Background: Diarrhea is a significant cause of morbidity and mortality among children aged less than 5 years in sub-Saharan Africa. Bacterial organisms are important etiological agents and their identification is vital to effective management. Objective: To identify characteristics of bacterial isolates in the stools of children aged less than 5 years with acute diarrhea. Materials and Methods: The stools of children aged less than 5 years presenting with acute diarrhea were cultured using deoxycholate citrate agar and Salmonella-Shigella agar. Data were analyzed using Epi Info version 3.5.3 and P values <0.05 were regarded as significant. Results: Stool samples were obtained from 270 children aged 0.2 to 4.9 years (mean: 1.6 1.4 years). Majority of the children were males (156, 57.8%) and aged <2 years (64.1%). Diarrhea was bloody in 28 (11.8%) children. Antibiotic therapy was instituted in 185 (68.7%) children before presentation and mostly prescribed by caregiver (87, 47%). Metronidazole (154, 83.2%) was the commonest antibiotic prescribed. Bacteria were isolated in 175 (64.8%) samples. The commonest isolate was Escherichia coli (105, 60%). Bacteria were isolated from 7 (25%) of bloody diarrhea stools and the isolates were E. coli (2, 28.6%) and Shigella spp. (5, 71.4%). Isolates were most sensitive to ciprofloxacin (167, 95.4%). Bacterial isolation was significantly (P < 0.05) associated with age <2 years, nonuse of antibiotics, and bloody diarrhea. Conclusion: Enterobacteria are still important etiological agents of acute diarrhea among children. The study highlights the need for appropriate treatment of children with diarrhea and promotion of its prevention.
Keywords: Bacteria, children, diarrhea
|How to cite this article:
Eseigbe EE, Iriah S, Ibok S, Anyanwu F, Eseigbe P, Adama SJ, Ayuba GI. Bacterial isolates from the stools of children aged less than 5 years with acute diarrhea in Kaduna, Northwestern Nigeria. Ann Trop Med Public Health 2013;6:452-5
|How to cite this URL:
Eseigbe EE, Iriah S, Ibok S, Anyanwu F, Eseigbe P, Adama SJ, Ayuba GI. Bacterial isolates from the stools of children aged less than 5 years with acute diarrhea in Kaduna, Northwestern Nigeria. Ann Trop Med Public Health [serial online] 2013 [cited 2020 Sep 22];6:452-5. Available from: https://www.atmph.org/text.asp?2013/6/4/452/127798
Diarrhea is a leading cause of morbidity and mortality among children aged less than 5 years in sub-Saharan Africa. , In Nigeria, over 150, 000 deaths occurring yearly among children aged less than 5 years are attributable to diarrhea.  Prevailing poor sanitary conditions, scarce health services, and limited access to these services, in addition to the immaturity of the immune system associated with this age group are contributory factors. ,,
Bacterial enteropathogens are important etiological agents of acute diarrhea. ,,,,, While antibiotics provide effective therapy against bacterial diarrhea, increasing antibiotic drug resistance to microbes constitute a serious threat. , The implications of such resistance include prolonged duration of the illness, increased cost of treatment, development of complications, and even death.
Identifying these organisms and their antibiotic susceptibility pattern is important to institution and implementation of diarrhea control measures.  Consequently, a recurrent appraisal of bacterial diarrhea among children aged less than 5 years in susceptible communities is necessary.
The aim of the study was to identify bacterial agents of diarrhea and their antimicrobial sensitivity pattern in a susceptible child age group attending a tropical pediatric unit.
|Materials and Methods|
The study was conducted in the departments of pediatrics and microbiology of the 44 Nigeria Army Reference Hospital (NARH) in Kaduna, Northwestern Nigeria between January 2011 and December 2011. The hospital is a tertiary health facility that renders clinical and laboratory services to the civilian and military populations of Kaduna and its environs. Kaduna is a cosmopolitan community in north western zone of Nigeria. Even though there has been some improvement over the decades, the country still has one of the highest mortality rates among children less than 5 years in the world. 
