INFECTIOUS DISEASE CLINICS (OF NORTH AMERICA Acute Diarrheal Disease in Children: Epidemiology, Prevention, and Treatment ceurting in young children in developing, countries tates, 220,000 children younger than $ years86 besa ommon pathogens causing diarrhea! ilness in the ge groups (6). Rotaviruses and norovirusesare the most observed pathogens. Other viral pathogens tha have been rhea include astroviruses and major cause of 1 NP7 glycoprotein 18.G types nd 20 ty .é VPA protease cleaved hemagghutinin(P). To date, have been described for group A rolaviruses, and es cause human fection, Seveloping count ‘cause of hospii responsible for 600 20 doaths cach present in high titers in stools of infected py before the onset of diarrhea. Rotavirus shedding ean persist for 21 days afterACUTE ARINHESL BBEASE IN CHLDREN se the onset of symptoms in immunocompetent hosts. Virus can be found on toys and hard surfaces in daycare centers, indicating that fomites may serve asa mechanism of transmission [1 |]. Spread within is common. Rotavirus ie the most common cause af hosp is an important cause of acute gastroenterit children attending daycare centers s, disease is most prevalent during the cooler mouths, Seasonal pattecns in Lopical climates are less pronounced, but disease is more common during the drier, cooler months. © infected by 3 years of age, Rotavirus gastroenteritis most commonly occurs in infants and ‘months old. Infections during the first 3 months of life and reinfections Thirty percent to though most movements per nd electrolyte those with HIV, solid-organ or bone marrow transplantation, and natural ler ceil deficiency, may have more severe or prolonged diarthe Enzyme immunoassay and latex agglutination assays for group A rotavirus antigen detection in stool are available commercially. Virvs also can be let cron micreseopy and by reverse transcriptase polymerase chain reaction No specie antivical therapy is avai ble, Oral or parenteral fluids are ‘A vaccine to prevent rotavirus la ly. The rhesus rotavirus i veecine (RotsShield) licensed by the US Food and Drug Administration in August 1998 and incorporated into the 1999 routine rno longer recommended for use because of the jon of this vaccine with intussusception [20| This product was alent live A second vaccine, has just sed within the next vaccine, completed clinical trials and is expected to be several years [22] Caltctvirus infecitons Caliciviruses are & family of single-stranded, nonenyeloped RNA viruses, The two recognized genera that cause diarth ase in humans arechildcen younger than 4 yecrs of age [24 re the most commion cause of outbreaks of nonbacterial ‘ated that they are responsible lor 68% to 80% enteritis in irdustrislized countries. The Centers estiatey that at least 50% of all food- can be attributed to noroviruses. Among. ness reported 10 the Centers for Disease 1 gastroente inating surfaces or entering the on Noroviruses are highly contagious. An inoculum of | particles may be sufficient 10 infect an indi Norovirus: jection usually presents with acute onset of voting, watery abdominal crimps, and nausea. Low-grade fever ly ‘more common in children. De- ‘most common ion, especially among young and Symptoms usually Tast 24 19 60 hours. iagnosis of norovirus outbreaks has improved wit ing use of reverse transcript yymerase chain reaction 27 state public health labo noroviruses by reverse trance be used 10 lest st noroviruses on environmental swabs. No specific therapy exists for calicivicus gastroenterit py vonsisis of seplacing Mui nd cortccting cles jougD oral and mntravendus ffuid admmstraton. lasses iple antigeaic types co-cireulats in the same region [29].ACUTE ARRIEAL DBEASE A CHELIRE se Astroviruses are increasingly recognized as significant grstrointestinal pathogens. ‘These viruses have been detected in 10% of sporadic cases acterial 3 in children: younger than 4 years of age and he winter. ‘Transmission is person to person via the ial tesis for diagwosis of estiovitus infection are not available 1m the Umted States. Enzyme immunoassays are availible in many other countries, Treaiment of astrovirus infection is supportive. Rehyération with oral or {intravenous fluid and electrolyte solution is the mainstay of therapy. Emeric adenorirus infections viruses are double-stranded, nonenveloped DNA viruses; serotypes cause Luar infections. Serotypes 41, are associated with gastroenteritis. the first few days of an acute illness, but persistent and intermittent shedding. for longer periods is common. Transmission is vin the feealoral route. Asymptomatic infections are common, and reinfections >an occur. ‘The clinical picture is similar to that of rot: nonanterie adenoviruses, high fours and Disease cin be pet with oral or intravenous fluid and electrolyte solution is the mail therapy. tay of Bacterial causes of diarrhea In developed countries, bacte ceases of diarrhea 33]. Campylohact thogens account for 2% to 10% of . Salmonella, Sivgella, and EHECson pews account for most coses in the United States. Yersi species including Vibrio cholerae and non-O1 cholera, main vehicles of y, particularly fi and outbreaks of diarchea in daycare centers have been reported infrequently. Sheciding of Campylobacter organisms usvally lasts 2 to 3 weeks. Campylobacter infec from: mild diarrhea to include ted in more severe cases .