Bacterial diarrhoea and its treatment

Empiric therapy for treatment of infection and the influence of antibiotic guidelines on outcomes

The appropriateness of empiric therapy, how closely prescribers adhered to hospital guidelines for use of antimicrobial drugs and how relevant these guidelines proved in providing cover for the infecting pathogen were assessed from a retrospective survey of culture and sensitivity reports issued during a one-month period in a district general hospital. Blood, stool, pus, sputum and mid-stream urine specimens were reviewed. Urine specimens from a fundholding general practice unit were also included. Catheter specimens of urine and specimens from other body sites were excluded. Of 290 specimens sent for culture, 99 (34 per cent) were positive. One hundred patients, of whom 54 (19 per cent of the total) were subsequently demonstrated to have a positive culture, had been treated empirically. In 38 per cent of cases the pre-report empiric treatment was considered appropriate for the isolated pathogen, while 46 per cent of patients had negative cultures and 16 per cent had positive cultures but had been given unsuitable antibiotics. In hospitalised patients, 73 per cent of antibiotic treatments were prescribed according to hospital guidelines, although this was the case for only 45 per cent of community-based patients. Hospital guidelines were a relevant and useful aid to rational prescribing in that 75 per cent of organisms isolated were sensitive to guideline antibiotics. The guidelines were least appropriate for urine specimens from hospital. This reflects the range of organisms encountered and the emergence of resistant strains, reinforcing the need for regular updating and amending of prescribing recommendations.

Live Lactobacillus rhamnosus [corrected] is essential for the inhibitory effect on tumor necrosis factor alpha-induced interleukin-8 expression

The mechanism of the apparent anti-inflammatory action of probiotic organisms is unclear. Lactobacillus reuteri is effective in inhibiting colitis in interleukin-10 (IL-10)-deficient mice. Nerve growth factor (NGF), in addition to its activity on neuronal cell growth, has significant anti-inflammatory effects in several experimental systems in vitro and in vivo, including a model of colitis. Our experiments were designed to explore the mechanism of effect of L. reuteri in the human epithelial cell lines T84 and HT29 on cytokine and NGF synthesis and IL-8 response to tumor necrosis factor alpha (TNF-alpha). Epithelial cells were cultured for various times with live and killed L. reuteri and examined by reverse transcription-PCR for NGF, IL-10, and TNF-alpha-induced IL-8 expression. An enzyme-linked immunosorbent assay was used to quantitate intracellular IL-8 and secreted product. Western blotting and confocal microscopy were used to determine the effects on IkappaB and NF-kappaB, respectively. Live but not heat-killed or gamma-irradiated L. reuteri upregulated NGF and dose dependently inhibited constitutive synthesis by T84 and HT29 cells of IL-8 and that induced by TNF-alpha in terms of mRNA and intracellular and secreted protein. Similarly, L. reuteri inhibited IL-8 synthesis induced by Salmonella enterica serovar Typhimurium. L. reuteri required preincubation and adherence for effect, inhibited translocation of NF-kappaB to the nuclei of HeLa cells, and prevented degradation of IkappaB. Neither cellular lysates nor media supernatants had any effect on TNF-alpha-induced IL-8. The conclusion is that L. reuteri has potent direct anti-inflammatory activity on human epithelial cells, which is likely to be related to the activity of ingested probiotics. L. reuteri also upregulates an unusual anti-inflammatory molecule, NGF, and inhibits NF-kappaB translocation to the nucleus.

Gastrointestinal infections in children

Gastrointestinal infections in children are a major cause of morbidity and mortality worldwide. Children living in developing countries are particularly susceptible to infectious diarrhea because of poor standards of hygiene and sanitation. Although the magnitude of diarrheal illnesses in developed countries is less, costly hospital admissions are still frequent. The causal agent of infectious diarrhea is most frequently related to age, geographical location, lifestyle habits, use of antibiotics, associated medical conditions, social circumstances, and degree of immune competence. In this article we present some of the most important articles published in the field during the last year. The role of Helicobacter pylori in the pathogenesis of gastritis and peptic ulcer disease has been shown in adults and children. Information about the natural history of H. pylori, symptomatology, and diagnostic therapeutic approaches for children are being generated constantly; we discuss some of the most relevant information in this review.

