修回日期: 2018-03-19
接受日期: 2018-03-28
在线出版日期: 2018-04-18
研究本院住院患儿细菌性腹泻的病原菌分布与耐药性, 对患儿细菌性腹泻临床治疗的经验性抗菌药物方案选择进行指导.
选取2012-05/2017-10期间我院收治的细菌性腹泻患儿1107例进行回顾性分析, 根据所有患儿的临床资料(包括病案、实验室检查结果、粪便病原学检查结果和药敏实验结果), 统计1107例细菌性腹泻患儿的粪便病原菌分布和构成、临床症状、主要病原菌的耐药性及患儿治疗后的效果和预后.
在1107例细菌性腹泻患儿的粪便中共分离鉴定得到病原菌206株, 其中革兰氏阳性菌(如金黄色葡萄球菌)39例, 革兰氏阴性菌(如志贺菌属、致病性大肠埃希菌属、沙门氏菌属)167例. 患儿粪便中病原菌的检出率以<1岁的婴幼儿最高, 检出率随年龄的增加而减少. 而且全年均有病原菌检出, 尤其是夏季的病原菌检出率最高. 而且致病性大肠埃希菌与金黄色葡萄球菌导致的发热、腹痛、排便次数、里急后重及脱水等细菌性腹泻临床症状发生率具有统计学差异(P<0.05). 主要的革兰氏阳性菌对抗菌药物莫西沙星、万古霉素、利奈唑胺的耐药率小于30%, 主要的革兰氏阴性菌对头孢类抗菌药头孢他啶、复方新诺明、美罗培南和亚胺培南的耐药率小于30%. 1107例细菌性腹泻患儿通过经验性抗菌药物和选择敏感抗菌药物进行治疗后, 1 wk后的治愈率达96.48%(1068/1107).
儿童细菌性腹泻的病原菌分布情况复杂, 临床医生需参考患儿的病原菌组成和分布情况以及药敏检测结果选择患儿耐药率小于30%的抗菌药物对细菌性腹泻进行治疗.
核心提要: 细菌性腹泻是常见的儿童疾病, 其病原菌组成复杂. 本研究分析了1107例细菌性腹泻住院患儿的病原菌分布及其耐药性, 以期为儿童细菌性腹泻临床治疗的经验性抗菌药物方案选择提供依据.
引文著录: 魏寒松. 住院患儿细菌性腹泻的病原菌分布与耐药性情况观察. 世界华人消化杂志 2018; 26(11): 680-686
Revised: March 19, 2018
Accepted: March 28, 2018
Published online: April 18, 2018
To study the pathogen distribution and drug resistance in hospitalized children with bacterial diarrhea to guide the selection of appropriate antimicrobial drug regimen for the clinical treatment of bacterial diarrhea in children.
A total of 1107 children with bacterial diarrhea treated at our hospital from May 2012 to October 2017 were retrospectively analyzed. According to the clinical data of all children (including medical records, laboratory examination results, fecal pathogen detection results, and drug susceptibility test results), the distribution and composition of pathogenic bacteria, clinical symptoms, the drug resistance of main pathogenic bacteria, therapeutic effects, and prognosis were analyzed.
In feces from 1107 children with bacterial diarrhea, 206 strains of pathogenic bacteria were isolated, including 39 cases of Gram-positive bacteria (such as Staphylococcus aureus) and 167 cases of Gram-negative bacteria (such as shigella, pathogenic Escherichia coli, and salmonella). The detection rate of pathogenic bacteria in the feces was the highest in children aged < 1 year, and the detection rate decreased with the increase of age. Pathogenic bacteria were detected throughout the year, especially in summer. There was a statistically significant difference (P < 0.05) in clinical symptoms (such as fever, abdominal pain, defecation, and rehydration) between bacterial diarrhea caused by Escherichia coli and Staphylococcus aureus. The rate of resistance of main Gram-positive bacteria to antimicrobial drugs moxifloxacin, vancomycin, and linezolid was less than 30%, and the rate of resistance of Gram-negative bacteria to antibiotics ceftazidime, trimethoprim/sulfamethoxazole, meropenem, and imipenem was less than 30%. The cure rate of bacterial diarrhea was 96.48% (1068/1107) after one week of treatment with antibiotics and selective antibacterial agents.
