title: Diarrhea etiology in a Children's Hospital Emergency Department: a prospective cohort study.
abstract: BACKGROUND
  We evaluated the frequency of recovery of pathogens from children with diarrhea who presented to a pediatric emergency department and characterized the associated illnesses, to develop guidelines for performing a bacterial enteric culture.
  
  
  METHODS
  We conducted a prospective cohort study of all patients with diarrhea who presented to a large regional pediatric emergency department during the period from November 1998 through October 2001. A thorough microbiologic evaluation was performed on stool specimens, and the findings were correlated with case, physician, and laboratory data.
  
  
  RESULTS
  A total of 1626 stool specimens were studied to detect diarrheagenic bacteria and, if there was a sufficient amount of stool, Clostridium difficile toxin (688 specimens), parasites (656 specimens), and viruses (417 specimens). One hundred seventy-six (47%) of 372 specimens that underwent complete testing yielded a bacterial pathogen (Shiga toxin-producing Escherichia coli, 39 specimens [of which 28 were serotype O157:H7]; Salmonella species, 39; Campylobacter species, 25; Shigella species, 14; and Yersinia enterocolitica, 2), a viral pathogen (rotavirus, 85 specimens; astrovirus, 27; adenovirus, 18; or rotavirus and astrovirus, 8), a diarrheagenic parasite (5 specimens); or C. difficile toxin (46 specimens). Samples from 2 patients yielded both bacterial and viral pathogens. A model to identify predictors of bacterial infection found that international travel, fever, and the passing of >10 stools in the prior 24 h were associated with the presence of a bacterial pathogen. Physician judgment regarding the need to perform a stool culture was almost as accurate as the model in predicting bacterial pathogens.
  
  
  CONCLUSIONS
  Nearly one-half of the patients who presented to the emergency department with diarrhea had a definite or plausible pathogen in their stool specimens. We were unable to develop a model that was substantially better than physician judgment in identifying patients for whom bacterial culture would yield positive results. The unexpectedly high rate of C. difficile toxin warrants further examination.
authors.affiliation: Department of Pediatrics, University of Washington and Children's Hospital and Regional Medical Center, Seattle, WA, USA.
authors.forename: Eileen J
authors.initials: EJ
authors.lastname: Klein
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Boster
authors.forename: Jennifer R
authors.initials: JR
authors.lastname: Stapp
authors.forename: Joy G
authors.initials: JG
authors.lastname: Wells
authors.forename: Xuan
authors.initials: X
authors.lastname: Qin
authors.forename: Carla R
authors.initials: CR
authors.lastname: Clausen
authors.forename: David L
authors.initials: DL
authors.lastname: Swerdlow
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Braden
authors.forename: Phillip I
authors.initials: PI
authors.lastname: Tarr
mesh_terms: D001427:Bacterial Toxins / Q000032:analysis; D002648:Child; D016360:Clostridioides difficile / Q000737:chemistry*; D015331:Cohort Studies; D046508:Culture Techniques; D003967:Diarrhea / Q000382:microbiology* / Q000821:virology; D004630:Emergencies; D005243:Feces / Q000382:microbiology* / Q000821:virology; D006748:Hospital Departments; D006801:Humans; D011446:Prospective Studies
chemical_list: D001427:Bacterial Toxins