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We aimed to characterize the association between intestinal inflammation and enteric pathogens among children in low- and middle-income countries (LMICs) who presented to care with diarrhea.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methodology\/principle findings<\/jats:title>\n                    <jats:p>\n                      We conducted a cross-sectional analysis within the Enterics for Global Health -\n                      <jats:italic>Shigella<\/jats:italic>\n                      surveillance study at six LMIC sites: Bangladesh, Kenya, Malawi, Pakistan, Peru, and The Gambia. From August 2022 to July 2024, rectal swabs and whole stool samples were collected from 4,903 children with medically attended diarrhea aged 6\u201335 months (44.4% females, n\u2009=\u20092178\/4903; mean age: 15.4 months \u2009\u00b1 \u20097.4 months) and were analyzed for\n                      <jats:italic>Shigella<\/jats:italic>\n                      and four fecal inflammatory biomarkers: hemoglobin, lipocalin-2, myeloperoxidase, and calprotectin via Enzyme Linked Immunosorbent Assays. Caregivers and clinicians demonstrated moderate accuracy in identifying blood in stool compared to fecal hemoglobin (area under the curve (AUC)=0.70). Among 10 pathogens evaluated,\n                      <jats:italic>Shigella<\/jats:italic>\n                      -attributable diarrhea had the highest concentrations of calprotectin, hemoglobin, and myeloperoxidase.\n                      <jats:italic>Shigella<\/jats:italic>\n                      culture-\/PCR+ episodes had intermediate levels of inflammation between culture-\/PCR- and culture+ episodes. In multivariable models restricted to\n                      <jats:italic>Shigella<\/jats:italic>\n                      episodes, dysentery was positively associated and vomiting was negatively associated with biomarker concentrations, with the strongest associations observed for hemoglobin (dysentery geometric mean ratio: 12.82 (95% CI: 7.21, 22.77) and vomiting geometric mean ratio: 0.45 (95% CI: 0.23, 0.86)). Age, sex, and both acute and chronic malnutrition were not associated with inflammatory biomarker concentrations.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Conclusions\/significance<\/jats:title>\n                    <jats:p>\n                      Hemoglobin appeared to be a more sensitive marker of blood in stool than visual observation. While\n                      <jats:italic>Shigella<\/jats:italic>\n                      was associated with heightened levels of all inflammatory biomarkers, hemoglobin was most strongly associated with\n                      <jats:italic>Shigella<\/jats:italic>\n                      , especially among attributable and culture positive episodes. The distinct clinical characteristics of\n                      <jats:italic>Shigella<\/jats:italic>\n                      were most closely associated with elevated hemoglobin concentrations.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pntd.0014320","type":"journal-article","created":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T18:03:23Z","timestamp":1789495403000},"page":"e0014320","update-policy":"https:\/\/doi.org\/10.1371\/journal.pntd.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Fecal biomarkers to characterize intestinal inflammation among children with medically attended diarrhea across six low-resource settings: Findings from the Enterics for Global Health (EFGH) Shigella surveillance study"],"prefix":"10.1371","volume":"20","author":[{"given":"Bri\u2019Anna","family":"Horne","sequence":"first","affiliation":[{"name":"Center for Vaccine Development and Global Health, University of Maryland 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