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Brief Reports
Bacterial Aetiology and Anti-microbial Resistance of
Childhood Diarrhoea in Yemen

by Salem M. Banajeh,a Nadia H. S. Ba-oum,b and Raja M. N. Al-Sanabanib

aDepartment of Pediatrics, Sanaa University, Yemen
bDepartment of Microbiology, The Central Laboratory, Ministry of Health, Sanaa, Yemen

Summary
In a 12-month period, 561 stool cultures from Yemeni children aged 1–60 months and presenting
with diarrhoea, were analysed to identify the bacterial aetiology and their anti-microbial resistance
to the commonly used antibiotics. A total of 190 (33.9 per cent) were positive for bacterial culture.
Most of the positive cultures (58 per cent) were from children aged 1–12 months. The majority of
the positive cultures were enteropathogenic Escherichia coli (58.4 per cent) Salmonella spp., and
Shigella spp. (20 per cent each). Campylobacter were found to be an extremely uncommon agent of
childhood diarrhoea making only 1.6 per cent of the positive cultures. The majority of the Salmo-
nella were group C (60.5 per cent) and group B (29 per cent). Of the Shigella isolates, 13 (34 per
cent) were S. flexneri, and seven (18 per cent) S. dysentrea. More than two-thirds of the Salmonella
isolates were resistant to nalidixic acid, chloramphenicol, co-trimoxazole, gentamicin, and amoxy-
cillin, while 42 per cent were resistant to cefotaxime. Most of the Shigella isolates were susceptible
to nalidixic acid and cefotaxime, and resistant to the other antibiotics. All the tested enteropatho-
genic E. coli isolates were resistant to amoxycillin, 83 per cent were resistant to co-trimoxazole, 62
per cent to chloramphenicol, and 54 per cent to gentamicin, while only 16 and 6 per cent were resis-
tant to nalidixic acid and cefotaxime, respectively. This study, the first in Yemen, draws attention to
the urgent need of a national surveillance system, essential for the containment of anti-microbial
resistance.

Introduction Materials and Methods

In Yemen diarrhoea is the leading cause of morbidity
and mortality among children under 5 years old. It is
reported to be the probable cause of death in 58 per
cent of those aged 1–11 months and 56 per cent of
those aged 12–59 months.1
It has been suggested that in addition to oral rehy-
dration therapy (ORT), other curative measures
including antibiotics for non-watery diarrhoea, may
be necessary to reduce diarrhoea-related mortality.2
Anti-microbial resistance in childhood diarrhoea
has not been reported before in Yemen and is of
great concern since resistance to antibiotics results in
increasing morbidity and mortality from infectious
diseases.
In this study, an attempt has been made to
document the bacterial aetiology of diarrhoea in
infants and children, and their sensitivity patterns to
the commonly available antibiotics.
Correspondence: Dr Salem M. Banajeh, P.O. Box 2257, Sanaa,
Yemen. Fax 9671416722. E-mail <shaithami@unicef.org>.
In 1998, 561 fresh stool specimens from Yemeni
children aged 1–60 months, presenting with severe
diarrhoea, were collected and sent to the central
government laboratory, the only referral laboratory,
located in Sana’a city. The stool specimens were
cultured within 3 h of collection for Escherichia coli,
Salmonella, Shigella and Campylobacter, using
standard procedures.
In vitro antibiotic sensitivity testing was performed
by the standard disc diffusion method. The antibiotic
discs tested (Bio-Merieux-France) were: amoxy-
cillin, nalidixic acid, chloramphenicol, co-trimoxa-
zole, gentamicin, and cefotaxime.
Results
Tables 1 and 2 show the age group distribution, the
bacterial aetiology of diarrhoea and the anti-micro-
bial resistance pattern.
Of 190 positive cultures, 20 per cent were non-
typhoid Salmonella, 20 per cent Shigella, 58.4 per
cent enteropathogenic E. coli and 1.6 per cent were
Campylobacter. Of the Salmonella, 23 were group C
and 11 were group B. Among the Shigella isolates, 13

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BRIEF REPORTS

TABLE 1
Childhood diarrhoea in Yemen: bacterial aetiology and age group distribution

