1
|
Stambolliu E, Giannou P, Nomikou E, Aggelis G, Petras D. Two cases of typical HUS in adults treated with an anti-C5 monoclonal antibody: a new perspective? J Nephrol 2024:10.1007/s40620-024-02034-2. [PMID: 39073701 DOI: 10.1007/s40620-024-02034-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 07/10/2024] [Indexed: 07/30/2024]
Abstract
Hemolytic uremic syndrome (HUS) is a rare clinical entity, especially in adults. In its typical form the causative factor that triggers the cascade of immunologic and inflammatory events is a Shiga toxin-producing pathogen, found in the patient's stool. Renal and neurologic involvement usually prevails and requires immediate care. Regarding this potentially life-threatening condition, little is known and the mainstay is supportive care. However, some interesting evidence has come up about the use of eculizumab, an anti-C5 monoclonal antibody, mainly in pediatric patients with typical HUS. Herein, we present two cases with typical HUS caused by two different strains of Escherichia coli (Shiga toxin-producing enterohemorrhagic and enteropathogenic) who were both treated effectively with anti-C5 monoclonal antibodies (eculizumab and ravulizumab).
Collapse
Affiliation(s)
- Emelina Stambolliu
- Nephrology Department, Hippokration General Hospital, Vasilissis Sofias 108, 11527, Athens, Greece.
| | - Panagiota Giannou
- Nephrology Department, Hippokration General Hospital, Vasilissis Sofias 108, 11527, Athens, Greece
| | - Efrossyni Nomikou
- Blood Bank and Haemophilia Unit, Hippokration General Hospital, Athens, Greece
| | - George Aggelis
- Nephrology Department, Hippokration General Hospital, Vasilissis Sofias 108, 11527, Athens, Greece
| | - Dimitrios Petras
- Nephrology Department, Hippokration General Hospital, Vasilissis Sofias 108, 11527, Athens, Greece
| |
Collapse
|
2
|
de Zwart PL, Mueller TF, Spartà G, Luyckx VA. Eculizumab in Shiga toxin-producing Escherichia coli hemolytic uremic syndrome: a systematic review. Pediatr Nephrol 2024; 39:1369-1385. [PMID: 38057431 PMCID: PMC10943142 DOI: 10.1007/s00467-023-06216-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/24/2023] [Accepted: 10/24/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Infection-associated hemolytic uremic syndrome (IA-HUS), most often due to infection with Shiga toxin-producing bacteria, mainly affects young children. It can be acutely life-threatening, as well as cause long-term kidney and neurological morbidity. Specific treatment with proven efficacy is lacking. Since activation of the alternative complement pathway occurs in HUS, the monoclonal C5 antibody eculizumab is often used off-label once complications, e.g., seizures, occur. Eculizumab is prohibitively expensive and carries risk of infection. Its utility in IA-HUS has not been systematically studied. This systematic review aims to present, summarize, and evaluate all currently available data regarding the effect of eculizumab administration on medium- to long-term outcomes (i.e., outcomes after the acute phase, with a permanent character) in IA-HUS. METHODS PubMed, Embase, and Web of Science were systematically searched for studies reporting the impact of eculizumab on medium- to long-term outcomes in IA-HUS. The final search occurred on March 2, 2022. Studies providing original data regarding medium- to long-term outcomes in at least 5 patients with IA-HUS, treated with at least one dose of eculizumab during the acute illness, were included. No other restrictions were imposed regarding patient population. Studies were excluded if data overlapped substantially with other studies, or if outcomes of IA-HUS patients were not reported separately. Study quality was assessed using the ROBINS-I tool for risk of bias in non-randomized studies of interventions. Data were analyzed descriptively. RESULTS A total of 2944 studies were identified. Of these, 14 studies including 386 eculizumab-treated patients met inclusion criteria. All studies were observational. Shiga toxin-producing E. coli (STEC) was identified as the infectious agent in 381 of 386 patients (98.7%), effectively limiting the interpretation of the data to STEC-HUS patients. Pooling of data across studies was not possible. No study reported a statistically significant positive effect of eculizumab on any medium- to long-term outcome. Most studies were, however, subject to critical risk of bias due to confounding, as more severely ill patients received eculizumab. Three studies attempted to control for confounding through patient matching, although residual bias persisted due to matching limitations. DISCUSSION Current observational evidence does not permit any conclusion regarding the impact of eculizumab in IA-HUS given critical risk of bias. Results of randomized clinical trials are eagerly awaited, as new therapeutic strategies are urgently needed to prevent long-term morbidity in these severely ill patients. SYSTEMATIC REVIEW REGISTRATION NUMBER OSF Registries, MSZY4, Registration DOI https://doi.org/10.17605/OSF.IO/MSZY4 .
