter) might be considered when rapid control of symptoms is required — for example during travelling where toilet amenities are limited or unavailable.
• This is in line with expert opinion [Ericsson, 2003; Hill et al, 2006; DuPont et al, 2009a].
• Recommended indications and precautions for loperamide and bismuth subsalicylate (Pepto-Bismol^®)
• These are in line with recommendations issued by the manufacturers of loperamide and bismuth subsalicylate [ABPI Medicines Compendium, 2008; ABPI Medicines Compendium, 2009a; ABPI Medicines Compendium, 2009b].
• Loperamide should be avoided in people with fever or bloody diarrhoea and in people with acute ulcerative colitis; this is because loperamide can inhibit peristalsis, resulting in complications such ileus, megacolon, and toxic megacolon [ABPI Medicines Compendium, 2008].
• As the benefits over placebo were generally reported only for the first 2 days of treatment in trials, CKS does not recommend their use beyond 2 days.

When to seek medical assistance

• The recommendations on when to seek medical assistance are in line with guidance issued by WHO and expert opinion [Hill et al, 2006; WHO, 2007; WHO, 2009].