CHICAGO — Aggressive fluid management and avoidance of medication are key in preventing the development of hemolytic uremic syndrome in children with Escherichia coli diarrhea, said Dr. Marianne Gausche-Hill at a meeting sponsored by the American College of Emergency Physicians.
Although other types of diarrhea may require antibiotic therapy, E. coli O157:H7 infection can be distinguished from them by its hallmarks: acute, bloody diarrhea; abdominal pain out of proportion to diarrhea; and pain on defecation, said Dr. Gausche-Hill, who is director of emergency medical services and pediatric emergency medicine fellowships at Harbor-UCLA Medical Center and professor of medicine at the University of California, Los Angeles.
“Children with E. coli also tend to be afebrile vs. those with other forms of diarrhea, such as Shigella, who are often highly febrile. So, although they could have a fever, the absence of a fever would be another clue.” Despite being afebrile on presentation, about half of children with E. coli have a history of fever before presentation, she added.
In addition to elderly people, children younger than 5 years are the highest-risk group for E. coli infection. And although 2%–7% of adult E. coli infections result in hemolytic uremic syndrome (HUS), 15% of infected children are at risk for this potentially fatal complication, she said.
Avoidance of antibiotics is key in this population, based on a prospective study showing higher rates of HUS among E. coli-infected children receiving antibiotic therapy (56%), compared with those who did not receive antibiotics (8%)—a relative risk of 14 (N. Engl. J. Med. 2000;342:1930–6). The increased risk is likely due to the antibiotic's liberation of shiga toxin, she noted.
Antimotility agents should also be avoided, based on the theory that they keep the toxin in the intestine. Narcotic opioids should be avoided because they have an antimotility effect and can increase the risk of neurologic complications.
Aggressive fluid management offers nephroprotection and should be started as soon as possible, she said. “Oral rehydration is not enough—they need intravenous fluid resuscitation. We highly recommend they receive saline boluses … and then they should be carefully watched for early signs of HUS,” she said.