Prevalence of non-O157:H7 shiga toxin-producing Escherichia coli in diarrheal stool samples from Nebraska

Emerging infections of the gastrointestinal tract

Infections account for significant GI morbidity and mortality worldwide. New organisms are being identified, associated with diarrhoeal illness and some with other gastrointestinal illness as well. Among GI viruses, Sapovirus is now recognised to cause diarrhoea, especially in children. A hypervirulent strain of Clostridium difficile has caused epidemics in many countries. Newly identified bacterial species that may cause diarrhoea include Campylobacter concisus, Arcobacteria, Edwardsiella tarda, Aeromonas, Plesiomonas and Laribacter. Helicobacteria are reviewed, as well as the role of gastric acid suppression in predisposing to enteric infections.

Enteric infections and diagnostic testing

PURPOSE OF REVIEW

Gastrointestinal pathogens profoundly affect human health and well being. The provider's ability to render optimal care often highly depends on diagnostic microbiologic support. We aim to provide a clinically pertinent assessment of the current state of our ability to diagnose human gastrointestinal pathogens and describe (and decry) the unsophistication of many current diagnostic methods and strategies.

RECENT FINDINGS

Recent advances involve improved stool polymerase chain reaction assays and application of this technology to a broader panel of pathogens, stool antigen assays, and improved culture techniques, but there is little penetration of such diagnostic advances into clinical practice. Many such techniques remain limited to research or epidemiologic use and are not typically available in the clinical laboratory.

SUMMARY

Multiple clinical and laboratory factors need to be considered when attempting to diagnose the wide variety of gastrointestinal pathogens afflicting humans. Careful interpretation of diagnostic tests with attention to the population studied and the characteristics of each test is necessary.

Phenotypic and genotypic characterization of verotoxin-producing Escherichia coli O103:H2 isolates from cattle and humans

Characterization of important non-O157 verotoxin-producing Escherichia coli (VTEC) has lagged considerably behind that of O157:H7 strains. This study characterized 91 VTEC O103:H2 strains from bovine and human sources and of North American and European origins by virulence or putative virulence genes, pulsed-field gel electrophoresis (PFGE) patterns, plasmid profiles, antimicrobial resistance, and colicin production. All strains were positive for vt1 and eae-epsilon; 97% were positive for ehxA; and all were negative for hlyA. Two strains carried vt2. There were 66 PFGE patterns grouped in six clusters, and there were 25 different plasmid profiles. Plasmid-encoded katP and etp genes were significantly more frequent in European than in North American human strains. The distribution of selected phenotypes was as follows: enterohemorrhagic E. coli (EHEC) hemolysin, 95%; colicin production, 38%; antimicrobial resistance, 58%. All the strains were negative for the alpha-hemolytic phenotype. In conclusion, the VTEC O103:H2 strains were diverse, as shown by PFGE, plasmid profiles, virulence markers, and antimicrobial resistance patterns, and all strains showed an EHEC hemolytic phenotype instead of the alpha-hemolytic phenotype that has been shown previously.

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.

Sequence-based typing of genetic targets encoded outside of the O-antigen gene cluster is indicative of Shiga toxin-producing Escherichia coli serogroup lineages

Serogroup classifications based upon the O-somatic antigen of Shiga toxin-producing Escherichia coli (STEC) provide significant epidemiological information on clinical isolates. Each O-antigen determinant is encoded by a unique cluster of genes present between the gnd and galF chromosomal genes. Alternatively, serogroup-specific polymorphisms might be encoded in loci that are encoded outside of the O-antigen gene cluster. Segments of the core bacterial loci mdh, gnd, gcl, ppk, metA, ftsZ, relA and metG for 30 O26 STEC strains have previously been sequenced, and comparative analyses to O157 distinguished these two serogroups. To screen these loci for serogroup-specific traits within a broader range of clinically significant serogroups, DNA sequences were obtained for 19 strains of 10 additional STEC serogroups. Unique alleles were observed at the gnd locus for each examined STEC serogroup, and this correlation persisted when comparative analyses were extended to 144 gnd sequences from 26 O-serogroups (comprising 42 O : H-serotypes). These included O157, O121, O103, O26, O5 : non-motile (NM), O145 : NM, O113 : H21, O111 : NM and O117 : H7 STEC; and furthermore, non-toxin encoding O157, O26, O55, O6 and O117 strains encoded distinct gnd alleles compared to STEC strains of the same serogroup. DNA sequencing of a 643 bp region of gnd was, therefore, sufficient to minimally determine the O-antigen of STEC through molecular means, and the location of gnd next to the O-antigen gene cluster offered additional support for the co-inheritance of these determinants. The gnd DNA sequence-based serogrouping method could improve the typing capabilities for STEC in clinical laboratories, and was used successfully to characterize O121 : H19, O26 : H11 and O177 : NM clinical isolates prior to serological confirmation during outbreak investigations.

