History

Fact Explanation
Symptoms of neonatal meningitis [2,3] Newborns present with fever, jaundice, decreased feeding, listlessness and failure to thrive. [4] Irritability, lethargy, vomiting, lack of appetite, and seizures are seen in neonates. Older children presents with headache, neck pain, photophobia, vomiting, seizures and fever. [5]
Symptoms of pneumonia [6] Patients with pneumonia presents with fever, shortness of breath, cough and chest pain.
Symptoms of biliary tract infection [7] Acute onset fever with chills, right upper quadrant abdominal pain, jaundice, dark urine and pale stools are characteristic of cholangitis. Charcot triad (fever, pain, and jaundice) is seen in majority. [12]
Symptoms of intra-abdominal abscess [8] Low grade fever and abdominal pain are presenting complains. Some patients can develop prostatic abscesses.
Watery diarrhea Enterotoxigenic E coli (ETEC), enteropathogenic E coli (EPPEC) and enteroaggregative E coli (EAEC) can cause watery diarrhea. ETEC release enterotoxins which affect the small intestinal cells and stimulates excessive chloride ion secretion in to the bowel lumen. This increases the osmotic pressure in the lumen causing osmotic diarrhea. Toxins produced by EPEC cause destruction of absorptive microvilli in the small intestine. EAEC causes mucous hypersecretion by the goblet cells. [13] Diarrhea can be accompanied by fever, tenesmus and symptoms of dehydration like increased thirst and reduced urine output. [1]
Blood and mucous diarrhea Enteroinvasive E coli (EIEC) and enterohemorrhagic E coli (EHEC) can cause blood and mucous diarrhea. Both EHEC and EIEC initially cause watery diarrhea which later become bloody diarrhea. Abdominal cramps and absence of fever are characteristic of infection with EHEC. EHEC have cytotoxic action and cause hemorrhage and edema of the lamina propria in the ascending and transverse colon. EIEC produces enterotoxin and affects the colonic epithelial cells. [13]
Symptoms of urinary tract infection (UTI) [9] Low-grade fever, dysuria, increased frequency of micturition and urgency are common. Some complain of suprapubic pain. Patients with complicated UTI present with high fever with chills and rigors, and flank pain. [10,11]
References
  1. NATARO JP, KAPER JB. Diarrheagenic Escherichia coli Clin Microbiol Rev [online] 1998 Jan, 11(1):142-201 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC121379
  2. GLODE MP, SUTTON A, ROBBINS JB, MCCRACKEN GH, GOTSCHLICH EC, KAIJSER B, HANSON LA. Neonatal meningitis due of Escherichia coli K1. J Infect Dis [online] 1977 Aug:S93-7 [viewed 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/330780
  3. MULDER CJ, VAN ALPHEN L, ZANEN HC. Neonatal meningitis caused by Escherichia coli in The Netherlands. J Infect Dis [online] 1984 Dec, 150(6):935-40 [viewed 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/6389721
  4. EL BASHIR H, LAUNDY M, BOOY R. Diagnosis and treatment of bacterial meningitis. Arch Dis Child [online] 2003 Jul, 88(7):615-20 [viewed 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12818910
  5. SAEZ-LLORENS X, MCCRACKEN GH JR. Bacterial meningitis in children. Lancet [online] 2003 Jun 21, 361(9375):2139-48 [viewed 20 May 2014] Available from: doi:10.1016/S0140-6736(03)13693-8
  6. Escherichia coli pneumonia Br Med J [online] 1967 Nov 18, 4(5576):374 [viewed 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1748694
  7. AAGAARD BD, HEYWORTH MF, OESTERLE AL, JONES AL, WAY LW. Intestinal immunisation with Escherichia coli protects rats against Escherichia coli induced cholangitis. Gut [online] 1996 Jul, 39(1):136-40 [viewed 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8881825
  8. ONDERDONK AB, BARTLETT JG, LOUIE T, SULLIVAN-SEIGLER N, GORBACH SL. Microbial synergy in experimental intra-abdominal abscess. Infect Immun [online] 1976 Jan, 13(1):22-26 [viewed 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC420571
  9. TOTSIKA M, MORIEL DG, IDRIS A, ROGERS BA, WURPEL DJ, PHAN MD, PATERSON DL, SCHEMBRI MA. Uropathogenic Escherichia coli mediated urinary tract infection. Curr Drug Targets [online] 2012 Oct, 13(11):1386-99 [viewed 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22664092
  10. COLGAN R, WILLIAMS M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician [online] 2011 Oct 1, 84(7):771-6 [viewed 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22010614
  11. COLGAN R, WILLIAMS M, JOHNSON JR. Diagnosis and treatment of acute pyelonephritis in women. Am Fam Physician [online] 2011 Sep 1, 84(5):519-26 [viewed 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21888302
  12. FROSSARD JL, BONVIN F. Charcot's triad Int J Emerg Med [online] :18 [viewed 20 May 2014] Available from: doi:10.1186/1865-1380-4-18
  13. Diarrheagenic Escherichia coli Clin Microbiol Rev [online] 1998 Jan, 11(1):142-201 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC121379

