Vero cytotoxin-producing Escherichia coli, particularly serogroup O 157, associated with human infections in the United Kingdom: 1989-91

Homologous and Heterologous Antibody Responses to Lipopolysaccharide after EnterohemorrhagicEscherichia coliInfection

To evaluate antibody responses against lipopolysaccharide (LPS: O157, O26, and O111) in enterohemorrhagic Escherichia coli(EHEC) infection, sera of 24 schoolchildren associated with the Morioka outbreak in 1997 and of 74 sporadic patients suspected of having EHEC infection were examined. Using a positive standard serum, quantitative evaluation of LPS antibodies by an enzyme-linked immunosorbent assay (ELISA) was established. High levels of specific IgM and IgA antibodies against homologous E. coli LPS were present in the acute period and are characteristic of EHEC. This could be used for the serological diagnosis of EHEC infection, except for early infants and the elderly. In addition to the specific homologous response, multiple antibody responses against different serotypes other than those isolated were demonstrated in many cases by qualitative analysis using Western blotting.

Gnotobiotic piglet infection model for evaluating the safe use of antibiotics against Escherichia coli O157:H7 infection

BACKGROUND

Shiga toxin (Stx)-producing Escherichia coli (STEC), especially O157:H7, cause bloody diarrhea, and in 3%-15% of individuals the infection leads to hemolytic uremic syndrome (HUS) or other complications. Use of antibiotics to treat STEC infections is controversial. Here, we describe the use of piglets to evaluate the efficacy and mechanism of action of antibiotics in these infections.

METHODS

The effects of 2 antibiotics on STEC toxin production and their mechanisms of action were first determined by enzyme-linked immunosorbent assay and subsequently evaluated clinically in the gnotobiotic piglet infection model.

RESULTS

In vitro treatment of clinical and isogenic strains with ciprofloxacin increased the production of Stx2 via phage induction but not the production of Stx1. Azithromycin caused no significant increase in toxin production. After treatment with ciprofloxacin, infected piglets had diarrhea and the severe fatal neurological symptoms associated with Stx2 intoxication. Characteristic petechial hemorrhages in the cerebellum were more severe in ciprofloxacin-treated animals than in control animals. In contrast, azithromycin-treated piglets survived the infection and had little or no brain hemorrhaging.

CONCLUSIONS

The increased in vitro toxin production caused by ciprofloxacin was strongly correlated with death and an increased rate of cerebellar hemorrhage, in contrast to the effect of azithromycin. The piglet is a suitable model for determining the effectiveness and safety of antibiotics available to treat patients.

Escherichia coli O-157-induced hemolytic uremic syndrome: Usefulness of SCWP score for the prediction of neurological complication

BACKGROUND

Hemolytic uremic syndrome (HUS) is commonly caused by hemorrhagic colitis with Shiga toxin-producing Escherichia coli O-157. Central nervous system (CNS) involvements, including seizures, encephalopathy and brain infarction, are serious complications, but there are no useful scores for the prediction of CNS complications.

METHODS

Routine laboratory data at onset of HUS were re-evaluated in 14 patients to find useful parameters for the prediction of CNS complication.

RESULTS

Serum sodium and total protein were significantly lower and C-reactive protein (CRP) and white blood cell counts were significantly higher in patients with CNS complications than in patients without. A cumulated score, SCWP score (sodium, CRP, white blood cell count, and total protein) discriminated better between patients with/without CNS complications than individual values.

CONCLUSIONS

SCWP score would be useful for prediction of CNS complications.

Human infections with verocytotoxin-producing Escherichia coli O157--10 years of E. coli O157 serodiagnosis

From 1997 to 2007, the Laboratory of Enteric Pathogens (LEP), Health Protection Agency, UK, received sera from 2148 patients for testing for antibodies to the LPS of verocytotoxin-producing Escherichia coli (VTEC) O157. A total of 676 (31.5 %) sera had antibodies binding the LPS of E. coli O157 and the majority of patients were below the age of 10 years, a trend observed for both males and females. Antibody-positive patients had haemolytic uraemic syndrome (HUS) in 79.3 % of cases and most of these presented with the atypical (D-) form of HUS. Nine patients were shown to have antibodies to the LPS of E. coli belonging to serogroups O26 (4), O103 (2), O111 (1) and O145 (2) and one patient had antibodies to the somatic antigens of both E. coli O26 and O103. The serodiagnosis of infections with E. coli O157 and other VTEC continues to be an important adjunct to bacteriology. Where clinicians suspect the involvement of a VTEC in disease, patients' sera should be submitted to the LEP for analysis without delay.

Microbiological characterization of lamb carcasses at commercial processing plants in the United States

Although the United States produces 203 million lb (ca. 92.1 kg) of domestic lamb and mutton each year, thorough studies of the microbiological safety during lamb processing are lacking. To address this missing information, a total of 2,548 sponge samples from pelts, preevisceration carcasses, and postintervention carcasses were collected from multiple large commercial lamb processing plants to determine aerobic plate counts, the prevalences of Escherichia coli O157:H7, non-O157 Shiga toxin-producing E. coli (STEC), and Salmonella. The averages of the aerobic plate counts from pelts, the preevisceration carcasses, and the postintervention carcasses were 6.3, 4.4, and 2.4 log CFU/100 cm2, respectively. The prevalences of E. coli O157:H7 from the pelts, the preevisceration carcasses, and the postintervention carcasses were 12.8, 1.6, and 2.9%, respectively. The average Salmonella prevalences were 14.4, 4.3, and 1.8% for pelts, preevisceration carcasses, and postintervention carcasses, respectively. The most frequently identified Salmonella serotype was Heidelberg. The prevalences of non-O157 STEC from pelts, preevisceration carcasses, and postintervention carcasses averaged 86.2, 78.6, and 81.6%, respectively. A total of 488 non-O157 S0TEC strains were isolated from postintervention carcasses. Sixty-nine different serotypes of non-O157 STEC were identified. The most frequently detected serotypes were O91:H14 (40.8%), followed by O5:H19 (18.4%). A small number of STEC serotypes associated with severe human illness were isolated from postintervention carcasses. These were serotypes O76:H19, O128:H2 (0.8%), O146:H8 (2.1%), ) O146:H21, O163:H19, and O174:H8 (1.3%). The results of this study establish a baseline for microbiological quality and prevalences of Salmonella, E. coli O157:H7, and STEC in U.S. lamb processing plants.

