To use antibiotics or not: E. coli O80:H2 in France

Jenina Pellegren of Contagion Live writes that Enterohemorrhagic Escherichia coli (EHEC) are a subset of Shiga toxin–producing E. coli (STEC) that cause diarrhea and hemorrhagic colitis. The illness can progress to hemolytic uremic syndrome (HUS) in 5%-10% of cases.

maxresdefaultIn France between 2005 – 2014, a total of 54 patients were infected with EHEC O80:H2; 91% had HUS. Two patients had invasive infections and 2 died. Similar strains were found in Spain with all isolates belonging to the same clonal group.  

“Azithromycin decreased Shiga toxin in subinhibitory concentrations significantly. Ciproflaxacin increased it substantially and ceftriaxone had no major effect. The occurrence of bacteremia during EHEC infections warranted antibiotic treatment. However, antibiotics are not usually recommended because of the risk for worsening HUS, notably by the secretion of Shiga toxin (Stx). This represents a therapeutic challenge.”  

In 2011, an outbreak in Germany linked to EHEC O104:H4 underscored the potential benefit of certain antibiotics when HUS occurs, making the use of antibiotics a source of debate. To determine the incidence rate of HUS cases associated with the singular EHEC O80:H2, a study examined the effects of different antibiotics on Stx production in representative strains.  

During January 2005 – October 2014 The Centre National de Reference Associe Escherichia coli, in France, collected 57 different strains of EHEC O80:H2. Isolated from stool specimens of over 54 patients; 2 and 3 isolates each were recovered from 2 patients.  

According to the Center for Disease Control and Prevention (CDC) “Among the 53 patients for whom clinical data were available, 49 (91%) had HUS; 27 (51%) were male. Median age for these 48 patients was 1.2 years (range 0.2–39 years, interquartile range [IQR] 0.7–1.6 years). Only 1 adult HUS patient (a 39-year-old) was reported. The 5 (9%) non-HUS patients were largely older (1, 2, 6, 21, and 40 years old). Among HUS patients, fever was present in 45%; median leukocyte count was 13,000 cells/mm3 (data were not available for 14 patients), and 56% had leukocytosis (>11,500 leukocytes/mm3).”  

Several studies demonstrated that the effect of antibiotics on HUS depends on their class.  Ciprofloxacin raises the production and release of Stx in vitro and is associated with a higher mortality rate in pigs. Yet, other studies indicate azithromycin might decrease the production and release of Stx. However, during a 2011 outbreak of EHEC O104 infection in Germany, a patient treated by ciprofloxacin plus imipenem unexpectedly had a better prognosis.  

Despite promising in vitro results, the authors of the study could not advocate the use of these antibiotics for treatment of patients infected with EHEC O80:H2. While potentially promising, these findings are preliminary and require confirmation.

Health Canada proposes rules for veterinary drugs in livestock

John Cotter of Canadian Press reports the Canadian government is proposing new rules for veterinary drugs used in livestock as it works to reduce human health risks associated with resistance to antibiotics and other antimicrobials.

ab.prudentHealth Canada says the decreasing effectiveness of antimicrobials is having a significant impact on the government’s ability to protect Canadians from infectious diseases.

“The overuse and misuse of antimicrobials in animals is a contributing factor to the development and spread of AMR (antimicrobial-resistance),” reads a summary of the proposed rules.

“The development of antimicrobial-resistant pathogens in animals can pose serious risks to human health when they are transmitted as food-borne or water-borne contaminants. Antimicrobial-resistant infections are associated with a greater risk of death, more complex illnesses, longer hospital stays and higher treatment costs.”

The department says current regulations do not provide the necessary regulatory oversight to mitigate the risk.

The proposed changes would restrict the importation of some veterinary drugs used in livestock, require drug manufacturers to follow stricter rules regarding the quality of active ingredients and allow for increased monitoring of drug sales.

The department is seeking feedback on the proposals until Sept. 8.

Health Canada says the proposed changes will align Canada with policies in the United States and the European Union.

