Occurrence of Salmonella typhi and Salmonella paratyphi in Jordan

In order to justify the surveillance control system and hygiene policy in Jordan, this study evaluated the occurrence of diarrhoea during the period 1988-2000, focusing on cases caused by Salmonella typhi and Salmonella paratyphi. From January 1988 to December 2000, the number of notified diarrhoeal cases by the Ministry of Health in Jordan was 1,399,563 million. Other groups of patients confined to the Governorate of Amman was diagnosed at Al-Battikhi Medical Laboratories. One-way ANOVA and Least Significant Difference (LSD) were carried out for statistical analysis. The number of reported diarrhea cases was 1,399,563, 53.0% were males, and 47.0% were females, among them, 80.3% were < 20 years and 19.7%, were > 20 years. Out of 245,255 patients tested for S. typhi and S. pararyphi, positive stool culture were 1992 (0.6%). Out of these, 960 (48.2%) were males and 1,032 (51.8%) were females (P = 0.028). The highest incidence rate (10.8) was observed in the year 1993, while the lowest incidence rate (0.9) was found in year 2000. A significant difference (P < 0.001) was found between the number of S. typhi and S. Paratyphi cases and year. The seasonal variation was also found to be significant (P < 0.0001), with the summer period showing the highest incident rate. A significant difference (P < 0.001) was observed between number of typhoid and paratyphoid cases and districts. A significance difference between number of typhoid and paratyphoid cases with age and sex. The group most affected was school age and adolescence. The demographic situation plays an important role in reporting typhoid and paratyphoid cases, where there might be an urgent indication for a better surveillance control system on water resources and disposal systems. S. typhi and S. paratyphi antibiotics resistance pattern showed they were resistant to tetracycline (56.0%, 58.0%), ampicillin (45.0%, 48.0%), trimethoprim (43.0%, 47.0%), cephtazidime (12.0%, 13.5%) chloramphenicol (6.8%, 7.2%), gentamycin (3.0%, 4.0%) neomycin (2.1. 1.8%), calvulanic acid (augmentin (1.4%, 2.2%) and norofloxacin (0.92%, 1.1%). Susceptibility to amikacin, ciprofloxacin, cetfriaxone, ofloxacine, imepenim, cefixime and cefotaxime was 100.0%. The increase in percentage of antibiotic resistant strain might indicate a need for a further prescribing policy for treatment.     

Evaluation of a vero cell toxicity test to detect EHEC infection

An epidemiologic investigation was carried out in Modena (Italy) to evaluate the prevalence of faecal VEROtoxin (FVT) in diarrhoeal stool specimens. One thousand and sixty-six stool specimens, submitted to the Clinical Microbiology Laboratory of the University Hospital of Modena, were collected and faecal filtrates tested for neutralizable cytotoxin by a toxicity test on VERO cells. Cytopathic effect on VERO cells was produced by 301 stool specimens (28%); neutralizable VT was detected in 40 (13%) out of 301 positive samples (3.7% of 1066 specimens). The prevalent FVT type was VT2 (50%), followed by VT1 (32.5%) and VT1+2 (17.5%). We evaluated an assay that detects both VTs directly from stool specimens to demonstrate that enterohemorrhagic strains (EHEC) should be considerated a causative agent of sporadic non-bloody diarrhoea. Our results suggest that toxin neutralization assay is a sensitive and specific technique and may be used as an alternative method to diagnose diarrhoeal infections caused by EHEC.     

