Enteropathogens associated with cases of gastroenteritis in a rural population in Jordan

High rates of macrolide and fluoroquinolone resistance in human campylobacteriosis in the Middle East and North Africa

Campylobacter is one of the main causative agents of bacterial gastrointestinal infections. Recently, a rise in the incidence of campylobacteriosis has been reported worldwide. Despite the clinical importance of this zoonotic disease, its microbiological diagnosis is not systematically performed in clinical laboratories in developing countries such as the Middle East and North Africa region. Multidrug-resistant Campylobacter isolates, particularly against erythromycin and ciprofloxacin, have been highly reported. The findings of this study highlight the critical need to urge clinical laboratories in the Middle East and North Africa region to include screening for Campylobacter in the routine stool culture of diarrheal patients. Although there is a paucity of data regarding the epidemiology of human campylobacteriosis, alarming rates of infection prevalence and antimicrobial resistance were found in Egypt, Iran, Qatar and Lebanon.

Molecular characterization of Entamoeba, Blastocystis and Cryptosporidium species in stool samples collected from Jordanian patients suffering from gastroenteritis

Little is known about the prevalence of intestinal protozoa in patients suffering from diarrhea in Jordan. The present study aimed to detect and speciate Entamoeba, Blastocystis, and Cryptosporidium species in a total of 159 human patients with diarrhea from November 2014 to October 2016. The overall prevalence for the three parasites was 19.5% (31/159). Entamoeba spp. (Entamoeba. dispar and/or Entamoeba histolytica), Blastocystis hominis, and Cryptosporidium parvum subtype IIaA15G2R1 were detected in 12.6%, 6%, and 0.6 of samples, respectively. This is the first molecular study in Jordan to confirm the diagnosis of Entamoeba species and to discriminate between E. histolytica and E. dispar.

Global Prevalence of Yersinia enterocolitica in Cases of Gastroenteritis: A Systematic Review and Meta-Analysis

The prevalence of Yersinia enterocolitica in gastroenteritis is often underestimated. It relates considerably to morbidity and medical expenses around the world. Understanding the cause of gastroenteritis leads to making the appropriate treatment decisions. We systematically searched PubMed, Science Direct, Embase, and Scopus to identify all published studies between Jan. 1, 2000, and Dec. 31, 2019, to assess the prevalence of Y. enterocolitica in gastroenteritis patients. A total of 5039 articles were identified that lead to the extraction of data from 47 of them. The pooled prevalence of Y. enterocolitica in cases of gastroenteritis was estimated as 1.97% (1.32–2.74%) in the culture method and 2.41% (1.07–4.22%) in the molecular method. Among the biotypes of Y. enterocolitica, 1A (62.48%) and 1B (2.14%) had the most and least prevalence, respectively. Serotype O3 Y. enterocolitica with 39.46% had the highest and O5,27 with 0.0% had the least prevalence in gastroenteritis cases. In conclusion, the findings of this systematic review show that Y. enterocolitica is prevalent in gastroenteritis in all age groups. Serotypes O3 and O9 of Y. enterocolitica had the highest prevalence and O5,27 had the least prevalence in diarrheal patients. The prevalence of Y. enterocolitica was similar in both gender and different seasons. It should be noted that to determine the role of the organism, more studies are needed especially in food-borne diseases.

Antimicrobial treatment of morganella morganii invasive infections: Systematic review

BACKGROUND

Morganella morganii is a Gram-negative, rod-shaped, facultative anaerobic bacillus divided into two subspecies, morganii and sibonii. Previously classified as Proteus morganii, it belongs to human gut commensal microbiota. Nevertheless, on rare occasions, especially in nosocomial and postoperative environment as well as in patients with the impaired immune system and young children, it may cause potentially fatal systemic infection.

OBJECTIVES

The aim of our systematic review was to determine whether and what invasive infections in humans were caused by Morganella morganii and to estimate outcomes of administered antibiotic management.

DATA SOURCES

This systematic review was registered at the PROSPERO database of systematic reviews and meta-analyses before initiation of the research (registration number CRD42020171919). Study eligibility criteria and participants. patients of any age and both sex harbouring Morganella morganii as the only microorganism in bodily fluids or tissues, from where it was isolated and identified by one or more of the following diagnostic methods: conventional techniques including colony morphology, Vitek 2, API or BD Phoenix biochemical systems, as well as more sophisticated methods, such as Matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS) and species-specific PCR for M. morganii.

METHODS AND INTERVENTIONS

We have systematically searched MEDLINE, EBSCO, SCOPUS, SCINDEX and GOOGLE SCHOLAR for case reports and case series with M. morganii invasive infections.

