Verocytotoxin-producing Escherichia Coli Infection Research Articles

Genotypic and phenotypic characterization of Escherichia coli isolated from indigenous individuals in Malaysia.

Objective(s):The occurrence of asymptomatic verocytotoxin (VT)-producing Escherichia coli (VTEC) infections among humans in recent years is posing a high risk to public health. Thus, the role of asymptomatic human carriers as a source of dissemination should not be underestimated. This study aimed to elucidate the phenotypic and genotypic characteristics of E. coli in the stool samples collected from indigenous individuals in Malaysia. Materials and Methods: E. coli strains (n=108) were isolated from stool samples obtained from 41 indigenous individuals. All strains were subjected to Repetitive Extragenic Palindromic-Polymerase Chain Reaction (REP-PCR) typing and confirmation of VTEC variants. Non-duplicate strains were selected based on REP-PCR profiles and further subjected to antimicrobial susceptibility test (AST). The genotypic and phenotypic characteristics of the strains were then correlated with the demographic data of the subjects. Results:A total of 66 REP-PCR profiles grouped in 53 clusters (F=85%) were obtained. Four genetically distinct strains were confirmed as VTEC (eaeA-positive). The predominant resistance was against ampicillin (34.2%), followed by trimethoprim-sulfamethoxazole (32.9%), ampicillin-sulbactam (5.5%), and ciprofloxacin (1.4%). All isolates were sensitive to amoxicillin-clavulanate, cefuroxime, ceftriaxone, imipenem, and meropenem. Conclusion:Genetically diverse E. coli and VTEC strains were found to colonize the intestines of the indigenous populations. This study is important for the prospective surveillance of E. coli among the indigenous individuals in Malaysia, especially in asymptomatic VTEC infection and antimicrobial resistance phenomenon.

Development and evaluation of latex agglutination tests for the detection of human antibodies to the lipopolysaccharides of verocytotoxin-producing Escherichia coli (VTEC) serogroups O157 and non-O157

Latex agglutination tests (LAT) were developed and evaluated for the rapid detection of LPS antibodies against E. coli serogroup O157, O26, O104, O111 and O145. The latex tests have been proved to be sensitive, fast, easy-to-perform and cost-efficient tools for the screening serodiagnosis of VTEC infections causing haemolytic-uraemic syndrome.

School outbreak of Escherichia coli O157 with high levels of transmission, Staffordshire, England, February 2012.

Verocytotoxin-producing Escherichia coli (VTEC) are bacteria that cause infectious gastroenteritis and in certain settings can cause widespread infection due to secondary transmission. We describe the findings of an investigation of a school-based outbreak of VTEC in Staffordshire, England. Outbreak investigation at a school in February 2012 after two children were diagnosed with VTEC infection. Cases were defined as pupils and staff (or their household contacts) with gastrointestinal symptoms or asymptomatic screened persons, with laboratory confirmed VTEC O157 infection (phage type 32, verocytotoxin 2) occurring on or after 1 February 2012. Microbiological tests of food and faecal samples plus screening of asymptomatic contacts were undertaken. Epidemiological and clinical data were descriptively analysed. Thirty-eight cases were detected. Nineteen were asymptomatic and identified via screening of 191 pupils. Infection was introduced into the school from an earlier household cluster, followed by extensive person-to-person transmission within the nursery/infant group with limited spread to the wider school population. Control measures included several interventions, in particular, universal screening of pupils and staff. Screening during school outbreaks is not underpinned by guidance but proved to be a key control measure. Screening of asymptomatic contacts should be considered in similar outbreaks.

The proficiency testing program of the European Union Reference Laboratory for E. coli

Since 2006, the European Union Reference Laboratory for E. coli (EU-RL) has developed and evaluated standard operating procedures for the identification and typing of verocytotoxin-producing Escherichia coli (VTEC) and for their detection in food, mainly based on PCR detection of virulence genes. In particular, the EU-RL coordinated the development of the Technical Specification ISO TS 13136:2012 on the detection of VTEC in food and animal feed, based on the real-time PCR screening of food enrichment cultures. A total of 13 proficiency testing (PT) rounds were organized: 7 PTs on the identification and typing of VTEC and other pathogenic E. coli strains (detection of virulence genes by PCR and identification of the VTEC serogroups by serological and molecular methods) and 6 PTs on the detection of VTEC in different matrices (carcass swabs, milk, spinach, water, seeds and sprouts), analyzed by using the ISO TS 13136 method. A Web-based platform for submitting the PT results was developed and used since 2010. Between 2007 and 2014, a positive trend was observed in both the number of participants and their performance. Through its PT program, the EU-RL has consolidated a network of reference laboratories for the control of pathogenic E. coli in the EU Member States. Such a network can contribute to gather harmonized data on the prevalence of VTEC in food, to improve the knowledge of the epidemiology of VTEC infections in Europe, and to provide the EC with more standardized operative structures and tools to face possible emergencies in this field of food safety.

