ABSTRACT
Escherichia coli infections and poor
nutritional status have implications on the growth and development of
children under five years, physically, mentally and healthwise with
consequences such as diarrhoea, stunting, wasting, underweight and often times
leading to death, depending on their severity. This study evaluated the
antibiogram of Escherichia coli O157 and VerocytotoxigenicEscherichia
coli(VTEC)and the nutritional status of diarrhoeic children under
five years in Kaduna State, Nigeria, using Conventional isolation methods,
latex agglutination tests, VTEC-ELISA tests, Chi-square (SPSS Version 19) and
WHO Antro (Version 3.2.2). Purposive sampling was used to select 350 children
presenting with diarrhoea in six government hospitals within the three
senatorial zones of Kaduna State. The results obtained revealed that 76(21.7%)
of the 350 stool samples were positive for E. coli, 28(36.8%) of which
were positive for E. coli O157:H7serotype and 1(1.3%) verocytotoxigenic E.
coli (VTEC) serotype. High susceptibility to ciprofloxacin, chloramphenicol
and high resistance to sulphamethoxazole, cefotaxime, amoxicillin, gentamicin
and tetracycline by the isolates were observed. The nutritional status
assessment showed 34.3, 24.3 and 13.1% of the children were stunted, wasted and
underweight, respectivelyand Kaduna South senatorial zone also recorded the
highest prevalence of undernutrition, indicating poor nutrition and poor health
accumulated overtime. The study concluded that antibiotics have not been very
effective in the treatment of E. coli-related diarrhoea, with VTEC now
emerging in this part of the world, making it a serious public health issue and
its severity enhanced by malnutrition, confirming that the relationship between
diarrhoea and malnutrition is bidirectional, resulting in severe limitations in
the growth and development of the children, some of which may
be irreversible. The study
therefore recommends the implementation of programmes geared towards good
hygiene, good nutrition and good health.
CHAPTER ONE
1.0 INTRODUCTION
Diarrhoea can be defined as the occurrence of three or more
loose, liquid or watery stools or at least one bloody loose stool in a 24h
period(Gondweet al., 2006).Diarrhoea is also defined as the occurrence of loose
or watery stools at least three times per day, or more frequently than normal
for an individual (WHO,2013). Diarrhoeal diseases of the bowel make up a
veritable augean stable of entities. Microbiological agents cause many
diarrhoeal diseases; others arise in the setting of malabsorptic disorder and
idiopathic inflammatory. An increase in stool mass, stool frequency or stool
fluidity is perceived as diarrhoea by most patients (Crawford, 1999). For many
individuals, this consists of daily stool production in excess of 250 gm,
containing 70 – 95% water. More than 14 litres of fluid may be lost per day in
severe cases of diarrhoea (i.e the equivalent of the circulating blood
volumes). Diarrhoea is often accompanied by pain, urgency, perianal discomfort,
and incontinence. Low-volume, painful, bloody diarrhoea is known as dysentery
(Crawford, 1999).
The World Health Organisation defined diarrhoea as the
voiding of more than two unformed watery stools in any 24 h period, or any
voiding of watery stools if accompanied by fever, abdominal pain and / or
vomiting (Crawford, 1999 and Gondwe et al., 2006). Diarrhoea accounts for more
deaths in childhood than any other disease in the developing world(Crawford,
1999).It has been pointed out that in developing countries; a child of less
than seven years of age still has a 50% chance of dying from diarrhoeal
diseases (Crawford, 1999; Guerrant et al., 2001; Gondwe et al., 2006).
Infantile diarrhoea remains one of the leading causes of childhood morbidity and
mortality in developing countries, with children in the developing world having
an average of 5-6 episodes a year (Crawford, 1999).There are three major forms
of diarrhoea namely: acute watery diarrhoea, acute bloody diarrhoea and
persistent diarrhoea (Guerrantet al., 2001).Diarrhoeal diseaseforms one of the
two major killer diseases in children under five years of age in the developing
world. Escherichia coli is one of the major bacterial causes of diarrhoeal
diseases (Abdullahi et al., 2010). The bacterium E. coli is one of the best and
most thoroughly studied free-living organisms. It is also a remarkably diverse
species because some E. coli strains live as harmless commensals in animal
intestines. External contact and subsequent ingestion of bacteria from faecal
contamination can cause detrimental health effects (Money et al., 2009).
Acute watery diarrhoea is diarrhoea with a high volume of
watery stool occurring over a period of less than 14 days. It usually results
in severe dehydration if intervention measures are not sought. Acute bloody
diarrhoea is diarrhoea manifested by loose or watery stools with the shedding
of red blood cells. Persistent diarrhoea is usually associated with loose or
watery stools with or without visible blood occurring over a period of 14 days.
Diarrhoeal disease caused by microbial agents is principally a food borne and
water borne illness. Foodborne and waterborne illnesses are leading global
health problems accounting for more morbidity and mortality than tuberculosis
and malaria (Besser et al., 2003).According to World health organization (WHO)
Report, approximately 11 million children under the age offive, die because of E.
coli-mediated gastroenteritis (WHO, 2005).
