Inter-society consensus on the management of acute bloody diarrhea and shiga toxin-producing Escherichia Coli infection in the molecular microbiology era

Hemolytic uremic syndrome associated with Shiga toxin-producing Escherichia coli (STEC-HUS) infection is a major individual and public health challenge, and the leading cause of acute kidney injury in children. In Western countries, HUS complicates about 15% of STEC infections, which are responsible for acute bloody diarrhea (ABD) in at least 6–7% of cases in children (rising to over 15% during late summer). The widespread use of molecular microbiology techniques enables the diagnosis of STEC infection before HUS onset in an increasing number of patients, creating a potential window of preventive and therapeutic opportunities. Given the rapid progression of the disease, all children with ABD should be tested for Shiga toxin (Stx) encoding genes as early as possible. Stx-positive patients should then be closely monitored for HUS development by urine dipstick, to detect hemoglobinuria. This proactive diagnostic approach creates the opportunity to anticipate the application of measures that have already been proven to mitigate the severity of HUS, among which stands the early and generous fluid administration, but most importantly opens a window to explore preventive and therapeutic interventions. In detail, even though antibiotics are not historically recommended in STEC infections, recent data suggest a promising potential preventive role for bacteriostatic agents (e.g., azithromycin) during the initial stages of the infection. The aim of the present contribution is to share this approach to ABD and STEC infection as endorsed by the Italian scientific societies actively engaged in this area (AMCLI, SIGENP, SIMEUP, SIN, SIP, SIPPS, SITIP) through an intersocietal consensus. The goal is to promote the early diagnosis of STEC infection nationwide, thereby improving our understanding of the mechanisms of disease spreading, and hopefully reduce the rate of progression to HUS, its case fatality rate and possibly improve both short- and long-term outcomes.