Infectious diarrhea. Pathogenesis and risk factors

The effect of temperature on infectious diarrhea disease: A systematic review

This study aimed to ascertain the delayed effects of various exposure temperatures on infectious diarrhea. We performed a Bayesian random-effects network meta-analysis to calculate relative risks (RR) with 95 % confidence intervals (95 % CI). The heterogeneity was analyzed by subgroup analysis. There were 25 cross-sectional studies totaling 6858735 patients included in this analysis, with 12 articles each investigating the effects of both hyperthermia and hypothermia. Results revealed that both high temperature (RRsingle = 1.22, 95%CI:1.04-1.44, RRcum = 2.96, 95%CI:1.60-5.48, P < 0.05) and low temperature (RRsingle = 1.17, 95%CI:1.02-1.37, RRcum = 2.19, 95%CI:1.33-3.64, P < 0.05) significantly increased the risk of infectious diarrhea, while high temperature caused greater. As-sociations with strengthening in bacillary dysentery were found for high temperatures (RRcum = 2.03, 95%CI:1.41-3.01, P < 0.05; RRsingle = 1.17, 95%CI:0.90-1.62, P > 0.05), while the statistical significance of low temperatures in lowering bacterial dysentery had vanished. This investigation examined that high temperature and low temperature were the conditions that posed the greatest risk for infectious diarrhea. This research offers fresh perspectives on preventing infectious diarrhea and will hopefully enlighten future studies on the impact of temperature management on infectious diarrhea.

Progress in understanding the relationship between diarrhea and intestinal ion transport

Diarrhea is a major cause of morbidity and mortality in the world. There are millions of people dying of diarrhea, and most of them are children. Diarrhea can be divided into acute diarrhea and chronic diarrhea based on the length of the course, and into infectious diarrhea and noninfectious diarrhea according to the etiology. Diarrhea is an imbalance in absorption and secretion of water and electrolytes in the intestine, which involves abnormal ion transport. This paper reviews recent advances in understanding the causes of diarrhea, the relationship between intestinal ion transport and diarrhea, and ion transport in different kinds of diarrhea, with an aim to providing a reference and some new ideas on the comprehensive understanding of the pathogenesis, pathophysiology and treatment of diarrhea.

Mechanisms of uropathogenic Escherichia coli persistence and eradication from the urinary tract

Recurrent urinary tract infections (rUTIs) are a source of considerable morbidity in women. The infecting bacteria in both rUTIs and a de novo acute infection have been thought to originate from an extraurinary location. Here, we show in a murine model of UTI that uropathogenic Escherichia coli (UPEC) established quiescent intracellular reservoirs (QIRs) in Lamp1+ endosomes within the urinary bladder epithelium. Depending on the integrity of the urothelial barriers at the time of initial infection, these QIRs were established within terminally differentiated superficial facet cells and/or underlying transitional epithelial cells. Treatment of infected bladders harboring exclusively superficial facet cell QIRs with the cationic protein, protamine sulfate, led to epithelial exfoliation and eradication of bacteria in 100% of treated animals. However, when the bacterial QIRs were harbored in underlying transitional cells, stimulation of epithelial turnover triggered reemergence of viable organisms and recurrence of infection. Thus, our results suggest (i) that bacterial QIRs within the bladder may be a previously unappreciated source of recurrent UTIs and (ii) that inducing epithelial exfoliation may be a therapeutic avenue for treating this heretofore recalcitrant disease.

Infectious Diarrhea

Infectious diarrhea constitutes a major source of morbidity and mortality for all age groups. The focus of this article is to identify high risk host and pathogenic risk determinants of enteric infections, discuss pathophysiologic mechanisms for diarrhea, review conventional and upcoming therapeutic managements of bacterial, protozoal or viral-type diarrhea, and describe the integral role of the pharmacist in the overall care of patients having this illness.

