ENTEROPATHOGENIC

Escherichia coli

I.

DEFINITION OF DISEASE

Enteropathogenic E. coli (EPEC)

gastrointestinal pathogen
diarrheagenic E. coli [1].
enterovirulent E. coli [1]
causes a fatal form of diarrhea in infants (Infantile diarrhea) [2].
RELEVANT SEROTYPES
O55:NM
O55:H6
O111:NM
O111:H2
O114:NM
O114:H2 [1]

PHOTO 1 and 2: EPEC adhering to intestinal wall

Enteropathogenic Escherichia coli (EPEC) are in the family Enterobacteriaceae. The

bacteria are gram negative, rod shaped, non-spore forming, motile with peritrichous flagella or
nonmotile, and grow on MacConkey agar (colonies are 2 to 3 mm in diameter and red or
colorless). They can grow under aerobic and anaerobic conditions and do not produce
enterotoxins.
II . SYNONYMS
EPEC [2]
Enteroadherent E. coli [1].
Intestinal Pathogenic E. coli [3].
Acute and protracted infant diarrhea [4].
Diffusely Adherent E. coli (DAEC) [10].

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III . MORPHOLOGICAL DESCRIPTION

EPEC has specialized adherence factors which facilitate their attachment to the intestinal cells [1].
The prominent feature is that it typically does not produce exotoxins [6]. The bacteria is
moderately invasive.
MAJOR VIRULENCE FACTORS

Pathogenicity islands*- encodes proteins which modulate the actin microtubule and
intermediate filament networks to allow intimate attachment of bacteria (J Bacteriol
2006;188:3110)

Intimin (adherence to intestinal mucosa) & Translocated intimin receptor [1].

Bundle forming pili

Surface-associated filaments

Photo: EPEC adhering to the intestinal wall

EPEC causes disruption and destruction of the brush border of the cells and other
intestinal cell derangements, reducing the absorptive capacity [1]

Photo: EPEC adhering to intestinal mucosa

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Adherence/ invasion without multiplication is the predominant pathogenic mechanism

of the bacteria [6] and is usually Human (infant) gastrointestinal tract is the reservoir. Human
serotypes are not found in animals. [7]
Diarrheal outbreaks commonly affect children in nurseries and daycare centers whilst
cases in adults are rarely seen [1]. The bacteria have a worldwide distribution [6].

IV . CLINICAL HORIZON

Photo 1: watery diarrhea

Signs are a type of indicator that other people can directly observe. The signs are as followed.
There is presence of watery diarrhea due to mucosal deformation caused by binding of E. coli
cells to the mucosa [2]. The stool has large amounts of mucus but apparent blood is not present.
Low grade fever (37 - 38 C) is also detected and also there is vomiting.
Symptoms, however is experienced by the individual affected by the disease. One symptom
is malaise or the feeling of discomfort, illness, or lack of well-being.

V . INCUBATION PERIOD
For EPEC, the incubation period is between 6-48 hours

[11].

Infants are protected by breastfeeding, and they become infected following weaning due
to weaning foods prepared with contaminated water [7].

VI . PERIOD OF COMMUNICABILITY

EPEC invades without multiplication [6] therefore it can be readily transmitted through the
fecal-oral route [2].
Infectious dose is 106 organisms [10]
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Most infections of the GI tract occur after the first 6 months (after birth) however
newborns can acquire typical EPEC during the first day of life [8].

VII . LABORATORY DIAGNOSIS

Photo: HeLa cell adherence assay

In cases of severe diarrhea in children, younger than 1 year, infection with EPEC should be
suspected [1].
HeLa cell adherence assay [1].
DNA probes [1].
Serologic typing with pooled antisera (generally used for epidemiologic studies) [1].

