title: Involvement of main diarrheagenic Escherichia coli, with emphasis on enteroaggregative E. coli, in severe non-epidemic pediatric diarrhea in a high-income country.
abstract: BACKGROUND
  Bacterial and viral enteric pathogens are the leading cause of diarrhea in infants and children. We aimed to identify and characterize the main human diarrheagenic E. coli (DEC) in stool samples obtained from children less than 5 years of age, hospitalized for acute gastroenteritis in Israel, and to examine the hypothesis that co-infection with DEC and other enteropathogens is associated with the severity of symptoms.
  
  
  METHODS
  Stool specimens obtained from 307 patients were tested by multiplex PCR (mPCR) to identify enteroaggregative E. coli (EAEC), enterohemorrhagic (EHEC), enteropathogenic E. coli (EPEC) and enterotoxigenic E. coli (ETEC). Specimens were also examined for the presence of rotavirus by immunochromatography, and of Shigella, Salmonella and Campylobacter by stool culture; clinical information was also obtained.
  
  
  RESULTS
  Fifty nine (19%) children tested positive for DEC; EAEC and atypical EPEC were most common, each detected in 27 (46%), followed by ETEC (n = 3; 5%), EHEC and typical EPEC (each in 1 child; 1.5%). Most EAEC isolates were resistant to cephalexin, cefixime, cephalothin and ampicillin, and genotypic characterization of EAEC isolates by O-typing and pulsed-field gel electrophoresis showed possible clonal relatedness among some. The likelihood of having > 10 loose/watery stools on the most severe day of illness was significantly increased among patients with EAEC and rotavirus co-infection compared to children who tested negative for both pathogens: adjusted odds ratio 7.0 (95% CI 1.45-33.71, P = 0.015).
  
  
  CONCLUSIONS
  DEC was common in this pediatric population, in a high-income country, and mixed EAEC and rotavirus infection was characterized by especially severe diarrhea.
authors.affiliation: University of Gothenburg Vaccine Research Institute (GUVAX), Department of Microbiology and Immunology, The Sahlgrenska Academy of University of Gothenburg, Gothenburg, P.O. Box 435, S-40530, Sweden. joshua.tobias@microbio.gu.se.
authors.forename: Joshua
authors.initials: J
authors.lastname: Tobias
authors.affiliation: Department of Pediatrics, Hillel Yaffe Medical Center, Hadera, Israel. eias.kassem@gmail.com.
authors.forename: Eias
authors.initials: E
authors.lastname: Kassem
authors.affiliation: Department of Pediatrics, Laniado Medical Center, Natanya, Israel. urirubinst@gmail.com.
authors.forename: Uri
authors.initials: U
authors.lastname: Rubinstein
authors.affiliation: Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel. BialikA@post.tau.ac.il.
authors.forename: Anya
authors.initials: A
authors.lastname: Bialik
authors.affiliation: University of Gothenburg Vaccine Research Institute (GUVAX), Department of Microbiology and Immunology, The Sahlgrenska Academy of University of Gothenburg, Gothenburg, P.O. Box 435, S-40530, Sweden. sreekanth0905@gmail.com.
authors.forename: Sreekanth-Reddy
authors.initials: SR
authors.lastname: Vutukuru
authors.affiliation: Facultad de Medicina, Universidad Nacional Autónoma de México (UNAM). 3er piso Edificio de Investigación, Circuito interior s/n Ciudad Universitaria, Coyoacán, Mexico. arnava@unam.mx.
authors.forename: Armando
authors.initials: A
authors.lastname: Navaro
authors.affiliation: Central Laboratories, Ministry of Health, Jerusalem, Israel. Assaf.Rokney@MOH.HEALTH.GOV.IL.
authors.forename: Assaf
authors.initials: A
authors.lastname: Rokney
authors.affiliation: Central Laboratories, Ministry of Health, Jerusalem, Israel. Lea.Valinsky@eliav.health.gov.il.
authors.forename: Lea
authors.initials: L
authors.lastname: Valinsky
authors.affiliation: Pediatric Infectious Disease Unit, Carmel Medical Center, Haifa; and Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel. mefrat@tx.technion.ac.il.
authors.forename: Moshe
authors.initials: M
authors.lastname: Ephros
authors.affiliation: Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel. dancohen@post.tau.ac.il.
authors.forename: Dani
authors.initials: D
authors.lastname: Cohen
authors.affiliation: Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel. kmuhsen@post.tau.ac.il.
authors.forename: Khitam
authors.initials: K
authors.lastname: Muhsen
mesh_terms: D002675:Child, Preschool; D019049:Developed Countries; D003967:Diarrhea / Q000382:microbiology*; D054308:Enteropathogenic Escherichia coli / Q000302:isolation & purification*; D054307:Enterotoxigenic Escherichia coli / Q000302:isolation & purification*; D004927:Escherichia coli Infections / Q000150:complications / Q000175:diagnosis* / Q000382:microbiology; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007557:Israel; D008297:Male; D060885:Multiplex Polymerase Chain Reaction; D011446:Prospective Studies; D012720:Severity of Illness Index