Sensitivities and specificities of premier E. coli O157 and premier EHEC enzyme immunoassays for diagnosis of infection with verotxin (Shiga-like toxin)-producing Escherichia coli. The SYNSORB Pk Study investigators

Low cost and real-time surveillance of enteric infection and diarrhoeal disease using rapid diagnostic tests in Cox's Bazar, Bangladesh

BACKGROUND

Real-time disease surveillance is an important component of infection control in at-risk populations. However, data on cases or from lab testing is often not available in many low-resource settings. Rapid diagnostic tests (RDT), including immunochromatographic assays, may provide a low cost, expedited source of infection data.

METHODS

We conducted a pilot survey-based prevalence mapping study of enteric infection in Camp 24 of the camps for the forcibly displaced Rohingya population from Myanmar in Cox's Bazar, Bangladesh. We randomly sampled the population and collected and tested stool from under-fives for eight pathogens using RDTs in January-March 2021 and September-October 2021. A Bayesian geospatial statistical model allowing for imperfect sensitivity and specificity of the tests was adapted.

RESULTS

We collected and tested 396 and 181 stools in the two data collection rounds. Corrected prevalence estimates ranged from 0.5% (Norovirus) to 27.4% (Giardia). Prevalence of Escherichia coli O157, Campylobacter, and Cryptosporidium were predicted to be higher in the high density area of the camp with relatively high probability (70-95%), while Adenovirus, Norovirus, and Rotavirus were lower in the areas with high water chlorination. Clustering of cases of Giardia and Shigella was also observed, although associated with relatively high uncertainty.

CONCLUSIONS

With an appropriate correction for diagnostic performance RDTs can be used to generate reliable prevalence estimates, maps, and well-calibrated uncertainty estimates at a significantly lower cost than lab-based studies, providing a useful approach for disease surveillance in these settings.

Advances in endotoxin analysis

The outer membrane of gram-negative bacteria is primarily composed of lipopolysaccharide (LPS). In addition to protection, LPS defines the distinct serogroups used to identify bacteria specifically. Furthermore, LPS also act as highly potent stimulators of innate immune cells, a phenomenon essential to understanding pathogen invasion in the body. The complex multi-step process of LPS binding to cells involves several binding partners, including LPS binding protein (LBP), CD14 in both membrane-bound and soluble forms, membrane protein MD-2, and toll-like receptor 4 (TLR4). Once these pathways are activated, pro-inflammatory cytokines are eventually expressed. These binding events are also affected by the presence of monomeric or aggregated LPS. Traditional techniques to detect LPS include the rabbit pyrogen test, the monocyte activation test and Limulus-based tests. Modern approaches are based on protein, antibodies or aptamer binding. Recently, novel techniques including electrochemical methods, HPLC, quartz crystal microbalance (QCM), and molecular imprinting have been developed. These approaches often use nanomaterials such as gold nanoparticles, quantum dots, nanotubes, and magnetic nanoparticles. This chapter reviews current developments in endotoxin detection with a focus on modern novel techniques that use various sensing components, ranging from natural biomolecules to synthetic materials. Highly integrated and miniaturized commercial endotoxin detection devices offer a variety of options as the scientific and technologic revolution proceeds.

Evaluation of immunochromatography test for detection of four enteropathogens in the feces of sheep and goats in Kuwait

Background:

Diarrhea in newborn small ruminants continues to be the cause of significant financial loss in sheep and goat farms worldwide. Commercial immunochromatographic (IC) assays have been designed and evaluated to be used for the diagnosis of diarrhea in cattle; however, there are no trials to use rapid tests in small ruminants.

Aim:

This study was carried out in Kuwait to evaluate the performance of the rapid immunochromatography test (BoviD-4, BioNote, Inc, Korea) for diagnostics of Cryptosporidium, rotavirus A (RVA), bovine coronavirus (BCoV), and Escherichia coli K99 (E. coli K99) in fecal samples of sheep and goats.

Methods:

A total of 85 samples were examined using BoviD-4, and the results were compared with that of polymerase chain reaction for Cryptosporidium, RVA, and BCoV, whereas for E. coli K99 it was by isolation and identification as reference tests.

Results:

The kappa test agreement results between the BoviD-4 and reference tests were 0.870 (perfect), 0.783 (substantial), 0.728 (substantial), and 0.281 (fair) for the detection of E. coli K99, Cryptosporidium, RVA, and BCoV, respectively. The sensitivity of BoviD-4 kit was 91.2%, 80.0%, 90.0%, and 37.5% and the specificity was 88.2%, 96.0%, 96.4%, and 92.2% for Cryptosporidium, RVA, E. coli K99, and BCoV, respectively.

Conclusion:

The Bovid-4 kit can be used as a rapid pen-side test for Cryptosporidium spp., E. coli K99, and RVA in the field. Nonetheless, care must be taken while interpreting the BCoV results of the kit.

Interventions for preventing diarrhoea-associated haemolytic uraemic syndrome

BACKGROUND

Haemolytic uraemic syndrome (HUS) is a common cause of acquired kidney failure in children and rarely in adults. The most important risk factor for development of HUS is a gastrointestinal infection by Shiga toxin-producing Escherichia coli (STEC). This review addressed the interventions aimed at secondary prevention of HUS in patients with diarrhoea who were infected with a bacteria that increase the risk of HUS.