The pathogen distribution in children with bacterial diarrhea is complex, and clinicians should select antimicrobial drugs with a resistance rate less than 30% based on drug susceptibility test results.
- Citation: Wei HS. Bacterial diarrhea in hospitalized children: Pathogen distribution and drug resistance. Shijie Huaren Xiaohua Zazhi 2018; 26(11): 680-686
- URL: https://www.wjgnet.com/1009-3079/full/v26/i11/680.htm
- DOI: https://dx.doi.org/10.11569/wcjd.v26.i11.680
细菌性腹泻是儿童腹泻中常见的类型, 导致其发生的病原菌组成较复杂, 主要包括致病性大肠埃希菌、志贺属及沙门氏菌等[1,2]. 儿童细菌性腹泻多发于5岁以下幼儿, 临床主要表现为粪便性状的改变及次数增多, 能导致患儿营养不良而生长发育迟缓和免疫功能低下, 因而需要临床工作者的重视并及时给予有效治疗[3,4]. 由于儿童肠道功能较弱, 在治疗细菌性腹泻时选择抗菌药物更需谨慎, β-内酰胺类和第三代头孢菌素类抗生素是治疗的首选药物[5,6]. 但随着广谱抗菌药物的广泛应用, 儿童肠道病原菌的耐药问题也日益加重[7,8]. 为了更好的了解儿童细菌性感染的病原学特征, 本研究选择本院的1107例细菌性腹泻住院患儿, 分析其病原菌分布与耐药性, 以期为儿童细菌性腹泻临床治疗的经验性抗菌药物方案选择提供依据.
选取2012-05/2017-10期间天津市宁河区医院收治的细菌性腹泻患儿1107例进行回顾性分析. 纳入标准: (1)0-5岁的患儿; (2)患儿如有排便次数明显增多, 粪便性质稀薄或含血液黏液等临床症状, 可确诊为细菌性腹泻; (3)患儿所有的临床资料(病案、实验室检查结果、粪便病原学检查结果和药敏实验结果)保存完整. 排除标准: 临床资料不完整的或不符合上述纳入标准的患儿. 纳入本研究的患儿年龄0-5岁, 平均年龄2.02岁±0.35岁; 男564例, 女543例. 所有患儿粪便取样检查后, 同时进行血常规、肝肾功能检查及药敏试验.
1.2.1 治疗方法: 所有纳入本研究的患儿就诊后均给予补液、止泻和营养补充等对症治疗, 同时给予经验性抗菌药物. 实时观察患儿排便次数和粪便性状等临床症状变化, 并监测患儿的血常规等实验室检查指标.
1.2.2 病原菌的分离鉴定及药敏试验: 将患儿治疗前的粪便样本按照《全国临床检验操作规程》的操作规范接种于相应培养基中进行病原菌的培养, 并收集菌落进行进一步的分离纯化. 在显微镜下观察病原菌的形态对病原菌菌种进行初步判断, 并采用梅里埃Vitek 2 Compact 全自动细菌鉴定药敏分析系统对菌种进行鉴定. 将分离纯化得到的主要病原菌, 致病性大肠埃希菌、弧菌、变形杆菌及金黄色葡萄球菌采用仪器法进行药敏试验. 药敏结果判定标准参考《美国临床和实验室标准委员会抗菌药物敏感性试验执行标准 CLSI-M100》制定.
统计学处理 采用SPSS21.0软件对数据进行处理及分析, 各统计数据采用构成比表示, 计数资料组间采用χ2检验比较差异, 以P<0.05为差异有统计学意义.
