Acute diarrhoea in children treated in an outpatient setting in Athens, Greece.

OBJECTIVE: To describe the epidemiology and aetiology of acute diarrhoea among children treated exclusively in an outpatient setting in Greece. METHODS: During 1999, children with acute diarrhoea who attended the emergency department of our hospital were prospectively studied. Patients requiring hospitalization were excluded. Stool specimens were tested microscopically, for bacterial enteropathogens by standard and selective medium cultures and for rotavirus and adenovirus by latex agglutination test. RESULTS: One hundred and thirty-two children (median age: 2 years) were included in the study; an enteropathogen was detected in 63 (48%) of them. Isolates included rotavirus (19 patients), Salmonella sp (12), Campylobacter sp (10), Aeromonas sp (9), enteropathogenic Escherichia coli (6), adenovirus (6), Giardia lamblia (4), Yersinia enterocolitica (2) and Shigella sp (1). Half of the bacterial cases occurred from August to October, and two rotavirus-associated peaks occurred during February and August. Acute diarrhoea caused by viruses affected exclusively children under six years of age, mainly those attending day care centres. Macroscopic blood in stools was reported only among patients with a bacterial infection. Socioeconomic characteristics were not helpful in differentiating disease due to specific enteropathogens. CONCLUSIONS: Bacterial enteropathogens account for a significant proportion of acute diarrhoea in children treated in the outpatient setting in Greece. Rotavirus is also a frequent cause affecting mostly younger children and those attending day care centers. The presence of blood in stools and the seasonality of bacterial infections may enable their presumptive diagnosis.     

Microbiologic and clinical study of acute diarrhea in children in Aswan, Egypt

Children with diarrhea presenting to a Government Rehydration Center in Aswan, Egypt, were investigated to determine the etiology and clinical presentation of acute childhood diarrhea in southern Egypt. Among 126 outpatients and 25 inpatients with diarrhea (mean age 18 months), enterotoxigenic Escherichia coli (ETEC) (17% of cases), Cryptosporidium (9%), Salmonella spp. (7%), Campylobacter jejuni/coli (7%), and Shigella spp. (5%) were the most common enteropathogens identified during the high incidence season of July. Enteropathogens were isolated as often from inpatients as outpatients, except for Salmonella spp. and Cryptosporidium, which were recovered more often from inpatients. Salmonella-infected children, in particular, were more ill, feverish, and dehydrated on presentation than other children, resulting in more frequent hospitalization. Except for Salmonella-infected children, children with acute diarrhea usually presented without severe dehydration, which may have been due to frequent initiation of oral rehydration therapy (ORT) by mothers trained by local health care providers. A potential environmental source of ETEC was identified in clay water storage containers commonly used in this area.     

Detection and identification of bacterial enteropathogens by polymerase chain reaction and conventional techniques in childhood acute gastroenteritis in Gaza, Palestine.

BACKGROUND: Acute gastroenteritis and diarrhea are common and costly problems that cause significant morbidity and mortality in children worldwide. In Palestine, diarrhea is one of the major causes of outpatient visits and hospitalizations. METHODS: To improve knowledge on the etiology of gastroenteritis and diarrhea in our patient population, stool specimens from 150 children under 5 years of age suffering from acute gastroenteritis were investigated for various common bacterial enteropathogens by conventional and molecular techniques. RESULTS: Bacterial enteropathogens were detected in 17.3% of the diarrheal samples. Shigella spp was the most common bacterial pathogen (6.0%), followed by Campylobacter coli/jejuni (4.7%), Escherichia coli O157:H7 (4.7%), and Salmonella spp (2.0%). Shigella and Salmonella isolates were tested for their susceptibility to common antimicrobial agents and most of the Shigella isolates were resistant to ampicillin, trimethoprim/sulfamethoxazole and doxycycline and most of the Salmonella isolates showed resistant to ampicillin, trimethoprim/sulfamethoxazole, doxycycline and nalidixic acid. CONCLUSIONS: The results highlight the value of using a combination of traditional and molecular techniques (PCR) in the diagnosis of bacterial gastroenteritis. Furthermore, this study demonstrated that E. coli O157:H7 and Campylobacter, which are not screened for routinely in the Gaza Strip, were significant enteropathogens.     

