الرحيم الرحمن الله بسم

Ghenghesh KS, Ali MB, Abeid S, Tawil KA, Taher IA, Tobgi R,

and Franka EA

Diarrhea in Libyan Children: Causative agents, Clinical features, Treatment and

Prevention

INTRODUCTION

• Diarrhea remains one of the principle causes of morbidity and mortality in children worldwide.

• In Libya, studies on the causative agents of children diarrhea are few.

• However, from the available data, the causative agents, clinical features, treatment and prevention of childhood diarrhea in Libya will be presented in this lecture.

Causative Agents of Childhood Diarrhea in Libya

Agent Rate of occurrence-----------------------------------------------------------------------------------------• Single 35-44%• Multiple 6-13%• Not-identified 43-59%• Bacteria

1. EPEC* 4-11%2. EAEC** NK#3. EHEC*** 7%4. Salmonella sp. 6-11%5. Shigella sp. 4-6%6. Yersinia enterocolitica <1%7. Campylobacter sp. 2-6%8. Aeromonas sp. 0-15%

• Parasitic1. Entamoeba histolyitca/disapr 12%2. Giardia lamblia 1%3. Cryptosporidium 13%

• Rotavirus 24-31%

#Not known *Enteropathogenic Escherichia coli**Enteroaggregative E. coli.***Enterohemorrhagic E. coli

Age distribution of causative agents of childhood diarrhea in Zliten

% positive Agents <12m >12m

(n=124) (n=45)-----------------------------------------------------------------------------------------------• Single 44 44• Multiple 13 11• Rotavirus 34* 7• Salmonella 18* 2• Shigella 0 13**• Aeromonas 2 13**• Cryptosporidium 16.5* 0• Entamoeba histolytica/dispar 5 31**• Giardia lamblia 1 2• Not-identifiable 43 45

Seasonal distribution of causative agents of childhood diarrhea in Zliten

% positive Agent Spr Sum Aut Wi

(n=25) (n=62) (n=51) (n=31)---------------------------------------------------------------------------------------------------------

-• Single 40 45 45 45• Multiple 8 6.5 10 32***• Rotavirus 32 19 25.5 39***• Salmonella 12 3 20*** 26***• Shigella 4 5 4 0• Aeromonas 8 11* 0 0• Cryptosporidium 0 6 2 35.5***• Entamoeba histolytica/ 0 18* 14** 6.5 dispar• Giardia lamblia 0 2 0 3• Not-identifiable 52 48 45 23

Nosocomial Children Diarrhea

• Salmonella

• Multiple agents

• Rotavirus??

• Salmonella is the major bacterial cause of childhood diarrhea in Libya

• Over the years different Salmonella serotypes associated with children diarrhea were reported from different Libyan cities.

Salmonella Serotypes Isolated from Diarrhoeic Faeces in Tripoli (1975-1980)

– S. Wien– S. Muenchen– S. Typhimurium

Salmonella Serotypes Isolated from Children with Diarrhoea in Tripoli (1992-1993)

– S. Saintpaul– S. Muenchen

Salmonella Serotypes Isolated from Children with Diarrhoea in Zliten (2000-2001)

– S. Heidelberg– S. Enteritids

Clinical Features

• Fever and severe dehydration are common clinical features among diarrheic children particularly those affected by rotavirus.

• Around 10% of children with diarrhea were given oral rehydration salts (ORS) before stool collection.

Table 2. Information about Libyan children with diarrhea in Tripoli and their Shigella isolates

Patient Sex Age Month of Length of Episode Species and(Mo) occurrence diarrhea per day serotype of

(days) Shigella-------------------------------------------------------------------------------------------------------1. F 11 Sep 1 5 S. sonnei2. F 30 Sep 2 3 S. flexneri type23. M 27 Oct 1 6 S. sonnei4. F 18 Oct 1 8 S. flexneri type25. F 36 Oct 2 5-7 S. flexneri type26. M 7 Dec 7 7-8 S. flexneri type17. M 7 Apr 1 10 S. flexneri type28. M 13 Jun 10 6-7 S. flexneri type39. M 32 Jul 1 4 S. sonnei

