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Imdad A, Mackoff SP, Urciuoli DM, Syed T, Tanner-Smith EE, Huang D, Gomez-Duarte OG. Interventions for preventing diarrhoea-associated haemolytic uraemic syndrome. Cochrane Database Syst Rev 2021; 7:CD012997. [PMID: 34219224 PMCID: PMC8255341 DOI: 10.1002/14651858.cd012997.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Haemolytic uraemic syndrome (HUS) is a common cause of acquired kidney failure in children and rarely in adults. The most important risk factor for development of HUS is a gastrointestinal infection by Shiga toxin-producing Escherichia coli (STEC). This review addressed the interventions aimed at secondary prevention of HUS in patients with diarrhoea who were infected with a bacteria that increase the risk of HUS. OBJECTIVES Our objective was to evaluate evidence regarding secondary preventative strategies for HUS associated with STEC infections. In doing so, we sought to assess the effectiveness and safety of interventions as well as their potential to impact the morbidity and death associated with this condition. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 November 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Studies were considered based on the methods, participants, and research goals. Only randomised controlled trials were considered eligible for inclusion. The participants of the studies were paediatric and adult patients with diarrhoeal illnesses due to STEC. The primary outcome of interest was incidence of HUS. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as recommended by Cochrane. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We identified four studies (536 participants) for inclusion that investigated four different interventions including antibiotics (trimethoprim-sulfamethoxazole), anti-Shiga toxin antibody-containing bovine colostrum, Shiga toxin binding agent (Synsorb Pk: a silicon dioxide-based agent), and a monoclonal antibody against Shiga toxin (urtoxazumab). The overall risk of bias was unclear for selection, performance and detection bias and low for attrition, reporting and other sources of bias. It was uncertain if trimethoprim-sulfamethoxazole reduced the incidence of HUS compared to no treatment (47 participants: RR 0.57, 95% CI 0.11-2.81, very low certainty evidence). Adverse events relative to this review, need for acute dialysis, neurological complication and death were not reported. There were no incidences of HUS in either the bovine colostrum group or the placebo group. It was uncertain if bovine colostrum caused more adverse events (27 participants: RR 0.92, 95% CI 0.42 to 2.03; very low certainty evidence). The need for acute dialysis, neurological complications or death were not reported. It is uncertain whether Synsorb Pk reduces the incidence of HUS compared to placebo (353 participants: RR 0.93, 95% CI 0.39 to 2.22; very low certainty evidence). Adverse events relevant to this review, need for acute dialysis, neurological complications or death were not reported. One study compared two doses of urtoxazumab (3.0 mg/kg and 1.0 mg/kg) to placebo. It is uncertain if either 3.0 mg/kg urtoxazumab (71 participants: RR 0.34, 95% CI 0.01 to 8.14) or 1.0 mg/kg urtoxazumab (74 participants: RR 0.95, 95% CI 0.79 to 1.13) reduced the incidence of HUS compared to placebo (very low certainty evidence). Low certainty evidence showed there may be little or no difference in the number of treatment-emergent adverse events with either 3.0 mg/kg urtoxazumab (71 participants: RR 1.00, 95% CI 0.84 to 1.18) or 1.0 mg/kg urtoxazumab (74 participants: RR 0.95, 95% CI 0.79 to 1.13) compared to placebo. There were 25 serious adverse events reported in 18 patients: 10 in the placebo group, and 9 and 6 serious adverse events in the 1.0 mg/kg and 3.0 mg/kg urtoxazumab groups, respectively. It is unclear how many patients experienced these adverse events in each group, and how many patients experienced more than one event. It is uncertain if either dose of urtoxazumab increased the risk of neurological complications or death (very low certainty evidence). Need for acute dialysis was not reported. AUTHORS' CONCLUSIONS The included studies assessed antibiotics, bovine milk, and Shiga toxin inhibitor (Synsorb Pk) and monoclonal antibodies (Urtoxazumab) against Shiga toxin for secondary prevention of HUS in patients with diarrhoea due to STEC. However, no firm conclusions about the efficacy of these interventions can be drawn given the small number of included studies and the small sample sizes of those included studies. Additional studies, including larger multicentre studies, are needed to assess the efficacy of interventions to prevent development of HUS in patients with diarrhoea due to STEC infection.
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Affiliation(s)
- Aamer Imdad
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Samuel P Mackoff
- College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - David M Urciuoli
- College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | | | - Emily E Tanner-Smith
- Counseling Psychology and Human Services, University of Oregon, Eugene, Oregon, USA
| | - Dongmei Huang
- Department of Pediatrics, Division of Pediatric Nephrology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Oscar G Gomez-Duarte
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University at Buffalo, State University of New York, Buffalo, NY, USA
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McKee RS, Schnadower D, Tarr PI, Xie J, Finkelstein Y, Desai N, Lane RD, Bergmann KR, Kaplan RL, Hariharan S, Cruz AT, Cohen DM, Dixon A, Ramgopal S, Rominger A, Powell EC, Kilgar J, Michelson KA, Beer D, Bitzan M, Pruitt CM, Yen K, Meckler GD, Plint AC, Bradin S, Abramo TJ, Gouin S, Kam AJ, Schuh A, Balamuth F, Hunley TE, Kanegaye JT, Jones NE, Avva U, Porter R, Fein DM, Louie JP, Freedman SB. Predicting Hemolytic Uremic Syndrome and Renal Replacement Therapy in Shiga Toxin-producing Escherichia coli-infected Children. Clin Infect Dis 2021; 70:1643-1651. [PMID: 31125419 DOI: 10.1093/cid/ciz432] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 05/23/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Shiga toxin-producing Escherichia coli (STEC) infections are leading causes of pediatric acute renal failure. Identifying hemolytic uremic syndrome (HUS) risk factors is needed to guide care. METHODS We conducted a multicenter, historical cohort study to identify features associated with development of HUS (primary outcome) and need for renal replacement therapy (RRT) (secondary outcome) in STEC-infected children without HUS at initial presentation. Children aged <18 years who submitted STEC-positive specimens between January 2011 and December 2015 at a participating study institution were eligible. RESULTS Of 927 STEC-infected children, 41 (4.4%) had HUS at presentation; of the remaining 886, 126 (14.2%) developed HUS. Predictors (all shown as odds ratio [OR] with 95% confidence interval [CI]) of HUS included younger age (0.77 [.69-.85] per year), leukocyte count ≥13.0 × 103/μL (2.54 [1.42-4.54]), higher hematocrit (1.83 [1.21-2.77] per 5% increase) and serum creatinine (10.82 [1.49-78.69] per 1 mg/dL increase), platelet count <250 × 103/μL (1.92 [1.02-3.60]), lower serum sodium (1.12 [1.02-1.23 per 1 mmol/L decrease), and intravenous fluid administration initiated ≥4 days following diarrhea onset (2.50 [1.14-5.46]). A longer interval from diarrhea onset to index visit was associated with reduced HUS risk (OR, 0.70 [95% CI, .54-.90]). RRT predictors (all shown as OR [95% CI]) included female sex (2.27 [1.14-4.50]), younger age (0.83 [.74-.92] per year), lower serum sodium (1.15 [1.04-1.27] per mmol/L decrease), higher leukocyte count ≥13.0 × 103/μL (2.35 [1.17-4.72]) and creatinine (7.75 [1.20-50.16] per 1 mg/dL increase) concentrations, and initial intravenous fluid administration ≥4 days following diarrhea onset (2.71 [1.18-6.21]). CONCLUSIONS The complex nature of STEC infection renders predicting its course a challenge. Risk factors we identified highlight the importance of avoiding dehydration and performing close clinical and laboratory monitoring.
