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Objective: To provide information about the characteristics of diarrheal stool in multi-drug resistant typhoid fever and observe the clinical course after treatment with furazolidone or ciprofloxacin., Setting: Hospital based., Subjects and Methods: Twenty one male children who were positive for multi-drug resistant S. typhi by blood and stool cultures, having diarrhea at the time of hospitalization comprised the subjects. Serum and stool electrolytes were estimated. Stool samples were also processed to detect established enteropathogens, leukocytes and red blood cells. Children were treated either with furazolidone or ciprofloxacin and evaluated till recovery., Results: Mean (+/- SD) pre-admission duration of fever and diarrhea of these cases were 19.1 (+/- 5.6) and 15.8 (+/- 4.6) days, respectively. Stool character in 81% of the patients was watery with mean (+/- SD) volume of stool 51.4 (+/- 25.1) ml per kg body weight in the first 24 hours of observation. Leukocyte count varied between 20-49 per high power field in 66.7% stool samples. Occult blood was present in only 19% cases. Fecal red blood cells in high power field were detected in 52.4% cases. Mean fecal electrolytes (mmol/liter) were as follows: sodium-53.8, potassium-51.4, chloride-41.6 and total CO2-24.3. Most of the children (71.4%) had no dehydration and had normal serum electrolytes. The isolated strains of S. typhi were multi-drug resistant. These children were treated successfully either with furazolidone or ciprofloxacin., Conclusion: The stools of multi-drug resistant typhoid fever patients were watery with little blood. Their electrolyte contents were more similar to the diarrheal stool seen in shigellosis rather than cholera. Uncontrolled observations revealed that children recovered with furazolidone or ciprofloxacin therapy.

Records of all the diarrheal patients up to the age of 5 years who were admitted to and died in Dr. B.C. Roy Memorial Hospital for Children, Calcutta, between January and December 1990 were analyzed. The records were reviewed to assess the relative importance of three clinical types of diarrhea (acute watery diarrhea, acute dysentery and persistent diarrhea) as the causes of mortality. Annual hospital death rates of children suffering from acute watery diarrhea, dysentery and persistent diarrhea were 13.6%, 18.2% and 25.9%, respectively. Overall death rates in dysentery (p = 0.03) and persistent diarrhea groups (p < .00001) were significantly higher than watery diarrhea group. Maximum deaths occurred among children aged between 7 and 36 months in all categories of diarrhea. Shigella infected children had higher case fatality rate. In acute watery diarrhea, 30.9% cases were assigned to associated causes of death whereas the same could be assigned to 92.6% and 93.2% cases in dysentery and persistent diarrhea group, respectively. Deaths occurred in most of the cases who had bronchopneumonia as underlying cause, septicemia as immediate cause and protein calorie malnutrition as associated cause and these were most frequently associated in patients suffering from dysentery and persistent diarrhea. Only 2.0% children suffering from acute watery diarrhea had dehydration at the time of death. Significantly, a high percentage of deaths occurred among malnourished children who suffered from dysentery (54.4%) and persistent diarrhea. These data suggest that Diarrheal Disease Control Programme should also give emphasis on management of non watery, non-dehydrating type of diarrhea with complications.

Efficacy of furazolidone and nalidixic acid was compared in a randomized trial involving 72 children with acute invasive diarrhea. Thirty six children received furazolidone (7.5 mg/kg/day) and 36 children received nalidixic acid (55 mg/kg/day). Clinical characteristics of the two treatment groups were comparable on admission. Of these, 34 children in furazolidone treated group and 29 children in nalidixic acid treated group completed the full course of treatment and were analyzed finally for clinical efficacy. Clinical cure was observed in 29(85.3%) children treated with furazolidone and 29(100.0%) children treated with nalidixic acid. Nalidixic acid treated group had statistically significantly higher cure rate (p = 0.039) as compared to furazolidone treated group. However, 85% cure rate in furazolidone treated group may be potentially useful for the treatment of acute invasive diarrhea because of decreasing efficacy of nalidixic acid against shigellosis in many countries.

A case control study was carried out at the medical wards of Dr. B.C. Roy Memorial Hospital for Children, Calcutta, between January and September 1989. One hundred eleven hospitalized children up to the age of 5 years, receiving antibiotics for different medical problems, developed antibiotic associated diarrhea. Isolation of Clostridium difficile as sole pathogen was very low (3.6%) from these patients. Fecal samples of 111 case matched control children were also screened for C.difficile. Only 2.7% fecal samples of control children were positive for C.difficile. All the strains of C.difficile isolated from antibiotic associated diarrhea cases showed neutralisable cytotoxin in in vitro test. In contrast none of the strains isolated from control children showed cytotoxicity. This study suggests that C.difficile is not an important pathogen related to antibiotic associated diarrhea in children at this hospital.

Hospital acquired enteric infections were investigated by studying 3138 children under 5 years of age who were admitted without diarrhea in nine medical words of a pediatric hospital, Calcutta during the period between March and September 1987. Three hundred and twenty (10.2%) children developed nosocomial diarrhea during their hospital stay. Fecal samples from 178 nosocomial diarrhea, 345 hospitalized diarrhea cases, 178 hospital controls and 200 outpatient controls were collected for detection of established enteropathogens. There were no statistically significant differences in the detection of most of the enteropathogens from fecal samples of nosocomial diarrhea, hospitalized diarrhea and hospital controls. Enteric pathogens were detected at a higher frequency (statistically significant) from fecal samples of nosocomial diarrhea cases as compared to outpatient controls. This study highlights the importance of most of the enteropathogens like Shigella, Salmonella, rotavirus, enteropathogenic E. coli as the cause of hospital cross infection. This study reinforces the importance of developing preventive measures in order to reduce the frequency of illness.

From 1985 to 1988, fecal samples of 950 hospitalized children suffering from diarrhea or dysentery were screened for Shigella species using standard methods. Shigella species were isolated as sole pathogen from 192 (20.2%) cases and S. flexneri type 2 was the predominant serotype. Shigella infection was prevalent throughout the year with high isolation rate during the summer and early monsoon months. Shigella strains isolated during the period were resistant to most of the commonly used drugs for the treatment of shigellosis. Nearly 16% of the Shigella strains were also resistant to nalidixic acid. Presence of blood and mucus in stools (dysentery) was the common clinical presentation of shigellosis cases. Malnutrition was associated with longer duration of illness. High cases fatality rate (16.7%) was observed among hospitalized children infected with Shigella.

A total of 498 children, aged 0-14 years, admitted at the B.C. Roy Memorial Hospital for Children, Calcutta, were investigated for the occurrence of Clostridium difficile and its cytotoxin. Of the children in the investigation, 369 suffered from acute diarrhea. Only 8.4% of these children had C. difficile in fecal samples and in vitro cytotoxin was demonstrated in 7%. In 27 (7.3%) of the patients with acute diarrhea C. difficile was isolated as the only pathogen. In contrast, among 129 control children not suffering from acute diarrhea, only 4 (3.1%) harboured C. difficile. Isolation of C. difficile was significantly higher in children under one year of age. None of these patients had any history of prior antibiotic therapy.