Objective: To understand the etiological characteristics of bacterial diarrhea in different areas, including large cities, mid-sized/small cities and rural area, in China. Methods: A cross-sectional surveillance was conducted in 17 provinces of China from 2010 to 2014. The acute diarrhea outpatients were selected from clinics or hospitals in large cities, mid-sized/small cities, including rural-urban fringe zones, and rural areas. The demographical and clinical characteristics of the patients were collected by using questionnaire, and stool samples were taken from them for laboratory detection of 17 kinds of bacteria. The differences in pathogen positive rates (PPR) and pathogen spectrum across the cases from three-type areas were compared. The different infection risk in different cases were analyzed with unconditional logistic regression model. Results: In our study, we enrolled 9 253 cases from large cities, 5 138 cases from rural areas and 13 683 cases from midsized/small cites. The pathogen with largest differences in infection rate across the three-type areas was Shigella (S.) flexneri (rural area: 5.81%, mid-sized/small city: 2.78%, large city: 0.46%), followed by Aeromonas (A.) hydrophila (rural area: 2.14%, mid-sized/small city: 0.96%, large city: 0.48%). Compared with cases in large cities, the cases in mid-sized/small cities and rural areas had higher infection risks for S. flexneri (mid-sized/small city: OR=6.481, 95%CI: 4.666-9.002, rural area: OR=11.304, 95%CI: 8.018-15.938) and A. hydrophila (mid-sized/small city: OR=1.992, 95%CI:1.401-2.832, rural area: OR=4.083, 95%CI: 2.833-5.884). The constituent ratio of diarrheagenic Escherichia coli and Salmonella increased with the urbanization development, while the ratios of Shigella and A. hydrophila had an opposite trend. S. sonnei (60.00%) was the predominant serogroup of Shigella in urban infections, while S. flexneri (77.37%) was the predominant serogroup in rural infections. Conclusion: The differences in pathogen spectrum of bacterial diarrhea were obvious across large cities, mid-sized/small cities and rural areas in China, especially the differences in the infection rates of S. flexneri and A. hydrophila.
Adolescent ; Adult ; Bacterial Infections/microbiology* ; Child ; China/epidemiology* ; Cross-Sectional Studies ; Diarrhea/microbiology* ; Dysentery/epidemiology* ; Escherichia coli/pathogenicity* ; Feces/virology* ; Female ; Humans ; Male ; Middle Aged ; Prevalence ; Rural Population ; Salmonella/pathogenicity* ; Shigella/pathogenicity* ; Suburban Population ; Urban Population

Infectious diarrhea is endemic in most developing countries. We aimed to investigate the protozoan, viral, and bacterial causes of acute diarrhea in Taif, Saudi Arabia. A cross-sectional prospective 1-year study was conducted on 163 diarrheal patients of various ages. Stool samples were collected, 1 per patient, and tested for 3 protozoa, 3 viruses, and 9 bacteria with the Luminex Gastrointestinal Pathogen Panel. Overall, 53.4% (87/163) of samples were positives (20.8% protozoa, 19.6% viruses, 2.8% bacteria, and 9.8% mixed). Rotavirus (19.6%), Giardia duodenalis (16.5%), and Cryptosporidium spp. (8.5%) were the mostly detected pathogens. Adenovirus 40/41 (4.2%), Salmonella (3%), Shiga toxin-producing Escherichia coli (3%), and Entamoeba histolytica (2.4%) were also detected. Norovirus GI/II, Vibrio cholerae, Yersinia enterocolitica, and Clostridium difficile toxin A/B were not detected in any patients. All pathogens were involved in coinfections except E. histolytica. Giardia (5.5%) and rotavirus (3%) were the most commonly detected in co-infections. Enterotoxigenic E. coli (2.4%), Campylobacter spp. (2.4%), E. coli 0157 (1.8%), and Shigella spp. (1.2%) were detected in patients only as co-infections. Infections were more in children 0–4 years, less in adults < 40 years, and least >40 years, with statistically significant differences in risk across age groups observed with rotavirus (P < 0.001), Giardia (P=0.006), and Cryptosporidium (P=0.036) infections. Lastly, infections were not significantly more in the spring. This report demonstrates the high burden of various enteropathogens in the setting. Further studies are needed to define the impact of these findings on the clinical course of the disease.
Adenoviridae ; Adult ; Bacteria ; Campylobacter ; Child ; Clostridium difficile ; Coinfection ; Cryptosporidium ; Developing Countries ; Diarrhea ; Entamoeba histolytica ; Enterotoxigenic Escherichia coli ; Giardia ; Giardia lamblia ; Humans ; Norovirus ; Prospective Studies ; Rotavirus ; Salmonella ; Saudi Arabia ; Shiga-Toxigenic Escherichia coli ; Shigella ; Vibrio cholerae ; Yersinia enterocolitica