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Affiliation(s)
- Ryan S McKee
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City
| | - David Schnadower
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Ohio
| | - Phillip I Tarr
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Jianling Xie
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary
| | - Yaron Finkelstein
- Divisions of Emergency Medicine, and Clinical Pharmacology and Toxicology, Hospital for Sick Children, University of Toronto, Ontario
| | - Neil Desai
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Roni D Lane
- Division of Pediatric Emergency Medicine, University of Utah School of Medicine, Salt Lake City
| | - Kelly R Bergmann
- Department of Emergency Medicine, Children's Minnesota, Minneapolis
| | - Ron L Kaplan
- Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital
| | - Selena Hariharan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Andrea T Cruz
- Sections of Pediatric Emergency Medicine and Pediatric Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Daniel M Cohen
- Division of Emergency Medicine, Nationwide Children's Hospital and Ohio State University, Columbus
| | - Andrew Dixon
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Stollery Children's Hospital, Women and Children's Research Institute, University of Alberta, Edmonton, Canada
| | - Sriram Ramgopal
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine Children's Hospital, Pennsylvania
| | - Annie Rominger
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Louisville, Kentucky
| | - Elizabeth C Powell
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jennifer Kilgar
- Department of Pediatrics and Division of Emergency Medicine, Children's Hospital, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | | | - Darcy Beer
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Martin Bitzan
- Division of Nephrology, Department of Pediatrics, McGill University Health Centre, Montreal, Québec, Canada
| | - Christopher M Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham
| | - Kenneth Yen
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Texas Southwestern, Children's Health, Dallas
| | - Garth D Meckler
- Division of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Ottawa, Ontario, Canada
| | - Stuart Bradin
- Departments of Pediatrics and Emergency Medicine, University of Michigan Health System, Ann Arbor
| | - Thomas J Abramo
- Departments of Pediatrics and Emergency Medicine, University of Arkansas School of Medicine, Arkansas Children's Hospital Research Institute, Little Rock
| | - Serge Gouin
- Departments of Pediatric Emergency Medicine and Pediatrics, Université de Montréal, Québec
| | - April J Kam
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Abigail Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee
| | - Fran Balamuth
- University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia
| | - Tracy E Hunley
- Division of Pediatric Nephrology, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - John T Kanegaye
- Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla.,Rady Children's Hospital San Diego, California
| | - Nicholas E Jones
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Georgia
| | - Usha Avva
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hackensack Meridian School of Medicine at Seton Hall, Joseph M. Sanzari Children's Hospital, New Jersey
| | - Robert Porter
- Discipline of Pediatrics, Faculty of Medicine, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Daniel M Fein
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Jeffrey P Louie
- Department of Pediatrics, Division of Emergency Medicine, University of Minnesota, Masonic Children's Hospital, Minneapolis
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
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Pang JX, Singh J, Freedman SB, Xie J, Hu J. Improving follow-up testing in children with Shiga toxin-producing Escherichia coli through provision of a provider information sheet. Aust J Prim Health 2020; 26:479-483. [PMID: 33296623 DOI: 10.1071/py20136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/12/2020] [Indexed: 11/23/2022]
Abstract
The aim of this study was to improve follow-up laboratory testing for children infected by Shiga toxin-producing Escherichia coli (STEC) through the provision of an information sheet to healthcare providers in the province of Alberta, Canada. An information sheet recommending the performance of laboratory tests, every 24-48h until 3 days after diarrhoea resolves or the platelet count stabilises or begins to rise, was sent to all physicians who ordered a STEC-positive stool test as of 1 November 2016. The information sheet was only distributed to physicians in one of the province's five healthcare delivery zones (i.e. intervention zone). Medical records for children aged <18 years with laboratory confirmed STEC-positive stool samples between November 2014 and November 2018 were reviewed to determine the performance of recommended laboratory tests. Post-intervention, follow-up testing in all categories increased significantly for cases that occurred in the intervention zone, with odds ratios (OR) ranging from 3.02 (95% CI: 1.35-6.78) to 3.94 (95% CI: 1.70-9.16) when compared with pre-intervention. No increase in any of the laboratory testing categories was detected outside of the intervention zone. The provision of a targeted information sheet to healthcare providers improved the monitoring of STEC-infected children.
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Affiliation(s)
- Jack X Pang
- Population, Public, and Indigenous Health, Alberta Health Services, Calgary, AB T2N 1N4, Canada
| | - Jaskaran Singh
- Population, Public, and Indigenous Health, Alberta Health Services, Calgary, AB T2N 1N4, Canada
| | - Stephen B Freedman
- Departments of Pediatrics and Emergency Medicine, Division of Pediatric Emergency Medicine, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada; and Corresponding author.
| | - Jianling Xie
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Jia Hu
- Population, Public, and Indigenous Health, Alberta Health Services, Calgary, AB T2N 1N4, Canada
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4
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Adams N, Byrne L, Rose T, Adak B, Jenkins C, Charlett A, Violato M, O'Brien S, Whitehead M, Barr B, Taylor-Robinson D, Hawker J. Sociodemographic and clinical risk factors for paediatric typical haemolytic uraemic syndrome: retrospective cohort study. BMJ Paediatr Open 2019; 3:e000465. [PMID: 31909217 PMCID: PMC6936988 DOI: 10.1136/bmjpo-2019-000465] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 08/07/2019] [Accepted: 08/25/2019] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Haemolytic uraemic syndrome (HUS) following Shiga toxin-producing Escherichia coli (STEC) infection is the the most common cause of acute renal failure among children in the UK. This study explored differential progression from STEC to HUS by social, demographic and clinical risk factors. METHODS We undertook a retrospective cohort study linking two datasets. We extracted data on paediatric STEC and HUS cases identified in the Public Health England National Enhanced Surveillance System for STEC and British Paediatric Surveillance Unit HUS surveillance from 1 October 2011 to 31 October 2014. Using logistic regression, we estimated the odds of HUS progression by risk factors. RESULTS 1059 paediatric STEC cases were included in the study, of which 207 (19.55%, 95% CI 17% to 22%) developed HUS. In the fully adjusted model, the odds of progression to HUS were highest in those aged 1-4 years (OR 4.93, 95% CI 2.30 to 10.56, compared with 10-15 years), were infected with an Shiga toxin (stx) 2-only strain (OR 5.92, 95% CI 2.49 to 14.10), were prescribed antibiotics (OR 8.46, 95% CI 4.71 to 15.18) and had bloody diarrhoea (OR 3.56, 95% CI 2.04 to 6.24) or vomiting (OR 4.47, 95% CI 2.62 to 7.63), but there was no association with progression to HUS by socioeconomic circumstances or rurality. CONCLUSION Combining data from an active clinical surveillance system for HUS with the national enhanced STEC surveillance system suggests that 20% of diagnosed paediatric STEC infections in England resulted in HUS. No relationship was found with socioeconomic status or rurality of cases, but differences were demonstrated by age, stx type and presenting symptoms.
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Affiliation(s)
- Natalie Adams
- Health Protection Research Unit in Gastrointestinal Infections, National Institute for Health Research, Liverpool, UK
- National Infection Service, Public Health England, London, UK
| | - Lisa Byrne
- National Infection Service, Public Health England, London, UK
| | - Tanith Rose
- Health Protection Research Unit in Gastrointestinal Infections, National Institute for Health Research, Liverpool, UK
- Department of Public Health and Policy, University of Liverpool, Liverpool, UK
| | - Bob Adak
- Health Protection Research Unit in Gastrointestinal Infections, National Institute for Health Research, Liverpool, UK
| | - Claire Jenkins
- Health Protection Research Unit in Gastrointestinal Infections, National Institute for Health Research, Liverpool, UK
- National Infection Service, Public Health England, London, UK
| | - Andre Charlett
- National Infection Service, Public Health England, London, UK
| | - Mara Violato
- Health Protection Research Unit in Gastrointestinal Infections, National Institute for Health Research, Liverpool, UK
- Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Sarah O'Brien
- Health Protection Research Unit in Gastrointestinal Infections, National Institute for Health Research, Liverpool, UK
- Department of Public Health and Policy, University of Liverpool, Liverpool, UK
| | - Margaret Whitehead
- Health Protection Research Unit in Gastrointestinal Infections, National Institute for Health Research, Liverpool, UK
- Department of Public Health and Policy, University of Liverpool, Liverpool, UK
| | - Benjamin Barr
- Health Protection Research Unit in Gastrointestinal Infections, National Institute for Health Research, Liverpool, UK
- Department of Public Health and Policy, University of Liverpool, Liverpool, UK
| | - David Taylor-Robinson
- Health Protection Research Unit in Gastrointestinal Infections, National Institute for Health Research, Liverpool, UK
- Department of Public Health and Policy, University of Liverpool, Liverpool, UK
| | - Jeremy Hawker
- Health Protection Research Unit in Gastrointestinal Infections, National Institute for Health Research, Liverpool, UK
- National Infection Service, Public Health England, Birmingham, UK
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Kumar G, Bitzan M. Practical diagnostic approach and management of children presenting with hemolytic uremic syndrome. Nephrol Dial Transplant 2019; 35:2054-2058. [PMID: 33275761 DOI: 10.1093/ndt/gfz138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gurinder Kumar
- Division of Pediatric Nephrology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Martin Bitzan
- Kidney Centre of Excellence, Al Jalila Children's Hospital, Al Jadaf, Dubai, United Arab Emirates
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Imdad A, Syed T, Gomez-Duarte OG, Tanner-Smith EE, Huang D. Interventions for preventing diarrhoea-associated haemolytic uraemic syndrome. Hippokratia 2018. [DOI: 10.1002/14651858.cd012997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Aamer Imdad
- SUNY Upstate Medical University; Department of Pediatrics, Karjoo Family Center for Pediatric Gastroenterology; 725, Irving Street, Suit 501 Syracuse NY USA 13210
| | - Tamkeenat Syed
- Meharry Medical College; 1005 Dr D.B. Todd Jr Blvd Nashville Tennessee USA 37208
| | - Oscar G. Gomez-Duarte
- University at Buffalo, State University of New York; Division of Pediatric Infectious Diseases, Department of Pediatrics; 875 Ellicott Street Room 6092 Buffalo NY USA 14203
| | - Emily E Tanner-Smith
- University of Oregon; Counseling Psychology and Human Services; 5251 University of Oregon Eugene Oregon USA 97403
| | - Dongmei Huang
- SUNY Upstate Medical University; Department of Pediatrics; 805, 725 Irving Avenue Syracuse NY USA 13210
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7
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Freedman SB, Grisaru S, Xie J, Samuel S, Dixon A, Plint AC, Schnadower D. Management of Shiga toxin producing Escherichia coli-infected children: A multi-national, multi-specialty survey. J Paediatr Child Health 2018; 54:390-397. [PMID: 29111613 DOI: 10.1111/jpc.13778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 09/03/2017] [Indexed: 12/19/2022]
Abstract
AIM Research has highlighted the potential role that hydration status may play in predicting outcomes in Shiga toxin-producing Escherichia coli (STEC)-infected children. Because little is known about the management of STEC-infected children in the pre-haemolytic uremic syndrome phase, we compared paediatric emergency medicine and nephrologist-stated management approaches to STEC-infected children. METHODS Members of the Pediatric Emergency Research Canada (PERC; n = 228), the Pediatric Emergency Medicine Collaborative Research Committee (PEM CRC; n = 221) and the Canadian Association of Pediatric Nephrologists (CAPN; n = 66) were surveyed. Five individualised e-mail requests containing a link to a 42-question web-based survey were sent to eligible participants. RESULTS Of 496 potentially eligible participants, 276 (56%) submitted complete survey responses. In children with classic features of STEC infection, baseline haemoglobin/haematocrit is obtained by 54% of PERC, 41% of PEM CRC and 83% of CAPN members (P < 0.001), and baseline renal function is obtained by 51% of PERC, 38% of PEM CRC and 83% of CAPN members (P < 0.001). Intravenous fluids are more often recommended by nephrologists (28%) compared with PEM physicians (7%), P < 0.001. In children with known E. coli O157:H7 infection, nephrologists more commonly recommend clinical follow-up (P = 0.003), complete blood counts (P < 0.001) and renal function/electrolyte testing (P < 0.001). Intravenous fluid administration and admission are more commonly recommended by nephrologists (P = 0.03 and P < 0.001, respectively). CONCLUSION Compared with paediatric nephrologists, paediatric emergency medicine physicians are less likely to perform baseline and follow-up blood tests and to administer intravascular volume expansion in children at risk of, and with confirmed, E. coli O157:H7 infection.
