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Mortality and morbidity associated with cholera acquired in a modern endemic setting have not been well defined. In Dhaka, Bangladesh from 1986 to 1996, we found that causative agents of cholera shifted over time, varying by serogroup, biotype, and serotype. At the International Centre for Diarrhoeal Disease Research (ICDDR,B: Centre for Health and Population Research) in 1996, 19,100 cholera patients were treated, 887 (4.6%) were admitted, and 33 died (mortality rate = 3.7% of cholera inpatients, 0.14% of all cholera patients). When cholera inpatients who were discharged improved were compared with those who died, bacteremia (odds ratio [OR] = 10.5, 95% confidence interval [CI] = 2.9-37.9), radiographic evidence of pneumonia (OR = 3.1, 95% CI = 1.2-7.7), and acidosis as estimated by the serum bicarbonate value (OR = 0.893, 95% CI = 0.825-0.963) were independently associated with death by multivariate analysis. Pneumonia was the leading cause of death and accounted for two-thirds of all deaths among individuals with cholera in this study. Death in hospitalized patients with cholera acquired in a modern endemic setting is, therefore, extremely rare, and most frequently due to concomitant infection, especially pneumonia.

Treatment of shigellosis is currently limited by the high prevalence of multidrug-resistant strains of Shigella. Objective: To determine the efficacy of azithromycin in the treatment of shigellosis. Design; Randomized, double- blind clinical trial. Setting: Diarrhea treatment center in Dhaka, Bangladesh. Patients: 70 men with shigellosis that had lasted 72 hours or less. Interventions: Patients stayed in the hospital for 6 days. Thirty-four patients were randomly assigned to receive 500 mg of azithromycin on study day 1, followed by 250 mg once daily for 4 days; 36 patients were assigned to receive 500 mg of ciprofloxacin every 12 hours for 5 days. Measurements: Clinical treatment failure was considered to have occurred if frank dysentery persisted for 72 hours after therapy began or if on study day 5 a patient had more than six stools, had any bloody-mucoid stools, had more than one watery stool, or had an oral body temperature exceeding 37.8 °C. Bacteriologic treatment failure was considered to have occurred if Shigella strains could be isolated from a stool sample after study day 2. Therapy was considered either clinically or bacteriologically successful in patients who completed therapy and did not meet criteria for failure. Results: Therapy was clinically successful in 28 (82%) patients who received azithromycin and 32 (89%) patients who received ciprofloxacin (difference, 7% [95% CI, 23% to 10%]). Therapy was bacteriologically successful in 32 (94%) patients receiving azithromycin and 36 (100%) patients receiving ciprofloxacin (difference, 6% [CI, 14% to 2%]). Peak serum concentrations of azithromycin were equal to the minimum inhibitory concentration (MIC) of the infecting Shigella strains, whereas serum concentrations of ciprofloxacin were 28 times the MIC. Stool concentrations of both drugs were more than 200 times the MIC. Conclusion: Azithromycin is effective in the treatment of moderate to severe shigellosis caused by multidrug-resistant Shigella strains.

We prospectively compared the clinical features of cholera due to Vibrio cholerae O1 and V. cholerae O139 in 242 men 18-60 years of age, with a history of diarrhoea of 24 h or less, and moderate or severe dehydration. The antimicrobial susceptibility of all of the V. cholerae strains isolated from these patients was determined, and in vitro cholera toxin production determined for 68 isolates. On admission, the 110 patients infected with V. cholerae O1 significantly more often had body temperature36 degrees C (85% vs. 66%, Por = 0.05), faecal leucocyte count50/high power microscope field (40% vs. 12%), and lower mean faecal chloride content (94 vs. 103 mmol/L) than did the 132 patients infected with V. cholerae O139. Patients infected with V. cholerae O1 also initially had significantly higher median volumes of stool (13 vs. 11 mL per kg body weight per h), vomitus (1 mL/kg/h vs. nil), and intravenous fluid requirements (23 vs. 21 mL/kg/h). All V. cholerae O1 and O139 isolates were susceptible to ciprofloxacin, all but one were susceptible to doxycycline and erythromycin, and the majority of both serogroups were resistant to co-trimoxazole (95% and 97%, respectively). V. cholerae O1 and O139 susceptibilities differed for tetracycline (58% vs. 100%) and furazolidone (27% vs. 93%) (P0.001 in both cases). The amount of cholera toxin produced in vitro by strains of V. cholerae O1 and O139 was similar, and did not correlate with stool volume. The results demonstrated that V. cholerae O139 does not cause more severe, or more invasive, disease than V. cholerae O1, as had been previously suggested, but that clinically important differences in antimicrobial susceptibility do exist among strains isolated in Bangladesh.

Acute bacterial meningitis (ABM) is a medical emergency and a global health problem associated with significant mortality and neurologic sequelae (1, 2). An aetiologic diagnosis and determination of the antimicrobial susceptibility require good laboratory services that are lacking in most developing countries. We have retrospectively reviewed 448 patients admitted to our hospital from January 1988 to June 1994 with suspected meningitis...

Serotyping of Vibrio cholerae is based on the somatic '0' antigen. Cholera is caused by the 01 serotype ev. cholerae 01), and there were pre­ viously a total of 138 serotypes identified. A new serotype of V. cholerae has recently been identified as the pathogen responsible for explosive outbreaks of severe dehydrating diarrhoea in India and Bangladesh. This has been designated V. cholerae 0139. [1] Since it produces an illness that is clinically indistinguishable from cholera, it is considered to be another serotype of V. cholerae that can cause cholera.[2] The synonym 'Bengal' has been proposed because the serotype was first isolated along the Bay of Bengal. Replacement of fluid and electrolyte losses is the most important part of tbe management of patients with cholera caused by V. cholerae 01 or V. cholerae 0139. Treatment of cholera due to V. cholerae 01 with effective antimicrobials has been useful in shortening the duration of diarrhoea and faecal excretion of the pathogen, and in reduc­ ing the volume of watery stools, with subsequent decreased requirement for rehydration fluids. This randomised clinical trial was conducted at the Diarrhoea Treatment Centre of the Interna­