Characteristics of the enteroaggregative Shiga toxin/verotoxin-producing Escherichia coli O104:H4 strain causing the outbreak of haemolytic uraemic syndrome in Germany, May to June 2011

The Escherichia coli strain causing a large outbreak of haemolytic uraemic syndrome and bloody diarrhoea in Germany in May and June 2011 possesses an unusual combination of pathogenic features typical of enteroaggregative E. coli together with the capacity to produce Shiga toxin. Through rapid national and international exchange of information and strains the known occurrence in humans was quickly assessed.We describe simple diagnostic screening tools to detect the outbreak strain in clinical specimens and a novel real-time PCR for its detection in foods.

A tool based on Ligation Detection Reaction-Universal Array (LDR-UA) for the characterization of VTEC by identification of virulence-associated and serogroup-specific genes

Verocytoxigenic Escherichia coli (VTEC) are zoonotic pathogens whose natural reservoir is represented by ruminants, particularly cattle. Infections are mainly acquired by consumption of undercooked contaminated food of animal origin, contact with infected animals and contaminated environment. VTEC O157 is the most frequently isolated serogroup from cases of human disease, however, other VTEC serogroups, such as O26, O111, O145 and O103, are increasingly reported as causing Hemolytic Uremic Syndrome (HUS) worldwide. The identification of VTEC is troublesome, hindering the development of effective prevention strategies. In fact, VTEC are morphologically indistinguishable from harmless E. coli and their pathogenic potential is not strictly dependent on the serogroup, but relies on the presence of a collection of virulence genes. We developed a diagnostic tool for VTEC based on the Ligation Detection Reaction coupled to Universal Array (LDR-UA) for the simultaneous identification of virulence factors and serogroup-associated genes. The method includes the investigation of 40 sites located in 13 fragments from 12 genes (sodCF1/F2, adfO, terB, ehxA, eae, vtx1, vtx2, ihp1, wzx, wbdI, rfbE, dnaK) and was evaluated by performing a trial on a collection of 67 E. coli strains, both VTEC and VT-negative E. coli, as well as on 25 isolates belonging to other related species. Results of this study showed that the LDR-UA technique was specific in identifying the target microorganism. Moreover, due to its higher throughput, the LDR-UA can be a valid and cheaper alternative to real time PCR-based (rt-PCR) methods for VTEC identification.

[Continuous renal replacement therapies (CRRT) will remain the most widely adopted dialysis modality in the critically ill]

In the last 10-15 years, user-friendly continuous renal replacement therapy (CRRT) machines have played a major role in increasing the popularity of these techniques in intensive care settings. At present it is not clear which modality of renal replacement therapy (RRT) is optimal for critically ill patients with acute kidney injury (AKI). The choice between different modalities should therefore not be based on unproven ''outcome'' advantages but on evaluation of the clinical picture and logistical circumstances. In hypercatabolic patients, CRRT and sustained low-efficiency dialysis (SLED) have been shown to provide similar metabolic control, but uncontrolled studies suggested a better hemodynamic stability during CRRT, intended as a higher mean arterial pressure and/or less frequent need to increase inotropic or vasoactive drugs. The incidence of hemorrhagic complications is higher with CRRT; however, in particular conditions, such as in patients at high risk of bleeding, CRRT can be performed without anticoagulation or with the use of alternative anticoagulation protocols. Among the different modalities, regional anticoagulation with citrate appears to be the most promising, and the continuous development of simplified protocols for citrate CRRT might facilitate the more extensive use of this technique in the near future. The presence of a mismatch between prescribed and delivered dialysis dose is frequently reported as an important drawback of CRRT. However, data from a recent study designed to evaluate the prognostic impact of the intensity of renal support in critically ill patients with AKI showed that the target Kt/V was obtained in only 67-69% of intermittent hemodialysis (IHD) sessions. Data from several studies comparing the costs of different RRT modalities showed that CRRT is more expensive than IHD or SLED. However, the costs related to SLED can fluctuate within a wide range and in particular settings the higher costs of CRRT could be partially justified by logistical advantages. Further improvements in CRRT device characteristics, anticoagulation protocols, and adaptation of dialysis/replacement fluids to clinical needs will possibly contribute to maintaining, in the coming years, the key role of CRRT in the treatment of hemodynamically unstable critically ill patients requiring RRT.

