The emergence of E coli O157:H7 in Malta is a sign of the times. It represents one of the newly emerging infections associated with food. The first two documented cases of E coli 0157:H7 infection in Malta occurred in July and August, 1996. Food types classically incriminated were surveyed by the Department of Public Health. Epidemiological investigation aimed to trace the environmental sources of infection.• Microbiology was performed jointly by diagnostic and public health laboratories. Facts about infection and control of the disease are highlighted with a view to alerting local practitioners to the condition.peer-reviewe

Borg, T.

Cuschieri, Paul

Falzon, Dennis

Stokes, N.

English

OAR@UM

33 Maltese Medical Journal. 1')<)6; R (2): 33-l4 All rights reser,ed Escherichia coli 0157:H7 in Malta for the first time P. Cuschieri*, D. Falzon**, T. 8org***, N. Stokes**** ABSTRACT: The emergence of E coli 0157:H7 in Malta is a sign of the times. It represents one of the newly emerging infections associated with food . The first two documented cases of E coli 0157:H7 infection in Malta occurred in July and August, 1996. Food types classically incriminated were surveyed by the Department of Public Health. Epidemiological investigation aimed to trace the environmental sources of infection.· Microbiology was performed jointly by diagnostic and public health laboratories. Facts about infection and control of the disease are highlighted with a view to alerting local practitioners to the condition. *Department of Pathology. St Luke's Hospital. Gwardamangia. **Department of Public Health. 15 Merchants Street. Valletta. ***Department of Pharmacy. University of Malta. Tal-Qroqq. Msida. ****Public Health Laboratory. Evans Building. Merchants Str. Valletta. Correspolldellce: Dr D Falzon. Department of Public Health, 15 Merchants Street. Valletta. Keywords: Escherichia coli 0 157:H7. epidemiology, verocytotoxin, food hygiene. beef. haemolytic uraemic syndrome. haemorrhagic colitis Escherichia coli 0157:H7 in Malta for the first time E coli 0157:H7 infection occupies a low profile amongst Maltese health professionals. With the emergence of the local disease, clinicians should now be alerted to the possibility of this condition in their patients. Hence the scope of this paper. As fever is commonly not marked in patients with E coli 0157:H7 colitis. non-infectious conditions are important in differential diagnosis (Table I). Abdominal pain and tenderness are known features of the disease and patients may come to exploratory laparotomy J, as in Case 2 below. Meanwhile. microbiological laboratory diagnosis is simple, inexpensive, and invaluable for patient management. outbreak investigation and contact screentng. Table 1 - Differential diagnosis of E coli 0157:H7 colitis Infectious Non-infectious Shigella. Salmonella. Ulcerative colitis. Crohn's Campylobacrer, disease. Intussusception, Yersinia elltCJ'oco/iric(J. Ischaemic colitis, Closrridilllll dijji'cile, Diverticulosis. El1laflloeba hisrolyrica Appendicitis Apart from their curati ve role, health care workers are in a strategic position to help limit infection through personal hygiene and patient education (Table 2). A raised index of suspicion coupled with reasoned timely action (treating patient and notifying disease) can avoid much of the' harm classically associated with complicated E coli 0157:H7 disease. The first two documented cases of E coli 0157 :H7 infection in Malta were recorded in the summer of 1996. Table 2 - The take-home messages All cases of suspected food-borne disease are to be notified to the Department of Public Health for further follow-up. The legal obligation on doctors to notify is intended to limit preventable transmission of infection • 	 E coli 0157:H7 has to be excluded in episodes of bloody diarrhoea • 	 Haemolysis and renal insufficiency in connection with gastroenteritis should be considered a likely case of E coli OI57:H7. more so in paediatric patients. Close monitoring and timely expert opinion are crucial • 	 Most cases of gastroenteritis can be managed without antimicrobials. which at times may actually be harmful. There is evidence that patients with E coli 0157:H7 given antibiotics have similar or increased risk for HUS compared to those not receiving antil1licrobials 2.3 • 	 Adequate cooking of food lowers the likelihood of food­borne illness. Cross contamination of ready to eat food with uncooked meat has been implicated in a recent outbreak of E coli 0157: H7 in the US 4 • 	 Consumption of known risky food items like rarely cooked meats. raw milk products. unwashed vegetables and untreated surface water should be avoided. • 	 For health care workers and child minders. proper hand hygiene tS emphasised panicularly after physical handling of symptomatic persons or body substances -P. Cuschieri , et al. 34 Case 1 On 10 July 1<)96, at the St Luke's Hospital (SLH) Bacteriology Laboratory, E coli 0 I 57 was isolated from the stoo,ls of a foreign patient seen at a Health Centre on 7 July with a 2 day history of gastroenteritis. The strain was further characterised by Evans Public Health Laboratories as E coli 0157:H7; phagetype 32; VT2. As the laboratory request form was incompletely filled, the patient - known to be a 28-year old female foreigner ­could not be located despite diverse attempts by the Department of Public Health. Hence the patient remained ignorant to the diagnosis, and epidemiological research was defeated. Case 2 Case 2 was a 47 year old male tourist from the UK who arrived in Malta on August 10, I <)96 with his wife and 13-year old daughter. He worked in the UK as a social security inspector, was previously well and had no significant medical. social , family or drug history. On 15 August, the patient developed profuse watery diarrhoea. This