ドイツ連邦(国立)疫病研究所(RKI)による医者への病原性(出血性)大腸菌(EHEC)感染の案内

ドイツ連邦(国立)疫病研究所(RKI)による医者への病原性(出血性)大腸菌(EHEC)感染の案内

You are here: HomeSearch infectious diseases A - ZEHEC infections Diseases due to Enterohemorrhagic Escherichia coli (EHEC) RKI Guide for Physicians
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  Recommendations for laboratory diagnosis of EHEC infection-control measures and preventive therapy
  1st Preventive measures2. Preventing the proliferation - measures for patients, and Kontaktpersonen3 shedders. Measures in reporting outbreaks mandatory counseling and special diagnostics InformationsquellenDie selected publication in this series by the Robert Koch Institute (RKI) is based on § 4 of the Infection Protection Act (IPA). Practically important information on key infectious diseases and are currently focused orientation. The contributions are worked out in cooperation with the National Reference Centres, advisory laboratories and other experts. The first publication is in the Epidemiologic Bulletin and the Internet (http://www.rki.de). An update is based on the requirements, usually replace the Internet, updated versions of the older ones.

Updated version of June 2011, first published in the Epidemiological Bulletin 31/1999
Pathogen Enterohaemorrhagic Escherichia (E.) coli bacteria (Gram-negative rods) that the fundamental property of the formation of certain cytotoxins, the shigatoxins - Stx (synonyms: Shiga-like toxins - VT - SLT, verotoxins) possess. They are grouped under the term Shiga toxin-or verotoxin-producing E. coli (STEC or VTEC). STEC were historically referred to as EHEC those who were capable of serious illnesses (hemorrhagic colitis and hemolytic-uremic syndrome - HUS) cause. In the past two decades, however, a variety of STEC strains from patients with mild gastroenteritischen symptoms was isolated, so that will be understood in the Infection Protection Act (IPA) under the term EHEC those STEC, which are capable of triggering human ills, are human pathogens that . Because their antigen structure they belong to different serogroups (classification according to surface O antigens) on. The world's most commonly isolated EHEC O157 serogroup is. This also applies to Germany, where they account for the gastroenteritischen sent to the RKI EHEC disease less than 20%. Other frequently isolated serotypes are O26, O91, O103 and O145. Since in connection with EHEC disease in humans is still new serogroups or serovars (classification according to O and H antigens, such as O157: H7) can be determined, is a definition of human pathogenic STEC is not currently possible. For this reason, the time of each STEC considered a potential EHEC. Those produced by EHEC shigatoxins be divided into two main groups (Stx 1 and Stx 2), of which there are, again, different versions (eg Stx 2c). Severe illnesses, such as HUS, are caused mainly by Stx 2 (or Stx 2c)-producing EHEC.
Pathogenesis Shigatoxins bind to specific cell wall receptors, mainly in the capillary endothelium, where the blocking protein synthesis and lead to rapid cell death. In addition, many EHEC a so-called pathogenicity island (LEE - locus of enterocytes effacement), which is responsible for a type III secretion apparatus. With its help you EHEC cytotoxic or inhibitory or modulating proteins - Apply directly to the target cell - in the manner of a hypodermic needle. This can lead to further clinical and pathogenic effects, and thereby increase the virulence of EHEC. Key indicators for the type III secretion apparatus is the eae gene. Its gene, the protein intimin enables the pathogen among others, to adhere closely to intestinal epithelial cells. EHEC the eae gene have no form, from other Adhärenzsysteme, but are rarely able to trigger a HUS. Besides their particular virulence of EHEC possess a relatively high environmental stability and a good ability to survive in an acidic environment.
Occurrence EHEC infections occur worldwide. The registered after IfSG incidence in Germany is currently very dependent on the use of laboratory diagnostic capabilities. Since the introduction of mandatory reporting in 2001 were under IfSG annually 925-1183 EHEC diseases reported to the RKI. The median age of the transmitted EHEC disease is 4 years and both sexes are affected almost equally.
Data states of the current year can be taken with 3-week delay, and the Epidemiological Bulletin SurvStat @ RKI on the sides of the RKI (www.rki.de> infection control). In addition, find themselves in SurvStat @ RKI and yearbooks in the infection epidemiological data in recent years.
