Incidence Of Hemolytic Uremic Syndrome Research Articles

Detection of plasma anti-lipopolysaccharide (LPS) antibodies against enterohemorrhagic Escherichia coli (EHEC) in asymptomatic kindergarten teachers from Buenos Aires province

In Argentina, hemolytic uremic syndrome (HUS) caused by EHEC has the highest incidence in the world. EHEC infection has an endemo-epidemic behavior, causing 20–30% of acute bloody diarrhea syndrome in children under 5 years old. In the period 2016–2020, 272 new cases per year were notified to the National Health Surveillance System. Multiple factors are responsible for HUS incidence in Argentina including person-to-person transmission. In order to detect possible EHEC carriers, we carried out a preliminary study of the frequency of kindergarten teachers with anti-LPS antibodies against the most prevalent EHEC serotypes in Argentina. We analyzed 61 kindergarten teachers from 26 institutions from José C. Paz district, located in the suburban area of Buenos Aires province, Argentina. Fifty-one percent of the plasma samples had antibodies against O157, O145, O121 and O103 LPS: 6.4% of the positive samples had IgM isotype (n=2), 61.3% IgG isotype (n=19) and 32.3% IgM and IgG (n=10). Given that antibodies against LPS antigens are usually short-lived specific IgM detection may indicate a recent infection. In addition, the high percentage of positive samples may indicate a frequent exposure to EHEC strains in the cohort studied, as well as the existence of a large non-symptomatic population of adults carrying pathogenic strains that could contribute to the endemic behavior through person-to-person transmission. The improvement of continuous educational programs in kindergarten institutions could be a mandatory measure to reduce HUS cases not only in Argentina but also globally.

Shiga-Toxin-Producing Strains of Escherichia coli O104:H4 and a Strain of O157:H7, Which Can Cause Human Hemolytic Uremic Syndrome, Differ in Biofilm Formation in the Presence of CO2 and in Their Ability to Grow in a Novel Cell Culture Medium.

One pathogen that commonly causes gastrointestinal illnesses from the consumption of contaminated food is Escherichia coli O157:H7. In 2011 in Germany, however, there was a prominent outbreak of bloody diarrhea with a high incidence of hemolytic uremic syndrome (HUS) caused by an atypical, more virulent E. coli O104:H4 strain. To facilitate the identification of this lesser-known, atypical E. coli O104:H4 strain, we wanted to identify phenotypic differences between it and a strain of O157:H7 in different media and culture conditions. We found that E. coli O104:H4 strains produced considerably more biofilm than the strain of O157:H7 at 37 °C (p = 0.0470-0.0182) Biofilm production was significantly enhanced by the presence of 5% CO2 (p = 0.0348-0.0320). In our study on the innate immune response to the E. coli strains, we used HEK293 cells that express Toll-like receptors (TLRs) 2 or 4. We found that E. coli O104:H4 strains had the ability to grow in a novel HEK293 cell culture medium, while the E. coli O157:H7 strain could not. Thus, we uncovered previously unknown phenotypic properties of E. coli O104:H4 to further differentiate this pathogen from E. coli O157:H7.

The Prevalence and Incidence of Hemolytic Uremic Syndrome: A Systematic Review.

A hemolytic uremic syndrome is an uncommon but severe condition brought on by an overactive alternative complement system, typically involving a hereditary component. It will be crucial to comprehend the epidemiology of hemolytic uremic syndrome as research advances toward bettering its diagnosis and treatment. A systematic review was conducted to evaluate the incidence and prevalence estimates of hemolytic uremic syndrome (HUS) internationally. A thorough literature search was conducted using PubMed, Springer, Cochrane Library for Systematic Reviews, and Embase databases between 2012 and 2023 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 recommendations. A further source of data was the PubMed Central search engine. To make sure that the evaluation included just the studies that were the most pertinent, a population, interventions, comparators, and outcomes (PICO) eligibility criterion was also used. Eight articles were included in this review. HUS had an annual crude incidence of 0.66 per 100,000 people and a standard annual incidence of 0.57 per 100,000 people. Females were more likely than males to develop HUS, but only marginally more frequently. Patients under 20 years old were the age group where HUS was most common. HUS had an average cost of $21,500 per patient, which was more expensive than the country's overall inpatient average cost for the same period. This is due to patients requiring supportive care, antibiotics, plasma exchange, plasma infusion, and renal replacement therapy, and it could take multiple courses of treatment before they improve. It was concluded that several variables, including the region, the age group affected, and the frequency of the underlying bacterial infection, determine the prevalence and incidence of HUS. HUS is often more common in children than adults and is more common in some nations. Overall, HUS is an uncommon disorder that can have significant repercussions for people who have it. For better results and fewer consequences, HUS must be diagnosed and treated as soon as possible.