Collapse
Affiliation(s)
- Paul L de Zwart
- Department of Nephrology, University Children's Hospital Zurich, Zurich, Switzerland.
| | - Thomas F Mueller
- Clinic of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Giuseppina Spartà
- Department of Nephrology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Valerie A Luyckx
- Department of Nephrology, University Children's Hospital Zurich, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute, Department of Public and Global Health, University of Zurich, Zurich, Switzerland
- Brigham and Women's Hospital, Renal Division, Harvard Medical School, Boston, MA, USA
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
3
|
Ortiz Y, Heredia N, García S. Boundaries That Prevent or May Lead Animals to be Reservoirs of Escherichia coli O104:H4. J Food Prot 2023; 86:100053. [PMID: 36916560 DOI: 10.1016/j.jfp.2023.100053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/18/2023] [Accepted: 01/21/2023] [Indexed: 02/05/2023]
Abstract
Escherichia coli O104:H4, a hybrid serotype carrying virulence factors from enteroaggregative (EAEC) and Shiga toxin-producing (STEC) pathotypes, is the reported cause of a multicountry outbreak in 2011. Evaluation of potential routes of human contamination revealed that this strain is a foodborne pathogen. In contrast to STEC strains, whose main reservoir is cattle, serotype O104:H4 has not been commonly isolated from animals or related environments, suggesting an inability to naturally colonize the gut in hosts other than humans. However, contrary to this view, this strain has been shown to colonize the intestines of experimental animals in infectious studies. In this minireview, we provide a systematic summary of reports highlighting potential evolutionary changes that could facilitate the colonization of new reservoirs by these bacteria.
Collapse
Affiliation(s)
- Yaraymi Ortiz
- Departamento de Microbiología e Inmunología, Facultad de Ciencias Biológicas, Universidad Autónoma de Nuevo León, Ciudad Universitaria, San Nicolás de los Garza, NL 66455, Mexico
| | - Norma Heredia
- Departamento de Microbiología e Inmunología, Facultad de Ciencias Biológicas, Universidad Autónoma de Nuevo León, Ciudad Universitaria, San Nicolás de los Garza, NL 66455, Mexico
| | - Santos García
- Departamento de Microbiología e Inmunología, Facultad de Ciencias Biológicas, Universidad Autónoma de Nuevo León, Ciudad Universitaria, San Nicolás de los Garza, NL 66455, Mexico.
| |
Collapse
|
4
|
Fründt T, Leuffert J, Groth S, Rösch T, Steurer S, Lohse AW, Ullrich S, Lüth S. Low incidence of colonic complications after severe Shiga toxin-producing E. coli O104:H4 infection. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 60:1104-1110. [PMID: 34820797 DOI: 10.1055/a-1545-5322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND In summer 2011, Shiga toxin producing Escherichia coli (EHEC) serotype O104:H4 caused the most severe EHEC outbreak in Germany to date. The case of a previously recovered patient with symptomatic postinflammatory colonic stenosis following EHEC- infection prompted us to conduct a prospective study to assess the macro- and microscopic intestinal long-term damage in a cohort of patients who had suffered from severe EHEC colitis. METHODS Following EHEC infection in 2011, 182 patients were offered to participate in this study between January 2013 and October 2014 as part of the post-inpatient follow-up care at the University Medical Center Hamburg-Eppendorf and to undergo colonoscopy with stepwise biopsies. Prior to colonoscopy, medical history and persistent post-infectious complaints were assessed. RESULTS Out of 182 patients, 22 (12%) participated in the study, 18 (82%) were female. All patients had been hospitalized due severe EHEC enterocolitis: 20 patients (90%) had subsequently developed hemolytic uremic syndrome (HUS), 16 patients (72%) had additionally required dialysis. On assessment prior to colonoscopy, all patients denied any abdominal complaints before EHEC-infection but 8 (36%) patients reported persistent post-infectious symptoms. According to the ROME IV criteria, 4 (18%) patients met the definition for post-infectious irritable bowel syndrome (PI-IBS). In all patients with persistent symptoms, colonoscopies and histological examination were unremarkable. Only in one symptom-free patient, biopsy revealed a locally limited cryptitis of the caecum, while all patients without complaints had inconspicuous histological and endoscopical findings. CONCLUSION Following infection colonic stenosis is a serious but rare long-term complication in patients who had suffered from severe enterocolitis. However, a significant proportion of these patients develop PI-IBS.
