Nontyphoid salmonellosis in taiwan children: clinical manifestations, outcome and antibiotic resistance

Management and Outcomes of Salmonella Gastroenteritis in the Era of Rapid Molecular Testing

BACKGROUND AND OBJECTIVES

Molecular diagnostics provide a rapid and sensitive diagnosis of gastroenteritis compared with a stool culture. In this study, we seek to describe the changes in medical management and outcomes of children with Salmonella gastroenteritis as our hospital system adopted molecular diagnostics.

METHODS

This study is a retrospective chart review of children <18 years of age diagnosed with nontyphoidal Salmonella gastroenteritis between 2008 and 2018 at a large pediatric health care system in the southeastern United States. Those with immunocompromising conditions and hemoglobinopathies were excluded. Patients diagnosed via molecular testing were compared with those diagnosed solely by stool culture for aspects of management including admission rates, blood culture obtainment, and antibiotic administration.

RESULTS

Of 965 eligible patients with Salmonella gastroenteritis, 264 (27%) had a stool molecular test and 701 (73%) only had a stool culture performed. Groups were similar in age and presentation. Those diagnosed by molecular methods had higher hospitalization rates (69% vs 50%, P <.001), more blood cultures obtained (54% vs 44%, P <.01), and received more antibiotics (49% vs 34%, P <.001) despite statistically similar rates of bacteremia (11% vs 19%, P = .05).

CONCLUSIONS

The rapid diagnosis of Salmonella gastroenteritis by molecular methods was associated with increased hospital admission rates, blood culture obtainment, and antibiotic use. This suggests possible overmedicalization of uncomplicated Salmonella gastroenteritis, and clinicians should remain cognizant of the possibility of providing low-value care for uncomplicated disease.

Clinical Features, Antimicrobial Resistance, and Serogroups of Nontyphoidal Salmonella Isolated From Infants Less Than 3 Months Old in the Recent Decade

BACKGROUND

Antibiotic treatment is indicated for infants with nontyphoidal Salmonella (NTS) enterocolitis. However, whether antimicrobial resistance (AMR) is a problem among young infants is unknown. This study investigated the characteristics of NTS infections in young infants.

METHODS

Infants less than 3 months old with NTS infections were enrolled and grouped into 2 cohorts (diagnosed 2010-2015 or 2016-2021). Salmonella isolated from blood or cerebrospinal fluid was defined as invasive NTS (iNTS). The clinical features, AMR and serogroups were compared between cohorts.

RESULTS

In total, 102 young infants had NTS infections, 6.9% of which were iNTS. Infants with iNTS infections were younger, hospitalized longer, and received longer antibiotic courses. More than half of cases of iNTS were resistant to ciprofloxacin, ceftriaxone and greater than or equal to 3 antibiotics. iNTS was mainly observed in Salmonella groups C2 and E. Over the past decade, group B (44%), group E (26%) and group C2 (16%) have been the most common serogroups. NTS significantly increased AMR to ciprofloxacin, ceftriaxone and trimethoprim-sulfamethoxazole, and greater than or equal to 3 antibiotics. Both multidrug resistance and extensive drug resistance in NTS also significantly increased.

CONCLUSIONS

The serogroups varied with time, and the main causes of iNTS, groups C2 and E, increased over the past decade. The prevalence of AMR also increased, especially for iNTS. Given the low iNTS rate and high AMR, routine antibiotic use among infants with NTS infections between 1 and 3 months old should be reconsidered. Further large-scale research is required to formulate therapeutic strategies.

Complications and mortality of non-typhoidal salmonella invasive disease: a global systematic review and meta-analysis

BACKGROUND

Non-typhoidal salmonella can cause serious, life-threatening invasive infections involving the bloodstream and other normally sterile sites. We aimed to systematically review the prevalence of complications and case-fatality ratio (CFR) of non-typhoidal salmonella invasive disease to provide contemporary global estimates and inform the development of vaccine and non-vaccine interventions.