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Affiliation(s)
- Stephen B Freedman
- Section of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Silviu Grisaru
- Section of Pediatric Nephrology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jianling Xie
- Section of Pediatric Emergency Medicine, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Susan Samuel
- Section of Pediatric Nephrology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Dixon
- Division of Pediatric Emergency Medicine, Stollery Children's Hospital, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - David Schnadower
- Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, United States
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Galia W, Leriche F, Cruveiller S, Garnier C, Navratil V, Dubost A, Blanquet-Diot S, Thevenot-Sergentet D. Strand-specific transcriptomes of Enterohemorrhagic Escherichia coli in response to interactions with ground beef microbiota: interactions between microorganisms in raw meat. BMC Genomics 2017; 18:574. [PMID: 28774270 PMCID: PMC5543532 DOI: 10.1186/s12864-017-3957-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 07/24/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Enterohemorrhagic Escherichia coli (EHEC) are zoonotic agents associated with outbreaks worldwide. Growth of EHEC strains in ground beef could be inhibited by background microbiota that is present initially at levels greater than that of the pathogen E. coli. However, how the microbiota outcompetes the pathogenic bacteria is unknown. Our objective was to identify metabolic pathways of EHEC that were altered by natural microbiota in order to improve our understanding of the mechanisms controlling the growth and survival of EHECs in ground beef. RESULTS Based on 16S metagenomics analysis, we identified the microbial community structure in our beef samples which was an essential preliminary for subtractively analyzing the gene expression of the EHEC strains. Then, we applied strand-specific RNA-seq to investigate the effects of this microbiota on the global gene expression of EHEC O2621765 and O157EDL933 strains by comparison with their behavior in beef meat without microbiota. In strain O2621765, the expression of genes connected with nitrate metabolism and nitrite detoxification, DNA repair, iron and nickel acquisition and carbohydrate metabolism, and numerous genes involved in amino acid metabolism were down-regulated. Further, the observed repression of ftsL and murF, involved respectively in building the cytokinetic ring apparatus and in synthesizing the cytoplasmic precursor of cell wall peptidoglycan, might help to explain the microbiota's inhibitory effect on EHECs. For strain O157EDL933, the induced expression of the genes implicated in detoxification and the general stress response and the repressed expression of the peR gene, a gene negatively associated with the virulence phenotype, might be linked to the survival and virulence of O157:H7 in ground beef with microbiota. CONCLUSION In the present study, we show how RNA-Seq coupled with a 16S metagenomics analysis can be used to identify the effects of a complex microbial community on relevant functions of an individual microbe within it. These findings add to our understanding of the behavior of EHECs in ground beef. By measuring transcriptional responses of EHEC, we could identify putative targets which may be useful to develop new strategies to limit their shedding in ground meat thus reducing the risk of human illnesses.
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Affiliation(s)
- Wessam Galia
- UMR 5557 Ecologie Microbienne, Research Group on Bacterial Opportunistic Pathogens and Environment, CNRS, VetAgro Sup and Université de Lyon, Lyon, France.
- Université Clermont Auvergne, INRA, UMRF, F-15000, Aurillac, France.
- UMR UCA INRA 454 MEDIS Microbiota Digestive environment and Health, Université Clermont Auvergne, 63000, Clermont-Ferrand, France.
- VetAgro Sup, Campus Agronomique de Lempdes, Lempdes, France.
| | - Francoise Leriche
- Université Clermont Auvergne, INRA, UMRF, F-15000, Aurillac, France
- VetAgro Sup, Campus Agronomique de Lempdes, Lempdes, France
| | - Stéphane Cruveiller
- Alternative Energies and Atomic Energy Commission (CEA), Genomic Institute Genoscope & CNRS-UMR8030 & Evry University, Laboratory of Bioinformatics Analysis in Genomics and Metabolism, Evry, France
| | - Cindy Garnier
- UMR 5557 Ecologie Microbienne, Research Group on Bacterial Opportunistic Pathogens and Environment, CNRS, VetAgro Sup and Université de Lyon, Lyon, France
| | - Vincent Navratil
- PRABI, Rhône Alpes Bioinformatics Center, UCBL, Lyon1, Université de Lyon, Lyon, France
| | - Audrey Dubost
- UMR 5557 Ecologie Microbienne, CNRS, Université de Lyon, Lyon, France
| | - Stéphanie Blanquet-Diot
- UMR UCA INRA 454 MEDIS Microbiota Digestive environment and Health, Université Clermont Auvergne, 63000, Clermont-Ferrand, France
| | - Delphine Thevenot-Sergentet
- UMR 5557 Ecologie Microbienne, Research Group on Bacterial Opportunistic Pathogens and Environment, CNRS, VetAgro Sup and Université de Lyon, Lyon, France
- Reference Laboratory for Escherichia coli including Shiga Toxin-Producing E. coli, VetAgro Sup, Campus Vétérinaire de Lyon, Université de Lyon, Marcy l'Etoile, Lyon, France
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9
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Freedman SB, Eltorki M, Chui L, Xie J, Feng S, MacDonald J, Dixon A, Ali S, Louie M, Lee BE, Osterreicher L, Thull-Freedman J. Province-Wide Review of Pediatric Shiga Toxin-Producing Escherichia coli Case Management. J Pediatr 2017; 180:184-190.e1. [PMID: 27745751 DOI: 10.1016/j.jpeds.2016.09.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/27/2016] [Accepted: 09/08/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To identify the gaps in the care of children infected with Shiga toxin-producing Escherichia coli (STEC), we sought to quantitate care received and management timelines. Such knowledge is crucial to the design of interventions to prevent the development of hemolytic uremic syndrome (HUS). STUDY DESIGN We conducted a retrospective case-series study of 78 children infected with STEC in Alberta, Canada, through the linkage of microbiology and laboratory results, telephone health advice records, hospital charts, physician billing submissions, and outpatient antimicrobial dispensing databases. Outcomes were the time intervals between initial presentation and reporting of positive culture result and symptom onset to HUS and to describe the proportions that had baseline blood work performed and received antibiotics. RESULTS Seventy-eight children infected with STEC were identified; 13% (10/78) developed HUS. Median time from initial presentation to laboratory stool sample receipt was 33 hours (IQR 18, 42); time to positive culture was 120 hours (IQR 86, 205). Time from symptom onset to HUS diagnosis was 188 ± 37 hours. Baseline blood tests were obtained in 74% (58/78) of infected children. Antibiotics were administered to 50% (5/10) of those who developed HUS and 22% (15/78) of those who did not; P = .11. The provincial telephone advice system received 31 calls regarding 24 children infected with STEC; 23% (7/31) of callers were recommended to seek emergency department care. CONCLUSIONS A significant proportion of children developed HUS following multiple interactions with the health care system. Delays in the confirmation of STEC infection occurred. There are numerous opportunities to improve the timing, monitoring, and interventions in children infected with STEC.
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Affiliation(s)
- Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Mohamed Eltorki
- Division of Pediatric Emergency Medicine, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Linda Chui
- Provincial Laboratory for Public Health, Edmonton, Alberta, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Jianling Xie
- Section of Pediatric Emergency Medicine, Alberta Children's Hospital, Department of Pediatrics, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Sharon Feng
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Judy MacDonald
- Population, Public and Indigenous Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Dixon
- Department of Pediatrics, Faculty of Medicine & Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine & Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta
| | - Marie Louie
- Provincial Laboratory for Public Health, Edmonton, Alberta, Canada; Department of Microbiology Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Bonita E Lee
- Department of Pediatrics, Faculty of Medicine & Dentistry, Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta
| | - Lara Osterreicher
- Provincial Clinical Programs, Health Link, Alberta Health Services, Edmonton, Alberta, Canada
| | - Jennifer Thull-Freedman
- Section of Pediatric Emergency Medicine, Alberta Children's Hospital, Department of Pediatrics, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
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10
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Purwar S, Roy S, Metgud S. Non-O157:H7 Shiga Toxin Producing Diarrhoeagenic Escherichia coli (STEC) in Southern India: A Tinderbox for Starting Epidemic. J Clin Diagn Res 2016; 10:DC11-DC15. [PMID: 27891338 DOI: 10.7860/jcdr/2016/21462.8714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 07/28/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Outbreaks due to non-O157:H7 Shiga toxin producing Escherichia coli (STEC) resulting in Haemolytic Uraemic Syndrome (HUS) have garnered much attention because of associated mortality transcending across continents and also because diarrhoea due to E.coli itself is rare in developed countries. The actual incidence of non-O157:H7 STEC in sporadic acute diarrhoea is not fully elucidated, both in developing as well as in developed countries. Due to larger extent of faecal-oral transmission in developing countries it is prudent to look for non-O157: H7 STEC in such epidemiological settings because of very high potential to spread across larger geographical regions and cause life threatening illness. AIM To determine the extent of acute diarrhoea caused by Shiga toxin producing E. coli and measure their genotypic diversity. MATERIALS AND METHODS The study was designed as a cross-sectional study and conducted between 2009-2011 in department of Microbiology at JN Medical College Belgaum (Karnataka) and Regional Medical Research Center, Belgaum (RMRC-ICMR). Stool samples from 300 sporadic cases of acute diarrhoea were processed by microscopy, culture, for the identification of diarrhoeagenic pathogens viz. Vibrio cholera, Shigella spp., Salmonella spp. and protozoan parasites. PCR was performed for the detection of eae and stx genes in E. coli isolates. Their relatedness was determined by Random Amplification of Polymorphic DNA (RAPD). RESULTS PCR detected stx along with eae in 23.2% culture isolates of E.coli isolated from diarrhoea samples. Only three isolates were identified as STEC by serology as O59, O60 and O69 serotypes. Eleven clones were detected by RAPD fingerprinting in the 46 STEC isolates. CONCLUSION Non-O157:H7 STEC are prevalent in this region and laboratories shall look beyond O157:H7 serotype of E.coli. These isolates have potential of causing outbreaks transcending borders. Hence they shall be reported and efforts be made to identify their sources and prevent spread.
