Diarrhea Among International Travelers in Bali-Indonesia: Clinical and Microbiological Finding

Document Type : Original Article


1 Departement of Internal Medicine, Faculty of Medicine and Health Science, Warmadewa University, Bali, Indonesia

2 Faculty of Medicine, Udayana University, Bali, Indonesia

3 Kasih Ibu Hospital Denpasar, Bali, Indonesia


Introduction: Diarrhea is a common illness among travelers to developing countries. Located in a tropical region, Bali has a potentially high prevalence of travelers diarrhea. This hospital-based cross-sectional study was carried out to assess the clinical and microbiological profiles of diarrhea among travelers admitted to Kasih Ibu hospital, Denpasar-Bali.
Methods: This study enrolled a total of 71 patients at Kasih Ibu hospital between April 2015 and August 2016. All patients completed an epidemiologic questionnaire; their clinical histories were taken, and physical examinations were performed. Stool samples were collected for bacterial and parasitologic studies and susceptibility testing.
Results: Most patients were female (70.4%), and the nationality of most patients was Dutch (15.5%). Secretory diarrhea was the most frequently found diarrheal type (88.7%), with only 5.6% of cases having severe dehydration which developed into acute kidney injury. A high percentage of Entamoeba spp. was also seen in this study (54.9%). Of the 37 stool samples available for microbiological testing, 62.2% showed growth; Escherichia coli was the most commonly isolated bacteria (54.1%). Patients not infected by Entamoeba spp. were found more likely to experience nausea and vomiting (P<0.005).
Conclusion: Secretory diarrhea was the most prevalent type of diarrhea among travelers admitted to Kasih Ibu hospital, Bali. The most frequently found pathogens were Entamoeba spp. and E. coli. Although most patients had only mild dehydration as a complication, acute kidney injury did occur in some cases.


  1. Fox TG, Manaloor JJ, Christenson JC. Travel-related infections in children. Pediatr Clin North Am. 2013;60(2):507-527. doi: 10.1016/j.pcl.2012.12.004.
  2. Steffen R, Hill DR, DuPont HL. Traveler’s diarrhea: a clinical review. JAMA. 2015;313(1):71-80. doi: 10.1001/jama.2014.17006.
  3. Casburn-Jones AC, Farthing MJ. Traveler’s diarrhea. J Gastroenterol Hepatol. 2004;19(6):610-8. doi:10.1111/j.1440- 1746.2003.03287.x.
  4. Steffen R. Epidemiology of traveler’s diarrhea. Clin Infect Dis. 2005;41 Suppl 8:S536-S540. doi: 10.1086/432948.
  5. Yates J. Traveler’s diarrhea. Am Fam Physician. 2005;71(11):2095- 2100.
  6. de la Cabada Bauche J, DuPont HL. New developments in traveler’s diarrhea. Gastroenterol Hepatol. 2011;7(2):88-95.
  7. Kollaritsch H, Paulke-Korinek M, Wiedermann U. Traveler’s diarrhea. Infect Dis Clin North Am. 2012;26(3):691-706. doi: 10.1016/j.idc.2012.06.002.
  8. Connor BA. Chronic diarrhea in travelers. Curr Infect Dis Rep. 2013;15(3):203-210. doi: 10.1007/s11908-013-0328-2.
  9. Stermer E, Lubezky A, Potasman I, Paster E, Lavy A. Is traveler’s diarrhea a significant risk factor for the development of irritable bowel syndrome? A prospective study. Clin Infect Dis. 2006;43(7):898-901. doi: 10.1086/507540.
  10. 1Statistik Bali Post. Wisatawan Mancanegara November 2015 capai 777,5 Ribu, Naik 1,70% dari November 2014. https://www.bps. go.id/brs/view/id/1054. Published 2016.
  11. Duggan C, Santosham M, Glass RI. The management of acute diarrhea in children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 1992;41(RR-16):1-20.
  12. World Health Organization. The treatment of diarrhoea: a manual for physicians and other senior health workers. Geneva, Switzerland: WHO; 2005.
  13. Baron EJ, Miller JM, Weinstein MP, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM) (a). Clin Infect Dis. 2013;57(4):e22-e121. doi: 10.1093/cid/cit278.
  14. Ahn JY, Chung JW, Chang KJ, et al. Clinical characteristics and etiology of travelers’ diarrhea among Korean travelers visiting South-East Asia. J Korean Med Sci. 2011;26(2):196-200. doi: 10.3346/jkms.2011.26.2.196.
  15. Gascón J. Epidemiology, etiology and pathophysiology of traveler’s diarrhea. Digestion. 2006;73 Suppl 1:102-108. doi: 10.1159/000089785.
  16. Gallardo F, Gascon J, Ruiz J, Corachan M, Jimenez de Anta M, Vila J. Campylobacter jejuni as a cause of traveler’s diarrhea: clinical features and antimicrobial susceptibility. J Travel Med. 1998;5(1):23-26. doi: 10.1111/j.1708-8305.1998.tb00451.x.
  17. Vila J, Ruiz J, Gallardo F, et al. Aeromonas spp. and traveler’s diarrhea: clinical features and antimicrobial resistance. Emerg Infect Dis. 2003;9(5):552-555. doi: 10.3201/eid0905.020451.
  18. Okhuysen PC. Traveler’s diarrhea due to intestinal protozoa. Clin Infect Dis. 2001;33(1):110-114. doi: 10.1086/320894.
  19. Yu JR, Sohn WM. A case of human cyclosporiasis causing traveler’s diarrhea after visiting Indonesia. J Korean Med Sci. 2003;18(5):738- 741. doi: 10.3346/jkms.2003.18.5.738.
  20. Gascon J. Epidemiology, etiology and pathophysiology of traveler’s diarrhea. Digestion. 2006;73 Suppl 1:102-108. doi: 10.1159/000089785.
  21. Murphy H, Pandey P. Pathogens for travelers’ diarrhea in Nepal and resistance patterns. Curr Infect Dis Rep. 2012;14(3):238-245. doi: 10.1007/s11908-012-0253-9.
  22. Peltola H, Gorbach SL. Traveler’s diarrhea. In: DuPont HL, Steffen R, eds. Travel Medicine. 2nd ed. London: Decker; 2001.
  23. Taylor DN, Houston R, Shlim DR, Bhaibulaya M, Ungar BL, Echeverria P. Etiology of diarrhea among travelers and foreign residents in Nepal. JAMA. 1988;260(9):1245-1248. doi:10.1001/ jama.1988.03410090077034.