Variability in tellurite resistance and the ter gene cluster among Shiga toxin-producing Escherichia coli isolated from humans, animals and food

Tellurite-containing media are widely used for the screening and isolation of Shiga toxin-producing Escherichia coli (STEC) O157:H7, but tellurite resistance among non-O157 STEC is poorly characterized. Therefore, we investigated 202 STEC strains representing 61 different serotypes from humans, animals or food for the presence of ter genes by PCR and their correlation with tellurite resistance, by assessing growth on cefixime-tellurite sorbitol MacConkey agar. All strains were screened for terC, terE and terF as markers for the ter gene cluster. Of the 202 strains, 127 contained terC and terE and were tellurite-resistant, but only 121 of these also contained terF. All 72 non-sorbitol-fermenting O157:H7 and O157:NM (non-motile) strains contained terC, terE and terF and expressed tellurite resistance. In contrast, all eight sorbitol-fermenting STEC O157:NM were terC-, terE- and terF-negative and tellurite-sensitive. Among non-O157 STEC, terC, terE and terF were found in all seven O145:NM, four O111:H8/NM, 17 of 18 O26:H11/NM and in 21 strains of 14 other serotypes. The strong correlation between the presence of ter genes and the ability to grow on tellurite-containing media suggest that the ter genes encode tellurite resistance in the vast majority of these strains. The presence of the ter gene cluster was significantly (P<0.00001) associated with the presence of eae genes. We conclude that the use of tellurite-containing media in screening for STEC will allow the detection of STEC O26, O111, O145 and non-sorbitol-fermenting O157, but most strains (in this study 74.3%) from other serotypes will be missed.

The emerging clinical importance of non-O157 Shiga toxin-producing Escherichia coli

In 1982, hemorrhagic colitis and hemolytic-uremic syndrome were linked to infection with Escherichia coli O157:H7, a serotype now classified as Shiga toxin-producing E. coli (STEC). Thereafter, hemorrhagic colitis and hemolytic-uremic syndrome associated with non-O157 STEC serogroups were reported, with the frequency of non-O157 STEC illness rivaling that of O157:H7 in certain geographic regions. In the United States, non-O157 E. coli may account for up to 20%-50% of all STEC infections. A high index of suspicion, paired with options to test for non-O157 STEC infection, are necessary for early recognition and appropriate treatment of these infections. Supportive care without the use of antibiotics is currently considered to be optimal treatment for all STEC infections. This commentary provides a perspective on the non-O157 STEC as human pathogens, how and when the clinician should approach the diagnosis of these organisms, and the challenges ahead.

Emerging enterohaemorrhagic Escherichia coli, causes and effects of the rise of a human pathogen

Shiga toxin (Stx) [Verotoxin (VT)]-producing Escherichia coli (STEC), also called enterohaemorrhagic E. coli or VTEC are emerging zoonotic agents and became most important as human pathogens, particularly in the industrialized countries. Production of cytotoxins, also called Stx or VT, is the major pathogenicity determinant of STEC, which can cause life-threatening haemorrhagic diseases in humans. The spectrum of STEC phenotypes is diverse and domestic and wildlife animals constitute important reservoirs for these bacteria. STEC are spread from animal faeces to the environment, water and food. Ingestion of contaminated foodstuff and water, as well as contact with the environment, STEC-excreting animals or humans are the major sources of human infection. Economical changes in animal and food production, alteration of consumer habits and lack of specific immune response, particularly in urbanized populations, have contributed to the recent spread of STEC as a zoonotic agent. Supranational surveillance networks as well as national reference laboratories as sentinels play an important role in the prevention and control of STEC infections in humans. Development of new vaccines and probiotics may serve as future tools to control the spread of STEC in animals and humans.