Shigellosis

Shigellosis is a global human health problem. Four species of Shigella i.e. S. dysenteriae, S. flexneri, S. boydii and S. sonnei are able to cause the disease. These species are subdivided into serotypes on the basis of O-specific polysaccharide of the LPS. Shigella dysenteriae type 1 produces severe disease and may be associated with life-threatening complications. The symptoms of shigellosis include diarrhoea and/or dysentery with frequent mucoid bloody stools, abdominal cramps and tenesmus. Shigella spp. cause dysentery by invading the colonic mucosa. Shigella bacteria multiply within colonic epithelial cells, cause cell death and spread laterally to infect and kill adjacent epithelial cells, causing mucosal ulceration, inflammation and bleeding. Transmission usually occurs via contaminated food and water or through person-to-person contact. Laboratory diagnosis is made by culturing the stool samples using selective/differential agar media. Shigella spp. are highly fragile organism and considerable care must be exercised in collecting faecal specimens, transporting them to the laboratories and in using appropriate media for isolation. Antimicrobial agents are the mainstay of therapy of all cases of shigellosis. Due to the global emergence of drug resistance, the choice of antimicrobial agents for treating shigellosis is limited. Although single dose of norfloxacin and ciprofloxacin has been shown to be effective, they are currently less effective against S. dysenteriae type 1 infection. Newer quinolones, cephalosporin derivatives, and azithromycin are the drug of choice. However, fluoroquinolone-resistant S. dysenteriae type 1 infection have been reported. Currently, no vaccines against Shigella infection exist. Both live and subunit parenteral vaccine candidates are under development. Because immunity to Shigella is serotype-specific, the priority is to develop vaccine against S. dysenteriae type 1 and S. flexneri type 2a. Shigella species are important pathogens responsible for diarrhoeal diseases and dysentery occurring all over the world. The morbidity and mortality due to shigellosis are especially high among children in developing countries. A recent review of literature (Kotloff et al.,1999) concluded that, of the estimated 165 million cases of Shigella diarrhoea that occur annually, 99% occur in developing countries, and in developing countries 69% of episodes occur in children under five years of age. Moreover, of the ca.1.1 million deaths attributed to Shigella infections in developing countries, 60% of deaths occur in the under-five age group. Travellers from developed to developing regions and soldiers serving under field conditions are also at an increased risk to develop shigellosis.     

Polymicrobial infections in children with diarrhoea in a rural area of Jordan

Polymicrobial infections associated with diarrhoea are common in developing countries. Stool specimens were collected from 220 patient children and 100 controls. Potential pathogenic agents isolated from 143 (65%) children were identified by molecular and standard microbiological methods. Co-infections with two or more agents were detected in 50 (35%) cases. Escherichia coli, Shigella dysenteriae, Giardia and Entamoeba histolytica were found to be predominant. The etiologic agents could not be determined in 77 (35%) cases. The most significant risk factors were the age, the education level of the mother and the use of non-chlorinated water. The high infection rate of diarrhoeal diseases is a strong indication that these pathogens circulate easily through the population.     

Value of stool examination in patients with diarrhoea.

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

婴幼儿腹泻病原学及其快速诊断

目的探讨小儿腹泻标本病原学特点及流行病学特征,寻求小儿感染性腹泻的快速诊断方法。方法对我院2003年10月至2005年9月门诊及住院的1160例2个月-5岁腹泻患儿的腹泻标本进行细菌学检查及pH检测。结果(1)1160例患儿腹泻标本病原学阳性605例(52.16%),检出病原20种621株,外源性肠道病原菌、内源性肠道条件致病菌以及轮状病毒3种病原构成比依次为35.75%、32.69%、31.56%。主要病原:(1)轮状病毒196株(31.56%),志贺菌118株(19.00%),克雷伯菌86株(13.8%),枸橼酸杆菌67株(10.79%),致泻性大肠埃希菌60株(9.66%)。(2)1160例患儿腹泻标本6个月-2岁患儿占881例(69.91%)。轮状病毒腹泻多发于秋冬季、大便为水样、多见于2岁以内婴幼儿,志贺菌以夏秋季与脓血便检出率较高。(3)病原菌分离阳性腹泻标本pH>7占明显优势,轮状病毒阳性标本、病原检查阴性标本、健康体检对照标本pH<6占明显优势,前者pH与后三者pH统计学比较,差异有高度显著性(P<0.01)。结论引起小儿腹泻的病原种类繁多,轮状病毒居首位,内源性肠道条件致病菌在腹泻标本中的构成比已接近外源性肠道致病菌而成为腹泻的重要病原菌,大便pH可作为急性腹泻病早期简单、快速、准确、价廉的初步诊断及合理应用抗生素的重要指标。     

Multi-gene amplification: simultaneous detection of three virulence genes in diarrhoeal stool

Enterotoxigenic Escherichia coli (ETEC) and Shigella account for a substantial proportion of acute diarrhoeal illnesses among Third-World children. Rapid detection of these infectious agents in faeces followed by the prompt implementation of public health measures could help reduce their spread during the early phase of epidemics. Towards this end, three pairs of synthetic oligonucleotide primers were prepared and shown to hybridize specifically to the genes encoding the heat-stable (ST) and the heat-labile (LT) enterotoxins of ETEC and to invasion-associated loci (ial) of the large Shigella virulence plasmid. When the three primer pairs were used together in the polymerase chain reaction (PCR), the three corresponding genetic loci could be simultaneously amplified using DNA extracted directly from stool; the amplified products were readily detected by ST-, LT- and ial-specific, alkaline phosphatase-labelled oligonucleotide probes (AP probes). The performance of this system was evaluated in a Mayan community in southeastern Mexico, where diarrhoeal illnesses are a common cause of childhood morbidity and mortality. Using only simple and inexpensive laboratory equipment, multigene amplification with these primers and probes led to the identification of ETEC and/or Shigella in the stools of 20 out of 71 children with diarrhoea; the procedure could be completed in seven hours and was more sensitive than conventional diagnostic tests or DNA probes used without amplification.     