Distribution, functional expression, and genetic organization of Cif, a phage-encoded type III-secreted effector from enteropathogenic and enterohemorrhagic Escherichia coli

Enteropathogenic Escherichia coli (EPEC) and enterohemorrhagic E. coli (EHEC) inject effector proteins into host cells via a type III secretion system encoded by the locus of enterocyte effacement (LEE). One of these effectors is Cif, encoded outside the LEE by a lambdoid prophage. In this study, we demonstrated that the Cif-encoding prophage of EPEC strain E22 is inducible and produces infectious phage particles. We investigated the distribution and functional expression of Cif in 5,049 E. coli strains of human, animal, and environmental origins. A total of 115 E. coli isolates from diverse origins and geographic locations carried cif. The presence of cif was tightly associated with the LEE, since all the cif-positive isolates were positive for the LEE. These results suggested that the Cif-encoding prophages have been widely disseminated within the natural population of E. coli but positively selected within the population of LEE-positive strains. Nonetheless, 66% of cif-positive E. coli strains did not induce a typical Cif-related phenotype in eukaryotic cells due to frameshift mutations or insertion of an IS element in the cif gene. The passenger region of the prophages carrying cif was highly variable and showed various combinations of IS elements and genes coding for other effectors such as nleB, nleC, nleH, nleG, espJ, and nleA/espI (some of which were also truncated). This diversity and the presence of nonfunctional effectors should be taken into account to assess EPEC and EHEC pathogenicity and tropism.

TccP2 of O157:H7 and non-O157 enterohemorrhagic Escherichia coli (EHEC): challenging the dogma of EHEC-induced actin polymerization

Enterohemorrhagic Escherichia coli (EHEC) O157:H7 and enteropathogenic E. coli (EPEC) trigger actin polymerization at the site of bacterial adhesion by inducing different signaling pathways. Actin assembly by EPEC requires tyrosine phosphorylation of Tir, which subsequently binds the host adaptor protein Nck. In contrast, Tir(EHEC O157) is not tyrosine phosphorylated and instead of Nck utilizes the bacterially encoded Tir-cytoskeleton coupling protein (TccP)/EspF(U), which mimics the function of Nck. tccP is carried on prophage CP-933U/Sp14 (TccP). Typical isolates of EHEC O157:H7 harbor a pseudo-tccP gene that is carried on prophage CP-933 M/Sp4 (tccP2). Here we report that atypical, beta-glucuronidase-positive and sorbitol-fermenting, strains of EHEC O157 harbor intact tccP and tccP2 genes, both of which are secreted by the LEE-encoded type III secretion system. Non-O157 EHEC strains, including O26, O103, O111, and O145, are typically tccP negative and translocate a Tir protein that encompasses an Nck binding site. Unexpectedly, we found that most clinical non-O157 EHEC isolates carry a functional tccP2 gene that encodes a secreted protein that can complement an EHEC O157:H7 DeltatccP mutant. Using discriminatory, allele-specific PCR, we have demonstrated that over 90% of tccP2-positive non-O157 EHEC strains contain a Tir protein that can be tyrosine phosphorylated. These results suggest that the TccP pathway can be used by both O157 and non-O157 EHEC and that non-O157 EHEC can also trigger actin polymerization via the Nck pathway.