METHODS

We did a global systematic review and meta-analysis of studies investigating the complications and mortality associated with non-typhoidal salmonella invasive disease. We searched Embase, MEDLINE, Web of Science, and PubMed for peer-reviewed, primary research articles published from database inception up to June 4, 2021, with no restrictions on language, country, date, or participant demographics. Only studies reporting the proportion of complications or deaths associated with non-typhoidal salmonella invasive disease, confirmed by culture of samples taken from a normally sterile site (eg, blood or bone marrow) were included. We excluded case reports, case series, policy reports, commentaries, editorials, and conference abstracts. Data on the prevalence of complications and CFR were abstracted. The primary outcomes were to estimate the prevalence of complications and CFR of non-typhoidal salmonella invasive disease. We calculated an overall pooled CFR estimate and pooled CFR stratified by UN region, subregion, age group, and by serovar when available with a random-effects meta-analysis. A risk-of-bias assessment was done, and heterogeneity was assessed with Cochran's Q Test, I2, and τ2. This study was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, and is registered with PROSPERO, CRD42020202293.

FINDINGS

The systematic review returned a total of 8770 records. After duplicates were removed, 5837 titles and abstracts were screened, yielding 84 studies from 35 countries after exclusions. Of these included studies, 77 (91·7%) were hospital-based and 66 (78·6%) were located in Africa or Asia. Among 55 studies reporting non-typhoidal salmonella disease-associated complications, a total of 45 different complications were reported and 1824 complication events were identified among 6974 study participants. The most prevalent complication was septicaemia, occurring in 171 (57·2%) of 299 participants, followed by anaemia in 580 (47·3%) of 1225 participants. From 81 studies reporting the CFR of non-typhoidal salmonella invasive disease, the overall pooled CFR estimate was 14·7% (95% CI 12·2-17·3). When stratified by UN region, the pooled CFR was 17·1% (13·6-21·0) in Africa, 14·0% (9·4-19·4) in Asia, 9·9% (6·4-14·0) in Europe, and 9·6% (0·0-25·1) in the Americas. Of all 84 studies, 66 (78·6%) had an overall high risk of bias, 18 (21·4%) had a moderate risk, and none had a low risk. Substantial heterogeneity (I2>80%) was observed in most (15 [65·2%] of 23) CFR estimates.

INTERPRETATION

Complications were frequent among individuals with non-typhoidal salmonella invasive disease and approximately 15% of patients died. Clinicians, especially in African countries, should be aware of non-typhoidal salmonella invasive disease as a cause of severe febrile illness. Prompt diagnoses and management decisions, including empiric antimicrobial therapy, would improve patient outcomes. Additionally, investments in improving clinical microbiology facilities to identify non-typhoidal salmonella and research efforts towards vaccine development and non-vaccine prevention measures would prevent non-typhoidal salmonella invasive disease-associated illness and death.

FUNDING

EU Horizon 2020 research and innovation programme.

Non-Typhoidal Salmonella Infection in Children: Influence of Antibiotic Therapy on Postconvalescent Excretion and Clinical Course-A Systematic Review

(1) Background: Although published recommendations are available, the use of antibiotics in non-typhoidal Salmonella (NTS) infections in children is still controversially debated in clinical practice. Patients might even be put at risk, with necessary antibiotic therapy being withheld due to the widespread concern of prolonged post-convalescent shedding. The authors conducted a systematic review to assess whether antibiotic treatment influences fecal excretion or the clinical course in children with NTS infection. (2) Methods: The review was carried out following the PRISMA guidelines. In a Medline database search, studies assessing the influence of antibiotic therapy on excretion and/or the clinical course of NTS infections were selected. Studies reporting on adults only were not considered. Out of 532 publications which were identified during the systematic literature search, 14 publications were finally included (3273 patients in total). Quality and bias assessment was performed using the Newcastle-Ottawa scale (NOS) or the Cochrane risk-of bias tool (ROB-2). (3) Results: Four early studies from decades ago demonstrated a prolongation of intestinal NTS excretion in children after antibiotic treatment, whereas most studies published more recently observed no significant influence, which might be due to having used more “modern” antibiotic regimes (n = 7 studies). Most studies did not describe significant differences regarding the severity and duration of symptoms between untreated patients and those treated with antibiotics. Quality and bias were mainly moderate (NOS) or variable (ROB-2), respectively. (4) Conclusions: There is no substantial evidence of prolonged excretion of NTS in pediatric patients after treatment with newer antimicrobials. Consequently, clinicians should not withhold antibiotics in NTS infection for children at risk, such as for very young children, children with comorbidities, and those with suspected invasive disease due to concerns about prolonged post-convalescent bacterial excretion. In the majority of cases with uncomplicated NTS diarrhea, clinicians should refrain from applying antibiotics.