Isolates Under 6 months (n = 136) 6–12 months (n = 162) 13–60 months (n = 263) Total (561)

Salmonella spp. 5 (3.7) 17 (10.5) 16 (6.1) 38 (6.8)

Shigella spp. 8 (5.9) 11 (6.8) 19 (7.2) 38 (6.8)
Enteropathogenic E. coli 30 (22.1) 38 (23.5) 43 (16.4) 111 (19.8)
Campylobacter 1 (0.7) 1 (0.6) 1 (0.4) 3 (0.5)
Total positive culture 44 (32.4) 67 (41.4) 70 (30) 190 (33.9)
Total negative culture 92 (67.6) 95 (58.6) 184 (70) 371 (66.1)

TABLE 2
Bacterial aetiology of childhood diarrhoea in Yemen: total isolates tested (TIT) and antibiotic-resistant
isolates (RI)

Nalidixic acid Chloramphenicol Co-trimoxazole Gentamicin Amoxicillin Cefotaxime

TIT RI TIT RI TIT RI TIT RI TIT RI TIT RI

Salmonella spp. 32 20 37 21 38 33 29 22 3 2 31 13
(62.5%) (77.8%) 86.4%) (76%) (42%)
Shigella spp. 31 6 23 12 37 31 25 12 2 2 31 2
(19.4%) (52%) (84%) (48%)
Enteropathogenic E. coli spp. 96 15 66 41 98 81 57 31 11 11 95 6
(15.6%) (62%) (82.6%) (54.4%) (100%) (6.3%)
Campylobacter spp. – – 1 0 2 2 4 2 3 0 1 0

were flexneri, seven dysentrea, four boydii, three
sonnie, and 10 were non-typable. Among the
enteropathogenic E. coli, nine were type 0114, six
type 044, four type 0125, three type 0126, three type
0111, and two were type 0119.
Discussion
The results of this study showed that enteropatho-
genic E. coli accounts for 58 per cent of all isolates
and is the principal bacterial agent of diarrhoea in
children under 5 years in Yemen, which is similar to
other studies.3,4 Campylobacter on the other hand
was found to be an extremely uncommon cause of
childhood diarrhoea in Yemen (Table 1), in contrast
with studies from neighbouring countries.5,6
Malnutrition in Yemen stands among the highest
in the world with 52 per cent of children aged under
5 years being stunted, and 46 per cent under weight,1
making them vulnerable to developing bacteraemia
when they suffer bacterial diarrhoea.
The pattern of Shigella and enteropathogenic E.
coli resistance to the commonly used antibiotics in
this study is comparable to those reported in other
studies.7,8 The alarming high rate of resistant bacteria
to the commonly used antibiotics is of great concern,
since in vulnerable malnourished children who are
hospitalized with complicated diarrhoea and
evidence of bacteraemia, only expensive third-gener-
ation cephalosporin may be life saving, in addition to
rehydration therapy. Also nalidixic acid would be the
only effective antibiotic for treating Shigella dysen-
tery in the childhood community in Yemen.
Although the resistance rate of the common
pathogens can vary greatly over short distances,9 our
study draws attention to the urgent need for national
anti-microbial surveillance to be undertaken in
Yemen.
References
1. Central Statistical Organization (Yemen), Marco International
Inc. Yemen Demographic and Maternal and Child Health
Survey, 1997. Marco International, Calverton, MD, 1998.
2. Fauveau V, Yunus M, Zaman K, Chakraborty J, Sarder AM.
Diarrhoea mortality in rural Bangladeshi children. J Trop Pediatr
1991; 37: 31–6.
3. Levine MM. Escherichia coli that cause diarrhoea: enterotoxi-
genic, enteropathogenic, entero invasive, entero hemorrhagic
and entero adherent. J Infect Dis 1987; 155: 377–89.
4. Gomes TAT, Rassi V, MacDonald KL, et al. Enteropathogens
associated with acute diarrheal disease in urban infants in Sao
Paulo, Brazil. J Infect Dis 1991; 164: 331–37.
5. Zaman R. Campylobacter enteritis in Saudi Arabia. Epidemiol
Infect 1992; 108: 51–8.
6. Gedlu E, Aseffa A. Campylobacter enteritis among children in
north-west Ethiopia: a 1-year prospective study. Ann Trop
Paediatr 1996; 16: 207–9.

