Antibiotic resistance trends for common bacterial aetiologies of childhood diarrhoea in low- and middle-income countries: A systematic review

Macleaya cordata protopine total alkaloids as potential treatment for diarrhoea: Mechanistic insights and target identification

Diarrhoea remains a major public health concern, particularly affecting young children and livestock. Macleaya cordata protopine total alkaloids (MPTA), a standardized extract approved in China for poultry diarrhoea, has demonstrated anti-inflammatory properties in intestinal disorders. The study aims to investigate the antidiarrheal mechanism of MPTA using castor oil- and E. coli-induced diarrhoea models in mice. We first tested MPTA for acute oral toxicity. Subsequently, the effect of MPTA on castor oil- and E. coli-induced diarrhoea in mice based on LD50 results. Network pharmacology analysis and target competition assays (inhibitors and antagonists) were integrated to identify targets for MPTA's antidiarrheal effects. Molecular docking was used to verify the binding ability of MPTA components to these receptors. The LD50 of MPTA was determined to be 426.1 mg/kg. The optimal MPTA activity was found at 8 mg/kg in both castor oil and in infectious models. Network pharmacology analysis revealed potential targets and pathways of MPTA against intestinal motility. The impact of MPTA on cholinergic, serotonin, dopaminergic, and adrenergic receptors was assessed using standard inhibitors and agonists to induce intestinal smooth muscle contractions or relaxations. Molecular docking confirmed the binding ability of MPTA components to these receptors. In conclusion, MPTA exhibits significant antidiarrheal effects in both castor oil and E. coli-induced diarrhoea models. Its mechanism may involve modulation of cholinergic, serotonin, dopaminergic, and adrenergic receptors, as well as inhibition of ion channels and anti-inflammatory actions. These findings highlight the potential of MPTA as a novel therapeutic agent for diarrhoea.

Fighting Antibiotic Resistance: Insights Into Human Barriers and New Opportunities: Antibiotic Resistance Constantly Rises With the Development of Human Activities. We discuss Barriers and Opportunities to Get It Under Control

The public health issue of bacterial multi-resistance to antibiotics has gained awareness among the public, researchers, and the pharmaceutical sector. Nevertheless, the spread of antimicrobial resistance has been considerably aggravated by human activities, climate change, and the subsequent increased release of antibiotics, drug-resistant bacteria, and antibiotic resistance genes in the environment. The extensive use of antibiotics for medical and veterinary purposes has not only induced increasing resistance but also other health problems, including negative effects on the patient's microbiome. Preventive strategies, new treatment modalities, and increased surveillance are progressively set up. A comprehensive approach is, however, lacking for urgently tackling this adverse situation. To address this challenge, we discussed here the main causes driving antimicrobial resistance and pollution of the environment by factors favorable to the emergence of drug resistance. We next propose some key priorities for research, prevention, surveillance, and education to supervise an effective clinical and sustainable response.

WHO Workshop Report: Regulatory Science to Inform Clinical Pathways for Shigella Vaccines Intended for Use in Children in Low- and Middle-Income Countries

Infectious diarrhea caused by Shigella remains a significant global health concern, and several vaccine candidates are approaching phase III clinical studies in the target population of young children in low- and middle-income countries. The World Health Organization (WHO) has published preferred product characteristics (PPCs) for Shigella vaccines to provide strategic guidance that aids in advancing product development and highlights policy considerations for use in LMIC settings where the vaccine is most needed. However, the selection of appropriate clinical endpoints was not clearly defined within the PPCs and remains an important issue for phase III study design. Previously, an expert panel identified areas of alignment and consensus on many clinical study design components while also recognizing that further discussions and data were required to solidify recommendations on key study design aspects. Therefore, WHO convened a diverse range of stakeholders, including manufacturers, regulators, and policymakers across national, regional, and global levels, with the aim of achieving consensus and soliciting inputs from the regulatory community surrounding vaccine phase III study design considerations. The intent of this report is to outline the key points from those discussions to inform the phase III design strategies and investment decisions of product developers and donors and to share recommendations for next steps.

Updating global estimates of pathogen-attributable diarrhoeal disease burden: a methodology and integrated protocol for a broad-scope systematic review of a syndrome with diverse infectious aetiologies

INTRODUCTION

Sustaining declines in global infectious disease burden will increasingly require efforts targeted to specific aetiological agents and common transmission pathways, particularly in this era of global change and human interconnectivity accelerating transmission and emergence of infectious pathogens. Systematic reviews and meta-analyses can be an effective and resource-efficient method for synthesising evidence regarding disease epidemiology for a wide range of pathogens and are the evidence source used by initiatives like the Planetary Child Health and Enterics Observatory (Plan-EO) and the WHO to determine the aetiology-specific epidemiology of diarrhoeal disease. Therefore, we developed this integrated systematic review methodology and protocol that aims to compile a database of published prevalence estimates for 17 diarrhoea-causing pathogens as inputs for disease burden estimation.

