The Frequency of Diarrheagenic Escherichia coli Isolates in Children with Acute Diarrhea

The role of zinc and vitamin A in persistent diarrhea among infants and young children.

Acute Bloody Diarrhea: A Medical Emergency for Patients of All Ages

Some new progress and evidence have been made in the diagnosis and treatment of pediatric acute infectious diarrhea since the publication of the "Chinese clinical practice guidelines foracute infectious diarrhea inchildren" (2018 edition guidelines). The updated "Chinese clinical practice guidelines for acute infectious diarrhea in children" incorporates new evidence-based recommendations for managing acute infectious diarrhea in the Chinese pediatric population. Building on the 2018 edition guidelines, expert panels reviewed clinical evidence, assessed preliminary recommendations, and conducted open-ended discussions to finalize the updated guidelines. These guidelines are founded on the latest literature and evidence-based practices. A literature review was performed in databases such as PubMed, Cochrane, EMBASE, China Biomedical Database, and the Chinese Journal Full-text Database up to June 2024. The search focused on the terms "acute diarrhea" or "enteritis", along with "adolescent", "child", "pediatric patient", "baby", or "infant". The updated guidelines address various aspects of acute infectious diarrhea, including diagnosis, etiological evaluation, dehydration assessment, fluid therapy, diet therapy, medical therapy, and prevention strategies. The main updates focused on etiological diagnosis and the use of probiotics, racecadotril, zinc, and antibiotics in treating acute infectious diarrhea. The updated guidelines address disputed treatments for acute infectious diarrhea through evidence-based revisions. Standardized etiological evaluations guide management. Probiotics are moderately advised for viral watery diarrhea; racecadotril remains unsupported. Zinc supplementation is recommended for children >6 months in deficient regions. Antibiotics are restricted to cases with dysenteric-like symptoms, suspected cholera with severe dehydration, or comorbidities.

Objective: Rotavirus and Enteric Adenoviruses (EA) are most important viral enteric agents which cause acute infectious gastroenteritis. Little is known about the epidemiology of Rotavirus and EA gastroenteritis in our city. In this study, it was purposed to determine of the frequency of Rotavirus, EA, and to detect of the seasonal distribution among pediatric patients with acute gastroenteritis in Kiziltepe General Hospital, Mardin-Turkey. Materials and methods: The records of acute infectious gastroenteritis cases caused by Rotavirus and EA were reviewed retrospectively. In a total of 426 pediatric patients admitted between May 2010 and March 2011 were diagnosed as acute gastroenteritis. Rotavirus and EA antigens were examined in the fresh stool specimens with immunochromatographic assay method by a commercial rapid diagnostic kit (RIDA, QuickRota-Adeno-CombiR-Biopharm AG, Germany). Results: A total of 426 pediatric patients with acute gastroenteritis were followed during the study between May 2010 and March 2011. The eight (1.9%) stool samples were favorable for EA, 40 (9.4%) stool samples were favorable for Rotavirus and in ten (2.3%) stool samples were favorable with both Rrotavirus and EA. The high-positivity-rates were detected on average of 24.7% for Rotavirus between October 2010 and January 2011. The high-positivity-rates of EA were determined on average of 8.4% between October and November 2010, and on average 7.9% between May and August 2010. Viral antigen-positive cases were observed in autumn and winter months with most common 0-2 month age-group. Conclusion: Rotavirus is foremost viral enteric agent among children with acute infectious gastroenteritis. The antigens of Rotavirus and EA should be performed regularly in fresh fecal samples among children ≤5 years of age, especially in the autumn and winter months. J Microbiol Infect Dis 2011;1(2): 64-67