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Affiliation(s)
- Shashank Purwar
- Associate Professor, Department of Microbiology, All India Institute of Medical Sciences (AIIMS) , Bhopal, (M.P.), India
| | - Subrana Roy
- Scientist E, Regional Medical Research Centre (ICMR) , Belgaum, Karnataka, India
| | - Sharada Metgud
- Professor, Department of Microbiology, Jawaharlal Nehru Medical College Belgaum, Karnataka, India
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11
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Abstract
Post-infectious hemolytic uremic syndrome (HUS) is caused by specific pathogens in patients with no identifiable HUS-associated genetic mutation or autoantibody. The majority of episodes is due to infections by Shiga toxin (Stx) producing Escherichia coli (STEC). This chapter reviews the epidemiology and pathogenesis of STEC-HUS, including bacterial-derived factors and host responses. STEC disease is characterized by hematological (microangiopathic hemolytic anemia), renal (acute kidney injury) and extrarenal organ involvement. Clinicians should always strive for an etiological diagnosis through the microbiological or molecular identification of Stx-producing bacteria and Stx or, if negative, serological assays. Treatment of STEC-HUS is supportive; more investigations are needed to evaluate the efficacy of putative preventive and therapeutic measures, such as non-phage-inducing antibiotics, volume expansion and anti-complement agents. The outcome of STEC-HUS is generally favorable, but chronic kidney disease, permanent extrarenal, mainly cerebral complication and death (in less than 5 %) occur and long-term follow-up is recommended. The remainder of this chapter highlights rarer forms of (post-infectious) HUS due to S. dysenteriae, S. pneumoniae, influenza A and HIV and discusses potential interactions between these pathogens and the complement system.
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Affiliation(s)
- Denis F. Geary
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Franz Schaefer
- Division of Pediatric Nephrology, University of Heidelberg, Heidelberg, Germany
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Abstract
Beef and leafy vegetables were the most common sources of these outbreaks.
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Verotoxigenic Escherichia coli transmission in Ireland: a review of notified outbreaks, 2004-2012. Epidemiol Infect 2015; 144:917-26. [PMID: 26384128 DOI: 10.1017/s0950268815002034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Verotoxigenic Escherichia coli (VTEC) are significant for their low infectious dose, their potential clinical severity and the frequency with which they generate outbreaks. To describe the relative importance of different outbreak transmission routes for VTEC infection in Ireland, we reviewed outbreak notification data for the period 2004-2012, describing the burden and characteristics of foodborne, waterborne, animal contact and person-to-person outbreaks. Outbreaks where person-to-person spread was reported as the sole transmission route accounted for more than half of all outbreaks and outbreaks cases, most notably in childcare facilities. The next most significant transmission route was waterborne spread from untreated or poorly treated private water supplies. The focus for reducing incidence of VTEC should be on reducing waterborne and person-to-person transmission, by publicizing Health Service Executive materials developed for consumers on private well management, and for childcare facility managers and public health professionals on prevention of person-to-person spread.
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Parello CSL, Mayer CL, Lee BC, Motomochi A, Kurosawa S, Stearns-Kurosawa DJ. Shiga toxin 2-induced endoplasmic reticulum stress is minimized by activated protein C but does not correlate with lethal kidney injury. Toxins (Basel) 2015; 7:170-86. [PMID: 25609181 PMCID: PMC4303821 DOI: 10.3390/toxins7010170] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 12/22/2014] [Accepted: 01/14/2015] [Indexed: 12/26/2022] Open
Abstract
Enterohemorrhagic Escherichia coli produce ribotoxic Shiga toxins (Stx), which are responsible for kidney injury and development of hemolytic uremic syndrome. The endoplasmic reticulum (ER) stress response is hypothesized to induce apoptosis contributing to organ injury; however, this process has been described only in vitro. ER stress marker transcripts of spliced XBP1 (1.78-fold), HSP40 (4.45-fold) and CHOP (7.69-fold) were up-regulated early in kidneys of Stx2 challenged mice compared to saline controls. Anti-apoptotic Bcl2 decreased (−2.41-fold vs. saline) and pro-apoptotic DR5 increased (6.38-fold vs. saline) at later time points. Cytoprotective activated protein C (APC) reduced early CHOP expression (−3.3-fold vs. untreated), increased later Bcl2 expression (5.8-fold vs. untreated), and had early effects on survival but did not alter DR5 expression. Changes in kidney ER stress and apoptotic marker transcripts were observed in Stx2-producing C. rodentium challenged mice compared to mice infected with a non-toxigenic control strain. CHOP (4.14-fold) and DR5 (2.81-fold) were increased and Bcl2 (−1.65-fold) was decreased. APC reduced CHOP expression and increased Bcl2 expression, but did not alter mortality. These data indicate that Stx2 induces renal ER stress and apoptosis in murine models of Stx2-induced kidney injury, but decreasing these processes alone was not sufficient to alter survival outcome.
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Affiliation(s)
- Caitlin S L Parello
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, 670 Albany Street, Boston, MA 02118, USA.
| | - Chad L Mayer
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, 670 Albany Street, Boston, MA 02118, USA.
| | - Benjamin C Lee
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, 670 Albany Street, Boston, MA 02118, USA.
| | - Amanda Motomochi
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, 670 Albany Street, Boston, MA 02118, USA.
| | - Shinichiro Kurosawa
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, 670 Albany Street, Boston, MA 02118, USA.
| | - Deborah J Stearns-Kurosawa
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, 670 Albany Street, Boston, MA 02118, USA.
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15
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Shabani A, Marquette CA, Mandeville R, Lawrence MF. Modern Probe-Assisted Methods for the Specific Detection of Bacteria. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/jbise.2015.82011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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16
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Shiga Toxin/Verocytotoxin-Producing
Escherichia coli
Infections: Practical Clinical Perspectives. Microbiol Spectr 2014; 2:EHEC-0025-2014. [DOI: 10.1128/microbiolspec.ehec-0025-2014] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
ABSTRACT
Escherichia coli
strains that produce Shiga toxins/verotoxins are rare, but important, causes of human disease. They are responsible for a spectrum of illnesses that range from the asymptomatic to the life-threatening hemolytic-uremic syndrome; diseases caused by
E. coli
belonging to serotype O157:H7 are exceptionally severe. Each illness has a fairly predictable trajectory, and good clinical practice at one phase can be inappropriate at other phases. Early recognition, rapid and definitive microbiology, and strategic selection of tests increase the likelihood of good outcomes. The best management of these infections consists of avoiding antibiotics, antimotility agents, and narcotics and implementing aggressive intravenous volume expansion, especially in the early phases of illness.
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17
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Shiga toxin-producing Escherichia coli: a single-center, 11-year pediatric experience. J Clin Microbiol 2014; 52:3647-53. [PMID: 25078916 DOI: 10.1128/jcm.01231-14] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The aim of this study was to identify the best practices for the detection of Shiga toxin-producing Escherichia coli (STEC) in children with diarrheal illness treated at a tertiary care center, i.e., sorbitol-MacConkey (SMAC) agar culture, enzyme immunoassay (EIA) for Shiga toxin, or the simultaneous use of both methods. STEC was detected in 100 of 14,997 stool specimens submitted for enteric culture (0.7%), with 65 cases of E. coli O157. Among E. coli O157 isolates, 57 (88%) were identified by both SMAC agar culture and EIA, 6 (9%) by SMAC agar culture alone, and 2 (3%) by EIA alone. Of the 62 individuals with diarrheal hemolytic uremic syndrome (HUS) seen at our institution during the study period, 16 (26%) had STEC isolated from cultures at our institution and 15 (24%) had STEC isolated at other institutions. No STEC was recovered in 31 cases (50%). Of the HUS cases in which STEC was isolated, 28 (90%) were attributable to E. coli O157 and 3 (10%) were attributable to non-O157 STEC. Consistent with previous studies, we have determined that a subset of E. coli O157 infections will not be detected if an agar-based method is excluded from the enteric culture workup; this has both clinical and public health implications. The best practice would be concomitant use of an agar-based method and a Shiga toxin EIA, but a Shiga toxin EIA should not be considered to be an adequate stand-alone test for detection of E. coli O157 in clinical samples.