Acute diarrhea due to enteropathogenic bacteria in patients at hospitals in Tehran

During a study examining causes of diarrhea from May 2004 to May 2005, 808 stool specimens were collected from patients with acute diarrhea in Tehran. Fecal samples were cultured and identified according to the standard biochemical methods. Molecular identification of enteropathogens was carried out by amplification of their virulence genes by polymerase chain reaction. A total of 369 (45.6%) bacterial pathogens were recovered from 808 patients as follows: Shigella spp., 155 (45.6%); diarrheagenic Escherichia coli 143 (38.8%); Salmonella spp., 51 (13.8%); and Campylobacter spp., 20 (5.4%). Most of the diarrheagenic E. coli were Shiga toxin-producing E. coli, with 64 (44.7%) isolates, followed by 47 (32.9%) enterotoxigenic E. coli isolates; among Shigella spp. isolates, 69 (44.5%) Shigella flexneri were predominant. The molecular diagnosis of enteropathogens yielded a more accurate characterization of the prevalence of diarrhea-causing bacterial strains in Iran. The present study revealed a high prevalence of Shigella and diarrheagenic E. coli as the predominant causes of bacterial diarrhea in this region of the world. These two types of bacteria should therefore be considered when designing preventive strategies for people living in Iran.     

Etiology of diarrhea in children less than five years of age in Ifakara, Tanzania

A total of 451 stool specimens were collected from children less than five years of age with acute diarrhea from Ifakara, Tanzania and processed to detect bacterial enteropathogens, parasites, and rotaviruses. These specimens were divided into 348 from the dry season and 103 from the rainy season. Overall, diarrheogenic Escherichia coli (35.7%) were the predominant enteropathogens, with enterotoxigenic E. coli, enteroaggregative E. coli, and enteropathogenic E. coli being the most prevalent. Moreover, enteroaggregative E. coli (63% versus 35.5%; P < 0.05), Shigella spp. (24% versus 12%; P < 0.05), and rotavirus (23% versus 4%; P < 0.05) were more prevalent in the dry season than in the rainy season and enterotoxigenic E. coli (51.6% versus 20%; P < 0.05) and Giardia lamblia (14% versus 1%; P < 0.05) were more prevalent in the rainy season.     

Incidence of bacterial enteropathogens among hospitalized diarrhea patients from Orissa, India

Bacteriological analysis of 1,551 stool/rectal swabs from all age groups of diarrhea patients of different hospitals of Orissa from January 2004 to December 2006 was carried out using standard procedures. Among all enteropathogens isolated in 886 culture-positive samples, Escherichia coli constituted 75.5%, including 13.2% pathogenic E. coli; Vibrio cholerae O1 constituted 17.3%; V. cholerae O139, 1%; Shigella spp., 4.5% (Shigella flexneri type 6, 2.9%, S. dysenteriae type I, 0.7%, S. sonnei, 0.6%, and S. boydii, 0.3%); Salmonella spp., 0.7%; and Aeromonas spp., only 2.0%. The isolation of bacterial enteropathogens was highest during July, 2005, followed by September, 2006. The prevalence of shigellosis in this region was relatively low. Cholera cases were more frequent during the rainy seasons. The dominance of V. cholerae O1 Inaba over Ogawa serotypes was observed in 2005, whereas this trend was reversed in 2006. The resistance profile of V. cholerae O1 was co-trimoxazole (Co), furazolidone (Fr), and nalidixic acid (Na); for Aeromonas spp., it was ampicillin (A), Fr, ciprofloxacin (Cf), Na, norfloxacin (Nx), and Co. Pathogenic E. coli strains were resistant to A, Fr, Co, streptomycin (S), Cf, Na, Nx, and neomycin (N); Shigella spp. were resistant to Fr, Na, Co, and S; and Salmonella spp. were resistant to A and Fr. Active surveillance should be continued among diarrhea patients to look for different enteropathogens and to define the shifting antibiogram patterns in this region.     

