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Update on Emerging Infections from the Centers for Disease Control and Prevention
CDC U P D A T E
U p d a t e on Emerging Infections from the Centers for Disease Control and Prevention Outbreaks of Escherichia coil O157:H7 Infection Associated With Drinking Unpasteurized Apple Cider Centers for Disease Control and Prevention
Commentary David A Talan, MD Laurence Slutsleer, MD
Section Editors David A Tala~a, MD
From the Editors: Thispiece is the first of a regular series on emerging infections from the Centers for Disease Controland Prevention (CDC)and the EMERGEncyID NET, an EDbased and CDC-collaborativesurveillance network. Importantinfectious diseasepublic health information with relevance to emergency physicians will be reported. The goals of this series are to advance knowledge about communicable diseases in emergency medicine and foster cooperation between the front line of clinical medicine and public health agencies.
Gregory] Moran, MD UCLA Medical Center 5ylmar, CA Robert W Pinneg MD Laurence Slutsher, ME) Centers for Disease Control and Prevention Atlanta, GA
Outbreaks of Escherichia coli O157:H7 Infection Associated With Drinking Unpasteurized Apple Cider October 1996 [Centers for Disease Control and Prevention: Outbreaks of Escherichia coil 0157:H7 infection associated with drinking unpasteurized apple cider--October 1996. Ann EmergMed May 1997;29:645.] In October 1996, unpasteurized apple cider or juice was associated with two outbreaks of gastrointestinal illness due to infection with Escherichb cofiO157:HT. In the western United States, an outbreak associated with unpasteurized commercial apple juice caused illness in 66 persons and one death. ~ The clinical and epidemiologic features of another outbreak in Connecticut are described below. 2 On October 11, 1996, the Connecticut Department of Public Health (DPH) was notified of four reported cases of EcofiO157:H7 infection in residents of New Haven County. Investigation of this cluster by case finding at state clini-
MAY 1997 29:5
ANNALS OF EMERGENCY MEDICINE
cal laboratories and a case-control study was conducted by the DPH. Cases were defined by the onset of diarrhea during October 1-11, with confirmed E coil 0157:H7 infection. Controis matched for age, sex, and town of residence reported no diarrhea during the 2g-day period spanning the 10 days before illness onset and the duration of illness in their matched cases, illness was associated with the drinking of fresh apple cider during the 7 days preceding the illness (matched odds ratio [OR], I2.0; 95% confidence interval [Cl], 1.3 to 111.3; P<.gl), specifically with one brand of apple cider. Fourteen cases were eventually identified; of these, 3 patients were hospitalized with hemolytic uremic syndrome (HUS) and 1 with thrombotic thrombocytopenic purpura (TTP). As result of the investigation, the DPH advised Connecticut residents to discard or boil before drinking any of the implicated cider, and this brand was recalled from retail outlets. Cattle are thought to be the primary reservoir of E coil 0157:H7. In this outbreak, cider was pressed from apples purchased from multiple sources; some were "drop" apples (ie, apples picked up from the ground} that may have had contact with ground contaminated with manure. Pasteurization or boiling of apple cider minimizes the risk of E coil infection. m
Commentary [Yalan D, Slutsker L: CDC Update commentary. Ann Emerg Med May 1997;29:645-646.] Escherichb cofiO157:H7 can cause asymptomatic infection. However, the typical illness begins with severe abdominal cramps and nonbloody diarrhea, which becomes bloody by the second or third day of illness. About half of
64 5
CDC U P D A T E
