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DOI: 10.5455/medarh.2013.67.17-21
Med Arh. 2013 Feb; 67(1): 17-21
Received: September 28th 2012 | Accepted: December 15th 2012
CONFLICT OF INTEREST: NONE DECLARED
Original paper
im: The aim of this work has been a presentation of causes of acute infectious diarrhea.
Material and methodology: The examinees have been the infants treated at the Pediatric
Clinic. The diagnosis has been established on the basis of anamnesis, physical examination
and feces examination on bacteria, viruses, protozoa and fungi. Results: During the period
of seven years a number of patients that suffered from acute infectious diarrhea was 1050
(31.82%) out of a total number (3300) with diarrhea. The bacteriological examination proved
positive on majority of them or in 655 (62.38%) cases, the viral examination proved positive
in 375 (35.72%) cases, whereas fungi examination proved positive in only 3 cases (0.28%). The
most frequent bacteria have been Salmonellae species in 255 (38.93%) cases and E. coli in
142 (21.69%) cases, the less frequent have been Yersinia enterocolitica in 16 (2.44.%) cases and
Bacillus cereus in 4 (0.61%) cases. The most frequent serotypes of Salmonella have been S.Wien
in 92 (36.07%) and S.Gloucester in 42 (16.47%) cases. Enteropathogenic E. Coli (most frequent
serotypes O111 and O55) has been found in 112 (78.88%) cases. From the group of Shigella the
most frequent has been Sh. Flexneri (most frequent serotypes 6 and 4) in 35 (58.33%) cases. The
same feces sample of the majority of examinees 501 (76.48%) cases contained only one bacteria
(single bacteria), two bacteria (associated bacteria) have been found in 102 (15.17%) cases, three
types of bacteria have been found in 17 (2.59%) cases. Rotavirus has been isolated in 271 (72.26%)
cases in comparison to adenoviruses that have been isolated in 65 (17.33%) cases. Rotavirus and
adenoviruses have been isolated in 39 (10.40%) cases. Conclusion: Infectious acute diarrhea
appears frequently, and as causes of it usually appear to be pathogenic bacteria in comparison to
viruses, protozoa and fungi. Key words: Acute diarrhea, etiology.
Corresponding author: Assoc prof Mehmedali Azemi MD PhD, Pediatric Clinic, University Clinical Center of
Kosovo, Mother Teresa street nn, Prishtin. Tel: +377(44)146-463; email: mehmedaliazemi@hotmail.com
1. INTRODUCTION
Acute diarrhea is one of the most
frequent symptoms that the children
suffer from, whereas majority of diarrhea types that doctor faces with are
caused by acute intestine infection (120). In the developing countries, infectious acute diarrhea is one of the most
frequent causes of morbidity and mortality among infants and children between 1-3 years (21-29). Those countries
2. AIM
The aim of the work has been to
present the most frequent causes of
infectious acute diarrhea on infants
treated at the Pediatric Clinic.
3. MATERIAL AND
METHODOLOGY
The examinees have been infants
with acute diarrhea treated at the Pediatric Clinic of Prishtina during the
period of 7 years. Feces samples taken
from patients have been referred to
the Department of Microbiology, the
National Institute of Public Health of
Kosova for identification of diarrheal
causative pathogen. Each sample has
been cultivated in selective media according to the laboratory protocol, respectively in Salmonella-Shigella (SS)
agar and Selenit F Broth for Salmonella
and Shigella species, Sorbitol MConkey (SMAC) for E. coli O157, Cefsulo-
17
X2-test
Relation
No.
%
X2-test
din Irgasan Novobiocin (CIN) agar forNon infectious
of infants suffered from infectious acute
X =436.4;
acute diarrhea
2250
68.18
X2=436.4;
Df=1;
Yersinia enterocolitica and Campylo-Infectious acute
diarrhea (Figure 1 and 2), the difference
Non infectious
p<0.00001
68.18 Df=1;
diarrhea
1050
31.82 2250
acute diarrhea
bacter Blood Free Agar for Campylowas statistically significant (p<0.00001).
p<0.00001
Total
3300
100
bacter species. Medias for cultivationFigure 1. Relation
Figure 3 shows the relation of feces
Infectious
between infectious and noninfectious diarrhea
1050 31.82
acute diarrhea
have been prepared at the Department
examination of bacteria, viruses, proTotal
3300 100
of Microbiology from dried forms of
tozoa and fungi. Feces examination of
media produced by Liofilchem, Italy. Figure 1. Relation between infectious and
bacteria proved positive with the majorSS agar, Selenit F broth and SMAC agar noninfectious diarrhea
ity of patients 655 (62.38%), of viruses
have been incubated at 35-37 C for 16with 375 (35.72%) cases, of protozoa
24 hours in air atmosphere, Campylowith 17 (1.61%) cases and of fungi with
bacter Blood Free Agar at 42C for
3 (0.28%) cases, (p<0.00001).
