Disease due to enterotoxigenic Escherichia coli in Bangladeshi adults: clinical aspects and a controlled trial of tetracycline

Human β-Defensin 118 Attenuates Escherichia coli K88-Induced Inflammation and Intestinal Injury in Mice

Antibiotics are widely used to treat various inflammatory bowel diseases caused by enterotoxigenic Escherichia coli (ETEC). However, continuous use of antibiotics may lead to drug resistance. In this study, we investigated the role of human β-defensin 118 (DEFB118) in regulating the ETEC-induced inflammation and intestinal injury. ETEC-challenged or non-challenged mice were treated by different concentrations of DEFB118. We show that ETEC infection significantly increased fecal score (P < 0.05) and serum concentrations of interlukin-6 (IL-6) and tumor necrosis factor-α (TNF-α). Moreover, the concentrations of D-lactic acid, C-reactive protein (CRP), creatinine (CREA), and urea (P < 0.05) were both increased in the ETEC-challenged mice. However, DEFB118 significantly decreased their concentrations in the serum (P < 0.05). DEFB118 not only alleviated tissue damage in spleen upon ETEC challenge, but also increased the villus height in duodenum and ileum (P < 0.05). Moreover, DEFB118 improved the localization and abundance of tight junction protein ZO-1 in jejunal epithelium. Interestingly, DEFB118 decreased the expression levels of critical genes involving in mucosal inflammatory responses (NF-κB, TLR4, IL-1β, and TNF-α) and the apoptosis (caspase3) upon ETEC challenge (P < 0.05), whereas DEFB118 significantly upregulated the expression of mucosa functional genes such as the mucin1 (MUC1) and sodium-glucose transporter-1 (SGLT-1) in the ETEC-challenged mice (P < 0.05). These results indicated a novel function of the DEFB118. The anti-inflammatory effect of DEFB118 should make it an attractive candidate to prevent various bacteria-induced inflammatory bowel diseases.

Resistance Pattern and Molecular Characterization of Enterotoxigenic Escherichia coli (ETEC) Strains Isolated in Bangladesh

Background

Enterotoxigenic Escherichia coli (ETEC) is a common cause of bacterial infection leading to acute watery diarrhea in infants and young children as well as in travellers to ETEC endemic countries. Ciprofloxacin is a broad-spectrum antimicrobial agent nowadays used for the treatment of diarrhea. This study aimed to characterize ciprofloxacin resistant ETEC strains isolated from diarrheal patients in Bangladesh.

Methods

A total of 8580 stool specimens from diarrheal patients attending the icddr,b Dhaka hospital was screened for ETEC between 2005 and 2009. PCR and Ganglioside GM1- Enzyme Linked Immuno sorbent Assay (ELISA) was used for detection of Heat labile (LT) and Heat stable (ST) toxins of ETEC. Antimicrobial susceptibilities for commonly used antibiotics and the minimum inhibitory concentration (MIC) of nalidixic acid, ciprofloxacin and azithromycin were examined. DNA sequencing of representative ciprofloxacin resistant strains was performed to analyze mutations of the quinolone resistance-determining region of gyrA, gyrB, parC and parE. PCR was used for the detection of qnr, a plasmid mediated ciprofloxacin resistance gene. Clonal variations among ciprofloxacin resistant (Cip^R) and ciprofloxacin susceptible (Cip^S) strains were determined by Pulsed-field gel electrophoresis (PFGE).

Results

Among 1067 (12%) ETEC isolates identified, 42% produced LT/ST, 28% ST and 30% LT alone. Forty nine percent (n = 523) of the ETEC strains expressed one or more of the 13 tested colonization factors (CFs) as determined by dot blot immunoassay. Antibiotic resistance of the ETEC strains was observed as follows: ampicillin 66%, azithromycin 27%, ciprofloxacin 27%, ceftriazone 13%, cotrimaxazole 46%, doxycycline 44%, erythromycin 96%, nalidixic acid 83%, norfloxacin 27%, streptomycin 48% and tetracycline 42%. Resistance to ciprofloxacin increased from 13% in 2005 to 34% in 2009. None of the strains was resistant to mecillinam. The MIC of the nalidixic acid and ciprofloxacin of representative Cip^R strains were 256 μg/ml and 32μg/ml respectively. A single mutation (Ser⁸³-Leu) in gyrA was observed in the nalidixic acid resistant ETEC strains. In contrast, double mutation in gyrA (Ser⁸³-Leu, Asp⁸⁷-Asn) and a single mutation in parC (Glu⁸⁴-Ly) were found in ciprofloxacin resistant strains. Mutation of gyrB was not found in either the nalidixic acid or ciprofloxacin resistant strains. None of the ciprofloxacin resistant strains was found to be positive for the qnr gene. Diverse clones were identified from all ciprofloxacin resistant strains by PFGE analysis in both CF positive and CF negative ETEC strains.