1107例细菌性腹泻患儿的粪便标本共分离鉴别出206株病原菌, 包括革兰氏阳性菌(如金黄色葡萄球菌)39例, 革兰氏阴性菌(如志贺菌属、致病性大肠埃希菌属、沙门氏菌属)167例(表1).
| 病原菌/属 | 菌株(株) | 构成比(%) |
| 致病性大肠埃希菌属 | 97 | 47.09 |
| 金黄色葡萄球菌 | 39 | 18.93 |
| 气单胞菌和邻单胞菌 | 19 | 9.22 |
| 变形杆菌 | 19 | 9.22 |
| 弧菌属 | 17 | 8.25 |
| 白色念珠菌 | 7 | 3.40 |
| 铜绿假单胞菌 | 3 | 1.46 |
| 沙门氏菌属 | 3 | 1.46 |
| 志贺菌属 | 2 | 0.97 |
| 合计 | 206 | 100 |
患儿粪便中病原菌的检出率以<1岁的婴幼儿最高, 检出率随年龄的增加而减少. 全年各季节均有病原菌检出, 各季节的检出率存在差异, 尤其是夏季的病原菌检出率最高(表2).
| 病原菌 | 发病季节 | 发病年龄 (岁) | |||||
| 春 | 夏 | 秋 | 冬 | <1 | 1-2 | 3-5 | |
| 金黄色葡萄球菌 | 3 (1.46) | 24 (11.65) | 15 (7.28) | 2 (0.97) | 20 (9.71) | 14 (6.80) | 5 (2.43) |
| 弧菌属 | 3 (1.46) | 11 (5.34) | 2 (0.97) | 1 (0.49) | 10 (4.85) | 5 (2.43) | 2 (0.97) |
| 致病性大肠埃希菌属 | 15 (7.28) | 56 (27.18) | 14 (6.80) | 12 (5.83) | 67 (32.52) | 23 (11.17) | 8 (3.88) |
| 变形杆菌 | 2 (0.97) | 12 (5.83) | 3 (1.46) | 2 (0.97) | 11 (5.34) | 5 (2.43) | 3 (1.46) |
| 合计 | 23 (11.17) | 103 (50.00) | 34 (16.50) | 17 (8.25) | 108 (52.43) | 47 (18.93) | 18 (8.74) |
致病性大肠埃希菌与金黄色葡萄球菌导致的发热、腹痛、排便次数、里急后重及脱水等细菌性腹泻临床症状发生率具有统计学差异(P<0.05)(表3).
| 临床症状 | 致病性大肠埃希菌 | 金黄色葡萄球菌 | 弧菌 | 变形杆菌 | P |
| 发热 | 36 (37.11)a | 32 (82.05) | 3 (17.65) | 3 (15.79) | 0.015 |
| 腹痛 | 36 (37.11)a | 26 (66.67) | 6 (35.29) | 3 (15.79) | 0.031 |
| 呕吐 | 50 (51.55) | 14 (35.90) | 10 (58.82) | 3 (15.79) | 0.125 |
| 里急后重 | 14 (14.43)a | 28 (71.79) | 3 (17.65) | 5 (26.32) | 0.453 |
| 脱水 | 14 (14.43)a | 31 (79.49) | 8 (47.06) | 4 (21.05) | 0.037 |
| 排便次数>5次 | 58 (59.79)a | 35 (89.74) | 10 (58.82) | 8 (42.11) | 0.009 |
| 便常规阳性 | 39 (40.21) | 31 (79.49) | 8 (47.06) | 16 (84.21) | 0.522 |
分离得到的主要革兰氏阳性菌金黄色葡萄球菌对抗菌药物替考拉宁、莫西沙星、苯唑西林、万古霉素、利奈唑胺的耐药率小于30%(表4).
| 抗菌药物 | 金黄色葡萄球菌(n = 39) | |
| 耐药株(株) | 耐药率(%) | |
| 青霉素 | 36 | 92.31 |
| 克林霉素 | 21 | 53.85 |
| 红霉素 | 18 | 46.15 |
| 左氧氟沙星 | 15 | 38.46 |
| 阿奇霉素 | 8 | 20.51 |
| 苯唑西林 | 4 | 10.26 |
| 莫西沙星 | 0 | 0.00 |
| 利奈唑胺 | 0 | 0.00 |
| 万古霉素 | 0 | 0.00 |
分离得到的主要革兰氏阴性菌包括弧属、致病性大肠埃希菌属、变形杆菌对抗菌药物头孢他啶、复方新诺明、美罗培南和亚胺培南的耐药率小于30%(表5).
