The indelible toll of enteric pathogens: Prevalence, clinical characterization, and seasonal trends in patients with acute community-acquired diarrhea in disenfranchised communities

Abstract

Background There is little information on the epidemiology of enteric pathogens in Lebanon, a low- and middle-income country that suffers from a myriad of public health challenges. To address this knowledge gap, we aimed to assess the prevalence of enteric pathogens, identify risk factors and seasonal variations, and describe associations between pathogens among diarrheic patients in the Lebanese community. Methodology and principal findings A multicenter cross-sectional community-based study was conducted in the north of Lebanon. Stool samples were collected from 360 outpatients suffering from acute diarrhea. Based on fecal examination using the BioFire® FilmArray® Gastrointestinal Panel assay, the overall prevalence of enteric infections was 86.1%. Enteroaggregative Escherichia coli (EAEC) was the most frequently identified (41.7%), followed by enteropathogenic E. coli (EPEC) (40.8%) and rotavirus A (27.5%). Notably, two cases of Vibrio cholerae were identified, while Cryptosporidium spp. (6.9%) was the most common parasitic agent. Overall, 27.7% (86/310) of the cases were single infections, and the majority, 73.3% (224/310), were mixed infections. Multivariable logistic regression models showed that enterotoxigenic E. coli (ETEC) and rotavirus A infections were significantly more likely to occur in the fall and winter compared to the summer. Rotavirus A infections significantly decreased with age but increased in patients living in rural areas or suffering from vomiting. We identified strong associations in the co-occurrence of EAEC, EPEC, and ETEC infections and a higher percentage of rotavirus A and norovirus GI/GII infections among EAEC-positive cases. Conclusions Several of the enteric pathogens reported in this study are not routinely tested in Lebanese clinical laboratories. However, anecdotal evidence suggests that diarrheal diseases are on the rise due to widespread pollution and the deterioration of the economy. Therefore, this study is of paramount importance to identify circulating etiologic agents and prioritize dwindling resources to control them and limit outbreaks in the future.

Enhancing enteric pathogen detection: implementation and impact of multiplex PCR for improved diagnosis and surveillance

“…The primary aim of this study was to assess the utility of implementing the multiplex PCR assay for the identification of enteric pathogens in Lebanon especially those traditionally challenging to identify using conventional diagnostic methods. Our results are consistent with the work of Osman et al, who utilized the BioFire FilmArray [ 26 ]. This alignment strengthens the validity of our findings, highlighting the effectiveness of multiplex PCR for comprehensive pathogen detection.…”

“…In our current study, implementation of multiplex PCR as a stool diagnostic test revealed a high positivity rate of 71% (192/271) for enteropathogens, 46% (88/192) as single infections and 54% (104/192) as mixed infections. Our study is consistent with previous study conducted in Lebanon which strengthens the validity of our findings, demonstrating the effectiveness of multiplex PCR for comprehensive pathogen detection [ 26 ]. A total of 29% of our samples (79/271) were negative; this could have been attributed to a non-infectious origin or immediate start of empiric treatment prior to sample collection and other idiopathic causes.…”

“…Our results are comparable with the finding of another study published in Lebanon that has found that the prevalence of diarrheagenic E. coli in the population was as high as 70% [ 26 ]; it is worth mentioning that their sample population was collected mainly from the north of the country and distributed between rural and urban populations while the vast majority of our sample size came from in and around the capital and was more of urban in nature. The relatively high prevalence of diarrheagenic E. coli , observed in our study and in a recent publication of Osman et al [ 26 ] express the importance of including EPEC, ETEC and EAEC in diagnosing the etiology of diarrheal disease. These bacteria can be acquired through maternal transmission, prior exposure, or geographic factors [ 30 – 32 ].…”

Epidemiology of pathogens causing acute diarrhea in patients presenting to the emergency departments in 4 hospitals in Lebanon

“…As for viruses, rotavirus (27.5%) and norovirus (7.5%) were the primary viral causes of diarrhea. [12] The findings in the present study, as well as the trends seen in recent years and in the literature, all point to an increase in infectious diarrheal cases caused by pathogens that thrive in poor living conditions. This is the main reason why diarrheal illness is more prevalent in developing countries, where poor knowledge about sanitation and hygiene, contamination of water with fecal material, the use of left-over food, and a low nutritional and public health status all contribute to propagation of diarrheal disease.…”

Genomic analysis of Shigella isolates from Lebanon reveals marked genetic diversity and antimicrobial resistance

“…This lack of clarity is compounded by the limited epidemiological data for Shigella in Lebanon due to the lack of robust and sustainable epidemiological surveillance programmes and the challenges faced by most clinical laboratories in the identification of Shigella and its differentiation from enteroinvasive Escherichia coli (EIEC) [12, 13]. A study recently conducted in two Lebanese tertiary healthcare settings showed that EIEC and Shigella accounted for 18.9 % of the enteric pathogens isolated from patients with acute community-acquired diarrhoea [12]. Lebanon is currently grappling with calamitous challenges to its infrastructure and political stability, together with pollution, associated with a severe economic collapse that resulted in an acute devaluation of its currency by more than 95 % and shortages of imported goods, limiting the availability and increasing the prices of essential goods, with an impact on public health, including critically important antimicrobial drugs (CIAs) [14].…”