Causes and management of diarrhoea in children in a clinical setting

Evaluation of In Vitro Synergistic Effects of Tetracycline with Alkaloid-Related Compounds against Diarrhoeic Bacteria

Diarrhoea remains an important public health concern, particularly in developing countries, and has become difficult to treat because of antibacterial resistance. The development of synergistic antimicrobial agents appears to be a promising alternative treatment against diarrhoeic infections. In this study, the combined effect of tetracycline together with either nitroxoline, sanguinarine, or zinc pyrithione (representing various classes of plant-based compounds) was evaluated in vitro against selected diarrhoeic bacteria (Enterococcus faecalis, Escherichia coli, Listeria monocytogenes, Shigella flexneri, Vibrio parahaemolyticus, and Yersinia enterocolitica). The chequerboard method in 96-well microtiter plates was used to determine the sum of the fractional inhibitory concentration indices (FICIs). Three independent experiments were performed per combination, each in triplicate. It was observed that the combination of tetracycline with either nitroxoline, sanguinarine, or zinc pyrithione produced synergistic effects against most of the pathogenic bacteria tested, with FICI values ranging from 0.086 to 0.5. Tetracycline-nitroxoline combinations produced the greatest synergistic action against S. flexneri at a FICI value of 0.086. The combinations of the agents tested in this study can thus be used for the development of new anti-diarrhoeic medications. However, studies focusing on their in vivo anti-diarrhoeic activity and safety are required before any consideration for utilization in human medicine.

In Vitro Selective Combinatory Effect of Ciprofloxacin with Nitroxoline, Sanguinarine, and Zinc Pyrithione against Diarrhea-Causing and Gut Beneficial Bacteria

Antibiotic resistance in diarrhea-causing bacteria and its disruption of gut microbiota composition are health problems worldwide. The development of combinatory agents that increase the selective inhibitory effect (synergism) against diarrheagenic pathogens and, simultaneously, have a lowered impact (antagonism) or no negative action on the gut microbiota is therefore proposed as a new strategy efficient for chemotherapy against diarrheal conditions. In this study, the in vitro selective combinatory effect of ciprofloxacin with nitroxoline, sanguinarine, and zinc pyrithione, representing various classes of alkaloid-related compounds (nitroquinolines, benzylisoquinolines and metal-pyridine derivative complexes) against selected standard diarrhea-causing (Bacillus cereus, Enterococcus faecalis, Listeria monocytogenes, Shigella flexneri, and Vibrio parahaemolyticus) and gut-beneficial (Bifidobacterium adolescentis, Bifidobacterium animalis subsp. lactis, Bifidobacterium breve, Lactobacillus casei, and Lactobacillus rhamnosus) bacteria, was evaluated according to the sum of fractional inhibitory concentration indices (FICIs) obtained by the checkerboard method. The results showed that the individual combination of ciprofloxacin with nitroxoline, sanguinarine, and zinc pyrithione produced a synergistic effect against the pathogenic bacteria, with FICI values ranging from 0.071 to 0.5, whereas their antagonistic interaction toward the Bifidobacterium strains (with FICI values ranging from 4.012 to 8.023) was observed. Ciprofloxacin-zinc pyrithione produced significant synergistic action against S. flexneri, whereas a strong antagonistic interaction was observed toward B. breve for the ciprofloxacin-nitroxoline combination. These findings suggest that certain combinations of agents tested in this study can be used for the development of antidiarrheal therapeutic agents with reduced harmful action on the gastrointestinal microbiome. However, further studies focused on their pharmacological efficacy and safety are needed before they are considered for clinical trials. IMPORTANCE Diarrheal infections, which are commonly treated by antibiotics, are still responsible for over 4 to 5 million cases of human deaths annually. Moreover, the rising incidence of antibiotic resistance and its negative effect on beneficial bacteria (e.g., Bifidobacteria) of the gut microbial community are another problem. Thus, the development of selective agents able to inhibit diarrheal bacteria and, simultaneously, that have no negative impact on the gut microbiota, is important. Our results showed that individual combinations of ciprofloxacin with nitroxoline, sanguinarine, and zinc pyrithione produced synergism against the pathogenic bacteria, whereas their antagonistic interaction toward the beneficial strains was observed. The antagonism can be considered a positive effect contributing to the safety of the therapeutic agents, whereas their synergism against diarrheal bacteria significantly potentiates total antimicrobial efficacy. The certain combinations tested in this study can be used for the development of antidiarrheal agents with reduced harmful action on the gastrointestinal microbiome.