Antibiotic treatment of verocytotoxin-producing Escherichia coli (VTEC) infection: a systematic review and a proposal.

A consensus has existed on not to treat verocytotoxin-producing Escherichia coli (VTEC)-infected individuals with antibiotics because of possible subsequent increased risk of developing haemolytic uraemic syndrome (HUS). The aim of this systematic review is to clarify the risk associated with antibiotic treatment during acute VTEC infection and in chronic VTEC carrier states. A systematic search in PubMed identified 1 meta-analysis, 10 clinical studies and 22 in vitro/in vivo studies. Four clinical studies found an increased risk of HUS, four studies found no altered risk of HUS and two studies found a protective effect of antibiotics. In vitro and clinical studies suggest that DNA synthesis inhibitors should be avoided, whereas evidence from in vitro studies indicates that certain protein and cell wall synthesis inhibitors reduce the release of toxins from VTEC isolates. Overall, these studies provide a more nuanced view of the diversity of responses by VTEC strains to antibiotics. Based on these data, as well as data from the Danish cohort of registered VTEC infections, we propose that antibiotic treatment with protein and cell wall synthesis inhibitors can be considered when specific criteria regarding patient group, serotype, virulence profile and duration of disease are met.

Incidence and Virulence Determinants of Verocytotoxin-Producing Escherichia coli Infections in the Brussels-Capital Region, Belgium, in 2008–2010

The incidence of verocytotoxin-producing Escherichia coli (VTEC) was investigated by PCR in all human stools from Universitair Ziekenhuis Brussel (UZB) and in selected stools from six other hospital laboratories in the Brussels-Capital Region, Belgium, collected between April 2008 and October 2010. The stools selected to be included in this study were those from patients with hemolytic-uremic syndrome (HUS), patients with a history of bloody diarrhea, patients linked to clusters of diarrhea, children up to the age of 6 years, and stools containing macroscopic blood. Verocytotoxin genes (vtx) were detected significantly more frequently in stools from patients with the selected conditions (2.04%) than in unselected stools from UZB (1.20%) (P = 0.001). VTEC was detected most frequently in patients with HUS (35.3%), a history of bloody diarrhea (5.15%), or stools containing macroscopic blood (1.85%). Stools from patients up to the age of 17 years were significantly more frequently vtx positive than those from adult patients between the ages of 18 and 65 years (P = 0.022). Although stools from patients older than 65 years were also more frequently positive for vtx than those from patients between 18 and 65 years, this trend was not significant. VTEC was isolated from 140 (67.9%) vtx-positive stools. One sample yielded two different serotypes; thus, 141 isolates could be characterized. Sixty different O:H serotypes harboring 85 different virulence profiles were identified. Serotypes O157:H7/H- (n = 34), O26:H11/H- (n = 21), O63:H6 (n = 8), O111:H8/H- (n = 7), and O146:H21/H- (n = 6) accounted for 53.9% of isolates. All O157 isolates carried vtx2, eae, and a complete O island 122 (COI-122); 15 also carried vtx1. Non-O157 isolates (n = 107), however, accounted for the bulk (75.9%) of isolates. Fifty-nine (55.1%) isolates were positive for vtx1, 36 (33.6%) were positive for vtx2, and 12 (11.2%) carried both vtx1 and vtx2. Pulsed-field gel electrophoresis revealed wide genetic diversity; however, small clusters of O157, O26, and O63:H6 VTEC that could have been part of unidentified outbreaks were identified. Antimicrobial resistance was observed in 63 (44.7%) isolates, and 34 (24.1%) showed multidrug resistance. Our data show that VTEC infections were not limited to patients with HUS or bloody diarrhea. Clinical laboratories should, therefore, screen all stools for O157 and non-O157 VTEC using selective media and a method for detecting verocytotoxins or vtx genes.

