Enterohemorrhagic Escherichia coli

from Wikipedia, the free encyclopedia
Classification according to ICD-10
A04 Other intestinal bacterial infections
A04.3 Enterohaemorrhagic Escherichia coli intestinal infection
ICD-10 online (WHO version 2019)

Enterohaemorrhagic Escherichia coli ( EHEC ) are certain disease-causing strains of the intestinal bacterium Escherichia coli (E. coli) , named after the discoverer of the pathogen Theodor Escherich . There are verotoxin -forming E. coli (VTEC).

The name prefix enterohaemorrhagic ( entero from ancient Greek ἔντερον enteron - intestine and haemorrhagic for bleeding ) indicates that EHEC can cause bloody diarrheal diseases ( enterohaemorrhagic colitis ) in humans.

Pathogen

Topographic images of E. coli O157 colonies : H7 (A) 43895OW (non- curli -producing ) and (B) 43895OR ( curli -producing ) on agar (48 h at 28 ° C)

E. coli is a common gram-negative rod bacterium . Several non-pathogenic strains are part of the normal human intestinal flora . However, there are some serologically distinguishable strains that cause intestinal diseases in humans. In addition to the EHEC discussed here, which were first described in 1977, there are other pathogenic E. coli : enteropathogenic E. coli ( EPEC ), enterotoxin-producing E. coli ( ETEC ) and enteroinvasive E. coli ( EIEC ), enteroaggregative E. coli ( EAEC ) as well as diffusely adherent E. coli (DAEC).

Enterohaemorrhagic E. coli bacteria (EHEC) have several peculiarities that increase their pathogenic potency: First, they can attach to the epithelial cells of the intestinal wall through a special coat protein ( adhesin ) . Secondly, through a phage infection , they have a gene for the production of a toxin that is similar to the neurotoxic and necrotizing toxin of the bacterium Shigella dysenteriae and is known as Shiga toxin 2 or Vero toxin (the name Vero toxin derives from Vero Cells , a cell culture from monkey kidneys on which the toxin was first tested). Finally, the EHEC strains also produce a plasmid-coded hemolysin (blood cell-destroying toxin). Almost 60% of the pathogens were distributed among the three most common serogroups O157, O103 and O26. The letter “O” (not the number “zero”) stands for the respective lipopolysaccharides of the outer cell membrane of the bacteria, which act as surface antigens . The presence of the sensor protein QseC is also essential for virulence .

Enterohaemorrhagic E. coli bacteria are Shiga toxin producing E. coli (STEC), or more precisely: Shiga-like toxin producing E. coli (SLTEC) or Vero toxin producing E. coli (VTEC). However, only the pathogenic strains are named EHEC.

transmission

The pathogen and the infectious diseases it causes occur worldwide. The main reservoir of the pathogen is formed by ruminants, especially cattle, but also sheep and goats, in whose intestines they occur regularly without causing them any diseases.

The pathogens are transmitted in a variety of ways, primarily through direct or indirect oral ingestion of traces of faeces. The pathogen can be ingested with food, especially raw meat or raw milk. Infection is also possible through drinking or bathing water contaminated with faeces. Drinking water contaminated with animal waste caused more than 2000 illnesses and 18 deaths in Walkerton, Canada in 2000. In addition, infection from person to person and transmission through animal-human contact are possible. Flies can represent vectors of EHEC. Human-to-human transmission has been demonstrated in families, day care centers, old people's homes and hospitals. Less than 100 bacteria can be enough for infection.

Epidemiology

Transmitted EHEC / STEC and HUS cases by year and reporting category in Germany, cases according to the reference definition of the RKI;

In various countries around the world there were major outbreaks of EHEC diseases, primarily due to the serotype O157: H7: For example, in 1982, when many people in the USA fell ill after consuming inadequately heated hamburgers, followed by around 9,000 school children in Japan in 1996 with around 9,000 sick schoolchildren the consumption of radish sprouts, and in 2006 starting in California in 26 states of the USA.

In Germany, a continuous increase in the number of registrations was noted in 2003 since the introduction of the nationwide reporting requirement in 1998. However, an increasingly complete recording of the cases of illness probably also played a role. More than half of the cases reported involved children under the age of five. The geographical distribution of the diseases varies greatly. The federal states with the highest incidences are Bavaria, Rhineland-Palatinate and Lower Saxony. Information on the serogroup is available in just under half of the cases reported, so these figures on the epidemiology of the various serogroups in Germany are of limited significance. Almost 60% of the pathogens with information on the serogroup were distributed among the three most common serogroups O157, O103 and O26. About 15 percent of the cases were transmitted in clusters. There is also still a considerable need for research into the epidemiology of EHEC infections.

