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Percheron L, Gramada R, Tellier S, Salomon R, Harambat J, Llanas B, Fila M, Allain-Launay E, Lapeyraque AL, Leroy V, Adra AL, Bérard E, Bourdat-Michel G, Chehade H, Eckart P, Merieau E, Piètrement C, Sellier-Leclerc AL, Frémeaux-Bacchi V, Dimeglio C, Garnier A. Eculizumab treatment in severe pediatric STEC-HUS: a multicenter retrospective study. Pediatr Nephrol 2018; 33:1385-1394. [PMID: 29572749 DOI: 10.1007/s00467-018-3903-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 01/20/2018] [Accepted: 01/24/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hemolytic uremic syndrome related to Shiga-toxin-secreting Escherichia coli infection (STEC-HUS) remains a common cause of acute kidney injury in young children. No specific treatment has been validated for this severe disease. Recently, experimental studies highlight the potential role of complement in STEC-HUS pathophysiology. Eculizumab (EC), a monoclonal antibody against terminal complement complex, has been used in severe STEC-HUS patients, mostly during the 2011 German outbreak, with conflicting results. METHODS On behalf of the French Society of Pediatric Nephrology, we retrospectively studied 33 children from 15 centers treated with EC for severe STEC-HUS. Indication for EC was neurologic involvement in 20 patients, cardiac and neurologic involvement in 8, cardiac involvement in 2, and digestive involvement in 3. Based on medical status at last follow-up, patients were divided into two groups: favorable (n = 15) and unfavorable outcomes (n = 18). RESULTS Among patients with favorable outcome, 11/14 patients (79%) displayed persistent blockade of complement activity before each EC reinjection. Conversely, in patients with unfavorable outcome, only 9/15 (53%) had persistent blockade (p = n.s.). Among 28 patients presenting neurological symptoms, 19 had favorable neurological outcome including 17 with prompt recovery following first EC injection. Only two adverse effects potentially related to EC treatment were reported. CONCLUSIONS Taken together, these results may support EC use in severe STEC-HUS patients, especially those presenting severe neurological symptoms. The study, however, is limited by absence of a control group and use of multiple therapeutic interventions in treatment groups. Thus, prospective, controlled trials should be undertaken.
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Affiliation(s)
- Lucas Percheron
- Service de Néphrologie Pédiatrique, Hôpital des enfants, CHU Purpan, Toulouse, France.
| | - Raluca Gramada
- Service de Neuroradiologie Diagnostique et Thérapeutique, CHU Purpan, Toulouse, France
| | - Stéphanie Tellier
- Service de Néphrologie Pédiatrique, Hôpital des enfants, CHU Purpan, Toulouse, France
| | - Remi Salomon
- Service de Néphrologie Pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jérôme Harambat
- Service de Néphrologie Pédiatrique, Hôpital Pellegrin-Enfants, CHU Bordeaux, Bordeaux, France
| | - Brigitte Llanas
- Service de Néphrologie Pédiatrique, Hôpital Pellegrin-Enfants, CHU Bordeaux, Bordeaux, France
| | - Marc Fila
- Service de Néphrologie Pédiatrique, Hôpital Robert Debré-Paris, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Emma Allain-Launay
- Service de Néphrologie Pédiatrique, Hôpital Mère-Enfants, CHU Nantes, Nantes, France
| | - Anne-Laure Lapeyraque
- Service de Néphrologie Pédiatrique, CHU de Sainte-Justine à Montréal Canada, Montréal, Canada
| | - Valerie Leroy
- Service de Néphrologie Pédiatrique, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
| | - Anne-Laure Adra
- Service de Néphrologie Pédiatrique, Hôpital Arnaud de Villeneuve, CHU Montpellier, Montpellier, France
| | - Etienne Bérard
- Service de Néphrologie Pédiatrique, Hôpital Archet 2, CHU Nice, Nice, France
| | | | - Hassid Chehade
- Service de Néphrologie Pédiatrique, CHU de Lausanne Suisse, Lausanne, Switzerland
| | - Philippe Eckart
- Service de Pédiatrie Médicale, Hôpital côte de nacre, CHU Caen, Caen, France
| | - Elodie Merieau
- Service de Néphrologie, Hôpital Clocheville, CHU Tours, Tours, France
| | | | | | - Véronique Frémeaux-Bacchi
- Laboratoire d'immunologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Chloe Dimeglio
- Biostatistiques, Informatique Médicale, UMR 1027 Inserm, Université Paul Sabatier, Toulouse, France
| | - Arnaud Garnier
- Service de Néphrologie Pédiatrique, Hôpital des enfants, CHU Purpan, Toulouse, France.
