Relationship between enteric pathogens and acute gastroenteritis disease severity: a prospective cohort study

J Xie; A Nettel-Aguirre; B E Lee; L Chui; X L Pang; R Zhuo; B Parsons; O G Vanderkooi; P I Tarr; S Ali; J A Dickinson; E Hagen; L W Svenson; S E MacDonald; S J Drews; R Tellier; T Graham; M Lavoie; J MacDonald; S B Freedman; Pediatric Emergency Research Canada (PERC) and the Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE Team)

doi:10.1016/j.cmi.2018.06.016

Relationship between enteric pathogens and acute gastroenteritis disease severity: a prospective cohort study

Clin Microbiol Infect. 2019 Apr;25(4):454-461. doi: 10.1016/j.cmi.2018.06.016. Epub 2018 Jun 28.

Authors

J Xie¹, A Nettel-Aguirre², B E Lee³, L Chui⁴, X L Pang⁴, R Zhuo⁵, B Parsons⁵, O G Vanderkooi⁶, P I Tarr⁷, S Ali³, J A Dickinson⁸, E Hagen¹, L W Svenson⁹, S E MacDonald¹⁰, S J Drews⁴, R Tellier¹¹, T Graham¹², M Lavoie¹³, J MacDonald¹⁴, S B Freedman¹⁵; Pediatric Emergency Research Canada (PERC) and the Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE Team)

Affiliations

¹ Section of Pediatric Emergency Medicine, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada.
² Departments of Pediatrics and of Community Health Sciences, Cumming School of Medicine, Faculty of Kinesiology, Alberta Children's Hospital Research Institute, O'Brien Population Health Institute, University of Calgary, Calgary, Alberta, Canada.
³ Department of Pediatrics, Faculty of Medicine and Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada.
⁴ Provincial Laboratory for Public Health, Alberta, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada.
⁵ Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada.
⁶ Departments of Pediatrics, Microbiology, Immunology and Infectious Diseases, Pathology and Laboratory Medicine and Community Health Sciences and the Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.
⁷ Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA.
⁸ Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
⁹ Analytics and Performance Reporting, Alberta Health Division of Preventive Medicine, School of Public Health, University of Alberta, Edmonton, Alberta, Canada.
¹⁰ Faculty of Nursing, University of Alberta, Edmonton, Canada; School of Public Health, University of Alberta, Edmonton, Canada; Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.
¹¹ Provincial Laboratory for Public Health, Alberta, Canada; Departments of Pathology and Laboratory Medicine and Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada.
¹² Alberta Health Services, Edmonton Zone, Alberta, Canada; Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.
¹³ Population and Public Health, Fraser Health, Surrey, British Columbia, Canada.
¹⁴ Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
¹⁵ Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. Electronic address: Stephen.freedman@ahs.ca.

PMID: 29964235
DOI: 10.1016/j.cmi.2018.06.016

Abstract

Objectives: To evaluate the relationship between individual bacterial and viral pathogens and disease severity.

Methods: Children <18 years with three or more episodes of vomiting and/or diarrhoea were enrolled in two Canadian paediatric emergency departments between December 2014 and August 2016. Specimens were analysed employing molecular panels, and outcome data were collected 14 days after enrolment. The primary outcome was severe disease over the entire illness (symptom onset until 14-day follow-up), quantified employing the Modified Vesikari Scale (MVS) score. The score was additionally analysed in two other time periods: index (symptom onset until enrolment) and follow-up (enrolment until 14-day follow-up).

Results: Median participant age was 20.7 (IQR: 11.3, 44.2) months; 47.4% (518/1093) and 73.4% (802/1093) of participants had index and total MVS scores ≥11, respectively. The most commonly identified pathogens were rotavirus (289/1093; 26.4%) and norovirus (258/1093; 23.6%). In multivariable analysis, severe disease over the entire illness was associated with rotavirus (OR = 9.60; 95%CI: 5.69, 16.19), Salmonella (OR = 6.61; 95%CI: 1.50, 29.17), adenovirus (OR = 2.53; 95%CI: 1.62, 3.97), and norovirus (OR = 1.43; 95%CI: 1.01, 2.01). Pathogens associated with severe disease at the index visit were: rotavirus only (OR = 6.13; 95%CI: 4.29, 8.75), Salmonella (OR = 4.59; 95%CI: 1.71, 12.29), adenovirus only (OR = 2.06; 95%CI: 1.41, 3.00), rotavirus plus adenovirus (OR = 3.15; 95%CI: 1.35, 7.37), and norovirus (OR = 0.68; 95%CI: 0.49, 0.94). During the follow-up period, rotavirus (OR = 2.21; 95%CI: 1.50, 3.25) and adenovirus (OR = 2.10; 95%CI: 1.39, 3.18) were associated with severe disease.

Conclusions: In children presenting for emergency department care with acute gastroenteritis, pathogens identified were predominantly viruses, and several of which were associated with severe disease. Salmonella was the sole bacterium independently associated with severe disease.

Keywords: Adenoviridae; Child; Diarrhoea; Gastroenteritis; Hospital Emergency Service; Norovirus; Rotavirus; Salmonella; Vomiting.

MeSH terms

Adenoviridae / isolation & purification*
Adolescent
Adult
Canada
Child
Gastroenteritis* / diagnosis
Gastroenteritis* / drug therapy
Gastroenteritis* / microbiology
Humans
Infant
Norovirus / isolation & purification*
Prospective Studies
Rotavirus / isolation & purification*
Salmonella / isolation & purification*
Treatment Outcome
Young Adult