Factors affecting fecal excretion time in pediatric nontyphoid Salmonella infection

BACKGROUND

This study investigated whether the appropriate antibiotics therapy affects the fecal excretion time in pediatric salmonellosis of different severities and explored the factors associated with the fecal excretion time of nontyphoid Salmonella.

METHODS

Between 2012 and 2017, admitted children with nontyphoid salmonellosis who consented to receive consecutive stool cultures every 4-7 days until 2 consecutive negative results were obtained were enrolled. Patients were stratified into no, appropriate (bacteremia or severe patients receiving antibiotics active in vitro), and inappropriate antibiotics (patients with mild or moderate severity receiving antibiotics or severe receiving antibiotics resistant in vitro) therapy groups. A previously proposed severity score was used to classify the patients into severe, moderate, and mild severity classes. The demographics, clinical manifestations, laboratory data and severity were compared among the groups. To explore the factors associated with the fecal excretion time of nontyphoid Salmonella, univariate and multivariate analyses were performed using linear regression analysis.

RESULTS

This study enrolled 126 children with nontyphoid salmonellosis; 58 and 18 in the mild and severe classes, respectively. The no, appropriate and inappropriate antibiotics therapy groups comprised 69, 24 and 33 patients, respectively. The mean fecal excretion time was 12.17 days. The appropriate antibiotics therapy group had comparable fecal excretion time with that of no antibiotics group. Age <1 year, increased white blood cell count, decreased hemoglobin, and inappropriate antibiotics therapy significantly prolonged fecal excretion time in univariate analysis (p < 0.05). The multivariate analysis showed that inappropriate antibiotics therapy and decreased hemoglobin significantly prolonged the fecal excretion time.

CONCLUSION

Inappropriate antibiotics therapy and decreased hemoglobin prolong the fecal excretion time of nontyphoid Salmonella, whereas appropriate antibiotics therapy does not. Continuous monitoring of antibiotic resistance and judicious use of antibiotics in children with nontyphoid salmonellosis are necessary.

Rapid identification of bloodstream bacterial and fungal pathogens and their antibiotic resistance determinants from positively flagged blood cultures using the BioFire FilmArray blood culture identification panel

BACKGROUND/PURPOSE

Rapid and accurate identification of pathogens and their antibiotic resistance directly from flagged blood cultures can aid clinicians in optimizing early antibiotic treatment and improve the clinical outcomes, especially in settings associated with high rates of bloodstream infection caused by vancomycin-resistant Enterococci (VRE) and carbapenem-resistant Enterobacteriaceae (CRE). We compared the results of the BioFire FilmArray Blood Culture Identification (BCID) panel with those of conventional methods for identifying the pathogens and their antibiotic susceptibility status.

METHODS

In total, 100 randomly selected positive blood cultures (BACTEC Plus Aerobic/F bottles or BACTEC Anaerobic Lytic/10 bottles) were analyzed. The pathogen detection efficiency of FilmArray BCID panel was compared with that of conventional method using MALDI-TOF MS system (Bruker MALDI Biotyper) and susceptibility testing by the Vitek 2 system. The sequencing analysis of antibiotic resistance genes was performed for discrepant results obtained from MALDI Biotyper and Vitek 2.

