Diarrhea in young children associated with Escherichia coli non-O157 organisms that produce Shiga-like toxin,☆☆,,★★

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Abstract

OBJECTIVE: To assess the clinical manifestations and incidence of infection associated with Shiga-like toxin-producing Escherichia coli (SLTEC). STUDY DESIGN: Children with diarrhea within a defined geographic area during a 12-month period were examined for the presence of SLTEC in their stools by polymerase chain reaction with the use of primers that were complementary to sequences of Shiga-like toxins types I and II and to other virulence factors. RESULTS: There were 13 SLTEC infections among 468 children with diarrhea. Besides Shiga-like toxin sequences, the virulence genes eae and EHEC-hly were found in 10 isolates; these isolates were categorized as enterohemorrhagic E. coli (EHEC). Only 2 of 13 isolates were of the O157 strain. All reported cases occurred in summer (June through September) with the exception of one case in April. The infections were sporadic, and the infected children lived in rural and urban areas. Three infections in children with disabilities were hospital acquired. The majority of children had watery diarrhea, two had bloody diarrhea, and one had mild hemolytic-uremic syndrome. The overall incidence of SLTEC infection was 12.5 hospitalized children per 100,000 children less than 16 years of age. CONCLUSIONS: The most frequent clinical manifestation of SLTEC infection was watery diarrhea indistinguishable from other forms of infectious diarrhea. The shift from the O157 strain toward non-O157 SLTEC strains associated with diarrhea, also observed in German patients with hemolytic-uremic syndrome, points to a change in the epidemiologic features of SLTEC-associated disease. Testing for non-O157 SLTEC should be considered in children with diarrhea without a recognized cause. (J PEDIATR 1996;128:341-6)

Section snippets

Patients

In 1994 we examined all children and adolescents less than 16 years of age who were hospitalized in either of the two children's hospitals in Würzburg, Germany, for the presence of diarrhea and recorded their clinical and demographic data. The two hospitals serve the children of a population of about 600,000 people, 104,000 of whom are less than 16 years of age and 39,000 less than 6 years of age.27 About 150,000 people live in the metropolitan area, the rest in a rural environment; the mean

RESULTS

During the 12-month period of 1994, a total of 468 hospitalized children were recognized as having diarrhea. The median age of patients was 3 years 4 months; 201 patients (43%) were female.

By standard culture techniques, a bacterial pathogen was identified in the stools of 71 children (15%). Salmonella was found in 63 children (13.5%). Of 63 isolates, 47 were Salmonella enteritidis. Campylobacter jejuni was found in 6 children (1.3%), and Yersinia enterocolitica in 2 (0.4%).

Colonies of E. coli

DISCUSSION

Non-O157:H7 SLTEC organisms were the second most frequent bacterial agent associated with diarrheal disease in this cohort of hospitalized children with diarrhea. The spectrum of illness was broader than previously reported25, 26 and did not differ from other infectious diarrhea. Among 13 children, we found two patients with bloody diarrhea, and one of them had incomplete HUS. A study from Seattle found one case of bloody diarrhea and no case of HUS among five children infected with non-O157:H7

Acknowledgements

We are grateful to Dr. G. Fricke, Kinderklinik am Mönchberg, Würzburg, for allowing us to study his patients. We thank Barbara Plaschke for technical assistance.

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    From Children's Hospital and the Institute for Hygiene and Medical Microbiology, University of Würzburg, Würzburg, Germany, and the National Reference Center for Enterobacteriaceae, Hamburg, Germany

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    Supported by Biotest GmbH, Dreieich, Germany.

    Reprint requests: Hans-Iko Huppertz, MD, Universitätskinderklinik, Josef-Schneider-Str. 2, D-97080 Würzburg, Germany.

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    0022-3476/96/$5.00 + 0 9/20/70008

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