Collapse
Affiliation(s)
- Thorben Fründt
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Leuffert
- Department of Anatomy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Thomas Rösch
- Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Steurer
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian Ullrich
- Department of Gastroenterology, Städtisches Krankenhaus Kiel, Kiel, Germany
| | - Stefan Lüth
- Zentrum für Innere Medizin II, Städtisches Klinikum Brandenburg GmbH, Brandenburg an der Havel, Germany
| |
Collapse
|
5
|
Victoria VM, Rocío C, Silvina E, Inés EA, Lía PN. Biofilm formation by LEE-negative Shiga Toxin-Producing Escherichia coli strains. Microb Pathog 2021; 157:105006. [PMID: 34044049 DOI: 10.1016/j.micpath.2021.105006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 11/27/2022]
Abstract
Shiga toxin-producing Escherichia coli (STEC) include several serotypes isolated from cases of hemorrhagic colitis and, hemolytic uremic syndrome. Although O157:H7 is the most predominant STEC serotype, more than 100 non-O157 serogroups cause diseases in humans. Some STEC carry a Locus of Enterocyte Effacement (LEE-positive); however, STEC that do not carry LEE (LEE-negative) have also been associated with illness, mainly those harbouring the Locus of Adhesion and Autoaggregation (LAA). LAA carry some genes such as hes, iha, tpsA, and agn43, related with pathogenicity. One of them is the ability to form biofilms on different environments, which can contaminate food and generate infections while protecting themselves against adverse conditions. Considering that LAA could be responsible for some adherence mechanisms, the aims of this study were to compare different serogroup of LEE-negative STEC strains in their ability to form biofilms and to evaluate the participation of some genes encoding in LAA. A total of 348 LEE-negative STEC strains was analyzed. The presence of hes, iha, tpsA and agn43 were determined by monoplex PCR. From them, 48 STEC strains belonging to serogroups O113, O130, O171, O174 and, O178 were assayed for their ability to form biofilm. The most prevalent genes detected were agn43 (72.1%) and tpsA (69.5%). The iha and hes genes were present in 63.7% and 54% of the strains, respectively. Although all STEC strains were able to form biofilm, it was found a high variability between them. The relation between the biofilm formation and the presence of each gene was not statistically significant, suggesting that biofilm formation is independent of the presence of those genes. Highlighting that there is no treatment for HUS, it is once again notable that prevention measures and control strategies to prevent biofilm formation are important factors in reducing STEC transmission.
Collapse
Affiliation(s)
- Vélez María Victoria
- Laboratorio de Inmunoquímica y Biotecnología. Centro de Investigación Veterinaria Tandil CONICET- CICPBA, Facultad de Ciencias Veterinarias, UNCPBA CIVETAN. (7000) Tandil, Buenos Aires, Argentina
| | - Colello Rocío
- Laboratorio de Inmunoquímica y Biotecnología. Centro de Investigación Veterinaria Tandil CONICET- CICPBA, Facultad de Ciencias Veterinarias, UNCPBA CIVETAN. (7000) Tandil, Buenos Aires, Argentina.
| | - Etcheverría Silvina
- Cátedra Estadística, Econometría y Modelización. Tandil, Facultad de Ciencias Económicas, UNCPBA. (7000) Tandil, Buenos Aires, Argentina
| | - Etcheverría Analía Inés
- Laboratorio de Inmunoquímica y Biotecnología. Centro de Investigación Veterinaria Tandil CONICET- CICPBA, Facultad de Ciencias Veterinarias, UNCPBA CIVETAN. (7000) Tandil, Buenos Aires, Argentina
| | - Padola Nora Lía
- Laboratorio de Inmunoquímica y Biotecnología. Centro de Investigación Veterinaria Tandil CONICET- CICPBA, Facultad de Ciencias Veterinarias, UNCPBA CIVETAN. (7000) Tandil, Buenos Aires, Argentina
| |
Collapse
|
6
|
Adler A, Katz DE, Marchaim D. The Continuing Plague of Extended-Spectrum β-Lactamase Producing Enterbacterales Infections: An Update. Infect Dis Clin North Am 2020; 34:677-708. [PMID: 33011052 DOI: 10.1016/j.idc.2020.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Antimicrobial resistance is a common iatrogenic complication of modern life and medical care. One of the most demonstrative examples is the exponential increase in the incidence of extended-spectrum β-lactamases (ESBLs) production among Enterobacteriaceae, that is, the most common human pathogens outside of the hospital setting. Infections resulting from ESBL-producing bacteria are associated with devastating outcomes, now affecting even previously healthy individuals. This poses an enormous burden and threat to public health. This article aims to narrate the evolving epidemiology of ESBL infections and highlights current challenges in terms of management and prevention of these common infections.
Collapse
Affiliation(s)
- Amos Adler
- Clinical Microbiology Laboratory, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 6423906 Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David E Katz
- Division of Internal Medicine, Shaare Zedek Medical Center, 12 Shmuel Bait Street, Jerusalem 9103102, Israel
| | - Dror Marchaim
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Unit of Infection Control, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.
