E.

COLI
0104:H4
EMERGING PATHOGEN – NEW CONCERNS

Dr.T.V.Rao.MD

DR.T.V.RAO MD 1
 SHIGA TOXIN-PRODUCING
ESCHERICHIA COLI (STEC)
CURRENT OUTBREAK
• Shiga toxin-producing
Escherichia coli (STEC) can
cause severe enteric infections
and the potentially life
threatening hemolytic uremic
syndrome (HUS). Prompt
diagnosis of these infections is
important to implement early
clinical management that
minimizes the likelihood of
developing HUS, to reduce the
risk of transmitting the infection
to others, and to detect outbreak
• Commonly consumed vegetables
are source of spread.
DR.T.V.RAO MD 2
DR.T.V.RAO MD 3
NEW REPORT ON E.COLI 0104 H4 OUTBREAK
• Large outbreak of Shiga toxin-
producing Escherichia coli O104:H4
(STEC O104:H4) infections ongoing
in Germany. The responsible strain
shares virulence characteristics with
enter aggregative E. coli (EAEC). As
of June 2, 2011, case counts
confirmed by Germany’s Robert
Koch Institute* include 520 patients
with hemolytic uremic syndrome
(HUS) – a type of kidney failure that
is associated with E. coli or STEC
infections – and deaths.

DR.T.V.RAO MD 4
 EUROPEAN CENTRE FOR DISEASE PREVENTION
AND CONTROL (ECDC)
REPORTS
• Disease Prevention
and Control (ECDC)
said the "causative
agent" was a strain
of bacteria that are
called Shiga toxin-
producing
Escherichia coli, or
STEC.
DR.T.V.RAO MD 5
 VEGETABLES AS SOURCE OF
E.COLI INFECTIONS
• While suspicion has fallen on raw
tomatoes, cucumbers and lettuce
as the source of the germ,
researchers have been unable to
pinpoint the food responsible.
The outbreak is considered the
third-largest involving E. coli in
recent world history, and it is
already the deadliest. Twelve
people died in a 1996 Japanese
outbreak that reportedly sickened
more than 9,000, and seven died
in a Canadian outbreak in 2000.

DR.T.V.RAO MD 6
 CYCLE OF EVENTS IN SPREAD OF STEC
RUMINANTS AND CONTAMINATION CYCLE

DR.T.V.RAO MD 7
 CYCLE OF EVENTS IN SPREAD OF STEC
STEC RUMINANTS AND CONTAMINATION CYCLE

DR.T.V.RAO MD 8
 SHIGA TOXINS
• E-coli isn’t usually disease- causing, a
major commensal in humans.
• Shiga toxin is one of the most
potent toxins known to man, so
much so that the Centers for
Disease Control and Prevention
lists it as a potential bioterrorist
agent
• Most kinds of E. coli bacteria
do not cause disease in
humans, indeed, some are
beneficial, and some cause
infections other than
gastrointestinal infections,
such urinary tract infections.

DR.T.V.RAO MD 9
 WHAT ARE SHIGA TOXIN-PRODUCING E. COLI?

• Some kinds of E. coli cause disease

by making a toxin called Shiga toxin.
The bacteria that make these toxins
are called ―Shiga toxin-producing‖ E.
coli, or STEC for short. You might hear
them called Vero cytotoxic E. coli
(VTEC) or Enterohemorrhagic E. coli
(EHEC); these all refer generally to the
same group of bacteria. The most
commonly identified STEC in North
America is E. coli O157:H7 (often
shortened to E. coli O157 or even just
―O157‖). When you hear news reports
about outbreaks of ―E. coli‖ infections,
they are usually talking about E. coli
O157.

DR.T.V.RAO MD 10
 E.COLI 0104: H4 RESEMBLES
E. COLI SEROTYPE O157:H7
• E. coli serotype O157:H7 is a rare
variety of E. coli that produces
toxins which are capable of inflicting
damage to the lining of the intestine.
These toxins are closely related or
identical to the toxin produced by
Shigella dysenteriae and are
referred to as Shiga toxins. In very
rare instances, the infection can
progress to hemolytic uremic
syndrome ("HUS") and kidney
failure. E. coli O157:H7 can survive
at low temperatures as well as under
acidic conditions, and the infectious
dose is relatively small.

