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Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE
Yong Chan Lee |
Professor of Medicine Director, Gastrointestinal Research Laboratory Veterans Affairs Medical Center, Univ. California San Francisco San Francisco, USA |
Jong Pil Im | Seoul National University College of Medicine, Seoul, Korea |
Robert S. Bresalier | University of Texas M. D. Anderson Cancer Center, Houston, USA |
Steven H. Itzkowitz | Mount Sinai Medical Center, NY, USA |
All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
The remaining articles are usually sent to two reviewers. It would be very helpful if you could suggest a selection of reviewers and include their contact details. We may not always use the reviewers you recommend, but suggesting reviewers will make our reviewer database much richer; in the end, everyone will benefit. We reserve the right to return manuscripts in which no reviewers are suggested.
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Hae Mi Lee*, Seungok Lee†, Bo-In Lee‡, Dong Wook Jekarl†, Joo-Yong Song*, Hye-Jung Choi*, Bong Koo Kang*, Eun Joo Im*, Joon Sung Kim*, Jong In Kim*, Byung-Wook Kim*, and Hwang Choi*
*Department of Internal Medicine, Incheon St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
†Department of Laboratory Medicine, Incheon St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
‡Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
Correspondence to: Seungok Lee1 and Bo-In Lee2, 1Department of Laboratory Medicine, Incheon St. Mary’s Hospital, The Catholic University of Korea College of Medicine, 56 Dongsu-ro, Bupyeong-gu, Incheon 403-720, Korea, Tel: +82-32-280-5512, Fax: +82-32-280-5520, E-mail: lsok@catholic.ac.kr. 2Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea College of Medicine, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Korea, Tel: +82-2-2258-2902, Fax: +82-2-2258-3589, E-mail: gidoc4u@catholic.ac.kr
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Gut Liver 2015;9(5):636-640. https://doi.org/10.5009/gnl14106
Published online December 5, 2014, Published date September 30, 2015
Copyright © Gut and Liver.
The diagnostic yield of fecal leukocyte and stool cultures is unsatisfactory in patients with acute diarrhea. This study was performed to evaluate the clinical significance of the fecal lactoferrin test and fecal multiplex polymerase chain reaction (PCR) in patients with acute diarrhea.
Clinical parameters and laboratory findings, including fecal leukocytes, fecal lactoferrin, stool cultures and stool multiplex PCR for bacteria and viruses, were evaluated prospectively for patients who were hospitalized due to acute diarrhea.
A total of 54 patients were included (male, 23; median age, 42.5 years). Fecal leukocytes and fecal lactoferrin were positive in 33 (61.1%) and 14 (25.4%) patients, respectively. Among the 31 patients who were available for fecal pathogen evaluation, fecal multiplex PCR detected bacterial pathogens in 21 patients, whereas conventional stool cultures were positive in only one patient (67.7% vs 3.2%, p=0.000). Positive fecal lactoferrin was associated with presence of moderate to severe dehydration and detection of bacterial pathogens by multiplex PCR (21.4% vs 2.5%, p=0.049; 100% vs 56.5%, p=0.032, respectively).
Fecal lactoferrin is a useful marker for more severe dehydration and bacterial etiology in patients with acute diarrhea. Fecal multiplex PCR can detect more causative organisms than conventional stool cultures in patients with acute diarrhea.
