title: Etiologies and manifestations of persistent diarrhea in adults with HIV-1 infection: a case-control study in Lima, Peru.
abstract: OBJECTIVE We sought to determine the etiologies, manifestations, and risk factors for persistent (> or =7 days) diarrhea in human immunodeficiency virus type 1 (HIV-1)-infected persons in Peru.
  
  
  METHODS
  The present study is a case-control study of 147 HIV-1-infected case subjects with persistent diarrhea and 147 HIV-1-infected control subjects without diarrhea.
  
  
  METHODS
  We obtained clinical, demographic, and exposure data, CD4 lymphocyte counts, and stool samples for detection of enteric parasitic and bacterial pathogens and rotavirus.
  
  
  RESULTS
  One or more enteric pathogen was identified in 55% of case subjects and 21% of control subjects (odds ratio adjusted for CD4 lymphocyte count, 3.8; 95% confidence interval, 2.2-6.5). The median CD4 lymphocyte count was highest with pathogen-free diarrhea and lowest with Cryptosporidium infection. Cryptosporidium species (the most frequent pathogen), Giardia lamblia, Aeromonas species, Campylobacter species, and rotavirus were all significantly associated with diarrhea. Bacterial pathogens were significantly associated with G. lamblia and rotavirus infection. Of the bacterial pathogens (Aeromonas, Campylobacter, Salmonella, and Vibrio species and enterotoxigenic Escherichia coli), only 24% were susceptible to cotrimoxazole, whereas 90% were susceptible to ciprofloxacin. In no case did the sensitivity or positive predictive value of specific clinical and laboratory findings for curable enteric infections exceed 50%.
  
  
  CONCLUSIONS
  Several enteric pathogens were associated with diarrhea in HIV-1-infected case subjects in Peru, especially among those who were heterosexual. Clinical findings were poor predictors of detectable microbial etiology. The guidelines for initial management of chronic diarrhea with sulfamethoxazole-trimethoprim in HIV-1-infected persons require revision, at least in settings where prophylaxis with this agent is common.
authors.affiliation: Departments of Epidemiology, University of Washington, Seattle, Washington 98140, USA.
authors.forename: César
authors.initials: C
authors.lastname: Cárcamo
authors.forename: Thomas
authors.initials: T
authors.lastname: Hooton
authors.forename: Mark H
authors.initials: MH
authors.lastname: Wener
authors.forename: Noel S
authors.initials: NS
authors.lastname: Weiss
authors.forename: Robert
authors.initials: R
authors.lastname: Gilman
authors.forename: Jorge
authors.initials: J
authors.lastname: Arevalo
authors.forename: Juan
authors.initials: J
authors.lastname: Carrasco
authors.forename: Carlos
authors.initials: C
authors.lastname: Seas
authors.forename: Martin
authors.initials: M
authors.lastname: Caballero
authors.forename: King K
authors.initials: KK
authors.lastname: Holmes
mesh_terms: D000328:Adult; D000333:Aeromonas / Q000187:drug effects / Q000302:isolation & purification; D000818:Animals; D000890:Anti-Infective Agents / Q000494:pharmacology / Q000627:therapeutic use; D001424:Bacterial Infections / Q000150:complications / Q000188:drug therapy / Q000382:microbiology; D018791:CD4 Lymphocyte Count; D002167:Campylobacter / Q000302:isolation & purification; D016022:Case-Control Studies; D002939:Ciprofloxacin / Q000494:pharmacology; D003458:Cryptosporidium / Q000302:isolation & purification; D003967:Diarrhea / Q000188:drug therapy / Q000209:etiology* / Q000382:microbiology / Q000469:parasitology; D004926:Escherichia coli / Q000187:drug effects; D005243:Feces / Q000382:microbiology / Q000469:parasitology / Q000821:virology; D005260:Female; D016829:Giardia lamblia / Q000302:isolation & purification; D015658:HIV Infections / Q000150:complications*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010568:Peru; D011528:Protozoan Infections / Q000150:complications / Q000188:drug therapy / Q000469:parasitology; D012307:Risk Factors; D012401:Rotavirus / Q000302:isolation & purification; D012400:Rotavirus Infections / Q000150:complications / Q000188:drug therapy / Q000821:virology; D012475:Salmonella / Q000187:drug effects; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000494:pharmacology; D014733:Vibrio / Q000187:drug effects
chemical_list: D000890:Anti-Infective Agents; D002939:Ciprofloxacin; D015662:Trimethoprim, Sulfamethoxazole Drug Combination