Introduction:
Managing diabetes can be a complex and challenging task. As a healthcare professional, you understand the importance of providing comprehensive care to your patients. However, the increasing number of people with diabetes and the demands on your time can make it difficult to offer individualized support. This is where a diabetes educator can make a significant difference. In this article, we explore the role of a diabetes educator and how they can assist you in improving patient outcomes and practice efficiency.

What is a Diabetes Educator?
Diabetes educators are licensed healthcare professionals, including registered nurses, registered dietitians, and pharmacists, who specialize in helping individuals with diabetes effectively manage their condition. They provide diabetes education or diabetes self-management training (DSMT) to empower patients with the knowledge and skills needed for successful diabetes management. Many diabetes educators also hold the Certified Diabetes Educator (CDE) designation, further highlighting their expertise in the field.

The Benefits of Partnering with a Diabetes Educator:
By collaborating with a diabetes educator, you can enhance patient care and achieve better outcomes. Here’s how a diabetes educator can support you and your patients:

1. Time Efficiency:
   Diabetes educators can take on time-consuming patient training, counseling, and follow-up responsibilities, allowing you to focus on other aspects of patient care. By delegating these tasks, you can improve the efficiency of your practice and optimize your workflow.
2. Pay-for-Performance and Quality Improvement:
   Working with a diabetes educator can help you meet pay-for-performance and quality improvement goals. Their expertise in tracking and monitoring patients’ progress can provide you with valuable status reports, aiding in the assessment of patient outcomes and adherence to care guidelines.
3. Prevention and Self-Management:
   Diabetes educators play a crucial role in diabetes prevention and self-management training. They can provide education and support to patients at high risk of developing diabetes, equipping them with the knowledge and skills to make lifestyle changes that reduce their chances of developing the disease.

How Can Diabetes Educators Help Your Patients?
Diabetes educators focus on empowering patients to take control of their diabetes management. Here are some key areas in which they provide guidance and support:

1. Education and Device Training:
   They help patients understand the basics of diabetes and teach them how to use diabetes devices such as blood glucose meters, insulin pens, pumps, and continuous glucose monitors effectively.
2. Nutrition Counseling:
   Diabetes educators provide personalized nutrition education, including meal planning, weight-loss strategies, and disease-specific nutrition counseling. They help patients adopt healthy eating habits tailored to their diabetes management goals.
3. Self-Management Skills:
   Diabetes educators assist patients in developing problem-solving strategies and skills to self-manage their diabetes. They empower individuals to monitor their blood glucose levels, interpret the results, and respond appropriately.
4. Medication Management:
   They educate patients about their medications, including their actions, side effects, proper dosage, and more. By improving medication understanding, patients can enhance their medication adherence and overall treatment outcomes.
5. Emotional Support:
   Diabetes educators help patients develop coping mechanisms for handling stressful situations related to diabetes. They provide emotional support and guide patients in maintaining a positive mindset throughout their diabetes journey.

The Benefits of Diabetes Education:
Research shows that individuals who receive diabetes education are more likely to use primary care and preventative services, adhere to medication regimens, and achieve better glucose, blood pressure, and cholesterol control. Moreover, diabetes self-management training is a covered benefit under Medicare and most health plans when provided by a diabetes educator within an accredited program.

Conclusion:
Incorporating a diabetes educator into your healthcare team can significantly improve patient outcomes, enhance practice efficiency, and promote better overall diabetes management. By providing comprehensive education, support, and empowerment, diabetes educators play a vital role in helping patients achieve optimal health and well-being.

If you’re interested in partnering with a diabetes educator or would like to learn more about our services, please reach out to us. Together, we can make a positive impact on the lives of individuals living with diabetes.

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We all know what explicit bias is and some even have firsthand knowledge or experience. When we think about health care, we all would like to think that boas do not exist in the professions of healthcare. But nothing can be further from the truth. As a nation, we started to question systemic biases and here I want to explore implicit biases in Healthcare.