Role of antibiotic therapy on long-term germ excretion in faeces and digestive symptoms after Salmonella infection

BACKGROUND

The role of antibiotic therapy on Salmonella faecal excretion is controversial. Acute Salmonella gastroenteritis induces long-lasting digestive symptoms in up to one-third of subjects. The role of antimicrobial therapy on persistent post-infectious symptoms is unknown.

AIM

To investigate the role of antibiotic therapy on long-term germ faecal excretion and digestive symptoms after Salmonella infection.

SUBJECTS AND METHODS

1543 subjects [518 aged between 3 and 5 years (35.3%); 950 between 6 and 10 years (64.7%) and 75 adults (4.9%)] involved in a single outbreak of Salmonella enteritis fulfilled the study criteria by repeating stool cultures and answering a symptom questionnaire 3 months post-infection.

RESULTS

327 subjects (21.2%) were treated with antibiotics during the acute infection [121 children aged 3-5 years (23.4%), 175 children aged 6-10 years (18.4%) and 31 adults (41.3%)]. Antibiotic treatment did not affect Salmonella excretion at any of the time points studied up to three months post-infection in any age group as compared to age-matched untreated controls. Persistent digestive symptoms were more common among the patients treated with antibiotics (9.5% vs. 2.9%; P=0.003).

CONCLUSIONS

Antibiotic therapy does not affect Salmonella enteritis excretion. Digestive symptoms after clearance of the infectious agent are significantly higher in patients treated with antibiotics during acute gastroenteritis.

Antibiotic dispensing by drug retailers in Kathmandu, Nepal

OBJECTIVES To assess over-the-counter antimicrobial dispensing by drug retailers in Kathmandu, Nepal, for rationality, safety, and compliance with existing government regulations.

METHODS

Standardized cases of dysuria in a young adult male and acute watery diarrhoea in a child were presented by a mock patient to retailers at 100 randomly selected pharmacies. Questions asked by retailers and advice and medications given at their initiative were recorded.

RESULTS

All retailers engaged in diagnostic and therapeutic behaviour beyond their scope of training or legal mandate. Historical information obtained by retailers was inadequate to determine the nature or severity of disease or appropriateness of antimicrobial therapy. 97% (95% CI = 91.5-99.4%) of retailers dispensed unnecessary antimicrobials in diarrhoea, while only 44% (95% CI = 34.1-54.3%) recommended oral rehydration therapy and only 3% (95% CI = 0.6-8.5%) suggested evaluation by a physician. 38% (95% CI = 28.5-48.2%) gave antimicrobials in dysuria, yet only 4% (95% CI = 1.1-9.9%) adequately covered cystitis. None covered upper urinary tract or sexually transmitted infections, conditions which could not be ruled out based on the interviews, and only 7% (95% CI = 2.9-13. 9%) referred for a medical history and physical examination necessary to guide therapy.

CONCLUSIONS

Although legislation in Nepal mandates a medical prescription for purchase of antibiotics, unauthorized dispensing is clearly problematic. Drug retailers in our study did not demonstrate adequate understanding of the disease processes in question to justify their use of these drugs. Risks of such indiscretion include harm to individual patients as well as spread of antimicrobial resistance. More intensive efforts to educate drug retailers on their role in dispensing, along with increased enforcement of existing regulations, must be pursued.

C-reactive protein in viral and bacterial gastroenteritis in childhood

To differentiate bacterial from viral infections the level of C-reactive protein in serum samples was studied in three groups of children under 5 years of age with gastroenteritis. Of the 53 children with bacterial infection, 41 (77%) had C-reactive protein levels > or = 12 mg1 -1, 32 (66%) > or = 20 mgl-1 and 24 (45%) > or = 35 mgl-1. Of the 35 patients with viral infection, 4 (11%) had C-reactive protein levels > or = 12 mgl-1, 3 (9%) > or = 20 mgl-1 and 1 (3%) > or = 35 mgl-1. The best balance between sensitivity and specificity of C-reactive protein was obtained for a cut-off level > or = 12 mgl-1 (sensitivity 77%, specificity 89%) as compared to > or = 20 mgl-1 (sensitivity 58%, specificity 97%) and > or = 35 mgl-1 (sensitivity 44%, specificity 97%). Our results suggest that the determination of C-reactive protein values may be a useful tool for predicting bacterial gastroenteritis in children.

