eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Escherichia Coli Infections: Differential Diagnoses & Workup

Author: Archana Chatterjee, MD, PhD, Professor of Pediatrics, Medical Microbiology and Immunology, and Pharmacy, Division of Pediatric Infectious Diseases, Chief of Division of Pediatric Infectious Diseases, Creighton University School of Medicine; Hospital Epidemiologist and Medical Director of Infection Control, Children's Hospital
Coauthor(s): Catherine O'Keefe, DNP, APRN, Assistant Professor of Nursing, Pediatric Nurse Practitioner, Pediatric Infectious Diseases, Creighton University School of Nursing; Sara L Cuthill, MD, Fellow, Developmental and Behavioral Pediatrics, Departmental and Behavioral Pediatrics, Interstate Medical Office East; Meera Varman, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Infectious Diseases, Creighton University School of Medicine
Contributor Information and Disclosures

Updated: Jan 8, 2009

Differential Diagnoses

Appendicitis
Hemolytic-Uremic Syndrome
Bacteremia
Intussusception
Campylobacter Infections
Meningitis, Bacterial
Colic
Necrotizing Enterocolitis
Colitis
Neonatal Sepsis
Constipation
Pyelonephritis
Crohn Disease
Salmonella Infection
Fever in the Toddler
Shigella Infection
Fever in the Young Infant
Ulcerative Colitis
Fever Without a Focus
Urinary Tract Infection
Food Poisoning
Gastroenteritis

Other Problems to Be Considered

Yersinia enterocolitica infection
Clostridium difficile colitis
GI bleeding

Workup

Laboratory Studies

  • Culture stools in all patients with bloody diarrhea for pathogenic Escherichia coli, primarily the 0157:H7 serotype. If exposure is suspected (ie, as in the case of a known outbreak), assay even watery stools without blood for these pathogens. Enterohemorrhagic E coli (EHEC) isolation from stool may be impossible by the time hemolytic-uremic syndrome (HUS) has developed; thus, when EHEC is suspected, a stool culture should be obtained as early in the illness as possible (eg, within the first week).
  • Routine stool cultures generally screen for Salmonella, Shigella and Campylobacter species. Because E coli organisms are normal fecal flora, laboratories must be advised specifically to assay for pathogenic E coli when a sample is submitted. Most 0157:H7 isolates do not ferment sorbitol; therefore, cultivation of specimens on sorbitol MacConkey medium is a convenient method for detection. Confirmation requires identification of presumptive isolates with O and H antiserum.
  • Detection of Shiga-toxin–producing E coli in contaminated food or a patient's stool specimens may present a diagnostic challenge because of low copy numbers in the sample. Recently, more sensitive nucleic acid amplification methods, such as polymerase chain reaction (PCR) assays, have been developed for rapid identification of this organism directly from clinical specimens. Multiplex PCR assays for detection of all categories of diarrheagenic E coli are also available.2,18
  • Rapid enzyme immunoassays (nonculture tests) for E coli 0157:H7 have been developed.19 Such tests may be available at large university hospitals or through reference laboratories. Stool culture remains the diagnostic criterion standard.
  • Enterotoxigenic E coli (ETEC) diarrhea (traveler's diarrhea) is primarily diagnosed by clinical history, and treatment is empirically initiated. Laboratory assays involve detection of the associated enterotoxin, usually by enzyme immunoassay, and are not widely available.20
  • Fecal leukocyte presence varies but is more likely with enteroinvasive E coli (EIEC). Stool guaiac testing may reveal occult blood. Test the stools of infants and toddlers with profuse watery diarrhea for rotavirus antigen, especially during fall and winter.
  • Other laboratory findings associated with bacterial enteritis are nonspecific. Electrolyte changes may reflect fluid loss, and CBC counts generally reveal an elevated leukocyte count with left shift.
    • Accurate urinary tract infection (UTI) diagnosis requires an appropriately collected urine specimen. A clean-catch specimen is acceptable if the child is able to provide it. If not, urethral catheterization or suprapubic bladder aspiration is necessary.
    • Externally collected bag urine specimens are unsuitable for accurate diagnosis of pediatric UTI, and use of this collection technique is strongly discouraged.
  • Externally collected urine samples are likely to be contaminated with skin or rectal flora, rendering them unreliable and their cultures uninterpretable.  
    • Urinalysis results help make the decision whether to begin antibiotic treatment.
    • Urinary nitrite and leukocyte esterase are specific but poorly sensitive assays for UTI.
    • Pyuria strongly suggests a UTI, but may be absent even when infection is present.
  • Perform a urine culture despite negative urinalysis results, particularly in infants and children younger than 3 years.
  • All neonates with suspected sepsis should have specimens of blood, urine, and cerebrospinal fluid sent for culture and Gram stain prior to initiating antimicrobial therapy.