In 2001, 65 cases of the haemolytic uremic syndrome (HUS) were reported to the Robert Koch Institute (RKI) in Berlin, in 2002 there were almost twice as many with 118, in 2003 there were 82 cases. Two supraregional clusters of HUS illnesses that were investigated in cooperation between the RKI and the state health authorities concerned contributed to the increase in the number of cases in 2002. Both accumulations were caused by the otherwise rarely found "sorbitol-fermenting variant" of EHEC O157: H− , which had already led to outbreaks in Bavaria in 1988 and 1996 . A case control study carried out in December 2002 revealed indications of individual products as possible risk factors (self-pressed apple juice and a yogurt product); however, the definitive cause of the outbreak could not be established.

In 2008, there were more EHEC outbreaks in the Diepholz area , which was a classic outbreak caused by the consumption of raw milk .

In 2009, a total of 836 EHEC-related diarrhea cases without HUS were reported to the Robert Koch Institute in Germany, 44% of those affected were children under five years of age.

As of May 2011, it came first in Northern Germany (Hamburg, Schleswig-Holstein), and later in other states and countries to increased numbers of cases of haemolytic uraemic syndrome (HUS), which extended into an epidemic and by the strain O104: H4 were triggered , see HUS epidemic 2011 .

Course of the disease, complications

An infection can be symptom-free. Otherwise, gastroenteritis (gastrointestinal flu, vomiting, diarrhea) occurs after an incubation period of typically three to four days, but occasionally also after two to ten days , which can develop into enterohaemorrhagic colitis . The toxins destroy the cells of the intestinal wall and the blood vessel walls, especially in the brain and kidneys. In addition to the Shiga toxins, EHEC also has other virulence factors such as LEE-coded proteins, EHEC hemolysin, CDT (cytolethal distending toxin), the serine protease EspP and iron uptake proteins, which is why the various clinical pictures caused by EHEC are to be viewed as multifactorial processes.

Reportable enteropathic haemolytic uremic syndrome (HUS) with or without neurological complications is also possible as a serious complication of EHEC intestinal infections . HUS can be traced back to an EHEC / STEC infection in around 85 percent of cases, but it also occurs in Shigella or other pathogens. Recent studies have shown that thrombotic thrombocytopenic purpura (TTP) , which was usually also mentioned in this context, is a different clinical picture with different causes, which is why it is no longer recorded by official statistics and is also not included here.

The bacteria are typically excreted over a period of five to twenty days, but can extend over several months, especially in children. During this time, it is possible for other people to be infected.

diagnosis

The diagnosis is made by a polymerase chain reaction (PCR) with primers that bind to EHEC-specific DNA segments and thus enable the DNA polymerase to replicate the genes typical for EHEC (stx1, stx2). The products of the PCR can thus be checked for EHEC-typical DNA. In VO (EG) 2073/2005, the European Union prescribes this as a reference method for food manufacturers with reference to DIN CEN ISO / TS 13136.

In addition, the toxins Shiga toxin 1 and 2 produced by the pathogen are detected. Enzyme immunoassays or mass spectrometric methods can be used as methods for this . In addition to the classic chromatographic / mass spectrometric coupling techniques, MALDI-TOF analysis is also increasingly being used, which enables highly specific analytical statements.

Quick value ( INR ) and PTT are inconspicuous. The bleeding time is prolonged due to the existing thrombocytopenia.

therapy

Fighting the pathogen with antibiotics is not promising, as this can prolong the excretion of the bacteria or the course of the disease can be aggravated by increased toxin formation. Treatment is symptom-oriented by replacing the water and electrolyte loss that occurs in severe diarrhea. The bowel movement inflammatory drugs such as loperamide are not displayed , not to hinder the excretion of pathogens and toxins. The HUS complication must be treated in intensive care, for example through blood transfusions , stimulation of urine excretion using diuretics , blood washing in the form of hemofiltration and plasma exchange . Hospital patients are housed in isolation , observing general hygiene measures .

Since 2009 there have been a few case reports of the use of the monoclonal antibody eculizumab in children with HUS who did not respond to plasmapheresis, and in atypical HUS after kidney transplantation . On the basis of these reports, eculizumab has been used on a trial basis in some clinics in Germany since May 28, 2011 for severe courses with HUS that show no tendency to improve under plasmapheresis. According to Rolf Stahl, University Medical Center Hamburg-Eppendorf , whether and to what extent this measure will lead to success can only be said about 3–4 weeks after the start of therapy.

