title: Interventions for preventing diarrhea-associated hemolytic uremic syndrome: systematic review.
abstract: BACKGROUND
  Hemolytic Uremic Syndrome (HUS) may follow infection with Shiga-toxin-producing organisms, principally E. coli O157: H7 (STEC), causing high morbidity and mortality. Our aim was to identify interventions to prevent diarrhea-associated HUS.
  
  
  METHODS
  Systematic search of the literature for relevant systematic reviews (SRs), randomised controlled trials (RCTs) and public health guidelines.
  
  
  RESULTS
  Of 1097 animal and 762 human studies, 18 animal studies (2 SRs, 2 reviews, plus 14 RCTs) and 6 human studies (3 SRs, plus 3 RCTs) met inclusion criteria. E. coli O157: H7 Type III secreted protein vaccination decreased fecal E. coli O157 shedding in cattle (P = 0.002). E. coli O157: H7 siderophore receptor and porin proteins (SRP) vaccines reduced fecal shedding in cows (OR 0.42 (95% CI 0.25 to 0.73) and increased anti-E. coli 0157: H7 SRP antibodies in their calves (P < 0.001). Bacterin vaccines had no effect. Probiotic or sodium chlorate additives in feeds reduced fecal E. coli O157 load as did improved farm hygiene (P < 0.05). Solarization of soil reduced E. coli O157: H7 contamination in the soil (P < 0.05). In an RCT examining the role of antibiotic treatment of E. coli O157: H7 diarrhea, HUS rates were similar in children treated with Trimethoprim-sulfamethoxazole and controls (RR 0.57; 95% CI 0.11 to 2.81). In another RCT, HUS rates were similar in children receiving Synsorb-Pk and placebo (RR 0.93; 95% CI 0.39 to 2.22). In one SR, hand washing reduced diarrhea by 39% in institutions (IRR 0.61; 95% CI 0.40 to 0.92) and 32% in community settings (IRR 0.68; 95% CI 0.52 to 0.90) compared to controls. Guidelines contained recommendations to prevent STEC transmission from animals and environments to humans, including appropriate food preparation, personal hygiene, community education, and control of environmental contamination, food and water quality.
  
  
  CONCLUSIONS
  Animal carriage of STEC is decreased by vaccination and improved farm practices. Treatment of STEC diarrhea with antibiotics and toxin-binders did not prevent HUS. Public health interventions are the key to preventing STEC-associated diarrhea and HUS.
authors.affiliation: Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, Australia. diana.thomas@health.nsw.gov.au.
authors.forename: Diana E
authors.initials: DE
authors.lastname: Thomas
authors.forename: Elizabeth J
authors.initials: EJ
authors.lastname: Elliott
mesh_terms: D000822:Animal Husbandry; D000818:Animals; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D002417:Cattle; D002648:Child; D003967:Diarrhea / Q000150:complications*; D004927:Escherichia coli Infections / Q000150:complications*; D019453:Escherichia coli O157 / Q000472:pathogenicity; D006463:Hemolytic-Uremic Syndrome / Q000188:drug therapy* / Q000209:etiology; D006801:Humans; D008460:Meat; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use*; D014611:Vaccination / Q000662:veterinary
chemical_list: D000890:Anti-Infective Agents; D015662:Trimethoprim, Sulfamethoxazole Drug Combination