Conclusion

Emergence of ciprofloxacin resistant ETEC strains results in a major challenge in current treatment strategies of ETEC diarrhea.

Aetiologies of diarrhoea in adults from urban and rural treatment facilities in Bangladesh

The objective of our analysis was to describe the aetiology, clinical features, and socio-demographic background of adults with diarrhoea attending different urban and rural diarrhoeal disease hospitals in Bangladesh. Between January 2010 and December 2011, a total of 5054 adult diarrhoeal patients aged ⩾20 years were enrolled into the Diarrhoeal Disease Surveillance Systems at four different hospitals (two rural and two urban) of Bangladesh. Middle-aged [adjusted odds ratio (aOR) 0·28, 95% confidence interval (CI) 0·23-0·35, P < 0·001] and elderly (aOR 0·15, 95% CI 0·11-0·20, P < 0·001) patients were more likely to present to rural diarrhoeal disease facilities than urban ones. Vibrio cholerae was the most commonly isolated pathogen (16%) of the four pathogens tested followed by rotavirus (5%), enterotoxigenic Escherichia coli (ETEC) (4%), and Shigella (4%). Of these pathogens, V. cholerae (19% vs. 11%, P < 0·001), ETEC (9% vs. 4%, P < 0·001), and rotavirus (5% vs. 3%, P = 0·013) were more commonly detected from patients presenting to urban hospitals than rural hospitals, but Shigella was more frequently isolated from patients presenting to rural hospitals than urban hospitals (7% vs. 2%, P < 0·001). The isolation rate of Shigella was higher in the elderly than in younger adults (8% vs. 3%, P < 0·001). Some or severe dehydration was higher in urban adults than rural adults (P < 0·001). Our findings indicate that despite economic and other progress made, conditions facilitating transmission of V. cholerae and Shigella prevail in adults with diarrhoea in Bangladesh and further efforts are needed to control these infections.

Shift in phenotypic characteristics of enterotoxigenic Escherichia coli (ETEC) isolated from diarrheal patients in Bangladesh

Background

Enterotoxigenic Escherichia coli (ETEC) is one of the most common causes of bacterial diarrhea. Over the last decade, from 1996 to 2012, changes in the virulence antigen properties of ETEC such as heat labile (LT) and heat stable (ST) toxins, colonization factors (CFs), and ‘O’-serogroups have been observed. The aim of this prospective study was to compare changes in antigenic profiles of ETEC strains isolated from a 2% surveillance system at the icddr,b hospital in Dhaka, Bangladesh between 2007–2012 and an earlier time period of 1996–1998 conducted at the same surveillance site.

Methodology

In the surveillance system every 50^th patient attending the hospital was screened for major enteric pathogens including ETEC, Vibrio cholerae, Shigella spp. and Salmonella spp. from January 2007 to December 2012.

Principal Findings

Of the 15,152 diarrheal specimens tested between 2007–2012, the overall rate of ETEC isolation was 11%; of these, 43% were LT/ST, 27% LT and 30% ST positive. Isolation rate of ST-ETEC (p<0.009) and LT/ST ETEC (p<0.011) during 2007–2012 period differed significantly compared to those seen between 1996–1998. In comparison to the 1996–1998 period, difference in CF profile of ETEC isolates during 2007–2012 was observed particularly for strains expressing CS7 (12.4%), CS14 (9.5%) and CS17 (10.0%). The predominant CF types were CS5+CS6, CFA/I, CS7, CS17, CS1+CS3, CS6 and CS14. The most common serogroups among the CF positive ETEC isolates were O115, O114, O6, O25 and O8. A strong association was found between CFs and ‘O’ serogroups i.e. between CS5+CS6 and (O115 and O126); CS7 and (O114), CFA/I and (O78 and O126), CS17 and (O8 and O167) and CS1/CS2+CS3 and (O6).

