Diarrhea associated with adherent enteropathogenic Escherichia coli in an infant and toddler center, Seattle, Washington

During November 1983, the Seattle-King County Department of Public Health investigated an outbreak of diarrhea associated with enteropathogenic Escherichia coli, serogroup 0111:K58, in an infant and toddler day-care center. Of the 25 children in the center, ranging in age from 4 to 30 months (median age 11 months), diarrhea occurred in 14 characterized by watery, greenish stools. The median duration of diarrhea was 12 days. Two of the ill children were hospitalized because of severe dehydration. Stool cultures from the children diagnosed initially did not yield the common bacterial pathogens, parasites, or rotavirus. Stool cultures from 11 of 14 ill children and two of 11 well children (P less than .005), however, yielded an E coli serogroup, 0111:K58, which was not invasive or toxigenic by standard tests. The source of the organism was not identified. Although this organism has been recognized as a cause of diarrhea in newborn nurseries, this is the first published report of a documented outbreak of enteropathogenic E coli-induced diarrhea in a day-care center in the United States.

Intrafamilial spreading of Escherichia coli resistant to trimethoprim

Bacterial resistance to trimethoprim has mainly been considered a problem confined to hospitals. The present investigation was undertaken to check for any possible spread of trimethoprim resistance borne by uropathogenic Escherichia coli among families of outpatients. Family members, living in the same household as outpatients with urinary tract infections caused by a trimethoprim-resistant E. coli strain, were asked to deliver faecal specimens. Of a total number of 51 family members 16 were found to be carrying trimethoprim-resistant E. coli in their faecal flora. A comparison of serotypes showed 8 of the 16 family members to have the same E. coli strain in their faeces as originally isolated in the urine of the index patient from the same family. The results indicate that resistance to trimethoprim not only spreads in hospitals with intensive use of antibiotics, but also among the families of trimethoprim-treated outpatients.

Sexual acquisition of urinary tract infection in a man

A man was admitted with acute pyelonephritis due to Escherichia coli. Three days prior to the onset of his symptoms his wife presented with a 7-day history of cystitis due to E. coli. Before the wife developed her symptoms the couple were having vaginal intercourse every night, and this continued for the first 3 days of her symptoms. The organisms isolated from the urine of both patients were found to have the same biotype, an identical antibiogram, and the same serotype. The temporal sequence of events and the bacteriological findings strongly suggest the sexual transmission of this organism from the wife to her husband.

Hemorrhagic colitis with Escherichia coli O157:H7 preceding adult hemolytic uremic syndrome

Escherichia coli serotype O157:H7 is a rarely identified organism that has recently been associated with hemorrhagic colitis in all age groups and with the hemolytic uremic syndrome (HUS) in children. We now report the development of HUS in two young women following enteric infection with E coli O157:H7. Both patients were hospitalized because of the severity of their colitis. They later developed major hemolysis requiring transfusion and significant renal failure requiring, in one case, hemodialysis. One patient underwent laparotomy, where sterile ascites, marked right colonic edema, and intraserosal hemorrhage were noted. Both women survived and are currently improving. Fecal E coli serotype O157:H7 was sought only after routine cultures were negative and features of HUS were recognized. The search for the E coli was facilitated by the continued availability of stool cultures obtained early in the course of the illness. The source of infection was not ascertained, but ingestion of untreated water was a feature of both cases. The HUS is a potential complication of the hemorrhagic colitis associated with E coli serotype O157:H7 and may develop in adults as well as children following enteric infection with this organism.

Septicemic colibacillosis and failure of passive transfer of colostral immunoglobulin in calves

Septicemic colibacillosis is a highly fatal disease that occurs in calves less than 2 weeks of age. The disease occurs when a calf that fails to absorb protective levels of immunoglobulin from colostrum is exposed to an invasive serotype of E. coli. Management to ensure good passive transfer of colostral immunoglobulin will prevent this disease and reduce calf mortality caused by other infectious diseases as well.

Person-to-person transmission in an outbreak of enteroinvasive Escherichia coli

In the summer of 1981, an outbreak of diarrhea occurred in students and staff at a school for mentally retarded adults and children in Columbia, Missouri. Forty-one (48%) of 86 students and 38 (28%) of 137 staff members in the two dormitories with the lowest functioning students were ill. Enteroinvasive Escherichia coli 0124:H30 was isolated from 20 persons including six staff members, 13 students, and the ill mother of one of the students. Contact with students was associated with illness. Thirty-eight (33%) of the 115 student-care staff members and none of the 22 nonstudent-care staff members who worked in the two dormitories were ill (p = 0.004, chi-square). In the dormitory with the most dependent students, illness in student-care staff was associated with the number of contacts with ill students and with having taken a student home during the outbreak. Control measures to interrupt transmission included separation of symptomatic or culture-positive students from those who were well, and emphasizing handwashing. The authors present these findings as the first report of person-to-person transmission in an outbreak of enteroinvasive E. coli.

Etiology and epidemiology of diarrheal diseases in the United States

Accurate data on the frequency of acute diarrheal illness and the distribution of pathogens are not available for several reasons, including the facts that only a small fraction of cases come to the attention of physicians and that available diagnostic tests establish an etiology in only about half of these. In a survey of three groups of patients in a community (upper-middle class and lower class outpatients and hospitalized infants), a possible cause was found in fewer than 20 percent of outpatients, and rotavirus accounted for the majority. However, asymptomatic colonization with rotavirus is very common in early infancy, and demonstration of the antigen correlates with a causative role in diarrhea in only about one half of cases. Data on cases of shigellosis over a 15-year period in Dallas compared with the Centers for Disease Control national data demonstrate that epidemiologic patterns in any given community can differ substantially from the national data. Day-care centers are important sources of Giardia and Shigella infections in the community. The epidemiologic roles of newly reported causes of diarrhea (Campylobacter laridis, Blastocystis hominis, Cryptosporidium species, and Aeromonas hydrophila) are being explored. Generalizations about etiology and epidemiology of pathogens in diarrheal disease are invalid unless the population group is defined socioeconomically and geographically.

Increased risk of illness among nursery staff caring for neonates with necrotizing enterocolitis

In 1983 an outbreak of necrotizing enterocolitis (NEC) and hemorrhagic gastroenteritis occurred in our newborn nurseries. Eleven children were ill and three required bowel resections. During the outbreak many of the medical and nursing staff in the nurseries also were ill, prompting a microbiologic and epidemiologic investigation. Bacterial and viral cultures, Clostridium difficile toxin assays, enzyme-linked immunosorbent assays for viral antigens and immunoelectron microscopy of stools identified no associated pathogen. However, using a method of calculating relative risk as an incidence density ratio, we found that nurses who had cared for ill infants were at higher risk for sick call within the 9 days following exposure than nurses who had cared for babies without NEC (relative risk, 1.96; P = 0.05). These results provide additional evidence that a transmissible agent may be responsible for some cases of NEC and support the recommendation for infection control measures during outbreaks. The epidemiologic methods used in this study may be useful in prospective studies of NEC and may help to provide further clues to the cause of this disease.

A multistate outbreak of gastrointestinal illness caused by enterotoxigenic Escherichia coli in imported semisoft cheese

In September 1983, three clusters of gastrointestinal illness with similar symptoms affected 45 persons in Washington, D.C., after office parties. The illness lasted a mean of 4.4 days and was characterized by watery diarrhea (91%), abdominal cramps (80%), headache (38%), nausea (38%), and subjective fever (20%). Illness was strongly associated with having eaten imported French Brie cheese one to six days before onset of illness (P less than .0001 by Fisher's two-tailed exact test). After publicity about these outbreaks, additional cheese-associated cases were identified over an eight-week period in Illinois, Wisconsin, Georgia, and Colorado. Stool specimens from ill persons in four states yielded Escherichia coli serotype O27:H20. These organisms produced heat-stable enterotoxin and had similar plasmid profiles. When commercially distributed foods are contaminated, enterotoxigenic E. coli can cause widespread disease even in a developed country, and the disease can easily escape correct diagnosis.

Epidemic outbreaks of acute pyelonephritis caused by nosocomial spread of P fimbriated Escherichia coli in children

In a study of pyelonephritis in children less than two years of age we found a high incidence of acute first-time pyelonephritis among children who had been previously cared for in a particular hospital neonatal ward. In 1981 and 1982 more than 50% of the children with pyelonephritis from the referral area of Danderyd Hospital (Danderyd, Sweden) had previously attended this particular neonatal ward; the expected incidence was 15% (P less than .001). The majority of these cases of pyelonephritis were caused by Escherichia coli that were P fimbriated and of serotype O6:K5. An E. coli strain with the same characteristics was found in the stools of personnel in the neonatal ward and in a high proportion of the stools and cord stumps of neonates in the ward. These findings support the opinion that certain P fimbriated E. coli clones may be nosocomially spread and cause epidemic outbreaks of pyelonephritis and that fecal colonization with such E. coli predisposes to this disease.