The non-O157 shiga-toxigenic (verocytotoxigenic) Escherichia coli; under-rated pathogens

Following a brief review of the ecology of Escherichia coli in general, the role of Shiga-Toxigenic (Verocytotoxigenic) E. coli (STEC) as pathogens is addressed. While STEC belonging to the serogroup O157 have been extensively studied and shown to be involved in many cases and outbreaks of human disease, the importance of STEC belonging to other serogroups has not been recognized as much. This review addresses the problems associated with these pathogens, demonstrating that increasing the awareness of them is a major part of the problem. This review then demonstrates how widespread isolations especially from food animals and human disease have been, discussing in particular STEC belonging to serogroups O8, O26, O103, O111, O113 and O128. The animal host-specificity of these STEC is also reviewed. In conclusion some methods of improving isolation of these pathogens is addressed.

QseA and GrlR/GrlA regulation of the locus of enterocyte effacement genes in enterohemorrhagic Escherichia coli

Transcription of the locus of enterocyte effacement (LEE) genes in enterohemorrhagic Escherichia coli (EHEC) is regulated by the LEE-encoded Ler and GrlR/GrlA proteins as well as the non-LEE-encoded regulator QseA. This work demonstrates that GrlR/GrlA activate LEE2 transcription in a Ler-independent fashion, whereas transcription of grlRA is activated by QseA in both Ler-dependent and -independent manners.

Shiga-toxin-producing Escherichia coli and haemolytic uraemic syndrome

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.

Serotypes and virulence gene profiles of shiga toxin-producing Escherichia coli strains isolated from feces of pasture-fed and lot-fed sheep

Shiga toxin-producing Escherichia coli (STEC) strains possessing genes for enterohemolysin (ehxA) and/or intimin (eae), referred to here as complex STEC (cSTEC), are more commonly recovered from the feces of humans with hemolytic uremic syndrome and hemorrhagic colitis than STEC strains that do not possess these accessory virulence genes. Ruminants, particularly cattle and sheep, are recognized reservoirs of STEC populations that may contaminate foods destined for human consumption. We isolated cSTEC strains from the feces of longitudinally sampled pasture-fed sheep, lot-fed sheep maintained on diets comprising various combinations of silage and grain, and sheep simultaneously grazing pastures with cattle to explore the diversity of cSTEC serotypes capable of colonizing healthy sheep. A total of 67 cSTEC serotypes were isolated, of which 21 (31.3%), mainly isolated from lambs, have not been reported. Of the total isolations, 58 (86.6%) were different from cSTEC serotypes isolated from a recent study of longitudinally sampled healthy Australian cattle (M. Hornitzky, B. A. Vanselow, K. Walker, K. A. Bettelheim, B. Corney, P. Gill, G. Bailey, and S. P. Djordjevic, Appl. Environ. Microbiol. 68:6439-6445, 2002). Our data suggest that cSTEC serotypes O5:H(-), O75:H8, O91:H(-), O123:H(-), and O128:H2 are well adapted to colonizing the ovine gastrointestinal tract, since they were the most prevalent serotypes isolated from both pasture-fed and lot-fed sheep. Collectively, our data show that Australian sheep are colonized by diverse cSTEC serotypes that are rarely isolated from healthy Australian cattle.

The prevalence and spread of Escherichia coli O157:H7 at a commercial beef abattoir

AIMS

To investigate the prevalence and virulence characteristics of Escherichia coli O157:H7 after a number of beef process operations at a commercial Irish abattoir.

METHODS AND RESULTS

Two 12-month studies were carried out. The first study (study 1) examined the prevalence of E. coli O157:H7 at up to six sites on carcasses at eight stages of the dressing, washing, chilling and boning process. The second study (study 2) examined the prevalence of E. coli O157:H7 in bovine faeces and rumen contents post-slaughter and on dressed, washed carcasses. Isolates from both studies were phage-typed and the presence of genes encoding verocytotoxin, enterohaemolysin and intimin production was determined. E. coli O157:H7 was isolated from four of 36 carcasses in study 1. E. coli O157:H7 was detected during hide removal and was detected at multiple carcass sites and multiple process stages, including boning. On two carcasses, contamination was first detected at the bung following its freeing and tying. All isolates from study 1 were phage type (PT) 2, eaeAO157 and ehlyA positive, but were verocytotoxin 1 (VT1) and verocytotoxin 2 (VT2) negative. In study 2, E. coli O157:H7 was isolated from 2.4% of faecal, 0.8% of rumen and 3.2% of carcass samples. In some cases, isolates recovered from the faeces of a particular animal, the resulting carcass and adjacent carcasses on the line had the same phage typing and virulence characteristic profile patterns. All isolates from study 2 were eaeAO157 and ehlyA positive and only one isolate was VT1 and VT2 negative. Most isolates were PT 32. A higher frequency of positive isolations was noted from samples taken during spring and late summer.