OBJECTIVES

Our objective was to evaluate evidence regarding secondary preventative strategies for HUS associated with STEC infections. In doing so, we sought to assess the effectiveness and safety of interventions as well as their potential to impact the morbidity and death associated with this condition.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 12 November 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Studies were considered based on the methods, participants, and research goals. Only randomised controlled trials were considered eligible for inclusion. The participants of the studies were paediatric and adult patients with diarrhoeal illnesses due to STEC. The primary outcome of interest was incidence of HUS.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as recommended by Cochrane. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We identified four studies (536 participants) for inclusion that investigated four different interventions including antibiotics (trimethoprim-sulfamethoxazole), anti-Shiga toxin antibody-containing bovine colostrum, Shiga toxin binding agent (Synsorb Pk: a silicon dioxide-based agent), and a monoclonal antibody against Shiga toxin (urtoxazumab). The overall risk of bias was unclear for selection, performance and detection bias and low for attrition, reporting and other sources of bias. It was uncertain if trimethoprim-sulfamethoxazole reduced the incidence of HUS compared to no treatment (47 participants: RR 0.57, 95% CI 0.11-2.81, very low certainty evidence). Adverse events relative to this review, need for acute dialysis, neurological complication and death were not reported. There were no incidences of HUS in either the bovine colostrum group or the placebo group. It was uncertain if bovine colostrum caused more adverse events (27 participants: RR 0.92, 95% CI 0.42 to 2.03; very low certainty evidence). The need for acute dialysis, neurological complications or death were not reported. It is uncertain whether Synsorb Pk reduces the incidence of HUS compared to placebo (353 participants: RR 0.93, 95% CI 0.39 to 2.22; very low certainty evidence). Adverse events relevant to this review, need for acute dialysis, neurological complications or death were not reported. One study compared two doses of urtoxazumab (3.0 mg/kg and 1.0 mg/kg) to placebo. It is uncertain if either 3.0 mg/kg urtoxazumab (71 participants: RR 0.34, 95% CI 0.01 to 8.14) or 1.0 mg/kg urtoxazumab (74 participants: RR 0.95, 95% CI 0.79 to 1.13) reduced the incidence of HUS compared to placebo (very low certainty evidence). Low certainty evidence showed there may be little or no difference in the number of treatment-emergent adverse events with either 3.0 mg/kg urtoxazumab (71 participants: RR 1.00, 95% CI 0.84 to 1.18) or 1.0 mg/kg urtoxazumab (74 participants: RR 0.95, 95% CI 0.79 to 1.13) compared to placebo. There were 25 serious adverse events reported in 18 patients: 10 in the placebo group, and 9 and 6 serious adverse events in the 1.0 mg/kg and 3.0 mg/kg urtoxazumab groups, respectively. It is unclear how many patients experienced these adverse events in each group, and how many patients experienced more than one event. It is uncertain if either dose of urtoxazumab increased the risk of neurological complications or death (very low certainty evidence). Need for acute dialysis was not reported.

AUTHORS' CONCLUSIONS

The included studies assessed antibiotics, bovine milk, and Shiga toxin inhibitor (Synsorb Pk) and monoclonal antibodies (Urtoxazumab) against Shiga toxin for secondary prevention of HUS in patients with diarrhoea due to STEC. However, no firm conclusions about the efficacy of these interventions can be drawn given the small number of included studies and the small sample sizes of those included studies. Additional studies, including larger multicentre studies, are needed to assess the efficacy of interventions to prevent development of HUS in patients with diarrhoea due to STEC infection.

Infectious diseases

The measurement of biochemical parameters such as blood glucose, blood gases, electrolytes and cardiac markers have particularly benefited from recent advances in POCT. More and more, this form of analysis is now positively impacting the field of infectious diseases. Many microbiological POCT systems tend to be designed as rapid tests. In general, such tests can be carried out in a few simple steps by medical assistants or physicians without laboratory equipment or laboratory experience. It is even possible for the patients themselves to perform a series of such tests.

Diarrheagenic Escherichia coli

Most Escherichia coli strains live harmlessly in the intestines and rarely cause disease in healthy individuals. Nonetheless, a number of pathogenic strains can cause diarrhea or extraintestinal diseases both in healthy and immunocompromised individuals. Diarrheal illnesses are a severe public health problem and a major cause of morbidity and mortality in infants and young children, especially in developing countries. E. coli strains that cause diarrhea have evolved by acquiring, through horizontal gene transfer, a particular set of characteristics that have successfully persisted in the host. According to the group of virulence determinants acquired, specific combinations were formed determining the currently known E. coli pathotypes, which are collectively known as diarrheagenic E. coli. In this review, we have gathered information on current definitions, serotypes, lineages, virulence mechanisms, epidemiology, and diagnosis of the major diarrheagenic E. coli pathotypes.