Examination

Fact Explanation
Signs of meningitis Patients are febrile. Presence of neck stiffness is indicated by positive Kernig's Sign and Brudzinski's Sign. [1] Bulging and tense fontanels are seen in young children with open fontanels. [2]
Signs of pneumonia [3] Localized area of reduced chest expansion, dull percussion note, reduced air entry and bronchial breathing are suggestive of pneumonia.
Hypotension Seen in severe cases of cholangitis, cholecystitis and sepsis. [4]
Jaundice Newborns present with jaundice with infection and sepsis. [5] Older patients can have jaundice in cholangitis.
Signs of dehydration Diarrhea can result in dehydration. Patients have reduced skin turgor, sunken fontanels and eyes, dried mucus membranes, low blood pressure, small volume pulses and altered consciousness. [6]
Signs of UTI Renal angle tenderness is present in pyelonephritis. [7]
Per-rectal examination Tender, hot prostate is palpated in prostatic abscess. [8]
References
  1. THOMAS KAREN E., HASBUN RODRIGO, JEKEL JAMES, QUAGLIARELLO VINCENT J.. The Diagnostic Accuracy of Kernig’s Sign, Brudzinski’s Sign, and Nuchal Rigidity in Adults with Suspected Meningitis. CLIN INFECT DIS [online] 2002 July, 35(1):46-52 [viewed 20 May 2014] Available from: doi:10.1086/340979
  2. BERKLEY JA, VERSTEEG AC, MWANGI I, LOWE BS, NEWTON CR. Indicators of acute bacterial meningitis in children at a rural Kenyan district hospital. Pediatrics [online] 2004 Dec, 114(6):e713-9 [viewed 20 May 2014] Available from: doi:10.1542/peds.2004-0007
  3. Escherichia coli pneumonia Br Med J [online] 1967 Nov 18, 4(5576):374 [viewed 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1748694
  4. PHILIP S BARIE. ed. HOLZHEIMER RG, MANNICK JA.: Acute acalculous cholecystitis. Munich, Zuckschwerdt; 2001.
  5. SIMKISS D., MARTIN R.. Neonatal Jaundice. Journal of Tropical Pediatrics [online] December, 58(5):339-340 [viewed 20 May 2014] Available from: doi:10.1093/tropej/fms051
  6. CANAVAN A, ARANT BS JR. Diagnosis and management of dehydration in children. Am Fam Physician [online] 2009 Oct 1, 80(7):692-6 [viewed 21 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19817339
  7. LEE DG, JEON SH, LEE CH, LEE SJ, KIM JI, CHANG SG. Acute Pyelonephritis: Clinical Characteristics and the Role of the Surgical Treatment J Korean Med Sci [online] 2009 Apr, 24(2):296-301 [viewed 21 May 2014] Available from: doi:10.3346/jkms.2009.24.2.296
  8. TIWARI P, PAL DK, TRIPATHI A, KUMAR S, VIJAY M, GOEL A, SHARMA P, DUTTA A, KUNDU AK. Prostatic abscess: diagnosis and management in the modern antibiotic era. Saudi J Kidney Dis Transpl [online] 2011 Mar, 22(2):298-301 [viewed 21 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21422629

