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.     

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.     

Comparative value of colonic biopsy and intraluminal fluid culture for diagnosis of bacterial acute colitis in immunocompetent patients. Infectious Colitis Study Group.

We compared the yield of intraluminal fluid culture to that of biopsy specimens obtained during colonoscopy for the diagnosis of bacterial colitis in 93 immunocompetent patients with a recent episode of diarrhea and macroscopic lesions of colitis. Stool culture findings were also available for 68 patients. At least one bacterial pathogen was isolated from the biopsy specimen, intraluminal fluid, or stool from 48 patients (51.6%). Salmonella species, Clostridium difficile, Klebsiella oxytoca, Shigella species, and Campylobacter species were recovered from 16 (17.2%), 15 (16.1%), 8 (8.6%), 7 (7.5%), and 4 (4.3%) of the patients, respectively. One Shigella species and one K. oxytoca strain were isolated from biopsy specimens but not from intraluminal fluid, and intraluminal fluid was the only positive specimen in 12 cases (yielding 1 Salmonella species, 2 Shigella species, 2 K. oxytoca, and 7 C. difficile isolates). In nine cases out of 10, toxin B was detected only in intraluminal fluid. A correlation of 91.2% was observed between stool and intraluminal fluid cultures for Salmonella, Shigella, and Campylobacter species isolations. Culture of biopsy specimens adds little to the diagnosis of infectious colitis, and stools and intraluminal fluids appear to have comparable value.     

Bacterial enteric pathogens in children with acute dysentery in Thailand: increasing importance of quinolone-resistant Campylobacter

Current data on pathogen prevalence and drug resistance patterns are important for treatment and vaccine-development strategies. An etiologic study of acute bacterial dysentery was conducted in children up to 12 years of age in 2 major hospitals in and around Bangkok. Stool samples or rectal swabs and clinical data were collected. Standard microbiological methods were used to detect Salmonella, Shigella, Campylobacter, Vibrio, Aeromonas and Plesiomonas. Pathogenic E. coli (ETEC, EIEC, STEC) was identified by digoxigenin-labeled probes. A total of 623 cases were enrolled: median age 11.0 months (range 1 month-12 years). At least one bacterial pathogen was isolated in 55% of cases. Campylobacter was the most common pathogen found (28%), whereas Salmonella, Shigella and ETEC were isolated from 18%, 9% and 6% respectively. EIEC, Vibrio and Plesiomonas were isolated from <1% and no STEC was detected. C. jejuni serotypes 36, 4 and 11 were the most common. The mean age of cases with Campylobacter was significantly lower than with Shigella (17.9 vs 52.8 months, p<0.001). Clinical presentations of Campylobacter and Shigella infections were compared: fever (28% vs 37%), abdominal colic (62% vs 80%, p<0.05), vomiting (38% vs 70%, p<0.001) and bloody stools (52% vs 48%). The Campylobacter isolates (80% C. jejuni, 20% C. coli) were 90% resistant to ciprofloxacin but sensitive to macrolides. All the Shigella isolates (70% S. sonnei) were sensitive to quinolones. Our study illustrates the increasing importance of quinolone-resistant Campylobacter and the decline of Shigella in the etiology of dysentery in Thailand. The clinical presentation of campylobacteriosis is similar to that of shigellosis, except that the patients may be younger and there may be less association with colic and vomiting; having fecal leukocytes will be >10/HPF. The use of macrolide antibiotics rather than quinolones would be reasonable in children <24 months of age; fluoroquinolones will be ineffective in at least half of culture-positive cases.     