Keywords: Acute diarrhea, Fecal lactoferrin, Fecal leukocytes, Multiplex polymerase chain reaction
About half the population of the world is affected with diarrhea every year and diarrhea remains a significant cause of morbidity and mortality worldwide. Infection is the most common cause of acute diarrhea, but microbiological tests are not usually required unless patients present with dehydration, fever, or bloody feces since most acute diarrheal illnesses are self-limited and the diagnostic yield of stool cultures ranges from only 1.5% to 5.6%.1
The presence of fecal leukocytes is believed to suggest an inflammatory etiology and a more serious illness in patients with acute diarrhea and further diagnostic workup such as stool cultures may be indicated.2 However, the results of microscopy are largely dependent on the technician and the freshness of the specimen.3 In contrast, lactoferrin, which is a major constituent in the second granules of neutrophils, can be a useful marker for fecal leukocytes,4 and an increase of fecal lactoferrin is related to greater disease severity in children with infectious diarrhea.5 The test can detect lactoferrin even after the morphologic loss of leukocytes and the subjectivity in the reading is minimal.3
Accurate and rapid detection of causative organisms in patients with acute diarrhea may be helpful for decreasing the duration of morbidity and complications. Recently, simultaneous and rapid detection of pathogens in patients with acute diarrhea is enabled by multiplex molecular biology techniques, which are expected to be more sensitive than conventional cultures and highly specific.6
Thus, this study was performed to evaluate the clinical significance of noninvasive fecal markers including lactoferrin and multiplex PCR in patients with moderate to severe acute diarrhea.
The prospective study protocol was approved by the Institutional Review Board of Incheon St. Mary’s Hospital. From June 2010 to August 2011, patients were included according to the following criteria: age (20 to 80 years), acute diarrheal symptoms (≥5 times/day) within 2 weeks, and hospitalization due to diarrhea-associated symptoms or signs (dehydration, fever >37°C, or bloody diarrhea). Patients with underlying gastrointestinal diseases such as inflammatory bowel syndrome, gastrointestinal cancer, liver cirrhosis, chronic pancreatitis, hospital-acquired diarrhea, administration of antibiotics within 1 month, or other chronic diseases requiring intensive care were excluded. Clinical parameters including bloody diarrhea, dehydration, duration of diarrhea, length of hospital stay, and complications including acute kidney injury (serum creatinine >1.5 mg/dL) were also evaluated. Moderate to severe dehydration was defined when the patient showed orthostatic hypotension (decrease in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg at standing position), overt hypotension (systolic blood pressure less than 80 mm Hg or diastolic blood pressure less than 60 mm Hg), or mental aberration (mental status other than alert).
Conservative care including parenteral hydration was provided for all the patients, and intravenous ciprofloxacin 500 mg was administered twice a day to patients with fever. Use of antibiotics was delayed until stool specimens were obtained. All the stool specimens were collected within 24 hours after admission.
Routine blood tests including complete blood count, erythrocyte sedimentation rate, C-reactive protein (CRP), and fecal tests including microscopic examination of leukocytes, a latex agglutination assay for detection of lactoferrin (LEUKO-TEST; TechLab, Blacksburg, VA, USA), and a quantitative immunochemical occult blood test (OC-Sensor Diana; Eiken Chemical Co., Ltd., Tokyo, Japan) were performed within 24 hours after admission. Fecal leukocytes were examined under a microscope by two laboratory technicians and cross-checked within 2 hours after collection.
Conventional stool cultures using selective agars for
Within 48 hours after admission, sigmoidoscopy was performed without bowel preparation after informed consent. The endoscope was inserted until the patient complained of procedure-related pain (≥numeric rate scale 4).
The results are presented as median (range) or number (percentage). All statistical analyses were performed by SPSS version 19.0 (SPSS Inc., Chicago, IL, USA). Categorical data were tested using the chi-square test or Fisher exact test for small expected frequencies. Mann-Whitney U-test was used for continuous data. Detection rates for fecal bacterial pathogens between conventional stool cultures and multiplex PCR were compared with the McNemar test. A p-value ≤0.05 was considered statistically significant.
A total of 54 patients was included in this study. The median age of patients was 42.5 years (range, 20 to 74 years), and the clinical parameters and findings are summarized in Table 1. The median values for frequency of diarrhea and duration of diarrhea were 10 times/day (range, 5 to 30 times/day) and 6 days (range, 2 to 13 days), respectively. Bloody diarrhea for 10 patients (18.5%), fever for 24 patients (44.4%), and moderate to severe dehydration for four patients (7.4%) were found. Acute kidney injury as a complication was present in four patients (7.4%).