| |
Collapse
|
7
|
Dammermann W, Mihajlov V, Middendorf B, Mellmann A, Karch H, Lüth S, Ullrich S. Anti-Shiga toxin 2 antibodies in enterohemorrhagic Escherichia coli O104:H4 infected patients may predict hemolytic uremic syndrome. J Gastroenterol Hepatol 2018; 33:1353-1356. [PMID: 29280264 DOI: 10.1111/jgh.14082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 11/21/2017] [Accepted: 12/19/2017] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM An outbreak of Shiga toxin 2 (Stx2) producing enterohemorrhagic and enteroaggregative Escherichia coli O104:H4 infection in May 2011 in Germany caused enterocolitis and an unprecedented high 22% rate of hemolytic uremic syndrome (HUS). We hypothesized that anti-Stx2 IgM or IgG titers might predict HUS development. METHODS Thirty-two patients infected with enterohemorrhagic Escherichia coli O104:H4 (HUS: n = 23; non-HUS: n = 9) were retrospectively screened for anti-Stx2 IgM/IgG and matched with clinical data regarding HUS development, fever, superinfection, dialysis, neurological symptoms, intensive care, antibiotic treatment, and plasmapheresis. RESULTS Only HUS patients showed a prominent Stx2-specific humoral response in the early acute phase. Despite a strong trend towards prediction of HUS development, statistical analysis revealed no significant correlation between high IgM/IgG titers and further key clinical parameters such as fever, superinfection, neurological symptoms, antibiotic treatment, and plasmapheresis. CONCLUSIONS Anti-Stx2 antibodies seem to accompany or even precede HUS development.
Collapse
Affiliation(s)
- Werner Dammermann
- Center of Internal Medicine II, University Hospital Brandenburg, Brandenburg Medical School, Brandenburg, Germany.,Department of Anatomy and Experimental Morphology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Valentin Mihajlov
- Department of Anatomy and Experimental Morphology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Barbara Middendorf
- Institute of Hygiene and National Consulting Laboratory for Hemolytic Uremic Syndrome (HUS), University Hospital Münster, Münster, Germany
| | - Alexander Mellmann
- Institute of Hygiene and National Consulting Laboratory for Hemolytic Uremic Syndrome (HUS), University Hospital Münster, Münster, Germany
| | - Helge Karch
- Institute of Hygiene and National Consulting Laboratory for Hemolytic Uremic Syndrome (HUS), University Hospital Münster, Münster, Germany
| | - Stefan Lüth
- Center of Internal Medicine II, University Hospital Brandenburg, Brandenburg Medical School, Brandenburg, Germany
| | - Sebastian Ullrich
- Department of Anatomy and Experimental Morphology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,I. Department of Medicine, Asklepios Klinik Altona, Hamburg, Germany
| |
Collapse
|
8
|
Albersmeier JP, Bremer JP, Dammermann W, Lüth S, Hagenmüller F, Rüther C, Otto H, Nielsen AM, Schumacher U, Ullrich S. Outcome and clinical course of EHEC O104 infection in hospitalized patients: A prospective single center study. PLoS One 2018; 13:e0191544. [PMID: 29420567 PMCID: PMC5805174 DOI: 10.1371/journal.pone.0191544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 01/08/2018] [Indexed: 12/05/2022] Open
Abstract
Objectives Shiga-toxin producing O157:H7 Entero Haemorrhagic E. coli [STEC/EHEC] are the most common cause of Haemolytic Uraemic Syndrome [HUS] related to infectious haemorrhagic colitis. Nearly all recommendations on long term treatment of EHEC infections refer to this strain. The 2011 outbreak in Northern Europe was the first of this dimension to be caused by the serotype O104:H4. We report on the 3.5 year follow up of 61 patients diagnosed with symptomatic EHEC O104:H4 infection in spring 2011. Methods Patients with EHEC O104 infection were followed in a monocentric, prospective observational study at four time points: 4, 12, 24 and 36 months. These data include the patients’ histories, clinical findings, and complications. Results Sixty-one patients suffering from EHEC O104:H4 associated enterocolitis participated in the study at the time of hospital discharge. The mean age of patients was 43 ± 2 years, 37 females and 24 males. 48 patients participated in follow up 1 [FU 1], 34 patients in follow up 2 [FU 2], 23 patients in follow up 3 [FU 3] and 18 patients in follow up 4 [FU 4]. Out of 61 patients discharged from the hospital and included in the study, 54 [84%] were examined at least at one additional follow up. Serum creatinine decreased significantly between discharge and FU 1 from 1.3 ± 0.1 mg/dl to 0.7 ± 0.1 mg/dl [p = 0.0045]. From FU 1 until FU 4, no further change in creatinine levels could be observed. The patients need of antihypertensive medications decreased significantly [p = 0.0005] between discharge and FU 1 after four months. From FU 1 until FU 3, 24 months later, no further significant change in antihypertensive treatment was observed. Conclusions Our findings suggest that patients free of pathological findings at time of discharge do not need a specific follow up. Patients with persistent health problems at hospital discharge should be clinically monitored over four months to evaluate chronic organ damage. Progressive or new emerging renal damage could not be observed over time in any patient.