Occurrence of verocytotoxin-producing Escherichia coli in the faeces of free-ranging wild lagomorphs in southwest Spain

Verocytotoxin-producing Escherichia coli (VTEC) is an important group of emerging food-borne pathogens and represents a major public health concern worldwide. The aim of this work was to analyse faecal samples from hunted wild lagomorphs for the presence of E. coli O157:H7 and non-O157 VTEC. During two hunting seasons, faecal samples from 241 animals were collected, including wild rabbit (Oryctolagus cuniculus) and hare (Lepus granatensis) and were examined for VTEC. Overall, VTEC were detected and isolated in four (1.66%) of the 241 animals sampled. E. coli O157:H7 was isolated only from one of 124 (0.81%) wild rabbit faecal samples while non-O157 VTEC were isolated from two of 124 (1.61%) wild rabbit faecal samples and one of 117 (0.85%) hare faecal samples. VTEC isolates obtained in the present study (four in total) belonged to four different O:H serotypes, including two serotypes (O84:H− and O157:H7) previously associated with human infection and in particular with causing the life-threatening haemolytic–uraemic syndrome. Although these results indicate a low prevalence of VTEC infection in free-ranging wild lagomorphs, they may play an important role as a source of exposure to human beings and livestock and as a vehicle for dispersing these pathogens. These findings have implications for the zoonotic risk to hunters, people consuming meat from wild animals and others in contact with wild animal faeces, and also in the development of programmes for controlling VTEC at the farm level.

A longitudinal study of Escherichia coli O157 in cattle of a Dutch dairy farm and in the farm environment

From July 1999 till November 2000, a longitudinal study was conducted on a dairy farm in The Netherlands to study within herd prevalence and types of verocytotoxin producing Escherichia coli (VTEC) of serogroup O157 over time, and determine environmental reservoirs and possible transmission routes. Faeces, blood, milk and environmental samples were collected 14 times with intervals varying from 4 to 10 weeks during the study period. Faecal samples were selectively cultured for Escherichia coli O157. Isolates were tested by PCR for the most common virulence genes, VTI, VTII and eae, and typed by pulsed field gel electrophoresis. In total, 71 isolates were obtained, of which 49 from dairy cows, 8 from young stock, 5 from other animals and 9 from the environment. Positive samples were all detected in summer and early fall. VT- and eae-genes were found in all tested isolates, except in one. DNA typing showed that three clusters of O157 isolates could be identified. One of these clusters contained samples of two shedding seasons, indicating persistence on the farm during winter and spring. Repeated measures analysis of variance showed that cows with O157 VTEC infection had higher daily milk production in the period preceding sampling (p = 0.0055). There was no significant association between the results of the LPS-ELISA on serum samples from dairy cows and their O157 status.

Role of non-polio enterovirus infection in pediatric hemolytic uremic syndrome.

Verocytotoxin-producing Escherichia coli(VTEC) infections cause most cases of hemolytic uremic syndrome (HUS); 10-30% of patients, however, are negative for VTEC infection. The etiology of HUS in VTEC-negative cases remains poorly understood. Before the association between VTEC infection and HUS was recognized, sporadic cases of HUS with enterovirus infection were reported in the literature. Since May 1988, most cases of HUS in Italy have been reported to the Italian surveillance system, and in 73% of these, evidence of VTEC infection was demonstrated. The aim of this study was to determine whether the frequency of enteroviral infections was different in the acute phase of VTEC-positive and VTEC-negative HUS. Eighty-nine patients were investigated for enteroviral infection, of whom 58 were VTEC positive and 31 VTEC negative. Two serum samples from each patient were examined for seroconversion to enterovirus (coxsackie, echovirus, and picornavirus) by a complement fixation test. Serological evidence of acute infection with non-polio enterovirus was found in 33 patients (37%) [20/58 (34.5%) VTEC positive and 13/31 (41.9%) VTEC negative]. There was no statistically significant difference between the two groups. These results demonstrate that there are no significant differences for enteroviral infection in VTEC-positive and VTEC-negative patients and, therefore, enteroviral infections should not be considered a cause of HUS in VTEC-negative children.