RESULTS

M. morganii can cause serious infections of different tissue in patients of any age. The most isolates were susceptible to ceftazidime, imipenem and amikacin. Majority of the patients completely recovered after antibiotic treatment. About 15% of the patients died despite of the therapy. Gentamicin was the most frequently used antibiotic in the treatment of infection caused by M. morganii.

CONCLUSION

M. morganii invasive infections should be taken into consideration by the clinicians, especially in hospital conditions, due to its high degree of mortality and high potential of this bacterium to develop multidrug resistance. Treatment of M. morganii infections should include gentamycin in combination with third generation cephalosporin or another antibiotic to which M. morganii is susceptible (after testing isolates for third cephalosporin generation for the production of AmpC β -lactamases).

Enteroparasitism in Hard-to-Reach Community Dwellers: A Cross-Sectional Study in Ga West Municipality in Ghana

Ga West Municipality in Ghana is predominantly rural with about forty-eight hard-to-reach communities. Several infectious diseases such as Buruli ulcer, tuberculosis, yaws, schistosomiasis, and malaria are prevalent in the municipality. However, the prevalence and characteristics of enteroparasites in the municipality are unknown. Therefore, this cross-sectional study determined the prevalence of enteroparasites in these hard-to-reach communities. Samples were collected from five communities, namely, Opah, Otuaplem, Dedeman, Onyansana, and Manchie. A total of 538 stool samples were collected from the community dwellers. Each sample was examined with eosin-saline wet preparation and formol-ether concentration technique. Body mass index, haemoglobin, and albumin concentrations were used to assess nutritional status. Seven different parasite species were identified in 178 community dwellers (33.1% prevalence (95% CI: 0.29–0.37)). The individual prevalence of the identified parasites was Schistosoma mansoni (13.4%), Entamoeba histolytica (7.2%), Ascaris lumbricoides (6.9%), Giardia lamblia (5.0%), hookworm (4.8%), Strongyloides stercoralis (4.8%), and Balantidium coli (1.6%). Among the 178 parasitized individuals, 68.0% were singly infected while 31.5% had dual parasitism. Significantly higher infections were associated with Onyansana dwellers (p = 0.019), participants aged 16–20 years (p = 0.006), unmarried participants (p < 0.001), those without formal education (p = 0.044), and crop farmers (p = 0.044). However, among the Akan tribe (p = 0.015), Christians (p = 0.03), and participants with higher incomes (p = 0.012), infections were found to be lower. Compared to monoparasitism, dual parasitism was significantly associated with underweight (17.8 vs. 20.3 kg/m²), anaemia (7.7 vs. 9.8 g/dL), and malnutrition (27.6 vs. 31.9 g/L of albumin concentration). These findings underscore the fact that the Ga West Municipality is heavily burdened with different species of enteroparasites. Therefore, education on personal hygiene to reduce parasitic infections must be intensified while implementing regular mass deworming exercise in the municipality.

Etiologies of diarrhea and drug susceptibility patterns of bacterial isolates among under-five year children in refugee camps in Gambella Region, Ethiopia: a case control study

Background

Despite substantial global effort and updated clinical management guidelines, diarrhea continues to be among leading worldwide causes of morbidity and mortality in children. Infectious diarrhea, the most common form of diarrhea causes substantial morbidity and mortality among children in developing countries, and the muddled use of antibiotics needs caution due to potential problems of drug-resistance. The aim of this study is to identify etiologies of diarrhea and drug susceptibility patterns of bacterial isolates in under-five children in refugee camps in Gambella Region, Ethiopia.

Methods

An institution- based matched case control study was conducted using a questionnaire-based interview from June to December 2017 in Pugnido and Teirkidi refugee camps. Stool samples were collected and parasites causing diarrhea were identified by wet mount microscopy. Conventional culture supplemented with API 20E identification kit was used to identify Salmonella and Shigella species. Antibiotic susceptibility of bacterial isolates was investigated by using the disk diffusion method. The association between etiologies and diarrhea was analyzed using McNemar test or Fisher exact test with 95% confidence interval at a level of significance of P < 0.05.

Results

The overall prevalence of enteric pathogens were 55 (41.0%) in diarrhea cases and 18 (13.4%) in healthy controls. The detected etiologies include Giardia lambia (28), Shigella spp. (16), E. hystolyotica/dispar (13), Ascaris lumbricoides (10), Salmonella spp. (6), Cryptosporidium parvum (6), Hymenolepis nana (4) and Isospora belli (3). All isolates were sensitive to kanamycine and ceftazidime. The high resistance rate was observed against ampicillin (100%), amoxicillin (100%), erythromycin (52%), chloramphenicol (47.5%), tetracycline (40.5%), cotrimoxazole (34.8%) and amoxicillin-clavulanic acid (33%). The majorities of the isolates had a low rate of resistance to ciprofloxacin (8.7%), naldxic acid (8.7%) and amikacin (13%).