Collapse
Affiliation(s)
- J. P. Albersmeier
- Anatomie und Experimentelle Morphologie, Universitätsklinikum Hamburg Eppendorf, Hamburg, Germany
| | - J. P. Bremer
- Abteilung für Rheumatologie und Immunology, Klinikum Bad Bramstedt, Bad Bramstedt, Germany
| | - W. Dammermann
- Center of Internal Medicine II, Brandenburg Medical School, Campus Brandenburg a.d.H., Brandenburg an der Havel, Germany
| | - S. Lüth
- Center of Internal Medicine II, Brandenburg Medical School, Campus Brandenburg a.d.H., Brandenburg an der Havel, Germany
| | - F. Hagenmüller
- I. Medizinische Klinik, Asklepios Klinik Altona, Hamburg, Germany
| | - C. Rüther
- I. Medizinische Klinik, Asklepios Klinik Altona, Hamburg, Germany
| | - H. Otto
- I. Medizinische Klinik, Asklepios Klinik Altona, Hamburg, Germany
| | - A. M. Nielsen
- I. Medizinische Klinik, Asklepios Klinik Altona, Hamburg, Germany
| | - U. Schumacher
- Anatomie und Experimentelle Morphologie, Universitätsklinikum Hamburg Eppendorf, Hamburg, Germany
| | - S. Ullrich
- Anatomie und Experimentelle Morphologie, Universitätsklinikum Hamburg Eppendorf, Hamburg, Germany
- * E-mail:
| |
Collapse
|
9
|
Kampmeier S, Berger M, Mellmann A, Karch H, Berger P. The 2011 German Enterohemorrhagic Escherichia Coli O104:H4 Outbreak-The Danger Is Still Out There. Curr Top Microbiol Immunol 2018; 416:117-148. [PMID: 30062592 DOI: 10.1007/82_2018_107] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Enterohemorrhagic Escherichia coli (EHEC) are Shiga toxin (Stx) producing bacteria causing a disease characterized by bloody (or non-bloody) diarrhea, which might progress to hemolytic uremic syndrome (HUS). EHEC O104:H4 caused the largest ever recorded EHEC outbreak in Germany in 2011, which in addition showed the so far highest incidence rate of EHEC-related HUS worldwide. The aggressive outbreak strain carries an unusual combination of virulence traits characteristic to both EHEC-a chromosomally integrated Stx-encoding bacteriophage, and enteroaggregative Escherichia coli-pAA plasmid-encoded aggregative adherence fimbriae mediating its tight adhesion to epithelia cells. There are currently still open questions regarding the 2011 EHEC outbreak, e.g., with respect to the exact molecular mechanisms resulting in the hypervirulence of the strain, the natural reservoir of EHEC O104:H4, and suitable therapeutic strategies. Nevertheless, our knowledge on these issues has substantially expanded since 2011. Here, we present an overview of the epidemiological, clinical, microbiological, and molecular biological data available on the 2011 German EHEC O104:H4 outbreak.
Collapse
Affiliation(s)
| | - Michael Berger
- Institute of Hygiene, University of Münster, Münster, Germany
| | | | - Helge Karch
- Institute of Hygiene, University of Münster, Münster, Germany
| | - Petya Berger
- Institute of Hygiene, University of Münster, Münster, Germany.
| |
Collapse
|
10
|
Köckerling E, Karrasch L, Schweitzer A, Razum O, Krause G. Public Health Research Resulting from One of the World's Largest Outbreaks Caused by Entero-Hemorrhagic Escherichia coli in Germany 2011: A Review. Front Public Health 2017; 5:332. [PMID: 29312915 PMCID: PMC5732330 DOI: 10.3389/fpubh.2017.00332] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 11/23/2017] [Indexed: 02/04/2023] Open
Abstract
In 2011, Germany experienced one of the largest outbreaks of entero-hemorrhagic Escherichia coli (EHEC) ever reported. Four years thereafter, we systematically searched for scientific publications in PubMed and MEDPILOT relating to this outbreak in order to assess the pattern of respective research activities and to assess the main findings and recommendations in the field of public health. Following PRISMA guidelines, we selected 133 publications, half of which were published within 17 months after outbreak onset. Clinical medicine was covered by 71, microbiology by 60, epidemiology by 46, outbreak reporting by 11, and food safety by 9 papers. Those on the last three topics drew conclusions on methods in surveillance, diagnosis, and outbreak investigation, on resources in public health, as well as on inter-agency collaboration, and public communication. Although the outbreak primarily affected Germany, most publications were conducted by multinational cooperations. Our findings document how soon and in which fields research was conducted with respect to this outbreak.
Collapse
Affiliation(s)
- Elena Köckerling
- Department of Epidemiology and International Public Health, Bielefeld University, Bielefeld, Germany.,Department Münster, Institute for Rehabilitation Research IfR, Münster, Germany
| | - Laura Karrasch
- Department of Epidemiology and International Public Health, Bielefeld University, Bielefeld, Germany
| | - Aparna Schweitzer
- Department of Epidemiology, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Oliver Razum
- Department of Epidemiology and International Public Health, Bielefeld University, Bielefeld, Germany
| | - Gérard Krause
- Department of Epidemiology, Helmholtz Centre for Infection Research, Braunschweig, Germany.,Hannover Medical School, Hannover, Germany
| |
Collapse
|
11
|
Adler A, Katz DE, Marchaim D. The Continuing Plague of Extended-spectrum β-lactamase-producing Enterobacteriaceae Infections. Infect Dis Clin North Am 2017; 30:347-375. [PMID: 27208763 DOI: 10.1016/j.idc.2016.02.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Antimicrobial resistance is a common iatrogenic complication of modern life and medical care. One of the most demonstrative examples is the exponential increase in the incidence of extended-spectrum β-lactamases (ESBLs) production among Enterobacteriaceae, which is the most common human pathogens outside of the hospital settings. Infections resulting from ESBL-producing bacteria are associated with devastating outcomes, now affecting even previously healthy individuals. This development poses an enormous burden and threat to public health. This paper aims to narrate the evolving epidemiology of ESBL infections, and highlight current challenges in terms of management and prevention of these common infections.
