THE LIBYAN JOURNAL OF

Infectious Diseases
The Official Periodical of the Libyan National Center
for Infectious Diseases Prevention and Control
Review Article Vol. 2 No. 1 Jan. - 2008

Infectious acute diarrhea in Libyan children: causative

agents, clinical features, treatment and prevention

Khalifa Sifaw Ghenghesh1,

ABSTRACT Ezzadin A. Franka1,
Diarrhea remains one of the principle causes of morbidity and Khaled A. Tawil1,
mortality in children in the world. Although studies on causative Salah Abeid1,
agents of children diarrhea in Libya are few, the available data shows Mustafa Ben Ali2,
that rotavirus is the major cause of diarrhea in Libyan children. Ibrahim A. Taher3,
However, bacterial and parasitic pathogens also play an important Rajab Tobgi3.
role in the etiology of diarrhea in children in Libya with salmonellae 1
Faculty of Medicine, Al-Fateh University,
and Cryptosporidium as major agents, respectively. Fever and Tripoli,
severe dehydration are common clinical features among diarrheic 2
Faculty of Arts and Sciences, El-
children particularly those affected by rotavirus. The emergence of Khomes University,El-Khomes,
antimicrobial-resistant enteric bacterial pathogens in this population 3
Faculty of Medicine, Gharyounis
has been noted and may complicate treatment options. The ease
University, Benghazi, Libya
Vol. 2 No.1 Jan. 2008

by which antimicrobial agents can be obtained over the counter in

Libya may play a role in the emergence of this problem. A serious
educational program in the country on the benefits of breast feeding
is needed. Also, the introduction of a rotavirus vaccine into the Key words:
vaccination program in Libya to protect the pediatric population Children, diarrhea, rotavirus,
should be taken into consideration.. Salmonella, Cryptosporidium, Libya

INTRODUCTION which may or may not be of an infectious nature

The Official Periodical of the Libyan National Center for Infectious Diseases Prevention and Control
Infectious Diseases

(2). The causative agents of infective diarrhea

Diarrhea remains one of the principle
causes of morbidity and mortality in children
worldwide. Recently, the World Health
Organization (WHO) estimated that diarrhea
accounts for 1.6 to 2.5 million deaths annually,
with children below five years of age in
developing countries being most affected (1).
THE LIBYAN JOURNAL OF
include bacteria, viruses and parasites. This
review is aimed at providing comprehensive
information on the etiological agents, clinical
features, treatment and prevention of diarrhea
in Libyan children. The data was obtained from
Highwire Press (including PubMed) search for
the period 1980-2007 using the terms «Diarrhea

Diarrhea can be a symptom of various diseases,
Correspondence and reprint request : Khalifa Sifaw Ghenghesh
Dept. of Microbiology and Immunology, Faculty of Medicine,
Al-Fateh University.
Phone: (+218) 092 397 3908
P.O.Box: 80013 Tripoli - Libya
Email: ghenghesh_micro@yahoo.com, Website: www.dmi.ly
Received : 3/ 11/ 2007, Accepted : 5 / 12/ 2007
in Libya» and «Libyan children», «Salmonella
in Libya», «Shigella in Libya» and so forth for
other enteric pathogens. Also, papers published
in local biomedical journals, and when available
abstracts presented in local and international
meetings on the subject were included.

