The emerging importance of Shiga toxin-producing Escherichia coli other than serogroup O157 in England

Introduction. Shiga toxin-producing Escherichia coli (STEC) can cause severe disease and large outbreaks. In England, the incidence and clinical significance of STEC serogroups other than O157 (non-O157) is unknown due to a testing bias for detection of STEC O157. Since 2013, the implementation of PCR to detect all STEC serogroups by an increasing number of diagnostic laboratories has led to an increase in the detection of non-O157 STEC. Hypothesis/Gap statement. Due to a bias in testing methodologies to select for STEC serogroup O157 in frontline diagnostic laboratories in most countries, very little surveillance data have been previously generated on non-O157 STEC. Aim. Five years (2014–2018) of STEC national surveillance data were extracted and descriptive analysis undertaken to assess disease severity of non-O157 STEC strains. Methods. Data from 1 January 2014 to 31 December 2018 were extracted from the National Enhanced Surveillance System for STEC and analysed. Results. The implementation of Gastrointestinal Polymerase Chain Reaction (GI-PCR) has resulted in a four-fold increase in the detection of non-O157 STEC cases between 2014 and 2018. There were 2579 cases infected with 97 different non-O157 serogroups. The gender distribution was similar amongst STEC O157 and non-O157 STEC cases with 57 and 56 % of cases being female respectively, but a significantly higher proportion of cases (P <0.001) under 5 years of age was observed among STEC O157 (22 %) cases compared to non-O157 STEC (14 %). The most common non-O157 serogroups were O26 (16 %), O146 (11 %), O91 (10 %), O128 (7 %), O103 (5 %) and O117 (3 %). Overall, rates of bloody diarrhoea were highest in O26 (44 %) and O103 (48 %) cases and lowest in STEC O117 cases (17 %). Strains harbouring Shiga toxin stx1a caused the highest proportion of diarrhoea (93 %) and caused the same level of bloody diarrhoea as stx2a (39 %). However, stx2a caused the highest proportion of vomiting (46 %), hospitalisation (49 %) and considerably more HUS (29 %) than other stx profiles. Conclusion. The implementation of PCR targeting stx at diagnostic laboratories has shown that non-O157 STEC, most notably STEC O26, are an emerging risk to public health.

Trends in Diarrhoeal Diseases, City of Bulawayo Clinics, 2007-2012

Diarrhoeal Diseases Are A Public Health Concern And Constitute About 5% Of All Main Causes Of Out-Patient Department Visits In The City Of Bulawayo. We Conducted A Dataset Analysis Of Diarrhoeal Diseases To Determine How The Trends Have Varied Over The Years. A Descriptive Cross-Sectional Study Based On An Electronic Database For Diarrhoeal Diseases (2007-2012) Was Conducted. Data Was Collected Using Compilation Forms And Checklists, Then Analysed Using Microsoft Excel. Three Key Informants Were Interviewed. The Formula, (Mean + 1.5SD), Was Used To Calculate Thresholds For Bloody Diarrhoea. There Were More Watery Than Bloody Diarrhoeal Cases Throughout The Review Period, With 2008 Having The Highest Number Of Such Cases Under 5. In Northern Suburbs, There Was A General Decrease In Both Types Of Diarrhoea Cases In Both Age Groups (<5 And >5) Whilst In Emakhandeni; There Was An Increase In Bloody Diarrhoea Incidence After 2009. The Incidence Rate For Bloody Diarrhoea Was Higher For Females Throughout. There Was An Increase In The Number Of Stool Specimens Collected For Examination Between 2008 And 2012. Overall, There Was A Decrease In The Incidence Of Diarrhoea In Bulawayo City, Partly Due To Regular Anti-Diarrhoeal Campaigns. Following The Study, The Following Measures Were Implemented: Health Education To Improve Hygienic Practices; Advocacy For Improved Water And Sanitation In Cowdray Park; Rotavirus Vaccination For Under-Fives; Maintenance Of All Records On Diarrhoea And Up To Date Thresholds In All Clinics For Use In Monitoring Diarrhoea.