BACKGROUND: Although Escherichia coli is a common cause of bacterial enteritis in Korea, reports on community-acquired E. coli enteritis in Korean children are scarce. This study aimed to determine the clinical characteristics and pathotype distribution of community-acquired E. coli enteritis diagnosed by a multiplex polymerase chain reaction (PCR) assay in Korean children. MATERIALS AND METHODS: The medical records of children aged 18 years or less who were diagnosed with acute gastroenteritis by the attending physician between 2013 and 2016 were retrospectively reviewed. The clinical characteristics of children diagnosed with E. coli enteritis were investigated and compared with those diagnosed with Salmonella enteritis. E. coli and Salmonella infections were diagnosed by a stool PCR assay. RESULTS: Among 279 children, in whom PCR assays for E. coli and Salmonella spp. were performed, Salmonella enteritis and E. coli enteritis were diagnosed in 43 (15.4%) and 39 (14.0%) children, respectively. Among the 39 children with E. coli enteritis, enteropathogenic E. coli (n=21, 53.8%) and enteroaggregative E. coli (n=15, 38.4%) were the most common causative agents. Empirical antibiotics were administered to 33 (84.6%) children. A total of 31 (79.5%) children developed fever, and 25 (80.6%) of them had the fever for 3 days or less, which resolved a median of 1 day (range 0-3 days) after hospitalization. The most frequent gastrointestinal symptom was diarrhea (n=36, 92.3%). Significantly more children with E. coli enteritis were aged 2 years or less as compared with those with Salmonella enteritis (41.0% vs. 21.9%, P = 0.021). Children with Salmonella enteritis more frequently complained of fever (97.7% vs. 79.5%, P = 0.012), abdominal pain (90.7% vs. 64.1%, P = 0.004), and hematochezia (46.5% vs. 10.3%, P < 0.001) than those with E. coli enteritis. Erythrocyte sedimentation rate and C-reactive protein levels were significantly higher in children with Salmonella enteritis than those with E. coli enteritis (P < 0.001). CONCLUSION: Enteropathogenic E. coli was the most frequent pathotype in Korean children with E. coli enteritis that caused mild clinical symptoms. A stool PCR assay for E. coli may be useful for epidemiological purpose and for an early diagnosis of E. coli enteritis.
Abdominal Pain ; Anti-Bacterial Agents ; Blood Sedimentation ; C-Reactive Protein ; Child* ; Diarrhea ; Early Diagnosis ; Enteritis* ; Enteropathogenic Escherichia coli ; Escherichia coli* ; Escherichia* ; Fever ; Gastroenteritis ; Gastrointestinal Hemorrhage ; Hospitalization ; Humans ; Korea ; Medical Records ; Multiplex Polymerase Chain Reaction ; Polymerase Chain Reaction* ; Retrospective Studies ; Salmonella ; Salmonella Infections

OBJECTIVETo understand the epidemiologic and etiologic characteristics of diarrheagenic Escherichia (E.) coli infections in Shenzhen.

METHODSStool samples were collected from acute diarrheal patients in four sentinel hospitals in Shenzhen and diarrheagenic E. coli strains were isolated and identified with multiplex real-time PCR. Serotyping and pulsed-field gel electrophoresis (PFGE) typing were conducted for the diarrheagenic E. coli isolates.

