Research Article
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Exploring the Less Common Pathogens of Infectious Diarrhea

Year 2019, , 1 - 9, 15.03.2019
https://doi.org/10.5799/jmid.537127

Abstract

ABSTRACT



Objective: Gastrointestinal (GI) panels have allowed for faster
and accurate detection, treatment, and control of pathogens. Because of the
large number of potential pathogens included in the panel the clinical
significance and manifestations of some organisms, such as Enteroaggregative Escherichia coli (EAEC) and
Enteropathogenic E. coli (EPEC),
remains undetermined.



Methodology: We performed a single-institution retrospective chart
review for 222 patients with a stool sample tested on BioFire FilmArray
Gastrointestinal Panel (GI Panel) between June 1, 2016 and March 9, 2017.



Results:
Of
the 222 patients, four had EAEC and 17 and EPEC. Patients who tested positive
for EAEC and EPEC were younger (26.3 years and 33.9 years, respectively) than
patients that did not test positive for a GI pathogen (47.7 years). In cases
where multiple organisms were detected, EPEC was present 56.3% of the time.
Analysis of symptoms showed that EPEC patients had a high prevalence of
abdominal pain (p=0.0425) and vomiting (p=0.0045), but not diarrhea, when
compared to the presence of these symptoms in patients with no targets
detected. With only four patients positive for EAEC in this study, the results
of symptoms in EAEC patients were inconclusive. Cases involving EPEC and EAEC
were treated similarly to other cases of diarrhea with no significant
difference in the number of imaging studies and medication changes.



Conclusions: While further studies
are required to determine the specific clinical significance of EAEC or EPEC,
it is evident that patients positive for EPEC often experience abdominal pain
and diarrhea, suggesting EPEC may be more pathogenic than previously thought.  J
Microbiol Infect Dis 2019; 9(1):1-9.

