Short-term ceftriaxone therapy for treatment of severe non-typhoidal Salmonella enterocolitis

Aim: To evaluate the clinical efficacy of a short-course ceftriaxone therapy in the treatment of paediatric patients with severe non-typhoidal Salmonella enterocolitis. Methods: During a 1 y period, all paediatric patients who were suspected having Salmonella enterocolitis by the presentation of bloody and/or mucoid diarrhoea with or without fever were eligible for the study. Patients with either negative stool cultures or bacteraemia were excluded. Severe enterocolitis was defined as a bloody and/or mucoid diarrhoea associated with high fever persisting for longer than 48 h and signs of moderate or severe dehydration. The patients with severe enterocolitis were assigned to treatment with ceftriaxone (50 mg kg^-1 d^-1) for 3-5 d, while the rest were given supportive treatment only. Before treatment all study patients received blood testing for white blood cell (WBC) count, C-reactive protein (CRP) level and blood culture. The duration of the fevers was recorded. Patients were followed up after clinical recovery for the possibility of relapse. Results: Seventy-three patients with culture-confirmed Salmonella enterocolitis without bacteraemia were analysed. The duration of fever was longer in severe cases who were treated with ceftriaxone than those who were not. However, rapid defervescene was found after short-course ceftriaxone therapy in those patients with severe enterocolitis. CRP was significantly higher in severe cases. There was no significant difference in the WBC count between the two groups of patients. No relapse was found in these patients.

Conclusion: High CRP, prolonged high fever and signs of moderate or severe dehydration appear appropriate to define severe cases of Salmonella enterocolitis. Short-course ceftriaxone therapy is clinically beneficial to these patients. Neither clinical nor microbiological relapse was seen after therapy.     

Azithromycin in the treatment of cholera in children

Aim: To evaluate the efficacy of azithromycin in the treatment of cholera in children. Methods: A double-blind, randomized, controlled clinical trial on 80 children with acute watery diarrhoea and moderate to severe dehydration compared the efficacy of azithromycin and erythromycin in treating cholera. Data were analysed for 56 patients who were stool culture positive for Vibrio cholerae. In conjunction with rehydration therapy, 29 patients received azithromycin and 27 patients received erythromycin. Patients in the two treatment groups had comparable clinical and blood biochemical characteristics on admission. Results: Patients who received azithromycin had significantly less stool output, shorter duration of diarrhoea and lower fluid intake compared with patients who received erythromycin.

Conclusion: Azithromycin appears to be superior to erythromycin for treating cholera in children.     

Vibrio cholerae O139 in Calcutta.

Vibrio cholerae O139 was recovered from 28 of 79 children with acute watery diarrhoea. Clinically, they presented with watery diarrhoea (100%), vomiting (79%), abdominal cramps (61%), anorexia (61%), dehydration (100%), and absence of fever. Both clinical and blood biochemical parameters of these cases were similar to the illness caused by the new strain in adults. Hypoglycaemia was seen in 40% of those screened.     

Breast feeding and oral rehydration at home during diarrhoea to prevent dehydration.

In a case-control study we evaluated the role of maternal behaviour, as reflected in maintenance of breast feeding and the use of oral rehydration therapy (ORT) at home during acute diarrhoea, in preventing dehydration in infants and young children. A systematic 5% sample was taken of all children aged 1-35 months attending the treatment centre of the International Centre for Diarrhoeal Disease Research, Bangladesh, with acute watery diarrhoea of six days or less between August 1988 and September 1989. There were 285 children with moderate or severe dehydration as cases and 728 with no dehydration as controls in the study. In a multivariate analysis using a logistic regression model we showed that withdrawal of breast feeding during diarrhoea was associated with a five times higher risk of dehydration compared with continuation of breast feeding during diarrhoea at home. Lack of ORT with either complete formula or a salt and sugar solution at home was associated with 57% higher risk of dehydration compared with receipt of a reasonable amount of ORT after controlling for several confounders. The confounding variables--that is, lack of maternal education, history of vomiting, high stool frequency, young age and infection with Vibrio cholerae 01--were also shown to be risk factors of dehydration. Health education programmes should promote continued breast feeding and adequate oral rehydration therapy for infants with acute diarrhoea at home.     

