17 Med Arh. 2013 Feb; 67(1): 17-21 ORIGINAL pApeR

Causes of Infectious acute diarrhea in Infants Treated at Pediatric Clinic

DOI: 10.5455/medarh.2013.67.17-21Med Arh. 2013 Feb; 67(1): 17-21Received: September 28th 2012 | Accepted: December 15th 2012

CONFLICT OF INTEREST: NONE DECLARED

orIGINal PaPer

Causes of Infectious acute Diarrhea in Infants treated at Pediatric ClinicMehmedali Azemi1, Vlora Ismaili-Jaha1, Selim Kolgreci2, Majlinda Berisha1, Xhevat Jakupi3, Sanije Gashi4, Teuta Hoxha-Kamberi1

Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo1

Obstetrics and Gynecology Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo2

National Institute of Public Health, Department of Microbiology, Prishtina, Kosovo3

National Institute of Public Health, Department of Social Medicine, Prishtina, Kosovo4

Aim: 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. INTRODUCTIONAcute diarrhea is one of the most

frequent symptoms that the children suffer from, whereas majority of diar-rhea types that doctor faces with are caused by acute intestine infection (1-20). In the developing countries, infec-tious acute diarrhea is one of the most frequent causes of morbidity and mor-tality among infants and children be-tween 1-3 years (21-29). Those countries

meet the requirements for multiplica-tion of pathogenic bacteria and viruses that are the most frequent causes of di-arrhea that appears to be very frequent during the summer season. In Kosovo (as developing country), infectious acute diarrhea is still a major cause of morbidity and mortality of children, es-pecially of infants, and the summer sea-son is the period of its greatest presence.

Acute infective diarrhea is due to infection acquired the fecal-oral route or by ingestion of contaminated food or water. Acute infective diarrhea is asso-ciated with poverty, poor environmen-tal hygiene and development indices. The most frequent causes of infectious acute diarrhea are bacteria, followed by viruses, whereas in the developed coun-tries the first place occupy viruses fol-lowed by bacteria and protozoa (8, 14, 20, 22, 30-35).

2. AIMThe 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 Pe-diatric 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 ac-cording to the laboratory protocol, re-spectively in Salmonella-Shigella (SS) agar and Selenit F Broth for Salmonella and Shigella species, Sorbitol MCon-key (SMAC) for E. coli O157, Cefsulo-

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Causes of Infectious acute diarrhea in Infants Treated at Pediatric Clinic

din Irgasan Novobiocin (CIN) agar for Yersinia enterocolitica and Campylo-bacter Blood Free Agar for Campylo-bacter species. Medias for cultivation have been prepared at the Department of Microbiology from dried forms of media produced by Liofilchem, Italy. SS agar, Selenit F broth and SMAC agar have been incubated at 35-37 C for 16-24 hours in air atmosphere, Campylo-bacter Blood Free Agar at 42C for 48 hours in micro-aerobic atmosphere conditions, CIN agar at 28-30C for 24-48 hours at air atmosphere. After 24 hours of incubation, subcultivation to SS agar has been conducted from Selenit F broth for Salmonella. Sus-pected colonies in SS agar (lactose neg-ative, transparent, with or without H2S) have been transferred to Kligler Iron Agar and in case of positive biochemi-cal identification, serotyping was con-ducted using appropriate antisera (In-stitute of Immunology, Zagreb, Croatia and Sifin, Germany) for Salmonella or Shigella. Serotyping was initially done with polyvalent Salmonella followed by group specific antisera based on Kaufman White classification scheme. Similar process was conducted for sero-typing of Shigella species and serotypes. Sorbitol negative colonies in SMAC have been biochemically confirmed for E.Coli and serotyped with appropriate antisera (E. coli O157).

Suspected colonies for Campylo-bacter at Campylobacter Blood Free Agar have been tested with Oxidase and Catalase test (which are both posi-tive for Campylobacter spp.), and gram stained (Campylobacter species are curved, gram negative bacilli). Bulls-eye-like colonies on CIN agar have been biochemically processed and se-rotyped for Yersinia enterocolitica with appropriate antisera.

Clinically suspected cases for diar-rhoeic E. coli were also investigated for enterotoxigenic E. coli (ETEC), entero-pathogenic E. coli (EPEC), enteroinva-sive E. coli (EIEC) and enteroaggrega-tive E. coli (EAEC) through slide agglu-tination with poly specific O-antisera, Anti coli I, Anti coli II, and Anti coli III and in case of positivity, with O:K specific antisera from Sifin, Germany. Presence of Pseudomonas aeruginosa was also notified (19, 24, 28).

In addition, based on pediatricians request, feces samples have been pro-cessed for ova/parasites identification and testing on presence of the rotavirus and adenoviruses. Ova/parasites micro-scopic examination has been conducted with Lugols Iodine on microscopic slide and rotavirus/adenoviruses presence has been detected with help of immu-nochromatographic test (25). Data were presented with tables, charts and were verified with X2-test. For Candida albi-cans the sample of feces has been culti-vated in selected media saboro.