Why implicit biases? Because it is very rare to encounter explicit or all-out biases in healthcare.  Most of the time we face implicit or unconscious biases and most of the time we do not know what not do about them.

*The majority of the material for this presentation came from a Pri-Med presentation.

Implicit vs. Unconscious Bias

Implicit

• “implied though not plainly expressed”

• “inherent”

• “inbuilt”

• “understood”

Unconscious

• “inaccessible to the conscious mind”

• “done without realizing”

• “instinctive”

• “unthinking”

Implicit/Unconscious Bias:  We all have them. It is like a blind spot that most of the time we don’t see.

• Hidden Biases of Good People − Mahzarin Banaji and Anthony Greenwald
• Implicit Association Tests (Project Implicit®)

Often a result of our cultural conditioning or a byproduct of our societal norms. Often biases are contrary to our personal values and implicit bias:

• Can be Personal: internalized, interpersonal
• or systemic: institutionalized or structured

Assumptions: We have been socialized into a society in which there exists individual, institutional and societal biases associated with race, gender, and sexual orientation. None of us are immune from inheriting the biases of our ancestors, institutions, and society. It is not “old-fashioned” racism, sexism, and heterosexism that is most harmful to people of color, women, and LGBT persons but the contemporary forms known as microaggressions.

“Old Fashion Racism” or Microassaults: it is uncommon, it is usually deliberate, conscious, and explicit. It often has the intention to hurt, oppress, or discriminate.  Examples:  −Refusing service to minorities −Displaying the hood of the Ku Klux Klan

Microaggressions

Microaggressions are constant and continual without an end date (an everyday hassle may be time-limited). Microaggressions are cumulative and anyone may represent the feather that breaks the camel’s back.  Microaggressions must be deciphered because they contain double messages (especially micro invalidations). Microaggressions are constant reminders of a person’s second-class status in society. Microaggressions symbolize past historic injustices.

Micro insults and Microinvalidations

•Not Intentional−Typically occur due to underlying biases and prejudices outside of awareness

• Microinsults −Convey insensitivity, are rude, or demean an individual’s identity or heritage

• Microinvalidations−Exclude, negate or nullify an individual’s thoughts or feelings

Definition of Microaggressions

“Microaggressions are brief and commonplace verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults that potentially have harmful or unpleasant psychological impact on the target person or group.”

Could be based on race, income, social capital, religion, ableness, gender, immigration status, sexual orientation, and/or other characteristics

Sue DW, et al. Racial Microaggressions in Everyday Life. Implications for Clinical Practice. Am Pschol. 2007;62(4):271-276.

Examples of Microaggressions

“Are you a nurse?” to a female physician examining a patient?
“Are you the sitter?” to a black physician walking into a patient room?
“You look too masculine,” to a self-identified lesbian physician.
“Minorities are still hung up on race” to a fellow physician.
“Your people must be so proud of you” to a physician with an accent.

“You speak English really well,” to someone born and raised in the United States.

Montenegro RE. My Name Is Not “Interpreter”. JAMA. 2016.

Psychological Consequences of Microaggressions

Many times, the person at the receiving end is not aware in the moment of the consequences of the microaggression but as time pass they may feel anxious or depressed. Many times we internalize these feelings to be our own thoughts and feelings without realizing where they came from.

•Anxiety

•Depression

•Sleep difficulties

•Diminished confidence

•Helplessness

•Loss of Drive

Cumulative Consequences

• Assail the mental health of recipients (Sue, Capodilupo, & Holder, 2008),
• Create a hostile and invalidating campus climate (Solórzano, Ceja, & Yosso, 2000),
• Perpetuate stereotype threat (Steele, Spencer, & Aronson, 2002),
• Create physical health problems (Clark, Anderson, Clark, & Williams, 1999),
• Saturate the broader society with cues that signal devaluation of social group identities (Purdie-Vaughns, Steele, Davies, & Ditlmann, 2008),
• Lower work productivity and problem-solving abilities (Dovidio, 2001; Salvatore & Shelton, 2007).
• Responsible for creating inequities in education, employment and health care (Purdie- Vaughns, et al, 2008; Sue, 2010).

