A Hospital-based Case-control Study of Diarrhea in Children in Shanghai.
BACKGROUND
Prevention and control of childhood diarrhea is a global priority. We conducted a case-control study of childhood diarrhea in Shanghai.


METHODS
We prospectively recruited diarrheal children in an outpatient setting. Nondiarrheal controls were individually matched to cases. Rotavirus, norovirus and bacterial pathogens were examined. Clinical and epidemiologic data were obtained at enrollment and follow-up.


RESULTS
Potential pathogens identified in 680 diarrheal cases and 680 controls were rotavirus (19.0% vs. 1.3%), norovirus (13.4% vs. 4.7%), nontyphoidal Salmonella (9.3% vs. 1.9%), enteropathogenic Escherichia coli (8.4% vs. 6.9%) and enteroaggregative Escherichia coli (7.2% vs. 6.2%) and Campylobacter (5.1% vs. 1.2%), enterotoxigenic Escherichia coli (1.2% vs. 0.6%), enterohemorrhagic Escherichia coli (0.3% vs. 0%) and Shigella (0.15% vs. 0%), respectively. The specificity and sensitivity of fecal leukocytes >5 per high-power field for the diagnosis of bacterial diarrhea were 94.2% and 22.8%. Salmonella were susceptible to ciprofloxacin, ceftriaxone and amoxicillin-clavulanate and showed low frequency of resistance to azithromycin. Campylobacter showed low frequency of resistance to azithromycin and high frequency of resistance to ciprofloxacin. Diarrheagenic Escherichia coli was highly susceptible to ciprofloxacin and amoxicillin-clavulanate. Contact with diarrheal patients was a risk factor for rotavirus [adjusted odds ratio (aOR): 11.7], norovirus (aOR: 7.5) and Campylobacter (aOR: 27.1) infections. Mother's education was positively associated with Salmonella infection (aOR: 2.1). Good hand hygiene was protective against rotavirus (aOR: 0.6), norovirus (aOR: 0.5) and Salmonella (aOR: 0.3) infections.


CONCLUSIONS
Rotavirus, norovirus, nontyphoidal Salmonella and Campylobacter are significantly associated with diarrhea in Chinese children. Fecal leukocytes >5 per high-power field can predict bacterial diarrhea. Target prevention and appropriate treatment of diarrhea should consider the potential pathogen and resistance pattern.
From the *Department of Infectious Diseases, Children's Hospital of Fudan University, and †Department of Microbiology, Shanghai Changning District Center for Disease Control and Prevention, Shanghai, China; ‡Office of China-US Collaborative Program on Emerging and Re-emerging Infectious Diseases, Chinese Center for Disease Control and Prevention, Beijing, China; and §Department of Microbiology, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China.
Hailing
H
Chang
Ling
L
Zhang
Yanling
Y
Ge
Jiehao
J
Cai
Xiangshi
X
Wang
Zheng
Z
Huang
Jiayin
J
Guo
Hao
H
Xu
Zhen
Z
Gu
Hong
H
Chen
Xuebin
X
Xu
Mei
M
Zeng
D001419:Bacteria / Q000187:drug effects / Q000302:isolation & purification; D001424:Bacterial Infections / Q000453:epidemiology / Q000821:virology; D017250:Caliciviridae Infections / Q000453:epidemiology / Q000821:virology; D016022:Case-Control Studies; D002675:Child, Preschool; D002681:China / Q000453:epidemiology; D003967:Diarrhea / Q000453:epidemiology / Q000382:microbiology / Q000821:virology; D024881:Drug Resistance, Bacterial; D005243:Feces / Q000166:cytology / Q000382:microbiology / Q000821:virology; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D029322:Norovirus / Q000302:isolation & purification; D012307:Risk Factors; D012401:Rotavirus / Q000302:isolation & purification; D012400:Rotavirus Infections / Q000453:epidemiology / Q000382:microbiology