Clinical manifestations and stool load of atypical enteropathogenic E. coli infections in U.S. children and adults.


Grant support: NIAID R21-AI142515-02

Disclosures: The authors have nothing to disclose.

Author Contributions:

Sarah E. Kralicek, MS (First Authorship: equal; Conceptualization: equal; Data curation: equal; Formal analysis: equal; Investigation: equal; Methodology: equal; Visualization: lead; Writing – original draft: lead; Writing – review & editing: equal).

Lalitha M. Sitaraman, MD (First Authorship: equal; Conceptualization: supporting; Formal analysis: supporting; Investigation: equal; Methodology: equal; Writing – original draft: supporting; Writing – review & editing: supporting).

Paulius V. Kuprys, PhD (Investigation: supporting; Writing – review and editing: supporting).

Amanda T. Harrington, PhD, D(ABMM) (Resources: supporting; Writing – review: supporting)

Bharat Ramakrishna, MBBS (Resources: supporting; Writing – review and editing: supporting).

Majdi Osman, MD (Resources: supporting; Writing – review and editing: supporting).

Gail A. Hecht, MD (Conceptualization: equal; Data curation: equal; Formal analysis: equal; Funding acquisition: lead; Resources: lead; Supervision: lead; Writing – review & editing: equal).

Data Transparency Statement: Data and study materials will be made available upon request.

Acknowledgements: The authors would like to thank William H. Adams, PhD with the Department of Medicine and Stritch School of Medicine at Loyola University Chicago for his careful consideration and review of the statistical approaches applied in this work and Susan Zelisko, Information Clinical Research Sr. Clinical Data/Programmer Analyst, whose help extracting data from the Clinical Research Database at Loyola University Chicago was essential to completing this work.


Atypical enteropathogenic E. coli causes a wide array of symptoms ranging from asymptomatic carriage to severe, prolonged diarrhea often with vomiting, abdominal pain, or fever. Higher stool loads are associated with symptoms.


BACKGROUND AND CONTEXT: Atypical enteropathogenic E. coli (aEPEC) infections are increasing worldwide but there is confusion regarding the clinical significance, especially in adults, due to asymptomatic carriage, paucity of data regarding clinical manifestations, and strain heterogeneity.

NEW FINDINGS: aEPEC infection is associated with disease in children and adults but symptoms vary ranging from asymptomatic carriage to severe diarrhea. High stool EPEC load correlates with symptoms but does not predict severity.

LIMITATIONS: Modified Vesikari score has only been validated in children with acute gastroenteritis. EPEC-negative controls in this retrospective study likely had greater prevalence of gastrointestinal symptoms than the general population. Distinguishing continued from nascent infections in the longitudinal data was not possible.

IMPACT: To our knowledge, this is the first study detailing the clinical manifestations of aEPEC sporadic infection in adults and children in the US, thus providing better understanding of aEPEC disease.

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