Allelic subtyping of the intimin locus (eae) of pathogenic Escherichia coli by fluorescent RFLP

Intimin is a highly polymorphic protein encoded by the eae gene and plays a crucial role in the attaching-effacing phenotype of diarrheagenic Escherichia coli and related pathogens. We have developed a method to quickly and accurately uncover allelic variation at the eae locus through the use of fluorescent RFLP (fRFLP). Application of fRFLP to 151 eae-positive strains (including the newly described Escherichia albertii) revealed 26 different fRFLP types that correspond to 20 of the 28 previously described eae alleles. Two sequence variants of the gamma, iota, kappa, and zeta alleles and three variants of epsilon were also observed. In addition to being reliable and accurate, the method can be easily adapted to accommodate new eae allelic sequences, as they become known.

Physiologic and molecular markers for detection of shiga toxin-producing Escherichia coli serotype O26 strains

Knowledge of physiologic/phenotypic and genetic variation of Escherichia coli O157 and its tight clonality was the basis for development of successful detection protocols for Shiga toxin-producing E. coli (STEC) O157:H7/H. Phenotypic and genetic characteristics of diarrheagenic E. coli O26 isolates from different geographical regions may differ as indicated by representative reports from all continents. In this review, we summarize current knowledge on STEC O26, a pathogen whose emergence predates that of other STEC, including O157:H7/H-. The overall objectives are to integrate information available from peer-reviewed literature on the clinical and public health significance of STEC O26 worldwide, and to highlight phenotypic and genetic markers that could be used for routine detection of this pathogen. Our ultimate goal is to render information that will allow quick, accurate, and specific detection of STEC O26 genotypic variants worldwide, so as to aid with control of this pathogen. The information herein will be invaluable to a variety of scientists that include epidemiologists and microbiologists (medical, veterinary, food, and environmental) with interest in STEC O26--a zoonotic and emerging foodborne pathogen.

Verocytotoxin-producing Escherichia coli, Japan, 1999-2004

In 1999, an infectious disease prevention law was enacted in Japan that affected the nationwide infectious surveillance system. A total of 19,304 laboratory-confirmed verocytotoxin-producing Escherichia coli cases were reported through 2004. The annual incidence was 2.74/100,000 population; its fluctuation over time and space was associated with climate, socioeconomic, and population factors.

Enterohaemorrhagic Escherichia coli in human medicine

Enterohaemorrhagic Escherichia coli (EHEC) are the pathogenic subgroup of Shiga toxin (Stx)-producing E. coli. EHEC can cause non-bloody and bloody diarrhoea, and the haemolytic uraemic syndrome (HUS). HUS is a major cause of acute renal failure in children. E. coli O57:H7 is the predominant, but far from being the only, serotype that can cause HUS. The cascade leading from gastrointestinal infection to renal impairment is complex, with the microvascular endothelium being the major histopathological target. EHEC also produce non-Stx molecules, such as cytolethal distending toxin, which can contribute to the endothelial or vascular injury. Because there are no specific therapies for EHEC infections, efficient reservoir and human preventive strategies are important areas of ongoing investigations. This review will focus on the microbiology, epidemiology, and pathophysiology of EHEC-associated diseases, and illustrate future challenges and opportunities for their control.

Variation in acid resistance among shiga toxin-producing clones of pathogenic Escherichia coli

Pathogenic strains of Escherichia coli, such as E. coli O157:H7, have a low infectious dose and an ability to survive in acidic foods. These bacteria have evolved at least three distinct mechanisms of acid resistance (AR), including two amino acid decarboxylase-dependent systems (arginine and glutamate) and a glucose catabolite-repressed system. We quantified the survival rates for each AR mechanism separately in clinical isolates representing three groups of Shiga toxin-producing E. coli (STEC) clones (O157:H7, O26:H11/O111:H8, and O121:H19) and six commensal strains from ECOR group A. Members of the STEC clones were not significantly more acid resistant than the commensal strains when analyzed using any individual AR mechanism. The glutamate system provided the best protection in a highly acidic environment for all groups of isolates (<0.1 log reduction in CFU/ml per hour at pH 2.0). Under these conditions, there was notable variation in survival rates among the 30 O157:H7 strains, which depended in part on Mg(2+) concentration. The arginine system provided better protection at pH 2.5, with a range of 0.03 to 0.41 log reduction per hour, compared to the oxidative system, with a range of 0.13 to 0.64 log reduction per hour. The average survival rate for the O157:H7 clonal group was significantly less than that of the other STEC clones in the glutamate and arginine systems and significantly less than that of the O26/O111 clone in the oxidative system, indicating that this clonal group is not exceptionally acid resistant with these specific mechanisms.

