Acute Diarrheal Episodes Research Articles

Evaluation of Efficacy and Tolerability of Fixed Dose Combination of Rifaximin and Metronidazole in The Management of Acute Diarrhea

Background: Infectious diarrhea is endemic in many parts of the world. It is generally mixed in etiology involving virus, bacteria, and parasite. Antibiotics belonging to fluoroquinolones class are most commonly used but are beneficial only in certain types of acute diarrhoea with side-effects like tendinopathy, arthropathy, neuropathy, arrhythmia, hypoglycemia, and hyperglycemia. Rifaximin with its unique mechanism, along with established metronidazole is proposed as a treatment option for acute diarrhea caused due to mixed gastrointestinal infections. The aim of this study is to evaluate the efficacy and tolerability of a fixed dose combination of rifaximin and metronidazole in the empirical management of acute diarrhea.Method: An open-label, non-comparative, non-randomized, multicenter trial was conducted in 238 patients presenting with acute diarrheal episodes involving various etiologies. Patients were given fixed dose combination tablet containing rifaximin 200 mg and metronidazole 400 mg twice a day for 5 days. Primary outcomes were change from baseline in number of soft or watery stools, fever, nausea, vomiting, abdominal pain, and gas/flatulence at day 5.Results: In final analysis 150 patients were included, as 88 patients lost to follow up. After 5 days of therapy, mean number of watery stools per day were reduced from 7.133 ± 2.055 to 0.733 ± 0.833 (p 0.0001). Minor incidences of gastritis, nausea, and metallic taste were reported.Conclusion: Combination of rifaximin and metronidazole significantly reduces number of watery stools and associated symptoms and is a clinically effective and safe option in the empirical management of acute diarrhea of various etiologies.

Compare the Effect of Zinc–Probiotic versus Zinc Therapy in Acute Watery Diarrhea in Children

Background: Acute watery diarrhea still remains a major health problem among under 5 children worldwide. Apart from oral rehydration solution, continued feeding and oral zinc therapy the administration of adequate amounts of probiotics seems beneficial for acute diarrheal episodes in children in the developing world. Objective: To compare the efficacy of zinc-probiotic combination therapy versus zinc-only therapy in children with acute watery diarrhea. Materials and Methods: This was a hospital based randomized controlled clinical trial (RCT) conducted from July 2019 to June 2021 in the Department of Pediatrics, Khwaja Yunus Ali Medical College & Hospital. Total 70 children aged 6 months to 5 years admitted in hospital with acute watery diarrhea (AWD) with severe dehydration or some dehydration with intractable vomiting were included in this study. Patients were equally divided into 2 groups. Group A received oral zinc sulfate 20 mg/day for 10 days combined with oral Bacillus clausii probiotic 4million spores/day for 5 days. Group B received only oral zinc sulfate at the same dosage as group A. We also studied the relationship between mother`s education, knowledge of ORS preparation and child’s feeding practices and nutritional status with the occurrence of diarrhea in children. Results: Frequency of diarrhoea was significantly higher in group B (Zinc only) in comparison to group A (Zinc and probiotic). Mean frequency of diarrhea, Mean duration of diarrhea and Mean length of hospital stay was significantly higher in group B (Zinc) than group A (Zinc+Probiotic). Conclusion: Compared to oral Zinc therapy only; the combination of oral zinc and probiotic therapy is clinically more effective in reducing the frequency of acute watery diarrhea in under 5 years children. KYAMC Journal Vol. 13, No. 04, January 2023: 218-222

Application of the Human Viral Surrogate Pepper Mild Mottle Virus for Wastewater Fecal Pollution Management

Global water scarcity has led to significant dependence on reclaimed or recycled water for potable uses. Effluents arising from human and animal gut microbiomes highly influence water quality. Wastewater pollution is, therefore, frequently monitored using bacterial indicators (BI). However, threats to public health arise from the frequent incidence of wastewater-mediated viral infections–undetected by BI. Moreover, the enteric viromes contaminating wastewater are characterized by high abundance, genetic diversity and persistence in various water environments. Furthermore, humans usually suffer a minimum of a single acute diarrheal episode over their lifetime arising from extraneously acquired enteric microbiomes. A wide range of management methods are employed—in particular, microbial source tracking (MST) approaches to confront infections arising from exposure to contaminated wastewater. This review elaborates the viral contamination of treated wastewater and associated public health issues. Latterly, we discuss the various management strategies of wastewater pollution using conventional fecal indicators, viral indicators and human viral surrogates, with particular interest in the pepper mild mottle virus (PMMoV). Globally, PMMoV has been detected in rivers, aquifers, irrigation systems, and coastal and marine waters at high prevalence rates and concentrations greater than 105 genome copies per liter (gc/L). PMMoV was also found in almost all untreated wastewater environments. PMMoV concentrations in wastewater vary from 103 to 107 gc/L. These values are more than the maximum recorded viral indicator concentrations in wastewater for other proposed indicators. Limited variability in the daily concentrations of PMMoV in fecal wastewater has been studied, with an estimated average concentration of 105 gc/L with insignificant seasonal variability. The information summarized in this article offers fundamental knowledge for decision making in terms of defining the suitability criteria of candidate fecal indicators, risk assessment application and efficient wastewater management.

