DRUG SUSCEPTIBILITY PATTERN AND ASSOCIATED FACTORS
AMONG UNDER FIVE CHILDREN IN DIRE DAWA, EASTERN
ETHIOPIA
MSc Research Thesis
Mohammed Mekonnen (BSc)
April 2015
Haramaya University, Haramaya
Drug Susceptibility Pattern and Associated Factors among Under Five
Children in Dire Dawa, Eastern Ethiopia
A thesis submitted to College of Health and Medical Sciences,
School of Graduate Studies,
HARAMAYA UNIVERSITY
In partial fulfillment of the requirements for the degree of
MASTER OF SCIENCE IN MEDICAL MICROBIOLOGY
Mohammed Mekonnen
Major Advisor: Senthilkumar Balakrishnan (MSc, PhD)
Co-Advisor: Biftu Geda (MScN, PhD candidate)
April, 2015
Haramaya University, Haramaya
HARAMAYA UNIVERSITY
SCHOOL OF GRADUATE STUDIES
APPROVAL SHET
I hereby certify that I have read and evaluated this Thesis entitled “Bacterial Diarrhoea, Their
Antibiotic Susceptibility Pattern And Associated Risk Factors Among Under Five Children
In Dil-Chora Referral Hospital, Dire Dawa, Ethiopia” prepared under my guidance by
Mohammed Mekonnen. I recommend that it be submitted as fulfilling the thesis
requirements.
____________________
Major Advisor
____________________
Co-Advisor Advisor
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Signature
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Signature
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Date
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Date
As a member of the Board of Examiners of the MSc Thesis Open Defense Examination, I
certify that I have read and evaluated the Thesis prepared by Mohammed Mekonnen and
examined the candidate. I recommend that the thesis be accepted as fulfilling the Thesis
requirements for the degree of Masters of Science in Medical Microbiology.
______________________
Chairperson
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Signature
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Internal Examiner
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External Examiner
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Final approval and acceptance of the Thesis is contingent upon the submission of its final
copy to the Council of Graduate Studies (CGS) through the candidate’s department or school
graduate committee (DGC or SGC)
STATEMENT OF THE AUTHOR
By my signature below, I, Mohammed Mekonnen, declare and affirm that this thesis is my
own work. I have followed all ethical and technical principles of scholarship in the
preparation, data collection, data analysis and compilation of this thesis. Any scholarly matter
that is included in the thesis has been given recognition through citation.
This thesis is submitted in partial fulfillment of the requirements for the degree of maters of
sciences in Medical Microbiology at the Haramaya University. The thesis is deposited in the
Haramaya University Library and is made available to borrowers under the rules of the
Library. I solemnly declare that this thesis has not been submitted any other institution
anywhere for the award of any academic degree, diploma or certificate.
Brief questions from thesis may be made without special permission provided that accurate
and complete acknowledgement of the source is made. Requests for permission for extended
quotations from or reproduction of this thesis in whole or part may be granted by the head of
the school or department when in his or judgment the proposed use of the material is in the
interest of scholarship. In all other instances, however, permission must be obtained from the
author of the thesis.
Name: _________________________
Signature________________
Date: ______________________________
School/Department: _____________________________
iii
BIOGRAPHICAL SKETCH
I was born in 1983 GC in South Wollo, Combolcha Town. I completed my Elementary and
junior education in Combolcha Elementary School, Grade 9 and 10 in Nifas Silk High School
and Grade 11 in Abiot Kirse High School, both in Addis Ababa, and Grade 12 in Fasiledes
High School in Gondar. Then I have graduated from Jimma University with Bachelors of
Science in Medical Laboratory Technology in 2006. After graduation, I have been working at
different health facilities such as Mizan Teferi Health Center for one year, Dire Dawa Bilal
Hospital for one and half year and Dire Dawa rural health center for two years. However,
since 2011 I am working at Dire Dawa Dil Chora Referral Hospital as Senior Laboratory
Technologist.
iv
ACKNOWLEDGEMENTS
First and for most, I Would like to thank School of Graduate Studies, Haramaya University in
laying fertile ground in preparation of this thesis.
My acknowledgement goes to my advisors Dr. SenthilKumar Balakrishnan and Mr. Biftu
Geda for their valuable guidance, suggestions and support since the development of the
proposal until the preparation of this thesis.
.My heartfelt gratitude also extends to all the Institutional Health Research Ethics Review
Committee for their constructive comments given to finalize the development of this thesis.
I am also grateful to all my research team who dedicated their full time and effort during data
collection. I would like to thank Dire Dawa Administrative Health Bureau and Dil-Chora
Referral Hospital for their cooperation in undertaking this research and also to all participated
under five children together with their families for their participation and support in
providing the required information for this research.
I would like to thank all staff member of Dil-Chora Hospital Laboratory for their precious
support in every circumstance.
vi
ACRONYMS AND ABBREVIATIONS
CSA- Central Statistics Agency
DDA- Dire Dawa Administration
DTC- Drug Therapeutic Committee
EBR- Ethiopian Birr
EDHS- Ethiopian Disease and Health Survey
EIEC- Enter Invasive Escherichia coli
EPEC- Enteropathogenic Escherichia coli
ETEC- Enterotoxigenic Escherichia coli
MAC- MacConkey
MIU- Motility Indole Urea
ORS- Oral Rehydration Salts
SS- Salmonella and Shigella
UNICEF- United Nations International Children Emergency Fund
WHO- World Health Organization
MDR – Multi- Drug Resistance
vii
TABLE OF CONTENTS
STATEMENT OF THE AUTHOR
iii
BIOGRAPHICAL SKETCH
iv
ACKNOWLEDGEMENTS
vi
ACRONYMS AND ABBREVIATIONS
vii
TABLE OF CONTENTS
viii
ABSTRACT
xii
1. INTRODUCTION
1
1.1 Background
1
1.2 Statement of the Problem
3
1.3 Significance of the Study
5
1.4. Objectives
5
1.4.1 General Objective:
5
1.4.2 Specific Objectives:
5
6
2. LITERATURE REVIEW
2.1. Review of Studies on Prevalence of Common Bacterial Cause of Diarrhoea
6
2.3. Drug Resistance Patterns Of Common Bacterial cause of diarrhoea
7
2.4. Associated Risk Factors of Bacterial Cause of Diarrhoea
9
3. MATERIALS AND METHODS
11
3.1. Study Area
11
3.2. Study Period
11
3.3. Study Design
11
3.4. Population
12
3.4.1. Source Population
12
3.4.2. Study population
12
3.4.3. Inclusion and Exclusion Criteria
12
3.5. Sampling
12
3.5.1. Sample Size Determination
12
3.5.2. Sampling Procedure
13
3.6. Data Collection
13
3.7. Screening and Identification of Bacterial Agents Causing Diarrhoea
13
3.7.1. Stool Sample Collection
13
3.7.2. Inoculation and Incubation
14
3.7.3. Isolation and Identification
14
viii
3.7.4. Antibiotic Sensitivity Test
14
3.8. Study Variables
15
3.8.1. Dependent/ Outcome variable
15
3.8.2. Independent/ Explanatory Variables
15
3.9. Operational Definition of Variables
15
3.10. Data Quality Control
16
3.11. Data Analysis
17
3.12. Data Dissemination
17
4. RESULTS
18
4.1. Prevalence of Enteric Bacteria
19
4.2. Antibiotic Susceptibility Pattern of Bacterial Isolate
22
4.3. Possible Associated Factors of Bacterial Diarrhoea
25
5. DISCUSION
27
6. STRENGTH AND LIMITATION OF THE STUDY
32
6.1. STRENGTH
32
6.2. LIMITATION OF THE STUDY
32
7. CONCLUSION AND RECOMMNDATION
33
7.1. Conclusion
33
8. REFERENCE
35
9. ANNEXURES
39
Annexure- 1: Participant Information Sheet and Informed Consent Form for Parents or
Guardians of Under Five Children Involved In the Study
39
Annexure-2: በጥናቱ ላይ ለሚሳተፉ የህፃኑ እናት ወይም ጠባቂ
43
Annexure-3: Odeefannon hirmattotaa Qo’annoo waa’ee jermilee garaa kaasaa fidaniifi
qorichaa waliin walbaruu isaanii daa’immani ilaala
47
Annexure-4: Waxaan akhriyey warqada warbixinta Xaaladaha cayayaanka ili ma argtayda
iyo kudul noolayaasha ku keena shuubanka iyo ka hortaga u nuglaanshahooda caruurta 5
sano ka yare e dhakhtarka
51
Annexure- 5:- Informed Consent Form for Dil Chora Hospital Chief Executive Officer
55
Annexure -6: Laboratory Data
57
Annexure-7: Curriculum Vitae
59
ix
LIST OF TABLES
PAGE
Table-1:- Distribution of E. coli, Shigella and Salmonella sp among under five children with
diarrhea at Dil-Chora Referral Hospital from February to March 2015, Dire Dawa,
Eastern Ethiopia.
19
Table-2:- Distribution of E. coli, Shigella and Salmonella sp with clinical data among under
five children with diarrhea at Dil-Chora Referral Hospital from February to March
2015, Dire Dawa, Eastern Ethiopia.
20
Table-3:- Distribution of E. coli, Shigella and Salmonella sp with environmental
characteristics among under five children with diarrhea at Dil-Chora Referral
Hospital from February to March 2015, Dire Dawa, Eastern Ethiopia.
22
Table- 4: Antimicrobial sensitivity and resistant pattern of bacteria isolate among children
under age of five years at Dil-Chora Referral Hospital from February to March
2015, Dire Dawa, Eastern Ethiopia.
23
Table-5: Antibiogram of bacterial pathogens isolated from under-five children with diarrhea
at Dil-Chora Referral Hospital from February to March 2015, Dire Dawa, Eastern
Ethiopia.
24
Table- 6: Multivariable analysis of risk factors for bacterial diarrhoea among under 5 children
at Dil-Chora Referral Hospital from February to April 2015, Dire Dawa.
x
26
LIST OF FIGURE
PAGE
Figure-1: Conceptual Framework of Associated Factors for enteric bacterial pathogens and
Drug Resistance pattern
10
Figure- 2: Age and Sex Distribution of study participants
xi
18
ABSTRACT
Globally, diarrhoea remains the second leading cause of death among under five children. In
developing countries including Ethiopia reports indicated that 50-60% of diarrhoea is caused
by bacteria of which Enteropathogenic Escherichia coli (EPEC) accounts 25%,
Enterotoxigenic E.coli (ETEC) accounts 10-20%, Campylobacter jejuni 10-18%, Shigella
species 5-15%, and Salmonella species accounts 5%. In addition, the emergence of multidrug resistance enteric bacteria is becoming a major medical and public health problem.
Therefore, this study aimed to identify the bacterial cause of diarrhoea, antibiotic
susceptibility pattern and associated factors among under five children at Dil-Chora Hospital
from Feb 20 to March 30/2015. A hospital based cross-sectional study was conducted and a
total of 196 under-five children with diarrhea were included consecutively. Demographic,
environmental and clinical data were collected using questionnaire. Stool samples were
collected and inoculated on Selenite-F broth, SS agar, MacConky and DCA. Antimicrobial
susceptibility test was performed following standard bacteriological techniques. Descriptive
statistics was used to present the findings. Binary logistic regression was used to measure the
association between dependent and independent variables and significant variables were
further adjusted using multivariate analysis. A p-value <0.05 was considered as level of
significance. The overall prevalence of enteric bacteria in this study was 21.9%. E. coli was
the dominant bacteria isolated (12.8%), followed by Shigella (5.6%) and Salmonella sp
(3.6%). None of the bacteria isolates showed resistance to Ceftriaxone, while 100%
resistance to Amoxicillin was observed by Shigella sp, 85.7% by Salmonella and 56% by E.
coli. Resistance for Ampicillin was 90.9%, 71.4% and 52% by Shigella, Salmonella and E.
coli isolates. All Shigella isolates were found to be multi drug resistant. Hand washing after
toilet use showed statistical significant association with culture positivity of Salmonella and
Shigella sp. Therefore, children’s family should be educated to wash their hands after toilet as
this is cost-effective public health interventions.
KEYWORDS: Under-Five Diarrhoea, Enteric Bacteria, Drug Resistant, Risk Factors.
xii
13
1. INTRODUCTION
1.1 Background
Enteric bacteria are microorganisms which have the potential of causing disease in the
intestinal track (WHO, 2013). These organisms are abundant and ubiquitous in nature: they
exist in soil, water, air, and food; they can evolve quickly by exchanging genetic materials to
acquire properties that help them to create new strain and to colonize new host (El-Astal,
2005). When ingested with contaminated water and food, they invade and colonize the host
tissue, causing diarrhoea (WHO, 2007). The common bacterial agent of childhood diarrhoea
includes diarrhoeagenic E.coli, Salmonella and Shigella sp, Vibrio cholerae, Campylobacter
sp (Merson et al., 2005). Majority of children infected with these enteropathogens often
experience symptoms of watery and loose stools, fever, abdominal cramps, nausea, vomiting,
loss of appetite, weight loss, and dehydration due to loss of fluids and electrolyte is the most
common complication of infectious diarrhoea (UNICEF/WHO, 2009).
Globally, diarrhoea remains the second leading cause of death among under five children,
and is responsible for killing around 760,000 children every year (WHO, 2013; Christa et al.,
2013). About 72% of deaths associated with diarrhoea happen in the first 2 years of life,
suggesting that an increased emphasis on prevention and treatment in neonates and children
younger than 2 years is crucial (Christa et al., 2013). It was indicated that, nearly three
quarters of child deaths in the world occurs in 15 countries and Ethiopia was at the fifth rank
with estimated 73,700 total number of annual child deaths due to diarrhoea (WHO, 2007).
Diarrhoea due to microbial infection is widespread throughout developing countries (WHO,
2013). It is reported that 50-60% diarrhoeal cases in developing countries including Ethiopia
are of bacterial origin: Enteropathogenic E.coli (EPEC) accounts 25%, Enterotoxigenic E.coli
(ETEC) accounts 10-20%, Campylobacter jejuni 10-18%, Shigella sp 5-15%, and Salmonella
sp accounts 5% (Naghipour et al, 2008; Elliott, 2007). All these pathogens share a similar
feco-oral route of transmission. Fecal contamination of food and drinking water is considered
as the common source of enteric pathogens (UNICEF/WHO, 2009).
