Escherichia coli is the predominant nonpathogenic facultative flora of the human intestine. Some E. coli strains, however, have developed the ability to cause disease of the gastrointestinal, urinary, or central nervous system in even the most robust human hosts. Diarrheagenic strains of E. coli can be divided into at least six different categories with corresponding distinct pathogenic schemes. Taken together, these organisms probably represent the most common cause of pediatric diarrhea worldwide. Several distinct clinical syndromes accompany infection with diarrheagenic E. coli categories, including traveler’s diarrhea (enterotoxigenic E. coli), hemorrhagic colitis and hemolytic-uremic syndrome (enterohemorrhagic E. coli), persistent diarrhea (enteroaggregative E. coli), and watery diarrhea of infants (enteropathogenic E. coli). This review discusses the current level of understanding of the pathogenesis of the diarrheagenic E. coli strains and describes how their pathogenic schemes underlie the clinical manifestations, diagnostic approach, and epidemiologic investigation of these important pathogens.

Diarrheagenic Escherichia coli

Gram-negative bacteria characteristically are surrounded by an additional membrane layer, the outer membrane. Although outer membrane components often play important roles in the interaction of symbiotic or pathogenic bacteria with their host organisms, the major role of this membrane must usually be to serve as a permeability barrier to prevent the entry of noxious compounds and at the same time to allow the influx of nutrient molecules. This review summarizes the development in the field since our previous review (H. Nikaido and M. Vaara, Microbiol. Rev. 49:1-32, 1985) was published. With the discovery of protein channels, structural knowledge enables us to understand in molecular detail how porins, specific channels, TonB-linked receptors, and other proteins function. We are now beginning to see how the export of large proteins occurs across the outer membrane. With our knowledge of the lipopolysaccharide-phospholipid asymmetric bilayer of the outer membrane, we are finally beginning to understand how this bilayer can retard the entry of lipophilic compounds, owing to our increasing knowledge about the chemistry of lipopolysaccharide from diverse organisms and the way in which lipopolysaccharide structure is modified by environmental conditions.

Molecular Basis of Bacterial Outer Membrane Permeability Revisited

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(13)60844-2.pdf

Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study.

We investigated two outbreaks of an unusual gastrointestinal illness that affected at least 47 people in Oregon and Michigan in February through March and May through June 1982. The illness was characterized by severe crampy abdominal pain, initially watery diarrhea followed by grossly bloody diarrhea, and little or no fever. It was associated with eating at restaurants belonging to the same fast-food restaurant chain in Oregon (P less than 0.005) and Michigan (P = 0.0005) and with eating any of three sandwiches containing three ingredients in common (beef patty, rehydrated onions, and pickles). Stool cultures did not yield previously recognized pathogens. However, a rare Escherichia coli serotype, O157:H7, that was not invasive or toxigenic by standard tests was isolated from 9 of 12 stools collected within four days of onset of illness in both outbreaks combined, and from a beef patty from a suspected lot of meat in Michigan. The only known previous isolation of this serotype was from a sporadic case of hemorrhagic colitis in 1975. This report describes a clinically distinctive gastrointestinal illness associated with E. coli O157:H7, apparently transmitted by undercooked meat.

Hemorrhagic colitis associated with a rare Escherichia coli serotype

Since their initial recognition 20 years ago, Shiga toxin-producing Escherichia coli (STEC) strains have emerged as an important cause of serious human gastrointestinal disease, which may result in life-threatening complications such as hemolytic-uremic syndrome. Food-borne outbreaks of STEC disease appear to be increasing and, when mass-produced and mass-distributed foods are concerned, can involve large numbers of people. Development of therapeutic and preventative strategies to combat STEC disease requires a thorough understanding of the mechanisms by which STEC organisms colonize the human intestinal tract and cause local and systemic pathological changes. While our knowledge remains incomplete, recent studies have improved our understanding of these processes, particularly the complex interaction between Shiga toxins and host cells, which is central to the pathogenesis of STEC disease. In addition, several putative accessory virulence factors have been identified and partly characterized. The capacity to limit the scale and severity of STEC disease is also dependent upon rapid and sensitive diagnostic procedures for analysis of human samples and suspect vehicles. The increased application of advanced molecular technologies in clinical laboratories has significantly improved our capacity to diagnose STEC infection early in the course of disease and to detect low levels of environmental contamination. This, in turn, has created a potential window of opportunity for future therapeutic intervention.