Isolation and characterization of verocytotoxin-producing Escherichia coli O157 from slaughter pigs and poultry

Rectal contents and tonsils from Dutch slaughter pigs collected immediately after slaughter were examined for the presence of verocytotoxin (VT)-producing Escherichia coli (VTEC) of serogroup O157 (O157 VTEC). In addition, fresh fecal material from poultry layer flocks and turkey flocks collected on poultry farms was examined for the presence of O157 VTEC. E. coli O157 strains were isolated from two (1.4%) of 145 pigs. The strains were isolated from samples of rectal contents, all samples of tonsils being negative. While all 501 fecal samples from chicken flocks were found negative, E. coli O157 strains were isolated from six (1.3%) of 459 pooled fecal samples from turkey flocks. One of the porcine isolates and one of the turkey isolates contained the VT2 gene, the E. coli attaching-and-effacing gene, as well as the enterohemorrhagic E. coli hemolysin gene. Production of VT was confirmed by cytotoxicity tests on Vero cells. Based on these characteristics, the two stains were regarded as potentially pathogenic for humans. The porcine and the turkey isolate were further characterized as being of phage types 4 and 14, respectively. While biochemically typical of E. coli O157, the remaining six isolates were nonverocytotoxigenic and negative for both the E. coli attaching-and-effacing gene and the enterohemorrhagic E. coli hemolysin gene. All eight E. coli O157 isolates did not carry genes that encode E. coli heat-labile and heat-stable enterotoxins. It was concluded that pigs and poultry can be a source of O157 VTEC strains characteristic of those causing illness in man. The extent to which pigs and poultry play a role in the epidemiology of human O157 VTEC infection needs further research.

Verocytotoxin-producing Escherichia coli infection in household members of children with hemolytic-uremic syndrome in The Netherlands.

Strains of verocytotoxin-producing Escherichia coli (VTEC) belonging to serogroup O157 (O157 VTEC) can cause a spectrum of disease that includes nonspecific diarrhea, hemorrhagic colitis and the diarrhea-associated form of the hemolytic uremic syndrome (D+ HUS). We conducted a retrospective study of 34 children with D+ HUS caused by O157 VTEC to determine the frequency of VTEC infection in their household members. Gastrointestinal tract symptoms were reported in 1 or more household contacts of 17 (50%) of the 34 index cases. Of the 26 household members with gastrointestinal tract symptoms, 15 were parents and 11 were siblings. Evidence of VTEC infection was reported in 1 or more household contacts in 23 (68%) of the 34 families (in 46% of the siblings and in 28% of the parents). Nineteen (48%) siblings had a positive stool sample and in only 5 (12%) of the siblings IgM class serum antibodies to O157-lipopolysaccharide (LPS) were detected. Nineteen (31%) parents had a positive stool sample. Antibodies to O157-LPS were not detected in any of the parents. The occurrence of (bloody) diarrhea significantly correlated with the occurrence of IgM class serum antibodies to O157-LPS. It was concluded that household members of children with D+ HUS are often asymptomatically infected with O157 VTEC. Differences in the pathogenesis of the infection between infected individuals may be related to differences in the number of ingested O157 VTEC bacteria and to differences in susceptibility.

Prevalence and serotypes of verocytotoxin-producing Escherichia coli (VTEC) isolates from dairy cattle

To clarify the source of infection and route of transmission of Verocytotoxin-producing Escherichia coli (VTEC) in humans, we collected fresh feces from healthy dairy cattle reared in Hokkaido, Fukushima, Kanagawa and Okinawa prefectures between June 1996 and March 1997, and attempted to isolate VTEC. The results are described below. 1) VTEC was isolated from 68 (27.1%) of 251 fecal samples tested. VTEC was isolated from 14 (28.0%) of 50 in Hokkaido, 13 (26.0%) of 50 in Fukushima, 20 (39.2%) of 51 in Kanagawa and 21 (21.0%) of 100 in Okinawa. There were no difference in the prevalence among the prefectures. 2) Toxin type and serotype of 85 isolates were determined. Thirty-three isolaties (38.8%) were classified into VT1 toxin and VT2 toxin, respectively, and 19 isolates (22.4%) were classified as the strain that produces both VT1 and VT2 toxins. The toxin types of these isolates were divided by serotypes. The VT1-producing isolates were the most frequent among O111:H-. The VT2-producing isolates included O2:H12, O2:H29, O2:H-, O82:H8, O82:HUT, O153:H19, O153:H42 and O153:H-. Among the isolates producing both VT1 and VT2 toxins, O153:H19 was relatively frequent. Based on findings that many bacterial strains coinciding with toxin types and serotypes of human-derived VTEC isolated from dairy cattle, it was suggested that dairy cattle are closely related to VTEC infection in human as a source of infection.