The detection of Vero cytotoxin-producing Escherichia coli and Shigella dysenteriae type 1 in faecal specimens using polymerase chain reaction gene amplification

Fifty consecutive faecal specimens received by the LEP were examined for the presence of Vero cytotoxin (VT) genes by polymerase chain reaction (PCR) gene amplification. Nineteen were positive by PCR and from 16 of these, VT positive Escherichia coli O157 were isolated. The remaining three samples were positive for VT genes by PCR but VTEC were not isolated. In a preliminary experiment, Shigella dysenteriae type 1 was isolated from a case of bloody diarrhoea following a positive amplification result.     

Telematics: a new tool for epidemiological surveillance of diarrhoeal diseases in the Aquitaine sentinel network.

A sentinel health information system using telematics and a network of general practitioners was set up in Aquitaine in south western France in 1986. Among the health problems under surveillance was acute diarrhoea. Data for each patient who fulfilled the usual case definition for acute diarrhoea were reported by general practitioners using home terminals (Minitels) connected to a central computer by telephone. Over one year 2234 cases of diarrhoea were reported, the incidence varying from 0.8 to 1.5 cases per doctor per week. Seasonal variations in incidence were observed, with peaks in the winter and in the summer. Only 379 (17%) episodes of diarrhoea were classified as severe, and these patients consulted their general practitioners earlier than patients whose diarrhoea was less severe. Foreign travel was rarely found in the patients'' histories, but clusters of cases were found in communities (4.6%) and in families (22.3%). The advantages of this system were easy reporting and immediate feedback, but it was difficult to extrapolate the data, and the system was inadequate for intervening in outbreaks of diarrhoeal disease. Our knowledge of diarrhoeal diseases in south west France improved.     

Shigella sonnei: virulence and antibiotic resistance

Archives of Microbiology - Shigella sonnei is the emerging pathogen globally, as it is the second common infectious species of shigellosis (bloody diarrhoea) in low- and middle-income countries...     

Epidemiological study on Jordanian patients suffering from diarrhoea

Stool specimens from 1400 Diarrhoeal patients from the Jordanian population were examined for bacterial pathogens and Rotavirus during a four- year period (1997-2000). Pathogenic bacteria were identified in 343 patients (24.5%), most often from children. Salmonella spp. was the most frequent isolated organism in 10.7% of the patient's cultures, followed by enteropathogenic Escherichia coli (EPEC) in 3.9%, Shigella spp. in 0.8% and Campylobacter spp. in 0.9%. Vibrio spp. was not identified in the stools tested. Resistance to ampicillin was observed in 42.2% of the Salmonella, 77.0% of the Shigella, and 31.0% of the EPEC isolates. Cotrimoxazole resistance was observed in 34.0% of the Shigella and 13.0% of the EPEC isolates and 77.0% of Campylobacter isolates. Rotavirus was identified in 373 samples (26.6%) of the patients     

Epidemiological features of rotavirus infection in Goiânia,Goiás,Brazil, from 1986 to 2000

A total of 2,605 faecal specimens from children up to 10 years old with or without diarrhoea were collected. Samples were obtained from 1986 to 2000 in hospitals, outpatient clinics and day-care centers in Goiania, Goiás. Two methodologies for viral detection were utilized: a combined enzyme immunoassay for rotavirus and adenovirus and polyacrylamide gel electrophoresis. Results showed 374 (14.4%) faecal specimens positive for Rotavirus A, most of them collected from hospitalized children. A significant detection rate of rotavirus during the period from April to August, dry season in Goiania, and different frequencies of viral detection throughout the years of study were also observed. Rotavirus was significantly related to hospitalization and to diarrhoeal illness in children up to 24 months old. This study reinforces the importance of rotavirus as a cause of diarrhoea in children and may be important in regards to the implementation of rotavirus vaccination strategies in our country.     

Risk factors for persistent diarrhoea.