Postinfectious Hemolytic Uremic Syndrome

Post-infectious hemolytic uremic syndrome (HUS) is caused by specific pathogens in patients with no identifiable HUS-associated genetic mutation or autoantibody. The majority of episodes is due to infections by Shiga toxin (Stx) producing Escherichia coli (STEC). This chapter reviews the epidemiology and pathogenesis of STEC-HUS, including bacterial-derived factors and host responses. STEC disease is characterized by hematological (microangiopathic hemolytic anemia), renal (acute kidney injury) and extrarenal organ involvement. Clinicians should always strive for an etiological diagnosis through the microbiological or molecular identification of Stx-producing bacteria and Stx or, if negative, serological assays. Treatment of STEC-HUS is supportive; more investigations are needed to evaluate the efficacy of putative preventive and therapeutic measures, such as non-phage-inducing antibiotics, volume expansion and anti-complement agents. The outcome of STEC-HUS is generally favorable, but chronic kidney disease, permanent extrarenal, mainly cerebral complication and death (in less than 5 %) occur and long-term follow-up is recommended. The remainder of this chapter highlights rarer forms of (post-infectious) HUS due to S. dysenteriae, S. pneumoniae, influenza A and HIV and discusses potential interactions between these pathogens and the complement system.

Quantitative Detection of Shiga Toxins Directly from Stool Specimens of Patients Associated with an Outbreak of Enterohemorrhagic Escherichia coli in Japan--Quantitative Shiga toxin detection from stool during EHEC outbreak

Detection of Shiga toxins (Stx) is important for accurate diagnosis of Enterohemorrhagic Escherichia coli infection. In this study, we quantitatively analyzed Stx protein in nine patients’ stool during an outbreak that occurred in Japan. Highly sensitive immunoassay (bead enzyme-linked immunosorbent assay (bead-ELISA)) revealed that the concentrations of toxins in stool of patients ranged from 0.71 to 10.44 ng/mL for Stx1 and 2.75 to 51.61 ng/mL for Stx2. To our knowledge, this is the first report that reveals the range of Stx protein concentrations in human stools.

Salmonella, Shigella, and yersinia

Salmonella, Shigella, and Yersinia cause a well-characterized spectrum of disease in humans, ranging from asymptomatic carriage to hemorrhagic colitis and fatal typhoidal fever. These pathogens are responsible for millions of cases of food-borne illness in the United States each year, with substantial costs measured in hospitalizations and lost productivity. In the developing world, illness caused by these pathogens is not only more prevalent but also associated with a greater case-fatality rate. Classic methods for identification rely on selective media and serology, but newer methods based on mass spectrometry and polymerase chain reaction show great promise for routine clinical testing.

Occurrence of potentially human-pathogenic Escherichia coli O103 in Norwegian sheep

The investigation of an outbreak of hemorrhagic-uremic syndrome in Norway in 2006 indicated that the outbreak strain Escherichia coli O103:H25 could originate from sheep. A national survey of the Norwegian sheep population was performed, with the aim of identifying and describing a possible reservoir of potentially human-pathogenic E. coli O103, in particular of the H types 2 and 25. The investigation of fecal samples from 585 sheep flocks resulted in 1,222 E. coli O103 isolates that were analyzed for the presence of eae and stx genes, while a subset of 369 isolates was further examined for flagellar antigens (H typing), stx subtypes, bfpA, astA, and molecular typing by pulsed-field gel electrophoresis (PFGE). The total ovine E. coli O103 serogroup was genetically diverse by numbers of H types, virulotypes, and PFGE banding patterns identified, although a tendency of clustering toward serotypes was seen. The flocks positive for potentially human-pathogenic E. coli O103 were geographically widely distributed, and no association could be found with county or geographical region. The survey showed that eae-negative, stx-negative E. coli O103, probably nonpathogenic to humans, is very common in sheep, with 27.5% of flocks positive. Moreover, the study documented a low prevalence (0.7%) of potentially human-pathogenic Shiga toxin-producing E. coli O103:H2, while STEC O103:H25 was not detected. However, 3.1% and 5.8% of the flocks were positive for enteropathogenic E. coli O103 belonging to H types 2 and 25, respectively. These isolates are of concern as potential human pathogens by themselves but more importantly as possible precursors for human-pathogenic STEC.

[Enterohemorragic Escherichia coli (EHEC): topical enterobacteriaceae]

Since the 1980s, EnterohaemorrhagicEscherichia coli (EHEC) have been recognised as emergent pathogens causing foodborne outbreaks. The latest one is the E. coli O104:H4 outbreak which occurred in Germany in May 2011 then in France. In France, the surveillance of EHEC infections is based on surveillance of hemolytic-uremic syndrome (HUS) in children under 15 years old. The average annual incidence is 0.8/100,000 children under 15 years old with a predominance of the O157:H7 serotype. EHEC are one of the six clinical pathovars of E. coli defined by their capacity to produce Shiga-toxins and for that reason, are part of a larger group called: Shigatoxin-producingE. coli (STEC). EHEC are a cause of different troubles ranging from mild diarrhea to haemorrhagic colitis which might be complicated by HUS in young children and thrombocytopenic thrombotic purpura in adults. The reservoir of EHEC is mainly the intestinal tract of ruminants: EHEC are transmitted via ingestion of contaminated food or water, person-to-person contact, direct animal contact and exposure to the environment. The diagnosis of the EHEC infections relies on isolation of STEC in stool samples or detection of genes encoding for Shiga-toxins. Treatment is mainly symptomatic. Use of antibiotics is controversial because the risk of HUS could be increased (release of toxins).