Predictors of aetiology and outcomes of acute gastrointestinal illness in returning travellers: a retrospective cohort analysis

Background Gastrointestinal illness is a major cause of morbidity in travellers and is a common reason for presentation to healthcare services on return. Whilst the aetiology of imported gastrointestinal disease is predominantly infectious, outcomes are variable due to a range of phenomena such as post-infectious irritable bowel syndrome, drug resistance and occult pathology (both infectious and non-infectious). Previous studies have focussed on predictors of aetiology of gastrointestinal disease in travellers; we present a retrospective study combining both aetiological and early outcome data in a large cohort of returned travellers. Method We identified 1450 patients who attended our post-travel walk-in clinic with gastrointestinal symptoms between 2010 and 2016. Demographic, travel, clinical and laboratory data was collected through case note review. Logistic regression analysis to examine correlates of aetiology and outcome were performed in R (CRAN Project 2017). Results Of 1450 patients in our cohort 153 reported bloody diarrhoea and 1081 (74.6%) reported non-bloody diarrhoea. A definitive microbiological diagnosis was made in 310 (20.8%) of which 137 (9.4%) had a parasite identified and 111 (7.7%) had a bacterial cause identified. Factors associated with a parasitological diagnosis included history of travel to South Asia (aOR = 2.55; 95%CI 1.75–3.70, p < 0.0001) and absence of bloody diarrhoea (aOR = 0.22; 95%CI 0.066–0.53, p < 0.005). Factors associated with a bacteriological diagnosis included male gender (aOR = 1.69; 95%CI 1.10–2.62, p < 0.05), an age < 37 years on presentation (aOR = 2.04; 95%CI 1.25–3.43, p < 0.01), white cells on stool microscopy (aOR = 3.52; 95%CI 2.09–5.86, p < 0.0001) and a C-reactive protein level of >5iu/dL (aOR = 4.68; 95%CI 2.91–7.72, p < 0.0001). The majority (1235/1450, 82.6%) reported full symptomatic resolution by the first follow up visit; factors associated with lack of symptomatic resolution included female gender (aOR = 1.45 95%CI 1.06–1.99, p < 0.05), dysenteric diarrhoea (aOR = 2.14 (95%CI 1.38–3.25, p < 0.0005) and elevated peripheral leukocyte count (aOR = 1.58 95%CI 1.02–2.40, p < 0.05). Conclusions In a cohort of returned travellers, we were able to identify multiple factors that are correlated with both aetiology and outcome of imported gastrointestinal syndromes. We predict these data will be valuable in the development of diagnostic and therapeutic pathways for patients with imported gastrointestinal infections.

P659 Colonoscopic screening of symptomatic patients suggests an emerging inflammatory bowel disease (IBD) in urban and rural south India