[Pharmacotherapy of sepsis]

Despite an increasingly understanding of the pathogenetic mechanisms of sepsis, its mortality remains extremely high, caused mainly by hemodynamic impairment-related alterations frequently present in severe sepsis. Currently, treatment of sepsis is based on hemodynamic support, antibiotic therapy, surgical excision of infectious foci and immunomodulatory therapy. In fact, a massive host inflammatory infection response has recently emerged to substantially contribute to the development of septic shock and multiple organ dysfunction. Many clinical trials on various pharmacological agents have been conducted: glucocorticoids, nonsteroidal anti-inflammatory drugs (NSAIDs), antithrombin III (AT III), anti-endotoxin monoclonal antibodies, nitric oxide inhibitors, interleukin-1 receptor antagonist, anti-tumor necrosis factor (TNF) antibodies. Apart from some likely favourable findings connected to low doses of glucocorticoids, most studies yielded disappointing results. Nevertheless, the use of recombinant human activated protein C (drotrecogin-alpha) has recently proven to have a mortality reduction effect particularly in patients with severe sepsis and dysfunction of at least two organs. Furthermore, the early treatment of hemodynamic instability with volume expanders and vasopressors (early goal-directed therapy), and a strict glycemic control represent important measures in order to significantly reduce mortality from severe sepsis and septic shock, and are fundamental guidelines recommended by most scientific societies (Surviving Sepsis Campaign).

[Polymyxin-B direct hemoperfusion (PMX-DHP) in gram negative sepsis]

Severe sepsis and septic shock have a mortality rate that may range between 28 and 50%. It is estimated that approximately 200,000 patients die per annum in the USA as a consequence of sepsis. The reduction of plasma endotoxin levels to achieve a favourable outcome for septic patients has been previously demonstrated but the effectiveness of treatments targeting single inflammatory mediators during established sepsis has been disappointing. Furthermore,some clinical study clinically showed valuable reduction in cytokine levels by hemofiltration alone. The prompt removal of endotoxins could be an effective way to reduce the immunological activation and the amount of NO produced by endotoxin-activated inducible NO-synthase in many tissues and cells. The polymyxin B cartridge is an extracorporeal hemoperfusion device (PMX-DHP) known to remove circulating endotoxins. Open-label clinical trials testing PMX-DHP have demonstrated its safety in the septic shock treatment while the overall survival rate significantly improved in comparison with the control groups. The purpose of this study was to investigate the effects of PMX-DHP on redox status, inflammatory cytokine profile, monocytes and PMN leukocyte activation in Gram-negative sepsis. Prospective study: six patients, 2 males and 4 females 60.5+/-24.5 years old, in ICU for severe Gram-negative sepsis (emergency surgery for intra abdominal infection). Two PMX-DHP runs, at T0 and T1; 2 hours each; the first within 24 hours from sepsis diagnosis or 12 hours after emergency surgery, the first PMX-DHP at T0, the second after 24 hours.; APACHE II score at T0: 20.1+/-3.7; SOFA score 14.2+/-2.5; organ failure: 3+/-1.5; norepinephrine(Ne) in 1 patient; Ne + dopamine (DA) in 4 patients; DA in 1 patient only. Mean dosage: Ne 0.24 mcg/kg/min; DA 8.9 mcg/kg/min. Four patients in CRRT (continuous veno-venous hemofiltration, AN69 hemofilter) for the entire length of the study. QB 100+/-10 ml/min. Pre and post PMX-DHP, plasma endotoxins as well as anti-IL 1-beta, IL2, IL4, IL5, IL6, IL8, IL10, TNF-alpha, GM-CSF, IFN-gamma levels were measured. Expression of CD64 on monocytes and PMN leukocytes and I -2r CD25 on CD4+ T cells by flow cytometry. Total and reduced plasma cysteine, homocysteine, glutathione (GSH); plasma glutathione peroxidase (GSH-Px) and reductase (GSH-Rx); erythrocyte GSH (eGSH), eGSH-Px and eGSH-Rx; NADP and NADPH and their ratio assessed pre and post PMX-DHP, all compared with 15 age and gender-matched healthy subjects for complete REDOX characterization.

