The drugs listed in this section are among the most important for preventing or treating many travel-related illnesses (e.g., malaria, travelers' diarrhea, and acute mountain sickness).

ACETAZOLAMIDE
ATOVAQUONE/PROGUANIL
AZITHROMYCIN
CHLOROQUINE
CIPROFLOXACIN
DOXYCYCLINE
LEVOFLOXACIN
LOPERAMIDE
MEFLOQUINE

ACETAZOLAMIDE (Diamox^®)—125 mg or 250 mg tablet, or 500 mg timed-release sequel

For acute mountain sickness (AMS)—prevention and treatment

• The drug of first choice for prevention of AMS. About 60% effective.
  
• Contains sulfa: Do not take if you have a sulfa allergy.
  
• Use with caution in pregnancy.
  
• Indicated for elevations above 8000 feet, especially if there is rapid ascent.
  
• Dose: Usual dose for both prevention and treatment is 250 mg twice daily, or 500 mg of the slow-release tablet, once daily. Above 12,000 feet, a total daily dose of 750 mg may be more effective.
  
• Side effects: The most common side effect is a tingling "pins and needles" sensation of the face, lips, or around the mouth.
  
• Diamox is a mild diuretic.
  
• Note: The most effective treatment for AMS is descent.

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ATOVAQUONE/PROGUANIL (Malarone^®)—Atovaquone 250 mg and Proguanil Hcl 100 mg; Pediatric formulation: Atovaquone 62.5 mg and Proguanil Hcl 25 mg

Effective for the prevention or treatment of acute, uncomplicated falciparum malaria and other malarias

• Atovaquone/proguanil (Malarone) is considered the drug of choice for travelers taking relatively brief trips to chloroquine-resistant areas because of its favorable safety profile and its short period of pre-exposure and postexposure dosing. The dosing schedule is ideal for frequent travelers, travelers who depart on short notice, and for those who live in the tropics and have repeated short exposures outside urban areas.
  
• Adult dose: 1 tablet daily, starting 1-2 days prior to entering a malarious area and continuing for 7 days after leaving the malarious area.
  
• Pediatric dose is based on body weight: 11-20 kg: 1 pediatric tablet daily; 21-30 kg: 2 pediatric tablets; 31-40 kg: 3 pediatric tablets; more than 40 kg, use 4 pediatric tablets or 1 adult tablet.
  
• Approved for use by children weighing more than 10 kg.
  
• Not FDA-approved for use in pregnancy, but the individual components of this drug have been shown to be safe in pregnancy; therefore, the use of atovaquone/proguanil (Malarone) in pregnancy should be considered when the probable benefits outweigh possible risks.
  
• Side effects: Relatively few. Side effects include headache, upset stomach, cough, and a rash. Atovaquone/proguanil (Malarone) should be taken at the same time each day with food or a milky drink. If vomiting occurs within one hour of taking a dose, repeat the dose.
  
• May not be effective if used with tetracycline or rifampin (because of decreased absorption).

For malaria treatment: Atovaquone/proguanil (Malarone) is considered, in most cases, to be the drug of choice for self-treatment of malaria when it is not being taken for prophylaxis. The treatment dose is 4 tablets, once daily, for 3 days.

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AZITHROMYCIN (Zithromax^®)—250 mg tablet; or oral suspension

For travelers' diarrhea and other infections

• Available in tablet, capsule, or oral suspension.
  
• Safe in pregnancy.
  
• Usual adult dose for travelers' diarrhea and most other infections: 500 mg (2 tablets) the first day, followed by a single 250 mg tablet daily for the next 4 days. An alternative dosing schedule is 2 tablets (500 mg) daily for 3 days.
  
• Pediatric dose: 10-12 mg/kg as a single dose the first day, followed by 5-6 mg/kg on days 2-5.
  
• Single-dose treatment for travelers' diarrhea: 4 tablets (1000 mg) immediately.
  