Don’t use antibiotics to treat STEC

Objectives Assess the disease severity of Shiga toxin-producing Escherichia coli (STEC) O157 infection and factors influencing the development of typical haemolytic uraemic syndrome (tHUS).

e.coli.O157.strawberryDesign A retrospective cohort study using data collected through routine surveillance questionnaires between 2009 and 2012.

Participants 3323 symptomatic cases of STEC O157.

Main outcome measures Incidence of human STEC O157 and tHUS, proportion of cases reporting bloody diarrhoea, hospitalisation, tHUS and death. Odds of progression to tHUS and predicted percentage chance of developing tHUS based on case demographics, STEC O157 strain characteristics and clinical symptoms.

Results From 2009 to 2012, 3323 cases of symptomatic STEC O157 with completed questionnaires were reported, of which 172 developed tHUS (5.18%). Being aged 1–4 years (OR 8.65, 95% CI 5.01 to 14.94, p=0.004) or female (OR 1.61, 95% CI 1.12 to 2.30, p=0.009), being infected with phage type (PT) 21/28 (OR 2.07, 95% CI 1.25 to 3.42, p=0.005) or PT 2 (OR 2.18, 95% CI 1.06 to 4.50, p=0.034), receiving β-lactam antibiotics (OR 4.08, 95% CI 1.43 to 11.68, p=0.009) and presenting with vomiting (OR 3.16, 95% CI 2.16 to 4.62, p<0.001) or bloody diarrhoea (OR 2.10, 95% CI 1.38 to 3.20, p=0.001) were found to be significant risk factors for progression to tHUS. The predicted percentage chance of developing tHUS varied from under 1% to 50% if all risk factors were present.

Conclusions The data from this study indicate the use of β-lactam antibiotics should be avoided in suspected cases of STEC infection in all age groups, particularly in those under the age of 5.

Disease severity of Shiga toxin-producing E. coli O157 and factors influencing the development of typical haemolytic uraemic syndrome: a retrospective cohort study, 2009–2012

BMJ Open 2016;6:e009933

N Launders, L Byrne, C Jenkins, K Harker, A Charlett, G K Adak

37 now sick from E. coli O26 linked to Chipotle; focus on produce

I’d rather have microbiologically safe food. officials say 37 people have E. coli in Washington state and Oregon amid an outbreak tied to Chipotle restaurants in the Northwest, an increase from 22 cases reported earlier.

Washington health officials are still testing samples from people who have fallen ill in Clark, Cowlitz, Island, King and Skagit counties to see if they all have the same form of the potentially deadly illness.

Officials say most of those sickened by E. coli have eaten at the Mexican food chain.

Nine people in Washington and three in Oregon have been hospitalized, but no one has died. People with E. coli connected with the outbreak have ranged in age from 5 to 60.

Dr. Scott Lindquist, state epidemiologist, says knowing the type of E. coli that’s sickened nearly two dozen people will help officials determine the exact source of the illness.

Food from six Chipotle stores connected with the outbreak is being tested. Lindquist says officials may know by Wednesday what type of food tests positive for the same microorganism. They’ve asked Chipotle to turn over information about its food suppliers so officials can determine where the product came from.

chipotlawayMeanwhile, Chipote is taking a hit on its antibiotics stance.

Dan Charles of NPR writes that when you’re a nationwide food company, it can be tough to live up to your own lofty marketing slogans.

Chipotle claims to serve only “food with integrity.”

That’s not the same as microbiologically safe food.

Chipotle is also having difficulty living up to another claim: Its promise to sell only meat that’s “antibiotic-free” — or “produced without the use of antibiotics.”

It’s an increasingly popular label among consumers. Chipotle has ridiculed its drug-using competitors with catchy online videos featuring cartoon versions of big meat factories, where machines inject animals with drugs that turn them grotesquely plump.

In reality, though, Chipotle’s hard line on antibiotics isn’t quite as uncompromising as the ads make it seem. The company’s suppliers can, in fact, use these drugs.

“Under our protocol, if an animal is sick and needs to be treated with antibiotics, then it’s treated with antibiotics, but then it’s removed from our program,” says Chris Arnold, Chipotle’s director of public relations.