RESULTS

We observed a significant reduction of endotoxin levels post PMX-DHP; CD64 monocytes and PMN leukocytes overexpression returned to normal; pro-inflammatory cytokines Il6, Il 10 and TNF-alpha were significantly reduced. We detected no differences in plasma levels of anti-IL 1-beta, IL2, IL4, IL5, IL8, GM-CSF, IFN-gamma pre versus post PMX-DHP. SOFA score from 14.2+/-2.5 to 8.9+/-2.1 post PMX-DHP runs. Four out of six patients survived and were discharged; mortality was 33% versus the anticipated 51%.

CONCLUSION

PMX-DHP reduces circulating endotoxins, down-activates monocytes and PMN leukocytes, reduces pro-Inflammatory cytokines and corrects the redox environment imbalance preventing oxidative damage to endothelial cells and the metabolic and functional microvascular derangements that usually lead to multi-organ failure and septic shock.

[Pharmacokinetic principles and drug-dosing adjustments during continuous renal replacement therapies (CRRT)]

In the critically ill, acute renal failure (ARF) and "Multiple Organ Dysfunction Syndrome" (MODS) can be associated with significant modifications of many pharmacokinetic parameters, such as protein binding, volume of distribution and total body clearance. The start of renal replacement therapy (RRT) represents an additional variable to take in consideration for drug-dosing adjustments. Drugs significantly eliminated by the kidney are likely to be removed during RRT and a supplemental dose or further dosing adjustments are required if extracorporeal clearance is more than 25-30% of total body clearance. The impact of RRT on plasma drug concentrations can be substantially different in relation to the type of treatment (diffusive, convective or both), membrane characteristics (low-flux or high-flux), filter surface area and prescribed dialysis dose. The molecular weight cut-offs of high-flux membrane are much higher than the molecular weight of most drugs. Therefore, molecular size will not be a limitation for the removal of the unbound fraction of the drugs most commonly used in the critically ill undergoing continuous renal replacement therapy (CRRT). However, diffusive clearance could be significantly lower than convective clearance for drugs in the middle molecular weight range. In any case, the extracorporeal clearances report-ed with the use of high-volume CRRT (>50-60 L/2 h) are often surprisingly elevated and can lead to drug underdosing in clinical conditions where adequate antibiotic treatment is essential.

[Acute renal failure following cardiac surgery]

Acute renal failure (ARF) develops in 1-30% of patients who undergo cardiac surgery and is associated with a high mortality rate (15-30%). Several risk factors (pre- and intra-operative) for ARF have been identified. Pre-operative factors are strictly related to cardiovascular disease, advanced age and baseline renal dysfunction, while intra-operative factors are linked with the type of cardiac surgery, the duration of cardiopulmonary bypass and aortic cross-clamping. These factors provide an opportunity to quantify the risk of ARF based on pre-operative data, and for this purpose a clinical score to predict post-operative ARF has recently been developed. Moreover, this score could allow the identification of those patients who may take advantage of preventive strategies. Mortality in patients who develop severe ARF requiring dialysis is particularly high (50-80%). Therefore, an early diagnosis of ARF and a timely and aggressive renal replacement therapy could improve the outcome.

Public health implications of a case of haemolytic-uraemic syndrome associated with a concomitant outbreak of mild gastroenteritis in a small rural community

The concomitant occurrence of a case of haemolytic-uraemic syndrome (HUS) and 62 cases of mild gastroenteritis in schools of a small rural community in southern Italy induced the health authorities to suspect a foodborne outbreak of shiga-toxin-producing Escherichia coli (STEC) infection. The schools were closed and the catering service involved was investigated. However, STEC were not isolated from the HUS case or from the 56 cases of gastroenteritis examined, and the HUS case and the outbreak of gastroenteritis were probably just coincidental. A retrospective cohort study failed to show any correlation with consumption of school meals and suggested that the outbreak probably started outside the school setting and then spread within the schools by person-to-person transmission. All the cases examined were negative for common enteric pathogens and the responsible agent for the cases of gastroenteritis was not identified. The concern raised in the small community by the occurrence of a severe case of HUS and the lack of a rapid epidemiological assessment excluding the occurrence of a STEC outbreak, turned an epidemic episode of mild gastroenteritis into a public health emergency with relevant socioeconomic consequences. Prompt intervention in outbreaks following timely and effective risk communication are crucial for taking the most appropriate control measures and avoiding the spread of fear and panic in the community.