Conclusion

The analyses show a shift in prevalence of antigenic types of ETEC over the study period; the information is important in designing effective ETEC vaccines with broad protective coverage.

Diarrheal diseases constitute a major health problem in Bangladesh, where Vibrio cholerae and enterotoxigenic Escherichia coli (ETEC) are two most important causes of bacterial diarrhea. Prevention through vaccination is helpful to reduce the incidence and severity of diarrheal disease due to ETEC, particularly among children in low-resource settings. In this context, we collected stool and/or rectal swab (RS) specimens from patients with diarrhea between 2007 to 2012 under the 2% systematic routine surveillance system at the icddr,b hospital in Dhaka, Bangladesh and screened for ETEC infection. We tested the specimens for two major virulence factors of ETEC: toxins and colonization factors. In this research article, we have focused on changes in toxin as well as colonization factor profiles of ETEC strains isolated from diarrheal patients seeking care at the icddr,b hospital between 2007–2012 and an earlier time period of 1996–1998. We concluded that, such shift in antigenic profile of ETEC over the study period is important in designing effective ETEC vaccines with broad protective coverage.

T4-like phage Bp7, a potential antimicrobial agent for controlling drug-resistant Escherichia coli in chickens

Chicken-pathogenic Escherichia coli is severely endangering the poultry industry in China and worldwide, and antibiotic therapy is facing an increasing problem of antibiotic resistance. Bacteriophages can kill bacteria with no known activity in human or animal cells, making them an attractive alternative to antibiotics. In this study, we present the characteristics of a novel virulent bacteriophage, Bp7, specifically infecting pathogenic multidrug-resistant E. coli. Phage Bp7 was isolated from chicken feces. Bp7 belongs to the family Myoviridae, possessing an elongated icosahedral head and contractile sheathed tail. It has a 168-kb double-stranded DNA genome. For larger yields, its optimal multiplicity of infection (MOI) to infect E. coli was about 0.001. The latent period was 10 to 15 min, and the burst size was 90 PFU/infected cell. It was stable both at pH 5.0 to 10.0 and at 40°C or 50°C for at least 1 h. Bp7 could infect 46% of pathogenic clinical E. coli strains. Bp7 harbored 791 open reading frames (ORFs) and 263 possible genes. Among the 263 genes, 199 possessed amino acid sequence identities with ORFs of phage T4, 62 had identities with other T4-like phages, and only one lacked any database match. The genome of Bp7 manifested obvious division and rearrangement compared to phages T4, JS98, and IME08. Bp7 is a new member of the "T4-like" genus, family Myoviridae. Its wide host range, strong cell-killing activity, and high stability to pH make it an alternative to antimicrobials for controlling drug-resistant E. coli in chickens.

Progress and hurdles in the development of vaccines against enterotoxigenic Escherichia coli in humans

Diarrhea is the second leading cause of death in children younger than 5 years. Enterotoxigenic Escherichia coli (ETEC) strains are the most common bacterial cause of diarrhea in young children living in endemic countries and children and adults traveling to these areas. Pathogenesis of ETEC diarrhea has been well studied, and the key virulence factors are bacterial colonization factor antigens and enterotoxins produced by ETEC strains. Colonization factor antigens mediate bacteria attachment to host small intestinal epithelial cells and subsequent colonization, whereas enterotoxins including heat-labile and heat-stable toxins disrupt fluid homeostasis in host epithelial cells, which leads to fluid and electrolyte hypersecretion and diarrhea. Vaccines stimulating host anti-adhesin immunity to block ETEC attachment and colonization and also antitoxin immunity to neutralize enterotoxicity are considered optimal for prevention of ETEC diarrhea. Vaccines under development have been designed to stimulate local intestinal immunity and are either oral vaccines or transcutaneous vaccines. A cholera vaccine (Dukoral®) does stimulate anti-heat-labile toxin immunity and is licensed for short-term protection of ETEC diarrhea in travelers in some countries. Newer experimental ETEC vaccine candidates are being developed with hope to provide long-lasting and more broad-based protection against ETEC. Some have shown promising results in safety and immunogenicity studies and are approaching field trials for efficacy. A key problem is the development of a vaccine that is both practical and inexpensive so that it can be affordable for use in poor countries where it is needed.

