Pattern of bacteriological and biochemical profile and determinants of metabolic acidosis among under-fives with diarrheal diseases at the diarrhea treatment and training unit of the University of Calabar Teaching Hospital, Calabar, Nigeria

INTRODUCTION

Diarrheal diseases are estimated by the World Health Organization (WHO) to cause about 1.9 million deaths in under-fives, mostly in low- and middle-income countries (LMICs).^[1,2] Of these deaths, 78% occur in the African and Southeast Asian regions.^[1-7] Diarrhea is common in regions with poor hygiene and sanitation, coupled with limited access to safe water.^[8] Most cases of diarrheal disease in the under-fives are due to viruses. Enteroviruses and rotavirus are dominant enteric pathogens in children.^[9-11] Occasionally, the diarrheal disease could be caused by bacterial organisms such as Escherichia coli, Shigella, Campylobacter jejuni, Salmonella, and Vibrio cholerae. Rarely, parasitic organisms such as Entamoeba histolytica, giardiasis, and cryptosporidium could cause diarrhea in children.^{[1,2,9,10,12]} These organisms are transmitted feco-orally^[8] and open defecation remains a major challenge in some LMICs.^[13]

The common complications of diarrheal diseases are fluid loss, electrolyte imbalance, septicemia, and malnutrition.^[1,14] Acidosis is a strong prognostic factor for poor outcomes in children with diarrheal disease.^[15,16]

The accurate assessment of dehydration status and a high index of suspicion for electrolyte derangement among under-fives with diarrheal diseases are very central to the prevention of morbidity and mortality. The severity of dehydration can be associated with the degree of electrolyte and metabolic derangement that requires prompt care and interventions.^[15,16]

Several studies documented positive stool cultures in children below the age of 5 years.^[1,8,14,17] Environmental changes and genomic and immune responses of children may impact the current bacterial and biochemical pattern of diarrhea.^[18]

Diarrheal diseases and their sequelae can be prevented with simple measures such as personal and environmental hygiene, water and food sanitation, and diarrhea treatment training for health workers and mothers. Furthermore, the use of oral rehydration salt solution (ORS), probiotics, zinc sulfate tablet, and timely treatment of shock, and comorbidities are major means of prevention.^[1,2]

We aimed to evaluate the pattern and predictors of electrolyte derangements and one isolate in stool sample concerning dehydration of under-fives with diarrhea at a tertiary hospital in South-South Nigeria, to guide early interventions.

MATERIAL AND METHODS

RESULTS

Diagnosis

Diarrheal disease with some dehydration was the most common diagnosis (n = 98/136, 72%) among the patients while dysentery was the diagnosis in only 9.6% (n = 13/136) of the patients [Figure 1].

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Figure 1:

Frequency distribution of patient’s diagnoses.

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Investigation results

In this study, stool samples from 5 (3.7%) children were culture positive, with three growths of non-specified E. coli and two of E. histolytica [Figure 2]. The antimicrobial sensitivity result of the stool samples that were growth positive showed that all the organisms were sensitive to ceftriaxone, gentamycin, ciprofloxacin, and nalidixic acid [Table 2]. Almost half (n = 56/136, 41.2%) of the children had acidosis while creatinine was normal in all of them. Nearly, all (n = 132/136; 97.0%) the babies had normal RBS result [Figure 3].

Table 2: The antibiotic sensitivity pattern of the five stool samples that were growth positive.

S. No.	Antimicrobial	Sensitivity analysis of five growth-positive stool samples
		Sensitive	Moderately sensitive	Resistant
1	Ampicillin			5
2	Cloxacillin			5
3	Ceftriaxone	5
4	Cefixime
5	Cefuroxime
6	gentamycin	5
7	Erythromycin			5
8	Ciprofloxacin
9	Nalidixic acid	5
10	Tetracycline			5
11	Cotrimoxazole	5
12	Chloramphenicol			5

c2nalysisbercol0mmol/lion

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Figure 2:

Pie chart of organism cultured in the patient’s stool.