A nursery outbreak of multiple-aminoglycoside-resistant Escherichia coli

In the neonatal intensive care unit (NICU) of one hospital, 16 infants became colonized or infected with multiply-resistant Escherichia coli (MR-E.coli) over an 8-month period. Isolates were obtained from blood, urine, and sputum of three patients and from rectal surveillance cultures of 13 patients. The one patient with the blood isolate died. A matched case-control study identified continuous feeding (nine of 16 cases vs. one of 16 controls, p less than or equal to 0.001) and receipt of aminoglycosides (p less than or equal to 0.03) as risk factors. For case-babies not exposed to continuous feeding, duration of bolus feeding was significantly greater than for their controls (cases, 22 days; controls, 7 days; p less than or equal to 0.02). All 16 isolates were the same serotype and were resistant to amikacin, tobramycin, kanamycin, and gentamicin. The epidemiologic investigation suggested that MR-E. coli may have spread from person-to-person on the hands of personnel and that MR-E. coli persisted in the NICU for 8 months until effective control measures were instituted.

The potential of Escherichia coli in enteral feeds to cause food poisoning: a study under simulated ward conditions

The growth of Escherichia coli over a period of 8 h under simulated ward conditions was compared in feeding systems containing either Clinifeed ISO or Nutrient Broth. In both, counts increased from 10(2) to 10(7) ml-1. Other systems containing Clinifeed ISO were inoculated with E. coli and sampled over 24 h. At 8 and 16 h the contaminated reservoir was replaced, refilled or replaced together with the gastric drip line. When the reservoir was replaced or refilled it was always recontaminated by residual organisms. Even when the reservoir and drip line were replaced, although the contents of the reservoir were sterile, E. coli was still detected in feed collected from the end of the fine-bore tube. Experiments with varying numbers of E. coli in the inoculum demonstrated that even one organism in the reservoir could, within 16 h, multiply to a level that might be harmful, especially to compromised patients.

Outbreak of invasive Escherichia coli gastroenteritis on a cruise ship

An invasive strain of Escherichia coli (ONT:NM) was isolated from stool specimens from 7 of 10 ill passengers who developed diarrhea during a 5-day ocean cruise. The ill passengers had shared no common exposures off the ship before or during the cruise. Three of the persons whose stools were cultured were part of a tour group of 219 persons, and a food consumption and health history questionnaire was completed by 190 members (87%) of this tour group. Forty-seven (25%) had had diarrhea during the cruise; other symptoms among those with diarrhea included nausea (72%), abdominal cramps (68%), headache (68%), chills (60%), dizziness (53%), myalgias (43%), subjective fever (36%), and vomiting (26%). The median duration of symptoms was 3 days. Eating at cold buffets on ship and eating potato salad, a buffet food item, were significantly associated with illness. No evidence of secondary spread of illness in household contacts of the ill person was found.

Effect of chlortetracycline on the spread of R-100 plasmid-containing Escherichia coli BEL15R from experimentally infected pigs to uninfected pigs and chicks

Swine from two herds with different histories of antibiotic exposure were fed diets containing 0 or 55 mg of chlortetracycline (CTC)/kg. One of five pigs in each herd-diet treatment group was infected orally with Escherichia coli strain BEL15R that was resistant to nalidixic acid (NA), chloramphenicol (C), streptomycin (S), sulfamethizole (TH) and tetracycline (TE). Effects of CTC on the quantity and duration of fecal shedding of E. coli BEL15R and on the transmission of strain BEL15R and its R-100 plasmid from infected pigs to uninfected pigs and chicks were determined. Quantity and duration of shedding were greater in infected antibiotic-herd pigs than in infected nonantibiotic-herd pigs. Feeding on CTC increased the duration of shedding in infected pigs from both herds. Strain BEL15R colonized and was shed in one uninfected antibiotic pig in each treatment group, but it did not colonize in any of the uninfected nonantibiotic-herd pigs or in the uninfected chicks. In vivo transfer of resistance to C, S, TH and TE occurred in the infected antibiotic-herd pigs but not in the infected nonantibiotic-herd pigs. Transfer of the R-100 plasmid occurred from the infected to the uninfected antibiotic-herd pigs and to the uninfected chicks housed near the antibiotic-herd pigs fed CTC, but not to the chicks housed with the antibiotic-herd pigs fed the control diet. No transfer of resistance occurred from the infected nonantibiotic-herd pigs fed either CTC or control diet.