Enterotoxigenic Escherichia coli (ETEC): a recurring decimal in infants' and travelers' diarrhea

Enterotoxigenic Escherichia coli (ETEC) is an important cause of diarrhea in infants and in travelers from developed to underdeveloped countries, especially in regions of poor sanitation. The ETEC are acquired by the ingestion of contaminated food and water, and adults living in endemic areas develop immunity. The disease condition manifests as a minor discomfort to a severe cholera-like syndrome and requires colonization by the microorganism and the elaboration of one or more enterotoxins. The ETEC attach to the epithelial cells of the gastrointestinal tract and release substances that affect the normal functioning of the tract, thereby resulting in diarrhea, and subsequently millions of deaths everyday, particularly in children. The prevention of the spread of this strain of diarrheagenic E. coli depends on ensuring appropriate sanitary measures; hand-washing and proper preparation of food; chlorination of water supplies; and appropriate sewage treatment and disposal. Parenteral or oral fluid and electrolyte replacement is used to prevent dehydration, and broad-spectrum antibiotics are used in chronic or life-threatening cases, but in most cases, should be avoided because of severe side effects.

Genome analysis of phage JS98 defines a fourth major subgroup of T4-like phages in Escherichia coli

Numerous T4-like Escherichia coli phages were isolated from human stool and environmental wastewater samples in Bangladesh and Switzerland. The sequences of the major head gene (g23) revealed that these coliphages could be placed into four subgroups, represented by the phages T4, RB69, RB49, and JS98. Thus, JS98 defines a new major subgroup of E. coli T4-like phages. We conducted an analysis of the 169-kb JS98 genome sequence. Overall, 198 of the 266 JS98 open reading frames (ORFs) shared amino acid sequence identity with the reference T4 phage, 41 shared identity with other T4-like phages, and 27 ORFs lacked any database matches. Genes on the plus strand encoded virion proteins, which showed moderate to high sequence identity with T4 proteins. The right genome half of JS98 showed a higher degree of sequence conservation with T4 and RB69, even for the nonstructural genes, than did the left genome half, containing exclusively nonstructural genes. Most of the JS98-specific genes were found in the left genome half. Two came as a hypervariability cluster, but most represented isolated genes, suggesting that they were acquired separately in multiple acquisition events. No evidence for DNA exchange between JS98 phage and the E. coli host genome or coliphages other than T4 was observed. No undesired genes which could compromise its medical use were detected in the JS98 genome sequence.

Infectious diarrhea in developed and developing countries

Diarrhea from gastrointestinal infection remains a common problem. In industrialized countries, management is aimed at reducing morbidity and defining groups that may benefit from further investigation. Most infectious diarrhea is self-limiting and only requires supportive management. Viral agents are increasingly recognized as causative agents of epidemic and sporadic diarrhea. In developing countries, diarrhea is a major cause of mortality in children. Oral rehydration therapy, guided by a clinical assessment of the degree of dehydration, is cheap, simple, and effective and remains the mainstay of management of infant diarrhea. Controversies focus on the optimal formulation of oral rehydration solution. A vaccine against rotavirus has the potential to save millions of lives worldwide.

Enterotoxigenic Escherichia coli in developing countries: epidemiology, microbiology, clinical features, treatment, and prevention

ETEC is an underrecognized but extremely important cause of diarrhea in the developing world where there is inadequate clean water and poor sanitation. It is the most frequent bacterial cause of diarrhea in children and adults living in these areas and also the most common cause of traveler's diarrhea. ETEC diarrhea is most frequently seen in children, suggesting that a protective immune response occurs with age. The pathogenesis of ETEC-induced diarrhea is similar to that of cholera and includes the production of enterotoxins and colonization factors. The clinical symptoms of ETEC infection can range from mild diarrhea to a severe cholera-like syndrome. The effective treatment of ETEC diarrhea by rehydration is similar to treatment for cholera, but antibiotics are not used routinely for treatment except in traveler's diarrhea. The frequency and characterization of ETEC on a worldwide scale are inadequate because of the difficulty in recognizing the organisms; no simple diagnostic tests are presently available. Protection strategies, as for other enteric infections, include improvements in hygiene and development of effective vaccines. Increases in antimicrobial resistance will dictate the drugs used for the treatment of traveler's diarrhea. Efforts need to be made to improve our understanding of the worldwide importance of ETEC.