RESULTSA total of 74 diarrheagenic E. coli strains were isolated from 1 823 stool samples (4.06%). The patients were mainly young children aged <3 years and adults aged 20-39 years, and the infections mainly occurred during May-September of a year. Enterotoxigenic E. coli (ETEC) and enteropathognic E. coli (EPEC) were predominant (45.9% and 31.1%). Serogroups and PFGE patterns varied among the diarrheagenic E. coli isolates. However, serogroup O159 were predominant in ETEC and there were 5 clusters with ≥2 strains sharing same PFGE patterns.

CONCLUSIONSETEC and EPEC were predominant in diarrheagenic E. coli strains isolated from diarrheal patients in Shenzhen. Age and season specific characteristics of diarrheagenic E. coli infections were observed. The serotypes and PFGE patterns of diarrheagenic E. coli strains varied. Close attention should be paid to the possible ETEC outbreak.

Adult ; Child, Preschool ; China ; epidemiology ; Diarrhea ; epidemiology ; microbiology ; Disease Outbreaks ; Electrophoresis, Gel, Pulsed-Field ; Enterotoxigenic Escherichia coli ; classification ; isolation & purification ; Escherichia coli Infections ; epidemiology ; Humans ; Real-Time Polymerase Chain Reaction ; Serotyping ; Young Adult

BACKGROUNDAcute diarrhea remains the serious problem in developing countries, especially among children under 5 years of age. Currently, only two or three common diarrhea pathogens were screened at most hospitals in China. The aim of this study was to provide a wide variety of diarrhea pathogens and their antimicrobial resistance patterns in children under 5 years of age.

METHODSTotally 381 stool samples collected from Tongji Hospital between July 1, 2014 and June 30, 2015 were tested by culture and/or polymerase chain reaction for eight kinds of bacteria and five kinds of viruses. An antimicrobial sensitivity test was performed using dilution method recommended by the Clinical and Laboratory Standards Institute.

RESULTSViral infections were mainly identified in infants (0-11 months), whereas bacterial infections were more prevalent in the age of 24-59 months. About 69.8% of samples were positive for at least one pathogen, 51.7% of samples were virus positive, followed by bacteria positive cases (19.4%), and 12.6% of cases displayed co-infections with two viruses or a virus and a bacterium. Rotavirus was the most prevalent pathogen, followed closely by norovirus, while Salmonella was the most commonly isolated bacteria, followed by diarrheagenic Escherichia coli (DEC) and Campylobacter. More than 40% of Salmonella spp. and DEC isolates were resistant to first-line antibiotics (ampicillin, trimethoprim-sulfamethoxazole, and tetracycline). Around 10% of Salmonella spp. isolates were resistant to ceftriaxone and ciprofloxacin simultaneously. Campylobacter spp. displayed high resistance to ciprofloxacin but kept low resistance to azithromycin and doxycycline.

CONCLUSIONSThe etiology of acute diarrhea varies in children of different age groups. The high frequency of infection with viruses suggests the urgent demand for new viral vaccine development. Proper use of antibiotics in the treatment of acute diarrhea is crucial due to the high level of antibiotic resistance.

Acute Disease ; Anti-Bacterial Agents ; therapeutic use ; Azithromycin ; therapeutic use ; Campylobacter ; drug effects ; pathogenicity ; Child, Preschool ; China ; Ciprofloxacin ; therapeutic use ; Diarrhea ; drug therapy ; etiology ; microbiology ; virology ; Doxycycline ; therapeutic use ; Escherichia coli ; drug effects ; pathogenicity ; Female ; Humans ; Infant ; Infant, Newborn ; Male ; Salmonella ; drug effects ; pathogenicity

