Management of Pediatric Gastroenteritis Caused by Enteroaggregative E. coli
The primary management of pediatric gastroenteritis caused by enteroaggregative E. coli (EAEC) should focus on oral rehydration therapy with appropriate fluid and electrolyte replacement, while antimicrobial therapy should be reserved for severe or persistent cases, with azithromycin being the preferred agent when indicated. 1
Assessment of Dehydration
Accurate assessment of hydration status is crucial for determining management:
Mild dehydration (3-5% fluid deficit):
- Increased thirst
- Slightly dry mucous membranes
Moderate dehydration (6-9% fluid deficit):
- Loss of skin turgor
- Tenting of skin when pinched
- Dry mucous membranes
Severe dehydration (≥10% fluid deficit):
- Severe lethargy or altered consciousness
- Prolonged skin tenting (>2 seconds)
- Cool, poorly perfused extremities
- Decreased capillary refill
- Rapid, deep breathing (sign of acidosis) 2
Treatment Approach
1. Fluid and Electrolyte Management
Mild dehydration:
Moderate dehydration:
- Oral rehydration solutions (ORS)
- Consider ondansetron if vomiting is preventing adequate oral intake 3
Severe dehydration:
- Hospitalization for intravenous fluid therapy
- Close monitoring of electrolytes 3
2. Antimicrobial Therapy
Antimicrobial therapy is not routinely indicated for all cases of EAEC gastroenteritis but should be considered in:
- Children with persistent diarrhea (>10-14 days)
- Severe dehydrating illness despite adequate oral rehydration
- Immunocompromised patients
- Infants <6 months with systemic symptoms 2, 1
Recommended antimicrobial options when indicated:
- First-line: Azithromycin (shown to shorten course of EAEC diarrhea) 1
- Alternative options (based on susceptibility):
- TMP-SMZ (if susceptible)
- Ciprofloxacin (for children with severe reactions to β-lactam antibiotics) 2
3. Nutritional Management
- Resume normal feeding as soon as possible
- Avoid restricting food during diarrheal illness
- Continue breastfeeding throughout the illness 2, 4
4. Avoid Ineffective Treatments
- Do not use:
- Nonspecific antidiarrheal agents (kaolin-pectin)
- Antimotility agents (loperamide)
- Antisecretory drugs
- Toxin binders (cholestyramine) 2
Special Considerations
- Nursery/daycare outbreaks: Implement strict hygiene measures, symptomatic case eviction, and specific cleaning/disinfection protocols 5
- Hypervirulent strains: Be aware of the potential for EAHEC (enteroaggregative hemorrhagic E. coli), a hybrid pathotype that combines virulence factors of EAEC and EHEC, which may require more aggressive management 6
Prevention
- Emphasize handwashing and proper hygiene practices
- Ensure safe food and water handling
- Proper sanitation in daycare settings 3
Monitoring and Follow-up
- Monitor hydration status and response to therapy
- Follow up on stool cultures and antimicrobial susceptibility when obtained
- Consider referral to a pediatric infectious disease specialist for severe or persistent cases
The management of EAEC gastroenteritis in children should prioritize rehydration while being judicious with antimicrobial use, reserving it for cases where the benefits clearly outweigh the risks of prolonging bacterial shedding or promoting antimicrobial resistance.