Published Date: 2008-12-01 21:00:37
Subject: PRO/AH/EDR> E. coli VTEC non-O157, restaurant - USA (04): (OK), O111
Archive Number: 20081201.3779
E. COLI VTEC NON-O157, RESTAURANT - USA (04): (OKLAHOMA), O111
A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases
Date: Sat 29 Nov 2008
Source: Emax Health [edited]
The Oklahoma State Department of Health announced today [29 Nov 2008]
that the Country Cottage restaurant in Locust Grove, Oklahoma has
undergone a rigorous inspection process and has been cleared to
resume normal business operations. The restaurant had been closed
since 25 Aug 2008 after being identified as the source of a large
foodborne outbreak in northeastern Oklahoma resulting in severe
The restaurant passed an inspection conducted by state and local
health inspectors on 12 Nov 2008. The inspection included
environmental swabbing of 35 locations within the restaurant, and no
_E. coli_ O111 contamination was identified.
The outbreak was linked in August 2008 to contamination by _E. coli_
O111, a rare toxin-producing bacterium not normally associated with a
foodborne outbreak of the magnitude experienced in Oklahoma. While no
single food item was found to be the source of illness at the
restaurant, the Oklahoma State Department of Health believes several
different foods became contaminated with the _E. coli_ O111 bacteria,
leading to exposure of restaurant customers from 15-24 Aug 2008.
Health officials note that toxin-producing _E. coli_ are notoriously
difficult to culture from food or the environment. This provided a
challenge throughout the investigation. Despite testing numerous
surfaces within the restaurant, various food items, stool specimens
from food handlers, and well water specimens, no specimen yielded the
_E. coli_ O111 bacteria.
A total of 341 outbreak-related cases were reported; 56 were children
less than 18 years of age. The age range of cases was 3 months to 88
years. 72 persons were hospitalized; one person died.
[This outbreak underscores the relevance of non-O157 strains of
verotoxin-producing _E. coli_. Other _E. coli_ serogroups that have
been associated with VTEC (verotoxin-producing _E. coli_) disease
include motile ones such as O26:H11 and O104:H21 and non-motile ones
such as O111:NM (or H-). Such non-O157 isolates can be obtained from
sheep and cattle and, although they cause as many as 30 percent of
outbreaks of VTEC (1), appear to be somewhat less (or at least more
variably) virulent in a variety of in vivo and in vitro assays (2-4).
In analyzing the genetic and phenotypic profiles of non-O157 groups,
it has been found that they belong to their own lineages and have
unique profiles of virulence traits different from O157 (5). The
serogroups appearing to be most prominent are O26, O111, O128, and
O103 (6), the former serotype being the implicated strain in this
If a laboratory is using sorbitol-MacConkey (sMAC) plates to identify
VTEC by virtue of O157's inability to ferment sorbitol, the non-O157
strains will be missed. In a 3-year pediatric study from the
University of Washington, USA (7), 1851 stool samples were processed
for sorbitol fermentation as well as toxin production by EIA (enzyme
immunoassay), and 28 strains of O157 were found along with O103 (4
strains), O118 (2 strains), O111 (2 strains), and 3 other strains.
Clinically, the O157 infections had a higher frequency of bloody
stools, fecal leukocytes, and abdominal pain with shorter symptom
duration. Five (18 percent) of O157 infections developed HUS; none of
the non-O157 strains did. Since toxin assay did not identify all O157
strains found on sMAC plates, the investigators did not advocate
performing toxin assay alone. Non-O157 can produce hemolytic-uremic
syndrome, as demonstrated by a cluster of O121 cases associated with
a lake in Connecticut, USA (8).
Since toxin assays are not uniformly performed in many areas, and
most cases do not produce HUS, it is likely that cases due to
non-O157 strains are being missed. How frequent this phenomenon will
become over time is unclear.
a report documented the recognition of a non-O157 VTEC strain (an
O26) in some UK cattle that was multi-antimicrobial resistant by
virtue of producing an extended spectrum beta-lactamase (ESBL). No
human cases of infection with this strain were reported. Because of
the higher risk of morbidity and mortality in VTEC infections treated
with antimicrobials (9), antimicrobials are not used for known acute
1. Hussain HS, Omaye ST: Introduction to the food safety concerns of
verotoxin-producing _Escherichia coli_. Exp Biol Med 2003; 228: 331-2.
2. Blanco J, Blanco M, Blanco JE, et al: Verotoxin-producing
_Escherichia coli_ in Spain: prevalence, serotypes, and virulence
genes of O157:H7 and non-O157 VTEC in ruminants, raw beef products,
and humans. Exp Biol Med 2003; 228: 345-51.
3. Law D, Kelly J: Use of heme and hemoglobin by _Escherichia coli_
O157 and other Shiga-toxin-producing _E. coli_ serogroups. Infect
Immun 1995; 63: 700-2.
4. Tzipori S, Wachsmuth KI, Smithers J, Jackson C: Studies in
gnotobiotic piglets on non-O157:H7 _Escherichia coli_ serotypes
isolated from patients with hemorrhagic colitis. Gastroenterology
1988; 94: 590-7.
5. Schmidt H, Geitz C, Tarr PI, et al: Non-O157:H7 pathogenic
Shiga-toxin producing _Escherichia coli_: phenotypic and genetic
profiling of virulence traits and evidence for clonality. J Infect
Dis 1999; 179: 115-23.
6. Bettelheim KA: Role of non-O157 VTEC. Symp Ser Soc Appl Microbiol
2000; (29): 38-50S.
7. Klein EJ, Stapp JR, Calusen CR, et al: Shiga toxin-producing
_Escherichia coli_ in children with diarrhea: a prospective
point-of-care study. J Pediatr 2002; 141: 172-7.
8. McCarthy TA, Barrett NL, Hadler JL, et al: Hemolytic-uremic
syndrome and _Escherichia coli_ O121 at a lake in Connecticut, 1999.
Pediatrics 2001; 108: E59.
9. Iijima K, Kamioka I, Nozu K: Management of diarrhea-associated
hemolytic uremic syndrome in children. Clin Exp Nephrol 2008;12: 16-9.
Locust Grove is located in Mayes County, Oklahoma and can be found on a map at