Lactobacillus rhamnosus GG Evaluation in Acute Diarrhea (LEAD): An Observational Study.

Background and objectiveProbiotics with documented efficacy such as Lactobacillus rhamnosus GG(LGG) and Saccharomyces boulardii might be utilized as adjuncts to rehydration for the management of acute gastroenteritis (AGE) in children. In this study, we aimed to evaluate the potential role of LGG in acute diarrhea in the Indian pediatric population.MethodsAn observational, cross-sectional study [Lactobacillus rhamnosus GG Evaluation in Acute Diarrhea (LEAD)] was conducted among children aged one month to 12 years with acute watery diarrhea. In addition to standard management of diarrhea, LGG was given as an adjuvant treatment at the discretion of treating physicians based on their routine practice. Observations were documented on days one, three, and five. Outcomes such as frequency and duration of diarrhea, time to change in consistency of stools, Bristol Stool Chart (BSC) reading, and global assessment by healthcare practitioners (HCPs) and patients were also recorded.ResultsOf the 2,080 patients enrolled, 1,900 completed the five-day follow-up. There was marked improvement observed in the number of incidences of loose stools from day one (mean: 7.33) to day five (mean: 1.6). The mean time to improvement in stool consistency was 34 hours. The mean duration of diarrhea was 44.63 hours. A relatively shorter duration of diarrhea was reported among participants in this study. There was also a significant improvement in the number of vomiting episodes. Most patients and HCPs reported the product to be excellent/very good on the global assessment scale. No adverse effects were noted in any of the groups.ConclusionBased on our findings, LGG supplementation may be a beneficial adjuvant treatment in reducing the severity and duration of acute diarrheal episodes.

Induction of Endotoxin Tolerance Delays Acute Rejection in a Hindlimb Transplantation Model in Rats.

Acute rejection is seen in 85 percent of composite vascular allogeneic transplants despite long-term immunosuppression. Recently, it was reported that the induction of endotoxin tolerance prolonged heart allograft survival in mice. However, it produced side effects in all the animals secondary to the inflammatory reaction. Galactomannan has shown endotoxin tolerance without this side effect in vitro. The authors hypothesized that galactomannan-induced endotoxin tolerance delays acute rejection in vascular allogeneic transplantation without the side effects produced by lipopolysaccharide. Twenty-four rat hindlimb transplants were divided into four groups according to the preconditioning received: control, lipopolysaccharide (0.16 ml/kg), galactomannan 72 hours before (galactomannan-72) (8 ml/kg), and galactomannan 24 hours before (galactomannan-24) (8 ml/kg). Median acute rejection time, weight loss, and diarrheal episodes were monitored. Blood samples were collected at 0, 7, 21, 30, 45, and 60 days. Plasma cytokines (i.e., tumor necrosis factor alpha, interferon gamma), peripheral chimerism, and lymphocyte percentages were analyzed. Median allograft survival was 40 days (range, 40 to 44 days) in the control group, 68 days (range, 61 to 71 days) in the lipopolysaccharide group, and 70 days (range, 69 to 73 days) in both galactomannan groups (p = 0.001). Weight loss was higher in the lipopolysaccharide group (p < 0.001), as was the 83.3 percent rate of diarrheal episodes (control, 0 percent, p = 0.015; galactomannan-72, 0 percent, p = 0.015; and galactomannan-24, 16.7 percent, p = 0.02). Preconditioned rats had higher peripheral blood chimerism (lipopolysaccharide, 2.30 ± 0.13 percent; galactomannan-72, 2.63 ±1.46 percent; and galactomannan-24, 2.47 ± 0.19 percent) compared to the control group (2.06 ± 0.36 percent) (lipopolysaccharide, p = 0.04; galactomannan-72, p = 0.002; and galactomannan-24, p = 0.002). Induction of endotoxin tolerance delays acute rejection in the rat hindlimb transplantation model. Galactomannan preconditioning has no lipopolysaccharide side effects and was equally effective in delaying acute rejection. The contributions of this experimental work are very incipient. Although the use of galactomannan in clinical practice requires more studies to assess its safety, there is no doubt that immunomodulation may be one of the responses that solve the problem of long-term immunosuppression.