CT evaluation of infectious colitis]

Computed tomography (CT) is useful for evaluating the diagnosis of gastrointestinal disease, such as infectious colitis, in patients with severe pain and bloody diarrhea. During the 7 years between November 1993 and October 2000, 34 patients with infectious colitis (18 male, 16 female; mean age 42 +/- 19 yrs), received emergency CT and colonoscopy because of severe abdominal pain and dysentery. The following organisms were isolated: pathogenic Escherichia coli (12), 6 of which were O157:H7 (O-157), Salmonella species (11), Campylobacter species (5), Vibrio parahaemolyticus (3), Yersinia enterocolotica (2) and Shigella species (1). Thickening of the intestinal wall greater than 10 mm was seen in the ascending colon in the 6 cases with E. coli O 157, in 5/11 cases with Salmonella, 4/5 with Campylobacter and 1/6 with non-O157 pathogenic E. Coli. Marked intestinal wall thickening, greater than 20 mm, was seen in the ascending colon of the 4 of the patients with an O-157 infection. In all patients with O-157 colitis, slight ascites was noted in the pelvic space. In additions, ascites was also seen in 3/13 patients with Salmonella and 1/5 patients with Campylobacter colitis. The CT findings, in the patients with infectious colitis, are non-specific but knowledge and recognition of the findings will help in patient evaluation and proper treatment.     

Isolation of enteropathogenic microorganism from patients with infection of the digestive tract during 1976 to 1988 in Tenri Hospital]

Enteropathogenic microorganisms isolated from feces of 9,393 patients with diarrhea or enteritis in our hospital between 1976 and 1988 were analyzed. As the result of the examination of 5,443 outpatients, 1,811 strains of pathogens were isolated from 1,686 cases (31.0%). Several species including Salmonella spp., Escherichia coli serotype, Vibrio parahaemolyticus, were isolated before 1978, and the incidence of pathogens was low (14.8%). For the 10-year period since 1979, the incidence markedly increased to 34.4%, and the number of pathogens isolated also increased to about twice that before 1978. The main cause of the increase was Campylobacter species. The major pathogens detected since 1979 were Campylobacter spp., E. coli serotype, Salmonella spp., V. parahaemolyticus, etc., but Rota virus, Clostridium difficile, Aeromonas spp., Vibrio fluvialis, etc. have also been detected, showing an increase in the number and diversity of the detected pathogens. As the result of the examination of 3,950 inpatients, 835 strains of pathogens were isolated from 800 cases (20.3%). The incidence of C. difficile was the highest, 423 of 800, followed by E. coli serotype, Salmonella spp., Campylobacter spp., V. parahaemolyticus and Aeromonas spp., in that order. All the inpatients from whom C. difficile was isolated manifested diarrhea or enteritis after administration of antimicrobial agents. The pathogens causing communicable disease were Salmonella spp. serovar Typhi, Salmonella spp. serovar Paratyphi A, Shigella flexneri, Shigella sonnei and Entamoeba histolytica, which were isolated from 5, 1, 3, 2 and inpatients, respectively.     

Toxic megacolon complicating Escherichia coli O157 infection

Toxic megacolon is a well known complication in inflammatory bowel disease such as ulcerative colitis or Crohn's disease. The development of toxic megacolon as a complication of infectious colitis is rare. However it is recognised as a complication of enteric infections caused by Clostridium difficile, Campylobacter jejuni, Shigella, Salmonella species, Cytomegalovirus and amoebae. We describe a case of necrotising haemorrhagic ileo-colitis in a previously fit and healthy young adult female caused by Escherichia coli O157 where toxic megacolon developed as a complication along with hemolytic uremic syndrome (HUS).     