¢ duration of illness andbakery products, have been by contact implicated in outbreaks. These foods usua ‘with an animal product or, occasional ighest in poople of life elderly people; and people thies, malignant neoplasms, and ATDS [42], Most ndespread outbreaks have been reported. Was second 10 Ci weeks after infection, 45% of children younger than is compared with 5% of older ehildfen and adults. therapy can prolong shedding. Approximately 1% of shed Salmonella for more than | year and are chronic infection with nontyphoidal Salmonella causes a spectrum of illness ranging from asymptomatic curriane, roenteritis besause therapy jorten the duration of disease and may prolong the duration of carriage. Although of unproven benefit, antimicrobial therapy # rocom- ‘mended for gastroenteritis caused by Salmonella species in patents with an increased risk of invasive ts younger than 3 months of age and. patientsa benny uscept in patients for whom therapy is indicated (39) quired in developing countries often exhibit resistance 10 many robial agents, but us to ceftriaxone or axime and to fluoroquinolones Shigella infections rare in ¢ Indian subcontinent, Humans are the natural nal symptoms 0 more severe symptoms, including fever, abdominal cromps or tendecness, tenesimus, and mucoid stools wi Dresentations vary with § fection usually produces watery diarrhea, whereas S, hemolytic. u symptoms snteriae type 1 infection), toxic megacolon syndrome (HUS) and perfor Cultures of feves isease, the primary indication or treatment is to prevent spread of therman. seas eM =o data in 200 and 47% were 5 days. Antidiarrheal compounds that inh dicated because they may prolo able 2, Transmission of most ditrrhea-associated £ coli strains is from Food or water contaminated with human or animal feces or from symptomatic pec diarrhea ia the shed in feces of cattle, EHEC can be transmitted by undercooked ground heel, contaminated water and produce, unpasteurized milk, and a wide ed to ground beef, petting d vegetables, salami, yogurt, Water Enteroitrasie lcody or tonbloody, fyenery Enlcosgutegaite Acute and earonie diarrhea in infenss werery, cecaial acd398 swe water in recreational areas. The infectious dose is approximately 100 organisms, and person-to-person transmission is conmen during outbreaks. rolypes. HUS occurs in develops in HUS. If patients have no laboratory evi penia, or nephropathy 3 days after resclution of diarrhs developing HUS is low. Atthoush some stucies have suggested that children with hem: ltis caused by EHEC have a greater riskof developing HUS agenis, a meta-analysis failed 16]. Most experis ward co such treatment may increase the tisk of HUS [39,45].ACUTE DUAR. ISEASE NCIS 9s nthe environment. C dificle is accuired from the envitonment or from stool of| cotter colonized or infected persons by the feeal-oral rovte, Intex jon rates in heal and young infants can be 30%, bi ane less than $% in children older than 2 years of age and in a 1d daycare centers sire major reservoirs ry robial agent toxin rarely is recovered from siool specimens of 8 it may be recovered from stool specimens from neonsies and infants who have no gestroint confounds the interpretation of positive to than 12 months of ago. yndromes associated with infections include pseudomembranous eolitis| icrobial-associated diarrhea. Pseudomembranous ol acterized by dinsrhea, abdominal cramps, fever, sy le toxins to diagnose ‘Symptomatic infants younger than 1 year of age should be investigated for causes of diarrhea other than C difficile because te carriage of C diffielle is the rule rather than the exception in this age group, and the presence of C dificile toxin may not be responsible for clinical therapy should be discontinued as soon severe disease or in whom ¢i discontinued. Mi9% esmeny ral vancomycin is, ralis is a fiagellated protozoan that hes a worldwide is also the most common parasite cause of diarrhea in the trophozoite and cyst forms, led to the small intestine and bil iycare centers and in in excretion may last for many months. The disease as long as the infected person exeretes cysts, Symptomatic infection causes a broad spectrum of clinical manifesta- ‘Many people who become infected with G plonatic, Most symptomatic ss have mnild di ting and cramping also are common.roimidazole, has a cure rate of 90% to 100% ot ellcacy data are available © 100% effective when given for 7 to 10 days. Albendazole [48} and mebendazoie have boon shown to be as effective as metronidazole for treating giardiasis in children, and they have fewer adverse effects, A 3-day course of aitazoxanide oral suspension is as efactive as metronidazole and has the advantage of treating mt 2 course can be repeated with the same crug immanocompromised patients, who