Seropositivity to Shiga toxin 2 among Argentinian urban and rural residents. Association with sociodemographic and exposure factors.

Shiga toxin-producing Escherichia coli (STEC) are enteric pathogens that cause hemolytic-uremic syndrome (HUS). Ruminants, especially cattle, are their main reservoir. This study describes the seroepidemiology of STEC in rural and urban populations in Argentina, a country with a high HUS incidence. A cross-sectional study was performed in patients without gastrointestinal symptoms. IgG antibodies against Stx2 were detected by western blotting. Anti-Stx2 antibodies were detected in 14.56% of serum samples, more frequently in rural (19.38%) than urban residents (12%). Seropositivity was associated with lower socioeconomic status (SES). Among the other variables considered, thawing homemade hamburgers before cooking them, and the lack of knowledge about HUS were also associated with seropositivity. A multivariate logistic regression analysis performed with the variables that were statistically significant showed that only the SES index remained significant. As SES was measured based on several variables, we further analyzed each one of them and found that the lack of a high education level was statistically associated with seropositivity. The present findings have implications for STEC prevention efforts, highlighting the importance of considering SES and risks factors linked to different SES levels when targeting consumer-level public health interventions.

Genomic analysis of shiga toxin-containing Escherichia coli O157:H7 isolated from Argentinean cattle.

Cattle are the main reservoir of Enterohemorrhagic Escherichia coli (EHEC), with O157:H7 the distinctive serotype. EHEC is the main causative agent of a severe systemic disease, Hemolytic Uremic Syndrome (HUS). Argentina has the highest pediatric HUS incidence worldwide with 12-14 cases per 100,000 children. Herein, we assessed the genomes of EHEC O157:H7 isolates recovered from cattle in the humid Pampas of Argentina. According to phylogenetic studies, EHEC O157 can be divided into clades. Clade 8 strains that were classified as hypervirulent. Most of the strains of this clade have a Shiga toxin stx2a-stx2c genotype. To better understand the molecular bases related to virulence, pathogenicity and evolution of EHEC O157:H7, we performed a comparative genomic analysis of these isolates through whole genome sequencing. The isolates classified as clade 8 (four strains) and clade 6 (four strains) contained 13 to 16 lambdoid prophages per genome, and the observed variability of prophages was analysed. An inter strain comparison show that while some prophages are highly related and can be grouped into families, other are unique. Prophages encoding for stx2a were highly diverse, while those encoding for stx2c were conserved. A cluster of genes exclusively found in clade 8 contained 13 genes that mostly encoded for DNA binding proteins. In the studied strains, polymorphisms in Q antiterminator, the Q-stx2A intergenic region and the O and P γ alleles of prophage replication proteins are associated with different levels of Stx2a production. As expected, all strains had the pO157 plasmid that was highly conserved, although one strain displayed a transposon interruption in the protease EspP gene. This genomic analysis may contribute to the understanding of the genetic basis of the hypervirulence of EHEC O157:H7 strains circulating in Argentine cattle. This work aligns with other studies of O157 strain variation in other populations that shows key differences in Stx2a-encoding prophages.

Potential Zoonotic Pathovars of Diarrheagenic Escherichia coli Detected in Lambs for Human Consumption from Tierra del Fuego, Argentina.

