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A Death due to non-0157 STEC

A Death due to non-0157 STEC. Susan Farley R.N. Communicable Disease Programs Contra Costa Health Services. A Death due to non-0157 STEC Objectives. Public health workers will: understand the potential severity of non-O157 STEC infection

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A Death due to non-0157 STEC

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  1. A Death due to non-0157 STEC Susan Farley R.N. Communicable Disease Programs Contra Costa Health Services

  2. A Death due to non-0157 STECObjectives • Public health workers will: • understand the potential severity of non-O157 STEC infection • recognize the importance of following up with a shiga toxin-positive result to have the fecal broth saved and forwarded to a public health laboratory

  3. A Death due to non- 0157 STECCASE-PATIENT • 20-year-old • Single • Female • College student • Vegetarian • Living with boyfriend

  4. A Death due to non-0157 STEC Office Visit with PMD on 2/23 • Onset of symptoms 2 days prior to visit • Lower abdominal cramping • No fever • Frequent loose bowels • No vomiting, some nausea • Bright red bleeding

  5. A Death due to non-0157 stec • No history of Inflammatory Bowel Disease or colitis • PMD documented in patient record “no suspect foods” • Rectal exam was negative for hemorrhoids and fissures • Stool Guaic was positive

  6. A death due to non-0157 stec • Plan: • Treat with metronidazole and ciprofloxacin • Obtain stool testing for Giardia, Clostridium difficile, WBC and C & S • Patient sent home

  7. A Death due to non-0157 stec Patient sought care same day via ED  Admit to Hospital 2/23 c/o Increased rectal bleeding HgB12.5 BP 121/77 WBC 10.6 HR 70 Plt 212,000 T 98.5 Diagnosis R/O Inflammatory Bowel disease Plan Colonoscopy

  8. A death due to non-0157 stec • Hospitalized 2/23 - 2/27 • Colonoscopy:“moderate active colitis” • Continued on Flagyl, Asocal • Vital Signs stable • Chemistry panel WNL • Abdominal discomfort resolved • Continued 1-2 loose stools • Discharged home with boyfriend 2/27 Monday

  9. A death due to non-0157 stec 2/28 Tuesday • Returned to ED with c/o nausea, vomiting, abdominal pain and brownish urine. • ED physician noted stool EIA positive for E. Coli Shiga toxin;Cipro, Asocal and Flagylwere discontinued • Readmitted to Hospital

  10. A Death due to non-0157 STEC 2/28 Tuesday - Public Health received notification of STEC case via Lab: Labcorp E coli Shiga Toxin EIA, Result- Positive Collection date 2/24 Result Date 2/27 -NO demographic info on lab report -message to MD office requesting additional patient information -no contact with patient at this point

  11. A Death due to non-0157 stec 2/29 Wednesday (CD control not aware of this) Patient transferred to ICU • Altered mental status • Decreased urine output • Worsening renal function

  12. A death due to non-0157 stec 3/2 Friday - Mother of patient contacted CDPH FDB to report daughter had history of consuming raw milk products - Contra Costa CD was contacted by CDPH regarding this case - Contra Costa CD attempted to contact case-patient; however, patient not available (in ICU) - Hospital ICN managed brief interview with patient - Food history: raw milk, raw spinach, raw broccoli, raw milk cheese - Boyfriend offered some information regarding grocery stores where foods purchased - Raw milk products were picked up by CDPH FDB at patient’s home

  13. A Death Due to Non-0157 stec 3/2 (continued) • Contra Costa CD contacted Lab Corp regarding specimen; advised that specimen was forwarded to State MDL for serotyping and confirmation • Further investigation into location of specimen found specimen at Contra Costa Public Health Lab. • PHL is able to do STEC culture but not typing • Results were negative for E.coli 0157, positive ST2

  14. A Death due to Non-0157 stec 3/3 Friday Pt transferred to UCSF Clinical status was poor T > 39° CNS failure 2° to s/p seizure Anuric acute renal failure Anemia Thrombocytopenia Leukocytosis Hypocalcemia • TTP-HUS

  15. A death due to non-0157 stec Patient developed left ventricular systolic failure requiring ECMO on 3/5 3/8 Thursday Patient expired immediately after life support withdrawn. 3/7 Specimen forwarded on to State MDL 4/19 State MDL reported STEC 021:H19, Stx 2 Milk from patient’s home tested negative

  16. A death due to non-0157 stecDiscussion Tragic HUS death due to non-O157 STEC Should admitting MD notify Public Health when stool EIA positive for Shiga toxin? Did delay in identifying non-O157 STEC contribute to follow up delay? Difficult to implicate source if only one case identified

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