Efficacy of a Green Banana-Mixed Diet in the Management of Persistent Diarrhea: Protocol for an Open-Labeled, Randomized Controlled Trial.

BackgroundDiarrhea is the second-leading cause of death in children under 5 years of age. In low- and middle-income countries, 3%-20% of acute diarrheal episodes become persistent diarrhea (PD) (ie, duration ≥14 days), which results in 36%-56% of all diarrheal deaths. In Bangladesh, PD causes >25% of diarrhea-related deaths. Commensal gut microbiota dysbiosis is increasingly recognized in the pathogenesis of PD. Hospital-based management of PD requires a hospital stay, which increases the risk of infection and hospital costs. The higher cost of treatment and high case-fatality rates reiterate PD as an important public health problem. At the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), for the last two decades, a consensus-based guideline has been followed for PD. Observation has revealed that green banana helps in the resolution of diarrhea. However, no larger prospective study has been conducted to evaluate the efficacy of green banana in the management of PD among children older than 6 months of age.ObjectiveOur objective is to assess the efficacy of full-strength rice suji (semolina) with and without green banana compared to three-quarter-strength rice suji in the management of PD in children aged 6-36 months at the Dhaka Hospital of the icddr,b.MethodsThis open-labeled, randomized controlled study aims to enroll a total of 145 children with PD who have not been improving on a diet of milk suji. Children will be randomized into three different diet-specific groups: full-strength rice suji containing green banana, full-strength rice suji alone, and three-quarter-strength rice suji. The primary outcome is the percentage of children who recovered from diarrhea by day 5.ResultsRecruitment and data collection began in December 2017 and were completed in November 2019. Results are expected by April 2020.ConclusionsThis study is expected to provide insights into the incorporation of green banana into the dietary management of PD. This would be the first study to investigate the role of microbiota and metabolomics in the pathogenesis of PD.Trial RegistrationClinicalTrials.gov NCT03366740; https://clinicaltrials.gov/ct2/show/NCT03366740International Registered Report Identifier (IRRID)DERR1-10.2196/15759

Compliance with 14 day zinc therapy for acute diarrhoea: a prospective observational study

Background: Acute diarrheal diseases remain a leading cause of global morbidity and mortality in young children. The effective implementation of provision of zinc in addition to low osmolarity ORS remains very poor.Methods: A prospective observational study was done to determine compliance with zinc therapy on 103 children aged between two months to five years with acute gastroenteritis. They were started on WHO ORS and zinc in the form of syrup (20 mg/day in those &gt;6 months of age and 10mg/day in those &lt;6 months of age) and advised to continue for 14 days. Further episodes of diarrhea was considered as the primary outcome variable. Number of days zinc taken was considered as the primary explanatory variable. p-value &lt;0.05 was considered statistically significant.Results: The mean age was 19.49±14.41 months. The compliance to complete 14-day zinc therapy was 62.14%. The mean number of days zinc was taken was 11.28±3.81 days. In 11.65% of participants, there was further episodes of diarrhea. The main reasons for discontinuation were diarrhea stopped (45%), Ignorance (37.5%), URI (12.5%).Conclusions: Findings indicate that the syrup formulation is acceptable, but further efforts are required to enhance adherence. These findings also highlight the importance of guiding in ensuring adherence to zinc duration while also addressing the tendency of caregivers to terminate treatment once a child appears to have recovered from an acute diarrheal episode.

