Persistent diarrhea: still a serious public health problem in developing countries

Prevalence and associated factors of chronic diarrhea among adults with obesity in the United States: Evidence from the National Health and Nutrition Examination Survey 2005 to 2010

OBJECTIVE

Diarrhea in populations with obesity is underappreciated and factors associated with chronic diarrhea in individuals with obesity have not been studied. We aimed to analyze the prevalence of chronic diarrhea and associated factors among adults with obesity in a nationally representative population.

METHODS

Data of adults with obesity in the National Health and Nutrition Examination Survey (NHANES) during 2005-2010 were analyzed. Chronic diarrhea was defined according to the Bristol Stool Form Scale. Demographic, lifestyle, dietary, and metabolic factors were considered. Prevalence estimates were described by group, and odds ratios (ORs) for associated factors were calculated in multivariate logistic regression.

RESULTS

Overall, 5048 respondents with obesity (weighted sample, 63,493,500) completed the bowel health questionnaire and met eligibility criteria. The chronic diarrhea prevalence in adults with obesity was 8.18 % (95 % confidence interval [CI], 7.17 %, 9.19 %). Female sex, older age, obesity severity, high dietary sugar intake, depression, and history of diabetes or prediabetes were positively correlated with chronic diarrhea. Differences occurred in the distribution of associated factors between males and females.

CONCLUSION

The overall chronic diarrhea prevalence in adults with obesity was 8.18 % in the nationally representative US population. We identified sex differences in associated demographic, dietary, and metabolic factors with chronic diarrhea in adults with obesity.

Promising clinical and immunological efficacy of Bacillus clausii spore probiotics for supportive treatment of persistent diarrhea in children

Persistent diarrhea is a severe gastroenteric disease with relatively high risk of pediatric mortality in developing countries. We conducted a randomized, double-blind, controlled clinical trial to evaluate the efficacy of liquid-form Bacillus clausii spore probiotics (LiveSpo CLAUSY; 2 billion CFU/5 mL ampoule) at high dosages of 4-6 ampoules a day in supporting treatment of children with persistent diarrhea. Our findings showed that B. clausii spores significantly improved treatment outcomes, resulting in a 2-day shorter recovery period (p < 0.05) and a 1.5-1.6 folds greater efficacy in reducing diarrhea symptoms, such as high frequency of bowel movement of ≥ 3 stools a day, presence of fecal mucus, and diapered infant stool scale types 4-5B. LiveSpo CLAUSY supportive treatment achieved 3 days (p < 0.0001) faster recovery from diarrhea disease, with 1.6-fold improved treatment efficacy. At day 5 of treatment, a significant decrease in blood levels of pro-inflammatory cytokines TNF-α, IL-17, and IL-23 by 3.24% (p = 0.0409), 29.76% (p = 0.0001), and 10.87% (p = 0.0036), respectively, was observed in the Clausy group. Simultaneously, there was a significant 37.97% decrease (p = 0.0326) in the excreted IgA in stool at day 5 in the Clausy group. Overall, the clinical study demonstrates the efficacy of B. clausii spores (LiveSpo CLAUSY) as an effective symptomatic treatment and immunomodulatory agent for persistent diarrhea in children.Trial registration: NCT05812820.

Effect of Panax ginseng and Fructus Mume on Intestinal Barrier and Gut Microbiota in Rats with Diarrhea

