1. ‫بسم ا الرحمن الرحيم‬
Diarrhea in Libyan Children:
Causative agents, Clinical
features, Treatment and
Prevention
Ghenghesh KS, Ali MB,
Abeid S, Tawil KA,
Taher IA, Tobgi R,
and Franka EA

2. INTRODUCTION
• Diarrhea remains one of the principle causes of
morbidity and mortality in children worldwide.
• In Libya, studies on the causative agents of
children diarrhea are few.
• However, from the available data, the causative
agents, clinical features, treatment and
prevention of childhood diarrhea in Libya will
be presented in this lecture.

3. Causative Agents of Childhood
Diarrhea in Libya

4. Agent
Rate of occurrence
----------------------------------------------------------------------------------------• Single
35-44%
• Multiple
6-13%
• Not-identified
43-59%
• Bacteria
1. EPEC*
4-11%
2. EAEC**
NK#
3. EHEC***
7%
4. Salmonella sp.
6-11%
5. Shigella sp.
4-6%
6. Yersinia enterocolitica
<1%
7. Campylobacter sp.
2-6%
8. Aeromonas sp.
0-15%
• Parasitic
1. Entamoeba histolyitca/disapr 12%
2. Giardia lamblia
1%
3. Cryptosporidium
13%
• Rotavirus
24-31%
#Not known
*Enteropathogenic Escherichia coli
**Enteroaggregative E. coli.
***Enterohemorrhagic E. coli

5. Age distribution of causative agents of
childhood diarrhea in Zliten
% positive
Agents
<12m
>12m
(n=124)
(n=45)
----------------------------------------------------------------------------------------------• Single
44
44
• Multiple
13
11
• Rotavirus
34*
7
• Salmonella
18*
2
• Shigella
0
13**
• Aeromonas
2
13**
• Cryptosporidium
16.5*
0
• Entamoeba histolytica/dispar
5
31**
• Giardia lamblia
1
2
• Not-identifiable
43
45

6. Seasonal distribution of causative agents of
childhood diarrhea in Zliten
% positive
Agent
Spr
Sum
Aut
Wi
(n=25) (n=62) (n=51) (n=31)
--------------------------------------------------------------------------------------------------------• Single
40
45
45
45
• Multiple
8
6.5
10
32***
• Rotavirus
32
19
25.5
39***
• Salmonella
12
3
20***
26***
• Shigella
4
5
4
0
• Aeromonas
8
11*
0
0
• Cryptosporidium
0
6
2
35.5***
• Entamoeba histolytica/
0
18*
14**
6.5
dispar
• Giardia lamblia
0
2
0
3
• Not-identifiable
52
48
45
23

7. Nosocomial Children Diarrhea
• Salmonella
• Multiple agents
• Rotavirus??

8. • Salmonella is the major bacterial cause
of childhood diarrhea in Libya
• Over the years different Salmonella
serotypes associated with children
diarrhea were reported from different
Libyan cities.

9. Salmonella Serotypes Isolated from Diarrhoeic
Faeces in Tripoli (1975-1980)
– S. Wien
– S. Muenchen
– S. Typhimurium
Salmonella Serotypes Isolated from Children with
Diarrhoea in Tripoli (1992-1993)
– S. Saintpaul
– S. Muenchen
Salmonella Serotypes Isolated from Children with
Diarrhoea in Zliten (2000-2001)
– S. Heidelberg
– S. Enteritids

10. Clinical Features
• Fever and severe dehydration are
common clinical features among
diarrheic children particularly those
affected by rotavirus.
• Around 10% of children with diarrhea
were given oral rehydration salts (ORS)
before stool collection.

11. Table 2. Information about Libyan children with
diarrhea in Tripoli and their Shigella isolates
Patient Sex
Age
(Mo)
Month of Length of Episode Species and
occurrence diarrhea
per day serotype of
(days)
Shigella
------------------------------------------------------------------------------------------------------1.
F
11
Sep
1
5
S. sonnei
2.
F
30
Sep
2
3
S. flexneri type2
3.
M
27
Oct
1
6
S. sonnei
4.
F
18
Oct
1
8
S. flexneri type2
5.
F
36
Oct
2
5-7 S. flexneri type2
6.
M
7
Dec
7
7-8 S. flexneri type1
7.
M
7
Apr
1
10
S. flexneri type2
8.
M
13
Jun
10
6-7 S. flexneri type3
9.
M
32
Jul
1
4
S. sonnei