Verocytotoxin‐producing Escherichia coli infection: The Hong Kong experience

Infection by verocytotoxin‐producing Escherichia coli (VTEC) is prevalent in many parts of the world but relatively uncommon in Asia, except Japan. A territory wide screening for VTEC (April to August 1996) in diarrhoeal stool samples sent to six hospital microbiology laboratories in Hong Kong revealed only four isolates of VTEC and one isolate of E. coli O157:NM in 1003 specimens (incidence 0.5%). Two isolates carrying the verocytotoxin (VT) genes belonged to the O157:H7 serotype while the other two were non‐O157. One non‐toxigenic E. coli O157:NM was also isolated. All isolates positive for VT genes by polymerase chain reaction (PCR) were also positive for the Vero toxin assayed by the Vero cell culture. The 97 kDa eaeA outer membrane protein gene and 60 MDa fimbrial plasmid pcVD419 were present only in the two O157:H7 isolates. All patients presented with uncomplicated watery diarrhoea; no one suffered from haemorrhagic colitis or the haemolytic uraemic syndrome. All patients recovered uneventfully without antibiotic treatment. Although VTEC infection is still uncommon in Hong Kong, continued surveillance is essential to prevent future outbreaks.

Verocytotoxin-producing Escherichia coli infection: The Hong Kong experience.

Infection by verocytotoxin-producing Escherichia coli (VTEC) is prevalent in many parts of the world but relatively uncommon in Asia, except Japan. A territory wide screening for VTEC (April to August 1996) in diarrhoeal stool samples sent to six hospital microbiology laboratories in Hong Kong revealed only four isolates of VTEC and one isolate of E. coli O157:NM in 1003 specimens (incidence 0.5%). Two isolates carrying the verocytotoxin (VT) genes belonged to the O157:H7 serotype while the other two were non-O157. One non-toxigenic E. coli O157:NM was also isolated. All isolates positive for VT genes by polymerase chain reaction (PCR) were also positive for the Vero toxin assayed by the Vero cell culture. The 97 kDa eaeA outer membrane protein gene and 60 MDa fimbrial plasmid pcVD419 were present only in the two O157:H7 isolates. All patients presented with uncomplicated watery diarrhoea; no one suffered from haemorrhagic colitis or the haemolytic uraemic syndrome. All patients recovered uneventfully without antibiotic treatment. Although VTEC infection is still uncommon in Hong Kong, continued surveillance is essential to prevent future outbreaks.

Canadian Perspectives on Verocytotoxin-Producing Escherichia coli Infection

Infection with verocytotoxin-producing Escherichia coli (VTEC) became nationally reportable in 1990. Between 1990 and 1994, the national incidence of reported infections ranged from 3 to 5.3 per 100,000 inhabitants. Most cases are sporadic and are caused by E. coli O157:H7. Recent investigations have identified that, in addition to exposure to undercooked ground beef, contact with cattle, consumption of well water, and exposure to rural environments are important risk factors for VTEC infection. Also, results of case control studies and detection of asymptomatic fecal carriage of E. coli O157:H7 and other VTEC in farm family members and abattoir workers have led to an increasing emphasis on person-to-person spread in the epidemiology of VTEC infection. Controlling E. coli O157:H7 and other VTEC at the farm level may therefore have a broader impact than simply reducing the risk of foodborne VTEC infection. Longitudinal studies on dairy farms have demonstrated that E. coli O157:H7 carriage by cattle at the farm and animal level is often transient, and that cattle, rather than the farm environment, are the major reservoir for this organism on dairy farms. Small herds that are controlled by traditional management practices have the highest risk for VTEC infection. Further studies are likely to result in development of effective strategies to control VTEC at the farm level.

Vero cytotoxigenic Escherichia coli infection in dairy farm families.

Fecal samples from 335 dairy farm residents and 1458 cattle on 80 farms were tested for Vero cytotoxin (VT)-producing Escherichia coli (VTEC). Residents were also tested for antibodies to VT1 and O157 lipopolysaccharide (LPS). Residents and cattle on farms with VTEC-positive persons or E. coli O157:H7-positive cattle were retested. Twenty-one persons (6.3%) on 16 farms (20.8%) and 46% of cattle on 100% of the farms had VTEC in fecal samples. Human VTEC isolates included E. coli O157:H7 and 8 other serotypes, 4 of which were present in cattle on the same farms. More persons had antibodies to VT1 (41%) than to O157 LPS (12.5%). Seropositivity to O157 LPS was associated with isolation of E. coli O157:H7 on the farm (P = .022). Human VTEC infection was negatively associated with age (P < .05) and was not associated with clinical illness. Many dairy farm residents experience subclinical immunizing VTEC infections at a young age, which frequently involve non-O157 VTEC found in cattle.