patients experience nausea and vomiting. Unlike Salmonella, Shigella, or Campylobacter infection, fever is usually absent or of low grade in EcofiO157:H7 infection. Because abdominal tenderness and bloody diarrhea are often prominent features of E cofi 0157:1-17infection, it may be misdiagnosed as appendicitis or intussusception, resulting in unnecessary surgery. Although gastrointestinal infection typically resolves 2 to 14 days (median, 6 days) after the onset of illness, in 5% to 10% of patients HUS or TTP develops. In North America, Ecofi 0157:H7 is the most common cause of HUS, which is the most common cause of kidney failure in children. HUS has also been associated with gastrointestinal infection due to Shigella dysenteriae type 1, as well as other non-0157 Shiga toxin-producing Ecofi(STEC) strains. HUS is believed to result from endothelial damage caused by Shiga toxins released by these pathogens. Most E cofi 0157:H7 infections occur in the summertime, and children are the most common victims. Undercoeked hamburger meat is the foodstuff most commonly associated with infection; however, other vehicles indirectly contaminated with infected cattle feces (eg, unpasteurized apple cider and milk, salami, yogurt, and water) have been implicated. Risk factors for the development of HUS include age younger than 10 years, bloody diarrhea, initial illness with fever or increased peripheral WBC count, and the use of antidiarrheal agents. 3,4 Many clinicians choose to avoid the use of antibiotics in children with diarrhea or dysentery and suspected EcofiO157:H7 infection because several retrospective studies have suggested an increased risk of HUS associated with antibiotic use. However, prospective treatment trials are needed to address this question. E coil0157:H7 gastroenteritis has been associated with increased incidence of EO visits, suggesting that the ED may be a useful setting for early outbreak recognition. 5 Outbreak evaluation of potential risk activity has been successfully initiated in the ED for foodborne outbreaks. 6 Stool cultures are recommended in cases of severe or bloody diarrhea and when an outbreak is suspected. Any clinician considering a diagnosis of EcofiO157:H7 gastroenteritis should determine whether a special request for culture of E coil 0157:H7 is required by the laboratory because the range of enteric pathogens included in "routine" stool cultures varies
6 46
widely by laboratory. Recently, rapid assays for the E coil 0157 cell wall antigen and Shiga toxins (including those produced by other non0157 STECstrains) have become commercially available. In most states diarrheal outbreaks (defined as two or more persons with a common exposure) and confirmed cases caused by enteric pathogens, including E cofiO157:H7, are reportable. Cases of HUS or TTP may be sentinel events indicating an Ecofi 0157:H7 outbreak and should be reported to the local or state health department. Early reporting is critical in identifying the source and preventing further infections. An orally administered toxin-binding resin may be a possible future therapy to prevent the development of HUS.7 1. Centersfor Disease Control and Prevention: Outbreak of Escherichia coli 0157:H7 infections associated with drinking unpasteurized commerical applejuice--British Columbia, California, and Washington, October i996. MMWR Morbid Mortal Wkly Rep 1996;45:975. 2. Centersfor Disease Control and Prevention: Outbreaks of Escherichia coli 0157:H7 infection and cryptosporidiosis associated with drinking unpasteurized applie cider-Connecticut and New York, October 1996. MMWR Morbid Mortal Wkly Rep 1997;46:4-7. 3. Cimolai N, CarterJE, Morrison BJ, et al: Riskfactors for the progression of Escherichia coli 0157:H7 enteritis to hemolytic-uremic syndrome. J Pediatr 1990;I 16:589-592. 4. Pavia AT, Nichols CR, Green DP, et al: Hemolyticuremic syndrome during an outbreak of Eschertchia coli 0157:H7 infections in institutionsfor mentally retarded persons: Clinical and epidemioloo~cobservations. J Pediatr 1990;116:544-551. 5. Del Beccaro MA, Brownstein DR, Cummings P, et al: Outbreak of Escherichia coli 0157:H7 hemorrhagic colitis and hemolytic uremic syndrome: Effect on use of a pediatric emergency department. Ann Emerg Med 1995;26:598-603. 6. Goodman LJ, LisowskiJM, Harris AA, et al: Evaluation of an outbreak offoodbome illness in the emergency department. Ann Emerg Med i993;22:1291-1294. 7. Armstrong GD, Fodor E, Vanmaele R: Investigation of Shiga-like toxin binding to chemically synthesized oligosaccharide sequences. J Infect Dis 1991;164:1160-1167.