12. Information about Libyan children with
diarrhea and their Shigella isolates
Faeces with
Patient
Mucus
Presence of
Blood
Fever
Vomiting
Species and
serotype of
Shigella
--------------------------------------------------------------------------------------------------------------------1.
+
+
--S. sonnei
2.
----S. flexneri type2
3.
--+
-S. sonnei
4.
----S. flexneri type2
5.
+
+
+
-S. flexneri type2
6.
--+
-S. flexneri type1
7.
+
+
+
+
S. flexneri type2
8.
+
+
+
+
S. flexneri type3
9.
+
+
+
+
S. sonnei

13. Table 2: Frequency distribution of clinical features in
relation to different enteropathogens. Benghazi
Clinical Features (% of patients)
Agent
Rotavirus
Salmonella spp.
Shigella spp.
Campylobacter spp.
Vomiting
97
89
88
100
Fever
71
85
94
94
Tenesmus Severe
dehydration
21
31
12
0
6
12
6
13
Cough
30
39
18
25

14. Breast Feeding
• A statistically significant association was
observed between the diarrheic children and
artificial feeding and between controls and
breast – feeding.
• In a Benghazi study, about 50% of diarrheic
children were bottle-fed, while only 14% of
breast-fed children were diarrheic.
• Similar findings were reported from studies
carried out in Tripoli and Zliten.

15. Emergence of multi-resistant
enteric pathogens from Libyan
children with Diarrhea

16. • The emergence of antimicrobialresistant enteric bacterial pathogens in
this population has been noted and may
complicate treatment options.
• The ease by which antimicrobial agents
can be obtained over the counter in
Libya may a play role in the emergence
of this problem.

17. Resistance of Salmonella Isolated from
Libyan Children with Diarrhea to Antibiotics
% resistant
Antibiotic
Zliten
Tripoli
Benghazi
(n=23)
(n=21)
(n=26)
---------------------------------------------------------------------------------------------------Ampicillin
100@
52
84
Amoxicillin+ clavulanic acid
87
NT
76
Cefoxitin
87
43
84
Chloramphenicol
96
52
65
Doxycycline
91
14*
68*
Nalidixic acid
4
NT
12
Norfloxacin
0.0
0.0**
NT
Gentamicin
78
43***
44
Trimethoprim+ sulphamethoxazole
4
NT
52
---------------------------------------------------------------------------------------------*Tetracycline, **Ciprofloxacin, ***Tobramycin, NT=not tested.

18. Availability of antibiotics in local
pharmacies of Zliten
Antibiotic
Pharmacies
(n=5)
------------------------------------------------------------------------------------Ampicillin
100
Amoxicillin+ clavulanic acid
100
Cefoxitin
100
Chloramphenicol
100
Doxycycline
100
Nalidixic acid
0.0
Norfloxacin
0.0
Gentamicin
100
Trimethoprim+ sulphamethoxazole
0.0

19. • A strong relationship was observed
between the availability of antibiotics in
the pharmacies of Zliten city and
resistance of the isolated salmonellae
to these drugs.

20. TRANSMISSION
• Fecal to oral contact
–
–
–
–
•
•
•
•
Nurseries
Schools
Play grounds
Others
Contaminated food
Water supply
Poor sanitary conditions
Pets
• Important:
– Children to adults transmission

21. TREATMENT
• Maintaining Fluid and Electrolyte Balance.
• Antibiotics
– Usually contraindicated
>> WHY?
– Used in:
• Severe cases
>> systematic infections
– e.g. Enteric fever
• Bacillary dysentery and cholera if the organisms
are susceptible.
– disease duration diminished

22. CONTROL AND PREVENTION
• Hand Washing
– Parents, care-providers in nurseries, and older children.
• Breast Feeding >> very important
• Proper Sewage Disposal and Water Standards Be
Observed (i.e. chlorination of water).
• Food Cooked Properly
– Bottled milk should be prepared hygienically.
• FLIES >>>>>>>>>>>>>>>>
• Vaccination:
– Two new oral rotavirus vaccines, developed by Merck & Co. and
GlaxoSmithKline Biologicals, prevented at least 98% of severe
cases of gastroenteritis, or intestinal inflammation.
– Must be tailored for strains unique to certain countries or
geographical regions.

23. SUMMARY
• Viral, bacterial and parasitic pathogens play an
important role in the etiology of diarrhea in
children in Libya with rotavirus, salmonellae and
Cryptosporidium as the major agents.
• The misuse of antibiotics by the community and
clinicians may be an important factor in the
emergence of multi-resistance among the
enteric bacterial pathogens isolated from
diarrheic Libyan children to the commonly used
antibiotics.

24. RECOMMENDATIONS
• A vigorous educational program that
promotes the benefits of using ORS and
breast feeding is needed.
•
• Also, the introduction of a rotavirus
vaccine into the vaccination program in
Libya to protect the pediatric population
should be taken into consideration.