Clinic-based surveillance for bacterial- and rotavirus-associated diarrhea in Egyptian children

To identify enteropathogens for vaccine development, we implemented clinic-based surveillance for severe pediatric diarrhea in Egypt's Nile River Delta. Over 2 years, a physician clinically evaluated and obtained stool samples for microbiology from patients with diarrhea and less than 6 years of age. In the first (N = 714) and second clinic (N = 561), respectively, 36% (N = 254) and 46% (N = 260) of children were infected with rotavirus, enterotoxigenic Escherichia coli (ETEC), Campylobacter, or Shigella. When excluding mixed rotavirus-bacterial infections, for the first and second clinic, 23% and 10% had rotavirus-associated diarrhea, and 14% and 17% had ETEC-associated diarrhea, respectively. Campylobacter-associated diarrhea was 1% and 3%, and Shigella-associated diarrhea was 2% and 1%, respectively, for the two clinics. Rotavirus-associated diarrhea peaked in late summer to early winter, while bacterial agents were prevalent during summer. Rotavirus-associated cases presented with dehydration, vomiting, and were often hospitalized. Children with Shigella- or Campylobacter-associated diarrhea reported as watery diarrhea and rarely dysentery. ETEC did not have any clinically distinct characteristics. For vaccine development and/or deployment, our study suggests that rotavirus is of principle concern, followed by ETEC, Shigella, and Campylobacter.     

Etiology of acute diarrhea among children in Ribeirão Preto-SP, Brazil

To study the main enteropathogens causing diarrhea in the region of Ribeir?o Preto regarding serogroups and serotypes, the feces of 1836 children under 10 years old, from both sexes, attack of acute gastroenteritis, were analysed during a period of 4 years in Adolfo Lutz Institute - Ribeir?o Preto, SP. The pathogens identified by standard methods were the following: Escherichia coli, Salmonella spp., Shigella spp., Campylobacter spp., Yersinia spp., and Cryptosporidium spp. Positive samples were 22.8% (419) with 1.7% association of pathogens. Larger isolates were mainly from children 0 to 11 months old. Enteropathogenic E. coli (EPEC) was most frequent (8.7%) with predominance of serogroup O119 (40.2%), followed by Shigella (6.2%), 63.6% of which S. sonnei.     

Etiology of acute diarrhea in children and adults in Tunis, Tunisia, with emphasis on diarrheagenic Escherichia coli: prevalence, phenotyping, and molecular epidemiology

A total of 271 stool specimens were collected from children (diarrheagenic, n = 115 and control, n = 54) and adults (diarrheagenic, n = 73 and control, n = 29) from Tunis, Tunisia, and processed to detect bacterial enteropathogens, parasites, and viruses. Diarrheagenic Escherichia coli (DEC) were identified by their virulence genes (polymerase chain reaction) and adherence patterns (tissue culture assays). The most frequently isolated enteric pathogens from diarrheagenic children were enterotoxigenic E. coli (ETEC, 32.3%), enteroaggregative E. coli (EAEC, 11.3%), enteroinvasive E. coli (EIEC, (11.3%), adenovirus (10.4%), enterohemorrhagic E. coli (EHEC, 10.4%), and Salmonella spp. (9.5%). For children in the control group, ETEC (37%), EAEC (15%), EHEC (11.1%), and typical enteropathogenic E. coli (EPEC, 11.1%) were the most common enteric pathogens. In adults in the diarrheagenic group, Salmonella spp. (34.2%), ETEC (12.3%), adenovirus (7%), and Shigella spp. (4%) were the most common enteric pathogens. In adults in the control group, ETEC (31%) was the most common enteric pathogen. Multiple pathogens were recovered from 22% of the diarrheagenic children and 7% of the diarrheagenic adults. Escherichia coli strains showed high resistance rates to tetracycline, streptomycin, and beta-lactams. The most frequent combinations were ETEC-rotavirus and ETEC-adenovirus. Pulsed-field gel electrophoresis for DEC indicated a large number of DEC clones (five major clones) persistent in the community reservoir for a considerable period of time that caused diarrhea in the population. This suggests the confluence of small epidemics by clonally related DEC strains circulating in this region.     

Enteropathogens in adult patients with diarrhea and healthy control subjects: a 1-year prospective study in a Swedish clinic for infectious diseases.