CONCLUSION

These studies show that in a typical Irish beef abattoir, carcass contamination with E. coli O157:H7 can occur during hide removal and bung tying and this contamination can remain on the carcass during subsequent processing.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study provides data that is necessary for the understanding of how E. coli O157:H7 contamination of beef occurs.

Prevalence of faecal excretion of verocytotoxigenic Escherichia coli 0157 in cattle in England and Wales

During the decade to 1999, the incidence of human infections with the zoonotic pathogen verocytotoxin-producing Escherichia coli O157 (VTEC O157) increased in England and Wales. This paper describes the results of a survey of 75 farms to determine the prevalence of faecal excretion of VTEC O157 by cattle, its primary reservoir host, in England and Wales. Faecal samples were collected from 4663 cattle between June and December 1999. The prevalence of excretion by individual cattle was 4.2 per cent (95 per cent confidence interval [CI] 2.0 to 6.4) and 10.3 per cent (95 per cent CI 5.8 to 14.8) among animals in infected herds. The within-herd prevalence on positive farms ranged from 1.1 to 51.4 per cent. At least one positive animal was identified on 29 (38.7 per cent; 95 per cent CI 28.1 to 50.4) of the farms, including dairy, suckler and fattening herds. The prevalence of excretion was least in the calves under two months of age, peaked in the calves aged between two and six months and declined thereafter. The phage types identified most widely were 4, 34 and 2, which were each found on six of the 29 positive farms.

Molecular and functional analysis of Shiga toxin-induced response patterns in human vascular endothelial cells

Enterohemorrhagic Escherichia coli (EHEC) is the major cause of hemolyticuremic syndrome (HUS) characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. EHEC produces one or more Shiga toxins (Stx1 and Stx2), and it was assumed that Stx's only relevant biologic activity was cell destruction through inhibition of protein synthesis. However, recent data indicate that in vivo the cytokine milieu may determine whether endothelial cells survive or undergo apoptosis/necrosis when exposed to Stxs. In this study, we analyzed the genome-wide expression patterns of human endothelial cells stimulated with subinhibitory concentrations of Stxs in order to characterize the genomic expression program involved in the vascular pathology of HUS. We found that Stxs elicited few, but reproducible, changes in gene expression. The majority of genes reported in this study encodes for chemokines and cytokines, which might contribute to the multifaceted inflammatory response of host endothelial cells observed in patients suffering from EHEC disease. In addition, our data provide for the first time molecular insights into the epidemiologically well-established higher pathogenicity of Stx2 over Stx1.

Non-O157 verotoxin-producing Escherichia coli: a problem, paradox, and paradigm

The problems associated with identification and characterization of non-O157 verotoxin-producing Escherichia coli (VTEC) are discussed. The paradox of VTEC is that most reports of human illnesses are associated with serotypes such as O157:H7, O111:H- (nonmotile), O26:H11, and O113:H21, which are rarely found in domestic animals. However, those VTEC serotypes commonly found in domestic animals, especially ruminants, rarely cause human illnesses. When they cause human illnesses, the symptoms are similar to those caused by the serotypes E. coli O157:H7, O111:H-, O26:H11, and O113:H21. The impact of VTEC on human and animal health is also addressed. The VTEC and their toxicity are considered as a paradigm for emerging pathogens. The question on how such pathogens could arise from a basic commensal population is also addressed.

Production of serum antibodies that recognise epitopes located on the R3 region of Escherichia coli core lipopolysaccharides by patients infected with strains of enterohaemorrhagic E. coli

Antibody-antigen cross-reactions were examined with sera from patients with Escherichia coli O157 infection and lipopolysaccharide (LPS) purified from a range of enterohaemorrhagic E. coli (EHEC) including those belonging to serogroups O26, O103, O111, O145 and O157. Six of 10 patients infected with an O157 EHEC produced serum antibodies that cross-reacted with common LPS-core epitopes, which were expressed by 23 of 33 strains of EHEC examined. These common LPS-core epitopes were also present on strains of E. coli O26 which did not produce verocytotoxin. These cross-reacting antibodies did not influence the basic immunoblotting procedures used for the routine serodiagnosis of infections with E. coli O157.

Shiga-like toxin II modifies brain distribution of a P-glycoprotein substrate, doxorubicin, and P-glycoprotein expression in mice

The effect of Shiga-like toxin II (SLT-II), which was derived from Escherichia coli O157:H7, on doxorubicin transport across the blood-brain barrier (BBB) and P-glycoprotein function, was investigated in ddY mice. Doxorubicin (30 mg kg(-1)) was administered intravenously or fluorescein isothiocyanate labeled dextran (FD-4) was infused (20 microg min(-1)) to the mice, who had received an intravenous injection of SLT-II (0.2 microg/animal) 6 or 24 h earlier. Blood and brain were removed 4 h after injection of doxorubicin or 60 min after infusion of FD-4. SLT-II significantly elevated the brain concentration and brain-to-plasma concentration ratio (K(p)) of doxorubicin and FD-4 24 h after injection, but did not alter 6 h after. Cyclosporin A (200 mg kg(-1)) significantly increased the K(p) value of doxorubicin in the control mice, but did not alter it in mice treated 24 h earlier with SLT-II. Pentoxifylline (100 mg kg(-1)) a TNF-alpha production inhibitor, ameliorated SLT-II-induced increases in the brain concentrations of both drugs and the K(p) value of FD-4, suggesting that TNF-alpha, at least in part, causes damage to the brain capillaries. Western blot analysis revealed that SLT-II increased the protein level of P-glycoprotein in the brain of mice 6 h after injection and the increased level remained unchanged for 24 h. SLT-II did not change ATP content in the brain of mice. These results suggest that the increased P-glycoprotein level cannot explain SLT-II-induced increase in the doxorubicin accumulation in brain. The present findings indicate that SLT-II impairs the BBB function and doxorubicin transport across the BBB, while it overexpresses P-glycoprotein.

