Clinical Course of Children with Campylobacter Gastroenteritis With and Without Co-Infection in Lima, Peru.

This study describes the clinical course of gastroenteritis caused by Campylobacter spp. as a single-infection versus coinfection and the corresponding changes that occur according to the treatment received, in children between 12 and 24 months of age. This descriptive study is based on the data of a pediatric cohort conducted between 2008 and 2011 of 555 children in Lima, Peru. Ninety-six diarrheal episodes with positive cultures for Campylobacter spp. were evaluated. In 52 episodes, empirical antibiotic treatment was started before pathogen isolation. Of these 96 episodes, 64.6% were coinfections with other pathogens. Coinfections were led by Escherichia coli, norovirus, and Giardia. Compared with single-infection episodes, coinfections had a mean symptom duration of 6.6 versus 5.7 days, a mean frequency of bowel movements per episode of 18.9 versus 14.8, and occurrence of vomiting and fever in 24.2% versus 14.7% of patients. Most of the patients with more severe clinical features at diagnosis were prescribed macrolides as empiric treatment. In the single-infection group, symptom duration was 7.2 ± 3.3 days in the macrolide-treated group and 7.9 ± 2.7 days in the nonmacrolide group. Diarrhea caused by coinfection appeared to be generally more severe than a single-pathogen. Patients with more severe clinical courses who received macrolides treatment might have had a faster recovery than patients who received nonmacrolides.

High Prevalence and Increased Severity of Norovirus Mixed Infections Among Children 12-24 Months of Age Living in the Suburban Areas of Lima, Peru.

In an active diarrhea surveillance study of children aged 12-24 months in Lima, Peru, norovirus was the most common pathogen identified. The percentage of mixed (bacterial and noroviral) infections was significantly higher among norovirus-positive samples (53%) than among norovirus-negative samples (12%). The combination of norovirus with the most common bacterial pathogens was associated with increased clinical severity over that of either single-pathogen norovirus or single-pathogen bacterial infections.

Comparative analysis of antimicrobial resistance in enterotoxigenic Escherichia coli isolates from two paediatric cohort studies in Lima, Peru.

BACKGROUND: Antibiotic resistance is increasing worldwide, being of special concern in low- and middle-income countries. The aim of this study was to determine the antimicrobial susceptibility and mechanisms of resistance in 205 enterotoxigenic Escherichia coli (ETEC) isolates from two cohort studies in children <24 months in Lima, Peru. METHODS: ETEC were identified by an in-house multiplex real-time PCR. Susceptibility to 13 antimicrobial agents was tested by disk diffusion; mechanisms of resistance were evaluated by PCR. RESULTS: ETEC isolates were resistant to ampicillin (64%), cotrimoxazole (52%), tetracycline (37%); 39% of the isolates were multidrug-resistant. Heat-stable toxin producing (ETEC-st) (48%) and heat-labile toxin producing ETEC (ETEC-lt) (40%) had higher rates of multidrug resistance than isolates producing both toxins (ETEC-lt-st) (21%), p<0.05. Only 10% of isolates were resistant to nalidixic acid and none to ciprofloxacin or cefotaxime. Ampicillin and sulfamethoxazole resistance were most often associated with blaTEM (69%) and sul2 genes (68%), respectively. Tetracycline resistance was associated with tet(A) (49%) and tet(B) (39%) genes. Azithromycin inhibitory diameters were ≤15 mm in 36% of isolates, with 5% of those presenting the mph(A) gene. CONCLUSIONS: ETEC from Peruvian children are often resistant to older, inexpensive antibiotics, while remaining susceptible to ciprofloxacin, cephalosporins and furazolidone. Fluoroquinolones and azithromycin remain the drugs of choice for ETEC infections in Peru. However, further development of resistance should be closely monitored.

Rotavirus seasonal distribution and prevalence before and after the introduction of rotavirus vaccine in a peri-urban community of Lima, Peru.