Panax ginseng and Fructus mume (Renshen Wumei in Chinese, RW) are natural medicines with high nutritional and pharmacological value. They have been widely used together in China to treat gastrointestinal diseases, especially persistent diarrhea, but the potential mechanisms remain elusive. In this study, a diarrhea model was established in rats using a 30% aqueous extract of senna. The therapeutic effects of RW were evaluated by recording the prevalence of loose stools, the diarrhea index, and histopathological changes in colon tissue. The levels of mucins, tight junction (TJ) proteins, inflammatory cytokines, and phosphoinositide 3-kinase/Akt/nuclear factor-κB (PI3K/Akt/NF-κB) signaling pathway proteins were measured. Metagenomic sequencing was used to analyze the gut microbiota. Treatment with RW alleviated injury to the intestinal barrier in rats with diarrhea and also upregulated levels of Muc2 and TJ proteins, such as occludin, zonula occludens-1, and claudin-1. Administration of RW regulated the structure of the gut microbiota in diarrheal rats. Furthermore, RW suppressed levels of interleukin (IL), tumor necrosis factor (TNF)-α, IL-1, PI3K, Akt, and p-NF-κB p65 and also increased IL-4 levels. Our study indicates that P. ginseng and Fructus mume help improve the symptoms of diarrhea, possibly by alleviating the intestinal barrier injury, regulating intestinal flora composition, and inhibiting the PI3K/Akt/NF-κB signaling pathway.

Intestinal Parasitic Infections Among Pediatric Patients in a Metropolitan City of Bangladesh With Emphasis on Cryptosporidiosis

Introduction Gastrointestinal parasitic infections are one of the global health concerns in developing countries like Bangladesh. Among them, Cryptosporidium spp. plays an essential role in causing diarrhea, malnutrition, and poor cognitive function, especially in children. This study was conducted to identify the frequency of Cryptosporidium cases and other parasitic agents.  Methods A cross-sectional observational study was conducted among 219 hospitalized children with diarrhea. The conventional microscopic technique was applied for parasitic detection. Particular staining (modified Ziehl-Neelsen) procedure was performed to identify oocysts of Cryptosporidium spp. A polymerase chain reaction (PCR) was performed to determine the SSU rRNA and gp60 gene of Cryptosporidium.  Results Cysts of Giardia duodenalis (2.3%), ova of Ascaris lumbricoides (1.4%,), Trichuris trichiura (0.5%), and both A. lumbricoides and T. trichiura (0.9%) were identified in samples through wet mount preparation. The distribution of Cryptosporidium spp. as detected by the staining method and nested PCR was 1.4% and 4.1%, respectively.  Conclusion Factors independently associated with Cryptosporidium infection are unsafe water, lack of regular hand washing, and insufficiency of exclusive breastfeeding. This study reports, presumably for the first time, the detection of Cryptosporidium oocysts in Chattogram metropolitan city of Bangladesh.

Development and validation of a high-content screening assay for inhibitors of enteropathogenic E. coli adhesion

Enteropathogenic E. coli (EPEC) causes intestinal infections leading to severe diarrhea. EPEC attaches to the host cell causing lesions to the intestinal epithelium coupled with the effacement of microvilli. In the process, actin accumulates into a pedestal-like structure under bacterial microcolonies. We designed an automated fluorescence microscopy-based screening method for discovering compounds capable of inhibiting EPEC adhesion and virulence using aurodox, a type three secretion system (T3SS) inhibitor, as a positive control. The screening assay employs an EPEC strain (2348/69) expressing a fluorescent protein and actin staining for monitoring the bacteria and their pedestals respectively, analyzing these with a custom image analysis pipeline. The assay allows for the discovery of compounds capable of preventing the formation of pathogenic actin rearrangements. These compounds may be interfering with virulence-related molecular pathways relevant for developing antivirulence leads.

Enteroviruses in gastrointestinal diseases

Gastrointestinal diseases including diarrhoea constitute a major cause of morbidity and mortality in infants and young children especially in developing countries. Worldwide deaths among all ages due to diarrhoea during 2015 were estimated to be about 1.31 million, diarrhoeal deaths in children below 5 years of age being 499 000. Rotavirus accounted for about 200 000 deaths. Although diarrhoeal deaths decreased significantly during the last two decades, they still represent the third largest cause of infantile deaths. Several bacterial, viral, parasitic, fungal and non-infectious diarrhoea causing agents have been identified, but 30% to 40% of diarrhoeal cases remain undiagnosed. Enteroviruses transmit by the faecal-oral route and replicate first in intestinal cells before spreading to the target organ. They have been associated with diarrhoea in a few studies, but their causative role in diarrhoea in humans has not been systematically demonstrated. In view of the recent demonstration that enteroviruses cause diarrhoea in newborn mice pups, thus validating Koch's postulates, the purpose of this review is to emphasise the importance of recognising enteroviruses as major gastrointestinal pathogens associated with acute and persistent diarrhoea and non-diarrhoeal increased frequency of bowel movements in infants, young children and adults. Our studies and several other subsequent studies reported from different countries should stimulate strategies to reduce the burden of infantile gastrointestinal disease, which has hitherto remained unaddressed.