10 www.nidcc.org.ly
 Infectious acute diarrhea in Libyan children
Causative Agents and Clinical Table 1. Agents of infective acute diarrhea in
Libyan children1
Features of Diarrhea in Libyan
Rate of
Children Agents
occurrence
In general, younger children with Bacterial
diarrhea (<2 years) are more likely to harbor
1. EPEC2 4 - 11 %
enteropathogens than older diarrheic children
2. EAEC 3
NK4
with no significant differences among the
3. Salmonella sp. 6 -11 %
sexes (3,4). Bacterial, parasitic and viral agents
4. Shigella sp. 4-6%
of acute infectious diarrhea in Libyan children
are shown in Table 1. 5. Yersinia enterocolitica <1 %
6. Campylobacter sp. 2-6%
I. Bacterial agents: 7. Aeromonas sp. 0 - 15 %
1. Diarrheagenic Escherichia coli: At least six Parasitic
different pathotypes are known up to date 1. Entamoeba histolyitca/disapr 12 %
that cause enteric disease, such as diarrhea 2. Giardia lamblia 1 - 18 %
or dysentery and these include entero- 3. Cryptosporidium 13 %
pathogenic E. coli (EPEC), enterotoxigenic Rotavirus 24 - 31 %
E. coli (ETEC), enteroinvasive E. coli
Multiple agents 12 - 14.5 %
(EIEC), enterohaemorrhagic E. coli
(EHEC), entero-aggregative E. coli (EAEC) 1
Data obtained from references 3,4,6,7,14,28,29,34.
2
Enteropathogenic Escherichia coli,
and diffusely adherent E. coli (DAEC) 3
Enteroaggregative E. coli,

Vol. 2 No.1 Jan. 2008

(5). Of these pathotypes only EPEC can 4
not known.

be detected by specific antisera. Others

require the use of animals (e.g. ETEC and
EIEC) tissue culture (e.g. EAEC, DAEC) or
immunological techniques (ELISA, RIA)
(e.g. EHEC), however molecular procedures
(e.g. PCR) can be used to detect all different
pathotypes of E. coli.
In the nineties of last century, a study
carried out in Tripoli reported EPEC from
11% of 157 Libyan children with diarrhea
and from 7% of 157 controls with O114
and O119 being among the serogroups
detected (6). In the same period a study
from Benghazi reported EPEC from 4% of
356 diarrheic children and none from 100
controls with different serogroups being
(EAEC) strains. Significantly (P=0.001)
more EPEC strains were identified from
diarrheal children (n=8) than from healthy
controls (n=1), six EAEC strains were
identified from diarrheal and three from
healthy control. Most of the EPEC strains
belonged to serogroups O55, O114 and
The Official Periodical of the Libyan National Center for Infectious Diseases Prevention and Control
O127. No ETEC, EIEC, STEC or EHEC Infectious Diseases
were detected in the above mentioned study.
Although these findings indicate that EPEC
and EAEC could be the main pathotypes
of diarrheagenic E. coli in Libyan children
more studies are needed on larger collections
of E. coli isolated from children with and
without diarrhea and from different regions
THE LIBYAN JOURNAL OF

detected that included O111 and O127 (4).
Recently, Dow et al (7) examined 50 E.
coli strains (20 from diarrheic and 30 from
non-diarrheic Libyan children) for virulence
genes using PCR. They detected nine eae-
positive (EPEC) and nine aggR-positive
of the country to confirm this observation.
EHEC, also known as verotoxin-
producing E. coli, produces a Shiga-
like toxin (Stx). More than one hundred
different serogroups were reported to
produce Stx however, E.coli O157:H7 is