Managing Microaggressions in the Moment Use of the Interrupt Framework

The following is a framework on how to handle microaggressions without attacking the person but rather guide them to understand that their words are hurtful:

• The “Interrupt” framework can help observers to respectfully address microaggressions in the moment:

− Inquire
− Nonthreatening
− Take responsibility
− Empower
− Reframe
− Redirect
− Use impact questions

− Paraphrase
− Teach using “I” phrases

       Inquire

Ask the speaker to elaborate on what they meant −Helps us understand their perspective

Examples:
− “I’m curious. What makes you ask that?”

− “What makes you believe that?”

Avoid “Why?” questions as can increase defensiveness

Paraphrase/reflect

Same skills we use in motivational interviewing

•Demonstrates understanding

Reduces defensiveness in rest of conversation

Examples:
− “You’re saying…”
− “So it sounds like you think…”

Re-direct

Shift the focus to a different person

−Particularly helpful when someone is asked to speak for his/her entire race, cultural group, etc.

Examples:

− “Let’s shift the conversation…”

− “Let’s open up this question to others and see what they think.”

Use Impact and “I” Statements

A clear, nonthreatening way to directly address these issues on behalf of oneself

• It communicates the impact of the situation while avoiding blaming
• Examples:
  • “I felt … when you said … and it ….(describe impact on you)”

Use Preference Statements

Clearly communicate one’s preferences rather than stating them as demands or having another guess what is needed

• Examples:
  −In response to racist, sexist, homophobic, etc. jokes
  • “I don’t think this is funny. I would like you to stop.” −“It would be helpful to me…”

Use strategic questions

The skill of asking questions that will make a difference

• A question that creates motion and options can lead to transformation
  • Examples:
    − “How might we examine our implicit bias to ensure that gender plays no part in this and we have a fair process.
  • What do we need to be aware of?”
    − “What would you need to approach this situation differently next time?”

Revisit

Even if the moment of the microaggression has passed, go back and address it. Research indicates that an unaddressed microaggression can leave just as much of a negative impact as the microaggression itself.

• Examples:
  − “I want to go back to something that was brought up in our meeting…”

Individual Response

•Assume offense was not the intent.

•Explain how the slight was interpreted.

•Ask a follow up question.

•Identify and talk to individuals with whom you feel comfortable

When You Meet Resistance

•Will further conversation be beneficial and productive?

•What is my current level of stress?

•Am I able to respond non-emotionally?

• Reiterate that you are not blaming the person, only expressing the way the comment/action made you feel.

•Explain the cumulative effect of these occurrences.

Final Thoughts

Microaggressions are unfortunately present in our health and health education systems. As healthcare professionals and educators, we can employ tools to address implicit bias and microaggressions when encountered. As healthcare leaders, we can work to reduce the occurrence of microaggressions with a systems-based approach.

References

• Microaggressions: Understanding What They Are, Why They Are Harmful and How to Manage Them Aarati Didwania, MD, MSCI, FACP Primary Care NOW July 2020
• Banks, B. M. (2015). Microaggressions directed at Black college women: The moderating role of racial identity on self-control depletion.
• Murphy, M. C., Richeson, J. A., Shelton, J. N., Rheinschmidt, M. L., & Bergsieker, H. B. (2012). Cognitive costs of contemporary prejudice. Group Processes & Intergroup Relations, 1-12.
• Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. John Wiley & Sons.
• Sue, D. W., Capodilupo, C. M., & Holder, A. (2008). Racial microaggressions in the life experience of Black Americans. Professional Psychology: Research and Practice, 39, 329-336.
• Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life. American Psychologist, 62, 271-286.
• White AA, Logghe HJ, Goodenough DA, et al. Self-Awareness and Cultural Identity as an Effort to Reduce Bias in Medicine. J Racial and Ethnic Health Disparities. 5 (1):34-49, Feb 2018.
• Wong-Padoongpatt G, Zane N, Okazaki S, et al. Decreases in implicit self-esteem explain the racial impact of microaggressions among Asian Americans. J of Counseling Psychology, 64(5), 574-583.