DR.T.V.RAO MD 11
 E.COLI 0104;H4 PICKED UP NEW
GENES
• t's observed that E. coli O104:H4
has picked up some new genes,
almost certainly through horizontal
gene transfer, in which stretches of
DNA are picked up from other E. coli
strains, or possibly different species
entirely. Once incorporated into the
genome, the new genes can provide
the bacteria with entirely novel
properties. In the case of E. coli
O104:H4, tests have shown that it
now carries a gene for shigatoxin,
which is commonly found in other
disease-causing strains of this
species.

DR.T.V.RAO MD 12
 STRUCTURE OF STEC
• The toxins produced by STEC
were named based on their
similarity in structure and
function to Shiga toxins produced
by Shigella dystenteriae type .
Shiga toxin 1 (Stx1) is
neutralized by antibodies
against Shiga toxin, whereas
Shiga toxin 2 (Stx2) is not
neutralized by antibodies against
Shiga toxin but is neutralized by
homologous antibodies

DR.T.V.RAO MD 13
 THE NEW STRAIN OF E.COLI 0104 H4
A HYBRID STRAIN
• Strain appeared "to be a
hybrid of two different
E. coli types.
• The hybrid strain also
contains the Shiga-like
toxin from
Enterohaemorrhagic E.coli,
This toxin binds to and
damages kidney cells and
can lead to potentially fatal
HUS.

DR.T.V.RAO MD 14
 GENOME OF A KILLER: GERMAN AND CHINESE SCIENTISTS
CRACKED THE GENETIC CODE BEHIND THE STRAIN OF
ESCHERICHIA COLI

DR.T.V.RAO MD 15
 STEC ARE REFERRED AS VEROCYTOTOXINS
• STEC are also
referred to as
verocytotoxigenic E.
coli; STEC that
cause human illness
are also referred to
as Enterohemorrhagic
E. coli.

DR.T.V.RAO MD 16
 HOW THE PATIENTS PRESENT
• Symptoms of STEC infection
include severe stomach cramps,
diarrhea (which is often bloody),
and vomiting. If there is fever, it
usually is not very high. Most
people get better within 5–7
days, but some patients go on to
develop HUS—usually about a
week after the diarrhea starts.
Symptoms of HUS include
decreased frequency of
urination, feeling very tired, and
losing pink color to skin and
membranes due to anemia.

DR.T.V.RAO MD 17
 HEMOLYTIC UREMIC SYNDROME (HUS)
• Around 5–10% of those who are
diagnosed with STEC infection
develop a potentially life-
threatening complication known
as hemolytic uremic syndrome
(HUS). Clues that a person is
developing HUS include
decreased frequency of urination,
feeling very tired, and Persons
with HUS should be hospitalized
because their kidneys may stop
working and they may develop
other serious problems. Most
persons with HUS recover within
a few weeks, but some suffer
permanent damage or die.

DR.T.V.RAO MD 18
DR.T.V.RAO MD 19
 NEED FOR EARLY DIAGNOSIS –
REDUCES RENAL DAMAGE
• Early diagnosis of
STEC infection is
important for
determining the proper
treatment promptly.
Initiation of parenteral
volume expansion early
in the course of O157
STEC infection might
decrease renal damage
and improve patient
outcome
DR.T.V.RAO MD 20
 PROMPT LABORATORY DIAGNOSIS
• Prompt laboratory diagnosis of STEC infection
facilitates rapid subtyping of STEC isolates by public
health laboratories and submission of PFGE patterns to
PulseNet, the national molecular subtyping network for
foodborne disease surveillance . Rapid laboratory
diagnosis and subtyping of STEC isolates leads to
prompt detection of outbreaks, timely public health
actions, and detection of emerging STEC strains.