Reprint no. 47/1/81407
ANNALS OF EMERGENCY MEDICINE
29:5 MAY 1997
U p d a t e on Emerging Infections from the Centers for Disease Control and Prevention Outbreaks of Escherichia coil O157:H7 Infection Associated With Drinking Unpasteurized Apple Cider Centers for Disease Control and Prevention
Commentary David A Talan, MD Laurence Slutsleer, MD
Section Editors David A Tala~a, MD
From the Editors: Thispiece is the first of a regular series on emerging infections from the Centers for Disease Controland Prevention (CDC)and the EMERGEncyID NET, an EDbased and CDC-collaborativesurveillance network. Importantinfectious diseasepublic health information with relevance to emergency physicians will be reported. The goals of this series are to advance knowledge about communicable diseases in emergency medicine and foster cooperation between the front line of clinical medicine and public health agencies.
Gregory] Moran, MD UCLA Medical Center 5ylmar, CA Robert W Pinneg MD Laurence Slutsher, ME) Centers for Disease Control and Prevention Atlanta, GA
Outbreaks of Escherichia coli O157:H7 Infection Associated With Drinking Unpasteurized Apple Cider October 1996 [Centers for Disease Control and Prevention: Outbreaks of Escherichia coil 0157:H7 infection associated with drinking unpasteurized apple cider--October 1996. Ann EmergMed May 1997;29:645.] In October 1996, unpasteurized apple cider or juice was associated with two outbreaks of gastrointestinal illness due to infection with Escherichb cofiO157:HT. In the western United States, an outbreak associated with unpasteurized commercial apple juice caused illness in 66 persons and one death. ~ The clinical and epidemiologic features of another outbreak in Connecticut are described below. 2 On October 11, 1996, the Connecticut Department of Public Health (DPH) was notified of four reported cases of EcofiO157:H7 infection in residents of New Haven County. Investigation of this cluster by case finding at state clini-
MAY 1997 29:5
ANNALS OF EMERGENCY MEDICINE
cal laboratories and a case-control study was conducted by the DPH. Cases were defined by the onset of diarrhea during October 1-11, with confirmed E coil 0157:H7 infection. Controis matched for age, sex, and town of residence reported no diarrhea during the 2g-day period spanning the 10 days before illness onset and the duration of illness in their matched cases, illness was associated with the drinking of fresh apple cider during the 7 days preceding the illness (matched odds ratio [OR], I2.0; 95% confidence interval [Cl], 1.3 to 111.3; P<.gl), specifically with one brand of apple cider. Fourteen cases were eventually identified; of these, 3 patients were hospitalized with hemolytic uremic syndrome (HUS) and 1 with thrombotic thrombocytopenic purpura (TTP). As result of the investigation, the DPH advised Connecticut residents to discard or boil before drinking any of the implicated cider, and this brand was recalled from retail outlets. Cattle are thought to be the primary reservoir of E coil 0157:H7. In this outbreak, cider was pressed from apples purchased from multiple sources; some were "drop" apples (ie, apples picked up from the ground} that may have had contact with ground contaminated with manure. Pasteurization or boiling of apple cider minimizes the risk of E coil infection. m
Commentary [Yalan D, Slutsker L: CDC Update commentary. Ann Emerg Med May 1997;29:645-646.] Escherichb cofiO157:H7 can cause asymptomatic infection. However, the typical illness begins with severe abdominal cramps and nonbloody diarrhea, which becomes bloody by the second or third day of illness. About half of
64 5
CDC U P D A T E