Information about Libyan children with diarrhea and their Shigella isolates

Faeces with Presence ofPatient Mucus Blood Fever Vomiting Species and

serotype ofShigella

---------------------------------------------------------------------------------------------------------------------1. + + -- -- S. sonnei2. -- -- -- -- S. flexneri

type23. -- -- + -- S. sonnei4. -- -- -- -- S. flexneri

type25. + + + -- S. flexneri

type26. -- -- + -- S. flexneri

type17. + + + + S. flexneri

type28. + + + + S. flexneri

type39. + + + + S. sonnei

Table 2: Frequency distribution of clinical features in relation to different enteropathogens. Benghazi

Clinical Features (% of patients)Agent Vomiting Fever Tenesmus Severe

Cough

dehydration

Rotavirus 97 71 21 6 30

Salmonella spp. 89 85 31 12 39

Shigella spp. 88 94 12 6 18

Campylobacter spp. 100 94 0 13 25

Breast Feeding

• A statistically significant association was observed between the diarrheic children and artificial feeding and between controls and breast – feeding.

• In a Benghazi study, about 50% of diarrheic children were bottle-fed, while only 14% of breast-fed children were diarrheic.

• Similar findings were reported from studies carried out in Tripoli and Zliten.

Emergence of multi-resistant enteric pathogens from Libyan

children with Diarrhea

• The emergence of antimicrobial-resistant enteric bacterial pathogens in this population has been noted and may complicate treatment options.

• The ease by which antimicrobial agents can be obtained over the counter in Libya may a play role in the emergence of this problem.

Resistance of Salmonella Isolated from Libyan Children with Diarrhea to Antibiotics

% resistantAntibiotic Zliten Tripoli Benghazi

(n=23) (n=21) (n=26)----------------------------------------------------------------------------------------------------

-Ampicillin 100@ 52 84Amoxicillin+ clavulanic acid 87 NT 76Cefoxitin 87 43 84Chloramphenicol 96 52 65Doxycycline 91 14* 68*Nalidixic acid 4 NT 12Norfloxacin 0.0 0.0** NTGentamicin 78 43*** 44Trimethoprim+ sulphamethoxazole 4 NT 52----------------------------------------------------------------------------------------------*Tetracycline, **Ciprofloxacin, ***Tobramycin, NT=not tested.

Availability of antibiotics in local pharmacies of Zliten

Antibiotic Pharmacies (n=5)

-------------------------------------------------------------------------------------Ampicillin 100Amoxicillin+ clavulanic acid 100Cefoxitin 100Chloramphenicol 100Doxycycline 100Nalidixic acid 0.0Norfloxacin 0.0Gentamicin 100Trimethoprim+ sulphamethoxazole 0.0

• A strong relationship was observed between the availability of antibiotics in the pharmacies of Zliten city and resistance of the isolated salmonellae to these drugs.

TRANSMISSION

• Fecal to oral contact– Nurseries– Schools– Play grounds– Others

• Contaminated food• Water supply • Poor sanitary conditions• Pets

• Important:– Children to adults transmission

TREATMENT

• Maintaining Fluid and Electrolyte Balance.• Antibiotics

– Usually contraindicated >> WHY?– Used in:

• Severe cases >> systematic infections– e.g. Enteric fever

• Bacillary dysentery and cholera if the organisms are susceptible.

– disease duration diminished

CONTROL AND PREVENTION

• Hand Washing– Parents, care-providers in nurseries, and older children.

• Breast Feeding >> very important• Proper Sewage Disposal and Water Standards Be

Observed (i.e. chlorination of water).• Food Cooked Properly

– Bottled milk should be prepared hygienically.• FLIES >>>>>>>>>>>>>>>>

• Vaccination:– Two new oral rotavirus vaccines, developed by Merck & Co. and

GlaxoSmithKline Biologicals, prevented at least 98% of severe cases of gastroenteritis, or intestinal inflammation.

– Must be tailored for strains unique to certain countries or geographical regions.

SUMMARY

• Viral, bacterial and parasitic pathogens play an important role in the etiology of diarrhea in children in Libya with rotavirus, salmonellae and Cryptosporidium as the major agents.

• The misuse of antibiotics by the community and clinicians may be an important factor in the emergence of multi-resistance among the enteric bacterial pathogens isolated from diarrheic Libyan children to the commonly used antibiotics.

RECOMMENDATIONS

• A vigorous educational program that promotes the benefits of using ORS and breast feeding is needed.

•

• Also, the introduction of a rotavirus vaccine into the vaccination program in Libya to protect the pediatric population should be taken into consideration.