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Swaminathan G, Kamyabi N, Carter HE, Rajan A, Karandikar U, Criss ZK, Shroyer NF, Robertson MJ, Coarfa C, Huang C, Shannon TE, Tadros M, Estes MK, Maresso AW, Grande-Allen KJ. Effect of substrate stiffness on human intestinal enteroids' infectivity by enteroaggregative Escherichia coli. Acta Biomater 2021; 132:245-259. [PMID: 34280559 DOI: 10.1016/j.actbio.2021.07.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 06/24/2021] [Accepted: 07/12/2021] [Indexed: 01/08/2023]
Abstract
Human intestinal enteroids (HIE) models have contributed significantly to our understanding of diarrheal diseases and other intestinal infections, but their routine culture conditions fail to mimic the mechanical environment of the native intestinal wall. Because the mechanical characteristics of the intestine significantly alter how pathogens interact with the intestinal epithelium, we used different concentrations of polyethylene glycol (PEG) to generate soft (~2 kPa), medium (~10 kPa), and stiff (~100 kPa) hydrogel biomaterial scaffolds. The height of HIEs cultured in monolayers atop these hydrogels was 18 µm whereas HIEs grown on rigid tissue culture surfaces (with stiffness in the GPa range) were 10 µm. Substrate stiffness also influenced the amount of enteroaggregative E. coli (EAEC strain 042) adhered to the HIEs. We quantified a striking difference in adherence pattern; on the medium and soft gels, the bacteria formed clusters of > 100 and even > 1000 on both duodenal and jejunal HIEs (such as would be found in biofilms), but did not on glass slides and stiff hydrogels. All hydrogel cultured HIEs showed significant enrichment for gene and signaling pathways related to epithelial differentiation, cell junctions and adhesions, extracellular matrix, mucins, and cell signaling compared to the HIEs cultured on rigid tissue culture surfaces. Collectively, these results indicate that the HIE monolayers cultured on the hydrogels are primed for a robust engagement with their mechanical environment, and that the soft hydrogels promote the formation of larger EAEC aggregates, likely through an indirect differential effect on mucus. STATEMENT OF SIGNIFICANCE: Enteroids are a form of in vitro experimental mini-guts created from intestinal stem cells. Enteroids are usually cultured in 3D within Matrigel atop rigid glass or plastic substrates, which fail to mimic the native intestinal mechanical environment. Because intestinal mechanics significantly alter how pathogens interact with the intestinal epithelium, we grew human intestinal enteroids in 2D atop polyethylene glycol (PEG) hydrogel scaffolds that were soft, medium, or stiff. Compared with enteroids grown in 2D atop glass or plastic, the enteroids grown on hydrogels were taller and more enriched in mechanobiology-related gene signaling pathways. Additionally, enteroids on the softest hydrogels supported adhesion of large aggregates of enteroaggregative E. coli. Thus, this platform offers a more biomimetic model for studying enteric diseases.
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Kubiak J, Davidson E, Soave R, Kodiyanplakkal RP, Robertson A, Besien KV, Shore TB, Lee JR, Westblade LF, Satlin MJ. Colonization with Gastrointestinal Pathogens Prior to Hematopoietic Cell Transplantation and Associated Clinical Implications. Transplant Cell Ther 2021; 27:499.e1-499.e6. [PMID: 33811020 DOI: 10.1016/j.jtct.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/09/2021] [Accepted: 02/14/2021] [Indexed: 11/29/2022]
Abstract
Infectious diarrhea following hematopoietic cell transplantation (HCT) significantly contributes to morbidity and mortality. Most HCT recipients experience diarrhea in the post-transplantation period, and infectious pathogens are frequently detected during diarrheal episodes. However, little is known about how frequently these patients are colonized with gastrointestinal (GI) pathogens before their transplantation and whether colonization predicts future diarrheal illness. We sought to determine how frequently HCT recipients are colonized with GI pathogens before HCT and the degree to which pre-HCT colonization predicts post-transplantation infectious diarrheal illness. We conducted a prospective cohort study of allogeneic and autologous HCT recipients at a single center between December 2016 and January 2019. Stool samples were collected during the week before HCT, and formed samples were evaluated for the presence of 22 diarrheal pathogens using the BioFire FilmArray GI panel. We determined the frequency with which participants were colonized with each pathogen and identified factors associated with colonization. We then determined how frequently pretransplantation colonization led to post-transplantation diarrheal infections due to the colonizing pathogen and whether colonization was associated with increased number of days of post-transplantation diarrhea during the transplant hospitalization. We enrolled 112 asymptomatic patients (allogeneic, 61%; autologous, 39%) who had a formed stool specimen before HCT, of whom 41 (37%) had a GI pathogen detected. The most commonly detected organisms were Clostridioides difficile (n = 21; 19%), Yersinia enterocolitica (n = 9; 8%), enteropathogenic Escherichia coli (EPEC) (n = 6; 6%), and norovirus (n = 5; 4%). Female sex and previous C. difficile infection were associated with C. difficile colonization, and having non-Hodgkin lymphoma was associated with being colonized with a diarrheal pathogen other than C. difficile. Thirteen of 21 patients (62%) with pretransplantation C. difficile colonization developed a clinical C. difficile infection post-transplantation, and 8 of 10 patients (80%) colonized with EPEC or enteroaggregative E. coli developed post-transplantation infections due to their colonizing pathogen. Pretransplantation C. difficile colonization was also associated with an increased duration of post-transplantation diarrhea (P = .048). Conversely, none of the 9 patients with pretransplantation Yersinia enterocolitica colonization developed a post-transplantation Y. enterocolitica infection. Patients admitted for HCT are frequently colonized with a diverse range of GI pathogens. Colonization with C. difficile colonization and diarrheagenic E. coli is frequently associated with post-transplantation diarrheal infections caused by these organisms, but the clinical significance of colonization with other GI pathogens is not clear.
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Affiliation(s)
- Jeffrey Kubiak
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Emily Davidson
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Rosemary Soave
- Department of Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Rosy Priya Kodiyanplakkal
- Department of Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Amy Robertson
- New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Koen van Besien
- Department of Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Tsiporah B Shore
- Department of Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - John R Lee
- Department of Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Lars F Westblade
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York; Department of Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Michael J Satlin
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York; Department of Medicine, Weill Cornell Medicine, New York, New York; New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York.
