Do we treat enteropathogenic (EPEC) Escherichia coli (E. coli) in stool with antibiotics?

From the Guidelines

Enteropathogenic E. coli (EPEC) infections in stool should not be treated with antibiotics as a first-line approach, except in severe cases or immunocompromised patients. The management of EPEC infections primarily involves supportive care with oral rehydration therapy, as the infection is typically self-limiting and resolves within 5-15 days 1. Antibiotics are generally reserved for cases with systemic involvement, persistent symptoms, or in patients with compromised immune systems. When antibiotic treatment is deemed necessary, options such as trimethoprim-sulfamethoxazole, azithromycin, or ciprofloxacin may be considered, based on susceptibility patterns and the specific clinical context 1.

Key considerations in the management of EPEC infections include:

• The potential for antibiotics to not significantly shorten the duration of illness
• The risk of disrupting gut microbiota
• The contribution to antimicrobial resistance
• The potential increase in toxin release in some cases, as observed with certain pathogens like STEC 1

The primary focus should remain on preventing dehydration through adequate fluid replacement, addressing the disruption of intestinal absorption and increased secretion that leads to watery diarrhea, which is the primary pathophysiological consequence of EPEC infection. This approach prioritizes the reduction of morbidity and improvement of quality of life for patients with EPEC infections.

From the FDA Drug Label

Infectious Diarrhea caused by Escherichia coli (enterotoxigenic strains), Campylobacter jejuni, Shigella boydii†, Shigella dysenteriae, Shigella flexneri or Shigella sonnei† when antibacterial therapy is indicated.

The presence of enteropathogenic E. coli (EPEC) in stool is not explicitly mentioned as an indication for treatment with ciprofloxacin. However, infectious diarrhea caused by Escherichia coli (enterotoxigenic strains) is listed as an indication.

• EPEC is a different pathotype than enterotoxigenic E. coli.
• The drug label does not provide direct information on the treatment of EPEC with ciprofloxacin. Therefore, based on the provided drug label, no conclusion can be drawn regarding the treatment of EPEC in stool with antibiotics like ciprofloxacin 2.

From the Research

Treatment of Enteropathogenic E. coli with Antibiotics

• The use of antibiotics to treat enteropathogenic E. coli (EPEC) in stool is a topic of discussion, with some studies suggesting that antibiotics may be effective in certain cases 3.
• A study published in 2021 found that 92% of patients with EPEC as the sole pathogen responded to antimicrobial therapy, although antimicrobial resistance was common 3.
• However, another study published in 2020 used a murine model to examine the effects of EPEC infection and found that antibiotic disruption of intestinal microbiota enabled efficient colonization by wild-type EPEC, resulting in growth impairment and diarrhea 4.
• The study from 2021 also noted that immunosuppressed cancer patients with EPEC-associated diarrhea carried a high burden of EPEC with strains that were resistant to antibiotics 3.

Pathogenesis and Epidemiology of EPEC

• EPEC is recognized as one of the leading bacterial causes of infantile diarrhea worldwide, and its pathogenesis involves an enteroadhesiveness step and production of a toxin identical to Shigella toxin 5.
• The epidemiology of EPEC is complex, with case-control studies documenting that EPEC remains an important cause of sporadic infant diarrhea in the community, particularly in developing countries 5.
• New diagnostic techniques are needed to simplify the task of identifying EPEC and assessing its relative importance as a cause of sporadic diarrhea in both industrialized and developing countries 5.

Diagnosis and Identification of EPEC

• Fluorescent antibody techniques have been developed for rapid identification of EPEC in faecal smears, with excellent correlation between the fluorescent antibody technique and conventional serological methods 6.
• Other studies have used quantitative polymerase chain reaction (qRT-PCR) to study EPEC genes and characterize strains for virulence factors and adherence to human intestinal enteroids (HIEs) 3.