Rotavirus Diarrhea in Children Under Five in Basrah: Hospital Based Study

Background: Human rotaviruses, particularly of group A are the most important cause of severe dehydrating diarrhea in young children worldwide in both developed and developing countries. Although rotavirus accounts for up to 50% of hospitalizations for severe diarrhea in infants and children, it has been underestimated within the public health community, particularly in developing countries. This is a cross sectional study which was carried out to determine the frequency of rotavirus diarrhea in hospitalized children under 5 yrs in Basra by stool enzyme linked immunosorbant assay test and study the relation of selected patients’ variables to rotavirus diarrhea. Methods: A hospital-based study includes 120 children aged less than 5 yrs who were admitted to the pediatric wards with acute gastroenteritis over a period of five months from the October 1st, 2015 till March 15th, 2016. All patients underwent physical examination for sign of dehydration and assessment of severity of diarrheal episode by Vesikari score which considered various parameters including frequency, duration of diarrhea, vomiting, temperature, hydration status and the treatment received by the patients. A score of <7 was considered mild, 7-11 was moderate and ≥ was 11 severe. Stool samples were collected within 48 hrs of hospitalization and examination for rotavirus was done by Enzyme Linked Immunosorbant Assay; One Step rotavirus Test (ABON biopharm, China) which is a qualitative immunoassay kit used for the detection of rotavirus in human stool sample. Result: The frequency of rotavirus infection was 32.5%, about two thirds of admitted children presented with severe diarrheal episodes and one third with moderate diarrhea. Sixty two percent of the studied patients aged 3-12 months with higher frequency of males than females (62.5%, 37.5%) respectively. All studied children with rotavirus infection were below 24 months of age, with higher frequency in males than females (74.36%, 25.64%) respectively with P value 0.001. Reviewing the immunization status history of rotavaccine reveals that; 64 (53.3%) of patients have missed or did not receive any vaccine with approximate percentage (53.8%) in patients who were positive for rotavirus with significant result (P value 0.001) and only 36.7% of children had an immunization status that was appropriate for their age. One third of studied parents were illiterate with higher frequency in mothers than fathers (22.5%, 14.1%) with rotavirus infection in children belong to illiterate parents (25.6%, 7.6%) respectively, with statistically significant results. Bottle feeding with or without complementary diet had been reported in higher frequency of studied patients (59.2%) with positive rotavirus stool test in 71.8% with statistically significant result. Inpatient management of studied children reveals that zinc therapy, oral rehydration solution and antibiotics prescribed for (56.4%, 66.7% and 89.7%) of patients with rotavirus infection respectively. Conclusion: Routine evaluation of children with acute diarrheal episodes by stool test for rotavirus is recommended to avoid un-rational prescription of antibiotics and proper practice according to integrated management of childhood illness program.

High Frequency of Enteric Protozoan, Viral, and Bacterial Potential Pathogens in Community-Acquired Acute Diarrheal Episodes: Evidence Based on Results of Luminex Gastrointestinal Pathogen Panel Assay.

Infectious diarrhea is endemic in most developing countries. We aimed to investigate the protozoan, viral, and bacterial causes of acute diarrhea in Taif, Saudi Arabia. A cross-sectional prospective 1-year study was conducted on 163 diarrheal patients of various ages. Stool samples were collected, 1 per patient, and tested for 3 protozoa, 3 viruses, and 9 bacteria with the Luminex Gastrointestinal Pathogen Panel. Overall, 53.4% (87/163) of samples were positives (20.8% protozoa, 19.6% viruses, 2.8% bacteria, and 9.8% mixed). Rotavirus (19.6%), Giardia duodenalis (16.5%), and Cryptosporidium spp. (8.5%) were the mostly detected pathogens. Adenovirus 40/41 (4.2%), Salmonella (3%), Shiga toxin-producing Escherichia coli (3%), and Entamoeba histolytica (2.4%) were also detected. Norovirus GI/II, Vibrio cholerae, Yersinia enterocolitica, and Clostridium difficile toxin A/B were not detected in any patients. All pathogens were involved in coinfections except E. histolytica. Giardia (5.5%) and rotavirus (3%) were the most commonly detected in co-infections. Enterotoxigenic E. coli (2.4%), Campylobacter spp. (2.4%), E. coli 0157 (1.8%), and Shigella spp. (1.2%) were detected in patients only as co-infections. Infections were more in children 0–4 years, less in adults <40 years, and least >40 years, with statistically significant differences in risk across age groups observed with rotavirus (P<0.001), Giardia (P=0.006), and Cryptosporidium (P=0.036) infections. Lastly, infections were not significantly more in the spring. This report demonstrates the high burden of various enteropathogens in the setting. Further studies are needed to define the impact of these findings on the clinical course of the disease.

Serum Zinc Level and Its Correlation with Vesikari System Scoring in Acute Pediatric Diarrhea.