Glucagon-like Peptide 2 Concentrations Vary in Zambian Children During Diarrhoea, in Malnutrition and Seasonally

OBJECTIVES

Glucagon-like peptide 2 (GLP-2) is a 33 amino acid peptide hormone released from enteroendocrine L-cells following nutrient ingestion. It has been shown to exert trophic effects on the gut. We set out to measure GLP-2 concentrations in blood in children with diarrhoea and malnutrition.

METHODS

GLP-2 levels were measured in blood samples collected from 5 different groups of children (n = 324) at different time points: those with acute diarrhoea, during illness and 3 weeks after recovery; persistent diarrhoea and severe acute malnutrition; controls contemporaneous for diarrhoea; stunted children from the community; and controls contemporaneous for the stunted children. Stool biomarkers and pathogen analysis were carried out on the children with stunting.

RESULTS

GLP-2 concentrations were higher during acute diarrhoea (median 3.1 ng/mL, interquartile range 2.1, 4.4) than on recovery (median 1.8, interquartile range 1.4, 3.1; P = 0.001), but were not elevated in children with persistent diarrhoea and severe acute malnutrition. In stunted children, there was a progressive decline in GLP-2 levels from 3.2 ng/mL (1.9, 4.9) to 1.0 (0.0, 2.0; P < 0.001) as the children became more stunted. Measures of seasonality (rainfall, temperature,Food Price Index, and Shiga toxin-producing Escherichia coli) were found to be significantly associated with GLP-2 concentrations in multivariable analysis. We also found a correlation between stool inflammatory biomarkers and GLP-2.

CONCLUSIONS

In diarrhoea, GLP-2 levels increased in acute but not persistent diarrhoea. Malnutrition was associated with reduced concentrations. GLP-2 displayed seasonal variation consistent with variations in nutrient availability.

Associations between intestinal parasitic infections, anaemia, and diarrhoea among school aged children, and the impact of hand-washing and nail clipping

Objective

In marginalized setting, under-nutrition and illnesses due to infectious agents create a vicious circle. In our previous study, we reported that easy-to-do hand hygiene interventions were effective in preventing intestinal parasite infections (IPIs) and reduce the rate of anaemia among school-aged children. The aim of this study was to assess the pattern of associations between IPIs, anaemia and diarrhoea among the school-aged children and to explore if the observed impact of hand-washing and nail clipping interventions in our findings was similar across children with different baseline demographic and disease characteristics. The study was based on the analysis of data that was collected during the randomized controlled trial and hence have used the same study participants and study area.

Results

Children with IPIs had a much higher chance of also being anaemic (AOR 2.09, 95% CI 1.15–3.80), having diarrhoea (AOR 2.83, 95% CI 1.57–5.09), and vice versa. Anaemia and diarrhoea were very strongly related (AOR 9.62, 95% CI 5.18–17.85). Overall, hand-washing with soap at key times and weekly nail clipping were efficacious in preventing intestinal parasite re-infection among children despite the differences in baseline demographic characteristics.

Trial registration: NCT01619254 (June 09/2012)

The management of persistent diarrhoea at Dhaka Hospital of the International Centre for Diarrhoeal Disease and Research: a clinical chart review

BACKGROUND

Persistent diarrhoea (PD) is poorly recognised and it requires proper assessment and early intervention to ensure effective treatment. The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) has been managing children with PD for more than two decades. This review focuses on different aspects of the management of PD in a hospital setting.