1
It is recommended that antibiotics should be given in cases of cholera, dysentery/shigellosis
and campylobacteriosis (Dutta et al., 2003). Doxycycline/ Tetracycline, both are used in the
treatment of Cholera. Coterimoxazole suspension (240mg/5ml) is commonly prescribed
drugs for shigella dysentery (Ravi et al., 2004). Although the severity of symptoms caused by
these enteropathogens can be reduced with antibiotics, in this era of the 21th century, majority
are becoming resistant to the latest antibiotics (Reda et al., 2011).
Stool culture and microscopy are very important in identifying enteropathogens in the
management of diarrhoea, particularly during outbreak investigations (WHO, 2005).
Guidelines from physician groups and public health agencies also promote the use of
diagnostic stool cultures when prescribing antibiotics for childhood diarrhea (Guerrant et al.,
2001). It is known that antimicrobial treatment that is tested and properly selected using stool
culture has the advantages of reducing the emergence of resistant strain as well as minimizing
the risk of over-dose (El-Astal, 2005).
Hence, one way to control and lessen the burden caused by infectious diarrhoea can be
achieved through the use of diagnostic stool culture for identifying common enteric
pathogens and the development of antibiotic profile for early and better treatment. Assessing
associated factors of diarrhoea is important to know the source of the outbreak and thereby
limiting the spread of these enteropathogens (UNICEF/WHO, 2009). In addition, Programme
planning and implementation needs to be adjusted to the specific requirements and needs of a
local setting (IOM, 2009). Thus, understanding nature of the problem, its magnitude and
distribution among children at the study area is the key in designing strategies in the
prevention and control of childhood diarrhoea.
2
1.2 Statement of the Problem
Childhood diarrhoea, caused by a host of bacterial, viral and parasitic pathogens, is the
second leading cause of child mortality and morbidity in the world (UNICEF, 2012). Despite
major advance in prevention and treatment, each year nearly 1.7 billion cases of diarrhoea
occurred (WHO, 2013). Childhood diarrhoea accounted for 700,000 deaths among under
five children worldwide and the highest mortality rate occurred in Sub-Saharan Africa and
Southeast Asia (Bhutta et al., 2013). This is because children living in poor or remote
communities are most at risk and evidence shows children are dying from this preventable
disease because effective interventions are not provided equitably across all communities
(WHO/UNICEF, 2013).
In addition to the high burden of mortality, the effect diarrhoea in children are many,
including concomitant infections, recurrent diarrhoea, failure to thrive as well as school
performance (frequent absenteeism from school), increased cost for medical expenses, and
other socio and emotional problems (Alvin et al.,2013).
In Ethiopia, diarrhea is the second leading cause of morbidity and mortality among under five
children (Global Burden of Disease, 2010). In addition, the emergence of antibiotic resistant
enteric bacterial strain is becoming major medical and public health problem (Asrat, 2008).
According to the report of study conducted in Harar, Shigella sp showed high resistance
against Amoxicillin (100), Ampicillin (100%) and Tetracycline (70.6%) (Reda et al., 2011).
Similar study reported that the most strains of Shigella sp in Ethiopia was resistant to
Erythromycin (100.0%), Tetracycline (97.3%), Cephalothin (86.7%), Ampicillin (78.7%),
Chloramphenicol (74.7%) and Sulfonamide (54.7%) (Asrat, 2008). This is because antibiotics
are frequently used inappropriately and this leads to adverse outcomes, increased costs, and
drug resistance due to very fast arising and spread of mutant strains of enteric bacteria that
are insusceptible to treatment (El-Astal, 2005). The increasing antibiotic resistance because
of overuse and misuse of antibiotics for the treatment of diarrheal diseases in developing
countries is becoming an alarming issue (Reda et al., 2011).
3
Despite the current effort in the prevention and control of childhood diarrhoea, data showed
that the prevalence of bloody diarrhoea increased in Dire Dawa (EDHS, 2011). Although
early diagnosis followed by immediate and adequate therapy is essential to treat diarrhoea, in
Dire Dawa and most regions of Ethiopia, antibiotic treatment is largely empiric. There is also
information gap identified in the study area: information about common bacterial causes of
diarrhoea, their antibiotic profile and associated factors not available. The high prevalence of
infectious diarrhoea and the emergence of resistant bacteria to common antibiotics though
necessitate identifying common enteric bacteria and testing their antibiotics susceptibility, no
previous study conducted in Dire Dawa. However, few studies approach the problem only by
focusing on the prevalence and determinants of diarrhoea. Thus, in order to effectively
prevent diarrhea, it is imperative that the common etiological agents, their antibiotic
susceptibility pattern and associated factors should be identified first (Ansari et al, 2012).
Therefore, this study aimed to identify the bacterial cause of diarrhoea, antibiotic
susceptibility pattern and associated factors among children under age of five years at DilChora Referral Hospital.
4
1.3 Significance of the Study
The finding of this study expected to provide important information about common bacterial
cause of childhood diarrhoea, their antibiotic sensitivity and resistance pattern and local risk
factors. The data obtained from drug sensitivity test will help and guide other health care
workers to select the best antibiotics for diarrhoea treatment, helps to minimize inappropriate
use of antibiotics so that the emergence of multi-drug resistant strain of enteric bacteria will
be reduced. In addition it will also guide Drug Therapeutic Committee (DTC) in the
distribution of essential antibiotics among the health facilities. Identification of pathogens and
risk factors, and then recommendations of simple, immediate, and effective risk-reduction
measures will help local health care services to reduce morbidity and mortality due to
diarrhea among children <5 years in the area.
1.4. Objectives
1.4.1 General Objective:
The objective of this study was to identify bacterial cause of diarrhoea, drug susceptibility
pattern and associated factors among under five children in Dire Dawa from February 20March 30/2015.
1.4.2 Specific Objectives:
1. To identify common bacterial cause of diarrhea among under five children.
2. To determine the antibiotic sensitivity and resistance pattern of the bacterial isolate.
3. To assess associated factors of bacterial cause of diarrhoea.
5
2. LITERATURE REVIEW
2.1. Review of Studies on Prevalence of Common Bacterial Cause of Diarrhoea
A hospital based cross sectional study was conducted on prevalence and etiology of diarrhoea
among under five children in Tikrit, Iraq (2004 to 2005). It was reported that the prevalence
was 32.4% and the most commonly isolated microbial agent was EPEC (25.9%), followed by
C. difficile (21.0%). Bacterial infectious agents were the most common cause of infectious
diarrhoea accounting 67.9% isolates. Single infectious agents caused 63.1% of the cases,
while mixed infections were detected in 16.7% (Alrifai et al., 2009).
Another study conducted on bacterial etiology of acute diarrhoea among children under age
of five in Nepal (2011) indicated that the prevalence of Shigella sp was 4.6% followed by E.
coli 2.3% and Salmonella sp 1.9%. In this study Shigella sp was the only pathogen
significantly associated with diarrhea (Ansari .et al., 2012).
Similar study done by Jeevan et al in Nepal (2009) indicates that overall prevalence of
pathogenic bacteria was 57/285 (20%). Among the pathogenic bacteria isolated, the
predominant
bacteria
were Shigella
sp(36.8%), Vibrio
sp (26.3%), E.coli (22.8%)
and Salmonella sp (14.03%) respectively. It was concluded that the infection was peak in
children under 2 years of age and was highest in rainy season (Jeevan et al., 2009).
Different Studies conducted in developing countries indicated that 50-60% diarrhoeal cases
are of bacterial origin of which Enteropathogenic E.coli (EPEC) accounts 25%, C. jejuni 1018%, Salmonella and Shigella sp accounts 5% each (Elliott, 2007; Naghipour, 2008). In
Botswana (1998), 21% Shigella and 3% Salmonella sp was isolated from children under 5
years (Urio et al., 2001). Another study conducted in Nepal (2004) reported that the incidence
of Vibrio cholerae O1 to be 42.2% (Roshani, 2007) and 0.07% in Kenya (2007 to 2008)
(Willie, 2012) while Enteropathogenic E. coli (25.9%) and Cl.difficile (21.0%) isolated in
Tikrit, Iraq (2004 to 2005) (Alrifai, 2009). A study in Kenya conducted from 2007 to 2008
stated that 17.7% enteropathogens were identified, among these pathogenic E. coli accounts
11.2%, Salmonella 3.5%, Shigella 2% and V. cholerae O1 0.7% (Willie et al 2012).
6
A hospital based cross-sectional study conducted at Hawassa in 2011 indicated that
35(22.2%) bacterial pathogens were isolated. The isolated bacteria were Campylobacter sp
20 (12.7%), Shigella sp 11 (7.0%), and Salmonella sp 4 (2.5%) (Mulatu et al., 2014).
2.3. Drug Resistance Patterns of Common Bacterial Cause of Diarrhoea
In Nepal (2004), Tetracycline was found to be 100% effective antibiotics followed by
Norfloxacin and Ciprofloxacin to V. cholerae O1 (Roshani, 2007). Whereas, in 2011 in
Nepal, Chloramphenicol and Tetracycline showed efficacy in 90.0% isolates of Salmonella
sp, Gentamicin showed efficacy in 91.7% isolates of Shigella sp and Chloramphenicol
showed 100% efficacy against E.coli. Similarly 70.0% isolates of Salmonella sp were
resistant to ampicillin in vitro. MDR was highest 70.0% in Salmonella sp (Ansari .et al.,
2012).
In Botswana (1998), antibiograms of the predominant isolates showed that most Shigella sp
was resistant to Ampicillin but susceptible to Chloramphenicol, and Gentamicin. Salmonella
sp were susceptible to Chloramphenicol, Collistin-Sulphate, Gentamicin, Cotrimoxazole, and
Ampicillin (Urio et al., 2001). In Kenya (2008), the highest level of antimicrobial resistance
among E.coli isolates were observed in Ampicillin and Trimethoprim/Sulphamethoxazole
each at 95% followed by Tetracycline at 81% (Willie et al 2012).
In other similar study conducted in Madagascar (2008 to 2009) found that many E. coli and
Shigella isolates (around 80%) but fewer Salmonella isolates were resistant to Ampicillin and
Trimethoprim/Sulfamethoxazole. A small proportion of strains of each species were resistant
to Ciprofloxacin and only 3% of E. coli strains presented a resistance to third generation
Cephalosporins due to the production of extended-spectrum beta-lactamases. The resistance
of Campylobacter sp to Ampicillin was the most prevalent, whereas less than 5% of isolates
were resistant to each of the other antibiotics. The highest prevalence of antimicrobial
resistance was to Ampicillin and Trimethoprim/Sulfamethoxazole (Randrianirina et al. 2014).
According to Asrat (2008), the most strains of Shigella sp in Ethiopia was resistant to
Erythromycin (100.0%), Tetracycline (97.3%), Cephalothin (86.7%), Ampicillin (78.7%),
Chloramphenicol (74.7%) and Sulfonamide (54.7%) (Asrat, 2008). Moreover, Yismaw et al
7
(2006) in Gondar also revealed that there was high resistance of Shigella sp against
Ampicillin (79.9%), Tetracycline (86 %) and Cotrimoxazole (73.4%) (Yismaw et al., 2006).
In addition, a similar study done in Harar (2010) on drug susceptibility of Shigella sp showed
high resistance against Amoxicillin (100), Ampicillin (100%) and Tetracycline (70.6%)
(Reda et al., 2011), whereas resistance for Salmonella sp against Ampicillin (81.2%),
Cephalothin (86.4%), Chloramphenicol (83.7%), Erythromycin (100.0%), Gentamicin
(75.6%), Sulfonamide (81.1%), Tetracycline (94.5%) and Trimethoprim-Sulfamethoxazole
(75.7%) was reported by Asrat (2008) done in Ethiopia (Asrat, 2008). Likewise, the
resistance to Amoxicillin (100%), Ampicillin (100%), Tetracycline (71.4%) and
Chloramphenicol (62.3%) of Salmonellas spp was reported by Reda et al in 2010, Harar
(Reda et al., 2011).
A similar study in Hawassa (2011) indicated that the majority of the bacterial isolates such as
Campylobacter, Shigella and Salmonella spp were sensitive to Chloramphenicol,
Ciprofloxacin, Nalidixic acid and Cotrimoxazole and high rate of drug resistance was
observed against Erythromycin and Amoxicillin (Mulatu et al., 2014).
A health institution based cross sectional study was conducted on the prevalence of bacterial
and parasitic cause of diarrhoea in 2012, Jimma and 6 (2.3%) and 16 (6.2%) samples were
positive for Shigella and Salmonella spp respectively. Shigella sp showed hundred percent
resistances to Ampicillin, Amoxicillin, and Cotrimoxazole. All Salmonella isolates were
resistant against Amoxicillin. All Shigella and Salmonella sp were susceptible to Ceftriaxone,
Ciprofloxacin and Gentamycin (Beyene and Tasew, 2014).
Moreover, a study on antimicrobial susceptibility of Shigella sp in Hawassa (2000), indicated
the presence of high resistance against Gentamicin (96%), Nalidixic acid (90%), Ampicillin
(93%), Erythromycin (90%) and Tetracycline (90%). MDR Shigella isolates which showed
resistance to six antibiotics (Ampicillin, Erythromycin, Cephalothin, Chloramphenicol,
Tetracycline and Trimethoprim-sulfamethoxazole) has also been observed (Roma et al.,
2000). Another study conducted in Jimma (2004) on drug susceptibility profile of
Campylobacter sp reported that the isolates showed 50% and 60% resistance rate to
Ampicillin and Trimethoprim-sulfamethoxazole respectively (Beyene and Haile-Amlak,
2004).
8
2.4. Associated Factors of Bacterial Cause of Diarrhoea
It is widely recognized that exposure to diarrhoea pathogens in developing countries is
associated with the age of the child, quality and quantity of water, availability of toilet
facilities, housing conditions, household economic status, place of residence, feeding
practices, and the general sanitary conditions (personal or domestic hygiene) in the vicinity of
the house (Andualem, 2010; WHO/UNICEF, 2009; Wondwossen, 2008).