BACKGROUND:Diarrhea remains the most common infectious disease worldwide. Zinc has been studied extensively recently for its potential effect on prevention, control and treatment of acute diarrhoea.AIM:This study was designed to correlate the level of zinc with the severity of pediatric diarrhoea estimated by Vesikari Scoring System.PATIENTS AND METHODS:The present study included 80 children aged two months to 30 months from those suffering from the acute diarrheal episode and admitted to Pediatric Hospital “Abo El Rish” Cairo University. Serum Zinc level was assessed by a colorimetric method with a spectrophotometer.RESULTS:Zinc deficiency was detected in 45 (56.2%) patient of the studied group Significant negative correlations were found between serum zinc level and severity of dehydration and duration of hospitalization (p < 0.05).CONCLUSION:Zinc level has an essential role in acute pediatric diarrhoea. Zinc therapy should be considered beside Oral rehydration salts (ORS) to achieve maximum impact on diarrheal diseases; clinical trials are recommended to support the zinc supplementation in developing countries.

Effects of zinc supplementation in the prevention of respiratory tract infections and diarrheal disease in Colombian children: A 12-month randomised controlled trial

BackgroundAmong the preventive strategies for lowering the incidence of upper respiratory tract infections (URTI) and acute diarrhoea episodes, two of the most common diseases in children, zinc supplementation has received special interest. However, there is a need for additional studies that determine the preventive effects of different doses of zinc on URTI and diarrhoeal disease episodes in children. MethodsIn a randomised, triple-blind clinical trial, we evaluated the efficacy of 12 months of daily zinc supplementation in the incidence of URTI and acute diarrhoea in a population of healthy children aged between 6 and 12 months living in Bogota, Colombia. The outcomes analysed were incidence of URTI, acute diarrhoeal disease episodes, and side effects of the interventions. ResultsBetween 2010 and 2013, a total of 355 children underwent randomisation, with 174 assigned to the zinc supplementation group and 181 to the control group. In the multivariate analyses, having been randomised to the non-supplemented control group (IRR 1.73, 95% CI 1.52–1.97, p<0.001), and nursery attendance (IRR 1.41, 95% CI 1.07–1.87, p=0.016) were independently linked to the number of URTI. Likewise, having been randomised to the non-supplemented group (IRR 1.43, 95% CI 1.20–1.71, p<0.001), and lower socioeconomic status (IRR 1.86, 95% CI 1.11–3.13, p=0.018) were independently associated to the number of diarrhoeal disease episodes. ConclusionsDaily supplementation of 5mg of zinc during 12 months significantly decreased the incidence of URTI and diarrhoeal disease episodes in a healthy population of children aged between 6 and 12 months.

Feeding practices among the infants presenting with acute diarrhea

Introduction: To study various feeding practices in children who present with acute watery diarrhea. The objective of the study was not only to study the feeding patterns but also draw an association between different feeding patterns and acute diarrheal episodes. Setting: Outdoor and indoor unit of Department of Paediatrics Jinnah Hospital affiliated with Allama Iqbal Medical College Lahore. Subject: Two hundred and fifty patients with acute watery diarrhea of less then 14 days between the ages of 1 month to 1 year were included in the study. Methods: It was a case control cross sectional study. The data related to 250 patients was collected. The required information was obtained from mother/ attendant of the infant in the questionnaire. All the questionnaire were filled by the doctors. Results: The majority of the infants with acute diarrhea were between 4 months to 1 year 195 (78%). Forty two (17%) were exclusively breastfed while 78 (31 %) exclusively bottle-fed. Fifty five (22%) had both breast feeding as well as bottle feeding. A large number of mothers 112 (44.8%) gave the reason of insufficient milk for the baby. Conclusion: Majority of the infants with acute diarrhea episodes were between 8 and 12 months when either breast milk is being replaced by bottle milk or improper weaning practices are being used. A large number of infants with acute diarrhea were either mixed fed or bottle fed. Because of increased mixed and bottle feeding there is high incidence of diarrhea in our community.

Adherence to zinc supplementation guidelines for the treatment of diarrhea among children under-five in Uttar Pradesh, India.

