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Causes of Infectious Acute Diarrhea in Infants Treated at Pediatric Clinic

DOI: 10.5455/medarh.2013.67.17-21
Med Arh. 2013 Feb; 67(1): 17-21
Received: September 28th 2012 | Accepted: December 15th 2012
CONFLICT OF INTEREST: NONE DECLARED

Original paper

Causes of Infectious Acute Diarrhea in Infants


Treated at Pediatric Clinic
Mehmedali Azemi1, Vlora Ismaili-Jaha1, Selim Kolgreci2, Majlinda Berisha1, Xhevat Jakupi3, Sanije Gashi4, Teuta Hoxha-Kamberi1
Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo1
Obstetrics and Gynecology Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo2
National Institute of Public Health, Department of Microbiology, Prishtina, Kosovo3
National Institute of Public Health, Department of Social Medicine, Prishtina, Kosovo4

im: The aim of this work has been a presentation of causes of acute infectious diarrhea.
Material and methodology: The examinees have been the infants treated at the Pediatric
Clinic. The diagnosis has been established on the basis of anamnesis, physical examination
and feces examination on bacteria, viruses, protozoa and fungi. Results: During the period
of seven years a number of patients that suffered from acute infectious diarrhea was 1050
(31.82%) out of a total number (3300) with diarrhea. The bacteriological examination proved
positive on majority of them or in 655 (62.38%) cases, the viral examination proved positive
in 375 (35.72%) cases, whereas fungi examination proved positive in only 3 cases (0.28%). The
most frequent bacteria have been Salmonellae species in 255 (38.93%) cases and E. coli in
142 (21.69%) cases, the less frequent have been Yersinia enterocolitica in 16 (2.44.%) cases and
Bacillus cereus in 4 (0.61%) cases. The most frequent serotypes of Salmonella have been S.Wien
in 92 (36.07%) and S.Gloucester in 42 (16.47%) cases. Enteropathogenic E. Coli (most frequent
serotypes O111 and O55) has been found in 112 (78.88%) cases. From the group of Shigella the
most frequent has been Sh. Flexneri (most frequent serotypes 6 and 4) in 35 (58.33%) cases. The
same feces sample of the majority of examinees 501 (76.48%) cases contained only one bacteria
(single bacteria), two bacteria (associated bacteria) have been found in 102 (15.17%) cases, three
types of bacteria have been found in 17 (2.59%) cases. Rotavirus has been isolated in 271 (72.26%)
cases in comparison to adenoviruses that have been isolated in 65 (17.33%) cases. Rotavirus and
adenoviruses have been isolated in 39 (10.40%) cases. Conclusion: Infectious acute diarrhea
appears frequently, and as causes of it usually appear to be pathogenic bacteria in comparison to
viruses, protozoa and fungi. Key words: Acute diarrhea, etiology.

Corresponding author: Assoc prof Mehmedali Azemi MD PhD, Pediatric Clinic, University Clinical Center of
Kosovo, Mother Teresa street nn, Prishtin. Tel: +377(44)146-463; email: mehmedaliazemi@hotmail.com

1. INTRODUCTION
Acute diarrhea is one of the most
frequent symptoms that the children
suffer from, whereas majority of diarrhea types that doctor faces with are
caused by acute intestine infection (120). In the developing countries, infectious acute diarrhea is one of the most
frequent causes of morbidity and mortality among infants and children between 1-3 years (21-29). Those countries

meet the requirements for multiplication of pathogenic bacteria and viruses


that are the most frequent causes of diarrhea that appears to be very frequent
during the summer season. In Kosovo
(as developing country), infectious
acute diarrhea is still a major cause of
morbidity and mortality of children, especially of infants, and the summer season is the period of its greatest presence.

Acute infective diarrhea is due to


infection acquired the fecal-oral route
or by ingestion of contaminated food or
water. Acute infective diarrhea is associated with poverty, poor environmental hygiene and development indices.
The most frequent causes of infectious
acute diarrhea are bacteria, followed by
viruses, whereas in the developed countries the first place occupy viruses followed by bacteria and protozoa (8, 14,
20, 22, 30-35).

