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Persistent diarrhea: a persistent infection with enteropathogens or a gut commensal dysbiosis?

In children from developing countries 5-10% of acute diarrhea (AD) episodes develop into persistent diarrhea (PD) defined by > 14 days of diarrhea duration. PD represents a major health burden leading to growth faltering. It is also associated with half of all diarrhea mortality. A rational intervention is thus crucial, but depends on an understanding of the pathogenesis of PD, which is still lacking. Many surveys were conducted in Latin America and in South Asia; they differ, however, with respect to enteropathogens associated with PD. Enteroaggregative strains of Escherichia coli (EAEC) were identified by several studies, but they may reflect selection by the frequent antibiotic use during the preceding AD episode. Epidemiologists have in fact identified antibiotic misuse as a major risk factor for PD. Together with the effectiveness of empirical treatment based on nutritional interventions with lactose-reduced and lactose-free diets and particularly complex plant polysaccharides from green banana, one might suspect a role of commensal gut microbiota dysbiosis instead of a persistent infection with enteropathogens in many PD cases. An analysis of the commensal gut microbiota development in persistent diarrhea during nutritional interventions is likely to increase our understanding of PD pathogenesis.