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3
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Rajan A, Robertson MJ, Carter HE, Poole NM, Clark JR, Green SI, Criss ZK, Zhao B, Karandikar U, Xing Y, Margalef-Català M, Jain N, Wilson RL, Bai F, Hyser JM, Petrosino J, Shroyer NF, Blutt SE, Coarfa C, Song X, Prasad BVV, Amieva MR, Grande-Allen J, Estes MK, Okhuysen PC, Maresso AW. Enteroaggregative E. coli Adherence to Human Heparan Sulfate Proteoglycans Drives Segment and Host Specific Responses to Infection. PLoS Pathog 2020; 16:e1008851. [PMID: 32986782 PMCID: PMC7553275 DOI: 10.1371/journal.ppat.1008851] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 10/13/2020] [Accepted: 08/01/2020] [Indexed: 02/06/2023] Open
Abstract
Enteroaggregative Escherichia coli (EAEC) is a significant cause of acute and chronic diarrhea, foodborne outbreaks, infections of the immunocompromised, and growth stunting in children in developing nations. There is no vaccine and resistance to antibiotics is rising. Unlike related E. coli pathotypes that are often associated with acute bouts of infection, EAEC is associated with persistent diarrhea and subclinical long-term colonization. Several secreted virulence factors have been associated with EAEC pathogenesis and linked to disease in humans, less certain are the molecular drivers of adherence to the intestinal mucosa. We previously established human intestinal enteroids (HIEs) as a model system to study host-EAEC interactions and aggregative adherence fimbriae A (AafA) as a major driver of EAEC adherence to HIEs. Here, we report a large-scale assessment of the host response to EAEC adherence from all four segments of the intestine across at least three donor lines for five E. coli pathotypes. The data demonstrate that the host response in the duodenum is driven largely by the infecting pathotype, whereas the response in the colon diverges in a patient-specific manner. Major pathways altered in gene expression in each of the four enteroid segments differed dramatically, with responses observed for inflammation, apoptosis and an overwhelming response to different mucin genes. In particular, EAEC both associated with large mucus droplets and specific mucins at the epithelial surface, binding that was ameliorated when mucins were removed, a process dependent on AafA. Pan-screening for glycans for binding to purified AafA identified the human ligand as heparan sulfate proteoglycans (HSPGs). Removal of HSPG abrogated EAEC association with HIEs. These results may mean that the human intestine responds remarkably different to distinct pathobionts that is dependent on the both the individual and intestinal segment in question, and uncover a major role for surface heparan sulfate proteoglycans as tropism-driving factor in adherence and/or colonization.
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Affiliation(s)
- Anubama Rajan
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States of America
| | - Matthew J. Robertson
- Molecular and Cell Biology-Mol. Regulation, Baylor College of Medicine, Houston, TX, United States of America
| | - Hannah E. Carter
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States of America
| | - Nina M. Poole
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States of America
| | - Justin R. Clark
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States of America
| | - Sabrina I. Green
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States of America
| | - Zachary K. Criss
- Department of Medicine Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, United States of America
| | - Boyang Zhao
- Verna and Marrs McLean Department of Biochemistry and Molecular Biology, Baylor College of Medicine, Houston, TX, United States of America
| | - Umesh Karandikar
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States of America
| | - Yikun Xing
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States of America
| | - Mar Margalef-Català
- Department of Pediatrics, Division of Infectious Diseases, Stanford University, Stanford, CA, United States of America
| | - Nikhil Jain
- Verna and Marrs McLean Department of Biochemistry and Molecular Biology, Baylor College of Medicine, Houston, TX, United States of America
| | - Reid L. Wilson
- Department of Bioengineering, Rice University, Houston, TX, United States of America
| | - Fan Bai
- Department of Biochemistry, Emory Comprehensive Glycomics Core, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Joseph M. Hyser
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States of America
| | - Joseph Petrosino
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States of America
| | - Noah F. Shroyer
- Department of Medicine Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, United States of America
| | - Sarah E. Blutt
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States of America
| | - Cristian Coarfa
- Molecular and Cell Biology-Mol. Regulation, Baylor College of Medicine, Houston, TX, United States of America
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, United States of America
| | - Xuezheng Song
- Department of Biochemistry, Emory Comprehensive Glycomics Core, Emory University School of Medicine, Atlanta, GA, United States of America
| | - BV Venkataram Prasad
- Verna and Marrs McLean Department of Biochemistry and Molecular Biology, Baylor College of Medicine, Houston, TX, United States of America
| | - Manuel R. Amieva
- Department of Pediatrics, Division of Infectious Diseases, Stanford University, Stanford, CA, United States of America
| | - Jane Grande-Allen
- Department of Bioengineering, Rice University, Houston, TX, United States of America
| | - Mary K. Estes
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States of America
| | - Pablo C. Okhuysen
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Anthony W. Maresso
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States of America
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Fang FC, Patel R. 2017 Infectious Diseases Society of America Infectious Diarrhea Guidelines: A View From the Clinical Laboratory. Clin Infect Dis 2019; 65:1974-1976. [PMID: 29053793 DOI: 10.1093/cid/cix730] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 08/10/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ferric C Fang
- Departments of Laboratory Medicine and Microbiology, University of Washington School of Medicine, Seattle
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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5
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Hebbelstrup Jensen B, Adler Sørensen C, Hebbelstrup Rye Rasmussen S, Rejkjær Holm D, Friis-Møller A, Engberg J, Mirsepasi-Lauridsen HC, Struve C, Hammerum AM, Porsbo LJ, Petersen RF, Petersen AM, Krogfelt KA. Characterization of Diarrheagenic Enteroaggregative Escherichia coli in Danish Adults-Antibiotic Treatment Does Not Reduce Duration of Diarrhea. Front Cell Infect Microbiol 2018; 8:306. [PMID: 30319991 PMCID: PMC6170641 DOI: 10.3389/fcimb.2018.00306] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 08/08/2018] [Indexed: 01/18/2023] Open
Abstract
Enteroaggregative Escherichia coli (EAEC) is frequently isolated from sporadic cases of diarrhea and in outbreaks of gastroenteritis in several regions of the world. The pathophysiology of EAEC continues to be enigmatic, and the efficacy of antibiotic treatment in EAEC-associated diarrhea has been discussed. Since the level of antibiotic resistance is increasing, it is essential to restrict the use of antibiotics to prevent further resistance development. We aimed to investigate EAEC strains in adult Danish patients suffering from diarrhea and from healthy controls. We examined the antibiotic resistance in EAEC strains, the clinical response to antibiotic treatment in EAEC diarrheal cases, and the distribution of virulence genes in diarrheal cases. The EAEC strains were collected from patients suffering from diarrhea in a Danish multicenter study. A medical doctor interviewed the patients by using a questionnaire regarding gastrointestinal symptoms, exposures, and use of antibiotic and over-the-counter antidiarrheal drugs. Follow-up was performed after 3–5 months to inquire about differential diagnosis to gastrointestinal disease. A multiplex polymerase chain reaction characterized virulence genes in diarrheal cases. Finally, the level of antibiotic resistance was examined by using the disc diffusion method. Asymptomatic carriage of EAEC in the adult Danish population was rare, in contrast to findings in healthy Danish children. The duration of diarrhea was not shortened by antibiotic treatment, specifically ciprofloxacin treatment, or by over-the-counter antidiarrheal drugs. Follow-up revealed no pathology in diarrheal patients apart from irritable bowel syndrome in two patients. A high number of patients suffered from long-term diarrhea, which was associated with the enterotoxin EAST-1 and a high virulence factor score. A high level of antibiotic resistance was observed and 58% of the EAEC strains were multidrug resistant. Multidrug resistance was most pronounced in cases of travelers' diarrhea, and it was seen that antibiotic treatment did not reduce the duration of diarrhea.
