Case-management protocol for bloody diarrhea as a model to reduce the clinical impact of Shiga toxin-producing Escherichia coli infections. Experience from Southern Italy

Gaia Scavia,Mario Giordano,Daniela Loconsole,Bloody Diarrhea Apulia Working Group ,Nicola Laforgia,Michele Quarto,Luisa Santangelo,Vincenza Carbone,Antonio Parisi,Maria Chironna,Diletta Torres

doi:10.1007/s10096-019-03755-0

Abstract

To describe an operating protocol for bloody diarrhea (BD) in a pediatric population as a rapid response to a public health threat represented by an excess of pediatric HUS cases in the Apulia region (Southern Italy) starting from 2013. The protocol was set up with the goal of correct clinical management of Shiga toxin-producing Escherichia coli (STEC) infections, reductions in subsequent cases of hemolytic uremic syndrome (HUS), and improved short- and long-term disease outcomes. The protocol consisted of rapid hospitalization of children with bloody diarrhea (BD), hematochemical laboratory tests every 12–24 hours, and prompt laboratory diagnosis of STEC. No antibiotics were recommended until diagnosis. Children positive for STEC infections underwent early vigorous volume expansion. In June–December 2018, 438 children with BD were hospitalized, of which 53 (12.1%) had a STEC infection. The most common serogroups were O26 (36.1%), O111 (23.0%), and O157 (14.8%). Thirty-one samples carried the stx2 gene. Four cases evolved into HUS (7.5%), all with favorable outcome despite neurological involvement in two cases. Prompt and accurate laboratory diagnosis of STEC infections is of the utmost importance in patients with BD for correct clinical management. The strict adherence to the protocol could reduce the progression rate of STEC infections to HUS and prevents complications. Enhanced BD surveillance may help reduce cases of pediatric HUS in Southern Italy.

Highlights

Shiga toxin-producing Escherichia coli (STEC) infections are a persisting public health concern
The surveillance protocol described in the present study represents the rapid response to an emerging public health threat in the Apulia region, Southern Italy, comprising an excess of pediatric hemolytic-uraemic syndrome (HUS) cases starting in 2013, with three deaths between 2017 and 2018 [13, 15]
It has been shown that 10–15% of patients with a STEC infection develop HUS after a median interval of 7 days from the onset of diarrhea [10, 17, 18]

Summary

Introduction

Shiga toxin-producing Escherichia coli (STEC) infections are a persisting public health concern. HUS is characterized by microangiopathic hemolysis, platelet consumption, and multiple organ damage ( renal failure), with a case-fatality rate ranging from 3% to 5% [1, 2]. Children with a STEC infection and BD are not hospitalized until HUS development [10], missing the opportunity to mitigate the progression of the disease through early volume expansion to reduce organ damage [3, 11]. Such early interventions have positive effects on both short- and long-term disease outcomes [12]

Methods

Results

Conclusion