BackgroundProbiotics may offer a safe intervention in acute infectious diarrhoea to reduce the duration and severity of the illness.ObjectivesTo assess the effects of probiotics in proven or presumed acute infectious diarrhoea.Search strategyWe searched the Cochrane Infectious Diseases Group's trials register (July 2010), the Cochrane Controlled Trials Register (The Cochrane Library Issue 2, 2010), MEDLINE (1966 to July 2010), EMBASE (1988 to July 2010), and reference lists from studies and reviews. We also contacted organizations and individuals working in the field, and pharmaceutical companies manufacturing probiotic agents.Selection criteriaRandomized and quasi‐randomized controlled trials comparing a specified probiotic agent with a placebo or no probiotic in people with acute diarrhoea that is proven or presumed to be caused by an infectious agent.Data collection and analysisTwo reviewers independently assessed the methodological quality of the trial and extracted data. Primary outcomes were the mean duration of diarrhoea, stool frequency on day 2 after intervention and ongoing diarrhoea on day 4. A random‐effects model was used.Main resultsSixty‐three studies met the inclusion criteria with a total of 8014 participants. Of these, 56 trials recruited infants and young children. The trials varied in the definition used for acute diarrhoea and the end of the diarrhoeal illness, as well as in the risk of bias. The trials were undertaken in a wide range of different settings and also varied greatly in organisms tested, dosage, and participants' characteristics. No adverse events were attributed to the probiotic intervention.Probiotics reduced the duration of diarrhoea, although the size of the effect varied considerably between studies.The average of the effect was significant for mean duration of diarrhoea (mean difference 24.76 hours; 95% confidence interval 15.9 to 33.6 hours; n=4555, trials=35) diarrhoea lasting ≥4 days (risk ratio 0.41; 0.32 to 0.53; n=2853, trials=29) and stool frequency on day 2 (mean difference 0.80; 0.45 to 1.14; n=2751, trials=20).The differences in effect size between studies was not explained by study quality, probiotic strain, the number of different strains, the viability of the organisms, dosage of organisms, the causes of diarrhoea, or the severity of the diarrhoea, or whether the studies were done in developed or developing countries.Authors' conclusionsUsed alongside rehydration therapy, probiotics appear to be safe and have clear beneficial effects in shortening the duration and reducing stool frequency in acute infectious diarrhoea. However, more research is needed to guide the use of particular probiotic regimens in specific patient groups.Plain Language SummaryProbiotics for treating acute infectious diarrhoeaEpisodes of acute infectious diarrhoea remain a major disease burden throughout the world, especially in developing countries. They are due to infection by many different organisms. Most episodes are self‐limiting and usually investigations are not done to identify the infectious agent. The main risk to health is dehydration and management aims to improve and maintain hydration status. However, rehydration fluids do not reduce the stool volume or shorten the episode of diarrhoea. Probiotics are "friendly" bacteria that improve health and are not harmful in themselves. A number of randomized controlled trials have been done to see whether probiotics are beneficial in acute infectious diarrhoea. We have searched for as many of these trials as possible and collected together the data in a systematic way to try to discover whether or not probiotics are beneficial in acute diarrhoea. We identified 63 trials, which included a total of 8014 people ‐ mainly infants and children. Probiotics were not associated with any adverse effects. Nearly all studies reported a shortened duration of diarrhoea and reduced stool frequency in people who received probiotics compared to the controls. Overall, probiotics reduced the duration of diarrhoea by around 25 hours, the risk of diarrhoea lasting four or more days by 59% and resulted in about one fewer diarrhoeal stool on day 2 after the intervention. However, there was very marked variability in the study findings and so these estimates are approximate. We concluded that these results were very encouraging but more research is needed to identify exactly which probiotics should be used for which groups of people, and also to assess the cost effectiveness of this treatment.

Children in developing countries are at a high risk for zinc deficiency. Supplemental zinc has previously been shown to provide therapeutic benefits in diarrhea. The objective of this study was to examine the efficacy and safety of supplemental oral zinc therapy during recovery from acute or persistent diarrhea. We conducted a meta-analysis of randomized, controlled trials to compare the efficacy and safety of supplementary oral zinc with placebo in children with acute and persistent diarrhea. Results were reported using a pooled relative risk or a weighted mean difference. A total of 22 studies were identified for inclusion: 16 examined acute diarrhea (n = 15,231), and 6 examined persistent diarrhea (n = 2968). Mean duration of acute diarrhea and persistent diarrhea was significantly lower for zinc compared with placebo. Presence of diarrhea between zinc and placebo at day 1 was not significantly different in acute diarrhea or persistent diarrhea trials. At day 3, presence was significantly lower for zinc in persistent diarrhea trials (n = 221) but not in acute diarrhea trials. Vomiting after therapy was significantly higher for zinc in 11 acute diarrhea trials (n = 4438) and 4 persistent diarrhea trials (n = 2969). Those who received zinc gluconate in comparison with zinc sulfate/acetate vomited more frequently. Overall, children who received zinc reported an 18.8% and 12.5% reduction in average stool frequency, 15.0% and 15.5% shortening of diarrhea duration, and a 17.9% and 18.0% probability of reducing diarrhea over placebo in acute and persistent trials, respectively. Zinc supplementation reduces the duration and severity of acute and persistent diarrhea; however, the mechanisms by which zinc exerts its antidiarrheal effect have not been fully elucidated.

