Travelers' diarrhea in the new millennium: consensus among experts from German-speaking countries

Travelers’ diarrhea (TD) of varying severity grades continues to be a very frequent health problem among travelers originating from industrialized countries and visiting developing countries (Fig. 1).1,2 Fresh-water resources, particularly in densely populated areas, including recently developed tourist centers are often contaminated.3,4 Contaminated food and improper food handling also play an important role. High-risk destinations with incidence rates of 20 to 90% of TD for a 2-week stay include most parts of Africa, Asia, and Latin America, some islands in the Caribbean, including the Dominican Republic and Haiti, and some remote destinations in Eastern Europe. Intermediate-risk destinations with incidence rates of 8 to 20% of TD include South Africa, some destinations in Southern Europe, Israel, Japan, most destinations in the Caribbean, Argentina, and Chile. TD is associated with fecally contaminated food and beverages. The most frequent etiologic agents detected at most destinations are enterotoxigenic Escherichia coli (ETEC) and enteroaggregative E. coli (EAEC), mainly active in the small bowel.5 Many other bacterial pathogens are frequently detected, but viral and parasitic agents also play a certain role.Cryptosporidia, ranking among emerging pathogens, are increasingly detected.6 Speculations about noninfectious causes for TD are usually unwarranted. TD is frustrating at times of high expectations, such as a vacation, honeymoon, or a business trip; however, it is hardly ever life threatening in adults. Besides diarrhea and fecal urgency, the leading symptoms are abdominal cramps, nausea,vomiting, and general malaise. This results in incapacitation often costing more than 10% of the total time abroad.1 Differentiation into classical, moderate, and mild TD is arbitrary because often travelers treat themselves at an early stage, and, furthermore, chronology and etiology in the various severity forms of TD suggests identical causes