48 hours in micro-aerobic atmosphere
Isolated bacteria
No. %
X2-test
conditions, CIN agar at 28-30C for
X2=803.12;
Salmonellae spp.
255 38.9 Df=9;
24-48 hours at air atmosphere. After
p<0.00001
24 hours of incubation, subcultivation
Escherichia coli spp.
142 21.7
to SS agar has been conducted from
Shigella spp.
60
9.2
Selenit F broth for Salmonella. Sus- Figure 2. Graphic presentation between
Campylobacter jejuni
41
6.3
infectious and noninfectious diarrhea
Pseudomonas
pected colonies in SS agar (lactose neg-Figure 2. Graphic presentation between infectious and noninfectious diarrhea
38
5.8
aeruginosa
ative, transparent, with or without H2S)
In addition, based on pediatricians
Clostridium difficile
36
5.5
have been transferred to Kligler Iron request, feces samples have been proClostridium
36
5.5
perfringens
Agar and in case of positive biochemi- cessed for ova/parasites identification
Staphylococcus
cal identification, serotyping was con- and testing on presence of the rotavirus
27
4.1
aureus
ducted using appropriate antisera (In- and adenoviruses. Ova/parasites microYersinia enterocolitica 16
2.4
stitute of Immunology, Zagreb, Croatia scopic examination has been conducted
Bacillus cereus
4
0.6
Total
655 100 and Sifin, Germany) for Salmonella or with Lugols Iodine on microscopic slide
Shigella. Serotyping was initially done and rotavirus/adenoviruses presence Figure 4. Bacteriological examination of feces
with polyvalent Salmonella followed has been detected with help of immuby group specific antisera based on nochromatographic test (25). Data were
Kaufman White classification scheme. presented with tables, charts and were
Similar process was conducted for sero- verified with X2-test. For Candida albityping of Shigella species and serotypes. cans the sample of feces has been cultiSorbitol negative colonies in SMAC vated in selected media saboro.
have been biochemically confirmed for
E.Coli and serotyped with appropriate 4. RESULTS
antisera (E. coli O157).
During the time period of 7 years,
Suspected colonies for Campylo- 5200 infants i.e. (21.71%) of total numbacter at Campylobacter Blood Free ber of 17500 hospitalized children of
Agar have been tested with Oxidase different age groups were treated at
and Catalase test (which are both posi- the Pediatric Clinic. Out of the total
tive for Campylobacter spp.), and gram number of infants (5200) there were
stained (Campylobacter species are 3300 (63.46%) of infants suffered from
curved, gram negative bacilli). Bulls- acute diarrhea. From that number, 2250 Figure 5. Range of the most frequent bacteria
Figure 5. Range
of the most frequent bacteria isolated
isolated
eye-like colonies on CIN agar have (68.18%) suffered from noninfectious
been biochemically processed and se- acute diarrhea, whereas 1050 (31.82%)
On bacterial examination of feces,
rotyped for Yersinia enterocolitica with
the most frequently isolated has been
Type of feces
appropriate antisera.
SalmonellaSerotypes
in 255 (38.93%)
cases, fol- %
Groups
Number
No.
%
X2-test
examination
Clinically suspected cases for diarE. coli in 142 (21.67%)
cases,36.07
O:4 (B) lowed by Wien
92
X2=578.7;
rhoeic E. coli were also investigated for
Shigella
in
60
(9.16%)
cases,
CampyloO:4
(B)
Gloucester
42
16.47
Bacteriological 655
62.4
Df=2;
enterotoxigenic E. coli (ETEC), enteroin 41 (6.25%) cases,
Pseu-12.94
p<0.00001
O:4 (B) bacter jejuni
Typhimurium
33
Viral
375
35.7
pathogenic E. coli (EPEC), enteroinvaaeruginosa
in 38 (5.805)
cases,9.09
O:8 (C2 -domonas
C3)
Muenchen
23
Protozoa
sive E. coli (EIEC) and enteroaggregaClostridium
difficile
and
Clostridium
O:8 (C2 - C3)
Newport
20
7.84
(Giardia17
1.61
tive E. coli (EAEC) through slide aggluhave been isolated
in the6.66
O:4 (B) perfringens
Abony
17
Lamblia)
tination with poly specific O-antisera,
in 36 (5.49%)17cases each,6.66
O:9 (D1)same number
Enteritidis
Fungi
Anti coli I, Anti coli II, and Anti coli
Staphylococcus
en-3.13
(Candida
3
0.28
O:4 (B)
Stanley aureus (preformed
8
albicans)
III and in case of positivity, with O:K
in 27 (4.12%) cases,
O:8 (C2 -terotoxin)
C3)
Gatuni
3 Yersinia1.17
Total
1050 100.0 specific antisera from Sifin, Germany.
enterocolitica
Total in 16 (2.44%)
255cases and100
Presence of Pseudomonas aeruginosa Figure 3. Findings in examination of feces with
Bacillus cereus in a smaller number in
Figure 6. Groups and serotypes of isolated Salmonella's
bacteria, viruses, protozoa and fungi
was also notified (19, 24, 28).