The public health significance of VTEC O157

Surveillance of human VTEC O157 has been reported in several countries, based on laboratory evidence. The incidence is generally less than 10 per 100000 (the highest incidence is in children), with regional variations and a marked seasonality. Laboratory selection criteria and reporting have contributed to, but cannot entirely explain, variations within and between countries. Surveillance data and outbreaks in definable cohorts indicate that the spectrum of illness ranges from diarrhoea through acute bloody diarrhoea, with about 5% of cases developing haemolytic uraemic syndrome; less than 50% of patients report frank blood in their stools. Studies of sporadic cases have associated illness with beef products (particularly if undercooked and eaten outside the home), cooked sliced meat meals and contact with a household member with diarrhoea. Outbreaks have been attributed to contaminated foods (including beefburgers) and water, animal contact and person-to-person spread. Secondary transmission by the primary case in a household is of particular concern, and household transmission has been estimated at 4%, with patients excreting for around 10 days following onset. Recommendations for control have highlighted measures on farms, in slaughterhouses, retail and catering food premises, and in the home.

Role of non-O157 VTEC

Non-O157 VTEC are typical Escherichia coli that differ only in their ability to produce verocytotoxins (VT). The transmission of VTEC is discussed in relation to the transmission of commensal E. coli. The emergence over the last few decades of a great variety of VTEC serotypes from healthy and diseased humans and animals is described. Particular attention is given to the distribution of the more important serogroups pathogenic for humans that have been described from around the world, particularly serogroups O26, O111, O128 and O103. The possible role of ruminants as reservoirs is discussed. The problems of laboratory diagnosis of non-O157 VTEC are considered and various laboratory methods are assessed. Evidence is presented that the particular E. coli serotypes now known to be VTEC were present in humans and animals many years ago, but have acquired the ability to produce VT and probably other virulence factors. Finally, predictions are made of the possible increase in problems associated with these emerging pathogens.

A foodborne outbreak of Vero cytotoxin-producing Escherichia coli O157:H-phage type 8 in hospital

This paper describes the epidemiological and microbiological aspects of the largest outbreak of Vero cytotoxin-producing Escherichia coli O157 (VTEC O157) infection in a hospital setting in which the route of transmission was foodborne. The outbreak, which was caused by a relatively uncommon phage type of VTEC O157, occurred in four geriatric continuing care wards in May 1997. The total number of people found to be excreting the organism was 37, of whom 16 were inpatients and 11 were staff. Twelve people displayed enteric symptoms. In addition, all but two of 10 cases identified in the local community were thought to be associated with the outbreak. An epidemiological investigation amongst the hospital patients revealed a statistically significant association between VTEC O157 infection and attendance at a concert party on the continuing care wards on 17 May 1997 (relative risk = 3.22;P= 0.006). There was an even stronger relationship between consumption of home-baked cream-filled cakes brought to that party and evidence of infection (relative risk = 19.35;P= 0.00002). Further investigations in the local community, coupled with microbiological evidence, supported the epidemiological finding that homemade cream cakes brought into the hospital were the vehicle of infection for the outbreak. There was no secondary spread within the hospital. The outbreak serves as a reminder of the hazard posed by foodstuffs brought into a hospital from outside.

Toxicity of Shiga toxin 1 in the central nervous system of rabbits

The action of Shiga toxin (Stx) on the central nervous system was examined in rabbits. Intravenous Stx1 was 44 times more lethal than Stx2 and acted more rapidly than Stx2. However, Stx1 accumulated more slowly in the cerebrospinal fluid than did Stx2. Magnetic resonance imaging demonstrated a predominance of Stx1-dependent lesions in the spinal cord. Pretreatment of the animals with anti-Stx1 antiserum intravenously completely protected against both development of brain lesions and mortality.

[Hemolytic-uremic syndrome: microbiological aspects]

Escherichia coli O157: H7 became an important pathogen starting in the early 1980s. It has caused epidemics and sporadic cases of often bloody diarrhea which may progress to severe hemolytic and uremic syndrome or thrombotic thrombocytopenia purpura. E. coli O157: H7 is mainly transmitted in food, water and interhuman transmission, but direct animal-to-man transmission has also been documented. E. coli O157: H7 can adhere tightly to the enterocyte brush border (eae gene) and produce verotoxins or Shiga-like toxins and hemolysine (ehxA gene). Diagnosis of E. coli O157: H7 infections is based on evidencing the germ in stools and/or by identifying the genes coding for verotoxins or by serology which increased serum titre of specific antilipopolysaccharide antibodies. Antidiarrheal drugs and antibiotics have little place in the treatment of bloody diarrhea. This public health problem, requires careful identification of animal reservoirs and improved population education in food hygiene.

