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Drug Misadventures in Shiga Toxin–Producing Escherichia coli Diarrhea

The difficulties of managing pharmacotherapy in patients with Shiga toxin–producing Escherichia coli (STEC) are discussed in a review article on associated hemolytic-uremic syndrome. “It is important to avoid potentially harmful interventions in patients with possible or confirmed STEC infection,” the authors write. “Multiple studies have shown an association between antibiotic administration and an increased risk of [hemolytic–uremic syndrome (HUS)] among patients infected with high-risk STEC. Thus, avoiding empirical antibiotic administration in immunocompetent patients with bloody diarrhea is important.”

Other potential drug-related complications are also of concern: “Although it is tempting to try to relieve abdominal pain, narcotics and antimotility drugs have been observed to prolong bloody diarrhea in E. coli O157 infection and to increase the risk of HUS and neurologic complications. Nonsteroidal antiinflammatory drugs can cause acute kidney injury during gastrointestinal infection and are best avoided. Although a single dose of oral ondansetron facilitates oral rehydration in children with acute gastroenteritis, multiple doses and intravenous administration have no added benefit, can increase the frequency of diarrhea, and may prolong the QT interval. Thus, multiple doses and intravenous administration should not be routinely used.”

The authors conclude: “STEC infection causes severe illness, particularly in children. Diagnostic approaches that include the testing of all children with bloody diarrhea for bacterial pathogens with the use of techniques that can identify O157 and non-O157 STEC, the use of rectal swabs to obtain specimens when stool specimens are unavailable, and reporting toxin genotypes when STEC are identified, are important components of care. Close monitoring of persons infected with high-risk STEC, avoidance of potentially harmful interventions, and prevention of volume depletion may avert complications. Unless and until specific treatments emerge, the possibility of adverse outcomes in a patient with a high-risk STEC infection must be considered. Thus, it is important to monitor the evolution of the disease and mitigate, to the extent possible, modifiable risk factors to improve outcomes.”

Source: New England Journal of Medicine