E. Coli Treatments and Medications

Everyone lives with Escherichia coli (E. coli), a normally harmless bacteria that takes up housekeeping in the colon. Sometimes, however, the microbe can end up moving in where it shouldn’t, causing serious urinary tract infections, blood infections, and even pneumonia. Still, the nastiest E. coli bugs are the strains found in the colon that can cause serious and even fatal intestinal infections. When the news covers stories about E. coli outbreaks sending people to the hospital, or resulting in death, it’s these more infectious E. coli strains they’re reporting on. Despite the panic, most of these infections resolve after a few days. Only a small number of people get very sick from E. coli gut infections.

What is E. coli?

Escherichia coli, or E. coli, is a bacteria that lives harmlessly in the human gut along with other bacteria. Certain strains of E. coli, however, are invasive, toxic, or both, and can cause a severe infection called E. coli infection. Characterized by watery diarrhea, abdominal cramps, and vomiting, E. coli gut infections are one of the most common causes of food poisoning. The more toxic E. coli strains, however, can be life-threatening.

Besides gut infections, E. coli can cause several other types of infections. The human body has evolved to live with E. coli colonies in the intestines, but not other organs. If normally harmless E. coli bacteria travel to other parts of the body, they can cause serious infections. For instance, 80% to 90% of urinary tract infections (UTIs) are caused by E. coli from the gut traveling up the urethra and infecting the urethra, bladder, or kidneys. Peritonitis (infection of the abdomen’s lining), bacteremia (blood infection), meningitis (infection of the membranes surrounding the brain), and cholangitis (inflammation of the bile ducts) can all be caused by E. coli bacteria finding their way to other parts of the body.

Many E. coli infections strike newborns, such as neonatal meningitis, neonatal pneumonia, or neonatal sepsis. All of these opportunistic E. coli infections are distinct conditions with different complications and treatments. This article will focus on intestinal infections caused by infectious E. coli that normally live in animals.

For more information about E. coli urinary tract infections, read our article on UTI Treatments and Medications.

The infectious strains of E. coli normally live in animals but are spread to humans through the ingestion of animal feces in contaminated food or water. Cattle are the principal reservoir of infectious or toxic forms of E. coli.

E.coli infection is usually acquired from:

• Uncooked or partially cooked ground beef

• Unpasteurized or raw milk

• Raw meat

• Fresh, unwashed produce (because of the use of animal feces fertilizer or runoff from cattle farms)

• Contaminated drinking water, particularly well water

• Contaminated food preparation surfaces, such as dirty cutting boards

• Physical contact with farm animals, such as petting zoos

• Person-to-person contact

Although animals are the main source of Escherichia coli infections, anywhere from 10% to 15% of infections are spread from person to person. The most common cause of person-to-person spread is poor hygiene. E. coli infections can also be caught from other people by using improperly maintained swimming pools, but this is relatively uncommon.

The infectious strains of E. coli are classified by how they infect people:

• Enterotoxigenic E. coli (ETEC) and enteroaggregative E. coli (EAEC) attach themselves to the lining of the intestines and secrete toxins that cause intestinal membranes to lose ions and water, leading to watery diarrhea, but without any fever. ETEC and EAEC infections are commonly called “traveler’s diarrhea” because the infection is usually picked up by traveling to a developing country.

• Enteropathogenic E. coli (EPEC) and diffusely adherent E. coli (DAEC) also attach themselves to the intestinal lining and secrete toxins that cause the intestinal membranes to secrete water, leading to watery diarrhea without fever. EPEC and DAEC, though, are infections that are more common in young children or infants (infant diarrhea).

• Enteroinvasive E. coli (EIEC) invades intestinal cells and causes watery diarrhea and fever. Enteroinvasive E. coli is a rare form of E. coli that does not produce toxins.

• Enterohemorrhagic E. coli (EHEC) are bacteria that both attach to the intestinal lining and invade intestinal cells. Enterohemorrhagic E. coli includes those types of E. coli that produce Shiga toxin (Shiga toxigenic E. coli or STEC) or verotoxin (verotoxigenic E. coli or VTEC). Shiga toxin (Stx) and verotoxin (also called Shiga-like toxin) are serious poisons. These poisons attack and break down the lining of the intestines leading to hemorrhagic colitis, or bloody diarrhea. These poisons can also attack the lining of the glomerulus (an important filtering structure of the kidney) and lead to serious complications such as hemolytic uremic syndrome (HUS), kidney failure, and kidney injury.

Deadly E. coli outbreaks are almost always outbreaks of enterohemorrhagic E. coli, particularly a Shiga toxin-producing strain called E. coli O157:H7. According to the Centers for Disease Control and Prevention (CDC), approximately 73,000 people in the United States are infected each year with Escherichia coli O157:H7. Most people ride out the infection, but about 2,000 people will be hospitalized and about 60 will die each year. The number of people infected annually with less deadly pathogenic E. coli is uncertain.