Background Recent studies suggest that IBD is on the rise in the developing world. This is also the region with limited access to healthcare facilities, poor physician and patient awareness of the disease and diagnostic dilemmas with the infectious bacterial diarrheas preventing adequate diagnosis. There is very limited data on the relative prevalence of IBD compared to the infectious diarrhoeas. We screened symptomatic patients to assess the diagnostic profile in the real world settings with free of cost service to people below poverty line and the un-insured. Methods The study is being conducted in a large tertiary care centre in Southern India from March 2020 till date. We present the results of an interim analysis. Symptomatic patients with diarrhea, unintentional weight loss, bleeding per rectum, chronic abdominal pain and unexplained anemia were screened with a blood test (Haemogram, liver function, serum protein), abdominal ultrasound and colonoscopy/ileoscopy to ensure an early diagnosis and initiation of treatment. Data including the demographics of the patients, predominant symptoms, rural/urban residence, investigations, biopsy and final diagnosis were entered into an excel spreadsheet and analysed. Results 6878 patients, 2188 female (32%), median 44 years (1–82 years) were screened between March 2020 to January 2021. Bloody diarrhoea was noted in 1212(18%), chronic non-bloody diarrhoea in 887 (13%), altered bowel habits in 2381 (35%), pain abdomen in 4030 (59%), un-intentional weight loss in 648 (10%) and anemia in188 (3%). IBD was diagnosed in 397 patients (6%) of which 169 (2.5%) were UC and 228 (3.3%) were CD. Infective etiology including intestinal tuberculosis was seen in 577 (8.3%). Colorectal cancer was diagnosed in 251 (3.6%), polyps in 614 (8.9%). Overall, 4921 (71.5%) were urban and 1957 (28.5%) rural. The proportion of UC (2.3% rural vs 2.5% urban, p=0.65) and CD (3.6% rural and 3.2% urban, p=0.43) were not different in rural and urban groups. There was significantly higher proportion of infectious colitis in the rural subgroup (p=0.01)(Table 1). Conclusion This interim analysis indicates a rising IBD in both urban and rural India vis a vis the infectious diarrheas. However, proportion of infectious colitis was significantly higher in the rural subgroup compared to the urban.

Reddish Diarrhoea Caused by Excessive Ingestion of Watermelon: Mimicker of Bacterial Colitis

Bloody diarrhoea in children is indicative of serious diseases. Although bloody diarrhoea following bacterial colitis is well known, reddish diarrhoea caused by excessive ingestion of watermelon is unknown. A two year old girl who excessively ingested watermelon presented with repeated reddish diarrhoea. A kit for fecal occult blood testing revealed that the reddish diarrhoea did not contain blood. Reddish diarrhoea caused by excessive ingestion of watermelon can be a mimicker of bacterial colitis. The kit for fecal occult blood testing was useful for differential diagnosis. We should be aware that this pitfall can be hidden in daily nutrition.

Predictors of Aetiology and Outcomes of Acute Gastrointestinal Illness in Returning Travellers: a Retrospective Cohort Analysis

Background: Gastrointestinal illness is a major cause of morbidity in travellers and is a common reason for presentation to healthcare services on return. Whilst the aetiology of imported gastrointestinal disease is predominantly infectious, outcomes are variable due to a range of phenomena such as post-infectious irritable bowel syndrome, drug resistance and occult pathology (both infectious and non-infectious). Previous studies have focussed on predictors of aetiology of gastrointestinal disease in travellers; we present a retrospective study combining both aetiological and early outcome data in a large cohort of returned travellers. Method: We identified 1450 patients who attended our post-travel walk-in clinic with gastrointestinal symptoms between 2010 and 2016. Demographic, travel, clinical and laboratory data was collected through case note review. Logistic regression analysis to examine correlates of aetiology and outcome were performed in R (CRAN Project 2017). Results: Of 1450 patients in our cohort 153 reported bloody diarrhoea and 1081 (74.6%) reported non-bloody diarrhoea. A definitive microbiological diagnosis was made in 310 (20.8%) of which 137 (9.4%) had a parasite identified and 111 (7.7%) had a bacterial cause identified. Factors associated with a parasitological diagnosis included history of travel to South Asia (aOR=2.55; 95%CI 1.75-3.70, p<0.0001) and absence of bloody diarrhoea (aOR=0.22; 95%CI 0.066-0.53, p<0.005). Factors associated with a bacteriological diagnosis included male gender (aOR=1.69; 95%CI 1.10-2.62, p<0.05), an age <37 years on presentation (aOR=2.04; 95%CI 1.25-3.43, p<0.01), white cells on stool microscopy (aOR=3.52; 95%CI 2.09-5.86, p<0.0001) and a C-reactive protein level of >5iu/dL (aOR=4.68; 95%CI 2.91-7.72, p<0.0001). The majority (1235/1450, 82.6%) reported full symptomatic resolution by the first follow up visit; factors associated with lack of symptomatic resolution included female gender (aOR=1.45 95%CI 1.06-1.99, p<0.05), dysenteric diarrhoea (aOR=2.14 (95%CI 1.38-3.25, p<0.0005) and elevated peripheral leukocyte count (aOR=1.58 95%CI 1.02-2.40, p<0.05).Conclusions: In a cohort of returned travellers, we were able to identify multiple factors that are correlated with both aetiology and outcome of imported gastrointestinal syndromes. We predict these data will be valuable in the development of diagnostic and therapeutic pathways for patients with imported gastrointestinal infections.