The morbidity of travelers' diarrhea (TD) is still high. This study examined the incidence of common pathogens and characteristics of TD among Korean travelers who visited South-East Asian countries. We performed a prospective study involving 479 Korean travelers with diarrheal disease from February 2009 to April 2009 and stool samples were examined and questionnaire surveys were done after arrival. Enterotoxigenic Escherichia coli (ETEC) was found in 36.0% of TD cases, as were the following: Enteroaggregative Escherichia coli (EAEC) in 27.0%, Vibrio parahaemolyticus in 13.1%, and Norovirus in 11.5%. The detected rate of classic TD was higher in men (P = 0.007), in patients who had a shorter duration trip (P = 0.023) and in patients who drank more than 1 liter of water per day (P = 0.037). Positive stool culture rates were higher in men (P = 0.005), in hospitalized patients (P = 0.013). and in those who consumed impure water or raw foods (P = 0.033). A higher severity of disease corresponded to a significantly higher culture positivity rate (P = 0.029). We should consider the possibility of other pathogens in addition to ETEC in patients with TD who visit South-East Asia. Travelers need to educate about risk factors associated with TD.
Adolescent ; Adult ; Aged ; Asia, Southeastern/epidemiology ; *Asian Continental Ancestry Group ; Caliciviridae Infections/epidemiology/virology ; Child ; Diarrhea/epidemiology/*etiology/microbiology/virology ; Escherichia coli/isolation & purification/pathogenicity ; Escherichia coli Infections/epidemiology/microbiology ; Feces/microbiology/virology ; Female ; Humans ; Male ; Middle Aged ; Norovirus/isolation & purification/pathogenicity ; Prospective Studies ; Questionnaires ; Republic of Korea ; Risk Factors ; *Travel ; Travel Medicine ; Vibrio parahaemolyticus/isolation & purification/pathogenicity ; Young Adult

Enterohemorrhagic Escherichia coli (EHEC) is an important cause of bloody diarrhea in children, but is considered to be rare in infants. Herein, a case of infant hemorrhagic colitis of verotoxin-producing E. coli O157:H7 diagnosed by multiplex PCR is reported. A nine-month-old boy was admitted to our hospital with bloody diarrhea for the previous two days. Multiplex PCR using Seeplex(R) Diarrhea ACE Detection Kit (Seegene, Seoul, Korea) was directly applied to the stool specimens. Amplified bands specific for verotoxin, O157, and H7 indicated the presence of O157:H7 EHEC. The stool specimens were inoculated on sorbitol-MacConkey agar (SMA) and tryptic soy broth containing mitomycin C (TSB-M). Colorless colonies on sorbitol-MacConkey agar were O157-positive. TSB-M enrichment cultures of the stool specimen and the isolates were positive for verotoxin according to an enzyme immunoassay (EIA). The prepared ingredients of baby foods for the patient including ground meat, chopped carrot, chopped cabbage, and white rice porridge showed no EHEC on TSB-M and SMA. The patient's parents and three-year-old sister did not recently have any gastrointestinal symptoms. Cefdinir was administered for one day and was ceased after diagnosis of EHEC colitis. The stool culture and verotoxin assay were negative on the second day of hospitalization. Application of multiplex PCR and verotoxin EIA directly to diarrheal stool warrants the rapid diagnosis and appropriate treatment of EHEC colitis.
Agar ; Brassica ; Caseins ; Cephalosporins ; Child ; Colitis ; Daucus carota ; Diarrhea ; Enterohemorrhagic Escherichia coli ; European Continental Ancestry Group ; Hospitalization ; Humans ; Immunoenzyme Techniques ; Infant ; Meat ; Mitomycin ; Multiplex Polymerase Chain Reaction ; Parents ; Protein Hydrolysates ; Shiga Toxins ; Shiga-Toxigenic Escherichia coli ; Siblings

OBJECTIVETo survey the prevalence of enterotoxigenic Escherichia coli (ETEC) and Laribacter hongkongensis (LH) and their drug resistance in diarrhea patients in Guangzhou.

METHODSWe detected 646 fecal cases collected between Sep 2008 and Oct 2009 from the out-patient and emergency departments in a hospital. EC enriched culture medium was used for enrichment. MAC- and CMAC-specific culture media were used to isolate ETEC and LH from the specimens. The biochemical agents API20NE and API20E were employed for biochemical identification, and PCR was used for genetic identification. K-B disk diffusion method was used for antimicrobial susceptibility testing.

RESULTSNo LH was detected in the total 646 patients, and 38 patients were positive for ETEC, with a detection rate of 6%. Antibiotics resistance test showed that 38 strains of ETEC had a high resistance rate to penicillin, tetracycline and sulfa, but remained sensitive to cephalosporins.