Differential Diagnoses

Fact Explanation
Sepsis Neonatal sepsis is caused by group B streptococci, Klebsiella, Escherichia coli, Pseudomonas, Salmonella, Staphylococcus aureus, coagulase negative staphylococci, Streptococcus pneumoniae and Streptococcus pyogenes. [1] Other possible organisms causing sepsis should also be considered. [2]
Cerebral abscess Viridans streptococci is the commonest causative organism of brain abscess. Klebsiella pneumoniae, Pseudominas aeruginosa, are gram negative organisms causing cerebral abscess other than E. coli. [3]
Neonatal tetanus or seizure disorders Present as abnormal movements. [4]
Diarrhea Other than E coli, Camphylobacter, Shigella, Salmonella, Ameba, Clostridium and some viruses are common infective causes of diarrhea. Non-infective causes include ulcerative colitis, Chron’s disease, malabsorption and diverticulitis. [5]
References
  1. VERGNANO S, SHARLAND M, KAZEMBE P, MWANSAMBO C, HEATH P. Neonatal sepsis: an international perspective Arch Dis Child Fetal Neonatal Ed [online] 2005 May, 90(3):F220-F224 [viewed 21 May 2014] Available from: doi:10.1136/adc.2002.022863
  2. PARKER MT. Causes and prevention of sepsis due to gram-negative bacteria. Ecology of the infecting organisms. Proc R Soc Med [online] 1971 Sep, 64(9):979-980 [viewed 21 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1812800
  3. LU C.-H.. Bacterial brain abscess: microbiological features, epidemiological trends and therapeutic outcomes. [online] 2002 August, 95(8):501-509 [viewed 21 May 2014] Available from: doi:10.1093/qjmed/95.8.501
  4. STANFIELD JP, GALAZKA A. Neonatal tetanus in the world today Bull World Health Organ [online] 1984, 62(4):647-669 [viewed 21 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2536335
  5. JUCKETT G, TRIVEDI R. Evaluation of chronic diarrhea. Am Fam Physician [online] 2011 Nov 15, 84(10):1119-26 [viewed 21 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22085666

Investigations - for Diagnosis

Fact Explanation
Full blood count Leukocytosis or a left shift is seen due to infection. Hemoglobin and platelets are low if hemolytic uremic syndrome occurs. [2]
Blood picture Hemolysis and thrombocytopenia are seen in hemolytic uremic syndrome. [2]
Microscopic examination E coli are seen as a gram-negative bacillus under the microscope. [1]
Culture Blood, cerebrospinal fluid, urine, sputum, stool or abscess fluid can be cultured. [1,3,9,11] Presence of more than 105 organisms is diagnostic of UTI. [1,3]
Urine full report [3] Pyuria and hematuria are present. [6]
Urine dipstick test [3] Presence of blood, leucocyte esterase, nitrite, and protein can be detected. [7]
Chest X-ray Chest X ray is important in diagnosing pneumonia. [8]
CT scan Aids in diagnosing pyelonephritis and pneumonia. [10]
Ultrasounds scan kidney-ureter-bladder Detects pyelonephritis. [10]
Polymerase chain reaction [1] Allows rapid and accurate diagnosis. [4]
Cerebro-spinal fluid full report Aids in differentiating viral meningitis and bacterial meningitis. [11]
References
  1. NATARO JP, KAPER JB. Diarrheagenic Escherichia coli Clin Microbiol Rev [online] 1998 Jan, 11(1):142-201 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC121379
  2. RAZZAQ S. Hemolytic uremic syndrome: an emerging health risk. Am Fam Physician [online] 2006 Sep 15, 74(6):991-6 [viewed 21 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17002034
  3. COLGAN R, WILLIAMS M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician [online] 2011 Oct 1, 84(7):771-6 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22010614
  4. FUJIOKA M, KASAI K, MIURA T, SATO T, OTOMO Y. Rapid diagnostic method for the detection of diarrheagenic Escherichia coli by multiplex PCR. Jpn J Infect Dis [online] 2009 Nov, 62(6):476-80 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19934545
  5. CARPENTER L. RAND, et al. Stool Cultures and Antimicrobial Prescriptions Related to Infectious Diarrhea. J INFECT DIS [online] 2008 June, 197(12):1709-1712 [viewed 22 May 2014] Available from: doi:10.1086/588142
  6. WILSON MICHAEL L., GAIDO LORETTA. Laboratory Diagnosis of Urinary Tract Infections in Adult Patients. CLIN INFECT DIS [online] 2004 April, 38(8):1150-1158 [viewed 22 May 2014] Available from: doi:10.1086/383029
  7. PATEL HD, LIVSEY SA, SWANN RA, BUKHARI SS. Can urine dipstick testing for urinary tract infection at point of care reduce laboratory workload? J Clin Pathol [online] 2005 Sep, 58(9):951-954 [viewed 22 May 2014] Available from: doi:10.1136/jcp.2004.025429
  8. EVERTSEN J, BAUMGARDNER DJ, REGNERY A, BANERJEE I. Diagnosis and management of pneumonia and bronchitis in outpatient primary care practices Prim Care Respir J [online] 2010 Sep, 19(3):237-241 [viewed 22 May 2014] Available from: doi:10.4104/pcrj.2010.00024
  9. TALAN D. A., MORAN G. J., NEWDOW M., ONG S., MOWER W. R., NAKASE J. Y., PINNER R. W., SLUTSKER L.. Etiology of Bloody Diarrhea among Patients Presenting to United States Emergency Departments: Prevalence of Escherichia coli O157:H7 and Other Enteropathogens. Clinical Infectious Diseases [online] 2001 February, 32(4):573-580 [viewed 22 May 2014] Available from: doi:10.1086/318718
  10. ROLLINO C., BELTRAME G., FERRO M., QUATTROCCHIO G., SANDRONE M., QUARELLO F.. Acute pyelonephritis in adults: a case series of 223 patients. Nephrology Dialysis Transplantation [online] December, 27(9):3488-3493 [viewed 22 May 2014] Available from: doi:10.1093/ndt/gfr810
  11. GARGES HP, MOODY MA, COTTEN CM, SMITH PB, TIFFANY KF, LENFESTEY R, LI JS, FOWLER VG JR, BENJAMIN DK JR. Neonatal meningitis: what is the correlation among cerebrospinal fluid cultures, blood cultures, and cerebrospinal fluid parameters? Pediatrics [online] 2006 Apr, 117(4):1094-100 [viewed 23 May 2014] Available from: doi:10.1542/peds.2005-1132