DR.T.V.RAO MD 21
 SAMPLES ARE TAKEN FROM A CUCUMBER
FOR A MOLECULAR BIOLOGICAL STUDY
• As a major outbreak
of a highly toxic
strain of E. coli
bacteria continues
to sicken residents
of Europe, medical
experts are racing to
find the source

DR.T.V.RAO MD 22
 EARLY PROCESSING OF RESULTS – YIELDS
BETTER RESULTS.
• Specimens should be sent to the
laboratory as soon as possible
for O157 or 0104 STEC culture
and Shiga toxin testing. Ideally,
specimens should be processed
as soon as they are received by
the laboratory. Specimens that
are not processed immediately
should be refrigerated until
tested; if possible, they should
not be held for >24 hours
unpreserved or for >48 hours in
transport medium.

DR.T.V.RAO MD 23
 STEC INFECTIONS DIAGNOSED WITH..

• STEC infections are usually diagnosed through

laboratory testing of stool specimens (feces).
Identifying the specific strain of STEC is essential for
public health purposes, such as finding outbreak. Slabs
that test for the presence of Shiga toxins in stool can
detect non-O157 STEC infections. However, for the
O group (Serogroup) and other characteristics of non-
O157 STEC to be identified. Shiga toxin-positive
specimens must be sent to a Reference laboraoreis in
doubtful cases of 0104 serotypes

DR.T.V.RAO MD 24
 0157AND 0104 CAN BE ISOLATED ON
SELECTIVE MEDIUM
• To isolate O157 STEC,
a stool specimen
should be plated onto a
selective and
differential medium
such as sorbitol-
MacConkey agar
(SMAC) , cefixime
tellurite-sorbitol
MacConkey agar (CT-
SMAC), or
DR.T.V.RAO MD
CHROMagar O157. 25
 CULTURE FOR STEC
• O157 and 0104 STEC
can usually be easily
distinguished from most
E. coli that are
members of the normal
intestinal flora by their
inability to ferment
sorbitol within 24
hours on sorbitol-
containing agar
isolation media
DR.T.V.RAO MD 26
 CHROMAGAR FOR E.COLI O157

• Rapid and reliable detection of the

enterohaemorrhagic E.coli O157. Easily
distinguishable colonies due to the purple
colouring they have aquired. Most other
bacterial species are inhibited, giving
blue or colourles colonies. Despite
specifity is improved in comparison to
Sorbitol MacConkey Agar, when direct
isolation method is used, the false
positive must be screened out by
additional tests and candidates must be
further studied for confirmation.
• . E.coli O157 - purple
• other bacterial colonies -
inhibited, blue or colourles

DR.T.V.RAO MD 27
 COLONIES APPEAR AS PINK ON
CHROMAGAR
• After incubation for 16–
24 hours at 37°C
(99°F), the plate should
be examined for
possible O157 colonies,
which are colorless on
SMAC or CT-SMAC
and are mauve or pink
on CHROMagar O157

DR.T.V.RAO MD 28
 IDENTIFICATION OF 0157
LATEX AGGLUTINATION TEST
• To identify O157 STEC, a portion of a
well-isolated colony (i.e., a distinct,
single colony) should be selected from
the culture plate and tested in O157-
specific antiserum or O157 latex
reagent as recommended by the
manufacturer . Colonies that
agglutinate with one of the O157-
specific reagents and do not
agglutinate with normal serum or
control latex reagent are presumed to
be O157 STEC. At least three colonies
should be screened (CDC,
unpublished data, 2009). If O157
STEC bacteria are identified in any
one of the three colonies, no additional
colonies need to be tested

DR.T.V.RAO MD 29
 IDENTIFICATION WITH BIOCHEMICAL
METHODS
• The colony in which
O157 STEC are
detected should be
streaked onto SMAC or
a nonselective agar
medium such as tryptic
soy agar (TSA), heart
infusion agar (HIA), or
blood agar and
biochemically confirmed
to be E. coli
DR.T.V.RAO MD 30
 PCR ASSAYS CAN DETECT GENETIC
BASIS OF STEC
• PCR assays to detect the stx1
and stx2 genes are used
by many public health laboratories
for diagnosis and confirmation of
STEC infection. Depending on the
primers used, these assays can
distinguish between stx1
and stx2 Assays also have
been developed that determine the
specific O group of an organism,
detect virulence factors such as
intimin and enterohemolysin and can
differentiate among the subtypes of
Shiga toxins

