Neonatal deaths in Cambodia: findings from a community-based mortality review.

OBJECTIVES: The aim of this study was to describe potential factors contributing to neonatal mortality in Takeo, Cambodia through assessment of verbal autopsies collected following newborn deaths in the community. The mortality review was nested within a trial of a behavioral intervention to improve newborn survival, and was conducted after the close of the trial, within the study setting. The World Health Organization standardized definition of neonatal mortality was employed, and two pediatricians independently reviewed data collected from each event to assign a cause of death. RESULTS: Thirteen newborn deaths of infants born in health facilities participating in a community based, behavioral intervention were reported during February 2015-November 2016. Ten deaths (76.92%) were early neonatal deaths, two (15.38%) were late neonatal deaths, and one was a stillbirth. Five out of 13 deaths (38.46%) occurred within the first day of life. The largest single contributor to mortality was neonatal sepsis; six of 13 deaths (46.15%) were attributed to some form of sepsis. Twenty-three percent of deaths were attributed to asphyxia. The study highlights the continuing need to improve quality of care and infection prevention and control, and to fully address causes of sepsis, in order to effectively reduce mortality in the newborn period.

Molecular characterization of the human immunodeficiency virus type 1 among children in Lima, Peru.

In Peru, there is a lack of information on molecular analysis in pediatric human immunodeficiency virus (HIV) infection. At present, the mother-to-child transmission rate is estimated at approximately 2-4%. The objective of this study was to assess the molecular epidemiology of HIV-1 in infected children. Children with suspected or confirmed pulmonary tuberculosis were evaluated at two public hospitals between 2002 and 2007. Whole blood samples were obtained from 90 HIV-positive children, who were confirmed to be positive by enzyme-linked immunosorbent assay and Western blot. The specimens were subjected to envelope heteroduplex mobility assay (env HMA) followed by gag and pol gene region sequence analysis. Subtype B was found in 88 (98%) of 90 children and 2 (2%) children were subtype BF recombinants. This is the first report of recombinant HIV strains in HIV-infected children in Peru. Understanding the origin, diversity, and spread of HIV strains worldwide will be necessary for the development of an effective vaccine that targets pediatric populations throughout the world.

Asymptomatic salmonellosis among children in day-care centers in Mérida, Yucatan, Mexico.

BACKGROUND: Child day-care centers (DCC) have become common in many lower and middle income countries, presenting new problems that may differ from those of DCC in more developed countries. Diarrhea is a common problem in DCC in the United States, but information on the prevalence of diarrhea or specific enteropathogens among children in DCC in tropical and developing countries is limited. METHODS: Because of preliminary data from newborns and DCC attendees in Mérida, Mexico, with high rates of Salmonella infection, we conducted a 12-month longitudinal surveillance study of enteropathogens in two Mérida DCC. Seventy-eight children ages 2 months to 4 years were evaluated with demographic and clinical data, and stools were cultured monthly. RESULTS: Salmonella sp. was the most common enteropathogen detected (46 of 683 specimens, 6.7%), with higher rates in children younger than 18 months (P < 0.02), but it was found in only 1 of 10 diarrhea episodes that coincided with sampling. Other common organisms identified included Giardia lamblia (21 of 683, 3.0%) and LT-producing enterotoxigenic Escherichia coli (16 of 683, 2.3%). Salmonella was recovered from as many as 19% of children in a single month, but the large multiplicity of serotypes recovered suggested multiple sources rather than a common source outbreak. Children with Salmonella tended to have more liquid stools during the preceding 2 weeks. Salmonella was also isolated from the stool of teachers in 1 of the 2 DCC in 10 of 94 specimens (10.6%), and again multiple serotypes were represented. CONCLUSION: These data indicate the presence of multiple sources of Salmonella infection in the DCC, posing a complex situation for infection control.

Probiotic agents and infectious diseases: a modern perspective on a traditional therapy.

There is an increasing scientific and commercial interest in the use of beneficial microorganisms, or "probiotics," for the prevention and treatment of disease. The microorganisms most frequently used as probiotic agents are lactic-acid bacteria such as Lactobacillus rhamnosus GG (LGG), which has been extensively studied in recent literature. Multiple mechanisms of action have been postulated, including lactose digestion, production of antimicrobial agents, competition for space or nutrients, and immunomodulation. We have reviewed recent studies of probiotics for the treatment and control of infectious diseases. Studies of pediatric diarrhea show substantial evidence of clinical benefits from probiotic therapy in patients with viral gastroenteritis, and data on LGG treatment for Clostridium difficile diarrhea appear promising. However, data to support use of probiotics for prevention of traveler's diarrhea are more limited. New research suggests potential applications in vaccine development and prevention of sexually transmitted diseases. Further studies are needed to take full advantage of this traditional medical approach and to apply it to the infectious diseases of the new millennium.