That animal is sold to someone else, who usually pays less for the animals than Chipotle does. And Chipotle can say that its animals never get antibiotics.

“It’s easier to explain to people,” Arnold says.

Now, though, Chipotle is being forced to do a bit more explaining, because it’s running into some trouble living up to its marketing slogans: It’s running into a pork shortage.

A lot of farmers don’t want to raise pigs the way Chipotle demands. It’s not so much because of restrictions on antibiotics. Chipotle also requires suppliers to let pigs root around outdoors or in buildings with dirt floors.

So to get enough pork, Chipotle has turned to a British supplier, named Karro.

And Karro has a different policy on antibiotics. It treats pigs when they get sick, and when they recover, those pigs go right back into the regular pork supply.

Some will become Chipotle’s carnitas. Chipotle restaurants that serve pork from this supplier will have a little sign explaining how that pork is different.

Actually, the pork itself isn’t different at all. There shouldn’t be traces of antibiotics in any of it.

Veterinarian Gail Hansen points out that such residues are against the law in all meat, “so you’re not eating antibiotic-laden meat.”


No antibiotics for kids with E. coli O157:H7

Wong et al. conclude in Clinical Infectious Disease that for every four children infected with E. coli O157:H7 treated with antibiotics, one will develop hemolytic uremic syndrome (HUS). The authors state antibiotic use during E. coli O157:H7 infections is associated with a higher rate of subsequent HUS, and should be avoided.

The authors enrolled children infected with E. coli O157:H7 in this prospective cohort study in five states over 9.5 years within one week of the onset of diarrhea. The primary and secondary outcomes were HUS (hematocrit < 30% with smear evidence of hemolysis, platelet count < 150 x 103/mm3, and serum creatinine concentration > upper limit of normal for age) and oligoanuric HUS. Univariate and multivariable and ordinal multinomial regression analyses were used to test associations between factors apparent during the first week of illness and outcomes.

Of the 259 children analyzed, 36 (14%) developed HUS. Univariate analysis demonstrated that children who received antibiotics during the diarrhea phase more frequently developed HUS than those who did not (36% vs. 12%, p=0.001). The higher rate of HUS was observed across all antibiotic classes used. In multivariable analysis, a higher leukocyte count (aOR 1.10; 95%CI 1.03, 1.19), vomiting (aOR 3.05; 95%CI 1.23-7.56), and exposure to antibiotics (aOR 3.62; 95% CI 1.23-10.6) during the first week of onset of illness were each independently associated with development of HUS. Multinomial ordinal logistic regression confirmed that initial leukocyte count and antibiotic use were independently associated HUS, and, additionally, these variables were each associated with the development of oligoanuric HUS.

Risk Factors for the Hemolytic Uremic Syndrome in Children Infected with Escherichia coli O157:H7: a Multivariable Analysis

Whole Foods safety sucks but they care …

I bought a turkey yesterday for Thursday’s Thanksgiving food orgy – 15 pounds at $0.68 per pound at Dillions supermarket in Manhattan (Kansas).

We usually don’t go anywhere because the town is more serene with the students gone, and we host a dinner for various international stragglers with nowhere else to go.

At least I didn’t have to go to Whole Foods. Terrible food safety and so insufferable.

For the past couple of weeks, Whole Foods has been pushing their turkeys like some form of food porn crack, and repeating the following statements as mantra:

“No antibiotics — ever
No supplemental growth hormones*
No animal byproducts in feed

“*Federal regulations prohibit the use of hormones when raising poultry”

Whole Foods lets birds suffer if they are sick, and follows the law by not using hormones. Should sick animals be deprived antibiotics? Wouldn’t that go against animal welfare standards? I don’t see how this is the basis for an advertizing campaign. Federal regulators may want to have a look, seeing as they cracked down on Tyson’s BS claims that they didn’t use antibiotics in poultry production that no one else used.

Whole Foods does have a bunch of homespun tales about turkeys raised by farmers the way our grandparents did it. Apparently society has learned nothing about food production over the past 60 years.

Whole Foods also has a thing against modern technology like freezing, and says it only sells fresh birds – big cross-contamination problem

I bought fresh birds a couple of times in the 1990s, and concluded they were overpriced and sucked. Same with fresh pasta. Some things are meant to be preserved using technology.