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Affiliation(s)
- Betina Hebbelstrup Jensen
- Department of Bacteria, Parasites & Fungi, Statens Serum Institut, Copenhagen, Denmark.,The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Dorthe Rejkjær Holm
- Department of Bacteria, Parasites & Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Alice Friis-Møller
- Department of Clinical Microbiology, Hvidovre Hospital, Copenhagen, Denmark
| | - Jørgen Engberg
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark
| | | | - Carsten Struve
- Department of Bacteria, Parasites & Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Anette M Hammerum
- Department of Bacteria, Parasites & Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Lone Jannok Porsbo
- National Food Institute, Technical University of Denmark, Copenhagen, Denmark
| | - Randi Føns Petersen
- Department of Virus & Microbiological Special Diagnostics, Statens Serum Institut, Copenhagen, Denmark
| | - Andreas Munk Petersen
- Department of Clinical Microbiology, Hvidovre Hospital, Copenhagen, Denmark.,Department of Gastroenterology, Hvidovre Hospital, Copenhagen, Denmark
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6
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Clinical Impact of a Multiplex Gastrointestinal Polymerase Chain Reaction Panel in Patients With Acute Gastroenteritis. Clin Infect Dis 2018; 67:1688-1696. [DOI: 10.1093/cid/ciy357] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 04/20/2018] [Indexed: 02/06/2023] Open
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7
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Novel Segment- and Host-Specific Patterns of Enteroaggregative Escherichia coli Adherence to Human Intestinal Enteroids. mBio 2018; 9:mBio.02419-17. [PMID: 29463660 PMCID: PMC5821088 DOI: 10.1128/mbio.02419-17] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Enteroaggregative Escherichia coli (EAEC) is an important diarrheal pathogen and a cause of both acute and chronic diarrhea. It is a common cause of pediatric bacterial diarrhea in developing countries. Despite its discovery in 1987, the intestinal tropism of the pathogen remains unknown. Cell lines used to study EAEC adherence include the HEp-2, T-84, and Caco-2 lines, but they exhibit abnormal metabolism and large variations in gene expression. Animal models either do not faithfully manifest human clinical symptoms or are cumbersome and expensive. Using human intestinal enteroids derived from all four segments of the human intestine, we find that EAEC demonstrates aggregative adherence to duodenal and ileal enteroids, with donor-driven differences driving a sheet-like and layered pattern. This contrasts with the colon, where segment-specific tropisms yielded a mesh-like adherence pattern dominated by interconnecting filaments. Very little to no aggregative adherence to jejunal enteroids was observed, regardless of the strain or donor, in contrast to a strong duodenal association across all donors and strains. These unique patterns of intestinal segment- or donor-specific adherence, but not the overall numbers of associated bacteria, were dependent on the major subunit protein of aggregative adherence fimbriae II (AafA), implying that the morphology of adherent clusters and the overall intestinal cell association of EAEC occur by different mechanisms. Our results suggest that we must give serious consideration to inter- and intrapatient variations in what is arguably the first step in pathogenesis, that of adherence, when considering the clinical manifestation of these infections. EAEC is a leading cause of pediatric bacterial diarrhea and a common cause of diarrhea among travelers and immunocompromised individuals. Heterogeneity in EAEC strains and lack of a good model system are major roadblocks to the understanding of its pathogenesis. Utilizing human intestinal enteroids to study the adherence of EAEC, we demonstrate that unique patterns of adherence are largely driven by unidentified factors present in different intestinal segments and from different donors. These patterns are also dependent on aggregative adherence fimbriae II encoded by EAEC. These results imply that we must also consider the contribution of the host to understand the pathogenesis of EAEC-induced inflammation and diarrhea.
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8
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Abbott AN, Fang FC. Clinical Impact of Multiplex Syndromic Panels in the Diagnosis of Bloodstream, Gastrointestinal, Respiratory, and Central Nervous System Infections. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.clinmicnews.2017.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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9
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Hebbelstrup Jensen B, Poulsen A, Hebbelstrup Rye Rasmussen S, Struve C, Engberg JH, Friis-Møller A, Boisen N, Jønsson R, Petersen RF, Petersen AM, Krogfelt KA. Genetic Virulence Profile of Enteroaggregative Escherichia coli Strains Isolated from Danish Children with Either Acute or Persistent Diarrhea. Front Cell Infect Microbiol 2017; 7:230. [PMID: 28611957 PMCID: PMC5447714 DOI: 10.3389/fcimb.2017.00230] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 05/17/2017] [Indexed: 11/13/2022] Open
Abstract
Enteroaggregative Escherichia coli (EAEC) is frequently found in diarrheal stools worldwide. It has been associated with persistent diarrhea, weight loss, and failure to thrive in children living in developing countries. A number of important EAEC virulence genes are identified; however, their roles in acute and persistent diarrhea have not been previously investigated. The aim of this study was to identify specific EAEC virulence genes associated with duration and type of diarrhea in Danish children. We aimed to improve the current diagnostics of EAEC and enable targeting of strains with an expected severe disease course. Questionnaires answered by parents provided information regarding duration of diarrhea and presence of blood or mucus. A total of 295 EAEC strains were collected from children with acute (≤7 days) and persistent diarrhea (≥14 days) and were compared by using multiplex PCR targeting the genes sat, sepA, pic, sigA, pet, astA, aatA, aggR, aaiC, aap, agg3/4C, ORF3, aafA, aggA, agg3A, agg4A, and agg5A. Furthermore, the distribution of EAEC genes in strains collected from cases of bloody, mucoid, and watery diarrhea was investigated. The classification and regression tree analysis (CART) was applied to investigate the relationship between EAEC virulence genes and diarrheal duration and type. Persistent diarrhea was associated with strains lacking the pic gene (p = 0.002) and with the combination of the genes pic, sat, and absence of the aggA gene (p = 0.05). Prolonged diarrhea was associated with the combination of the genes aatA and astA (p = 0.03). Non-mucoid diarrhea was associated with strains lacking the aatA gene (p = 0.004). Acute diarrhea was associated with the genes aggR, aap, and aggA by individual odds ratios. Resistance toward gentamicin and ciprofloxacin was observed in 7.5 and 3% of strains, respectively. Multi-drug resistance was observed in 38% of strains. Genetic host factors have been associated with an increased risk of EAEC-associated disease. Therefore, we investigated a panel of risk factors in two groups of children—EAEC-positive and EAEC-negative—to identify additional factors predisposing to disease. The duration of breastfeeding was positively correlated with the likelihood of belonging to the EAEC-negative group of children.
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Affiliation(s)
| | - Anja Poulsen
- Department of Gastroenterology, Copenhagen University Hospital HvidovreCopenhagen, Denmark
| | | | - Carsten Struve
- Department of Bacteria, Parasites and Fungi, Statens Serum InstitutCopenhagen, Denmark
| | - Jørgen H Engberg
- Department of Clinical Microbiology, Slagelse HospitalSlagelse, Denmark
| | - Alice Friis-Møller
- Department of Clinical Microbiology, Copenhagen University Hospital HvidovreCopenhagen, Denmark
| | - Nadia Boisen
- Department of Bacteria, Parasites and Fungi, Statens Serum InstitutCopenhagen, Denmark
| | - Rie Jønsson
- Department of Bacteria, Parasites and Fungi, Statens Serum InstitutCopenhagen, Denmark
| | - Randi F Petersen
- Department of Bacteria, Parasites and Fungi, Statens Serum InstitutCopenhagen, Denmark
| | - Andreas M Petersen
- Department of Bacteria, Parasites and Fungi, Statens Serum InstitutCopenhagen, Denmark.,Department of Gastroenterology, Copenhagen University Hospital HvidovreCopenhagen, Denmark.,Department of Clinical Microbiology, Copenhagen University Hospital HvidovreCopenhagen, Denmark
| | - Karen A Krogfelt
- Department of Bacteria, Parasites and Fungi, Statens Serum InstitutCopenhagen, Denmark
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10
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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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11
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Philipson CW, Bassaganya-Riera J, Hontecillas R. Animal models of enteroaggregative Escherichia coli infection. Gut Microbes 2013; 4:281-91. [PMID: 23680797 PMCID: PMC3744513 DOI: 10.4161/gmic.24826] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Enteroaggregative Escherichia coli (EAEC) has been acknowledged as an emerging cause of gastroenteritis worldwide for over two decades. Epidemiologists are revealing the role of EAEC in diarrheal outbreaks as a more common occurrence than ever suggested before. EAEC induced diarrhea is most commonly associated with travelers, children and immunocompromised individuals however its afflictions are not limited to any particular demographic. Many attributes have been discovered and characterized surrounding the capability of EAEC to provoke a potent pro-inflammatory immune response, however cellular and molecular mechanisms underlying initiation, progression and outcomes are largely unknown. This limited understanding can be attributed to heterogeneity in strains and the lack of adequate animal models. This review aims to summarize current knowledge about EAEC etiology, pathogenesis and clinical manifestation. Additionally, current animal models and their limitations will be discussed along with the value of applying systems-wide approaches such as computational modeling to study host-EAEC interactions.
