Journal of Applied Biology & Biotechnology Vol. 1 (02), pp. 013-017, July- Aug, 2013 Available online at http://www.jabonline.in DOI: 10.7324/JABB.2013.1203
Gastroenteritis with Escherichacoli in pediatric hospital in N’Djamena-Chad
Bessimbaye N1,5, Tidjani A2*, Moussa AM1,2, Brahim BO2, Mbanga D 1,2, Ndoutamia G3, Sangare L4, Barro N5, Traore AS5
1General Hospital of National Reference of N'Djamena (HGRN)
2Faculty of Human Health (FSSH), University of N'Djamena 3University of Doba, Chad 4Unit Training and Research in Health Sciences (UFR / SDS)University of Ouagadougou, University Hospital of Yalgado Ouedraogo of Ouagadougou (CHU-YO) 5Centre for Research in Biological Food and Nutritional Sciences (CRSBAN)University of Ouagadougou.
ARTICLE INFO ABSTRACT
Gastroenteritis with Escherichia coli diarrhea is severe and recurrent fatal diseases in children under 5 years
especially in Africa. A prospective study of acute diarrhea was conducted at the General Hospital of National
Reference of N'Djamena (HGRN). The aim of this study was to investigate the epidemiological, clinical and
evolutionary characteristics of acute diarrhea with enteropathogenic Escherichiacoli. This study involved 167
children aged 0-2 years having seen in outpatients or hospitalized for acute diarrhea in children. Stool samples
were collected and analyzed according to standard procedures of clinical microbiology. Identification of
pathotypes of E. coli was performed by Nonavalents serum agglutination, Trivalent I, Trivalent II, Trivalent III and mixture IV. Antimicrobial susceptibility was performed by disk diffusion method in solid medium according
MH Kirby Bauer. Examination of 167 stool showed 26 cases (15.56%) bloody, 141 cases (84.83%), mucous, 122
cases (73.05%) and liquid 45 cases (26.94%) soft. The enteropathogenic Escherichia coli (EPEC) were detected
in 58 cases (34.73%). On the other hand parasites (16.76%) were identified to direct microscopic observation that Trichomonas intestinalis 13 cases (7.78%), Giardia intestinalis 9 cases (5.38%), Entamoeba histolytica 6 cases (3.59%) and cases of intestinal candidiasis (15.56%). The sensibility of origins in antibiotics was varied, 89.65 % of the ECEP, were resistant in Sulpha drugs, 56% were it towards beta-lactamines. An average rate of 26% of resistance was observed by the families of fluoroquinolones and quinolones. This study allowed us not only to include the characteristics of diarrheas at the children of less than two years, but also, the necessity of an effective coverage as well as the implementation of a program of prevention against the diarrheas of the children in a hospital environment.
380,000 deaths per year. They produce heat-labile and heat-stable
Diarrhoeal diseases are very common in the world,
enteroadherents (EAAGG, DAEC) are responsible for chronic
especially in developing countries where they are endemic state
diarrhea in children in underdeveloped countries and produce an
. Currently diarrheal diseases arrive in third place among the
enterotoxin and hemolysin . The entero-invasive Escherichia
most deadly infectious diseases in the world with 2.5 million
coli (EIEC) cause bloody diarrhea [8; 9]. Currently,
deaths any confused age. In terms of years of life lost adjusted
Escherichia coli are considered emerging pathogens, the leading
for disability, diarrhea come in second with 73 million behind
cause of bacterial diarrhea in children and are a major problem of
public health . Instead of Eschericha coli diarrhea in
Escherichia coli (STEC) are responsible for foodborne infections
developing countries, particularly in Chad is not well known
that result in diarrhea but also more serious syndromes in man as
because very few studies have been devoted. Chad has few
hemolytic uremic syndrome that can cause death [3;4].
reliable national statistics on the most frequently encountered
Enterotoxigenic Escherichia coli (ETEC) are an important cause
enteropathogens in diarrheal diseases. However, data from the
of diarrhea in children in developing countries and an estimated
registers of stool cultures of some hospitals and typhoidal
perforation recorded in the service of visceral surgery,
these different hospitals attest diarrhoeal disease due to
e-mail : firstname.lastname@example.org /email@example.com
enteric pathogens (bacteria, viruses, parasites and fungal agents)
2013 Bessimbaye N et al. This is an open access article distributed under the terms of the Creative Commons Attribution License -NonCommercial-ShareAlike Unported License (http://creativecommons.org/licenses/by-nc-sa/3.0/).