But this marketing is aimed directly at the consumers’ pocketbook.

It just makes sense that the more care and time that goes into raising the turkeys, the more they will cost.”

Good for you if people will pay.

The Chicago Tribune reports that Whole Foods is also piloting a new humane meat-rating system in the South and scheduled for national expansion early next year. If the six-step, color-coded labeling system works as planned, it could allow American consumers at many supermarket chains unprecedented levels of specificity when it comes to choosing meat to match their principles.

I’d really like to be able to choose meat and other foods by levels of microbial contamination. American retailers will market anything to make a buck, but why not reward those producers, processors and retailers who consistently deliver food that doesn’t make people barf.

“Developed by the Global Animal Partnership, a nonprofit group made up of farmers, scientists, retailers, sustainability experts and animal welfare advocates, the rating system aims to address growing consumer concerns over the way animals are raised for food. It could also, not coincidentally, boost sales for certified farmers and participating stores, likely to include another unidentified major national retailer and restaurant group in the coming year, according to the nonprofit.

“Its six-step approach establishes baseline standards for all meat sold in the store, while offering producers an opportunity to achieve higher ratings as their animal welfare standards improve based on the program’s benchmarks.

“So, for example, the highest rating (5+, colored green) would go to a chicken that, among other things, had been bred, hatched and raised on a single farm, lived year-round on pasture covered with at least 75 percent vegetation and had legs that were healthy enough to support it by the time it reached market weight.

“And the lowest rating (1, colored yellow) would reflect adherence to several dozen baseline provisions about feed, antibiotics and treatment, but also a provision that the animal must not have been caged or crowded.”

The Whole Foods folks could have learned something from those studying restaurant inspection disclosure and the use of colors or grading schemes. I also expect absolutely no verification that the system communicates to shoppers what was intended.

"We get an enormous amount of questions from customers who want to know everything about the meat and animals, really detailed questions," said Anne Malleau, global animal production and welfare coordinator for Whole Foods Market. But the program is also aimed at customers who don’t want the gory details so much as assurances that their "food has been humanely produced," Malleau said.

Although the company has no set formula for pricing GAP levels, it did share some examples from an Atlanta-area store that started rolling out the program in 2009. Grain-fed rib-eye steak rated a Step 1 costs $14.99 lb., while local grass-fed rib-eye, rated Step 4, costs $15.99 lb. And Canadian bone-in pork chops rated Step 1 cost $6.99 lb., while local bone-in pork chops rated Step 4 cost $7.99 lb.

Who pays that? And relying on auditors? You have heard of Peanut Corporation of America and DeCoster eggs and dozens of other outbreaks. Anne, who used to go to the University of Guelph and even hang out with the folks in my lab (above, right, exactly as shown) I want microbiologically safe food. That’s something I’d pay for.

All natural norovirus at Chipotle in Ohio

The Chipotle restaurant across from Kent State University in Ohio appears to be the source of hundreds of norovirus illnesses this weekend.

One report cited Kent health officials as saying that 432 people had reported norovirus symptoms as of Monday afternoon.

Victims began showing up at local hospitals Thursday evening and the restaurant closed Friday.

Many of those who got ill were Kent State University students. The restaurant is directly across from the campus, and students who took part in a recent American Red Cross blood drive received a coupon for free food at Chipotle.

Kent Health Commissioner John Ferlito said Saturday the health department and the Denver-based restaurant chain agreed to switch employees out of concern that the outbreak might be caused by a sick employee. Several of the restaurant’s employees had been ill, but they also had eaten the restaurant’s food.

Chipotle spokesman Chris Arnold said in a statement Saturday,

"Local health department officials have found no violations in inspections of our Kent State restaurant conducted after this incident was first reported, and again in an inspection this morning. We have reopened our restaurant with their full support. We have taken preventative steps that meet or exceed health department requirements, and will continue to assist them in their investigation."

If someone wants to check out Kent State University and Chipotle on Facebook, I bet there’s lots of stories to hear.

Antibiotics? How about norovirus?