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Affiliation(s)
- Casandra W. Philipson
- Nutritional Immunology and Molecular Medicine Laboratory; Virginia Bioinformatics Institute; Virginia Tech; Blacksburg, VA USA,Center for Modeling Immunity to Enteric Pathogens; Virginia Bioinformatics Institute; Virginia Tech; Blacksburg, VA USA
| | - Josep Bassaganya-Riera
- Nutritional Immunology and Molecular Medicine Laboratory; Virginia Bioinformatics Institute; Virginia Tech; Blacksburg, VA USA,Center for Modeling Immunity to Enteric Pathogens; Virginia Bioinformatics Institute; Virginia Tech; Blacksburg, VA USA,Department of Biomedical Sciences and Pathobiology; VA-MD Regional College of Veterinary Medicine; Virginia Tech; Blacksburg, VA USA
| | - Raquel Hontecillas
- Nutritional Immunology and Molecular Medicine Laboratory; Virginia Bioinformatics Institute; Virginia Tech; Blacksburg, VA USA,Center for Modeling Immunity to Enteric Pathogens; Virginia Bioinformatics Institute; Virginia Tech; Blacksburg, VA USA,Correspondence to: Raquel Hontecillas,
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Harris S, Morris C, Morris D, Cormican M, Cummins E. Simulation model to predict the fate of ciprofloxacin in the environment after wastewater treatment. JOURNAL OF ENVIRONMENTAL SCIENCE AND HEALTH. PART A, TOXIC/HAZARDOUS SUBSTANCES & ENVIRONMENTAL ENGINEERING 2013; 48:675-685. [PMID: 23445411 DOI: 10.1080/10934529.2013.744568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The extent hospital effluent contributes to antimicrobial presence in the environment and its impact on resistance dissemination remains unknown. To investigate the fate of the antimicrobial ciprofloxacin in hospital effluent a Monte Carlo simulation model was developed to model levels from hospital use to wastewater treatment plant (WWTP) effluent release, in addition to modeling resistance formation potential, hazard quotient (HQ) and swimmer exposure. The mean predicted concentration (PC) of ciprofloxacin in hospital effluent, urban effluent, WWTP effluent, sludge, soil and sea water was 579, 6.06, 2.59, 3.48, 0.006 and 0.15 mg/m(3), respectively. A parallel surveillance study confirmed levels of ciprofloxacin above or below the limit of detection. The model predicted levels would never exceed the ECOSAR toxicity value. The model predicted a 98% probability of ciprofloxacin exhibiting a HQ > 1 (low toxicity concern). The mean ciprofloxacin PC in WWTP effluent was less than the minimum inhibitory concentration (MIC). The probability of conditions in WWTP effluent being favorable for resistance at 20% and 80% of the MIC was 3% and 72%, respectively. In all instances, when the MIC was bound, the probability for resistance formation within soil and sea water was < 1%. The probability of a swimmer being exposed to a level of ciprofloxacin greater than the acceptable daily intake was negligible. The study concluded that release of hospital effluent into the environment may lead to concentrations of ciprofloxacin which are of low toxicity concern but may be conducive to resistance formation and allow for the dissemination of resistance.
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Affiliation(s)
- Suvi Harris
- UCD School of Biosystems Engineering, Belfield, Dublin, Ireland
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13
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Tokuda K, Nishi J, Imuta N, Fujiyama R, Kamenosono A, Manago K, Kawano Y. Characterization of typical and atypical enteroaggregative escherichia coli in Kagoshima, Japan: biofilm formation and acid resistance. Microbiol Immunol 2010; 54:320-9. [PMID: 20536730 DOI: 10.1111/j.1348-0421.2010.00210.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
EAEC is increasingly recognized as an emerging enteric pathogen. Typical EAEC expressing the AggR regulon have been proven to be an important cause of childhood diarrhea in industrialized countries as well as in the developing world, while atypical EAEC without this regulon have not been thoroughly investigated. To investigate the bacteriological characteristics of EAEC, including both typical and atypical strains in Kagoshima, Japan, 2417 E. coli strains from Japanese children with diarrhea were screened by a quantitative biofilm assay to detect possible EAEC strains, resulting in the identification of 102 (4.2%) of these strains by the HEp-2 cell adherence test. Virulence gene patterns, PFGE analysis and O-serogrouping demonstrated the heterogeneity of the EAEC. The EAEC strains were classified into two groups: typical EAEC with aggR (74.5%, 76/102) and atypical EAEC without aggR (25.5%, 26/102). There was no significant difference between the typical EAEC strains (median OD(570)= 0.73) and the atypical strains (median OD(570)= 0.61) in biofilm formation (P= 0.17). Incidences of resistance against ampicillin, cefotaxime and tetracycline were significantly higher in the typical EAEC strains than the atypical EAEC strains (84.2% vs. 53.8%, 36.8% vs. 7.7% and 93.4% vs. 73.1%, respectively, P < 0.05). The typical EAEC strains showed significantly higher resistance ratios against HCl and lactate than the atypical strains (94.7% vs. 61.5% and 92.1% vs. 57.7%, respectively, P < 0.001). To investigate the pathogenicity of not only typical but also atypical EAEC, further bacteriological and epidemiologic studies including atypical EAEC are needed.
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Affiliation(s)
- Koichi Tokuda
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan.
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Enteroaggregative Escherichia coli: An Emerging Enteric Food Borne Pathogen. Interdiscip Perspect Infect Dis 2010; 2010:254159. [PMID: 20300577 PMCID: PMC2837894 DOI: 10.1155/2010/254159] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 11/30/2009] [Accepted: 01/21/2010] [Indexed: 01/21/2023] Open
Abstract
Enteroaggregative Escherichia coli (EAEC) are quite heterogeneous category of an emerging enteric pathogen associated with cases of acute or persistent diarrhea worldwide in children and adults, and over the past decade has received increasing attention as a cause of watery diarrhea, which is often persistent. EAEC infection is an important cause of diarrhea in outbreak and non-outbreak settings in developing and developed countries. Recently, EAEC has been implicated in the development of irritable bowel syndrome, but this remains to be confirmed. EAEC is defined as a diarrheal pathogen based on its characteristic aggregative adherence (AA) to HEp-2 cells in culture and its biofilm formation on the intestinal mucosa with a “stacked-brick” adherence phenotype, which is related to the presence of a 60 MDa plasmid (pAA). At the molecular level, strains demonstrating the aggregative phenotype are quite heterogeneous; several virulence factors are detected by polymerase chain reaction; however, none exhibited 100% specificity. Although several studies have identified specific virulence factor(s) unique to EAEC, the mechanism by which EAEC exerts its pathogenesis is, thus, far unknown. The present review updates the current knowledge on the epidemiology, chronic complications, detection, virulence factors, and treatment of EAEC, an emerging enteric food borne pathogen.
