Medscape is available in 5 Language Editions – Choose your Edition here.


Pediatric Escherichia Coli Infections Clinical Presentation

  • Author: Archana Chatterjee, MD, PhD; Chief Editor: Russell W Steele, MD  more...
Updated: Oct 07, 2015


Symptoms of Escherichia coli infection may be subtle and nonspecific in infants and young children. Even in older children, symptoms may resemble those of common viral illnesses, leading to missed or delayed diagnosis. A thorough history, including any history of a prior urinary tract infection (UTI), and thoughtful analysis of the information provided is essential. Pertinent details can guide further diagnostic investigation.

  • Neonates and infants with UTIs, bacteremia, or sepsis may present with the following symptoms:
    • Fever
    • Hypothermia
    • Jaundice
    • Respiratory distress
    • Apnea
    • Poor feeding
    • Vomiting
    • Diarrhea
    • Fussiness
    • Irritability
    • Lethargy
  • Particularly in young infants, meningitis may be present without overt signs attributable to the CNS.
  • Infants with histories of prematurity, low birth weight, difficult or prolonged labor, intrapartum maternal fever, or antibiotic administration may have higher risk for serious bacterial infection.
  • Older children with bacterial enteritis or UTI may have fever, vomiting, abdominal pain, or diarrhea with or without blood or mucus. In young children with UTI, urinary symptoms (eg, frequency, urgency, dysuria) vary and are often not present; daytime urinary incontinence or new onset of bedwetting may be more suggestive of UTI. Always consider UTI in the differential diagnosis of fever without apparent source. Constipation is not a symptom of UTI but is instead associated with incomplete voiding and urinary stasis. Constipation may predispose a child to UTI and may complicate treatment. In children with recurrent UTI, aggressive treatment of constipation may reduce subsequent UTIs.
  • In cases of diarrheal illness, determine stool frequency (ie, number of stools or diaper changes in past 12-24 h), appearance (eg, loose, watery), and presence of blood or mucus. Inquire about a history of exposure to a child with bloody diarrhea or a known local outbreak of hemorrhagic colitis. Specific quantification of stool number and character is important because parents often describe a single loose stool as diarrhea. Also, remember various substances (eg, Kool-Aid, other foods containing red dyes) may tint stools red. Guaiac testing confirms the presence of blood.
    • Enterotoxigenic E coli (ETEC) diarrhea is watery without blood, mucous, or fecal leukocytes and ranges from mild to severe.
    • Enterohemorrhagic E coli (EHEC) disease ranges from mild watery diarrhea to severe hemorrhagic colitis, often accompanied by abdominal cramping and vomiting. Diarrhea becomes bloody in 1-2 days in most patients but is usually not associated with fecal leukocytes. Fever is present in about a third of cases.
    • Enteroinvasive E coli (EIEC) causes watery diarrhea, dysentery, fever, vomiting, painful abdominal cramps, and tenesmus. Stools often contain blood and leukocytes.
    • Enteropathogenic E coli (EPEC) and Enteroaggregative E coli (EAEC) cause watery diarrhea and dysentery. The resultant acute watery diarrhea may cause dehydration or become chronic and lead to failure to thrive.
  • Evaluate the ability of patients who are vomiting or at risk of dehydration to take and tolerate fluids orally. Assess frequency of urination (ie, last void or wet diaper, number of voids in past 8-24 h). Vomiting may occur with ETEC.
  • If the patient is experiencing abdominal pain, assess pain for the following features:
    • Severity and character (eg, sharp, dull, cramplike)
    • Location
    • Radiation
    • Duration
    • Nature (eg, constant, intermittent)
    • Aggravating and relieving factors


The child's overall appearance and behaviors (eg, alert, playful, fussy but consolable, lethargic, irritable, toxic) are valuable because these factors may direct diagnostic and therapeutic choices and influence decisions regarding outpatient management or admission.

