Additional exclusion criteria included: current use

of antibiotic or antidiarrheal medication (ie, Pepto-Bismol, loperamide, etc.) or their use within 2 weeks prior to departure for the trip, a history of inflammatory bowel disease (Crohn’s disease or chronic ulcerative colitis), known bowel cancer, congenital or acquired Fluorouracil cell line immunocompromised states such as human immunodeficiency virus infection (HIV/AIDS), current or recent chemotherapy or immunomodulating agents (corticosteroids and TNF-α inhibitors), short-gut syndrome, use of oral typhoid vaccine within 48 hours of starting AKSB, pregnancy, ongoing probiotic use, and previous participation in this study. Women of child-bearing age were required to have a negative pregnancy test within 2 weeks of starting the study drug and were counseled not to get

pregnant during the study period. Subjects seen at the TTMC for pre-travel counseling for international travel were screened and offered enrollment into the TD study. All enrolled subjects received standard counseling and education about food and water precautions and self-management of TD. They were also offered antimicrobials (ciprofloxacin, levofloxacin, or azithromycin) to carry with them to treat TD if needed. They were instructed not to use antibiotics prophylactically. The subjects were instructed to continue taking the study drug even if TD developed and were initiating antibiotics and/or loperamide. A letter was provided to the patient to allow carriage of the study drug JQ1 ic50 across international

borders. The letter also contained telephone numbers for on-call personnel in case subjects experienced side-effects or had questions during their trip. This trial was approved by the Mayo Clinic Institutional Review Board (IRB) (Protocol 566–02) and all subjects enrolled in this study provided written informed consent. Two capsules of AKSB or placebo were ingested Thiamet G daily with food, beginning 3 days prior to travel, throughout the trip, and for 7 days after return. The two capsules could be taken either at once or one twice a day. The AKSB and placebo capsules were identical in color, packaging, and smell. Subjects were allowed to reduce the dose to one capsule per day if they had uncomfortable increase in intestinal gas. They were allowed to increase back to two capsules per day or one capsule twice a day as symptoms dictated. AKSB has three ingredients: a probiotic bacteria (4.5 billion CFU of Enterococcus faecium, microencapsulated SF68 or Ventrux ME 30 from Cerbios-Pharma SA, Barbengo/Lugano, Switzerland), a probiotic yeast (500 million CFU of S cerevisiae strain CNCM I 4444 from Lesaffre, Marcq-en-Barœul, France), and a prebiotic (FOS, NutraFlora from GTC Nutrition, Westchester, IL, USA). All doses were recorded daily in a provided diary. Subjects were randomly allocated to receive AKSB or placebo. Randomization was performed in a block of size 4 using a random number generator from sas software (version 8.0; SAS, Inc.