patients experience nausea and vomiting. Unlike Salmonella, Shigella, or Campylobacter infection, fever is usually absent or of low grade in EcofiO157:H7 infection. Because abdominal tenderness and bloody diarrhea are often prominent features of E cofi 0157:1-17infection, it may be misdiagnosed as appendicitis or intussusception, resulting in unnecessary surgery. Although gastrointestinal infection typically resolves 2 to 14 days (median, 6 days) after the onset of illness, in 5% to 10% of patients HUS or TTP develops. In North America, Ecofi 0157:H7 is the most common cause of HUS, which is the most common cause of kidney failure in children. HUS has also been associated with gastrointestinal infection due to Shigella dysenteriae type 1, as well as other non-0157 Shiga toxin-producing Ecofi(STEC) strains. HUS is believed to result from endothelial damage caused by Shiga toxins released by these pathogens. Most E cofi 0157:H7 infections occur in the summertime, and children are the most common victims. Undercoeked hamburger meat is the foodstuff most commonly associated with infection; however, other vehicles indirectly contaminated with infected cattle feces (eg, unpasteurized apple cider and milk, salami, yogurt, and water) have been implicated. Risk factors for the development of HUS include age younger than 10 years, bloody diarrhea, initial illness with fever or increased peripheral WBC count, and the use of antidiarrheal agents. 3,4 Many clinicians choose to avoid the use of antibiotics in children with diarrhea or dysentery and suspected EcofiO157:H7 infection because several retrospective studies have suggested an increased risk of HUS associated with antibiotic use. However, prospective treatment trials are needed to address this question. E coil0157:H7 gastroenteritis has been associated with increased incidence of EO visits, suggesting that the ED may be a useful setting for early outbreak recognition. 5 Outbreak evaluation of potential risk activity has been successfully initiated in the ED for foodborne outbreaks. 6 Stool cultures are recommended in cases of severe or bloody diarrhea and when an outbreak is suspected. Any clinician considering a diagnosis of EcofiO157:H7 gastroenteritis should determine whether a special request for culture of E coil 0157:H7 is required by the laboratory because the range of enteric pathogens included in "routine" stool cultures varies
6 46
widely by laboratory. Recently, rapid assays for the E coil 0157 cell wall antigen and Shiga toxins (including those produced by other non0157 STECstrains) have become commercially available. In most states diarrheal outbreaks (defined as two or more persons with a common exposure) and confirmed cases caused by enteric pathogens, including E cofiO157:H7, are reportable. Cases of HUS or TTP may be sentinel events indicating an Ecofi 0157:H7 outbreak and should be reported to the local or state health department. Early reporting is critical in identifying the source and preventing further infections. An orally administered toxin-binding resin may be a possible future therapy to prevent the development of HUS.7 1. Centersfor Disease Control and Prevention: Outbreak of Escherichia coli 0157:H7 infections associated with drinking unpasteurized commerical applejuice--British Columbia, California, and Washington, October i996. MMWR Morbid Mortal Wkly Rep 1996;45:975. 2. Centersfor Disease Control and Prevention: Outbreaks of Escherichia coli 0157:H7 infection and cryptosporidiosis associated with drinking unpasteurized applie cider-Connecticut and New York, October 1996. MMWR Morbid Mortal Wkly Rep 1997;46:4-7. 3. Cimolai N, CarterJE, Morrison BJ, et al: Riskfactors for the progression of Escherichia coli 0157:H7 enteritis to hemolytic-uremic syndrome. J Pediatr 1990;I 16:589-592. 4. Pavia AT, Nichols CR, Green DP, et al: Hemolyticuremic syndrome during an outbreak of Eschertchia coli 0157:H7 infections in institutionsfor mentally retarded persons: Clinical and epidemioloo~cobservations. J Pediatr 1990;116:544-551. 5. Del Beccaro MA, Brownstein DR, Cummings P, et al: Outbreak of Escherichia coli 0157:H7 hemorrhagic colitis and hemolytic uremic syndrome: Effect on use of a pediatric emergency department. Ann Emerg Med 1995;26:598-603. 6. Goodman LJ, LisowskiJM, Harris AA, et al: Evaluation of an outbreak offoodbome illness in the emergency department. Ann Emerg Med i993;22:1291-1294. 7. Armstrong GD, Fodor E, Vanmaele R: Investigation of Shiga-like toxin binding to chemically synthesized oligosaccharide sequences. J Infect Dis 1991;164:1160-1167.
Reprint no. 47/1/81407
ANNALS OF EMERGENCY MEDICINE
29:5 MAY 1997