Causative pathogens were detected in only one patient (
The detection rate of fecal bacterial pathogens was significantly higher for multiplex PCR than for conventional stool cultures (67.7% vs 3.2%, p=0.000).
Among 44 patients who received sigmoidoscopy, mucosal erosion or ulcers were found in 16 patients (36.4%).
Among 54 patients, 33 (61.1%) were positive for fecal leukocytes, 14 (25.9%) for fecal lactoferrin, and 34 (63.0%) for fecal occult blood (Table 2). The median value of CRP was 51.1 mg/L (range, 1.9 to 310.6 mg/L).
Clinical parameters including frequency of diarrhea, fever, moderate to severe dehydration, duration of diarrhea, acute kidney injury, and bacterial and/or viral pathogen detection by multiplex PCR were not different statistically between fecal leukocyte-positive and negative groups (Table 3). However, moderate to severe dehydration was more prevalent in the fecal lactoferrin-positive group than in the negative group (21.4% vs 2.5%, p=0.049). Bacterial detection by multiplex PCR was also more frequent in the fecal lactoferrin-positive group than in the negative group (100% vs 56.5%, p=0.032). Thirteen bacterial pathogens were detected in eight lactoferrin-positive patients as follows:
Although there was no statistically significant difference in detection rates of bacterial pathogens by multiplex PCR between fecal occult blood positive and negative groups,
All the clinical parameters including frequency of diarrhea, bloody diarrhea, fever, moderate to severe dehydration, duration of diarrhea, acute kidney injury, bacterial and viral pathogen detection by multiplex PCR, and mucosal erosion or ulcers were not correlated significantly with CRP levels.
This study showed that fecal lactoferrin can be a more useful clinical marker than fecal leukocyte testing in patients with acute diarrhea. Positive fecal lactoferrin was significantly associated with presence of moderate to severe dehydration and fecal bacterial pathogen detection by multiplex PCR. These findings are comparable with the results of a previous report by Chen
So far, fecal lactoferrin has been considered a useful noninvasive test for differentiating inflammatory bowel diseases (IBD) from irritable bowel syndrome or differentiating active IBD from inactive IBD.7–9 However, the results of our study suggested that fecal lactoferrin can also be used as a marker for presence of more severe dehydration and bacterial etiology in patients with acute diarrhea.
Secondly, fecal multiplex PCR detected significantly more bacterial pathogens than conventional stool cultures and also detected viral pathogens simultaneously. This result is compatible with previous studies using fecal multiplex PCR.10–12 According to the study using stool samples collected from 245 pediatric patients with suspected infectious gastroenteritis, multiplex PCR was found to have a higher level of sensitivity than our routine detection methods for common enteric pathogens, with the exception of
Although most cases of acute infectious diarrhea are self-limited, the efficacy of antimicrobial therapy has been addressed in selected patients with bacterial diarrhea.14,15 However, antibiotics should be avoided in patients with VTEC infection since there is concern about an increase in the risk of hemolytic-uremic syndrome.16 Thus, earlier and more accurate detection of pathogens may be very helpful for appropriate management in patients with acute diarrhea.
Bloody diarrhea is known to be helpful for discrimination of infectious colitis including
There may be some limitations to the present study. First, a relatively small number of patients were enrolled in the study. Secondly, the possibility of “innocent bystanders” among pathogens detected by multiplex PCR exists since a certain amount of infectious dose is required for the onset of an illness.
In conclusion, fecal lactoferrin is a useful marker for more severe dehydration and bacterial etiology in patients hospitalized for acute diarrhea. Fecal multiplex PCR can detect more causative organisms than conventional stool cultures and therefore may be helpful for management of patients with acute diarrhea.