References

  • 1. DuPont HL. Persistent Diarrhea: A Clinical Review. JAMA 2016 Jun 28; 315(24):2712. 2. Riddle MS, DuPont, Herbert L., Connor, Bradley A. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol 2016; 111. 3. World Health Organization. World Health Organization: Diarrhoeal disease. 2016 Dec 20. http://www.who.int/mediacentre/factsheets/fs330/en/ 4. Dickinson B, Surawicz CM. Infectious Diarrhea: An Overview. Curr Gastroenterol Rep 2014; 2016 16(8):399. 5. Huang JY. Infection with Pathogens Transmitted Commonly Through Food and the Effect of Increasing Use of Culture-Independent Diagnostic Tests on Surveillance-Foodborne Diseases Active Surveillance Network, 10 US Sites, 2012–2015. MMWR Morb Mortal Wkly Rep 2016; 65(14):368-371. 6. Liu J, Gratz J, Maro A, et al. Simultaneous Detection of Six Diarrhea-Causing Bacterial Pathogens with an In-House PCR-Luminex Assay. J Clin Microbiol 2012; 50(1):98-103. 7. Guerrant RL, Gilder TV, Steiner TS, et al. Practice Guidelines for the Management of Infectious Diarrhea. Clin Infect Dis 2001; 32(3):331-351. 8. Barr W, Smith A. Acute diarrhea. Am Fam Physician 2014; 89(3):180-189. 9. Buss SN, Leber A, Chapin K, et al. Multicenter Evaluation of the BioFire FilmArray Gastrointestinal Panel for Etiologic Diagnosis of Infectious Gastroenteritis. J Clin Microbiol 2015; 53(3):915-925. 10. Piralla A, Lunghi G, Ardissino G, et al. FilmArrayTM GI panel performance for the diagnosis of acute gastroenteritis or hemorragic diarrhea. BMC Microbiol 2017: 17(1): 111. 11. Arenas-Hernández MMP, Martínez-Laguna Y, Torres AG. Clinical Implications of Enteroadherent Escherichia coli. Curr Gastroenterol Rep 2012; 14(5):386-394. 12. Law RJ, Gur-Arie L, Rosenshine I, Finlay BB. In Vitro and In Vivo Model Systems for Studying Enteropathogenic Escherichia coli Infections. Cold Spring Harb Perspect Med 2013; 3(3):a009977. 13. Estrada-Garcia T, Navarro-Garcia F. Enteroaggregative Escherichia coli pathotype: a genetically heterogeneous emerging foodborne enteropathogen. FEMS Immunol Med Microbiol. 2012; 66(3):281-298. 14. Nataro JP, Kaper JB. Diarrheagenic Escherichia coli. Clin Microbiol Rev 1998; 11(1):142-201. 15. Okhuysen PC, DuPont HL. Enteroaggregative Escherichia coli (EAEC): A Cause of Acute and Persistent Diarrhea of Worldwide Importance. J Infect Dis 2010; 15; 202(4):503-505. 16. Huppertz HI, Rutkowski S, Aleksic S, Karch H. Acute and chronic diarrhoea and abdominal colic associated with enteroaggregative Escherichia coli in young children living in Western Europe. The Lancet 1997; 349(9066):1660-1662. 17. Shin J, Oh S-S, Oh K-H, et al. An Outbreak of Foodborne Illness Caused by Enteroaggregative Escherichia coli in a High School in South Korea. Jpn J Infect Dis 2015; 68(6):514-519. 18. Hebbelstrup Jensen B, Olsen KEP, Struve C, Krogfelt KA, Petersen AM. Epidemiology and Clinical Manifestations of Enteroaggregative Escherichia coli. Clin Microbiol Rev. 2014; 27(3):614-630. 19. Aslani MM, Alikhani MY, Zavari A, Yousefi R, Zamani AR. Characterization of enteroaggregative Escherichia coli (EAEC) clinical isolates and their antibiotic resistance pattern. Int J Infect Dis 2011; 15(2):e136-e139. 20. Nataro JP, Yikang D, Yingkang D, Walker K. AggR, a transcriptional activator of aggregative adherence fimbria I expression in enteroaggregative Escherichia coli. J Bacteriol 1994; 176(15):4691-4699. 21. Hu J, Torres AG. Enteropathogenic Escherichia coli: foe or innocent bystander? Clin Microbiol Infect 2015; 21(8):729-734. 