Imaging Studies

  • Abdominal radiography is not necessarily indicated. Consider flat and upright views when the differential diagnosis includes appendicitis or obstruction, including constipation. A CT scan of the abdomen with contrast is more sensitive than plain radiography for detection of E coli– induced colitis.21
  • An air-contrast enema is both diagnostic and therapeutic for patients with a suspected intussusception.
  • All children with a documented UTI should have imaging studies of the urinary tract to exclude an anatomic abnormality or vesicoureteral reflux. Renal ultrasonography and voiding cystourethrography are the currently recommended tests. Schedule both tests promptly. Girls older than 10 years with their first UTI may not require such extensive evaluation.

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
References
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References

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Further Reading

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Keywords

Escherichia coli infections, E coli infections, Escherichia coli, E coli, colibacillus, diarrhea, diarrheal illness, hemolytic-uremic syndrome, HUS, urinary tract infection, UTI, neonatal sepsis, meningitis, enterotoxigenic E coli, ETEC, enterohemorrhagic E coli, EHEC, enteropathogenic E coli, EPEC, enteroinvasive E coli, EIEC, enteroaggregative E coli, EAEC, hemolytic anemia, thrombocytopenia, renal insufficiency, diarrhea, oliguria, anuria, traveler's diarrhea, bacteremia, sepsis, respiratory distress, prematurity, low birth weight, hemorrhagic colitis, abdominal cramping, dysentery

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Contributor Information and Disclosures

Author

Archana Chatterjee, MD, PhD, Professor of Pediatrics, Medical Microbiology and Immunology, and Pharmacy, Division of Pediatric Infectious Diseases, Chief of Division of Pediatric Infectious Diseases, Creighton University School of Medicine; Hospital Epidemiologist and Medical Director of Infection Control, Children's Hospital
Archana Chatterjee, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, International Society for Infectious Diseases, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: GlaxosmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi-Pasteur Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; GlaxoSmithKline Grant/research funds Other; MedImmune  Other; Merck Grant/research funds Other; Novartis Grant/research funds Other; Sanofi-Pasteur Grant/research funds Other

Coauthor(s)

Catherine O'Keefe, DNP, APRN, Assistant Professor of Nursing, Pediatric Nurse Practitioner, Pediatric Infectious Diseases, Creighton University School of Nursing
Catherine O'Keefe, DNP, APRN is a member of the following medical societies: American Academy of Nurse Practitioners, National Association of Pediatric Nurse Practitioners, and Nebraska Nurse Practitioners
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, Assistant Professor, Department of Pediatrics, Section of Pediatric Infectious Diseases, Creighton University School of Medicine
Meera Varman, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: phamaceutical companies Honoraria Speaking and teaching; phamaceutical companies Grant/research funds clinical trials

Medical Editor

Ashir Kumar, MBBS, MD, FAAP, Professor, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University; Consulting Staff, Department of Pediatrics, EW Sparrow Hospital
Ashir Kumar, MBBS, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association of Physicians of Indian Origin, American Federation for Clinical Research, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota School of Medicine
Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
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, and Southern Medical Association
Disclosure: None None None

 
 
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