• Azithromycin (Zithromax) is an excellent drug to treat a variety of infections, such as bronchitis, pneumonia, otitis media, some skin infections, and urethritis and cervicitis due to chlamydia or gonorrhea.
  
• Azithromycin (Zithromax) is effective against typhoid fever in a dose of 1000 mg (4 tablets) the first day, followed by 500 mg (2 tablets) daily for an additional 6 days. For children, the treatment for typhoid is 10 mg/kg daily for 7 days.

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CHLOROQUINE (ARALEN^®)—500 mg (300 mg base) & 250 mg (150 mg base). (Trade names in other countries include Avloclot, Nivaquine, and Resorchin.)

For malaria prevention (prophylaxis)

• For sensitive P. vivax and P. falciparum, chloroquine remains the drug of choice to prevent malaria. However, because of widespread chloroquine-resistant P. falciparum, the use of chloroquine is limited to persons traveling in Central America, the Caribbean, and parts of the Middle East.
  
• While chloroquine remains effective against most strains of P. ovale and P. malariae, resistance to P. vivax is increasing, particularly in the South Pacific, Southeast Asia, and parts of South America (Guyana).
  
• Adult dose: 500 mg salt (300 mg base) once weekly, beginning one week before and continuing 4 weeks after leaving the malarious area. Starting chloroquine before you leave gives you a protective blood level and also lets you know if any unusual side effects will occur.
  
• Child dose: 8.3 mg/kg salt (5 mg/kg base) once weekly, up to maximum adult dose of 500 mg salt/week.
  
• Generic chloroquine tablets are sold in the United States in strengths of 250 mg and 500 mg. Only the tablet form of chloroquine is available in the United States. For young children, liquid chloroquine is generally available overseas.
  
• Side effects: Chloroquine is generally well tolerated; nausea, however, is not uncommon. Taking chloroquine with meals can usually control gastrointestinal side effects. Dizziness, headache, blurred vision, and itching may also occur, but these symptoms will rarely require you to stop taking the drug.
  
• Chloroquine can safely be taken by pregnant women and children, including infants.
  
• Caution: An overdose of chloroquine (even one tablet in a small child) can be fatal. The drug should be kept in a child-safe container at all times.
  
• Chloroquine is considered safe when taken regularly for malaria prevention, even for long periods of time (years).

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CIPROFLOXACIN (Cipro^®)—500 mg and 250 mg tablets

For travelers' diarrhea and other infections

• Used primarily to self-treat (and occasionally prevent) travelers' diarrhea.
  
• Usual dose: 500 mg twice daily for 1-3 days.
  
• For greater effectiveness, take Cipro with the antidiarrheal agent Imodium (loperamide). Take 2 caplets of Imodium (loperamide) with the first dose of Cipro. Follow Imodium-AD package directions regarding further doses.
  
• Do not use Imodium-AD (loperamide) if the diarrhea is accompanied by bloody stools or a high fever.
  
• Single-dose treatment: 750 mg of Cipro, in a single dose, can be taken as immediate treatment for travelers' diarrhea. If taken early, this may be enough to stop symptoms in a few hours. For faster effect, take Imodium along with the Cipro (see above). If diarrhea persists after 12 hours, continue Cipro, 500 mg twice daily, for 2-3 more days.
  
• Cautions: The use of Cipro (ciprofloxacin) in pregnant women, and children under age 18, is controversial; however, for more severe diarrhea (especially when there is fever and blood in stools), treatment for these groups is accepted by most infectious disease specialists.
  
• Do not take Cipro with milk, yogurt, antacids, probenecid, theophylline, or Carafate (sucralfate) because absorption will be reduced.
  
• Side effects: Cipro may cause nausea, diarrhea, headaches, dizziness, or lightheadedness. Cipro may cause (rarely) photosensitivity reactions if patients are exposed to strong sunlight.
  