A placebo-controlled trial of Lactobacillus GG to prevent diarrhea in undernourished Peruvian children.

OBJECTIVE: Lactobacillus GG (L-GG), an acid- and bile-resistant strain that colonizes the intestinal mucosa, has been used to manage diarrhea in children. Our objective was to evaluate the prophylactic use of L-GG to prevent diarrhea in children at high risk from a developing country in a randomized, placebo-controlled trial. STUDY DESIGN: Two hundred four undernourished children 6 to 24 months old from an indigent peri-urban Peruvian town received either L-GG or placebo in flavored gelatin once daily, 6 days a week, for 15 months. Episodes of diarrhea were documented by daily home visits, and diagnostic studies were done in a subset of cases. Recovery of L-GG in stool from subjects and from family contacts was examined. RESULTS: Subjects in the L-GG group had significantly fewer episodes of diarrhea (5.21 episodes diarrhea/child/year ['ecy'] L-GG group, 6. 02 ecy placebo group; P =.028). The decreased incidence of diarrhea in the L-GG group was greatest in the 18- to 29-month age group (P =. 004) and was largely limited to nonbreastfed children (Breastfed: 6. 59 ecy L-GG, 6.32 ecy placebo, P =.7; Nonbreastfed: 4.69 ecy L-GG, 5. 86 ecy placebo, P =.005). The duration of diarrhea episodes and the causes of diarrhea were similar in both groups, except adenovirus was more common in the placebo group. CONCLUSION: L-GG supplementation may be useful as a prophylactic measure to control diarrhea in undernourished children at increased risk, especially nonbreastfed children in the toddler age group.

PIP: This article features a placebo-controlled trial of Lactobacillus GG (L-GG) for diarrhea prevention in undernourished children in Peru. The purpose of the study was to evaluate the use of L-GG as prophylactic treatment for diarrhea. The study population included 204 undernourished children aged 6-24 months, 99 of which were on L-GG and 105 on placebo. Subjects were followed by daily home visits to document diarrhea episodes and diagnostic studies were conducted. Results revealed that children receiving L-GG experienced fewer episodes of diarrhea, which were more pronounced among 18-29 month old children and largely limited to non-breast-fed children. Moreover, the duration of diarrhea episodes and its causes were similar in both groups, except that adenovirus was detected more frequently in the placebo group. In conclusion, L-GG supplementation would decrease diarrhea incidence in high-risk children.

Correlations between intestinal parasitosis, physical growth, and psychomotor development among infants and children from rural Nicaragua.

The correlations between malnutrition, parasitosis (especially helminth infections), and child development are complex, and studies of these interrelationships will allow health agencies to maximize screening and intervention strategies for developing countries. We examined these correlations in a cross-sectional program in Carazo State, Nicaragua. Nine hundred sixty-one children in two age strata (ages 0-24 months and ages 2-10 years) from one urban and three rural communities were screened for intestinal parasites (direct smear and ZnSO4 flotation), malnutrition, and developmental delays. Nutritional status was determined as weight-for-age (WFA), weight-for-height (WFH), and height-for-age (HFA). Developmental status (normal, suspect) was determined for the four subtests of the Denver II Screening Test. The prevalence of malnutrition was 14.6% (WFA), 8.4% (WFH), and 36.3% (HFA). Parasitosis was more prevalent in children less than 24 months of age with low HFA, whereas in older children low WFA was more closely associated with parasitic infections. Ascaris and Trichuris were more prevalent in malnourished children. On the Denver II, suspect test results in all four categories (language, social, gross motor, and fine motor) were associated with low WFA, and suspect language tests were associated with both intestinal parasites (P = 0.0003) and Ascaris infection in particular (P = 0.044). Developmental disabilities are a significant and frequently undetected health problem in developing countries, and malnutrition associated with intestinal helminth infections may be an important contributory factor for these disabilities.