Parameters assessed reviewed were age, sex, type of bacteria isolated, antimicrobial sensitivity pattern of the isolates, and use of antibiotics in the children prior to presentation.
The records of children aged less than 5 years who presented with only acute diarrhea, passage of loose stools 3 of more times in a day, or of a higher daily frequency lasting less than 14 days,  in the department of pediatrics and whose stools were analyzed in the department of microbiology of 44 NARH in Kaduna, were retrieved and reviewed. The stool samples were cultured on both deoxycholate citrate agar and Salmonella More Details-Shigella agar using standard methods.  Antibiotic susceptibility testing of isolates was carried out and sensitivity to antimicrobial agents determined using commercially prepared antibiotic discs (Maxicare Medical Laboratory Ltd., Nigeria) containing the following antibiotics: Ciprofloxacin (10 ug), ofloxacin (10 ug), perfloxacin (10 ug), sparfloxacin (10 ug), ceftriaxone (25 ug), cefuroxime (20 ug), gentamycin (10 ug), streptomycin (30 ug), ampicillin/cloxacillin (30 ug), amoxicillin (30 ug), amoxicillin/clavulanic acid (30 ug), cotrimoxazole (30 ug), and chloramphenicol (30 ug).
Data were analyzed using Epi Info version 3.5.3 and P values <0.05 were regarded as statistically significant. Ethical approval was obtained from the research ethics committee of 44 NARHK.
Of 270 stool samples analyzed, 28 (10.4%) were bloody and 175 (64.8%) yielded positive bacterial isolates.
Age and sex distribution
Of the 270 samples, 156 were from males and 114 from females (M: F, 1.4:1). The age range of the children was 0.2 to 4.9 years (mean: 1.6 ± 1.4 years). Majority (173, 64.1%) were less than 2 years old [Table 1]. Bacteria was isolated from the stool samples of 130 (74.3%) children in this age group and this was significant when compared with the number of children older than 2 years (45, 25.7%) from which bacteria was isolated from their stool samples (P = 0.00). Also majority of the bacterial isolates (103, 58.9%) were from the males as against 72 (41.1%) from the females but this was not significant (P = 0.63).
|Table 1: Distribution of age, sex, and bacterial isolates among 270 children with acute diarrhea
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Characteristics of antibiotic usage before presentation at 44 NARHK
A total of 185 (68.5%) stool samples were associated with antibiotic usage. Among the antibiotics [Table 2], oral metronidazole (154, 83.2%) was the commonest drug utilized. There was antibiotic usage in all (28, 10.4%) who had bloody stools. Of those (85, 31.5%) who did not receive antibiotics, 72 (84.7%) children had bacteria isolated from their stool samples. This was significant (P = 0.00) when compared with the number of children who had of bacteria isolated from their stool samples and had used antibiotics (103, 55.7%). The antibiotics were prescribed by caregiver (87, 47%), patent medicine seller (48, 25.9%), in a health facility (30, 16.2%), and by nonhealth practitioners in the community (11, 10.8%), respectively.
|Table 2: Type of antibiotic used in 185 children with acute diarrhea
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Distribution of bacterial isolates and their antibiotic susceptibility pattern
Escherichia More Details coli constituted 60% (105) of the total bacterial isolates, while the least was Staphylococcus aureus (4, 2.3%) as shown in [Table 3]. Of the 28 bloody stool samples, seven (25%) yielded bacterial isolates and these were E. coli (2, 28.6%) and Shigella spp. (5, 71.4%). The isolation of Shigella spp. was significantly (P = 0.00) more in the bloody stools. Overall, the bacterial isolates were mostly (167, 95.4%) sensitive to ciprofloxacin. However, the E. coli isolates were slightly more sensitive to cefuroxime, ceftriaxone, and streptomycin than ciprofloxacin. The bacterial isolates were least sensitive to the ampicillin/cloxacllin combination (38, 21.7%).
|Table 3: Antimicrobial susceptibility profile of 175 bacterial isolates
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Outcome at 44 NARHK
All the children were treated using oral rehydration therapy, given a 10-day course of oral zinc supplementation and counseled on diarrhea prevention. Antibiotics and parenteral fluids were administered where indicated in the department of pediatrics 44 NARHK. There was no documented mortality among the 270 cases.
