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Medical Author:

Charles Patrick Davis, MD, PhD

Charles Patrick Davis, MD, PhD

Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

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Medical Editor:

Bhupinder Anand, MD

Although this article was originally written for E. coli 0157:H7, information on the newest EEC E. coli strain (0104:H4) will be discussed because of its similarity to the 0157:H7 strain. In the spring of 2011, the E. coli 0104:H4 strain was identified in Germany (in early 2011) and has now been documented in 11 European countries; at least four people who traveled to Germany and returned to the US have been infected with this strain. In most people, exposure to the infection occurred in Germany, most likely when they ate contaminated food (salads). The strain has been identified as E. coli 0104:H4 (also termed STEC 0104:H4).

E. coli 0104:H4 is being reviewed in this article because this new strain seems to exhibit some of the worst overlap features in the diseases caused by ECC group members. For example, E. coli 0104:H4 is reported to contain about 93% of E. coli 0157:H7 and produces the Shiga (Vero) toxin and many patients (about 30%) develop HUS. However, it also seems to have the ability like EAEC strains to attach to the gastrointestinal cells. Currently, the outbreak is the third largest ever reported for E. coli (about 2200 infected patients) and is the most lethal (at least 22 dead as of 6/6/2011). In addition, most strains isolated are resistant to multiple antibiotics (aminoglycosides, macrolides, and Beta-lactams).

The source of the infection may be contaminated bean sprouts grown organically and then shipped to many German restaurants, but this is still a speculation. One major difference in E. coli 0104:H4 from other E. coli that cause HUS (mainly E. coli 0157:H7) is that the organism is causing HUS in adults, particularly young adult females. Usually, HUS caused by E. coli 0157:H7 is seen in children, the elderly, and the relatively not healthy adults.

The diagnosis, treatment, prognosis, prevention and complications are very similar to those listed in this article for E. coli 0157:H7. However, this outbreak of E. coli 0104:H4 is still ongoing and being studied intensively; other differences may become evident as data collection and research progresses.

The most recent (June 3, 2011) guidelines from the CDC are as follows:

It is recommended that antibiotics should not be given to patients with suspected STEC infections until complete diagnostic testing is performed and STEC infection is ruled out. Some studies have shown that administering antibiotics to patients with STEC infections may increase the risk of developing HUS. However, clinical decision making must be tailored to each individual patient. There may be indications for antibiotics in patients with severe intestinal inflammation, especially if perforation is of concern. Of note, isolates of STEC O104:H4 from patients in Germany have demonstrated resistance to multiple antibiotics.

Guidelines to ensure as complete as possible detection and characterization of STEC infections include the following:

• All stools submitted for testing from patients with acute community-acquired diarrhea should be cultured for STEC O157:H7. These stools should be simultaneously assayed for non-O157 STEC strains with a test that detects the Shiga toxins or the genes encoding these toxins.
• Clinical laboratories should report and send E. coli O157:H7 isolates and Shiga toxin-positive samples to state or local public health laboratories as soon as possible for additional characterization.
• Specimens or enrichment broths in which Shiga toxin or STEC are detected, but from which O157:H7 STEC isolates were not recovered, should be forwarded as soon as possible to a state or local public health laboratory so that non-O157:H7 STEC strains can be isolated.
• It is often difficult to isolate STEC in stool by the time a patient presents with HUS. Immunomagnetic separation (IMS) has been shown to increase recovery of STEC from HUS patients. For any patient with HUS without a culture-confirmed STEC infection, stool can be sent to a public health laboratory that performs IMS or to the CDC (through a state public health laboratory). In addition, serum can be sent to CDC (through a state public health laboratory) for serologic testing of common STEC serogroups.

The benefits of adhering to the recommended testing strategy include early diagnosis, improved patient outcome, and detection of all STEC serotypes.

All patients with Shiga toxin-positive diarrheal illness or HUS should be reported to health departments, regardless of a travel history to Germany.

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