Collapse
Affiliation(s)
- Amos Adler
- Clinical Microbiology Laboratory, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David E Katz
- Department of Internal Medicine D, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem, Israel
| | - Dror Marchaim
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin 70300, Israel.
| |
Collapse
|
12
|
Löbel U, Forkert ND, Schmitt P, Dohrmann T, Schroeder M, Magnus T, Kluge S, Weiler-Normann C, Bi X, Fiehler J, Sedlacik J. Cerebral Hemodynamics in Patients with Hemolytic Uremic Syndrome Assessed by Susceptibility Weighted Imaging and Four-Dimensional Non-Contrast MR Angiography. PLoS One 2016; 11:e0164863. [PMID: 27802295 PMCID: PMC5089757 DOI: 10.1371/journal.pone.0164863] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 10/03/2016] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose Conventional magnetic resonance imaging (MRI) of patients with hemolytic uremic syndrome (HUS) and neurological symptoms performed during an epidemic outbreak of Escherichia coli O104:H4 in Northern Europe has previously shown pathological changes in only approximately 50% of patients. In contrast, susceptibility-weighted imaging (SWI) revealed a loss of venous contrast in a large number of patients. We hypothesized that this observation may be due to an increase in cerebral blood flow (CBF) and aimed to identify a plausible cause. Materials and Methods Baseline 1.5T MRI scans of 36 patients (female, 26; male, 10; mean age, 38.2±19.3 years) were evaluated. Venous contrast was rated on standard SWI minimum intensity projections. A prototype four-dimensional (time resolved) magnetic resonance angiography (4D MRA) assessed cerebral hemodynamics by global time-to-peak (TTP), as a surrogate marker for CBF. Clinical parameters studied were hemoglobin, hematocrit, creatinine, urea levels, blood pressure, heart rate, and end-tidal CO2. Results SWI venous contrast was abnormally low in 33 of 36 patients. TTP ranged from 3.7 to 10.2 frames (mean, 7.9 ± 1.4). Hemoglobin at the time of MRI (n = 35) was decreased in all patients (range, 5.0 to 12.6 g/dL; mean, 8.2 ± 1.4); hematocrit (n = 33) was abnormally low in all but a single patient (range, 14.3 to 37.2%; mean, 23.7 ± 4.2). Creatinine was abnormally high in 30 of 36 patients (83%) (range, 0.8 to 9.7; mean, 3.7 ± 2.2). SWI venous contrast correlated significantly with hemoglobin (r = 0.52, P = 0.0015), hematocrit (r = 0.65, P < 0.001), and TTP (r = 0.35, P = 0.036). No correlation of SWI with blood pressure, heart rate, end-tidal CO2, creatinine, and urea level was observed. Findings suggest that the loss of venous contrast is related to an increase in CBF secondary to severe anemia related to HUS. SWI contrast of patients with pathological conventional MRI findings was significantly lower compared to patients with normal MRI (mean SWI score, 1.41 and 2.05, respectively; P = 0.04). In patients with abnormal conventional MRI, mean TTP (7.45), mean hemoglobin (7.65), and mean hematocrit (22.0) were lower compared to patients with normal conventional MRI scans (mean TTP = 8.28, mean hemoglobin = 8.63, mean hematocrit = 25.23). Conclusion In contrast to conventional MRI, almost all patients showed pathological changes in cerebral hemodynamics assessed by SWI and 4D MRA. Loss of venous contrast on SWI is most likely the result of an increase in CBF and may be related to the acute onset of anemia. Future studies will be needed to assess a possible therapeutic effect of blood transfusions in patients with HUS and neurological symptoms.