2. AIM
The aim of the work has been to
present the most frequent causes of
infectious acute diarrhea on infants
treated at the Pediatric Clinic.

3. MATERIAL AND
METHODOLOGY
The examinees have been infants
with acute diarrhea treated at the Pediatric Clinic of Prishtina during the
period of 7 years. Feces samples taken
from patients have been referred to
the Department of Microbiology, the
National Institute of Public Health of
Kosova for identification of diarrheal
causative pathogen. Each sample has
been cultivated in selective media according to the laboratory protocol, respectively in Salmonella-Shigella (SS)
agar and Selenit F Broth for Salmonella
and Shigella species, Sorbitol MConkey (SMAC) for E. coli O157, Cefsulo-

Med Arh. 2013 Feb; 67(1): 17-21 Original paper

17

Causes of Infectious Acute Diarrhea in Infants Treated at Pediatric Clinic

X2-test

Relation
No.
%
X2-test
din Irgasan Novobiocin (CIN) agar forNon infectious
of infants suffered from infectious acute
X =436.4;
acute diarrhea
2250
68.18
X2=436.4;
Df=1;
Yersinia enterocolitica and Campylo-Infectious acute
diarrhea (Figure 1 and 2), the difference
Non infectious
p<0.00001
68.18 Df=1;
diarrhea
1050
31.82 2250
acute diarrhea
bacter Blood Free Agar for Campylowas statistically significant (p<0.00001).
p<0.00001
Total
3300
100
bacter species. Medias for cultivationFigure 1. Relation
Figure 3 shows the relation of feces
Infectious
between infectious and noninfectious diarrhea
1050 31.82
acute diarrhea
have been prepared at the Department
examination of bacteria, viruses, proTotal
3300 100
of Microbiology from dried forms of
tozoa and fungi. Feces examination of
media produced by Liofilchem, Italy. Figure 1. Relation between infectious and
bacteria proved positive with the majorSS agar, Selenit F broth and SMAC agar noninfectious diarrhea
ity of patients 655 (62.38%), of viruses
have been incubated at 35-37 C for 16with 375 (35.72%) cases, of protozoa
24 hours in air atmosphere, Campylowith 17 (1.61%) cases and of fungi with
bacter Blood Free Agar at 42C for
3 (0.28%) cases, (p<0.00001).
48 hours in micro-aerobic atmosphere
Isolated bacteria
No. %
X2-test
conditions, CIN agar at 28-30C for
X2=803.12;
Salmonellae spp.
255 38.9 Df=9;
24-48 hours at air atmosphere. After
p<0.00001
24 hours of incubation, subcultivation
Escherichia coli spp.
142 21.7
to SS agar has been conducted from
Shigella spp.
60
9.2
Selenit F broth for Salmonella. Sus- Figure 2. Graphic presentation between
Campylobacter jejuni
41
6.3
infectious and noninfectious diarrhea
Pseudomonas
pected colonies in SS agar (lactose neg-Figure 2. Graphic presentation between infectious and noninfectious diarrhea
38
5.8
aeruginosa
ative, transparent, with or without H2S)
In addition, based on pediatricians
Clostridium difficile
36
5.5
have been transferred to Kligler Iron request, feces samples have been proClostridium
36
5.5
perfringens
Agar and in case of positive biochemi- cessed for ova/parasites identification
Staphylococcus
cal identification, serotyping was con- and testing on presence of the rotavirus
27
4.1
aureus
ducted using appropriate antisera (In- and adenoviruses. Ova/parasites microYersinia enterocolitica 16
2.4
stitute of Immunology, Zagreb, Croatia scopic examination has been conducted