We evaluated the monthly distribution of rotavirus diarrhea in a cohort of children 12-24 months of age followed as part of a diarrhea clinical trial in a peri-urban community of Lima. We observed a peak of rotavirus diarrhea in the winter months and a decrease in rotavirus prevalence after the introduction of the rotavirus vaccine in Peru.

Randomized double-blind controlled trial of bovine lactoferrin for prevention of diarrhea in children.

OBJECTIVE: To determine the effect of bovine lactoferrin (bLF) on prevention of diarrhea in children. STUDY DESIGN: We conducted a community-based randomized double-blind placebo controlled trial comparing supplementation with bLF vs placebo. Previously weaned children were enrolled at 12-18 months and followed for 6 months with daily home visits for data collection and supplement administration. Anthropometric measures were done monthly. RESULTS: Five hundred fifty-five children were randomized: 277 to bLF and 278 to placebo; 65 dropped out; 147 894 doses were administered (92% compliance). Overall there were 91 446 child-days of observation and 1235 diarrhea episodes lasting 6219 days. The main pathogens isolated during diarrheal episodes were norovirus (35.0%), enteropathogenic E coli (11.4%), Campylobacter (10.6%), enteroaggregative E coli (8.4%), enterotoxigenic E coli (6.9%), and Shigella (6.6%). The diarrhea incidence was not different between groups: 5.4 vs 5.2 episodes/child/year for bLF and placebo, respectively (P = .375). However, the diarrhea longitudinal prevalence was lower in the bLF group vs placebo (6.6% vs 7.0%, P = .017), as well as the median duration of episodes (4.8 vs 5.3 days, P = .046), proportion of episodes with moderate or severe dehydration (1.0% vs 2.6%, P = .045), and liquid stools load (95.0 vs 98.6) liquid stools/child/year, P < .001). There were no adverse events related to the intervention. CONCLUSIONS: Although there was no decrease in diarrhea incidence, longitudinal prevalence and severity were decreased with LF.

Clinical studies of lactoferrin in children.

Much has been learned in recent years about the mechanisms by which breastfeeding improves child health and survival. However, there has been little progress in using these insights to improve pediatric care. The aim of this study was to review all clinical studies of lactoferrin (LF) in children in an effort to determine which interventions may improve pediatric care or require further research. We conducted a systematic and critical review of published literature and found 19 clinical studies that have used human or bovine LF for different outcomes: iron metabolisms and anemia (6 studies), fecal flora (5 studies), enteric infections (3 studies), common pediatric illnesses (1 study), immunomodulation (3 studies), and neonatal sepsis (1 study). Although the efficacies have varied in each trial, the main finding of all published studies is the safety of the intervention. Protection against enteric infections and neonatal sepsis are the most likely biologically relevant activities of LF in children. Future studies on neonatal sepsis should answer critically important questions. If the data from these sepsis studies are proven to be correct, it will profoundly affect the treatment of low birth weight neonates and will aid in the reduction of child mortality worldwide.

Shiga toxin-producing Escherichia coli in Peruvian children with bloody diarrhea.

Shiga toxin-producing Escherichia coli (STEC) is not routinely sought in clinical laboratories in developing counties. Among 131 bloody diarrhea samples in Peruvian children <5 years of age, STEC was found in 9.2% and was associated with absence of fever, an observation that may increase suspicion of these pathogens. Because of the significant prevalence of STEC locally, proper diagnostics methods should be implemented in the region.

Impact of lactoferrin supplementation on growth and prevalence of Giardia colonization in children.

We conducted a randomized, double-blind, placebo-controlled trial comparing supplementation with bovine lactoferrin versus placebo for the prevention of diarrhea in children. Comparison of overall diarrhea incidence and prevalence rates found no significant difference between the 2 groups. However, there was a lower prevalence of colonization with Giardia species and better growth among children in the lactoferrin group.

Lactobacillus casei strain GG in the treatment of infants with acute watery diarrhea: a randomized, double-blind, placebo controlled clinical trial [ISRCTN67363048].