Collapse
Affiliation(s)
- Ulrike Löbel
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
| | - Nils Daniel Forkert
- Department of Radiology and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Torsten Dohrmann
- Department of Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria Schroeder
- Department of Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Magnus
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christina Weiler-Normann
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Xiaoming Bi
- Siemens Healthcare, Los Angeles, California, United States
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Sedlacik
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
13
|
Delannoy S, Beutin L, Fach P. Improved traceability of Shiga-toxin-producing Escherichia coli using CRISPRs for detection and typing. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2016; 23:8163-8174. [PMID: 26449676 DOI: 10.1007/s11356-015-5446-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 09/16/2015] [Indexed: 06/05/2023]
Abstract
Among strains of Shiga-toxin-producing Escherichia coli (STEC), seven serogroups (O26, O45, O103, O111, O121, O145, and O157) are frequently associated with severe clinical illness in humans. The development of methods for their reliable detection from complex samples such as food has been challenging thus far, and is currently based on the PCR detection of the major virulence genes stx1, stx2, and eae, and O-serogroup-specific genes. However, this approach lacks resolution. Moreover, new STEC serotypes are continuously emerging worldwide. For example, in May 2011, strains belonging to the hitherto rarely detected STEC serotype O104:H4 were identified as causative agents of one of the world's largest outbreak of disease with a high incidence of hemorrhagic colitis and hemolytic uremic syndrome in the infected patients. Discriminant typing of pathogens is crucial for epidemiological surveillance and investigations of outbreaks, and especially for tracking and tracing in case of accidental and deliberate contamination of food and water samples. Clustered regularly interspaced short palindromic repeats (CRISPRs) are composed of short, highly conserved DNA repeats separated by unique sequences of similar length. This distinctive sequence signature of CRISPRs can be used for strain typing in several bacterial species including STEC. This review discusses how CRISPRs have recently been used for STEC identification and typing.
Collapse
Affiliation(s)
- Sabine Delannoy
- ANSES, Food Safety Laboratory, Platform IdentyPath, Université Paris-Est, Maisons-Alfort, France.
| | - Lothar Beutin
- Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Patrick Fach
- ANSES, Food Safety Laboratory, Platform IdentyPath, Université Paris-Est, Maisons-Alfort, France
| |
Collapse
|
14
|
Teoh CW, Riedl M, Licht C. The alternative pathway of complement and the thrombotic microangiopathies. Transfus Apher Sci 2016; 54:220-31. [PMID: 27160864 DOI: 10.1016/j.transci.2016.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Thrombotic microangiopathies (TMA) are disorders defined by microangiopathic hemolytic anemia, non-immune thrombocytopenia and have multi-organ involvement including the kidneys, brain, gastrointestinal, respiratory tract and skin. Emerging evidence points to the central role of complement dysregulation in leading to microvascular endothelial injury which is crucial for the development of TMAs. This key insight has led to the development of complement-targeted therapy. Eculizumab is an anti-C5 monoclonal antibody, which has revolutionized the treatment of atypical hemolytic uremic syndrome. Several other anti-complement therapeutic agents are currently in development, offering a potential armamentarium of therapies available to treat complement-mediated TMAs. The development of sensitive, reliable and easy to perform assays to monitor complement activity and therapeutic efficacy will be key to devising an individualized treatment regime with the potential of safely weaning or discontinuing treatment in the appropriate clinical setting.
Collapse
Affiliation(s)
- Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Magdalena Riedl
- Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Innsbruck Medical University, Innsbruck, Austria
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
15
|
Clinical-Pathological Conference Series from the Medical University of Graz Case No 155: 26-year-old woman in third trimester of pregnancy with epigastric pain and thrombocytopenia. Wien Klin Wochenschr 2015; 127:707-14. [PMID: 26248584 DOI: 10.1007/s00508-015-0829-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 06/06/2015] [Indexed: 10/23/2022]
|
16
|
Angel Villegas N, Baronetti J, Albesa I, Etcheverría A, Becerra MC, Padola NL, Paraje MG. Effect of antibiotics on cellular stress generated in Shiga toxin-producing Escherichia coli O157:H7 and non-O157 biofilms. Toxicol In Vitro 2015; 29:1692-700. [PMID: 26130220 DOI: 10.1016/j.tiv.2015.06.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 06/25/2015] [Accepted: 06/26/2015] [Indexed: 11/28/2022]
Abstract
Shiga toxin-producing Escherichia coli (STEC) are important food-borne pathogens, with the main virulence factor of this bacterium being its capacity to secrete Shiga toxins (Stxs). Therefore, the use of certain antibiotics for the treatment of this infection, which induces the liberation of Stxs, is controversial. Reactive oxygen and nitrogen species are also involved in the pathogenesis of different diseases. The purpose of this study was to analyze the effects of antibiotics on biofilms of STEC and the relationships between cellular stress and the release of Stx. To this end, biofilms of reference and clinical strains were treated with antibiotics (ciprofloxacin, fosfomycin and rifaximin) and the production of oxidants, the antioxidant defense system and toxin release were evaluated. Ciprofloxacin altered the prooxidant-antioxidant balance, with a decrease of oxidant metabolites and an increase of superoxide dismutase and catalase activity, being associated with high-levels of Stx production. Furthermore, inhibition of oxidative stress by exogenous antioxidants was correlated with a reduction in the liberation of Stx, indicating the participation of this phenomenon in the release of this toxin. In contrast, fosfomycin and rifaximin produced less alteration with a minimal production of Stx. Our data show that treatment of biofilm-STEC with these antibiotics induces oxidative stress-mediated release of Stx.