Nutrition is a science that concerns itself with the
relationship between food and the functioning of the human body and it
encompasses the ingestion of food, digestion, absorption, metabolism and excretion of waste products.
Nutrition plays a key role in physical, mental and emotional development of
children and much emphasis has been given to provide goodnutrition to growing
populations especially in the formative years of life, which is one thousand
(1,000) days. Globally, more thanone- third of child deaths are attributable to
under nutrition. Malnutrition refers to a case of faulty nutrition which can
spread through a broad spectrum, from under nutrition to over nutrition,
causing diseases like Obesity, Marasmus, Kwashiorkor, Protein-Energy
Malnutrition (PEM), underweight and other chronic diseases (Alim and Jahan,
2012).Diarrhoeal illness isoften attributed to contaminated water (or food)
consumptionalthough the percentage specifically due to waterbornepathogens is
still unknown (Hunter et al., 2003). Transmission of agents that cause
diarrhoea are usually by the faecal oral route, which include the ingestion
offaecal contaminated water or food, person to person contact and direct
contact with infected faeces. Host factorsthat increase susceptibility to
diarrhoea include under nutrition, current or recent measles and immune
deficiencyor immunosupression (Andu et al., 2002). Among the bacterial
pathogens of diarrhoeal diseases, the most commonly implicated in the endemic
form of childhooddiarrhoea on a global scale are strains of Escherichia coli
(Huilan et al., 1991; Iruka et al., 2003; WHO, 2005).Diarrhoeal diseases and
other related gastrointestinal disorders are one of the most important causes
of illness and death all over the world, particularly among infants and young
children (Elias et al., 1999;Clarke, 2001; Sarantuya et al., 2004). The major
causes of diarrhoeal illness include, among others, limited access to / or poor
quality of water, poor food hygiene, and sanitation. The bacterial pathogens
usually responsible for diarrhoeal illness include Escherichia coli, Shigella, Salmonella,
Campylobacter, Yersinia, Aeromonas(Presterl et al., 2003).The relationship between diarrhoea and malnutrition is bidirectional:
diarrhoea leads to malnutrition while malnutrition aggravates the course of
diarrhoea. Many factors contribute to the detrimental effect of diarrhoea on
nutrition. Reduced intake (due to anorexia, vomiting, andwithholding of food),
maldigestion, malabsorption, increased nutrient losses, and the effects of the
inflammatory response are some of the factors involved in malnutrition (Nel,
2010).
Diarrhoeal disease may cause, precipitate, or exacerbate
protein-energy and micronutrient malnutrition through five possible mechanisms:
1) reduced food intake-reduction of food intake during diarrhoea may be due to
the child's anorexia, maternal food-withholding behaviour, or both; 2)
decreased absorption of nutrients due to structural damage to the intestine, as
well as the physical action of increased intestinal movement and reduced fluid
transit time, all interact to produce decreased absorption of nutrients; 3)
increased catabolic losses-under the influence of the inflammatory process,
diarrhoea of infectious origin induces an average daily negative nitrogen
balance of 0.9 g/kg/day, as muscle protein is converted to glucose through
gluconeogenesis by the liver; this glucose is used as a fuel by tissues to
sustain the hypermetabolism associated with fever; 4) nutrient loss from the
intestine-in diarrhoea nutrients are lost directly from the intestinal tract;
5) metabolic inefficiency due to micronutrient deficiency-the increased rate of
tissue synthesis displayed by children recovering from protein-energy
malnutrition may be hampered by a limited supply of nutrients from the body
pool, which in turn may not be replenished fast enough by dietary intake
(Martinez and Tomkins, 1993).
1.1 Statement of the research problem
Diarrhoeal diseases ranks second as a major cause of
morbidity among the modifiable diseases in Nigeria, where, according to the
Federal Statistic Bulletin, 300 children die every day from malnutrition and
dehydration caused by diarrhoea (Barua, 1981; FMH, 1987).Severe and prolonged
episodes of diarrhoea cause malnutrition in individual patients; while
malnourished children are more likely to develop complications with diarrhoea.
Many studies, addressing the relationship between diarrhoea and malnutrition,
have demonstrated a detrimental effect of diarrhoea on nutritional status(Nel,
2010).
The impact of diarrhoeal illness is most felt in sub-saharan
Africa where out of the 25million children born each year, 4.3 million are
expected to die by the age of 5 years and about 20% of these deaths will be
from diarrhoea (Cunliffe et al., 1998). Although no specific organism has
consistently been identified as a cause of persistent diarrhoea, in certain
geographic areas Entero-aggregative E. coli, Cryptosporidium, and Giardia
lamblia have been identified as important causes of persistent diarrhoea and
malnutrition( Nweze, 2010).In Nigeria, the aetiology of diarrhoeagenic bacteria
and the virulence of various Escherichia coli pathotypes have not been well
studied as most currently published data are from the southwestern axis of the
country (Nweze, 2010). Although in developed countries and in a few developing
countries, the mortality rates have declined considerably in recent times due
to improvement in general hygiene and advances in health care. The problem
still persists in so many other countries where outbreaks of diarrhoeal
diseases continue to affect millions of infants and young children (Hart, 1989;
Presterlet al., 2003).
