Preface: Guidelines for the Treatment of Travelers’ Diarrhea in Deployed Military Personnel

Abstract

Diarrheal disease frequently affects military personnel deployed to developing countries, resulting in decreased job performance and potential negative impacts on military operational readiness. Travelers’ diarrhea is a self-limiting illness; however, antibiotic treatment (with and without use of adjunct loperamide therapy) has been shown to significantly reduce clinical presentation of symptoms and duration of illness. Nonetheless, the choice of first-line antibiotics must be carefully considered as increasing resistance of enteric pathogens in endemic regions has rendered many first-line antibiotics ineffective (e.g., Campylobacter spp. are resistant to fluoroquinolones in Southeast Asia). Presently, there are no standardized recommendations for the treatment of travelers’ diarrhea among deployed military personnel. Therefore, an expert panel was convened to develop evidence-based, consensus-driven guidelines that address key clinical issues related to self-treatment, antibiotic treatment for acute watery diarrhea and febrile diarrhea/dysentery, and diagnostics. These guidelines ‘Management of Acute Diarrheal Illness during Deployment’ are published in this supplement along with articles reviewing the evidence-based data that supported their development.

Acute diarrheal disease is a common clinical syndrome among travelers to developing nations and is characterized in most studies by the occurrence of at least three unformed stools within 24 hours, in addition to abdominal pain, cramping, nausea, and/or vomiting.^1,2 Travelers’ diarrhea is not only frequently diagnosed among vacationing civilians, but it also impacts deployed military personnel. During Operations Iraqi and Enduring Freedom, more than half of the service members who were surveyed reported having at least one diarrheal episode.^3,4 Predominantly, travelers’ diarrhea is the result of enteric bacterial pathogens, including enterotoxigenic Escherichia coli, enteroaggregative E. coli, Campylobacter jejuni, Shigella spp., and non-typhoidal Salmonella species.^2,5,6 Although it is a self-limiting illness that is often resolved within five days following the onset of symptoms,^1,2,7 enteric bacteria recovered from patients with travelers’ diarrhea have been associated with post-infectious sequelae, such irritable bowel syndrome (IBS).^8,9

Empiric antibiotic therapy (e.g., azithromycin, ciprofloxacin, levofloxacin, and rifaximin) has been shown to significantly lessen clinical symptoms and reduce the overall duration of illness with the time to last unformed stool frequently occurring within approximately 1.5 days.^6,10–13 In addition, antimotility agents, such as loperamide, may be used to mitigate the symptoms of acute diarrheal episodes. While use of loperamide does not result in clinical cure,^2,14 there is an additive benefit when it is administered in combination with antibiotic therapy. Specifically, the duration of diarrheal illness is significantly shortened with combination therapy compared to use of antibiotics alone.^14–18

Although there are similarities between civilian and military travelers, there are noteworthy differences in the circumstances of travel, such as group size (i.e., civilians often travel alone or in small groups, while military populations are comprised of larger groups). The length of civilian travel also generally ranges from days to weeks, while military deployments may last for months. In addition, while travelers’ diarrhea may be a nuisance by disrupting a business trip or vacation, occurrence of the disease has a greater impact on military populations. If a service member is not able to conduct patrols or perform their required duties because of fecal incontinence, being bed-ridden, or hospitalization, there is an effect on operational readiness.^3,19 One assessment found that 45% of service members in Iraq and Afghanistan who experienced an acute diarrheal episode reported that their job performance decreased while they were ill.¹⁹

Military personnel who seek care for travelers’ diarrhea may be prescribed antibiotics, loperamide, or both. Choice of antibiotic is left to the clinician and is dependent on location due to regional differences in the distribution of enteric pathogens.^2,20 Although rarely employed in a deployment setting, antibiotic selection may be supported through use of diagnostic methods; however, approximately 30–55% of diarrheal cases do not have detectable pathogens and multiple different methodologies are often needed to identify the etiologic agent.^21,22 Furthermore, in forward deployed military bases, there are many limitations related to the use of diagnostic methods, making the identification of specific pathogens even more difficult. Another consideration is that enteric pathogens are becoming increasingly resistant to preferred first-line antibiotics. One example is the high level of fluoroquinolone resistance among Campylobacter spp. in Southeast Asia, particularly in Thailand.^12,23–25 Resistance of enteric pathogens may also be increasing due to the acquisition and transmission of multidrug-resistant bacteria through travel.