DR.T.V.RAO MD 31
 NEED FOR FOOLPROOF METHODS IN
DIAGNOSIS

• The new isolates of

E.coli 0104 : H4 are
emerging pathogens with
a potential to cause
morbidity and mortality
with community concern,
• The search is for the fool
proof method for isolation
and identification of the
Bacteria

DR.T.V.RAO MD 32
 SUPPORTIVE TREATMENT
• Non-specific supportive
therapy, including
hydration, is important.
Antibiotics should not be
used to treat this
infection. There is no
evidence that treatment
with antibiotics is helpful,
and taking antibiotics may
increase the risk of HUS.
Antidiarrheal agents like
Imodium® may also
increase that risk.
DR.T.V.RAO MD 33
 HOW CAN STEC INFECTIONS BE
PREVENTED?

DR.T.V.RAO MD 34
 HANDING WASHING THE MOST ESSENTIAL
STEP
• WASH HANDS
thoroughly after using the
bathroom or changing
diapers and before
preparing or eating food.
WASH YOUR HANDS
after contact with animals
or their environments (at
farms, petting zoos, fairs,
even your own backyard).

DR.T.V.RAO MD 35
 PROPER COOKING MOST ESSENTIAL STEP
• COOK meats thoroughly.
Ground beef and meat that
has been needle-
tenderized should be
cooked to a temperature of
at least 160°F/70˚C. It’s
best to use a thermometer,
as color is not a very
reliable indicator of
―doneness.‖

DR.T.V.RAO MD 36
 AVOID
• AVOID raw milk,
unpasteurized dairy
products, and
unpasteurized juices
(like fresh apple cider).
• AVOID swallowing water
when swimming or
playing in lakes, ponds,
streams, swimming
pools, and backyard
―kiddie‖ pools.

DR.T.V.RAO MD 37
 NEED FOR PREVENTION
• PREVENT cross
contamination in food
preparation areas by
thoroughly washing
hands, counters, cutting
boards, and utensils
after they touch raw
meat.

DR.T.V.RAO MD 38
 ROLE OF ANTIBIOTICS – CAN THEY HARM ?
• Antibiotics might
increase the risk for
HUS in patients
infected with O157
STEC, and
antidiarrheal
medications might
worsen the illness.
• True with 0104:H4

DR.T.V.RAO MD 39
 DELAYED DIAGNOSIS LEADS TO
OUTBREAKS
• Delayed diagnosis of STEC
infections might lead to
secondary transmission in
homes, child-care
settings, nursing homes,
and food service
establishments and might
delay detection of
multistate outbreaks related
to widely distributed foods .
Outbreaks caused by STEC
with multiple Serogroups
or PFGE patterns have
DR.T.V.RAO MD
been documented. 40
 WHO ADVISES
• The World Health
Organization is warning
people not to take
antibiotics if they get sick in
the E. coli outbreak that
began in Germany last
month.
• Anti-diarrhea medication
isn't recommended either,
as it stops the bacteria from
quickly leaving the body.

DR.T.V.RAO MD 41
 WHY DRUGS ARE DANGEROUS
• Use of antibiotics other
Antidiarrheal treatments "can
actually make the situation
worse." That's because killing
toxin-producing bacteria, such as
the ones responsible for this
outbreak, can actually cause
them to release more toxins. can
actually make the situation
worse." That's because killing
toxin-producing bacteria, such as
the ones responsible for this
outbreak, can actually cause
them to release more toxins.

DR.T.V.RAO MD 42
 VEGETABLES TOO ARE INFECTIOUS
DO BELIEVE IT ???

DR.T.V.RAO MD 43
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INFECTIOUS DISEASES AND MICROBIOLOGY ..

DR.T.V.RAO MD 44
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Professionals in the Development World
• Email
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DR.T.V.RAO MD 45