Evaluation of in-vivo antidiarrhoeal and in-vitro antibacterial activities of the root extract of Brucea antidysenterica J. F. Mill (Simaroubaceae)

BACKGROUND

Diarrhoea has been the major cause of death especially in children of developing countries. Brucea antidysenterica is one of the several medicinal plants used traditionally for the treatment of diarrhoea in Ethiopia. Hence, the present study was undertaken to investigate the antidiarrhoeal and antibacterial activities of the root extract of B. antidysenterica.

METHODS

Plant material was extracted by maceration technique using 80% methanol. The antidiarrhoeal activity was tested using castor oil-induced diarrhoea, castor oil-induced charcoal meal test, and castor oil-induced enteropooling models in mice. Whilst, the antibacterial activity of the crude extract was evaluated using agar well diffusion and broth microdilution methods.

RESULTS

The 80% methanolic crude extract significantly delayed the diarrhoeal onset at the two higher doses (p < 0.001) and it has also inhibited the number and weight of faecal output at all tested doses as compared with the negative control. Moreover, it showed a significant anti-motility effect (p < 0.001) at all tested doses. Whereas it displayed a significant reduction in the weight and volume of intestinal contents at the doses of 200 and 400 mg/kg (p < 0.01). The highest concentration (800 mg/mL) of test extract showed maximum zone of inhibition in all tested standard strains of bacteria (18.3 mm-22 mm). While MIC and MBC values (0.39 mg/mL and 1.56 mg/mL) showed that S. flexneri was the most susceptible pathogen for test extract.

CONCLUSION

The study revealed that the root extract of B. antidysenterica has antidiarrhoeal and antibacterial activities.

Assessment of the Management of Diarrhoea Among Children Under Five in Addis Ababa, Ethiopia

Purpose

Irrational antibiotic use is a worldwide problem. One of the main reasons for excessive use of antibiotics is the failure to follow the clinical guidelines. Inappropriate use of antibiotics for infectious diarrhea is associated with the risk of increasing the development of antimicrobial resistance and the cost of health care. We therefore pursued to assess the appropriateness of the management of diarrhea in children in Addis Ababa.

Materials and Methods

A retrospective cross-sectional study was conducted in the health centers of Addis Ababa, Ethiopia, between September 2014 and February 2015. Demographic characteristics, signs of dehydration, stool characteristics, drug types and other relevant information have been collected. Data analysis was performed using version 20 of the SPSS. Logistic regression was used to examine the association between dependent and independent variables. Indicators for the appropriateness of diarrhoea management have been established on the basis of the Standard Treatment Guideline and the guidelines of the World Health Organization.

Results

A total of 803 medical records of children have been checked. Of this, 54.4% had received inappropriate management. At least one antimicrobial was prescribed to 73.2% of the children who visited the health centres. Oral rehydration solution (ORS) and zinc were prescribed only in 66.7% and 47.5%, respectively. Appropriate management among children diagnosed with dysentery was found to be 6.38 times higher adjusted odds ratios (AOR=6.38 (3.11, 13.63)) than children with watery diarrhea. Although antibiotics are prescribed inappropriately for most children, it is appropriate when the diarrhea is bloody. Appropriate management of diarrhoea among infants aged 2-11 months was 54% less compared to children aged 12-59 months (AOR=0.46 (0.24, 0.90)).

Conclusion

The magnitude of inadequate antibiotic prescription while managing diarrhoea in our setting was high. On the contrary, a low prescribing rate of ORS and zinc was observed. Our result highlights the need for urgent action to prevent the development of antibiotic-resistant microorganisms. Health-care professionals should have clear information on the risks of inadequate diarrhoea treatment in children under five.

Diarrheagenic Escherichia coli Associated with Acute Gastroenteritis in Children from Soriano, Uruguay

INTRODUCTION

Acute diarrheal disease still deserves worldwide attention due to its high morbidity and mortality, especially in developing countries. While etiologic determination is not mandatory for management of all individual cases, it is needed for generating useful epidemiologic knowledge. Diarrheagenic Escherichia coli (DEC) are relevant enteropathogens, and their investigation requires specific procedures to which resources and training should be dedicated in reference laboratories.

METHODOLOGY

Following the hypothesis that enteric pathogens affecting children in towns located in the interior of Uruguay may be different from those found in Montevideo, we conducted a diagnostic survey on acute diarrheal disease in 83 children under 5 years of age from populations in the south of the country.

RESULTS

DEC pathotypes were the only bacterial pathogens found in diarrheal feces (20.48%), followed by rotavirus (14.45%) and enteric adenovirus (4.81%). Atypical EPEC (aEPEC) was the most frequent DEC pathotype identified, and unexpectedly, it was associated with bloody diarrheal cases. These patients were of concern and provided with early consultation, as were children who presented with vomiting, which occurred most frequently in rotavirus infections. aEPEC serotypes were diverse and different from those previously reported in Montevideo children within the same age group and different from serotypes identified in regional and international studies. Enteroinvasive (EIEC) O96 : H19, associated with large outbreaks in Europe, was also isolated from two patients. Antibiotic susceptibility of pathogenic bacteria identified in this study was higher than that observed in previous national studies, which had been mainly carried out in children from Montevideo.