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Figure 3:

Pattern random blood sugar, urea, and electrolytes.

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DISCUSSION

We evaluated the pattern and predictors of electrolyte derangements and isolates in stool samples concerning dehydration of under-fives admitted to a tertiary hospital on account of diarrheal disease over 1 year period.

In this study, more than three-quarters of patients presented with fever (79.4%) and vomiting (76.5%). In contrast, studies from Benin^[22] and Vietnam [23] documented fever in 52.5% and 43.6% while vomiting occurred in 52.5%^[22] and 53.8%, respectively, of their patients in addition to the diarrheal episodes. However, studies from India reported higher rates of fever (89.6%) and a lower rate of vomiting (61.8%) in comparison to our study.^[24] The observed differences in the prevalence of fever and vomiting concerning diarrheal disease may represent regional variations in microbial patterns and seasonal variations. Nonetheless, our result supports a close relationship between fever, vomiting, and diarrheal disease.

Our study found that the most common home remedy offered by caregivers was mainly ORS (79.4%) which is in keeping with the 47–72.3% rate within the country,^[25,26] and the most common source of drinking water was sachet/bottled water (47.8%). This finding is reassuring and in line with the WHO/UNICEF^[1] recommendation. However, the ORS rate from our study was slightly lower than the reported rate of 89.1% in a study from Vietnam.^[23] Efforts should be geared to educate and sustain the high utilization rate of ORS by mothers as first aid for diarrheal diseases.

Our study revealed that only about one-quarter (n = 33, 24.3%) of the caregivers regularly washed their hands with soap before feeding their babies. Since the hand washing procedure with soap before feeding a child is among the veritable tool for reducing the incidence of diarrheal disease in children, public health interventions to increase awareness on improving hand washing practices in the community are of the essence.^[23,27,28] This poor hand-washing practice among the respondents is surprising as the majority of our study participants were educated, urban dwellers.

Contrary to the 2017 report of UNICEF that Nigeria ranked high in open defecation with over 46 million Nigerians still defecating openly,^[13] our study revealed that water closet was readily available in 84.6% of the patients’ homes while the majority 84 (61.8%) of the babies defecated in the potty. Thus, it may be projected that a high proportion of the catchment population of the hospital had access to a good toilet facility. Nonetheless, poor hand washing practices and the use of sachet water among our respondents may increase feco-oral transmission of pathogens.^[8]

The majority of the children (72.1%) had mild-to-moderate dehydration which is similar to the reports by other authors.^[24-26] The majority of our cohort of babies had moderate dehydration, at presentation, possibly because more than four-fifth of them had ORS before the presentation. Thus, public health interventions that promoted ORS administration at home should be enhanced to reduce the sequelae of severe dehydration.

Nearly all (n = 131/136; 96.3%), of the stool, analyzed yielded microscopic and culture-negative results. In line with the previous studies,^{[10,21,23,29]} our result suggests that viral infection (possibly rotavirus) that was not cultured contributes hugely to the burden of diarrheal diseases among our cohort of babies. Five children that had positive stool growth were below 3 years of age and also were those with blood in the stool. The isolated organisms were unspecified E. coli in 3 (2.2%) patients and E. histolytic in 2 (1.5%). This pattern is similar to the report of other studies.^[8,12,21,29] The finding of E. histolytica in the stool sample is not common but it has been isolated in under-fives.^[11,12] The much expected Shigella and Salmonella species were not isolated in this study as in other similar studies.^[23,30] Our study may just be highlighting a changing pattern in the microbial load in the stool of diarrhea patients. Future population-based studies are required to confirm if indeed there is a changing pattern of pathogens associated with diarrheal disease.