The guidelines addressed the evidence-based indications for the management of children with acute infectious diarrhea in Chinese pediatric population. The experts group of evidence development put forward clinical problems, collects evidence, forms preliminary recommendations, and then uses open-ended discussions to form recommendations. The literature review was done for developing this guideline in databases including PubMed, Cochrane, EMBASE, China Biomedical Database, and Chinese Journal Full-text Database up to June 2013. Search the topic "acute diarrhea" or "enteritis" and "adolescent" or "child" or "Pediatric patient" or "Baby" or "Infant". For the treatment of mild, moderate dehydration, hypotonic oral rehydration solutions (ORS) are strongly recommended. Intravenous (IV) rehydration is recommended for severe dehydration, with a mixture of alkali-containing dextrose sodium solution. Nasogastric feeding tube rehydration is used for children with severe dehydration without IV infusion conditions with ORS solution. Regular feeding should resume as soon as possible after oral rehydration or IV rehydration. The lactose-free diet can shorten the diarrhea duration. Zinc supplements are recommended in children with acute infectious diarrhea. Saccharomyces boulardii and Lactobacillus Rhamnus are recommended to be used in acute watery diarrhea. Saccharomyces boulardii is recommended in children with antibiotic-associated diarrhea as well. Montmorillonite and Racecadotril (acetorphan) can improve the symptoms of diarrhea or shorten the course of acute watery diarrhea. Antibiotics are recommended with dysenteric-like diarrhea, suspected cholera with severe dehydration, immunodeficiency, and premature delivery children with chronic underlying disease; otherwise, antibiotics are not recommended. The principles of the most controversial treatments with of acute infectious disease are reaching to a consensus in China.

Prospective Multicenter Study Evaluating Fecal Calprotectin in Adult Acute Bacterial Diarrhea

BackgroundCurrent WHO guidelines on the management and treatment of diarrhea in children strongly recommend continued feeding alongside the administration of oral rehydration solution and zinc therapy, but there remains some debate regarding the optimal diet or dietary ingredients for feeding children with diarrhea.MethodsWe conducted a systematic search for all published randomized controlled trials evaluating food-based interventions among children under five years old with diarrhea in low- and middle-income countries. We classified 29 eligible studies into one or more comparisons: reduced versus regular lactose liquid feeds, lactose-free versus lactose-containing liquid feeds, lactose-free liquid feeds versus lactose-containing mixed diets, and commercial/specialized ingredients versus home-available ingredients. We used all available outcome data to conduct random-effects meta-analyses to estimate the average effect of each intervention on diarrhea duration, stool output, weight gain and treatment failure risk for studies on acute and persistent diarrhea separately.ResultsEvidence of low-to-moderate quality suggests that among children with acute diarrhea, diluting or fermenting lactose-containing liquid feeds does not affect any outcome when compared with an ordinary lactose-containing liquid feeds. In contrast, moderate quality evidence suggests that lactose-free liquid feeds reduce duration and the risk of treatment failure compared to lactose-containing liquid feeds in acute diarrhea. Only limited evidence of low quality was available to assess either of these two approaches in persistent diarrhea, or to assess lactose-free liquid feeds compared to lactose-containing mixed diets in either acute or persistent diarrhea. For commercially prepared or specialized ingredients compared to home-available ingredients, we found low-to-moderate quality evidence of no effect on any outcome in either acute or persistent diarrhea, though when we restricted these analyses to studies where both intervention and control diets were lactose-free, weight gain in children with acute diarrhea was shown to be greater among those fed with a home-available diet.ConclusionsAmong children in low- and middle-income countries, where the dual burden of diarrhea and malnutrition is greatest and where access to proprietary formulas and specialized ingredients is limited, the use of locally available age-appropriate foods should be promoted for the majority of acute diarrhea cases. Lactose intolerance is an important complication in some cases, but even among those children for whom lactose avoidance may be necessary, nutritionally complete diets comprised of locally available ingredients can be used at least as effectively as commercial preparations or specialized ingredients. These same conclusions may also apply to the dietary management of children with persistent diarrhea, but the evidence remains limited.