Relation
Number
18
X2
X2=
D
p<0.
Serotypes
(according to
frequency)
O111, O55, O125,
O26
O115, O153,
O159
O124
-
No.
X2-test
112
78.9
X2=312.5; Df=4;
p<0.00001
17
12.0
7
5
4.9
3.5
O157:H7
0.7
142
100.0
Serotypes
Num(according to
ber
frequency)
No.
X2-test
Rotavirus
271
72.3
X2=258.5; Df=2;
p<0.00001
Adenoviruses
65
17.3
Associated
rotavirus and
adenoviruses
39
10.4
Total
375
100.0
5. DISCUSSION
Based on our data for the period of
7 years, it is evident a high percentage
(63. 46%) of infants with acute diarrhea,
even though there is a tendency from
year to year of reduction of the number of infants with acute diarrhea compared to the previous years. Non-infectious acute diarrhea was apparently
more frequent (68.18%) in comparison
to the infective one (31.82%).
In examining the feces, there were
most frequently isolated various pathogenic bacteria (62.39%), compared to
viruses (35.72%), whereas, there were
rarely isolated protozoa and only the
Giardia-Lamblia (1.61%), while fungi
(Candida albicans) was only in three
19
from 25-30 years ago. With infants having diarrhea in Iran (13), Shigella was
isolated in 6.2%, their serogroups and
stereotypes were not indicated. With
infants having diarrhea in (Libya) Shigella spp was isolated very rarely (0.8%).
With children of Ghana (9) having diarrhea, Shigella was isolated in 3.8% of
the cases, with regard to frequency they
rank the fourth as causes of diarrhea
(coming after E. coli, E. histolytica and
Cryptosporidium).
One bacteria (single bacteria) has
been isolated in the same feces sample among the majority of infants with
diarrhea (76.48%), two bacteria (associated bacteria) have been isolated in
15.57% of cases, whereas three bacteria
in only 5.24% of cases. On the other side
the same feces sample contained both
bacteria and rotavirus in 2.59% of cases.
Mixed infections consisted of 2-3 bacteria of different gender, but there are also
some cases when one feces sample contained 2-3 serotypes of the same bacteria. It should also be mentioned that
clinical manifestations were different
and more severe in the cases with two or
three bacteria were accompanied with
rotavirus. According to other authors
(4) bacteriological examination of feces resulted with one bacteria in 37.3%
cases, whereas in 13.8% cases 2-3 bacteria in the same feces sample. There
have also been 2-5 bacteria isolated on
the same feces sample in 20.4% of cases
among children under five years in Dar
es Salaam, from that number the feces
sample of 75 % of cases contained two
bacteria, in 20.4% of cases three bacteria have been isolated and four bacteria
in 3.7% of cases (10, 18). In 12 % of cases
with acute diarrhea Torres (15) isolated
associated (mixed) bacteria (he did not
mention the number of them) at the
same feces sample.
From the total number of infants
with acute diarrhea (1050), viral examination was positive with 375 (35.72%)
of cases. Relatively high percentage of
acute diarrhea (20-80%) was caused by
rotavirus. In the developed countries
the diarrhea appears mostly during the
winter season, whereas in the developing countries during the summer season. There are different data regarding
the causes of viral diarrhea. Davidson
6. CONCLUSION
In Kosovo, infectious acute diarrhea
presents a main cause of morbidity and
mortality of infants and it is therefore a
medical and social issue. However, the
fact that the number of infants with infectious acute diarrhea and mortality
scale is decreasing is promising.
Infectious acute diarrhea that may
appear during the infancy has a great
medical attention in comparison to the
one appearing in other periods of childhood due to a greater predisposition of
infants to intestine infection, manner of
nutrition, weakness of homeostasis and
dehydration causes followed by acid-basic and electrolyte disorder during the
period of intensive growth.
With the aim of decreasing the
number of infants with acute diarrhea
the following should be taken into consideration:
a) Promoting a breast feeding. If,
due to some reasons, the breast feeding is not successful, the milk formulas
should be used instead of the commercial milk and cows milk; b) Imposing
precautionary measures for contamination of additional food; c)Immunization against rotavirus, whereas vac-
REFERENCES
1.
Votava A. Uee gastroenterolokih bolesti u sindromu toksikoze
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
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