The role of antibiotics in the treatment of infectious diarrhea

Infectious diarrhea is a significant cause of morbidity and mortality and a common complaint in clinical practice. Routine empirical use of antibiotics for infectious diarrhea should be avoided because of the self-limited nature of most cases, the cost of antibiotics, and the potential to worsen the already significant problem of antibiotic resistance of enteric pathogens. For patients with severe invasive or prolonged diarrhea or who are at high risk of complications, such as the elderly, diabetics, cirrhotics, and immunocompromised patients, empirical treatment with a quinolone antibiotic for 3 to 5 days can be considered. Antibiotic treatment can be highly effective for Shigella, ETEC, and V. cholerae infections, and metronidazole is indicated for C. difficile colitis. The impact of antibiotics for other specific pathogens is modest, and antibiotic therapy should be reserved for the same group of patients who would be considered for empirical treatment. The most significant problem in the antibiotic treatment of infectious diarrhea is the progressive increase in resistance among enteric pathogens; only the prudent use of antimicrobials in all areas of daily practice can limit or delay the impact of this serious problem.

Quinolone resistance in enterotoxigenic Escherichia coli causing diarrhea in travelers to India in comparison with other geographical areas

Enterotoxigenic Escherichia coli isolates were identified as a cause of traveler's diarrhea in 82 of 520 (16%) patients and tested for resistance to seven antimicrobial agents. Thirty patients (36%) needed antimicrobial therapy: 17 (56%) for persistence of symptoms and 13 (44%) for severity of symptoms. Ampicillin, tetracycline, and trimethoprim-sulfamethoxazole resistance was high. Chloramphenicol showed moderate activity, and amoxicillin plus clavulanic acid, nalidixic acid, and ciprofloxacin showed very good activity. Five nalidixic acid-resistant strains were isolated, four from patients visiting India.

Prevalence of toxin types and colonization factors in enterotoxigenic Escherichia coli isolated during a 2-year period from diarrheal patients in Bangladesh

The prevalence of toxin types and colonization factors (CFs) of enterotoxigenic Escherichia coli (ETEC) was prospectively studied with fresh samples (n = 4,662) obtained from a 2% routine surveillance of diarrheal stool samples over 2 years, from September 1996 to August 1998. Stool samples were tested by enzyme-linked immunoassay techniques and with specific monoclonal antibodies for the toxins and CFs. The prevalence of ETEC was 14% (n = 662), with over 70% of the strains isolated from children 0 to 5 years of age, of whom 93% were in the 0- to 3-year-old age range. Of the total ETEC isolates, 49.4% were positive for the heat-stable toxin (ST), 25.4% were positive for the heat-labile toxin (LT) only, and 25.2% were positive for both LT and ST. The rate of ETEC isolation peaked in the hot summer months of May to September and decreased in winter. About 56% of the samples were positive for 1 or more of the 12 CFs that were screened for. The coli surface antigens CS4, CS5, and/or CS6 of the colonization factor antigen (CFA)/IV complex were most prevalent (incidence, 31%), followed by CFA/I (23.5%) and coli surface antigens CS1, CS2, and CS3 of CFA/II (21%). In addition, other CFs detected in decreasing order were CS7 (8%), CS14 (PCFO166) (7%), CS12 (PCFO159) (4%), CS17 (3%), and CS8 (CFA/III) (2.7%). The ST- or LT- and ST-positive ETEC isolates expressed the CFs known to be the most prevalent (i.e., CFA/I, CFA/II, and CFA/IV), while the strains positive for LT only did not. Among children who were infected with ETEC as the single pathogen, a trend of relatively more severe disease in children infected with ST-positive (P < 0.001) or LT- and ST-positive (P < 0.001) ETEC isolates compared to the severity of the disease in children infected with LT only-positive ETEC isolates was seen. This study supports the fact that ETEC is still a major cause of childhood diarrhea in Bangladesh, especially in children up to 3 years of age, and that measures to prevent such infections are needed in developing countries.