Hypo-osmolar oral rehydration salts solution in dehydrating persistent diarrhoea in children: double-blind, randomized, controlled clinical trial

A double-blind, randomized, controlled trial was conducted to compare the clinical efficacy of hypo-osmolar oral rehydration salts (ORS) solution (224 mmol/L) and standard ORS solution (311 mmol/L) in children with persistent diarrhoea who were prone to develop dehydration. Initially, 95 children aged between 3 and 24 mo were included in the study for overnight observation. Of these, 70 children who passed stool more than 2 g/kg/h were finally enrolled in the study and were randomly assigned either standard ORS or hypo-osmolar ORS. After decoding the identity of ORS, it was observed that 37 children were in the standard ORS group and 33 in the hypo-osmolar ORS group. Clinical parameters and microbiological findings of stool samples were comparable in the two groups at the time of enrolment. Total stool output (2.5 ± 1.1 vs 3.2 ± 1.6 kg; p = 0.04), duration of diarrhoea (114.8 ± 38.3 vs 145.4 ± 40.0 h; p = 0.002), total intake of ORS (5.4 ± 1.6 vs 7.8 ± 1.8 l; p = 0.002) and total fluid intake (7.9 ± 2.6 vs 10.0 ± 4.1 l, p = 0.01) were significantly less in the hypo-osmolar ORS group compared to the standard ORS group. However, the percentage of weight gain on recovery in the hypo-osmolar group was less compared to that of the standard ORS group, though the difference was statistically insignificant. Thirty-five (95%) children in the standard ORS and 33 (100%) children in the hypo-osmolar group recovered within 10 d of initiation of therapy and modified dietary management. Conclusion: Our findings suggest that hypo-osmolar ORS has beneficial effects on the clinical course of dehydrating persistent diarrhoea.     

Risk factors for development of dehydration in young children with acute watery diarrhoea: a case-control study

In a case-control study to understand the risk factors for development of life-threatening dehydration, a total of 379 children comprising 243 cases (moderate or severe dehydration) and 136 controls (non or mild dehydration) up to 2 years of age suffering from acute watery diarrhoea were studied. By univariate analysis, the presence of vibrios in stool, withdrawal of breast feeding during diarrhoea, not giving fluids, including oral rehydration solution (ORS), during diarrhoea, frequent purging (> 8/ day), vomiting (> 2/day) and undernutrition were identified as risk factors. However, by multivariate analysis after controlling for confounders, withdrawal of breast feeding during diarrhoea (odds ratio (OR) = 6.8, p < 0.00001) and not giving ORS during diarrhoea (OR = 2.1, p < 0.006) were identified as significant risk factors. The confounding variables which also contributed significantly to increasing the risk were age (≤ 12 months; OR = 2.7, p = 0.001), frequent purging (> 8/day; OR = 4.1, p < 0.00001), vomiting (> 2/day; OR = 2.4, p = 0.001) and severe undernutrition (%median <60 weight-for-age of Indian Academy of Paediatrics classification; OR = 3.1, p = 0.001). We feel that these findings will be useful for Global and National Diarrhoeal Diseases Control Programmes for formulating intervention strategies for preventing death due to diarrhoeal dehydration.     

Campylobacter diarrhea in children in Trivandrum

One hundred and fifty two stool samples from patients belonging to the pediatric age group clinically diagnosed as acute diarrhea/dysentery were processed for thermophilic campylobacters.C. jejuni was isolated from 9 samples (5.9%). Five of the C.jejuni isolates were from children who presented with bloody diarrhea and 4 were from those who had watery diarrhoea. Though the pathogenic role of C.jejuni in these cases is not proved, this study indicates the prevalence of the organism in Trivandrum district.     