VTEC, verocytotoxin-producing
Summary of Clinical Parameters and Findings for a Total of 54 Patients
Clinical finding | Value |
---|---|
Age, yr | 42.5 (20–74) |
Male sex | 23 (42.6) |
Diarrhea, times/day* | 10 (5–30) |
Bloody diarrhea* | 10 (18.5) |
Fever* | 24 (44.4) |
Moderate to severe dehydration* | 4 (7.4) |
Duration of diarrhea, day* | 6 (2–13) |
Acute kidney injury* | 4 (7.4) |
Bacteria detected by multiplex PCR (n=31)* | 21 (67.7) |
Virus detected by multiplex PCR (n=31)* | 4 (12.9) |
Mucosal erosion or ulcer (n=44)* | 16 (36.4) |
Values are presented as median (range) or number (%).
PCR, polymerase chain reaction.
Summary of Laboratory Findings and Inflammatory Markers for the 54 Patients
Laboratory finding | Value |
---|---|
Fecal leukocytes-positive* | 33 (61.1) |
Fecal lactoferrin-positive* | 14 (25.9) |
Fecal occult blood-positive* | 34 (63.0) |
ESR, mm/hr | 14 (1–83) |
CRP, mg/L* | 51.1 (1.9–310.6) |
Leukocytes, /μL | 9,960 (2,040–33,000) |
Neutrophil ratio, % | 77.8 (35.0–92.0) |
Lymphocyte ratio, % | 11.6 (2.0–48.0) |
Platelets, /μL | 207,000 (101,000–313,000) |
Values are presented as number (%) or median (range).
ESR, erythrocyte sedimentation rate; CRP, C-reactive protein.
Differences (p-Values) in Clinical Parameters in the Fecal Leukocyte, Lactoferrin, and Occult Blood-Positive versus Negative Groups
Fecal leukocytes | Fecal lactoferrin | Fecal occult blood | |
---|---|---|---|
Diarrhea, times/day | 0.239 | 0.959 | 0.207 |
Fever | 0.263 | 0.540 | 1.000 |
Moderate to severe dehydration | 0.638 | 0.049 | 1.000 |
Duration of diarrhea, day | 0.687 | 0.604 | 0.172 |
Acute kidney injury | 1.000 | 1.000 | 0.622 |
Bacterial pathogen detection by multiplex PCR (n=31) | 0.697 | 0.032 | 0.423 |
Viral pathogen detection by multiplex PCR (n=31) | 1.000 | 0.550 | 1.000 |
Mucosal erosion or ulcer (n=44) | 0.352 | 0.724 | 0.510 |
Gut Liver 2015; 9(5): 636-640
Published online September 30, 2015 https://doi.org/10.5009/gnl14106
Copyright © Gut and Liver.
Hae Mi Lee*, Seungok Lee†, Bo-In Lee‡, Dong Wook Jekarl†, Joo-Yong Song*, Hye-Jung Choi*, Bong Koo Kang*, Eun Joo Im*, Joon Sung Kim*, Jong In Kim*, Byung-Wook Kim*, and Hwang Choi*
*Department of Internal Medicine, Incheon St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
†Department of Laboratory Medicine, Incheon St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
‡Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
Correspondence to: Seungok Lee1 and Bo-In Lee2, 1Department of Laboratory Medicine, Incheon St. Mary’s Hospital, The Catholic University of Korea College of Medicine, 56 Dongsu-ro, Bupyeong-gu, Incheon 403-720, Korea, Tel: +82-32-280-5512, Fax: +82-32-280-5520, E-mail: lsok@catholic.ac.kr. 2Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea College of Medicine, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Korea, Tel: +82-2-2258-2902, Fax: +82-2-2258-3589, E-mail: gidoc4u@catholic.ac.kr
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
The diagnostic yield of fecal leukocyte and stool cultures is unsatisfactory in patients with acute diarrhea. This study was performed to evaluate the clinical significance of the fecal lactoferrin test and fecal multiplex polymerase chain reaction (PCR) in patients with acute diarrhea.
Clinical parameters and laboratory findings, including fecal leukocytes, fecal lactoferrin, stool cultures and stool multiplex PCR for bacteria and viruses, were evaluated prospectively for patients who were hospitalized due to acute diarrhea.