| 抗菌药物 | 弧菌(n = 17) | 致病性大肠埃希菌属(n = 97) | 变形杆菌(n = 19) | |||
| 耐药株(株) | 耐药率(%) | 耐药株(株) | 耐药率(%) | 耐药株(株) | 耐药率(%) | |
| 氨苄西林 | 6 | 35.29 | 37 | 38.14 | 7 | 36.84 |
| 头孢曲松 | 7 | 41.18 | 20 | 20.62 | 4 | 21.05 |
| 头孢他啶 | 3 | 17.65 | 11 | 11.34 | 2 | 10.53 |
| 头孢克肟 | 6 | 35.29 | 41 | 42.27 | 4 | 21.05 |
| 复方新诺明 | 3 | 17.65 | 25 | 25.77 | 4 | 21.05 |
| 亚胺培南 | 0 | 0.00 | 0 | 0.00 | 2 | 10.53 |
| 美罗培南 | 0 | 0.00 | 0 | 0.00 | 0 | 0.00 |
| 四环素 | 8 | 47.06 | 39 | 40.21 | 8 | 42.11 |
| 环丙沙星 | 9 | 52.94 | 44 | 45.36 | 7 | 36.84 |
1107例细菌性腹泻患儿经常规对症治疗和经验性抗菌药物治疗1 wk后, 患儿粪便的性质和排便次数明显好转的有1069例, 治愈率达96.48%.
小儿细菌性腹泻是由多种病原体和多种因素引起的儿科常见疾病[9,10]. 据世界卫生组织统计, 儿童细菌性腹泻的主要病原菌为沙门氏菌、志贺菌及大肠埃希菌, 不同地区细菌性腹泻的病原菌分布也略有不同[11,12]. 应用对患儿所感染的病原菌敏感的抗菌药物是治疗儿童细菌性腹泻的主要方法[13]. 但儿童细菌性腹泻一般发病较急, 粪便样本分离鉴定出感染的病原菌并完成药敏试验需要较长时间, 所以患儿在治疗时通常采用的是经验性抗菌药物治疗. 而且不合理使用抗菌药物会增加病原菌的耐药性, 影响疾病的治疗难度[14,15]. 故了解患儿的病原菌组成和分布以及耐药性情况对指导儿童细菌性腹泻经验性抗菌药物治疗有至关重要的作用.
近年来, 儿童细菌性腹泻病原菌的检出率逐年降低, 病原菌大肠埃希菌及沙门氏菌等所占比例有明显上升的趋势[16,17]. 本研究收集的1107例患儿粪便共分类培养出206株病原菌. 分离得到的病原菌主要有金黄色葡萄球菌、弧菌、变形杆菌和致病性大肠埃希菌等, 且革兰氏阴性菌的比例高于革兰氏阳性菌. 大肠埃希菌是人正常肠道中存在的菌群, 但其是一种条件致病菌, 而变形杆菌一般不致病, 是一种机会致病菌, 在患儿抵抗力下降或发生肠道菌群失调时, 这两种细菌均易导致患儿腹泻[18,19]. 该结果与已有的相关研究报道基本一致[14]. 从分离到病原菌的季节来看, 夏季是检出率最高的季节, 这可能与夏季天气炎热, 蚊虫较多, 易于疾病传播的原因有关. 此外, 1岁以下的婴幼儿病原菌的检出率最高, 但随着年龄的增加, 病原菌的检出率逐渐降低. 可能是由于婴幼儿消化系统尚未完善, 肠道内易发生病原菌的繁殖, 引起消化系统紊乱, 而随着年龄的增大, 儿童的消化系统逐步完善并能形成良好的卫生习惯, 减少了胃肠道感染性疾病的发生[20]. 临床研究报道, 变形杆菌和致病性大肠埃希菌是导致儿童细菌性腹泻的主要病原体, 这些细菌在感染后能潜伏数小时至数天, 若能得到及时治疗可迅速痊愈, 相反则可能转为慢性疾病, 严重影响儿童的生长发育情况[21]. 因此, 可将致病性大肠埃希菌作为儿童细菌性腹泻诊断的常规检查项目之一, 尽量减少误诊和漏诊的发生, 指导科学的抗菌药物治疗方案, 防止抗生素的滥用.