Spectrum of digestive tract diseases 1985-1987 at the Pediatric Gastroenterology Outpatient Clinic of Dr. Pirngadi General Hospital, Medan

A retrospective study has been done on infants and children attending to the Pediatric Gastroenterology Outpatient Clinic of Dr. Pirngadi General Hospital in Medan, from 1985 through 1987. During the study there were 874 patients, 477 (54.58%) suffered from diarrhea, 209 (23.91%) had bloody stool, 20 (2.99%) jaundice, 57 (6.52%) abdominal pain, 48 (5.49%) abdominal distention, 30 (3.43%) vomiting, 13 (1.49%) constipation, and 20 (2.29%) others. Of all cases with diarrhoea, watery diarrhoea were found in only 319 (66.88%), diarrhoea with vomiting 84 (17.61%), and bloody diarrhoea 74 (15.51%). Stool examination in patients with diarrhoea revealed 144 (30.19%) cases with Candida albicans, while 16 (3.35%) of them with steatorrhoea. Of 63 patients with diarrhoea on which the clinitest had been performed, sugar intolerance were found in 30 (47.62%) cases.     

Rotavirus infections in children (author's transl)]

In 43 out of 90 children suffering from acute gastroenteritis Rotaviruses could be identified in stool-specimens by electronmicroscopy. Symptoms were watery diarrhoea (100%), vomiting (88%), fever (77%), dehydration (47%) and upper respiratory tract infection (21%). In 3 out of 9 patients liver involvement could be documented. In 29 children i.v.-fluid therapy for 1-2 days was necessary. Only in 1 patient severe diarrhoea persisted for 11 days.     

Neutropaenic enteropathy

Neutropaenic enterocolitis is an acute necrotising inflammation involving segments of small and large bowel occurring in patients with agranulocytosis, most commonly with acute leukaemia, after commencement of immunosuppressive chemotherapy. Twelve children aged 4 months to 15 years, 9 of whom were receiving treatment for acute lymphocytic leukaemia; were treated during the 9 year period 1983–1991. The symptoms included bile-stained vomiting, abdominal distension, and watery diarrhoea with right iliac fossa pain and tenderness. Eight children are alive following conservative management, and 1 survived following surgical resection of necrotic ileum. This study supports the conservative management of neutropaenic enterocolitis. Correspondence to: D. C. S. Gough     

Acute diarrhea in children

Acute diarrhea is a common problem in children. Understanding the different pathologic processes that cause diarrhea, and the agents that are associated with those processes, can aid the clinician in predicting the etiology of the diarrhea in an individual patient. Small bowel involvement, most commonly caused by Rotavirus, produces a high incidence of vomiting, often before the onset of diarrhea, and large, watery, and relatively infrequent stools. Large bowel involvement, usually due to Campylobacter, Salmonella, or Shigella produces frequent, often bloody stools containing leukocytes. Treatment of diarrhea should be focused on correcting dehydration, principally with oral rehydration solutions containing appropriate concentrations of electrolytes and carbohydrates. Early refeeding, avoiding foods containing lactose, should be considered for most pediatric patients with acute diarrhea. Antimicrobial therapy should be reserved primarily for parasitic infectious, pseudomembranous enterocolitis, and the early stages of a Campylobacter dysentery. The etiology of acute pediatric diarrhea can be predicted in most patients and early, appropriate treatment can be instituted.     

Rotavirus as an important cause of diarrhoea in a hospital for children in Dammam, Saudi Arabia

A major cause of morbidity and mortality among children in developing countries is acute diarrhoea and rotavirus, a reovirus-like agent, is found to be a leading causative agent. We report here the incidence of rotavirus infection among infants and young children with gastro-enteritis treated at the Children's Hospital in Dammam, Kingdom of Saudi Arabia. One hundred and fifty children, aged between 1 and 60 months, suffering from diarrhoeal illness, were selected as the study cohort; another 150 hospitalized children of the same age group, but not suffering from diarrhoea, served as controls. Sixty-two per cent of the study children complained of watery diarrhoea and 39% of vomiting; all had mild to moderate dehydration. Seventy-two per cent had fever and 30% associated respiratory illness. Worst affected were those 7-12 months old, among whom rotavirus was detected by ELISA techniques in 39.6%, compared with 7.5% of the control children of comparable age group. We could not detect any rotavirus from control children aged over 36 months, whereas approximately 15% of the study children in this age group yielded rotavirus from the stool. The second most common pathogen isolated was Shigella ssp. It was isolated from 18.7% of children under study as against 3% of the controls.     