Reservoir Ruminants, especially cattle, sheep and goats, but also wild ruminants (eg deer) can be viewed as an important reservoir and main source of EHEC infection in humans. Chance has been shown that excrete other farm animals and pets EHEC. The importance of non-ruminants for the spread of the pathogen and infection in humans is however considered to be low.
Infection EHEC infection can be transmitted in many ways. It is always about the accidental ingestion of Fäkalspuren, such as in contact with ruminant animals or the consumption of contaminated food. In addition, EHEC can be transmitted through contaminated water (eg bathing). Also human-to-human transmission, in contrast to other bacterial gastroenteritis pathogens a significant transmission route - probably favored by the very low infectious dose of EHEC (<100 exciter for EHEC O157).
In Germany, according to an age-dependent by the Robert Koch Institute conducted case-control study, the means of transmission of sporadic EHEC disease. Therefore holds with children under three years - the age group with the highest incidence reporting for EHEC and HUS diseases - the direct contact to a ruminant (cattle, sheep or goat), the highest risk. Other risk factors include the consumption of raw milk and the incidence of diarrhea in family members. In children over nine years and adults, however, it is probably primarily a foodborne disease, in particular the consumption of lamb meat and spreadable raw sausages (Zwiebelmettwurst, string sausage, sausage spread) with an increased risk of disease is affected. About half of all EHEC isolates from food in Germany carry with increased virulence for humans associated toxins Stx 2, Stx 2c and / or Stx 2d. Among these are the most common serogroups O113 and O91.
International have been since the first description of the pathogen in 1977 in particular outbreak investigations by a variety of vehicles or evidence of transmission of human EHEC disease. In the U.S., for example, food-conditioned over 50% of the outbreaks, and ground beef (eg hamburgers) was the most commonly identified food. But other foods such as salami, sausage, raw milk, unpasteurized apple juice and consumed raw green leafy vegetables (eg sprouts, spinach) were responsible for outbreaks, such as epidemiological and microbiological investigations have shown.
Occurred in Germany in recent years, several large clusters of HUS disease, all caused by a sorbitol-fermenting variant of EHEC O157 serogroup without an infectious cause has been determined. Other hand, this country traditional EHEC outbreaks (which are mostly non-HUS illness beobachtetet) are rare on the current data situation. In addition, the source of infection could be clarified only in few cases.
Incubation period The incubation period is about 2 to 10 days (average 3 to 4 days). These findings are based mainly on studies of EHEC O157 serogroup. EHEC-associated HUS symptoms of disease begin about 7 days (5-12 days) after onset of diarrhea.
Duration of infectivity A contagion exists as long as EHEC bacteria are detected in the stool. Information on the average length of germ elimination are available only for serogroup O157 and vary considerably from several days to several weeks. The general rule is that the pathogen can be detected longer in children than in adults in the chair. With a duration of excretion over a month in clinically unremarkable picture must be expected therefore.
Clinical symptoms EHEC infection may be clinically inapparent run and thus remain undetected. The majority of manifest disease occurs as a bloodless, usually watery diarrhea in appearance. Associated symptoms include nausea, vomiting and increasing abdominal pain, fever rare. At 10-20% of patients developing severe form as a hemorrhagic colitis with crampy abdominal pain, bloody stool and sometimes fever. Infants, young children, the elderly and immunocompromised people ill more often heavy. Feared is occurring primarily among children HUS, which is characterized by the triad of hemolytic anemia, thrombocytopenia and renal failure to anuria. This serious complication occurs in approximately 50-10% of symptomatic EHEC infections and is the most common cause of acute renal failure in childhood. It is common for short-term dialysis, less often irreversible loss of renal function in chronic dialysis. In the acute phase of HUS mortality is approximately 2%.
Diagnosis An EHEC infection should be considered in the differential diagnosis of any acute gastroenteritis in children. This applies, regardless of age, also for outbreaks of gastroenteritis (two or more diseases in which an epidemiological link is probable or suspected). In these situations, always an indication for the microbiological examination of stool samples for EHEC:
• diarrhea and one of the following conditions: a) because of diarrhea hospitalized children up to 6 Age b) visible blood in the stool c) hemorrhagic colitis endoscopically proven d) A patient is directly related to production, handling or marketing of food or work involved in lit kitchens of restaurants or other establishments with / caterers (§ 42 para 1 No 3. IfSG a and b) • HUS • contacts of patients with HUS • pediatric patients with acute renal failure Recommendations for laboratory diagnosis of EHEC infections The most important diagnostic feature of the toxin gene or toxin detection. Therefore, the aim of the laboratory diagnostics, pathogen or toxin gene isolated by toxin detection. The Toxingennachweis to PCR (conventional or in the Light-Cycler) carried out Kolonieabschwemmung or stool enrichment, the toxin detection is performed by ELISA (EIA) from the E. coli culture (the detection of Stx by ELISA is straight out of the chair too unspecific ). The further characterization of the pathogen, particularly for epidemiological questions should be made depending on the origin of the isolates in one of the below specialized laboratories. In addition, HUS should be made an investigation of the serum on LPS antibodies against E. coli O157 among others.