The highly virulent 2006 Norwegian EHEC O103:H25 outbreak strain is related to the 2011 German O104:H4 outbreak strain

In 2006, a severe foodborne EHEC outbreak occured in Norway. Seventeen cases were recorded and the HUS frequency was 60%. The causative strain, Esherichia coli O103:H25, is considered to be particularly virulent. Sequencing of the outbreak strain revealed resemblance to the 2011 German outbreak strain E. coli O104:H4, both in genome and Shiga toxin 2-encoding (Stx2) phage sequence. The nucleotide identity between the Stx2 phages from the Norwegian and German outbreak strains was 90%. During the 2006 outbreak, stx₂-positive O103:H25 E. coli was isolated from two patients. All the other outbreak associated isolates, including all food isolates, were stx-negative, and carried a different phage replacing the Stx2 phage. This phage was of similar size to the Stx2 phage, but had a distinctive early phage region and no stx gene. The sequence of the early region of this phage was not retrieved from the bacterial host genome, and the origin of the phage is unknown. The contaminated food most likely contained a mixture of E. coli O103:H25 cells with either one of the phages.

Shiga toxin-producing Escherichia coli in children: diagnosis and clinical manifestations of O157:H7 and non-O157:H7 infection

Shiga toxin-producing Escherichia coli (STEC), a cause of food-borne colitis and hemolytic-uremic syndrome in children, can be serotype O157:H7 (O157) or other serotypes (non-O157). E. coli O157 can be detected by culture with sorbitol-MacConkey agar (SMAC), but non-O157 STEC cannot be detected with this medium. Both O157 and non-O157 STEC can be detected by immunoassay for Shiga toxins 1 and 2. The objectives of this study were first to compare the diagnostic utility of SMAC to that of the Premier EHEC enzyme immunoassay (Meridian Diagnostics) for detection of STEC in children and second to compare the clinical and laboratory characteristics of children with serotype O157:H7 STEC and non-O157:H7 STEC infections. Stool samples submitted for testing for STEC between April 2004 and September 2009 were tested by both SMAC culture and the Premier EHEC assay at Children's Hospital Boston. Samples positive by either test were sent for confirmatory testing and serotyping at the Hinton State Laboratory Institute (HSLI). Chart review was performed on children with confirmed STEC infection. Of 5,110 children tested for STEC, 50 (0.9%) had STEC infection confirmed by culture; 33 were O157:H7 and 17 were non-O157:H7. The Premier EHEC assay and SMAC culture detected 96.0% and 58.0% of culture-confirmed STEC isolates (any serotype), respectively, and 93.9% and 87.9% of STEC O157:H7 isolates, respectively. There were no significant differences in disease severity or laboratory manifestations of STEC infection between children with O157:H7 and those with non-O157 STEC. The Premier EHEC assay was significantly more sensitive than SMAC culture for diagnosis of STEC, and O157:H7 and non-O157:H7 STEC caused infections of similar severity in children.

Evaluation of three commercially available enzyme-linked immunosorbent assay kits for detection of Shiga toxin

Three commercially available Shiga toxin (Stx) enzyme-linked immunosorbent assay (ELISA) kits were evaluated for their ability to detect Stx in pure cultures of Stx-producing Escherichia coli (specificity). The detection limits (sensitivity) of each ELISA kit were also evaluated. Seventy-eight Stx-producing E. coli (STEC) isolates that produced Stx1, Stx2, or Stx1 and Stx2 variants were examined in this study. The specificities of the tests were comparable, and the sensitivities of two of the tests (Premier EHEC and rBiopharm Ridascreen Verotoxin Enzyme Immunoassay) were within the same order of magnitude. The ProSpecT Shiga Toxin E. coli Microplate Assay was approximately 10-fold less sensitive. The inability of all three tests to detect the Stx2d and Stx2e variants indicated that some STEC strains may not be detected by Stx ELISA. The ability of the Premier EHEC ELISA to detect toxin in artificially inoculated bovine fecal samples (following enrichment) indicated that this kit may be used to screen cattle for the presence of Stx as an indicator of the presence of STEC. In particular, such a screening method could be useful during the summer, when the number of STEC-positive animals and the number of STEC that they shed increase.

Production and characterization of rabbit polyclonal sera against Shiga toxins Stx1 and Stx2 for detection of Shiga toxin-producing Escherichia coli

STEC has emerged as an important group of enteric pathogens worldwide. In this study, rabbit polyclonal Stx1 and Stx2 antisera were raised and employed in the standardization of immunoassays for STEC detection. Using their respective antisera, the limit of detection of the toxin was 35.0 pg for Stx1 and 5.4 pg for Stx2. By immunoblotting, these antisera recognized both toxin subunits. Cross-reactivity was observed in the A subunit, but only Stx2 antiserum was able to neutralize the cytotoxicity of both toxins in the Vero cell assay. Six stx-harboring E. coli isolates were analyzed for their virulence traits. They belonged to different serotypes, including the O48:H7, described for the first time in Brazil. Only three strains harbored eae, and the e-hly gene and hemolytic activity was detected in five strains. Three isolates showed new stx2 variants (stx(2v-ha) and stx(2vb-hb)). The ELISA assay detected all six isolates, including one VCA-negative isolate, while the immunodot assay failed to detect one isolate, which was VCA-positive. In contrast, the colony-immunoblot assay detected only one VCA-positive isolate. Our results demonstrate that among the immunoassays developed in this study, the immunodot, and particularly the ELISA, appear as perspective for STEC detection in developing countries.