近年来, 随着细菌对抗生素大量出现耐药的情况日益严重, 已经成为临床工作者们不可忽视的问题[22]. 针对抗菌药物的临床使用, 我国已经制定了《抗菌药物临床应用管理办法》, 要求在临床应用抗菌药物时对疾病病原菌的耐药性需小于30%, 并结合发布的该疾病病原菌分布特点可将其作为经验性抗菌药物应用于临床治疗[23,24]. 儿童的体质较为特殊, 临床上在治疗儿童细菌性腹泻时比较谨慎, 一般选用高效低毒的抗菌药物, 如β-内酰胺类和第三代头孢菌素[25]. 本研究的药敏试验发现, 主要的革兰氏阳性菌对临床一线抗菌药物莫西沙星、万古霉素、利奈唑胺的耐药率30%, 主要的革兰氏阴性菌对头孢他啶、复方新诺明、美罗培南和亚胺培南的耐药率小30%. 细菌耐药性产生原因既有细菌本身的因素, 也与生活中抗生素的不合理使用有关[26]. 而且致病菌的耐药率会随着抗生素的大量不合理使用和选择性竞争的状态下, 形成恶性循环, 不断提高[27]. 虽然β-内酰胺类抗生素, 包括青霉素、氨苄西林等, 广泛应用于儿童泌尿系统和肠道感染等疾病, 但近年来随着抗生素不合理使用的增多, 细菌性腹泻的病原菌对其的耐药性逐渐增加[28]. 第三代头孢菌素, 如头孢曲松和头孢他啶, 与β-内酰胺类抗生素相比, 疗效好, 毒性更低, 而且不易产生耐药性, 对肠道病原菌的抗菌效果较好[29]. 本研究中, 对患儿进行对症治疗和经验性抗菌药物治疗后, 细菌性腹泻患儿一周内痊愈率达96.43%, 效果良好. 该结果说明临床目前抗菌药物基本可以作为经验性抗菌药物用于治疗儿童细菌性腹泻, 但对患儿制定经验性抗菌药物治疗方案时, 可综合考虑患儿的临床症状和病原菌耐药情况, 尽量选择耐药性低疗效好的抗菌药物.
总之, 儿童细菌性腹泻的病原菌分布非常复杂, 病原菌对许多常用抗菌药物的耐药性较高, 临床工作者应及时了解本地区或本医院患儿的病原菌构成和耐药情况, 根据药敏实验的结果尽量选择耐药性低疗效好的抗菌药物.
小儿细菌性腹泻是由多种病原体引起的儿科常见疾病. 不同地区儿童细菌性腹泻的病原菌分布也略有不同. 儿童细菌性腹泻一般发病较急, 患儿在治疗时通常采用的是经验性抗菌药物治疗.
本研究主要分析了患儿的病原菌组成和分布以及耐药性情况, 以期为指导儿童细菌性腹泻经验性抗菌药物治疗提供依据.
本研究阐明了天津地区细菌性腹泻患儿的病原菌组成和分布以及耐药性情况, 为给患儿治疗时选择耐药性低疗效好的抗菌药物提供了依据.
通过对2012-05/2017-10期间天津市宁河区医院收治的1107例细菌性腹泻患儿进行回顾性分析, 统计分析了1107例细菌性腹泻患儿的粪便病原菌分布和构成、临床症状、主要病原菌的耐药性及患儿治疗后的效果和预后.
本实验结果表明本地区儿童细菌性腹泻的病原菌分布非常复杂, 病原菌对许多常用抗菌药物的耐药性较高.