CONCLUSION

The reduced number of detected species, the marked prevalence of aEPEC, the scarce resistance traits, and the diverse range of serotypes in the virulent DEC identified in this study confirm that differences exist between enteropathogens affecting children from interior towns of Uruguay and those circulating among children in Montevideo.

The global problem of childhood diarrhoeal diseases: emerging strategies in prevention and management

Acute diarrhoeal diseases remain a leading cause of global morbidity and mortality particularly among young children in resource-limited countries. Recent large studies utilizing case-control design, prospective sampling and more sensitive and broad diagnostic techniques have shed light on particular pathogens of importance and highlighted the previously under recognized impact of these infections on post-acute illness mortality and growth. Vaccination, particularly against rotavirus, has emerged as a key effective means of preventing significant morbidity and mortality from childhood diarrhoeal disease. Other candidate vaccines against leading diarrhoeal pathogens, such as enterotoxigenic Escherichia coli and Shigella spp., also hold significant promise in further ameliorating the burden of enteric infections in children. Large studies are also currently underway evaluating novel and potential easy-to-implement water, sanitation and hygiene (WASH) preventive strategies. Given the ongoing global burden of this illness, the paucity of new advances in case management over the last several decades remains a challenge. The increasing recognition of post-acute illness mortality and growth impairment has highlighted the need for interventions that go beyond management of dehydration and electrolyte disturbances. The few trials of novel promising interventions such as probiotics have mainly been conducted in high-income settings. Trials of antimicrobials have also been primarily conducted in high-income settings or in travellers from high-income settings. Bloody diarrhoea has been shown to be a poor marker of potentially treatable bacterial enteritis, and rising antimicrobial resistance has also made empiric antimicrobial therapy more challenging in many settings. Novel effective and sustainable interventions and diagnostic strategies are clearly needed to help improve case management. Diarrhoeal disease and other enteric infections remain an unmet challenge in global child health. Most promising recent developments have been focused around preventive measures, in particular vaccination. Further advances in prevention and case management including the possible use of targeted antimicrobial treatment are also required to fully address this critical burden on child health and human potential.

Management of Diarrhoeal Dehydration in Childhood: A Review for Clinicians in Developing Countries

The survival of a child with severe volume depletion at the emergency department depends on the competency of the first responder to recognize and promptly treat hypovolemic shock. Although the basic principles on fluid and electrolytes therapy have been investigated for decades, the topic remains a challenge, as consensus on clinical management protocol is difficult to reach, and more adverse events are reported from fluid administration than for any other drug. While the old principles proposed by Holliday and Segar, and Finberg have stood the test of time, recent systematic reviews and meta-analyses have highlighted the risk of hyponatraemia, and hyponatraemic encephalopathy in some children treated with hypotonic fluids. In the midst of conflicting literature on fluid and electrolytes therapy, it would appear that isotonic fluids are best suitable for the correction of hypotonic, isonatraemic, and hypernatraemic dehydration. Although oral rehydration therapy is adequate to correct mild to moderate isonatraemic dehydration, parenteral fluid therapy is safer for the child with severe dehydration and those with changes in serum sodium. The article reviews the pathophysiology of water and sodium metabolism and, it uses the clinical case examples to illustrate the bed-side approach to the management of three different types of dehydration using a pre-mixed isotonic fluid solution (with 20 or 40 mmol/L of potassium chloride added depending on the absence or presence of hypokalemia, respectively). When 3% sodium chloride is unavailable to treat hyponatraemic encephalopathy, 0.9% sodium chloride becomes inevitable, albeit, a closer monitoring of serum sodium is required. The importance of a keen and regular clinical and laboratory monitoring of a child being rehydrated is emphasized. The article would be valuable to clinicians in less-developed countries, who must use pre-mixed fluids, and who often cannot get some suitable rehydrating solutions.