The antimicrobial sensitivity result of the stool samples that were growth positive showed that all the organisms were sensitive to ceftriaxone, gentamycin, ciprofloxacin, and nalidixic acid. This is similar to an Indian study.^[24,30] Thus, the empirical use of these antibiotics in suspected bacterial diarrheal infections may be justified.

This study documented acidosis as the most common electrolyte derangement in children with diarrheal disease, and all occurred in children below 2 years. Studies^[6,7,29,31] have shown that acidosis is a prognostic feature of diarrheal disease in children. Eke et al. reported a similar finding and also highlighted a higher association between acidosis and mortality. Our findings were lower than the reported prevalence of acidosis in Nigeria.^[25,26] In contrast, hypernatremia (37.9%) was the most common electrolyte derangement as reported by researchers from Tanzania.^[32]

Our study revealed that none of the babies managed for diarrhea had hypoglycemia. A similar low prevalence of hypoglycemia was previously reported.^[6,26] Although hypoglycemia may not occur commonly in children with diarrheal disease, it could significantly contribute to diarrhea mortality when it occurred.^[6]

The sociodemographic characteristics did not seem to have an association with the dehydration status of patients in this study. The fact that all the patients reside in the metropolis and are likely to have similar characteristics and responses to diarrhea in their children may explain the finding.

The clinical findings of vomiting, nutritional appearance/ status of the baby, pulse volume, and level of consciousness were associated significantly with dehydration status. This is in keeping with other studies^[15,16] as copious vomiting, underweight, and low pulse volume are poor prognostic factors in diarrheal disease.

Concerning electrolyte derangement, the mother’s education, father’s education and father’s occupation, fever in a patient, and breastfeeding history for <3 months, all had a significant relationship with the child’s hydration status. Married parents who are empowered economically are more likely to seek and afford health care early to prevent complications. For children that were breastfed for 3 months and less, the introduction of complementary feeds increases the chances of using feeders and issues of hand hygiene in caregivers which predisposes the child to diarrhea disease and its complication. Fever as well as moderate and severe dehydration in our study cohorts were associated with metabolic acidosis, while exclusive breastfeeding (EBF) shows non-association, hence, protective against acidosis. This will definitely impact treatment outcomes positively and the practice of EBF should be strengthened through targeted interventions among women of childbearing age. Although not reaching statistical significance, there were reduced odds of metabolic acidosis among babies who had pre-hospital oral rehydration and this has clinical significance.

The limitations of this study include the inability of the laboratory to isolate viruses. Since blood culture was not done, our study might have missed the diagnosis of Salmonella species. Another limitation of the study may be the issue of social desirability, as the caregivers may not honestly respond to self-reported practices. Nevertheless, this study is the first in our environment to robustly evaluate and model the predictors of metabolic acidosis among under-fives with diarrheal diseases using regression modeling.

The post-regression analysis showed that the data fit the model, and the AUC of the ROC was 75% showing that the model will accurately predict metabolic acidosis on 75 out of 100 occasions. We recommend that for future studies, more variables may be included to improve the predictive value of the model. Furthermore, we avoided multicollinearity of the variables that may reduce the efficiency of our conclusion.

CONCLUSION

Diarrhea disease is a major cause of morbidity and mortality. Fluid and electrolyte derangement, especially acidosis, is an untoward complication that must be tackled by strengthening oral rehydration solution use and EBF. Isolation of E. histolytica in stools of children below 3 years calls for urgent and conscious efforts to ensure hygiene and the provision of safe portable water supply to homes. The low burden of bacterial isolates among our cohort suggests viral origin and, hence, strongly supports the introduction of the rotavirus vaccine in our national routine immunization schedule as its isolation is a challenge. Furthermore, the government should implement and enforce prescription control to prevent the development of drug resistance.

This study provides information about the clinical correlates of metabolic acidosis that may be a quick guide in emergency clinical practice in the tropics where laboratory results may not be available early. A larger multicenter study is, however, warranted to establish our findings.