儿童细菌性腹泻的病原菌分布复杂, 且病原菌对多数常用抗菌药物的耐药性较高, 临床工作者应依据本地区患儿的病原菌构成和耐药情况, 尽量选择耐药性低疗效好的抗菌药物.
儿童细菌性腹泻的病原菌分布及耐药性情况对指导患儿经验性抗菌药物治疗非常重要, 具有一定的临床意义.
学科分类: 胃肠病学和肝病学
手稿来源地: 天津市
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| 1. | Iijima Y, Oundo JO, Hibino T, Saidi SM, Hinenoya A, Osawa K, Shirakawa T, Osawa R, Yamasaki S. High Prevalence of Diarrheagenic Escherichia coli among Children with Diarrhea in Kenya. Jpn J Infect Dis. 2017;70:80-83. [PubMed] [DOI] |
| 2. | Chang H, Zhang L, Ge Y, Cai J, Wang X, Huang Z, Guo J, Xu H, Gu Z, Chen H. A Hospital-based Case-control Study of Diarrhea in Children in Shanghai. Pediatr Infect Dis J. 2017;36:1057-1063. [PubMed] [DOI] |
| 3. | Leung DT, Chisti MJ, Pavia AT. Prevention and Control of Childhood Pneumonia and Diarrhea. Pediatr Clin North Am. 2016;63:67-79. [PubMed] [DOI] |
| 4. | Breurec S, Vanel N, Bata P, Chartier L, Farra A, Favennec L, Franck T, Giles-Vernick T, Gody JC, Luong Nguyen LB. Etiology and Epidemiology of Diarrhea in Hospitalized Children from Low Income Country: A Matched Case-Control Study in Central African Republic. PLoS Negl Trop Dis. 2016;10:e0004283. [PubMed] [DOI] |
| 5. | 吴 蕾. 240例小儿细菌性腹泻病原学检测与临床用药效果研究. 湖南师范大学学报(医学版). 2017;14:32-34. |
| 6. | Jones T. Overutilization of Antibiotics in Children With Diarrhea: First Do No Harm. Clin Infect Dis. 2018;66:512-513. [PubMed] [DOI] |
| 7. | Qu M, Lv B, Zhang X, Yan H, Huang Y, Qian H, Pang B, Jia L, Kan B, Wang Q. Prevalence and antibiotic resistance of bacterial pathogens isolated from childhood diarrhea in Beijing, China (2010-2014). Gut Pathog. 2016;8:31. [PubMed] [DOI] |
| 8. | Brander RL, Walson JL, John-Stewart GC, Naulikha JM, Ndonye J, Kipkemoi N, Rwigi D, Singa BO, Pavlinac PB. Correlates of multi-drug non-susceptibility in enteric bacteria isolated from Kenyan children with acute diarrhea. PLoS Negl Trop Dis. 2017;11:e0005974. [PubMed] [DOI] |
| 10. | Gallardo P, Izquierdo M, Vidal RM, Chamorro-Veloso N, Rosselló-Móra R, O'Ryan M, Farfán MJ. Distinctive Gut Microbiota Is Associated with Diarrheagenic Escherichia coli Infections in Chilean Children. Front Cell Infect Microbiol. 2017;7:424. [PubMed] [DOI] |
| 11. | Slinger R, Lau K, Slinger M, Moldovan I, Chan F. Higher atypical enteropathogenic Escherichia coli (a-EPEC) bacterial loads in children with diarrhea are associated with PCR detection of the EHEC factor for adherence 1/lymphocyte inhibitory factor A (efa1/lifa) gene. Ann Clin Microbiol Antimicrob. 2017;16:16. [PubMed] [DOI] |
| 12. | Yin X, Gu X, Yin T, Wen H, Gao X, Zheng X. Study of enteropathogenic bacteria in children with acute diarrhoea aged from 7 to 10 years in Xuzhou, China. Microb Pathog. 2016;91:41-45. [PubMed] [DOI] |
| 13. | Dinleyici EC. Pre-, probiotics and synbiotics in infectious diarrhea. J Pediatr Gastroenterol Nutr. 2016;63:S50-S51. [DOI] |
| 15. | Monira S, Shabnam SA, Ali SI, Sadique A, Johura FT, Rahman KZ, Alam NH, Watanabe H, Alam M. Multi-drug resistant pathogenic bacteria in the gut of young children in Bangladesh. Gut Pathog. 2017;9:19. [PubMed] [DOI] |