BackgroundAcute diarrhoea is one of the principal causes of morbidity and mortality among children in low‐income countries. Glucose‐based ORS helps replace fluid and prevent further dehydration from acute diarrhoea. Since 2004, the World Health Organization has recommended the osmolarity < 270 mOsm/L (ORS ≤ 270 ) over the > 310 mOsm/L formulation (ORS ≥ 310). Glucose polymer‐based ORS (eg prepared using rice or wheat) slowly releases glucose and may be superior.ObjectivesTo compare polymer‐based ORS with glucose‐based ORS for treating acute watery diarrhoea.Search strategyIn September 2008, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library2008, Issue 3), MEDLINE, EMBASE, LILACS, andmRCT. We also contacted researchers, organizations, and pharmaceutical companies, and searched reference lists.Selection criteriaRandomized controlled trials of people with acute watery diarrhoea (cholera and non‐cholera associated) comparing polymer‐based and glucose‐based ORS (with identical electrolyte contents).Data collection and analysisTwo authors independently assessed the search results and risk of bias, and extracted data. In multiple treatment arms with two or more treatment groups, we combined outcomes as appropriate and compared collectively with the control group.Main resultsThirty‐four trials involving 4214 participants met the inclusion criteria: 27 in children, five in adults and two in both. Twelve trials used adequate methods to conceal allocation. Most compared polymer‐based ORS with ORS ≥ 310. There were fewer unscheduled intravenous infusions in the polymer‐based ORS group compared with glucose‐based ORS (ORS ≥ 310 and ≤ 270 groups combined) (RR 0.75, 95% CI 0.59 to 0.95; 2235 participants, 19 trials). Adults positive forVibrio choleraehad a shorter duration of diarrhoea with polymer‐based ORS than with ORS ≤ 270 (MD ‐7.11 hours, SD ‐11.91 to ‐2.32; 228 participants, 4 trials). Wheat‐based ORS resulted in lower total stool output in the first 24 hours compared with ORS ≤ 270 (MD ‐119.85 g/kg, SD ‐114.73 to ‐124.97; 129 participants, 2 trials). Adverse effects were similar for polymer‐based ORS and glucose‐based ORS.Authors' conclusionsPolymer‐based ORS shows some advantages compared to ORS ≥ 310 for treating all‐cause diarrhoea, and in diarrhoea caused by cholera. Comparisons favoured the polymer‐based ORS over ORS ≤ 270, but the analysis was underpowered. If specialists consider a potential role for polymer‐based ORS, further trials against the current standard (ORS ≤ 270) will be required.Plain Language SummaryPolymer‐based oral rehydration solution (ORS) ORS for acute diarrhoeaAcute diarrhoea is a common cause of death and illness in developing countries. Oral rehydration solutions (ORS) have had a massive impact worldwide in reducing the number of deaths related to diarrhoea.Most ORS is in the form of a sugar–salt solution, but over the years people have tried adding a variety of compounds ('glucose polymers') such as whole rice, wheat, sorghum, and maize. The aim is to slowly release glucose into the gut and improve the absorption of the water and salt in the solution. This review updates and expands on a 1998 Cochrane Review of rice‐based ORS, and assesses the available evidence on the use of polymer‐based ORS (both rice and non‐rice based) in comparison with the glucose‐based ORS.The original ORS was based on glucose and had an osmolarity of ≥ 310 mOsm/L (ORS ≥ 310). Glucose‐based ORS with a lower osmolarity was later introduced in attempts to improve efficacy, and is considered better at reducing the amount and duration of diarrhoea.Thirty‐four trials involving 4214 participants met the inclusion criteria: 27 in children; five in adults; and two in both. Most trials compared polymer‐based ORS with a sugar–salt ORS with a particular strength (ORS ≥ 310), which is slightly more salty than the currently agreed best formula (≤ 270 mOsm/L). The trials' methodological quality was variable.Fewer people in the polymer‐based ORS group needed a drip to be rehydrated compared with those in the glucose‐based ORS group. Adverse events were similar for polymer‐based ORS and glucose‐based ORS.The authors conclude that polymer‐based ORS show some advantages compared to glucose‐based ORS for treating diarrhoea of any cause and in diarrhoea caused by cholera. Limited evidence favoured the polymer‐based ORS over ORS ≤ 270. Further trials should compare the efficiency of ORS ≤ 270 with a polymer‐based ORS.