AIM

To estimate the prevalence, socio-demographic and clinical characteristics, treatment outcome and hospital course in under-5 children with persistent diarrhoea (PD).

METHODS

The hospital records of all children under 5 years admitted with PD to Dhaka Hospital of the International Centre for Diarrhoeal Disease Research between January 2012 and December 2013 were reviewed. Data were retrieved from the hospital's electronic database.

RESULTS

Of 8638 children under 5 years of age admitted with diarrhoea, 551 (6.4%) had PD and one-third had developed PD during their hospital stay. The incidence of PD was highest (228, 41.4%) in summer (April-June). Half (51%) of the children with PD had dehydration on admission. Fifty-seven (10.3%) had never been breastfed, 138 (25.1%) were severely wasted and 21 (3.8%) had bipedal oedema. Following the steps of a dietary algorithm, 224 (40.6%) patients responded to a milk-based low-lactose diet, 235 (42.6%) to a lactose-, sucrose- and milk-free diet, 48 (8.7%) to a comminuted chicken and glucose-based diet, 41 (7.4%) to exclusive breastfeeding, and 3 (0.5%) required a partially hydrolysed, semi-elemental diet. Major stool pathogens were Campylobacter species (23/59, 39%), Salmonella (10/59, 16.9%) and Shigella (10/59, 16.9%). The overall recovery rate from PD was 95.6% (527/551) and the duration of treatment until resolution of diarrhoea was 6 (3-9) days. The case-fatality rate was 2% (11/551).

CONCLUSION

Persistent diarrhoea remains an important public health problem in children under-5 in Bangladesh. Algorithm-based dietary management with simple clinical guidelines was effective in most cases. This treatment is appropriate in low-income settings where resources are limited.

Resveratrol dimer trans-ε-viniferin prevents rotaviral diarrhea in mice by inhibition of the intestinal calcium-activated chloride channel

We previously identified, by a natural-product screen, resveratrol oligomers as inhibitors of the cystic fibrosis transmembrane conductance regulator (CFTR) chloride channel. Here, we report the resveratrol dimer trans-ε-viniferin (TV) and tetramer r-2-viniferin (RV) as inhibitors of the intestinal calcium-activated chloride channel (CaCC) and demonstrate their antisecretory efficacy in a neonatal mouse model of rotaviral diarrhea. Short-circuit measurements show inhibition of CaCC current in the human colonic cell line HT-29 by TV and RV with IC₅₀∼1 and 20μM, respectively. TV primarily inhibited the physiologically relevant, long-term CaCC current following agonist stimulation, without effect on cytoplasmic Ca²⁺ signaling. TV and RV inhibited short-circuit current in mouse colon as well. In a neonatal mouse model of rotaviral secretory diarrhea produced by oral inoculation with rotavirus, 2μg TV or 11μg RV inhibited secretory diarrhea by >50%, without effect on the rotaviral infection. Our results support the antisecretory efficacy of non-toxic, natural-product resveratrol oligomers for diarrheas produced by CaCC activation. Because these compounds also inhibit the CFTR chloride channel, they may be useful for antisecretory therapy of a wide range of diarrheas.

Treatment outcome of children with persistent Diarrhoea admitted to an Urban Hospital, Dhaka during 2012-2013

BACKGROUND

Despite availability of treatment guidelines, persistent diarrhoea (PD) has been a major contributor of diarrhoeal deaths in low and middle income countries. We evaluated the outcome of children under the age of 5 years who were treated for PD using management algorithm with locally available foods in a diarrhoeal disease hospital in Dhaka.

METHODS

We extracted retrospective data from electronic database for all the under-five children admitted for PD in the Longer Stay Ward and Intensive Care Unit of the Dhaka hospital at icddr,b between 2012 and 2013. Descriptive analysis was done to explore available baseline socio-demographic, nutritional, and co-morbid statuses, pathogens from stool isolates, duration of treatment, use of antibiotics, duration of hospital stay and treatment success rates. We sought to investigate above mentioned descriptive features in addition to associated factors with time to recover from PD using survival analysis with Cox proportional hazard model.