www.nidcc.org.ly 11
 Ghenghesh et al.
the predominant serogroup associated with
diarrhea. Ghenghesh et al (6) using specific
antisera reported the detection of this
serogroup in 7% of diarrheic children and in
4% of controls. Other types of diarrheagenic
E. coli (i.e. ETEC, EIEC and DAEC) have
not been reported previously from Libyan
children with diarrhea.
2. Salmonella: It is widely accepted at present,
by microbial taxonomists, that almost all
of the Salmonella that infect mammals
and birds to be one species (S. enterica)
divided into six subspecies (8). Within
these subspecies there are at least more than
2000 serotypes. Most serotypes cause only
gastroenteritis, while specific serotypes (S.
typhi and S.paratyphi) cause enteric fever
(9).
As shown in Table 1, nontyphoid
salmonellae are the major bacterial cause of
diarrhea in Libyan children. In industrialized
countries S. typhimurium and S. enteriditis
are the predominant serotypes responsible
Vol. 2 No.1 Jan. 2008
for Salmonella-associated diarrhea in
children (10). In Libya, serotypes other than
S. enteritidis predominated since 1970s to
present. However, S. enteritidis has been
reported from diarrheic Libyan children
during 21st century (3). Table 2 shows
Table 2. Predominant Salmonella serotypes isolated from Libyan Children with Diarrhea
The Official Periodical of the Libyan National Center for Infectious Diseases Prevention and Control
Infectious Diseases
Years of
City
isolation
Tripoli 1975-1980
Tripoli 1992-1993
THE LIBYAN JOURNAL OF
Benghazi 2000-2001
Zliten 2000-2001
12
the predominant serotypes of Salmonella
associated with diarrhea in Libyan children
from different cities. Ghanim et al. (4)
reported that more 89%, 85% and 31%
of Salmonella-positive children with
diarrhea had vomiting, fever and tenesmus,
respectively.
3. Shigella: Diarrhea associated with Shigella
infections results in nearly one million
deaths each year, especially among children
in developing countries (11). There are four
species (groups) of Shigella: S. dysenteriae
(group A), S. flexneri (group B), S. boydii
(group C) and S. sonnei (group D) with 49
recognized serovars, represnting subtypes
from three of the four groups (12).
S.sonnei is the major cause of shigellosis in
developed countries, while in developing
countries S. flexneri and S. dysenteriae
predominate. Studies from Libya show
S.flexneri (mainly subtypes 2 and 4) as the
major cause of Shigella-associated diarrhea
in children (3,4,13,14). Ali et al (3) reported
that in Shigella-positive children with
diarrhea 100%, 50% and 83% of them had
fever, convulsions and blood in the stool,
respectively. Table 3 shows information
about Libyan children with diarrhea in
Tripoli and their Shigella isolates.
Predominant
Reference
serotype
S. wein
S. muenchen 64
S. typhimurium
S. saintpaul
62
S. muenchen
S. typhimurium
S. muenchen 63
S. paratyphi
S. Heidelberg
3
S. enteritidis
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 Infectious acute diarrhea in Libyan children
Table 3. Information about Libyan Children with Diarrhea in Tripoli and their Shigella Isolates (14)

Age Month of Length of diarrhea Episodes Species and

Patient Sex
(Mo) occurrence (days) per day serotype of Shigella
1 F 11 Sep 1 5 S. sonnei
2 F 30 Sep 2 3 S. flexneri type 2
3 M 27 Oct 1 6 S. sonnei
4 F 18 Oct 1 8 S. flexneri type 2
5 F 36 Oct 2 5-7 S. flexneri type 2
6 M 7 Dec 7 7-8 S. flexneri type 1
7 M 7 Apr 1 10 S. flexneri type 2
8 M 13 Jun 10 6-7 S. flexneri type 3
9 M 32 Jul 1 4 S. sonnei

4. Yersinia enterocolitica: A gastrointestinal 1. diarrheic.

tract pathogen that causes acute enteritis
with fever and inflammatory, occasionally
bloody, watery diarrhea is the most frequent
occurrence, particularly in children (15).
This organism has been reported only
once from Libyan children with diarrhea at
less than one percent and it appears not to
6. Aeromonas: At least 14 species hybrization
groups are known in this genus with
A.hydrophila, A. sobria and A. caviae being
the prevalent species involved in human
disease (19-21). In children, the common
clinical picture caused by Aeromonas is
the acute onset of watery diarrhea with

Vol. 2 No.1 Jan. 2008

be an important cause of diarrhea in such
a population (6). This view is supported
by a study carried out in Benghazi by
Ghanim et al (4). They examined stools of
diarrheic children and none was positive for
Y.enterocolitica.
5. Campylobacter: Campylobacter jejuni
and C. coli are the most important human
pathogens in this genus, with the former
usually responsible for the majority (80-
90%) of enteric Campylobacter infections
(16). In developing countries, non-
inflammatory, watery diarrhea is seemingly
the most common clinical pattern of disease
seen with Campylobacter infection and
usually restricted to children (16,17).
Campylobacter was reported from Libyan
slightly raised body temperature (20). In
developing countries the rate of occurrence
of Aeromonas in diarrheal children ranges
between 4-22% (22-24) while in developed
countries it is usually less than 3% (25-
27). The rate of occurrence of Aeromonas
in Libyan children from different cities
ranges between 0-15% with A. caviae being
the predominant species. A study from
The Official Periodical of the Libyan National Center for Infectious Diseases Prevention and Control
Tripoli, reported that of the 23 diarrheal Infectious Diseases
children with fecal Aeromonas, 43.5% had
mucus, and 26.1% had blood in their stools;
34.8% and 39.1% presenting with fever and
vomiting respectively (28).
II. Parasitic agents:
These include the intestinal protozoa
THE LIBYAN JOURNAL OF

