Patterns of antibiotic prescription and use for travellers’ diarrhoea among travellers

Most international travellers who are prescribed standby antibiotics for travellers’ diarrhoea (TD) return home with unused medication. These antibiotics are frequently retained, misdirected or disposed of improperly, creating environmental and antibiotic stewardship risks. This represents an under-recognized opportunity for targeted stewardship interventions during pre-travel counselling. TD remains one of the most common travel-associated illnesses and is often managed with empiric antibiotics provided prior to departure.1–5 We conducted a cross-sectional survey to assess the use, retention and disposal of antibiotics prescribed for the self-treatment of TD among patients attending a university-based travel medicine clinic. Eligible participants were evaluated at the UConn Health International Travel and Immunization Clinic between January 2018 and December 2019 and were prescribed antibiotics for TD prior to international travel. A 16-item electronic survey distributed 6–18 months after the clinic visit assessed demographics, travel destinations, the antibiotic prescribed, antibiotic use during travel, the completion or discontinuation of therapy and the post-travel management of unused medication. Results are presented in Figure 1. An online survey was distributed to 1466 patients who utilized travel medicine services at the University of Connecticut Health Center from January 2018 to December 2019. A total of 177 respondents (response rate 12.1%) were included in the analysis. Responses from participants regarding location of travel, antibiotic use during travel, and antibiotic use following travel. Participants represented a broad adult age range, with a mean age in the early fifties, and travelled predominantly to regions associated with a moderate to high risk for TD, including Asia, Africa and Central and South America.1,3 Azithromycin was the most frequently prescribed antibiotic (94.9%), consistent with management guidelines favouring macrolides in many regions.2–4 Smaller numbers of respondents reported prescriptions for fluoroquinolones or rifaximin. When asked to identify their prescribed antibiotic, fewer than two-thirds of participants correctly named the medication, while others named an incorrect agent or reported that they could not recall the antibiotic. This finding suggests a limited long-term retention of antibiotic-specific information when medications are prescribed anticipatorily, rather than for immediate use. Approximately one-quarter of participants reported taking at least one dose of their prescribed antibiotic during travel. Among those who used antibiotics, most completed the full prescribed course, while a smaller subset discontinued therapy early, most commonly because symptoms had resolved. A majority of respondents did not use any antibiotics during travel and returned home with unused medication, reflecting the preventive and precautionary nature of TD prescribing and is consistent with prior studies demonstrating that most travellers provided with standby antibiotics do not ultimately require them.4 Management of unused antibiotics after travel varied considerably. A substantial proportion of participants reported still possessing the antibiotics at the time of the survey. Among these individuals, most stated that they were intentionally retaining the medication for potential future use, while others reported no specific plan for use or disposal. Many expressed uncertainty regarding appropriate disposal practices. Among respondents who no longer possessed unused antibiotics, the reported disposal methods were heterogeneous. Only a minority used disposal methods consistent with federal recommendations, such as medication take-back programs6 or appropriate packaging for community waste streams. More commonly, antibiotics were discarded in household trash or flushed, practices that may contribute to environmental antibiotic contamination.5,6 Most respondents correctly identified that the antibiotics were prescribed for TD. However, a small proportion reported using leftover antibiotics for illnesses unrelated to travel or during subsequent trips, indicating a diversion beyond the original clinical intent. Such practices raise stewardship concerns, as inappropriate antibiotic use contributes to antimicrobial resistance and undermines guideline-based care.4 This study demonstrates that returning with unused antibiotics after international travel is the norm rather than the exception. While standby antibiotics for TD are clinically appropriate in many travel medicine settings,2–5 their anticipatory nature creates a substantial potential for inappropriate diversion and improper disposal. The findings highlight several modifiable stewardship vulnerabilities within routine travel medicine practice. Limited patient recall of antibiotic details months after travel suggests that pre-travel counselling may not be durable. Counselling should emphasize simple, actionable stewardship messages. Written after-visit summaries or standardized educational materials should reinforce appropriate indications for use and provide clear post-travel instructions for unused medications. Explicit counselling that TD antibiotics are intended for a specific indication, and travel period, and should not be retained for future self-directed use, may reduce diversion. Clear guidance regarding appropriate methods of disposal into community waste streams, and a referral to pharmacy-based or community take-back programmes6 should be incorporated into routine counselling. Travel clinics may also consider offering opportunities for patients to return unused antibiotics for appropriate disposal, using medical waste streams. Travel medicine encounters are preventive, planned and education-focused, making them particularly well-suited for anticipatory stewardship interventions. Integrating brief, standardized antibiotic stewardship messaging into pre-travel visits represents a practical strategy to reduce inappropriate antibiotic self-management, and to mitigate downstream environmental and resistance-related harms. Beth Lippman (Data curation [equal], Formal analysis [equal], Writing—original draft [equal], Writing—review & editing [equal]), Abigail Immanuel (Conceptualization [equal], Methodology [equal], Project administration [equal]), and Kevin Dieckhaus (Conceptualization [equal], Data curation [equal], Formal analysis [equal], Investigation [equal], Methodology [equal], Project administration [equal], Supervision [equal], Writing—original draft [equal], Writing—review & editing [equal]) None declared.