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Clinical Features of Critically Ill Patients With Shiga Toxin–Induced Hemolytic Uremic Syndrome

Braune, Stephan A. MD, MPH1; Wichmann, Dominic MD1; von Heinz, Marie C.1; Nierhaus, Axel MD1; Becker, Heinrich MD2; Meyer, Tobias N. MD3; Meyer, Gerd P. MD4; Müller-Schulz, Matthias MD5; Fricke, Jens MD6; de Weerth, Andreas MD7; Hoepker, Wilhelm-W. MD8; Fiehler, Jens MD9; Magnus, Tim MD10; Gerloff, Christian MD10; Panzer, Ulf MD11; Stahl, Rolf A. K. MD11; Wegscheider, Karl PhD12; Kluge, Stefan MD1

doi: 10.1097/CCM.0b013e31828a24a8
Clinical Investigations

Objective: In Spring 2011, an unprecedented outbreak of Shiga toxin–producing Escherichia coli serotype O104:H4–associated hemolytic uremic syndrome occurred in Northern Germany. The aim of this study was to describe the clinical characteristics, treatments, and outcomes of critically ill patients with Shiga toxin–producing E. coli–associated hemolytic uremic syndrome during this outbreak.

Design, Setting, and Patients: Multicenter, retrospective, observational study of critically ill adult patients with Shiga toxin–producing E. coli–associated hemolytic uremic syndrome in six hospitals in Hamburg, Germany, between May 2011 and August 2011.

Measurements and Main Results: During the study period, 106 patients with Shiga toxin–producing E. coli–associated hemolytic uremic syndrome were admitted to eight ICUs. The median age was 40 years (range, 18–83) with a female:male ratio of 3:1. The median time from onset of clinical symptoms to hospital admission was 3 days and from hospital to ICU admission an additional 3 days. A total of 101 patients (95.3%) had acute renal failure and 78 (73.6%) required renal replacement therapy. Intubation and mechanical ventilation were required in 38 patients (35.8%) and noninvasive ventilation was required in 17 patients (16.0%). The median duration of invasive ventilation was 7 days (range, 1–32 days) and the median ICU stay was 10 days (range, 1–45 days). Fifty-one patients (48.1%) developed sepsis; of these 51 patients, 27 (25.4%) developed septic shock. Seventy patients (66.0%) developed severe neurological symptoms. Ninety-seven patients (91.5%) were treated with plasma exchange and 50 patients (47.2%) received eculizumab (monoclonal anti-C5 antibody). The mortality rate was 4.7%. Mild residual neurological symptoms were present in 21.7% of patients at ICU discharge, and no patient required renal replacement therapy 6 months after ICU admission.

Conclusions: During the 2011 Shiga toxin–producing E. coli–associated hemolytic uremic syndrome outbreak in Germany, critical illness developed rapidly after hospital admission, often in young women. The infection was associated with severe neurological and renal symptoms, requiring mechanical ventilation and renal replacement therapy in a substantial proportion of patients. Overall, recovery was much better than expected.

1Department of Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

2Department of Pneumology and Intensive Care, Asklepios Klinik Barmbek, Hamburg, Germany.

3Department of Nephrology, Asklepios Klinik Barmbek, Hamburg, Germany.

4Department of Cardiology, Pneumology, and Intensive Care, Asklepios Klinik Altona, Hamburg, Germany.

5Department of Internal Medicine, Marienkrankenhaus, Hamburg, Germany.

6Department of Cardiology and Intensive Care, Asklepios Klinik Harburg, Hamburg, Germany.

7Department of Internal Medicine, Agaplesion Diakonieklinikum, Hamburg, Germany.

8Department of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

9Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

10Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

11Department of Nephrology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

12Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

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Dr. Gerloff is a board member: Boehringer Ingelheim, Silk Road Medicals, consultant: Boehringer Ingelheim, Lundbeck, GlaxoSmithKline, Bayer Vital, UCB, EBS Technologies, Sanofi Aventis, grants pending: German Ministry of Science (BMBF), German Research Council (DFG), European Community (FP7), payment for lectures: Boehringer Ingelheim. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: skluge@uke.de

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins