Epidemic profile of Shiga-toxin-producing Escherichia coli O104:H4 outbreak in Germany

N Engl J Med. 2011 Nov 10;365(19):1771-80. doi: 10.1056/NEJMoa1106483. Epub 2011 Jun 22.


Background: We describe an outbreak of gastroenteritis and the hemolytic-uremic syndrome caused by Shiga-toxin-producing Escherichia coli in Germany in May, June, and July, 2011. The consumption of sprouts was identified as the most likely vehicle of infection.

Methods: We analyzed data from reports in Germany of Shiga-toxin-producing E. coli gastroenteritis and the hemolytic-uremic syndrome and clinical information on patients presenting to Hamburg University Medical Center (HUMC). An outbreak case was defined as a reported case of the hemolytic-uremic syndrome or of gastroenteritis in a patient infected by Shiga-toxin-producing E. coli, serogroup O104 or serogroup unknown, with an onset of disease during the period from May 1 through July 4, 2011, in Germany.

Results: A total of 3816 cases (including 54 deaths) were reported in Germany, 845 of which (22%) involved the hemolytic-uremic syndrome. The outbreak was centered in northern Germany and peaked around May 21 to 22. Most of the patients in whom the hemolytic-uremic syndrome developed were adults (88%; median age, 42 years), and women were overrepresented (68%). The estimated median incubation period was 8 days, with a median of 5 days from the onset of diarrhea to the development of the hemolytic-uremic syndrome. Among 59 patients prospectively followed at HUMC, the hemolytic-uremic syndrome developed in 12 (20%), with no significant differences according to sex or reported initial symptoms and signs. The outbreak strain was typed as an enteroaggregative Shiga-toxin-producing E. coli O104:H4, producing extended-spectrum beta-lactamase.

Conclusions: In this outbreak, caused by an unusual E. coli strain, cases of the hemolytic-uremic syndrome occurred predominantly in adults, with a preponderance of cases occurring in women. The hemolytic-uremic syndrome developed in more than 20% of the identified cases.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Child
  • Child, Preschool
  • Cohort Studies
  • Diarrhea / microbiology
  • Disease Outbreaks*
  • Escherichia coli Infections / epidemiology*
  • Escherichia coli Infections / etiology
  • Fabaceae / microbiology
  • Female
  • Food Microbiology*
  • Gastroenteritis / epidemiology*
  • Gastroenteritis / microbiology
  • Germany / epidemiology
  • Hemolytic-Uremic Syndrome / epidemiology*
  • Hemolytic-Uremic Syndrome / microbiology
  • Humans
  • Infant
  • Male
  • Medicago sativa / microbiology
  • Middle Aged
  • Plant Shoots / microbiology*
  • Restaurants
  • Shiga-Toxigenic Escherichia coli* / classification