Etiology of Severely Dehydrating Diarrheal Illness in Infants and Young Children Residing in Low- and Middle-Income Countries

Background. Severe dehydration due to acute infectious diarrhea remains a leading cause of death among young children worldwide. Diarrhea with severe dehydration is a clinical syndrome with distinct management per the World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) and the WHO Global Task Force on Cholera Control (GTFCC) guidelines. We sought to characterize the pathogens causing severe dehydration using data from the Global Enteric Multicenter Study. Methods. We used the IMCI and GTFCC guidelines to define severe dehydration and quantitative polymerase chain reaction- based attribution models to assign the etiology of diarrhea associated with severe dehydration. Results. The IMCI or GTFCC guidelines classified 2284 of the 5304 (43%) cases with moderate-to-severe diarrhea as having severe dehydration. In one-third of the cases with severe dehydration, no pathogens were attributed. The top pathogens attributed to children with guidelines-classified severe dehydration varied by age and were similar among those requiring intravenous hydration and hospitalization. Rotavirus (30.9%), Cryptosporidium (12.0%), and heat-stable (ST) enterotoxigenic Escherichia coli (ETEC) (10.3%) were the most common pathogens for ages 0-11 months, while Shigella /enteroinvasive E coli (EIEC) (25.8%), rotavirus (19.3%), and ST-ETEC (10.9%) were the most common for ages 12-23 months. Shigella/EIEC (25.9%), Vibrio cholerae (10.4%), and rotavirus (9.2%) were the most common among ages 24-59 months. Conclusions. The findings inform prioritization of pathogens, in addition to V cholerae, that cause severe dehydration for future preventive and treatment efforts. The schema for prioritization is driven primarily by age stratifications.