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Nitazoxanide inhibits biofilm production and hemagglutination by enteroaggregative Escherichia coli strains by blocking assembly of AafA fimbriae. Antimicrob Agents Chemother 2010; 54:1526-33. [PMID: 20086145 DOI: 10.1128/aac.01279-09] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Enteroaggregative Escherichia coli (EAEC) strains have emerged as common causes of persistent diarrhea and malnutrition among children and HIV-infected persons. During infection, EAEC typically adheres to the intestinal mucosa via fimbrial adhesins, which results in a characteristic aggregative pattern. In the study described here we investigated whether the broad-spectrum antiparasitic and antidiarrheal drug nitazoxanide (NTZ) might be active against EAEC in vitro. While E. coli strains were resistant to NTZ in rich Luria-Bertani medium (MIC > 64 microg/ml), the drug was slightly inhibitory in a minimal medium supplemented with glucose (MinA-G medium; MIC, approximately 32 microg/ml). NTZ also inhibited biofilm production by strain EAEC 042 in both Dulbecco's modified Eagle's medium and MinA-G medium with a 50% inhibitory concentration of approximately 12 microg/ml. Immunofluorescence and immunoblot analyses with antibody against the major fimbrial subunit AafA of aggregative adherence fimbriae vaariant II (AAF/II) established that the numbers of AAF/II filaments on bacteria grown in the presence of NTZ were dramatically reduced. Comparative quantitative reverse transcription-PCR and reporter gene fusions (aafA::phoA) indicated that aafA expression was unaffected by NTZ, while aggR transcript levels and aggR::lacZ expression were increased approximately 10- and 2.5-fold, respectively, compared with that for the untreated controls. More generally, NTZ inhibited hemagglutination (HA) of red blood cells by the non-biofilm-producing strain JM221 expressing either AAF/I or type I fimbriae. Our findings suggest that the inhibitory action of NTZ on biofilm formation and HA is likely due to inhibition of fimbrial assembly. Antimicrobial agents that inhibit the assembly or function of fimbrial filaments should be good candidates for the prevention of infection.
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16
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PCR-based assay using occult blood detection cards for detection of diarrheagenic Escherichia coli in specimens from U.S. travelers to Mexico with acute diarrhea. J Clin Microbiol 2008; 46:2227-30. [PMID: 18480224 DOI: 10.1128/jcm.00073-08] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Large field studies of travelers' diarrhea for multiple destinations are limited by the need to perform stool cultures on site in a timely manner. A method for the collection, transport, and storage of fecal specimens that does not require immediate processing and refrigeration and that is stable for months would be advantageous. This study was designed to determine if enterotoxigenic Escherichia coli (ETEC) and enteroaggregative E. coli (EAEC) DNA could be identified from cards that were processed for the evaluation of fecal occult blood. U.S. students traveling to Mexico during 2005 to 2007 were monitored for the occurrence of diarrheal illness. When ill, students provided a stool specimen for culture and occult blood by the standard methods. Cards then were stored at room temperature prior to DNA extraction. Fecal PCR was performed to identify ETEC and EAEC in DNA extracted from stools and from occult blood cards. Significantly more EAEC cases were identified by PCR that was performed on DNA that was extracted from cards (49%) or from frozen feces (40%) than from culture methods that used HEp-2 adherence assays (13%) (P < 0.001). Similarly, more ETEC cases were detected from card DNA (38%) than from fecal DNA (30%) or by culture that was followed by hybridization (10%) (P < 0.001). The sensitivity and specificity of the card test were 75 and 62%, respectively, compared to those for EAEC by culture and were 50 and 63%, respectively, compared to those for ETEC. DNA extracted from fecal cards that was used for the detection of occult blood is of use in identifying diarrheagenic E. coli.
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17
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New adhesin of enteroaggregative Escherichia coli related to the Afa/Dr/AAF family. Infect Immun 2008; 76:3281-92. [PMID: 18443096 DOI: 10.1128/iai.01646-07] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Enteroaggregative Escherichia coli (EAEC) is an important cause of diarrhea worldwide. We analyzed 17 Danish EAEC strains, isolated in the course of a case control study, for phenotypic and genotypic properties. The strains belonged to at least 14 different serotypes. Using PCR to investigate the prevalence of various putative virulence genes, we found that all but two strains were typical EAEC, as they harbored all or part of the previously described AggR regulon. The majority of the strains harbored genes encoding aggregative adherence fimbriae (AAF). The most common was AAF/I, found in nine strains; eight strains carried no known AAF-related genes. We utilized TnphoA mutagenesis to localize the aggregative adherence (AA) adhesin from one typical EAEC strain, C1010-00, which lacked a known AAF. We identified a TnphoA insertion in a hypothetical Dr-related pilin deposited in GenBank as HdaA. Four additional Danish strains harbored HdaA, and all but one displayed AA to HEp-2 cells. By using PCR primers derived from the pilins and ushers from the three AAF and Hda, we found that 16 of 17 strains exhibited evidence of one of these factors; importantly, the one negative strain also lacked the aggR gene. Cloning of the complete Hda gene cluster and expression in E. coli DH5alpha resulted in AA and complementation of the C1010-00 nonadherent mutant. Four related adhesins have now been found to confer AA in typical EAEC strains; our data suggest that, together, these variants may account for AA in the large majority of strains.
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18
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Ricci KA, Girosi F, Tarr PI, Lim YW, Mason C, Miller M, Hughes J, von Seidlein L, Agosti JM, Guerrant RL. Reducing stunting among children: the potential contribution of diagnostics. Nature 2006. [DOI: 10.1038/nature05444] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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19
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Affiliation(s)
- Deepak Kamat
- Wayne State University, Institute of Medical Education, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Detroit 48201, USA.
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20
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Adachi JA, Barriga J, Ericsson CD. Bacterial gut infections. Curr Opin Infect Dis 2006; 12:459-66. [PMID: 17035812 DOI: 10.1097/00001432-199910000-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Infections of the bowel as a result of bacterial enteropathogens are one of the most common medical problems. The use of novel molecular biology techniques and the recent development of new antimicrobial drugs and vaccines are helping us to identify, understand, treat and prevent these infections.
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Affiliation(s)
- J A Adachi
- Department of Internal Medicine, Division of Infectious Diseases, University of Texas-Houston Medical School, Houston, TX 77030, USA
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21
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Huang DB, Mohanty A, DuPont HL, Okhuysen PC, Chiang T. A review of an emerging enteric pathogen: enteroaggregative Escherichia coli. J Med Microbiol 2006; 55:1303-1311. [PMID: 17005776 DOI: 10.1099/jmm.0.46674-0] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Enteroaggregative Escherichia coli (EAEC) is an increasingly recognized enteric pathogen. It is a cause of both acute and persistent diarrhoea among children, adults and HIV-infected persons, in both developing and developed countries. In challenge studies, EAEC has caused diarrhoeal illness with the ingestion of 1010 c.f.u. Outbreaks of diarrhoeal illness due to EAEC have been reported, and linked to the ingestion of contaminated food. Diarrhoeal illness due to EAEC is the result of a complex pathogen–host interaction. Some infections due to EAEC result in diarrhoeal illness and elicit an inflammatory response, whereas other infections do not result in a symptomatic infection. Many putative virulence genes and EAEC strains that produce biofilm have been identified; however, the clinical significance of these genes and of biofilm production has yet to be defined. A −251 AA single nucleotide polymorphism (SNP) in the interleukin (IL)-8 promoter region is reported to increase host susceptibility to EAEC diarrhoea. Ciprofloxacin and rifaximin continue to be an effective treatment in persons infected with EAEC. This review is intended to provide an updated review for healthcare workers on EAEC, an emerging enteric pathogen.