22. Goosney DL, Gryenheid S, Finlay BB. Gut Feelings: Enteropathogenic E. coli (EPEC) Interactions with the host. Annu Rev Cell Dev Biol 2000; 16:173-189. 23. Trabulsi LR, Keller R, Gomes TAT. Typical and atypical Enteropathogenic Escherichia coli. (Synopsis). Emerg Infect Dis 2002; 8(5):508-514. 24. Ochoa TJ, Barletta F, Contreras C, Mercado E. New insights into the epidemiology of enteropathogenic Escherichia coli infection. Trans R Soc Trop Med Hyg 2008; 102(9):852-856. 25. Ochoa TJ, Contreras CA. Enteropathogenic Escherichia coli infection in children: Curr Opin Infect Dis 2011; 24(5):478-483. 26. Afset JE. Association of atypical enteropathogenic Escherichia coli (EPEC) with prolonged diarrhoea. J Med Microbiol 2004; 53(11):1137-1144. 27. Hernandes RT, Elias WP, Vieira MAM, Gomes TAT. An overview of atypical enteropathogenic Escherichia coli. FEMS Microbiol Lett 2009; 297(2):137-149. 28. Knutton S, Shaw R, Phillips AD, et al. Phenotypic and genetic analysis of diarrhea-associated Escherichia coli isolated from children in the United Kingdom. J Pediatr Gastroenterol Nutr 2001; 33(1):32-40. 29. Araujo JM, Tabarelli GF, Aranda KRS, et al. Typical Enteroaggregative and Atypical Enteropathogenic Types of Escherichia coli Are the Most Prevalent Diarrhea-Associated Pathotypes among Brazilian Children. J Clin Microbiol 2007; 45(10):3396-3399. 30. Yatsuyanagi J, Saito S, Sato H, Miyajima Y, Amano K-I, Enomoto K. Characterization of Enteropathogenic and Enteroaggregative Escherichia coli Isolated from Diarrheal Outbreaks. J Clin Microbiol. 2002; 40(1):294-297. 31. Dulguer MV, Fabbricotti SH, Bando SY, Moreira-Filho CA, Fagundes-Neto U, Scaletsky IC. Atypical Enteropathogenic Escherichia coli Strains: Phenotypic and Genetic Profiling Reveals Strong Association between Enteroaggregative E. coli Heat Stable Enterotoxin and DIarrhea. J Infect Dis. 2003; 188:1685-1694. 32. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) -- A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42(2):377-381. 33. Campbell I. Chi-squared and Fisher-Irwin tests of two-by-two tables with small sample recommendations. Stat Med 2007; 30; 26(19):3661-3675. 34. Richardson JTE. The analysis of 2 × 2 contingency tables--yet again. Stat Med. 2011 Apr 15; 30(8):890; author reply 891-892. 35. Chen J, Ryu E, Hathcock M, et al. Impact of demographics on human gut microbial diversity in a US Midwest population. Peer J 2016; 4:e1514. 36. Brooks AW, Priya S, Blekhman R, Bordenstein SR. Gut microbiota diversity across ethnicities in the United States. PLoS Biol 2018; 16(12):e2006842. 37. Davis SC, Yadav JS, Barrow SD, Robertson BK. Gut microbiome diversity influenced more by the Westernized dietary regime than the body mass index as assessed using effect size statistic. Microbiology Open 2017; 6(4):e00476. 38. Wen L, Duffy A. Factors Influencing the Gut Microbiota, Inflammation, and Type 2 Diabetes. J Nutr 2017; 147(7):1468S-1475S. 39. Spina A, Kerr KG, Cormican M, et al. Spectrum of enteropathogens detected by the FilmArray GI Panel in a multicentre study of community-acquired gastroenteritis. Clin Microbiol Infect 2015; 21(8):719-728. 40. Khare R, Espy MJ, Cebelinski E, et al. Comparative Evaluation of Two Commercial Multiplex Panels for Detection of Gastrointestinal Pathogens by Use of Clinical Stool Specimens. J Clin Microbiol 2014; 52(10):3667-3673. 41. Mercado EH, Ochoa TJ, Ecker L, et al. Fecal Leukocytes in Children Infected with Diarrheagenic Escherichia coli. J Clin Microbiol 2011; 49(4):1376-1381.
Year 2019, , 1 - 9, 15.03.2019
https://doi.org/10.5799/jmid.537127