Serotypes and intimin types of intestinal and faecal strains of eae+ Escherichia coli from weaned pigs

Enteropathogenic Escherichia coli (EPEC) that are known to cause severe diarrhoea in children and young rabbits are well characterized, but there are few reports on the serotypes and intimin (eae) types of EPEC in weaned pigs. Based on detection of the eae gene by PCR and by DNA-hybridisation with LEE specific gene probes, 20 intestinal and 17 faecal eae(+) strains from diarrhoeal (164) and non-diarrhoeal (57) weaned pigs from 13 Hungarian farms, representing 12.8% of diarrhoeal and 14.0% of non-diarrhoeal pigs, were identified. The dominant serotype was O123:H11 (40%) among intestinal, and O108:H9 (23%) among faecal strains. The majority (85%) of the intestinal strains possessed eae-beta and 10% carried eae-gamma gene. In contrast, significantly (p<0.025) fewer faecal strains (53%) harboured the eae-beta gene, and 23% were eae-gamma positive. In vitro adhesion tests of intestinal and faecal eae(+) strains indicated adhesion of 20/37 of the strains to PK15 (porcine kidney) cells while only 3/37 strains adhered to HeLa cells. The ultrastructure of intimate bacterial attachment of representative porcine eae(+) strains to PK15 cells showed no pedestal formation, in contrast to the human EPEC (O127:H5, eae-alpha) strain. In conclusion, the data do not demonstrate a significant role for the eae(+)E. coli in porcine post-weaning diarrhoea, but provide new information on a dominant porcine serotype (O123:H11, eae-beta), and on differences of serotypes and intimin types of porcine eae(+) strains according to their site of isolation. Furthermore there was an indication that the PK15 cell line could be used as a model to study in vitro adherence of eae(+)E. coli of some human and porcine origin.

Prevalence of Escherichia coli O157 in lambs at slaughter in Rome, central Italy

A study on the prevalence of the faecal carriage of Escherichia coli O157 in lambs was performed in the major slaughterhouse in Rome, central Italy, during 2002. A total of 643 animals, consisting of 378 weaned and 265 suckling lambs, were assayed for the presence of E. coli O157. Five O157-agglutinating E. coli strains were isolated (0.8%, 95% CI 0.3-1.9). Only one was positive to PCR specific for the eae gene and produced verocytotoxin VT2, with a VTEC O157 overall prevalence of 0.2% (95% CI 0.0-1.0), whereas one strain possessed the eae gene only. All the other isolates were negative for the presence of all the virulence genes considered. The animals were either from local farms or imported from Eastern Europe. The results suggest an age-specific difference since the microorganism was isolated only from 0.3% (95% CI 0.0-1.7) of weaned lambs, while all samples from suckling lambs tested negative. From this study, the overall risk of human exposure to pathogenic E. coli O157 from lamb meat consumption derived from the major slaughterhouse in Rome can be considered reasonably low, particularly when suckling lamb meat is considered.