Conclusions

Giardia lamblia, E. Hystolytica/dispar, and Shigella spp are the common etiologies of diarrhea in children in the studied refugee camps. The study also showed that significant numbers of bacterial isolates were resistant to the commonly used antimicrobial drugs. Therefore, improving clinical laboratory services and promoting evidence-based drug prescription may reinforce proper use of antibiotics and reduce the emergence of microbial resistance.

Blastocystis spp. and Giardia intestinalis co-infection profile in children suffering from acute diarrhea

Giardia intestinalis and Blastocystis spp. are two common zoonotic intestinal parasites responsible for the majority of diarrheic cases, especially in children. The study was planned to determine the impact role of both Giardia and Blastocystis co-infection in children up to 12 years old with acute diarrhea in Beni-Suef, Egypt. Also, to estimate the general prevalence rates and risk factors associated with intestinal parasitic infections. Stool samples collected from 125 children, within a period of 7 months, were examined using direct wet mount and trichrome stain in comparison to in vitro culture on Jones medium (for detecting Blastocystis spp.) and Immunochromatography techniques (for detecting Giardia). At least one type of intestinal parasites was harbored in 72% of the studied children, single infection constituted 37.6% while, 34.4% were polyparasitized children. The predominant parasites involved were Blastocystis spp.(53.6%), followed by Giardia intestinalis (27.2%). Co-infection between both parasites was recorded in 20% of cases. Two risk factors were significantly associated with higher risk of Giardia-Blastocystis co-infection including age category (5-7 years) and family size (≥ 6 members) by univariate analysis (P = 0.004, 0.009 respectively) and also by the multivariate model (OR = 0.526, 0.336). Abdominal pain was the only gastrointestinal manifestation associated with the co-infection using the univariate analysis (P = 0.0427). The present study detects a high prevalence of intestinal parasitic infection; in particular, Giardia-Blastocystis co-infection in diarrheic young children (up to 12 years) in Beni-Suef Governorate, Egypt and recommends further subtypes identification of both parasites.

Whatman Protein Saver Cards for Storage and Detection of Parasitic Enteropathogens

Current methods to identify the etiology of diarrhea require laboratory facilities for storage of pathogens, which is often challenging in low-resource settings. This study evaluated the efficacy of a low-cost method for preserving stool specimens for the detection of parasitic enteropathogens using Whatman 903 protein saver cards (Sigma-Aldrich, St. Louis, MO). Stool samples known to be positive by multiplex real-time polymerase chain reaction for Giardia lamblia, Cryptosporidium spp., and Entamoeba histolytica parasites were preserved on 232 Whatman cards. DNA was then extracted from cards using Chelex and Qiagen extraction protocols, and tested for these parasites using multiplex real-time PCR. We included stool samples known to have a higher parasite load (cycle threshold [ct]-value < 30) and those with a lower parasite load (ct values 30-35). Sensitivities and specificities were determined using DNA extracted directly from whole stool samples using Qiagen kits (QIAGEN, Hilden, Germany). For whole stool samples with ct values < 30, preserved directly on Whatman 903 protein saver cards for Giardia analysis, the sensitivity was 100% for both Qiagen and Chelex DNA extraction. For E. histolytica, this was 100% for sensitivity for Qiagen and 80% for Chelex DNA extractions, and for Cryptosporidium, this was 80% for Qiagen and 50% for Chelex DNA extraction. The specificity was 100% for all parasites for all extraction procedures. Given the high sensitivity for stool samples with higher parasite loads, we recommend the use of the Whatman 903 protein saver card for preserving fecal specimens for the analysis of Giardia and E. histolytica using Qiagen DNA extractions in low-resource settings.

Prevalence of enteric non-typhoidal Salmonella in humans in the Middle East and North Africa: A systematic review and meta-analysis

