October 20, 2017
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Azithromycin, levofloxacin, rifaximin all effective for travelers' diarrhea

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Three single-dose antibiotic regimens – azithromycin, rifaximin and levofloxacin – were all comparable for treating travelers’ diarrhea when paired with loperamide, according to findings recently published in Clinical Infectious Diseases.

Travelers’ diarrhea affects anywhere from 10% to 40% of short-term international travelers, resulting in 12%-46% having to change their itinerary,” Mark S. Riddle, MD, DrPH, of the enteric disease department of the Naval Medical Research Center, Silver Spring, Maryland, and colleagues wrote. “To minimize the impact of [travelers’ diarrhea], empiric treatment regimens are generally recommended, consisting of an oral antibiotic plus the antimotility agent loperamide. Fluoroquinolones have been considered a first-line antibiotic therapy; however, owing to increasing concerns associated with this drug class, other antibiotics are now being used.”

The researchers performed a randomized, double-blind controlled trial of U.S. and U.K. military service members in Afghanistan, Djibouti, Kenya and Honduras from September 2012 to July 2015. All patients had acute watery diarrhea and were randomly assigned to treatment with either single-dose azithromycin (500 mg; n = 106), levofloxacin (500 mg; n = 111) or rifaximin (1,650 mg; n = 107), all of which were paired with loperamide. The main outcomes were time to patients’ last unformed stool and clinical cure at 24 hours.

Levofloxacin showed the highest cure rate at 24 hours, with 81.4%, followed by azithromycin (78.3%) and rifaximin (74.8%), the researchers reported. Neither azithromycin nor rifaximin was inferior to levofloxacin (P = .01), and researchers could not identify noninferiority with rifaximin (P = .07). The three drugs showed roughly equivalent efficacy at the 48-hour (91%) and 72-hour (96%) mark, Riddle and colleagues wrote. Furthermore, the three treatment arms showed similar median times to last unformed stool (3.8 hours for azithromycin, 6.4 hours for levofloxacin and 5.6 hours for rifaxmin).

Only a small minority of patients experienced treatment failures in any group (3.8% for azithromycin, 4.4% for levofloxacin and 1.9% for rifaximin; P = .55), according to Riddle and colleagues. There was no difference in adverse events across any of the groups.

“Overall, our findings provide strong evidence that loperamide-adjuncted, single-dose antibiotic therapy for [acute watery diarrhea] among travelers is safe and highly effective,” the researchers wrote. “Furthermore, these results highlight rapid clinically relevant improvement of illness and diarrheal symptoms associated with combination therapy.” – by Andy Polhamus

Disclosures: The authors report no relevant financial disclosures.