Factors associated with typical enteropathogenic Escherichia coli infection among children <5 years old with moderate-to-severe diarrhoea in rural western Kenya, 2008-2012.

Typical enteropathogenic Escherichia coli (tEPEC) infection is a major cause of diarrhoea and contributor to mortality in children <5 years old in developing countries. Data were analysed from the Global Enteric Multicenter Study examining children <5 years old seeking care for moderate-to-severe diarrhoea (MSD) in Kenya. Stool specimens were tested for enteric pathogens, including by multiplex polymerase chain reaction for gene targets of tEPEC. Demographic, clinical and anthropometric data were collected at enrolment and ~60-days later; multivariable logistic regressions were constructed. Of 1778 MSD cases enrolled from 2008 to 2012, 135 (7.6%) children tested positive for tEPEC. In a case-to-case comparison among MSD cases, tEPEC was independently associated with presentation at enrolment with a loss of skin turgor (adjusted odds ratio (aOR) 2.08, 95% confidence interval (CI) 1.37-3.17), and convulsions (aOR 2.83, 95% CI 1.12-7.14). At follow-up, infants with tEPEC compared to those without were associated with being underweight (OR 2.2, 95% CI 1.3-3.6) and wasted (OR 2.5, 95% CI 1.3-4.6). Among MSD cases, tEPEC was associated with mortality (aOR 2.85, 95% CI 1.47-5.55). This study suggests that tEPEC contributes to morbidity and mortality in children. Interventions aimed at defining and reducing the burden of tEPEC and its sequelae should be urgently investigated, prioritised and implemented.

Diarrhoea, enteric pathogen detection and nutritional indicators among controls in the Global Enteric Multicenter Study, Kenya site: an opportunity to understand reference populations in case-control studies of diarrhoea.

Given the challenges in accurately identifying unexposed controls in case-control studies of diarrhoea, we examined diarrhoea incidence, subclinical enteric infections and growth stunting within a reference population in the Global Enteric Multicenter Study, Kenya site. Within 'control' children (0-59 months old without diarrhoea in the 7 days before enrolment, n = 2384), we examined surveys at enrolment and 60-day follow-up, stool at enrolment and a 14-day post-enrolment memory aid for diarrhoea incidence. At enrolment, 19% of controls had ⩾1 enteric pathogen associated with moderate-to-severe diarrhoea ('MSD pathogens') in stool; following enrolment, many reported diarrhoea (27% in 7 days, 39% in 14 days). Controls with and without reported diarrhoea had similar carriage of MSD pathogens at enrolment; however, controls reporting diarrhoea were more likely to report visiting a health facility for diarrhoea (27% vs. 7%) or fever (23% vs. 16%) at follow-up than controls without diarrhoea. Odds of stunting differed by both MSD and 'any' (including non-MSD pathogens) enteric pathogen carriage, but not diarrhoea, suggesting control classification may warrant modification when assessing long-term outcomes. High diarrhoea incidence following enrolment and prevalent carriage of enteric pathogens have implications for sequelae associated with subclinical enteric infections and for design and interpretation of case-control studies examining diarrhoea.

Realities of practice. Engaging parents and GPs in developing clinical practice guidelines.

OBJECTIVE: To integrate evidence based medicine with the experience and expectations of consumers and GPs in the development of clinical practice guidelines for acute respiratory infections (ARI) in young children. METHOD: Focus groups and workshops were held with 21 GPs and 27 patients of young children involved in a 2 year randomised controlled trial. RESULTS: The acceptability of the guideline development process for participants was determined. Barriers were identified which would impede clinical change, including: inadequate time; lack of knowledge; fear of patient dissatisfaction; and fear of poor health outcome. CONCLUSION: This paper details a process of guideline development that addresses the realities of general practice in Australia and the concerns of consumers. We identified potential barriers to change and integrated intervention strategies with the evidence to produce realistic clinical practice guidelines.

Antibiotic resistance in Streptococcus pneumoniae isolated from children.

OBJECTIVE: To determine the level of antibiotic resistance in pneumoniae (S. pneumoniae) isolated from nasal swabs of healthy children. METHOD: Cross-sectional community survey. SETTING: Survey was undertaken in general practice settings in Canberra during March and April 1998. SUBJECTS: Four hundred and sixty-one children under 3 years of age enrolled in general practice trial of clinical practice guidelines for antibiotic use. OUTCOME MEASURES: Resistance to penicillin, erythromycin, co-trimoxazole, tetracycline, chloramphenicol and cefotaxime among the isolates of S. pneumoniae. RESULTS: A total of 461 nasal swabs were collected and S. pneumoniae was isolated from 171 (37.1%). Penicillin resistance was found in 12.3% of these isolates, with high level resistance in 0.6%. Resistance rates were higher for cotrimoxazole (44.4%) and erythromycin (18.1%) than for penicillin. Multidrug resistance was found in 19% of these isolates. There was a significant association between the attendance at a day care centre and carriage of pneumococcus (53% vs 32%, odds ratio (OR) 2.4, 95% confidence interval (CI) 1.5-3.7, P < 0.001). Children who attended day care centers and had received antibiotics during the 4 months prior to swab collection were three times more likely to carry an antibiotic-resistant isolate than children who had neither attended a day care centre nor received antibiotics (68% vs 40%, OR 3.1, 95% CI 1.2-8.4, P = 0.02). CONCLUSION: The level of antibiotic resistance in pneumococci from healthy children was of concern. Carriage of pneumococcus was significantly higher in children who attended a day care centre. Resistance was significantly correlated with antibiotic use in combination with day-care attendance. These findings warrant more judicious use of antibiotics in children.