With a systematically sampled population of children aged under 5 attending this centre for diarrhoeal disease research during 1983-5 a retrospective analysis of persistent diarrhoea (defined as greater than 14 days'' duration) was performed to identify the possible risk factors for this syndrome. Of the 4155 children included in the analysis, 410 (10%) gave a history of persistent diarrhoea. A comparison with children with acute diarrhoea matched for age showed that 11 factors were correlated with persistent diarrhoea, and strongly associated factors were stools with blood or mucus, or both, lower respiratory tract infection, malnutrition, vitamin A deficiency, and antibiotic use before presentation. The peak age was 2 years, and there was no sex difference. Deaths occurred more often in the group with persistent diarrhoea. Although Shigella spp, Campylobacter jejuni, and Giardia lamblia were frequently identified, their rates of isolation were not significantly higher among patients with persistent diarrhoea. No seasonal variation was observed in the rates of persistent diarrhoea. Although the introduction of family food to the diet was associated with higher rates, this factor was difficult to separate from the age dependent risks.     

Pilot studies on the occurrence of some infectious diseases in two different areas in south Yemen (Aden) (part II. Microbiology).

This paper is the second part of the article dealing with intestinal bacteria. The findings are relatively poor in comparing with the frequency of intestinal protozoa. Among 83 stool specimens taken for bacteriological examination 14 isolations of different bacteria were proved. One S. muenchen was isolated from a 3 year old boy with fever, diarrhoea. Five cases of Alkalescens dispar 05 manit negative and 05 manit positive were identified. Two of these cases were without clinical symptoms. All were males aged 10-17 years. One isolation of E. coli EPEC 086 K6 H11 was in a 10 year-old boy with diarrhoea, four watery stools daily and cramps. Six cases of other E. coli were of different types, all with clinical symptoms. Of them three were males and three females at the age from 3-46 years. One case had a mixed infection of Citrobacter, E. coli and Klebsiella with diarrhoea, about 5 watery stools daily and abdominal pain. The frequency of intestinal bacteria in males was nearly three times higher than in females. The occurrence in age groups 10-20 was almost equal 20.0-22.2%, in 0-4 it was 42.9% and surprisingly low in 5-9 years old--3.4% only.     

Acute diarrhea outbreak caused by Shigella flexneri at a school in Madrid,Cundinamarca: phenotypic and genotypic characterization of the isolates

Shigellosis is an acute diarrhoeal disease that is the main cause of morbidity and mortality in developing countries. In 1997, the Colombian Instituto Nacional de Salud Microbiology Group organized a network surveillance program with the country's Public Health Laboratories (PHLs) to monitor the principal etiological agents responsible for acute diarrhoeal disease. In May, 2001, the PHL of the state of Cundinamarca reported a food poisoning outbreak involving an elementary school community. The main goal of the Microbiology Group involvement was to establish the molecular relationships among the isolates from the outbreak by phenotypic and genotypic methods of characterization. Stool cultures were obtained from 22 of 195 affected individuals. The Microbiology Group confirmed the identification of the isolates by biochemical and serological probes. The antimicrobial susceptibilities were tested against the following battery of antibiotics: chloramphenicol, trimehoprim-sulfamethozazole, cefotaxime, gentamicin, ampicillin and ciprofloxacin. The isolates were subjected to pulsed field gel electrophoresis (PFGE) using the following CDC (U.S. Centers for Disease Control) protocols: Xbal restriction enzyme, Shigella sonnei CDC F2353 as the reference standard, and lambda phage as a molecular weight marker. In 15 of 22 (68%) stool cultures Shigella was recovered, all isolates were identified as Shigella flexneri serotype 6 biotype Newcastle with the same antimicrobial susceptibility profile. PFGE showed that 3 (20%) isolates were identical (100% genetic similarity) and the other 12 (80%) were very closely related (genetic similarity between 86-98%). The network system permitted the INS ready access to the isolates and the implementation of the PFGE permitted a quantitative characterization of the clonal relationship among the isolates from the outbreak.     

Polymicrobial infection in Campylobacter jejuni enteritis in Karachi

Between September 1984 and April 1985, 210 stool specimens from patients with acute enteritis, in the city of Karachi, Pakistan were cultured for the presence of different enteropathogenic bacterial agents.Campylobacter jejuni was isolated from 62 (29.5%) of these specimens from children under 2 years of age. The highest incidence of C. jejuni was found among infants from birth to 6 months of age. The frequency of isolation gradually decreased among the 7–12-month-old infants and again among children from 13–24 months of age, respectively. C. jejuni was more frequently isolated in stool specimens from males (61.2%) and reflected the higher incidence of illness caused by C. jejuni in males. Our results emphasise the importance of this newly recognised enteropathogen, C. jejuni, in the etiology of diarrhoeal disease in Pakistan.     