Shiga-toxigenic Escherichia coli-inoculated neonatal piglets develop kidney lesions that are comparable to those in humans with hemolytic-uremic syndrome

Kidney lesions similar to those in humans with hemolytic-uremic syndrome were observed histologically in 82 of 122 piglets inoculated intragastrically with Shiga-toxigenic Escherichia coli but not in 29 controls. The locations of lesions matched locations where Stx-2 binding and Gb3 (globotriasylceramide receptors for Stx) were identified immunohistochemically.

Evaluation of performance and potential clinical impact of ProSpecT Shiga toxin Escherichia coli microplate assay for detection of Shiga Toxin-producing E. coli in stool samples

Shiga toxin-producing Escherichia coli bacteria (STEC) are emerging pathogens capable of producing sporadic and epidemic diarrhea, hemorrhagic colitis, and potentially life-threatening hemolytic-uremic syndrome. Although the presence of E. coli O157 can be readily detected in stool by sorbitol-MacConkey agar culture (SMAC), STEC non-O157 serotypes cannot. In contrast to culture, testing for the presence of Shiga toxins 1 and 2 in stool detects both O157 and non-O157 STEC serotypes capable of causing disease. Over two consecutive summers, we evaluated the performance of the ProSpecT Shiga toxin E. coli Microplate assay (Alexon-Trend, Ramsey, Minn.), an enzyme immunoassay for the detection of Shiga toxins 1 and 2, on all stools submitted for culture of enteric pathogens, and the potential clinical impact of Shiga toxin detection. Twenty-nine stool specimens were STEC positive by ProSpecT assay. Twenty-seven of 29 STEC-positive isolates were confirmed by SMAC and serotyping or by a second enzyme immunoassay and PCR (positive predictive value, 93%). Thirteen of 27 confirmed Shiga toxin-producing strains were serotype O157. The remaining 14 strains represented 8 other serotypes. The ProSpecT assay was 100% sensitive and specific for detection of E. coli O157 in stool (7 of 7) compared to SMAC. In addition, the ProSpecT assay detected twice as many STEC as SMAC. Fifty-two percent of confirmed STEC-positive stools were nonbloody. Thus, in our population, screening strategies that test only visibly bloody stools for STEC would miss a majority of cases. Eleven (41%) STEC-positive patients were hospitalized, and eight (30%) developed severe disease (two developed hemolytic-uremic syndrome, and six developed hemorrhagic colitis). Prior to detection of STEC infection, seven (26%) and eight patients (30%) underwent unnecessary diagnostic procedures or received potentially deleterious empirical treatment, respectively. We propose that establishing a specific diagnosis of STEC may have prevented these potentially harmful interventions. We conclude that the ProSpecT assay is sensitive and specific for the detection of Shiga toxins 1 and 2 in stool and has potentially significant clinical impact for the individual patient and public health. Shiga toxin assays should be considered for routine use in settings where prevalence of STEC disease warrants testing.

Comparison of shiga-toxigenic Escherichia coli prevalences among dairy, feedlot, and cow-calf herds in Washington State

Shiga-toxigenic Escherichia coli (STEC) strains were isolated from 7.4% of 1,440 fecal and farm environmental samples. Shiga toxin gene and STEC prevalences were significantly associated with animal production type and season. A range of serogroups were identified. Nine percent of isolates possessed all three principal virulence markers: stx(2), eae, and ehx.