RESULTS

A total number of 426 children with a median age of 7.46 (inter-quartile range IQR; 5.39, 9.43) months were admitted for PD during the study period. Of these, 95% of children were recovered from PD and discharged from the hospital. The median duration of treatment response was 6 (IQR 4, 9) days. The case fatality rate was 1.17%. Multivariate analysis among the children of 6 months or less showed that the rate of recovery from PD was 57% lower in children with severe stunting compared to those without severe stunting (HR 0.43, 95% CI 0.22, 0.88, p < 0.05), 42% lower in children with severe wasting (HR 0.58, 95% CI 0.36, 0.95, p < 0.05), and 81% reduced in children who developed hospital acquired infection (HAI) compared to those without HAI (HR 0.19, 95% CI 0.06, 0.62, p < 0.05). Among the children who were more than 6 months old, age in months (HR 1.05, 95% CI 1.02, 1.09) and female gender (HR 1.41, 95% CI 1.09, 1.84) had better rates of recovery from PD (p < 0.05). Moreover, among children more than 6 months of age, HAI (HR 0.44, 95% CI 0.26, 0.75), and antibiotic use (HR 0.40, 95% CI 0.28, 0.56) were associated with impeded recovery rates from PD (p < 0.05).

CONCLUSION

The treatment guideline for persistent diarrhoea patients followed at icddr,b Dhaka hospital was found to be successful and can be used in other treatment facilities of Bangladesh and other developing countries where any treatment algorithm for PD is unavailable. More emphasis is required to be given for the prevention of hospital acquired infection that may help to limit the use of antibiotic in order to enhance the recovery rate from PD.

Anti-microbial peptide gene expression during oral vaccination: analysis of a randomized controlled trial

We have observed previously that micronutrient supplementation ameliorated suppression of α‐defensin expression during diarrhoea. However, how interactions between anti‐microbial peptide (AMP) expression and diarrhoeal disease are altered by micronutrient supplementation remain unclear. Using oral vaccination as a model of intestinal infection, we measured changes in AMP expression during multiple micronutrient supplementation. In the first part, volunteers underwent duodenal jejunal biopsy before and at 1, 2, 4 or 7 days after administration of one of three live, attenuated oral vaccines against rotavirus, typhoid and enterotoxigenic Escherichia coli. In the second part, participants were randomized to receive a multiple micronutrient supplement or placebo for 6 weeks before undergoing intestinal biopsy, vaccination against typhoid and rebiopsy after 14 days. Expression of human alpha‐defensin (HD)5, HD6, hBD1, hBD2 and LL‐37 was measured by quantitative reverse transcription–polymerase chain reaction. Taken together, the bacterial vaccines, but not rotavirus vaccine, reduced HD5 expression (P = 0·02, signed‐rank test) and reduced LL‐37 expression in seven of the eight individuals whose biopsies had expression prevaccination (P = 0·03). hBD2 was not detected. In the controlled trial, HD5 and HD6 expression after vaccination was lower [median ratio 0·5, interquartile range (IQR) = 0·07–2·2 and 0·58, IQR = 0·13–2·3, respectively] than before vaccination. There was no significant effect detected of micronutrient supplementation on expression of HD5, HD6, hBD1 or LL‐37. We conclude that live attenuated bacterial vaccines, but not rotavirus vaccine, can reduce intestinal α‐defensins, and typhoid vaccine reduced LL‐37 expression. We found no evidence that micronutrient supplementation in the short term had any impact on anti‐microbial peptide expression.