A study conducted in Nepal (2011) showed that bacterial infection was found to be of highest
(78.3%) in the age group between 6-24 months. Occurrence of bacterial pathogens in children
below 2 years of age was statistically significant than in those above 2 years of age. Boys had
higher diarrheal cases (64.2%) than girls (35.8%). Bacterial pathogen infected cases were
47.8% among male while it was 52.2% among female (Ansari et al., 2012). A similar study
conducted by Alrifai et al in Tikrit, Iraq (2004 to 2005) reported that the age group > 6–12
months was the age group most affected by nosocomial diarrhoea (30.9% of isolates),
followed by age group 1–6 months (25.9 % of isolates) (Alrifai et al., 2009).
In Ethiopia, many factors have been indicated to contribute for childhood diarrhoea, such as
history of maternal diarrhea illness, mode of feeding practice and nutritional status in
Shebedino District in 2013 (Alemu et al., 2014); latrine ownership, availability of home
based water treatment and source of water in Derash District in 2012 (Wanzahun, 2013);
while in 2013 in North Shoa Zone occupation of mothers (private workers), maternal history
of recent diarrhoea, living with cattle in one house, address (rural), feeding of gruel, feeding
of adult’s food for children, method of dipping to take water from water containers and water
storage container without cover had significant association with diarrheal diseases (Mamo
and Hailu, 2014). In 2010 Diarrhoea prevalence is highest among those children residing in
households that drink from unprotected wells (18%), and those residing in rural areas (14%)
(EDHS, 2011).
9
Conceptual Framework
Socio-demographic
 Age and Sex
of child
 Residence
of the child
Previous History of
Diarrhoea And
previous treatment
OUTCOME
Environmental
Factors



⁞
Bacterial cause of
diarrhoea and Drug
Resistance
water
source
Refuse
Disposal
Sanitation
Behavioral Factors


Hand washing
behavior of
child’s parents
Feeding practices
Figure-1: Conceptual Framework of Associated Factors for Bacterial Cause of Diarrhoea and
Drug Resistance pattern
10
3. MATERIALS AND METHODS
3.1. Study Area
The study was conducted in Dil-Chora Referral Hospital, Dire Dawa Administration. Dire
Dawa is one of the two chartered cities in Ethiopia. It is located in the eastern part of Ethiopia
which is 550 Km away from Addis Ababa, and it lies with a latitude and longitude of 9o36’N
41o52’E. The administration has nine urban and thirty eight rural kebeles. Based on the 2007
Census conducted by the Central Statistical Agency of Ethiopia (CSA), Dire Dawa has a total
population of 342,827. Of whom, 171,930 were men and 170,897 women; 232,854 (69.92%)
of the population are considered urban inhabitants, with an estimated area of 1,231.20 square
kilometers (CSA, 2007).
Currently the Administration has six hospitals (2 governmental, 3 private and 1 EthioDjibouti hospitals), 16 health centers, 34 health posts, and 32 private clinics. As referral
hospital, Dil-Chora has no demarcated catchment area and it gives referral service for all
eastern Ethiopian populations. The hospital has an emergency, central and microbiology
referral laboratory staffed with 10 laboratory technologists and 7 laboratory technicians.
Central laboratory and Microbiology department gives service to the hospital and the
referring health facility found in and around Dire Dawa. The pediatric unit, consisting of two
pediatrician, one clinician and 10 clinical nurses, gives outpatient and inpatient service as
well as oral rehydration therapy (ORT) for severely dehydrated patients. According to 2014
estimates of CSA, the total number of under five child population is 12.14% and the
prevalence of diarrhoea among children under the age of five years is 9.4% with 3 diarrhoeal
episodes (CSA, 2014 Unpublished).
3.2. Study Period
The study was conducted in Dire Dawa, Dil-Chora Referral Hospital pediatric unit from
February 20 to March 30, 2015.
3.3. Study Design
A hospital based cross-sectional study was conducted using pre-tested and structured
questionnaire.
11
3.4. Population
3.4.1. Source Population
All children under the age of five years visiting Dil-Chora Referral Hospital
3.4.2. Study population
Children under age of five years who have diarrhea and available during data collection
period
3.4.3. Inclusion and Exclusion Criteria
Children less than five years of age with diarrhoea and who had not taken any antibiotic in
the past five days for the disease was included in the study. Thus either medical records or
parents of the child were used to check whether the child took antibiotic or not. Those
children who did not fulfill the above criteria and whose parents not volunteer to participate
in the study were excluded.
3.5. Sampling
3.5.1. Sample Size Determination
The sample size for this study was calculated using the formula for estimation of single
n= z2 x p (1-p)/ r2
proportion (Kelsey et al., 1996)
Where: P is the prevalence of campylobacter species (12.7%) among under five children
taken from previous study conducted in Hawassa town (Mulatu et al., 2014); Z value is 95%
confidence level which is 1.96; and r is the 5% margin error of estimation.
Thus n= (1.96)2x 0.135(1-0.135)/ (0.05)2
n= (3.8416) x (0.11087)/ (0.0025)
n= 170.36≈ 171
Adding 10% contingency for non-response rate makes the total sample size n = 171+17= 188
This Table displays isolated bacteria among under five children in Hawassa town (Mulatu et
al., 2014) and used in this study for calculating the sample size
Bacterial pathogens
Campylobacter sp
Shigella sp
Salmonella sp
Frequency (%)
20 (12.7%)
11 (7.0%)
4 (2.5%)
12
Sample size (n= z2 x p (1-p)/ r2)
170
100
38
For the specific objective 3: sample size and power for cross sectional study was calculated
using Epi-info version 7.1.0.6; taking confidence interval (confidence level or 1-α) = 95%;
power (1-β) = 80%; ratio (unexposed to exposed) = 1:1; prevalence of enteropathogenic E.
coli causing diarrhoea in unexposed children 10% (unexposed= previous history of
diarrhoea), and AOR closest to 1= 2.1 (Jan, 2007). Thus the calculated sample size was 170.
Adding 15% contingency for non-response rate, the final sample size was 170+26= 196. The
final sample size for third objective was larger than the previous one, so 196 taken.
3.5.2. Sampling Procedure
Eligible participants who fulfilled the inclusion criteria were included consecutively until the
sample size reached 196.
3.6. Data Collection
A face to face interview using structured questionnaires was employed to collect primary data
among the participating under five children. The questionnaire was adapted from previous
study conducted in prevalence of enteric bacteria among under five children (Mulatu et al.,
2014). This questionnaire provides detailed background information, clinical and laboratory
data useful for the study. The questionnaires was translated by language experts to Amharic,
Afan Oromo and Somale language then back to English by another person to ensure
consistency. One clinical nurse and one laboratory technologist were assigned as interviewer
and stool sample collector respectively. The principal investigator gave two days training to
data collectors about the questionnaire and data collection techniques. Then the questionnaire
was pre-tested at Sabian Primary Hospital on 5% of the total sample size which did not
included as part of the study group before the start of data collection. Data collection was
conducted from February 20 to March 30/2015. After written informed consent obtained
from the parents or guardians of the child, background information useful for the study was
asked and collected in a form of questionnaire.
3.7. Screening and Identification of Bacterial Agents Causing Diarrhoea
3.7.1. Stool Sample Collection
Fresh stool sample and/or rectal swab were collected, placed immediately into screw capped
Cary Blair transport media (PARK, Northampton) and transported to Microbiology
Laboratory of Dil-Chora Referral Hospital for isolation and identification of enteric bacteria.
13
3.7.2. Inoculation and Incubation
The stool sample was inoculated on MacConky agar (PARK, Northampton), Selenite-F-broth
(PARK, Northampton), Salmonella and Shigella agar (PARK, Northampton) using streak
plate method following the Standard Microbiological techniques and procedures
(Cheesbrough, 2006). All culture plates were incubated aerobically for 18 to 24 h at 37oC.
Desoxycholate Citrate Agar (PARK, Northampton) was used to subculture from Selenite-F
broth and further incubated aerobically for 24h at 37oC. The aseptic condition, purity plate
and quality control were maintained throughout the experiment.
3.7.3. Isolation and Identification
All positive stool cultures were identified by their physical characteristics such as colony
morphology and using Gram stain. Then it was further confirmed by the pattern of
biochemical reactions using the standard procedures (Cheesbrough, 2006). Thus Gramnegative rods were identified with the help of a series of biochemical tests such as Kligler
Iron slant agar (KIA) (PARK, Northampton), Motility Indole Urea test (MIU) (PARK,
Northampton), and Oxidase test (PARK, Northampton) (Cheesbrough, 2006). To obtain the
true picture of biochemical tests, pure colonies obtained by sub-culturing on Nutrient broth
were used to maximize the process of identification, that is, morphologically identical
colonies of the suspected strains were taken from the agar plates and suspended in nutrient
broth. Then the suspensions were inoculated to the butt and slant of the biochemical testing
media. The inoculated media was incubated aerobically at 37°C and after overnight
incubation bacteria was identified following the standard flow chart.
3.7.4. Antibiotic Sensitivity Test
The antibiotic susceptibility patterns of the pathogens isolated from the clinical
specimen against different antibiotics was done on Mueller Hinton agar (MHA)
(PARKS, Northampton). The standard disk diffusion technique of modified KirbyBauer method was used as recommended by Clinical and Laboratory Standard Institute
(CLSI, 2014). For disk diffusion testing, antibiotics such as Amoxicillin (30 μg),
Ampicillin (10 μg), Ceftriaxone (5 μg), Chloramphenicol (30 μg), Ciprofloxacin (5 μg),
Cotrimoxazole (23.75/1.25 μg), Gentamycin (10 μg), and Nalidixic acid (30 μg) were
used. Three to five colonies of bacteria from pure culture were
picked with an
inoculating loop and transferred into a tube containing 5ml nutrient broth and mixed
14
gently until a homogenous suspension formed and incubated at 37oC for 3-5 h until the
turbidity of the suspension adjusted to a density of 0.5 McFarland standards, which
yield a uniform suspension containing 105-106 cells/ml. Using a sterile non-toxic dry
cotton swab, the standardized inoculums were streaked on the entire surface of MuellerHinton agar plate three times, turning the plate at 60º angle between each streaking to
ensure even distribution. The inoculums were allowed to dry for 5-15 min. and the
selected antibiotic disk were applied onto the plates at a distance of 15 mm away from
the edge and 24 mm apart from each other. After incubating the plates at 37oC for
overnight, diameters of the zone of bacterial growth inhibition around the disk was
measured to the nearest millimeter and the susceptibility or resistance to the agent in
each disk was determined and the isolates were classified as sensitive, intermediate or
resistant according to the standardized Table provided by the manufacturer (CLSI,
2010). In this study isolated bacteria that was resistant to at least two or more than two
groups of antimicrobial agents are regarded as multi-drug resistant (MDR) (Pokharel,
2006).
3.8. Study Variables
3.8.1. Dependent/ Outcome variable
Bacterial cause of diarrhoea and drug resistance pattern
3.8.2. Independent/ Explanatory Variables
Socio-demographic variables like age and sex of child, place of residence
Environmental variables like type of water source, availability of latrine, refuse disposal
Behavioral variables like hand washing practice, feeding practices
Clinical data like previous history of diarrhoea and treatment, presence of fever, nausea
3.9. Operational Definition of Variables
Bacterial diarrhoea: Type of diarrhoea caused by enteric bacteria that invade and colonize
host tissue as clinically diagnosed based on symptoms and confirmed by isolation and
identification of these bacteria using stool culture.
Susceptible (S): The “susceptible” category implies that isolates are inhibited by the usually
achievable concentrations of antimicrobial agent when the dosage recommended to treat
the site of infection is used.
15
Intermediate (I): The “intermediate” category includes isolates with antimicrobial agent MICs
that approach usually attainable blood and tissue levels, and for which response rates
may be lower than for susceptible isolates. The intermediate category implies clinical
efficacy in body sites where the drugs are physiologically concentrated (eg, quinolones
and β-lactams in urine) or when a higher than normal dosage of a drug can be used (eg,
β-lactams).
Resistant (R): The “resistant” category implies that isolates are not inhibited by the usually
achievable concentrations of the agent with normal dosage schedules, and/or that
demonstrate MICs or zone diameters that fall in the range where specific microbial
resistance mechanisms (eg, β-lactamases) are likely, and clinical efficacy of the agent
against the isolate has not been reliably shown in treatment studies.
Improved water sources: included household connections, public standpipes, protected dug
wells, protected springs. Water sources that are considered as "unimproved" are:
unprotected dug wells, unprotected springs. An “Improved” source is one that is likely to
provide "safe" water.
Proper disposal: is a way of disposal refuses that which included burning, burying in a pit or
storing in a container and disposing in designed site, whereas disposing in open fields
considered as improper disposal method.
3.10. Data Quality Control
The principal investigator gave two days training to data collectors about the questionnaire
and data collection techniques. Then the questionnaire was pre-tested on sample populations
which did not included in the study. The interviewer was submitted the collected data to the
supervisors on daily basis. The principal investigator performed the supervision of data
collection procedures on daily basis. Then the collected data was checked for completeness at
the end of data collection. During laboratory analysis of stool culture, standard operating
procedures were followed. Calibrated equipments were used for measuring reagents and all
other materials were checked for proper functionality. Culture media was prepared and
sterilized based on the manufactures instruction. Then the sterility of culture media was
checked by incubating 3–5% of the batch at 37°C overnight and observed for bacterial
growth. Finally, those media which showed any growth were discarded. The American Type
Culture Collection (ATCC) strains such as Escherichia coli ATCC 25922, Shigella flexneri
ATCC 12021, Salmonella typhimurium ATCC 13311 and Campylobacter jejuni ATCC
16
33560 obtained from Ethiopian Public Health Institute were used as a quality control during
stool culture, biochemical test and antimicrobial susceptibility testing.
3.11. Data Analysis
The Collected data was checked for completeness, coded, entered and cleaned using Epi-Data
version 3.02. Analysis of data was done using SPSS version 16. Descriptive statistics such as
frequency, percentage and cross tabulation was used to present the findings. Multivariate
analysis was performed using stepwise logistic regression techniques to evaluate whether
individual predictors of interest were independently significantly associated with the
outcomes of interest. In order to reduce excessive number of variables and resulting
instability of the model, only variables with significance P< 0.25 in the bivariate analysis
were considered for inclusion in the multivariable analysis. Variables with P < 0.05 in the
multivariable analysis were considered significant.