Diarrheagenic Escherichia coli (DEC) pathovars impact childhood health. The southern region of Argentina shows the highest incidence of hemolytic uremic syndrome (HUS) in children of the country. The big island of Tierra del Fuego (TDF) in Argentina registered an incidence of five cases/100,000 inhabitants of HUS in 2019. This work aimed to establish the prevalence of STEC, EPEC, and EAEC in lambs slaughtered in abattoirs from TDF as well as to characterize the phenotypes and the genotypes of the isolated pathogens. The prevalence was 26.6% for stx+, 5.7% for eae+, and 0.27% for aagR+/aaiC+. Twelve STEC isolates were obtained and belonged to the following serotypes: O70:HNT, O81:H21, O81:HNT, O102:H6, O128ab:H2, O174:H8, and O174:HNT. Their genotypic profiles were stx1c (2), stx1c/ehxA (3), stx2b/ehxA (1), stx1c/stx2b (2), and stx1c/stx2/ehxA (4). Six EPEC isolates were obtained and corresponded to five serotypes: O2:H40, O32:H8, O56:H6, O108:H21, and O177:H25. All the EPEC isolates were bfpA- and two were ehxA+. By XbaI-PFGE of 17 isolates, two clusters were identified. By antimicrobial susceptibility tests, 8/12 STEC and 5/6 EPEC were resistant to at least one antibiotic. This work provides new data to understand the ecology of DEC in TDF and confirms that ovine are an important carrier of these pathogens in the region.

Interventions for preventing diarrhoea-associated haemolytic uraemic syndrome.

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. 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. 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. 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. 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. 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. 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.

Facilitating Evaluation of Hemolytic Uremic Syndrome Long-Term Health Outcomes Through Social Media Support Groups.

Individual burden and cost of hemolytic uremic syndrome (HUS)—a medical condition characterized by acute kidney failure—can be substantial when accounting for long-term health outcomes (LTHOs). Because of the low incidence of HUS, evaluation of associated LTHOs is often restricted to physician and outbreak cohorts, both of which may not be representative of all HUS cases. This exploratory study recruited participants from private social media support groups for families of HUS cases to identify potential LTHOs and costs of HUS that are not currently measured. Additionally, this study sought to identify case characteristics that may confound or modify these LTHOs and costs of HUS. Respondents self-selected to complete an online cross-sectional survey on acute and chronic illness history, treatments, and public health follow-up for HUS cases. Posttraumatic stress among respondents (typically case parents) was also evaluated. Responses were received for 74 HUS cases from 71 families representing all geographic regions, and levels of urbanicity within the US self-reported symptoms were typical for HUS, while 35.1% of cases reported antibiotic treatment at any point during the acute illness. Hospital transfers were reported by 71.6% of cases introducing possible delays to care. More than 70% of cases reported experiencing at least one LTHO, with 45% of cases reporting renal sequelae. Posttraumatic stress symptoms were frequently reported by respondents indirectly affected by HUS. Potentially large economic costs that are not addressed in existing analyses were identified including both financial and more general welfare losses (lost utility). While biases in the study design limit the generalizability of results to all HUS cases, this study provides new insights into unmeasured LTHOs and costs associated with HUS. These results suggest that robustly designed cohort studies on HUS should include measures of psychosocial impacts on both the affected individual and their family members.

Quantitative risk assessment of haemolytic uremic syndrome associated with beef consumption in Argentina.