Acute infectious diarrhea

Diarrhea continues to be a major cause of mortality and morbidity in third world countries as well as a major symptomatic complaint in the primary care setting in the United States. The etiologic pathogen depends on an exposure history to include recent travel to foreign countries, consuming fecally contaminated water or food, prior use of antibiotics, or homosexual behavior. A careful history from patients directed at attempting to identify particular risk factors may help in making a diagnosis. Not all patients require a diagnostic workup. A large number of patients may only require oral rehydration, careful observation over time with or without use of antimotility agents. In toxic appearing patients or patients with fever, however, bloody stools, abdominal pain or tenesmus, a selective diagnostic workup is indicated. Antimicrobial treatments are not always required, some pathogens clearly call for treatment while some have less clear indications and other pathogens are not responsive to antimicrobial agents at all. Finally, one needs to remember that the differential diagnosis of acute diarrhea includes many noninfectious origins.

HeLa cell adherence, actin aggregation, and invasion by nonenteropathogenic Escherichia coli possessing the eae gene

Enteropathogenic Escherichia coli (EPEC) produce diarrhea in humans by a mechanism that involves close adherence to epithelial cells in the intestine and colon. Close adherence is associated with effacement of microvilli and condensation of actin beneath the bacteria, a process termed attaching/effacing adherence. Attaching/effacing adherence of EPEC occurs in vitro in tissue culture, simplifying the study of the molecular genetics of this process. An EPEC gene (eae) necessary for attaching/effacing adherence was recently characterized. Enterohemorrhagic E. coli and the rabbit-specific RDEC-1 strain adhere in a like fashion in vivo and hybridize with eae. However, these strains adhere poorly to tissue culture cells, complicating the in vitro study of attaching/effacing adherence. In order to develop an in vitro model for the study of attaching/effacing activity of non-EPEC bacteria, a plasmid encoding the F1845 adhesin of an E. coli strain (C1845) isolated from a patient with diarrhea was transformed into RDEC-1 and enterohemorrhagic E. coli. The transformed strains adhered in a diffuse pattern to HeLa cells, and they aggregated HeLa cell actin at points of adherence in the fluorescein-isothiocyanate-labeled phalloidin assay. They also invaded HeLa cells in a gentamicin invasion assay, although not to the extent seen with EPEC. The construction of adherent non-EPEC strains facilitates the molecular study of the attaching/effacing properties and invasiveness of these strains in tissue culture models.

Infectious Gastroenteritis

Infectious gastroenteritis currently constitutes the greatest source of morbidity and mortality among various age groups. Issues of focus for this article include establishing epidemiological determinants of risk for enteric infection, describing host factors that favor survival of the infecting enteric pathogen, defining pathophysiological mechanisms of diarrhea, and reviewing the therapeutic management of bacterial, protozoal, and viral infectious diarrhea.

Amebiasis: clinical and laboratory perspectives

Entamoeba histolytica, the premier intestinal protozoan, has traversed time in its relentless quest for survival in its dichotomous role of parasite and pathogen. Enigmatic in its transition from human intestinal commensal to invader of human tissue, diverse in its pathogenicity for the human host, and intricate in its bacterial interrelationship in the bowel, E. histolytica has become the focal point of intensive investigation in its basic biology underscoring human pathogenicity. This review will focus on facets of cell biology, pathophysiology, clinical, therapeutic, and epidemiologic, correlates, along with diagnostic modalities and future research trends.

Microbiologic and clinical evidence supporting the role of Aeromonas caviae as a pediatric enteric pathogen

Aeromonas caviae was recovered as the sole potential enteric pathogen from the stools of 14 of 17 symptomatic children (10 younger than 1 year of age) while Aeromonas hydrophila, Aeromonas sobria, and Plesiomonas shigelloides were isolated once each. The infants from whom A. caviae was isolated all presented with a watery diarrhea lasting 1 to 3 weeks. None of these infants was breast-fed, and all had a stool pH of greater than 7.5. All of the A. caviae isolates, including a reference strain (ATCC 15468), adhered to HEp-2 cells, and preliminary data showed that they produced a cytotoxin as well. Because A. caviae can survive at an elevated pH, as found in the gastrointestinal tract of formula-fed infants, and because of the adherence and cytotoxin production capabilities of the species, it should be regarded as an enteric pathogen in pediatric patients and most probably among adults as well.