Outbreak of haemolytic uraemic syndrome in Norway caused by stx2-positive Escherichia coli O103:H25 traced to cured mutton sausages

BACKGROUND

On 20-21 February 2006, six cases of diarrhoea-associated haemolytic uraemic syndrome (HUS) were reported by paediatricians to the Norwegian Institute of Public Health. We initiated an investigation to identify the etiologic agent and determine the source of the outbreak in order to implement control measures.

METHODS

A case was defined as a child with diarrhoea-associated HUS or any person with an infection with the outbreak strain of E. coli O103 (defined by the multi-locus variable number tandem repeats analysis (MLVA) profile) both with illness onset after January 1st 2006 in Norway. After initial hypotheses-generating interviews, we performed a case-control study with the first fifteen cases and three controls for each case matched by age, sex and municipality. Suspected food items were sampled, and any E. coli O103 strains were typed by MLVA.

RESULTS

Between 20 February and 6 April 2006, 17 cases were identified, of which 10 children developed HUS, including one fatal case. After pilot interviews, a matched case-control study was performed indicating an association between a traditional cured sausage (odds ratio 19.4 (95% CI: 2.4-156)) and STEC infection. E. coli O103:H25 identical to the outbreak strain defined by MLVA profile was found in the product and traced back to contaminated mutton.

CONCLUSION

We report an outbreak caused by a rare STEC variant (O103:H25, stx2-positive). More than half of the diagnosed patients developed HUS, indicating that the causative organism is particularly virulent. Small ruminants continue to be important reservoirs for human-pathogen STEC. Improved slaughtering hygiene and good manufacturing practices for cured sausage products are needed to minimise the possibility of STEC surviving through the entire sausage production process.

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.

Detection of enterohaemorrhagic Escherichia coli in patients attending hospital in Melbourne, Australia

AIMS

The objectives of this study were (i) to determine the prevalence of enterohaemorrhagic Escherichia coli (EHEC) in adults and children with diarrhoea attending hospital in Melbourne, and (ii) to evaluate diagnostic assays for the detection of EHEC.

METHODS

EHEC were sought in 860 faecal samples (655 from children) using direct plating, a cytotoxicity assay and an enzyme immunoassay for Shiga toxin (Stx), and PCR for virulence-associated genes of EHEC.

RESULTS

EHEC were isolated from 14 of 858 (1.6%) faecal samples (excluding repeat isolates from one patient). Isolation rates in children (1.7%) and adults (1.5%) were similar. EHEC was detected 2.5 times more frequently in samples that contained blood, but this was not statistically significant. EHEC isolates were heterogeneous in terms of serotype and virulence profile, although all produced EHEC haemolysin. Of the screening assays used, direct plating on EHEC agar, assays for Stx in MacConkey broth inoculated with faeces, and detection of the genes for Stx and EHEC haemolysin were highly sensitive and specific.

CONCLUSIONS

EHEC are an infrequent cause of diarrhoea in Melbourne. EHEC can readily be isolated from faeces by screening enrichment broth cultures for Stx using PCR or enzyme immunoassay, followed by isolation of the bacteria on EHEC agar.

Serotypes, virulence genes, and intimin types of Shiga toxin (verotoxin)-producing Escherichia coli isolates from human patients: prevalence in Lugo, Spain, from 1992 through 1999

We have analyzed the prevalence of Shiga toxin-producing Escherichia coli (STEC) in stool specimens of patients with diarrhea or other gastrointestinal alterations from the Xeral-Calde Hospital of Lugo City (Spain). STEC strains were detected in 126 (2.5%) of 5,054 cases investigated, with a progressive increase in the incidence from 0% in 1992 to 4.4% in 1999. STEC O157:H7 was isolated in 24 cases (0.5%), whereas non-O157 STEC strains were isolated from 87 patients (1.7%). STEC strains were (after Salmonella and Campylobacter strains) the third most frequently recovered enteropathogenic bacteria. A total of 126 human STEC isolates were characterized in this study. PCR showed that 43 (34%) isolates carried stx(1) genes, 45 (36%) possessed stx(2) genes and 38 (30%) carried both stx(1) and stx(2). A total of 88 (70%) isolates carried an ehxA enterohemolysin gene, and 70 (56%) isolates possessed an eae intimin gene (27 isolates with type gamma1, 20 with type beta1, 8 with type zeta, 5 with type gamma2, and 3 with type epsilon). STEC isolates belonged to 41 O serogroups and 66 O:H serotypes, including 21 serotypes associated with hemolytic uremic syndrome and 30 new serotypes not previously reported among human STEC strains in other studies. Although the 126 STEC isolates belonged to 81 different seropathotypes (associations between serotypes and virulence genes), only four accounted for 31% of isolates. Seropathotype O157:H7 stx(1) stx(2) eae-gamma1 ehxA was the most common (13 isolates) followed by O157:H7 stx(2) eae-gamma1 ehxA (11 isolates), O26:H11 stx(1) eae-beta1 ehxA (11 isolates), and O111:H- stx(1) stx(2) eae-gamma2 ehxA (4 isolates). Our results suggest that STEC strains are a significant cause of human infections in Spain and confirm that in continental Europe, infections caused by STEC non-O157 strains are more common than those caused by O157:H7 isolates. The high prevalence of STEC strains (both O157:H7 and non-O157 strains) in human patients, and their association with serious complications, strongly supports the utilization of protocols for detection of all serotypes of STEC in Spanish clinical microbiology laboratories.