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Affiliation(s)
- David B Huang
- Infectious Diseases Section, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, 535EE, Houston, TX 77030, USA
| | - Alakananda Mohanty
- University of Texas at Houston School of Public Health, 1200 Herman Pressler - E50, Houston, TX 77030, USA
| | - Herbert L DuPont
- Infectious Diseases Section, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, 535EE, Houston, TX 77030, USA
- University of Texas at Houston Medical School, 6431 Fannin Street, Houston, TX 77030, USA
- University of Texas at Houston School of Public Health, 1200 Herman Pressler - E50, Houston, TX 77030, USA
- St. Luke's Episcopal Hospital, 6720 Bertner Avenue, MC 1-164, Houston, TX 77030, USA
| | - Pablo C Okhuysen
- University of Texas at Houston Medical School, 6431 Fannin Street, Houston, TX 77030, USA
- University of Texas at Houston School of Public Health, 1200 Herman Pressler - E50, Houston, TX 77030, USA
| | - Tom Chiang
- New Jersey Veterans Affairs Medical Center, 385 Tremont Avenue, East Orange, NJ 07018-1023, USA
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22
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Huang DB, Nataro JP, DuPont HL, Kamat PP, Mhatre AD, Okhuysen PC, Chiang T. Enteroaggregative Escherichia coli Is a Cause of Acute Diarrheal Illness: A Meta-Analysis. Clin Infect Dis 2006; 43:556-63. [PMID: 16886146 DOI: 10.1086/505869] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Accepted: 05/10/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Conflicting studies exist regarding the role of enteroaggregative Escherichia coli (EAEC) as a cause of acute diarrheal illness. The objective of this meta-analysis was to determine whether identification of EAEC in stool samples is associated with acute diarrheal illness among different subpopulations, by geographic area. METHODS A comprehensive search of electronic bibliographic databases (Medline and PubMed) from August 1985 to January 2006, as well as a search of conference proceedings, references of articles, and contacts with investigators of EAEC, yielded 354 studies. RESULTS Forty-one studies (12%) that met the selection criteria (i.e., that examined the association between acute diarrheal illness and the excretion of EAEC among different subpopulations) were included. In this meta-analysis, presence of EAEC identified with the HEp-2 cell adherence assay was found to be significantly associated with acute diarrheal illness among children residing in developing regions (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.36-1.83) and industrialized regions (OR, 1.23; 95% CI, 1.03-1.48), adults with human immunodeficiency virus infection residing in developing regions (OR, 6.43; 95% CI, 2.91-14.16), adults residing in developing regions (OR, 7.15; 95% CI, 1.96-26.04), and international travelers to developing regions (OR, 6.72; 95% CI, 2.62-17.20). A limited number of studies were available that examined the role of EAEC identified by its virulence genes by a DNA probe. CONCLUSIONS On the basis of this meta-analysis, we conclude that EAEC is a cause of acute diarrheal illness among many different subpopulations in both developing and industrialized regions, that EAEC strains are very heterogeneous and that additional studies that examine the role of EAEC in acute diarrheal illness are needed.
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Affiliation(s)
- David B Huang
- Division of Infectious Diseases, Baylor College of Medicine, University of Texas at Houston, USA
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23
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Abstract
BACKGROUND With more persons traveling to (sub)tropical destinations, travel medicine is an increasing challenge for the health care system in many countries. This study investigated the role and scope of travel medicine provided by general practitioners (GPs) in primary health care, assessed the determinants of specific prophylactic recommendations, and identified the needs of GPs regarding training and cooperation in travel medicine. METHODS A national survey was conducted among randomly selected GPs in Germany. Information on the type and extent of activities in travel medicine, the number and characteristics of patients, the use of specific information systems, and training and cooperation, was obtained with a standardized postal questionnaire. Representativeness was assessed by a computer-assisted telephone survey among nonrespondents. Univariate and multivariate statistical analysis was performed. RESULTS Of all GPs (n=1,320), 95% provided medical pretravel advice or post-travel counseling (13.2 patients/month). The most common topics in pretravel consultation were immunizations (95%), malaria chemoprophylaxis (94%), advice on exposure prophylaxis (41%), and advice on protection from sexually transmitted infections (STIs) (43%). GPs frequently advised certain patient groups (e.g., cardiovascular patients 68%, pregnant women 20%). Travelers' diarrhea was the most common topic in post-travel consultation (89%), followed by fever (38%). Of the GPs, 25% cooperated regularly with institutions with special expertise in travel medicine or tropical diseases. Sixty-four percent had received some training in travel medicine, and 86% stated a need for additional training. In the multivariate analysis, independent determinants for advice on exposure prophylaxis and STI risks included special training in travel medicine, use of country-specific information sources, and location of the practice in the former West Germany and urban areas. CONCLUSIONS Travel medicine is of importance in primary health care in Germany. There is a need for improved counseling on exposure and STI prophylaxis. GPs' training in travel medicine and cooperation with institutions such as institutes, clinics and laboratories for tropical medicine should be improved.
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Affiliation(s)
- Amy L Pakyz
- Department of Pharmacy, Virginia Commonwealth University, Medical College of Virginia Campus, Smith Building, 410 North 12th St., PO Box 980533, Richmond, VA 23298-0533, USA.
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24
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Ashley DVM, Walters C, Dockery-Brown C, McNab A, Ashley DEC. Interventions to prevent and control food-borne diseases associated with a reduction in traveler's diarrhea in tourists to Jamaica. J Travel Med 2004; 11:364-7. [PMID: 15569573 DOI: 10.2310/7060.2004.19205] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND In 1996 a study found that approximately one in four tourists to Jamaica were affected with traveler's diarrhea (TD) during their stay. That year the Ministry of Health initiated a program for the prevention and control of TD. The aim of this ongoing program was to reduce attack rates of TD from 25% to 12% over a 5-year period by improving the environmental health and food safety standards of hotels. METHODS Hotel-based surveillance procedures for TD were implemented in sentinel hotels in Negril and Montego Bay in 1996, Ocho Rios in 1997, and Kingston in 1999. A structured program provided training and technical assistance to nurses, food and beverage staff, and environmental sanitation personnel in the implementation of Hazard Analysis Critical Control Point principles for monitoring food safety standards. The impact of interventions on TD was assessed in a survey of tourists departing from the international airport in Montego Bay in 1997-1998 and from the international airport in Kingston in 1999-2000. The impact of the training and technical assistance program on food safety standards and practices was assessed in hotels in Ocho Rios as of 1998 and in Kingston from 1999. RESULTS At the end of May 2002, TD incidence rates were 72% lower than in 1996, when the Ministry of Health initiated its program for the prevention and control of TD. Both hotel surveillance data and airport surveillance data suggest that the vast majority of travelers to Kingston and southern regions are not afflicted with TD during their stay. The training and technical assistance program improved compliance to food safety standards over time. CONCLUSION Interventions to prevent and control TD in visitors to Jamaica are positively associated with a reduction in TD in the visitor population and improvements in food safety standards and practices in hotels.