BackgroundThere is limited evidence on adherence to the recommended dose and duration of zinc supplementation for diarrheal episodes in children under five years of age. In selected districts of Uttar Pradesh, India, we sought to assess adherence to the nationally advised zinc treatment regimen (ie, 10 mg/day for ages 2–6 months and 20 mg/day for ages 7–59 months for 14 days) among caregivers of zinc–prescribed children.MethodsWe identified and conducted follow–up visits to children advised zinc for the treatment of diarrhea. At the initial visit, we collected data on the treatment instructions received from providers. Caregivers were asked to record treatments administered on a pictorial tracking form and were asked to retain all packaging for collection at follow–up. We quantified the average dose and duration of zinc therapy and built logistic regression models to assess the factors associated with caregiver adherence to national guidelines.ResultsCaregivers administered zinc for an average of 10.7 days (standard deviation (SD) = 3.9 days; median = 13 days), and 47.8% continued treatment for the complete 14 days. Among children receiving zinc syrups and tablets respectively, the age appropriate dose was received by 30.8% and 67.3%. Adherence to age appropriate dose and continuation of zinc for 14 days were highly associated with having received appropriate provider instructions.ConclusionsOur results indicate moderate–to–good adherence to national zinc treatment guidelines for diarrhea among caregivers in rural India. Our findings also highlight the importance of provider guidance in ensuring adherence to zinc dose and duration. Programs aiming to scale–up zinc treatment for childhood diarrhea should train providers to successfully communicate dosing instructions to caregivers, while also addressing the tendency of caregivers to terminate treatment once a child appears to have recovered from an acute diarrheal episode.

Combined stool-based multiplex PCR and microscopy for enhanced pathogen detection in patients with persistent diarrhoea and asymptomatic controls from Côte d’Ivoire

Infectious diarrhoea ranks among the leading causes of morbidity worldwide. Although most acute diarrhoeal episodes are self-limiting, the diagnosis and treatment of persistent diarrhoea (≥2 weeks) are cumbersome and require laboratory identification of the causative pathogen. Stool-based PCR assays have greatly improved the previously disappointing pathogen detection rates in high-income countries, but there is a paucity of quality data from tropical settings. We performed a case–control study to elucidate the spectrum of intestinal pathogens in patients with persistent diarrhoea and asymptomatic controls in southern Côte d’Ivoire. Stool samples from 68 patients and 68 controls were obtained and subjected to molecular multiplex testing with the Luminex® Gastrointestinal Pathogen Panel (GPP), microscopy and rapid antigen detection tests for the diagnosis of diarrhoeagenic pathogens. Overall, 20 different bacteria, parasites and viruses were detected by the suite of diagnostic methods employed. At least one pathogen was observed in 84% of the participants, and co-infections were observed in >50% of the participants. Enterotoxigenic Escherichia coli (32%), Giardia intestinalis (29%) and Shigella species (20%) were the predominant pathogens, and Strongyloides stercoralis (10%) was the most prevalent helminth. Pathogen frequencies and numbers of co-infections were similar in patients and controls. Although the Luminex® GPP detects a broad range of pathogens, microscopy for helminths and intestinal protozoa remains necessary to cover the full aetiological spectrum in tropical settings. We conclude that highly sensitive multiplex PCR assays constitute a useful screening tool, but that positive results might need to be confirmed by independent methods to discriminate active infection from asymptomatic faecal shedding of nucleic acids.

The burden of different pathogens in acute diarrhoeal episodes among a cohort of Egyptian children less than five years old.

IntroductionDiarrhoea continues to cause significant morbidity in Egypt.AimTo determine the frequency and distribution of different enteropathogens in acute diarrhoeal episodes, utilising an expanded testing regimen, and to correlate clinical signs and symptoms associated with the detected pathogens.Material and methodsThe case-control study enrolled 356 patients < 5 years old with acute diarrhoea and 356 age and sex-matched healthy controls. Both cases and controls underwent a full history and physical examination, and provided two rectal swab specimens and a stool sample. Laboratory analysis included stool culture, microscopy, and indirect methods.ResultsRotavirus was detected in 11% of patients. Enterotoxigenic Escherichia coli (ETEC), Campylobacter, Shigella, and Salmonella were detected in 7%, 3.7%, 1.1%, and 1.4% of patients, respectively; and in 11.1%, 3.1%, 0.6%, and 0.6% of controls, respectively, with no significant statistical difference. Cryptosporidium was detected in 3.9% of cases. Mixed infection was detected in 5.9% of cases and 0.9% of controls, with a significant difference (p < 0.001). No pathogen was detected in 66.3% of cases and in 83.5% of controls. Rotavirus infection was associated with recurrent vomiting, dehydration, and hospitalisation. Bacterial diarrhoea was associated with vomiting (52%) in ETEC infections, fever (80%) in Salmonella infections, mucus (100%) and blood (50%) in stools of Shigella infections, and convulsions (15%) in Campylobacter infections.ConclusionsRotavirus is a prominent cause of diarrhoea among Egyptian children. Despite utilising an expanded testing regimen, more work is still needed for identification of other enteropathogens that constitute other causative agents of diarrhoea.

