604 CAMPYLOBACTER ENTERITIS IN CENTRAL AFRICA
SIR,-Our laboratory experience1,2 prompted us to investigate the role of Campylobacter in the infantile diarrhreas of developing countries. During October, 1977, we cultured a single stool from each of 262 children living in the area of Kigali, the capital of Rwanda. Kigali has a rural appearance and has no
shantytown.
We looked for Campylobacter by inoculating the stools on sheep blood agar containing novobiocin (5 g/ml), actidione (50 g/ml), colistin (10 units/ml), cephalothin (15g/ml), and bacitracin (25 i.u./ml) and incubating it at 43 °C for 48 h. We followed the first technique described by Simmons3 for generating an appropriate atmosphere. The inoculated plates were put into a sealed jar (2.5 litres) containing an activated BBL ’Gas-Pak’, without a catalyst; this produces an atmosphere of hydrogen and carbon dioxide. There were no explosions. Parasites were sought by direct examination of the fasces. Shigella, Salmonella, and Yersinia were looked for by culture and enrichment procedures. The children investigated were all inpatients or outpatients at the department of paediatrics in the Kigali Hospital Centre (Medical Mission of the University of Brussels). There were 102 cases of gastroenteritis on ambulatory treatment, 18 healthy children coming to be vaccinated (first control group), 54 children admitted to hospital with measles (who always have some diarrhoea), 48 cases of gastroenteritis admitted to hospital, and 40 children admitted with diseases other than gastroenteritis (second control group). The pathogenicity of Campylobacter was confirmed by comparing the findings in children with diarrhoea with those in the controls (see table). The frequency with which Campylobacter was isolated (11% of those with diarrhoea) was remarkable. Among the inpatients with diarrhoea Salmonella was the most prevalent organism apart from parasites. Two explanations can be put forward: Salmonella infection might have been endemic in the hospital population (though only 3 children without diarrhoea were found to be carriers) or the gastroenteritis due to Salmonella might have been more severe and thus justified admission to hospital more frequently. Among the children with measles, the lesions in the digestive tract due to the virus may well have influenced the nature of the bacterial superinfection and so have favoured the multiplication of Salmonella. The frequency of Campylobacter was highest in children aged 12-24 months with diarrhoea, probably reflecting selfinfection with contaminated soil. Campylobacter was the agent most often found in patients whose gastroenteritis lasted more than 2 weeks or who had diarrhoea associated with violent abdominal pain. (The high proportion of children in hospital who were carrying parasites ’
reflects socioeconomic conditions in Rwanda: there was no evidence that the diarrhoeas investigated were due to parasites.) Since Campylobacter are important enteropathogemc bacteria in developing countries this organism should be identified as a target in the struggle against infantile diarrhreal disease in the third world. Laboratory of Microbiology, St. Pierre University Hospital, Brussels, Belgium, and Department of Pædiatrics, Kigali Hospital Centre Laboratory of Kigali Hospital Centre, Rwanda
P. DE MOL E. BOSMANS
CAMPYLOBACTER ENTERITIS IN BRUSSELS
SIR,-Since 1970, we have looked for Campylobacter in 22 000 specimens of human stools using the technique of filtration and culture on a selective medium, but a year ago we gave up filtration and made our medium more selective by adding to it cephalothin, which is inactive against C. jejuni. The new medium includes bacitracin (25 i.u./ml), novobiocin (5 p.g/ml), actidione (50 g/ml), colistin (10 units/mi), and cephalothin (15 g/ml). We used to incubate at 37°C because we were also looking for C. fetus, which grows very poorly at 43 °C.’’ However, we isolated C. fetus intestinalis from only 3 of 22 000 stools so we now incubate at 43 °C which allows C. jejuni to grow in 24 h instead of the 48 h or more needed at 370C. C. jejuni was isolated from 5.9% of diarrhoeal stools and from 1.3% of normal stools. Thus, as with all other enteropathogenic bacteria, there are healthy carriers. The isolationrate varies with the season in Brussels and can increase to 8-9% during July, August, and September. Positive stool cultures may be found among contacts of patients with Campylo.. bacter enteritis, and we have seen outbreaks of Campylobacter enteritis in five day-nurseries in the Brussels region. 20-50% of the infants were infected and had diarrhoea. From seven children from a creche where infection was prevalent, we were able to examine specimens aspirated from different levels of the intestinal tract. In four of the seven children Campylobacter was isolated on the same occasion from both stool and small intestine (stomach, jejunum, and ileum in one, jejunum but not ileum in another, and ileum but not jejunum in the two). All the isolates were C. jejuni, and all had the same biochemical and antigenic characters. The clinical manifestations of campylobacteriosis can vary but diarrhoea lasting several days with or without fever is the most frequent pattern. Though often trivial, the diarrhoea may sometimes be frankly watery or mucosanguinous and accom-
panied by vomiting.33
The mode of transmission of campylobacteriosis involves in1.
Butzler, J. P., Dekeyser, P., Detrain, M., Dehaen,
F. Pediatrics.
1973, 82,
493
Butzler, J. P., Dekegel, D., Hubrechts, J. M., Lauwers, S., Zissis, G., Paper presented at joint meeting of the British Society for the Study of Infection and the Infectious Diseases Society of America, held in Glasgow, in 1976. 3. Simmons, N. A. Br. med. J. 1977, ii, 707. 2.
1.
Butzler, J. P., Dekeyser, P., Detrain, M., Dehaen, F. J. Pediat. 1973, 82,
2. 3.
Butzler, J. P. Lancet, 1973, ii, 858. Skirrow, M. B. Br. med. J. 1977, ii, 9.
493.
