Multiple etiologies of infectious diarrhea and concurrent infections in a pediatric outpatient-based screening study in Odisha, India

Abstract

Background: There are multiple etiologies responsible for infectious gastroenteritis causing acute diarrhea which are often under diagnosed. Also acute diarrhea is one of the major causes of morbidity and mortality among children less than 5 years of age.

Methods: In our study, fecal samples (n = 130) were collected from children (<5 years) presenting with symptoms of acute diarrhea. Samples were screened for viral, bacterial, and parasitic etiologies. Rotavirus and Adenovirus were screened by immunochromatographic tests. Diarrheagenic Escherichia coli (EPEC, EHEC, STEC, EAEC, O157, O111), Shigella spp., Salmonella spp., Vibrio cholera, Cryptosporidium spp., and Giardia spp. were detected by gene-specific polymerase chain reaction.

Results: Escherichia coli was detected to be the major etiological agent (30.07%) followed by Rotavirus (26.15%), Shigella (23.84%), Adenovirus (4.61%), Cryptosporidium (3.07%), and Giardia (0.77%). Concurrent infections with two or more pathogens were observed in 44 of 130 (33.84%) cases with a predominant incidence particularly in <2-year-old children (65.90%) compared to children of 2-5 years age group (34.09%). An overall result showed significantly higher detection rates among children with diarrhea in both combinations of two as well as three infections concurrently (p = 0.004915 and 0.03917, respectively).

Conclusion: Suspecting possible multiple infectious etiologies and diagnosis of the right causative agent(s) can aid in a better pharmacological management of acute childhood diarrhea. It is hypothesized that in cases with concurrent infections the etiological agents might be complementing each other's strategies of pathogenesis resulting in severe diarrhea that could be studied better in experimental infections.

Keywords: Children; Co-infection; Concurrent infection; Diarrhea; Infectious diarrhea; Odisha.

Fig. 1

Bar graphs showing detection rates of infections with a single etiological agent among children presenting with diarrhea in comparison to non-diarrheal controls. In a 2 × 2 table analysis for comparison of proportions between cases and controls for cases with detection of a single infection, all expected values (row total X column total/grand total) were ≥5. So Chi-square analysis was recommended. Two-tailed p value by Mantel–Haenszel Chi-square test = 0.02680. For single infection with Rotavirus, at least one expected value (row total X column total/grand total) was <5. So Mid-P exact test was recommended rather than Chi-square (http://www.openepi.com). Two-tailed p value by Mid-P exact test = 0.005014. *Statistically significant.# DEC: any strain of diarrheagenic E. coli

Fig. 2

Bar graphs comparing detection rates of mono-infections and co-infections among children of different age groups. Data were analyzed considering the cases with no infectious agent detection as control groups (30 cases under <2 years age group, and 26 cases under 2–5 years age group). In 2 × 2 table analysis for comparison of proportions between cases with detection of single/multiple infections in both age groups, all expected values (row total X column total/grand total) were ≥5. So Chi-square analysis was recommended. Two-tailed p value by Mantel–Haenszel Chi-square test = 0.0369 for single infections. Two-tailed p value was 0.2158 for multiple infections. When the data were compared between singe vs multiple infections under both age groups, the two-tailed p value was 0.3235. *Statistically significant