We developed a quantitative microbiological risk assessment (QMRA) of haemolytic uremic syndrome (HUS) associated with Shiga toxin-producing Escherichia coli (STEC)-contaminated beef (intact beef cuts, ground beef and commercial hamburgers) in children under 15 years of age from Argentina. The QMRA was used to characterize STEC prevalence and concentration levels in each product through the Argentinean beef supply chain, including cattle primary production, cattle transport, processing and storage in the abattoir, retail and home preparation, and consumption. Median HUS probability from beef cut, ground beef and commercial hamburger consumption was <10−15, 5.4x10-8 and 3.5x10-8, respectively. The expected average annual number of HUS cases was 0, 28 and 4, respectively. Risk of infection and HUS probability were sensitive to the type of abattoir, the application or not of Hazard Analysis and Critical Control Points (HACCP) for STEC (HACCP-STEC), stx prevalence in carcasses and trimmings, storage conditions from the abattoir to retailers and home, the joint consumption of salads and beef products, and cooking preference. The QMRA results showed that the probability of HUS was higher if beef cuts (1.7x) and ground beef (1.2x) were from carcasses provided by abattoirs not applying HACCP-STEC. Thus, the use of a single sanitary standard that included the application of HACCP-STEC in all Argentinean abattoirs would greatly reduce HUS incidence. The average number of annual HUS cases estimated by the QMRA (n = 32) would explain about 10.0% of cases in children under 15 years per year in Argentina. Since other routes of contamination can be involved, including those not related to food, further research on the beef production chain, other food chains, person-to-person transmission and outbreak studies should be conducted to reduce the impact of HUS on the child population of Argentina.

Differential expression of the virulence gene nleB among Shiga toxin-producing Escherichia coli strains

Shiga toxin-producing Escherichia coli (STEC) is a zoonotic foodborne pathogen associated with hemolytic uremic syndrome (HUS) that vary in their ability to cause disease in humans. STEC represents a serious problem for public health and Argentina is the country with the highest HUS incidence worldwide. Non-LEE effector (nle) genes, present on pathogenicity islands (PAIs), encode translocated substrates of the type III secretion system (T3SS), which could have an important role in STEC virulence. Particularly, nleB is one of the main effector genes proposed as a virulence marker that is involved in the action of T3SS during the STEC infection. NleB inhibits the inflammatory response of the host cell allowing the bacteria to persist in the first stage of the infection. In order to identify the potential risk of STEC strains for public health, the aim of this study was to evaluate and compare basal nleB transcription of 24 STEC strains belonging to 10 serotypes isolated from cattle, food and patients. The results showed differences in nleB transcription among strains. Some non-O157:H7 strains presented transcription levels above the control, an O157:H7 HUS-producing strain. On the other hand, no significant differences were found in basal transcription levels associated with origin or serotype but differences were found between HUS and non-HUS strains. These differences in nleB transcription may be of importance in STEC pathogenesis and could help to differentiate high and low virulence STEC strains.

Molecular subtyping and clonal relatedness of human and cattle verotoxin-producing Escherichia coli O157:H7 isolates

Verotoxin-producing Escherichia coli O157:H7 is the dominant serotype isolated from patients with hemolytic-uremic syndrome (HUS) and, Argentina has the highest rate of HUS in the world. However, not all O157:H7 isolates have the same ability to infect and cause disease in humans. It has been postulated that O157:H7 strains integrate subpopulations related to the origin and virulence. In order to study the population structure and genetic diversity of VTEC O157:H7 from Argentina, a combination of molecular subtyping methods such as multiple loci VNTR analysis (MLVA), single nucleotide polymorphisms (SNP) and phylogroups assignment were used. According to MLVA, high genetic diversity was found among strains isolated from cattle, humans and food. On the other hand, 92% of the isolates presented the allele tir 255 T > A T and 95% were assigned to phylogroup E. We did not find a significant association between the isolates origin and the allele T presence (P > 0,05) postulated as significantly overrepresented in human isolates. Our results show that human and cattle VTEC O157:H7 isolates from Argentina are a homogeneous group and, although it presents high genetic diversity in relation to their MLVA and virulence profiles, it is not possible to distinguish divergent populations. The presence in all the strains of a high number of T3SS effectors genes and the no association of genetic subtypes with strain source, is an alert about the potential risk in public health that VTEC O157:H7 cattle strains possess and, at less, a partial explication about the high incidence of HUS in Argentina.