  • Among the aspects of general appearance to consider are alertness, activity, tone, age-appropriate interaction, and whether the child can be consoled. Observe, for example, whether the child explores the room, clings to the parent, or lies still on the table.
  • Evidence of dehydration may be present in patients with bacterial enteritis. Ill appearance, tachycardia, and dry mucous membranes suggest significant volume depletion. Fontanelle and/or eyes may be sunken, but skin turgor change is a late finding and is often not present. If previous weight is known, documented weight loss can help approximate the degree of dehydration.
  • Assess peripheral perfusion by observing for extremity mottling, coolness, or delayed capillary refill. Evaluate the quality of central and peripheral pulses.
  • Patients may have abdominal pain from either bacterial enteritis or a UTI. Flank pain or costovertebral angle tenderness suggests pyelonephritis. Abdominal pain sometimes is sufficiently severe to mimic appendicitis. Examine the abdomen for distention, increased or decreased bowel sounds, diffuse or localized tenderness, and signs of acute abdomen (eg, rigidity, rebound, guarding).
  • Examine anogenital region in children who have urinary or abdominal symptoms or a history of bloody stools. Examination may reveal vulvovaginitis, perianal excoriation, or anal fissures.
  • Complete examination should include adequate visualization of all skin surfaces. Subtle findings, such as petechiae or bruising, may be overlooked if the examination is rushed or limited.


See the list below:

  • ETEC infection: ETEC is the primary cause of traveler's diarrhea and the major cause of infantile diarrhea in less affluent countries. ETEC is widespread in areas with poor sanitation and is a ubiquitous contaminant of food and water sources. ETEC's incubation period is 1-3 days. Infection usually is self-limited and persists less than 5 days.[9, 10]
  • EHEC infection
    • EHEC is an emerging cause of food-borne illness, particularly in the northern United States and Canada.[18]
    • Recent highly publicized outbreaks of hemolytic-uremic syndrome (HUS) that caused fatalities have focused public attention on food safety.
    • Cattle are the primary reservoir of the EHEC strains that produce diarrhea in humans. Because EHEC is a common inhabitant of the bovine intestine, it may contaminate beef products or foods that contact bovine-exposed soil.
    • Sources identified in outbreaks include ground beef, apple juice, and alfalfa sprouts,[11, 12] as well as fecally contaminated drinking water and swimming pools.
    • Most outbreaks have been linked to 0157:H7 strains, although other serotypes have been implicated.[19, 13, 20, 21]
    • Of particular concern in pediatric populations, E coli 0157:H7 requires a relatively small inoculum for infection and spreads easily from child to child by the fecal-oral route. The incubation period of EHEC is 1-5 days, with illness duration typically 4-10 days.
    • HUS develops in 10-15% of pediatric patients. Chronic renal failure develops in as many as 10% of patients with HUS, and HUS kills 3-5% of affected patients.[22]
  • EPEC infection: EPEC is most often found in developing countries, primarily affecting infants and children. EPEC has been associated with outbreaks of diarrhea in newborn nurseries in the United States, primarily in the 1950s and 1960s.
  • EAEC infection: EAEC is similar in geographic distribution, mechanism, and effect to EPEC. The CDC's Traveler's Health Web site provides additional information to physicians and the public.
  • UTIs
    • E coli is the most commonly isolated pathogen in pediatric UTIs. Virulence factors, such as pili, contribute to the pathogenicity of UTIs.
    • HUS has been reported following UTIs with enterohemorrhagic serotypes of E coli in patients who did not have a diarrheal illness.
  • Neonatal infections
    • E coli infection in neonates may manifest as bacteremia, sepsis, UTI, or meningitis; it rarely manifests as pneumonia, soft tissue, or bone infection.
    • E coli strains with the K1 capsular polysaccharide antigen cause approximately 40% of the septicemia cases and 80% of the meningitis cases attributed to E coli.
    • The usual source of E coli in neonatal infections is the maternal GI tract. The organism also may be acquired nosocomially, particularly in infants who are premature or who require mechanical ventilation.
    • Predisposing factors include maternal perinatal infection, low birth weight, prolonged rupture of membranes, and traumatic delivery. Fetal hypoxia and skin or mucosal defects also increase the risk of gram-negative infection. Infants with galactosemia appear to have an increased susceptibility to serious bacterial infection, particularly E coli sepsis.
    • In intensive care nurseries, mechanical ventilation, invasive procedures, indwelling catheters, and the frequent use of antimicrobial agents allow selection and proliferation of resistant strains of pathogenic gram-negative bacilli.
Contributor Information and Disclosures