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18
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Abstract
Acute renal failure associated with a fulminant, life-threatening systemic disease is rare in previously healthy young children; however, when it occurs, the most common cause is hemolytic-uremic syndrome (HUS). In most cases (90%), this abrupt and devastating illness is a result of ingestion of food or drink contaminated with pathogens that produce very potent toxins. Currently, there are no proven treatment options that can directly inactivate the toxin or effectively interfere with the cascade of destructive events triggered by the toxin once it gains access to the bloodstream and binds its receptor. However, HUS is self-limited, and effective supportive management during the acute phase is proven to be a life saver for children affected by HUS. A minority of childhood HUS cases, approximately 5%, are caused by various genetic mutations causing uncontrolled activation of the complement system. These children, who used to have a poor prognosis leading to end-stage renal disease, now have access to exciting new treatment options that can preserve kidney function and avoid disease recurrences. This review provides a summary of the current knowledge on the epidemiology, pathophysiology, and clinical presentation of childhood HUS, focusing on a practical approach to best management measures.
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Affiliation(s)
- Silviu Grisaru
- University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
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19
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Keithlin J, Sargeant J, Thomas MK, Fazil A. Chronic sequelae of E. coli O157: systematic review and meta-analysis of the proportion of E. coli O157 cases that develop chronic sequelae. Foodborne Pathog Dis 2014; 11:79-95. [PMID: 24404780 PMCID: PMC3925333 DOI: 10.1089/fpd.2013.1572] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE This was a systematic review and meta-analysis to determine the proportion of Escherichia coli O157 cases that develop chronic sequelae. DATA SOURCES We conducted a systematic review of articles published prior to July 2011 in Pubmed, Agricola, CabDirect, or Food Safety and Technology Abstracts. STUDY SELECTION Studies were selected that reported the number of E. coli O157 cases that developed reactive arthritis (ReA), hemolytic uremic syndrome (HUS), irritable bowel syndrome, inflammatory bowel disease, or Guillain Barré syndrome. METHODS Three levels of screening and data extraction of articles were conducted using predefined data fields. Meta-analysis was performed on unique outcome measures using a random-effects model, and heterogeneity was assessed using the I² value. Meta-regression was used to explore the influence of nine study-level variables on heterogeneity. RESULTS A total of 82 studies were identified reporting 141 different outcome measures; 81 reported on HUS and one reported on ReA. Depending on the number of cases of E. coli O157, the estimate for the proportion of E. coli O157 cases that develop HUS ranged from 17.2% in extra-small studies (<50 cases) to 4.2% in extra-large studies (>1000 cases). Heterogeneity was significantly associated with group size (p<0.0001); however, the majority of the heterogeneity was unexplained. CONCLUSIONS High unexplained heterogeneity indicated that the study-level factors examined had a minimal influence on the variation of estimates reported.
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Affiliation(s)
- Jessica Keithlin
- Centre for Public Health and Zoonoses, University of Guelph, Guelph, Ontario, Canada
- Department of Population Medicine, Ontario Veterinary College, Guelph, Ontario, Canada
| | - Jan Sargeant
- Centre for Public Health and Zoonoses, University of Guelph, Guelph, Ontario, Canada
- Department of Population Medicine, Ontario Veterinary College, Guelph, Ontario, Canada
| | - M. Kate Thomas
- Centre for Food-borne, Environmental, and Zoonotic Infectious Diseases, Public Health Agency of Canada, Guelph, Ontario, Canada
| | - Aamir Fazil
- Laboratory for Foodborne Zoonoses, Public Health Agency of Canada, Guelph, Ontario, Canada
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20
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Printza N, Sapountzi E, Dotis J, Papachristou F. Hemolytic uremic syndrome related to cryptosporidium infection in an immunocompetent child. Pediatr Int 2013; 55:788-90. [PMID: 24330289 DOI: 10.1111/ped.12127] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 11/28/2012] [Accepted: 04/15/2013] [Indexed: 11/28/2022]
Abstract
Hemolytic-uremic syndrome (HUS) is characterized by the clinical and laboratory manifestations of acute renal failure, thrombocytopenia and microangiopathic hemolytic anemia. In children, the majority of cases occur after an infectious diarrhea mainly associated with the serotype Escherichia coli O157:H7. We present a case of a 5-year-old boy with post-diarrhea HUS due to cryptosporidium. The child remained on peritoneal dialysis for 24 days. However, he had a full recovery of his renal function and 6 months later, his overall condition was still very good. This is a particularly interesting case, not only due to the exceptionally rare cause of HUS, that is, the cryptosporidium, but also because of the serious gastroenteritis caused by the cryptosporidium in an immunocompetent child. It seems that in cases of post-diarrhea HUS, apart from E. coli O157:H7, even the rarest causes of gastroenteritis should be investigated.
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Affiliation(s)
- Nikoleta Printza
- 1st Pediatric Department, Hippokration General Hospital, Aristotle University, Thessaloniki, Greece
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21
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Davis TK, McKee R, Schnadower D, Tarr PI. Treatment of Shiga toxin-producing Escherichia coli infections. Infect Dis Clin North Am 2013; 27:577-97. [PMID: 24011831 DOI: 10.1016/j.idc.2013.05.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The management of Shiga toxin-producing Escherichia coli (STEC) infections is reviewed. Certain management practices optimize the likelihood of good outcomes, such as avoidance of antibiotics during the pre-hemolytic uremic syndrome phase, admission to hospital, and vigorous intravenous volume expansion using isotonic fluids. The successful management of STEC infections is based on recognition that a patient might have an STEC infection, and appropriate use of the microbiology laboratory. The timeliness of STEC identification cannot be overemphasized, because it avoids therapies prompted by inappropriate additional testing and directs the clinician to focus on effective management strategies. The opportunities during STEC infections to avert the worst outcomes are brief, and this article emphasizes practical matters relevant to making a diagnosis, anticipating the trajectory of illness, and optimizing care.
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Affiliation(s)
- T Keefe Davis
- Division of Nephrology, Department of Pediatrics, Washington University School of Medicine, 660 South Euclid, St Louis, MO 63110, USA
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22
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Zeinhom M, Tellez AM, Delcenserie V, El-Kholy AM, El-Shinawy SH, Griffiths MW. Yogurt containing bioactive molecules produced by Lactobacillus acidophilus La-5 exerts a protective effect against enterohemorrhagic Escherichia coli in mice. J Food Prot 2012; 75:1796-805. [PMID: 23043828 DOI: 10.4315/0362-028x.jfp-11-508] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
An active fraction extracted from Lactobacillus acidophilus La5 cell-free spent medium (LAla-5AF) was incorporated in a dairy matrix and tested to assess its antivirulent effect against enterohemorrhagic Escherichia coli (EHEC). Mice in experimental groups were fed for 4 days with yogurt supplemented with LAla-5AF. On the fifth day, mice were challenged with a single dose (10(7) CFU per mouse) of E. coli O157:H7. The clinical manifestations of the infection were significantly less severe in mice fed the yogurt supplemented with LAla-5AF. EHEC attachment and colonization was attenuated by LAla-5AF. Tumor necrosis factor alpha production was down-regulated, which might indicate a protective effect in the kidney during EHEC infection. To investigate the mechanisms associated with the in vivo effects observed, LAla-5AF was tested by reverse transcription real-time PCR to confirm its effects on the expression of several virulence genes of EHEC O157. The results showed that these fractions were able to down-regulate several virulence genes of EHEC, including stxB2, qseA, luxS, tir, ler, eaeA, and hlyB.
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Affiliation(s)
- Mohamed Zeinhom
- Food Hygiene & Control Department, Faculty of Veterinary Medicine, Beni-Suef University, Egypt
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23
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Chen KS, Neunert CE, Crary SE, Buchanan GR. Hemolytic non-uremic syndrome. Pediatr Blood Cancer 2012; 59:167-9. [PMID: 21809436 DOI: 10.1002/pbc.23264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Accepted: 06/09/2011] [Indexed: 11/11/2022]
Abstract
We describe three children who developed isolated but severe microangiopathic hemolytic anemia without other manifestations of hemolytic uremic syndrome (HUS) or thrombotic thrombocytopenic purpura (TTP). All three recovered without specific treatment. We propose that they represent a unique phenotype in the spectrum of TTP and HUS, which we term "hemolytic non-uremic syndrome."
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Affiliation(s)
- Kenneth S Chen
- Division of Hematology/Oncology, Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 75390, USA.
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24
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Prestidge C, Wong W. Ten years of pneumococcal-associated haemolytic uraemic syndrome in New Zealand children. J Paediatr Child Health 2009; 45:731-5. [PMID: 19863708 DOI: 10.1111/j.1440-1754.2009.01603.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To describe the epidemiology, clinical features, management and outcome of pneumococcal-associated haemolytic-uraemic syndrome (P-HUS) in New Zealand over the past decade. METHODS A retrospective chart review of children with P-HUS from 1998 to 2007 that were prospectively reported to the New Zealand Paediatric Surveillance Unit. P-HUS was defined as microangiopathic haemolytic anaemia (Hb <100 g/L with fragmented red blood cells), thrombocytopaenia (platelet count <130 x 10(9)/L), acute renal impairment with oliguria and elevated plasma creatinine, and confirmed or suspected pneumococcal infection. RESULTS Eleven children (nine male, two female), predominately Maori and Polynesian (10 children) were studied. The median age was 8.5 months. The median duration of hospitalisation was 25 days. Of the infections, 10 were confirmed pneumococcal (six pneumonia, four meningitis) and one pneumonia was suspected pneumococcal (culture negative, however T activation positive). Nine patients required dialysis for a median duration of 13 days. One child with meningitis died after therapy was withdrawn because of severe neurological injury. One patient developed end stage kidney disease and two further children had evidence of persisting renal sequelae at follow-up. CONCLUSIONS Pneumococcal disease remains an important public health problem in New Zealand children, particularly those of Maori and Pacific Island ethnicity. P-HUS should be considered in pneumococcal disease associated with severe haematological and renal abnormalities. These children should be monitored long-term, as they are at risk of permanent renal injury.