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.

Diarrhoea caused by Escherichia coli

Since the mid-1940s, Escherichia coli has been recognized as a cause of diarrhoea. Subsequently it has been shown that at least five different pathogenic mechanisms are used to cause disease. Enterotoxigenic E. coli (ETEC) and enteropathogenic E. coli (EPEC) produce a noninflammatory diarrhoea, whereas enteroinvasive E. coli (EIEC), enterohaemorrhagic E. coli (EHEC) and enteroaggregative E. coli (EAggEC) produce an inflammatory diarrhoea. ETEC are a major cause of diarrhoea in infants (up to three episodes per year) and travellers. They produce diarrhoea by attaching to the small intestinal mucosa and elaborate one or both of heat labile and heat stable toxins. EPEC attach firmly to the intestinal mucosa leading to dissolution of the brush border by inducing vesiculation of the microvilli. This process is known as attaching-effacement, and in the jejunum and ileum results in a loss of brush border disaccharidase enzymes and a large area of absorptive surface. EPEC are a major cause of summer diarrhoea in infants and neonatal diarrhoea. EIEC attach to colonic enterocytes, penetrate by an endocytotic mechanism and replicate therein. This results in necrosis and stripping of large areas of colonic mucosa and a dysentery similar to but usually less severe than Shigella dysentery. EHEC produce attaching-effacement to the terminal ileal and colonic mucosa and release the toxins, verocytotoxin (VT) 1 or 2. These kill colonic enterocytes and produce haemorrhagic colitis. In addition, VT can damage vascular endothelial cells, leading to haemolytic uraemic syndrome. The role of EHEC in diarrhoea in children in the tropics is not known. The most recently described group are the EAggEC. They damage and blunt colonic villi by haemorrhagic necrosis, although the precise pathogenic mechanisms are unclear. EAggEC are a major cause of chronic diarrhoea in children. Although certain O-serotypes are associated with the different enteropathic E. coli, serotyping is not sufficiently specific or sensitive for use as a diagnostic tool. Specific diagnosis is expensive and time consuming and depends upon demonstration of the pathogenicity trait, and the pathogenicity gene(s) or their gene product(s). At present, to undertake such testing is not recommended for routine diagnosis but is most useful when surveys of the aetiology of acute and chronic diarrhoea are undertaken.

Review article: antibiotics and the gut

Antibiotics have an important place in the management of gastrointestinal disease. Recent studies have demonstrated efficacy in acute bacterial gastroenteritis caused by salmonellae and campylobacteriaceae, shigellae and enterotoxigenic strains of E coli (ETEC). Tetracycline remains effective in cholera. Antibiotic resistance is widespread amongst the enteric pathogens and can quickly spread during epidemics of infective diarrhoeas. It is important that antibiotics are reserved for the treatment of serious infections lest their effectiveness in these conditions be lost. Campylobacter pylori appears to be an important cause of chronic active gastritis and is amenable to treatment with antibiotics and bismuth salts. The role of C. pylori in the pathogenesis of peptic ulcer disease is not yet established but there is mounting evidence that antibiotic treatment will have a place in the treatment of this common condition. The effect of antibiotics on the normal intestinal microflora can have serious consequences. It is a major cause of resistance in urinary tract pathogens, can result in outbreaks of hospital infection with resistant organisms and frequently results in C. difficile associated diarrhoea.