A 1-year prospective study was conducted to identify enteropathogens in adults with diarrhea (n=851) and in healthy control subjects (n=203) by use of conventional laboratory methods. Virulence factor genes for diarrheagenic Escherichia coli were detected by polymerase chain reaction. Enteropathogens were identified in 56% of patients and 16% of control subjects. The isolation rate was 65% for patients with symptoms for <1 week and for travelers; >1 pathogen was found in 11% of patients. The most frequent enteropathogens were Campylobacter (13% of patients), Clostridium difficile (13%), enterotoxigenic Escherichia coli (8%), Salmonella (7%), Shigella (4%), Blastocystis hominis (4%), calicivirus (3%), rotavirus (3%), enteroaggregative E. coli (2%), Aeromonas (2%), Giardia intestinalis (2%), Cryptosporidium (2%), and astrovirus (2%). Less frequently isolated (< or =1% of patients) were verotoxigenic E. coli, enteropathogenic E. coli, enteroinvasive E. coli, Entamoeba histolytica/Entamoeba dispar, microsporidia, and adenovirus. Fifty percent of the patients were hospitalized, and 43% needed intravenous fluids. The median duration of diarrhea was 14 days. Clinical features were not helpful for predicting the etiology of diarrhea.     

Reovirus-like agent and enterotoxigenic Escherichia coli infections in pediatric diarrhea in the Philippines.

Of 82 children hospitalized with diarrhea in the Philippines during January-June 1976, 14 (17%) had infections due to a reovirus-like agent as determined by detection of viral particles in stools by electron microscopy (12 [15%] of 82) and/or by a rise in titer of antibody to the serologically related Nebraska calf diarrhea virus (eight [20%] of 39). Escherichia coli producing heat-labile enterotoxin were found in six (7%) of 82 ill children and two (4%) of 49 healthy control children, while E. coli producing heat-stable enterotoxin were isolated from three children with diarrhea and two without gastroenteritis. Thirty-eight percent of enterotoxigenic E. coli isolated from children with diarrhea, but only 6% of isolates from healthy control, were of serotypes similar to those of enterotoxigenic E. coli isolated in previous studies of these pathogens by other investigators in geographically diverse areas (serotypes O6:H16, O8:H9, and O78:H12) (P less than 0.05). Eight (10%) of the children had infections with multiple enteric pathogens.     

Bacterial causes of AIDS-associated diarrhea in Thailand

The incidence of bacterial diarrhea in AIDS patients has increased steadily and has led to enormous medical and public health problems. In this study, the clinical data together with 350 rectal swab samples each from AIDS patients with diarrhea (APD) and non-AIDS patients with diarrhea (NAPD), were collected and examined for bacterial enteropathogens at the Bamrasnaradura Infectious Diseases Hospital (BIDH), Nonthaburi, Thailand from May to December 1996. Patients were matched by age and sex. The majority of these patients were male (79%, 554/700), aged between 15 and 34 years (70.9%). The study found that the isolation rates of bacterial enteropathogens causing diarrhea in APD (18%, 62/350) were considerably lower than those in NAPD (43%, 152/350) (p<0.05). The infection rate with Salmonella group B (19.7%, 12/61) in APD was found to be significantly higher than that in NAPD (14.3%, 2/14) (p<0.05). Vibrio parahaemolyticus (53.3%, 81/152), Plesiomonas shigelloides (27%, 41/152), Aeromonas spp (19.1%, 29/152) and V. cholerae O1 (15.1%, 23/152), were more frequently detected in NAPD than in APD (p<0.05). Only nine Escherichia coli strains were isolated from APD, of which six were enteroinvasive E. coli, two enterotoxigenic E. coli and one enterohemorrhagic E. coli (non O157) possessing both vtl and vt2. No V. cholerae strains were detected in APD. The least effective antibiotics were ampicillin, tetracycline and cotrimoxazole. Antibiotic resistant patterns of the isolated organisms were similar from both groups. The results from this study might be useful in Thailand in the diagnosis and management of clinical cases of bacterial diarrhea, especially APD.     