Archana Chatterjee, MD, PhD Professor and Chair, Department of Pediatrics, Senior Associate Dean for Faculty Development, Sanford School of Medicine, The University of South Dakota

Archana Chatterjee, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, International Society for Infectious Diseases, Pediatric Infectious Diseases Society, Society for Pediatric Research

Disclosure: Nothing to disclose.


Sara L Cuthill, MD Fellow, Developmental and Behavioral Pediatrics, Departmental and Behavioral Pediatrics, Interstate Medical Office East

Sara L Cuthill, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Meera Varman, MD Associate Professor, Department of Pediatrics, Section of Pediatric Infectious Diseases, Creighton University Medical Center

Meera Varman, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Healthcare Epidemiology of America

Disclosure: Received honoraria from phamaceutical companies for speaking and teaching; Received grant/research funds from phamaceutical companies for clinical trials research.

Catherine O’Keefe, DNP, APRN-NP Associate Professor of Nursing, Clinician-Educator Track Graduate Curriculum Coordinator, Nurse Practitioner Programs, Creighton University, School of Nursing; Pediatric Nurse Practitioner, Pediatric Infectious Diseases, Creighton University Medical Center

Catherine O’Keefe, DNP, APRN-NP is a member of the following medical societies: American Association of Nurse Practitioners, National Association of Pediatric Nurse Practitioners, Nebraska Nurse Practitioners

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Mark R Schleiss, MD Minnesota American Legion and Auxiliary Heart Research Foundation Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School

Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Ashir Kumar, MD, MBBS FAAP, Professor Emeritus, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine

Ashir Kumar, MD, MBBS is a member of the following medical societies: Infectious Diseases Society of America, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

  1. Nataro JP. Escherichia coli. Long S, Pickering LK, Prober CG (Editors). Principles and Practice of Pediatric Infectious Diseases. 3rd Edition. Orlando, Fl: Churchill Livingstone; 2008.

  2. Escherichia coli diarrhea. Pickering LK, Baker CJ, Overturf GD, Prober CG (Editors). American Academy of Pediatricians Report of the Committee on Infectious Diseases. Red Book. 2008. 291-6.

  3. Centers for Disease Control and Prevention. Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food--10 states, 2007. MMWR Morb Mortal Wkly Rep. 2008 Apr 11. 57(14):366-70. [Medline].

  4. WHO. Enterotoxigenic escherichia coli. World Health Organization. Available at Accessed: 10/01/2008.

  5. Gupta SK, Keck J, Ram PK, Crump JA, Miller MA, Mintz ED. Part III. Analysis of data gaps pertaining to enterotoxigenic Escherichia coli infections in low and medium human development index countries, 1984-2005. Epidemiol Infect. 2008 Jun. 136(6):721-38. [Medline].

  6. Qadri F, Svennerholm AM, Faruque AS, et al. Enterotoxigenic Escherichia coli in developing countries: epidemiology, microbiology, clinical features, treatment, and prevention. Clin Microbiol Rev. 2005 Jul. 18(3):465-83. [Medline].

  7. Bolin I, Wiklund G, Qadri F, et al. Enterotoxigenic Escherichia coli with STh and STp genotypes is associated with diarrhea both in children in areas of endemicity and in travelers. J Clin Microbiol. 2006 Nov. 44(11):3872-7. [Medline].

