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Kim SH, Kim YS, Kim SH, Yoon WE, Myung HJ, Moon JS, Whang DH. [Usefulness of Stool Multiplex Polymerase Chain Reaction Assays in Patients with Acute Diarrhea]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 79:118-125. [PMID: 35342169 DOI: 10.4166/kjg.2022.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/03/2022]
Abstract
Background/Aims There is a recent increase in the use of stool multiplex PCR assay-based diagnostic tests in patients with acute diarrhea. We used multiplex PCR assays to analyze the distribution of diarrhea-causing bacteria and viruses, as well as the clinical features of patients with acute diarrhea. Methods We retrospectively reviewed stool specimens of inpatients complaining of acute diarrhea from October 2018 to July 2020. The stool specimens had been tested for bacteria and viruses using multiplex PCR assays. Results A total of 414 stool specimens from 346 patients were tested, and 152 pathogens were detected in 131 stool samples (131/414, 31.6%). Co-infection was detected in 20 patients (20/346, 5.8%). The common pathogens detected as causes of acute diarrhea, including co-infection, were Clostridium perfringens (34.9%), Clostridioides difficile (19.7%), and Campylobacter spp. (18.4%). The average age of patients with multiplex PCR-positive tests was lower than those with multiplex PCR-negative tests (p=0.001). In patients with suspected C. difficile infection (CDI), the RT-PCR for toxin gene assay was performed in 370 stool samples, 35 of which were positive (9.5%). Furthermore, 16 of the 35 samples were positive on the multiplex PCR assay (45.7%). Conclusions The multiplex PCR assay revealed that C. perfringens was the most common diarrhea-causing pathogen. In addition, in patients with suspected CDI, the multiplex PCR assay alone was insufficiently sensitive to detect pathogens and a conventional CDI test was additionally required.
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Affiliation(s)
- Seo Hyun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - You Sun Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Seung Hyuk Kim
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Won Eui Yoon
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Hee Jun Myung
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jeong Seop Moon
- Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Dong Hee Whang
- Department of Laboratory Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Lόpez-Vélez R, Lebens M, Bundy L, Barriga J, Steffen R. Bacterial travellers' diarrhoea: A narrative review of literature published over the past 10 years. Travel Med Infect Dis 2022; 47:102293. [PMID: 35247581 DOI: 10.1016/j.tmaid.2022.102293] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
Travellers' diarrhoea (TD) is the most frequent illness experienced by international travellers to lower-income countries with bacterial agents considered to account for 80-90% of cases. In this review, we summarise evidence published on bacterial TD over the past 10 years, focusing on the epidemiology and aetiology of TD. Diarrhoeagenic Escherichia coli (DEC) continue to be the most commonly implicated bacteria in TD, although Enteropathogenic E. coli (EPEC) and Enteroaggregative E. coli (EAEC) now appear to be predominant where Enterotoxigenic E. coli (ETEC) was previously considered most prevalent globally. Where fluroquinolone resistance had primarily been documented for Campylobacter in Southeast Asia, widespread resistance has been observed in most regions of the world for multiple enteropathogens, including Shigella, Salmonella, ETEC and EAEC. Implementation of novel molecular methods for pathogen detection has led to identification of bacterial pathogens, including Clostridium difficile (with and without the use of prior antibiotics), Arcobacter species and Bacteroides fragilis, as aetiological agents in TD. The widespread resistance to first-line antibiotics in multiple bacterial enteropathogens warrants continued surveillance and re-evaluation of current treatment practices. Further investigations are required to determine the prevalence and geographical distribution of bacterial enteropathogens that have been more recently implicated in TD.
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Affiliation(s)
- Rogelio Lόpez-Vélez
- National Referral Unit for Tropical Diseases, Infectious Diseases Department, Ramón y Cajal University Hospital, IRYCIS, 28034, Madrid, Spain.
| | - Michael Lebens
- Department of Microbiology and Immunology, University of Gothenburg, Box 435, SE-40530, Gothenburg, Sweden.
| | - Leah Bundy
- Elements Communications Ltd, Westerham, TN16 1RQ, UK.
| | - Juan Barriga
- Department of Medical Affairs Europe, Emergent BioSolutions, 1455, Madrid, Spain.
| | - Robert Steffen
- Epidemiology, Biostatistics and Prevention Institute, World Health Organization Collaborating Centre for Travelers' Health, University of Zurich, Hirschengraben 84, CH-8001, Zurich, Switzerland; Epidemiology, Human Genetics and Environmental Sciences Division, University of Texas School of Public Health, Houston, TX 77030, Texas, USA.