Bessimbaye et al. / Journal of Applied Biology & Biotechnology 1 (02); 2013: 013-017
posed a real public health problem in Chad. The objective of this
strain (rough). In the absence of agglutination, we proceed in the
work is to contribute to better understanding the epidemiological
same way with Nonavalents serums, Ttrivalent I, Ttrivalent II,
characteristics of diarrhoea due to Escherichia coli in pediatric
Trivalent III and mixture IV (Bio-Rad®). The antibiotic sensitivity
hospital and the phenotype of the antibiotic susceptibility of the
tests were performed on solid Mueller-Hinton (Kirby-Bauer) by
epidemiological characteristics of Escherichia coli diarrhea in
diffusion method using discs impregnated with known antibiotics
pediatric hospitals and the phenotype of antibiotic sensitivity.
as recommended by the Committee on Antimicrobial Technique
doses of the French Society of Microbiology (CASFM). 58 strains
2. MATERIALS AND METHODS
of E. coli were tested with six antibiotics belonging to the family
of beta-lactam antibiotics (amoxicillin (25μg): Amoxicillin +
2.1 Period of the study site
clavulanic acid ((20/10 μg), Ceftriaxone (30 μg), quinolones
This is a prospective study carried out between 01
(nalidixic acid (30 μg), fluoroquinolones (ciprofloxacin (5 µg) and
November 2009 to 30 October 2010, which took place in the
sulfonamides (trimethoprim-sulfamethoxazole (SXT) (1.25/23.75
Pediatric Unit and Bacteriology Laboratory of General National
Hospital of Reference in N'Djamena (HGRN).
2.6 Data processing 2.2 Population
The data was entered and analyzed using Excel software.
The study involved 167 children aged 0-2 years, 97 girls
Statistical analysis was performed using the chi-square test (χ ²) for
(58.08%) and 70 males (41.91%) with acute diarrhea in
comparison of two variables. Differences were considered
hospitalized or come visit the Pediatric Department of HGRN.
Cases of acute diarrhea were determined according to the WHO
definition, namely the emission of at least three loose or liquid
stools per day lasting for less than fourteen days.
3.1 Epidemiological characteristics 2.3 Investigations
During the study period, out of 167 cases of children of
Investigations were made to parents or guardians of
0-2 years of age with acute diarrhea reported in Pediatrics, 107
children after obtaining their informed consent. They were: the
(64.07%) were hospitalized and 60 (35.92%) were followed on an
origin, sex, age, date of disease, ongoing treatment, number of
outpatient basis. The evaluation of the temporal distribution of
stools per day, education level of the mother and the suspected
diarrhea is shown in Fig. 1. It appears a respective predominance
origin of the contamination (the source drinking water, food and
of diarrhea cases in the months of January, March and June of
whole way of life of parents) signs and symptoms (diarrhea,
2010 with 18 (11%), 24 (14.4%) and 26 (16%) cases, respectively.
abdominal pain, vomiting, fever, etc.) and conditions associated
The number of Escherichia coli isolated from the same month
enteric was 7 (12.1%), 9 (15.5%) and 10 (17.2%) respectively. The
average age of children was 12 months and ranged from 1 day to
24 months (Table 1). Cases of diarrhea were mostly observed in
2.4 Sampling and analysis of stool
Feces were collected in sterile jars. Each sample was
examined for macroscopic aspects (Purulent, mucus, presence of
Table 1: Distribution of cases of diarrhea according to age and sex.