Death caused by E. coli infections is usually due to hemolytic uremic syndrome. The Shiga toxin is absorbed by the intestines and enters the bloodstream. There, the toxin kills off red blood cells, causing anemia, and platelets, the blood cells responsible for clotting. The dead blood cells clog up the tiniest filters in the kidneys, so the kidneys stop filtering waste products out of the blood. Waste products build up in the bloodstream (uremic syndrome) and threaten the health of other organs. Fortunately, HUS is only a rare complication.

An infection with E. coli usually produces symptoms in about three days following exposure to the bacteria. Symptoms can last for five to ten days. E. coli that produce Shiga or Shiga-like toxins will usually cause watery diarrhea for two or three days followed by bloody diarrhea for another seven days. However, some people infected with E. coli, including enterohemorrhagic E. coli, may experience no or only mild symptoms.

How is E. coli diagnosed?

E.coli is diagnosed from the symptoms and a stool sample.

Most E. coli infections will be diagnosed and treated by a primary care physician, but severe infections may require a digestive system doctor (gastroenterologist) or a kidney specialist (nephrologist).

The most common symptoms of E. coli infection are:

• Watery diarrhea

• Stomach cramps

• Nausea

• Vomiting

• Fatigue

Symptoms may also include bloody diarrhea or fever. Bloody diarrhea is often a serious symptom that may indicate an infection with Shiga toxin-producing bacteria.

The most serious (but rare) complication of an E. coli infection is hemolytic uremic syndrome, a medical emergency that requires immediate medical attention. The symptoms of hemolytic uremic syndrome are:

• Decreased urination

• Tiredness

• High blood pressure

• Yellow or pale skin

• Unusual bleeding or bruising

The patient history can help identify risk factors such as consumption of contaminated food or water, exposure to farm animals, or person-to-person transmission.

A stool culture is used to identify the infecting organism as well as antibodies to Shiga toxin or verotoxin. A blood test is performed to obtain a white blood cell count and to rule out other possible conditions. A urine test will determine how well the kidneys are functioning.

E. coli treatment options

E.coli is treated with supportive care. Medications are only rarely used, but hemolytic uremic syndrome due to Shigella poisoning may require hospitalization, intravenous fluid replacement, blood transfusions, or dialysis.

Supportive care

The primary goal of supportive care is to maintain hydration and electrolytes. Drinking fluids and consuming electrolytes are the principal treatments. IV fluids may be required for the most severe cases.

Medications

Medications are only rarely used to treat E. coli gut infections. Antibiotics may increase the number of toxins and the risk of hemolytic uremic syndrome, so they are used in only rare cases. They are never used if there’s any suspicion of an enterohemorrhagic E. coli infection. Antidiarrheal medications are also discouraged. They can slow down movement in the colon and increase the duration of the infection.

Dialysis

Most cases of hemolytic uremic syndrome can be treated with hospitalization and supportive care, such as IV fluids. For severe kidney failure, patients will be put on dialysis to remove waste products from the bloodstream.

Blood transfusions

Red blood cell transfusions or platelet transfusions may be necessary to treat low red blood cell or platelet counts caused by Shiga toxin poisoning in the bloodstream. The most extreme cases of hemolytic uremic syndrome may involve plasma replacement, but its effectiveness is not well-established.

E. coli medications

Most cases of E. coli infections, including enterohemorrhagic E. coli, resolve in a few days without medications. E. coli infections are only very rarely treated with medications. In rare cases, antibiotics may be used, but they are discouraged because they may increase the amount of bacterial toxins in the body. Antidiarrheal medications, because they slow down the colon, also lead to an increase in the concentration of bacterial toxins in the intestines, so they are strongly discouraged.

For severe hemolytic uremic syndrome with marked damage to the kidneys, a patient may receive an injection of the antibody Soliris (eculizumab) to prevent further damage to the kidneys. However, Soliris has not been approved for the treatment of HUS caused by Shiga toxin.

Antibiotics

Antibiotics are drugs that kill bacteria or prevent them from dividing and growing. E. coli does respond to antibiotics. However, antibiotics may increase the amount of toxins produced by the bacteria, increasing the risk of severe complications such as hemolytic uremic syndrome. For that reason, they are not used in the treatment of E. coli infections. They are never used if Shiga toxin-producing bacteria are present.

In rare cases, antibiotics are used for certain traveler’s diarrhea and infant diarrhea only in cases of fever or persistent diarrhea. Fluoroquinolones, such asciprofloxacin, andlevofloxacin, are usually the first-line therapy.Azithromycin is also commonly used as a treatment for invasive E. coli infections. Rifaximin and rifamycin SV are closely related antibiotics that are FDA-approved to treat traveler’s diarrhea caused by noninvasive strains of E. coli.

What is the best medication for E. coli?

Medications are only rarely used for E. coli infections. Antibiotics and antidiarrheal medications may make the problem worse. There is, then, no “best” medication for E. coli.

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Best medications for E.coli