Vitamin A deficiency impacts the structural segregation of gut microbiota in children with persistent diarrhea

To investigate whether gut microbiota is associated with vitamin A nutritional levels in children with persistent diarrhea, a total of 59 pediatric patients with persistent diarrhea aged 1-12 months were selected from the Department of Gastroenterology at the Children's Hospital of Chongqing Medical University, China. Subjects were hospitalized and divided into VA-deficient (n = 30) and VA-normal (n = 29) groups according to their venous serum retinol levels. Fecal samples from all 59 subjects were collected immediately after admission and analyzed by Illumina MiSeq for 16S rRNA genes to characterize the overall microbiota of the samples. The gut microbiota of the VA-deficient and VA-normal groups were compared using a bioinformatic statistical approach. The Shannon index (p = 0.02), Simpson index (p = 0.01) and component diagram data indicated significantly lower diversity in the VA-deficient than the VA-normal group. A metagenome analysis (LEfSe) and a differentially abundant features approach using Metastats revealed that Escherichia coli and Clostridium butyricum were the key phylotypes of the VA-normal group, while Enterococcus predominated the VA-deficient group. In conclusion, the diversity of gut microbiota and the key phylotypes are significantly different in children with persistent diarrhea at different VA nutritional levels.

Effect of vitamin A and Zn supplementation on indices of vitamin A status, haemoglobin level and defecation of children with persistent diarrhea

To investigate the effect of vitamin A and Zn supplementation on vitamin A status, haemoglobin level and defecation of children with persistent diarrhea, a total of 160 paediatric patients were randomly assigned to one of four intervention groups: daily supplementation of 1,500 IU VA for 14 days; daily Zn supplementation for 14 days; daily supplementation with both VA and Zn for 14 days; no supplementation. One hundred twenty-seven children with persistent diarrhea finished intervention (33 were lost to follow-up). Among the 127 children, 41 (32.28%) had anaemia, 104 (81.89%) had a VA deficiency and 38 (29.92%) had an iron insufficiency. Supplementation with VA or VA + Zn enhanced the serum VA levels and ameliorated anaemia. Supplementation with Zn and VA + Zn for 5 days significantly improved defecation, where the VA + Zn treatment resulted in superior outcomes. After 14 days of intervention, the total effectiveness rates were 93.94%, 96.77% and 96.67% in the three groups, significantly greater than that of the non-supplementation group (72.73%). These results indicate that single VA or concurrent VA + Zn supplementation can improve vitamin A status, haemoglobin level and defecation. However, concurrent VA + Zn supplementation is the optimal option and can shorten the duration of persistent diarrhea and markedly improve nutritional status. (www.clinicaltrials.gov registration number: ChiCTR-IOR-14005498)

Síntomas gastrointestinales en pediatría ¿conducen siempre al verdadero diagnóstico?

<p>Antecedentes. Los síntomas gastrointestinales son motivo frecuente de consulta pediátrica. Escasos estudios abordan la relación entre motivos de consulta (MC) y enfermedades gastrointestinales. Objetivos. Relacionar motivos de consulta con diagnósticos gastrointestinales definitivos (DGID) en pacientes pediátricos que acuden a una unidad de gastroenterología. Materiales y métodos. Estudio retrospectivo realizado entre enero del 2009 y diciembre del 2013. Se evaluó la relación entre los 10 principales MC con sus cinco primeros DGID bajo la prueba de ji cuadrado y la prueba exacta de Fisher. Resultados. Se reunieron 1171 pacientes. Los tres principales MC fueron dolor abdominal (DA) (12,3%), estreñimiento (12,1%) y reflujo gastroesofágico (8,4%). El Estreñimiento crónico funcional (ECF) (33,9%), la alergia alimentaria (AA), (17,3%) y la sospecha de AA (6,2%) constituyeron cerca del 50% de los DGID. El dolor abdominal, como motivo de consulta, se asoció con el diagnóstico de ECF, enfermedad ácido péptica (EAP) y AA; mientras que el estreñimiento como motivo de consulta se asoció con el diagnóstico de ECF, AA, sospecha AA e inercia colónica. Conclusión. El estreñimiento se ubica entre los primeros motivos de consulta y es el primer diagnóstico gastrointestinal directo con una asociación significativa entre ambos. Los profesionales de la salud deben estar atentos para detectar y diagnosticar esta entidad.</p>