children with diarrhea for the first time in
1994 (18). Ghanim et al (3) reported that
children infected with campylobacter are
also presented with fever and vominting.
The rate of occurrence of Campylobacter in
diarrheic Libyan children is shown in Table
Entamoeba histolytica, Giardia lamblia and
Cryptosporidium. These organisms are common
causes of diarrhea in children in developing
countries and asymptomatic infection is also
common in this population. Published studies
on children diarrhea due to parasitic agents

www.nidcc.org.ly 13
 Ghenghesh et al.
in Libya are few and lack the description of
clinical features associated with the causative
agents. However, Alsirieti et al (29) reported the
detection of intestinal protozoa in 532 (76%)
of 700 Libyan children attending Out Patient
Clinics in Sirt City complaining of diarrhea,
nausea, fever, vomiting, and abdominal pain.
1. Entamoeba histolytica: An important
cause of diarrhea in children in developing
countries and is usually characterized by
presence of blood in the stool. E. histolytica
is identical morphologically to the non-
pathogenic E. dispar. The latter is the new
species name for what was previously
called «non-invasive» or «non-pathogenic»
E.histolytica (30). Therefore, the prevalence
rates of E. histolytica in the literature,
particularly rates reported from developing
countries, should be interpreted carefully. In
this paper, prevalence rates will be reported
as E. histolytica/dispar. Rates of 5-34% from
diarrheal children in developing countries
(31-33) and 4-46% in Libya (3,29,34) have
Vol. 2 No.1 Jan. 2008
been reported previously for E. histolytica/
dispar. of 20 Libyan diarrheic children
positive for E. histolytica/dispar, 95% had
fever, 30% convulsions and 60% had blood
in the stool (3).
2. Giardia lamblia (syn. G. intestinalis, G.
duodenalis): The most commonly isolated
intestinal parasite throughout the world
The Official Periodical of the Libyan National Center for Infectious Diseases Prevention and Control
Infectious Diseases
and is particularly prevalent in children
in developing countries and it is the most
cause of waterborne outbreaks of diarrhea
in developed countries (35,36). Although
diarrhea is the most frequent symptom
associated with G. lamblia infection,
prolonged diarrhea with malnutrition and
growth failure in infancy have been also
reported (37).
THE LIBYAN JOURNAL OF
Prevalence rates of G. lamblia amongst
diarrheic children in developing countries
ranged between <1-38.5% (38-40) and in
Libya ranged between 1-18% (3,29,34).
High rates of G. lamblia have been reported
14
form urban areas (e.g. Tripoli) and low
rates from rural areas (e.g Zliten) in Libya.
Pockets of high and low prevalence have
been described previously, and they appear
to be more common in urban areas than in
rural areas (41).
3. Cryptosporidium: This organism is a
recognized cause of diarrhea among children
(mostly less than one year) in developing
countries and is associated with malnutrition
(42,43). Studies have also shown that
asymptomatic infection is common and
although its effect on children is less severe,
such infection may have a negative effect
on weight gain (44). Reported prevalence of
Cryptosporidium in diarrheic children from
developing countres ranged between 4 to
32% (38,45,46) and from Libya between
1 to 13% (3,34). It should be noted that in
the above mentioned studies lower rates of
Cryptosporidium were mostly reported from
populations in urban areas (e.g Tripoli)
and higher rates from non-urban areas (e.g
Zliten).
III. Viral agents:
Although different types of enteric viruses
are known to cause diarrhea in children, only
rotaviruses have been reported from Libya.
Rotaviruses are considered the most common
cause of acute diarrhea in young children in
developed and developing countries (47). In
the latter, it is estimated that 20% to 70% of
hospitalizations and around 900.000 children
below the age of 5 die annually as a result of
rotaviruses infection (48). Of the 7 groups (A-
G) of rotaviruses group A is usually the cause
of rotavirus-associated diarrhea. Rotaviruses
infections occur via the fecal-oral route.
Occurring rates are similar in developing and
developed countries. In Libya, rotavirus is
the leading cause of infectious diarrhea with
reported rates of 24% to 31% (3,4,6). There
