Severe acute gastroenteritis in African kids may require more-aggressive diagnostics

Last Updated: 2015-05-29

By Will Boggs MD

NEW YORK (Reuters Health) - Many children with severe acute gastroenteritis die with undetected but treatable bacterial enteropathogens, suggesting the need for more-aggressive approaches to diagnosis, according to new data from Botswana.

"Children with diarrhea found to have treatable bacteria in their stool were over 2.5 times more likely to die compared with diarrhea but without these bacteria detected," Dr. David M. Goldfarb from McMaster University in Hamilton, Ontario, Canada told Reuters Health by email.

The World Health Organization recommends against routine antimicrobial therapy in children with acute gastroenteritis who do not have blood in their stools.

But bacterial and parasitic pathogens can often be detected in enteric specimens from children living in many African and Asian regions who are experiencing acute nondysenteric diarrheal disease, Dr. Goldfarb and colleagues note in the Journal of the Pediatric Infectious Diseases Society, online May 16.

The team studied stool samples from 671 children (median age, 8.3 months) hospitalized with acute gastroenteritis in two major referral hospitals in Gaborone and Francistown, Botswana.

All but 17% of children had an enteropathogen isolated from their stool. About half had one pathogen, 24% had two, 7.8% had three, and 2.4% had four or five pathogens.

Rotavirus and Campylobacter were more commonly detected in younger children (12 to 24 months old), whereas Shigella and Salmonella were more commonly detected in older children.

Two-thirds of the 74 children presenting with bloody diarrhea had a detectable bacterial pathogen in the stool, but so did one-third of the children without bloody stools.

Children with any Campylobacter/Shigella/enterotoxigenic E. coli (ETEC) in their stools were 2.61 times more likely to die (p=0.01), but there was no significant association between bloody diarrhea and death.

"Blood in the stool is a poor marker of either treatable infection or severe disease in children requiring hospitalization for diarrhea in the African context," Dr. Goldfarb said.

Factors most strongly associated with mortality included detection of Campylobacter/Shigella/ETEC in the stools, the presence of severe acute malnutrition (11% of these children), and the provision of antimicrobials at admission.

"Adherence to antimicrobial therapy for dysentery was suboptimal, as just over one third of those with bloody stools were not treated, but this only serves to strengthen the argument that the presence of blood in the stool is not a useful diagnostic or prognostic factor for young children presenting with acute gastroenteritis in Botswana," the researchers note.

"Overall, our results would suggest that the current WHO treatment algorithm may not be effective in Botswana, where many children with acute gastroenteritis harboring a potentially treatable pathogen do not have bloody stools, and bacterial dysentery does not appear to be associated with worse outcomes than bacterial enteritis without blood in the stool, even when adjusted for antibiotic use," they add.

"Further research is needed to identify evidence-based approaches for managing and treating the children who present with this often life threatening infection," Dr. Goldfarb concluded. "We are currently working with partners in Botswana to evaluate the impact of improved diagnostics and targeted therapy for children with severe gastroenteritis in Botswana."

The study was funded by Grand Challenges Canada, and Luminex Molecular Diagnostics provided xTAG GPP reagents. The authors reported no conflicts of interest.

SOURCE: http://bit.ly/1ED3SaO

J Ped Infect Dis Soc 2015.