3.12. Ethical Considerations
Institutional ethical clearance was first sought from Institutional Health Research Ethics
Review Committee, Haramaya University, College of Health and Medical Sciences. Data was
collected after written consent from Dire Dawa Regional Health Bureau. During data
collection each participant was informed about the aim of the study. The data collectors had
discussed the issue of confidentiality and asked for written consent before the start of data
collection. Participants were informed that they have full right to refuse or discontinue
participating in the research. Based on the result of stool culture and AST, appropriate
treatment was given to the participated under five patients. The cost of treatment was covered
by the principal investigator.
3.13. Data Dissemination
The findings of this research will be submitted to Haramaya University, Dire Dawa health
bureau and Dil-Chora Referral Hospital and to other concerning bodies working on
prevention and control of childhood diarrhoea.
17
4. RESULTS
A total of 196 under five children with diarrhoea were included in this study with a response
rate of 100%. Of these participated children 125(63.8%) were from DCRH pediatric OPD
and Wards and the rest 71(36.2%) were from pediatric Emergency Triage.
Out of the 196 study participants, 105 (53.6%) were males and 91 (46.4%) were females with
an overall male to female ratio of 1:0.87. Regarding age of the study participants, 35 (17.9%)
were younger than 6 months, 60 (30.6%) were between 6 to 24 months, 49 (25.0%) were
between 25 to 36 months, and the rest 28 (14.3%) and 24 (12.2%) were in the age group of 37
to 48 months and 49 to 60 months respectively (Figure- 2). Majority of the participated under
five children were urban dwellers 104 (53.1%) while 92 (46.9%) were rural dwellers.
70
60
Male
60
50
40
35
22
21
Total
38
30
20
Female
49
23
28
26
24
16
14
12
11
13
10
0
< 6 months
6-24 months
25-36 months
37-48 months
49-59 months
Figure – 2: Age and Sex Distribution of Study Participants
18
4.1. Prevalence of Enteric Bacteria
Stool specimens from 196 under five children with diarrhoea were examined using culture
methods and a total of 43/196 (21.9%) enteric bacterial pathogens were identified. Of these
43 enteric bacteria, 25 (12.8%) were E. coli, 11 (5.6%) were Shigella sp, and the remaining 7
(3.6%) were Salmonella sp as confirmed by biochemical tests (Table-1).
The distribution of these enteric pathogens according to the different age groups, gender and
residence is listed in Table-1. Majority, 7(20.0%) children of age less than 6 months,
12(13.2%) female children and 15(16.3%) children from rural residence were positive for E.
coli infection. Likewise, 5(8.3%) children in the age group 6-24 months were infected with
Shigella sp. Higher positivity was observed among males 8(7.6%) and children from rural
residence 9(9.8%). On the other hand, culture positivity of Salmonella sp was higher in the
age group 49-59 months, among males and those from urban areas with a percentage of
12.5%, 4.8% and 4.8% respectively. Culture positivity of E. coli showed association with
rural residence (p =0.161). Likewise, residence and sex showed significant association with
Shigella sp (p = 0.017) and (p =0.190), respectively. But, no association was observed with
positivity of Salmonella sp.
Table-1:- Distribution of E. coli, Shigella and Salmonella sp with demographic characteristics
among under five children with diarrhea at Dil-Chora Referral Hospital from
February to March 2015, Dire Dawa, Eastern Ethiopia.
Demographic
E. coli (n=25)
Shigella sp (n=11)
Salmonella sp (n=7)
variables
Pos (%) Neg (%)
Pos (%) Neg (%)
Pos (%) Neg (%)
7(20.0)
28(80.)
1(2.9)
34(97.1)
2(5.7)
33(94.3)
Age in
<6
months
Sex
Residence
6-24
8(13.3)
52(86.7)
5(8.3)
55(91.7)
2(3.3)
58(96.7)
25-36
6(12.2)
43(87.8)
4(8.2)
45(91.8)
0(0.00)
49(100)
37-48
2(7.1)
26(92.9)
0(0.00)
28(100)
0(0.00)
28(100)
49-59
2(8.3)
22(91.7)
1(4.2)
23(95.8)
3(12.5)
21(87.5)
Male
13(12.4)
92(87.6)
8(7.6)
97(92.4)
5(4.8)
100(95.2
Female
12(13.2)
79(86.8)
88(96.7)
2(2.2)
89(97.8)
Urban
10(9.6)
94(90.4)
3(3.3)
p =.190
2(1.9)
102(98.1
5(4.8)
99(95.2)
Rural
15(16.3) 77(83.7)
p =.161
9(9.8)
p = .017
83(90.2)
2(2.2)
90(97.8)
p < 0.25
19
Considering clinical findings, 23(15.5%), 20(13.6%), 20(19.4%), and 17(11.4%) of E. coli
were detected among children with symptoms of vomiting, abdominal cramps, watery
diarrhoea and 1-5 days of diarrhoea duration respectively (Table- 2). However, only children
who had vomiting and watery diarrhoea were associated with positivity of E. coli (p = 0.05)
and (p = 0.009) respectively. Likewise, Shigella sp was isolated from children who had
symptoms of abdominal cramps 10(6.8%), nausea 8(7.2%) and vomiting 9(6.1%). Higher
culture positivity was detected from bloody diarrhoea 6(26.1%) than watery 2(1.9%) and
mucoid diarrhoea 3(4.3%). In addition, 10(6.7%) of the isolates were detected from children
with 1-5 days duration of diarrhoea and only 1(2.2%) isolated from diarrhoea cases with 6-10
days of duration (Table- 2). However, only bloody diarrhoea showed significant association
with isolation rate of Shigella sp (p = 0.006). High positivity of Salmonella sp was observed
among children who had vomiting 6(4.1%), fever 5(4.1%) and abdominal cramps 5(3.4%).
Majority of Salmonella sp was detected from mucoid diarrhoea 5(7.1%) than watery 1(1.0%)
and bloody diarrhoea 1(4.3%), while 4(2.7%) isolated from 1-5 days duration of diarrhoea.
Except mucoid diarrhoea (p= 0.063), none of the clinical data showed association with
positivity of Salmonella sp.
Table-2:- Distribution of E. coli, Shigella and Salmonella sp with clinical data among under
five children with diarrhea at Dil-Chora Referral Hospital from February to March
2015, Dire Dawa, Eastern Ethiopia.
Clinical Data
E. coli (n=25)
Shigella sp (n=11)
Salmonella sp (n=7)
Pos (%) Neg (%)
Pos (%) Neg (%)
Pos (%) Neg (%)
Fever
Yes
14(11.6) 107(88.4) 7(5.8)
114(94.2) 5(4.1)
116(95.9)
No
11(14.7) 64(85.3) 4(5.3)
71(94.7) 2(2.7)
73(97.3)
Abdominal Yes
20(13.6) 127(86.4) 10(6.8)
137(93.2) 5(3.4)
142(96.6)
cramps
No
5(10.2)
44(89.8) 1(2.0)
48(98.0) 2(4.1)
47(95.9)
Nausea
Yes
14(12.6) 97(87.4) 8(7.2)
103(92.8) 3(2.7)
108(97.3)
No
11(12.9) 74(87.1) 3(3.5)
82(96.5) 4(4.7)
81(95.3)
Vomiting
Yes
23(15.5) 125(84.5) 9(6.1)
139(93.9) 6(4.1)
142(95.9)
p = .05
No
2(4.2)
46(95.8) 2(4.2)
46(95.8) 1(2.1)
47(97.9)
Type of
Watery 20(19.4) 83(80.6) 2(1.9)
101(98.1) 1(1.0)
102(99.0
diarrhoea
p = .009
Bloody 2(8.7)
21(91.3) 6(26.1)
17(73.9) 1(4.3)
22(95.7)
p = .006
Mucoid 3(4.3)
67(95.7) 3(4.3)
67(95.7) 5(7.1)
65(92.9)
p = .063
Diarrhoea
1-5 day 17(11.4) 132(88.6) 10(6.7)
139(93.3) 4(2.7)
145(97.3)
duration
6-10
8(17.4)
38(82.6) 1(2.2)
45(97.8) 3(6.5)
43(93.5)
p < 0.25
20
Of the twenty five children who drunk from unimproved water source, 6(24.0%) were
positive for E. coli compared to those children who drunk from improved water source
19/168 (11.1%) (p= 0.071). Although, the variation was not statistically significant, culture
positivity of E. coli was relatively higher among children whose family improperly disposed
child’s feces and household refuses with a percentage of 15.4% and 17.30% respectively.
Among 25 children who drank from unimproved water sources like river, 4(16.0%) were
positive for Shigella sp. High culture positive rate of Shigella sp (11.8%) was observed
among children whose parents improperly disposed their household refuses. Similarly,
4/20(20.0%) of children whose parents did not wash their hands after toilet use were infected
by Shigella sp relative to 7/178(4.0%) children whose parents wash their hands. However,
water source for drinking and hand washing after toilet use showed associated with culture
positivity of Shigella sp (p= 0.016) and (p= 0.003) (Table- 3).
Higher positivity rate of Salmonella sp was also observed among children who drank from
unimproved water sources 2(8.0%), children whose parents had no latrine (4.8%) and
improperly disposed household refuses (5.9%). Similarly, 4(20.0%) of Salmonella sp was
detected from children whose family did not wash their hands after using toilet. Of the eleven
children whose parents did not wash their hand before feeding the child, 1(9.1%) was
infected by Salmonella sp compared to 6/185(3.2%) of children whose parents always wash
their hand. Likewise, 4(6.1%) of children who had not taken measles vaccination were
infected with Salmonella sp. However, only children who drank from unimproved water
sources, whose parents did not wash their hand after toilet use and who had not taken measles
vaccination were associated with Salmonella sp (p= 0.221), (p = 0.001) and (p = 0.187) as
shown in Table- 3 below.
21
Table-3:- Distribution of E. coli, Shigella and Salmonella sp with environmental
characteristics among under five children with diarrhea at Dil-Chora Referral
Hospital from February to March 2015, Dire Dawa, Eastern Ethiopia.
Environmental and
E. coli (n=25)
Shigella sp (n=11) Salmonella sp (n=7)
Behavioral Variables
Pos (%) Neg (%) Pos (%) Neg (%)
Pos (%) Neg (%)
Unimprov
Type of water
6(24.0) 19(76.0)
4(16.0) 21(84.0)
2(8.0) 23(92.0)
source
Improved 19(11.1) 152(88.9) 7(4.1) 164(95.9
5(2.9) 166(97.1
p= .071
p= .016
p= .221
Availability of Yes
18(13.4) 116(86.6) 9(6.7)
125(93.3) 4(3.0)
130(97.0)
latrine
No
7(11b.3) 55(88.7) 2(3.2)
60(96.8) 3(4.8)
59(95.2)
child’s feces
improper 6(15.4)
33(84.6) 2(5.1)
37(94.9) 1(2.6)
38(97.4)
disposal
proper
19(12.1) 138(87.9) 9(5.7)
148(94.3) 6(3.8)
151(96.2)
Refuse
improper 3(17.7)
14(82.3) 2(11.8) 15(88.2) 1(5.9)
16(94.1)
disposal
proper
22(12.3) 157(87.7) 9(5.0)
170(95.0) 6(3.3)
173(96.7)
Hand washing No
2(10.0)
18(90.0)
4(20.0) 16(80.0)
4(20.0) 16(80.0)
after toilet use Yes
23(13.1) 153(86.9) 7(4.0) 169(96.0
3(1.7) 173(98.3
p= .003
p = .001
Hand washing No
2(18.2)
9(81.8)
1(9.1)
10(90.9) 1(9.1)
10(90.9)
before feeding Yes
23(12.4) 162(87.6) 10(5.4) 175(94.6) 6(3.2)
179(96.8)
History of
Yes
23(12.9) 156(87.1) 10(5.6) 169(94.4) 6(3.3)
173(96.7)
diarrhoea
No
2(11.8)
15(88.2) 1(5.9)
16(94.1) 1(5.9)
16(94.1)
vaccinated
measles
Yes
17(13.0)
114(87.0) 7(5.3)
124(94.7)
3(2.3)
128(97.7
No
8(12.3)
57(87.7)
61(93.8)
4(6.1)
p = .187
61(93.9)
4(6.2)
p < 0.25
4.2. Antibiotic Susceptibility Pattern of Bacterial Isolate
All the isolated bacterial pathogens were subjected to antimicrobial susceptibility tests using
disk diffusion method. As it is displayed in Table-4 below, none of the isolates of E. coli,
Shigella and Salmonella sp were resistant to Ceftriaxone. But, for other antibiotics different
resistance pattern was observed. Accordingly, E. coli showed 56.0% and 52.0% resistance
against Amoxicillin and Ampicillin. Lower resistance rate was observed against
Ciprofloxacin, Gentamicin and Nalidixic acid (4.0% each) respectively. Likewise Shigella sp
showed high resistance against Amoxicillin (100%), Ampicillin (90.9%) and Cotrimoxazole
(72.7%) while low resistance rate was observed against Nalidixic acid (18.1%) and
Ciprofloxacin (9.1%). The overall rate of resistance of Salmonella sp was higher for
Ciprofloxacin (57.2) and Amoxicillin (85.7%) followed by Ampicillin (71.4%). Twenty-eight
percent resistance rate were observed against Cotrimoxazole and lower resistance rate was
observed against Chloramphenicol (14.3%), Gentamicin (14.3%), and Nalidixic acid (14.3%)
(Table- 4).
22
Table- 4: Antimicrobial sensitivity and resistant pattern of bacteria isolate among children
under age of five years at Dil-Chora Referral Hospital from February to March
2015, Dire Dawa, Eastern Ethiopia.