Enteropathogenic Escherichia coli of classic serotypes associated with infant diarrhea: epidemiology and pathogenesis

A series of O:H serotypes of E. coli were incriminated by epidemiologic studies in the period 1945-1960 as a cause of epidemic diarrhea in infant nurseries as well as a major cause of sporadic infant diarrhea in the community. The term enteropathogenic E. coli was coined to refer to these infant diarrhea-associated serotypes. In the early 1970s, with the advent of laboratory tests to assess heat-labile and heat-stable enterotoxin production and enteroinvasiveness of E. coli, the classic serotype enteropathogenic E. coli strains were found to lack those particular properties. These observations led some to question their pathogenicity. However, since 1978, enteropathogenic E. coli have come to be appreciated anew as a separate class of diarrheagenic E. coli that cause diarrhea by distinct pathogenic mechanisms. The pathogenesis of these strains, which have been shown to cause diarrhea in volunteers, appears to involve both an enteroadhesiveness step and production of a toxin identical to Shigella toxin. A 55- to 65-Mdalton plasmid is involved in the attachment of enteropathogenic E. coli to intestinal mucosa which results in a pathognomonic histopathologic lesion visualized by electron microscopy. The lesion involves dissolution of enterocyte microvilli by the bacteria, effacement of the enterocyte outer membrane, and formation of a pedestal around the bacterium at point of contact with the outer membrane of the enterocyte. Case-control epidemiologic studies carried out since 1975 document that enteropathogenic E. coli remain an important cause of sporadic infant diarrhea in the community with up to 30 per cent of cases of acute diarrhea in young infants in Brazil and South Africa being attributed to these pathogens. Although nursery epidemics of enteropathogenic E. coli diarrhea have virtually disappeared from industrialized countries, some sporadic enteropathogenic E. coli diarrhea in infants in the community continues to occur. The relative importance of enteropathogenic E. coli as a cause of sporadic diarrhea in both industrialized and developing countries needs to be reassessed. New diagnostic techniques are awaited to simplify this task.

Contamination of weaning foods and transmission of enterotoxigenic Escherichia coli diarrhoea in children in rural Bangladesh

In longitudinal studies of infectious diseases and nutrition in Bangladesh, we determined the degree of bacterial contamination of traditional weaning foods and evaluated the role of these foods in the transmission of diarrhoeal diseases. 41% of samples of food items fed to weaning aged children contained Escherichia coli; these organisms were used as indicators of faecal contamination. Milk and foods prepared particularly for infants were more frequently and heavily contaminated with E. coli than was boiled rice, and E. coli levels were found to be related to the storage of cooked foods at high environmental temperatures. 50% of drinking water specimens also contained E. coli, but colony counts were approximately 10-fold lower than in food specimens. The proportion of a child's food samples that contained E. coli was significantly related to the child's annual incidence of diarrhoea associated with enterotoxigenic E. coli. This observation underscores the importance of seeking locally available foods that are hygienic as well as nutritious to supplement the diets of breastfeeding children in developing countries.

Nosocomial infection of the urinary tract

Urinary tract infections appear to be responsible for 35 percent of all hospital-acquired infections, occurring in approximately two patients per 100 admissions. The great majority of infections are associated with urinary tract instrumentation. Female sex, advanced age and debilitating underlying illness appear to be associated with an increased risk of infection, but other risk factors have been poorly defined and case-control studies assessing excess morbidity and mortality associated with nosocomial bacteriuria have not been made. In most instances, the hospitalized patients are the reservoirs for the etiologic organisms, but cross-infection from other infected patients also occurs. Current preventive efforts have been primarily directed at aseptic catheter care techniques and reducing catheter use. Further developments in our prevention and control of these infections require an understanding of the mechanisms responsible for colonization of the urethra and bladder with gram-negative organisms and ways to discriminate patients at special risk.

Enterotoxigenic Escherichia coli diarrhoea: acquired immunity and transmission in an endemic area

Enterotoxigenic Escherichia coli (ETEC) are an important cause of diarrhoea in developing countries. Studies were made, in an endemic area of Bangladesh, of household contacts of patients with diarrhoea associated with E. coli producing heat-stable and heatlabile toxins (ST/LT) or heat-stable toxin (ST) only. It was found that 11% of contacts were infected in the 10-day study period, and that both the rate of infection and the proportion of infected persons with diarrhoea decreased with increasing age, suggesting the development of immunity. ETEC of the same serotype as that of the index patient were found in 9% of water sources used by index households, in a small number of food and drinking water specimens from the index homes, and in faeces from 3 healthy calves. The rate of infection of household members was highest in houses where there was contaminated food or water, which suggests that infection may take place in the home when contaminated water is brought in.