Pathogenesis of Shiga toxin-associated hemolytic uremic syndrome

The aim of this review is to examine recent advances in experimental and clinical research relevant to the pathogenesis of diarrhea-associated hemolytic uremic syndrome with special reference to histopathologic findings, virulence factors of Shiga toxin-producing Escherichia coli, the host response, and the prothrombotic state. Despite significant advances during the past decade, the exact mechanism by which Shiga toxin-producing E. coli leads to hemolytic uremic syndrome remains unclear. Factors such as Shiga toxin, lipopolysaccharide, the adhesins intimin and E. coli-secreted proteins A, B, and D, the 60-MD plasmid, and enterohemolysin likely contribute to the pathogenesis. Data on the inflammatory response of the host, including leukocytes and inflammatory mediators, are updated. The pathogenesis of the prothrombotic state leading to thrombocytopenia secondary to endothelial cell damage and platelet activation is also discussed. A hypothetical sequence of events from ingestion of the bacteria to the development of full-blown hemolytic uremic syndrome is proposed.

Two cases of human urinary tract infection complicated by hemolytic uremic syndrome caused by verotoxin-producing Escherichia coli

In 1993, 2 cases of urinary tract infection (UTI) caused by verotoxin-producing Escherichia coli were diagnosed at Rigshospitalet in Copenhagen, Denmark. Neither of the patients had any previous history of diarrhea. We suggest that E. coli strains isolated from UTI be examined for the production of verotoxin when hemolytic uremic syndrome is clinically suspected.

Modifications to methods for the enumeration and detection of injured Escherichia coli O157:H7 in foods

Reliable methods are required for the detection and enumeration of potentially injured E. coli O157 in food in the presence of outnumbering competing bacteria. Selective agents can prevent or inhibit the recovery and subsequent multiplication of injured cells and direct inoculation, either into selective enrichment broths or onto selective agar plates is still used in many methods for E. coli O157 detection and enumeration. When compared with tryptone soya agar (TSA), sorbitol MacConkey agar (SMAC) was shown to underestimate the concentration of viable E. coli O157:H7 subjected to low pH and high NaCl concentration. Using a resuscitation stage on TSA followed by membrane transfer to SMAC improved recovery to levels obtained on TSA. The membrane method was used to monitor the numbers of artificially contaminated E. coli O157:H7 during the fermentation of a meat product and demonstrated better survival when compared to counts on SMAC. Six rapid methods for the detection of E. coli O157 in food (BAX E. coli O157, Reveal 8 E. coli O157-H7 screening test, VIP EHEC, VIDAS E. coli O157 (ECO), EHEC-Tek and Tecra E. coli O157 visual immunoassay), were evaluated using beetburgers, parsley and fermented meat artificially contaminated with injured cells. Methods using direct selective enrichment, with or without an elevated incubation temperature gave false-negative results. The incorporation of a non-selective pre-enrichment medium improved the detection rates of these assays by up to ten fold.

Effects of Shiga toxin 2 on lethality, fetuses, delivery, and puerperal behavior in pregnant mice

Shiga toxin 2 (Stx2) is produced by enterohemorrhagic Escherichia coli (EHEC) and is known as the major virulence factor of EHEC. The aim of this study was to evaluate the effects of Stx2 on (i) maternal lethality, (ii) fetuses, (iii) delivery period, and (iv) maternal behavior after delivery. Timed pregnant ICR mice were injected intravenously with Stx2 on day 5 of pregnancy (early stage) or on day 15 (late stage). In early-stage experiments, the number of normal fetuses of mice injected with Stx2 was significantly lower than that of control mice. In late-stage experiments, mothers injected with Stx2 delivered normal numbers of neonates, but could not take care of them. The lethal doses of Stx2 were not different for pregnant and nonpregnant female mice at either stage. We conclude that Stx2 is toxic to the fetus in early pregnancy and affects maternal puerperal behavior in late pregnancy.

Shigella and Shiga toxin-producing Escherichia coli causing bloody diarrhea in Latin America

In Latin America, Shigella and shiga toxin-producing Escherichia coli are the two leading agents in the cause of bloody diarrhea. The already high and increasing antimicrobial resistance of Shigella also is a significant problem. Shiga toxin-producing E. coli is an emerging disease with life-threatening complications: hemolytic uremic syndrome. Although E. coli O157:H7 remains the most commonly recognized serotype, recently emerging, non-O157 bacteria may be the cause of a similar spectrum of disease in humans.

Shiga toxins 1 and 2 translocate differently across polarized intestinal epithelial cells

Shiga toxin-producing Escherichia coli (STEC) is an important food-borne pathogen that causes hemolytic-uremic syndrome. Following ingestion, STEC cells colonize the intestine and produce Shiga toxins (Stx), which appear to translocate across the intestinal epithelium and subsequently reach sensitive endothelial cell beds. STEC cells produce one or both of two major toxins, Stx1 and Stx2. Stx2-producing STEC is more often associated with disease for reasons as yet undetermined. In this study, we used polarized intestinal epithelial cells grown on permeable filters as a model to compare Stx1 and Stx2 movement across the intestinal epithelium. We have previously shown that biologically active Stx1 is able to translocate across cell monolayers in an energy-dependent, saturable manner. This study demonstrates that biologically active Stx2 is also capable of movement across the epithelium without affecting barrier function, but significantly less Stx2 crossed monolayers than Stx1. Chilling the monolayers to 4 degrees C reduced the amount of Stx1 and Stx2 movement by 200-fold and 20-fold respectively. Stx1 movement was clearly directional, favoring an apical-to-basolateral translocation, whereas Stx2 movement was not. Colchicine reduced Stx1, but not Stx2, translocation. Monensin reduced the translocation of both toxins, but the effect was more pronounced with Stx1. Brefeldin A had no effect on either toxin. Excess unlabeled Stx1 blocks the movement of (125)I-Stx1. Excess Stx2 failed to have any effect on Stx1 movement. Our data suggests that, despite the many common physical and biochemical properties of the two toxins, they appear to be crossing the epithelial cell barrier by different pathways.