Hemolytic Uremic Syndrome: A Contemporary Pediatric Experience

Background: Hemolytic uremic syndrome (HUS) is a significant cause for complicated acute kidney injury. In Western countries, >90% of HUS are Shiga toxin Escherichia coli (STEC) associated. Methods: This is a retrospective review of all Israeli children diagnosed with HUS in 4 major medical centers in Israel during 1999–2016. Patients were categorized into 4 HUS etiological groups according to international guidelines: I, inherited or acquired damage to the complement cascade (“atypical HUS” [aHUS]); II, infection associated (“typical” HUS – STEC associated, Pneumococcus); III, coexisting disease; IV: other and unknown causes. Results: Seventy-five children with HUS were identified; the mean annual incidence was 1.5 ± 0.7 cases/10⁶ per year. Distribution according to etiological groups was: I: 24.0%; II: 14.7%; III: 9.3%; IV: 52.0%. Group I comprised high proportions of Arabs (55.6%), children of consanguineous parents (61.0%), and hypertension. Group II included a high proportion of children with diarrhea on presentation and central nervous system involvement. Only 5 (6.6%) had proven STEC-HUS. Group IV was similar in most characteristics to group II. Logistic regression analysis revealed 3 independent factors associated with the diagnosis of aHUS: consanguinity, lack of diarrhea, and lack of leukocytosis at presentation. Receiver operating analysis curve showed an area under the curve of 0.9 (95% CI 0.82–0.98). Conclusions: HUS incidence is lower in Israel than in most countries, especially because STEC-HUS is very rare. aHUS is the largest defined etiological group; some distinctive characteristics were identified that could facilitate its diagnosis. The current classification system leaves a high rate of “unknown cause” HUS.

Did the ban on serving raw beef liver in restaurants decrease Enterohemorrhagic Escherichia coli infection in Japan?: an interrupted time-series analysis

BackgroundEnterohemorrhagic Escherichia coli (EHEC) is an important pathogen that causes diarrhea, hemorrhagic colitis, and hemolytic uremic syndrome (HUS). After an EHEC outbreak involving uncooked beef, serving raw beef liver dishes at restaurants was completely banned starting on July 1, 2012 in Japan. However, its long-term associations with the incidence rates of EHEC infections have never been assessed by formal interrupted time-series analysis (ITSA).MethodsA retrospective cohort study to assess the impact of banning raw beef liver provision at restaurants was conducted. The weekly incidence of asymptomatic and symptomatic EHEC infections, the incidence of HUS, and deaths were extracted from the national reportable diseases database from January 2008 to December 2017. ITSA was conducted to evaluate the impact of banning raw beef liver from July 2012. To account for a potential simultaneous external effect, the additional regulation on raw beef red meat handling (implemented in May 2011) and the seasonality were also incorporated into the model.ResultsThere were 32,179 asymptomatic and 21,250 symptomatic EHEC infections (including 717 HUS cases and 26 deaths) reported during the study period. During the pre-intervention period (before week 27, 2012), there were 0.45 asymptomatic EHEC infections per million-persons per week. The mean post-intervention asymptomatic EHEC infections were 0.51 per million-persons per week. ITSA revealed no baseline trend or change in the intercept and trend (0.002 infections per million-persons per week, 95% Confidence interval − 0.03-0.04, p = 0.93, 1.22, CI -1.96-4.39, p = 0.45, and − 0.006, CI -0.003-0.02, p = 0.68, respectively). For symptomatic EHEC infections, there were 0.30 cases per million per week during the pre-intervention period, and it became 0.33 cases per million per week after the intervention. Time series modeling again did not show a significant baseline trend or changes in the intercept and trend (0.0005, CI -0.02-0.02, p = 0.96, 0.69, CI -1.75-3.12, p = 0.58, and − 0.003, CI -0.02-0.01, p = 0.76, respectively).ConclusionWe did not find a statistically significant reduction in the overall incidence rates of both asymptomatic and symptomatic EHEC infections in Japan after implementing measures, including a ban on serving raw beef liver dishes in the restaurant industry.