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One of the hardest barriers to treat diabetes is the fear of starting insulin on patients. Not only do you have patient barriers but you may also have provider barriers. Her will discuss mainly patient barriers to starting insulin.

Addressing insulin fears

Patients come into the visit with many pre-conceived ideas about medications but especially insulin. The first step is to try to find out why they don’t want insulin, is it fear of needles or is it fear of insulin itself?

Is it fear of needles or fear of insulin?

Determining the root cause of patients’ fears or ambivalence toward insulin therapy can allow for more specific discussion, intervention and resolution.

Fear of needles:

Fear of pain or discomfort

• Compare the sensation to the current experience.
• Perform a mock injection with saline and an insulin syringe, and share your personal experience (if any) with subcutaneous injections. If appropriate, go through the exercise with the patient in the office with saline

Fear of exposures

• Review low risk for infection, explain the sterility of products and educate on safe injection techniques

Fear of insulin:

• Associating need for insulin with personal failure

Have frequent discussions and provide reassurances that the progression of diabetes and need for insulin is normal, and not a reflection of personal failure.

• Worry about side effects, costs, interference with life/routine, whether insulin will work or “fail”, and others

Early conversations can elucidate concerns, and allows time for patient-centered discussions and interventions to address worries and fears.

Include family members and other team members to address specific needs.

• Former experience with a friend or loved-one, e.g. “My uncle started insulin and then he needed to have his leg amputated.”

Review importance of balancing personalized goals of therapy with quality of life and show commitment to shared-decision making.

As part of early education, patients should be introduced to the possibility of insulin for treatment. Weather is because their disease state has progressed or they are sick and in the hospital or they have symptoms suggestive of insulin deficiency (weight loss, polyuria/polydipsia)

Fear of Hypoglycemia

Many times they feel anxious and feel like they may even die. When patients develop this fear, they will often skip their insulin doses or even reduce doses to avoid low blood sugars. In the same way they may not want to restart insulin if they had a bad hypoglycemic episode.

Many patients once they have experienced hypoglycemia will become very afraid of the feeling they get during low blood sugars.

Reassure patients that this time you will start the dosing low and go slow, review what to do if they get a low blood sugars

Talking Points For When You Start Insulin

• When insulin is indicated, explain why and how it will be helpful. Reinforce that the need for insulin does not represent a personal failure.
• Keep the conversation(s) dynamic and patient-centered. Use open-ended questions and reflective listening to learn the patient’s expectations, impressions, and fears about insulin. Tailor the conversation to their needs.
• Share your opinion as their provider, and show that you find value in the patient’s perspective.
• Involve the patient’s caregivers and all members of the patient’s care team in the conversation(s) (nurses, medical assistance, support staff, etc).

“Many patients have told me that once they get the hang of it, injecting the insulin is actually easier and less painful than checking your blood sugar with the fingerstick. I even tried it myself!”

Many times Provider barriers can also become a problem. Providers can delay starting insulin for fear of complications like severe hypoglycemia, lack of time for teaching or close follow-up, unsure how to start or adjust insulin, and complexity of newer insulins. This is where Pharmacists can have a role to help educate not only the patients but also the providers. Pharmacists can also help adjust insulin doses and monitor patients closely to avoid complications or side effects.