The serodiagnosis of infections caused by Verocytotoxin-producing Escherichia coli

Patients with haemolytic uraemic syndrome (HUS) and haemorrhagic colitis (HC) produce serum antibodies to the lipopolysaccharides (LPS) of Escherichia coli O157 and certain other E. coli serogroups. Patients may also make salivary antibodies to the LPS of E. coli O157. Serological tests based on these antibodies can be used to provide evidence of infection in the absence of culturable VTEC or the toxins they produce. Serum antibodies to LPS persist for several months following onset of disease, enabling both current and retrospective serological testing. The LPS of E. coli O157 shares epitopes with strains of Brucella abortus, Yersinia enterocolitica O9, Vibrio cholerae O1 Inaba, group N Salmonella and certain strains of Citrobacter freundii and E. hermanni. Serological tests for serum antibodies to E. coli O157 should be evaluated in the light of these cross-reactions. Serological tests to supply evidence of infection with E. coli O157 have been shown to provide a valuable adjunct to bacteriological procedures for detecting culturable VTEC and VT. The use of well characterized LPS antigens in association with the techniques of ELISA and immunoblotting provide valuable procedures for detecting evidence of infection with E. coli O157 and possibly other VTEC.

Associations between virulence factors of Shiga toxin-producing Escherichia coli and disease in humans

Associations between known or putative virulence factors of Shiga toxin-producing Escherichia coli and disease in humans were investigated. Univariate analysis and multivariate logistic regression analysis of a set of 237 isolates from 118 serotypes showed significant associations between the presence of genes for intimin (eae) and Shiga toxin 2 (stx2) and isolates from serotypes reported in humans. Similar associations were found with isolates from serotypes reported in hemorrhagic colitis and hemolytic-uremic syndrome. The enterohemorrhagic E. coli (EHEC) hemolysin gene was significantly associated with isolates from serotypes found in severe diseases in univariate analysis but not in multivariate logistic regression models. A strong association between the intimin and EHEC-hemolysin genes may explain the lack of statistical significance of EHEC hemolysin in these multivariate models, but a true lack of biological significance of the hemolysin in humans or in disease cannot be excluded. This result warrants further investigations of this topic. Multivariate analysis revealed an interaction between the eae and stx2 genes, thus supporting the hypothesis of the synergism between the adhesin intimin and Shiga toxin 2. A strong statistical association was observed between the stx2 gene and severity of disease for a set of 112 human isolates from eight major serotypes. A comparison of 77 isolates of bovine origin and 91 human isolates belonging to six major serotypes showed significant associations of the genes for Shiga toxin 1 and EspP protease with bovine isolates and an increased adherence on HEp-2 cell cultures for human isolates, particularly from diarrheic patients and healthy persons.

The surveillance of vero cytotoxin-producing Escherichia coli O157 in Wales, 1990 to 1998

Population-based surveillance for Vero cytotoxin-producing Escherichia coli (VTEC) O157 has been carried out in Wales since 1990. The annual incidence has remained stable during the 9-year period (mean: 1.6 cases per 100,000 population); the rate is highest in children younger than 5 years of age. Blood in the stool is reported in fewer than half the cases, indicating the importance of screening all fecal specimens for VTEC O157.

Isolation of an Escherichia coli O157:H7 strain producing Shiga toxin 1 but not Shiga toxin 2 from a patient with hemolytic uremic syndrome in Korea

Escherichia coli strains isolated from patients with diarrhea or hemolytic uremic syndrome (HUS) at Pusan University Hospital, South Korea, between 1990 and 1996 were examined for traits of the O157:H7 serogroup. One strain isolated from a patient with HUS belonged to the O157:H7 serotype, possessed a 60-MDa plasmid, the eae gene, and ability to produce Shiga toxin 1 but not Shiga toxin 2. Arbitrarily primed PCR analysis suggested that this strain is genetically very close to a O157:H7 strain isolated in Japan.

The use of serodiagnosis in the retrospective investigation of a nursery outbreak associated with Escherichia coli O157:H7

AIMS

To use serology to investigate an outbreak of verocytotoxin (VT) producing Escherichia coli O157 in a hospital nursery, following the detection of faecal E coli O157 (phage type 49) producing VT type 2.

METHODS

ELISA and immunoblotting techniques, based on lipopolysaccharide (LPS) purified from E coli O157; diagnostic bacteriology; serotyping and phage typing; DNA probes for VT.

RESULTS

29 of 126 sera contained antibodies to the LPS of E coli O157: 10 were from children, three were from staff, and 11 were from hospital kitchen staff. Five parents of children attending the nursery were antibody positive. Sixty four sera from other hospital staff and controls did not contain antibodies to the LPS of E coli O157.

CONCLUSIONS

Serology detected evidence of infection with E coli O157 in 23% of sera examined. By bacteriology alone, only a single case of infection with E coli O157 would have been detected. Serology is valuable in providing evidence of infection with E coli O157.

Risk of hemolytic uremic syndrome after sporadic Escherichia coli O157:H7 infection: results of a Canadian collaborative study. Investigators of the Canadian Pediatric Kidney Disease Research Center

OBJECTIVES

The objectives of this study were to better estimate the age-specific risks of hemolytic uremic syndrome (HUS) and hemolytic anemia after Escherichia coli O157:H7 infection among a representative cohort of both referred and nonreferred children with documented illness from the province of Alberta and to compare this with the rates in children evaluated at referral centers in the rest of Canada.

STUDY DESIGN

Children with HUS or E. coli O157:H7 gastroenteritis were eligible if they were < 15 years of age. Hemoglobin, blood smear, urinalysis, and serum creatinine were obtained 8 to 10 days after the onset of diarrhea to ascertain for hemolysis, anemia, thrombocytopenia, and renal injury. Subjects were monitored for 1 month.