Therapy The disease symptoms may only be symptomatic. An antibacterial therapy is not indicated. You can prolong the excretion of bacteria and stimulate the production of toxins lead. If there is a HUS are usually applied at global and forced diuresis renal hemodialysis or peritoneal dialysis. In atypical forms (particularly in extrarenal manifestations of HUS), a plasma treatment is recommended. The benefit of this therapy should be further substantiated by studies. In patients in whom the von Willebrand factor-cleaving protease ADAMTS13 (VWF-CP) is reduced or where there are antibodies against the VWF-CP, immunosuppressive therapy is recommended. The treatment should be performed in specialized centers.
Preventive and control measures 1st Preventive measures Particular attention should be given to measures to prevent EHEC infection by animal contact. For petting zoos or farms open to the public specific recommendations apply (Epid Bull 1 / 2005). The important aspect here the close supervision of children; fingers should be on the animal or contact with the ground put in your mouth, but thoroughly cleaned with warm water and soap. Food and drinks should only be taken outside the animal contact areas. Other preventive measures include the avoidance of human-to-human transmission (see section 2) and the safe handling of food. In particular, should raw foods of animal origin and other perishable foods (eg meat, sausage, cold cuts, milk and dairy products, deli salads) are always stored at refrigerator temperature. In the preparation of food (particularly meat) should be noted that the food is well cooked (internal temperature of at least 70 ° C for 10 min). Moreover, should meat and other raw foods to avoid cross-contamination is not possible simultaneously with other specific foods to be eaten immediately, but in no case be prepared using the same tools and work surfaces, while the latter were not thoroughly cleaned before further use. Hands should be washed in the meantime as well.
Milk should not be eaten raw, but only after heat treatment. The delivery of raw milk, raw cream, or not sufficiently heated milk to consumers is prohibited in public catering establishments legally. Their processing (eg for milk products) in these facilities is not legally permitted, for reasons of preventive health, however, is discouraged. Especially children and older people should thoroughly cooked foods of animal origin, or basically just take after any other bacteria-killing process itself. In the literature it is pointed out that even pregnant women and immunosuppressed persons should keep it. On the consumption of foods of animal origin, either during production or cooking prior to consumption or other bacteria-killing process can be subjected to such fresh sausage or raw milk cheeses should give these people (because of the possibility of other bacterial contaminants). If it is not known whether it is in a specific case or a milk product Rohfleischerzeugnis is, appropriate information should be sought.
2nd Preventing the proliferation - measures for patients excreting and contact persons In hospitals, nursing homes and other health care institutions Measures to prevent the spread of EHEC are based next to the observance of food hygiene (this, see the relevant instructions of the Federal Institute for Risk Assessment) on four pillars:
• Strict adherence to hand hygiene and other standard measures of hygiene, • Isolation of patients • Regular disinfection of all hand contact surfaces and sanitary area, • hygienic handling of contaminated laundry. The Commission's recommendations for hospital hygiene and infection prevention will contain important statements about:
• Hand hygiene • Surface disinfection. The documents are under www.rki.de, heading infection control, hospital hygiene keyword to view the subdirectory the Commission's recommendations for hospital hygiene.
Also on the recommendation to "infection prevention in residential care" is explicitly stated.
Household The pathogens are using the chair and possibly also with the urine and can already lead to a disease in low numbers. To prevent secondary infections, the strict observance of hygiene measures is needed. This means that is especially urgent in kitchen and bathroom extreme cleanliness. Apart from the direct consumption of contaminated food, the bacteria can be transmitted via contaminated hands or utensils. This is particularly important when the so-contaminated food is not heated then. Attention will also be dealing with in accordance with contaminated bed-and underwear.