Abstract

References

  • 1. DuPont HL. Persistent Diarrhea: A Clinical Review. JAMA 2016 Jun 28; 315(24):2712. 2. Riddle MS, DuPont, Herbert L., Connor, Bradley A. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol 2016; 111. 3. World Health Organization. World Health Organization: Diarrhoeal disease. 2016 Dec 20. http://www.who.int/mediacentre/factsheets/fs330/en/ 4. Dickinson B, Surawicz CM. Infectious Diarrhea: An Overview. Curr Gastroenterol Rep 2014; 2016 16(8):399. 5. Huang JY. Infection with Pathogens Transmitted Commonly Through Food and the Effect of Increasing Use of Culture-Independent Diagnostic Tests on Surveillance-Foodborne Diseases Active Surveillance Network, 10 US Sites, 2012–2015. MMWR Morb Mortal Wkly Rep 2016; 65(14):368-371. 6. Liu J, Gratz J, Maro A, et al. Simultaneous Detection of Six Diarrhea-Causing Bacterial Pathogens with an In-House PCR-Luminex Assay. J Clin Microbiol 2012; 50(1):98-103. 7. Guerrant RL, Gilder TV, Steiner TS, et al. Practice Guidelines for the Management of Infectious Diarrhea. Clin Infect Dis 2001; 32(3):331-351. 8. Barr W, Smith A. Acute diarrhea. Am Fam Physician 2014; 89(3):180-189. 9. Buss SN, Leber A, Chapin K, et al. Multicenter Evaluation of the BioFire FilmArray Gastrointestinal Panel for Etiologic Diagnosis of Infectious Gastroenteritis. J Clin Microbiol 2015; 53(3):915-925. 10. Piralla A, Lunghi G, Ardissino G, et al. FilmArrayTM GI panel performance for the diagnosis of acute gastroenteritis or hemorragic diarrhea. BMC Microbiol 2017: 17(1): 111. 11. Arenas-Hernández MMP, Martínez-Laguna Y, Torres AG. Clinical Implications of Enteroadherent Escherichia coli. Curr Gastroenterol Rep 2012; 14(5):386-394. 12. Law RJ, Gur-Arie L, Rosenshine I, Finlay BB. In Vitro and In Vivo Model Systems for Studying Enteropathogenic Escherichia coli Infections. Cold Spring Harb Perspect Med 2013; 3(3):a009977. 13. Estrada-Garcia T, Navarro-Garcia F. Enteroaggregative Escherichia coli pathotype: a genetically heterogeneous emerging foodborne enteropathogen. FEMS Immunol Med Microbiol. 2012; 66(3):281-298. 14. Nataro JP, Kaper JB. Diarrheagenic Escherichia coli. Clin Microbiol Rev 1998; 11(1):142-201. 15. Okhuysen PC, DuPont HL. Enteroaggregative Escherichia coli (EAEC): A Cause of Acute and Persistent Diarrhea of Worldwide Importance. J Infect Dis 2010; 15; 202(4):503-505. 16. Huppertz HI, Rutkowski S, Aleksic S, Karch H. Acute and chronic diarrhoea and abdominal colic associated with enteroaggregative Escherichia coli in young children living in Western Europe. The Lancet 1997; 349(9066):1660-1662. 17. Shin J, Oh S-S, Oh K-H, et al. An Outbreak of Foodborne Illness Caused by Enteroaggregative Escherichia coli in a High School in South Korea. Jpn J Infect Dis 2015; 68(6):514-519. 18. Hebbelstrup Jensen B, Olsen KEP, Struve C, Krogfelt KA, Petersen AM. Epidemiology and Clinical Manifestations of Enteroaggregative Escherichia coli. Clin Microbiol Rev. 2014; 27(3):614-630. 19. Aslani MM, Alikhani MY, Zavari A, Yousefi R, Zamani AR. Characterization of enteroaggregative Escherichia coli (EAEC) clinical isolates and their antibiotic resistance pattern. Int J Infect Dis 2011; 15(2):e136-e139. 20. Nataro JP, Yikang D, Yingkang D, Walker K. AggR, a transcriptional activator of aggregative adherence fimbria I expression in enteroaggregative Escherichia coli. J Bacteriol 1994; 176(15):4691-4699. 21. Hu J, Torres AG. Enteropathogenic Escherichia coli: foe or innocent bystander? Clin Microbiol Infect 2015; 21(8):729-734. 22. Goosney DL, Gryenheid S, Finlay BB. Gut Feelings: Enteropathogenic E. coli (EPEC) Interactions with the host. Annu Rev Cell Dev Biol 2000; 16:173-189. 23. Trabulsi LR, Keller R, Gomes TAT. Typical and atypical Enteropathogenic Escherichia coli. (Synopsis). Emerg Infect Dis 2002; 8(5):508-514. 24. Ochoa TJ, Barletta F, Contreras C, Mercado E. New insights into the epidemiology of enteropathogenic Escherichia coli infection. Trans R Soc Trop Med Hyg 2008; 102(9):852-856. 25. Ochoa TJ, Contreras CA. Enteropathogenic Escherichia coli infection in children: Curr Opin Infect Dis 2011; 24(5):478-483. 26. Afset JE. Association of atypical enteropathogenic Escherichia coli (EPEC) with prolonged diarrhoea. J Med Microbiol 2004; 53(11):1137-1144. 27. Hernandes RT, Elias WP, Vieira MAM, Gomes TAT. An overview of atypical enteropathogenic Escherichia coli. FEMS Microbiol Lett 2009; 297(2):137-149. 28. Knutton S, Shaw R, Phillips AD, et al. Phenotypic and genetic analysis of diarrhea-associated Escherichia coli isolated from children in the United Kingdom. J Pediatr Gastroenterol Nutr 2001; 33(1):32-40. 29. Araujo JM, Tabarelli GF, Aranda KRS, et al. Typical Enteroaggregative and Atypical Enteropathogenic Types of Escherichia coli Are the Most Prevalent Diarrhea-Associated Pathotypes among Brazilian Children. J Clin Microbiol 2007; 45(10):3396-3399. 30. Yatsuyanagi J, Saito S, Sato H, Miyajima Y, Amano K-I, Enomoto K. Characterization of Enteropathogenic and Enteroaggregative Escherichia coli Isolated from Diarrheal Outbreaks. J Clin Microbiol. 2002; 40(1):294-297. 31. Dulguer MV, Fabbricotti SH, Bando SY, Moreira-Filho CA, Fagundes-Neto U, Scaletsky IC. Atypical Enteropathogenic Escherichia coli Strains: Phenotypic and Genetic Profiling Reveals Strong Association between Enteroaggregative E. coli Heat Stable Enterotoxin and DIarrhea. J Infect Dis. 2003; 188:1685-1694. 32. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) -- A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42(2):377-381. 33. Campbell I. Chi-squared and Fisher-Irwin tests of two-by-two tables with small sample recommendations. Stat Med 2007; 30; 26(19):3661-3675. 34. Richardson JTE. The analysis of 2 × 2 contingency tables--yet again. Stat Med. 2011 Apr 15; 30(8):890; author reply 891-892. 35. Chen J, Ryu E, Hathcock M, et al. Impact of demographics on human gut microbial diversity in a US Midwest population. Peer J 2016; 4:e1514. 36. Brooks AW, Priya S, Blekhman R, Bordenstein SR. Gut microbiota diversity across ethnicities in the United States. PLoS Biol 2018; 16(12):e2006842. 37. Davis SC, Yadav JS, Barrow SD, Robertson BK. Gut microbiome diversity influenced more by the Westernized dietary regime than the body mass index as assessed using effect size statistic. Microbiology Open 2017; 6(4):e00476. 38. Wen L, Duffy A. Factors Influencing the Gut Microbiota, Inflammation, and Type 2 Diabetes. J Nutr 2017; 147(7):1468S-1475S. 39. Spina A, Kerr KG, Cormican M, et al. Spectrum of enteropathogens detected by the FilmArray GI Panel in a multicentre study of community-acquired gastroenteritis. Clin Microbiol Infect 2015; 21(8):719-728. 40. Khare R, Espy MJ, Cebelinski E, et al. Comparative Evaluation of Two Commercial Multiplex Panels for Detection of Gastrointestinal Pathogens by Use of Clinical Stool Specimens. J Clin Microbiol 2014; 52(10):3667-3673. 41. Mercado EH, Ochoa TJ, Ecker L, et al. Fecal Leukocytes in Children Infected with Diarrheagenic Escherichia coli. J Clin Microbiol 2011; 49(4):1376-1381.
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Details