Symptoms of food-borne diseases and gastroenteritis in Kyushu, Japan

In this study we analyzed the symptoms of gastroenteritis or food-borne disease caused by the 10 most prevalent pathogens: Norovirus, Salmonella, Vibrio parahaemolyticus, Campylobacter jejuni, Clostridium perfringens, Shiga toxin-producing Escherichia coli (STEC), enterotoxigenic E. coli (ETEC), Shigella sonnei/flexneri (Shigella), Staphylococcus aureus, and emetic-type Bacillus cereus. The symptoms diarrhea, vomiting, fever, abdominal pain, and headache, and the incubation period in 646 cases in 10 districts of Kyushu between January 2000 and December 2004 were recorded. The pathogen with the shortest mean incubation period was B. cereus (0.8 h), and was followed by S. aureus (3.3 h), C. perfringens (10.7 h) and V. parahaemolyticus (16.4 h). All the patients infected with B. cereus and S. aureus developed symptoms within 6 hours, and those infected with V. parahaemolyticus and C. perfringens developed symptoms within 24 hours. Bloody diarrhea was associated with STEC and Shigella, but rare with other pathogens. Vomiting was associated with almost all cases of S. aureus and B. cereus infection, and occurred in 71.5% of the Norovirus cases and 56.1% of the V. parahaemolyticus cases. Vomiting was less common in the C. perfringens (22.0%) and the ETEC and STEC (both about 5%). Bloody diarrhea, abdominal pain, and vomiting were statistically significantly more common with STEC 0157 infection than with STEC non-0157 infection. Since the cases analyzed in this study included all degrees of illness, mild to severe, and a wide range of ages, the information obtained will serve as a good reference material for administrative and laboratory work when an outbreak takes place.     

Evaluation of routine enteric pathogens in hospitalized patients: A Canadian perspective

Diarrhea is a frequently encountered problem in hospitalized patients. Since nosocomial spread of routine enteric pathogens such as Salmonella species, Shigella species, Campylobacter species and Escherichia coli O:157 H:7 seldom occurs, testing for these organisms in patients hospitalized for longer than three days has been questioned. The goal of this study was to determine the length of hospitalization preceding detection of routine enteric pathogens and Clostridium difficile cytotoxin, and to develop guidelines for enteric cultures from hospitalized patients. The enteric pathogens detected in 1991 were C difficile toxin B(+), 77%; Campylobacter species, 10%; Salmonella species, 9%; E coli O:157 H:7, 3%; and Shigella species, 1%. For 1992, these numbers were 86%, 9%, 3%, 2% and 0%, respectively. None of the routine enteric pathogens isolated in 1991 or 1992 was detected in patients after their second day of hospitalization. Routine cultures for enteric pathogens on hospitalized patients were eliminated in February 1993, and physician ordering practices were monitored. With the exception of one campylobacter isolate per year, all routine enteric pathogens isolated in 1993 and 1994 were detected by the second day of hospitalization. Compliance with the changed protocol was 76% measured over a four-month period in 1993 and 74% over the year 1994. Savings of $3,648.10 were associated with rejecting 191 'inappropriate' specimens in 1994. It was concluded that routine enteric cultures are unnecessary for patients hospitalized more than two days, and that appreciable financial savings can be achieved if revised protocols for processing stool cultures are instituted. However, when enteric protocol changes are in place compliance must be evaluated to ensure appropriate utilization.     

Shiga toxin-producing Escherichia coli in Montana: bacterial genotypes and clinical profiles

The diseases and virulence genes associated with Shiga toxin-producing Escherichia coli (STEC) are characterized incompletely. We analyzed, by polymerase chain reaction, 82 STEC isolates collected prospectively in Montana and profiled associated illnesses by patient chart review. All E. coli O157:H7 contained stx2-group genes, as well as eae, iha, espA, and ehxA; 84% contained stx1. Non-O157:H7 STEC less frequently contained stx1 (P=.046), stx2 (P<.001), iha (P<.001), eae, and espA (P=.039 for both), were isolated less often from patients treated in emergency departments (P=.022), and tended to be associated less frequently with bloody diarrhea (P=.061). There were no significant associations between stx genotype and bloody diarrhea, but isolates containing stx2c or stx(2d-activatable) were recovered more often from patients who underwent diagnostic or therapeutic procedures (P=.033). Non-O157:H7 STEC are more heterogeneous and cause bloody diarrhea less frequently than do E. coli O157:H7. Bloody diarrhea cannot be attributed simply to the stx genotype of the infecting organism.     