To enhance efforts related to controlling foodborne pathogens in the Middle East and North Africa (MENA), information on epidemiology of non-typhoidal Salmonella enterica (hereafter termed "Salmonella") is limited. We quantified the overall regional and country-specific Salmonella prevalence in different human populations and identified the most common serotypes. Published literature of Salmonella prevalence was systematically reviewed and reported following the Preferred Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Pooled Salmonella prevalence measures were estimated using a random-effects model. We identified 46 research reports that reported 84 Salmonella prevalence measures in 15 out of 24 countries in MENA. There were 252,831 tested humans with 6,356 Salmonella-positive cases. The pooled Salmonella prevalence in MENA was estimated at 6.6% (95% confidence interval (CI): 5.4%-7.9%). The highest pooled Salmonella prevalence measures were in Morocco (17.9%, 95% CI: 5.7%-34.8%, 1997-2012), Tunisia (10.2%, 95% CI: 4.3%-18.0%, 1988-2009) and Sudan (9.2%, 95% CI: 6.5%-12.2%, 2006-2008), while the lowest were in Jordan (1.1%, 95% CI: 0.1%-3.0%, 1993-2010), Oman (1.2%, 95% CI: 1.2%-1.3%, 1998-2002) and Palestine (1.2%, 95% CI: 0.4%-2.1%, 1999-2011). In MENA, Salmonella pooled prevalence in gastrointestinal symptomatic, gastrointestinal asymptomatic and food handlers population groups was 13.0% (95% CI: 7.6%-19.6%), 11.4% (95% CI: 2.2%-25.7%) and 3.8% (95% CI: 1.0%-8.0%), respectively. Salmonella prevalence was 14.5% (95% CI: 8.7%-26.1%) in studies tested <100 subjects, whereas 4.6% (95% CI: 3.6%-5.8%) in studies tested ≥100 subjects. Salmonella Enteritidis (29.8%) and Typhimurium (23.6%) were the most common serotypes. Salmonella was a common foodborne pathogen in MENA countries, particularly in North African countries. Findings inform the scientific community, the public and the decision-makers with Salmonella prevalence and gaps in evidence in MENA to support control and prevention strategies and could leverage more research studies.

Prevalence of Cryptosporidium, Blastocystis, and other opportunistic infections in patients with primary and acquired immunodeficiency

Intestinal opportunistic infections are often caused by unicellular parasites. Individuals with decreased immunity are particularly susceptible to infection by said microorganisms, and when they are infected, diarrhea can be the main clinical manifestation. However, intestinal parasites have rarely been taken into account in intestinal disorders. In our study, an investigation was conducted to determine the prevalence of intestinal micro-pathogens, such as Cryptosporidium, Giardia, Blastocystis, and microsporidia, in hospitalized patients with different immunological statuses. The study at hand indicates that protozoan parasitic infections are rare among immunodeficient patients in Poland. The overall prevalence of micro-pathogens among participants was 4.6%; it was three times higher in adults (12.5%) than in children (2.3%). Cryptosporidium and Cyclospora species (Apicomplexa) were diagnosed as the main cause of heavy diarrhea. Accordingly, adult patients were positive mainly for Blastocystis and microsporidia, while children were more often infected with the Cryptosporidium species.

Enteroparasites in Riverside Settlements in the Pantanal Wetlands Ecosystem

Background

Intestinal parasites are a major source of health problems in developing countries, where socioeconomic, cultural, and environmental conditions contribute in maintaining the biological cycles of various parasites and facilitating their spread. The objective of this study, conducted in Corumbá, Mato Grosso do Sul state, Brazil, was to investigate the occurrence of intestinal parasites in riverside communities in the South Pantanal wetlands and conduct educational interventions focused on health and environmental preservation.

Method

In total, 196 stool samples were tested for parasites using the merthiolate-iodine-formaldehyde concentration (MIFC) technique and spontaneous sedimentation and educational activities were carried out.

Results

Enteroparasite prevalence was 72% (65.6-78.2%; 95% CI). Of the 141 positive cases, monoparasitism was found in 34.7%, biparasitism in 23%, and polyparasitism in 14.3%. Entamoeba coli was the most frequent protozoan (70.2%). Among helminths, hookworms were the most prevalent. Enteroparasitosis prevalence did not differ for sex or place of abode but proved higher in individuals older than 10 years.

Conclusion

The high positivity rate for enteroparasites found for the communities stems from lack of sanitation and poor personal and environmental hygiene habits, indicating that effective health policies and educational interventions are needed to reduce the current risk levels.

Blastocystis subtypes isolated from irritable bowel syndrome patients and co-infection with Helicobacter pylori

Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disease presenting clinically by abdominal pain with alteration of bowel habits. Although IBS has uncertain etiology, chronic gut inflammation due to persistent exposure to an infectious agent including Blastocystis sp. was proposed. The aim of this study was to detect the prevalence of Blastocystis sp. subtype (ST) isolated from stool of IBS patients and to assess Blastocystis sp. and H. pylori co-infection in IBS patients from Beni-Suef Governorate, Egypt. Stool samples were collected from 115 IBS patients, following Rome III criteria. All stool samples were microscopically examined by wet mount and permanent trichrome stain, cultured on Jones' medium with further sequencing of positive Blastocystis isolates and screened for detection of H. pylori coproantigen. Blastocystis sp. was the predominant parasite in IBS patients; it had statistical significant association with both rural residence (OR = 10) and flatulence (OR = 8.2). There was a predominance of Blastocystis sp. ST3 (81%) followed by ST1 (19%). Blastocystis culture results (19.1%) were superior than microscopy (16.5%). The majority of Blastocystis-positive IBS patients (72.7%) were co-infected with H. pylori with statistical significance; however, H. pylori was higher in Blastocystis-negative IBS patients (47/64) than in Blastocystis-positive IBS patients (17/64). Interestingly, IBS is usually associated with gut dysbiosis, while the most prevalent parasite in our IBS patients was Blastocystis sp., which is frequently found in asymptomatic individuals. Whether Blastocystis sp. is a cause or a consequence of IBS still needs further investigation, with a particular focus on correlation of IBS with different Blastocystis sp. subtypes and gut microbiomes.