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.

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.

Evaluation of the VTEC-Screen "Seiken" test for detection of different types of Shiga toxin (verotoxin)-producing Escherichia coli (STEC) in human stool samples

An immunoassay for in vitro detection of Shiga (Vero) toxins Stx1 and Stx2 (VTEC-Screen "Seiken") was compared with the verocell toxicity test (VCA) and an stx-gene specific PCR for detection of Shiga toxin-producing E. coli (STEC) from 234 human stool samples selectively enriched on sorbitol-MacConkey (SMAC) agar. Culturable STEC were isolated from 59 (25.2%) of the 234 stool specimens and were found to be distributed over 20 different O-serogroups. Fifty-three (89.8%) of the 59 STEC-positive samples were identified with the VTEC-Screen compared to 55 (93.2%) with the PCR and 58 (98.3%) with the VCA. A possible false positive reaction with the VTEC-Screen was obtained with one sample and five samples showed aspecific reactions with both the test- and the control latex. The VTEC-Screen detected all samples which contained Stx1 producing strains (77.9% of STEC-positive samples) but was negative with six samples (10.2%) which contained Stx2 and/or Stx2 variant producers, although secondary enrichment of on brain-heart infusion agar detected three of these to improve the detection rate to 94.9%. Examination of reference strains encoding different genotypes of stx(1) and stx(2) indicated that certain variants of Stx2 reacted poorly (Stx2d-Ount, Stx2e and Stx2ev) or not at all with the VTEC-Screen. Overall, however, the test was found to be accurate, rapid and easy to perform, thus being suitable for the routine screening of clinical stool specimens for STEC.

Hemolytic-Uremic Syndrome and Escherichia coli O121 at a Lake in Connecticut, 1999

OBJECTIVE

Non-O157 Shiga toxin-producing Escherichia coli (STEC) have emerged as an important public health problem. Outbreaks attributed to non-O157 STEC rarely are reported. In 1999, follow-up of routine surveillance reports of children with hemolytic- uremic syndrome (HUS) identified a small cluster of 3 cases of HUS, all of whom had spent overlapping time in a Connecticut lake community in the week before onset of symptoms. We conducted an investigation to determine the magnitude and source of the outbreak and to determine risk factors associated with the transmission of illness.

METHODS

We conducted a cohort study and an environmental investigation. The study population included all people who were at the lake in a defined geographic area during July 16-25, 1999. This time and area were chosen on the basis of interviews with the 3 HUS case-patients. A case was defined as diarrhea (>/=3 loose stools/d for >/=3 days) in a person who was at the lake during July 16-25, 1999. Stool samples were requested from any lake resident with diarrheal illness. Stools were cultured for Salmonella, Shigella, Campylobacter, and E coli O157. Broth cultures of stools were tested for Shiga toxin. Case-patients were asked to submit a serum specimen for antibody testing to lipopolysaccharides of selected STEC. Environmental samples from sediment, drinking water, lake water, and ice were obtained and cultured for E coli and tested for Shiga toxin. An environmental evaluation of the lake was conducted to identify any septic, water supply system, or other environmental condition that could be related to the outbreak.

RESULTS

Information was obtained for 436 people from 165 (78%) households. Eleven (2.5%) people had illnesses that met the case definition, including the 3 children with HUS. The attack rate was highest among those who were younger than 10 years and who swam in the lake on July 17 or 18 (12%; relative risk [RR]: 7.3). Illness was associated with swimming (RR = 8.3) and with swallowing water while swimming (RR = 7.0) on these days. No person who swam only after July 18 developed illness. Clinical characteristics of case-patients included fever (27%), bloody diarrhea (27%), and severe abdominal cramping (73%). Only the 3 children with HUS required hospitalization. No bacterial pathogen was isolated from the stool of any case-patient. Among lake residents outside the study area, E coli O121:H19 was obtained from a Shiga toxin-producing isolate from a toddler who swam in the lake. Serum was obtained from 7 of 11 case-patients. Six of 7 case-patients had E coli O121 antibody titers that ranged from 1:320 to >1:20 480. E coli indicative of fecal contamination was identified from sediment and water samples taken from a storm drain that emptied into the beach area and from a stream bed located between 2 houses, but no Shiga toxin-producing strain was identified.

CONCLUSIONS

Our findings are consistent with a transient local beach contamination in mid-July, probably with E coli O121:H19, which seems to be able to cause severe illness. Without HUS surveillance, this outbreak may have gone undetected by public health officials. This outbreak might have been detected sooner if Shiga toxin screening had been conducted routinely in HUS cases. Laboratory testing that relies solely on the inability of an isolate to ferment sorbitol will miss non-O157 STEC, such as E coli O121. Serologic testing can be used as an adjunct in the diagnosis of STEC infections. Lake-specific recommendations included education, frequent water sampling, and alternative means for toddlers to use lake facilities.

Evaluation of a reversed passive latex agglutination test for the detection of Verocytotoxin (VT) expressed by strains of VT-producing Escherichia coli

AIMS

To compare an experimental Reversed-Passive Latex Agglutination (RPLA) with Vero cells for the detection of Verocytotoxin expressed by VT-producing strains of Escherichia coli (VTEC).