• The risk may therefore be reduced if hands and kitchen utensils before preparing food, especially those that are not cooked, washed thoroughly with soap and water and dry it carefully. (The recommendations of the BfR found at: www.bfr.bund.de> A - Z Index> EHEC.) • With stool or vomit soiled goods, clothing or surfaces should be promptly washed or cleaned, in contacts that should be worn in the usual household gloves. • The laundry should be washed with a detergent at temperatures above 60 ° C. • In addition, should the early separation of the sick person be considered by the household contacts. Since the transfer of persons to contact persons index often very early in the disease process takes place, this measure is all the more effective the earlier it is done. Transfers of gastroenteritischen infections often affect the household (siblings) children. Since they also carry the highest risk for forming a HUS, should be the primary focus of the measures for preventing the spread aimed at children in the household. Plays in particular the timeliness of actions play an important role.
In schools and other community facilities including nurseries and kindergartens According to § 34 para 1 of the IfSG, persons who are suffering from EHEC or the suspect, no teaching in community facilities, education, nursing, exercise supervisory or other activities where they have contact with the sheltered there until fear, according to medical opinion the further spread of the disease not through it. Supervised community facilities in the contracted or which are suspected of EHEC, which allowed the operation of the community facility serving areas not enter, do not use facilities of the Community body and not participating in community events facility. These rules also apply to persons, occurred in the residential community, according to medical opinion or a disease is suspected EHEC. Shedders of EHEC may also § 34 para 2 IfSG not visit community facilities.
A re-admission to community facilities after clinical recovery is usually possible, where three at intervals of 1 to 2 days examined available stool samples negative findings. A written certificate is required. This recommendation for re-approval also applies to separators, then there is no risk of further spread of infection in general. Exceptions are possible with the approval of the Health Department and their disposal in compliance with the facility to the community protection measures. In Langzeitausscheidern should Virulenzprofil of EHEC strain (including serotype, toxin type and presence of the eae gene) are included in the risk assessment.
In food establishments and caterers According to § 42 IfSG, persons who suffer from an infectious gastroenteritis or its suspected and eliminated those who EHEC, the manufacture, treatment or marketing of the foods listed in paragraph 2 (see below) should not be employed or be employed when they thereby come into contact with them. This also applies to workers in kitchens of restaurants and other facilities with or caterers.
Food within the meaning of § 42 para 2 IfSG are:
1.Fleisch, poultry meat and products thereof 2.Milch and milk-based products 3.Fische, crustaceans or molluscs and products thereof 4.Eiprodukte 5.Säuglings and infant nutrition 6.Speiseeis ice cream and semi-finished products 7.Backwaren with unbaked or-heated fillings or toppings 8.Feinkost, raw salads and potato salads, marinades, mayonnaise and other emulsified sauces, food yeasts 3rd Measures during outbreaks In EHEC outbreaks is rapid identification and elimination of the infection source is required. With suspicion, illness or death must therefore responsible public health official will be immediately informed and the quickest way to place the message. If you suspect an infection caused by certain foods or animals, should the health department and the relevant Food Authority without delay inform the competent veterinary authority. Conversely, it is necessary for Veterinary and Food Administration also inform the health department immediately if they become aware of any illnesses in people who are associated with food consumption or animal contact, or if there is evidence from human or animal studies, fear of the disease in humans can .
Obligation § 6 IfSG the suspected disease, the illness and death is at enteropathic hemolytic uremic syndrome (HUS), particularly from notifiable. Furthermore, according to § 6 IfSG suspected notifiable disease, and the illness of a microbial food poisoning or acute infectious gastroenteritis, if a person is concerned, engaged in an activity described in § 42 IfSG or occur when two or more identical diseases, context in which an epidemic is likely or suspected.
According to § 7 IfSG is the direct or indirect detection of enterohemorrhagic strains of E. coli (EHEC), particularly reportable, unless the evidence suggest an acute infection. For leaders of community facilities is in accordance with § 34 para 6 IfSG duty to notify the competent health authority immediately of the occurrence and came to the attention of this disease and to make personal statements.
