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PEDIATRICS Vol. 113 No. 3 March 2004, pp. 628-629

Culturing Practices and Antibiotic Use in Children With Diarrhea

Mark E. Beatty, MD, MPH, FAAP^*,
Patricia M. Griffin, MD
Assefa N. Tulu, MD, MSc, PhD, DLSHTM
Sonja J. Olsen, PhD
^* Epidemic Intelligence Service
Division of Applied Public Health Training
Epidemiology Program Office
Centers for Disease Control and Prevention
Atlanta, GA 30333
Foodborne and Diarrheal Diseases Branch
Division of Bacterial and Mycotic Diseases
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Atlanta, GA 30333
Dallas County Department of Health and Human Services
Dallas, TX 75207-2710

To the Editor.—

Escherichia coli O157:H7 is a common cause of bloody diarrhea and postdiarrheal hemolytic uremic syndrome (HUS) in the United States.¹ However, in many hospital laboratories, a routine stool culture does not include testing for E coli O157:H7.² Furthermore, some studies suggest that the empiric use of antibiotics in children with E coli O157:H7 infections may increase the risk of HUS.^3,4 During a recent investigation of E coli O157:H7 infections and HUS, we reviewed the culturing and antibiotic-prescribing practices at a metropolitan children’s hospital in Texas.

We reviewed all emergency department and urgent care records from July 6 to 29, 2000. Of the 2460 records reviewed, 287 (12%) recorded a diagnosis of acute diarrheal illness in a child 18 years of age (Fig 1). None of the 287 children were hospitalized; 25 (9%) had bloody diarrhea. Stool specimens from 63 (23%) of the 287 children were cultured, including specimens from 11 children with bloody diarrhea. Antibiotics for the treatment of diarrhea were prescribed for 70 (24%) children at the time of initial presentation. The frequency of prescribing empiric antibiotics for children with bloody diarrhea (25%) was similar to that for children with nonbloody diarrhea (24%) (Fisher’s exact test: P = 0.77). Obtaining a stool culture was significantly associated with treatment (culturing rate among treated children was 59% vs 3% in the nontreated; Pearsons ²: P < .01).

View larger version (26K): [in this window] [in a new window]   Fig 1. Number of stool cultures performed on children presenting with diarrhea to a pediatric emergency department.

 
In this hospital’s laboratory, a routine stool culture included testing for Campylobacter, Salmonella, Shigella, and Yersinia. Culturing for E coli O157:H7 and enzyme-linked immunoassay (ELISA) for Shiga toxin production were not part of a routine stool evaluation even in patients with bloody diarrhea. Nineteen (30%) of the 63 stool specimens yielded a pathogen; 14 grew Shigella spp. and 5 grew Salmonella spp. Stools from 2 (4%) patients who were prescribed antibiotics at the time of initial presentation grew Shigella sonnei. We did not know what proportion of the 63 cultured patients with diarrhea had E coli O157:H7 infections. Low rates of culturing combined with the use of empiric antibiotic treatment could result in a child with E coli O157:H7 infection being treated with antibiotics, thus possibly increasing the risk of HUS.^3,4 ELISAs for Shiga toxin are commercially available and can assist in the diagnosis of E coli O157:H7 infection. However, these rapid assays are not a substitute for culture. A positive ELISA result indicates the presence of Shiga toxins. False positives, generally caused by laboratory error, occur and can lead to confusion.⁵ The Council of State and Territorial Epidemiologists recommends that all positive results from rapid assays such as the Shiga toxin ELISA test should be confirmed by culture.^5,6

In Minnesota from April 12 to November 23, 1999, E coli O157:H7 was the fourth most common enteric pathogen cultured from the stools of patients presenting with sporadic diarrhea to health care providers.⁷ Furthermore, E coli O157:H7 infection is the primary cause of postdiarrheal HUS in the United States.⁸ We therefore encourage hospital and private laboratories to culture routinely stool specimens from patients with diarrhea on sorbitol-MacConkey agar, the standard culture medium for E coli O157:H7.⁹ Because E coli O157:H7 is a nationally notifiable disease, laboratories should report all laboratory-confirmed infections to the local or state health department. We also strongly encourage health care providers to determine the etiology of diarrhea before prescribing antibiotics.¹⁰

FOOTNOTES

Dr Beatty’s present address: Preventive Medicine Residency, Division of Applied Public Health Training, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, GA 30333; and the City of New York Department of Health and Mental Hygiene, Division of Disease Control, 125 Worth St, Rm 326 CN 22, New York, NY 10013.

Dr Olsen’s present address: International Emerging Infections Program, Centers for Disease Control and Prevention, Thai MOPH Collaboration, Thailand.

REFERENCES

1. Mead PS, Griffin PM. Escherichia coli O157:H7. Lancet.1998; 352(9135) :1207 –1212
2. Voetsch AC, Rabatsky-Ehr T, Shallow S, et al. Stool specimen practices in clinical laboratories, FoodNet sites, 1995–2000. International Conference on Emerging Infectious Diseases. Atlanta, GA: Centers for Disease Control and Prevention; 2002:94
3. Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tarr PI. The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections. N Engl J Med.2000; 342 :1930 –1936[Abstract/Free Full Text]
4. Pavia AT, Nichols CR, Green DP, et al. Hemolytic-uremic syndrome during an outbreak of Escherichia coli O157:H7 infections in institutions for mentally retarded persons: clinical and epidemiologic observations. J Pediatr.1990; 116 :544 –551[CrossRef][Web of Science][Medline]
5. University outbreak of calicivirus infections mistakenly attributed to Shiga toxin-producing Escherichia coli O157:H7—Virginia, 2000. MMWR Morb Mortal Wkly Rep.2001; 50 :489 –491[Medline]
6. Council of State and Territorial Epidemiologists. Position statements 2000 ID. Available at: www.cste.org/ps/2000/2000-id-04.htm. Accessed January 6, 2004
7. Sullivan MM, Besser J, Crouch N. High Incidence of Enterotoxigenic E. coli (ETEC) Isolated from stools among HMO patients with diarrhea in Minnesota. 100th General Meeting of the American Society for Microbiology. Washington, DC: American Society for Microbiology; 2000:683
8. Banatvala N, Giffin PM, Greene KD, et al. The United States National Prospective Hemolytic Uremic Syndrome Study: microbiologic, serologic, clinical, and epidemiologic findings. J Infect Dis.2001; 183 :1062 –1070
9. Bopp CA, Brenner FW, Fields PI, Wells JG, Strockbine NA. In: Murray PR, Baron EJ, Jorgensen JH, Pfaller MA, Yolken RH, eds. Escherichia, Shigella, and Salmonella. Manual of Clinical Microbiology. 8th ed. Washington, DC: American Society for Microbiology Press; 2003;654–671
10. Molbak K, Mead PS, Griffin PM. Antimicrobial therapy in patients with Escherichia coli O157:H7 infection. JAMA.2002; 288 :1014 –1016[Free Full Text]

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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics

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