| 16. | Tian L, Zhu X, Chen Z, Liu W, Li S, Yu W, Zhang W, Xiang X, Sun Z. Characteristics of bacterial pathogens associated with acute diarrhea in children under 5 years of age: a hospital-based cross-sectional study. BMC Infect Dis. 2016;16:253. [PubMed] [DOI] |
| 17. | Andersson ME, Elfving K, Shakely D, Nilsson S, Msellem M, Trollfors B, Mårtensson A, Björkman A, Lindh M. Rapid Clearance and Frequent Reinfection With Enteric Pathogens Among Children With Acute Diarrhea in Zanzibar. Clin Infect Dis. 2017;65:1371-1377. [PubMed] [DOI] |
| 18. | Chung N, Wang SM, Shen CF, Kuo FC, Ho TS, Hsiung CA, Mu JJ, Wu FT, Huang LM, Huang YC. Clinical and epidemiological characteristics in hospitalized young children with acute gastroenteritis in southern Taiwan: According to major pathogens. J Microbiol Immunol Infect. 2017;50:915-922. [PubMed] [DOI] |
| 19. | Dias RC, Dos Santos BC, Dos Santos LF, Vieira MA, Yamatogi RS, Mondelli AL, Sadatsune T, Sforcin JM, Gomes TA, Hernandes RT. Diarrheagenic Escherichia coli pathotypes investigation revealed atypical enteropathogenic E. coli as putative emerging diarrheal agents in children living in Botucatu, São Paulo State, Brazil. APMIS. 2016;124:299-308. [PubMed] [DOI] |
| 20. | Shane AL, Mody RK, Crump JA, Tarr PI, Steiner TS, Kotloff K, Langley JM, Wanke C, Warren CA, Cheng AC. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis. 2017;65:1963-1973. [PubMed] [DOI] |
| 21. | Zhu XH, Tian L, Cheng ZJ, Liu WY, Li S, Yu WT, Zhang WQ, Xiang X, Sun ZY. Viral and Bacterial Etiology of Acute Diarrhea among Children under 5 Years of Age in Wuhan, China. Chin Med J (Engl. ). 2016;129:1939-1944. [PubMed] [DOI] |
| 22. | Chellapandi K, Dutta TK, Sharma I, De Mandal S, Kumar NS, Ralte L. Prevalence of multi drug resistant enteropathogenic and enteroinvasive Escherichia coli isolated from children with and without diarrhea in Northeast Indian population. Ann Clin Microbiol Antimicrob. 2017;16:49. [PubMed] [DOI] |
| 24. | Song XX, Fang DH, Quan YQ, Feng DJ. The pathogenic detection for 126 children with diarrhea and drug sensitivity tests. Eur Rev Med Pharmacol Sci. 2017;21:95-99. [PubMed] |
| 25. | Chiyangi H, Muma JB, Malama S, Manyahi J, Abade A, Kwenda G, Matee MI. Identification and antimicrobial resistance patterns of bacterial enteropathogens from children aged 0-59 months at the University Teaching Hospital, Lusaka, Zambia: a prospective cross sectional study. BMC Infect Dis. 2017;17:117. [PubMed] [DOI] |
| 26. | McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, Dubberke ER, Garey KW, Gould CV, Kelly C. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66:e1-e48. [PubMed] [DOI] |
| 27. | Fang FC, Patel R. 2017 Infectious Diseases Society of America Infectious Diarrhea Guidelines: A View From the Clinical Laboratory. Clin Infect Dis. 2017;65:1974-1976. [PubMed] [DOI] |