Epidemiology, clinical features, and microbiology of patients with diarrhea in community clinics in Taiwan

OBJECTIVE

To investigate the clinical features and microbiology of patients with diarrheal diseases in Taiwan.

METHODS

From March 2014 to October 2014, patients with diarrheal diseases referred from the community clinics were enrolled into our prospective study. Demographics and clinical features of the participants were acquired. Stool samples were examined by the Luminex Gastrointestinal Pathogen Panel assay. Data were analyzed by SAS version 9.4.

RESULTS

A total of 545 patients were enrolled into this study. Male and adults accounted for 52.3% and 82.6% of patients, respectively. The median age was 36 years. Enteropathogen(s) was identified in 43.3% of patients and 8.5% of them had more than one agent in their stool samples. Viruses, especially norovirus GI/GII, were the predominant agents of gastroenteritis. Moreover, Campylobacter species was the most common bacterial agent. Bloody stool was frequently reported in patients with bacterial diarrhea (P = 0.002); contrarily, watery stool was significantly associated with viral diarrhea (P < 0.0001). Regional variation and seasonality of microbiological distribution were also observed.

CONCLUSION

In Taiwan, viruses were the predominant pathogens among patients with diarrheal diseases who visited community clinics. The therapeutic strategies for diarrheal patients should be based on the epidemiological and clinical characteristics.

Assessment of Macro-Level Socioeconomic Factors That Impact Waterborne Diseases: The Case of Jordan

The Hashemite Kingdom of Jordan is an example of a country that suffers from high water scarcity. Additionally, due to the economic drivers in the country, such as phosphate and potash extraction and pharmaceutical production, the little fresh water that remains is generally polluted. The infrastructure, often antiquated in urban areas and non-existent in rural areas, also contributes to poor water conditions and to the spread of waterborne diseases. This paper examines the socioeconomic factors that contribute to diarrhea and hepatitis A on a macro level in Jordan and discusses the public-policies that government officials could use to abate those problems. Ordinary least squares time series models are used to understand the macro-level variables that impact the incidence of these diseases in Jordan. Public health expenditure has a significant impact on reducing their incidence. Furthermore, investment in sanitation facilities in rural regions is likely to reduce the number of cases of hepatitis A. Perhaps the most surprising outcome is that importation of goods and services likely results in a decrease in cases of hepatitis A. However, income has little impact on the incidence of diarrhea and hepatitis A.

First genetic characterisation of Giardia in human isolates from Jordan

Little is known about the epidemiology of Giardia in Jordan and to date, no genotyping studies have been conducted on Giardia isolates from Jordanians. In the present study, a total of 49 microscopy-positive faecal samples from Jordanian patients suffering from giardiasis were analysed at two loci: the triose phosphate isomerase (tpi) gene and the glutamate dehydrogenase (gdh) gene. At the tpi locus, a total of 28 samples amplified and assemblage A was identified in 46.4 % (13/28) samples, while assemblage B was identified in 50 % (14/28) samples and a mixed assemblage A and B was identified in one sample (3.6 %) (Table 1). At the gdh locus 48 isolates amplified and of these assemblages A was identified in 43.7 % (21/48) of isolates and assemblage B in 56.3 % (27/48) of isolates. No mixed infections were detected at the gdh locus. Subtyping at the gdh locus identified sub-assemblage AII in 43.7 % (21/48) of isolates and sub-assemblages BIII and BIV in 25 % (12/48) and 31.2 % (15/48) of isolates, respectively, with more genetic diversity in AII isolates than BIII or BIV isolates. Novel sub-types within each sub-assemblage were identified suggesting unique endemicity and anthroponotic transmission of Giardia in Jordanian patients suffering from giardiasis. Further studies are required to better understand the epidemiology and transmission of Giardia in Jordan.