Metagenomic diagnostics for the simultaneous detection of multiple pathogens in human stool specimens from Côte d'Ivoire: a proof-of-concept study

BACKGROUND

The intestinal microbiome is a complex community and its role in influencing human health is poorly understood. While conventional microbiology commonly attributes digestive disorders to a single microorganism, a metagenomic approach can detect multiple pathogens simultaneously and might elucidate the role of microbial communities in the pathogenesis of intestinal diseases. We present a proof-of-concept that a shotgun metagenomic approach provides useful information on the diverse composition of intestinal pathogens and antimicrobial resistance profiles in human stool samples.

METHODS

In October 2012, we obtained stool specimens from patients with persistent diarrhea in south Côte d'Ivoire. Four stool samples were purposefully selected and subjected to microscopy, multiplex polymerase chain reaction (PCR), and a metagenomic approach. For the latter, we employed the National Center for Biotechnology Information nucleotide database and screened for 36 pathogenic organisms (bacteria, helminths, intestinal protozoa, and viruses) that may cause digestive disorders. We further characterized the bacterial population and the prevailing resistance patterns by comparing our metagenomic datasets with a genome-specific marker database and with a comprehensive antibiotic resistance database.

RESULTS

In the four patients, the metagenomic approach identified between eight and 11 pathogen classes that potentially cause digestive disorders. For bacterial pathogens, the diagnostic agreement between multiplex PCR and metagenomics was high; yet, metagenomics diagnosed several bacteria not detected by multiplex PCR. In contrast, some of the helminth and intestinal protozoa infections detected by microscopy were missed by metagenomics. The antimicrobial resistance analysis revealed the presence of genes conferring resistance to several commonly used antibiotics.

CONCLUSIONS

A metagenomic approach provides detailed information on the presence and diversity of pathogenic organisms in human stool samples. Metagenomic studies allow for in-depth molecular characterization such as the antimicrobial resistance status, which may be useful to develop setting-specific treatment algorithms. While metagenomic approaches remain challenging, the benefits of gaining new insights into intestinal microbial communities call for a broader application in epidemiologic studies.

TRIAL REGISTRATION

ISRCTN86951400.

Diagnosis of neglected tropical diseases among patients with persistent digestive disorders (diarrhoea and/or abdominal pain ≥14 days): Pierrea multi-country, prospective, non-experimental case-control study

Background

Diarrhoea still accounts for considerable mortality and morbidity worldwide. The highest burden is concentrated in tropical areas where populations lack access to clean water, adequate sanitation and hygiene. In contrast to acute diarrhoea (<14 days), the spectrum of pathogens that may give rise to persistent diarrhoea (≥14 days) and persistent abdominal pain is poorly understood. It is conceivable that pathogens causing neglected tropical diseases play a major role, but few studies investigated this issue. Clinical management and diagnostic work-up of persistent digestive disorders in the tropics therefore remain inadequate. Hence, important aspects regarding the pathogenesis, epidemiology, clinical symptomatology and treatment options for patients presenting with persistent diarrhoea and persistent abdominal pain should be investigated in multi-centric clinical studies.

Methods/Design

This multi-country, prospective, non-experimental case–control study will assess persistent diarrhoea (≥14 days; in individuals aged ≥1 year) and persistent abdominal pain (≥14 days; in children/adolescents aged 1–18 years) in up to 2000 symptomatic patients and 2000 matched controls. Subjects from Côte d’Ivoire, Indonesia, Mali and Nepal will be clinically examined and interviewed using a detailed case report form. Additionally, each participant will provide a stool sample that will be examined using a suite of diagnostic methods (i.e., microscopic techniques, rapid diagnostic tests, stool culture and polymerase chain reaction) for the presence of bacterial and parasitic pathogens. Treatment will be offered to all infected participants and the clinical treatment response will be recorded. Data obtained will be utilised to develop patient-centred clinical algorithms that will be validated in primary health care centres in the four study countries in subsequent studies.