METHODS AND ANALYSIS

We will seek estimates of the prevalence of each endemic enteric pathogen estimated from published population-based studies that diagnosed their presence in stool samples from both asymptomatic subjects and those experiencing diarrhoea. The pathogens include the enteric viruses adenovirus, astrovirus, norovirus, rotavirus and sapovirus, the bacteria Campylobacter, Shigella, Salmonella enterica, Vibrio cholerae and the Escherichia coli (E. coli) pathotypes enteroaggregative E. coli, enteropathogenic E. coli, enterotoxigenic E. coli and Shiga-toxin-producing E. coli and the intestinal protozoa Cryptosporidium, Cyclospora, Entamoeba histolytica and Giardia. Meta-analytical methods for analyses of the resulting database (including risk of bias analysis) will be published alongside their findings.

ETHICS AND DISSEMINATION

This systematic review is exempt from ethics approval because the work is carried out on published documents. The database that results from this review will be made available as a supplementary file of the resulting published manuscript. It will also be made available for download from the Plan-EO website, where updated versions will be posted on a quarterly basis.

PROSPERO REGISTRATION NUMBER

CRD42023427998.

Inappropriate use of antibiotics in the management of diarrhoea in children under five years admitted with acute diarrhoea in four provinces of Mozambique 2014-2019

BACKGROUND

Even with a great reduction in the last years, diarrhoea continues to be one of the leading causes of hospital admission and mortality in children less than five years of age globally. The success of diarrhoeal disease management relies on the rapid recognition of the symptoms and adequate treatment, with World Health Organization (WHO) guidelines, limiting the use of antibiotics for all diarrhoea cases being reserved to specific circumstances. Therefore, this study aimed to evaluate the frequency of antibiotics use in diarrhoea management in children aged 0-59 months admitted with acute diarrhoea in four provinces of Mozambique, from 2014 to 2019.

METHODS

A cross-sectional hospital-based surveillance was conducted from January 2014 to December 2019 in six sentinel sites located in four provinces. Socio-demographic, epidemiological and clinical data were obtained by interviewing the child's caregivers and by accessing the child's medical records and children's vaccination card. Data collected through National Surveillance of Diarrhoea (ViNaDia) was double-entered in Epi InfoTM3.5.1. (Centers for Disease Control and Prevention, Atlanta 2008), followed by data comparison. IBM SPSS software was used to conduct the data analysis.

RESULTS

During the study period 2014-2019 a total of 2382 children presenting at one of the designated health facilities were enrolled via ViNaDia surveillance. Of these 85.1% (2028/2382) provided data of antibiotics (ATB) usage and thus included in the present analysis. The majority was male with 59.3% (1203/2028), with infants aged 0-11 months composing the largest age group with 49.4% (1002/2028). Nutritional assessment revealed that 28.8% (585/2028) were underweight and 15.2% (308/2028) faced wasting. The comorbidities included human immunodeficiency virus (HIV) 7.8% (159/2028), malaria 7.0% (141/2028), and pneumonia 2.1% (42/2028). The rates of bloody diarrhoea and "rice-water" were reported in 1.5% (10/1664) and 2% (29/1664) respectively. Antibiotics use was reported in 93.2% of the children [95% CI: 92.0-94.2; 1890/2028], with s 49.1% [95% CI: 47.0-51.5; 930/1890] received more than one ATB. The most prescribed antibiotics were Ampicillin (46.2%), Gentamicin (38.4%) and Cotrimoxazole (30.5%).

CONCLUSIONS

The results of this study indicate inappropriate use of antibiotics in the management of acute diarrhoea in children attended in four provinces of Mozambique. The study suggests the drawing of a local guideline for the efficient management of acute diarrhoea, and the need for education on adherence of WHO recommendations on antibiotics use in acute diarrhoea.

Gut microbiota patterns associated with duration of diarrhea in children under five years of age in Ethiopia

Diarrhea claims >500,000 lives annually among children under five years of age in low- and middle-income countries. Mortality due to acute diarrhea (<7 days' duration) is decreasing, but prolonged (7-13 days) and persistent (≥14 days of duration) diarrhea remains a massive challenge. Here, we use a case-control study to decipher if fecal gut microbiota compositional differences between Ethiopian children with acute (n=554) or prolonged/persistent (n=95) diarrhea and frequency-matched non-diarrheal controls (n=663) are linked to diarrheal etiology. We show that diarrhea cases are associated with lower bacterial diversity and enriched in Escherichia spp., Campylobacter spp., and Streptococcus spp. Further, diarrhea cases are depleted in gut commensals such as Prevotella copri, Faecalibacterium prausnitzii, and Dialister succinatiphilus, with depletion being most pronounced in prolonged/persistent cases, suggesting that prolonged duration of diarrhea is accompanied by depletion of gut commensals and that re-establishing these via e.g., microbiota-directed food supplements offer a potential treatment strategy.

The Burden and Antibiotic Sensitivity of Salmonella Non-Typhi and Shigella Related Bloody Diarrhea in Children

Objectives

We sought to report the frequency of non-typhoidal Salmonella (SNT) and Shigella spp. diarrhea and the antibiotic sensitivity in children.