Bacillus cereus
4
0.6
Total
655 100 and Sifin, Germany) for Salmonella or with Lugols Iodine on microscopic slide
Shigella. Serotyping was initially done and rotavirus/adenoviruses presence Figure 4. Bacteriological examination of feces
with polyvalent Salmonella followed has been detected with help of immuby group specific antisera based on nochromatographic test (25). Data were
Kaufman White classification scheme. presented with tables, charts and were
Similar process was conducted for sero- verified with X2-test. For Candida albityping of Shigella species and serotypes. cans the sample of feces has been cultiSorbitol negative colonies in SMAC vated in selected media saboro.
have been biochemically confirmed for
E.Coli and serotyped with appropriate 4. RESULTS
antisera (E. coli O157).
During the time period of 7 years,
Suspected colonies for Campylo- 5200 infants i.e. (21.71%) of total numbacter at Campylobacter Blood Free ber of 17500 hospitalized children of
Agar have been tested with Oxidase different age groups were treated at
and Catalase test (which are both posi- the Pediatric Clinic. Out of the total
tive for Campylobacter spp.), and gram number of infants (5200) there were
stained (Campylobacter species are 3300 (63.46%) of infants suffered from
curved, gram negative bacilli). Bulls- acute diarrhea. From that number, 2250 Figure 5. Range of the most frequent bacteria
Figure 5. Range
of the most frequent bacteria isolated
isolated
eye-like colonies on CIN agar have (68.18%) suffered from noninfectious
been biochemically processed and se- acute diarrhea, whereas 1050 (31.82%)
On bacterial examination of feces,
rotyped for Yersinia enterocolitica with
the most frequently isolated has been
Type of feces
appropriate antisera.
SalmonellaSerotypes
in 255 (38.93%)
cases, fol- %
Groups
Number
No.
%
X2-test
examination
Clinically suspected cases for diarE. coli in 142 (21.67%)
cases,36.07
O:4 (B) lowed by Wien
92
X2=578.7;
rhoeic E. coli were also investigated for
Shigella
in
60
(9.16%)
cases,
CampyloO:4
(B)
Gloucester
42
16.47
Bacteriological 655
62.4
Df=2;
enterotoxigenic E. coli (ETEC), enteroin 41 (6.25%) cases,
Pseu-12.94
p<0.00001
O:4 (B) bacter jejuni
Typhimurium
33
Viral
375
35.7
pathogenic E. coli (EPEC), enteroinvaaeruginosa
in 38 (5.805)
cases,9.09
O:8 (C2 -domonas
C3)
Muenchen
23
Protozoa
sive E. coli (EIEC) and enteroaggregaClostridium
difficile
and
Clostridium
O:8 (C2 - C3)
Newport
20
7.84
(Giardia17
1.61
tive E. coli (EAEC) through slide aggluhave been isolated
in the6.66
O:4 (B) perfringens
Abony
17
Lamblia)
tination with poly specific O-antisera,
in 36 (5.49%)17cases each,6.66
O:9 (D1)same number
Enteritidis
Fungi
Anti coli I, Anti coli II, and Anti coli
Staphylococcus
en-3.13
(Candida
3
0.28
O:4 (B)
Stanley aureus (preformed
8
albicans)
III and in case of positivity, with O:K
in 27 (4.12%) cases,
O:8 (C2 -terotoxin)
C3)
Gatuni
3 Yersinia1.17
Total
1050 100.0 specific antisera from Sifin, Germany.
enterocolitica
Total in 16 (2.44%)
255cases and100
Presence of Pseudomonas aeruginosa Figure 3. Findings in examination of feces with
Bacillus cereus in a smaller number in
Figure 6. Groups and serotypes of isolated Salmonella's
bacteria, viruses, protozoa and fungi
was also notified (19, 24, 28).
Relation