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As patients get sick and they start to worry about the possibility of having Covid-19, they seek help from their Primary Care Doctors and clinics. Health care workers on the front lines expect to treat patients with Covid-19, many health care systems and many states are reported to be unprepared. Nurses accept risks as part of their daily work with patients and families, as do ER physicians, nurses’ aides, paramedics, physical and occupational therapists, and other health care workers such as Pharmacists who are on the front lines. But what degree of risks should they accept when resources are limited or not available?

health care workers often don’t receive the equipment and training they need, or they use the equipment improperly. How can they protect themselves?

More than 3,000 health care workers in China have been infected with the coronavirus, and their colleagues must care for them, but they must feel distress and have fear that the systems are not providing them with enough support.  Health care workers also have to think about protecting their own families once they go home.

A recent nursing survey exposed the worries that nurses share about Covid-19: About half didn’t have information on how to recognize or respond to Covid-19, about one in four didn’t know if a plan was in place to isolate Covid-19 patients, and only about two-thirds reported having access to N95 masks. And, many didn’t know if there was a policy in place for co-workers who were sick or otherwise exposed to Covid-19. We need to do better.

As ambulatory care Pharmacist we also come in contact with the highest risks patients and like all health care workers, we must think about how to not only protect the patients but for ourselves as well. Making sure we have the supplies necessary to keep ourselves safe is paramount. In many cases, lack of masks and even gloves are worrisome circumstances that as health workers we need to deal with.

The public has been asked to save masks for health care workers. Why do health care workers need masks, but the public has been told they’re not helpful?

There are no data to suggest that for regular people who are not sick, wearing a mask in public will do anything to reduce exposure to the virus. But, for health care workers, we need this workforce to stay healthy and prevent transmission to other, vulnerable patients. There are already reports of potential shortages in particular areas, so we have to be really thoughtful about how we use the supply that we have. The best use right now is for health care workers who have to go patient-to-patient and who, in the long run, will have to care for sick patients for months and months.

What kind of equipment keeps health care workers safe?

The most important thing is to wash your hands thoroughly with soap and water. Use a hand gel with 60% or higher alcohol concentration if soap and water aren’t available. For appropriate respiratory protection, the current recommendation from CDC is for health care workers to wear a gown, gloves, N-95 or higher-level respirator, and eye protection for patients with presumed or confirmed COVID-19. After removing the equipment carefully to avoid contamination, wash hands again. Unless you are told otherwise by the CDC, reusing personal protective equipment is not recommended.

How can patients safely interact with health care providers?

The most important thing a patient can do is alert the health care team they’re having respiratory symptoms immediately. The health care provider can put a mask on the patient, apply their own equipment, and alert the rest of the health care team.

As health care workers, many times we ourselves fall on the highest risk group. Having the necessary equipment, being educated on how to use equipment properly, protocols and guidance are extremely important to keep our health care work force healthy. Pharmacist are part of the health care workforce, we often interact face to face with patients, we need to know how to protect ourselves while taking care of our patients.

We can also help educate patients about the best ways to stay healthy, the importance of following the guidance from the CDC and the importance of making sure health care workers have access to the equipment they need. Patients do not need to wear masks, as they do not protect them. It is more important for them to wash their hands often and practice social isolation.

The most travel season is the Summer, but a close second is the holidays which is almost here. As part of my clinical practice, I see patients who are traveling. The travel clinic looks at what immunizations the patient will need for the travels and we definitely need to address Traveler’s diarrhea.

Bacterial and viral Traveler’s Diarrhea (TD) presents with the sudden onset of bothersome symptoms that can range from mild cramps and urgent loose stools to severe abdominal pain, fever, vomiting, and bloody diarrhea, although with norovirus vomiting may be more prominent. Protozoal diarrhea, such as that caused by Giardia intestinalis or E. histolytica, generally has a more gradual onset of low-grade symptoms, with 2–5 loose stools per day. The incubation period between exposure and clinical presentation can be a clue to the etiology:

• Bacterial toxins generally cause symptoms within a few hours.
• Bacterial and viral pathogens have an incubation period of 6–72 hours.
• Protozoal pathogens generally have an incubation period of 1–2 weeks and rarely present in the first few days of travel. An exception can be Cyclospora cayetanensis, which can present quickly in areas of high risk.