is no seasonal variation in the occurrence of
rotavirus infection, although it appears to peak
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in winter. A study from Zliten (3) reported 98%
of rotavirus-positive children with diarrhea
were dehydrated and more than 84% with fever
and vomiting.
IV. Multiple pathogens:
Although single enteric agents are
responsible for most cases of infectious
diarrhea, multiple agents (two agents or
more) may also play an important role in this
syndrome in developing countries. Multiple
enteric pathogens may act synergistically to
produce diarrhea (49). Rates of 12-14.5%
for multiple agents have been reported from
Libyan children with diarrhea (3,4).
V. Nosocomial (hospital-acquired)
diarrhea:
Within the hospital setting, pediatric
wards face both community and nosocomial
(hospital-acquired) diarrhea. The latter may
result in aggravating the underlying disease
and delay hospital discharge (50). Nosocomial
transmission of non-typhoid Salmonella
among children has been reported previously
from several cities in Libya (51,64). Although,
hand washing is considered the most important
method in preventing transmission of infection
by the fecal-oral route, compliance of
healthcare workers with standard precautions is
variable and often poor (52,53). In addition, the
high rate of the Salmonella carrier state among
health care workers in some Libyan hospitals
may contribute to this problem (64). Recently,
Ali et al. (3), in Zliten, reported significantly
higher rates of isolation of multiple agents
(mainly rotavirus plus another agent) from
children with nosocomial diarrhea than from
children with community acquired diarrhea.
Antimicrobial Resistance and
Treatment
In the last two decades, high rates of resistance
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Infectious acute diarrhea in Libyan children
to commonly used, cheap oral antibiotics
among enteric pathogens have been reported
from several developing countries (54-56). The
same can be said for enteric bacterial pathogens
isolated in this country. High rates of resistance
to multiple antimicrobial agents by different
enteric pathogenic bacteria have been reported
from different cities in Libya (13,62,64). The
ease of which antimicrobial agents can be
obtained in these countries including Libya
has been blamed for this problem (3,57).
There is dearth of information on the treatment
of acute infectious diarrhea in Libya. Sood
et al. (58), in Benghazi, studied the in vivo
sensitivity of salmonellae in 38 children with
gastroenteritis. The children were treated for 7
days with gentamicin, to which the organisms
were sensitive in vitro. Stool culture remained
positive in 30 of the 38 cases. The children
improved on supportive and symptomatic
therapy. Sood et al. (58) study shows that
antibiotics have no role in the management of
acute Salmonella gastroenteritis in children.
Vol. 2 No.1 Jan. 2008
Unfortunately, gentamicin and other broad-
spectrum antimicrobial agents are still used in
general practice in Libya to treat acute infectious
diarrhea in Libyan children. The use of up to 3
different antimicrobial agents by pediatricians
in treatment of diarrhea in children aged less
than one year has been observed in government
and private clinics in the last decade (K.S.
The Official Periodical of the Libyan National Center for Infectious Diseases Prevention and Control
Infectious Diseases
Ghenghesh, unpublished observation). There
is a serious problem among pediatricians
in Libya as far as the use of broad-spectrum
antimicrobial agents in treatment of infectious
acute diarrhea in children for the following
reasons: first, it is well established from the
published studies in this country that rotavirus
is the most common cause of diarrhea; second,
THE LIBYAN JOURNAL OF
most of the enteric bacteria associated with
children diarrhea (i.e. Salmonella and Shigella)
are multiple resistant to antimicrobial agents;
third, a high rate of children diarrhea is caused
by intestinal protozoa. Because antimicrobials
have no role in the treatment of the three groups
15
 Ghenghesh et al.
of diarrheagenic agents mentioned above,
pediatricians should refrain from prescribing
antimicrobial agents to patients with diarrhea
in this country. Furthermore, gastrointestinal