Number

18

Med Arh. 2013 Feb; 67(1): 17-21 Original paper

X2

X2=
D
p<0.

Causes of Infectious Acute Diarrhea in Infants Treated at Pediatric Clinic

4 (0.61%) cases (Figure Groups


Serotypes
No.
%
X2-test
4 and 5), p<0.00001.
X2=200.2; Df=8;
O:4 (B)
Wien
92
36.07
p<0.00001
Rega rd ing the
Gloucester
42
16.47
groups and serotypes O:4 (B)
Typhimurium 33
12.94
of Salmonella (Figure O:4 (B)
23
9.09
6) the most frequently O:8 (C2C3) Muenchen
O:8 (C2C3) Newport
20
7.84
isolated have been:
O:4 (B)
Abony
17
6.66
S.Wien group O: 4 (B)
O:9 (D1)
Enteritidis
17
6.66
in 92 (36.07%) cases. O:4 (B)
Stanley
8
3.13
S.Gloucester group O:8 (C2C3) Gatuni
3
1.17
O:4 (B) in 42 (16.47%),
Total
255
100
S.typhimurium group Figure 6. Groups and serotypes of isolated Salmonellas
O:4 (B) in 33 (12.94%),
Groups
Enteropathogenic E.coli (EPEC)
Enterotoxigenic E.coli (ETEC)
Enteroinvasive E.coli (EIEC)
Enteroagregative E.coli (EAGEC)
Shiga Toxin-Producing E.coli (STEC) as
Enterohaemorrhagic E coli (EHEC)
Total

Serotypes
(according to
frequency)
O111, O55, O125,
O26
O115, O153,
O159
O124
-

No.

X2-test

112

78.9

X2=312.5; Df=4;
p<0.00001

17

12.0

7
5

4.9
3.5

O157:H7

0.7

142

100.0

Figure 7. Groups and serotypes of isolated E. coli

orrhagic E. coli (serotype O157:H7) in only


Groups
%
X2-test
one case, (p<0.00001).
X2=37.5;
Rega rd i ng t he
Sh.Flexneri
B
6, 4, 8, 15
35
58.3
Df=3;
groups, serogroups
p<0.00001
and serotypes of ShiSh.Sonnei
D
11
18.3
gella the most freSh.dysenteriae A
1, 5, 7
10
16.7
Sh.boydii
C
2, 7, 16
4
6.7
quently isolated has
Total
-
-
60
100.0 been Sh.Flexneri (according to frequency
Figure 8. Groups, serogroups and serotypes of isolated Shigella
serotypes 6, 4, 8, 15)
S.Muenchen group O:8 (C2-C3) in 23 in 35 (58.33%) cases, followed by
(9.09%), S.Newport var. Puerto Rico Sh.Sonnei in 11 (18.33%) cases, Sh. dysgroup O:8 (C2-C3) in 20 (7.84%), S.abony enteriae (serotypes 1, 5, 7) in 10 (16.66%)
group O:4 (B) in 17 (6.66%), S. enteritidis cases and not that frequent Sh.boydii
group O:8 (D1) in 17 (6.66%), S.Stanley (serotypes 2, 7, 16) in only 4 (6.66%)
group O:4 (B) in 8 (3.13%) and S.Gatuni cases (Figure 8), p<0.00001.
group O:8 (C2-C3) in 3 (1.17%) cases,
Single and
(p<0.00001).
associated
No
%
X2-test
bacteria and
Groups and serotypes of diarrheic
rotavirus
E. coli are presented on figure 7. The
X2=950.6;
Single bacteria
501
76.5 Df=3;
most frequently isolated has been enp<0.00001
teropathogenic E.coli (according to freAssociated
quency serotypes O111,O55,O125 and
(multiple) two
102
15.6
bacteria
O26) in 112 (78.80%) cases, then enteroAssociated three
toxigenic E.coli (according to frequency
35
5.3
bacteria
serotypes O115, O153 and O159) in 17
Associated
(11.97%) cases, not that frequent has
bacteria and
17
2.6
rotavirus
been enteroinvasive E. coli (serotype
Total
655
100.0
O124) in 5 (4.92%) cases, enteroagregative E.coli in 5 (3.52%) cases and Shiga Figure 9. Number of cases with bacteria and
Toxin-Producing E. coli as enterohaem- viruses isolated on the same feces sample
Serogroups

Serotypes
Num(according to
ber
frequency)

The examination proved that the


feces of the biggest number of cases
with diarrhea 501 (76.48%) contained
only one bacteria (single bacteria), then
two bacteria (associated bacteria) have
been isolated in 102 (15.57%) cases and
three bacteria in 35 (5.34%), whereas in
17 (2.59%) cases bacteria has been isoTypes of viruses

No.

