eMedicine Specialties > Infectious Diseases > Bacterial Infections

Escherichia Coli Infections: Differential Diagnoses & Workup

Author: Tarun Madappa, MD, MPH, Critical Care Fellow, Section of Critical Care Medicine, St Vincent Catholic Medical Center, New York Medical College, New York.
Coauthor(s): Chi Hiong U Go, MD, Assistant Professor, Department of Internal Medicine, Texas Tech University Health Science Center at Odessa
Contributor Information and Disclosures

Updated: Feb 19, 2009

Differential Diagnoses

Enterobacter Infections
Pseudomonas Aeruginosa Infections
Enterococcal Infections
Serratia
Klebsiella Infections
Shigellosis
Proteus Infections
Streptococcus Group B Infections
Providencia Infections

Workup

Laboratory Studies

  • All patients with suspected E coli infection should undergo routine CBC count with differential to evaluate for leukocytosis or a left shift.
  • Gram stain results determine if the organism is gram-negative, but findings do not distinguish among the other aerobic gram-negative bacilli that cause similar infectious diseases.
  • E coli is a gram-negative bacillus that grows well on commonly used media. It is lactose-fermenting and beta-hemolytic on blood agar. Most E coli strains are nonpigmented (see Images 3-4).

    <EM>Escherichia coli</EM> on Gram stain. Gram-neg...

    Escherichia coli on Gram stain. Gram-negative bacilli.

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    <EM>Escherichia coli</EM> on Gram stain. Gram-neg...

    Escherichia coli on Gram stain. Gram-negative bacilli.



    <EM>Escherichia coli</EM> culture on MacConkey ag...

    Escherichia coli culture on MacConkey agar.

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    <EM>Escherichia coli</EM> culture on MacConkey ag...

    Escherichia coli culture on MacConkey agar.

  • Definitive diagnosis is based on the isolation of the organism in the microbiology laboratory from clinical specimens. Specimens may be blood, urine, sputum, or other fluids such as cerebrospinal, biliary, abscess, and peritoneal.
  • Recovery of the organism in contaminated sites, such as sputum and wounds, must be analyzed in the context of the patient's clinical state to determine if it represents colonization or infection. Recovery from sterile sites, such as the CSF, should be considered diagnostic of infection.
  • Lumbar puncture and a CSF culture positive for E coli establish the diagnosis of acute E coli meningitis; however, lumbar puncture is not justified in all babies presenting with sepsis. Indications for lumbar puncture include positive blood culture results, abnormal neurological signs, and detection of bacterial antigens in the urine.
  • Patients with pneumonia should undergo blood cultures and sputum Gram stain and culture. The results of a Gram stain of the sputum help to differentiate a good specimen (many PMN leukocytes, few squamous epithelial cells) from a bad specimen (few PMN leukocytes, many squamous epithelial cells). In addition, obtain the sputum culture before antibiotic therapy is initiated.
  • In enteric infections, the causative organism is suggested based on the clinical presentation and the characteristic of the patient's stool. Enterotoxigenic E coli (ETEC), enteropathogenic E coli (EPEC), enteroaggregative E coli (EAggEC), and enteroadherent E coli (EAEC) infections produce watery stools without inflammatory cells. Enteroinvasive E coli (EIEC) infection produces dysentery-type stools, and enterohemorrhagic E coli (EHEC) infection produces hemorrhagic-type stools.
  • In urinary tract infections, a urine dipstick test may be performed to rapidly determine if the patient has pyuria or bacteriuria based on the detection of leukocyte esterase and nitrites, respectively. Definitive diagnosis is based on urine culture results. Collect the specimen from a midstream clean void or from the catheter in patients with an indwelling Foley catheter. Colonization must be differentiated from infection based on urinalysis results. In cases of infection, pyuria is usually present.

Imaging Studies

  • In pneumonia, chest radiography or CT scanning is indicated.
  • In cholecystitis/cholangitis, ultrasonography or CT scanning of the RUQ is indicated.
  • In intra-abdominal abscess, abdominal and pelvic CT scanning is indicated; abscesses may be missed on sonograms.
  • In UTI, ultrasonography or CT scanning may be performed to help evaluate the kidneys and to look for any other source of abscess, stones, or obstruction.