Detection of toxB, a plasmid virulence gene of Escherichia coli O157, in enterohemorrhagic and enteropathogenic E. coli

The virulence plasmid of Escherichia coli O157 strain EDL933 carries a 10-kb putative virulence gene designated toxB. Little is known about the distribution of this gene among E. coli O157 strains or its presence in other enterohemorrhagic E. coli (EHEC) and enteropathogenic E. coli (EPEC) strains. We developed PCR and hybridization tools for the detection of the entire toxB sequence and investigated its presence in a collection of EHEC O157 strains and other EHEC and EPEC strains belonging to different serogroups and isolated from different sources. The EHEC O157 strains reacted with all of the PCR primers and probes used, thus indicating the presence of a complete toxB gene regardless of the human or bovine origin of the isolates. Similar positive reactions were observed for about 50% of the EHEC O26 strains tested and a few other EHEC and EPEC strains. However, the size of the DNA fragments hybridizing with the toxB probes differed from that of the positive fragments from EHEC O157, suggesting a polymorphism in the toxB genes present in the different E. coli serogroups. Moreover, several EHEC and EPEC strains belonging to different serogroups reacted with only some of the genetic tools used, suggesting either the existence of major variants of toxB or the presence of fragments of the gene. Southern blotting analysis showed that toxB sequences were located on large plasmids in EHEC and EPEC O26 as well.

Enterohaemorrhagic Escherichia coli: emerging issues on virulence and modes of transmission

Enterohaemorrhagic Escherichia coli (EHEC) constitute a subset of serotypes (E. coli O157 and some other serogroups) of Shiga toxin (Stx)-producing E. coli (STEC) firmly associated with severe human illnesses like bloody diarrhoea and haemolytic uraemic syndrome. Stx production is essential but not sufficient for EHEC virulence. Most strains are capable of colonising the intestinal mucosa of the host with the "attaching and effacing" mechanism, genetically governed by a large pathogenicity island (PAI) defined as the Locus of Enterocyte Effacement. Other virulence factors carried by mobile genetic elements like PAI and plasmids have been recently described, and their role in the pathogenic process has not been fully elucidated. EHEC are zoonotic pathogens. They rarely cause disease in animals, and ruminants are recognised as their main natural reservoir. Cattle are considered to be the most important source of human infections with EHEC O157, and the ecology of the organism in cattle farming has been extensively studied. The organism has also been reported in sheep, goats, water buffalos, and deer. Pigs and poultry are not considered to be a source of EHEC and the sporadic reports may derive from accidental exposure to ruminant dejections. The epidemiology of EHEC infections has remarkably changed during the past ten years and an increasing number of unusual food vehicles have been associated with human infections. New routes of transmission have emerged, like contact with animals during farm visits and a wide variety of environment-related exposures. As for other zoonotic agents, having animals and raw products that are free from EHEC is not possible in practice. However, their occurrence can be minimised by applying high standards of hygiene in all the steps of the food production chain.

Verocytotoxin-producing Escherichia coli O157 in minced beef and dairy products in Italy

A total of 3879 samples of foodstuffs were examined for the presence of Verocytotoxin-producing Escherichia coli O157 (VTEC O157). The survey was conducted by 9 of the 10 Italian Veterinary Public Health Laboratories. Samples were collected between May 2000 and September 2001 in 14 regions and comprised 931 minced beef specimens and 2948 dairy products (DP) with less than 60 days of ripening. The DP included 657 pasteurised and 811 unpasteurised bovine DP, 477 pasteurised and 502 unpasteurised ovine DP, and 501 water-buffalo's milk mozzarella cheese. Samples were collected at retail level, from plants processing minced beef and dairy plants and from farms directly manufacturing cheeses. All the samples were tested using a sensitive procedure based on ISO/DIS 16654:1999 (later ISO 16654:2001), which includes an immunomagnetic separation step. A preliminary inter-laboratory trial was organised with artificially contaminated samples to assess the ability of all the participating laboratories to isolate E. coli O157 by the established procedure. VTEC O157 was isolated from four (0.43%) of the minced beef samples, collected in four different regions and during different months, but was not detected in any of the dairy products. E. coli O157 VT-eae+ was isolated from one raw cow's milk cheese. This survey provided national data on the presence of VTEC O157 in foodstuffs, demonstrating a low prevalence of the organism. The survey also encouraged updating of knowledge and procedures on VTEC O157 in laboratories with official responsibility for microbiological testing of foods of animal origin.