The rabbit as a new reservoir host of enterohemorrhagic Escherichia coli

We investigated the prevalence of enterohemorrhagic Escherichia coli (EHEC) in rabbits acquired from two commercial vendors and a local petting zoo. Fecal samples from 34 Dutch Belted (DB) and 15 New Zealand White (NZW) rabbits were cultured; and isolates were biotyped, serotyped, tested by polymerase chain reaction (PCR), and genotyped by repetitive-element sequence–based PCR (Rep-PCR). Seven (25%) of 28 DB rabbits acquired from one commercial source were positive for EHEC, including O153:H- and O153:H7. One (9%) of 11 NZW rabbits from the same source was positive for eae-, stx1+ O153 strains. In contrast, six DB rabbits from another commercial source and four rabbits from a petting zoo were negative for EHEC. Rep-PCR demonstrated that the O153 EHEC and O145 enteropathogenic E.coli were two distinct clones. Our study indicates that rabbits are a new reservoir host of EHEC that may pose a zoonotic risk for humans.

Improved laboratory enrichment for enterohemorrhagic Escherichia coli by exposure to extremely acidic conditions

Analysis of food samples for E. coli O157:H7 using the standard U.S. Food and Drug Administration procedure is frequently complicated by overgrowth of nontarget microorganisms. A new procedure was developed for enrichment of enterohemorrhagic E. coli (EHEC) which utilizes exposure to pH 2.00 for 2 h. This procedure yielded larger populations of EHEC than the standard method by factors ranging from 2.7 to 7.7 and, when age-stressed cultures were used, by factors ranging from 2.7 to 11.5. Cultures of competing enterics were more effectively inhibited by the new enrichment protocol as well.

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.

An epidemiological study on Verotoxin-producing Escherichia coli (VTEC) infection among population of northern region of Iran (Mazandaran and Golestan provinces)

Faecal samples from 3268 randomly selected inhabitants of two provinces in the northern region of Iran were screened to detect Verotoxin-producing Escherichia coli (VTEC) using colony sweep polymyxin-B extraction method. Non-sorbitol fermentation phenotype and slide agglutination with O157 and H7 antisera used to detect this serotype. We found that 0.7% of the population were infected with VTEC, however none of the isolates belonged to O157:H7 serotype. We also found that children < 6 years of age were at highest risk of infection with VTEC (p < 0.05). Moreover, a significant association was found between the VTEC and diarrhoeal cases at the same age group (p < 0.001). Overall distribution of the VTEC isolates in the general population was found to be random, though a kind of clustered distribution could be noticed.

Comparative pathogenicity of Escherichia coli O157 and intimin-negative non-O157 Shiga toxin-producing E coli strains in neonatal pigs

We compared the pathogenicity of intimin-negative non-O157:H7 Shiga toxin (Stx)-producing Escherichia coli (STEC) O91:H21 and O104:H21 strains with the pathogenicity of intimin-positive O157:H7 and O157:H(-) strains in neonatal pigs. We also examined the role of Stx2d-activatable genes and the large hemolysin-encoding plasmid of O91:H21 strain B2F1 in the pathogenesis of STEC disease in pigs. We found that all E. coli strains that made wild-type levels of Stx caused systemic illness and histological lesions in the brain and intestinal crypts, whereas none of the control Stx-negative E. coli strains evoked comparable central nervous system signs or intestinal lesions. By contrast, the absence of intimin, hemolysin, or motility had little impact on the overall pathogenesis of systemic disease during STEC infection. The most striking differences between pigs inoculated with non-O157 STEC strains and pigs inoculated with O157 STEC strains were the absence of attaching and effacing intestinal lesions in pigs inoculated with non-O157:H7 strains and the apparent association between the level of Stx2d-activatable toxin produced by an STEC strain and the severity of lesions.

Strong association between shiga toxin-producing Escherichia coli O157 and virulence genes stx2 and eae as possible explanation for predominance of serogroup O157 in patients with haemolytic uraemic syndrome