Pathogenesis and Diagnosis of Shiga Toxin-Producing Escherichia coli Infections

Escherichia coli strains that cause diarrhœa but do not produce heat-labile or heat-stable enterotoxins and are non-invasive

Escherichia coli strains isolated from outbreaks of diarrheal disease were tested for the presence of adhesive factors. Fifty-one of these strains belonged to traditional infantile entero-pathogenic serotypes (EPEC) and 17 belonged to other serotypes. None of these strains were enterotoxigenic and none possessed colonization factors CFA/I or CFA/II, which have been described among strains of enterotoxigenicE. coli (ETEC). EnterotoxigenicE. coli strains from patients with diarrhea and strains which were neither EPEC nor ETEC from subjects without diarrhea were also examined. By means of a tissue culture technique using HEp-2 cells, a new adhesive factor was found to occur with greater frequency in EPEC strains. The adhesive factor was found less frequently in the other groups ofE. coli studied. It was distinct from type 1 pili and was not inhibited by the presence ofD-mannose.

An adhesive factor found in strains of Escherichia coli belonging to the traditional infantile enteropathogenic serotypes

Since 1989, strains of Salmonella typhi resistant to chloramphenicol, ampicillin, and trimethoprim (i.e., multidrug-resistant [MDR] strains) have been responsible for numerous outbreaks in countries in the Indian subcontinent, Southeast Asia, and Africa. MDR strains have also been isolated with increasing frequency from immigrant workers in countries in the Arabian Gulf, as well as in developed countries from returning travelers. In all MDR strains so far examined, multiple resistance has been encoded by plasmids of the H1 incompatibility group. As a result of the widespread dissemination of such strains, chloramphenicol can no longer be regarded as the first-line drug for typhoid fever. Because strains are also resistant to ampicillin and trimethoprim, the efficacy of these antibiotics has also been impaired, and ciprofloxacin is now the drug of choice for typhoid fever. Chromosomally encoded resistance to ciprofloxacin has now been observed in a small number of strains isolated in the United Kingdom from patients returning from the Indian subcontinent, and in at least one case the patient did not respond to treatment with this antibiotic. It is regrettable that resistance to ciprofloxacin has now emerged in MDR S. typhi, and it is of paramount importance to limit the unnecessary use of this vital drug so that its efficacy should not be further jeopardized.

Multidrug-Resistant Salmonella typhi: A Worldwide Epidemic

Five bacteriophage stocks were prepared after enrichment of a sewage sample using Escherichia coli 02:K1:H4 (strain U9/41). The bacteriophages were tested for their ability to lyse 224 strains of E. coli that had been tested for the presence of the K1 antigen by means of an antiserum-agar diffusion technique, using a meningococcus group B antiserum known to detect the E. coli K1 antigen. The standard test strains for E. coli K antigens 2 to 99 were used as control strains. Of the 101 strains found to possess the K1 antigen using the antiserum-agar technique, 93 were lysed by at least one of the bacteriophages, whereas 8 of the 123 strains apparently lacking K1 were lysed by one or more of the bacteriophages. None of the standard test strains for K antigens 2 to 99 was lysed by any of the bacteriophages. The eight strains thought to lack K1 but that were lysed by bacteriophage were re-examined by immunoelectrophoresis, using meningococcus group B antiserum; five of the eight strains gave a precipitin line corresponding to K1. The use of K1-specific bacteriophages offers an inexpensive and easy method for the identification of the K1 antigen.

Isolation of bacteriophages specific for the K1 polysaccharide antigen of Escherichia coli.

The incidence of multiple drug resistance (to four or more antimicrobials) in salmonellas from humans in England and Wales in 1996 has been compared with corresponding data for 1994. For Salmonella enteritidis multiple resistance has remained rare, although a high proportion of isolates of phage type 6A have shown resistance to amp ici Hin. For S. typhimurium multiple resistance has continued to increase, with 81% of isolates now multiresistant. Of particular importance in S. typhimurium has been the continued epidemic of multiresistant DT 104 and the increasing occurrence of strains of this phage type with additional resistance to trimethoprim and/or ciprofloxacin. For S. virchow, a 10% increase in multiple resistance is mainly concentrated in two phage types common in returning travellers. For S. hadar, there has been a substantial increase in the incidence of multiple resistance with over 50% of isolates now multiresistant. Substantial increases in the incidence of resistance to ciprofloxacin ...

Bernard Rowe

Papers

Escherichia coli strains that cause diarrhœa but do not produce heat-labile or heat-stable enterotoxins and are non-invasive

An adhesive factor found in strains of Escherichia coli belonging to the traditional infantile enteropathogenic serotypes

Multidrug-Resistant Salmonella typhi: A Worldwide Epidemic

Isolation of bacteriophages specific for the K1 polysaccharide antigen of Escherichia coli.

Increase in Multiple Antibiotic Resistance in Nontyphoidal Salmonellas from Humans in England and Wales: A Comparison of Data for 1994 and 1996