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Abstract
Enteroaggregative Escherichia coli (EAEC, formerly known as "EAggEC") cause acute or persistent watery diarrhoea (with or without mucus) in children, predominantly in low-income countries, and are associated with travellers' diarrhoea in children and adults in middle and high income countries. The diverse nature of EAEC is such that not all strains cause disease. Conversely, certain strains of EAEC possess additional virulence determinants associated with the ability to cause severe diarrhoea and other symptoms, which might be life-threatening in vulnerable patients. The EAEC virulence factors described to date are either encoded on the large virulence plasmid of EAEC (plasmid of aggregative adherence) or on pathogenicity islands on the chromosome. Testing of food and faecal samples involves the detection of EAEC-associated traits in the matrix followed by isolation of the organism and confirmation of the presence of EAEC-associated genes using PCR. The variability of the plasmid structure and virulence gene sequences and the possibility that this mobile genetic element may be lost has necessitated the inclusion of chromosomal markers in the molecular screening assays. There is evidence in the literature of foodborne transmission of EAEC, but currently no evidence of a zoonotic reservoir. Fimbriae-mediated adhesion and biofilm formation are likely to be involved in both clinical manifestations of infection and attachment to foodstuffs. Multidrug resistance appears to be common in EAEC and geographically widespread. Whole-genome sequencing has revealed the mosaic genomic structure of EAEC and provided evidence that horizontal gene transfer and recombination are the driving force for acquisition of novel genome features and potentially novel pathogenic mechanisms. This has significant public health implications in terms of the diversity and pathogenesis of EAEC and its ability to colonise and cause disease in the human host.
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Affiliation(s)
- Claire Jenkins
- Public Health England, 61 Colindale Avenue, London, NW9 5HT, UK.
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Croxen MA, Law RJ, Scholz R, Keeney KM, Wlodarska M, Finlay BB. Recent advances in understanding enteric pathogenic Escherichia coli. Clin Microbiol Rev 2013; 26:822-80. [PMID: 24092857 PMCID: PMC3811233 DOI: 10.1128/cmr.00022-13] [Citation(s) in RCA: 822] [Impact Index Per Article: 74.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Although Escherichia coli can be an innocuous resident of the gastrointestinal tract, it also has the pathogenic capacity to cause significant diarrheal and extraintestinal diseases. Pathogenic variants of E. coli (pathovars or pathotypes) cause much morbidity and mortality worldwide. Consequently, pathogenic E. coli is widely studied in humans, animals, food, and the environment. While there are many common features that these pathotypes employ to colonize the intestinal mucosa and cause disease, the course, onset, and complications vary significantly. Outbreaks are common in developed and developing countries, and they sometimes have fatal consequences. Many of these pathotypes are a major public health concern as they have low infectious doses and are transmitted through ubiquitous mediums, including food and water. The seriousness of pathogenic E. coli is exemplified by dedicated national and international surveillance programs that monitor and track outbreaks; unfortunately, this surveillance is often lacking in developing countries. While not all pathotypes carry the same public health profile, they all carry an enormous potential to cause disease and continue to present challenges to human health. This comprehensive review highlights recent advances in our understanding of the intestinal pathotypes of E. coli.
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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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Jandhyala DM, Vanguri V, Boll EJ, Lai Y, McCormick BA, Leong JM. Shiga toxin-producing Escherichia coli O104:H4: an emerging pathogen with enhanced virulence. Infect Dis Clin North Am 2013; 27:631-49. [PMID: 24011834 PMCID: PMC3800737 DOI: 10.1016/j.idc.2013.05.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pathogenic Escherichia coli are genetically diverse and encompass a broad variety of pathotypes, such as enteroaggregative E. coli (EAEC) or enterohemorrhagic E. coli (EHEC), which cause distinct clinical syndromes. The historically large 2011 German outbreak of hemolytic uremic syndrome (HUS), caused by a Shiga-toxin producing E. coli (STEC) of the serotype O104:H4, illustrated the emerging importance of non-O157 STEC. STEC O104:H4, with features characteristic of both enteroaggregative E. coli and enterohemorrhagic E. coli, represents a unique and highly virulent pathotype. The German outbreak both allowed for the evaluation of several potential therapeutic approaches to STEC-induced HUS and emphasizes the importance of early and specific detection of both O157 and non-O157 STEC.
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Affiliation(s)
- Dakshina M Jandhyala
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, 750 Washington Street, Boston, MA 02111, USA.
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