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7. Malkawi HT, Youssef MT. Antibiotic susceptibility testing and 9. Wise R, Andrews JM. Local surveillance of anti-miocrobial
plasmid profiles of Escherichia isolated from diarrhoea patients. resistance. Lancet 1998; 352: 657–58.
J Trop Pediatr 1998; 44: 128–32.
8. Chopra M, Wilkinson D, Stirling S. Epidemic Shigella dysentry in
northern KwaZulu – Natal. S Afr Med J 1997; 87: 48–51.

HBs Antigen in Children with Suspicion of HIV Infection

by Boubacar Nacroa, Blami Daob, and Honorine Dahourouc

aService de Pédiatrie and cBanque de Sang, Centre Hospitalier National Souro Sanou, Bobo Dioulasso, Burkina Faso
bUniversité de Ouagadougou- Faculté des Sciences de la Santé, Départément de Gynaécologie Obstétrique, Burkina Faso

Summary
In order to evaluate the prevalence rate of HBs antigen in children with a suspicion of HIV infec-
tion, 103 children were tested for HBs antigen and HIV. The mean age of the children was 2 years.
The prevalence of HBs antigen was 39.8 per cent in children and the HIV ELISA test was positive
in 57.7 per cent. A correlation was found between carrier of HBs antigen and HIV ELISA positiv-
ity (p = 0.04, RR = 1.46; 1.06 < RR < 2.02). There was a high prevalence of HBs antigen in children
with a suspicion of HIV infection. This calls for the promotion of antenal screening for HIV and
HBV along with immunization against hepatitis B in newborns in our setting.

Introduction testing. For that purpose, 2–5 ml of blood was drawn

Burkina Faso is a country of high endemicity for
hepatitis B1 and HIV infection with prevalence rates
of 7.4 and 17.4 per cent for HIV2 and HBs antigen,3
respectively, in pregnant women. Common features
of these two diseases are their route of transmission
(blood transfusion, i.v. drug use, sexual and maternal
route) and the possibility of infecting the same
subject.
This study was undertaken to evaluate the preva-
lence rate of HBs antigen being carried in children
with a suspicion of HIV infection.
Patients and Methods
The children were recruited from the pediatric ward
of Bobo-Dioulasso’s hospital in Burkina Faso. Inclu-
sion criteria were at least one of the following signs:
chronic cough, chronic fever, severe weight loss, born
to a HIV positive mother, repetitive digestive
candidiasis, chronic fever, extended lymphadenopa-
thy, repetitive or chronic gastroenteritis, bad evol-
ution of a marasmus status despite a good nutritional
supplementation, and interstitial pneumonia on
chest X-ray.
After inclusion of a child, informed consent of the
mother was obtained for HIV and HBs antigen
from the mother and the child. Kits from Sanofi
Diagnostic, Pasteur, France were used according to
the company’s instructions. No confirmation of HIV
infection was performed because the study is based
only on the suspicion of HIV.
Analysis of the data was performed by EPI Info 6.
The chi-squared test was used and a value of p < 0.05
was considered significant.
Results
A total of 103 children and their mothers were
included. The mean age of the children was 2 years
(range 0–14 years), and the sex ratio was 1. In
children, 59 were positive for HIV (57.3 per cent), 41
carried HBs antigens (39.8 per cent), and 29 (28.2 per
cent) were positive for both HBs antigen and HIV. In
mothers, 65 (63.1 per cent) were positive for HIV and
36 (35 per cent) carried HBs antigens. The data are
summarized in Table 1.
TABLE 1
Serological status of mothers and their children for
HIV and HBs antigen
Positive HBs Ag Positive HIV

Children 41 (39.8%) 59 (57.3%)

Correspondence: Dr Boubacar Nacro, 03 BP 4150 Bobo Dioulasso, Mothers 36 (35%) 65 (63.1%)
Burkina Faso.

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