RESULTS

Among the 100 positively flagged blood cultures, 94% of FilmArray BCID panel results were consistent with the MALDI Biotyper results. All five VRE isolates positive for vanA/vanB genes, 10 of 12 Staphylococcus species positive for mecA gene, and only one Klebsiella pneumoniae isolate positive for K. pneumoniae carbapenemase gene (bla_KPC) detected in the FilmArray BCID panel were also concordant with results by the results by conventional susceptibility testing/molecular confirmation.

CONCLUSIONS

The FilmArray BCID panel results not only demonstrated good correlation with conventional blood culture identification and susceptibility results but also provided results rapidly, especially for the early detection of MRSA, VRE and bla_KPC-mediated CRE.

Changes in epidemiology and antimicrobial susceptibility of nontyphoid Salmonella in children in southern Taiwan, 1997-2016

BACKGROUND

This study aimed to investigate the changing trends in serogroup distribution and antimicrobial susceptibility of nontyphoid Salmonella (NTS) isolated from children in the past two decades in Taiwan.

METHODS

This retrospective study enrolled patients aged younger than 18 years with culture-proven NTS infection in a tertiary medical center from 1997 to 2016. Data on age, Salmonella serogroup, culture sample, and antimicrobial susceptibility were obtained from medical records. The rates of Salmonella serogroups and antimicrobial resistance were compared between period 1 (1997-2006) and period 2 (2007-2016).

RESULTS

A total of 2075 NTS isolates were identified from 1997 to 2016 (1036 in period 1, 1039 in period 2). The major isolates were from feces (89.1%) and blood (10.4%). The most common serogroup was serogroup B (54.8%), followed by serogroup D (18.8%). There was a significant decline in the proportion of serogroup B with a concomitant rise in serogroup D in the past two decades. In period 2, resistance to cefotaxime and cefixime increased remarkably among serogroup B, whereas resistance to ampicillin increased notably among serogroup D. Furthermore, the incidence of multidrug-resistant (≥3 antibiotics) NTS significantly decreased in both serogroup B and serogroup D in period 2.

CONCLUSION

This study revealed a significant rise in serogroup D with a concomitant decline in serogroup B NTS infection in Taiwanese children. Moreover, antimicrobial resistance to third-generation cephalosporins increased in serogroup B. Continuous surveillance of NTS serogroup distribution and antimicrobial susceptibility is mandatory to formulate therapeutic strategies for NTS infections.

Non-typhoidal Salmonella infections in children: Review of literature and recommendations for management

Non-typhoidal Salmonellae are a major cause of infectious diarrhoea worldwide and can cause invasive diseases, including bacteraemia, meningitis and osteomyelitis. Young or immunocompromised children and those with underlying conditions such as sickle cell disease are particularly vulnerable to invasive disease. There has been an increase in the rate of resistant non-typhoidal Salmonella, which is associated with invasive disease and hospitalisation. The intracellular nature of non-typhoidal Salmonella protects against extracellular antibiotics and can facilitate disease relapse, particularly meningitis. Effective antimicrobial agents with good intracellular penetration include azithromycin, fluoroquinolones and third-generation cephalosporins. Antibiotic treatment of non-typhoidal Salmonella gastroenteritis is only indicated if there are risk factors for invasive disease as it can prolong excretion and does not shorten the duration of gastrointestinal symptoms. Optimal choice and length of therapy for gastroenteritis and invasive disease in children is not clear. Here, we provide a review of the literature and treatment recommendations.

The epidemiology of non-typhoidal Salmonella gastroenteritis and Campylobacter gastroenteritis in pediatric inpatients in northern Taiwan

BACKGROUND

Campylobacter and Non-typhoidal Salmonella (NTS) are the two most common bacterial pathogens associated with acute gastroenteritis in children. This study aims to elucidate the epidemiology of Campylobacter and NTS gastroenteritis and develop a scoring system to differentiate them.

MATERIALS AND METHODS

This retrospective study enrolled 886 children ≤18 years of age, hospitalized due to acute gastroenteritis with stool culture-proven Campylobacter or NTS infection from July 2012 to December 2015. Pearson's chi-square test and multivariate logistic regression were used to compare clinical manifestations and laboratory data. Receiver operating characteristic curves were plotted to evaluate the scoring system.