RESULTS

From June 1991 to March 1994, HUS was diagnosed in 205 children. Of these 77% had evidence of E. coli O157:H7 infection. A further 582 children had E. coli O157:H7 gastroenteritis, of whom 18 had hemolytic anemia. The risk of HUS after E. coli O157:H7 infection in Alberta was 8.1% (95% confidence interval, 5.3 to 11.6) compared with 31.4% in referral centers in the rest of Canada. In Alberta the highest age-specific risk of HUS/hemolytic anemia was 12.9% in those < 5 years of age.

CONCLUSIONS

These data will help guide clinical care and provide a basis for estimating the sample sizes required in future treatment trials for the secondary prevention of HUS.

Detection of cytotoxic activity on Vero cells in clinical isolates of Serratia marcescens

Cytotoxin production was studied in 60 Serratia marcescens strains isolated from hospitalized patients. Association of cytotoxic activity with serotype, source of isolation and presence of plasmids was also evaluated. Thirteen of the 60 S. marcescens strains produced a cytotoxic effect on Vero cells. These strains were isolated from distinct clinical sources and classified into seven different serotypes (O1:H7; O4:NM; O10:NT; O19:NM; O6,14:H4; O6,14:NM and O6,14:H1). No relationship was observed between cytotoxic activity and clinical source or serotypes of the strains. Plasmids from five cytotoxin-producing S. marcescens strains were transferred to E. coli K12/711. The transconjugants did not exhibit cytotoxicity, indicating that the cytotoxic effect is not plasmid-mediated among these strains. Although a cytotoxic activity was demonstrated in filtrates of some S. marcescens strains, further studies should be performed to assess the role of this toxin in pathogenesis.

Non-O157 Vero cytotoxin producing Escherichia coli: aetiological agents of diarrhoea in children in Dunedin, New Zealand

Strains of Escherichia coli that produce Vero cytotoxin (VTEC) commonly cause diarrhoea, haemorrhagic colitis and haemolytic-uraemic syndrome in many northern hemisphere countries. In these countries, serotype O157:H7/H-predominates and has caused large food-borne outbreaks of infection. In contrast, few cases of infection with this serotype have been reported in New Zealand. Over a 3-month period, 484 stool specimens submitted to medical laboratories in Dunedin were screened for E. coli O157:H7/H-using sorbitol MacConkey agar, Y1 and Vero cell assays. Where possible, Vero cytotoxin production was confirmed by an ELISA test. Specimens from children aged 12 years or less were additionally screened for non-O157 VTEC. In the specimens of the children tested, O157:H7/H-VTEC was not isolated, but VTEC belonging to other serogroups were isolated from the children. Of interest was the detection of other species of Enterobacteriaceae, which produced a cytopathic effect on Vero cells. This study confirms the low incidence of infection with O157:H7/H- VTEC in New Zealand and suggests that non-O157 VTEC is a more important cause of diarrhoeal disease.

Direct detection of verotoxin genes in stool samples by polymerase chain reaction in hemolytic uremic syndrome patients in France

OBJECTIVE: To reassess the occurrence of verocytotoxin-producing Escherichia coli (VTEC) in French hemolytic uremic syndrome (HUS) patients. METHODS: From March 1991 to January 1995, direct detection of verotoxin genes (VT) by the polymerase chain reaction (PCR) was performed on stool samples from 169 patients suffering from HUS. RESULTS: Fifty-one were PCR positive (30.1%); one was positive for the VT1 gene and the others for the VT2 gene. VTEC was isolated from only 32 of the 51 PCR-positive samples. E. coli O157:H7 was isolated from five patients. E. coli O111 was isolated from seven patients during an outbreak of HUS. Among the other VT2 E. coli strains, only four were serotypable. Of the 51 PCR-positive stools, 19 were culture negative for VTEC. CONCLUSIONS: This study provides evidence that in France E. coli O157 and other VTEC serotypes are involved in HUS.

Vero cytotoxin-producing Escherichia coli O157 outbreaks in England and Wales, 1995: phenotypic methods and genotypic subtyping

Vero cytotoxin-producing Escherichia coli O157 belonging to four phage types (PTs) caused 11 outbreaks of infection in England and Wales in 1995. Outbreak strains of different PTs were distinguishable by DNA-based methods. Pulsed-field gel electrophoresis best discriminated among strains belonging to the same PT, distinguishing six of the seven PT2 outbreak strains and both PT49 outbreak strains.

Haemolytic-uraemic syndrome in the Hunter: public health implications

Three cases of haemolytic-uraemic syndrome in the Hunter area were reported in February 1995. An investigation was initiated to identify any verocytotoxic Escherichia coli in clinical samples that could be associated with the development of the disease. Escherichia coli O6:H- and O2:H7 were isolated from Case 1. No organisms were identified for Case 2, and Case 3 samples yielded Campylobacter jejuni. In addition, efforts were made to trace sources of any such pathogens in food samples or in the environment generally. Shiga-like toxins were found in meat products sampled from butchers' shops patronised by the families of the three cases. However, it was not found possible to match stool samples with samples of food from sources used by the families of the children. Environmental factors seemed likely to have played a significant role in the development of haemolytic-uraemic syndrome in Case 3. It is suggested that the incidence of the disease may be reduced by increasing the frequency of testing of meat products for Shiga-like toxins I and II and through educational and research programs.