Campylobacter jejuni in hospitalized children with diarrhoea in Chiang Mai, Thailand

In this hospital based study, Campylobacter jejuni, although endemic in Northern Thailand was not found in a significantly higher percentage of diarrhoea than in control children. It was isolated from the stools of 14 of 208 diarrhoea (6.7%) and 6 of 108 (5.5%) control patients. Ten of the 14 positive diarrhoea cases were mixed infections, other pathogens isolated simultaneously were enteropathogenic E. coli 4x, Shigella spp. 3x, Salmonella spp. 4x, rotavirus 3x, Plesiomonas shigelloides 1x and parasites 3x. Infection with Campylobacter jejuni occurred mainly in the 1-2 year age group and was not found in patients over 5. It was distributed over the year without seasonal peaks. In four of the 14 positive C. jejuni cases no other pathogens were found. One of these suffered 2nd degree malnutrition with measles and one was a chronic diarrhoea case with a history of antibiotic use and past Salmonella and Shigella infections. The remaining two cases had no underlying or associated illnesses. It was concluded that Campylobacter jejuni may be important as an associated pathogen in complicated diarrhoea infections but is rare as a sole causative agent.     

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.     

Campylobacter jejuni pancolitis mimicking idiopathic ulcerative colitis

Campylobacter jejuni is the most common cause of community-acquired acute bacterial diarrhea. Campylobacter diarrhea is usually accompanied by fever and abdominal pain. Campylobacter diarrhea is usually watery. Nausea, vomiting, headache, and myalgias may also be present. Tenesmus is a common feature. The majority of patients with Campylobacter diarrhea have some component of segmental colitis, usually beginning in the small bowel and progressing distally to the cecum and colon. C. jejuni is a rare cause of pancolitis. Community-acquired colitis may be caused by C. jejuni or other enteric pathogens, for example, Shigella, Entamoeba, Yersinia, Escherichia coli 0157:H7, Clostridium difficile colitis, ischemic colitis, or idiopathic ulcerative colitis. We present a case of C. jejuni pancolitis in an elderly woman. Differential diagnosis is included in the discussion. The patient's C. jejuni pancolitis was successfully treated with a 7-day course of oral moxifloxacin.     

Dysentery in patients infected with human immunodeficiency virus in Zimbabwe: an emerging role for Schistosoma mansoni and Escherichia coli O157?

Information on bloody diarrhoea in HIV-positives is scarce. A prospective study was therefore performed, in Zimbabwe, to determine and compare the pathogens associated with bloody diarrhoea in 25 antiretroviral-na?ve HIV-infected patients and 15 non-HIV-infected patients. Stool cultures and colonic biopsies were performed. Shigella was isolated from 18 (45%) of the subjects, Schistosoma mansoni from eight (16%), Escherichia coli H7:O157 from three (8%) and Campylobacter jejunii from two (5%). There was no evidence of Salmonella, Entamoeba histolytica or cytomegalovirus infection. Shigella dysenteriae type-1 occurred more often in the HIV-negatives than the HIV-positives (P = 0.02). Although HIV-associated bloody diarrhoea in Zimbabwe appears to be most frequently caused by Shigella, it may also be commonly the result of infection with Sc. mansoni or shiga-toxin-producing E. coli. A larger study specifically to examine the role of Sc. mansoni and E. coli O157 is warranted.     

Campylobacter jejuni Infections: update on emerging issues and trends.

Infection with Campylobacter jejuni is one of the most common causes of gastroenteritis worldwide; it occurs more frequently than do infections caused by Salmonella species, Shigella species, or Escherichia coli O157:H7. In developed countries, the incidence of Campylobacter jejuni infections peaks during infancy and again during early adulthood. Most infections are acquired by the consumption and handling of poultry. A typical case is characterized by diarrhea, fever, and abdominal cramps. Obtaining cultures of the organism from stool samples remains the best way to diagnose this infection. An alarming recent trend is the rapid emergence of antimicrobial agent--resistant Campylobacter strains all over the world. Use of antibiotics in animals used for food has accelerated this trend. It is fortunate that complications of C. jejuni infections are rare, and most patients do not require antibiotics. Guillain-Barré syndrome is now recognized as a post-infectious complication of C. jejuni infection, but its incidence is <1 per 1000 infections. Careful food preparation and cooking practices may prevent some Campylobacter infections.     