RESULTS

Seasonality was found in NTS gastroenteritis from May to September, but no seasonality in Campylobacter gastroenteritis. Campylobacter jejuni and Salmonella serogroup B were the most common pathogens. The median ages were 68.2 and 18.5 months and the incidence rates of bacteremia were 0.6% and 7.1% in the Campylobacter and NTS groups, respectively. Salmonella serogroup C2 infection had the highest risk of bacteremia (OR: 5.9, 95% CI: 2.8-12.7, p < 0.001). Multivariate analysis showed significant differences in sex, age, fever, dehydration, immature WBC, CRP and Na between the two groups. A score of ≥2 points indicated Campylobacter gastroenteritis, with sensitivity 75%, specificity 77%. The positive and negative predictive values were of 73.3% and 93.9% after validation.

CONCLUSION

Campylobacter gastroenteritis is associated with older age and male sex, while NTS gastroenteritis is associated with moderate to severe dehydration and bacteremia. Salmonella serogroup C2 infection has the highest risk of bacteremia.

Nontyphoidal Salmonella infection in children: relation to bacteremia, age, and infecting serotype

BACKGROUND

Salmonella gastroenteritis, usually self- limited, can result in bacteremia and focal disease. This study was undertaken to determine the role of age and infecting Salmonella serotype on the risk of bacteremia in children.

METHODS

This was a review of medical records of children with positive nontyphoidal Salmonella cultures seen in an urban setting at the Children's Hospital of Michigan in Detroit between July 1993 and December 2007.

RESULTS

Isolates recovered from 633 patients, representing 50 serotypes, included 594 positive stool cultures and 72 (11.4% of all patients) positive blood cultures. Salmonella serotype Typhimurium was the most common serotype, accounting for 29.4% (186/633) of isolates, of which only 3 (1.6%) were recovered from blood. The most common serotype recovered from blood was serotype Heidelberg (40/120 of patients with Heidelberg serotype) accounting for 55.5% (40/72) of positive blood cultures. The patients' age range was 2 weeks to 20 years, with a median of 7 months (interquartile range, IQR = 4-23 months). Bacteremic patients (n = 72) had a median age of 6.5 months (IQR = 4-11 months) and were comparable in age to non-bacteremic patients (n = 266), who had a median age of 5.5 months (IQR = 3-11 months) (p = 0.24). The odds ratio (OR) for bacteremia in patients infected with serotype Typhimurium was 0.21 and in patients with serotype Heidelberg was 4.0. Patients with serotype Heidelberg infection in the age groups < 3 months, 3-6 months, 6-12 months, and > 12 months had an OR for bacteremia of 9.2, 2.5, 3.2, and 6.0, respectively.

CONCLUSION

In our patient population, children with Salmonella serotype Heidelberg infection are at higher risk of bacteremia than children infected with other Salmonella serotypes. The risk is highest during the first 3 months of life.

Avoidance of antibiotic administration to Campylobacter enterocolitis mimicking severe salmonellosis by clinical and laboratory features

BACKGROUND

To compare the clinical and laboratory features of non-typhoid Salmonella (NTS) and Campylobacter jejuni enterocolitis in children and formulate a risk scoring system (with receiver-operating characteristic curve) to facilitate early decision making and avoid antibiotic overuse in C. jejuni enterocolitis.

METHODS

Between January 2008 and December 2011, children (age <18 years) diagnosed as having C. jejuni enterocolitis and NTS enterocolitis in Kaohsiung Chang Gung Memorial Hospital were retrospectively enrolled. Clinical features and laboratory data were collected for analysis and a risk calculation score is created for the identification of Campylobacter infections.