In vitro activity of ciprofloxacin compared to trimethoprim-sulfamethoxazole against Campylobacter spp., Shigella spp. and Enterotoxigenic Escherichia coli causing travellers' diarrhea in Egypt

The in vitro activity of ciprofloxacin against bacterial enteropathogens isolated from cases of travellers' diarrhea in Egypt was compared to trimethoprim (TMP) and trimethoprim-sulfamethoxazole (SXT). No resistance to ciprofloxacin was noted for any of the Campylobacter jejuni/coli, Shigella spp., and enterotoxigenic Escherichia coli strains examined. However, resistance to TMP and SXT was noted among these same strains. Because of its broad spectrum and lack of resistance, ciprofloxacin is potentially a useful drug for the treatment of diarrhea caused by bacterial enteropathogens encountered in this region of the world.     

2005年天津地区血液系统疾病院内感染临床分析

目的:分析2005年天津地区血液病住院患者院内感染临床分离菌的分布情况及其耐药现状。方法:收集2005年1~12月天津地区住院血液病患者临床分离菌株,采用微量稀释法进行药敏实验。结果:125株临床分离菌株中,革兰阳性菌46株(36.8%),革兰阴性菌55株(44.0%),真菌24株(19.2%)。MRSA和MRC-NS检出率分别为81.8%(9/11)和71.4%(10/14),未检出对万古霉素耐药的葡萄球菌和肠球菌。血液科最常见革兰阴性菌种依次为大肠埃希氏菌14株(11.2%),鲍曼不动杆菌12株(9.6%),肺炎克雷伯氏菌9株(7.2%),铜绿假单胞菌5株(4.0%),嗜麦芽窄食假单胞菌3株(2.4%),区别于全院铜绿假单胞菌占首位的情况。大肠埃希菌和肺炎克雷伯菌ESBLs的检出率分别为35.7%(5/14)和11.1%(1/9)。肠杆菌科和不动杆菌属细菌对碳青霉烯类药物的敏感性最高。结论:本研究结果对血液系统疾病合并院内感染的经验性用药有一定的参考价值。     

Medikamentöse Therapie der infektiösen Diarrhö

Diarrheal diseases are among the most common diseases worldwide. In this review the current treatment recommendations for acute (Part 1) and chronic (Part 2) infectious diarrhea are summarized and typical enteropathogens are discussed. The second part of the article describes chronic diarrhea, its related pathogens and treatment. In contrast to acute diarrhea which is mainly caused by viral and typical bacterial pathogens, chronic diarrhea has mainly non-infectious origins. Protozoal pathogens, such as Giardia lamblia and Entamoeba histolytica in particular are found and more rarely bacterial pathogens, such as Tropheryma whipplei. Opportunistic pathogens cause diarrhea in immunocompromised patients, such as in HIV patients. In these patients cytomegalovirus (CMV) colitis or infections with Cryptosporidium spp., Cyclospora cayetanensis, Isospora belli or microsporidia have to be considered. Besides targeted specific antimicrobial therapy, anti-retroviral drugs improving the underlying immunosuppression and thus the reconstitution of the adaptive immune response remain a cornerstone of the treatment in HIV-positive patients.     

Etiology of bloody diarrhea among patients presenting to United States emergency departments: prevalence of Escherichia coli O157:H7 and other enteropathogens.

Escherichia coli O157:H7 and other Shiga toxin-producing E. coli (STEC) infections have been associated with bloody diarrhea. The prevalence of enteropathogens among patients with bloody diarrhea was determined by a prospective study at 11 US emergency departments. Eligible patients had bloody stools, > or =3 loose stool samples per 24-h period, and an illness lasting <7 days. Among 873 patients with 877 episodes of bloody diarrhea, stool samples for culture were obtained in 549 episodes (62.6%). Stool cultures were more frequently ordered for patients with fever, >10 stools/day, and visibly bloody stools than for patients without these findings. Enteropathogens were identified in 168 episodes (30.6%): Shigella (15.3%), Campylobacter (6.2%), Salmonella (5.8%), STEC (2.6%), and other (1.6%). Enteropathogens were isolated during 12.5% of episodes that physicians thought were due to a noninfectious cause. The prevalence of STEC infection varied by site from 0% to 6.2%. Hospital admissions resulted from 195 episodes (23.4%). These data support recommendations that stool samples be cultured for patients with acute bloody diarrhea.     