An outbreak of Vibrio cholerae in Vikas Nagar, Chandigarh, India

<b>Background</b> : On 1 July 2012, a large number of cases of acute diarrheal episodes were reported in Vikas Nagar, Chandigarh. A rapid response team was sent to investigate this outbreak on 3 July 2012. <b>Aim</b> : To determine the reasons for the outbreak and to focus on the identification of a gap in the management of the epidemic by applying remedial measures in the <i>Vibrio cholera</i> outbreak in the Vikas Nagar area of Chandigarh district. <b>Materials and Methods</b> : A house-to-house survey of 2765 houses was performed with 20 teams of Auxillary Nurse Midwife ANM/Anganwadi workers. Information regarding age, sex, place of residence, occupation, date of onset and treatment history and laboratory finding were collected. Environmental investigation and laboratory investigation of the stool samples were also performed. As the study was conducted during an emergency response to the outbreak, and was designed to provide information to orient the public health response, ethical approval was not required. Remedial measures were implemented. <b>Results</b> : A total of 1875 patients reported to the various health facilities of the Vikas Nagar area with complaints of increased frequency of loose watery diarrhea and a few had vomiting episodes during the time period of 1 ^- 14 July 2012. Four deaths were reported. Three hundred eighteen (318) cases were found in the house-to-house survey of 2765 houses of the area. Twenty-six percent of the cases were in the age group of <5 years. Hospitalization was required in 12.9% of the cases, while 87.1% were managed in the Outpatient Department. Eight samples were found to be positive for <i>Vibrio cholera</i> <i>El Tor</i> Serotype, <i>Ogawa</i> in samples from the house-to-house survey. A coliform count of >1800 MPN/100 mL was reported from 10 water samples. Investigations revealed that the epidemic was waterborne. Leakages in the pipes were found at many places leading to mixing of water with drainage, and water samples collected from the houses of the cases were found to be positive for <i>Vibrio cholerae</i>. <b>Conclusion</b> : Among the identified gaps, delays in the initiation of the investigation of the epidemic and pipe leakages were the most important. In India, waterborne epidemics are usual occurrences during the year. In this scenario, proper monitoring of water sources, proper sewage disposal, sanitation measures and creating awareness among the people should be undertaken.

Persistent diarrhea: still an important challenge for the pediatrician

To provide recent guidelines to reduce the incidence of diarrheal diseases. We discuss the definition, clinical aspects, pathophysiology, diagnosis, management, and prevention of persistent diarrhea. Electronic search of the MEDLINE database, Google search. Acute diarrhea may be caused by a variety of agents, including bacterial, viral, and protozoan pathogens. The top priority in treatment of diarrhea is replacement of fluid and electrolytes losses, particularly at the acute stage, and, under certain circumstances, eradication of the enteropathogenic agent. On the other hand, treatment of persistent diarrhea should focus on prevention and management of food intolerance and malnutrition. Promotion of breastfeeding, adequate interventions in the treatment of acute diarrheal episodes, introduction of safe dietary strategies for prevention of malnutrition, and improvements in sanitation and hygiene conditions, including sewage and clean water, are essential measures for the reduction of diarrheal morbidity and mortality rates in children under 5 years of age.

Zinc Treatment for 5 or 10 Days Is Equally Efficacious in Preventing Diarrhea in the Subsequent 3 Months among Bangladeshi Children1–4

We conducted a randomized, double-blind placebo controlled, community trial in rural Bangladesh in children 4–59 mo of age to compare the efficacy of a 5- and 10-d course of zinc therapy on the incidence and duration of diarrhea over the subsequent 90-d follow-up after initial treatment for an acute childhood diarrheal (ACD) episode. Children (n= 1622) with ACD were randomly allocated to either 5 or 10 d of zinc treatment. Female field workers visited each child daily, supervised the administration of zinc, recorded the duration of current episode, and the occurrence and duration of diarrhea over the subsequent 3 mo. The incidence of diarrhea over the 90 d of follow-up did not differ between the 5-d (1.08 ± 1.38 episodes) and 10-d (1.02 ± 1.35 episodes) groups (P= 0.35). Children in both groups experienced a comparable duration of diarrheal episodes (3.1 ± 5.6 d vs. 2.9 ± 5.6 d, 5-d vs. 10-d, respectively;P= 0.64) with a mean difference between groups within the defined range of equivalence. Time to onset of the first episode and the proportion children experiencing diarrhea during the 90-d follow-up also did not differ between groups. These findings suggest that among Bangladeshi children, a 5-d zinc treatment for ACD is as efficacious as 10 d in preventing diarrhea in the subsequent 3 mo.