RESULTS

A total of 309 cases of C. jejuni enterocolitis and 496 cases of NTS enterocolitis were enrolled. Compared with Salmonella group clinically, the Campylobacter group had older age (81.06 ± 50.65 vs. 32.70 ± 34.88 months, p <; 0.001), more abdominal pain (69.26% vs. 37.5%, p <; 0.001) and more watery diarrhea (79.94% vs. 20.77%, p <; 0.001). In laboratory data, the Campylobacter group had higher level of white blood cell count (11 208 ± 4380 vs. 9095 ± 3598 cell/mm3, p <; 0.001).

CONCLUSION

Four criteria including age (≥5 years), leukocytosis (≥10 000 cell/mm3), abdominal pain and watery diarrhea were identified as good predictors of Campylobacter enterocolitis. When three criteria were fulfilled, Campylobacter enterocolitis was highly suspected and antibiotic could be withheld even when C-reactive protein is high and before stool culture results are known. When four criteria were fulfilled, antibiotic usage was absolutely unnecessary.

The clinical outcomes of antimicrobial therapy in pediatric patients with nontyphoid salmonellosis with different levels of severity

BACKGROUND

To evaluate if a severity score could differentiate the severity of children with nontyphoid salmonellosis; clinical outcomes of antimicrobial therapy in nontyphoid salmonellosis children with different severities.

METHODS

Admitted children with nontyphoid salmonellosis from 1996 to 2009 were monitored. Enrolled patients were divided into no antibiotics, concordant, and discordant therapies. Besides, the patients were classified into mild, moderate, and severe group according to the severity score. Clinical outcomes were compared among them.

RESULTS

A total of 558 patients were enrolled. In no therapy subset, compared with mild group, patients had worse clinical outcomes and more complications in severe group. Patients receiving no therapy had better clinical outcomes in mild group. However, patients receiving concordant therapy (ceftriaxone) had better clinical outcomes in severe group.

CONCLUSIONS

The severity score and local antibiotic susceptibility could serve as guides for antibiotic prescription for severe nontyphoid salmonellosis in children. Inappropriate antibiotic use would worsen clinical outcomes in children with mild nontyphoid salmonellosis.

Laparoscopic management for non-traumatic colon perforation in children

PURPOSE

Although recent reports have seen an increase in acceptance of laparoscopic surgery as treatment for traumatic colon injury, its role in the management of non-traumatic colon perforation in children has not been reported. In this study, we review our experience in laparoscopic non-resectional management for children who presented with non-traumatic colonic perforation.

METHODS

Between October 2003 and May 2011, 15 children who had been diagnosed with colonic perforation and underwent laparoscopic surgery were included in the study. Their medical records were reviewed for analysis.

RESULTS

The clinical manifestation of non-traumatic colon perforation in children was non-specific. The most likely aetiology was infective colitis. Solitary perforation at the caecum was the most common finding. The exact perforation site could not be identified in 3 patients. Nine patients had primary closure while 3 patients underwent wedge resection. The single trocar laparoscopic surgery was successful in 12 patients. The mean postoperative hospital stay was 7.3 days.

CONCLUSION

For children presenting with suspected non-traumatic colon perforation, laparoscopic management is the desirable approach. The peritoneal lavage, wedge excision and primary repair can be performed with single trocar techniques and is associated with minimal morbidity. Future prospective studies are needed to compare this minimally invasive approach with conventional open surgery.

Clinical manifestations of nontyphoid salmonellosis in children younger than 2 years old--experiences of a tertiary hospital in southern Taiwan

BACKGROUND

Few published studies have explored the clinical manifestations of nontyphoid salmonellosis in children <2 years of age. The aim of this study was to investigate the clinical manifestations, microbiological features, complications, fecal excretion time, and responses to treatment in children <2 years of age with nontyphoid salmonellosis.

METHODS

Between January 2005 and December 2009, pediatric patients who were admitted to Kaohsiung Veterans General Hospital with positive cultures for nontyphoid Salmonella were enrolled. The following data were recorded: demographic, clinical, and microbiological features, underlying diseases, treatment regimen, complications, responses to treatment, and fecal excretion time. The clinical manifestations were compared between patients <2 years of age and patients >2 years of age.