Majority (64%) of the stool samples yielded bacterial isolates. The high prevalence of bacterial isolates in this study, when compared to studies by Bawa et al. (58.8%)  and Nweze (25.1%)  from other parts of the country, could be attributable to a high percentage (74%) of those aged below 2 years in this study. Increased risk behavior for diarrhea especially the indiscriminate putting of objects in the mouth, their vulnerability in poor sanitary environments, and immature state of acquired immunity are some of the susceptible factors associated with this age group. ,
E. coli constituted majority of the bacterial isolates. This is similar to the findings in other reports about bacterial diarrhea in childhood. ,,,,, The study also underscores the significance of Shigella spp. in the etiology of bloody diarrhea which has also been reported.  The isolation of these bacterial enteropathogens in the study highlights their relevance in the etiology of childhood diarrhea. While the specific bacterial species associated with diarrhea were not indicated in the study, the culture of these organisms emphasizes the need to strengthen antiproliferation and preventive initiatives against them. Such initiatives should equally contain and promote the global seven point plan for comprehensive diarrhea control which includes: Appropriate and adequate fluid replacement, zinc supplementation, rotavirus and measles vaccination, improved water supply and the promotion of exclusive breast feeding, hand washing with soap, and community wide sanitation. 
Appropriate and adequate use of antibiotics against causative bacteria is one modality for effective management of diarrhea. However, antimicrobial drug resistance over the years has impeded this modality. , Multidrug resistance of enteropathogens particularly Shigella spp. have been documented necessitating the recommendation by the World Health Organization that all patients with bloody diarrhea should be treated with either ciprofloxacin or 1 of the 3 second-line drugs( pivmecillinam, azithromycin, and ceftriaxone).  Evolving complex genetic systems in the organisms and over use of antibiotics are some mechanisms that have been identified as risk factors for development of antimicrobial drug resistance.  While the former has not been commonly assessed in our environment, the over use or inappropriate use of antibiotics is a well-documented practice. ,, In this study, antibiotics were prescribed by unauthorized persons in over 70% of those who used antibiotics. This practice increases the pressure on the used antibiotics and the risk of microbial resistance. Limited sensitivity of the microbes to most of these commonly prescribed antibiotics was equally observed in the study.
The fluoroquinolones, ciprofloxacin in particular, were the most sensitive antibiotics. This was in contrast to the more commonly used drugs, such as cotrimoxazole, in the treatment of bacterial diarrhea. The use of fluoroquinolones in pediatrics has been limited due to its reported impact on growth.  However, reported successes in its use when compared to more conventional drugs in severe disease conditions have compelled its use particularly where the benefits outweigh the risks.  The prevailing resistance to the usual antibiotics in potentially grave disease conditions such as diarrhea makes the use of more sensitive drugs like the fluoroquinolones compelling. However, there is need for a more extensive study in the community to ascertain the impact of fluoroquinolone use in management of bacterial diarrhea.
Bacterial enteropathogens still play an important etiological role in acute diarrhea among children aged less than 5 years in our environment. The organisms showed remarkable sensibility to ciprofloxacin and other fluoroquinolones while displaying limited sensitivity to the more commonly used antibiotics. The study highlights the need to explore further the impact of fluoroquinolones on childhood diarrhea and to effectively regulate the use of antibiotics in the management of diarrhea while promoting diarrhea prevention initiatives in the community.
The authors wish to thank Miss Bilikisu Iliya for her contribution in the data acquisition.
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Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]