Prevalence of enteric pathogen-associated community gastroenteritis among kindergarten children in Gaza

Gastroenteritis is considered as one of the leading causes of illness and death in children under 5 years age, especially in developing countries. It is one of the major public health problems among childhood in Gaza strip, Palestine. This study was conducted to determine the prevalence of enteric pathogen-associated community gastroenteritis among kindergarten children in Gaza. A total of 150 stool samples were collected and investigated for parasitic, viral and bacterial pathogens at Al Azhar microbiology laboratories by using standard microbiological and serological procedures. Out of the 150 study samples, the overall percentage of positive stool samples with a known enteric pathogen was 60.6%. The prevalence of different enteric pathogens causing community gastroenteritis among symptomatic cases (88.5%) was significantly higher than the prevalence in asymptomatic carriage (11.1%). The most prevalent isolated enteric pathogens were Entamoeba histolytica (28.0%) and Giardia lamblia (26.7%). Rotavirus was found in 3.1% of symptomatic cases but not detected in asymptomatic carriage. However, adenovirus type 40 and 41 were not detected in any of the study samples. The bacterial enteric pathogens Shigella and Enterohemorrhagic Escherichia coli O157:H7 (EHEC) have comparable occurrence as rotavirus (3.1%), meanwhile, Salmonella was not isolated. Mixed infection with more than 1 pathogen was found (11.4%) only among symptomatic cases. Children aged 3-year-old showed the highest prevalence of community gastroenteritis. This study demonstrates a high prevalence of parasitic enteropathogens and a relatively low prevalence of bacterial and viral enteropathogens among kindergarten children living in Gaza city, moreover, children aged 3 years old showed the highest prevalence of isolated enteropathogens.

A systematic review and meta-analysis of the association between Giardia lamblia and endemic pediatric diarrhea in developing countries

We performed a systematic literature review and meta-analysis examining the association between diarrhea in young children in nonindustrialized settings and Giardia lamblia infection. Eligible were case/control and longitudinal studies that defined the outcome as acute or persistent (>14 days) diarrhea, adjusted for confounders and lasting for at least 1 year. Data on G. lamblia detection (mainly in stools) from diarrhea patients and controls without diarrhea were abstracted. Random effects model meta-analysis obtained pooled odds ratios (ORs) and 95% confidence intervals (CIs). Twelve nonindustrialized-setting acute pediatric diarrhea studies met the meta-analysis inclusion criteria. Random-effects model meta-analysis of combined results (9774 acute diarrhea cases and 8766 controls) yielded a pooled OR of 0.60 (95% CI, .38-.94; P = .03), indicating that G. lamblia was not associated with acute diarrhea. However, limited data suggest that initial Giardia infections in early infancy may be positively associated with diarrhea. Meta-analysis of 5 persistent diarrhea studies showed a pooled OR of 3.18 (95% CI, 1.50-6.76; P < .001), positively linking Giardia with that syndrome. The well-powered Global Enteric Multicenter Study (GEMS) is prospectively addressing the association between G. lamblia infection and diarrhea in children in developing countries.

Cryptosporidium in countries of the Arab world: the past decade (2002-2011)

Introduction

Cryptosporidium is the causative agent of cryptosporidiosis. The disease is self-limited in immunocompetent persons but potentially life-threatening in immunocompromised individuals.

Methods

The data included in the present review were obtained mainly from a Highwire Press (including PubMed) search for the period 2002–2011.

Results

Information on cryptosporidiosis is lacking in some Arab countries; however available data show prevalence rates of <1–43% (mean = 8.7%) of Cryptosporidium infection in diarrheic immunocompetent pediatrics and <1–82% (mean 41%) in immunocompromised patients (including children and adults). Infection rate with Cryptosporidium species among pediatrics in rural and semiurban areas was higher than in urban areas. Cryptosporidium-associated diarrhea occurs mainly in younger children and inversely correlates with age, being more prevalent in children aged 1 year or less, particularly in rural and suburban regions. Although most Arab countries are characterized by a hot summer and a mild winter, infection with Cryptosporidium appears to occur at a higher rate of incidence during the rainy months that are usually associated with the cold season of the year. Contact with animals and contaminated waters are the main modes of transmission of cryptosporidia. Reports of C. hominis from the region indicate that person-to-person transmission is also important. Foreign housekeepers in oil-rich countries may be a source of Cryptosporidium.

Conclusion

Cryptosporidium species, mainly C. parvum, are important causes of diarrhea in countries of the Arab world, particularly in children. In addition to educational programs that promote personal, household, as well as food hygiene, improving water treatment processes and protection of treated waters from contamination should be implemented by the health and environmental authorities in each country. More studies employing molecular testing methods are needed in the future to provide data on circulating species/genospecies and subtypes and their modes of transmission in the community.