X2-test

Rotavirus

271

72.3

X2=258.5; Df=2;
p<0.00001

Adenoviruses

65

17.3

Associated
rotavirus and
adenoviruses

39

10.4

Total

375

100.0

Figure 10. Viral examination of feces

lated together with rotavirus (Figure


9), p<0.00001.
Viral examination of feces in rotavirus and adenoviruses was positive in
357 (35.28%) of cases. Rotavirus was
isolated in 271 (72.26%) cases, adenoviruses in 65 (17.33%) cases whereas
in 39 (10.40%) cases in the same feces
sample were isolated both viruses (rotavirus and adenoviruses) as shown in

Figure 11. Graphic presentation of viral


examination of feces
Figure 11. Graphic presentation of viral examination of feces

Figure 10 and 11 (p<0.00001).

5. DISCUSSION
Based on our data for the period of
7 years, it is evident a high percentage
(63. 46%) of infants with acute diarrhea,
even though there is a tendency from
year to year of reduction of the number of infants with acute diarrhea compared to the previous years. Non-infectious acute diarrhea was apparently
more frequent (68.18%) in comparison
to the infective one (31.82%).
In examining the feces, there were
most frequently isolated various pathogenic bacteria (62.39%), compared to
viruses (35.72%), whereas, there were
rarely isolated protozoa and only the
Giardia-Lamblia (1.61%), while fungi
(Candida albicans) was only in three

Med Arh. 2013 Feb; 67(1): 17-21 Original paper

19

Causes of Infectious Acute Diarrhea in Infants Treated at Pediatric Clinic

cases (0.28%). According to the data of


Votava (1) in 1982 with 67.58% of infants
with acute diarrhea, bacteriological examination of feces was positive, while in
rotavirus with 8.9% of the cases. Having
investigated the summer diarrhea with
the children of South Africa in 1980.
(2) bacteriological examination of feces was positive with 92.95%, in rotavirus with 4.0% and in parasites 1.4% of
cases. According to Hodzi (3) of 1986.
at 92% of cases with infectious acute diarrhea, bacteriological examination was
positive, while in rotavirus at 8%. According to the data of Amal Rohan (4)
about the children infectious acute diarrhea in examining the feces, viruses
were isolated more frequently at 34.3%,
then the bacteria at 26.8% and parasites
at 4.2% of the cases. Our data is similar
to the data of authors in the region (1,
3) of 1980 and 1986, in which the organization of health protection of infants
in these countries has been apparently
improved and the number of cases with
diarrhea is smaller.
In bacteriological examination of
feces the Salmonella was isolated most
frequently (38.93%) and the most frequent type was S.Wien at 92 cases, afterwards E. coli (21.69%), more rarely
Bacillus cereus (0.61%). The genus of
Salmonella numbers more than 2500
types and it comprises the most widespread bacteria in the nature, which is
spread through food, cows milk and
water. Some infants in our country
are still fed with pasteurized milk and
with unprocessed cows milk, which is
prepared under not very good hygienic
conditions, it is not kept in the fridge;
therefore, there is more possibility of
contamination with Salmonella (26).
The types of isolated infants with infectious diarrhea vary from one region to
another. In 1984, according to the data
of Votava (5), E. coli was mostly isolated in the children with acute infectious diarrhea at 32% of the cases. According to Jovanovi (6), in regard to infants with diarrhea, there were mostly
isolated Salmonella (14%), then E. coli
(2.3%), whereas, Shigella with 1.2% of
the cases. In the case of children of Ethiopia having acute infectious diarrhea
(7) there were mostly isolated E. coli according to the frequency (12%), Citrobacter (11%), Proteus (7%), Salmonella
20