Enterotoxigenic Escherichia coli associated diarrhoea among infants aged less than six months in Calcutta, India

The role of enterotoxigenic Escherichia coli (ETEC) as etiologic agents of diarrhoea in infants aged less than six months was assessed in a hospital based study in Calcutta, India. Of the 218 cases examined, ETEC strains were isolated from 26 (11.9%) cases. Among these, in 17 cases ETEC was the sole infecting pathogen (p = 0.0085). Of the 26 isolates (each isolate representing a case), 24 were distributed among seven different O:K:H serotypes and two different colonization factor antigens (CFAs) I and II. Two of the remaining isolation were untypable, non-haemagglutinating, and were non-hydrophobic as measured by the salt aggregation test (SAT). Of the 26 ETEC strains detected, 15 (57.7%) produced heat-labile toxin (LT) only, 8 (30.8%) liberated heat-stable toxin (ST) only, and the remaining 3 (11.5%) produced both LT and ST. No ETEC strain was isolated from the 102 age-matched controls included in this study. All the ETEC isolates were multiple drug resistant. The study showed that the diarrhoea due to ETEC was of brief duration, mostly within the range of 3 to 7 days.

Role of Candida in indirect pathogenesis of antibiotic associated diarrhoea in infants

One hundred and thirty seven isolates of Candida species were isolated from antibiotic associated diarrhoea cases and were examined to study the role of Candida in the pathogenesis of diarrhoea in infants. The quantitative estimation of yeast population by simple gram stain smear revealed more than 70% of the cases had 3+ score. The isolates further screened for detection of beta-lactamases. Among the isolated Candida sp, beta-lactamases was secreted by C. albicans, C. tropicalis, C. krusei and C. parapsilosis. Further, 46% of the Candida isolates were found to be produced 741-1110 mU/ml of beta-lactamases, suggesting that these enzyme would inactivate penicillin group of drugs and cause failure in the therapy directed against other diarrhoegenic bacteria.

Adhesion and its role in the virulence of enteropathogenic Escherichia coli

Enteropathogenic Escherichia coli (EPEC) organisms are an important cause of diarrheal disease in young children. The virulence of EPEC is a multifactorial process and involves a number of distinct stages. Initial adherence to intestinal mucosa is mediated by fimbriae which bring about a distinct form of adhesion, localized adhesion. Intimate adhesion of the bacterium to the eukaryotic membrane occurs, resulting in the activation of signal transduction pathways. Microvilli are disrupted and effaced from the apical membrane which then cups around the organism to form pedestal structures, the attaching and effacing lesion. Diarrhea may be produced by alteration of the permeability of the apical membrane and also through a malabsorption mechanism. The pathways involved in the production of the attaching and effacing lesion are described. EPEC organisms were originally thought to belong to a number of distinct serogroups; it is now apparent that many isolates belonging to these serogroups are not pathogenic or belong to other pathogenic groups of E. coli. In addition, isolates falling outside of these serogroups are considered to be true EPEC. The definition of EPEC based on serotyping is inaccurate and should be replaced by methods that specifically detect the virulence properties of EPEC.

Antibiotic misuse in diarrhea. A household survey in a Mexican community

A survey of 1659 households in a periurban community in Mexico City was carried out to assess the frequency of and risk factors for inappropriate antimicrobial therapy in acute diarrhea. The housewife was interviewed to obtain information of the occurrence of diarrhea or use of an antibiotic in the previous 2 weeks by any member of the family. An antibiotic was used in 37% or 287 diarrheal episodes although only in 5% of all episodes was this therapy indicated, based on the presence of gross blood in stools. Patients seen by a physician were 6 times more likely to be treated with an antibiotic compared to those who did not consult a physician (p < 0.001). Self-medication was associated with a higher risk of using an inadequate drug or dose (in 72% of treated episodes) and of following treatment for less than 5 days (in 66% of treated episodes). Other risk factors significantly and independently associated with antibiotic misuse were: an increased number of stools (odds ratio [OR] = 1.21; 95% confidence interval [CI] = 1.04, 1.41), bloody diarrhea (OR = 19.04; 95% CI = 2.52, 160.90) and family crowding (OR = 2.07; 95% CI = 1.17, 3.63). These findings support future community-oriented educational interventions aimed at improving physician prescribing practices and patient compliance behavior in order to achieve a more rational use of antibiotics.

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.