Serum and rectal mucosal magnesium content was estimated in children (6-18 months old) with acute diarrhoea (Group I: n = 50), chronic diarrhoea (Group II: n = 25), extra-intestinal infections (Group III: n = 15) and healthy controls (Group IV: n = 20). The sex and nutritional status of the different groups were comparable. The mean serum magnesium levels in acute and chronic diarrhoea were comparable to healthy and infected controls. The tissue magnesium content of infants with chronic diarrhoea was significantly (P less than 0.001) lower than other groups. Repeat estimation at discharge in 38 patients (25 in Group I, 13 in Group II) revealed a significant reduction in serum levels in both groups (P less than 0.05 and P less than 0.01, respectively) and in tissue levels in acute diarrhoea (P less than 0.05). A total of 23 infants (16 in Group I) were evaluated 2-3 weeks after discharge. There was an increase in tissue magnesium content at recovery in acute (P less than 0.02) and chronic (P greater than 0.05) diarrhoea groups. It is concluded that infants with chronic, but not acute diarrhoea, are magnesium depleted at presentation; with the continuation of diarrhoea there is a progressive depletion of magnesium; and there is a tendency to regain the magnesium status during the convalescent period.

Tumor Necrosis Factor-α and Interleukin-10 in Viral and Bacterial Gastroenteritis in Children

In developing countries, diarrhoea causes around two million child deaths annually. Zinc supplementation during acute diarrhoea is currently recommended by the World Health Organization and UNICEF. To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea. In February 2012, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2011, Issue 11), MEDLINE, EMBASE, LILACS, CINAHL, mRCT, and reference lists. We also contacted researchers. Randomized controlled trials comparing oral zinc supplementation with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery. Both authors assessed trial eligibility and risk of bias, extracted and analysed data, and drafted the review. Diarrhoea duration and severity were the primary outcomes. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses (using the fixed- or random-effects model) and assessed heterogeneity.The quality of evidence has been assessed using the GRADE methods Twenty-four trials, enrolling 9128 children, met our inclusion criteria. The majority of the data is from Asia, from countries at high risk of zinc deficiency, and may not be applicable elsewhere. Acute diarrhoea. There is currently not enough evidence from well conducted randomized controlled trials to be able to say whether zinc supplementation during acute diarrhoea reduces death or hospitalization (very low quality evidence).In children aged greater than six months with acute diarrhoea, zinc supplementation may shorten the duration of diarrhoea by around 10 hours (MD -10.44 hours, 95% CI -21.13 to 0.25; 2175 children, six trials, low quality evidence), and probably reduces the number of children whose diarrhoea persists until day seven (RR 0.73, 95% CI 0.61 to 0.88; 3865 children, six trials, moderate quality evidence). In children with signs of moderate malnutrition the effect appears greater, reducing the duration of diarrhoea by around 27 hours (MD -26.98 hours, 95% CI -14.62 to -39.34; 336 children, three trials, high quality evidence).Conversely, In children aged less than six months, the available evidence suggests zinc supplementation may have no effect on mean diarrhoea duration (MD 5.23 hours, 95% CI -4.00 to 14.45; 1334 children, two trials, low quality evidence), and may even increase the proportion of children whose diarrhoea persists until day seven (RR 1.24, 95% CI 0.99 to 1.54; 1074 children, one trial, moderate quality evidence).No trials reported serious adverse events, but zinc supplementation during acute diarrhoea causes vomiting in both age groups (RR 1.59, 95% 1.27 to 1.99; 5189 children, 10 trials, high quality evidence). Persistent diarrhoea. In children with persistent diarrhoea, zinc supplementation probably shortens the duration of diarrhoea by around 16 hours (MD -15.84 hours, 95% CI -25.43 to -6.24; 529 children, five trials, moderate quality evidence). In areas where the prevalence of zinc deficiency or the prevalence of moderate malnutrition is high, zinc may be of benefit in children aged six months or more.The current evidence does not support the use of zinc supplementation in children below six months of age.