A prospective clinical study of rotavirus diarrhoea in young children

The clinical and laboratory features of 96 children aged 6 to 36 months with acute rotavirus diarrhoea were compared to findings on 63 children of the same age with acute non-rotavirus diarrhoea. Of the rotavirus-associated cases 80% occurred between January and June. In general, the diarrhoea was more severe in these patients than in the others, but no difference was seen in duration of symptoms. Clinical features characteristic of rotavirus-associated cases included: dehydration and acidosis upon admission, vomiting, fever, neutropenia and sugar in the stools (Clinitest greater than or equal to 0.5%). In contrast, no difference was seen in the occurrence of respiratory symptoms (53% in the rotavirus, 62% in the non-rotavirus group), or in the presence of mucus strands, occult blood or leucocytes in stools. A combination of the above criteria may be helpful in the presumptive diagnosis of rotavirus diarrhoea.     

Efficacy of Lactobacillus rhamnosus GG in acute watery diarrhoea of Indian children: a randomised controlled trial

AIM: To evaluate the role of Lactobacillus rhamnosus GG (LGG) as probiotic in acute watery diarrhoea (AWD). SETTING: Hospital-based study. DESIGN: Randomised, controlled, blinded trial. PATIENTS AND METHOD: All patients of AWD (n = 684) admitted over 1-year period were invited to participate in the study as per predefined inclusion and exclusion criteria and were randomised to intervention and control groups. After adequate rehydration the intervention group (n = 330) received ORS with probiotic powder containing 60 million cells of LGG, while the control group (n = 332) received ORS alone twice daily for a minimum period of 7 days or till diarrhoea ceased. During the study period all patients received ORS and/or IV fluids for ongoing losses, and nutritional supplementation. None of them received any antibiotic or antidiarrhoeal medication. After exclusion of 16 patients, 646 (323 in each arm) patients completed the study. The daily frequency and total duration of diarrhoea and vomiting and the length of hospital stay were studied. Data were analysed by SPSS-10 software. Statistical significance was calculated by Student's t-test and chi2-test. RESULTS: Rotavirus was isolated in 75.85%. There was no significant difference between treatment groups in the daily frequency or duration of diarrhoea or vomiting or in the length of hospital stay. No complication was observed from the use of LGG. CONCLUSION: LGG supplementation does not decrease the frequency and duration of diarrhoea and vomiting in children with AWD, and does not reduce hospital stay in these patients.     

Changing trend of persistent diarrhoea in young children over two decades: observations from a large diarrhoeal disease hospital in Bangladesh

Aim: We studied the changing trend and factors associated with persistent diarrhoea (PD) in under‐five children presenting to a large diarrhoeal disease hospital in urban Dhaka, Bangladesh, over the last two decades. Methods: We used an unmatched case–control design, with a case (persistent diarrhoea; n = 944) to control (acute diarrhoea; n = 2832) ratio of 1:3 attending the Dhaka Hospital of icddr,b between 1991 and 2010. Results: The proportion of children with PD decreased significantly from 8% in 1991 to 1% in 2010. The proportion of breastfeeding practices, measles vaccination coverage and vitamin A supplementation among 12–59 months old improved from 79% to 85%, 69% to 85% and 26% to 74%, respectively, which were significant. Although the isolation of rotavirus from stool in children with PD and acute diarrhoea increased, the isolation of Shigella spp., and Vibrio cholerae O1 decreased significantly. In a logistic regression analysis, wasting (OR = 1.62), use of antibiotic before attending hospital (OR = 5.94), absent clinical dehydration (OR = 1.53) and bloody/mucoid stool (OR = 3.33) were significantly associated with persistent diarrhoea. Conclusion: There, thus, is a need to integrate an appropriate and sustainable deterrent strategy to take the benefit of the significant reduction in prevalence as well as risks of PD in such population.     

Oral rehydration solution without bicarbonate.