METHODS AND RESULTS

The RPLA was used alongside a Vero cell tissue culture assay for the detection of VT in bacterial culture supernatant fluids and patients' faecal extracts.

CONCLUSION

The RPLA was comparable with the Vero cell assay, although slightly less sensitive.

SIGNIFICANCE AND IMPACT OF THE STUDY

The RPLA test proved to be a simple, rapid and convenient method of detecting VT in bacterial culture supernatant fluids and in the faeces of patients infected with VTEC.

Development of a monoclonal sandwich ELISA for the detection of animal and human Escherichia coli O157 strains

AIMS

Production of a monoclonal antibody (MAb) to Escherichia coli O157 to develop a rapid test using a sandwich ELISA (sELISA) format.

METHODS AND RESULTS

A MAb (7A6) was developed to the long-chain lipopolysaccharide of E. coli O157. A sELISA developed with the MAb reacted with 28 bovine and seven human enterohaemorrhagic E. coli (EHEC) O157 strains and also with two enterotoxigenic E. coli O157 strains. Cross-reaction to a rabbit diarrhoeal E.coli O15, Citrobacter freundii, Salmonella urbana and Vibrio cholerae O1 Inaba was detected.

CONCLUSION

A MAb-based sELISA to detect E. coli O157 was produced. Its application to field samples is required to fully determine its prospective use for the detection of EHEC O157, to evaluate the non-specific interference of the cross-reacting strains.

SIGNIFICANCE AND IMPACT OF THE STUDY

The assay produced is not wholly specific to EHEC O157, but has the potential to be used as a rapid method for screening large numbers of samples for E. coli O157.

Solid-phase capture of proteins, spores, and bacteria

Current methods for the detection of pathogens in food and water samples generally require a preenrichment step that allows selective enrichment of the test organism. The objective of this research was to eliminate an enrichment step to allow detection of bacteria directly in food and water samples in 30 min. A high-flow-rate, fluidized bed to capture and concentrate large (bacteria and spores) and small (protein) molecules was developed. This format, ImmunoFlow, is volume independent and uses large beads (greater than 3 mm in diameter) when capturing bacteria to prevent sample clogging when testing food samples. Detection of bound targets was done using existing enzyme-linked immunosorbent assay (ELISA) protocols. Four antibodies (anti-Escherichia coli O157:H7, -Bacillus globigii, -bovine serum albumin [BSA], and -ovalbumin [OVA]) were covalently coupled to various glass and ceramic beads. Very small amounts of BSA (<1 ng) and OVA (0.2 to 4.0 microg) were detected. Various industrial and environmental samples were used to observe the effect of the sample composition on the capture of anti-B. globigii and anti-E. coli O157:H7 modified beads. The lower limit of detection for both E. coli O157:H7 and B. globigii was 1 spore/cell independent of the sample size. The activity of anti-B. globigii modified beads declined after 3 days. Anti-E. coli O157:H7 modified beads declined in their capture ability after 2 days in various storage buffers. Storage temperature (4 and 25 degrees C) did not influence the stability. The ImmunoFlow technology is capable of capturing bacteria and spores directly from samples, with subsequent detection in an ELISA format in 30 min.

Etiology of bloody diarrhea among patients presenting to United States emergency departments: prevalence of Escherichia coli O157:H7 and other enteropathogens

Escherichia coli O157:H7 and other Shiga toxin-producing E. coli (STEC) infections have been associated with bloody diarrhea. The prevalence of enteropathogens among patients with bloody diarrhea was determined by a prospective study at 11 US emergency departments. Eligible patients had bloody stools, > or =3 loose stool samples per 24-h period, and an illness lasting <7 days. Among 873 patients with 877 episodes of bloody diarrhea, stool samples for culture were obtained in 549 episodes (62.6%). Stool cultures were more frequently ordered for patients with fever, >10 stools/day, and visibly bloody stools than for patients without these findings. Enteropathogens were identified in 168 episodes (30.6%): Shigella (15.3%), Campylobacter (6.2%), Salmonella (5.8%), STEC (2.6%), and other (1.6%). Enteropathogens were isolated during 12.5% of episodes that physicians thought were due to a noninfectious cause. The prevalence of STEC infection varied by site from 0% to 6.2%. Hospital admissions resulted from 195 episodes (23.4%). These data support recommendations that stool samples be cultured for patients with acute bloody diarrhea.

4-Aminopyrazolo[3,4-d]pyrimidine (4-APP) as a novel inhibitor of the RNA and DNA depurination induced by Shiga toxin 1