The aim of this study was to investigate the association between Shiga toxin-producing Escherichia coli (STEC) O157 and the simultaneous presence of the virulence genes stx2 and eae in STEC from patients with gastroenteritis. In Germany, the proportion of serogroup O157 is substantially higher among STEC isolates from patients with haemolytic uraemic syndrome (HUS) than among STEC isolates from patients with gastroenteritis. The reason for this is unknown. Independent of serogroup, the virulence genes stx2 and eae have been associated with severe disease. Data collected in 2000-2001 from a Germany-wide laboratory-based surveillance system for STEC-associated gastroenteritis in patients <15 years were analysed. Overall, 18% of the STEC isolates belonged to serogroup O157. Compared with non-O157 strains, 0157 isolates were strongly associated with the simultaneous presence of both an stx2 gene and the eae gene (OR, 76; 95%CI, 27-230). Within the subset of STEC isolates that carried both virulence genes, 60% belonged to serogroup O157, a proportion similar to that found in STEC isolates from pediatric patients with HUS in Germany and Austria (67%, P=0.35). These data suggest that the more frequent carriage of both virulence genes, i.e. stx2 and eae, forms the basis of why STEC O157 predominates in patients with HUS.

Shiga toxin- and enterotoxin-producing Escherichia coli isolated from subjects with bloody and nonbloody diarrhea in Bangkok, Thailand

A total of 314 stool samples collected from 92 subjects with bloody diarrhea, 119 subjects with non-bloody diarrhea and 103 normal subjects in Bangkok, Thailand, were investigated for the presence of Shiga toxin-producing Escherichia coli (STEC) and enterotoxin-producing E. coli (ETEC) by multiplex PCR assay. Virulence genes and cytotoxic effect to Vero cells of STEC were also determined. STEC (5 isolates) and ETEC (18 isolates) were detected in 3 and 14 subjects, respectively. Among subjects containing ETEC, only one person belonged to normal control group. The detected STEC included two isolates (serotypes O26:H(-) and O111:H(-)) of Shiga toxin type 1 (Stx1-only) STEC from a child with non-bloody diarrhea, two isolates (Stx1-Stx2 STEC and Stx1-only STEC) from an adult with bloody diarrhea, and one isolate of Stx1-Stx2v STEC (O157:H7) from normal child. Only Stx1-Stx2 STEC isolate was found to exhibit toxicity to Vero cells and carry hlyA gene. The intimin encoding gene locus eaeA was not detected in any isolate. These results indicate that most of STEC isolates in Thailand were low virulent.

Evaluation of the duopath verotoxin test for detection of shiga toxins in cultures of human stools

The Duopath Verotoxin test (Merck KgaA, Darmstadt, Germany) is a newly developed immunochromatographic test for the confirmation of Shiga toxin (Stx)-producing Escherichia coli (STEC) strains from food products. This test detects both Stx 1 (Stx1)-positive and Stx2-positive samples individually with the same device. By modification of the original protocol, the present study evaluated its performance and feasibility for clinical application with human stool samples, consisting of 41 frozen samples known to contain STEC isolates (O157:H7 and non-O157 serotypes) and 250 fresh specimens. The test specimens were polymyxin B extracts of colony sweeps taken from overnight sorbitol-MacConkey agar cultures of stools containing STEC isolates and other bacteria. All 41 frozen STEC-positive stool samples were positive by the Duopath Verotoxin test, as were 2 fresh stool samples with culture-confirmed STEC O157 infection. Thus, 100% sensitivity and no false-positive results were obtained when the Premier EHEC assay (Meridian Bioscience, Cincinnati, Ohio) was used as the "gold standard." The Duopath Verotoxin test is simple to perform and easy to interpret, providing a turnaround time of 24 h. Despite its original intended use, the Duopath Verotoxin test has a great potential for clinical application.

Clostridium difficile colitis associated with hemolytic-uremic syndrome

The authors report the case of a 46-year-old woman who presented with vomiting and profuse bloody diarrhea. Laboratory studies were significant for a hematocrit of 27% and lactate dehydrogenase of 5,394 U/L (5,394 U/L). Her renal function deteriorated rapidly with a peak creatinine of 12.4 mg/dL (1,096.4 micromol/L), and platelet count dropped simultaneously to a nadir of 123,000/microL (123 x 10(9)/L]. Schistocytes were observed in peripheral blood smear. Stool was positive for Clostridium difficile toxin A by enzyme immunoassay (EIA). Stool assay for Shiga-like toxin was negative by EIA, and stool cultures returned negative for Escherichia coli O157:H7 and other enteric pathogens. A diagnosis of C difficile colitis associated with hemolytic-uremic syndrome was made; the patient received plasmapheresis and recovered with no relapse after 10 months of follow-up. This is the second reported case of C difficile colitis associated with hemolytic-uremic syndrome in an adult.