2177. The Impact of the BioFire® FilmArray® Gastrointestinal Syndromic Panel on the Management of Infectious Gastroenteritis due to Diarrheagenic E. coli Strains in a Large Community Hospital

BackgroundPCR-based rapid diagnostic tests (RDTs) provide rapid and accurate infectious gastroenteritis (IGE) etiologies within hours. However, there are limited data evaluating the impact of these panels on the appropriate management for diarrheagenic E. coli strains (DECS). This study evaluated the impact of the BioFire® FilmArray® GI panel on the appropriate antimicrobial management of DECS.MethodsA retrospective analysis was conducted at a large community hospital in San Antonio, TX. Patients with a positive infectious diarrhea diagnostic panel (IDDP) for DECS from October 1, 2016 through September 30, 2018 and admitted for ≥48 hours were included. Patients were excluded if they had a positive IDDP for multiple DECS. An algorithm based on all available literature was used to classify appropriate management of DECS, which included patients having prolonged diarrhea (≥7 days), immunocompromised hosts (ICHs), or the presence of systemic symptoms. Antimicrobial therapy changes based on IDDP results, presence of an ID consult, and incidence of hemolytic uremic syndrome (HUS) were evaluated.ResultsA total of 374 patients were included for analysis. Overall, the IDDP did not lead to a change of therapy in 290 cases. However, the IDDP resulted in 84 antimicrobial changes including initiation of appropriate antibiotics (n = 48) and de-escalation/discontinuation (n = 22), primarily in special populations, such as ICHs. The IDDP results led to appropriate therapy optimization in 63%, 17%, 16%, and 9% of enteroinvasive E. coli (EIEC), enteroaggregative E. coli (EAEC), enteropathogenic E. coli (EPEC), and enterotoxigenic E. coli (ETEC) cases, respectively. In contrast, 81% of Shiga toxin-producing E. coli (STEC) cases were inappropriately managed with antibiotics, and 33% developed HUS. Only 14% of all DECS cases generated an ID consult.ConclusionOf note, this study found that the IDDP did not lead to a change in the management of most pathotypes. However, it was associated with positive changes in the management of DECS in specific patients, particularly ICHs. RDTs assist providers in the timely identification and treatment of IGE pathogens, but both antimicrobial and diagnostic stewardship remain critical for the optimal management of DECS.Disclosures All authors: No reported disclosures.

Contribution and Interaction of Shiga Toxin Genes to Escherichia coli O157:H7 Virulence.

Escherichia coli O157:H7 is the predominant cause of diarrhea-associated hemolytic uremic syndrome (HUS) worldwide. Its cardinal virulence traits are Shiga toxins, which are encoded by stx genes, the most common of which are stx1a, stx2a, and stx2c. The toxins these genes encode differ in their in vitro and experimental phenotypes, but the human population-level impact of these differences is poorly understood. Using Shiga toxin-encoding bacteriophage insertion typing and real-time polymerase chain reaction, we genotyped isolates from 936 E. coli O157:H7 cases and verified HUS status via chart review. We compared the HUS risk between isolates with stx2a and those with stx2a and another gene and estimated additive interaction of the stx genes. Adjusted for age and symptoms, the HUS incidence of E. coli O157:H7 containing stx2a alone was 4.4% greater (95% confidence interval (CI) −0.3%, 9.1%) than when it occurred with stx1a. When stx1a and stx2a occur together, the risk of HUS was 27.1% lower (95% CI −87.8%, −2.3%) than would be expected if interaction were not present. At the population level, temporal or geographic shifts toward these genotypes should be monitored, and stx genotype may be an important consideration in clinically predicting HUS among E. coli O157:H7 cases.

Genotypic Features of Clinical and Bovine Escherichia coli O157 Strains Isolated in Countries with Different Associated-Disease Incidences.