Antibiotics
E.coli
No. (%)
Shigella sp
No. (%)
Salmonella sp
No. (%)
AMP
R
I
S
13(52.0)
7(28.0)
5(20.0)
10(90.9)
1(9.1)
0(0.00)
5(71.4)
2(28.6)
0(0.00)
AMC
R
I
S
14(56.0)
6(24.0)
5(20.0)
11(100.0)
0(0.00)
0(0.00)
6(85.7)
0(0.0)
1(14.3)
C
R
I
S
6(24.0)
8(32.0)
11(44.2)
5(45.4)
3(27.3)
3(27.3)
1(14.3)
2(28.6)
4(57.1)
CRO
R
I
S
0(0.00)
1(4.0)
24(96.0)
0(0.00)
1(9.1)
10(90.9)
0(0.00)
3(42.9)
4(57.1)
CIP
R
I
S
1(4.0)
5(20.0)
19(76.0)
1(9.1)
6(54.6)
4(36.3)
4(57.2)
2(28.6)
1(14.3)
GM
R
I
S
1(4.0)
5 (20.0)
19(76.0)
3(27.3)
0(0.0)
8(72.3)
1(14.3)
1(14.3)
5(71.4)
NA
R
I
S
1(4.0)
5(20.0)
19(76.0)
2(18.1)
3(27.3)
6(54.6)
1 (14.3)
1 (14.3)
5 (71.4)
SXT
R
I
S
4(16.0)
8(32.0)
13(52.0)
8(72.7)
2(18.2)
1(9.1)
2(28.6)
2(28.6)
3(42.8)
AMP = Ampicillin, CRO = Ceftriaxone, NA = Nalidixic acid, AMC = Amoxicillin,
C = Chloramphenicol, GM =Gentamicin, SXT = Cotrimoxazole, CIP = Ciprofloxacin
A total of 13, 9 and 6 distinct antibiograms (resistance pattern) were found among all isolates
of E. coli, Shigella and Salmonella sp as displayed on Table-3 below. Accordingly, 5(20.0%)
of E. coli were resistant to three antimicrobial agents, 10(40.0%) to two and 5(20.0%)
showed to one ABCs agents. All Shigella sp were found to be multiple drug resistant, while
5(20.0%) E.coli and 1(14.3%) Salmonella sp showed no resistance against the tested
antibiotics. Of the total isolated Shigella sp, 1(9.1%), 4(36.4%) 5(45.5%) and 1(9.1%) were
23
resistant to two, three, four and five drugs respectively. Whereas, 4(52.7%) and 1(14.3%)
Salmonella sp showed MDR against three and four drugs.
Table-5: Antibiogram of bacterial pathogens isolated from under-five children with diarrhea
at Dil-Chora Referral Hospital from February to March 2015, Dire Dawa, Eastern
Ethiopia.
Number
of ABC
resistant
E. coli
No of
Resistance
isolates
Antibiogram
No (%)
Zero
5(20.0)
None
-
-
Salmonella
No of Resistan
isolates
ce
No (%) Antibio
gram
1(14.3) None
One
2(8.0)
1(4.0)
1(4.0)
1(4.0)
AMC
AMP
C
SXT
-
-
1(14.3)
-
AMC
Two
6(24.0)
1(4.0)
1(4.0)
1(4.0)
1(4.0)
AMC,AMP
AMC,C
AMC,SXT
AMP,SXT
C,SXT
1(9.1)
-
AMC,AMP
-
-
-
Three
3(12.0)
AMC,AMP,C
1(9.1)
AMC,AMP,C
1(14.3)
1(4.0)
AMC,AMP,CIP
2(18.2)
AMC,AMP,SXT
2(28.6)
1(4.0)
AMC,GN,NA
1(9.1)
AMC,C,SXT
1(14.3)
AMC,A
MP,C
AMC,A
MP,SXT
AMC,A
MP,CIP
-
-
1(9.1)
AMC,AMP,GN,NA
1(14.3)
AMC,A
MP,GN,
NA
-
-
2(18.2)
1(9.1)
1(9.1)
AMC,AMP,C,SXT
AMC,AMP,C,CIP
AMC,AMP,SXT,GN
-
-
Five
-
-
1(9.1)
AMC,AMP,SXT,
GN,NA
-
-
TOTAL
25(100.)
Four
No of
isolates
No (%)
11(100)
24
Shigella
Resistance
Antibiogram
7(100.)
-
4.3. Possible Associated Factors of Bacterial Diarrhoea
Multivariate analyses were carried out to identify the risk factors associated with infection of
E. coli, Shigella and Salmonella sp. According to the finding of this study, E. coli was
independently associated with vomiting and watery diarrhoea. More specifically, children
with symptoms of vomiting had 5.1 times more affected by E. coli than children without
vomiting (AOR= 5.1; 95%CI= (1.12, 23.47); p= 0.022). Similarly, the culture positivity of E.
coli was 6.9 times higher among children with watery diarrhoea than children with mucoid
diarrhoea (AOR= 6.9; 95%CI= (1.92, 24.39); p= 0.003).
Shigella sp was also independently associated with residence, bloody diarrhoea and washing
hands after toilet use. Thus, the culture positivity of Shigella sp was 5.7 times more likely
among children living in rural areas than those from urban areas (AOR= 5.7; 95%CI= (1.05,
31.62); p= .043). Likewise, children with bloody diarrhoea had 11.6 times higher infection
with Shigella sp than those children with mucoid diarrhoea (AOR= 11.6; 95%CI= (2.0,
71.60); p= .008). Children whose family wash their hands after toilet use had 90% less likely
to be infected with Shigella sp than children whose family did not washed their hands (AOR=
0.1; 95%CI= (.01, .53); p= .008).
Salmonella sp was only independently associated with washing hands after toilet use.
Therefore, the culture positivity of Salmonella sp was 94% less likely among children whose
family wash their hands after toilet use than those children whose family did not wash their
hands after toilet use (AOR= 0.06; 95%CI= (.01, .33); p= .008).
25
Table- 6: Multivariable analysis of risk factors for bacterial diarrhoea among under five
children at Dil-Chora Referral Hospital from February to March 2015, Dire Dawa.
E. coli (n=25)
Associated Factors
COR(95% CI)
AOR(95% CI)
pvalu
1
1.8(.77, 4.30)
1
1.1( .40, .95)
.889
Urban
Rural
Pos (%)
10(9.6)
15(16.3)
Neg (%)
94(90.4)
77(83.7)
No
Yes
23(15.5)
2(4.2)
125(84.5) 1
46(95.8) 4.2(1.0, 18.1)
1
5.1(1.12,23.47)
.022
Type of
diarrhoea
Mucoid
Watery
Bloody
3(4.3)
20(19.4)
2(8.7)
67(95.7)
83(80.6)
21(91.3)
1
6.9(1.92,24.39)
2.9(.445,19.24)
.003
.262
Type of water
source
unimproved
improved
6(24.0)
19(11.1)
19(76.0) 1
152(88.9) 0.4(.14, 1.11)
Residence
Vomiting
Sex
Residence
Male
Female
Shigella sp (n=11)
8(7.6)
97(92.4)
3(3.3)
88(96.7)
1
5.4(1.53, 18.87)
2.1(.33, 13.60)
1
0.4(0.11-1.6)
1
0.6(.19, 1.78)
.357
1
0.2(.03, 1.33)
.098
Urban
Rural
2(1.9)
9(9.8)
102(98.1 1
83(90.2) 5.5(1.16-26.3)
1
5.7(1.05, 31.6)
.043
Type of
diarrhoea
Mucoid
Watery
Bloody
3(4.3)
2(1.9)
6(26.1)
67(95.7) 1
101(98.1 0.4(.07, 2.72)
17(73.9)
7.9(1.79,34.79)
)
1
0.6(.08, 4.32)
11.6(2.0, 71.6)
.613
.008
Type of water
source
unimproved
improved
4(16.0)
7(4.1)
1
0.2(.06, .83)
1
1.1(.13, 9.14)
.599
Hand washing
after toilet use
No
Yes
4(20.0)
7(4.0)
21(84.0)
164(95.9
)
16(80.0)
169(96.0
)
1
0.2(.043, .63)
1
0.1((.01, .53)
.008
1
0.1(.01, 1.10)
0.6(.06, 6.72)
.061
.713
Salmonella sp (n=7)
5(7.1)
65(92.9) 1
1(1.0)
102(99.0 0.13( .01, 1.12)
1(4.3)
22(95.7) 0.6( .07, 5.34)
Type of
diarrhoea
Mucoid
Watery
Bloody
Type of water
source
unimproved
improved
2(8.0)
5(2.9)
23(92.0) 1
166(97.1 0.4(.06, 1.89)
1
0.17(.02, 1.80)
.836
Hand washing
after toilet
No
Yes
4(20.0)
3(1.7)
16(80.0) 1
173(98.3 0.07(.01, .337)
1
0.06(.01, .33)
.001
Measles
vaccination
No
Yes
4(6.1)
3(2.3)
61(93.9) 1
128(97.7 0.4(.08-1.65)
1
0.5(.07, 3.81)
.280
26
5. DISCUSION
This study investigated the bacterial cause of diarrhoea, their antibiotic susceptibility pattern
and socio-demographic, environmental and behavioral risk factors of bacterial diarrhoea
among under five children in Dil-Chora Referral Hospital. The finding of this study revealed
that a total of 43 enteric bacterial pathogens identified. The most frequently isolated bacteria
in this study was E. coli (25), followed by Shigella sp (11) and Salmonella sp (7). None of
the isolated E. coli, Shigella and Salmonella sp showed resistance against Ceftriaxone. E. coli
showed 56% and 52% resistance to Amoxicillin and Ampicillin. Similarly, 100%, 91% and
72% of Shigella sp were resistance to Amoxicillin, Ampicillin and Cotrimoxazole
respectively. Likewise, Salmonella sp showed resistance to Amoxicillin, Ampicillin and
Ciprofloxacin with a rate of 85%, 71% and 57%, respectively. E. coli was independently
associated with vomiting and watery diarrhoea, while Shigella sp was independently
associated with residence, bloody diarrhoea and washing hands after toilet use. Whereas,
Salmonella sp was only independently associated with washing hands after toilet use.
The overall prevalence of enteric bacteria isolated in this study (21.9%) is comparable with a
similar studies conducted in Hawassa (22.2%) (Mulatu et al., 2014), Jimma (22.3%) (Beyene
and Haile-Amlak, 2004), Gondar (20.9%) (World Gastroenterology Organization, 2008) and
other country such as Kenya (17.2%) (Willie et al 2012) and Nepal (20.0%) (Jeevan et al.,
2009). However, the prevalence is higher compared with previous studies conducted in
Butajira (15%) (Mengestu et al., 2014).
Globally, diarrhoea caused by enteropathogens remains the second leading cause of death
among children under five years of age (USAID, 2010; Ahs et al., 2010) and enteric bacteria
are among the major causes of diarrhea (Mitikie et al., 2000). In this study the dominant
bacterial pathogens isolated was E. coli (12.8%) which is comparable with previous study
conducted in Kenya 11.2% (Willie et al 2012). But, the prevalence is lower compared with
the studies done in Nepal (22.8%) (Jeevan et al., 2009) and Tikrit, Iraq (25.9%) (Alrifai et al.,
2009). The possible reason for such difference could be different geographical location and
study period.
Higher prevalence of Shigella sp was reported in Hawassa (20.1%) (Roma et al., 2000), other
countries like Botswana (21.0%) (Urio et al., 2001) and Nepal (36.8%) (Jeevan et al., 2009)
in contrast to the prevalence of this study (5.6%) which is supported by the studies conducted
27
in Jimma (5.0%) (Beyene et al., 2014), Gondar (5.2%) (Mitikie et al., 2000), Harar (6.7%)
(Reda et al., 2011), and other country such as Nepal (4.6%) (Ansari .et al., 2012).
The overall prevalence of Salmonella sp in this study was 3.6%. It is lower compared with
the findings of other similar studies conducted in Gondar (5.2%) (Mitikie et al., 2000), Jimma
(5.2%) (Beyene et al., 2014) and other country such as Nepal (14.03%) (Jeevan et al., 2009).
But it is comparable with the finding of studies done in Hawassa (2.5%) (Mulatu et al., 2014)
and other developing countries such as Kenya (3.5 %) (Willie et al 2012) and Botswana
(3.0%) (Urio et al., 2001).
Antimicrobial resistance by enteric pathogen is of major concern because of indiscriminate
use of drugs (Temu et al., 2007). In this study low frequency of E. coli resistance was
observed relative to Salmonella and Shigella sp. None of the isolated E. coli, Shigella and
Salmonella sp showed resistance for Ceftriaxone which is supported by the study conducted
in Jimma where all Salmonella and Shigella sp were 100% sensitive for Ceftriaxone (Beyene
and Tasew, 2014). High resistance rate of E. coli to Amoxicillin (56.0%) and Ampicillin
(52.0%) is somewhat comparable with the report of study done in Madagascar (80%)
(Randrianirina et al., 2014).
The development of high resistance of Shigella spp against the commonly used antibiotics
was witnessed by other investigators in different periods. In Hawassa high rate of resistance
of Shigella spp to Ampicillin (93%) and Cotrimoxazole (56%) was reported (Roma et al.,
2000), in Gondar high antibiotic resistance was documented against Ampicillin (79.9%) and
Cotrimoxazole (73.4%) (Yismaw et al., 2006). High resistance against Amoxicillin (100%)
and Ampicillin (100%) was also reported in Harar (Reda et al., 2011). The finding of this
study revealed that Shigella sp was 100% resistant to Amoxicillin, 91.0% to Ampicillin and
72.7% to Cotrimoxazole, and lower resistance rate, 9.1% and 18.2%, to Ciprofloxacin and
Nalidixic acid was observed. Comparable rate of resistance to Ciprofloxacin (8.3%) was
reported in Gondar (Yismaw et al., 2006), 100% resistance to Ampicillin and Amoxicillin
reported in Jimma (Beyene and Tasew, 2014). High resistant Shigella isolates to
Cotrimoxazole (72.7%) in this study is supported by the study done in Jimma (100%)
(Beyene and Tasew, 2014) and Gondar (73.4%) (Yismaw et al., 2006).