Detection of Shiga toxins, intimin and enterohemolysin in Escherichia coli strains isolated from children in eastern Slovakia

Fifty Escherichia coli strains isolated from stool samples of 51 healthy children, 143 strains isolated from stool samples of 327 children with diarrhea and 24 strains isolated from stool samples of 21 children with suspected hemolytic uremic syndrome were examined for the presence of Shiga toxin-producing E. coli virulence factors (shiga toxin 1 and 2, intimin and enterohemolysin) and their genes. Vero-cell assay and latex agglutination were used for detection of Shiga toxin 1 and 2, TSB agar with washed erythrocytes was used for detection of enterohemolysin; genes encoding shiga toxin 1 and 2, intimin and enterohemolysin were detected using multiplex PCR. The presence of E. coli strains harboring genes encoding shiga toxin 1 and 2 (12 strains), intimin (34 strains) and enterohemolysin (12 strains) was demonstrated.

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.

Novel single-tube agar-based test system for motility enhancement and immunocapture of Escherichia coli O157:H7 by H7 flagellar antigen-specific antibodies

This paper describes a novel single-tube agar-based technique for motility enhancement and immunoimmobilization of Escherichia coli O157:H7. Motility indole ornithine medium and agar (0.4%, wt/vol) media containing either nutrient broth, tryptone broth, or tryptic soy broth (TSBA) were evaluated for their abilities to enhance bacterial motility. Twenty-six E. coli strains, including 19 O157:H7 strains, 1 O157:H(-) strain, and 6 generic E. coli strains, were evaluated. Test bacteria were stab inoculated in the center of the agar column, and tubes were incubated at 37 degrees C for 18 to 96 h. Nineteen to 24 of the 26 test strains (73.1 to 92.3%) were motile in the different media. TSBA medium performed best and was employed in subsequent studies of motility enhancement and H7 flagellar immunocapture. H7 flagellar antiserum (30 and 60 micro l) mixed with TSBA was placed as a band (1 ml) in the middle of an agar column separating the top (3-ml) and bottom (3-ml) agar layers. The top agar layer was inoculated with the test bacterial strains. The tubes were incubated at 37 degrees C for 12 to 18 h and for 18 to 96 h. The specificity and sensitivity of the H7 flagellar immunocapture tests were 75 and 100%, respectively. The procedure described is simple and sensitive and could be adapted easily for routine use in laboratories that do not have sophisticated equipment and resources for confirming the presence of H7 flagellar antigens. Accurate and rapid identification of H7 flagellar antigen is critical for the complete characterization of E. coli O157:H7, owing to the immense clinical, public health, and economic significance of this food-borne pathogen.

Molecular characterization of a serotype O121:H19 clone, a distinct Shiga toxin-producing clone of pathogenic Escherichia coli

Most illnesses caused by Shiga toxin-producing Escherichia coli (STEC) have been attributed to E. coli serotype O157:H7, but non-O157 STEC infections are now increasingly recognized as public health problems worldwide. The O121:H19 serotype is being isolated more frequently from clinical specimens and has been implicated in one waterborne outbreak. We used multilocus virulence gene profiling, a PCR-based assay, to characterize the virulence gene content of 24 isolates of serotype O121:H19 and nonmotile variants. We also performed multilocus enzyme electrophoresis and multilocus sequencing to establish the clonal relatedness of O121 isolates and to elucidate the relationship of O121 to common STEC clones. The 24 isolates were found to represent a single bacterial clone, as there was no allelic variation across 18 enzyme loci among the isolates. The complete nucleotide sequence of the intimin gene differed by four substitutions from that of the epsilon (Int- epsilon ) allele of O103:H2 strain PMK5. The typical O121 virulence gene profile was similar to the profiles of enterohemorrhagic E. coli (EHEC) clones of E. coli: it included a Shiga toxin 2 gene (stx(2)), two genes on the EHEC plasmid (toxB and ehxA), and the gene encoding intimin (eae). Despite the similarities, putative virulence genes distributed on O islands-large chromosomal DNA segments present in the O157:H7 genome-were useful for discriminating among STEC serotypes and the O121:H19 clone had a composite profile that was distinct from the profiles of the other major EHEC clones of pathogenic E. coli. On the basis of sequencing analysis with 13 housekeeping genes, the O121:H19 clone did not fall into any of the four classical EHEC and enteropathogenic E. coli groups but instead was closely related to two eae-negative STEC strains.