Verocytotoxin-producing Escherichia coli infection in hemolytic uremic syndrome in part of western Europe.

From September 1989 until September 1993, stool specimens and sera from 113 children with diarrhoea-associated haemolytic uraemic syndrome (HUS) from the Netherlands, two university hospitals in Belgium and one university hospital in Germany were examined for the presence of verocytotoxin-producing Escherichia coli (VTEC) infection. Evidence for VTEC infection was observed in 88 (78%) patients with HUS compared to 2 (3%) of the 65 children with acute gastro-enteritis Serotype O157 was the causative agent in 76 (86%) of these 88 patients with VTEC-associated HUS and verocytotoxin-2 (VT-2) was the most frequent toxin produced. Serological testing for antibodies to O157 O-antigen yielded the highest number of positive results compared to the other test methods. Antibodies to O157 were found in sera of 71 (65%) of 110 patients with HUS and one control serum. Stool and sera examination for VTEC in 95 family contacts of 28 patients with HUS demonstrated an evidence for VTEC infection 33 (35%). In contrast, in patients with HUS serological antibodies to O157 O-antigen were found in only 3 (4%) of 85 family contacts. In this part of Western Europe, VT2-producing Escherichia coli, mainly those belonging to serogroup O157, are the major cause of HUS in childhood.

Typing of verotoxins by DNA colony hybridization with poly- and oligonucleotide probes, a bead-enzyme-linked immunosorbent assay, and polymerase chain reaction.

To identify the type of Verotoxins (VT) produced by Verocytotoxin-producing Escherichia coli (VTEC), a sensitive bead-enzyme-linked immunosorbent assay and polymerase chain reaction with common and specific primers to various VTs (VT1, VT2, VT2vha, VT2vhb, and VT2vp1) were developed. Together with colony hybridization tests with oligo- and polynucleotide probes, these methods were applied to VTEC isolates to type the VT produced. The toxin types of 26 of 37 strains were identified, but the reaction profiles in assays of the remaining 11 strains suggested the existence of new VT2 variants. The application of these identification procedures may be useful as a tool for clinical and epidemiological studies of VTEC infection.

Haemolytic-uraemic syndrome in childhood: surveillance and case-control studies in Italy. Italian HUS Study Group.

Seventy-six cases of haemolytic-uraemic syndrome (HUS) were collected over a 4-year period during a surveillance and case-control study. The annual incidence of 0.2 per 100,000 children aged 0-14 years is lower than in other countries; 34% had no prodromal diarrhoea. Evidence for verocytotoxin-producing Escherichia coli (VTEC) infection was found in 72% of patients and 3% of controls; 88% of patients with bloody diarrhoea, 67% with non-bloody diarrhoea and 55% without diarrhoea were VTEC positive. Seventy-three percent of patients had creatinine clearance > or = 80 ml/min per 1.73 m2, normal blood pressure, no proteinuria and haematuria < 2+ after 1 year of follow-up. One patient died and none had non-renal sequelae. VTEC positivity was significantly correlated with a good outcome, while the absence of diarrhoea and a high total white blood cell count at onset were not predictors of a bad outcome. Household contacts of HUS patients had diarrhoea more frequently than those of the control group, supporting the hypothesis of person-to-person transmission of VTEC infection.

Community-wide outbreak of hemolytic-uremic syndrome associated with non-O157 verocytotoxin-producing Escherichia coli.

From 20 April through 13 May 1992, 9 children were hospitalized with hemolytic-uremic syndrome in Lombardia, Italy, where only 14 cases of this syndrome had occurred in the preceding 4 years. Cases were scattered in a large area encompassing five provinces, and the source of the outbreak was not identified. Eight patients needed dialysis, and there was 1 death. Seven of the 9 cases were examined for evidence of infection by Vero cytotoxin (VT)-producing Escherichia coli (VTEC). Six children had serum antibodies to the lipopolysaccharide of E. coli O111, and a VT-producing E. coli O111:NM was isolated from stool in 1 case. This is the first outbreak of VTEC infection recognized in Italy and the first associated with an E. coli serotype other than O157:H7.