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Brehm TT, Lütgehetmann M, Tannich E, Addo MM, Lohse AW, Rolling T, Vinnemeier CD. Risk factors for different intestinal pathogens among patients with traveler's diarrhea: A retrospective analysis at a German travel clinic (2009-2017). Travel Med Infect Dis 2020; 37:101706. [PMID: 32353630 DOI: 10.1016/j.tmaid.2020.101706] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 03/27/2020] [Accepted: 04/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Travelers' diarrhea (TD) is the most common illness experienced by travelers to developing regions of the world and may be caused by bacterial, parasitic or viral pathogens. The available diagnostic tests include stool microscopy for parasitic infections, culture-dependent methods for bacterial infections and molecular methods for bacterial, parasitic and viral infections. METHOD We retrospectively evaluated demographic, clinical and microbiological data of patients presenting with TD at our travel clinic between 2009 and 2017. RESULTS Among 676 patients with TD included in our study, at least one etiologic agent was found in 21% (n = 145) of cases. In total, 195 enteropathogens were detected of which 110 were bacteria, 70 protozoa and 15 helminths. Bacterial infections were significantly more common when symptoms were present less than 14 days and travel duration did not exceed 29 days. Protozoa and helminths were predominantly detected in patients with longer lasting complaints. After stool culture was replaced by a multiplex-PCR gastrointestinal pathogen panel (GPP) at our center, significantly more intestinal bacterial pathogens were detected. CONCLUSIONS Our results support an individualized approach in the diagnostic workup of patients with TD taking host and travel characteristics into account to avoid unnecessary diagnostic testing. Molecular culture-independent diagnostic stool tests provide better coverage of the variety of etiological agents than traditional stool culture and have the benefit of rapid detection. However, the high sensitivity bears challenges differentiating colonization from infection.
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Affiliation(s)
- Thomas Theo Brehm
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20249, Hamburg, Germany; German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Germany.
| | - Marc Lütgehetmann
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20249, Hamburg, Germany; German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Germany.
| | - Egbert Tannich
- National Reference Centre for Tropical Pathogens, Bernhard-Nocht-Institute for Tropical Medicine, Bernhard-Nocht-Straße 74, 20359, Hamburg, Germany; German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Germany.
| | - Marylyn M Addo
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20249, Hamburg, Germany; Department for Clinical Immunology of Infectious Diseases, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany; German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Germany.
| | - Ansgar W Lohse
- I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20249, Hamburg, Germany; German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Germany.
| | - Thierry Rolling
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20249, Hamburg, Germany; German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Germany.
| | - Christof D Vinnemeier
- Division of Tropical Medicine, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20249, Hamburg, Germany; German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Germany.
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Arbefeville S, Ferrieri P. Role of Multiplex Molecular Diagnosis for Acute Gastroenteritis. Curr Infect Dis Rep 2020. [DOI: 10.1007/s11908-020-0718-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Leshem E. Antibiotics for travelers' diarrhea in children?: To SBET or not to SBET? Travel Med Infect Dis 2020; 34:101681. [DOI: 10.1016/j.tmaid.2020.101681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/16/2020] [Accepted: 04/16/2020] [Indexed: 01/12/2023]
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Abstract
Infections are common during travel, and frontline physicians frequently must evaluate sick returned travelers. Sick travelers can be clinically challenging due to the wide range of endemic diseases in different geographic regions. To guide the diagnostic and treatment plan, consideration of endemic and emerging infections in the region of travel, as well as careful review of the travelers' exposures and preventative measures are necessary. Routine laboratory tests and cultures cannot confirm many tropical infections, and pathogen directed testing is typically required. Common tropical infections that can be severe, such as malaria, dengue, and enteric fever, should always be considered in the diagnostic evaluation. Providers should also be vigilant for rare but highly pathogenic emerging infections such as Ebola virus disease and Middle East respiratory syndrome (MERS).
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Affiliation(s)
- Henry M Wu
- Division of Infectious Diseases, Department of Medicine, Emory University, 550 Peachtree St NE, Atlanta, GA 30308, United States.