Prevalence and characterization of non-O157 Shiga toxin-producing Escherichia coli on carcasses in commercial beef cattle processing plants

Beef carcass sponge samples collected from July to August 1999 at four large processing plants in the United States were surveyed for the presence of non-O157 Shiga toxin-producing Escherichia coli (STEC). Twenty-eight (93%) of 30 single-source lots surveyed included at least one sample containing non-O157 STEC. Of 334 carcasses sampled prior to evisceration, 180 (54%) were found to harbor non-O157 STEC. Non-O157 STEC isolates were also recovered from 27 (8%) of 326 carcasses sampled after the application of antimicrobial interventions. Altogether, 361 non-O157 STEC isolates, comprising 41 different O serogroups, were recovered. O serogroups that previously have been associated with human disease accounted for 178 (49%) of 361 isolates. Although 40 isolates (11%) carried a combination of virulence factor genes (enterohemorrhagic E. coli hlyA, eae, and at least one stx gene) frequently associated with STEC strains causing severe human disease, only 12 of these isolates also belonged to an O serogroup previously associated with human disease. Combining previously reported data on O157-positive samples (R. O. Elder, J. E. Keen, G. R. Siragusa, G. A. Barkocy-Gallagher, M. Koohmaraie, and W. W. Laegreid, Proc. Natl. Acad. Sci. USA 97:2999-3003, 2000) with these data regarding non-O157-positive samples indicated total STEC prevalences of 72 and 10% in preevisceration and postprocessing beef carcass samples, respectively, showing that the interventions used by the beef-processing industry effected a sevenfold reduction in carcass contamination by STEC.

Prevalence and molecular characterization of Escherichia coli O157:H7 in bulk tank milk and fecal samples from cull cows: a 12-month survey of dairy farms in east Tennessee

A study on the prevalence of Escherichia coli O157:H7 was conducted on 30 dairy farms in east Tennessee between May 2000 and April 2001. This pathogen was isolated from 8 of 30 (26.7%) dairy farms at various sampling times. A total of 415 fecal samples from cull dairy cows and 268 bulk tank milk samples were analyzed. Overall, 10 of 683 (1.46%) samples (2 of 268 [0.75%] milk samples and 8 of 415 [1.93%] fecal samples) tested positive for E. coli O157:H7. Food and Drug Administration Bacteriological Analytical Manual protocols were used for the conventional isolation and confirmation of E. coli O157:H7. Samples were shake cultured (150 rpm) at 42 degrees C for 24 h in tryptic soy broth containing 2 mg of novobiocin per liter. White colonies isolated on cefixime-tellurite sorbitol MacConkey agar plates were evaluated for fluorescence on sorbitol MacConkey agar supplemented with 0.025 g of methylumbelliferyl-beta-D-glucuronide per liter. Nonfluorescing white colonies were biochemically typed and serologically confirmed. Multiplex polymerase chain reaction profiles of E. coli O157:H7 isolates indicated the presence of common virulence factors (Shiga toxin, enterohemolysin, and intimin) of Shiga toxin-producing E. coli, suggesting the potential human pathogenicity of bacterial isolates. Pulsed-field gel electrophoresis profiles of SpeI and XbaI restriction enzyme-digested genomic DNA were used to establish relatedness among bacterial isolates. Data from this study indicate that both cull dairy cows and bulk tank milk pose a potential hazard with regard to human foodborne illness. It is therefore imperative to develop on-farm and preharvest pathogen reduction programs to control the carriage of E. coli O157:H7 pathogens.

Usefulness of blood culture for hospitalized patients who are receiving antibiotic therapy

We conducted a retrospective study to determine the yield of blood samples drawn for culture during the initial 72 h of antibiotic therapy given to 139 patients who were admitted to the hospital for community-acquired infections or fever. The yield of these blood cultures was predictable and rarely (in only 1 patient [0.72%]) isolated new pathogens.