BACKGROUND: Adjuvant therapy to ORT with probiotic bacteria for infants with acute watery diarrhea has been under active investigation. Most studies have been done in the developed world showing benefit only for viral mild gastroenteritis. We evaluated the effect of a milk formula containing one billion (109) cfu/ml of Lactobacillus casei strain GG (LGG) upon duration and severity of diarrhea in infants in an environment with more severe acute diarrhea, where etiologic agents other than rotavirus are involved more frequently, and where mixed infections are more prevalent. METHODS: Male infants aged 3-36 months brought for treatment of acute watery diarrhea of less than 48 hours were eligible. After rehydration was completed with the WHO's oral rehydration solution, patients were randomly assigned to receive a milk formula either containing LGG or not. Stool volume was periodically measured using a devise suited to collect stools separate from urine. Duration of diarrhea was estimated based on stools physical characteristics. RESULTS: Eighty nine patients received the placebo milk formula and ninety received the LGG containing formula. Both groups were comparable in their baseline characteristics. Total stool output was significantly larger (p = 0.047) in the LGG group (247.8 ml/kg) than in the placebo group (195.0 ml/kg). No significant differences were found in duration of diarrhea (58.5 hours with LGG vs. 50.4 hours with placebo), rate of treatment failure (21.1% with LGG vs. 18.0% with placebo), and proportion of patients with unresolved diarrhea after 120 hours (12.2% with LGG vs. 12.5% with placebo). The rate of stools with reducing substances after 24 hours of treatment increased significantly in both groups (from 41.4% to 72.2% with LGG and from 45.9% to 68.0% with placebo). CONCLUSION: This study did not show a positive effect of LGG on the clinical course of acute watery diarrhea. Positive beneficial effects of LGG, as had been reported elsewhere, could have been masked in our study by worsening diarrhea due to transient lactose malabsorption. Further studies with low-lactose or non-lactose conveyors of LGG are desirable.

Bicarbonato vs. citrato en la solución de rehidratación oral para niños con diarrea aguda acuosa: un ensayo clínico controlado / Bicarbonate vs. citrate in oral rehidratation in acute diarrhea

Los paquetes conteniendo la mezcla de glucosa-electrolitos recomendada por la Organización Mundial de la Salud (OMS) para la rehidratación oral pueden hacerse inservibles cuando se almacenan bajo condiciones de humedad debido a que la glucosa sufre un proceso de polimerización, en una reacción favorecida por el bicarbonato de sodio, que causa un oscurecimiento de la mezcla y disminución de su solubilidad. La sustitución del bicarbonato por el citrato de sodio, sin embargo, mejora marcadamente la estabilidad de la mezcla. En un ensayo clínico randomizado, doble ciego, hemos comparado la eficacia de una solución de Rehidratación Oral (SRO)- conteniendo citrato con la SRO - conteniendo bicarbonato en el tratamiento de niños con deshidratación diarreica admitidos al Departamento de Pediatría del Hospital de la Universidad Cayetano Heredia. Noventaisiete niños, de tres a 24 meses de edad fueron estudiados; 49 fueron tratados con la SRO - conteniendo bicarbonato y 48, con la SRO - conteniendo citrato . Los dos grupos fueron similares en todos los parámetros medidos al empezar el tratamiento. El tratamiento fue igualmente eficaz en ambos grupos determinado por la respuesta clínica y el flujo fecal. La rehidratación oral fue exitosa (esto es, no se requirió fluidos endovenosos durante el tratamiento) en 85 por ciento de los pacientes estudiados; la tasa de éxito fue similar en ambos grupos. La concentración sérica de CO2 total incrementó de un modo similar en ambos grupos alzando valores casi normales a las 48 horas después de la admisión. Concluímos que el citrato de sodio puede sustituir al bicarbonato en la formulación de la SRO recomendado por la OMS para el tratamiento de rehidratación oral de niños con deshidratación diarréica.