Infectious colitis endoscopically simulating inflammatory bowel disease: a prospective evaluation

This prospective evaluation of patients presenting with mucoid bloody diarrhea and suspected idiopathic inflammatory bowel disease demonstrated a 38% incidence of infectious colitides. The infectious agents detected were Campylobacter, Salmonella, Shigella, Amoeba, and Clostridium difficile. An increased awareness and the utilization of selective culture media should allow the clinician to definitively diagnose patients who present with signs and symptoms suggestive of idiopathic inflammatory bowel disease.     

Markers of inflammation in bacterial diarrhea among travelers, with a focus on enteroaggregative Escherichia coli pathogenicity

The intestinal inflammatory response of traveler's diarrhea acquired in Goa, India, and Guadalajara, Mexico, was studied. Fecal lactoferrin was found in stool samples in which enteroaggregative Escherichia coli (EAEC), enterotoxigenic E. coli, or Salmonella or Shigella species were isolated, with Shigella-positive cases showing the highest level. Samples from cases of Shigella-associated diarrhea had the highest concentrations of fecal cytokines. Travelers to India who had EAEC-associated diarrhea showed elevated levels of interleukin (IL)-8 (median, 341.15 pg/mL) and IL-1beta (median, 749.90 pg/mL). Although 15 travelers to Mexico who had EAEC-associated diarrhea had a median concentration of 0 pg/mL for both IL-8 and IL-1beta, 2 had high levels of IL-8 (1853 and 11,786 pg/mL), and 5 showed elevated levels of IL-1beta (1-1240 pg/mL). Samples from patients in India who had pathogen-negative diarrhea or from patients in Mexico who had asymptomatic EAEC infection were negative for cytokines. Bacterial pathogens causing traveler's diarrhea commonly produce intestinal inflammation, although a subset of patients with EAEC-associated diarrhea fail to develop an inflammatory response.     

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.     

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.     

The detection of enteropathogens in acute diarrhea in a family cohort population in rural Egypt

In 8 villages of rural northeastern Egypt, a 2-year study of the etiologic agents associated with episodes of diarrhea was carried out. Stool specimens (3,243) from 3,513 episodes of diarrhea were processed for enteropathogens. The most commonly identified agents in the group with diarrhea were Giardia lamblia (44%), heat stable enterotoxin (ST)-producing enterotoxigenic Escherichia coli (ETEC) (15%), heat labile toxin (LT)-producing ETEC (12%), enteropathogenic E. coli (EPEC) (4%), rotavirus (3%), Shigella (2%) and Salmonella (1%). Isolation rates were increased in cases compared to controls for all agents except G. lamblia and EPEC strains. Rotavirus, Salmonella and ST-producing ETEC were more frequently isolated during cooler months and Shigella and LT-ETEC occurred more commonly in warmer months. Campylobacter, EPEC, Giardia and E. histolytica did not show a discernable seasonal pattern. Rotavirus was primarily associated with diarrhea in infants only. Forty-four percent of children experienced at least 1 bout of rotavirus diarrhea by the age of 3 years. Vomiting was reported in 65% of cases of rotavirus infection. Dehydration was reported in greater than 40% of those with rotavirus-, Salmonella-, Campylobacter-, LT-ETEC- and EPEC-associated illness and in those without an identifiable agent. While rotavirus was implicated in 3% of cases overall, when vomiting or vomiting plus dehydration occurred, rotavirus was identified with a rate of 10% and 12%, respectively. Dysentery was common only in Shigella cases, occurring in 24%. A decrease in occurrence of rotavirus, Campylobacter and possibly EPEC illness was seen in the infants less than 6 months of age who were breast-fed when compared to those who were not.