The efficacy of oral rehydration solution without bicarbonate was compared with World Health Organisation oral rehydration solution in 98 young children in a double blind and randomised clinical trial. These children had varying degrees of dehydration and acidosis caused by acute watery diarrhoea. The mean serum bicarbonate concentration on admission was 13.3 mmol(mEq)/1 in the former and 13.1 mmol(mEq)/1 in the latter group of children. All but three children who received the rehydration solution without bicarbonate were successfully treated; three treatment failures were attributed to persistent vomiting and severe diarrhoea (greater than 10 ml/kg/hour). Correction of acidosis was slower in the non-bicarbonate treated than the control group during the first 24 hours'' treatment (P less than 0.001). By 48 hours, however, acidosis was corrected and mean serum bicarbonate had risen to 17.1 mmol(mEq)/1 compared with 18.9 mmol(mEq)/1 in the control group (P greater than 0.05). Some failures due to sustained acidosis and persistent vomiting and diarrhoea should be expected. Oral rehydration solution without bicarbonate may be used where complete formula solution is not available.     

Evaluation of oral hypo-osmolar glucose-based and rice-based oral rehydration solutions in the treatment of cholera in children

In a randomized controlled clinical trial, the efficacy of a low-sodium low-glucose oral rehydration solution (ORS) and a low-sodium rice-based ORS was compared with standard WHO glucose ORS in the treatment of severe cholera in children aged 2-10y. In total, 120 children were evaluated for the study, of whom 58 patients were positive for Vibrio cholerae and were included in the study. Of these 58 cases, 19 received rice-based hypo-osmolar ORS, 20 received WHO-ORS and 19 received glucose-based hypo-osmolar ORS. The clinical characteristics (age, preadmission duration of diarrhoea, frequency of stool before admission, incidence of vomiting, body weight and volume of initial fluid requirement) were comparable in the three treatment groups. All patients received tetracycline in a dose of 50 mg/kg/d of body weight in 4 divided doses for 3 d. CONCLUSIONS: Patients who received rice-based hypo-osmolar ORS had subsequently reduced (p < 0.05) stool output, ORS consumption and diarrhoea duration than the patients who received either WHO-ORS or glucose-based hypo-osmolar ORS.     

A PROSPECTIVE CLINICAL STUDY OF ROTAVIRUS DIARRHOEA IN YOUNG CHILDREN

Abstract. Mäki, M. (Department of Paediatrics, Tampere Central Hospital, Tampere, Finland). A prospective clinical study of rotavirus diarrhoea in young children. Acta Paediatr Scand, 70:107, 1981.–The clinical and laboratory features of 96 children aged 6 to 36 months with acute rotavirus diarrhoea were compared to findings on 63 children of the same age with acute non-rotavirus diarrhoea. Of the rotavirus-associated cases 80% occurred between January and June. In general, the diarrhoea was more severe in these patients than in the others, but no difference was seen in duration of symptoms. Clinical features characteristic of rotavirus-associated cases included: dehydration and acidosis upon admission, vomiting, fever, neutropenia and sugar in the stools (Clinitesf® 0.5 %). In contrast, no difference was seen in the occurrence of respiratory symptoms (53 % in the rotavirus, 62% in the non-rotavirus group), or in the presence of mucus strands, occult blood or leucocytes in stools. A combination of the above criteria may be helpful in the presumptive diagnosis of rotavirus diarrhoea.     

Diarrhoea mortality in rural Bangladeshi children

Diarrhoeal mortality and hospital admissions for diarrhoea are described among children under the age of 5 years in a large rural Bangladeshi community during 1986-87. Acute watery (dehydrating) diarrhoea was associated with 11 per cent of all deaths among infants aged 1-11 months and 5 per cent among children aged 1-4 years. Acute non-watery diarrhoea, including bloody dysentery and diarrhoea with mucoid stools, was associated with 16 per cent of all deaths among children aged 1-4 years. In this age group, persistent diarrhoea, particularly when accompanied by recent and/or severe wasting, was associated with 63 per cent of all diarrhoeal deaths and 34 per cent of all deaths. These data suggest that exclusive emphasis on ORT will have little impact on diarrhoea mortality among children in rural Bangladesh. A broader strategy, both preventive and curative, including measles immunization, nutrition education, dietary management of diarrhoea, and the treatment of dysentery in the community, carries a greater potential.