Etiology of bacterial diarrhea in a major referral center in Saudi Arabia

A total of 34, 856 stool specimens from 19, 437 patients with symptoms of gastroenteritis were analyzed for bacterial enteropathogens during the period of January 1, 1985, to December 31, 1989, at a major tertiary care referral hospital in Saudi Arabia. Bacterial pathogens were isolate from 1426 (7.3%) patients, with Salmonella being the most frequent (3.8%), followed by Campylobacter (2.0%), Shigella (1.1%), and Aeromonas hydrophila (0.34%). Salmonella serogroups B and C and Shigella B and D constituted the majority of isolates in these two groups. Major clinical symptoms associated with bacterial gastroenteritis included mild to moderate diarrhea, abdominal discomfort, tenesmus, vomiting, fever, and dehydration. Bloody diarrhea was more common in patients with shigellosis (32%) than in those infected with other bacteria. Stool specimens from 80% of the patients with Shigella gastroenteritis had leukocytes, compared with about 40% of the patients with Salmonella or Campylobacter.

Role of candida in pathogenesis of antibiotic-associated diarrhoea in elderly inpatients

The part that candida plays in antibiotic-associated diarrhoea was investigated in 24 elderly inpatients (mean age 74 years) who tested negative for Clostridium difficile toxin and other intestinal pathogens. 7 had intestinal overgrowth of Candida species (greater than or equal to 10(5) cfu/ml). None of the 24 matched, antibiotic-treated controls without diarrhoea had candida overgrowth. All 5 patients with diarrhoea and candida overgrowth treated with oral nystatin responded with resolution of diarrhoea and lowering of faecal counts to less than 10(4) cfu/ml within 7 days of start of antifungal therapy despite continuation of antibacterial therapy. In the other 2 patients with candida overgrowth, the diarrhoea subsided spontaneously and faecal candida counts returned to normal (less than 10(4) cfu/ml) after antibacterial agents were withdrawn. In patients without candida overgrowth, diarrhoea persisted until antibiotics were withdrawn, at a mean of 16 days after study entry.

Use of ciprofloxacin to control a Salmonella outbreak in a long-stay psychiatric hospital

An outbreak of diarrhoea due to Salmonella virchow phage type 8 occurred in a major block of a large psychiatric hospital. The two other major blocks of the hospital remained unaffected. No source of infection was identified and the epidemiological investigations pointed to cross-infection as the mode of transmission. Infection control measures were implemented at an early stage but a total of 55 patients and four members of staff were affected. The disease was self-limiting and of short duration. During the course of the outbreak, Salmonella typhimurium phage type 66 also emerged as a pathogen and was isolated from the stools of symptomatic cases with diarrhoea. Owing to the size of the hospital, the lack of facilities for infection control, the nature of the patients' illnesses and an increasing number of affected patients, it was decided to treat all symptomatic and asymptomatic patients with oral ciprofloxacin 500 mg twice daily for 7 days. A quantitative stool culture for salmonellae was undertaken on days 3, 7, 10, 30, 60 and 90 from the start of treatment. All patients' and staff's stool cultures became negative on day 7 and remained negative for a period of 6 months during follow-up. We conclude that cross-infection outbreaks due to Salmonella spp. in psychiatric and geriatric hospitals can be controlled by isolation in a designated ward and supportive therapy, together with ciprofloxacin treatment.

Enteropathogenic Escherichia coli and life threatening chronic diarrhoea

Enteropathogenic Escherichia coli (EPEC) infection is not generally thought to cause severe diarrhoea after the neonatal period. Patients admitted to Queen Elizabeth Hospital for Children over the three years (1984-7) with diarrhoea and EPEC infection were reviewed. Clinical details, features of small intestinal mucosa, and treatment were recorded in those who developed chronic diarrhoea with failure to thrive. Twenty six children with EPEC required hospital admission for diarrhoea and six of these (23%) developed chronic diarrhoea. In contrast only two (5%) of 42 with other serogroups of E coli (p less than 0.01) and 28 (4%) of 764 children without EPEC admitted with acute diarrhoea developed chronic symptoms (p less than 0.01). EPEC serogroups detected in the stool of the six children with chronic diarrhoea were 0128 in three, 0114 in two, and 0119 in one. The patients' clinical characteristics were: previous good health, no significant immunodeficiency, age 4-10 months, foreign travel (three of six), severe life threatening secretory diarrhoea from 0.5 to 1.5 1 per day (four of six), small intestinal enteropathy (five of six) three of whom showed mucosal adherent, non-invasive E coli of the same serotype as that in the stool, in association with microvillous loss and pedestal formation. All were treated with hypoallergenic feeds, two with parenteral nutrition, and three with parenteral antibiotics. All eventually recovered. EPEC infection is a common treatable cause of life threatening chronic diarrhoea in infancy.