• Other infections: Ciprofloxacin may also be used for respiratory tract infections; some sinus infections; typhoid fever; infections of the bladder, kidney, and prostate; skin infections; and uncomplicated gonorrhea.
  
• Prophylaxis: In special circumstances, Cipro may be used to prevent travelers' diarrhea. Prophylactic dose: 1 tablet daily during travel and for 2 days after return. Do not take Cipro for more than 3 weeks for this indication.

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DOXYCYCLINE (Vibramycin^®)—100 mg

Used to prevent chloroquine—resistant falciparum malaria and to treat some other infections

• Can be used with quinine to treat falciparum malaria.
  
• Effective in many other infections, such as Lyme disease, African tick typhus, relapsing fever, anthrax, and ehrlichiosis. Doxycycline can also be used to treat respiratory infections, such as sinusitis, bronchitis, and pneumonia, and venereal diseases, such as gonorrhea and chlamydia.
  
• Dose: For prophylaxis (prevention) of malaria: Take 100 mg daily and continue for 4 weeks after leaving malarious area. To treat other infections, 100 mg twice daily.
  
• Pediatric dose (above 8 years of age): 2 mg/kg/day, up to the adult dose of 100 mg/day, for the prevention of malaria.
  
• Do not take with milk or antacids.
  
• Swallow with adequate amounts of fluids and in the upright position to avoid the risk of the tablet sticking and causing esophageal ulceration.
  
• Side effects: Doxycycline can cause a photosensitivity reaction characterized by sunburn-type symptoms. Use a broad-spectrum (UVA + UVB) sunblock to reduce UV effects. May predispose women to vaginal yeast infections; women may wish to carry an antifungal drug (such as Diflucan) for self-treatment.

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LOPERAMIDE (Imodium^®-AD 2 mg caplets; Imodium^®-AD liquid 1 mg/5mL; Imodium^® Advanced 2 mg chewable tablets)

For treatment of mild-to-moderate travelers' diarrhea

• Prescription not required. Available over the counter in caplet, chewable tablet, and liquid form.
  
• Loperamide (Imodium-AD) is an antimotility and antisecretory drug that reduces the rapid discharge of stool, but does not treat the underlying infection.
  
• Dose: Adults and children 12 years of age and older: 2 caplets (4 mg) or chewable tablets immediately for diarrhea, then one 2 mg caplet or chewable tablet after each bowel movement. Do not exceed 8 caplets in 24 hours. Do not use Loperamide for more than 48 hours.
  
• Use with ciprofloxacin (Cipro), levofloxacin (Levaquin), or azithromycin (Zithromax) for greater effectiveness.
  
• NOTE: When diarrhea is associated with high fever and bloody stools (dysentery), Loperamide (Imodium-AD) should not be used as the primary treatment. An antibiotic is the treatment of choice for severe diarrhea and dysentery. However, it is safe to take 1 or 2 doses of loperamide when an antibiotic is taken at the same time. (Loperamide alone is usually avoided when a high fever or bloody stools are present because it is possible, theoretically, for symptoms to be prolonged if intestinal motion is reduced in the face of an invasive bacterial gut wall infection. However, this has never been conclusively demonstrated.)
  
• Pediatric dose: Children 9-11 years old (27-43 kg): 2 teaspoons or 1 caplet or chewable tablet after the first loose bowel movement, and 1 teaspoon or 1/2 caplet or chewable tablet after each subsequent loose bowel movement, but no more than 6 teaspoons, caplets, or chewable tablets a day for no more than 2 days.
  
• Children 6-8 years old (22-26 kg): 2 teaspoons or 1 caplet or chewable tablet after the first loose bowel movement, and 1 teaspoon or 1/2 caplet or chewable tablet after each subsequent bowel movement, not to exceed 4 teaspoons or 2 caplets or chewable tablets a day for more than 2 days.
  
• Children 2-5 years old (11-21 kg): 1 teaspoon after the first loose bowel movement followed by 1 teaspoon after each subsequent loose bowel movement. Do not exceed 3 teaspoons a day.
  