  8. Rockabrand DM, Shaheen HI, Khalil SB, et al. Enterotoxigenic Escherichia coli colonization factor types collected from 1997 to 2001 in US military personnel during operation Bright Star in northern Egypt. Diagn Microbiol Infect Dis. 2006 May. 55(1):9-12. [Medline].

  9. Yolbas I, Tekin R, Kelekci S, Tekin A, Okur MH, Ece A, et al. Community-acquired urinary tract infections in children: pathogens, antibiotic susceptibility and seasonal changes. Eur Rev Med Pharmacol Sci. 2013 Apr. 17(7):971-6. [Medline].

  10. Canizalez-Roman A, Gonzalez-Nuñez E, Vidal JE, Flores-Villaseñor H, León-Sicairos N. Prevalence and antibiotic resistance profiles of diarrheagenic Escherichia coli strains isolated from food items in northwestern Mexico. Int J Food Microbiol. 2013 Mar 27. 164(1):36-45. [Medline].

  11. Buchholz U, Bernard H, Werber D, et al. German Outbreak of Escherichia coli O104:H4 Associated with Sprouts. N Engl J Med. 2011 Oct 26. [Medline].

  12. Frank C, Werber D, Cramer JP, et al. Epidemic Profile of Shiga-Toxin-Producing Escherichia coli O104:H4 Outbreak in Germany. N Engl J Med. 2011 Jun 22. [Medline].

  13. Centers for Disease Control and Prevention. Escherichia coli O157:H7 infection associated with drinking raw milk--Washington and Oregon, November-December 2005. MMWR Morb Mortal Wkly Rep. 2007 Mar 2. 56(8):165-7. [Medline].

  14. Rossit AR, de Almeida MT, Nogueira CA, et al. Bacterial, yeast, parasitic, and viral enteropathogens in HIV-infected children from São Paulo State, Southeastern Brazil. Diagn Microbiol Infect Dis. 2007 Jan. 57(1):59-66. [Medline].

  15. Gassama A, Sow PS, Fall F, et al. Ordinary and opportunistic enteropathogens associated with diarrhea in Senegalese adults in relation to human immunodeficiency virus serostatus. Int J Infect Dis. 2001. 5(4):192-8. [Medline].

  16. Hien BT, Scheutz F, Cam PD, et al. Diarrheagenic Escherichia coli and Shigella strains isolated from children in a hospital case-control study in Hanoi, Vietnam. J Clin Microbiol. 2008 Mar. 46(3):996-1004. [Medline].

  17. Al-Gallas N, Bahri O, Bouratbeen A, et al. Etiology of acute diarrhea in children and adults in Tunis, Tunisia, with emphasis on diarrheagenic Escherichia coli: prevalence, phenotyping, and molecular epidemiology. Am J Trop Med Hyg. 2007 Sep. 77(3):571-82. [Medline].

  18. Kim MJ, Kim SA, Kang YS, Hwang IG, Rhee MS. Microbial diversity and prevalence of foodborne pathogens in cheap and junk foods consumed by primary schoolchildren. Lett Appl Microbiol. 2013 Apr 1. [Medline].

  19. Centers for Disease Control and Prevention. Escherichia coli 0157:H7 infections in children associated with raw milk and raw colostrum from cows--California, 2006. MMWR Morb Mortal Wkly Rep. 2008 Jun 13. 57(23):625-8. [Medline].

  20. Centers for Disease Control and Prevention. Ongoing multistate outbreak of Escherichia coli serotype O157:H7 infections associated with consumption of fresh spinach--United States, September 2006. MMWR Morb Mortal Wkly Rep. 2006 Sep 29. 55(38):1045-6. [Medline].

  21. Diarrheagenic Escherichia coli. Centers for Disease Control and Prevention. Available at Accessed: October 1, 2008.

  22. Serna A 4th, Boedeker EC. Pathogenesis and treatment of Shiga toxin-producing Escherichia coli infections. Curr Opin Gastroenterol. 2008 Jan. 24(1):38-47. [Medline].