Nonfluid therapy and selected chemoprophylaxis of acute diarrhea

Various available forms of therapy can decrease morbidity and mortality associated with acute diarrhea. Oral fluids represent the cornerstone of therapy of all cases. A variety of agents acting nonspecifically can decrease diarrhea and improve other worrisome symptoms associated with enteric infection. Kaopectate makes the stool more formed but has little additional effects. Bismuth subsalicylate, an antisecretory agent, reduces the number of stools passed by about 50 percent and improves other associated symptomatology. The drugs that affect motility such as loperamide and diphenoxylate are the most active of the nonspecifically acting drugs. They must be avoided in patients with significant fever and dysentery. Trimethoprim/sulfamethoxazole is now considered the drug of choice for shigellosis due to the presence of ampicillin-resistant Shigella strains in most regions of the world. Trimethoprim/sulfamethoxazole is also an effective form of therapy for enterotoxigenic Escherichia coli infection and for traveler's diarrhea without definable cause. Erythromycin, although not proved to be effective against Campylobacter, probably shortens the disease. Furazolidone, although not dramatically effective, has a spectrum of activity that includes Shigella, enterotoxigenic E. coli, Campylobacter, and Giardia lamblia. It may not be effective in severely ill (hospitalized) patients with diarrhea. The various forms of available therapy can be administered empirically, depending on symptomatology. Mildly ill patients (one to three unformed stools in 24 hours with minimal additional symptoms) probably are best treated with fluids only. Mild to moderately ill persons (three to six unformed stools in 24 hours) can be treated with a drug that acts nonspecifically, such as bismuth subsalicylate or loperamide. Those with severe diseases (six or more unformed stools with moderate to severe associated symptoms), particularly when associated with fever and the passage of bloody mucoid stools, may be given an antimicrobial agent. The antimicrobial drug given will be determined by ancillary laboratory tests (dark-field examination or examination of a wet-mount preparation for motile Campylobacter or stool culture for Shigella, Campylobacter, or Salmonella) or may be administered on an empiric basis. Traveler's diarrhea can be eliminated in selected persons by the administration of a pharmacologic agent. Liquid bismuth subsalicylate is effective in large doses, which may be impractical. Studies with the tablet formulation suggest that it is partially effective in preventing the illness. Doxycycline and trimethoprim/sulfamethoxazole are more effective, particularly when admini

Traveler's diarrhea

Three hundred million people, mostly tourists, participate in international travel each year. Development of an acute diarrheal syndrome abroad, while returning home, or shortly after arriving home is referred to as traveler's diarrhea (TD). TD is not a specific diagnosis but, rather, a clinical syndrome with multiple etiologies. In this article, clinical and epidemiological features of TD, specific etiologies and their pathogenesis, as well as current means of diagnosis, treatment, and prevention will be reviewed.

A controlled study of endemic sporadic diarrhoea among adult residents of southern Brazil

The aetiology of sporadic summer diarrhoea and enterotoxin (LT) antibody titres was studied among 43 adult patients in southern Brazil who had an acute, untreated diarrhoeal illness and 43 age- and sex-matched controls from the same area. A potential pathogen was identified in 33 of 34 patients and in 17 of 43 controls (p less than 0.01). 10 Shigella, one invasive Escherichia coli, one Salmonella and one Entamoeba histolytica were identified in 17 patients with inflammatory diarrhoea (faecal polymorphonuclear neutrophil leucocytes (PMN) present). In the other four only enterotoxigenic strains of E. coli were identified. Among 26 patients with non-inflammatory (no faecal PMN) diarrhoea, heat-stable (ST) toxin-producing coliforms were the most common pathogens isolated (27%). Heat-labile (LT) toxin-producing coliforms or serological rises to LT were seen in five patients, Strongyloides larvae in five, Giardia lamblia trophozoites in four and an LT-producing Salmonella in one. No pathogen was found in 10 patients with non-inflammatory diarrhoea. Among 43 controls, 11 LT coliforms, two Shigella and two Strongyloides larvae were found. 40 of 41 controls had detectable serum anti-LT antibody. A single ST-producing E. coli was found in one other control. No pathogen was identified in 26 controls. No rotaviruses or Norwalk-like viral agents were seen by direct or immune electron microscopy of stool filtrates. While LT-producing E. coli are frequently associated with endemic summer childhood diarrhoea in southern Brazil and are recognized causes of travellers' diarrhoea, this study shows that they are often carried asymptomatically by adults living in this region.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in serotypes of enterotoxigenic Escherichia coli in Dhaka over time: usefulness of polyvalent antisera

The finding that enterotoxigenic (ET) Escherichia coli strains from many geographic areas belong to a limited number of serogroups led investigators to hope that polyvalent antisera could be used to screen for ET E. coli in areas of the world where more complicated tests of toxigenicity are not available. We compared the serotypes of 207 ET E. coli strains obtained from patients attending the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh, in 1980 with results obtained from similar surveys conducted in 1976 and 1978. During that time the distribution of serogroups changed significantly so that only 46% of our strains had O serogroups included in the polyvalent antisera capable of detecting 66% of ET E. coli strains in 1978. O167, a serogroup which was not included previously, was the third most common serogroup in our study. These findings suggest that polyvalent antisera used to screen for ET E. coli need to be reassessed over time as well as in different geographic areas and may not be as useful for field diagnosis as was originally hoped.