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Abstract
Kidney disease may be associated with a systemic disorder or found in isolation. With advances in the understanding of the pathophysiology of glomerular disorders, the distinction between primary and secondary glomerular disease is no longer valid. A wide spectrum of glomerular, vascular, and tubulointerstitial diseases may accompany autoimmune disorders, nephritogenic pharmaceuticals, infections, or complement dysregulation. This article focuses on renal manifestations of systemic diseases such as vasculitis, drug- and infection-related tubulointerstitial injury, and thrombotic disorders.
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Affiliation(s)
- Keisha L Gibson
- UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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26
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Abstract
Experiences with childhood hemolytic uremic syndrome (HUS) in Canada will focus on the development of the Canadian Pediatric Kidney Disease Research Centre (CPKDRC) and the results of our collaborative research over a 13-year period (1985-1998).
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27
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Psotka MA, Obata F, Kolling GL, Gross LK, Saleem MA, Satchell SC, Mathieson PW, Obrig TG. Shiga toxin 2 targets the murine renal collecting duct epithelium. Infect Immun 2009; 77:959-69. [PMID: 19124603 PMCID: PMC2643625 DOI: 10.1128/iai.00679-08] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Revised: 08/26/2008] [Accepted: 12/29/2008] [Indexed: 11/20/2022] Open
Abstract
Hemolytic-uremic syndrome (HUS) caused by Shiga toxin-producing Escherichia coli infection is a leading cause of pediatric acute renal failure. Bacterial toxins produced in the gut enter the circulation and cause a systemic toxemia and targeted cell damage. It had been previously shown that injection of Shiga toxin 2 (Stx2) and lipopolysaccharide (LPS) caused signs and symptoms of HUS in mice, but the mechanism leading to renal failure remained uncharacterized. The current study elucidated that murine cells of the glomerular filtration barrier were unresponsive to Stx2 because they lacked the receptor glycosphingolipid globotriaosylceramide (Gb(3)) in vitro and in vivo. In contrast to the analogous human cells, Stx2 did not alter inflammatory kinase activity, cytokine release, or cell viability of the murine glomerular cells. However, murine renal cortical and medullary tubular cells expressed Gb(3) and responded to Stx2 by undergoing apoptosis. Stx2-induced loss of functioning collecting ducts in vivo caused production of increased dilute urine, resulted in dehydration, and contributed to renal failure. Stx2-mediated renal dysfunction was ameliorated by administration of the nonselective caspase inhibitor Q-VD-OPH in vivo. Stx2 therefore targets the murine collecting duct, and this Stx2-induced injury can be blocked by inhibitors of apoptosis in vivo.
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Affiliation(s)
- Mitchell A Psotka
- Department of Microbiology and Immunology, University of Maryland, Baltimore, Baltimore, MD 21201, USA
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An outbreak of diarrhea-associated childhood hemolytic uremic syndrome: the Walkerton epidemic. Kidney Int 2009:S35-7. [DOI: 10.1038/ki.2008.628] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Shiga-toxin producing Escherichia coli and the hemolytic uremic syndrome: what have we learned in the past 25 years? ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2009; 634:1-17. [PMID: 19280844 DOI: 10.1007/978-0-387-79838-7_1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Scheiring J, Andreoli SP, Zimmerhackl LB. Treatment and outcome of Shiga-toxin-associated hemolytic uremic syndrome (HUS). Pediatr Nephrol 2008; 23:1749-60. [PMID: 18704506 PMCID: PMC6901419 DOI: 10.1007/s00467-008-0935-6] [Citation(s) in RCA: 172] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2008] [Revised: 06/03/2008] [Accepted: 06/09/2008] [Indexed: 12/28/2022]
Abstract
Hemolytic uremic syndrome (HUS) is the most common cause of acute renal failure in childhood and the reason for chronic renal replacement therapy. It leads to significant morbidity and mortality during the acute phase. In addition to acute morbidity and mortality, long-term renal and extrarenal complications can occur in a substantial number of children years after the acute episode of HUS. The most common infectious agents causing HUS are enterohemorrhagic Escherichia coli (EHEC)-producing Shiga toxin (and belonging to the serotype O157:H7) and several non-O157:H7 serotypes. D(+) HUS is an acute disease characterized by prodromal diarrhea followed by acute renal failure. The classic clinical features of HUS include the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. HUS mortality is reported to be between 3% and 5%, and death due to HUS is nearly always associated with severe extrarenal disease, including severe central nervous system (CNS) involvement. Approximately two thirds of children with HUS require dialysis therapy, and about one third have milder renal involvement without the need for dialysis therapy. General management of acute renal failure includes appropriate fluid and electrolyte management, antihypertensive therapy if necessary, and initiation of renal replacement therapy when appropriate. The prognosis of HUS depends on several contributing factors. In general "classic" HUS, induced by EHEC, has an overall better outcome. Totally different is the prognosis in patients with atypical and particularly recurrent HUS. However, patients with severe disease should be screened for genetic disorders of the complement system or other underlying diseases.
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Affiliation(s)
- Johanna Scheiring
- Department of Pediatrics I, Medical University Innsbruck, Anichstr. 35, A-6020 Innsbruck, Austria
| | | | - Lothar Bernd Zimmerhackl
- Department of Pediatrics I, Medical University Innsbruck, Anichstr. 35, A-6020 Innsbruck, Austria
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Karpac CA, Li X, Terrell DR, Kremer Hovinga JA, Lämmle B, Vesely SK, George JN. Sporadic bloody diarrhoea-associated thrombotic thrombocytopenic purpura-haemolytic uraemic syndrome: an adult and paediatric comparison. Br J Haematol 2008; 141:696-707. [DOI: 10.1111/j.1365-2141.2008.07116.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Pearl DL, Louie M, Chui L, Doré K, Grimsrud KM, Martin SW, Michel P, Svenson LW, McEwen SA. Epidemiological characteristics of reported sporadic and outbreak cases of E. coli O157 in people from Alberta, Canada (2000-2002): methodological challenges of comparing clustered to unclustered data. Epidemiol Infect 2008; 136:483-91. [PMID: 17565768 PMCID: PMC2870837 DOI: 10.1017/s0950268807008904] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Using multivariable models, we compared whether there were significant differences between reported outbreak and sporadic cases in terms of their sex, age, and mode and site of disease transmission. We also determined the potential role of administrative, temporal, and spatial factors within these models. We compared a variety of approaches to account for clustering of cases in outbreaks including weighted logistic regression, random effects models, general estimating equations, robust variance estimates, and the random selection of one case from each outbreak. Age and mode of transmission were the only epidemiologically and statistically significant covariates in our final models using the above approaches. Weighing observations in a logistic regression model by the inverse of their outbreak size appeared to be a relatively robust and valid means for modelling these data. Some analytical techniques, designed to account for clustering, had difficulty converging or producing realistic measures of association.
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Affiliation(s)
- D L Pearl
- Department of Population Medicine, University of Guelph, Guelph, Ontario, Canada.
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Abstract
Haemolytic uraemic syndrome (HUS) is the most common cause of acute renal failure in children. The syndrome is defined by triad of microangiopathic haemolytic anaemia, thrombocytopenia and acute renal failure (ARF). Incomplete HUS is ARF with either haemolytic anaemia or thrombocytopenia. HUS is classified into two subgroups. Typical HUS usually occurs after a prodrome of diarrhoea (D+HUS), and atypical (sporadic) HUS (aHUS), which is not associated with diarrhoea (D-HUS). The majority of D+HUS worldwide is caused by Shiga toxin-producing Esherichia coli (STEC), type O157:H7, transmitted to humans via different vehicles. Currently there are no specific therapies preventing or ameliorating the disease course. Although there are new therapeutic modalities in the horizon for D+HUS, present recommended therapy is merely symptomatic. Parenteral volume expansion may counteract the effect of thrombotic process before development of HUS and attenuate renal injury. Use of antibiotics, antimotility agents, narcotics and non-steroidal anti-inflammatory drugs should be avoided during the acute phase. Prevention is best done by preventing primary STEC infection. Underlying aetiology in many cases of aHUS is unknown. A significant number may result from underlying infectious diseases, namely Streptococcus pneumoniae and human immunedeficiency virus. Variety of genetic forms include HUS due to deficiencies of factor H, membrane cofactor protein, Von Willebrand factor-cleaving protease (ADAMTS 13) and intracellular defect in vitamin B12 metabolism. There are cases of aHUS with autosomal recessive and dominant modes of inheritance. Drug-induced aHUS in post-transplantation is due to calcineurin-inhibitors. Systemic lupus erythematosus and catastrophic antiphospholipid syndrome may also present with aHUS. Therapy is directed mainly towards underlying cause.
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Affiliation(s)
- Iradj Amirlak
- Department of Paediatrics, Faculty of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.