There is great geographical variation in the frequency of Escherichia coli O157 infections that correlates with important differences in the bovine reservoir of each country. Our group carried out a broad molecular characterization of human and bovine E. coli O157 strains circulating in Argentina using different methodologies. Our data allows us to conclude that in Argentina, a high homogeneity is observed in both cattle and human strains, with almost exclusive circulation of strains belonging to the hypervirulent clade 8 described by Manning. The aim of this review was to compare the genetic background of E. coli O157 strains isolated in countries that have conducted similar studies, to try to correlate specific O157 genotypes with the incidence and severity of E. coli O157 associated diseases. The characteristics of the strains that cause disease in humans reflect the predominant genotypes in cattle in each of the countries analyzed. The main features clearly linked to high incidence or severity of E. coli O157 infections are lineage-specific polymorphism assay-6 lineage I/II, clade 8 strains and probably, clade 6 strains, the stx2a/stx2c genotype, the presence of q933 and q21 simultaneously, and putative virulence factor EC_3286. In countries with an absence of these features in O157 strains, the overall incidence of O157 disease is low. Argentina, where these characteristics are detected in most strains, shows the highest incidence of hemolytic uremic syndrome (HUS) worldwide.

Sekuen Nukleotida Gene Shiga like toxin-2 dari Isolat Lokal Escherichia coli O157:H7 asal Hewan dan Manusia (NUCLEOTIDES SQUENCES OF SHIGA-LIKE TOXIN 2 GENES OF ESCHERICHIA COLI O157:H7 LOCAL ISOLATES ORIGINATED FROM ANIMALS AND HUMAN)

Animals/livestock, especially cattle, are known as the main reservoir of Escherichia coli O157: H7. As theonly one of zoonotic E. coli, the pathogenicity of these bacteria is determined by its ability to produce oneor more very potent cytotoxin known as Shiga-like toxin (Stx) or verocytotoxin, particularly of the Stx2 typethat is closely related to the incidence of hemolytic uremic syndrome (HUS) in humans. This study analyzedthe nucleotide sequences of stx2 gene between isolates from animals and humans in an effort to assess thepotential zoonoses of the agent. The research activity was initiated by cultivating 20 isolates of E. coliO157:H7 collection based on result in the previous study i.e. 2 isolates originated from cattle feces, 2isolates originated from beef, 2 isolates originated from chicken feces, 2 isolates originated from humanfaeces and 12 non-clinical isolates originated from human fecal who were suffering with renal failure. Allisolates were confirmed on selective medium Sorbitol MacConkey Agar (SMAC) followed by testing onaglutination O157 latex test, and H7 antisera. Molecular analysis of stx2 gene covering open reading frame (ORF) of the stx2 gene was performed using the primer which was designed by researcher i.e. Stx2 (F)/ Stx2 (R). The results showed, there were 2 isolates i.e. KL-48 (2) originated from human feces and SM-25(1) originated from cattle feces were positive for carrying a stx2 gene, which was marked by the 1587 bpPCR product. Analysis of sequencing showed both isolates had identical to stx2 nucleotide squences withE. phaga 933 as well as E. coli ATCC 933. These results indicate the both local isolates are potential aszoonotic agents with clinical effects similar to E. phaga 933 and E. coli ATCC 43894

Genetic Relatedness and Novel Sequence Types of Non-O157 Shiga Toxin-Producing Escherichia coli Strains Isolated in Argentina.

Shiga toxin-producing Escherichia coli (STEC) is a foodborne pathogen responsible for severe disease in humans such as hemolytic uremic syndrome (HUS) and cattle, the principal reservoir. Identification of the clones/lineages is important as several characteristics, among them propensity to cause disease varies with STEC phylogenetic origin. At present, we do not know what STEC clones, especially of non-O157:H7, are circulating in Argentina. To fill this knowledge gap we assessed the genetic diversity of STEC strains isolated in Argentina from various sources, mostly cattle and food, using multilocus sequence typing (MLST). Our objectives were to determine the phylogenetic relationships among strains and to compare them with strains from different geographic origins, especially with those from clinical human cases, in order to evaluate their potential health risk. A total of 59 STEC isolates from 41 serotypes were characterized by MLST. Analysis using EcMLST database identified 38 sequence types (ST), 17 (45%) of which were new STs detected in 18 serotypes. Fifteen out of 38 STs identified were grouped into 11 clonal groups (CGs) and, 23 not grouped in any of the defined CGs. Different STs were found in the same serotype. Results highlighted a high degree of phylogenetic heterogeneity among Argentinean strains and they showed that several cattle and food isolates belonged to the same STs that are commonly associated with clinical human cases in several geographical areas. STEC is a significant public health concern. Argentina has the highest incidence of HUS in the world and this study provides the first data about which STEC clones are circulating. Data showed that most of them might pose a serious zoonotic risk and this information is important for developing public health initiatives. However, the actual potential risk will be defined by the virulence profiles, which may differ among isolates belonging to the same ST.