RESULTS

Of a total 279 enrolled patients, 179 were >2 years of age. Compared with the patients who were ≥2 years of age, patients <2 years of age demonstrated a significantly higher incidence of bloody stool, mixed infection, extraintestinal infection, longer course of antibiotics, longer course of diarrhea after admission, and more days spent in the hospital. The rates of insusceptibility of nontyphoid Salmonella to ampicillin, chloramphenicol, trimethoprim/sulfamethoxazole, ceftriaxone, and ciprofloxacin in patients <2 years of age were 37.87%, 29.09%, 23.73%, 3.26%, and 2.25%, respectively. Younger patients were generally more susceptible to antibiotics than patients ≥2 years of age, although this result was not statistically significant.

CONCLUSION

The clinical manifestations of nontyphoid salmonellosis are more severe in younger children <2 years of age than older children. Local susceptibility patterns could serve as a guide for the prescription of antibiotics by clinicians.

Reappraisal of parenteral antimicrobial therapy for nontyphoidal Salmonella enteric infection in children

Increasing antimicrobial resistance in nontyphoidal Salmonella (NTS) species complicates the use of antibiotics if indicated. We investigated the impact of antimicrobial resistance on clinical outcomes and discussed how to use antibiotics rationally. Hospitalized children in 2005-2006 with stool cultures positive for NTS were identified. The clinical and microbiological features were retrospectively reviewed. A total of 683 children were included [371 (54.3%) male; 89.5% <5 years of age]. Antibiotics were given to 56.5% of the patients; third-generation cephalosporin was the most commonly used drug class. Cases receiving antibiotics that were inactive in vitro did not have more complications than those receiving antibiotics active in vitro. Complications occurred in 7.9% of the patients, with bacteraemia being the most common (57.4%). Compared to the others, patients with longer febrile duration and higher C-reactive protein (CRP) levels (CRP ≥100 mg/L) were more frequently put on empirical antimicrobial therapy and had more complications. These patients usually had shorter hospitalization and duration of fever if antimicrobial agents that can reach high tissue concentrations in the intestinal mucosa were administered, such as fluoroquinolone or ceftriaxone. It is concluded that adequate antibiotics may be clinically beneficial to a subset of patients with high CRP and longer duration of fever among children with NTS enteritis. To prevent the induction of antibiotic resistance from this therapy, we suggested a short course (3-5 days) of intravenous ceftriaxone for such patients, which would lead to a faster clinical recovery.

Microbial evaluation and public health implications of urine as alternative therapy in clinical pediatric cases: health implication of urine therapy

BACKGROUND

Cultural means of pediatric treatment during ill health is a mainstay in Africa, and though urine has been known to contain enteric pathogens, urine therapy is still culturally applicable in some health conditions and also advocated as alternative therapy. The study therefore, is to evaluate the microbial contents and safety of urine.

METHODS

Urinary bacteria from cows and healthy children aged 5-11 years were identified by conventional phenotypic methods and antimicrobial susceptibility testing was performed using modified agar disc and well-diffusion methods.

RESULTS

A total of 116 bacterial isolates (n = 77 children; n = 39 cows) were identified as Bacillus (10.4%; 5.1%)), Staphylococcus (2.6%; 2.6%), Citrobacter (3.9%; 12.8%), Escherichia coli (36.4%; 23.1%), Klebsiella (7.8%; 12.8%), Proteus (18.2%; 23.1%), Pseudomonas (9.1%; 2.6%), Salmonella (3.9%; 5.1%) and Shigella (7.8%; 12.8%) spp. Antibiotic resistance rates of the Gram-positive bacteria were high (50.0100%), except in Bacillus strains against chloramphenicol, gentamicin and tetracycline (14.3%), while higher resistance rates were recorded among the Gram-negative bacteria except in Citrobacter (0.0%) and Proteus (8.5%) spp. against gentamicin and tetracycline respectively. The Gram-negative bacteria from ito malu (cow urine) were more resistant bacteria except in Citrobacter (20.0%) and Shigella spp. (0.0%) against tetracycline and Proteus spp. (11.1%), (22.2%) against amoxicillin and tetracycline respectively. Multiple antibiotic resistance (MAR) rates recorded in children urinal bacterial species were 37.5-100% (Gram-positive) and 12.5-100% (Gram-negative), while MAR among the cow urinal bacteria was 12.5-75.0% (Gram-positive) and 25.0-100% (Gram-negative). Similar higher resistance rates were also recorded among the Gram-negative bacterial species from urine specimens against the pediatric antibiotic suspensions.