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Abstract
Enteroaggregative Escherichia coli (EAEC) is an emerging pathogen that causes enteric and food-borne infectious diseases. Children throughout the world appear to be susceptible to EAEC infection. EAEC pathogenesis involves the following three stages: 1) adherence to the intestinal mucosa; 2) increased production and deposition of a mucus biofilm; and 3) mucosal toxicity due to inflammation and cytokine release. The HEp-2 cell adherent assay allows identification of EAECs characteristic aggregative or "stacked brick" adherence pattern. Antimicrobial treatment of children who develop an EAEC infection should be individually based. All children with EAEC diarrhea should receive adequate oral fluid hydration. For children who have persistent diarrhea and severe dehydrating illness despite having received adequate oral rehydration, antimicrobials may be initiated. Azithromycin and rifaximin have been shown to shorten the course of EAEC diarrhea in adults and probably represent the recommended antimicrobials of choice for children with severe or persistent illness. The objective of this review is to increase awareness of this important emerging pathogen and to discuss the epidemiology, pathogenesis, and pathogen and host factors associated with EAEC infection in children.
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Affiliation(s)
- David B Huang
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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26
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Huang DB, Koo H, DuPont HL. Enteroaggregative Escherichia coli: An Emerging Pathogen. Curr Infect Dis Rep 2004; 6:83-86. [PMID: 15023269 DOI: 10.1007/s11908-996-0001-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- David B. Huang
- St. Luke's Episcopal Hospital, 6720 Bertner Avenue, MC 1-164, Houston, TX 77030, USA.
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27
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Abstract
Enteroaggregative Escherichia coli (EAEC) represents an emerging pathogen that causes enteric and food-borne infectious diseases. Subgroups in many populations throughout the world are susceptible to EAEC infection. EAEC pathogenesis involves adherence to the intestinal mucosa; increased production and deposition of a mucus biofilm; and mucosal toxicity due to inflammation and cytokine release. Due to the heterogeneity of EAEC strains and differing host immune responses, not all EAEC infections are symptomatic. Recent data suggest that individuals with a homozygous genotype -251 AA single nucleotide polymorphism (SNP), in the IL-8 promoter region, are more susceptible to EAEC diarrhea. The HEp-2 cell adherent assay allows identification of EAEC's characteristic aggregative or "stacked brick" adherence pattern. Antimicrobial treatment of individuals who develop EAEC diarrhea should be individually based. Ciprofloxacin and rifaximin, compared to placebo, have been shown to significantly shorten the course of diarrhea in patients who developed EAEC infection. The objective of this review is to increase awareness of this important emerging pathogen and to discuss the epidemiology, pathogenesis, and host-pathogen factors associated with EAEC infection.
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Affiliation(s)
- David B Huang
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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28
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Infante RM, Ericsson CD, Jiang ZD, Ke S, Steffen R, Riopel L, Sack DA, DuPont HL. Enteroaggregative Escherichia coli diarrhea in travelers: response to rifaximin therapy. Clin Gastroenterol Hepatol 2004; 2:135-8. [PMID: 15017618 DOI: 10.1016/s1542-3565(03)00322-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS We have recently shown that enteroaggregative Escherichia coli (EAEC) strains commonly cause travelers' diarrhea. The study was designed to determine whether U.S. travelers with EAEC diarrhea responded to rifaximin therapy. METHODS In a multicenter placebo-controlled clinical trial of travelers' diarrhea without non-EAEC pathogens we evaluated 2 doses of rifaximin. EAEC was sought in stool samples in enrolled subjects by HEp-2 cell assay. Response to rifaximin (both groups combined) and placebo were evaluated in EAEC-positive and EAEC-negative patient groups. RESULTS Compared with placebo, rifaximin shortened the postenrollment illness in travelers with EAEC diarrhea (median, 22 vs. 72 hours; P = 0.03). In subjects with EAEC-negative diarrhea, the median duration of post-treatment diarrhea was shorter with rifaximin (33 hours) than with placebo (52 hours), but this difference was not significantly different (P = 0.14). CONCLUSIONS Improvement of EAEC-mediated diarrhea with antibiotic treatment supports the pathogenicity of this organism in travelers to developing countries. The study provides information on the value of the poorly absorbed drug rifaximin in therapy of travelers' diarrhea.
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Affiliation(s)
- Rosa M Infante
- Center for Infectious Diseases, The University of Texas-Houston School of Public Health and Medical School, Houston, Texas, USA
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29
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Miqdady MS, Jiang ZD, Nataro JP, DuPont HL. Detection of enteroaggregative Escherichia coli with formalin-preserved HEp-2 cells. J Clin Microbiol 2002; 40:3066-7. [PMID: 12149382 PMCID: PMC120651 DOI: 10.1128/jcm.40.8.3066-3067.2002] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Formalin-stored HEp-2 cells were used to assay Escherichia coli for adherence. Cells refrigerated in formalin for up to 28 days and used in a wet assay format demonstrated an assay sensitivity ranging from 94 to 98% to detect enteroaggregative E. coli (EAEC). HEp-2 cells first fixed and stored with formalin and then stored dry in ambient conditions for 6 weeks demonstrated an assay sensitivity of 92% to detect EAEC. Using formalin-fixed HEp-2 cells will improve the efficiency of EAEC identification.
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30
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Abstract
Diarrhea is one of the most common health problems among travelers. Although enterotoxigenic Escherichia coli is implicated most commonly, enteroaggregative E. coli has recently been described as a major pathogen. Shigella, Campylobacter, and Salmonella organisms are less common causes of acute diarrhea, and intestinal protozoa are typical causes of protracted diarrhea. Although education is the mainstay of prevention measures, behavior modification has been shown to be difficult. Chemoprevention is rarely required with the availability of effective treatment, but there has been some interest in the use of vaccines. Maintenance of hydration is most important in children. In addition to bismuth preparations and loperamide, newer agents being developed for symptomatic relief include zaldaride maleate and racecadotril. Fluoroquinolones effectively treat severe traveler's diarrhea, and even a single dose may be sufficient. However, with the emergence of resistance, particularly in Campylobacter infection, other agents are required; interest has focused on azithromycin and rifaximin.
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Affiliation(s)
- Allen C. Cheng
- Room 0376, Orange Zone, Box 3152, Duke South, Division of Infectious Diseases, Duke University Medical Center, Durham, NC 27710, USA.
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31
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Affiliation(s)
- F Castelli
- Institute of Infectious and Tropical Diseases, Post-Graduate School of Tropical Medicine, University of Brescia, Brescia, Italy
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32
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Abstract
Enteroaggregative Escherichia coli (EAEC) are an increasingly important cause of diarrhoea. E. coli belonging to this category cause watery diarrhoea, which is often persistent and can be inflammatory. EAEC have been implicated in sporadic diarrhoea in children and adults, in both developing and developed countries, and have been identified as the cause of several outbreaks worldwide. EAEC are defined by their ability to adhere to epithelial cells in a characteristic "stacked-brick" pattern but are otherwise highly heterogeneous. Genes that could contribute to the pathogenicity of EAEC encode adhesins, toxins, and other factors, all of which are only partially conserved. Practicable tools are needed to improve diagnosis and identify risk factors. EAEC-infected individuals can be treated with fluoroquinolones but there is a need to examine alternative treatment protocols.
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Affiliation(s)
- I N Okeke
- Department of Biomedical Sciences, University of Bradford, West Yorkshire, UK.
