E. coli NON 0157:H7

Escherichia coli Diarrhea (Other than O157:H7)

Wisconsin Division of Public Health Disease Surveillance Manual (EpiNet, January 2001)

I.     IDENTIFICATION

A. CLINICAL DESCRIPTION: An infection of variable severity characterized by either watery or non-watery, and bloody or non-bloody diarrhea, depending upon the pathotype involved (see below). Asymptomatic infections may also occur.

NOTE: Escherichia coli O157:H7 is the most commonly occuring Enterohemorrhagic
E. coli (EHEC) serotype in the United States. Only EHEC with serotypes other than O157:H7 are described here.

E. coli

Pathotype
Acronym
Clinical
Epidemiology
Type of
Diarrhea

Enterohemorrhagic

(also Shiga-toxin or Verotoxin producing)

EHEC

(STEC or

VTEC)

Abdominal cramps, usually without fever. May be complicated by hemorrhagic colitis, hemolytic uremic syndrome (HUS) in all ages, and postdiarrheal thrombo-cytopenic purpura (TTP) in adults.

Severe, bloody or

non-bloody

Enteropathogenic

EPEC

Usually associated with chronic illness of infants in developing countries, resulting in dehydration.

Severe, watery

Enterotoxigenic

ETEC

Abdominal cramps, usually associated with infants in developing coutries or travelers of all ages. Self limited.

Moderately severe, watery

Enteroinvasive

EIEC

Usually with fever, similar to infection by Shigella species. May develop into dysentery.

Severe, bloody or

non-bloody

Enteroaggregative

EAEC

(EAggEC)

Persistent (>14 days), usually associated with infants in developing coutries.

Watery,

occasionally

bloody

B.     REPORTING CRITERIA: Laboratory confirmation.
C.    LABORATORY CRITERIA FOR CONFIRMATION:

Isolation of E. coli other than O157:H7 from a clinical specimen suspected to be associated with diarrhea, OR

Isolation of Shiga-toxin producing E. coli other than O157:H7 from a clinical specimen.

D.     WISCONSIN CASE DEFINITION: A case that is laboratory confirmed.

II.     ACTIONS REQUIRED / PREVENTION MEASURES

A.     WISCONSIN DISEASE SURVEILLANCE CATEGORY II: REPORT TO THE LOCAL HEALTH OFFICER within 72 hours of identification of a case or suspected case. Public health intervention expected.
B.    EPIDEMIOLOGY REPORTS REQUESTED:

Acute and Communicable Disease Case Report (DPH 4151).

Toxin-producing Pathogenic Escherichia coli Worksheet (optional).

C.    PUBLIC HEALTH INTERVENTIONS:

Conduct case control investigation if two or more cases occur in close geographic or temporal setting or if cases share a common potential exposure (e.g., food establishment, recreational water, community event, farm animal-related exposure).

Assess case for association with high risk (e.g., day care, food handling, or health care provider).

Educate public about proper handwashing after toileting or handling contaminated clothing or linens, before cooking, or associating with high risk individuals.

Exclude infected individuals from high risk settings until they are asymptomatic AND two consecutive negative stool cultures (collected at least 24 hours apart and obtained at least 48 hours after discontinuance of antimicrobial therapy) are obtained.

Source investigation by LHD.

Determine if case is outbreak-related and notify DPH Regional Office or CDES.

Obtain diarrheal-associated E. coli isolate from laboratory and forward to the Wisconsin State Laboratory of Hygiene for pulsed-field gel electrophoresis and serotyping analysis.

III.     CONTACTS FOR CONSULTATION

A.     DPH REGIONAL STAFF: See Epinet Introduction: "REGIONAL OFFICE CONTACTS".

B.     BCD / COMMUNICABLE DISEASE EPIDEMIOLOGY SECTION: (608) 267-7321.

C.     WSLH / BACTERIOLOGY: (608) 262-1616.

IV.     RELATED REFERENCES

1.    "E. coli Diarrhea, non-0157:H7" DPH Disease Fact Sheet Series: View a list of all current Communicable Disease Fact Sheets
2.    Chin J, ed. DIARRHEA CAUSED BY ESCHERICHIA COLI. In: Control of Communicable Diseases Manual. 17^th ed. Washington, DC: American Public Health Association, 2000:155-165.
3.    Pickering LK, ed. ESCHERICHIA COLI DIARRHEA. In: 2000 Red Book: Report of the Committee on Infectious Diseases. 25^th ed. Elk Grove Village, IL: American Academy of Pediatrics, 2000:243-247.
4.    Roels TH, Proctor ME, Robinson LC, Hulbert K, Bopp CA, and Davis JP. 1998. Clinical features of infections due to Escherichia coli producing heat-stable toxin during an outbreak in Wisconsin: A rarely suspected cause of diarrhea in the United States. Clin. Infect. Dis. 26:898-902.

DISEASE TRENDS

While the main EHEC serotype in North America is E. coli O157:H7, other non-O157:H7 serotypes such as O26:H11, O111:H8, O103:H2, O113:H21, and O104:H21 have been implicated in foodborne outbreaks in the United States. In Wisconsin, a large ETEC foodborne outbreak occurred in 1994 due to E. coli O153:H45.

*E. coli* Pathotype	Acronym	Clinical Epidemiology	Type of Diarrhea
Enterohemorrhagic (also Shiga-toxin or Verotoxin producing)	EHEC (STEC or VTEC)	Abdominal cramps, usually without fever. May be complicated by hemorrhagic colitis, hemolytic uremic syndrome (HUS) in all ages, and postdiarrheal thrombo-cytopenic purpura (TTP) in adults.	Severe, bloody or non-bloody
Enteropathogenic	EPEC	Usually associated with chronic illness of infants in developing countries, resulting in dehydration.	Severe, watery
Enterotoxigenic	ETEC	Abdominal cramps, usually associated with infants in developing coutries or travelers of all ages. Self limited.	Moderately severe, watery
Enteroinvasive	EIEC	Usually with fever, similar to infection by Shigella species. May develop into dysentery.	Severe, bloody or non-bloody
Enteroaggregative	EAEC (EAggEC)	Persistent (>14 days), usually associated with infants in developing coutries.	Watery, occasionally bloody

	Isolation of E. coli other than O157:H7 from a clinical specimen suspected to be associated with diarrhea, OR
	Isolation of Shiga-toxin producing E. coli other than O157:H7 from a clinical specimen.

	Acute and Communicable Disease Case Report (DPH 4151).
	Toxin-producing Pathogenic Escherichia coli Worksheet (optional).

	Conduct case control investigation if two or more cases occur in close geographic or temporal setting or if cases share a common potential exposure (e.g., food establishment, recreational water, community event, farm animal-related exposure).
	Assess case for association with high risk (e.g., day care, food handling, or health care provider).
	Educate public about proper handwashing after toileting or handling contaminated clothing or linens, before cooking, or associating with high risk individuals.
	Exclude infected individuals from high risk settings until they are asymptomatic AND two consecutive negative stool cultures (collected at least 24 hours apart and obtained at least 48 hours after discontinuance of antimicrobial therapy) are obtained.
	Source investigation by LHD.
	Determine if case is outbreak-related and notify DPH Regional Office or CDES.
	Obtain diarrheal-associated E. coli isolate from laboratory and forward to the Wisconsin State Laboratory of Hygiene for pulsed-field gel electrophoresis and serotyping analysis.