The CDC calls it the “most predictable travel-related illness. Attack rates range from 30%–70% of travelers’ during a 2-week period.” 1
That’s the bad news. The good news is that most episodes resolve in 24 hours and require symptomatic treatment only.
Antibiotic use should always be avoided if possible in any illness.
Travelers’ diarrhea cipro vs azithromycin, which antibiotic should you choose? In my opinion, there isn’t a debate.
This is among the most common ‘People also ask:’ questions when you google travelers’ diarrhea.
Disclaimer: Do not use antibiotics if you are allergic to them or their class. Always consult your doctor prior to traveling to ensure that you have no contraindications to medication.
But first, when would you consider using antibiotics?
As already mentioned, most cases only require supportive treatment.
Please read my other article on preventing travelers’ diarrhea and supportive treatment guidelines.
Next, decide how severe your illness is using the definitions below. Bear in mind that your situation might change daily. Then, choose the appropriate management.
Below are guidelines from the CDC’s Yellow Book 2024:
Acute travelers’ diarrhea: functional definitions
| MILD DIARRHEA |
| – Tolerable, not distressing, does not interfere with planned activities |
| MODERATE DIARRHEA |
| – Distressing or interferes with planned activities |
| SEVERE DIARRHEA |
| – Incapacitating or completely prevents planned activities; – Any bloody diarrhea |
Acute travelers’ diarrhea: treatment recommendations
| MILD DIARRHEA |
| – Antibiotic treatment is not recommended |
| MODERATE DIARRHEA |
| – Antibiotics may be used for treatment; azithromycin or ciprofloxacin |
| SEVERE BLOODY DIARRHEA |
| – Azithromycin only; start immediately |
| SEVERE DIARRHEA (NO BLOOD) |
| – Either antibiotic can be used; azithromycin is preferred; start immediately |
For moderate diarrhea, I recommend antibiotics after 48 to 72 hours of failure on supportive treatment.
Antibiotic class background
Ciprofloxacin
Cipro is short for ciprofloxacin. It is an antibiotic that falls into the fluoroquinolone class.
Until 2015, it was readily prescribed, in South Africa anyway, usually for bacterial urinary tract and bowel infections. Even now, it is often standardly issued in travel kits.
Now, there are black box warnings in its package insert.
I will get into the reasons for this shortly.
Azithromycin
Azithromycin is an antibiotic in the macrolide class.
It mainly treats respiratory tract infections, sexually transmitted diseases, and bacterial bowel infections.
If you have read my blocks on DIY and top-up travel medical kits containing antibiotics, you will already have this with you while on holiday or globetrotting.
Travelers’ diarrhea cipro vs azithromycin
Now, back to the topic question.
In my opinion, there isn’t very much to debate when it comes to cipro vs azithromycin for diarrhea.
Azithromycin is the first line every time. This might sound hardline, but it is a situation of ciprofloxacin having 99% cons and virtually no pros.
The shared downside of azithromycin and ciprofloxacin
All medications have the potential for drug interactions and side effects. I mention this in all my posts.
Both these antibiotics can potentially affect heart rhythm, although studies show low risk.
Increased heart rate and life-threatening cardiac arrhythmias caused by something fancy called QT prolongation. 2
Do not use either without consulting your doctor if you have a history of heart disease.
The overwhelming additional cons of ciprofloxacin
Don’t get me wrong, this is a great antibiotic, but it must be respected and used cautiously.
If you are allergic to azithromycin or macrolides, consult with your doctor to see if ciprofloxacin will be a safe option for you.
Tendonitis and tendon rupture
This is real, folks.
People who travel to exotic or third-world locations are generally active: walking, hiking, and exploring.
One of my patients took ciprofloxacin for diarrhea while hiking in Nepal. She ruptured her Achilles tendon and was airlifted out.
Even some of my Johannesburg patients warned of the risk, stopped excess activity, and developed severe tendonitis.
Tendonitis risk persists long after the antibiotic course is completed.
Joint pain and swelling
Do not use ciprofloxacin without consulting your doctor if you have a history of musculoskeletal injury or disease.
Ciprofloxacin can affect your brain and nerves
Lowers seizure threshold
This means an increased risk of fits or convulsions.
Fever and dehydration due to severe diarrhea and vomiting may further increase this risk.
Do not use ciprofloxacin without consulting your doctor if you are epileptic, have a history of head injury, or strokes.
Affect your mental health
Ciprofloxacin can cause or worsen existing depression and anxiety.
Psychosis is another potential side effect: seeing and hearing things that are not real and paranoid feelings.
Most scary of all, it might trigger thoughts of self-harm and suicide.
Do not use ciprofloxacin without consulting your doctor if you are on psychiatric medication or have a history of mental illness.
Adolescents (<18 years old) cannot use ciprofloxacin
This is due to the danger of joint cartilage damage, as seen in studies in young animals.
Patients over 60 should avoid ciprofloxacin because of the increased possibility of side effects
Side effects can, however, occur at any age but are more frequent and severe in older patients.
Dosages
| Vomiting | Not vomiting | |
|---|---|---|
| Azithromycin | – 500mg once a day for 3 days | – 1000mg immediately, once off |
| Ciprofloxacin | – 500mg twice a day for 3 days | – 500mg twice a day for 3 days |
Most moderate to severe travelers’ diarrhea cases resolve within 72 hours of completing the antibiotic course.
Chronic ongoing diarrhea
So, you’re back from holiday and still have a rumbling stomach, runny stools, and farty. Your gut has not settled down.
You took the azithromycin or ciprofloxacin as indicated, but are not 100%.
Three scenarios could cause this:
Villi destruction due to the original infection
This decreases the surface area of the intestines for absorption of water.
Parasitic infections
Giardia is the main offender. It is common in Africa, South America, and the Far East. 1
Your doctor can test for this by sending a stool sample to be analyzed.
It is very important to send a ‘bad’ sample away. Often, the loose stools are intermittent. The parasite might be missed if you don’t send a watery sample.
You need specific antibiotics to treat parasitic infections.
Antibiotic-associated colitis
Ironically, azithromycin or ciprofloxacin taken for travelers’ diarrhea may lead to pseudomembranous colitis. Antibiotics disrupt the colon’s biome and allow for the overgrowth of another bacteria, usually Clostridium difficile. This bacteria produces toxins and massive inflammation in the colon. 4
All the above situations require investigation. It is very important to visit your doctor and tell them where you have traveled, your initial symptoms, and what antibiotics you have already taken.
A five-point summary
- Try not to get ill in the first place.
- Consult your doctor about what antibiotics are safe for you.
- Bloody diarrhea = antibiotic immediately.
- Bloody diarrhea = azithromycin, not ciprofloxacin.
- Ongoing diarrhea needs investigating.
References
- Connor, B. (2023). Travelers’ diarrhea. Centers for Disease Control and Prevention. https://wwwnc.cdc.gov/travel/yellowbook/2024/preparing/travelers-diarrhea
- Troughton, R. (2023, February 9). Qt prolongation: Definition, causes, treatment, and more. Medical News Today. https://www.medicalnewstoday.com/articles/qt-prolongation
- Dela Cruz, M., Ershad, M. & Mostafa, A. (2021). QTc interval prolongation associated with inpatient azithromycin therapy for pneumonia. Journal of Osteopathic Medicine, 121(1), 5-9. https://doi.org/10.7556/jaoa.2020.142
- Salen P, Stankewicz HA. Pseudomembranous Colitis. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470319/