blood) and consistency (liquid, soft, molded). It has been
Age classes Total (%) Female (%)
researched parasites in association with diarrhea. The stools were
also processed and analyzed using standard methods of clinical
microbiology. The agar EMB (Eosin Methylene Blue) and MH
(Muller-Hinton) (Bio-Rad ®) were used for the isolation of
Escherichia coli. The Petri dishes containing the medium seeded
were incubated at 37 °C in an oven for 24 hours. The reflective
3.2 Clinical Features
metallic green colonies were searched and re-isolated on MH for
Fifty six (56) children (33.53%) were taken to the
the subsequent identification of enteropathogenic Escherichia coli.
consultation within 1 to 3 days after event emission liquid stools
The isolates were stored at -86 °C in brain heart broth with 15%
while 71 (42.51%) were found within 4 to 7 days and 40 (29.95%)
glycerol for future molecular characterization.
were seen in consultation after the first week. Total duration of
diarrhea could be specified in 114 children: it was 5.8 days on
2.5 Serotyping and antimicrobial susceptibility
average with the extremes of 1 to 14 days. Table 2 reported the
On pure cultures of E. coli, it was proceeded to
results of the manifestations of diarrhea in the group of children
serotypagee as recommended by WHO. For this a colony of
observed. The number of stools per day ranged from 3 to 18;
bacteria was deposited on a drop of saline water (0.85% Nacl) on a
Altogether 86 children (51.49%) expressed 3-5 bowel movements
slide and crushed. Agglutination indicates the presence of a rough
per day, 65 children (38.92%) were 6-10 stools and 16 (9, 58%)
Bessimbaye et al. / Journal of Applied Biology & Biotechnology 1 (02); 2013: 013-017
more than 10 stools per 24 days. The stools were bloody in 26
there are 47 (81.03%) of trivalent 1 (O111 + O55 + O26) and 11
cases (15.56%), mucous in 141 cases (84.83%), liquid in 122 cases
(18.96) enteropathogenic Escherichia coli (EPEC). Twenty-eight
(73.05%) and soft in 45 cases (26.94%). Table 3 shows the
cases (16.76%) of diarrhea parasites were identified to direct
distribution of signs and conditions associated with diarrhea. Fever
microscopic observation of which 13 cases (7.78%) Trichomonas
was the most common symptom associated with 55.68% of cases,
intestinalis, 9 cases (5.38%) of Giardia intestinalis and 6 cases
followed by vomiting in 72 cases (43.11%) and anemia in 15 cases
(9%). Acute respiratory infections were the most common
Candida albicans were isolated in 26 cases (15.56%).
ailments associated with diarrhea (24.55%) followed by
We highlighted six (3.6%) when combining Entamoeba
gastrointestinal candidiasis (15.56%) and malnutrition (10.17%).
histolytica / Giardia intestinalis and 4 (2.4%) when combining
Escherichia coli / Candida albicans, an overall prevalence of
Table 2: Distribution of cases of diarrhea by age according to the appearance Age classes Consistence 3.4 Evolution
Thirteen cases (12.14%) deaths were recorded among
107 hospitalized children. The evolution towards healing was
observed in 81 children (75.70%). Cases of escape were noted in
13 children (12.14%) escaped. The distribution function and
evolution of nutritional status is reported in Table 4. The analysis
shows that 61.53% of deaths (8 of 13) occurred in malnourished
Table 3 : Signs and diseases associated with diarrhea.
children. The observed difference is statistically significant. The
Signs and symptoms Percentage (%)
risk of death was significantly greater in malnourished children
than those with a normal nutritional status.
Table 4: Distribution of cases according to the evolution of the nutritional Affections Case Percentage (%) Evolution Nutritional status Malnutrition 3.3 Etiologic agents 3.5 Susceptibility testing E. coli was isolated in 34.73% of cases of diarrhea.