  23. Zhang W, Bielaszewska M, Pulz M, et al. New immuno-PCR assay for detection of low concentrations of shiga toxin 2 and its variants. J Clin Microbiol. 2008 Apr. 46(4):1292-7. [Medline].

  24. Beutin L, Steinruck H, Krause G, et al. Comparative evaluation of the Ridascreen Verotoxin enzyme immunoassay for detection of Shiga-toxin producing strains of Escherichia coli (STEC) from food and other sources. J Appl Microbiol. 2007 Mar. 102(3):630-9. [Medline].

  25. Lothigius A, Janzon A, Begum Y, et al. Enterotoxigenic Escherichia coli is detectable in water samples from an endemic area by real-time PCR. J Appl Microbiol. 2008 Apr. 104(4):1128-36. [Medline].

  26. Morgan J, Bell M, Sadler MA. CT imaging of acute E. Coli-related colitis. Emerg Radiol. 2007 Jul. 14(3):187-9. [Medline].

  27. Kliegman RM, Behrman RE, Jenson HB, et al. The pathophysiology of body fluids and fluid therapy. Nelson Textbook of Pediatrics, 18th ed. Elsevier Health Sciences,. 2007. Ch. 55.1.

  28. Faure C. Role of antidiarrhoeal drugs as adjunctive therapies for acute diarrhoea in children. Int J Pediatr. 2013. 2013:612403. [Medline]. [Full Text].

  29. Wong CS, Jelacic S, Habeeb RL, et al. The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections. N Engl J Med. 2000 Jun 29. 342(26):1930-6. [Medline].

  30. Scheiring J, Andreoli SP, Zimmerhackl LB. Treatment and outcome of Shiga-toxin-associated hemolytic uremic syndrome (HUS). Pediatr Nephrol. 2008 Oct. 23(10):1749-60. [Medline].

  31. Safdar N, Said A, Gangnon RE, Maki DG. Risk of hemolytic uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 enteritis: a meta-analysis. JAMA. 2002 Aug 28. 288(8):996-1001. [Medline].

  32. Ake JA, Jelacic S, Ciol MA, et al. Relative nephroprotection during Escherichia coli O157:H7 infections: association with intravenous volume expansion. Pediatrics. 2005 Jun. 115(6):e673-80. [Medline].

  33. Anjay MA, Anoop P, Britland A. Leukocytosis as a predictor for progression to haemolytic uraemic syndrome in Escherichia coli O157:H7 infection. Arch Dis Child. 2007 Sep. 92(9):820-3. [Medline].

  34. Joishy M, Jauhari P, Mathew AA, et al. Can we predict the development of haemolytic uraemic syndrome in the early stage of Escherichia coli O157 infection?. Arch Dis Child. 2008 Feb. 93(2):180-1. [Medline].

  35. Saps M, Pensabene L, Di Martino L, et al. Post-infectious functional gastrointestinal disorders in children. J Pediatr. 2008 Jun. 152(6):812-6, 816.e1. [Medline].

  36. Frech SA, Dupont HL, Bourgeois AL, et al. Use of a patch containing heat-labile toxin from Escherichia coli against travellers' diarrhoea: a phase II, randomised, double-blind, placebo-controlled field trial. Lancet. 2008 Jun 14. 371(9629):2019-25. [Medline].

  37. Glenn GM, Villar CP, Flyer DC, et al. Safety and immunogenicity of an enterotoxigenic Escherichia coli vaccine patch containing heat-labile toxin: use of skin pretreatment to disrupt the stratum corneum. Infect Immun. 2007 May. 75(5):2163-70. [Medline].