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Abstract
Traveller's diarrhoea is the most common illness acquired by visitors to developing countries, affecting 20-50% of the 35 million people who travel from industrialized countries each year. Important risk factors include point of origin and destination of the traveller, host factors, and exposure to contaminated food and water. The most common causes of traveller's diarrhoea in adults in developing countries include infection with Escherichia coli, Shigella spp., Salmonella spp., Campylobacter spp., Vibrio parahaemolyticus (in Asia), rotavirus (in Latin America), and protozoa (Giardia, Cryptosporidium and Cyclospora spp., and Entamoeba histolytica). No pathogen is identified in over half of patients with traveller's diarrhoea, however. The primary objectives of treatment of traveller's diarrhoea are to reduce the symptoms and duration of diarrhoeal illness, to reduce inconvenience caused by such illness and to prevent cancellation of planned activities. These important objectives are best accomplished by empirical self-therapy with a combination of antimicrobial agents and loperamide. Since the first use of ciprofloxacin, fluoroquinolones have become the drugs of choice in empirical therapy for moderate-to-severe traveller's diarrhoea in adults. The options for children include nalidixic acid, trimethoprim-sulfamethoxazole (along with erythromycin if Campylobacter infection is a possibility) and furazolidone. Education on hygiene and safe food preparation help to prevent many diarrhoeal diseases, including traveller's diarrhoea.
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Affiliation(s)
- A A Lima
- Institute of Biomedicine, Clinical Research Unit--University Hospital, Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
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34
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Abstract
This article presents a review of causes, presentation, and diagnosis of traveler's diarrhea. Treatment and prevention of this common problem is described in some detail. Finally, a practical and cost-effective approach to evaluating and treating a returning traveler is presented.
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Affiliation(s)
- N N Ramzan
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Medical School, Scottsdale, Arizona, USA
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Adachi JA, Jiang ZD, Mathewson JJ, Verenkar MP, Thompson S, Martinez-Sandoval F, Steffen R, Ericsson CD, DuPont HL. EnteroaggregativeEscherichia colias a Major Etiologic Agent in Traveler's Diarrhea in 3 Regions of the World. Clin Infect Dis 2001; 32:1706-9. [PMID: 11360211 DOI: 10.1086/320756] [Citation(s) in RCA: 165] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2000] [Revised: 10/31/2000] [Indexed: 11/03/2022] Open
Abstract
Enteroaggregative Escherichia coli (EAEC) has been reported to cause traveler's diarrhea and persistent diarrhea in children in developing countries and in immunocompromised patients. To clarify the prevalence of EAEC in traveler's diarrhea, we studied 636 US, Canadian, or European travelers with diarrhea: 218 in Guadalajara, Mexico (June--August 1997 and 1998), 125 in Ocho Rios, Jamaica (September 1997--May 1998), and 293 in Goa, India (January 1997--April 1997 and October 1997--February 1998). Stool samples were tested for conventional enteropathogens. EAEC strains were identified by use of the HEp-2 assay. EAEC was isolated in 26% of cases of traveler's diarrhea (ranging from 19% in Goa to 33% in Guadalajara) and was second only to enterotoxigenic E. coli as the most common enteropathogen in all areas. Identification of EAEC reduced the number of cases for which the pathogen was unknown from 327 (51%) to 237 (37%) and explained 28% of cases with unknown etiology. EAEC was a major cause of traveler's diarrhea in 3 geographically distinct study areas.
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Affiliation(s)
- J A Adachi
- Center for Infectious Diseases, University of Texas-Houston Medical School and School of Public Health, Houston, TX, USA
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36
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Gomi H, Jiang ZD, Adachi JA, Ashley D, Lowe B, Verenkar MP, Steffen R, DuPont HL. In vitro antimicrobial susceptibility testing of bacterial enteropathogens causing traveler's diarrhea in four geographic regions. Antimicrob Agents Chemother 2001; 45:212-6. [PMID: 11120968 PMCID: PMC90263 DOI: 10.1128/aac.45.1.212-216.2001] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The emergence of resistant enteropathogens has been reported worldwide. Few data are available on the contemporary in vitro activities of commonly used antimicrobial agents against enteropathogens causing traveler's diarrhea (TD). The susceptibility patterns of antimicrobial agents currently available or under evaluation against pathogens causing TD in four different areas of the world were evaluated. Pathogens were identified in stool samples from U.S., Canadian, or European adults (18 years of age or older) with TD during 1997, visiting India, Mexico, Jamaica, or Kenya. MICs of 11different antimicrobials were determined against 284 bacterial enteropathogens by the agar dilution method. Ciprofloxacin, levofloxacin, ceftriaxone, and azithromycin were highly active in vitro against the enteropathogens, while traditional antimicrobials such as ampicillin, trimethoprim, and trimethoprim/sulfamethoxazole showed high levels and high frequencies of resistance. Rifaximin, a promising and poorly absorbable drug, had an MIC at which 90% of the strains tested were inhibited of 32 microg/ml, 250 times lower than the concentration of this drug in the stools. Amdinocillin, nalidixic acid, and doxycycline showed moderate activity. Fluoroquinolones are still the drugs of choice for TD in most regions of the world, although our study has a limitation due to the lack of Escherichia coli samples from Kenya and possible bias in selection of the patients for evaluation. Azithromycin and rifaximin should be considered as promising new agents. The widespread in vitro resistance of the traditional antimicrobial agents reported since the 1980s and the new finding of resistance to fluoroquinolones in Southeast Asia are the main reasons for monitoring carefully the antimicrobial susceptibility patterns worldwide and for developing and evaluating new antimicrobial agents for the treatment of TD.
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Affiliation(s)
- H Gomi
- Center for Infectious Diseases, University of Texas-Houston Medical School and School of Public Health, Houston, Texas, USA
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37
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Adachi JA, Ostrosky-Zeichner L, DuPont HL, Ericsson CD. Empirical antimicrobial therapy for traveler's diarrhea. Clin Infect Dis 2000; 31:1079-83. [PMID: 11049792 DOI: 10.1086/318119] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2000] [Indexed: 11/03/2022] Open
Abstract
Over 7 million cases of traveler's diarrhea, defined as the passage of > or = 3 unformed stools in a 24-h period, occur each year among visitors to developing countries. Bacterial enteric pathogens are the most common etiologic agents isolated. Preliminary clinical results for patients with diarrhea predominantly caused by Campylobacter species have shown that azithromycin may be an effective alternative to fluoroquinolones for the treatment of traveler's diarrhea.
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Affiliation(s)
- J A Adachi
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas-Houston Medical School, Houston, TX 77030, USA
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Sutjita M, Bouckenooghe AR, Adachi JA, Jiang ZD, Mathewson JJ, Ericsson CD, DuPont HL. Intestinal secretory immunoglobulin A response to enteroaggregative Escherichia coli in travelers with diarrhea. CLINICAL AND DIAGNOSTIC LABORATORY IMMUNOLOGY 2000; 7:501-3. [PMID: 10799468 PMCID: PMC95901 DOI: 10.1128/cdli.7.3.501-503.2000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We examined stool samples from travelers for secretory immunoglobulin A (sIgA) to enteroaggregative Escherichia coli (EAEC) during episodes of acute diarrhea. Ten paired samples from 10 patients with diarrhea caused by EAEC were examined for the presence of specific sIgA by dot blot and Western blot immunoassays. Five samples were positive by dot blotting, and two samples were positive by Western blotting.
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Affiliation(s)
- M Sutjita
- Morehouse School of Medicine, Atlanta, GA, USA
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