Construction and Experimental Validation of a Quantitative Kinetic Model of Nitric Oxide Stress in Enterohemorrhagic Escherichia coli O157:H7.

Enterohemorrhagic Escherichia coli (EHEC) are responsible for large outbreaks of hemorrhagic colitis, which can progress to life-threatening hemolytic uremic syndrome (HUS) due to the release of Shiga-like toxins (Stx). The presence of a functional nitric oxide (NO·) reductase (NorV), which protects EHEC from NO· produced by immune cells, was previously found to correlate with high HUS incidence, and it was shown that NorV activity enabled prolonged EHEC survival and increased Stx production within macrophages. To enable quantitative study of EHEC NO· defenses and facilitate the development of NO·-potentiating therapeutics, we translated an existing kinetic model of the E. coli K-12 NO· response to an EHEC O157:H7 strain. To do this, we trained uncertain model parameters on measurements of [NO·] and [O2] in EHEC cultures, assessed parametric and prediction uncertainty with the use of a Markov chain Monte Carlo approach, and confirmed the predictive accuracy of the model with experimental data from genetic mutants lacking NorV or Hmp (NO· dioxygenase). Collectively, these results establish a methodology for the translation of quantitative models of NO· stress in model organisms to pathogenic sub-species, which is a critical step toward the application of these models for the study of infectious disease.

Genetic features of human and bovine Escherichia coli O157:H7 strains isolated in Argentina

Shiga toxin-producing Escherichia coli (STEC) are important food-borne pathogens associated with human diseases. In Argentina, O157:H7 is the dominant serotype in hemolytic uremic syndrome (HUS) cases. Previously, we have described the almost exclusive circulation of human E. coli O157 strains belonging to the hypervirulent clade 8 in Neuquén Province. The aim of the present study was to investigate, by a broad molecular characterization, if this particular distribution of E. coli O157 clades in Neuquén is similar to the situation in other regions of the country and if it may be originated in a similar profile in cattle, its main reservoir. Two-hundred and eighty O157 strains (54 bovine and 226 human) isolated between 2006 and 2008 in different regions of Argentina were studied. All strains harbored rfbO157, fliCH7, eae, and ehxA genes. The predominant genotype was stx2a/stx2c in human (76.1%) and bovine (55.5%) strains. All human isolates tested by Lineage-Specific Polymorphism Assay (LSPA-6), were lineage I/II; among bovine strains, 94.1% belonged to lineage I/II and 5.9% to lineage I. No LSPA-6 lineage II isolates were detected. Single nucleotide polymorphism (SNP) analysis has revealed the existence of nine clade phylogenetic groups. In our clinical strains collection, 87.6% belonged to the hypervirulent clade 8, and 12.4% were classified as clade 4/5. In bovine isolates, 59.3% strains were clade 8, 33.3% clade 4/5 and 7.4% clade 3. More than 80% of human strains showed the presence of 6 of the 7 virulence determinants described in the TW14359 O157 strain associated with the raw spinach outbreak in the U.S. in 2006. More than 80% of bovine strains showed the presence of 3 of these factors. The q933 allele, which has been related to high toxin production, was present in 98.2% of clinical strains and 75.9% of the bovine isolates. The molecular characterization of human STEC O157 strains allows us to conclude that the particular situation previously described for Neuquén Province, may actually be a characteristic of the whole country. These genetic features are quite similar to those observed in the bovine reservoir and may be derived from it. This data confirms that, unlike the rest of the world, in Argentina most of the STEC O157 strains present in cattle may cause human infections of varying severity and the marked virulence described for these strains may be related to the high incidence of HUS in our country.