Collapse
Affiliation(s)
- Natalia Angel Villegas
- IMBIV-CONICET y Departamento de Farmacia, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Argentina
| | - José Baronetti
- IMBIV-CONICET y Cátedra de Microbiología, Facultad de Ciencias Exactas Físicas y Naturales, Universidad Nacional de Córdoba, Argentina
| | - Inés Albesa
- IMBIV-CONICET y Departamento de Farmacia, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Argentina
| | - Analía Etcheverría
- Laboratorio de Inmunoquímica y Biotecnología, Dpto. SAMP, Facultad de Ciencias Veterinarias, Universidad Nacional del Centro de la Provincia de Buenos Aires, Tandil, Argentina
| | - M Cecilia Becerra
- IMBIV-CONICET y Departamento de Farmacia, Facultad de Ciencias Químicas, Universidad Nacional de Córdoba, Argentina
| | - Nora L Padola
- Laboratorio de Inmunoquímica y Biotecnología, Dpto. SAMP, Facultad de Ciencias Veterinarias, Universidad Nacional del Centro de la Provincia de Buenos Aires, Tandil, Argentina
| | - M Gabriela Paraje
- IMBIV-CONICET y Cátedra de Microbiología, Facultad de Ciencias Exactas Físicas y Naturales, Universidad Nacional de Córdoba, Argentina.
| |
Collapse
|
17
|
Abstract
ABSTRACT
Shiga toxin (Stx)-producing
Escherichia coli
(STEC) is an etiologic agent of bloody diarrhea. A serious sequela of disease, the hemolytic uremic syndrome (HUS) may arise in up to 25% of patients. The development of HUS after STEC infection is linked to the presence of Stx. STEC strains may produce one or more Stxs, and the Stxs come in two major immunological groups, Stx1 and Stx2. A multitude of possible therapeutics designed to inhibit the actions of the Stxs have been developed over the past 30 years. Such therapeutics are important because antibiotic treatment of STEC infections is contraindicated due to an increased potential for development of HUS. The reason for the increased risk of HUS after antibiotic treatment is likely because certain antibiotics induce expression of the Stxs, which are generally associated with lysogenic bacteriophages. There are a few potential therapeutics that either try to kill STEC without inducing Stx expression or target gene expression within STEC. However, the vast majority of the treatments under development are designed to limit Stx receptor generation or to prevent toxin binding, trafficking, processing, or activity within the cell. The potential therapies described in this review include some that have only been tested in vitro and several that demonstrate efficacy in animals. The therapeutics that are currently the furthest along in development (completed phase I and II trials) are monoclonal antibodies directed against Stx1 and Stx2.
Collapse
|
18
|
|
19
|
Petruzziello-Pellegrini TN, Moslemi-Naeini M, Marsden PA. New insights into Shiga toxin-mediated endothelial dysfunction in hemolytic uremic syndrome. Virulence 2013; 4:556-63. [PMID: 23955166 PMCID: PMC5359733 DOI: 10.4161/viru.26143] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Shiga toxin-producing E. coli represents a significant global health concern, especially as hypervirulent pathogens surface amidst outbreaks of hemolytic uremic syndrome (HUS). Shiga toxin (Stx) is key in the microangiopathic events underlying the disease and its central role is underscored by the unprecedented HUS outbreak in Germany in 2011. The mechanisms of Stx-mediated endothelial dysfunction have been a major focus of research that has contributed to the current understanding of the pathogenic changes in endothelial phenotype leading to HUS. Among the newer concepts are Stx-mediated gene regulation in the absence of protein synthesis inhibition, a potential role for complement activation, and accumulating evidence for detectable serum markers before the onset of the classic clinical features of HUS. Further investigation of newer therapeutic targets and potential prognostic markers is essential to assess their utility in mitigating disease and/or predicting outcomes and will provide an improved overall understanding of HUS pathogenesis.
Collapse
|
20
|
Quiescent complement in nonhuman primates during E coli Shiga toxin-induced hemolytic uremic syndrome and thrombotic microangiopathy. Blood 2013; 122:803-6. [PMID: 23733336 DOI: 10.1182/blood-2013-03-490060] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Enterohemorrhagic Escherichia coli (EHEC) produce ribosome-inactivating Shiga toxins (Stx1, Stx2) responsible for development of hemolytic uremic syndrome (HUS) and acute kidney injury (AKI). Some patients show complement activation during EHEC infection, raising the possibility of therapeutic targeting of complement for relief. Our juvenile nonhuman primate (Papio baboons) models of endotoxin-free Stx challenge exhibit full spectrum HUS, including thrombocytopenia, hemolytic anemia, and AKI with glomerular thrombotic microangiopathy. There were no significant increases in soluble terminal complement complex (C5b-9) levels after challenge with lethal Stx1 (n = 6) or Stx2 (n = 5) in plasma samples from T0 to euthanasia at 49.5 to 128 hours post-challenge. d-dimer and cell injury markers (HMGB1, histones) confirmed coagulopathy and cell injury. Thus, complement activation is not required for the development of thrombotic microangiopathy and HUS induced by EHEC Shiga toxins in these preclinical models, and benefits or risks of complement inhibition should be studied further for this infection.
Collapse
|