Antibiotic sensitivity of enteric pathogens in Vietnam

The in vitro antimicrobial susceptibilities of 675 common enteropathogenic isolates from faecal specimens of patients with diarrhea (E. coli, Shigella, Salmonella and V. cholerae), and 568 E. coli isolates from faecal flora of healthy persons, which were collected as part of a National antibiotic resistance surveillance in Vietnam, were determined. The agar dilution method was used for the following nine antibiotics: ampicillin, doxycycline, chloramphenicol, gentamicin, nalidixic acid, kanamycin, trimethoprim, trimethoprim in combination with sulfamethoxazole (1/20), and sulfisomidin. Gentamicin was the most active of the antibiotics tested against all bacterial species with MICs in the range 0.125-4 mg/l. All strains were susceptible to nalidixic acid (0.125-8 mg/l) and more than 90% were susceptible to kanamycin. Among E. coli and Shigella isolates from patients the frequencies of resistance to commonly used antibiotics were high: ampicillin 73% and 84%, doxycycline 83% and 94%, chloramphenicol 71% and 91%, sulfisomidin 82% and 92%, respectively. Resistance to trimethoprin, as well as to the combination with sulfamethoxazole was found in 21% and 23%, respectively. The frequencies of multiple resistance (resistance to three or more antibiotics) were also high (77% and 89%, respectively). Less than 10% of Salmonellae and V. cholerae isolates were resistant to ampicillin, sulfisomidin or trimethoprim. Among E. coli from healthy people the frequencies of resistance were lower than in isolates from patients: ampicillin 23%, doxycycline 40%, chloramphenicol 21% and sulfisomidin 34%. However, the same patterns of multiple resistance were found in both groups.

Infectious diarrhea. Managing a misery that is still worldwide

Infectious diarrhea is the largest single cause of morbidity and mortality in the world. Bacteria, viruses, and protozoan parasites are the most common causative agents. Treatment in most cases of bacterial and viral diseases consists of correcting fluid loss and electrolyte imbalance by oral or parenteral rehydration. Antimicrobial therapy is reserved for very ill patients only. With the exception of Cryptosporidium, for which no effective agent is yet available, all protozoan infections are treatable with metronidazole.

Bismuth therapy in gastrointestinal diseases

Bismuth therapy has shown efficacy against two major gastrointestinal disorders: peptic ulcer disease and diarrhea. In peptic ulcer disease it is as effective as the H2-receptor antagonists, costs considerably less, and offers a lower rate of relapse. When Helicobacter pylori is implicated, bismuth acts as an antimicrobial agent, suppressing the organism but not eliminating it. In recent studies, bismuth compounds have been used with conventional antibiotics, producing elimination of the organism, histological improvement, and amelioration of symptoms for periods longer than one year. Bismuth subsalicylate has shown modest efficacy in treating traveler's diarrhea and acute and chronic diarrhea in children, and it is effective prophylactically for traveler's diarrhea. An epidemic of neurological toxicity was reported in France in the 1970's with prolonged bismuth treatment, usually bismuth subgallate and subnitrate. Such toxicity has been rare with bismuth subsalicylate and colloidal bismuth subcitrate. However, recent studies have demonstrated intestinal absorption of bismuth (about 0.2% of the ingested dose) and sequestration of this heavy metal in multiple tissue sites, even occurring with conventional dosing over a 6-week period. These findings have inspired recommendations that treatment periods with any bismuth-containing compound should last no longer than 6-8 weeks, followed by 8-week bismuth-free intervals.

In vitro activity of norfloxacin and other antibacterial agents against gastro-intestinal pathogens isolated in Sweden

The in vitro activity of norfloxacin was compared to that of ampicillin, doxycycline, chloramphenicol, trimethoprim in combination with sulfamethoxazole (1/20), and erythromycin, against 272 clinical isolates of gastro-intestinal pathogens. Norfloxacin was the most active compound of those tested with MICs in the range 0.004-2 mg/l. Concentrations inhibiting 90% of the strains (MIC 90) were 0.008 mg/l for Vibrio cholerae, 0.016 mg/l for Aeromonas hydrophila, 0.032 mg/l for Vibrio cholerae non 01, 0.064 mg/l for Vibrio parahaemolyticus, Yersinia enterocolitica 03, enterotoxigenic (ETEC) and enteropathogenic (EPEC) Escherichia coli and Shigella species, 0.125 mg/l for Salmonella species, and 0.5 mg/l for Campylobacter species. Resistance to one or several of the other drugs was seen with higher or lower frequency in all the bacterial species tested. No cross-resistance between any of the other agents and norfloxacin was recorded.