Acute diarrhea in children leads to dehydration and death if not appropriately managed. World Health Organization (WHO) recommends treating diarrhea with oral rehydration therapy (ORT), fluids and foods. Proper management is hinged on accurate assessment of patients to identify the acute watery diarrhea. To compare the knowledge and attitude of community pharmacists in the management of acute diarrhea in children with their observed practice. THIS STUDY WAS CARRIED OUT USING TWO INSTRUMENTS: structured self-administered questionnaire to assess knowledge and attitude of community pharmacists in the management of acute diarrhea in children and simulated patient visits to evaluate assessment of patients, recommendation of products and instructions on feeding and fluid intake. The simulated patient visits were done in 186 pharmacies in the city of Lagos, Nigeria. The study reveals that the knowledge and attitude of community pharmacists in the management of acute diarrhea in children was different from their observed practice. The difference was statistically significant (p<0.05). During the simulations, 23% carried out appropriate assessment before recommending any products, and 15% recommended ORT alone. Although information to the pharmacists indicated non-dysentery, non-cholera, acute watery diarrhea, antibiotics and antidiarrheals were irrationally recommended and these were the mainstay of symptoms' management in practice. Questionnaire data revealed that 24% of pharmacists knew the correct instructions to give on food and fluid intake during diarrhea, whereas 8% followed WHO guideline on food and fluid intake during the visits. Assessment of patients to determine acute diarrhea was inadequate. Observed practice in managing acute diarrhea in children was inappropriate and significantly different from their claims in the questionnaire. The recommendation of ORT was scanty and advice on food and fluid intake was inadequate and sometimes inappropriate. This study shows that only 15% of community pharmacists managed acute diarrhea in children according to the WHO guidelines.

Gut microbiota is closely related to acute infectious diarrhea, one of the leading causes of mortality and morbidity in children worldwide. Understanding the dynamics of the recovery from this disease is of clinical interest. This work aims to correlate the dynamics of gut microbiota with the evolution of children who were suffering from acute infectious diarrhea caused by a rotavirus, and their recovery after the administration of a probiotic, Saccharomyces boulardii CNCM I-745. The experiment involved 10 children with acute infectious diarrhea caused by a rotavirus, and six healthy children, all aged between 3 and 4 years. The children who suffered the rotavirus infection received S. boulardii CNCM I-745 twice daily for the first 5 days of the experiment. Fecal samples were collected from each participant at 0, 3, 5, 10, and 30 days after probiotic administration. Microbial composition was characterized by 16S rRNA gene sequencing. Alpha and beta diversity were calculated, along with dynamical analysis based on Taylor's law to assess the temporal stability of the microbiota. All children infected with the rotavirus stopped having diarrhea at day 3 after the intervention. We observed low alpha diversities in the first 5 days (p-value < 0.05, Wilcoxon test), larger at 10 and 30 days after probiotic treatment. Canonical correspondence analysis (CCA) showed differences in the gut microbiota of healthy children and of those who suffered from acute diarrhea in the first days (p-value < 0.05, ADONIS test), but not in the last days of the experiment. Temporal variability was larger in children infected with the rotavirus than in healthy ones. In particular, Gammaproteobacteria class was found to be abundant in children with acute diarrhea. We identified the microbiota transition from a diseased state to a healthy one with time, whose characterization may lead to relevant clinical data. This work highlights the importance of using time series for the study of dysbiosis related to diarrhea.