(5.5%) etc. Other authors (8) with 54


children with acute infectious diarrhea,
there were most frequently isolated E.
coli (11.11%), then Salmonella (3.70%)
and rotavirus at 7% of the cases. With
the children of Ghana acute infectious
diarrhea as a cause to it predominates
E. coli (79.6%), followed by Klebsiella
(5.1%), then Shigella at 4% of the cases
(9). According to the authors (4) with
the children having diarrhea in Tripoli (Libya) there were most frequently
isolated E. coli (15.5%), followed by Salmonella 7.9%), adenoviruses (7.1%) and
Aeromonas (4.2%) of the cases. With
children under five years having acute
infectious diarrhea in Dar es Salami
(Tanzania) there was also E. coli, which
was isolated most frequently (22.9%),
followed by Cryptosporidium parvum
(18.9%), rotavirus (18.9) and norovirus
(13.7%) of the cases (10).
E. coli following Salmonellas takes
the second place a cause of acute infectious diarrhea of our patients (21.69%).
Enteropathogenic E. coli were isolated
the most frequently in particular the
serotype O111 (78.8%), followed by enterotoxygenic E. coli (11.97%), while at
only one case Shiga Toxin-Producing
E. coli isolated (serotype O 157: H7). It
is known that enteropathogenic E. coli
mostly causes diarrhea to the infants
(31). It does not produce enterotoxin
and it does not penetrate into mucosa,
but by adhering through small intestine, causing destruction and atrophies
of intestine cluster with inflammatory
reaction or diarrhea, whose pathogenesis is still not clear. Our data are to some
degree identical to the data of authors
in the region. According to Zivi (11) E.
coli is isolated at 9.8% of infants with
acute diarrhea, but he did not indicate
the groups of E. coli. According to Velisavljev (33) E. coli is isolated at 21.28%
of cases with diarrhea and in particular
only enteropathogenic E. coli, most frequently the stereotype O111. Nikolova
et al. (12) evidenced enteropathogenic
E. coli as the most frequent cause of diarrhea (34%) and in particular the serotype O111. Votova and Rai (5) with
infants having acute infectious diarrhea, they most frequently isolated enteropathogenic E. coli (serotype O111)
at 27% of the cases.

Med Arh. 2013 Feb; 67(1): 17-21 Original paper

According to Wdstrom et al. (7)


with children of Ethiopia having diarrhea E. coli was isolated most frequently
(38%), but he did not indicate the groups
and serotypes of bacteria. With the children of South Africa enterotoxygenic E.
coli was isolated most frequently (19%).
Results of Robins-Browne (2) do not
match with our results and with those
of our region concerning the types of
E. coli. The serotype O55 was isolated
most frequently followed by O86, O112,
O125, O142, O25, O26, O111 etc. With
children of Tanzania in (Dale es Salami) having diarrhea, E. coli was isolated most frequently with 22.9% (10).
Most frequently (64.1%) was isolated
enteroagregative E.coli, then enteropathogenic E.coli (20.3%) and enterotoxigenic E. coli (15.6%). The greatest
percentage (79.6%) of E. coli as a cause
of diarrhea was with children of Ghana
(9). According to Amal Rahouma (4)
with children of Libya (Tripoli) having
diarrhea, E. coli was isolated most frequently (15.5%), in the first place enteroagregative E. coli (4.11%). enteropathogenic E. coli (serotypes O111 and
O127) was isolated in 36.4% of the case
with diarrhea in Iran (13).
The groups of Shigella is isolated in
60 (9.16%) cases with acute infectious
diarrhea. Sh. Flexneri was isolated most
frequently in 35 (58.33%) cases (serotypes 6, 4, 8, 11), more rarely Sh. boydii
in 4 (6.66%) cases, but, it has to be noted
that in 10 (16.66%) cases Sh. dysenteriae
was isolated. Isolation of a great number of Sh. Flexneri is characteristic for
developing countries such as our country. After such isolation, patients were
advised to be treated in the Infective
Clinic. In a research done by Hoi (3)
with infants having diarrhea, Shigella
was isolated in 3 (12%) cases. According
to Vargazon (4) with children hospitalized in the Infective Clinic, Sh. Sonnei
was isolated the most frequently, followed by Sh. Flexneri that is typical for
developed countries. According to Robins-Browne (2) in 70 infants with acute
diarrhea, Shigella was isolated in 6 (9%)
cases without specifying their group
and serotypes. According to the data of
Filipovi (34) in infants with acute infectious diarrhea, Shigella was isolated
in 4% of the cases. It should be noted
that these data from the region date