Untreated bacterial diarrhea usually lasts 3–7 days. Viral diarrhea generally lasts 2–3 days. Protozoal diarrhea can persist for weeks to months without treatment.

Traveler’s Diarrhea (TD) recent updates

•Traveler’s diarrhea is the most predictable travel-related illness and affects 30%-70% of international travelers.

•Usually consists of 4-6 days of loose stools, sometimes accompanied by low-grade fever, nausea, abdominal cramping, headache, and/or general malaise

•Antibiotic-mediated disruption of the microbiome and subsequent colonization with resistant organisms

•Pre-travel counseling should include the risks and benefits of antibiotic use.

Destination Matters

Knowing where the patient is going is important, that will tell you what the risks are depending on the destination.

•Low risk: US, Canada, Australia, Japan, Northern and Western Europe

•Intermediate risk: Eastern Europe, South Africa, some Caribbean islands

•High risk: Asia, Middle East, Africa, Mexico, Central and South America  

In destinations in which effective food handling courses have been provided, the risk for TD has been demonstrated to decrease. However, even in developed countries, pathogens such as Shigella sonnei have caused TD linked to handling and preparation of food in restaurants.

TD occurs equally in male and female travelers and is more common in young adult travelers than in older travelers. In short-term travelers, bouts of TD do not appear to protect against future attacks, and >1 episode of TD may occur during a single trip.

Prophylaxis for TD

•Do not routinely use antibiotics for prophylactic treatment in travelers

To prevent overuse of antibiotics the panel strongly recommends against routine use of antibiotics.

Prophylactic antibiotics can prevent some TD, the emergence of antimicrobial resistance has made the decision of how and when to use antibiotic prophylaxis for TD difficult. Controlled studies have shown that use of antibiotics reduces diarrhea attack rates by 90% or more. The prophylactic antibiotic of choice has changed over the past few decades as resistance patterns have evolved. Fluoroquinolones have been the most effective antibiotics for the prophylaxis and treatment of bacterial TD pathogens but increasing resistance to these agents among Campylobacter and Shigella species globally limits their potential use. In addition, fluoroquinolones are associated with tendinitis and an increased risk of Clostridioides difficile infection, and current guidelines discourage their use for prophylaxis. Alternative considerations include azithromycin and rifaximin.

How to Prevent TD

•Advise patient to research the safety of water at destination, and if not safe…

–Refrain from drinking tap water

–Avoid food washed in tap water

–Be careful when choosing restaurants

You can find information regarding the water at the CDC- traveler website. Lack of safe water may lead to contaminated foods and drinks prepared with such water; inadequate water supply may lead to shortcuts in cleaning hands, surfaces, utensils, and foods such as fruits and vegetables. In addition, handwashing may not be a social norm and could be an extra expense; thus, there may be no handwashing stations in food preparation areas. In destinations in which effective food handling courses have been provided,

Consider Prophylaxis for TD

•Bismuth subsalicylate (BSS) may be considered for any traveler

Bismuth subsalicylate (BSS), is the active ingredient in adult formulations of Pepto-Bismol and Kaopectate.  Travelers with aspirin allergy, renal insufficiency, and gout, and those taking anticoagulants, probenecid, or methotrexate should not take BSS. In travelers taking aspirin or salicylates for other reasons, the use of BSS may result in salicylate toxicity. 

•Consider antibiotics for travelers at high risk of health-related complications of TD

–Rifaximin should be prescribed for all regions

–Fluoroquinolones (FQ) are no longer recommended for prophylaxis

Prophylactic antibiotics may be considered for short-term travelers who are high-risk hosts (such as those who are immunosuppressed or with significant medical comorbidities) or those who are taking critical trips (such as engaging in a sporting event) without the opportunity for time off in the event of sickness.