PIP: Studies of the correlations between malnutrition, parasitosis, and child development will help health agencies to maximize screening and intervention strategies for developing countries. Such correlations were examined in a cross-sectional study in Carazo State, Nicaragua. 961 children aged 0-24 months and 2-10 years from 1 urban and 3 rural communities were screened for infection with intestinal parasites, malnutrition, and developmental delays. Developmental status was determined for the 4 subtests of the Denver II Screening Test. The prevalence of malnutrition was 14.6% according to weight-for-age (WFA), 8.4% for weight-for-height (WFH), and 36.3% for height-for-age (HFA). Parasitosis was more prevalent among children under age 2 years with low HFA, while low WFA was more closely associated with parasitic infections in older children. Ascaris and Trichuris were more prevalent in malnourished children. On the Denver II, suspect test results in language, social, gross motor, and fine motor were associated with low WFA, while suspect language tests were associated with both intestinal parasites, and Ascaris infection in particular. Developmental disabilities are a significant and often undetected health problem in developing countries. Malnutrition associated with intestinal helminth infections may be an important contributory factor for such disabilities.

Colonization with enteroadherent, enterotoxigenic and enterohemorrhagic Escherichia coli among day-care center attendees in New Orleans, Louisiana.

BACKGROUND: E. coli strains producing specific virulence factors are frequently cited as causes of pediatric diarrhea in developing areas, although many well children from the same areas are colonized with these organisms. The role of these Escherichia coli in day-care center (DCC)-associated diarrhea in the United States has not been evaluated. METHODS: A cohort of 112 DCC attendees from 5 DCC in urban New Orleans were followed longitudinally with demographic data, biweekly routine stool samples and additional stool samples with episodes of diarrhea. E. coli isolates were routinely saved; diarrhea stool samples were tested to detect enterotoxigenic, enterohemorrhagic and enteroadherent strains; and the prevalence of these E. coli in children with and without diarrhea was investigated. RESULTS: During 225 child months of observation 21 episodes of diarrhea were documented and microbiologic data were available for 18. HEp-2 cell enteroadherent E. coli [mostly enteroaggregative (EAggEC) pattern] were identified in 6 of 18 (33.3%) diarrhea cases vs. 6 of 36 (16.6%) age-matched controls. However, the prevalence of EAggEC was very DCC-specific, with EAggEC found in 12 of 22 routine specimens from a DCC with recent EAggEC-related diarrhea vs. 0 of 11 routine specimens from age-matched children in another DCC without EAggEC-related diarrhea (P=0.002). Enterotoxigenic E. coli were uncommon in both ill and well children, and no enterohemorrhagic E. coli were detected. CONCLUSION: EAggEC were commonly isolated from children with and without diarrhea in certain DCC settings, although we cannot determine whether these strains caused diarrhea. Diarrhea-producing E. coli were not associated with diarrhea in this DCC population.

Frequency of adhesive factors and enterotoxins in strains of Escherichia coli isolated from piglets with diarrhea.

Neonatal colibacillosis is one of the most prevalent illnesses in pig farms. In order to examine the frequency of adherence factors and the production of enterotoxins in strains of E. coli, we collected stool specimens from 500 piglets between 1 and 10 days of age with diarrhea, including piglets from several different farms on the periphery of Mérida, Yucatán. One thousand and eighty (1080) strains of E. coli were isolated, of which 127 (11.76%) produced STa, and 62 (5.74%) produced adherence factors. Of these, 30 (48.39%) produced factor K88, 18 (29.03%) produced factor 987P, 12 (19.35%) produced K99, and 2 (3.23%) produced F41. Of the 62 strains which produced adherence factors, 42 (67.74%) also produced STa, and of these, 17 (40.84%) produced factor K88, 13 (30.95%) produced 987P, 10 (23.81%) produced K99, and 2 (4.76%) produced F41. In summary, of the 1080 strains isolated, 42 (3.89%) produced both STa toxin and adherence factors, 85 (7.87%) produced STa but did not produce adherence factors, and 933 (86.39%) produced neither STa or adherence factors. No LT-producing E. coli was detected in this study.

Occult blood versus fecal leukocytes in the diagnosis of bacterial diarrhea: a study of U.S. travelers to Mexico and Mexican children.