CONCLUSIONSLH may have a low prevalence in Guangzhou. The incidence of diarrhea caused by ETEC tends to decrease as compared with that a decade ago, and further multi-center survey is needed for confirmation. Consumption of aquatic products may be one of the major risk factors for ETEC infection. Cephalosporins can be used for ETEC-induced diarrhea.

Adolescent ; Adult ; Bacterial Infections ; epidemiology ; microbiology ; Cephalosporins ; pharmacology ; Child ; Child, Preschool ; China ; epidemiology ; Diarrhea ; epidemiology ; microbiology ; Drug Resistance, Bacterial ; Enterotoxigenic Escherichia coli ; drug effects ; isolation & purification ; Escherichia coli Infections ; epidemiology ; microbiology ; Female ; Humans ; Infant ; Male ; Microbial Sensitivity Tests ; Middle Aged ; Neisseriaceae ; drug effects ; isolation & purification ; Prevalence ; Young Adult

Escherichia coli O157 is an important serotype of enterohemorrhagic E. coli that causes hemorrhagic colitis worldwide. Outbreaks of E. coli O157 have been assocoated with contaminated food like meat, raw milk, and water, but recently vegetables and fruits have accounted for a growing number of recognized outbreaks. We isolated verotoxin producing E. coli O157 from the stool of a 3 year-old female with bloody diarrhea and abdominal pain. The child had been eating salad with vegetables and fruits frequently.
Abdominal Pain ; Child ; Colitis ; Diarrhea ; Disease Outbreaks ; Eating ; Enterohemorrhagic Escherichia coli ; Escherichia ; Escherichia coli ; Escherichia coli O157 ; Female ; Fruit ; Humans ; Meat ; Milk ; Shiga Toxins ; Vegetables

OBJECTIVETo investigate the etiologic value of diarrheagenic E. coil harboring genomic O island 28(OI-28) containing five putative virulence genes (Z0608, Z0609, Z0615, Z0634 and Z0635), which were related to RTX (Repeat in toxin) toxin family isolated from children with diarrheal disease in Taiyuan.

METHODSIn the study, 257 fecal samples from children with diarrheal disease collected in Shanxi Children's Hospital. Diarrheagenic E. coli and enteropathogenic bacteria were isolated and identified by conventional bacterial culture and typing specific diarrheagenic E. coli (EPEC, EIEC, ETEC and EHEC) diagnostic serum, while diarrheagenic E. coli harboring genomic 01-28 containing five putative virulence genes (Z0608, Z0609, Z0615, Z0634 and Z0635) were detected by PCR and DNA southern blot hybridization.

RESULTS206 strains (80.16%) of enteropathogenic bacteria were detected from 257 children with diarrhea disease, containing 149 strains (57.98%) of diarrheagenic E. coli and 57 strains(22.18%) of other entero-pathogenic bacteria. Among 3 strains (2.01%) of EPEC, 2 strains (1.34%) of ETEC, 2 strains (1.34%) EHEC were detected by typing specific serum, while all of the 142 strains (95.30%) isolated were suspected to be diarrheagenic E. coli. 21 strains (14.09%) of diarrheagenic E. coil harboring genomic O1-28 containing five putative virulence genes (Z0608, Z0609, Z0615, Z0634 and Z0635) were detected by polymerase chain reaction and DNA southen blot hybridization, 8 strains (5.37%) of diarrheagenic E. coli containing only one genomic OI-28 virulence gene, 2 strains (1.34%) of diarrheagenic E. coli containing two genomic OI-28 virulence gene. 21 children with diarrhea diseases caused OI-28-harboring E. coli containing five important putative virulence genes were among 0 to 3 years old (80.95%). These children correlating with OI-28-harboring E. coli did not present special clinical symptoms or signs.

CONCLUSIONThe diarrheagenic E. coil harboring genomic OI-28 was one of the important etiology for children with diarrheal disease in summer season.

Child ; China ; Diarrhea ; microbiology ; Escherichia coli ; genetics ; pathogenicity ; Escherichia coli Infections ; complications ; Genes, Bacterial ; Humans ; Virulence