PREVALENCE OF BACTERIA AND PARASITES IN STOOLS FROM RWANDAN CHILDREN
SIR,-Our laboratory experience1,2 prompted us to investigate the role of Campylobacter in the infantile diarrhreas of developing countries. During October, 1977, we cultured a single stool from each of 262 children living in the area of Kigali, the capital of Rwanda. Kigali has a rural appearance and has no
shantytown.
We looked for Campylobacter by inoculating the stools on sheep blood agar containing novobiocin (5 g/ml), actidione (50 g/ml), colistin (10 units/ml), cephalothin (15g/ml), and bacitracin (25 i.u./ml) and incubating it at 43 °C for 48 h. We followed the first technique described by Simmons3 for generating an appropriate atmosphere. The inoculated plates were put into a sealed jar (2.5 litres) containing an activated BBL ’Gas-Pak’, without a catalyst; this produces an atmosphere of hydrogen and carbon dioxide. There were no explosions. Parasites were sought by direct examination of the fasces. Shigella, Salmonella, and Yersinia were looked for by culture and enrichment procedures. The children investigated were all inpatients or outpatients at the department of paediatrics in the Kigali Hospital Centre (Medical Mission of the University of Brussels). There were 102 cases of gastroenteritis on ambulatory treatment, 18 healthy children coming to be vaccinated (first control group), 54 children admitted to hospital with measles (who always have some diarrhoea), 48 cases of gastroenteritis admitted to hospital, and 40 children admitted with diseases other than gastroenteritis (second control group). The pathogenicity of Campylobacter was confirmed by comparing the findings in children with diarrhoea with those in the controls (see table). The frequency with which Campylobacter was isolated (11% of those with diarrhoea) was remarkable. Among the inpatients with diarrhoea Salmonella was the most prevalent organism apart from parasites. Two explanations can be put forward: Salmonella infection might have been endemic in the hospital population (though only 3 children without diarrhoea were found to be carriers) or the gastroenteritis due to Salmonella might have been more severe and thus justified admission to hospital more frequently. Among the children with measles, the lesions in the digestive tract due to the virus may well have influenced the nature of the bacterial superinfection and so have favoured the multiplication of Salmonella. The frequency of Campylobacter was highest in children aged 12-24 months with diarrhoea, probably reflecting selfinfection with contaminated soil. Campylobacter was the agent most often found in patients whose gastroenteritis lasted more than 2 weeks or who had diarrhoea associated with violent abdominal pain. (The high proportion of children in hospital who were carrying parasites ’
reflects socioeconomic conditions in Rwanda: there was no evidence that the diarrhoeas investigated were due to parasites.) Since Campylobacter are important enteropathogemc bacteria in developing countries this organism should be identified as a target in the struggle against infantile diarrhreal disease in the third world. Laboratory of Microbiology, St. Pierre University Hospital, Brussels, Belgium, and Department of Pædiatrics, Kigali Hospital Centre Laboratory of Kigali Hospital Centre, Rwanda
P. DE MOL E. BOSMANS
CAMPYLOBACTER ENTERITIS IN BRUSSELS
SIR,-Since 1970, we have looked for Campylobacter in 22 000 specimens of human stools using the technique of filtration and culture on a selective medium, but a year ago we gave up filtration and made our medium more selective by adding to it cephalothin, which is inactive against C. jejuni. The new medium includes bacitracin (25 i.u./ml), novobiocin (5 p.g/ml), actidione (50 g/ml), colistin (10 units/mi), and cephalothin (15 g/ml). We used to incubate at 37°C because we were also looking for C. fetus, which grows very poorly at 43 °C.’’ However, we isolated C. fetus intestinalis from only 3 of 22 000 stools so we now incubate at 43 °C which allows C. jejuni to grow in 24 h instead of the 48 h or more needed at 370C. C. jejuni was isolated from 5.9% of diarrhoeal stools and from 1.3% of normal stools. Thus, as with all other enteropathogenic bacteria, there are healthy carriers. The isolationrate varies with the season in Brussels and can increase to 8-9% during July, August, and September. Positive stool cultures may be found among contacts of patients with Campylo.. bacter enteritis, and we have seen outbreaks of Campylobacter enteritis in five day-nurseries in the Brussels region. 20-50% of the infants were infected and had diarrhoea. From seven children from a creche where infection was prevalent, we were able to examine specimens aspirated from different levels of the intestinal tract. In four of the seven children Campylobacter was isolated on the same occasion from both stool and small intestine (stomach, jejunum, and ileum in one, jejunum but not ileum in another, and ileum but not jejunum in the two). All the isolates were C. jejuni, and all had the same biochemical and antigenic characters. The clinical manifestations of campylobacteriosis can vary but diarrhoea lasting several days with or without fever is the most frequent pattern. Though often trivial, the diarrhoea may sometimes be frankly watery or mucosanguinous and accom-
panied by vomiting.33
The mode of transmission of campylobacteriosis involves in1.
Butzler, J. P., Dekeyser, P., Detrain, M., Dehaen,
F. Pediatrics.
1973, 82,
493
Butzler, J. P., Dekegel, D., Hubrechts, J. M., Lauwers, S., Zissis, G., Paper presented at joint meeting of the British Society for the Study of Infection and the Infectious Diseases Society of America, held in Glasgow, in 1976. 3. Simmons, N. A. Br. med. J. 1977, ii, 707. 2.
1.
Butzler, J. P., Dekeyser, P., Detrain, M., Dehaen, F. J. Pediat. 1973, 82,
2. 3.
Butzler, J. P. Lancet, 1973, ii, 858. Skirrow, M. B. Br. med. J. 1977, ii, 9.
493.
PREVALENCE OF BACTERIA AND PARASITES IN STOOLS FROM RWANDAN CHILDREN