Investigations - Fitness for Management

Fact Explanation
Serum electrolytes Dehydration and hemolytic uremic syndrome can cause acute renal failure. [1]
Serum creatinine Elevated in acute renal failure. [1]
References
  1. RAZZAQ S. Hemolytic uremic syndrome: an emerging health risk. Am Fam Physician [online] 2006 Sep 15, 74(6):991-6 [viewed 21 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17002034

Management - General Measures

Fact Explanation
Health education Feco-oral transmission of the organism causes diarrhea. Hand hygiene and food hygiene are important preventive measures. Raw milk and under cooked meats should be avoided. [1] In order to minimize the incidence of neonatal meningitis, labor should be carried out as a sterile procedure by health care professionals. [3]
Hemodialysis Indicated in acute renal failure. Renal transplant may be needed in end-stage renal disease. [2]
Drainage of abscesses Since most of the antibiotics do not act in the presence of an acidic medium, drainage fasten the recovery. [4] Trans urethral resection of prostate (TURP) is done for prostatic abscesses. [5]
Hydration Hydration is important in management of diarrhea. Antibiotics and antidiarrheal agents should not be used in diarrhea. [1]
References
  1. E. coli (Escherichia coli) Centers for Disease Control and Prevention. [online] [viewed 22 May 2014] Available from: http://www.cdc.gov/ecoli/general/index.html?s_cid=cs_002
  2. NORIS M.. Hemolytic Uremic Syndrome. Journal of the American Society of Nephrology [online] 2005 February, 16(4):1035-1050 [viewed 22 May 2014] Available from: doi:10.1681/ASN.2004100861
  3. EDMOND KAREN, ZAIDI ANITA. New Approaches to Preventing, Diagnosing, and Treating Neonatal Sepsis. PLoS Med [online] 2010 March [viewed 23 May 2014] Available from: doi:10.1371/journal.pmed.1000213
  4. SCHEIN M. ed. HOLZHEIMER RG, MANNICK JA. Management of intra-abdominal abscesses. Munich: Zuckschwerdt; 2001.
  5. GOYAL NK, GOEL A, SANKHWAR S, DALELA D. Transurethral Resection of Prostate Abscess: Is It Different from Conventional Transurethral Resection for Benign Prostatic Hyperplasia? ISRN Urol [online] :109505 [viewed 23 May 2014] Available from: doi:10.1155/2013/109505

Management - Specific Treatments

Fact Explanation
Antibiotics [1] Third-generation cephalosporins and fluoroquinolones are frequently used to treat e coli infections. Fluoroquinolone, trimethoprim/sulfamethoxazole, or nitrofurantoin are used to treat uncomplicated UTIs. [2] However definitive treatment may depend on the antibiotic susceptibility of the organism.
References
  1. NATARO JP, KAPER JB. Diarrheagenic Escherichia coli Clin Microbiol Rev [online] 1998 Jan, 11(1):142-201 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC121379
  2. COLGAN R, WILLIAMS M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician [online] 2011 Oct 1, 84(7):771-6 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22010614