Predictors of Hemolytic Uremic Syndrome in Children During a Large Outbreak of Escherichia coli O157:H7 Infections

Abstract

Objective. To evaluate risk factors for progression of Escherichia coli O157:H7 infection to the hemolytic uremic syndrome (HUS). Study Design. We conducted a retrospective cohort study among 278 Washington State children <16 years old who developed symptomatic culture-confirmed E coli O157:H7 infection during a large 1993 outbreak. The purpose of the study was to determine the relative risk (RR) of developing HUS according to demographic characteristics, symptoms, laboratory test results, and medication use in the first 3 days of illness. Results. Thirty-seven (14%) children developed HUS. In univariate analysis, no associations were observed between HUS risk and any demographic characteristic, the presence of bloody diarrhea or of fever, or medication use. In multivariate analysis, HUS risk was associated with, in the first 3 days of illness, use of antimotility agents (odds ratio [OR] = 2.9; 95% confidence interval [CI] 1.2–7.5) and, among children <5.5 years old, vomiting (OR = 4.2; 95% CI 1.4–12.7). Among the 128 children tested, those whose white blood cell (WBC) count was ≥13 000/μL in the first 3 days of illness had a 7-fold increased risk of developing HUS (RR 7.2; 95% CI 2.8–18.5). Thirteen (38%) of the 34 patients with a WBC count ≥13 000/μL developed HUS, but only 5 (5%) of the 94 children whose initial WBC count was <13 000/μL progressed to HUS. Among children who did not develop HUS, use of antimotility agents in the first 3 days of illness was associated with longer duration of bloody diarrhea. Conclusions. Prospective studies are needed to further evaluate measures to prevent the progression of E coliO157:H7 infection to HUS and to assess further clinical and laboratory risk factors. These data argue against the use of antimotility agents in acute childhood diarrhea. Our finding that no intervention decreased HUS risk underscores the importance of preventing E coliO157:H7 infections.