Common themes in microbial pathogenicity

A bacterial pathogen is a highly adapted microorganism which has the capacity to cause disease. The mechanisms used by pathogenic bacteria to cause infection and disease usually include an interactive group of virulence determinants, sometimes coregulated, which are suited for the interaction of a particular microorganism with a specific host. Because pathogens must overcome similar host barriers, common themes in microbial pathogenesis have evolved. However, these mechanisms are diverse between species and not necessarily conserved; instead, convergent evolution has developed several different mechanisms to overcome host barriers. The success of a bacterial pathogen can be measured by the degree with which it replicates after entering the host and reaching its specific niche. Successful microbial infection reflects persistence within a host and avoidance or neutralization of the specific and nonspecific defense mechanisms of the host. The degree of success of a pathogen is dependent upon the status of the host. As pathogens pass through a host, they are exposed to new environments. Highly adapted pathogenic organisms have developed biochemical sensors exquisitely designed to measure and respond to such environmental stimuli and accordingly to regulate a cascade of virulence determinants essential for life within the host. The pathogenic state is the product of dynamic selective pressures on microbial populations.

Bacterial gastroenteritis

Acute diarrhea is a major cause of childhood morbidity. Important advances in the understanding of bacterial gastroenteritis have been made in the past two decades. This article reviews the epidemiology, pathogenesis, and methods of diagnosis of bacterial gastroenteritis. Bacterial enteric pathogens common to North America are discussed in more detail.

Effect of acidity and antimicrobial agent-like compounds on viability of Plesiomonas shigelloides

Nineteen Plesiomonas shigelloides strains were evaluated for their stability at acidic and slightly alkaline pHs and for their susceptibility to antimicrobial agent-like compounds produced by enteric flora. Most P. shigelloides isolates were rapidly inactivated under high-acid (pH 4 or less) conditions. Screening of enteric bacteria for elaboration of factors active against P. shigelloides revealed two organisms (Pseudomonas aeruginosa and Streptococcus [Enterococcus] faecium) capable of secreting such inhibitory substances. The results of this study suggest some factors potentially important in regulating gastrointestinal colonization by P. shigelloides from environmental sources.

Clinical and laboratory approaches to evaluate diarrheal disorders

Diarrheal disorders are the result of excessive fluid and electrolyte loss through the gastrointestinal tract. Many different underlying mechanisms are known to cause diarrhea. Fordtran suggested that in secretory diarrhea the osmolality of stool water should be accounted for by its electrolyte contents. Therefore, the osmotic gap between the measured osmolality and that estimated from electrolyte contents should be small. In osmotic diarrhea, due to the presence of the osmotic agent, there should be a greater gap between the measured and the estimated osmolalities. Osmotic gaps varying from 100 to 40 mOsm have been used arbitrarily in literatures to define the underlying pathogenesis. Because of the uncertainty, the usefulness of these measurements remains in question. In this article, methods used to measure stool osmolality and electrolyte contents are reviewed. Limitations of these measurements are discussed. Measurements derived from various diarrheal disorders revealed that the basic concepts put forward by Fordtran are corrected. However, we found that the osmotic gaps (measured osmolality - 2 [Na + K] in secretory diarrheal disorders are frequently negative numbers. In osmotic diarrhea, the osmotic gap (greater than 160 mOsm) is substantially greater than the figures used in the literature. In many diarrheal disorders the osmotic gap falls between the two extremes and the pathogenesis is multifactorial in origin. Under these circumstances, stool osmolality and electrolyte measurements provide little insight into the underlying mechanism causing the diarrhea. Furthermore, stool contains many biologically active organisms which can alter the stool osmolality. Unless these effects are appreciated, an inaccurate interpretation of these measurements may result.