Effect of bovine lactoferrin on the minimum inhibitory concentrations of ampicillin and trimethoprim–sulfamethoxazole for clinical Shigella spp. strains1This article is part of a Special Issue entitled Lactoferrin and has undergone the Journal’s usual peer review process

Here, we determined the effect of bovine lactoferrin (bLF) on the minimum inhibitory concentration (MIC) of ampicillin and trimethoprim–sulfamethoxazole in Shigella . Using a microdilution method, the MIC was determined in the presence or absence of bovine lactoferrin (10 mg/mL) on 88 Shigella strains (56 Shigella flexneri , 15 Shigella boydii , 13 Shigella sonnei , and 4 Shigella dysenteriae ) previously isolated from peruvian children <2 years old. A fold change of 2 or more in MIC values was considered significant. For ampicillin, 67 (76%) strains were highly resistant; one-third of the strains (32%) showed a decrease in ampicillin MIC in the presence of LF. This was more typical of MIC values in less resistant strains. For 7 (8%) ampicillin-resistant strains, the decrease in the MIC resulted in the strains reaching the cutoff for susceptible in the presence of bLF. For trimethoprim–sulfamethoxazole, 93% of the isolates (n = 82) were highly resistant and only 4 isolates (5%) decreased their MIC in the presence of bLF. None of the trimethoprim–sulfamethoxazole resistant strains became susceptible in the presence of LF. The decrease in the MIC in the presence of bLF seems to depend on the mechanisms of action of each antibiotic. In vivo studies are needed to further evaluate bLF as a coadjuvant to antibiotic treatment of resistant Shigella.

Quinolone-resistant Escherichia coli O127a:K63 serotype with an extended-spectrum-beta-lactamase phenotype from a food poisoning outbreak in China

We report an atypical enteropathogenic Escherichia coli O127a:K63 strain with resistance to quinolones and extended-spectrum cephalosporins isolated from a 2010 food poisoning outbreak involving 112 adults in China. Two resistance genes [bla(CTX-M-15), aac(6')-Ib-c] and five mutations (two in gyrA, two in parC, one in parE) coexisted in this enteropathogenic E. coli strain.

Bacterial enteropathogens and risk factors associated with childhood diarrhea

OBJECTIVE

To investigate the etiology of bacterial enteropathogens causing diarrhea among children; to elucidate the risk factors, sign and symptoms involved in developing of infection; and to identify the antimicrobial susceptibility pattern.

METHODS

Stool samples from diarrheal cases with clinical diagnosis of gastroenteritis compared to matched controls, were examined for detection of bacterial enteropathogens by conventional cultural method from February 2006 through January 2007.

RESULTS

Ninety three of diarrheal cases comprising enteropathogen isolates. A recognized bacterial enteric pathogen was identified in 31% of the cases and 8% of the control group. The frequency of isolated enteropathogens from faeces of diarrheal cases was recorded in the following order, Enterohemorrhagic E. coli 8.3%, Shigella spp. 6.7%, Campylobacter jejuni 5%, Salmonella spp. 4%, Yersinia enterocolitica 2.7%, Aeromonas spp. 4.7%, and Plesiomonas spp. 1.3%. E.H.E coli, Shigella and Salmonella had shown a significant statistical association with diarrhea (p<0.05). Compared to matched uninfected control, multivariate analysis revealed that malnutrition status (OR adjusted 8.37; p<0.001) was the only independent factor associated with infection. Antibiotic susceptibility profile indicated that enteropathogens were generally susceptible to meropenem, ceftriaxone, followed by amikacin and ciprofloxacin. Almost all enteropathogens were resistant to ampicillin and amoxicillin.

CONCLUSIONS

The results of this study emphasize the importance of bacterial enteropathogens in causing severe diarrhea in children. E.H.E. coli was the most predominant pathogen. Malnutrition was identified as the main independent risk factor associated with developing of infection. Ampicillin and amoxicillin should not be used as empirical treatment in acute diarrhea.

New insights on classification, identification, and clinical relevance of Blastocystis spp

SUMMARY

Blastocystis is an unusual enteric protozoan parasite of humans and many animals. It has a worldwide distribution and is often the most commonly isolated organism in parasitological surveys. The parasite has been described since the early 1900s, but only in the last decade or so have there been significant advances in our understanding of Blastocystis biology. However, the pleomorphic nature of the parasite and the lack of standardization in techniques have led to confusion and, in some cases, misinterpretation of data. This has hindered laboratory diagnosis and efforts to understand its mode of reproduction, life cycle, prevalence, and pathogenesis. Accumulating epidemiological, in vivo, and in vitro data strongly suggest that Blastocystis is a pathogen. Many genotypes exist in nature, and recent observations indicate that humans are, in reality, hosts to numerous zoonotic genotypes. Such genetic diversity has led to a suggestion that previously conflicting observations on the pathogenesis of Blastocystis are due to pathogenic and nonpathogenic genotypes. Recent epidemiological, animal infection, and in vitro host-Blastocystis interaction studies suggest that this may indeed be the case. This review focuses on such recent advances and also provides updates on laboratory and clinical aspects of Blastocystis spp.