28
The finding of this study also revealed that a total of 13, 9 and 6 antibiograms were observed
by E. coli, Shigella and Salmonella sp. In addition, all isolated Shigella sp was found to be
multi-drug resistant. One (9.1%) Shigella isolate was found to be resistance for 5 antibiotics
while 36% and 45% of the isolates were resistant to three and four drugs respectively. A
similar finding was seen in previous studies in Ethiopia (Asrat, 2008). MDR Shigella isolates
which showed resistance to six antibiotics (Ampicillin, Erythromycin, Cephalothin,
Chloramphenicol, Tetracycline and Trimethoprim-sulfamethoxazole) reported in Hawassa
(Roma et al., 2000). Likewise, in this study resistance to five drugs (Amoxicillin, Ampicillin,
Cotrimoxazole, Gentamicin, and Nalidixic acid) was observed. This may be an alarming issue
because majority of drugs commonly prescribed in Ethiopia are now becoming less effective
due to the emergence of MDRs Shigella sp mainly due to inappropriate prescribing of these
drugs.
It is widely recognized that exposure to diarrhoeal pathogens in developing countries is
associated with the age of the child, quality and quantity of water, availability of toilet
facilities, housing conditions, place of residence, feeding practices, and the general sanitary
conditions (personal or domestic hygiene) in the vicinity of the house (Andualem, 2010;
WHO/UNICEF, 2009; Wondwossen, 2008). This study also tried to find possible associated
socio-demographic, environmental and behavioral factors of bacterial cause of diarrhoea.
Although significant association was not observed between age and sex of the child with the
isolated enteric bacterial pathogens, overall infection rate was higher among children of age
6-24 months (35%) and among male patients (60.5%). This finding can be supported by the
study conducted in Nepal where infection rate was higher in the age group of 6-24 months
and boys had higher diarrhoeal cases than girls (78.3%) (Ansari et al., 2012). High frequency
of E. coli (80.0%) was detected among children with watery diarrhoea and only 12% and 8%
E. coli was isolated from mucoid and bloody diarrhoea respectively. Similarly 92.0% of E.
coli was detected among children who had symptoms of vomiting. The culture positivity of
E. coli were 5 times more likely among children who had vomiting than children without
vomiting (AOR= 5.1; 95%CI= (1.12, 23.47); P= 0.022). Likewise, positivity of E. coli was
6.9 times more likely among children with watery diarrhoea than children with mucoid
diarrhoea (AOR= 6.9; 95%CI= (1.92, 24.39); P= 0.003).
29
Majority, 8(7.6%) of Shigella sp were detected among male patients than female 3(3.3%).
The distribution of Shigella sp among females and males was not statistically significant (p=
.098), which agrees with the study reported in Gondar (Mitikie et al., 2000) and Jimma
(Beyene and Haile-Amlak, 2004). Whereas, 9(9.8%) of Shigella positive cases were from
children in rural area and this finding is in line with the finding in Yemen (Hassan et al.,
2007). Infection with Shigella sp showed statistical significant association with rural
residence. Thus, culture positivity of Shigella sp was 5.7 times more likely among children
living in rural areas than those from urban areas (AOR= 5.7; 95%CI= (1.05, 31.62); P= .043).
This may be due to unprotected water source and presence of domestic animals in almost all
rural house hold.
In this study, Shigella sp was frequently isolated from children with abdominal cramps
(90.9%), vomiting (81.8%), from bloody diarrhoea (90.9%) and with 1-5 days duration of
diarrhea (90.9%). This is comparable with the study done in Butajira; abdominal pain
(77.5%) and fever (52.5%) (Mengistu et al., 2014). Culture positivity of Shigella sp showed
statistically significant association with bloody diarrhoea. Therefore, positivity of Shigella sp
was 11.6 times more likely among children with bloody diarrhoea than those children with
mucoid diarrhoea (AOR= 11.6; 95%CI= (2.0, 71.60); P= .008). Regarding hand washing
practice, among twenty children whose family did not wash their hands after toilet use
4(20.0%) were infected by Shigella sp compared with 7(4.0%) of the total 176 children
whose family wash their hands and this showed statistical significant association with
Shigella sp. Thus, culture positivity rate of Shigella sp was 90% less likely among children
whose family wash their hands after toilet use than children whose family did not wash their
hands (AOR= 0.1; 95%CI= (.01, .53); P= .008). The possible reason could be due to fecooral transmission of this bacterium from the parents to the child during feeding and/or
handling.
Salmonella sp was frequently detected from mucoid diarrhoea (71.4%) than watery (14.3%)
and bloody diarrhoea (14.3%). Isolation of Salmonella sp from mucoid diarrhoea is
comparable with the study done in Butajira (50.0%) (Mengistu et al., 2014) and Harar
(42.8%) (Reda et al., 2011). Similarly, the low isolation rate of Salmonella sp from watery
diarrhoea in this study (14.7%) is supported by the study done in Harar where Salmonella sp
was not detected from watery diarrhoea (Reda et al., 2011). The finding of this study also
30
revealed that from a total of 20 children whose family did not wash their hands after toilet
use, 4(20.0%) were infected with Salmonella sp compared to 3(1.7%) out of 176 children
whose family wash their hands, and this was significantly associated with Salmonella sp.
Therefore, culture positivity of Salmonella sp was 94% less likely among children whose
family wash their hands after toilet use than those children whose family did not wash their
hands (AOR= 0.06; 95%CI= (.01, .33); P= .008). The possible reason could be due to fecooral transmission of this bacterium from the parents to the child during feeding and/or
handling. However, the other factors showed no significant association with positivity of
Salmonella sp.
31
6. STRENGTH AND LIMITATION OF THE STUDY
6.1. Strength
 All possible associated factors in the bivariate analysis were adjusted in the
multivariate logistic regression and the effect of confounding was controlled if its
inclusion in the model alters the estimated regression coefficient for the other
predictor variable by 15-20% or more.
 Accuracy of culture results was achieved by using validated and calibrated laboratory
instruments, and minimizing inter-observer variation during reading of positive
culture plates, biochemical and drug susceptibility tests.
6.2. Limitation of the Study
 Since the sample size used for this study was somehow small, some of the confidence
intervals were wide.
 There was lack of study on the prevalence and antibiotic profile of E. coli in Ethiopia,
so comparison could not be made.
 Similarly, comparison of associated factors for the isolated bacteria could not be made
due to lack of study done in this area.
32
7. CONCLUSION AND RECOMMNDATION
7.1. Conclusion
Childhood diarrhea caused by enteric bacteria remains an important health concern in the
study community. The overall prevalence of enteric bacterial pathogens identified in this
study was found to be high. Diarrhoegenic E. coli was the most predominant bacteria
isolated, followed by Shigella and Salmonella sp. Majority of these enteric bacteria
frequently isolated among children of age less than 24 months, from male children and those
from rural areas.
The finding of antibiotic resistance pattern revealed that Ceftriaxone, Gentamicin and
Nalidixic acid showed good efficacy against the three bacteria isolates. However,
Amoxicillin and Ampicillin found to be less effective antibiotics against isolated E. coli,
Shigella and Salmonella sp.
Ciprofloxacin is found to be less effective antibiotic for treatment of diarrhoea caused by
Salmonella sp. Similarly Cotrimoxazole is less effective antibiotics against Shigellosis.
All Shigella sp found to be multiple drug resistance for commonly prescribed drugs in
Ethiopia. One Shigella sp was found to be resistant to five antibiotics while five of the
isolated Shigella sp was resistant to four drugs. However, only one of the isolated Salmonella
sp showed resistance for four drugs.
Except Shigella which showed significant association with residence of the child, the other
bacteria did not shown association with demographic characteristics.
Majority of these enteric bacterial pathogens were detected among children with more than
one symptoms of diarrhoea in which vomiting and watery diarrhoea were significantly
associated with E. coli, while, bloody diarrhoea was significantly associated with isolation of
Shigella sp.
Among the environmental and behavioral characteristics, only washing hands after toilet use
showed statistical association with Salmonella and Shigella sp, but E. coli was not associated
with any of the environmental and behavioral factors.
33
7.2. Recommendations
 Gentamicin, Chloramphenicol and Cotrimoxazole may be prescribed as an effective
antibiotics to treat diarrhoea caused by Salmonella sp
 Ciprofloxacin and Gentamicin may be prescribed as an effective antibiotics to treat
diarrhoea caused by Shigella sp
 Since multi-drug resistant Shigella sp for commonly used drugs are emerging,
antibiotics for treatment of Shigellosis and other enteric bacteria must be used
appropriately
 Children’s families should be encouraged to wash their hands after toilet use because
it has protective effect for diarrhoea caused by Shigella and Salmonella sp.
 Children should always be given improved water
 Health education should be given to children’s families about proper disposal of
child’s feces and household refuses as this will decrease the source of transmission of
bacterial diarrhoea
 Interventions aimed to improve sanitation, hygiene and access to safe drinking water
should be strengthen as this will reduce the occurrence of diarrhea caused by enteric
bacteria.
 Further research on isolation of Campylobacter sp among under five children is
recommended for other researchers interested in this area.
34
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Alrifai S.B, Alsaadi A, Y.A. Mahmood, A.A. Ali, L.A. Al-Kaisi .2009. Prevalence and
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38
9. ANNEXURES
Annexure- 1: Participant Information Sheet and Informed Consent Form for Parents or
Guardians of Under Five Children Involved In the Study
My name is……………………………………. I am working as a data collector for the study
being conducted in this community by MOHAMMED MEKONNEN who is studying for his
master’s degree at Haramaya University, college of Health and Medical science. I kindly
request you to lend me your attention to explain you about the study and being selected as the
study participants.
The Study Title:
Bacterial diarrhoea, their antibiotic susceptibility pattern and associated risk factors among
under five children in Dil-Chora Referral Hospital, Dire Dawa, Ethiopia
Purpose/aim of the study:
The finding of this study can be of a paramount importance for the Regional Health Bureau to
plan intervention programs to prevent under five diarrhoea in your community and others;
thereby improving public health in general. Moreover, the aim of this study is to write a
thesis as a partial requirement for the fulfillment of a Master’s Program in Medical
Microbiology for the principal investigator.
Procedure and duration:
I will be interviewing you using a questionnaire to provide me with pertinent data that is
helpful for the study. There are 15 questions to answer where I will fill the questionnaire by
interviewing you. Then your child will give stool sample for laboratory investigation. The
interview will take about 10 minute, so I kindly request you to spare me this time for the
interview.
Risk and benefits:
The risk of being participating in this study is very minimal, but only taking few minutes
from your time. There would not be any direct payment for participating in this study. But the
findings from this research may reveal important information for the local health planners.
Confidentiality:
The information you will provide us will be confidential. There will be no information that
will identify you in particular. The findings of the study will be general for the study
community and will not reflect any thing particular of individual persons or housing. The
questionnaire will be coded to exclude showing names. No reference will be made in oral or
written reports that could link participants to the research.
39
Rights:
Participation for this study is fully voluntary. You, as the child’s parent or guardian, have the
right to declare participate or not in this study. If you decide to participate, you have the right
to withdraw from the study at any time and this will not label you for any loss of benefits
which you otherwise are entitled you do not have answer any questions that you do not want
to answer.
Contact Address:
If there are any questions or enquiries any time about the study or the procedure, please
contact: Mobile Phone: 0913278009 or Email Address: robelmekonnen@gmail.com
Contact address of the Institutional Health Research Ethics Review Committee (IHRERC)
Office phone: 0256661899 or P.O. Box 235, Harar.
Declaration of informed voluntary consent:
I have read/ was read to me the participant information sheet. I have clearly understood the
propose of the research, the procedures, the risk and benefits issues of confidentiality, the
rights of participating and the contact address of any queries. I have been given the
opportunity to ask questions for the things that may have been unclear. I, as child’s
parent/guardian, was informed that I have the right to withdraw my child from the study at
any time or not to answer any questions that I do not want. Therefore, I declare my voluntary
consent to participate in this study with my initials (signature) as indicated below).
Signatures of participants……………..
Signature of data collector…..
N.B:
This is signed face to face in the presence of the data collector. Please provide a copy of this
signed consent to the participant.
40
S.
No
1
Eligibility Questions
Responses
Does the child have diarrhoea?
2
Does the child took medication for the past 5 days
No
Yes
No
Yes
Code
0
1
0
1
Structured Questionnaire For Assessing Socio-demographic and Environmental Factors of
Bacterial Diarrhoea And Antibiotic Susceptibility Pattern Of The Isolates Among Children
Under Five Years Of Age At Dil-Chora Referral Hospital.
Date ____/_____/__________
Code Number_______
S. No Socio-demographic characteristics
Responses
Code
1.
Age of the child
Less than 6 months
0
6-24 Months
1
25-36 Months
2
37-48Months
3
49-60 Months
4
2.
Sex of the child
Male
0
Female
1
Urban
0
3.
Residence of the child
Rural
1
Clinical data (Symptoms of diarrhoea)
Presence of fever
No
0
4.
Yes
1
Presence of abdominal cramps
No
0
Yes
1
Presence of nausea
No
0
Yes
1
Presence of vomiting
No
0
Yes
1
Type of diarrhoea
watery diarrhoea
0
5.
bloody Diarrhoea
1
mucoid diarrhoea
2
Duration of diarrhoea?
1-5 days
0
6.
6-10 days
1
11-15 days
2
> 16 days
3
Previous history of diarrhoea and previous treatment
No
0
7.
Yes
1
Environmental and Behavioral Factors
8.
What is the type of water source your child use for Household connection
drinking?
Public standpipes
Protected well/ springs
Unprotected well/ spring
41
0
1
2
3
9.
Do you have a private latrine in your home?
10.
Does your child able to use a toilet?
11.
If no to Q. 10, How do you dispose of the feces?
12.
13.
How do you dispose of your Refuses?
Do you wash your hands
After using toilet?
Before feeding your child?
14.
Did your child had previous history of diarrhoea
15.
Do your child vaccinated against measles?