was preceded by constipation for 3 days. On 18 August he developed nausea and vomiting, and the colicky-type abdominal pain shifted to the right side of the abdomen. Examination revealed mild fever, dehydration and tenderness in the right iliac fossa with muscle guarding. He was hospitalised for further assessment. Routine blood investigations showed mild polymorphonuclear leucocytosis and save for pyuria normal renal function. Renal insufficiency did not occur at any stage. He underwent exploratory laparotomy on the day of admission. Marked mesenteric lymphadenitis and serous peritonitis were noted at operation. Appendicectomy was performed. Twelve hours post-operatively he had an episode of fresh bleeding per rectum (about 150cc) which was managed conservatively. He was given co­amoxyclav tid intravenously (later orally) and gentamicin intramuscularly was added for one week . Antimicrobials were continued till the 26 August. Following the preliminary stool findings, the patient was barrier nursed from 22 August. He made an otherwise uneventful recovery and was discharged on 28 August. Table 3 - Blood & Urine Findings (Case 2) Date Parameter Value Reference Ranges Aug'96 18 WBC 12.1 X 103/uL 4.5-10.5 X 103/uL Lymphocytes 10.0% 20.0-50.0% Granuloytes 81.8 % 30.0-70.0% 19 Urine deposit RBC + WBC++ Epithelial cells + Differential diagnosis The differential diagnosis for cases of E coli 0157 :H7 infection include other infectious causes of enteritis with blood, like Shigella, Salmonella, Yersinia, Clostridium difficile ,md Entamoeba histolitica. Non-infectious causes leading to a similar clinical picture include inflammatory bowel disease, intussusception, ischaemic colitis, diverticulosis and appendicitis. In both the cases mentioned, isolation of the causati ve organism clinched the diagnosi s. It is well established that surgical exploration may be indicated (as in case 2) as an emergency to exclude acute surgical conditions. Epidemiological investigation Case 2 is known to have arrived in Malta 5 days be forc starting to feel unwell. Given a known incubation period of 1-8 days, infection may well have been imported . Both his wife and child were asymptomatic and screened by stool culture. They tested negative . An extensive food history was taken from the index case, and four possible source food outlets identified. These included the hotel, a pleasure cruise boat, a restaurant and a supermarket. Sample food items were taken from all these outlets as well as their suppliers and tested at the Public Health Laboratories in Valletta. Items included ground beef products, ham, cheese, cheeselets, poultry, eggs, vegetable and swimming pool water. Hand swabs from food handlers and working tops were also taken. There were no relevant findings. Since September 1994, all stool samples submitted to the SLH Bacteriology Laboratory for culture (over 4000 so far) have been screened for E coli 0157 using standard isolation techniques. Up to the time of writing (October 1996)" only the two cases mentioned were confirmed as toxigenic E coli 0157 :H7. Phagetyping and toxigenicity tests were done at the Evans Public Health Laboratory (PHL), Valletta. From July 1995, a variety of meat-based food items have been analysed for E coli 0 I 57 :H7 at PHL. Typical items sampled included beef. chicken and ham burgers, minced meats and imported and local sausage. A total of 595 samples were tested up to 20 September 19<)6, sourced from various suppliers and retailers throughout the country. E coli 0157 was cultured once from a raw beef burger (September 1996): the isolate, however, was non-toxigenic and did not react with phages. Acknowledgements To all staff involved in patient care, the staff of SLH Bacteriology Laboratory, and the staff of the Department of Public Health and Public Health Laboratory. References 1. 	 Ostroff SM, Griffin PM, Tauxe RV et al. A state-wide outbreak of E coli 0157 :H7 infections in Washington State. AmJ of Epidem 1990; 132:239-247. 2. 	 Pavia AT, Nichols CR, Green DP et al. Haemolytic uraemic syndrome during an outbreak of E coli 0157:H7 infections in institutions for mentally retarded persons. Clinical and epidemiological observations. Journal of Ped 1990; 116:544-551. 3. 	 Ostroff SM, Kobayashi lM . Lewis JH. Infec tions with E coli Ol57:H7 in Washington State: the first year of state­wide disease surveillance. lAMA 1989; 262:355-359 4. 	 Cannon M, Thomas H, Sellers W et al. Outbreak of E coli 0157:H7 Infection - Georgia and Tennessee. June 1'195 . MMWRI996; 45(12):250-51. The copyright of this article belongs to the Editorial Board of the Malta Medical Journal. The Malta Medical Journal’s rights in respect of this work are as defined by the Copyright Act (Chapter 415) of the Laws of Malta or as modified by any successive legislation. Users may access this full-text article and can make use of the information contained in accordance with the Copyright Act provided that the author must be properly acknowledged.  Further distribution or reproduction in any format is prohibited without the prior permission of the copyright holder. This article has been reproduced with the authorization of the editor of the Malta Medical Journal (Ref. No 000001)  

A state-wide outbreak of E coli 0157 :H7 infections in Washington State. AmJ of Epidem

Haemolytic uraemic syndrome during an outbreak of E coli 0157:H7 infections in institutions for mentally retarded persons. Clinical and epidemiological observations.

State: the first year of state wide disease surveillance. lAMA

Escherichia coli O157:H7 in Malta for the first time

https://www.um.edu.mt/library/oar/bitstream/handle/123456789/228/mmj%201996%200802.pdf?sequence=1&isAllowed=y

Escherichia coli O157:H7 in Malta for the first time

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