• Do not use loperamide under 2 years of age.
  
• The cornerstone of treatment of travelers' diarrhea in children is oral fluid replacement.
  
• Antibiotics should be given to a child with moderate-to-severe diarrhea.
  
• Although azithromycin (Zithromax) is the preferred antibiotic to treat travelers'diarrhea in children, a fluoroquinolone antibiotic (Cipro or Levaquin) should be considered for severe diarrhea and dysentery (bloody diarrhea, usually with fever). No significant adverse effects have been seen in children who have taken fluoroquinolones, despite the theoretical concerns about joint cartilage injury.

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LEVOFLOXACIN (Levaquin^®)—500 mg, 250 mg tablets

A fluoroquinolone (quinolone) antibiotic used to treat travelers' diarrhea and other infections

• Levofloxacin (Levaquin) is an excellent drug to carry for standby self-treatment, not only for diarrhea, but also for a variety of other infections such as pneumonia, bacterial bronchitis, urinary tract infections, skin infections, uncomplicated gonorrhea, and pelvic inflammatory disease.
  
• Use by children under 18 is accepted by most infectious disease consultants for severe disease (e.g., diarrhea with fever and bloody stools).
  
• Category C pregnancy drug: To be used in pregnant women only when the risk of infection outweighs possible adverse effects. Indicated for severe diarrhea, high fever with toxicity, especially when there is the threat of dehydration.
  
• Dose: 500 mg once, or 500 mg twice daily for 1-3 days, if the drug is continued beyond the first dose.
  
• Symptoms will be controlled faster if taken with Imodium (loperamide).
  
• Take with meals, or on an empty stomach.
  
• Do not take with antacids containing magnesium or aluminum, sucralfate (Carafate), or iron preparations. These should be taken 2 hours before, or 2 hours after, taking Levaquin.
  
• Effective against typhoid fever in a dose of 500 mg daily for 5-7 days.

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MEFLOQUINE (Lariam)—250 mg (Trade names in other countries include Eloquin^® and Mephaquin^®.)

For malaria prevention and treatment

• Effective for prevention of chloroquine-sensitive and chloroquine-resistant malaria and other malarias.
  
• Not recommended for malaria self-treatment because of potentially severe neuropsychiatric side effects.
• Adult dose (prophylaxis): 1 tablet (250 mg) weekly, beginning 1-2 weeks before departure, continuing during exposure, and for an additional 4 weeks after leaving the malarious area. Do not take on an empty stomach.
  
• Pediatric dose: 5 mg/kg for infants under 15 kg; 1/4 tablet for those weighing 15-19 kg; 1/2 tablet for those weighing 20-30 kg; and 3/4 tablet for those weighing 31-45 kg.
  
• Contradicted for travelers with a history of epilepsy, cardiac conduction abnormalities, or psychiatric disorders.
  
• May be used by travelers taking beta blockers if they have no underlying cardiac arrhythmias.
  
• Should not be used with quinine, quinidine, halofantrine, chloroquine, or anticonvulsants.
  
• Mefloquine (Lariam) has no adverse cardiac effects when used by itself.
  
• Side effects: Generally well-tolerated in prophylactic doses, but about 25% of users report mild-to-moderate side effects—strange dreams, insomnia, mood alteration, nausea, dizziness, and weakness. About 3% of travelers taking mefloquine (Lariam) for prophylaxis discontinue the drug, primarily because of central nervous system side effects. Mefloquine (Lariam) should be discontinued if irritability, depression, confusion, or paranoia develops.
  
• Caution: People involved in tasks that require fine coordination (e.g., airline pilots, surgeons) should not take this drug.
  
• Mefloquine (Lariam) is approved for infants less than 15 kg when travel to a chloroquine-resistant area is unavoidable.
  
• Lariam is approved for use by pregnant women.
  
• Considered safe when taken regularly for prevention for as long as necessary.
  

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