Asymptomatic carriage of verocytotoxin-producing Escherichia coli O157 in farm workers in Northern Italy

Faecal samples from 350 farm workers on 276 dairy farms and 50 abattoir employees from seven different operations were examined for the presence of Verocytotoxin-producing Escherichia coli 0157 (VTEC O157) by an O157-specific enzyme-linked fluorescent assay followed by immunoconcentration. VTEC O157 was isolated from four (1.1%) of the farm workers. A second stool sample was obtained from the positive farm workers as well as from their household contacts. VTEC O157 was isolated from the wife of one of them. The strains from the same household shared the same Verocytotoxin genes profile, phage type and pulsed-field gel electrophoresis pattern. The VTEC O157-positive subjects had neither intestinal symptoms at the moment of sampling nor a history of bloody diarrhoea or renal failure. Our study seems to confirm the hypothesis that farm residents often develop immunity to VTEC O157 infection, possibly due to recurrent exposure to less virulent strains of VTEC.

Detection of Salmonella spp., Yersinia enterocolitica and verocytotoxin-producing Escherichia coli O157 in pigs at slaughter in Italy

From December 1999 to December 2000, 150 pigs were randomly selected in two large abattoirs of northern Italy. Caecal material and carcass swabs were collected and examined for Salmonella, Yersinia enterocolitica, and Escherichia coli O157. Tonsils were examined for Salmonella and Y. enterocolitica. Salmonella was isolated from the intestinal content of 55 (36.7%) specimens, from 8 (5.3%) tonsils, and from 9 (6.0%) carcasses. Ten different serotypes were detected; the more common were Salmonella derby (37.8%), Salmonella bredeney (21.6%), and Salmonella typhimurium (14.8%). S. typhimurium isolates that belonged to phage-types DT104 and DT208 were 45% and 27.3%, respectively; 18.2% belonged to U302 and 9.1% were non-typeable. Y. enterocolitica was detected in the intestinal matter of 6 (4.0%) slaughtered pigs and in 22 (14.7%) tonsils; however, this pathogen was not found on carcasses. The majority of Y. enterocolitica isolates (82.1%) belonged to serotype O:3 biotype 4, one (3.6%) belonged to serotype O:9, and 13% did not belong to any known biotype. Verocytotoxin-producing E. coli (VTEC) O157 was isolated from the intestinal content of one (0.7%) slaughtered pig and from one (0.7%) carcass; four (2.7%) faecal samples contained E. coli O157 strains negative for the presence of both eae and VT genes.

A mosaic pathogenicity island made up of the locus of enterocyte effacement and a pathogenicity island of Escherichia coli O157:H7 is frequently present in attaching and effacing E. coli

Enteropathogenic Escherichia coli (EPEC) and enterohemorragic E. coli (EHEC) possess a pathogenicity island (PAI), termed the locus of enterocyte effacement (LEE), which confers the capability to cause the characteristic attaching and effacing lesions of the brush border. Due to this common property, these organisms are also termed attaching and effacing E. coli (AEEC). Sequencing of the EHEC O157 genome recently revealed the presence of other putative PAIs in the chromosome of this organism. In this article, we report on the presence of four of those PAIs in a panel of 133 E. coli strains belonging to different pathogroups and serotypes. One of these PAIs, termed O122 in strain EDL 933 and SpLE3 in strain Sakai, was observed in most of the AEEC strains examined but not in the other groups of E. coli. It was also found to contain the virulence-associated gene efa1/lifA. In EHEC O157, PAI O122 is located 0.7 Mb away from the LEE. Conversely, we demonstrated that in many EHEC non-O157 strains and EPEC strains belonging to eight serogroups, PAI O122 and the LEE are physically linked to form a cointegrated structure. This structure can be considered a mosaic PAI that could have been acquired originally by AEEC. In some clones, such as EHEC O157, the LEE-O122 mosaic PAI might have undergone recombinational events, resulting in the insertion of the portion referred to as PAI O122 in a different location.