infections with enteric pathogens are generally
self-limiting. Although, treatment of patients
with symptoms of infectious diarrhea with
antibiotics remains controversial, antimicrobial
therapy should be initiated for those who are
severely ill and for patients with risk factors
for extraintestinal spread of infection after
obtaining appropriate blood and fecal cultures
(59). The current accepted treatment of all acute
infectious diarrheal diseases is rehydration,
antibiotic treatment (when indicated), and
nutritional therapy (57).
Prevention
Providing clean treated water for drinking
and for preparation of foods (e.g. bottled milk)
is the first step in preventing infectious acute
diarrhea in children. A strong association
Vol. 2 No.1 Jan. 2008
between isolation of enteric pathogens from
diarrheic children and use of untreated water
has been reported previously from Libya
(3,28). Ali et al. (3) reported that according
to type of water consumed, nearly 57% of
children with diarrhea had non-treated water
at home. Single pathogens, rotavirus, Shigella,
Aeromonas, E. histolytica/dispar, and G. lamblia
The Official Periodical of the Libyan National Center for Infectious Diseases Prevention and Control
Infectious Diseases
were isolated at higher rates from children with
non-treated than from children with treated
water at home. They also reported that nearly
all parents of diarrheic children stated that on
certain occasions, during shortages of water
particularly in summer, they used water from
other sources not known whether treated or
not.
Ghanim et al. (4), in Benghazi, reported a
THE LIBYAN JOURNAL OF
clear association between diarrhea and feeding
practices. They found nearly 50% of children
with diarrhea were bottle-fed compared with
14% and 11% among exclusively breast fed
babies and those on a combination of bottle
16
and breast feeding respectively. Ghenghesh
et al. (6), in Tripoli, reported similar findings.
A strong program by the health authorities and
other related agencies using the media and
other venues including schools, universities
and maternity clinics should be carried out
throughout the year to promote the benefits of
breast feeding among child bearing mothers
to reduce the incidence of diarrhea in children
less than two years of age.
Most of the bacterial enteric pathogens are
zoonetic organisms and therefore, different
types of meats (i.e. lamb, beef, chicken and
fish) are major sources of such organisms.
Animal products (i.e. eggs, raw milk) are
also major sources of enteric pathogens. The
problem arises when meats and animal products
are not handled in the kitchen properly and
cross contamination occurs. This in turn may
increase the exposure probability of children to
enteric pathogens. Mothers should be educated
on how to handle meats and foods properly
in the kitchen to prevent cross contamination.
When treated water is not available, mothers
need to be advised to boil the water used for
preparation of bottled milk for their children.
Also, the community should be educated on
the importance of hand washing and personnel
hygiene
The housefly is well known to carry enteric
pathogens and reducing its population has been
shown to result in lowering the incidence of
diarrheal disease in the community. Rahuma
et al. (60) isolated EPEC, Salmonella, Shigella,
Y.enterocolitica and Aeromonas from houseflies
collected from different locations in Misurata
City. The public needs to be informed of the role
of houseflies in transmitting human pathogens
and the need for the careful disposal of sewage
(and the excreta of other mammals). Control of
houseflies by health and municipal authorities
needs to be improved.
A very strong association of dehydrated
children with rotavirus diarrhea has been
reported from Libya (3). This observation
www.nidcc.org.ly

supports the view that rotavirus may be
responsible for a large part of the morbidity
and mortality associated with this syndrome
in this country and gives more weight to the
need of a rotavirus vaccine to protect the
pediatric population (61). However, a number
of questions have to be answered before
embarking on such a project that include,
among others, what are the groups, serotypes,
genotypes and electrophoretic types of the
strains that circulate in Libya.
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