Discussion

Our research will deepen the understanding of the importance of persistent diarrhoea and related digestive disorders in the tropics. A diversity of intestinal pathogens will be assessed for potential associations with persistent diarrhoea and persistent abdominal pain. Different diagnostic methods will be compared, clinical symptoms investigated and diagnosis-treatment algorithms developed for validation in selected primary health care centres. The findings from this study will improve differential diagnosis and evidence-based clinical management of digestive syndromes in the tropics.

Trial registration

ClinicalTrials.gov; identifier: NCT02105714.

Non-diarrhoeal increased frequency of bowel movements (IFoBM-ND): enterovirus association with the symptoms in children

OBJECTIVE

Infectious and non-infectious causes are associated with increased frequency of bowel movements (IFoBM). But, a viral aetiology to non-diarrhoeal IFoBM (IFoBM-ND) has not been described. Owing to an accidental infection by an echovirus 19 strain, persistent diarrhoea-associated virus, isolated from a child with persistent diarrhoea, DCR experienced persistent IFoBM-ND with an urgency to pass apparently normal stools more than once each day for about 3 months. A follow-up study was undertaken to determine the prevalence of IFoBM-ND, and association of non-polio enteroviruses (NPEVs) with the symptom in infants from birth to 2 years.

DESIGN

A cohort of 140 newborns was followed for 6 months to 2 years from birth for IFoBM-ND. Stool samples collected every 14 days were examined for NPEVs, rotavirus and other viral/bacterial agents for their possible association with IFoBM-ND and diarrhoea.

RESULTS

Of 403 NPEV infection episodes among 4545 oral polio vaccine strains-negative stool samples, approximately 29% were associated with IFoBM-ND (15% acute and 14% persistent), including resolution of 74% of constipation episodes, and 18% with diarrhoea, suggesting that about 47% of NPEV infection episodes in children below 2 years of age are associated with gastrointestinal symptoms. About 83% of IFoBM-ND episodes are associated with the NPEV infection and 17% of the episodes are of unknown aetiology.

CONCLUSIONS

NPEV is the single most frequently detected viral agent in children with IFoBM-ND and its association with the symptom is highly significant, warranting detailed investigations on the role of NPEVs in gastrointestinal diseases.

Non-polio enterovirus association with persistent diarrhea in children as revealed by a follow-up study of an Indian cohort during the first two years of life

BACKGROUND

We recently reported significant association of non-polio enteroviruses (NPEVs) with acute diarrhea in children. Persistent diarrhea (PD) remains a major cause of morbidity and mortality in infants below two years of age in developing countries. Understanding age-dependent frequency and duration of NPEV infections is important to determine their association with persistent diarrhea and disease burden.

OBJECTIVES

A cohort of 140 infants was followed for 6 months to 2 years of age to determine the frequency, duration, and association with PD of NPEV infections in comparison with rotavirus and other agents.

STUDY DESIGN

Stool samples were collected every 14 days, and diarrheal episodes and their duration were recorded. Enteroviruses were characterized by RT-PCR and VP1 gene sequence analysis, rotavirus by electropherotyping, and other agents by PCR.

RESULTS

Of 4545 samples, negative for oral polio vaccine strains, 3907 (85.96%) and 638 (14.04%) were NPEV-negative and NPEV-positive, respectively, representing 403 (8.87%) infection episodes. About 68% of NPEV infections occurred during the first year with every child having at least one episode lasting between four days and four months. Approximately 38% and 22% of total diarrheal episodes were positive for NPEV and RV, respectively. While about 18% of NPEV infection episodes were associated with diarrhea, 6% being persistent, 13% of total diarrheal episodes were persistent involving infections by monotype NPEV strains or sequential infections by multiple strains and other agents.

CONCLUSIONS

This is the first report revealing NPEVs as the single most frequently and persistently detected viral pathogen in every PD episode.