Treatment

Fluids and electrolytes are lost during TD, and replenishment is important, especially in young children or adults with chronic medical illness. In adult travelers who are otherwise healthy, severe dehydration resulting from TD is unusual unless vomiting is prolonged. Nonetheless, replacement of fluid losses remains an adjunct to other therapy and helps the traveler feel better more quickly. Travelers should remember to use only beverages that are sealed, treated with chlorine, boiled, or are otherwise known to be purified.

Treatment Based on Classification 

FDA warns that the potentially serious side effects of fluoroquinolones may outweigh their benefit in treating uncomplicated respiratory and urinary tract infections; however, because of the short duration of therapy for TD, these side effects are not believed to be a significant risk.

A potential alternative to fluoroquinolones is azithromycin, although enteropathogens with decreased azithromycin susceptibility have been documented in several countries. Rifaximin has been approved to treat TD caused by noninvasive strains of E. coli. However, since it is often difficult for travelers to distinguish between invasive and noninvasive diarrhea, and since they would have to carry a backup drug in the event of invasive diarrhea, the overall usefulness of rifaximin as empiric self-treatment remains to be determined.

Single-dose regimens are equivalent to multi­dose regimens and may be more convenient for the traveler. Single-dose therapy with a fluoroquinolone is well established, both by clinical trials and clinical experience. The best regimen for azithromycin treatment may also be a single dose of 1,000 mg, but side effects (mainly nausea) may limit the acceptability of this large dose. Giving azithromycin as 2 divided doses on the same day may limit this adverse event.

Classification

•Mild: Tolerable, not distressing, and does not interfere with planned activities–Supportive: Rehydration, BSS or loperamide–No antibiotics

•Moderate: Distressing or interferes with planned activities–Azithromycin–Rifaximin–FluoroQuinolones (FQs) may be used outside of Southeast and South Asia

•Severe: Incapacitating or completely prevents planned activities; all dysentery–Azithromycin: First line for dysentery or febrile diarrhea–FQs and rifaximin: Severe, non-dysenteric TD

•Single-dose antibiotics should be use

–Treat moderate or severe TD

–Azithromycin and FQs: Single dose for 3 days

•Adjunct therapy: Loperamide

–Moderate-to-severe TD: Symptomatic relief with curative treatment

–Moderate TD: Monotherapy

If symptoms have not resolved after 24 hours, the full course of antibiotics should be use for the three days

Persistent Diarrhea after Returning

Persistent Diarrhea:  is diarrhea lasting >2 weeks

–Functional bowel disease may occur after bouts of TD 

–May meet Rome III or IV criteria for irritable bowel syndrome

•Follow-up diagnostic testing

–Consider microbiological testing in returning travelers with severe or persistent symptoms, bloody/mucous diarrhea, or in those who fail empiric therapy

–Molecular testing: Preferred when rapid results are clinically important or nonmolecular tests have failed to establish a diagnosis

•Prebiotic or probiotic: Insufficient evidence for prevention or treatment

Take Home Points

• Prophylaxis should be considered only in high-risk groups; rifaximin is the first choice, and BSS is a second option
• Review the severity classification with travelers
• Travelers to destinations in developing countries should be provided with loperamide and an antibiotic for self-treatment
• Antibiotic choice is destination-dependent 
• If symptoms do not improve within 24-36 hours of beginning antibiotic therapy, may need to seek medical attention

References:

1. Centers for Disease Control and Prevention (CDC). https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/travelers-diarrhea. Updated June 24, 2019.Accessed July 29, 2019.CDC. 
2. https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/perspectives-antibiotics-in-travelers-diarrhea-balancing-the-risks-and-benefits. Updated June 24, 2019. Accessed July 29, 2019.Riddle MS, et al. J Travel Med. 2017;24(suppl 1):S57-S74.
3. CDC-https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/travelers-diarrhea. Updated June 24, 2019. Accessed July 29, 2019.