A total of 54 patients were included (male, 23; median age, 42.5 years). Fecal leukocytes and fecal lactoferrin were positive in 33 (61.1%) and 14 (25.4%) patients, respectively. Among the 31 patients who were available for fecal pathogen evaluation, fecal multiplex PCR detected bacterial pathogens in 21 patients, whereas conventional stool cultures were positive in only one patient (67.7% vs 3.2%, p=0.000). Positive fecal lactoferrin was associated with presence of moderate to severe dehydration and detection of bacterial pathogens by multiplex PCR (21.4% vs 2.5%, p=0.049; 100% vs 56.5%, p=0.032, respectively).
Fecal lactoferrin is a useful marker for more severe dehydration and bacterial etiology in patients with acute diarrhea. Fecal multiplex PCR can detect more causative organisms than conventional stool cultures in patients with acute diarrhea.
Keywords: Acute diarrhea, Fecal lactoferrin, Fecal leukocytes, Multiplex polymerase chain reaction
About half the population of the world is affected with diarrhea every year and diarrhea remains a significant cause of morbidity and mortality worldwide. Infection is the most common cause of acute diarrhea, but microbiological tests are not usually required unless patients present with dehydration, fever, or bloody feces since most acute diarrheal illnesses are self-limited and the diagnostic yield of stool cultures ranges from only 1.5% to 5.6%.1
The presence of fecal leukocytes is believed to suggest an inflammatory etiology and a more serious illness in patients with acute diarrhea and further diagnostic workup such as stool cultures may be indicated.2 However, the results of microscopy are largely dependent on the technician and the freshness of the specimen.3 In contrast, lactoferrin, which is a major constituent in the second granules of neutrophils, can be a useful marker for fecal leukocytes,4 and an increase of fecal lactoferrin is related to greater disease severity in children with infectious diarrhea.5 The test can detect lactoferrin even after the morphologic loss of leukocytes and the subjectivity in the reading is minimal.3
Accurate and rapid detection of causative organisms in patients with acute diarrhea may be helpful for decreasing the duration of morbidity and complications. Recently, simultaneous and rapid detection of pathogens in patients with acute diarrhea is enabled by multiplex molecular biology techniques, which are expected to be more sensitive than conventional cultures and highly specific.6
Thus, this study was performed to evaluate the clinical significance of noninvasive fecal markers including lactoferrin and multiplex PCR in patients with moderate to severe acute diarrhea.
The prospective study protocol was approved by the Institutional Review Board of Incheon St. Mary’s Hospital. From June 2010 to August 2011, patients were included according to the following criteria: age (20 to 80 years), acute diarrheal symptoms (≥5 times/day) within 2 weeks, and hospitalization due to diarrhea-associated symptoms or signs (dehydration, fever >37°C, or bloody diarrhea). Patients with underlying gastrointestinal diseases such as inflammatory bowel syndrome, gastrointestinal cancer, liver cirrhosis, chronic pancreatitis, hospital-acquired diarrhea, administration of antibiotics within 1 month, or other chronic diseases requiring intensive care were excluded. Clinical parameters including bloody diarrhea, dehydration, duration of diarrhea, length of hospital stay, and complications including acute kidney injury (serum creatinine >1.5 mg/dL) were also evaluated. Moderate to severe dehydration was defined when the patient showed orthostatic hypotension (decrease in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg at standing position), overt hypotension (systolic blood pressure less than 80 mm Hg or diastolic blood pressure less than 60 mm Hg), or mental aberration (mental status other than alert).
Conservative care including parenteral hydration was provided for all the patients, and intravenous ciprofloxacin 500 mg was administered twice a day to patients with fever. Use of antibiotics was delayed until stool specimens were obtained. All the stool specimens were collected within 24 hours after admission.