  38. Ahmed A, Li J, Shiloach Y, et al. Safety and immunogenicity of Escherichia coli O157 O-specific polysaccharide conjugate vaccine in 2-5-year-old children. J Infect Dis. 2006 Feb 15. 193(4):515-21. [Medline].

  39. Amieva MR. Important bacterial gastrointestinal pathogens in children: a pathogenesis perspective. Pediatr Clin North Am. 2005 Jun. 52(3):749-77, vi. [Medline].

  40. Blackall DP, Marques MB. Hemolytic uremic syndrome revisited: Shiga toxin, factor H, and fibrin generation. Am J Clin Pathol. 2004 Jun. 121 Suppl:S81-8. [Medline].

  41. David RD, DeBlieux PM, Press R. Rational antibiotic treatment of outpatient genitourinary infections in a changing environment. Am J Med. 2005 Jul. 118 Suppl 7A:7S-13S. [Medline].

  42. Investigation of multistate outbreak of E. coli O157:H7 infections: Updated July 18, 2008. Centers for Disease Control and Prevention. Available at Accessed: September 30, 2008.

  43. Li F, Zhao C, Zhang W, et al. Use of ramification amplification assay for detection of Escherichia coli O157:H7 and other E. coli Shiga toxin-producing strains. J Clin Microbiol. 2005 Dec. 43(12):6086-90. [Medline]. [Full Text].

  44. Mehnert-Kay SA. Diagnosis and management of uncomplicated urinary tract infections. Am Fam Physician. 2005 Aug 1. 72(3):451-6. [Medline].

  45. Stoll BJ, Hansen N. Infections in VLBW infants: studies from the NICHD Neonatal Research Network. Semin Perinatol. 2003 Aug. 27(4):293-301. [Medline].

  46. Tarr PI, Gordon CA, Chandler WL. Shiga-toxin-producing Escherichia coli and haemolytic uraemic syndrome. Lancet. 2005 Mar 19-25. 365(9464):1073-86. [Medline].

  47. Vidal M, Kruger E, Duran C, et al. Single multiplex PCR assay to identify simultaneously the six categories of diarrheagenic Escherichia coli associated with enteric infections. J Clin Microbiol. 2005 Oct. 43(10):5362-5. [Medline]. [Full Text].

  48. Yates J. Traveler's diarrhea. Am Fam Physician. 2005 Jun 1. 71(11):2095-100. [Medline].

  49. Yada N, Fujioka M, Bennett CL, Inoki K, Miki T, Watanabe A, et al. STEC:O111-HUS complicated by acute encephalopathy in a young girl was successfully treated with a set of hemodiafiltration, steroid pulse, and soluble thrombomodulin under plasma exchange. Clin Case Rep. 2015 Apr. 3 (4):208-12. [Medline]. [Full Text].

  50. Takanashi J, Taneichi H, Misaki T, Yahata Y, Okumura A, Ishida Y, et al. Clinical and radiologic features of encephalopathy during 2011 E coli O111 outbreak in Japan. Neurology. 2014 Feb 18. 82 (7):564-72. [Medline].

  51. Pape L, Hartmann H, Bange FC, Suerbaum S, Bueltmann E, Ahlenstiel-Grunow T. Eculizumab in Typical Hemolytic Uremic Syndrome (HUS) With Neurological Involvement. Medicine (Baltimore). 2015 Jun. 94 (24):e1000. [Medline].

  52. Dinh A, Anathasayanan A, Rubin LM. Safe and effective use of eculizumab in the treatment of severe Shiga toxin Escherichia coli-associated hemolytic uremic syndrome. Am J Health Syst Pharm. 2015 Jan 15. 72 (2):117-20. [Medline].

  53. Delmas Y, Vendrely B, Clouzeau B, Bachir H, Bui HN, Lacraz A, et al. Outbreak of Escherichia coli O104:H4 haemolytic uraemic syndrome in France: outcome with eculizumab. Nephrol Dial Transplant. 2014 Mar. 29 (3):565-72. [Medline]. [Full Text].

All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.