Distribution of Escherichia coli Pathotypes along an Urban–Rural Gradient in Ecuador

Lorena Montero Instituto de Microbiologia, Universidad San Francisco de Quito, Quito, Ecuador;

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Shanon M. Smith Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia;

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Kelsey J. Jesser Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington;

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Maritza Paez Instituto de Microbiologia, Universidad San Francisco de Quito, Quito, Ecuador;

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Estefanía Ortega Instituto de Microbiologia, Universidad San Francisco de Quito, Quito, Ecuador;

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Angela Peña-Gonzalez School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia;

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Maria Juliana Soto-Girón School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia;

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Janet K. Hatt School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia;

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Xavier Sánchez Centro de Biomedicina, Universidad Central del Ecuador, Quito, Ecuador

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Edison Puebla Centro de Biomedicina, Universidad Central del Ecuador, Quito, Ecuador

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Pablo Endara Instituto de Microbiologia, Universidad San Francisco de Quito, Quito, Ecuador;

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William Cevallos Centro de Biomedicina, Universidad Central del Ecuador, Quito, Ecuador

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Konstantinos T. Konstantinidis School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia;
School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia;

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Gabriel Trueba Instituto de Microbiologia, Universidad San Francisco de Quito, Quito, Ecuador;

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Karen Levy Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia;
Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington;

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Diarrheal diseases are a leading cause of mortality and morbidity in low- and middle-income countries. Diarrhea is associated with a wide array of etiological agents including bacterial, viral, and parasitic enteropathogens. Previous studies have captured between- but not within-country heterogeneities in enteropathogen prevalence and severity. We conducted a case-control study of diarrhea to understand how rates and outcomes of infection with diarrheagenic pathotypes of Escherichia coli vary across an urban–rural gradient in four sites in Ecuador. We found variability by site in enteropathogen prevalence and infection outcomes. Any pathogenic E. coli infection, coinfections, diffuse adherent E. coli (DAEC), enteroinvasive E. coli (EIEC), and rotavirus were significantly associated with acute diarrhea. DAEC was the most common pathotype overall and was more frequently associated with disease in urban areas. Enteropathogenic E. coli (EPEC) and enterotoxigenic E. coli (ETEC) were more common in rural areas. ETEC was only associated with diarrhea in one site. Phylogenetic analysis revealed that associations with disease were not driven by any single clonal complex. Higher levels of antibiotic resistance were detected in rural areas. Enteropathogen prevalence, virulence, and antibiotic resistance patterns vary substantially by site within Ecuador. The variations in E. coli pathotype prevalence and virulence in this study have important implications for control strategies by context and demonstrate the importance of capturing within-country differences in enteropathogen disease dynamics.

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Author Notes

Financial support: This work was supported by the NIH (Grant no. 1K01AI103544 to K. L.; Grant nos. 5T32ES007032-37 and 5T32ES012870-15 to K. J. J.) and Minciencias doctoral fellowships (to A. P.-G. and M. J. S.-G.). The funders had no role in the study design, data collection, or interpretation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.

Disclosure: Human subjects protocols and consent/assent forms were approved by the institutional review boards of Emory University (IRB00065781) and Universidad San Francisco de Quito (2013-145M). The research protocol was approved by the Ecuadorian Ministry of Health (MSP-DIS-2014-0055-O).

Authors’ addresses: Lorena Montero, Maritza Paez, Estefanía Ortega, Pablo Endara, and Gabriel Trueba, Instituto de Microbiologia, Universidad San Francisco de Quito, Quito, Ecuador, E-mails: lpmonterot@gmail.com, mpaezllerena86@gmail.com, estefania1058@gmail.com, pendara@usfq.edu.ec, and gtrueba@usfq.edu.ec. Shanon M. Smith, Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, E-mail: shanon.smith50@gmail.com. Kelsey J. Jesser, Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA, E-mail: kjesser@uw.edu. Angela Peña-Gonzalez and Maria Juliana Soto-Girón, School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, E-mails: angela.viviana.pena@gmail.com and dendroapsis@gmail.com. Janet K. Hatt, School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, E-mail: janet.hatt@ce.gatech.edu. Xavier Sánchez, Edison Puebla, and William Cevallos, Centro de Biomedicina, Universidad Central del Ecuador, Quito, Ecuador, E-mails: rodrigoxav_sanchez@hotmail.com, puebla.edison@gmail.com, and wcevallos@uce.edu.ec. Konstantinos T. Konstantinidis, School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, and School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, GA, E-mail: kostas.konstantinidis@gatech.edu. Karen Levy, Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, and Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA, E-mail: klevyx@uw.edu.

Address correspondence to Karen Levy, Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA 98915. E-mail: klevyx@uw.edu
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