CONCLUSION

The study reported presence of multiple antibiotic-resistant indicator bacteria in human urine and ito malu used as alternative remedy in pediatric health conditions like febrile convulsion.

Concomitant rotavirus and Salmonella infections in children with acute diarrhea

BACKGROUND AND PURPOSE

The incidence of concomitant rotavirus and Salmonella infection has been reported to be 1.3% to 7.4%. We designed this study to compare the clinical manifestations in children infected with rotavirus, Salmonella, or both.

METHODS

The medical records of admitted children with acute rotavirus or Salmonella gastroenteritis in 2001 were reviewed. They were divided into group R (rotavirus), group S (Salmonella) and group C (concomitant infection with both). The differences of clinical manifestations and laboratory data among the three groups were analyzed via chi-squared, analysis of variance (ANOVA), Bonferroni and Kruskal-Wallis tests, and odds ratios with 95% confidence intervals (95% CI).

RESULTS

Among the 895 cases reviewed, 550 were group R, 312 group S, and 33 (3.7%) group C. Group C had more vomiting compared with group S (p = 0.0017). Comparing with group R, group C had more prolonged and high fever (> or = 39 degrees C) (p < 0.05), more percentage of green coloration, with mucus and blood contained in the stool (p < 0.001). The C-reactive protein (CRP) value was significantly higher in group C (9.70 +/- 11.05 mg/dL) than in group R (1.33 +/- 3.62mg/dL) or S (5.22 +/- 6.11 mg/dL) (p < 0.05). Hypokalemia was found most frequently in group C (C: 30.0%, S: 8.8%, R: 7.3%) (p = 0.0026).

CONCLUSION

Concomitant rotavirus and Salmonella infections accounted for 3.7% of cases in this study. They had higher CRP as well as incidence of hypokalemia [corrected] In a child with rotavirus gastroenteritis, concomitant infection with Salmonella should be considered if the child has sustained a high fever (> or = 39 degrees C) for over 4 days and a green stool with mucus and blood.

Non-traumatic colon perforation in children: a 10-year review

Colon perforation is an abdominal surgical emergency in the pediatric population, but is seldom reported when occurring from non-traumatic causes in children beyond the neonate. The goal of this study was to identify the clinical characteristics, management, and outcomes of non-traumatic colon perforation in children. Medical records for the 10-year period from September 1994 to September 2004 were reviewed for children beyond the neonate with non-traumatic colon perforation. Data gathered included age, gender, symptoms, duration of symptoms, physical findings, and length of postoperative hospital stay. Diagnostic information included laboratory data, radiographic imaging, and operative findings. Forty-four patients with non-traumatic colon perforation were recruited into this study. The mean age was 2.22 +/- 1.87 years; 91.4% of cases were younger than 5 years old. The most common presenting symptom was fever (97.7%); the most common sign was abdominal distention (93.1%). The mean duration of symptoms prior to admission was 6.19 days. Pneumoperitoneum was presented in 86.3% of patients by plain abdominal radiograph. Ascending and transverse colon were the most common perforation sites. Non-typhoid salmonella was the leading pathogen isolated, causing 20.4% of episodes. One case died due to Clostridium speticum infection. Non-traumatic colon perforation most commonly affects children younger than 5 years of age. It may be secondary to infection, especially non-typhoid salmonella. Plain abdominal radiograph can be an adjuvant tool for the high index of suspicion for colon perforation in children with abdominal distention and history of fever or diarrhea for more than 5 days.