4. ReSULTSDuring the time period of 7 years,

5200 infants i.e. (21.71%) of total num-ber of 17500 hospitalized children of different age groups were treated at the Pediatric Clinic. Out of the total number of infants (5200) there were 3300 (63.46%) of infants suffered from acute diarrhea. From that number, 2250 (68.18%) suffered from noninfectious acute diarrhea, whereas 1050 (31.82%)

of infants suffered from infectious acute diarrhea (Figure 1 and 2), the difference was statistically significant (p

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Causes of Infectious acute diarrhea in Infants Treated at Pediatric Clinic

4 (0.61%) cases (Figure 4 and 5), p

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Causes of Infectious acute diarrhea in Infants Treated at Pediatric Clinic

cases (0.28%). According to the data of Votava (1) in 1982 with 67.58% of infants with acute diarrhea, bacteriological ex-amination of feces was positive, while in rotavirus with 8.9% of the cases. Having investigated the summer diarrhea with the children of South Africa in 1980. (2) bacteriological examination of fe-ces was positive with 92.95%, in rotavi-rus with 4.0% and in parasites 1.4% of cases. According to Hodzi (3) of 1986. at 92% of cases with infectious acute di-arrhea, bacteriological examination was positive, while in rotavirus at 8%. Ac-cording to the data of Amal Rohan (4) about the children infectious acute di-arrhea in examining the feces, viruses were isolated more frequently at 34.3%, then the bacteria at 26.8% and parasites at 4.2% of the cases. Our data is similar to the data of authors in the region (1, 3) of 1980 and 1986, in which the orga-nization of health protection of infants in these countries has been apparently improved and the number of cases with diarrhea is smaller.

In bacteriological examination of feces the Salmonella was isolated most frequently (38.93%) and the most fre-quent type was S.Wien at 92 cases, af-terwards E. coli (21.69%), more rarely Bacillus cereus (0.61%). The genus of Salmonella numbers more than 2500 types and it comprises the most wide-spread bacteria in the nature, which is spread through food, cows milk and water. Some infants in our country are still fed with pasteurized milk and with unprocessed cows milk, which is prepared under not very good hygienic conditions, it is not kept in the fridge; therefore, there is more possibility of contamination with Salmonella (26). The types of isolated infants with infec-tious diarrhea vary from one region to another. In 1984, according to the data of Votava (5), E. coli was mostly iso-lated in the children with acute infec-tious diarrhea at 32% of the cases. Ac-cording to Jovanovi (6), in regard to in-fants with diarrhea, there were mostly isolated Salmonella (14%), then E. coli (2.3%), whereas, Shigella with 1.2% of the cases. In the case of children of Ethi-opia having acute infectious diarrhea (7) there were mostly isolated E. coli ac-cording to the frequency (12%), Citro-bacter (11%), Proteus (7%), Salmonella

(5.5%) etc. Other authors (8) with 54 children with acute infectious diarrhea, there were most frequently isolated E. coli (11.11%), then Salmonella (3.70%) and rotavirus at 7% of the cases. With the children of Ghana acute infectious diarrhea as a cause to it predominates E. coli (79.6%), followed by Klebsiella (5.1%), then Shigella at 4% of the cases (9). According to the authors (4) with the children having diarrhea in Trip-oli (Libya) there were most frequently isolated E. coli (15.5%), followed by Sal-monella 7.9%), adenoviruses (7.1%) and Aeromonas (4.2%) of the cases. With children under five years having acute infectious diarrhea in Dar es Salami (Tanzania) there was also E. coli, which was isolated most frequently (22.9%), followed by Cryptosporidium parvum (18.9%), rotavirus (18.9) and norovirus (13.7%) of the cases (10).

E. coli following Salmonellas takes the second place a cause of acute infec-tious diarrhea of our patients (21.69%). Enteropathogenic E. coli were isolated the most frequently in particular the serotype O111 (78.8%), followed by en-terotoxygenic E. coli (11.97%), while at only one case Shiga Toxin-Producing E. coli isolated (serotype O 157: H7). It is known that enteropathogenic E. coli mostly causes diarrhea to the infants (31). It does not produce enterotoxin and it does not penetrate into mucosa, but by adhering through small intes-tine, causing destruction and atrophies of intestine cluster with inflammatory reaction or diarrhea, whose pathogene-sis is still not clear. Our data are to some degree identical to the data of authors in the region. According to Zivi (11) E. coli is isolated at 9.8% of infants with acute diarrhea, but he did not indicate the groups of E. coli. According to Ve-lisavljev (33) E. coli is isolated at 21.28% of cases with diarrhea and in particular only enteropathogenic E. coli, most fre-quently the stereotype O111. Nikolova et al. (12) evidenced enteropathogenic E. coli as the most frequent cause of di-arrhea (34%) and in particular the se-rotype O111. Votova and Rai (5) with infants having acute infectious diar-rhea, they most frequently isolated en-teropathogenic E. coli (serotype O111) at 27% of the cases.