202 Retinopathy and enteropathy in HIV patients, a hypothetical concept beyond Virus and CD4 levels- a study from Varanasi, North India

Background: Based on our previous observations which were published (Asian journal of ophthalmology, 2006. July p341-48 and BMC Infectious Diseases 2006, 6:39) we thought of re evaluating the results of the hospital based cohort to propose possible hypothesis and evaluate it in prospective manner. Aim: To evaluate the effect of local immunity on development of HIV retinopathy and enteropathy in a hospital based cohort at Institute of Medical Sciences, Banaras Hindu university, Varanasi, India. Methods: All the patients with HIV retinopathy or enteropathy (diagnosis of which was established by ruling out all other pathologies like opportunistic infections, malignancies in cases of enteropathy and infections, malignancies and other confounders like hypertension, diabetes in retinopathy cases) were enrolled and equal number of controls, who had similar symptoms during the same time was recruited for comparison. The baseline characters, CD4 levels, duration of symptoms, number of episodes and other possible confounders were compared in the groups. Results: The multivariate analysis for the retinopathy suggested that the local inflammation & immunity are most important risk factors as significant number of patients have near normal circulating CD4 counts. All retinopathy patients had some form of local infection (which indirectly indicated a decreased local immunity) which further supports our hypothesis. Similarly in patients with enteropathy, we found that around 78% of chronic and 45% of acute diarrheal episodes were experienced by patients with CD4 counts of >200 cells/μL, indicating a regional immunosuppression. Similar observations were made earlier (GUT. 1995;37:524-29) where authors observed that, loss of CD4 cells in intestinal mucosa of the patients with diarrhea, were more pronounced than peripheral CD4 levels and their relation is quite variable. Conclusions: The local immunity, an important factor to prevent retinopathy as well as enteropathy may therefore be variable and therefore they can be observed even in patients with good immunity (i.e. peripheral CD4 > 200). However, it would be premature to draw definitive conclusions beyond this, as the present study is retrospective one and number of patients analyzed was relatively small.

Lymphostatin – ein Multitalent

Gastrointestinal infections are a significant cause of diarrhea and a worldwide problem with annually one billion illnesses and 3 to 4 million deaths. Gram negative bacteria like Enteropathogenic E. coli (EPEC) in developing countries and Enterohemorrhagic E. coli (EHEC) in the developed world are responsible for the majority of acute diarrheal episodes, especially among children less than three years of age. Pathogenic E. coli are supplied with an arsenal of effector proteins to modify and neutralize specific cellular functions of the host organism.Based on personal and extensively published results we provide a selected overview of Gram negative virulence functions with a focus on lymphostatin.Lymphostatin is an effector protein encoded by lifA/efa-1 (lymphocyte inhibitory factor A/ EHEC factor for adherence). lifA/efa-1 and homologous genes have been identified in EPEC, EHEC, and mouse pathogen Citrobacter rodentium, as well as various Chlamydia strains. Multiple groups have shown that in various EHEC strains lifA/efa-1 is part of a larger pathogenicity island responsible for increased virulence. Statistically, DNA Microarray analysis associated lifA/efa-1 as the single most imortant gene with diarrhea caused by EPEC. Interestingly, lifA/efa-1 encodes for two critical enzymatic activities that have been identified in other pathogenic bacteria: glucosyltransferase- in Clostridium- and protease activity in Yersinia strains. In vitro studies identified lymphostatin as an effector protein with an immunosuppressive effect on peripheral blood and gastrointestinal mucosa T lymphocytes. Further, lymphostatin regulates the barrier function of epithelial monolayer cultures: activation of small GTPase RhoA and inhibition of Cdc42 lead to disassembly of adherens junctions and tight junctions, respectively. Besides an effect on immune and epithelial barrier function, lymphostatin also functions as an adhesion factor for EPEC and EHEC, is essential for colonization of mouse and calf intestine, and regulates bacterial effector proteins.Lymphostatin is a common toxin in Gram negative bacteria with multiple functions: cell adhesion, immunosuppression, disruption of epithelial barrier function, and intestinal colonization.