Detection of Cryptosporidium spp and other intestinal parasites in children with acute diarrhea and severe dehydration in Rio de Janeiro

The objective of the present study was to estimate the frequency of infection by Cryptosporidium spp and other intestinal parasites in dehydrated children with gastroenteritis who were admitted to a pediatric hospital. Stool examinations from 218 children were performed. Cryptosporidium spp was identified in eighteen out of 193 stool samples (9.3%) subjected to safranin-methylene blue staining. Giardia lamblia was detected in ten out of 213 (4.7%) samples examined via the direct or Ritchie methods. Other parasites identified were Ascaris lumbricoides (4.2%), Blastocystis hominis (1.4%), Entamoeba coli (0.9%), Entamoeba histolytica/Entamoeba dispar (0.5%), Endolimax nana (0.5%), Trichuris trichiura (0.5%) and Enterobius vermicularis (0.5%).

Incidence and characterization of diarrheal enterotoxins of fecal Bacillus cereus isolates associated with diarrhea

A total of 490 stool specimens were collected from patients with diarrhea and healthy controls without diarrhea to investigate the incidence of Bacillus cereus and its enterotoxins. B. cereus was found more significant in stools of persons with diarrhea than without diarrhea (9.5% versus 1.8%, P < 0.05), and was also detected more frequent but not significant in individuals aged > or =1 year and in adults than in children aged <1 year (11% and 8% versus 7.8%, P > 0.05). The hemolytic enterotoxin HBL genes of B. cereus isolates (hblA, hblC, hblD) were detected in 58%, 58%, and 68%, respectively, whereas the nonhemolytic enterotoxin NHE genes (nheA, nheB, nheC) were detected more frequent in 71.%, 84%, and 90% of the isolates, respectively. This study suggests that B. cereus isolates harboring 1 or more enterotoxin gene(s) can be a potential cause of diarrhea in Jordanian population.

Diarrhoeagenic Escherichia coli and other causes of childhood diarrhoea: a case-control study in children living in a wastewater-use area in Hanoi, Vietnam

A case-control study was conducted to identify the aetiology of diarrhoeal diseases in pre-school children in a suburban area of Hanoi where the use of untreated wastewater in agriculture and aquaculture is a common practice. Stool specimens and clinical information were collected from 111 pairs of children with diarrhoea and healthy controls. A total of 73 cases (66 %) and 41 controls (36 %) had an enteric pathogen. The pathogens most often associated with diarrhoea were rotavirus (17 % of cases) and Entamoeba histolytica (15 %), followed by Shigella (5 %). Diarrhoeagenic Escherichia coli (DEC) was found in 23 % of both patients and controls. Characterization of DEC by serotyping, antimicrobial susceptibility test and PFGE showed that DEC represented by different pathotypes belonged to various serotypes. Except for three enterotoxigenic E. coli strains, typing by PFGE revealed no correlation between pathotype and serotype of DEC strains. This suggests a high prevalence of a variety of DEC subtypes in this area. For this particular region, vaccine development strategies targeting rotavirus and Shigella are likely to be of public health benefit, whereas the role of DEC and preventive measures need to be further elaborated.

Cryptosporidiosis in Saudi Arabia and neighboring countries

Cryptosporidium is a coccidian protozoan parasite of the intestinal tract that causes severe and sometimes fatal watery diarrhea in immunocompromised patients, and self-limiting but prolonged diarrheal disease in immunocompetent individuals. It exists naturally in animals and can be zoonotic. Although cryptosporidiosis is a significant cause of diarrheal diseases in both developing and developed countries, it is more prevalent in developing countries and in tropical environments. We examined the epidemiology and disease burden of Cryptosporidium in Saudi Arabia and neighboring countries by reviewing 23 published studies of Cryptosporidium and the etiology of diarrhea between 1986 and 2006. The prevalence of Cryptosporidium infection in humans ranged from 1% to 37% with a median of 4%, while in animals it was different for different species of animals and geographic locations of the studies. Most cases of cryptosporidiosis occurred among children less than 7 years of age, and particularly in the first two years of life. The seasonality of Cryptosporidium varied depending on the geographic locations of the studies, but it was generally most prevalent in the rainy season. The most commonly identified species was Cryptosporidium parvum while C. hominis was detected in only one study from Kuwait. The cumulative experience from Saudi Arabia and four neighboring countries (Kuwait, Oman, Jordan and Iraq) suggest that Cryptosporidium is an important cause of diarrhea in humans and cattle. However, the findings of this review also demonstrate the limitations of the available data regarding Cryptosporidium species and strains in circulation in these countries.