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Packaged Salads – E. coli Infections

January 19, 2022
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Overview
As of January 6, 2022, a total of 10 people infected with the outbreak strain of E. coli O157:H7 have been reported from four states (see map) after eating contaminated organic power greens packaged salad (mix of spinach, mizuna, kale, and chard manufactured by Organic Power Greens and Nature’s Basket Organic Power Greens with “Best if used by” dates through December 20, 2021. Illnesses started on dates ranging from November 27, 2021 to December 9, 2021 (see timeline). Sick people range in age from 26 to 79 years, with a median age of 59. Of 10 people with information available, 4 have been hospitalized. No deaths have been reported.

Clinical Guidance

  • Presentation: Most people infected with Shiga toxin-producing E. coli experience severe stomach cramps, diarrhea (often bloody), and vomiting.
    • Symptoms usually start 3 to 4 days (range 1-10 days) after ingesting the bacteria.
    • Most people recover without treatment after 5 to 7 days.
    • Approximately 6% of individuals with confirmed E. coli O157:H7 diarrhea develop hemolytic-uremic syndrome (HUS) 1-3 weeks after onset of diarrhea. Children under 5 years of age are at higher risk of developing HUS (15% of confirmed E. coli O157:H7 cases develop HUS). HUS presents with microangiopathic hemolytic anemia, thrombocytopenia, and acute renal dysfunction.
  • Who is at highest risk/complications: Younger children (under age 5) are at higher risk of HUS and severe complications of E. coli O157:H7 infection. The risk of developing HUS is lower in children who have a longer interval between diarrhea onset and presentation to the emergency department. More than 50% of children with HUS require dialysis, and 3% to 5% die. Patients with HUS can develop neurologic complications (eg, seizures, coma, or cerebral vessel thrombosis). Children presenting with an increased white blood cell count (>20 x 109/mL) or oliguria or anuria are at higher risk of poor outcome, as are, seemingly paradoxically, children with hematocrit close to normal rather than low.
  • Patients should be seen by their pediatrician, if they have any of these severe symptoms:
    • Diarrhea and a fever higher than 102°F (though E. coli O157:H7 diarrhea is often not associated with fever)
    • Diarrhea for more than 3 days that is not improving
    • Bloody diarrhea (diarrhea due to E. coli O157:H7 may be non-bloody initially)
    • Not tolerating oral liquids
    • Signs of dehydration, such as:
      • Decreased urine output
      • Dry mucous membranes
      • Orthostatic hypotension
    • Neurologic symptoms, particularly seizures, which may occur in the setting of HUS.
  • Diagnosis: Several US Food and Drug Administration (FDA)-cleared multiplex polymerase chain reaction (PCR) assays (usually offered as diagnostic panels) can detect a variety of enteric pathogens, including EAEC, EPEC, ETEC, and STEC, the last by detection of the genes encoding Stx1 and Stx2. Rapid immunologic assays including immunochromatography or enzyme immunoassay (EIA) may be used for detection of Shiga toxin in stool samples.
  • Precautions: If you have any contaminated packaged salads or if you can’t tell where it is from, don’t eat it and throw it away.
  • Risk Mitigation: Wash items and containers that may have touched the contaminated product using hot soapy water or a dishwasher.
  • Treatment: Treatment is primarily supportive for all diarrhea-producing E. coli. Orally administered electrolyte-containing solutions usually are adequate to prevent or treat dehydration and electrolyte abnormalities. Antimotility agents should not be administered to children with inflammatory or bloody diarrhea. Patients with proven or suspected STEC infection should be rehydrated fully but prudently as soon as clinically feasible. Many experts advocate intravenous volume expansion during the first 4 days of proven STEC infection to maintain renal perfusion and reduce the risk of renal injury. Careful monitoring of patients with hemorrhagic colitis (including complete blood cell count with smear, blood urea nitrogen, and creatinine concentrations) is recommended to detect changes suggestive of HUS. If patients have no laboratory evidence of hemolysis, thrombocytopenia, or nephropathy 3 days after resolution of diarrhea, their risk of developing HUS is low. Most experts advise not prescribing antimicrobial therapy for children with E. coli O157 enteritis or a clinical or epidemiologic picture strongly suggestive of STEC infection.
  • Reporting: Suspected cases should be reported to a local department of public health.

Resources

Pediatric Practice Tools and Info

 

Public Health Resources

CDC case count map

Investigation Details | E. coli Outbreak Linked to Packaged Salads | CDC

Where Sick People Lived | E. coli Outbreak Linked to Packaged Salads | CDC

When People Got Sick | E. coli Outbreak Linked to Packaged Salads | CDC

 

Information for Patients and Caregivers

AAP HealthyChildren.org: Food Poisoning and Food Contamination

In Spanish: Intoxicación y contaminación alimentaria

 

Infection Prevention and Control Resources

Project Firstline (aap.org)

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