Effectiveness of rifaximin and fluoroquinolones in preventing travelers’ diarrhea (TD): a systematic review and meta-analysis

Abstract

BackgroundRecent developments related to a safe and effective nonabsorbable antibiotic, rifaximin, and identification of postinfectious irritable bowel syndrome as a frequent sequela call for a need to reconsider the value of primary prevention of traveler’s diarrhea (TD) with antibiotics.MethodsRandomized, placebo-controlled, double-blind studies evaluating the effectiveness and safety of rifaximin or a fluoroquinolone chemoprophylaxis against TD were pooled using a random effects model and assessed for heterogeneity.ResultsThe nine studies (four rifaximin and five fluoroquinolone) included resulted in pooled relative risk estimates of 0.33 (95% CI = 0.24–0.45, I2 = 3.1%) and 0.12 (95% CI = 0.07–0.20, I2 =0.0%), respectively. Similar rates of treatment emergent adverse events were found between antibiotic and placebo groups.ConclusionsThis meta-analysis supports the effectiveness of antibiotics in preventing TD. However, further studies that include prevention of secondary chronic health outcomes among travelers to different geographic regions, and a formal risk-benefit analysis for antibiotic chemoprophylaxis, are needed.

ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults

“…While no recent studies have been conducted, fl oroquinolones consistently demonstrate a higher eff ectiveness in the prevention of TD with a summary pooled estimate of 88% (95% CI: 80-93%) protective effi cacy ( 240 ). Th e emergence of fl uoroquinolone resistance to commonly encountered TD pathogens may be a factor today if these studies were replicated ( 139,247,248 ).…”

“…A recent systematic review summarized several studies showing a comparative advantage of antibiotic chemoprophylaxis for the prevention of TD ( 240 ). Four rifaximin studies included in the meta-analysis had a total of 604 subjects.…”

Traveler’s Diarrhea

“…27 Fluoroquinolones are effective prophylactic agents and they provide a broad spectrum of activity against many common travel-related enteropathogens including ETEC and EAEC. In a meta-analysis, they were shown to provide 88% protection against TD.…”

“…In a meta-analysis, they were shown to provide 88% protection against TD. 27 However, the risks of long term quinolone therapy, including tendon rupture (especially in those with pre-existing kidney disease or on systemic corticosteroids), QTc prolongation, and Clostridium difficile infection limit their usefulness as prophylaxis and should be discussed with the traveler.…”

Travel to Tropical Countries: A Review of Travel-Related Infectious Diseases

“…Azithromycin is recommended as an alternative antibiotic [48]. Rifaximin which acts locally in the gastrointestinal tract without systemic absorption can also be used [49]. Cholera is endemic in some African and Asian tropical countries and outbreaks have occurred in non-endemic areas after natural disasters as seen in Haiti [50].…”