Methods

We conducted a retrospective study of children with bloody diarrhea seen at Rustaq Hospital between 1 June 2019 and 31 June 2023. We collected data related to demographic characteristics, symptoms, blood investigations, stool bacterial culture, and antimicrobial sensitivity. Stool samples were tested for Salmonella and Shigella growth.

Results

Out of 1160 children with diarrhea, 153 (13.2%) had bloody diarrhea of which 129 (84.3%) were under five. Ninety-two (60.1%) children were positive for either Salmonella or Shigella. Among the positive cultures, 58 (63.0%) children had SNT, while 34 (37.0%) had Shigella infection. Three children had bacteremia, all under one year old. SNT demonstrated high sensitivity primarily to ceftriaxone (n = 41; 70.7%), ampicillin (n = 53; 91.4%), and ciprofloxacin (n = 54; 93.1%). In contrast, Shigella showed high resistance to ceftriaxone and only 15 (46.9%) patients showed sensitivity. Additionally, 29 children had Entamoeba histolytica trophozoites co-infection with Salmonella on stool microscopy.

Conclusions

Salmonella is more prevalent than Shigella in children under five years, while Shigella is more common in children over five. Salmonella is sensitive to both ceftriaxone and ampicillin. Shigella demonstrates resistance to multiple antibiotics, including ciprofloxacin. It is recommended that children under the age of one be admitted and treated empirically with either ceftriaxone or ampicillin. In older children, antibiotic therapy should be guided by stool culture results. Ciprofloxacin is not a good empirical choice for Shigella in our population due to its high resistance and is contraindicated in patients with glucose-6-phosphate dehydrogenase.

Enteric bacterial agents associated with diarrhea and their antimicrobial sensitivity profiles in children under 5 years from mukuru informal settlement, Nairobi, Kenya

BACKGROUND

In Kenya, diarrhoeal disease is the third leading cause of child mortality after malaria and pneumonia, accounting for nearly 100 deaths daily. We conducted a cross-sectional study in Mukuru informal settlements to determine the bacteria associated with diarrhea and their ASTs to provide data essential for implementing appropriate intervention measures.

METHODS

Diarrheagenic children (≤ 5 years) were purposively recruited from outpatient clinics of Municipal City Council, Mukuru kwa Reuben, Medical Missionaries of Mary, and Mama Lucy Kibaki Hospital, Nairobi. A total of 219 stool samples were collected between May 2021 and August 2021. Stool culture was done on MacConkey and Salmonella Shigella agar, while the recovered bacteria were identified using VITEK®2GNID and polymerase chain reaction (PCR) used for E. coli pathotyping. Antibiotic Susceptibility Testing was done using VITEK®2AST-GN83.

RESULTS

At least one bacterial organism was recovered from each of the 213 (97%) participants, with 115 (56%) participants having only one bacterial type isolated, 90 (43%) with two types of bacteria, and 2 (1%) with three types of bacteria recovered. The most predominant bacteria recovered was 85% (93/109) non-pathogenic E.coli and 15% (16/109)of pathogenic E.coli, with 2 (1%) were Enterohemorrhagic E.coli (EHEC), 6 (3%) were Enteroaggregative E.coli (EAEC), and 8 (4%) were Enteropathogenic E.coli (EPEC). Other potentially pathogenic bacteria included Enterobacter sp (27.8%), Klebsiella sp 33(11%), and Citrobacter sp 15(4.7%). Pathogenic isolates such as Salmonella 7 (2%), Proteus mirabilis 16 (6%), Providencia alcalifaciens 1 (0.3%), and Shigella 16 (4.7%) were detected. Isolates such as Pantoea spp 2(0.67%), Raoultella planticola 1(0.33%), and Kluyvera 6(2%) rarely reported but implicated with opportunistic diarrhoeal disease were also recovered. Ampicillin, cefazolin, and sulfamethoxazole-trimethoprim were the least effective antimicrobials at 64%, 57%, and 55% resistance, respectively, while meropenem (99%), amikacin (99%), tazobactam piperacillin (96%), and cefepime (95%) were the most effective. Overall, 33(21%) of all enterics recovered were multidrug-resistant.

CONCLUSION

The study documented different bacteria potentially implicated with childhood diarrhea that were not limited to E. coli, Shigella, and Salmonella, as previously observed in Kenya. The strains were resistant to the commonly used antibiotics, thus narrowing the treatment options for diarrheal disease.

What drives poor quality of care for child diarrhea? Experimental evidence from India

Most health care providers in developing countries know that oral rehydration salts (ORS) are a lifesaving and inexpensive treatment for child diarrhea, yet few prescribe it. This know-do gap has puzzled experts for decades. Using randomized experiments in India, we estimated the extent to which ORS underprescription is driven by perceptions that patients do not want ORS, provider's financial incentives, and ORS stock-outs (out-of-stock events). Patients expressing a preference for ORS increased ORS prescribing by 27 percentage points. Eliminating stock-outs increased ORS provision by 7 percentage points. Removing financial incentives did not affect ORS prescribing on average but did increase ORS prescribing at pharmacies. We estimate that perceptions that patients do not want ORS explain 42% of underprescribing, whereas stock-outs and financial incentives explain only 6 and 5%, respectively.