Reporting requirement

In Germany, the suspicion or proof of an EHEC infection according to Section 6 of the Infection Protection Act (IfSG) must be reported if either a) there is HUS , b) two or more people are sick and there is a suspicion of an epidemiological connection or c) a sick person is The food or hospitality industry. Likewise, the direct or indirect detection of Escherichia coli, enterohaemorrhagic strains (EHEC) must be reported by name according to § 7 IfSG, provided that the evidence indicates an acute infection. The diagnosing doctors or laboratories etc. are obliged to report ( § 8 IfSG).

In Germany, there is also a reporting obligation for infections of pets with verotoxin-producing Escherichia coli .

In Switzerland, the positive laboratory analysis of an enterohaemorrhagic Escherichia coli infection (EHEC, STEC, VTEC) must be reported by doctors, hospitals, etc. in accordance with the Epidemics Act (EpG) in conjunction with the Epidemics Ordinance and Appendix 1 of the Ordinance of the EDI on the Reporting observations of communicable diseases in humans . Likewise, the positive or negative laboratory analytical findings of the enterohaemorrhagic Escherichia coli pathogen (EHEC, STEC, VTEC) must be reported to laboratories according to the EpG i. V. m. of the Epidemics Ordinance and Annex 3 of the Ordinance of the FDHA.

Enterohemorrhagic Escherichia coli in animals

When weaning, the pathogen causes edema in pigs .

further reading

From a medical point of view

From a media science perspective

  • Th. Holbach, M. Maurer: News worth knowing. Agenda setting effects between media reporting and online information behavior using the example of the EHEC epidemic. In: Publizistik , vol. 59, number 1, February 2014, pp. 65–81, ISSN  0033-4006

Web links

Wiktionary: EHEC  - explanations of meanings, word origins, synonyms, translations
Wiktionary: enterohaemorrhagic Escherichia coli  - explanations of meanings, word origins, synonyms, translations
 Wikinews: EHEC  - in the news

