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Ciprofloxacin use and misuse in the treatment of travelers’ diarrhea

      To the Editor:
      Diarrhea affects 20% to 50% of persons who travel to tropical and semitropical areas. Fluoroquinolones, particularly ciprofloxacin, have become the drugs of choice for self-initiated treatment of travelers’ diarrhea given their excellent activity against enteropathogenic bacteria (
      • DuPont H.L.
      • Ericsson C.D.
      Prevention and treatment of traveler’s diarrhea.
      ,
      • Gomi H.
      • Jiang Z.D.
      • Adachi J.A.
      • et al.
      In vitro antimicrobial susceptibility testing of bacterial enteropathogens causing traveler’s diarrhea in four geographic regions.
      ). At our travel clinic, we provide a prescription for patient-initiated treatment to travelers visiting endemic areas. In addition, immunizations and malaria chemoprophylaxis are provided per Centers for Disease Control and Prevention guidelines.
      We identified 312 travelers (aged ≥16 years) who were visiting developing countries by review of antimalarial prescriptions. Post-travel telephone interviews consisting of a 34-item questionnaire were conducted during January and October 2000. Travelers’ diarrhea was defined as at least three loose bowel movements during a 24-hour period (
      • DuPont H.L.
      • Ericsson C.D.
      Prevention and treatment of traveler’s diarrhea.
      ). Adherence with antimicrobial prescriptions, side effects, and the disposal of unused ciprofloxacin were assessed.
      We obtained questionnaires from 99 patients (female sex, n = 49). Mean age was 44 years (range, 16 to 75 years). Mean travel duration was 4 weeks (range, 1 to 48 weeks). There were 47 trips to Asia, 33 to Africa, and 22 to Central or South America; 3 patients visited multiple regions. Seventy patients received prescriptions for a self-initiated, 3-day course of ciprofloxacin (500 mg twice daily) for travelers’ diarrhea.
      Only 7 (41%) of the 17 patients who had travelers’ diarrhea took ciprofloxacin; all reported that the medication was helpful. Two patients who had travelers’ diarrhea had not filled their ciprofloxacin prescriptions. Two patients took ciprofloxacin for gastrointestinal symptoms other than diarrhea. There was no correlation between age, travel destination, sex, or antimalarial compliance and ciprofloxacin use for travelers’ diarrhea.
      Sixty-seven (97%) of the 70 filled prescriptions were not used completely during travel (Table). Moreover, only 2 patients used the medication as directed. Most unused ciprofloxacin was stored, as was the case with 46 (66%) of the filled prescriptions. Eight prescriptions (11%) were used for nondiarrheal ailments, given away, or lost.
      TableUse of Ciprofloxacin by Travelers (N = 70)
      Measure TakenNumber% of All Filled Prescriptions
      Used all of the ciprofloxacin for:
       Travelers’ diarrhea22.9
       Sore throat, fever11.4
      Used part of the ciprofloxacin for:
      Of these 7 patients, 6 stored and 1 disposed of the remaining pills.
       Travelers’ diarrhea57.1
       Gas, bloating, or upset stomach2
      Did not use any ciprofloxacin, but:
       Stored unused pills4057.1
       Disposed of pills1318.6
       Donated pills2
       Unknown2
       Other34.3
      Gave to a friend1
      Gave to dog1
      Lost1
      * Of these 7 patients, 6 stored and 1 disposed of the remaining pills.
      The relatively low rate (41%) of self-treatment in our study is consistent with the findings of Hill (
      • Hill D.R.
      Occurrence and self-treatment of diarrhea in a large cohort of Americans traveling to developing countries.
      ). However, our study was smaller and did not address the use of adjunctive treatment for travelers’ diarrhea, including bismuth subsalicylate, loperamide, and probiotics. These agents were used by almost half of the patients in Hill’s study, obviating the need for antimicrobial therapy in many patients and contributing to the amount of unused antibiotics (
      • Hill D.R.
      Occurrence and self-treatment of diarrhea in a large cohort of Americans traveling to developing countries.
      ).
      The disposal of unused ciprofloxacin is a previously unappreciated aspect of this clinical problem. Studies have shown that 10% to 40% of oral antibiotics are either wasted or used in potentially dangerous ways, such as self-medication, particularly for upper respiratory tract infections (
      • Reyes H.
      • Guiscafre H.
      • Munoz O.
      • Perez-Cuevas R.
      • Martinez H.
      • Gutierrez G.
      Antibiotic noncompliance and waste in upper respiratory infections and acute diarrhea.
      ,
      • Hamilton-Miller J.M.
      Use and abuse of antibiotics.
      ,
      • Hart R.J.
      • Marshall F.S.
      Wastage of pharmaceuticals.
      ). The role of travel clinics in this alarming phenomenon has not been well described. How unused medications are “disposed” needs to be addressed. Patients could be informed with useful measures, such as revised medication labels to describe intended use and disposal procedures, targeted discussion at travel clinic follow-ups, and programs to recycle unused and unexpired medications.

      References

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        • Ericsson C.D.
        Prevention and treatment of traveler’s diarrhea.
        N Engl J Med. 1993; 328: 1821-1827
        • Gomi H.
        • Jiang Z.D.
        • Adachi J.A.
        • et al.
        In vitro antimicrobial susceptibility testing of bacterial enteropathogens causing traveler’s diarrhea in four geographic regions.
        Antimicrob Agents Chemother. 2001; 45: 212-216
        • Hill D.R.
        Occurrence and self-treatment of diarrhea in a large cohort of Americans traveling to developing countries.
        Am J Trop Med Hyg. 2000; 62: 585-589
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        • Guiscafre H.
        • Munoz O.
        • Perez-Cuevas R.
        • Martinez H.
        • Gutierrez G.
        Antibiotic noncompliance and waste in upper respiratory infections and acute diarrhea.
        J Clin Epidemiol. 1997; 50: 1297-1304
        • Hamilton-Miller J.M.
        Use and abuse of antibiotics.
        Br J Clin Pharm. 1984; 18: 469-474
        • Hart R.J.
        • Marshall F.S.
        Wastage of pharmaceuticals.
        Lancet. 1976; 2: 39-40