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Editorial commentary: Antibiotic self-treatment of travelers' diarrhea: helpful or harmful?

In recent years, numerous studies have focused on the importance of imported drug-resistant bacteria, especially extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL-PE) and carbapenemase-producing Enterobacteriaceae [1]. Although initial reports were related to travelers who sought healthcare in developing countries, it is now clear that healthy returned travelers are at risk for colonization with ESBL-PE and potentially spreading these into the community, especially to those whose underlying health problems put them at risk for severe infection due to antibiotic-resistant organisms.Travel,travelers’diarrhea(TD), and antibiotic use independent of travel have all been shown to be associated with carriage of ESBL-PE; however, previous studies have not looked at these risk factors in concert, particularly the role of antibiotic self-treatment of TD. In this edition, Kantele and colleagues present the results of an excellent prospective study that provides very compelling evidence that antimicrobials increase a traveler’s risk of colonization by ESBLPE [2]. In their study of 430 Finnish travelers, 21% became colonized by ESBL-PE. Remarkably, 80% of travelers who selftreated TD with antibiotics in the Indian subcontinent were found to be colonized with ESBL-PE. They found that geographic region, occurrence of TD, and the use of antimicrobials for TD were independent risk factors associated with acquisition of ESBL-PE, and call for caution in the reflexive use of antibiotics for mild or moderate TD. Unsurprisingly and quite reasonably, the authors’ primary concern is that colonized travelers might contribute to the spread of resistant intestinal bacteria to the population at large in developed countries. In reality, however, one can see why a traveler who spends a considerable amount of money on an exotic international trip would want to carry and use an antibiotic for self-treatment for rapid relief of TD. Furthermore, the widespread problem in developing countries of counterfeit drugs, and the use of injections not infrequently administered with unsterile equipment to treat TD, would be a strong impetus for travelers to carry an antibiotic for self-treatment. A survey of healthcare providers in tourist resorts showed that 20%–86% of travelers would have undergone an invasive procedure (infusions, injections, and diagnostic venipuncture) if they had presented with diarrhea and fever [3]. “So what?” you say. A global World Health Organization survey has shown that 10%–75% of injections administered in developing countries may be given with unsterile equipment [4].