Control of Shigella flexneri in Celebes black macaques (Macaca nigra)

Stool specimens collected systematically from a group of Celebes black macaques (Macaca nigra) with a high incidence of diarrhea were examined microbiologically. Numerous isolates of Shigella flexneri, Campylobacter jejuni and pathogenic Escherichia coli were recovered. Previous parasitology reports had revealed that the majority of the animals had Balantidium coli. Subsequently, the group was treated with trimethoprim-sulfamethoxazole, erythromycin and tetracycline. After treatment, Shigella flexneri was not detected in the stool of any animal for 1 year, and the clinical condition of the group was improved. Reduced recovery rates were obtained with other enteric pathogens.     

Direct Detection by PCR of Escherichia coli O157 and Enteropathogens in Patients with Bloody Diarrhea

Direct detection of Escherichia coli O157 and foodborne pathogens associated with bloody diarrhea were achieved using polymerase chain reaction (PCR) after the preparation of DNA from stool specimens using the microspin technique. PCR was compared with cultivation and toxin production tests with respect to the efficiency of detection of each pathogen; E. coli O157, Vibrio parahaemolyticus, Salmonella serovar Enteritidis and Campylobacter jejuni. Detection of some or all of the above pathogens in clinical stool specimens was achieved using PCR. The minimum number of cells required for the detection of the above pathogens by PCR was 10¹ CFUs/0.5 g of stool sample. PCR was completed within 6 hr. The above pathogens were also detected in cultivation and toxin production tests. Partial purification of the template DNA using the microspin technique was essential for the elimination of PCR inhibitors from the DNA samples. This PCR method is an accurate, easy-to-read screening method for the detection of Shiga-like toxin producing E. coli O157 and enteropathogens associated with bloody diarrhea in stool specimens.     

Association of antecedent malnutrition with persistent diarrhoea: a case-control study.

To determine the effect of nutritional state on persistent diarrhoea a case-control study was carried out on 756 children followed up prospectively for 18 months. Children who developed persistent diarrhoea were compared with population controls and controls with acute diarrhoea. The mean weight for age in the children with persistent diarrhoea (69.9%) was significantly lower than that in the population controls (77.0%) and the diarrhoeal controls (76.2%). Weight for age of less than or equal to 70% was associated with persistent diarrhoea in both case-control analyses (population controls, matched odds ratio 3.25; diarrhoeal controls, matched odds ratio 2.46). The corrected odds (multiple logistic regression) in the two analyses were 3.2 (95% confidence interval 1.3 to 8.1) and 3.4 (1.2 to 9.1). Weight for age of less than or equal to 70% increases the risk of persistent diarrhoea. In an underweight child there is a higher risk of diarrhoea becoming persistent. Prevention of malnutrition and intensive management of acute diarrhoea in malnourished children should help reduce the risk of the diarrhoea persisting.     

Acute diarrhoea in a community cohort of children who received an oral rotavirus vaccine in Northeast Brazil

Rotavirus is an important cause of childhood diarrhoea. A monovalent rotavirus vaccine (Rotarix?) was introduced into the Immunization Program of Brazil in 2006. In this study, we describe the incidence and burden of disease of rotavirus diarrhoea in two cohorts of children (vaccinated and unvaccinated). We followed two groups of 250 children under one year old, who were enrolled in December 2006 from a low-income residential area in Northeast Brazil. The children were monitored every two weeks for two years. Stool samples from children with diarrhoea were examined for the presence of rotavirus. Rotaviruses were genotyped using real time-polymerase chain reaction. The mean numbers of all-cause diarrhoea episodes/child (adjusted for age) in the first year were 0.87 and 0.84, in vaccinated and unvaccinated children, respectively. During the second year, the number of episodes/child decreased to 0.52 and 0.42. Only 16 (4.9%) of 330 stool samples were rotavirus-positive (10 vaccinated and 6 unvaccinated children) and only P[4]G2 rotaviruses were identified. All-cause diarrhoea episodes were more severe in unvaccinated children in the first year of age (p < 0.05), while vaccinated children had more severe episodes 18 months after vaccination. Rotavirus diarrhoea incidence was very low in both groups.