Routine blood tests including complete blood count, erythrocyte sedimentation rate, C-reactive protein (CRP), and fecal tests including microscopic examination of leukocytes, a latex agglutination assay for detection of lactoferrin (LEUKO-TEST; TechLab, Blacksburg, VA, USA), and a quantitative immunochemical occult blood test (OC-Sensor Diana; Eiken Chemical Co., Ltd., Tokyo, Japan) were performed within 24 hours after admission. Fecal leukocytes were examined under a microscope by two laboratory technicians and cross-checked within 2 hours after collection.
Conventional stool cultures using selective agars for
Within 48 hours after admission, sigmoidoscopy was performed without bowel preparation after informed consent. The endoscope was inserted until the patient complained of procedure-related pain (≥numeric rate scale 4).
The results are presented as median (range) or number (percentage). All statistical analyses were performed by SPSS version 19.0 (SPSS Inc., Chicago, IL, USA). Categorical data were tested using the chi-square test or Fisher exact test for small expected frequencies. Mann-Whitney U-test was used for continuous data. Detection rates for fecal bacterial pathogens between conventional stool cultures and multiplex PCR were compared with the McNemar test. A p-value ≤0.05 was considered statistically significant.
A total of 54 patients was included in this study. The median age of patients was 42.5 years (range, 20 to 74 years), and the clinical parameters and findings are summarized in Table 1. The median values for frequency of diarrhea and duration of diarrhea were 10 times/day (range, 5 to 30 times/day) and 6 days (range, 2 to 13 days), respectively. Bloody diarrhea for 10 patients (18.5%), fever for 24 patients (44.4%), and moderate to severe dehydration for four patients (7.4%) were found. Acute kidney injury as a complication was present in four patients (7.4%).
Causative pathogens were detected in only one patient (
The detection rate of fecal bacterial pathogens was significantly higher for multiplex PCR than for conventional stool cultures (67.7% vs 3.2%, p=0.000).
Among 44 patients who received sigmoidoscopy, mucosal erosion or ulcers were found in 16 patients (36.4%).
Among 54 patients, 33 (61.1%) were positive for fecal leukocytes, 14 (25.9%) for fecal lactoferrin, and 34 (63.0%) for fecal occult blood (Table 2). The median value of CRP was 51.1 mg/L (range, 1.9 to 310.6 mg/L).
Clinical parameters including frequency of diarrhea, fever, moderate to severe dehydration, duration of diarrhea, acute kidney injury, and bacterial and/or viral pathogen detection by multiplex PCR were not different statistically between fecal leukocyte-positive and negative groups (Table 3). However, moderate to severe dehydration was more prevalent in the fecal lactoferrin-positive group than in the negative group (21.4% vs 2.5%, p=0.049). Bacterial detection by multiplex PCR was also more frequent in the fecal lactoferrin-positive group than in the negative group (100% vs 56.5%, p=0.032). Thirteen bacterial pathogens were detected in eight lactoferrin-positive patients as follows:
Although there was no statistically significant difference in detection rates of bacterial pathogens by multiplex PCR between fecal occult blood positive and negative groups,
All the clinical parameters including frequency of diarrhea, bloody diarrhea, fever, moderate to severe dehydration, duration of diarrhea, acute kidney injury, bacterial and viral pathogen detection by multiplex PCR, and mucosal erosion or ulcers were not correlated significantly with CRP levels.
This study showed that fecal lactoferrin can be a more useful clinical marker than fecal leukocyte testing in patients with acute diarrhea. Positive fecal lactoferrin was significantly associated with presence of moderate to severe dehydration and fecal bacterial pathogen detection by multiplex PCR. These findings are comparable with the results of a previous report by Chen
So far, fecal lactoferrin has been considered a useful noninvasive test for differentiating inflammatory bowel diseases (IBD) from irritable bowel syndrome or differentiating active IBD from inactive IBD.7–9 However, the results of our study suggested that fecal lactoferrin can also be used as a marker for presence of more severe dehydration and bacterial etiology in patients with acute diarrhea.