No
Yes
No
Yes
Buried
Put in the latrine
Thrown away inopen surrounding
Other(specify………)
Burning
Burying in a pit
Storing and disposing
in designed site
Dispose on open fields
0
1
0
1
0
1
Never
Sometimes
Always
Never
Sometimes
Always
Yes
No
No
Yes
Do not remember
0
Stool culture result
Annexure-2: በጥናቱ ላይ ለሚሳተፉ የህፃኑ እናት ወይም ጠባቂ የተዘጋጀየተሳታፊዎች መረጃ እና የፍቃደኝነት
ማረጋገጫ ቅፅ
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42
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2
3
0
1
2
3
1
2
0
1
2
1
0
0
1
2
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መልስ ይሰጣሉ፡፡ ከዚያም ልጅዎት የሰገራ ናሙና ይሰጣልÝÝ መጠይቁም የሚፈጀዉ ጊዜ 10 ደቂቃ ይሆናል፤
በመሆኑም የህንን ጊዜ ከኔ ጋር እንዲያሳልፉ በትህትና እጠይቅዎታለሁ፡፡
™ÃÏና ጥቅም
በዚህ ጥናት በመሳተፍዎ ያለዉ አደጋ በጣም ጥቂት ነዉ፤ነገር ግን ትንሽ ጊዜ ከርስዎ የወስዳል፡፡ በዚህ ጥናት ሲሳተፉ
ሚከፈልዎት ክፍያ አይኖርም፡፡ ነገር ግን የህ ጥናት የጤና እቅድ ለማቀድ ጥሩ መረጃን የሰጣል፡፡
43
መተማመኛ
Y¸s-#N mr© ¸S_‰êE YçÂLÝÝ XRSãN ¥NnT y¸Gl} mr© xYñRMÝÝ k_ናቱም
የሚገኘዉ ዉጤት አጠዋላይ የህብረተሰቡ እንጂ የአንድን ግለሰብ ወይም ቤት አያመላክትም፡፡ መጠይቁም
ላይ ስም ወደ ሌላ የተረጎማል፡፡ምንም ዓይነት ማጣቀሻ ተሳታፊዉን ከጥናቱ ጋር የሚያያይዝ በቃላትም
ይሁን በፅሁፍ አይኖርም፡፡
Fq}…
o±ü; Õና| FXwð oFú>ú ðcÖŒ| ?Á ½wFWOw Œ¬ú$ o±ü; Õና| >FXwð ¬ÁH
?>FXwð Fq| ™>°|$ >FXwð ¬YŒ¬ú »<«! oë>Îú| Îû±þ »Õናቱ ማቃረጥ ይችላሉ፡ ይህም
የማይፈልጉትን ጥያቄ ባለመመለስዎ የሚያስቀርብዎት ጥቅም የለም፡፡
አድራሻ
ስለ ጥናቱ ወይም ሂደት በማንኛዉም ጊዜ ጥያቄ ካለዎት፤ በዚህ አድራሻ ያግኙን፡ ሞባይል ቁጥር፡ 0913278009
ወይም ኢሜይል አድራሻ፡ robelmekonnen@gmail.com
IHRERC አድራሻ፡ የቢሮ ስልክ ቁጥር፡ 0256661899 ወይም ፖ.ሳ.ቁ. 235 ሀረር
የፍቃደኝነት ማረጋገጫ
የተሳታፊዎች መረጃ አንብቤዋለሁ/ተነቦልኛል፡፡ የጥናቱንም ዓላማ፤ሂደቱን፤አደጋና ጥቅሙን፤መተማመኛዉን፤ የመሳተፍ
መብት እና አድራሻ በግልፅ ተረድቼዋለሁ፡፡የልተረዳሁትንም ነገር እንድጠይቅ ምቹ ሁኔታ ተመቻችቶልኛል፡፡ከጥናቱም
ልጄን በፈለኩት ሰዓት ለማቃረጥ ወይም የማልፈልገዉን ጥያቄ ላለመመለስ መብት እንዳለኝ ተነግሮኛል፡፡ስለዚህም
በዚህ ጥናት በፈቃደኝነት መሳተፌን ክዚህ በታች ባለዉ ፊርማዬ እገልፃለሁ፡፡
½wXzí¬ú íTG----------------------------------------------------------------
44
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ተ. ቁ
ለጥናቱ ለመሳተፍ መመዘኛ ጥያቄዎች
ምላሽ
1
ህፃኑ የተቅማጥ በሽታ አለዉ
2
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የለም
አዎ
1አልወሰደም
አዎ
1
መለያ
0
1
0
1
Æ@ÝR QëR@ <Yõz@ ;äና| ¡ð@ oweGÕ o]z H¡«¿| >;¡Hና »GûFÓú| ;äና| ¬úYÕ
®Œ” ½weGÕ o]z ™HÙ w;®Wü¿|« ›ና FÆ/Œû| FቋቋH p;Q ½GûÄYY FÓÁe
ቀን ____/_____/__________
መለያ ቁጥር …………………
ተ. ቁ
Y> GDoR­ /úŒýz ½Gû¿F?¡x Õ¿d°…
ምላሽ
1.
የህጻኑ/ና ዕድሜ ስንት ነዉ?
ከ6 ወር በታች
0
ከ6 እስከ 24 ወር
1
ከ25 እስከ 36 ወር
2
ከ37 እስከ 45 ወር
3
ከ49 እስከ 60 ወር
4
ወንድ
0
ሴት
1
ከተማ
0
ገጠር
1
ህፃኑ ትኩሳት አለዉ
የለም
አለ
0
1
ህፃኑ የሆድ ህመም አለዉ
የለም
አለ
0
1
ህፃኑ የማቅለሽለሽ ስሜት አለዉ
የለም
አለ
0
1
ህፃኑ ያስታዉከዋል
የለም
አለ
0
1
2.
3.
የህፃኑ/ና ፆታ ?
የህፃኑ መኖሪያ ቦታ የት ነዉ ?
መለያ
የበሽታዉ ምልክቶች
4.
45
5.
ፈሳሽ ዉሃ
የተቅማጡ አይነት?
0
ደም የቀላቀለ
1
ንፍጥ የቀላቀለ
2
1-5 ቀን
6-10 ቀን
11-15 ቀን
> 16 ቀን
6.
ተቅማጡ ምን ያህል ጊዜ ቆዬ?
7.
ህፃኑ ከዚህ በፊት ተቅማጥ ታሞ መድሃኒት የወሰደ መሆኑን የሚያሳይ የለም
የጤና መረጃ
አዎ
0
1
2
3
0
1
የአካባቢ እና ግላዊ የበሽታዉ መንስዔዎችን ዳሰሳ
8.
ለህፃኑ የመጠጥ ዉሃ ከየት ታገኛላችሁ?
ከባነባ
0
ከቦኖ ዉሃ
1
ከተከለለ ጉድጉዋድ/ምንጭ
2
ካልተከለለ ጉድጉዋድ/ምንጭ
3
9.
በቤታችሁ የግል ሽንት ቤት አለ ?
የለም
አዎ
0
1
10.
ልጅዎ ሽንት ቤት መጠቀም ይችላል ?
አይችልም
አዎ
0
1
11.
ለጥያቄ ቁጥር 10 መልስዎ አይችልም ከሆነ ሰገራዉን እንዴት ነዉ በመቅበር
የሚያስወግዱት ?
12.
የቤት ዉስጥ ቆሻሻን የሚያስወግዱት እንዴት ነዉ
0
ሽንት ቤት መክተት
1
ግላጭ መሬት ላይ መጣል
2
ሌላ መንገድ ካለዎት ይጥቀሱ
3
በማቃጠል
0
ጉድጉዋድ ዉስጥ በመቅበር
1
ዕቃ ዉስጥ በማጠራቀም
በተዘጋጀ የቆሻሻ ስፍራ መጣል 2
13.
3
በጭራሽ
0
አንዳንዴ
1
ሁል ጊዜ
2
በጭራሽ
0
አንዳንዴ
1
ሁል ጊዜ
2
እጅዎትን መቼ መቼ ይታጠባሉ
ከሽንት ቤት መልስ
ህፃኑን ከመመገብዎ በፊት
14.
ግላጭ ሜዳ ላይ በመጣል
ልጅዎ ከዚህ በፊት በተቅማጥ በሽታ ታሞ ያዉቃል
46
አዎ
አያዉቅም
1
2
15.
ልጅዎ ከዚህ በፊት የኩፍኝ ክትባት ተከትቦ ያዉቃል
አያዉቅም
አዎ
አላስታዉስም
0
1
2
Annexure-3: Odeefannon hirmattotaa Qo’annoo waa’ee jermilee garaa kaasaa fidaniifi
qorichaa waliin walbaruu isaanii daa’immani ilaala
Maqaan kiyya ------------------------- jedhama. Yeroo ammaa kana yunivarsitii Haroomayaatti
digrii lammataabarachaa kanjiru Mohammed Mekonnen wajjiiin odeeffannoo funaanaatiin
jira. Qo’annoo kanaaf waan filatamtaniif waa’ee qo’annichaa yeroon isinii himu akka na
dhageeffattan kabajaaniin inin gaafadha.
Mata Duree Qo’annoo
Qo’annoo waa’ee jermilee garaa kaasaa fidaniifi qorichaa waliin walbaruu isaanii hospitaala
Dilchoratii kutaa daa’immani ilaala.
Kaayyoo Qo’annoo
Qorannoon kun digrii lammataa ittiin ebbifamuuf tahullee fayidaan isaa kana qofaa miti.
Kuniis garaa kaasaaf jermilee sababa tahan beekuuf fi qorichaa wajjiin walbaruu isaanii ni
qo’ata. Akkasumaas sababa rakkoo beekuuf ni yaala. Kuniis dhukkuba garaa kaasaa ittisuufi
ta’achuuf ni gargaara.
Akkataa qo’nnnoofi yeroo fudhatu
Adeeffanno qo’annoof barbaachisu gaafille qo’annoof dhibaate gaafachuun deebisaanaaf
kennan walumaagalatii gaafilee deebisaa kennitu. dai’ma sagaraas ni kaniitaa. Yeroo hanga
daqiiqaa 10 fudhata. Kanaafuu yeroo kana na wajjiin akka dabarsitan kabajaan isin gaafanna.
Midhaafi fayidaa qoranno
47
Qorannoo kanarrati hirmaachuuf midhaan isin irra gahu baay’ee xiqqaadha. Haaata’uu malee,
yeroo keessan xiqqo fudhachuu ni danda’a. qorannoo kanarrattii yeroo hirmaattan kafalttin
isiniif kafalamu hin jiru. Qorannoon kun karoora fayyaarratti karroorsuuf odeeffannoo ni
kenna.
Amantummaa
Odeeffannoon kennitan icitiin isaakan eeggameedha. Waa’ee kee odeeffannon ibsu hin jiru.
Bu’aan qorannoorraa argamu ummata waligalaatiifi malee kan nama tokko hin ilaallatu.
Gaafilee yeroo gaafatamtan maqaan keessan lakkoofsa iciti ni kennamaaf.
Mirga
Qo’annoo kanarratti hirmaachuun fedhii keessan qofaan ta’a. hirmachuufiis hirmachuu
dhiisuufiis mirga qabdan. Hirmachuuf kan murteessitan taanaan, yeroo barbaaddanitti adda
muruuf mirga qabdan. Gaafilee hin barbaanne deebissu dhabuuf bu’aan sirraa hafu hin jiru.
Teessoo
Waa’ee qorannoorratti gaafii qabaannon yeroo barbaaddanitti teessoon kanaan nu argachu
dandeessu. Lekkoysa bilbilaa: 0913278009; email: robelmekonnen@gmail.com
IHRERC teesso፡ lakkoysa bilbilaa: 0256661899 ykn lekkoysaa postaa 235 Harar
Ibsa hayyamammaa
Odeefannon hirmattotaa dubbiseera/ naaf dubbifameera. Kaayyoo, adeemsa, midhaafi bu’aa,
amantummaa, mirga hirmachuufi teesso qo’annoo ifatti hubadheera. Waaniin hin hubatin
akkaan gaafadhuuf haalli mijjaawaan naaf uumameera. Qo’annoorraa yeroo berbaadetti
hafuufi akkasumaas gaafileen hin barbaanne deebisuu dhirsuuf mirga akkaan qabu naaf
himameera. Kanaafuu qo’annoo kanarratti hirmachuu kiyya mallattoo gaditti ibsa meeniin
mirkaneessa.
Mallatto hirmaataa……………………..
mallatto walitti qabaa odeeffannoo……….
48
Qo’annoo waa’ee jermilee garaa kaasaa fidaniifi qorichaa waliin walbaruu isaanii
hospitaala Dilchoratii kutaa daa’immani ilaala
guyya ____/_____/__________
lakkoyissaa …………………
1.
Ummri dai’ma
jia 6 gadi
jia 6 hanga 24
jia 25 hanga 36
jia 37 hanga 45
jia 46 hanga 60
1
2
3
4
5
2.
Daii’ma
Dhira
Dhala
1
2
3.
Bakka daii’mni itti jiratu
maglaa
badiya
1
2
Daii’ma leyadaa niqbaa?
eyee
mittii
1
2
Daii’ma garraa niimura?
eyee
mittii
1
2
Daii’ma niqoqiifaata?
eyee
mittii
1
2
Daii’ma haqissa niqaba?
eyee
mittii
1
2
Daii’ma allabati niqaba?
eyee
mittii
1
2
5.
Sagarran mal fakaata?
6.
Allabatii guyya meqqa ture?
Akka bishaani
diiggaa niqaba
furri niqaba
guyya 1 hangaa 5 ture
guyya 6 hangaa 10
1
2
3
1
2
4.
49
guyya 11 hangaa 15
guyya 16
7.
Sagarran mal fakaata?
8.
Bishaan dhugaattiiff tahuu essa irraa fayadamtan?
9.
Akka bishaani
diiggaa niqaba
furri niqaba
Bishaan Bonba irraa
Bishaan egamee
maddaa irraa
Bishaan haro irraa
3
4
1
2
3
1
2
3
11.
niijirraa
1
hinjiirru
2
Daii’manii mana fincanii nifayadamaa
niijirraa
1
hinjiirru
2
Yoo deebiin gaffii 10ffaa mittii ta’e sagarran daii’ma Laffa qottani kesati darbu 1
eyssatii harattan?
Karaa irraatti darbu
2
Manaa fincannitti darbu 3
Kanbirra
yooqabattan………….
4
12.
Qoshasha akkamitti harraattan
13.
harkaa keessan yoom dhiqatqn?
10.
Mana fincannii dhunfa niiqaabdanii ?
gubudhan
1
laffatti awaludhan
2
bakka
qoshashattiidarbudhan
3
karaa irrattii darbudhan 4
harkaa keessan mana fincanii boddaa niidhiqattani?
daii’maffa nyatta bilcheysun dura
14.
daiima amma dura allbattiin qabe niibeka?