Vero cytotoxin-producing Escherichia coli, particularly serogroup O157, associated with human infections in England and Wales: 1992-4

Investigations were performed by the Laboratory of Enteric Pathogens on Vero cytotoxin-producing Escherichia coli (VTEC) in England and Wales from 1992-4. Bacterial isolates, faeces and sera obtained from patients with diarrhoea, bloody diarrhoea and haemolytic uraemic syndrome were examined. Using serotyping, Vero cytotoxin gene probing and serodiagnostic tests for E. coli O157, evidence of infection was detected in 543, 434 and 491 individuals in 1992, 1993 and 1994 respectively; VTEC of serogroup O157 were isolated from 470, 385 and 411 cases. The O157 VTEC strains belonged to at least 19 different phage types (PT) although 84% belonged to PT2, PT49, PT8, PT1 or PT4. Antibodies to E. coli O157 lipopolysaccharide were detected in 13% of the cases. The average annual rate of infection with O157 VTEC was 0.83/100000 and 12% of the 1458 individuals with evidence of infection with VTEC or E. coli O157 developed haemolytic uraemic syndrome. There were at least 18 general outbreaks and many family outbreaks.

Verocytotoxin-producing Escherichia coli infection in hemolytic uremic syndrome in part of western Europe

From September 1989 until September 1993, stool specimens and sera from 113 children with diarrhoea-associated haemolytic uraemic syndrome (HUS) from the Netherlands, two university hospitals in Belgium and one university hospital in Germany were examined for the presence of verocytotoxin-producing Escherichia coli (VTEC) infection. Evidence for VTEC infection was observed in 88 (78%) patients with HUS compared to 2 (3%) of the 65 children with acute gastro-enteritis Serotype O157 was the causative agent in 76 (86%) of these 88 patients with VTEC-associated HUS and verocytotoxin-2 (VT-2) was the most frequent toxin produced. Serological testing for antibodies to O157 O-antigen yielded the highest number of positive results compared to the other test methods. Antibodies to O157 were found in sera of 71 (65%) of 110 patients with HUS and one control serum. Stool and sera examination for VTEC in 95 family contacts of 28 patients with HUS demonstrated an evidence for VTEC infection 33 (35%). In contrast, in patients with HUS serological antibodies to O157 O-antigen were found in only 3 (4%) of 85 family contacts.

CONCLUSION

In this part of Western Europe, VT2-producing Escherichia coli, mainly those belonging to serogroup O157, are the major cause of HUS in childhood.

Serum antibody responses of cattle following experimental infection with Escherichia coli O157:H7

Oral inoculation of calves and steers with 10(10) CFU of Escherichia coli O157:H7 induced prompt and sustained increases in serum antibodies to O157 lipopolysaccharide. Neutralizing antibodies to verotoxin 1 also increased rapidly in most steers but more gradually in calves. None of the animals developed neutralizing antibodies to verotoxin 2. These serological responses were not correlated with elimination of infection in calves or steers or protection of calves against reinfection with the same strain.

Cluster of cases of haemolytic uraemic syndrome due to unpasteurised cheese

A cluster of four patients (1 girl, 3 boys) from a French village (2,000 inhabitants) had acute haemolytic uraemic syndrome (HUS) between March 1992 and May 1993. All had prodromes with fever and diarrhoea, then acute renal failure, anaemia, schistocytosis and thrombocytopenia. Peritoneal dialysis was carried out in three children (duration 3-12 days). The verotoxin VT2 gene was identified by polymerase chain reaction in the stools of two children. Some days prior to the diarrhoea, all children had eaten a cheese made with unpasteurised mixed cows' and goats' milk from the same farm. A case control study showed that the occurrence of HUS was linked to the consumption of this milk product (P = 0.006). The VT 2 gene was isolated from the cheese and from the stools of goats and cows from the farm, but not from the stools of farm employees.

Molecular epidemiology of Escherichia coli O157:H7 by pulsed-field gel electrophoresis and comparison with that by bacteriophage typing

One hundred twenty-four Escherichia coli O157:H7 isolates were characterized by pulse-field gel electrophoresis, bacteriophage typing, and PCR of verotoxin genes. Diversity indices obtained--0.786 for phage types and 0.987 for pulsed-field gel electrophoresis types--demonstrated that phage typing falls below the critical value (0.9) required for confident interpretation of results.

Evaluation of methods for the isolation and detection of Escherichia coli O157 in minced beef

This study has evaluated enrichment and detection procedures for the isolation and detection of Escherichia coli O157 inoculated into minced beef. The use of a 24 h enrichment in modified EC broth containing novobiocin allowed low numbers of contaminating cells to multiply to levels detectable on culture media and by ELISA test kits. Total analysis time was reduced by the use of the Dynabead immunomagnetic separation system. The use of the Petrifilm Test Kit-HEC for E. coli O157:H7 and Organon Teknika EHEC-TEK system detected low numbers of contaminating cells following enrichment and reduced analysis time by 1 d. The incorporation of cefixime and tellurite into Sorbitol MacConkey Agar increased the rate and ease of isolation of E. coli O157 and its use is therefore recommended.

Detection of Escherichia coli O157:H7 in meat by an enzyme-linked immunosorbent assay, EHEC-Tek

Investigation of the specificity of an enzyme-linked immunosorbent assay (ELISA) for detection of Escherichia coli O157:H7 in raw meats (EHEC-Tek; Organon Teknika Corp.) revealed that the target antigens of the detection reagent, monoclonal antibody 4E8C12, were present in numerous serotypes of E. coli and that their ELISA reactivity was influenced by bile salts, acriflavine, and heat. The specificity of the ELISA was improved by a modified test protocol incorporating immunocapture.