Shiga toxin 1 (Stx1) catalyses the removal of a unique and specific adenine from 28S RNA in ribosomes (RNA-N-glycosidase activity) and the release of multiple adenines from DNA (DNA glycosylase activity). Added adenine behaves as an uncompetitive inhibitor of the RNA-N-glycosidase reaction binding more tightly to the Stx1-ribosome complex than to the free enzyme. Several purine derivatives and analogues have now been assayed as inhibitors of Stx1. Most of the compounds showed only minor differences in the rank order of activity on the two enzymatic reactions catalysed by Stx1. The survey highlights the importance of the amino group in the 6-position of the pyrimidine ring of adenine. Shifting (2-aminopurine) or substituting (hypoxanthine, 6-mercapto-purine, 6-methylpurine) the group greatly decreases the inhibitory power. The presence of a second ring, besides the pyrimidine one, is strictly required. Substitution, by introducing an additional nitrogen, of the imidazole ring of adenine with triazole leads to loss of inhibitory power, while rearrangement of the nitrogen atoms of the ring from the imidazole to the pyrazole configuration greatly enhances the inhibitory power. Thus 4-aminopyrazolo[3,4-d]pyrimidine (4-APP), the isomer of adenine with the five-membered ring in the pyrazole configuration, is by far the most potent inhibitor of both enzymatic reactions catalysed by Stx1. This finding opens perspectives on therapeutic strategies to protect endothelial renal cells once endocytosis of Stx1 has occurred (haemolytic uraemic syndrome). In the RNA-N-glycosidase reaction 4-APP binds, as adenine, predominantly to the Stx1-ribosome complex (uncompetitive inhibition), while inhibition of the DNA glycosylase activity by both inhibitors is of the mixed type.

Performance of the ImmunoCard STAT! E. coli O157:H7 test for detection of Escherichia coli O157:H7 in stools

ImmunoCard STAT! E. coli O157:H7 (Meridian Diagnostics, Inc., Cincinnati, Ohio) is a novel rapid (10-min) test for the presence of Escherichia coli O157:H7 in stools. The test may be performed either directly on stool specimens or on an overnight broth culture of stool. In a multicenter prospective study, 14 of 14 specimens positive by culture for E. coli O157:H7 were positive by the ImmunoCard STAT! O157:H7 test, and there were no false positives from 263 culture-negative specimens. In a retrospective study, the test was positive in 339 (81%) of 417 stored culture-positive specimens and the specificity was 95% (98 of 103 specimens). No false positives were associated with alternate stool pathogens. The ImmunoCard STAT! O157:H7 test has high sensitivity and specificity.

Epidemiology and diagnosis of Shiga toxin-producing Escherichia coli infections

Shiga toxin-producing Escherichia coli (STEC) have been identified as a worldwide cause of serious human gastrointestinal disease and the life-threatening hemolytic uremic syndrome. The most common serotype implicated is E. coli O157: H7, but infections involving various non-O157 serotypes have been found with increasing frequency in many countries. Food-borne outbreaks caused by STEC can affect large numbers of people and cause serious morbidity, making the bacteria one of the most important emerging pathogens. Because there is no specific treatment of the disease currently available, there is an urgent need for effective preventive measures based on a detailed understanding of the epidemiology of STEC infections. Such measures will also be dependent on the availability of rapid, sensitive, and simple procedures for the detection of the pathogens both in human samples and in samples of nonhuman origin such as food. This review summarizes the current knowledge on the epidemiology of STEC infection and presents a survey of laboratory methods currently available for diagnosis of STEC. Special attention is given to new diagnostic procedures for the less readily detectable non-O157 STEC strains and to simple procedures, usually based on commercially available kits, that can be used in routine clinical microbiological laboratories.

Pathogenesis, treatment, and therapeutic trials in hemolytic uremic syndrome

Diarrhea-associated hemolytic uremic syndrome is one of the most common causes of acute renal failure in childhood. Nearly all cases are the result of an antecedent infection by Shiga toxin--producing strains of Escherichia coli, especially the O157:H7 serotype. Most cases occur after ingestion of contaminated meat; however, new food sources such as leaf lettuce, alfalfa sprouts, and goat's milk have been identified, and diarrhea-associated hemolytic uremic syndrome can occur after exposure to contaminated water in recreational swimming sites. Diarrhea-associated hemolytic uremic syndrome is a systemic disease with activation of a variety of inflammatory cytokines. Kidney injury may result from direct effects of the Shiga toxin on renal tubular epithelial cells as well as endothelial cells. Early diagnosis of diarrhea-associated hemolytic uremic syndrome may be expedited by the introduction of new techniques to rapidly detect toxin and microorganism in stool samples. Optimal therapy of diarrhea-associated hemolytic uremic syndrome includes intensive management of the renal failure and serious extrarenal complications that may occur during the course of disease. The role of antibiotics in prevention and amelioration of diarrhea-associated hemolytic uremic syndrome remains controversial. Experimental therapies that are undergoing evaluation in clinical trials include SYNSORB Pk (SYNSORB Biotech, Inc., Calgary, Alberta, Canada), a drug designed to bind Shiga toxin in the lumen of gastrointestinal tract. Immunization strategies are also being developed and tested. It is hoped that with continued progress in this field the incidence of diarrhea-associated hemolytic uremic syndrome in children will be substantially reduced in the coming years.

Application of multiplex PCR for detection of non-O157 verocytotoxin-producing Escherichia coli in bloody stools: identification of serogroups O26 and O111

Primers were designed to amplify sequences of verocytotoxin genes and eaeA genes of Escherichia coli O26:H11, O111:H8, and O157:H7 in a multiplex PCR assay. This assay successfully detected E. coli O26:H11 in bloody stool specimens in which other enteric pathogens were not detected by culture-based methods. Rapid assays to detect non-O157:H7 verocytotoxin-producing E. coli is important to improve methods for the etiologic diagnosis of hemorrhagic colitis.