Table 5 shows the evaluation of the effectiveness of
65.27% of cases were due to parasitic infections, acute respiratory,
antibiotics with isolated bacterial agents. The study involved six
candidiasis and infection Ear Nose and Throat with proportions of
antibiotics tested on 58 enteropathogenic Escherichia coli isolated.
16.76%, 15.56%, 24.55 % and 8.37% respectively. Of 167
The proportions of resistance (R), intermediate (I) and sensitive
cultures performed, 58 enteropathogenic Escherichia coli were
(S) were obtained (Table 5). 56% of strains were resistant to beta-
isolated (34.73%), 46 cases (42.99%) among 107 children
lactam antibiotics tested. The quinolones and fluoroquinolones
hospitalized and 12 cases (20%) among children monitored
were very active on 64% and 85% respectively of the strains.
externally. Of the 58 serotypes isolated from Escherichia coli,
Figure 1: Monthly distribution of cases of diarrhea and enteropathogenic Escherichia coli. Bessimbaye et al. / Journal of Applied Biology & Biotechnology 1 (02); 2013: 013-017
Table 5 : Effectiveness of some antibiotics of the family of beta-lactam antibiotics, sulfonamides, quinolones and fluoroquinolones Nb tested
R = Resistance, I = Intermediate, S =Sensitive: Trimethoprim-sulfamethoxazole (SXT) : R < 1
0, 10 ≤ I≤ 18, S ≥ 19; Nalidixic acid (Nal) : R< 15, 15 ≤ I≤ 19, S ≥
20 ; Ciprofloxacin (Cip) : R< 15, 15 ≤ I≤ 20, S ≥ 21 ; Ampicillin (AM) :R<11, 11≤ I≤ 16, S≥
17 ; Ceftriaxone (CRO) : R< 15, 15 ≤ I≤ 20, S≥ 21 ; Amoxicillin
(AMX) : R< 14, 14 ≤ I≤ 20, S≥ 21(NCCLS, 1998, CASFM, 2010).
EIEC (0.4%). The identification of parasites such as Trichomonas
Diarrhoeal diseases are still a leading cause of
intestinalis and Giardia intestinalis in liquid stools in our study
hospitalization of children in developing countries. In this study
was also observed. By cons, in mucoid-bloody stools, were
children 0-6 months were the most affected by diarrhea 37.72% of
frequently reported the presence of Entamoeba histolytica. This
cases. Maaroufi et al.  in Tunisia reported higher frequencies
would explain why, from the appearance and consistency of stools,
of 55.7%. The child before one year of age are particularly
one might suspect the presence of such parasites or bacterial
vulnerable to diarrhea for two main reasons. It was during this
infection such. The frequency of 16.76% of parasites found in the
period that gradually develops the child's own immunity as it
faeces in our study is relatively higher than that reported by Diouf
occurs a decline in maternal antibodies. The infant is more
et al.  in Senegal, which was 10.7%. Gendrel  in Gabon
vulnerable to infections during this period . This age
found a 15% prevalence of carriage in disadvantaged children.
corresponds to the period when food diversification of the child
Entamoeba histolytica were found at a low rate of 3.59% of cases.
begins. When it is poorly managed, malnutrition and diarrhea may
The 6% of parasite/parasite or bacteria/candidiasis association
occur .The distribution of diarrhea by sex and age shows a
could be explained by the level of adverse social parents to Chad
predominance of diarrhea cases in the age group of 0-6 for females
or lack of food hygiene at the household level. Acute respiratory
(20.35%) than males (14.97%) but difference is not statistically
infections with 24.55% were disease most associated with
significant (x2 = 0.00781, df = 1; p ≥ 0.90).This could be explained
diarrhea. It is followed by malnutrition in 11.37% of cases.
by the fact that Chad, women's vital statistics are 51% against 49%
Kangah et al.  in Côte d'Ivoire reported a rate increase of 22%
for male according to INSEED (National Institute of Statistics and
association of malnutrition with diarrhea. These two conditions
Economic and Demographic Studies) in 2010. Barro et al. 