15.
amma duraa kittabatti shiifte fudhatte nibekaa
50
Mittii
Guyyaa tokko tokko
hooguu niidhiqana
Mittii
Guyyaa tokko tokko
hooguu niidhiqana
eyee
mittii
1
eyee
mittii
1
2
2
3
1
2
3
1
2
Annexure-4: Waxaan akhriyey warqada warbixinta Xaaladaha cayayaanka ili ma
argtayda iyo kudul noolayaasha ku keena shuubanka iyo ka hortaga u
nuglaanshahooda caruurta 5 sano ka yare e dhakhtarka
Magacaygu waa______________waxaan ahay xog ururriye ururrinaya daraasaad kusaabsan
bulshda, dhigtana barasha heerka labaad( master degree) ee jaamacada haramaya qaybta
caafimadka iyo sayniska magacayguna yahay MOHAMMED MEKONNEN waxaan si
naxariisle kaaga codsanyaa in aad isiiso dareenkaaka aad ku sharaxaso daraasadan isla
markana aad kaga qayb qaadato.
Ciwaanka daraasada
Xaaladaha cayayaanka ili ma argtayda iyo kudul noolayaasha ku keena shuubanka iyo ka
hortaga u nuglaanshahooda caruurta 5 sano ka yare e dhakhtarka DILCHORA,
Dire
Dawa,Ethiopia.
Ujeedada daraasada
Natiijada daraasadani waxay muhiiim u noqonaysaa xafiiska caafimaadka ee gobolka si ay u
qorsheeyaan waxqabadka iyo barnaamijyada lagaga hor tagayo shubanka caruurta ka yar 5
sano ee bulshada. Ujeedada daraasadani waa in la qoro cilm I baadhis kaaso qayb ka ah
barnaamijka wax barashada heerka labaad (master) eek u saabsan dawaynta cayayaanka
yaryar si baadhitaan dheeraada loogu sameeyo.
Habka iyo mudada
Waxaan kula yeelan doonaa waraysi anoo isticmaalaya qaab su aaleed qoraal ah si aad iisiiso
xog ku saabsan daraasadayda. Waxa jira suaalo aad ka jawaabaysid kaasi oon kaaga qaadi
doono hab waraysi 15 waraysigu. Ilmuhu Saxarahagu waa isee. wuxuu qaadan dooona 10
daqiiqo sidaa daraaded waxaan kaa codsanayaaa inaad ii hurto wakhtigaaaga muhiiimka ah.
Khatarta iyo faa,idada daraasadan:
Khatarta kaqayb qaadashada daraasadani waa mid aad u kooban laakiin waxay qaadan
doontaa daqiiqado yar oo kamida wakhtigaaga.. Majiri doonto kharash toosa oo lagaga qayb
qaadanayo daraasadan. laakiin natiijada cilmibaadhistani waxay war bixin muhiima siinaysaa
gadhwadeenada dajiya qorshayaasha caafimadka ee deegaanka..
Sirta daraasada
War bixinta aad nasiisaa waxay noqondoontaa mid qarsoon. Majiri doonto war bixin si gaara
u muujinasa ka qaybgalkaaga.natiijada daraasadani waxay u noqon doontaa bulshada mid
guud oo aan cid gaara khusayn. Hadaba qaab su aaleedkan waxaa lagu calaamadin doonaa
51
inaan la muujin wax magaca mana jiri doonto wax tixraaca oo ku saabsan warbixinta
qoraalka ama waraysiga ka qayb galaha
Xuquuqda Ka Qayb Galaha
Ka qaybgalka daraasadani waa mid muta dawac nimo ah. Waxaad xaq uu leedahy in aad
cadayso kaqayb galkaaga daraasadan iyo in kale. Hadii aad go aansato in aad ka qayb qaadato
waxaad xaq uleedahay inaad isaga tagto daraadan wakhtiga aad doonto taasina calaamad u
ma aha inay kaa luminayso faa idooyinka kuu gaarka ah.
Ciwaanka La Igala Soo Xidhiidhayo
Hadii ay jirto wax su aala ah oo ku saabsan habka daraasadan fadlan igala soo xidhiidh
Taleefanka gacanta: 0913278009 ama email address: robelmekonnen@gmail.com
Waxa kale oo la iga helaa numberka xafiiska cilmi baadhista iyo anshaxa
Lanbarka xafiisaka:0256661899 ama P,O BOX 235,HARAR
Cadaynta Mutadawacnimadayda.
Waxaan akhriyey warqada warbixinta ka qayb qaataha.waxaan si cad u fahmay u jeedada
daraasada,habka,khatarta iyo faaidada ,cadaymaha kalsoonaanta,xaqa ka qayb qaataha iyo
halka la igala soo xidhiidhayo wixii loo baahdo. waxaan ku siiyey fursad aad igu weydiiso
su,aalaha aan kuu cadayn.waxaan kuu sheegay inaan xaq u leeyahay inaan iska daayo
daraasadan wakhtiga aan doono ama aanad ka jawaabin su,aalaha aanan doonaynin. Sidaa
Ilmuhu daraadeed waxaan ku cadaynayaa mutadawacnimadayda khusaysa daraasadan
sexeexayga gaarka ah sida hoos ku qoran.
Sexeexa ka qaybqaataha_________________taarikhda____________________
Xog ururiyah:magaca____________________sexeexa________taarikhda________
52
Xaaladaha cayayaanka ili ma argtayda iyo kudul noolayaasha ku keena shuubanka iyo ka hortaga
u nuglaanshahooda caruurta 5 sano ka yare e dhakhtarka DILCHORA, Dire Dawa, Ethiopia.
malinta ____/_____/__________
nambbarka …………………
1.
Daada ilmuhu waimisa
6 bilod wax kahosiyo baa
6 bilod ilaa iyo 24 bilod
25 bilod ilaa iyo 36 bilod
37 bilod ilaa iyo 45Bilod
46 bilod ilaa iyo 60 bilod
2.
Ilmuhu wa maxa?
Niin
Naag
1
2
3.
Xalked kunoshahay
Wadan
Badiye
1
2
1
2
3
4
5
Xumad
4.
Xumad ?
Mugira
Magiro
1
2
Calool xanun?
Mugira
Magiro
1
Laganyo?
2
Mugira
Magiro
2
matag
Mugira
Magiro
1
2
5.
Shubanka midabkisa?
6.
Shubanka waa ilaiyo imisa isho?
7.
Saxarahagu wasede?
8.
Xalkid ka istic mashin biyaha cuntada aad ?
Maa biyo baa
1
Dhig mukugira
2
1-5 mallimod
1
6-10 mallimod
2
11-15 mallimod
3
>16 inkabadan baa
4
Maseda biyaba
1
Ghig mixu leyahay
2
Maseda senka
3
Banbada
1
Maa biyaha shicbkad istimaghin 2
Ciilka aan dadhahalin
3
Ciilka ladaholay
4
9.
Suuli garmadledinin?
10.
Ilmahagu suligu muistimalikara
Haa
Maay
Haa
Makarayo
53
1
1
2
1
2
11.
Hadu Karen inu istimalin xalkebu kuxura
12.
Qushashka xalkid baad kuturtin?
13.
Goormad midata gocmahago?
Aseed
Suligad kudhax rida
Maa dulkad kuturtin
Ama diriqkalay
15.
2
3
4
Maad gubtiin
Maa godbaad ku astiin
Maa alab’baad ku uririsin
Maa dhulkaad kuturtiin
Markad ka sohaxdid suliga
14.
1
Mamido
Marmar
Marwalba
Ilmaha intanad cunsenikur
Mamido
Marmar
Marwalba
Imika ka hor ilmahagu xanunka shaban ka mu ku Haa
dhacay?
Mayaa
Imika ka hor ilmahagu mu ku dhacay jodeco?
Haa
Mayaa
1
2
3
4
1
2
3
1
2
3
1
2
1
Annexure- 5:- Informed Consent Form for Dil Chora Hospital Chief Executive Officer
My name is MOHAMMED MEKONNEN who is studying for master’s degree at Haramaya
University, college of Health and Medical science. I kindly request you to lend me your
attention to explain you about the study being conducted in this Hospital.
The Study Title:
54
2
Bacterial diarrhoea, their antibiotic susceptibility pattern and associated risk factors among
under five children in Dil-Chora Referral Hospital, Dire Dawa, Ethiopia
Purpose/aim of the study:
The finding of this study can be of a paramount importance for the Regional Health Bureau to
plan intervention programs to prevent under five diarrhoea in the community and others;
thereby improving public health in general. Moreover, the aim of this study is to write a
thesis as a partial requirement for the fulfillment of a Master’s Program in Medical
Microbiology for the principal investigator.
Procedure and duration:
I will be interviewing parents or guardians of the children using a questionnaire to provide
me with pertinent data that is helpful for the study. There are 15 questions to answer where I
will fill the questionnaire by interviewing them. Then stool sample will be collected from the
participating under five children. The interview will take about 10 minute.
Risk and benefits:
The risk of being participating in this study is very minimal, but only taking few minutes
from parents or guardians of the participating under five children. There would not be any
direct payment for participating in this study. But the findings from this research may reveal
important information for the local health planners.
Confidentiality:
The information they will provide us will be confidential. There will be no information that
will identify the participating under five children in particular. The findings of the study will
be general for the study community and will not reflect any thing particular of individual
persons or housing. The questionnaire will be coded to exclude showing their names. No
reference will be made in oral or written reports that could link participants to the research.
Rights:
Participation for this study is fully voluntary. Parents or guardians of the participating under
five children have the right to declare participate or not in this study. If parents or guardians
decide to participate, they have the right to withdraw their children from the study at any time
and this will not label them for any loss of benefits which they otherwise are entitled they do
not have answer any questions that they do not want to answer.
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Contact Address:
If there are any questions or enquiries any time about the study or the procedure, please
contact: Mobile Phone: 0913278009 or Email Address: robelmekonnen@gmail.com
Contact address of the Institutional Health Research Ethics Review Committee (IHRERC)
Office phone: 0256661899 or P.O. Box 235, Harar.
Declaration of informed voluntary consent:
I, chief executive officer of Dil-Chora Hospital, have read the informed consent form. I have
clearly understood the propose of the research, the procedures, the risk and benefits issues of
confidentiality, the rights and the contact address of any queries. I was informed that I have
the right to stop the study at any time if there are any misconduct. Therefore, I declare my
voluntary consent of this study to be conducted in this hospital with my initials (signature) as
indicated below).
Signatures of chief executive officer……………..
N.B:
This is signed face to face in the presence of the data collector. Please provide a copy of this
signed consent to the participant.
Annexure -6: Laboratory Data
Laboratory Data (Stool culture request form)
Haramaya University, School Of Graduate Studies, College Of Health And Medical Sciences, Department Of
Medical Laboratory Science
Bacterial Diarrhoea, Antibiotic Susceptibility Pattern Of Isolates And Associated Risk Factors Among
56
Under Five Children At Dil-Chora Referral Hospital, Dire Dawa, Eastern Ethiopia.
LABORATORY REQUEST FORM
Label number: ________
Time of sample collection
____:_____
Age _______
Sex
Male
Female
Date of sample collection ____/_____/_____
Laboratory Results
Stool culture
Name of lab personnel
BIOCHEMICAL
PATHOGENS
Bacterial
isolates
signature
FLOW-CHARTS
KIA
TSI
FOR
IDENTIFICATION
Biochemical tests
Motility
Indole
57
OF
Urea
ENTERIC
Oxidase
S. typhi
S. paratyphi
Shigella spp
E. coli
V. cholerae
K/A
K/A
K/A
A/A,G
K/A
K/A
K/A
K/A
A/A,G
A/A
+
+
+
+
+/+
-
-
+
ENTERIC PATHOGENS: Salmonella and Shigella spp., V. cholerae, E. coli and others
Inoculums: Growth or direct colony suspension, equivalent to a 0.5 McFarland standard. Use
Mueller Hinton agar. Incubate at 35 ± 2oC ambient air for 16 – 18 hours.
Drug
Amoxicillin/clav
ulanate
Ampicillin
Ceftriaxone
Chloramphenicol
Ciprofloxacin
Trimethoprim/Su
lfamethoxazole
Gentamicin
Nalidixic-acid
Tetracycline
Conc. (μg)
20/10
Sensitive
≥ 18
Intermediate
14-17
Resistant
≤ 13
10
5
30
5
1.25/23.75
≥ 17
14-16
≤ 13
≥ 18
≥ 21
≥ 16
13-17
16-20
11-15
≤ 12
≤ 15
≤ 14
10
30
30
≥ 15
13-14
≤ 12
≥ 15
12-14
≤ 11
Annexure-7: Curriculum Vitae
1. PERSONAL INFORMATION
 NAME: -------------------------- MOHAMMED MEKONNEN
 Sex: - ----------------------------- Male
58





Date of Birth: ------------------- March 14/1983 GC
Marital Status: ------------------ Married
Nationality: ----------------------Ethiopian
Health status; --------------------Excellent
Residence: ------------------------Dire Dawa
 Tel:-------------------------------- 0913278009
Email: robelmekonnen@gmail.com
2. LANGUAGE PROFICIENCY
 English________________ Excellent in listening, speaking, writing and
reading.
 Amharic________________ Excellent in listening, speaking, writing and
reading.
 Oromipha ____________ Very Good in listening, speaking, writing and
reading.
3. EDUCATIONAL BACKGROUND
 Nifas Silk High School---------------EGSEC
 Fasiledes Preparatory School--------ESLCE
 Jimma University ---------------------BSC in Medical Laboratory Technology
4. WORK EXPERIENCE
From 1999-2000 EC at SNNPRS in Mizan Teferi health center as head of
laboratory advisor
From 2000-2001 EC at Dire Dawa Bilal Hospital(private hospital)
From 2001-2007 EC at Dire Dawa Dil Chora referral Hospital and different
health center
5. INTEREST



Reading medical books and Journals
Working with society.
Reading philosophy books
6. REFERENCES
 Dr, Gashaw Seid working at ICAP-CU program officer at Dire Dawa
o TEL :- 0911757592
 Mr. Endris Mekonnen working at JEPHIGO int.
o TEL;- 0911480080
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