Acute community-acquired diarrhea requiring hospital admission in Swiss children.

In order to ascertain the prevalence of agents that cause childhood diarrheal illness, stool specimens of 312 consecutive children with community-acquired diarrhea requiring admission were evaluated. Pathogens were detected in 166 (53%) of the 312 children (>/=2 pathogens in 28 children): Rotavirus (n=75), Salmonella spp. (n=37), Campylobacter spp. (n=24), Shigella spp. (n=5), Giardia spp. (n=4), Yersinia spp. (n=2), Aeromonas spp. (n=15), Cryptosporidium (n=15), enteropathogenic Escherichia coli (n=13), enterotoxigenic E. coli (n=7), and enterohemorrhagic E. coli (n=5). In conclusion, acute childhood diarrheal illness pathogens, such as Aeromonas, Cryptosporidium, and diarrheagenic E. coli, account for a large proportion of patients with a microbiologically positive stool specimen.     

Acute diarrhoea in adults: aetiology, clinical appearance and therapeutic aspects

A prospective study of acute diarrhoea was performed during 15 months 1981/1982 and included 731 patients and 240 controls. 43% had been infected abroad. A cluster of travellers with bacterial pathogens was diagnosed in July-August. The following pathogens were found: Campylobacter (18%), enterotoxigenic E. coli (6%), Salmonella spp. (5%), rotavirus (4%), Yersinia enterocolitica (3%), Giardia lamblia (3%), Shigella spp. (2%), Clostridium difficile (2%), enteroviruses (2%) and Entamoeba histolytica (less than 1%). More than 90% of the bacterial or parasitic enteropathogens were detected in the first stool sample. Only 10% of the patients needed hospital treatment and for 97% oral fluids were sufficient. The median duration of diarrhoea was 9 days. No fatal cases occurred and only 2 cases of chronic bowel disease were detected.     

Etiology of diarrhea in children younger than 5 years of age admitted in a rural hospital of southern Mozambique

Diarrhea is one of the main causes of morbidity and mortality among children in sub-Saharan Africa and one of the main causes of hospital admissions in rural areas. Stool samples were collected from 529 children admitted with diarrhea to the Manhi?a District Hospital (September 2000 to September 2001) and processed to detect bacterial enteropathogens, parasites, and virus. Diarrheagenic Escherichia coli, isolated from 120 samples (22.6%; enteroaggregative [corrected] [9.6%], enterotoxigenic [6.8%], enteropathogenic [corrected] [4.3%], and verotoxigenic [1.9%]) was the most frequently isolated pathogen, followed by Ascaris lumbricoides (9.3%). Others detected included Salmonella spp. and Giardia lamblia (2.5% each) and Campylobacter spp. (1.7%). A. lumbricoides (92% versus 8%; P<0.001) and Strongyloides stercolaris (100% versus 0%; P=0.008) were most frequently isolated in children older than 12 months of age. Resistance to trimethoprim-sulphametoxazole and ampicillin was high. Etiologic data on diarrheal diseases and susceptibility patterns of diarrheal pathogens are important tools for clinical management and control strategic planning.     

Enteropathogens associated with acute diarrheal disease in urban infants in S?o Paulo, Brazil

To determine the prevalence and epidemiology of enteropathogens in acute infantile diarrhea, 500 infants less than or equal to 12 months of age with diarrhea and 500 age-matched control subjects coming to a S?o Paulo emergency room were studied. Enteropathogens were identified in 55% of case infants and 10% of controls; enteropathogenic Escherichia coli (EPEC) of classic EPEC serotypes producing EPEC adherence factor (EAF) (26% of case infants), rotavirus (14%), Salmonella species (8%), enterotoxigenic E. coli (7%), and Shigella species (5%) were associated with diarrhea. Isolation of EAF+ classic EPEC decreased with increasing age of cases and peaked in spring, whereas rotavirus was least common in early infancy and peaked in fall and winter. Bloody stool had a 36% positive predictive value for Shigella infection, EAF+ classic EPEC were highly resistant to antimicrobial drugs. Among poor S?o Paulo infants, EAF+ classic EPEC equaled or exceeded rotavirus throughout the year as a cause of diarrhea bringing children to medical attention.