Cefpodoxime Proxetil associated bloody diarrhoea, itching and red rashes in child: A case report

Case Report: A case report of a five-year-old paediatric patient was presented here, who received Cefpodoxime proxetil for the treatment of Dengue fever and experienced bloody diarrhoea, itching and red rashes on hands. His laboratory data includes haemoglobin level 10.9 gm % (13-17 gm %), total leucocyte count 4100 /cmm (4000-1000 /cmm), neutrophils 73 % (40-75 %), lymphocytes 20 % (20-45 %), eosinophils 03 % (1-6 %), monocytes 04 % (2-10 %), platelet count 2.42 Lac /cµmm (1.5-4.5 Lac /cµmm), Lymph% 19.9 % (20-45), Gran% 72.5 % (40-75), HGB 10.9/103 /µL (11.0-16.0), HCT 34.9 % (37-54), MCV 68.1 fL (80-100), MCH 21.2 pg, MCHC 31.0 g /dL, RDW-CV 16.2 %, anti-Dengue-IgG and IgM tests are non-reactive and Dengue NS1 antigen test is weakly reactive. The patient recovered from red rashes and bloody diarrhoea after treatment discontinuation. Conclusions: Events bloody diarrhea and red rashes are probably due to Cefpodoxime Proxetil treatment as per WHO causality assessment.

Characterisation and identification of STEC O157 pathogenicity using machine learning

Shiga toxin-producing Escherichia coli O157: H7 (STEC) is a zoonotic pathogen that is globally dispersed, causing severe gastroenteritis when transmitted from ruminants to humans through direct or indirect contact with animals, their environment or contaminated food. Symptoms are varied in severity; from mild to bloody diarrhoea with more serious sequalae including hemolytic uremic syndrome (HUS) which can be fatal. Although there is compelling evidence that the Shiga toxin sub-type is a key predictor of disease severity, differences in virulence potential of strains with the same Shiga toxin profile are often observed. In this study, we employ machine learning algorithms to explore the relationship between the STEC genome with clinical outcome. Kmer-counts of variable length (9-100 base pair) from 1148 isolates of STEC O157:H7, representing two years of routine surveillance in England, were matched to their respective clinical outcome data. A Random Forest classifier was developed and validated with the objective of inferring the clinical symptoms associated with a given STEC genome. Clinical outcomes were categorised into asymptomatic, diarrhoea, bloody diarrhoea and HUS. The model correctly classified 160 out of 190 cases of bloody diarrhoea, 81 out of 128 cases of diarrhoea and 7 out of 12 cases of HUS, with average AUC ROC score of 90%. Kmers deemed important for distinct classification were characterised and matches related to Shiga toxin 2a phage integration and excision genes and adhesion and transporter proteins were identified. This is consistent with reported virulence factors in the literature, supporting this approach of de novo pathogen characterisation.