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Dennehy PH. Acute diarrheal disease in children: epidemiology, prevention, and treatment. Infect Dis Clin North Am 2006; 19:585-602. [PMID: 16102650 DOI: 10.1016/j.idc.2005.05.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Diarrhea is one of the most common causes of morbidity and mortality in children worldwide. The causes of acute diarrhea in children vary with the location, time of year, and population studied. There is increasing recognition of a widening array of enteric pathogens associated with diarrheal diseases. Adequate fluid and electrolyte replacement and maintenance are key to managing diarrheal illnesses. Thorough clinical and epidemiologic evaluation is needed to define the severity and type of illness, exposures, and whether the patient in is immunocompromised to direct the performance of selective diagnosis cultures, toxin testing, parasite studies, and the administration of antimicrobial therapy.
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Affiliation(s)
- Penelope H Dennehy
- Division of Pediatric Infectious Diseases, Rhode Island Hospital, Providence, 02903, USA.
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Abstract
Enterohaemorrhagic Escherichia coli has since the last 2 decades been known to cause severe and bloody diarrhoea as well as haemorrhagic colitis (HC) and haemorrhagic uraemic syndrome (HUS) especially among children. The importance of screening for EHEC among children and older patients with severe symptoms is apparent. Production of the verocytotoxins VT1 and VT2 are the main features of EHEC, and the VT types and mode of action during human infection is described. There are, however, other features adding to the pathogenicity. In this review we deal with the importance of properties such as fimbriae and adhesins as well as systems to meet the bacterial need for iron during infection. These factors are probably important for the establishment of EHEC in the gut and add to the bacterial virulence. It has now become evident that VT producing E. coli, irrespective of serogroup, might be human pathogens. We conclude that knowledge of the different possible virulence factors adds to the possibility of separating more virulent from less virulent isolates.
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Affiliation(s)
- Christina Welinder-Olsson
- Institute of Laboratory Medicine, Department of Clinical Bacteriology, Göteborg University, Göteborg, Sweden.
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Proulx F, Sockett P. Prospective surveillance of Canadian children with the haemolytic uraemic syndrome. Pediatr Nephrol 2005; 20:786-90. [PMID: 15834619 DOI: 10.1007/s00467-005-1843-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2004] [Revised: 12/14/2004] [Accepted: 12/15/2004] [Indexed: 12/25/2022]
Abstract
We determined prospectively the incidence of childhood diarrhoea associated haemolytic uraemic syndrome (D+ HUS) or HUS due to Streptococcus pneumoniae (SP+ HUS) in Canada through the Canadian Paediatric Surveillance Program (CPSP) network. From April 2000, to March 2002, 82% (1,886/2,300) of all Canadian paediatricians reported possible new cases of D+ HUS or SP+ HUS. Diagnosis was validated with a second questionnaire. There were a total of 136 children with D+ HUS (epidemic, n =15; endemic, n =121), corresponding to an annual incidence rate of 1.11 cases per 100,000 children under 16 years of age. Excluding incomplete forms, the annual incidence rate among endemic cases was 0.74 cases per 100,000. The provinces of Ontario (40%), Quebec (31%), and Alberta (18%) accounted for 89% of cases. Evidence of E. coli O157 or O157:H7 were found in 94% (79/84) of children who had positive stool cultures. The mortality rate was 4% (n =5) and 34% (n =41) of children underwent dialysis for a median of 12 days (2-60 days). SP-HUS was diagnosed in four children with pneumonia and pleural effusion (n =2) or meningitis (n =2) who survived. One child with positive direct Coombs testing had definitive evidence of SP+ HUS. The remaining three were considered possible cases. We conclude that SP+ HUS is rare in Canada. Over the last 15 years, the incidence of childhood D+ HUS in Canadian children may have decreased.
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Affiliation(s)
- François Proulx
- Department of Paediatrics, Sainte-Justine Hospital, Montreal (Quebec), Canada.
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Abstract
Most cases of diarrhoea-associated haemolytic uraemic syndrome (HUS) are caused by Shiga-toxin-producing bacteria; the pathophysiology differs from that of thrombotic thrombocytopenic purpura. Among Shiga-toxin-producing Escherichia coli (STEC), O157:H7 has the strongest association worldwide with HUS. Many different vehicles, in addition to the commonly suspected ground (minced) beef, can transmit this pathogen to people. Antibiotics, antimotility agents, narcotics, and non-steroidal anti-inflammatory drugs should not be given to acutely infected patients, and we advise hospital admission and administration of intravenous fluids. Management of HUS remains supportive; there are no specific therapies to ameliorate the course. The vascular injury leading to HUS is likely to be well under way by the time infected patients seek medical attention for diarrhoea. The best way to prevent HUS is to prevent primary infection with Shiga-toxin-producing bacteria.
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Affiliation(s)
- Phillip I Tarr
- Division of Gastroenterology, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, Campus Box 8208, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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Affiliation(s)
- Daniel M Musher
- Medical Service, Infectious Disease Section, Michael E. DeBakey Veterans Affairs Medical Center, and the Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA.
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Salerno AE, Meyers KEC, McGowan KL, Kaplan BS. Hemolytic uremic syndrome in a child with laboratory-acquired Escherichia coli O157:H7. J Pediatr 2004; 145:412-4. [PMID: 15343202 DOI: 10.1016/j.jpeds.2004.05.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 6-year-old girl touched an agar plate containing Escherichia coli O157:H7 while visiting a hospital laboratory, and subsequently, colitis and hemolytic uremic syndrome developed. Pulsed-field gel electrophoresis patterns of the isolate cultured from her stool and that from the laboratory were identical.
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Affiliation(s)
- Ann E Salerno
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th Street & Civic Center Boulevard, Philadelphia, PA 19104, USA
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41
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Meier PW, Pachlopnik JM, von der Weid NX, Rudin C, Bianchetti MG. Microangiopathic anemia without thrombocytopenia and kidney disease in a child with diarrhea caused by Shiga toxin-producing Escherichia coli. Clin Infect Dis 2004; 38:e25-6. [PMID: 14727232 DOI: 10.1086/381100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2003] [Accepted: 10/07/2003] [Indexed: 11/03/2022] Open
Abstract
A child with a history of diarrhea presented with transient anemia, reticolucytosis, and red blood cell fragmentation. Blood pressure and levels of blood platelets, creatinine, and urea were normal, as were results of urinalysis. Escherichia coli harboring genes for Shiga toxin were detected in stool specimens. It is concluded that extraintestinal diseases caused by Shiga toxin-producing bacteria sometimes present without any renal involvement.
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Affiliation(s)
- Paul W Meier
- University Children's Hospital Bern, Switzerland
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Abstract
Pediatric transplantation has seen remarkable advances over the past two decades with reduced morbidity and mortality, reduced rejection rates, and improved long-term patient and allograft survival. Infants currently have short-term patient and allograft survival rates better than any other age group; short-term allograft survival rates in CD recipients are equal to those in LD recipients. With decreased rejection, long-term allograft survival is improving dramatically. Transplantation allows for much reduced risks and improved metabolic status, growth and development, and more normal social interactions. The future of transplantation continues to be exciting, with opportunities for reduced immunosuppressive medications and their side effects, and the elusive goal of transplantation tolerance seems within reach.
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Affiliation(s)
- Mark R Benfield
- Division of Pediatric Nephrology, University of Alabama at Birmingham, 1600 7th Avenue S-ACC 516, Birmingham, AL 35233, USA.
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Johnson JYM, Thomas JE, Graham TA, Townshend I, Byrne J, Selinger LB, Gannon VPJ. Prevalence of Escherichia coli O157:H7 and Salmonella spp. in surface waters of southern Alberta and its relation to manure sources. Can J Microbiol 2003; 49:326-35. [PMID: 12897826 DOI: 10.1139/w03-046] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The Oldman River watershed in southern Alberta, Canada, is an extensively irrigated region in which intensive agricultural practices have flourished. Concern over water quality in the basin has been expressed because of high levels of enteric disease indigenous to the region. To address these concerns, we conducted a 2-year study to estimate the prevalence of Escherichia coli O157:H7 and Salmonella spp. in surface water within the basin. This study is the first of its kind to identify E. coli O157:H7 repeatedly in surface water collected from a Canadian watershed. Prevalence of E. coli O157:H7 and Salmonella spp. in water samples was 0.9% (n = 1,483) and 6.2% (n = 1,429), respectively. While data examined at a regional level show a relationship between high livestock density and high pathogen levels in southern Alberta, statistical analysis of point source data indicates that predicted manure output from bovine, swine, and poultry feeding operations was not directly associated with either Salmonella spp. or E. coli O157:H7 prevalence. However, geography and weather variables, which are likely to influence bacterial runoff, were not considered in this model. We also postulate that variations in time, amount, and frequency of manure application onto agricultural lands may have influenced levels of surface-water contamination with these bacterial pathogens.
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Affiliation(s)
- J Y M Johnson
- Department of Biological Sciences, University of Lethbridge, Lethbridge, AB T1K 3M4, Canada
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Abstract
This article describes the birth of the Canadian Pediatric Kidney Disease Research Centre (CPKDRC) in 1985 and the activities that have transpired as a result of collaborative research at paediatric centres across Canada. These include the National Retrospective Study of Childhood Hemolytic Uremic Syndrome (HUS), National Prospective Study of Risk Factors for Developing Escherichia coli O157:H7 Infection, and Intervention Studies for the Prevention of HUS. A look to the future describes possible studies to determine potential factors (surrogate markers) to identify children who are at risk for developing HUS following verotoxin-producing E coli gastroenteritis, other intervention studies and a more accurate understanding of permanent renal insufficiency in children who have had HUS.