Overall, military personnel experiencing diarrheal symptoms are treated with the goal to expedite their return to full duty status. Nonetheless, there are no standardized guidelines related to the treatment of travelers’ diarrhea among deployed military personnel. For these reasons, consensus-driven, evidence-based deployment health guidelines are needed.

DoD Travelers’ Diarrhea Deployment Health Guideline Workshop

On 14–15 March 2016, a panel of civilian and military experts met at the Naval Medical Research Center in Silver Spring, Maryland, with the objective of reaching a consensus on deployment health guideline recommendations related to the management of travelers’ diarrhea in deployed military personnel. Evidence reviewed included travelers’ diarrhea etiology, epidemiology, risk factors, and military impact; chronic health consequences of acute enteric infections; acquisition of multidrug-resistant bacteria through travel; diagnostics of enteropathogens in a forward deployed setting; non-antibiotic and antibiotic management; and current civilian treatment recommendations. The key clinical questions discussed by the panel were 1) how should military personnel on deployment with travelers’ diarrhea be directed with respect to self-care or seeking care? 2) Which service members should be prescribed antibiotics to self-treat travelers’ diarrhea? 3) What antibiotics/regimens should be considered for treatment of acute watery diarrhea? 4) What antibiotics/regimens should be considered for treatment of febrile diarrhea/dysentery? and 5) When and what laboratory diagnostics should be used to support management of deployment-related travelers’ diarrhea? The product of the workshop is contained within this supplement.

Travelers’ Diarrhea Deployment Health Guideline Expert Panel

• Captain Mark S. Riddle (US Navy Medical Corps) (Panel Chair)

  Enteric Disease Department, Naval Medical Research Center, Silver Spring, Maryland

• David R. Tribble, MD, DrPH (Panel Co-Chair)

  Infectious Disease Clinical Research Program, Bethesda, Maryland;

  Department of Preventive Medicine & Biostatistics and Department of Medicine, The F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

• Commander Andrew Baldwin (US Navy Medical Corps)

  Fort Belvoir Community Hospital, Virginia

• Lieutenant Colonel Timothy Ballard (US Air Force Medical Corps)

  Chief, Operational Medicine, Defense Institute for Medical Operations, JBSA-Lackland, Texas

• Captain Timothy Burgess (US Navy Medical Corps)

  Infectious Disease Clinical Research Program, Bethesda, Maryland;

  Navy Medicine Specialty Leader for Infectious Diseases, Department of Preventive Medicine & Biostatistics and Department of Medicine, The F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

• Bradley Connor, MD

  Weill Medical College of Cornell University, New York, New York

• Colonel Patrick Connor (United Kingdom L/RAMC)

  Military Enteric Disease Group, Academic Department of Military Medicine, Birmingham Research Park, Birmingham

• Chief Petty Officer Joseph Delacruz (US Navy Medical Corps)

  Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland

• Herbert Dupont, MD

  Center for Infectious Diseases, University of Texas Houston School of Public Health, Houston, Texas;

  Medicine-Infectious Disease, Baylor College of Medicine, Houston, Texas;

  Internal Medicine Service, Baylor St. Luke’s Medical Center, Houston, Texas;

• Lieutenant Colonel Patrick Hickey (US Army Medical Corps)

  Departments of Pediatrics and Preventive Medicine, F. Edward Hébert School of Medicine, Division of Tropical Public Health, Uniformed Services University of Health Sciences, Bethesda, Maryland

• Colonel James Mancuso (US Army Medical Corps)

  Department of Preventive Medicine & Biostatistics, The F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland

• Greg Martin, MD

  Tropical Medicine-Infectious Diseases, Bureau of Medical Services, US Department of State, Washington DC

• Colonel Clinton K. Murray (US Army Medical Corps)

  Deputy Medical Corps Chief, Medical Corps Specific Branch Proponent Officer, Professor of Medicine, F. Edward Hébert School of Medicine, Department of Preventive Medicine and Biostatistics, Uniformed Services University of Health Sciences, Bethesda, Maryland

• Lieutenant Colonel James Pairmore (US Army Medical Corps)

  Office of the Surgeon General (Army), Falls Church, Virginia

• John Powers, MD

  Collaborative Clinical Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland

• Major Elizabeth Schnaubelt (US Air Force Medical Corps)

  Infectious Disease Service, Landstuhl Regional Medical Center, Landstuhl Germany;

• Master Sargeant Melissa Worley (US Air Force Medical Corps)

  Air Force Special Operations Command, Eglin Air Force Base, Florida