A study was done to test the effectiveness of fecal occult blood as a screening test for invasive bacterial pathogens and as a substitute for the fecal leukocyte examination in adult and pediatric cases of acute diarrhea. United States citizens studying in Mexico and Mexican children, both with acute diarrhea had their stools cultured, examined for fecal leukocytes, and tested for occult blood. Using culture results as the criterion standard for detection of bacterial agents, and fecal leukocytes for diarrhea associated with diffuse colonic inflammation, occult blood was tested for its sensitivity, specificity, and predictive value using 2 x 2 tables. Analysis of the data found that occult blood negative samples were reliable indicators of a lack of invasive bacteria in both adult and pediatric patients (negative predictive values of 87% and 96%, respectively). Positive results for either test were not reliably predictive as indicators of invasive bacteria among adults. A positive occult blood test result was significantly more sensitive than a positive fecal leukocyte test result (79% versus 42%) in detecting invasive bacteria in the pediatric patients; however, the positive predictive value was only 24%. The fecal occult blood test is an uncomplicated, low-cost test that was reliable when giving a negative result in detecting a lack of invasive bacteria in adult and pediatric patients with diarrhea. In children, a positive result on a fecal occult blood test is sensitive but not specific in detecting invasive bacterial enteropathogens. These data also indicate that a commercially available test for occult blood represents a suitable alternative to microscopic examination of fecal samples for leukocytes obtained from patients with acute diarrhea.

Short report: a placebo-controlled study of Lactobacillus GG colonization in one-to-three-year-old Peruvian children.

A pilot, placebo-controlled study conducted in Peruvian toddlers in a periurban shanty-town community demonstrates that 1) a simple fluorescent antibody test performed on bacteria from colonies grown on solid culture media can be used as a presumptive screening tool for Lactobacillus GG, 2) Lactobacillus GG powder sprinkled on flavored gelatin as a nutritional supplement is well-accepted by infants and mothers in this population, and 3) daily doses of Lactobacillus GG result in efficient colonization of the gastrointestinal tract of Peruvian infants. This study demonstrates that Lactobacillus GG should be evaluated as an adjunct for diarrhea control programs at the community level as well as in hospital-based settings.

Pseudomonas vesicularis causing bacteremia in a child with sickle cell anemia.

Pseudomonas vesicularis is a gram-negative rod infrequently found in environmental sources or clinical specimens. We report a case of bacteremia due to Pseudomonas vesicularis in a child with sickle cell anemia, fever, and pneumonia. This is the first published report of invasive P vesicularis in a child.

Evaluation of alkaline phosphatase-labelled ipaH probe for diagnosis of Shigella infections.

The presence of many enteropathogens which are not easily detectable by routine stool culture has led to the development of alternative diagnostic methods. One of these techniques, nucleic acid probe hybridization, has been used to identify Shigella spp. and enteroinvasive Escherichia coli (EIEC) in stool specimens through the detection of genetic material encoded by a specific large approximately 200-kbp virulence-related plasmid. In the present study, an alkaline phosphatase-labelled oligonucleotide probe developed to detect the gene for ipaH, a repetitive genetic sequence thought to be present on both the virulence-related plasmid and the chromosomes of all strains of Shigella and EIEC, was tested in a developing-country setting through a prospective clinical trial. In a group of 219 Peruvian adults and children with acute gastroenteritis, the ipaH probe detected 85% of cases of shigellosis and demonstrated a specificity of 95% when compared with simultaneous detection by several stool culture techniques. Additionally, three cases of EIEC infection which could not be diagnosed by culture methods alone were detected with the ipaH probe and were confirmed by plasmid analysis and Sereny testing. These preliminary results suggest that, with further research, the ipaH probe should prove to be a useful and rapid adjunct in the diagnosis of acute gastroenteritis in developing countries.

Prospective study of systemic and mucosal immune responses in dysenteric patients to specific Shigella invasion plasmid antigens and lipopolysaccharides.

Shigellosis is a major cause of infant morbidity and mortality in developing countries. To find immunological correlates of specific protection against shigellosis, we examined chronological samples of sera, stool extracts, duodenal aspirates, and saliva samples from 39 adults and 22 children with shigellosis from Peru for the presence of specific antibody to invasion plasmid antigens (Ipa) common to all virulent Shigella strains, by using both a whole-organism enzyme-linked immunosorbent assay (ELISA) and a Western blot (immunoblot) assay. Antibody responses to lipopolysaccharide (LPS) from Shigella serotypes both homologous and heterologous to the infecting strain were also determined by ELISA. ELISAs showed that the highest serum immunoglobulin G (IgG) antibody titers to Shigella whole organisms both with and without surface Ipa were found in adults and malnourished children, the two groups with the shortest and longest durations of disease, respectively. Mucosal IgA antibody titers to Shigella strains decreased over time to a much greater extent than serum IgG titers, and IgA to Ipa in mucosal secretions was found in adults and well-nourished children but not in malnourished children. The presence of mucosal antibody to Ipa may limit the spread and severity of the infection, as indicated by the prolonged illness observed in malnourished children who have no significant mucosal antibody to Shigella Ipa. Serum antibody titers to the Ipa antigens were high relative to anti-Shigella LPS antibody titers, especially in pediatric patients. In contrast to the anti-Ipa responses observed, no differences in antibody responses to LPS in children compared by nutritional status were found. High levels of serum and mucosal cross-reacting antibody to heterologous serotype LPS were found between Shigella flexneri serotypes 1a and 2a. Different patterns of immune response to Ipa proteins and LPS that may aid in the definition of Shigella antigens important in host protection were observed in adults, well-nourished children, and malnourished children.