Primary Language English
Subjects Health Care Administration
Journal Section Research Article
Authors

Steven Toffel This is me

Lymaries Velez This is me

Elizabeth Tremblay This is me

Kairav Shah This is me

Kenneth Rand This is me

Jena Auerbach This is me

Kathryn Anne Potter This is me

Stacy G. Bea This is me

Publication Date March 15, 2019
Published in Issue Year 2019

Cite

APA Toffel, S., Velez, L., Tremblay, E., Shah, K., et al. (2019). Exploring the Less Common Pathogens of Infectious Diarrhea. Journal of Microbiology and Infectious Diseases, 09(01), 1-9. https://doi.org/10.5799/jmid.537127
AMA Toffel S, Velez L, Tremblay E, Shah K, Rand K, Auerbach J, Potter KA, Bea SG. Exploring the Less Common Pathogens of Infectious Diarrhea. J Microbil Infect Dis. March 2019;09(01):1-9. doi:10.5799/jmid.537127
Chicago Toffel, Steven, Lymaries Velez, Elizabeth Tremblay, Kairav Shah, Kenneth Rand, Jena Auerbach, Kathryn Anne Potter, and Stacy G. Bea. “Exploring the Less Common Pathogens of Infectious Diarrhea”. Journal of Microbiology and Infectious Diseases 09, no. 01 (March 2019): 1-9. https://doi.org/10.5799/jmid.537127.
EndNote Toffel S, Velez L, Tremblay E, Shah K, Rand K, Auerbach J, Potter KA, Bea SG (March 1, 2019) Exploring the Less Common Pathogens of Infectious Diarrhea. Journal of Microbiology and Infectious Diseases 09 01 1–9.
IEEE S. Toffel, L. Velez, E. Tremblay, K. Shah, K. Rand, J. Auerbach, K. A. Potter, and S. G. Bea, “Exploring the Less Common Pathogens of Infectious Diarrhea”, J Microbil Infect Dis, vol. 09, no. 01, pp. 1–9, 2019, doi: 10.5799/jmid.537127.
ISNAD Toffel, Steven et al. “Exploring the Less Common Pathogens of Infectious Diarrhea”. Journal of Microbiology and Infectious Diseases 09/01 (March 2019), 1-9. https://doi.org/10.5799/jmid.537127.
JAMA Toffel S, Velez L, Tremblay E, Shah K, Rand K, Auerbach J, Potter KA, Bea SG. Exploring the Less Common Pathogens of Infectious Diarrhea. J Microbil Infect Dis. 2019;09:1–9.
MLA Toffel, Steven et al. “Exploring the Less Common Pathogens of Infectious Diarrhea”. Journal of Microbiology and Infectious Diseases, vol. 09, no. 01, 2019, pp. 1-9, doi:10.5799/jmid.537127.
Vancouver Toffel S, Velez L, Tremblay E, Shah K, Rand K, Auerbach J, Potter KA, Bea SG. Exploring the Less Common Pathogens of Infectious Diarrhea. J Microbil Infect Dis. 2019;09(01):1-9.