Value of stool examination in patients with diarrhoea

Findings of stool examinations in 1593 patients with diarrhoea due to a single enteric pathogen--enterotoxigenic Escherichia coli rotavirus, Shigella, Campylobacter jejuni, Vibrio cholerae 0:1, Entamoeba histolytica, or Giardia lamblia--were reviewed to determine how well they predicted the agent associated with the diarrhoea. Specimens were examined visually for blood and mucus, tested for pH, and examined under a microscope for the presence of red and white blood cells, parasites, and stool fat. Although visible blood was more common in specimens from patients infected with Shigella (51%) and Ent histolytica (39%) than in those from patients infected with other agents (6%; p less than 0.01), patients infected with Shigella were most likely to have numerous faecal leucocytes (greater than 50/high power field: 39% v 8% of all patients and 7% of patients infected with Ent histolytica, p less than 0.01 in both cases). Patients infected with enterotoxigenic E coli, rotavirus, V cholerae 0:1, or C jejuni had loose stools with fewer red or white cells. Patients infected with rotavirus and C jejuni were more likely to have acid stools with 3 to 4+ fat, but these findings were related to young age and breast feeding. Stool examination is most useful in establishing a diagnosis of dysentery and in helping to distinguish between patients infected with Shigella and Ent histolytica; it is of limited usefulness in discriminating between pathogens causing watery diarrhoea.

Genetic transfer of antimicrobial resistance and enterotoxigenicity among Escherichia coli strains

To understand the role of enterotoxin (Ent) plasmids in epidemics of enterotoxigenic (ET) Escherichia coli diarrhea in the United States, we studied the genetics of Ent plasmids in relation to E. coli serotypes and R plasmids. Twenty-nine ET E. coli strains, including all epidemic isolates available at the Centers for Disease Control, Atlanta, Ga. (CDC), were assessed for the ability to transfer antimicrobial resistances (if present) by conjugation, to mobilize a nonconjugative R plasmid, and to cotransfer enterotoxigenicity with R determinants. Of the 12 ET E. coli strains isolated in the United States, 5 were able to transfer R plasmids; one strain cotransferred detectable enterotoxigenicity. Another four U.S. isolates were able to mobilize plasmid DNA, but no toxin production was detected in transconjugants. Of 17 resistant ET E. coli from South Asia, 13 were able to transfer R plasmids; 5 of those 13 cotransferred detectable Ent plasmids. In all, 22 ET E. coli strains (76%) were able to initiate conjugation and genetic transfers. Six of these strains (20%) were able to cotransfer enterotoxigenicity with a conjugative R plasmid at a detectable frequency. One of the six strains transferred R and Ent determinants on a single plasmid. These data are addressed in relation to the observed immobility of Ent and R during outbreaks of ET E. coli, the efficacy of prophylactic tetracycline, and the worldwide occurrence of a limited number of ET E. coli serotypes.

CFA/I-ST plasmids: comparison of enterotoxigenic Escherichia coli (ETEC) of serogroups O25, O63, O78, and O128 and mobilization from an R factor-containing epidemic ETEC isolate

Colonization factor antigen I (CFA/I) plays an important role in the pathogenesis of diarrhea due to enterotoxigenic Escherichia coli. In this study, we examined 11 CFA/I+ enterotoxigenic E. coli from serogroups O25, O63, O78, and O128 and found that with all strains, spontaneous loss of CFA/I was associated with the loss of heat-stable toxin (ST) and with the loss of a single plasmid ranging in size from 54 to 60 megadaltons; when heat-labile toxin was lost, this was associated with the loss of another plasmid. The R factor of one strain, TX432 (O78:H12:CFA/I+; ST+), was found to mobilize the CFA/I-ST plasmid into E. coli K-12 at a frequency of 20%. These studies provide further evidence that CFA/I production is plasmid mediated in enterotoxigenic E. coli belonging to serogroups O25, O63, O78, and O128.

Host-specific fimbrial adhesins of noninvasive enterotoxigenic Escherichia coli strains

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