may require Asymptomatic carriers should not be treated except to prevent spread in situations where they are in close contact with Cryprospor ‘are excreted in feces and are the infect a variety of hosts, including mara bore outbreaks have been associated with contamins water and exposure Lo contaminated 7 pools. Tr jumans can occur from farm lixestock, particularly young anime hose found in petting zoos, or pets. Person-to-person transmission cours with attack sates of 30% to birds, and reptiles. Extensive water- of municipaloe eerie ffor's to interrupt transmission of res to prevent spread of enteric pathogens include proper and exclusion of poople with diar (eg, swimming pools, lakes, ponds). Eggs and other foods of animal origin should be cooked thoroughly. should not be eaten. Washing hands: ting boards and utensils with soap and hygiene measures combined with staf training and monitoring of stat procedures. less sodium. Both ‘eating dehydration as acute diarrhea, Hydration status in children can be assessed observed signs and symptoms. Children who are nol mrucons membranes, wat diapers, and tears are aot dehydrated aad do not require ORS. In i be used to reniace ‘ongoing st required rehyd” ORS. ORS is contraindicated in a child who is obtunded or ydration therapy is complete, regular feeding should Eurly refeeding Barly refeeding is recommenced in diseases by immunization is Ia, cholera, and enter- References (a) Koeek M, ern Guerrant RL. Tae global barn of daria disease, sade published eiesn 1992 and 200, Bull Word Heath Organ 203AAFTE DIARRHEA DISEASE IN CHULOEEN 2 severely dehydrated with changes in vital signs of menial status req sion is a Tate mai ‘und perfusion are better indicators of severe dehydration and incipient ese childron can be given oral rehyd Children who ly or moderately dehydrated should receive 50 to jould be re-evaluated often for are vomiting generally tolerate Who is obtunded or al risk for cectcolyte disturbance or a need for intravenous therapy. ‘Almost all inf acute gestroenteritis can tolerate breastfeeding. formula-fed infants, diluted formula does not provide any benefit over J-sirength formula, Lafants with the most sevore diarrhea may require lactose-free formula until mucosal recovery is complete at around 2 wes. ‘Older children can consume a regular age-appropriate diet, No data suggest that-a, diet consisting of only bananas, rice, applesauce, and toast (the BRAT diet) speeds recovery from dinrsheal illnesses. Lactose restriction is, in diarrhea managernent and prevention decrease the a of diarrheal illnesses are. needed. few ORS that would decrease the volume of loose tural preducts that may bave an toxigenic £ coli infection are in elinicat tri References otek M, Been C,Guerrant RE. The global burden of iarhooal dices, a estimated fom ithe between 1992 and 2000. Bull Woe Health Ors 197-208600 pea fa} Glass x, Kagon & spositl songs, and etiologies AG, HreseeJS, Moiman RC, Parashar UD, Glass. CortefTetveness immunization program for the United States JAMA, 199827 1996: 74;Suppl 1) S30-6 (9) Parashar UD, Hunrslman EG, Brews JS. MiNorwalicite vrs” esosited Safet Dis 2002 1861-7 [26] Chicwick PR, McCass R. Transmission of small round structured virus by vouing ‘during bespta outoeak of gastrentemts. J Hosp fret 1994.26 251-8, [20] Chicwick PR, Walisr M, Reet AE, Airhoro rsnmision of small round sructced vv, Lancet 199343: [PR] Ammar RL, Emer MK. Diagnosis of sonculivatible assoenterits viruses, the human nts Transplunction 203:76 ‘Turkish VI, Monto AS, Gouvea V, Srivattiva 8, lascton RE, Patient snd ines elileal seis. Ad Net data on the insidence of sommeniy Rep 203:338-43, [35] Prisdame CR, Hoekstra RM, Semuel M, etal Risk actors for sporadic Campylubacter {infection inthe Listed States case-control stucy in FoodNs sites, Cin Inet Dis 2004, 38(Supp1 3} 5285.05 [30] Bluse MJ, Wels JG, Fekiman KA, Pollard KA, Allen JR. Canpyioba-tor ener ia the United Siti s maltewner suds. Ann Intem Med 1983 98:360-5, [37] Kapperud G, Lassen J, Ostru SM, Azsen S. Clinisal atures of sperade Campytabacter sans in Norway, Scan J Infet Ds 19:28°741-9 Hogg OG, Faitey CK. Prevalence 1 Gastroenterol Herat 238 IWR Morb Mortal Widy leMed Asoo! tal. Smoneiotic anepidemiolg 14] Levine 05, Levine MM. Houslies (fusca domestica) as mechanical vectors ef shigelini oy Infact Di 1991 13:681-96, (44) Rowe PC, Orrbine E, Lior Het a. Risk of bom tue uremic syndrome alter sporadic Enchorehia cot OISEMT infesion: Rewlte of & Canadien colluborutve. study. Investigators of the Canadian Pediacie Kidney Disease Research Cantt. J diate 19% 1277-92, [85] Tare PI, Gordon GA, Chandler WE. Shig-tonir-producing Hschenenis cot and haemolytic etic syerome, Larcet 2008/265:1079-8, [ad] Sufdor N, Suid A, Gangaon RE, Mahi DG. Risk of hemolytic uremic syedkome after icteealmentof Evherckia coli O1STH Texter a meta-analysis, JAMA 2002 288 0.tinal diseases, J Intern Med 2005;257:78-92, ¢ Jordan report 20t3 anniversary accelerated development of vaccines. 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