News items Scientists call for increased vigilance in E. coli outbreaks

20 November 2023

Greater knowledge and awareness of a harmful subtype of the intestinal bacterium E. coli are crucial, as this variant can, in rare cases, cause kidney failure in children. A recent outbreak at eleven daycare centers in Canada illustrates the importance of healthcare providers in primary care recognizing the infection promptly.

A major outbreak of the E. coli bacterium at eleven different daycare centers in Canada resulted in 96 infected children last September, with 22 of them requiring hospitalization. The cause? Contaminated food prepared in a communal kitchen. This outbreak reaffirmed the significance of the recent scientific review completed by pediatric nephrologist Nicole van de Kar from Radboud university medical center, now published in the New England Journal of Medicine

Van de Kar co-authored this review with two colleagues: one from Calgary, coincidentally the epicenter of the outbreak, and St. Louis in the United States. In it, they emphasize the importance of timely action during an outbreak of the harmful variant of E. coli. Van de Kar stated, ‘Because of their specialization in Calgary in the consequences of an E. coli infection, healthcare providers were able to act quickly. This truly prevented harm; they were there on time to prevent more cases.’

Severe Kidney Failure 

Most variants of the E. coli bacterium are not dangerous. However, a specific variant, the Shiga toxin-producing E. coli (STEC) bacterium, can indeed cause harm in some cases. This variant produces Shiga toxin, a type of toxin produced by the bacterium that damages cells after passing the intestinal wall. In majority of patients, the disease starts with severe, mostly bloody diarrhea. On average, these symptoms last for four days and resolve on their own.

In about 15 to 20 percent of patients, a severe kidney complication called hemolytic-uremic syndrome (HUS) occurs, up to two weeks after the onset of diarrhea. This type of acute kidney failure primarily affects children between 6 months and 5 years old but can also affect the elderly. It involves a sudden decline in kidney function due to the formation of small clots in the blood vessels of the kidneys and the breakdown of red blood cells. Children who experience this type of HUS often had bloody diarrhea initially. This condition can lead to kidney dialysis and even kidney transplantation.

Vigilance During Major Outbreaks 

Because HUS is so rare, it's essential for healthcare providers to remain vigilant during major E. coli outbreaks, according to Nicole van de Kar. In the Radboudumc Rare Kidney Diseases Expertise Center, the pediatric nephrology team encounters often patients with HUS and understands how severe the consequences can be. She said, ‘With this article, we wanted to inform primary care providers such as general practitioners and emergency room physicians about this disease. But this knowledge is also crucial for secondary care, such as pediatricians and internists. A good understanding of microbiology and the natural course of symptoms and complications can significantly improve diagnosis and treatment. Following these guidelines, our colleagues in Canada could provide the right care promptly during the recent outbreak, minimizing the number of children with adverse effects.’

One of the important findings in the article concerns the course of the infection. Van de Kar explained, ‘STEC infections are tricky because infected children often get better before they deteriorate. Subsequently, they develop complications. Monitoring is crucial; stopping too early or not monitoring frequently enough can lead to children deteriorating at home, with complications going unnoticed.’

Therefore, timely symptomatic treatment is crucial, and it does not involve giving antibiotics, but involves timely intravenously rehydration. If HUS results from a bacterial infection, doctors still rely on symptom management in treatment; there is still no specific treatment for STEC-HUS. The options are limited: taking over kidney function, maintaining fluid and mineral balance, and administering a blood transfusion. With timely measures, the majority of children recover, approximately 85%. 

Finally, the authors of the review emphasize the importance of close collaboration with microbiologists. Van de Kar noted, 'Healthcare providers need the right information so that they can deliver the right care. The Knowledge of laboratory procedures and accompanying information reports provided by microbiologist is crucial. The information we have gathered in this study assists healthcare providers.'

About this publication 

This review appeared in New England Journal of Medicine: Shiga Toxin–Producing Escherichia coli and the Hemolytic–Uremic Syndrome – Stephen B. Freedman, Nicole C.A.J. van de Kar, and Phillip I. Tarr. DOI: 10.1056/NEJMra2108739.

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Pauline Dekhuijzen

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