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Leung AK, Leung AA, Wong AH, Hon KL. Travelers' Diarrhea: A Clinical Review. RECENT PATENTS ON INFLAMMATION & ALLERGY DRUG DISCOVERY 2019; 13:38-48. [PMID: 31084597 PMCID: PMC6751351 DOI: 10.2174/1872213x13666190514105054] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 04/30/2019] [Accepted: 05/10/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Travelers' diarrhea is the most common travel-related malady. It affects millions of international travelers to developing countries annually and can significantly disrupt travel plans. OBJECTIVE To provide an update on the evaluation, diagnosis, treatment, and prevention of traveler's diarrhea. METHODS A PubMed search was completed in Clinical Queries using the key term "traveler's diarrhea". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature. Patents were searched using the key term "traveler's diarrhea" from www.freepatentsonline.com. RESULTS Between 10% and 40% of travelers develop diarrhea. The attack rate is highest for travelers from a developed country who visit a developing country. Children are at particular risk. Travelers' diarrhea is usually acquired through ingestion of food and water contaminated by feces. Most cases are due to a bacterial pathogen, commonly, Escherichia coli, and occur within the first few days after arrival in a foreign country. Dehydration is the most common complication. Pretravel education on hygiene and on the safe selection of food items is important in minimizing episodes. For mild travelers' diarrhea, the use of antibiotic is not recommended. The use of bismuth subsalicylate or loperamide may be considered. For moderate travelers' diarrhea, antibiotics such as fluoroquinolones, azithromycin, and rifaximin may be used. Loperamide may be considered as monotherapy or adjunctive therapy. For severe travelers' diarrhea, antibiotics such as azithromycin, fluoroquinolones, and rifaximin should be used. Azithromycin can be used even for the treatment of dysentery whereas fluoroquinolones and rifaximin cannot be used for such purpose. Recent patents related to the management of travelers' diarrhea are discussed. CONCLUSION Although travelers' diarrhea is usually self-limited, many travelers prefer expedient relief of diarrhea, especially when they are traveling for extended periods by air or ground. Judicious use of an antimotility agent and antimicrobial therapy reduces the duration and severity of diarrhea.
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Affiliation(s)
- Alexander K.C. Leung
- Address correspondence to this author at the University of Calgary, Alberta Children’s Hospital, #200, 233 - 16th Avenue NW, Calgary, Alberta, Canada T2M 0H5; Tel: (403) 230 3300; Fax: (403) 230 3322; E-mail:
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Hitch G, Fleming N. Antibiotic resistance in travellers' diarrhoeal disease, an external perspective. J Travel Med 2018; 25:S27-S37. [PMID: 29718437 DOI: 10.1093/jtm/tay014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/08/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are many recommendations on the use of antibiotics for prophylaxis and treatment of travellers' diarrhoea (TD). As pharmacists with a special interest in antimicrobial stewardship, we examine and offer our perspective on advice that is recommended to travellers in terms of prevention, treatment and management of TD with a focus on antibiotic use and resistance. METHODS Publications on TD were identified through PubMed, Google Scholar and Cochrane Library databases searches using search terms 'travellers diarrhoea', 'travellers diarrhoea', 'travellers' diarrhoea' 'guidelines', 'expert opinion', 'expert reviews', 'South Asia' and 'South East Asia' (S and SE Asia), 'antibiotics', 'resistance genes', 'travel advice', 'pharmacists', 'guidelines', 'prevention' and 'treatment'. References of articles were also screened for additional relevant studies. RESULTS Whilst most guidelines and expert reviews were in agreement with the restricted use of antibiotics unless there was a clinical need, the literature review identified gaps in research into behaviours of travellers regarding non-compliance with the pre-travel advice provided and the need for in depth training and education for all healthcare professionals in providing 'tailored' advice for travellers going to high-risk destinations. CONCLUSIONS Travellers should be made aware of the problems of antimicrobial resistance in their destination and home countries and offered alternative forms of prophylaxis for TD. Strategies for prevention of TD, other than the use of antibiotics, also need to be emphasized. All healthcare professionals involved in giving advice about TD should be familiar with the epidemiology of the condition as this will inform responsible behaviours, risk assessment and management strategies in different geographical areas.
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Affiliation(s)
- Geeta Hitch
- Department of Life Sciences/Pharmacy, JMS Building, University of Sussex, Falmer, Brighton BN1 9RH, UK
| | - Naomi Fleming
- Department of Pharmacy, Kettering General Hospital, Rothwell Road, Kettering, Northamptonshire NN16 8UZ, UK
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