According to Wdstrom et al. (7) with children of Ethiopia having diar-rhea E. coli was isolated most frequently (38%), but he did not indicate the groups and serotypes of bacteria. With the chil-dren of South Africa enterotoxygenic E. coli was isolated most frequently (19%). Results of Robins-Browne (2) do not match with our results and with those of our region concerning the types of E. coli. The serotype O55 was isolated most frequently followed by O86, O112, O125, O142, O25, O26, O111 etc. With children of Tanzania in (Dale es Sa-lami) having diarrhea, E. coli was iso-lated most frequently with 22.9% (10). Most frequently (64.1%) was isolated enteroagregative E.coli, then entero-pathogenic E.coli (20.3%) and entero-toxigenic E. coli (15.6%). The greatest percentage (79.6%) of E. coli as a cause of diarrhea was with children of Ghana (9). According to Amal Rahouma (4) with children of Libya (Tripoli) having diarrhea, E. coli was isolated most fre-quently (15.5%), in the first place en-teroagregative E. coli (4.11%). entero-pathogenic E. coli (serotypes O111 and O127) was isolated in 36.4% of the case with diarrhea in Iran (13).

The groups of Shigella is isolated in 60 (9.16%) cases with acute infectious diarrhea. Sh. Flexneri was isolated most frequently in 35 (58.33%) cases (sero-types 6, 4, 8, 11), more rarely Sh. boydii in 4 (6.66%) cases, but, it has to be noted that in 10 (16.66%) cases Sh. dysenteriae was isolated. Isolation of a great num-ber of Sh. Flexneri is characteristic for developing countries such as our coun-try. After such isolation, patients were advised to be treated in the Infective Clinic. In a research done by Hoi (3) with infants having diarrhea, Shigella was isolated in 3 (12%) cases. According to Vargazon (4) with children hospital-ized in the Infective Clinic, Sh. Sonnei was isolated the most frequently, fol-lowed by Sh. Flexneri that is typical for developed countries. According to Rob-ins-Browne (2) in 70 infants with acute diarrhea, Shigella was isolated in 6 (9%) cases without specifying their group and serotypes. According to the data of Filipovi (34) in infants with acute in-fectious diarrhea, Shigella was isolated in 4% of the cases. It should be noted that these data from the region date

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Causes of Infectious acute diarrhea in Infants Treated at Pediatric Clinic

from 25-30 years ago. With infants hav-ing diarrhea in Iran (13), Shigella was isolated in 6.2%, their serogroups and stereotypes were not indicated. With infants having diarrhea in (Libya) Shi-gella spp was isolated very rarely (0.8%). With children of Ghana (9) having di-arrhea, 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 sam-ple among the majority of infants with diarrhea (76.48%), two bacteria (asso-ciated 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 bacte-ria of different gender, but there are also some cases when one feces sample con-tained 2-3 serotypes of the same bac-teria. 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 fe-ces resulted with one bacteria in 37.3% cases, whereas in 13.8% cases 2-3 bac-teria 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 bacte-ria 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 exam-ination 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 develop-ing countries during the summer sea-son. There are different data regarding the causes of viral diarrhea. Davidson

(35) believes that 50-70% of cases with acute diarrhea are caused by viruses. According to Robins- Brown (2) rotavi-rus was isolated in 4.41% cases among children of South Africa with summer diarrhea. Rotavirus as a cause of acute diarrhea has been isolated in 11.94% among children treated at the London Hospital (16). According to Taylor et al. (17, 27) rotavirus has been isolated in 48 % cases of children with acute di-arrhea living in rural areas of Bangla-desh. According to Votava and Rai (5) rotavirus has been isolated in 12.13 % of cases of infants with acute diarrhea. In 18.1 % of cases the viral examina-tion of feces has proved positive on ro-tavirus, whereas 13.7% of children with acute diarrhea have been positive on norovirus in Tanzania (10). In a study in Tripoli (4), norovirus was mostly iso-lated among infant (15.5%) followed by rotavirus (13.4%). Appearance of rota-virus with adenoviruses on the same fe-ces sample has been confirmed by other authors as well.

6. CONCLUSIONIn 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 in-fectious 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 child-hood due to a greater predisposition of infants to intestine infection, manner of nutrition, weakness of homeostasis and dehydration causes followed by acid-ba-sic 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 con-sideration:

a) Promoting a breast feeding. If, due to some reasons, the breast feed-ing is not successful, the milk formulas should be used instead of the commer-cial milk and cows milk; b) Imposing precautionary measures for contami-nation of additional food; c)Immuni-zation against rotavirus, whereas vac-

cines against E. coli and Shigella shall reduce the number of infants with se-vere acute diarrhea; d) Improving the water quality, food quality and personal and domestic hygiene (In the majority of places on Earth Acute Diarrhea was reduced due to implementation of above mentioned measures); e) Improving the treatment of cases with acute diarrhea, presents the crucial factor in decreasing the infant mortality rate. This should be achieved in line with oral or intravenous rehydration, following a diet and selec-tive use of antimicrobials.

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