Secondly, fecal multiplex PCR detected significantly more bacterial pathogens than conventional stool cultures and also detected viral pathogens simultaneously. This result is compatible with previous studies using fecal multiplex PCR.10–12 According to the study using stool samples collected from 245 pediatric patients with suspected infectious gastroenteritis, multiplex PCR was found to have a higher level of sensitivity than our routine detection methods for common enteric pathogens, with the exception of
Although most cases of acute infectious diarrhea are self-limited, the efficacy of antimicrobial therapy has been addressed in selected patients with bacterial diarrhea.14,15 However, antibiotics should be avoided in patients with VTEC infection since there is concern about an increase in the risk of hemolytic-uremic syndrome.16 Thus, earlier and more accurate detection of pathogens may be very helpful for appropriate management in patients with acute diarrhea.
Bloody diarrhea is known to be helpful for discrimination of infectious colitis including
There may be some limitations to the present study. First, a relatively small number of patients were enrolled in the study. Secondly, the possibility of “innocent bystanders” among pathogens detected by multiplex PCR exists since a certain amount of infectious dose is required for the onset of an illness.
In conclusion, fecal lactoferrin is a useful marker for more severe dehydration and bacterial etiology in patients hospitalized for acute diarrhea. Fecal multiplex PCR can detect more causative organisms than conventional stool cultures and therefore may be helpful for management of patients with acute diarrhea.
VTEC, verocytotoxin-producing
Table 1 Summary of Clinical Parameters and Findings for a Total of 54 Patients
Clinical finding | Value |
---|---|
Age, yr | 42.5 (20–74) |
Male sex | 23 (42.6) |
Diarrhea, times/day* | 10 (5–30) |
Bloody diarrhea* | 10 (18.5) |
Fever* | 24 (44.4) |
Moderate to severe dehydration* | 4 (7.4) |
Duration of diarrhea, day* | 6 (2–13) |
Acute kidney injury* | 4 (7.4) |
Bacteria detected by multiplex PCR (n=31)* | 21 (67.7) |
Virus detected by multiplex PCR (n=31)* | 4 (12.9) |
Mucosal erosion or ulcer (n=44)* | 16 (36.4) |
Values are presented as median (range) or number (%).
PCR, polymerase chain reaction.
Table 2 Summary of Laboratory Findings and Inflammatory Markers for the 54 Patients
Laboratory finding | Value |
---|---|
Fecal leukocytes-positive* | 33 (61.1) |
Fecal lactoferrin-positive* | 14 (25.9) |
Fecal occult blood-positive* | 34 (63.0) |
ESR, mm/hr | 14 (1–83) |
CRP, mg/L* | 51.1 (1.9–310.6) |
Leukocytes, /μL | 9,960 (2,040–33,000) |
Neutrophil ratio, % | 77.8 (35.0–92.0) |
Lymphocyte ratio, % | 11.6 (2.0–48.0) |
Platelets, /μL | 207,000 (101,000–313,000) |
Values are presented as number (%) or median (range).
ESR, erythrocyte sedimentation rate; CRP, C-reactive protein.
Table 3 Differences (p-Values) in Clinical Parameters in the Fecal Leukocyte, Lactoferrin, and Occult Blood-Positive versus Negative Groups
Fecal leukocytes | Fecal lactoferrin | Fecal occult blood | |
---|---|---|---|
Diarrhea, times/day | 0.239 | 0.959 | 0.207 |
Fever | 0.263 | 0.540 | 1.000 |
Moderate to severe dehydration | 0.638 | 0.049 | 1.000 |
Duration of diarrhea, day | 0.687 | 0.604 | 0.172 |
Acute kidney injury | 1.000 | 1.000 | 0.622 |
Bacterial pathogen detection by multiplex PCR (n=31) | 0.697 | 0.032 | 0.423 |
Viral pathogen detection by multiplex PCR (n=31) | 1.000 | 0.550 | 1.000 |
Mucosal erosion or ulcer (n=44) | 0.352 | 0.724 | 0.510 |
PCR, polymerase chain reaction.