What is the management of Shiga toxin-producing Escherichia coli (E. coli) infection?

From the Guidelines

Management of Shiga toxin-producing Escherichia coli (STEC) infection should focus on supportive care, avoiding antibiotics, and providing aggressive intravenous fluid rehydration to prevent complications and reduce the risk of hemolytic uremic syndrome (HUS). The primary goal is to maintain adequate hydration, prevent electrolyte imbalances, and monitor for early signs of HUS, which can be life-threatening.

Key Considerations

• Patients should receive intravenous fluids with isotonic solutions like normal saline to maintain hydration and prevent complications 1.
• Antibiotics are generally contraindicated as they may increase the risk of HUS by promoting bacterial lysis and toxin release 1.
• Pain management with acetaminophen is preferred over NSAIDs, which may worsen kidney function.
• Careful monitoring of complete blood count, electrolytes, and renal function is essential, particularly during the first 1-2 weeks when HUS risk is highest 1.
• Patients with severe symptoms or developing HUS require hospitalization for intensive monitoring and support.
• Antidiarrheal medications like loperamide should be avoided as they may prolong toxin exposure in the intestines.
• Nutrition support may be needed, starting with clear liquids and advancing as tolerated.
• Prevention of transmission through proper hand hygiene and contact precautions is crucial, especially in healthcare settings.

Monitoring and Support

• Frequent monitoring of hemoglobin and platelet counts, electrolytes, and blood urea nitrogen and creatinine is recommended to detect hematologic and renal function abnormalities that are early manifestations of HUS and precede renal injury for people with diagnosed E. coli O157 or another STEC infection (especially STEC that produce Shiga toxin 2 or are associated with bloody diarrhea) 1.
• Examining a peripheral blood smear for the presence of red blood cell fragments is necessary when HUS is suspected 1.

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From the Research

Management of Shiga Toxin E coli Infection

• The management of Shiga toxin-producing Escherichia coli (STEC) infection is challenging, as patients often already have organ injuries when they seek medical treatment 2.
• Early diagnosis is of great significance for improving prognosis and reducing mortality and sequelae 2.
• Preventive and therapeutic strategies for STEC-HUS include vaccines, volume expansion, renal replacement therapy (RRT), antibiotics, plasma exchange, antibodies, and inhibitors that interfere with receptor binding, and the intracellular trafficking of the Shiga toxin 2.
• The use of antibiotics in individuals with STEC infections is not recommended, as it may be associated with an increased risk of developing hemolytic uremic syndrome (HUS) 3.
• Eculizumab, a monoclonal C5 antibody, is often used off-label to treat HUS, but its utility in IA-HUS has not been systematically studied, and current observational evidence does not permit any conclusion regarding its impact 4.

Risk Factors and Clinical Outcome

• Age under 3 years, stx2, and stx2a are risk factors for HUS in STEC-positive children 5.
• Age under 3 years, leukocyte count over 20 × 109/L, and need for dialysis are predictive factors for poor renal outcome 5.
• Complete renal recovery was observed in 57 patients after a median 4.0 years of follow-up, and major neurological symptoms were developed in 29 patients (33%) 5.

Treatment Strategies

• Renal replacement therapy (RRT) is a common treatment for STEC-HUS, and 55 patients (63%) needed dialysis 5.
• Plasma exchange is also a treatment strategy for STEC-HUS, but its effectiveness is not well established 2.
• Vaccines are being developed to prevent STEC infection, but their effectiveness is not yet known 2.