Traveller's diarrhea among Austrian tourists to warm climate countries: II. Clinical features

The syndrome "Traveller's Diarrhea" (TD) is important for tourists travelling to warm-climate countries. In this study a worldwide survey on the clinical features of enteritis among 1,455 Austrian tourists is reported. The clinical parameters of TD show that this disease exhibits a very uniform clinical course which is not influenced by different regions with considerable differences in aetiology or by travel-associated parameters such as accommodation, travel style and individual dietary hygiene: TD starts mainly at the end of first week of the stay and the average duration of illness is 3.6 +/- 2.7 days. Watery and mucous stools were reported by 99% of patients with a frequency of 4 bowel movements per day, while bloody diarrhea occurred very rarely. However, 57.2% of patients suffered from abdominal cramps, less than one third of patients reported nausea and/or vomiting and fever accompanied the acute disease in 13%. Symptoms indicate that TD should not be considered a severe disease. The diarrheal illness will show the characteristics of an enteroinvasive disease only in rare cases. Treatment of TD is discussed: symptomatic or other non-antibiotic agents are preferable as antibiotics will only occasionally be necessary for treatment of an illness with a self-limiting character. For prophylaxis of TD, the preferable way to resolve the problem of TD in international travel, very few effective preparations are currently available, emphasizing the need for extensive research in this field.

Traveller's diarrhea among Austrian tourists in warm climate countries: I. Epidemiology

Travellers from temperate climates to the tropics of the Third World face a high risk of acquiring traveller's diarrhea. Epidemiology plays a major role in the exact description of this syndrome. This paper describes the epidemiology of traveller's diarrhea in 3696 Austrian tourists and the influence of various epidemiologic parameters on incidence is evaluated. Destination and season of travel influences attack rates, in particular in the sub-tropics. High (up to app. 60% incidence) and low risk (below 35% incidence) regions can be described, exhibiting risk differences of nearly 100%. Individual parameters, like age and body weight, can influence the risk in an evident manner and, or course, the duration of stay plays a major role. It is pointed out that accommodation and travel characteristics are important factors for risk evaluation, as well as dietary hygiene.

Acute invasive diarrhea in the pediatric patient

In acute invasive diarrhea, the pathogen penetrates the epithelial cells of the intestinal mucosa. Symptoms are produced by one or more of the following mechanisms: production of enterotoxins, increased synthesis of prostaglandins, and impaired reabsorption of fluids and electrolytes. The invasive process often results in dysentery, which is characterized by watery stools containing blood and mucus, accompanied by cramps, rectal burning, fever, and, sometimes, toxicity. Among the complications are bacteremia and toxic megacolon. Diagnosis is based on the patient's clinical condition and examination of stools. Microscopic examination of stools can rule out parasites and detect leukocytes, particularly polymorphonuclear leukocytes, a finding that suggests a bacterial origin for the disease. Because most patients are not severely dehydrated, rehydration is not the mainstay of treatment; in most cases, fluids can be replaced orally. Absorbents are ineffective, and antiperistaltic drugs should not be used routinely in children. Although often unnecessary in simple cases of invasive diarrhea, antimicrobials are useful when risk factors related to age, clinical condition, malnourishment, dehydration, or underlying disease are present. In such cases, antimicrobial therapy should begin when the clinical diagnosis has been made, to ensure the best clinical response.

Two outbreaks of Yersinia pseudotuberculosis 5a infection in Japan

In the summer of 1984 there occurred 2 outbreaks of infection with Yersinia pseudotuberculosis 5a. 58 persons ate meat products, vegetables and rice at a Japanese barbecue restaurant. 39/58 (67%) developed symptoms. In 19/39 persons an infection with Y. pseudotuberculosis could be diagnosed by stool cultures and/or serological techniques. Fever occurred in all patients, exanthema in 68% and abdominal pain in 68%. Thus, human yersiniosis due to Y. pseudotuberculosis 5a could be a febrile disease with exanthema and gastrointestinal disturbances. A transient acute renal failure developed around the 10th day of illness in 4 children. The source and mode of spread of this infection could not be clarified.