Causes of Infectious Acute Diarrhea in Infants Treated at Pediatric Clinic

from 25-30 years ago. With infants having diarrhea in Iran (13), Shigella was
isolated in 6.2%, their serogroups and
stereotypes were not indicated. With
infants having diarrhea in (Libya) Shigella spp was isolated very rarely (0.8%).
With children of Ghana (9) having diarrhea, Shigella was isolated in 3.8% of
the cases, with regard to frequency they
rank the fourth as causes of diarrhea
(coming after E. coli, E. histolytica and
Cryptosporidium).
One bacteria (single bacteria) has
been isolated in the same feces sample among the majority of infants with
diarrhea (76.48%), two bacteria (associated bacteria) have been isolated in
15.57% of cases, whereas three bacteria
in only 5.24% of cases. On the other side
the same feces sample contained both
bacteria and rotavirus in 2.59% of cases.
Mixed infections consisted of 2-3 bacteria of different gender, but there are also
some cases when one feces sample contained 2-3 serotypes of the same bacteria. It should also be mentioned that
clinical manifestations were different
and more severe in the cases with two or
three bacteria were accompanied with
rotavirus. According to other authors
(4) bacteriological examination of feces resulted with one bacteria in 37.3%
cases, whereas in 13.8% cases 2-3 bacteria in the same feces sample. There
have also been 2-5 bacteria isolated on
the same feces sample in 20.4% of cases
among children under five years in Dar
es Salaam, from that number the feces
sample of 75 % of cases contained two
bacteria, in 20.4% of cases three bacteria have been isolated and four bacteria
in 3.7% of cases (10, 18). In 12 % of cases
with acute diarrhea Torres (15) isolated
associated (mixed) bacteria (he did not
mention the number of them) at the
same feces sample.
From the total number of infants
with acute diarrhea (1050), viral examination was positive with 375 (35.72%)
of cases. Relatively high percentage of
acute diarrhea (20-80%) was caused by
rotavirus. In the developed countries
the diarrhea appears mostly during the
winter season, whereas in the developing countries during the summer season. There are different data regarding
the causes of viral diarrhea. Davidson

(35) believes that 50-70% of cases with


acute diarrhea are caused by viruses.
According to Robins- Brown (2) rotavirus was isolated in 4.41% cases among
children of South Africa with summer
diarrhea. Rotavirus as a cause of acute
diarrhea has been isolated in 11.94%
among children treated at the London
Hospital (16). According to Taylor et
al. (17, 27) rotavirus has been isolated
in 48 % cases of children with acute diarrhea living in rural areas of Bangladesh. According to Votava and Rai (5)
rotavirus has been isolated in 12.13 %
of cases of infants with acute diarrhea.
In 18.1 % of cases the viral examination of feces has proved positive on rotavirus, whereas 13.7% of children with
acute diarrhea have been positive on
norovirus in Tanzania (10). In a study
in Tripoli (4), norovirus was mostly isolated among infant (15.5%) followed by
rotavirus (13.4%). Appearance of rotavirus with adenoviruses on the same feces sample has been confirmed by other
authors as well.

6. CONCLUSION
In Kosovo, infectious acute diarrhea
presents a main cause of morbidity and
mortality of infants and it is therefore a
medical and social issue. However, the
fact that the number of infants with infectious acute diarrhea and mortality
scale is decreasing is promising.
Infectious acute diarrhea that may
appear during the infancy has a great
medical attention in comparison to the
one appearing in other periods of childhood due to a greater predisposition of
infants to intestine infection, manner of
nutrition, weakness of homeostasis and
dehydration causes followed by acid-basic and electrolyte disorder during the
period of intensive growth.
With the aim of decreasing the
number of infants with acute diarrhea
the following should be taken into consideration:
a) Promoting a breast feeding. If,
due to some reasons, the breast feeding is not successful, the milk formulas
should be used instead of the commercial milk and cows milk; b) Imposing
precautionary measures for contamination of additional food; c)Immunization against rotavirus, whereas vac-

cines against E. coli and Shigella shall


reduce the number of infants with severe acute diarrhea; d) Improving the
water quality, food quality and personal
and domestic hygiene (In the majority
of places on Earth Acute Diarrhea was
reduced due to implementation of above
mentioned measures); e) Improving the
treatment of cases with acute diarrhea,
presents the crucial factor in decreasing
the infant mortality rate. This should be
achieved in line with oral or intravenous
rehydration, following a diet and selective use of antimicrobials.

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