Other Tests

  • E coli strains that cause diarrhea can be differentiated based on results from tests that are not widely used, such as DNA probes and polymerase chain reaction.
    • EPEC can be identified based on findings from serotyping, assays of adherence, and DNA probes. These tests are difficult to perform and not available widely. Also, results are difficult to interpret.
    • EIEC can be identified based on results from animal pathogenicity tests such as the Sereny test.
    • EHEC can be identified by looking for the major serotype involved, 0157:H7.
    • EHEC strains are cultured in a sorbitol MacConkey agar. Strains that are sorbitol-negative are then serotyped with 0157:H7 antisera.
    • EAEC and EAggEC are identified based on their adherence pattern on tissue culture cells. Serotyping is not useful.

Procedures

  • Meningitis - Lumbar puncture with CSF Gram stain/culture
  • Pneumonia - Bronchoscopy, blood and urine cultures
  • Cholecystitis/cholangitis - Decompression of biliary system through endoscopic drainage, sphincterotomy for stone extraction, or endoscopic cholangiography
  • Intra-abdominal abscess - Aspiration and drainage
  • UTI - In cases of ureteral obstruction, placement of stent or stone extraction
  • Prostatic hypertrophy - Transurethral prostatectomy or transurethral resection of the prostate (TURP)
  • Prostatic abscess - Drainage

More on Escherichia Coli Infections

Overview: Escherichia Coli Infections
Differential Diagnoses & Workup: Escherichia Coli Infections
Treatment & Medication: Escherichia Coli Infections
Follow-up: Escherichia Coli Infections
Multimedia: Escherichia Coli Infections
References
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Further Reading

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Keywords

E coli, Escherichia coli, traveler's diarrhea, traveler diarrhea, E coli cholecystitis, E coli bacteremia, E coli cholangitis, E coli urinary tract infection, E coli UTI, E coli neonatal meningitis, E coli pneumonia, E coli acute bacterial meningitis, E coli nosocomial pneumonia, E coli hospital-acquired pneumonia, E coli nosocomial infection, E coli hospital-acquired infection, E coli bronchopneumonia, enterotoxigenic E coli, ETEC, enteropathogenic E coli, EPEC, enteroinvasive E coli, EIEC, E coli dysentery

enterohemorrhagic E coli, EHEC, E coli hemorrhagic colitis, hemolytic-uremic syndrome, HUS, enteroaggregative E coli, EAggEC, enteroadherent E coli, EAEC, uncomplicated E coli urethritis, uncomplicated E coli cystitis, symptomatic E coli cystitis, E coli pyelonephritis, acute E coli prostatitis, E coli prostatic abscess, E coli urosepsis, E coli septic arthritis, E coli endophthalmitis, E coli suppurative thyroiditis, E coli sinusitis, E coli osteomyelitis, E coli endocarditis, E coli skin infection, E coli diabetic skin infection, E coli soft-tissue infection, E coli diarrheal disease

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Contributor Information and Disclosures

Author

Tarun Madappa, MD, MPH, Critical Care Fellow, Section of Critical Care Medicine, St Vincent Catholic Medical Center, New York Medical College, New York.
Tarun Madappa, MD, MPH is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society
Disclosure: Nothing to disclose.

Coauthor(s)

Chi Hiong U Go, MD, Assistant Professor, Department of Internal Medicine, Texas Tech University Health Science Center at Odessa
Chi Hiong U Go, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine
Disclosure: Nothing to disclose.

Medical Editor

Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus
Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Charles V Sanders, MD, Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center
Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, Alpha Omega Alpha, American Association for the Advancement of Science, American Association of University Professors, American Clinical and Climatological Association, American College of Physician Executives, American College of Physicians, American Federation for Medical Research, American Foundation for AIDS Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges, Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society for Obstetrics and Gynecology, Infectious Diseases Society of America, Louisiana State Medical Society, Orleans Parish Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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