feed off each other, creating a vicious circle of malnutrition
reported the infection rate among women (52.7%) which is slightly
increases the risk of diarrhea and diarrhea worsens malnutrition
higher than men (47%) during an etiological study of
[24; 25]. The average time taken to send the children in
gastroenteritis at the National Hospital Center Universitaire
consultation noted in this study, 33.53% of children were
Yalgado Ouedraogo (CHU-YO) of Ouagadougou, Burkina Faso.
consulted dice the first 3 days of diarrhea and two in five children
The rate of 15.56% of bloody diarrhea in our study is slightly
after a week reflects the neglect of diarrhea and ignorance of its
higher than the 10.2% reported by Diagne et al.  in Senegal.
consequences for mothers. This could be explained by the
The mucous stools were observed in 84.83% of cases and loose
conditions of precarious socio-economic life of the population in
stools in 73.05% of cases. The different aspects and consistency of
Chad. Access to health care due to the level of socio-economic life
stools were also reported by Dao et al.  at Bamako in Mali :
has also been reported by Poda et al.  in Burkina Faso. Most
aspects mucus in 14 cases (18.4%), the consistency of watery
recorded deaths in our study occurred in malnourished children (x2
stools in 40 cases (52.6%), and polymorphic consistency in 8 cases
= 21.27, df = 1; p ≥ 0.01 significant difference). The association is
(10.5%). Enteropathogenic Escherichia coli were much more
diarrhea-malnutrition in our areas of major concern. These deaths
isolated in the stools liquid consistency. Ingested bacteria adhere
could be explained by the fact that the department of pediatrics of
to enterocytes (intestinal cells) by a factor attachment and secrete
HGRN does not have a Therapy Centre Oral Rehydration (CTRO)
enterotoxin (ST a thermostable toxin and heat-labile toxin LT)
for the management of children with diarrhea and a Center for
which are responsible for watery diarrhea . The results of stool
Recovery and Nutritional Education (CREN) dealing with
cultures were positive in 37.12% of cases. This rate is three times
malnourished children. Most isolates were resistant to beta-lactam
that observed Luki et al.  in Zaire, it was 12%. The high rate in
antibiotics (Ampicillin, amoxicillin, ceftriaxone) at an average
our study could be explained by an unsatisfactory immunization
ratio of about 56%. Such resistance when observed, is linked to the
status, parental neglect due to present infants in health centers.
production of beta-lactamase Amp C types and penicillinases by
The frequency of enteropathogenic Escherichia coli isolated is
the strain in question [27; 28]. Our results can be explained by this
relatively high (34.73%)) in our case study. Sanou et al. 
phenomenon. This increase in resistance is due to the improper
reported a rate of 32% at the University Hospital Yalgado
and inappropriate prescribing of antibiotics by health workers.
Ouedraogo of Ouagadougou in Burkina Faso. Bonkoungou et al.
This is what was observed during our investigation. By cons, our
 showed that the major pathogroupes encountered is the ECEA
strains manifested good sensitivity to quinolones (64%) and
(12%), followed by EPEC (8%), ETEC (4%), ECST (0.4%) and
fluoroquinolones (85%). Strains have developed a resistance rate
Bessimbaye et al. / Journal of Applied Biology & Biotechnology 1 (02); 2013: 013-017
of 89.65% to trimethoprim-Sulfamoxazole. On the other hand, it
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How to cite this article:
Enterohaemorrhagic Escherichia coli: emerging issues on virulence
Bessimbaye N, Tidjani A, Moussa AM, Brahim BO, Mbanga D,
and modes of transmission. Vet. Res. 2005; 36 : 289-311.
Ndoutamia G, Sangare L, Barro N, Traore AS. Gastroenteritis
11. Maaroufi S, Ben Dridi MF, Ben Chaabane T, Zaimi ., Boujnah A,
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Zribi A, Ben Osman. Epidemiology of acute infantile diarrhea.
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