Individual evidence

  1. https://www.laves.niedersachsen.de/tiere/tiergesundheit/zoonosen/rohmilch--ein-unterschaetztes-risis-73633.html Message from the Lower Saxony Office for Food Safety and Consumer Protection: Raw milk - an underestimated risk? , Section: Dispensing of raw milk and preferred milk , accessed on Feb. 11, 2019
  2. Wolfgang F. Caspary, Manfred Kist, Jürgen Stein: Infectiology of the gastrointestinal tract p. 224 ff. Springer, Berlin / Heidelberg 2006, ISBN 3-540-41359-6 ( limited preview in the Google book search).
  3. a b RKI Guide for Doctors: Diseases caused by Enterohaemorrhagic Escherichia coli (EHEC), version from January 2008 ( Memento of the original from May 27, 2011 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. . Retrieved May 29, 2011. @1@ 2Template: Webachiv / IABot / www.rki.de
  4. Peter Schindler, Bavarian State Office for Health and Food Safety : Faecal contamination in drinking water ( Memento of the original from June 26, 2011 in the Internet Archive ) Info: The @1@ 2Template: Webachiv / IABot / www.helmholtz-muenchen.de archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF; 174 kB). In: Contribution to the FLUGS seminar: Water - Reservoir of Life. Current questions on water supply and hygiene , March 2004.
  5. Maike Förster: Dangerous pests - flies as carriers of microorganisms . ( Memento of the original from August 15, 2011 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF; 308 kB) In: Rundschau für Fleischhygiene und Lebensmittelkontrolle , 7/2009, pp. 4–6 @1@ 2Template: Webachiv / IABot / www.mosq-trap.net
  6. Infections caused by enterohaemorrhagic Escherichia coli (EHEC) . In: Epidemiological Bulletin , 31/1999 (PDF; 65 kB) Robert Koch Institute
  7. SurvStat ( Memento of the original from April 27, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Robert Koch Institute, data status: May 27, 2011 @1@ 2Template: Webachiv / IABot / www3.rki.de
  8. EHEC epidemic 1982 in the USA from infected hamburgers . fleischwirtschaft.de
  9. EHEC epidemics in Japan in 1996 and in the USA in 2006 One gram of EHEC can infect all of humanity.
  10. K. Alpers et al. a ( RKI ): Zoonotic infections in humans. Overview of the epidemiological situation in Germany . In: Federal Health Gazette Health Research Health Protection . No. 7 , 2004, p. 627 ( edoc.rki.de [PDF; 368 kB ]).
  11. Epidemiological Bulletin 22/2003 (PDF; 163 kB) Robert Koch Institute
  12. [1] WELT Online, May 19, 2008
  13. ^ Infection epidemiological yearbook for 2009 . (PDF) Robert Koch Institute, Berlin 2010, pp. 68–69.
  14. RKI guide for doctors: Diseases caused by enterohaemorrhagic Escherichia coli (EHEC) , version from June 2011. Accessed on January 1, 2013.
  15. a b Helge Karch, Alexander Mellmann, Martina Bielaszewska: Epidemiology and pathogenesis of infections with enterohaemorrhagic Escherichia coli . In: Berlin and Munich veterinary weekly . tape 122 , no. 11/12 , 2009, p. 417-424 ( online ). doi : 10.2376 / 0005-9366-122-417 (currently unavailable)
  16. Dr. Burkhard Schütze: Self-checks increase safety - modern analysis for the detection of EHEC in food, FleischWirtschaft, 10/2014, ISSN  0015-363X , PDF
  17. LM Clotilde, C 4th Bernard, GL Hartman, DK Lau, JM Carter: Microbead-based immunoassay for simultaneous detection of Shiga toxins and isolation of Escherichia coli O157 in foods . In: J Food Prot. , 2011 Mar, 74 (3), pp. 373-379, PMID 21375872
  18. F Kondo, H Saito, R Hayashi, H Onda, S Kobayashi, M Matsumoto, M Suzuki, Y Ito, H Oka, T Nakanishi, A Shimizu: Identification of Shiga toxins in Shiga toxin-producing Escherichia coli using immunoprecipitation and high- performance liquid chromatography-electrospray ionization mass spectrometry . In: Analyst. , 2003 Nov, 128 (11), pp. 1360-1364, PMID 14700230
  19. CK Fagerquist, O. Sultan: Induction and identification of disulfide-intact and disulfide-reduced β-subunit of Shiga toxin 2 from Escherichia coli O157: H7 using MALDI-TOF-TOF-MS / MS and top-down proteomics . In: Analyst. , 2011 Apr 21, 136 (8), pp. 1739-1746, PMID 21336382
  20. DEGAM: S1 guideline EHEC / HUS (as of June 10, 2011). (PDF; 107 kB) (No longer available online.) Archived from the original on January 14, 2012 ; Retrieved June 2, 2011 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.degam.de
  21. a b Peter Layer, Ulrich Rosien: Practical Gastroenterology . Elsevier, Urban & Fischer, Munich 2008, ISBN 978-3-437-23371-5 , pp. 359 f . ( limited preview in Google Book search).
  22. ^ Wolfgang F. Caspary, Manfred Kist, Jürgen Stein: Infectiology of the gastrointestinal tract . Springer, Berlin / Heidelberg 2006, ISBN 3-540-41359-6 , pp. 232 ( limited preview in Google Book search).
  23. a b Dieter Adam: The Infectiology . Springer, Berlin, Heidelberg 2003, ISBN 3-540-00075-5 , pp. 1032 f . ( limited preview in Google Book search).
  24. Niklaus E. Gyr, Fritz Koller: Internal emergencies: safe through the acute situation and the following 48 hours . Georg Thieme Verlag, Stuttgart 2003, ISBN 3-13-510607-1 , p. 321 ( limited preview in Google Book search).
  25. Hygiene measures for inpatients with haemolytic uremic syndrome (HUS) or bloody diarrhea due to enterohaemorrhagic Escherichia coli (EHEC). (PDF) Robert Koch Institute, accessed on January 1, 2013 .
  26. Anne-Laure Lapeyraque et al .: eculizumab in Severe Shiga toxin-associated HUS . In: N Engl J Med , 2011, 364, pp. 2561-2563, doi: 10.1056 / NEJMc1100859
  27. Ralph A. Gruppo, Russel P. Rother: Eculizumab for Congenital Atypical Hemolytic-Uremic Syndrome . In: N Engl J Med , 2009, 360, pp. 544-546, doi: 10.1056 / NEJMc0809959
  28. CF Larrea, F. Cofan et al .: Efficacy of eculizumab in the treatment of recurrent atypical hemolytic-uremic syndrome after renal transplantation . In: Transplantation , 2010, 89, pp. 903-904, PMID 20386298
  29. UKE currently cares for 64 patients who have developed the HU syndrome ( Memento of the original dated June 2, 2011 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Press release from May 28, 2011 @1@ 2Template: Webachiv / IABot / www.uke.de
  30. § 1 and Annex of the Ordinance on Notifiable Animal Diseases (TKrMeldpflV) in the version of the notice of February 11, 2011 ( Federal Law Gazette I p. 252 ), last amended by Article 381 of the Ordinance of August 31, 2015 ( Federal Law Gazette I p. 1474 )