VIII . TREATMENT

Photo1: Colistion ; Photo2: Gentamicin

In a Specific course of treatment, antimicrobial therapy in management of neonatal EPEC
is used when gastroenteritis is uncertain. This may shorten the duration of gastrointestinal
illness. A 3-day course of oral non-absorbable antibiotic colistin or gentamicin (Walker et al.,
2004) is used in case of severe cases. But still, many of these infections resolve without such
therapy. It is used with caution because organisms may develop resistance, therapy for non-life
threatening infections may be contraindicated [6].
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Photo1: ORS ; Photo 2: Lactated Ringers solution ; Photo3: Pedialyte

For relief of symptomatic cases, fluid replacement is critical to prevent dehydration
caused by diarrhea [2]. Oral rehydration is used for mild cases (ORS, pedialyte) while Parenteral
rehydration for severe cases (Lactated Ringers solution) [7].
In preventive/ Prophylaxis, an effective vaccine is not available (Willshaw, et al., 2000.;
Clark et al., 2002) [7].
IX . PROGNOSIS
Diarrhea in infants in developing, low-income nations; can cause a chronic diarrhea [6]. In
statistical data, the presence of typical EPEC resulted in a 2.6-fold increased risk of death at 60
days not necessarily because of the acute diarrhea episode [8]. Also, up to 50% mortality rates in
developing countries [8].

X . PREVENTION

Photo1: WHO 5 moments of hand hygiene

The WHO implemented 5 moments of hand hygiene and should be implemented for the
prevention of further contamination. Strict adherence to infection control and appropriate
hygiene can help prevent spread [8]. Also, Infants who are symptomatic or shedding EPEC should
be isolated to a section of the nursery [8]. After the involved infants are discharged, thorough
disinfection of the area should be warranted within the hospital [8].

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Sources
[1] Mahon, C. R., Lehman, D. C., & Manuselis, G. (2015). Textbook of diagnostic microbiology (5th
ed.). Saunders.
[2] Pommerville, J. C. (2014). Fundamentals of Microbiology (10th ed.). Jones and Bartlett
Learning.
[3] Baylis, C. L., Penn, C. W., Thielman, N. M., Guerrant, R. L., Jenkins, C., & Gillespie, S. H.
(2006). Escherichia coli and Shigella spp. In S. H. Gillespie, & P. M. Hawkey (Eds.), Principles and
Practice of Clinical Bacteriology (2nd ed., pp. 347-365). England, UK: John Wiley and Sons Ltd.
[4] Levine, ,Myron, & Vial, ,Pablo. (1988). Escherichia coli that cause diarrhea. Indian Journal of
Pediatrics, (2), 183-190. doi:10.1007/BF02722179
[5] Trabulsi, L. R., Keller, R., & Tardelli Gomes, T. A. (2002). Typical and atypical enteropathogenic
Escherichia coli. Emerging Infectious Diseases, 8(5), 508-513.
[6] Tille, P. M. (2014). Bailey & Scotts Diagnostic microbiology (13th ed.). Mosby.
[7] Smith, J. L. (2005). Foodborne Pathogens: Microbiology and Molecular Biology. Horizon
Scientific Press.
[8] Wilson, C. B., Nizet, V., Klein, J. O., Maldonado, Y. A., & Remington, J. S. (2015). Remington
and Klein's Infectious Diseases of the Fetus and Newborn Infant (8th ed.). Elsevier.
[9] Krauss, H., Weber, A., Appel, M., Enders, B., Isenberg, H. D., Schiefer, H. G., Slenczka, W.,
Graevenitz, A. V., & Zahner, H. (2003). Bacterial Zoonoses.Zoonoses: Infectious diseases
transmissible from animals to humans (3rd ed., pp. 196-200). Washington DC: ASM press.
[10] Lee, L. (2013, September). Colon non tumor. Retrieved August 19, 2016, from
http://www.pathologyoutlines.com/topic/colonecoli.html
[11] Chao, H. -., Chen, C. -., Chen, S. -., & Chiu, C. -. (2006). Bacterial enteric infections in children:
Etiology, clinical manifestations and antimicrobial therapy.Expert Review of Anti-Infective
Therapy, 4(4), 629-638.
[12] ESCHERICHIA COLI. (n.d.). Retrieved September 5, 2016, from http://www.phac aspc.gc.ca/lab-bio/res/psds-ftss/escherichia-coli-pa-eng.php#footnote17

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