Efficacy of an Oral Solution Prepared from the Ultrasonic Extract of Radix dichroae roots against Eimeria tenella in Broiler Chickens

This study was conducted to determine the optimal dose of the oral solution of the ultrasonic extract of Radix dichroae (UERD) and to provide experimental support for a safe clinical dose for anticoccidial treatment of broiler chickens. Radix dichroae root extracts were prepared using the ultrasonic extraction method. The anticoccidial activity of the oral solution prepared from the ultrasonic extract of Radix dichroae roots was tested in broiler chickens following oral infection with a field isolate of E. tenella. Ninety Lingnan yellow broiler chickens (14 days old) were randomly divided into nine groups (n = 10), including six UERD oral solution treatments (0.25, 0.50, 1.50, 2.50, 3.50, and 5.00%), a toltrazuril group (0.10%), an E. tenella-infected control group, and a healthy control group. All groups were inoculated orally with 7 × 104 sporulated E. tenella oocysts (Guangdong strain) except for the healthy control group. The chickens in the seven drug-treated groups were administered a UERD oral solution or toltrazuril in drinking water for 7 days. The anticoccidial efficacy of the UERD oral solution was evaluated by the bloody diarrhoea severity level, relative body weight gain (rBWG), lesion score, oocyst per gram (OPG), and anticoccidial index (ACI). Compared with the infected control group, there were no significant differences in the groups treated with UERD oral solution or toltrazuril with regard to the lesion changes in the caecal regions (P>0.05); however, the blood contents, OPG, and oocyst score in three UERD oral solution treatment groups (0.50, 1.50, and 2.50%) were significantly reduced, and the bloody diarrhoea was also alleviated. The ACI in three UERD oral solution treatment groups (0.50%, ACI = 143.7; 1.50%, ACI = 151.0; and 2.50%, ACI = 144.3) was higher than that in the toltrazuril group (ACI = 127.0), and the rBWG in the 1.50% UERD oral solution treatment group (95.0%) was similar to that in the healthy control group (100%), which was also 12.5% higher than that in the toltrazuril group (82.5%). The findings of this study demonstrated that the UERD oral solution (0.50% ～ 2.50% dose range) showed better prevention, anticoccidial efficacy, and growth promotion effects than toltrazuril (0.10%), and the 1.50% dose level of UERD oral solution in water is the clinically recommended dose according to the present study conditions.

Effectiveness of Peer-Supervision on Paediatric Fever Treatment Among Registered Private Drug Sellers in East-Central Uganda: An Interrupted Time Series Analysis

Background: Appropriate treatment of paediatric fever in rural areas remains a challenge and may be partly due to inadequate supervision of licensed drug sellers. This study assessed the effectiveness of peer-supervision among drug sellers on appropriate treatment of pneumonia symptoms, uncomplicated malaria and non-bloody diarrhoea among children less than five years of age in the intervention (Luuka) and comparison (Buyende) districts, in East-Central Uganda.Methods: Data on pneumonia symptoms, uncomplicated malaria and non-bloody diarrhoea among children less than five years of age was abstracted from drug shop sick child registers over a 12-month period; six months before and six months after introduction of peer-supervision. Interrupted time series was applied to determine the effectiveness of the peer-supervision intervention on appropriate treatment of pneumonia, uncomplicated malaria and non-bloody diarrhoea among children less than five years of age attending drug shops in East Central Uganda.Results: The proportion of children treated appropriately for pneumonia symptoms was 10.84% (P < 0.05, CI = [1.75, 19.9]) higher, for uncomplicated malaria was 1.46% (P = 0.79, CI = [-10.43, 13.36]) higher, and for non-bloody diarrhoea was 4.00% (p < 0.05, CI = [-7.95, -0.13]) lower in the intervention district than the comparison district, respectively.Post-intervention trend results showed an increase of 1.21% (p =0.008, CI = [0.36, 2.05]) in the proportion appropriately treated for pneumonia symptoms, no difference in appropriate treatment for uncomplicated malaria, and a reduction of 1% (p <0.06, CI = [-1.95, 0.02]) in the proportion of children appropriately treated for non-bloody diarrhoea, respectively.Conclusions: Peer-supervision increased the proportion of children less than five years of age that received appropriate treatment for pneumonia symptoms but not for uncomplicated malaria and non-bloody diarrhoea. Implementation of community level interventions to improve paediatric fever management should consider including peer-supervision among drug sellers.