Background. In May–July 2011, Germany experienced a large food-borne outbreak of Shiga toxin 2—producing Escherichia coli (STEC O104:H4) with 3842 cases, including 855 cases with hemolytic uremic ...syndrome (HUS) and 53 deaths. Methods. A multicenter study was initiated in 5 university hospitals to determine pathogen shedding duration. Diagnostics comprised culture on selective media, toxin enzyme-linked immunosorbent assay, and polymerase chain reaction. Results were correlated with clinical and epidemiologic findings. Testing for pathogen excretion was continued after discharge of the patient. Results. A total of 321 patients (104 male, 217 female) were included (median age, 40 years range, 1–89 days). Median delay from onset of symptoms to hospitalization was 4 days (range, 0–17 days). Two hundred nine patients presented with HUS. The estimate for the median duration of shedding was 17–18 days. Some patients remained STEC O104:H4 positive until the end of the observation time (maximum observed shedding duration: 157 days). There was no significant influence of sex on shedding duration. Patients presenting with HUS had a significantly shortened shedding duration (median, 13–14 days) compared to non-HUS patients (median, 33–34 days). Antimicrobial treatment was also significantly associated with reduced shedding duration. Children (age ≤15 years) had longer shedding durations than adults (median, 35–41 vs 14–15 days). Conclusions. STEC O104:H4 is usually eliminated from the human gut after 1 month, but may sometimes be excreted for several months. Proper follow-up of infected patients is important to avoid further pathogen spread.
An outbreak of Shiga toxin-producing enteroaggregative Escherichia coli (STEC O104:H4) infection with a high incidence of hemolytic uremic syndrome (HUS) occurred in Germany in May 2011. Antibiotic ...treatment of STEC infection is discouraged because it might increase the risk of HUS development. However, antibiotic therapy is widely used to treat enteroaggregative E coli infection. In the German outbreak, a substantial number of patients received prophylactic azithromycin treatment as part of a therapeutic regimen with the C5 antibody eculizumab.
To analyze the duration of bacterial shedding in patients with STEC infection who did and did not receive oral azithromycin therapy.
At a single center in Lübeck, Germany, 65 patients with STEC infection, including patients with HUS as well as STEC-infected outpatients without manifestation of HUS, were investigated between May 15 and July 26, 2011, and were monitored for a mean of 39.3 days after onset of clinical symptoms.
Carriage of STEC after azithromycin therapy.
Twenty-two patients received oral azithromycin and 43 patients did not receive antibiotic treatment. Among antibiotic-treated patients, long-term STEC carriage (>28 days) was observed in 1 of 22 patients (4.5%; 95% CI, 0%-13.3%) compared with 35 of 43 patients (81.4%; 95% CI, 69.8%-93.0%) who were not treated with antibiotics (P < .001). All 22 patients receiving azithromycin treatment had at least 3 STEC-negative stool specimens after the completion of treatment, and no recurrence of STEC was observed in these patients. As proof of principle, 15 patients who initially were not treated with antibiotics and were long-term STEC carriers were treated with oral azithromycin given for 3 days and subsequently had negative stool specimens.
Treatment with azithromycin was associated with a lower frequency of long-term STEC O104:H4 carriage.
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