Antidiarrheal Activity of Dissotis multiflora (Sm) Triana (Melastomataceae) Leaf Extract in Wistar Rats and Subacute Toxicity Evaluation

The present work was undertaken to evaluate antidiarrheal activity of ethanolic leaf extract of Dissotis multiflora (Sm) Triana (D. multiflora) on Shigella flexneri-induced diarrhea in Wistar rats and its subacute toxicity. Diarrhea was induced by oral administration of 1.2 × 10⁹ cells/mL S. flexneri to rats. Antidiarrheal activity was investigated in rats with the doses of 111.42 mg/kg, 222.84 mg/kg, and 445.68 mg/kg. The level of biochemical parameters was assessed and organs histology examined by 14 days' subacute toxicity. S. flexneri stool load decreased significantly in dose-dependent manner. The level of ALT increased (p < 0.05) in male rats treated with the dose of 445.68 mg/kg while creatinine level increased in rats treated with both doses. In female rats, a significant decrease (p < 0.05) of the level of AST and creatinine was noted in rats treated with the dose of 222.84 mg/kg of D. multiflora. Histological exams of kidney and liver of treated rats showed architectural modifications at the dose of 445.68 mg/kg. This finding suggests that D. multiflora leaf extract is efficient against diarrhea caused by S. flexneri but the treatment with doses lower than 222.84 mg/kg is recommended while further study is required to define the exact efficient nontoxic dose.

Oxidative and nitrosative stress defences of Helicobacter and Campylobacter species that counteract mammalian immunity

Helicobacter and Campylobacter species are Gram-negative microaerophilic host-associated heterotrophic bacteria that invade the digestive tract of humans and animals. Campylobacter jejuni is the major worldwide cause of foodborne gastroenteritis in humans, while Helicobacter pylori is ubiquitous in over half of the world's population causing gastric and duodenal ulcers. The colonisation of the gastrointestinal system by Helicobacter and Campylobacter relies on numerous cellular defences to sense the host environment and respond to adverse conditions, including those imposed by the host immunity. An important antimicrobial tool of the mammalian innate immune system is the generation of harmful oxidative and nitrosative stresses to which pathogens are exposed during phagocytosis. This review summarises the regulators, detoxifying enzymes and subversion mechanisms of Helicobacter and Campylobacter that ultimately promote the successful infection of humans.

Water use practices, water quality, and households' diarrheal encounters in communities along the Boro-Thamalakane-Boteti river system, Northern Botswana

BACKGROUND

Some rural African communities residing along rivers use the untreated river water for domestic purposes, making them vulnerable to waterborne diseases such as diarrhea.

METHODS

We determined water use practices and water quality, relating them to prevalence of diarrhea in communities along the Boro-Thamalakane-Boteti river system, northern Botswana. A total of 452 households were interviewed and 196 water samples collected show during February, May, September, and December 2012 in settlements of Boro, Maun, Xobe, Samedupi, Chanoga, and Motopi. Information was sought on water use practices (collection, storage, and handling) and diarrheal experience using questionnaires. Water quality was assessed for physicochemical and microbiological parameters using portable field meters and laboratory analysis, respectively.

RESULTS

All (100%) of the river water samples collected were fecally contaminated and unsuitable for domestic use without prior treatment. Samples had Escherichia coli (E.coli) and fecal streptococci levels reaching up to 186 and 140 CFU/100 ml, respectively. Study revealed high dependence on the fecally contaminated river water with low uptake of water treatment techniques. Up to 48% of households indicated that they experience diarrhea, with most cases occurring during the early flooding season (May). Nonetheless, there was no significant relationship between river water quality and households' diarrheal experience across studied settlements (p > 0.05). Failure to treat river water before use was a significant predictor of diarrhea (p = 0.028).

CONCLUSIONS

Even though the river water was unsafe for domestic use, results imply further recontamination of water at household level highlighting the need for simple and affordable household water treatment techniques.

Treatment of diarrhoea in rural African communities: an overview of measures to maximise the medicinal potentials of indigenous plants

Diarrhoea is a major cause of morbidity and mortality in rural communities in Africa, particularly in children under the age of five. This calls for the development of cost effective alternative strategies such as the use of herbal drugs in the treatment of diarrhoea in these communities. Expenses associated with the use of orthodox medicines have generated renewed interest and reliance on indigenous medicinal plants in the treatment and management of diarrhoeal infections in rural communities. The properties of many phenolic constituents of medicinal plants such as their ability to inhibit enteropooling and delay gastrointestinal transit are very useful in the control of diarrhoea, but problems such as scarcity of valuable medicinal plants, lack of standardization of methods of preparation, poor storage conditions and incertitude in some traditional health practitioners are issues that affect the efficacy and the practice of traditional medicine in rural African communities. This review appraises the current strategies used in the treatment of diarrhoea according to the Western orthodox and indigenous African health-care systems and points out major areas that could be targeted by health-promotion efforts as a means to improve management and alleviate suffering associated with diarrhoea in rural areas of the developing world. Community education and research with indigenous knowledge holders on ways to maximise the medicinal potentials in indigenous plants could improve diarrhoea management in African rural communities.