Comparison of single-dose treatment with norfloxacin and standard 5-day treatment with trimethoprim-sulfamethoxazole for acute shigellosis in adults.

Shigellae have been shown to be highly susceptible to new quinolone agents, with average MICs for 90% of isolates of less than 0.1 microgram/ml. Because these agents also reach high concentrations in the stool after a single dose, the effectiveness of a single 800-mg dose of norfloxacin and of 5-day treatment with trimethoprim-sulfamethoxazole (TMP-SMX) were compared in a randomized trial. Patients with clinical dysentery received one of these treatment regimens, and clinical data and follow-up culture results were analyzed for patients whose stool culture on presentation grew shigellae. When 55 patients with shigellosis (26 treated with TMP-SMX, 29 treated with norfloxacin) whose bacterial isolates were susceptible to the antibiotic given were compared by treatment group, no significant differences were seen in days of illness (mean, 2.5 +/- 0.65 days with TMP-SMX and 2.0 +/- 0.47 days with norfloxacin; P = 0.200) or number of unformed stools after starting treatment (mean, 9.7 +/- 2.37 stools with TMP-SMX and 7.6 +/- 3.19 stools with norfloxacin; P = 0.312). Resistance in vitro to TMP-SMX was seen in 15% of Shigella isolates, whereas none was resistant to norfloxacin. Bacteriologic failure was found in 1 patient among 24 receiving TMP-SMX and in none of 25 patients receiving norfloxacin. One single dose of norfloxacin was as effective as 5 days of treatment with TMP-SMX in these adults with shigellosis.

Enteroadherent Escherichia coli as a cause of diarrhea among children in Mexico.

Enteropathogenic Escherichia coli (EPEC) often exhibits localized adherence or diffuse adherence to HEp-2 cells. We recently provided evidence that HEp-2 cell-adherent or enteroadherent E. coli (EAEC) not belonging to EPEC serogroups was the cause of diarrhea among U.S. travelers to Mexico. In the present study, we looked for EAEC and EPEC in stool specimens from 154 children with acute diarrhea and 137 well children seen at several outpatient clinics in Guadalajara, Mexico. EAEC showing localized adherence (EAEC-L) was isolated from 13.0% of the patients and 0.7% of the controls (P less than 0.0001). EAEC showing diffuse adherence (EAEC-D) was recovered from 20.8% of the patients and 7.3% of the controls (P less than 0.001). EPEC was isolated from 4.5 and 6.7% of the patients and controls, respectively. Among all enteropathogens, only enterotoxigenic E. coli occurred as commonly (21.4%) as EAEC-D and EAEC-L did in children with diarrhea. Of the EAEC-L strains isolated from children with diarrhea, 20% belonged to recognized EPEC serogroups, and 3.1% of EAEC-D strains belonged to recognized EPEC serogroups. This study suggests that EAEC may be an important pediatric enteropathogen in Mexican children with diarrhea and further supports the observation that adherence to HEp-2 cells may be a marker of virulence independent of EPEC serogroup among E. coli strains.

Efficacy of trimethoprim-sulfamethoxazole in treatment of acute diarrhea in a Mexican pediatric population.

The efficacy of trimethoprim-sulfamethoxazole (TMP-SMX) and placebo were compared in a randomized double-blind study of 141 Mexican children with acute diarrhea. Patients who met specific entry criteria received TMP-SMX or an identical appearing placebo for 5 days. Stools were examined for bacterial, viral, and parasitic pathogens. Enterotoxigenic Escherichia coli were the most commonly isolated pathogens (22% of total). Patients given TMP-SMX had a significantly shorter time to "last illness stool" than did those given placebo, but no difference in number of unformed stools in 5 days was found between treatment groups. However, TMP-SMX significantly shortened the illness in patients with fever or many fecal leukocytes. When stool cultures positive for any bacterial pathogen or for enterotoxigenic E. coli were analyzed as separate groups, a significantly faster recovery was observed in patients given TMP-SMX. TMP-SMX is efficacious in the treatment of Mexican children with diarrhea and culture-proved bacterial infection or when the clinical signs and symptoms suggest bacterial enteritis.