Illnesses such as irritable bowel syndrome, Crohn‘s disease
and ulcerative colitis cause the patient to exhibit similar symptoms to
individuals who have developed gastroenteritis due to infection with a
pathogenic organism capable of causing diarrhoeal disease. After initial diagnosis of an inflammatory bowel disease, there is
typically no further investigation if a patient suffers a relapse due to the
underlying cause of the symptoms being known. There is however, the potential
that the onset of inflammatory bowel disease is triggered by infection with a
pathogenic organism such as Escherichia coli which results in gastroenteritis.
As such this is the primary cause of the symptoms rather than the result of a
weakened immune response due to the inflammatory bowel disease which is often
considered to be the case (Burke and Axon, 1988).
Similar effects have been seen after a bout of traveller‘s
diarrhoea with patients still suffering the effects of the infection two weeks
after initial contraction. In some individuals this long term effect of the
traveller‘s diarrhoea results in the onset of irritable bowel syndrome, again
suggesting that these pathogens are the primary cause of such illnesses
(Connor, 2005).The occurrence and distribution of bacterial pathogens causing
diarrhoea in humans has beenshown in various studies (Reyes et al., 2009).
Bando et al. (2009) reported that a high incidence of infantile diarrhoea is
associated with atypical Enteropathogenic E. coli (EPEC)
1.2 Justification
Worldwide, diarrhoeal diseases are estimated to cause over 2
million deaths annually (WHO, 2004), accounting for approximately 4.3% of the
total number of deaths and as a result ranking diarrhoeal diseases as the 5th
highest cause of death globally (UNICEF/WHO, 2011). Deaths due to diarrhoeal
diseases are more common in third world countries with a lower socio-economic
standing and which has a significant impact on child health and mortality rates
(WHO, 2004).Diarrhoea is one of the leading causes of death among children under five globally. More than one in ten
child deaths – about 800,000 each year – are due to diarrhoea. Today, only 44%
of children with diarrhoea in low-income countries receive the recommended
treatment, and limited data in literature suggests that there has been little
progress since 2000 (UNICEF/WHO, 2013).
Acute diarrhoeal disease is a major public health problem
throughout the world, with over two million deaths occurring each year, and
affecting mostly children under 5 years of age in developing countries (Kosek et
al., 2003; Bryce et al., 2005). This disease is especially common in developing
countries with poor hygiene and sanitation, and with limited access to safe
drinking water. Underlying conditions such as malnutrition, which increase the
risk of contracting diarrhoea, are also common in these countries. These
factors may result in a signficant disease burden with economic effects due to
direct medical costs, loss of work, lower quality of life and mortality
(Bonkongou et al., 2010; Bonkongouet al., 2013).Bacteria such as Escherichia
coli, Shigella and Vibrio cholerae are all known to cause diarrhoeal diseases
and are identifiable through electron microscopy and culturing of stool samples
(Gillespie and Bamford, 2007).In the United States and infact, all over the
world, few laboratories culture stool specimen routinely for E. coli O157: H7,
resulting in the actual incidence of infection with this organism being
unknown.
The number of outbreaks of E. coli O157:H7 infection reported
to the Centre for Disease Control and Prevention (CDC) has increased to 30 in
1994 (Boyce et al., 1995) and may be more now. This increase may be attributed
in part to increased reporting and screening of E. coli infection by
laboratories.Malnutrition is the syndrome that resultsfrom the interaction
between poor diets and diseases which leads to most of the
anthropometricdeficits observed among children inless developed countries (WHO,
1995).
This study was aimed at determining the antibiogram of
diarrhoeagenic Escherichia coliin diarrhoeic patients under-five years and
their nutritional status.
1.4 Objectives
The specific objectives of this work were to:
1. isolate and characterizeEscherichia coli O157,
Verocytotoxigenic E. colifrom diarrhoeal stools of children under 5yrs in
Kaduna State.
2. determine the antibiotic susceptibility pattern of the Escherichia
coli isolates.
3. assess the nutritional status of the diarrhoeic children
using Z-scores (internationally accepted reference standards).
4. obtain demographic data and risk factors associated with
diarrhoea using pre-adopted questionnaire.
1.5 Research questions
1. Is the target organism present in the faeces of the
children presenting with diarrhoea?
2. Is the organism isolated pathogenic?
3. Is the target organism susceptible or resistant to the
antibiotics to be used in the study?
1.6 Research hypothesis
Ho:E. coli is not the causative agent of diarrhoea in
children under five years.
H0: The organism isolated is not pathogenic in children under
five years.
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