Counseling and special diagnostics National Reference Center for Salmonella and other bacterial enteritis Robert Koch Institute (Wernigerode area) Castle Street 37, 38855 Wernigerode; Tel: 030 / 18754-4206, Fax: 030 / 18754-4207
Head: PD Dr. A. flier Tel: 030/18754-2522 E-mail: Dr. Antje flyer
Contact EHEC: Dr. A. Fruth Tel: 030 / 18754-4241 E-mail: Dr. Angelika Fruth
Hemolytic Uremic Syndrome-Konsiliarlaboratorium for (HUS) Institute for Hygiene at the University Hospital of Munster Robert-Koch-Str. 41, 48149 Münster
Univ.-Prof. Dr. H. Karch Tel: 0251/83-55363 Fax: 0251/83-55341, -55 688 E-mail: hkarch@uni-muenster.de
National veterinary medical reference laboratory for E. coli (NRL-EC) Federal Institute for Risk Assessment, Berlin-Marienfelde Diedersdorfer Weg 1, 12277 Berlin
Priv.-Doz. Dr. L. Beutin Tel: 030/8412-2259 Fax: 030/8412-2983 E-mail: @ l.beutin bfr.bund.de
Epidemiological aspects of contact for: Department of Gastrointestinal Infections, Zoonoses and Tropical Infections Robert Koch Institute Seestrasse 10, 13353 Berlin
Head: Prof. Dr. K. Stark Tel: 030 / 18754-3432 E-mail: Prof. Dr. Klaus Stark
Contact EHEC: Dr. D. Werber Tel: 030 / 18754-3466 E-mail: Dr. Dirk Werber
Selected information 1.Heymann DL (ed): Control of Communicable Diseases Manual. American Public Health Association, 2008, p. 181-194 2.Levine MM, Xu JG, Kaper JB, et al. A DNA probe to identify enterohemorrhagic Escherichia coli of O157: H7 and other serotypes that cause hemorrhagic colitis and hemolytic uremic syndrome. J Infect Dis 1987; 156: 175-182 3.Friedrich AW, Bielaszewska M, Zhang, et al. Escherichia coli harboring Shiga toxin 2 gene variants: frequency and association with clinical symptoms. J Infect Dis 2002; 185: 74-84 4.Werber D, Mason BW, Evans MR, Salmon RL: Preventing Household Transmission of Shiga Toxin-Producing Escherichia coli O157 Infection: Promptly Separating Siblings Might Be the Key. Clin Infect Dis 2008; 46 (8): 1189-1196 5.Falldefinitionen the Robert Koch Institute for the transmission of disease or death and evidence of pathogens. Bundesgesundheitsbl - Health - Gesundheitsschutz 2000, 43: 845-869. Springer-Verlag 2000 (in Internet: http://www.rki.de); current version December 2006 6.Beutin L, Miko A, Krause G, Pries K, Haby S, Steege K, Albrecht N: Identification of Human-Pathogenic Strains of Shiga Toxin-Producing Escherichia coli from Food by a Combination of Serotyping and Molecular Typing of Shiga Toxin Genes . Appl Environ Microbiol 2007, 73 (15): 4769-4775 7.Robert Koch Institute: An outbreak of HUS-sorbitol-fermenting EHEC of serovar O157: H-. Findings and lessons for surveillance. Epid Bull 2003; 22: 171-175 8.Händehygiene. Communication from the Commission for Hospital Hygiene and Infection Prevention at the Robert Koch Institute. Bundesgesundheitsbl - Health - Gesundheitsschutz 2000, 43: 230-233. Springer-Verlag 2000 (in Internet: http://www.rki.de). 9.Robert Koch Institute: Epidemiological infections Yearbook of notifiable diseases for 2009. Robert Koch Institute, Berlin, 2010 10.Robert Koch Institute: Risk factors for sporadic STEC (EHEC) disease. Results of a nationwide case-control study. Epid Bull 2004; 50: 433-436 11.Robert Koch Institute: Risk factors for sporadic STEC disease: recommendations for prevention. Epid Bull 2005; 1: 1-3 12.Werber D, Behnke SC, Fruth A, et al: Shiga toxin-producing Escherichia coli Infection in Germany - Different Risk Factors for Different Age Groups.. Am J Epidemiol 2007; 165 (4): 425-434 13.Tarr PI, Gordon CA and Chandler WL: Shiga-toxin-producing Escherichia coli and haemolytic uraemic syndrome. Lancet 2005; 365: 1073-1086 Notes to the series' RKI guide for doctors, "we pray to the Robert Koch Institute, Division of Infectious Disease Epidemiology (Tel: +49 (0) 30 - 18754-3312, Fax: +49 (0) 30 - 18754-3533) or be sent to the editorial staff of the Epidemiological Bulletin.
Stand: 17.06.2011