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Affiliation(s)
- Peter N McLaine
- Department of Pediatrics, University of Ottawa; Children's Hospital of Eastern Ontario; Canadian Pediatric Kidney Disease Research Centre, Ottawa, Ontario
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Kelton JG. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome: will recent insight into pathogenesis translate into better treatment? Transfusion 2002; 42:388-92. [PMID: 12076282 DOI: 10.1046/j.1525-1438.2002.00080.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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McCarthy TA, Barrett NL, Hadler JL, Salsbury B, Howard RT, Dingman DW, Brinkman CD, Bibb WF, Cartter ML. Hemolytic-Uremic Syndrome and Escherichia coli O121 at a Lake in Connecticut, 1999. Pediatrics 2001; 108:E59. [PMID: 11581467 DOI: 10.1542/peds.108.4.e59] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Non-O157 Shiga toxin-producing Escherichia coli (STEC) have emerged as an important public health problem. Outbreaks attributed to non-O157 STEC rarely are reported. In 1999, follow-up of routine surveillance reports of children with hemolytic- uremic syndrome (HUS) identified a small cluster of 3 cases of HUS, all of whom had spent overlapping time in a Connecticut lake community in the week before onset of symptoms. We conducted an investigation to determine the magnitude and source of the outbreak and to determine risk factors associated with the transmission of illness. METHODS We conducted a cohort study and an environmental investigation. The study population included all people who were at the lake in a defined geographic area during July 16-25, 1999. This time and area were chosen on the basis of interviews with the 3 HUS case-patients. A case was defined as diarrhea (>/=3 loose stools/d for >/=3 days) in a person who was at the lake during July 16-25, 1999. Stool samples were requested from any lake resident with diarrheal illness. Stools were cultured for Salmonella, Shigella, Campylobacter, and E coli O157. Broth cultures of stools were tested for Shiga toxin. Case-patients were asked to submit a serum specimen for antibody testing to lipopolysaccharides of selected STEC. Environmental samples from sediment, drinking water, lake water, and ice were obtained and cultured for E coli and tested for Shiga toxin. An environmental evaluation of the lake was conducted to identify any septic, water supply system, or other environmental condition that could be related to the outbreak. RESULTS Information was obtained for 436 people from 165 (78%) households. Eleven (2.5%) people had illnesses that met the case definition, including the 3 children with HUS. The attack rate was highest among those who were younger than 10 years and who swam in the lake on July 17 or 18 (12%; relative risk [RR]: 7.3). Illness was associated with swimming (RR = 8.3) and with swallowing water while swimming (RR = 7.0) on these days. No person who swam only after July 18 developed illness. Clinical characteristics of case-patients included fever (27%), bloody diarrhea (27%), and severe abdominal cramping (73%). Only the 3 children with HUS required hospitalization. No bacterial pathogen was isolated from the stool of any case-patient. Among lake residents outside the study area, E coli O121:H19 was obtained from a Shiga toxin-producing isolate from a toddler who swam in the lake. Serum was obtained from 7 of 11 case-patients. Six of 7 case-patients had E coli O121 antibody titers that ranged from 1:320 to >1:20 480. E coli indicative of fecal contamination was identified from sediment and water samples taken from a storm drain that emptied into the beach area and from a stream bed located between 2 houses, but no Shiga toxin-producing strain was identified. CONCLUSIONS Our findings are consistent with a transient local beach contamination in mid-July, probably with E coli O121:H19, which seems to be able to cause severe illness. Without HUS surveillance, this outbreak may have gone undetected by public health officials. This outbreak might have been detected sooner if Shiga toxin screening had been conducted routinely in HUS cases. Laboratory testing that relies solely on the inability of an isolate to ferment sorbitol will miss non-O157 STEC, such as E coli O121. Serologic testing can be used as an adjunct in the diagnosis of STEC infections. Lake-specific recommendations included education, frequent water sampling, and alternative means for toddlers to use lake facilities.
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Affiliation(s)
- T A McCarthy
- Epidemic Intelligence Service, Connecticut Department of Public Health, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
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Yu K, Newman MC, Archbold DD, Hamilton-Kemp TR. Survival of Escherichia coli O157:H7 on strawberry fruit and reduction of the pathogen population by chemical agents. J Food Prot 2001; 64:1334-40. [PMID: 11563509 DOI: 10.4315/0362-028x-64.9.1334] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Survival of Escherichia coli O157:H7 was studied on strawberry, a fruit that is not usually washed during production, harvest, or postharvest handling. Two strains of the bacteria were tested separately on the fruit surface or injected into the fruit. Both strains of E. coli O157:H7 survived externally and internally at 23 degrees C for 24 h and at 10, 5, and -20 degrees C for 3 days. The largest reduction in bacterial population occurred at -20 degrees C and on the fruit surface during refrigeration. In all experiments, the bacteria inside the fruit either survived as well as or better than bacteria on the surface, and ATCC 43895 frequently exhibited greater survival than did ATCC 35150. Two strains of E. coli also survived at 23 degrees C on the surface and particularly inside strawberry fruit. Chemical agents in aqueous solution comprising NaOCl (100 and 200 ppm), Tween 80 (100 and 200 ppm), acetic acid (2 and 5%), Na3PO4 (2 and 5%), and H2O2 (1 and 3%) were studied for their effects on reduction of surface-inoculated (10(8) CFU/ml) E. coli O157:H7 populations on strawberry fruit. Dipping the inoculated fruit in water alone reduced the pathogen population about 0.8 log unit. None of the compounds with the exception of H2O2 exhibited more than a 2-log CFU/g reduction of the bacteria on the fruit surface. Three percent H202, the most effective chemical treatment, reduced the bacterial population on strawberries by about 2.2 log CFU/g.
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Affiliation(s)
- K Yu
- Department of Horticulture, University of Kentucky, Lexington 40546, USA
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Abstract
E. coli O157:H7 can cause potentially lethal illness in hosts of all ages. These patients often are evaluated and treated by gastroenterologists. The treating physician should administer adequate hydration, usually parenterally, and avoid the use of antibiotics and antimotility agents. The physician needs to notify immediately the appropriate public health authorities of the diagnosis and to ensure that the isolate is recovered by the microbiologist and forwarded for molecular linkage analyses.
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Affiliation(s)
- P I Tarr
- Division of Gastroenterology, Children's Hospital and Regional Medical Center, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.
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Quan A, Sullivan EK, Alexander SR. Recurrence of hemolytic uremic syndrome after renal transplantation in children: a report of the North American Pediatric Renal Transplant Cooperative Study. Transplantation 2001; 72:742-5. [PMID: 11544443 DOI: 10.1097/00007890-200108270-00033] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) is the cause of renal failure in 2-4% of children on dialysis. After renal transplantation, HUS can recur, but recurrence rate and risk factors are controversial. METHODS We reviewed the recurrence of HUS within the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) registry and used a separate questionnaire to ascertain additional clinical information. RESULTS Of 68 renal allografts, HUS recurred in 6 allografts (8.8%) occurring in five patients (8.2%). Four patients had atypical HUS, whereas one patient had classic HUS. HUS recurred after transplantation in 33 days or less in all but one allograft. Outcome was poor with five of six allografts lost, despite treatment with fresh-frozen plasma or plasmapheresis. Cyclosporine had no effect on outcome or HUS recurrence. CONCLUSIONS The risk of HUS recurrence in the allograft is 8-9% and is heightened in atypical HUS. Treatment was not effective and graft outcome was poor. Cyclosporine does not affect HUS recurrence.
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Affiliation(s)
- A Quan
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas 75235-9063, USA.
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Ogawa M, Shimizu K, Nomoto K, Takahashi M, Watanuki M, Tanaka R, Tanaka T, Hamabata T, Yamasaki S, Takeda Y. Protective effect of Lactobacillus casei strain Shirota on Shiga toxin-producing Escherichia coli O157:H7 infection in infant rabbits. Infect Immun 2001; 69:1101-8. [PMID: 11160007 PMCID: PMC97991 DOI: 10.1128/iai.69.2.1101-1108.2001] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
We examined colonization patterns of Shiga toxin-producing Escherichia coli (STEC), concentrations of Shiga toxins (Stxs) and specific immunoglobulin A (lgA) against Stxs and STEC bacterial cell surface antigen in various portions of the gastrointestinal tract in an infant rabbit infection model. After inoculation of 3-day-old infant rabbits with STEC strain 89020087 at low doses (approximately 10(3) CFU/body), numbers of colonizing STEC bacteria and concentrations of Stxs in the intestine increased dramatically and the animals developed diarrhea within a couple of days after infection. Daily administration of Lactobacillus casei from the day of birth dramatically decreased the severity of diarrhea and lowered STEC colonization levels in the gastrointestinal tract 100-fold day 7 after infection. Both Stx1 and Stx2 concentrations in the intestines and histological damage to the intestinal mucus induced by STEC infection were decreased by the administration of L. casei. Examination of the concentrations of volatile fatty acids and pH of the intestinal contents revealed that the protective effect of L. casei administration against STEC infection was not due to fermented products such as lactic acid in the gastrointestinal tract. Administration of L. casei increased levels of lgAs against Stx1, Stx2, and formalin-killed STEC cells in the colon approximately two-, four-, and threefold, respectively, compared with those of the untreated controls by day 7 after infection. These results suggest that administration of L. casei strain Shirota enhances the local immune responses to STEC cells and Stxs and leads to elimination of STEC and thus decreases Stx concentrations in the intestines.
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Affiliation(s)
- M Ogawa
- Yakult Central Institute for Microbiological Research, 1796 Yaho, Kunitachi, Tokyo 186-8650, Japan
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