Post-diarrheal, pediatric hemolytic uremic syndrome (D+HUS) is a sequela of Shiga toxin-producing Escherichia coli (STEC) infection and is a common cause of acute kidney failure among US children. The Foodborne Diseases Active Surveillance Network (FoodNet) conducts surveillance in ten sites for physician-diagnosed D+HUS through a network of nephrologists and hospital discharge data review to estimate illness and corroborate STEC surveillance trends. The incidence of pediatric STEC overall in FoodNet sites has increased 18% from 2006 to 2014 while the incidence in STEC O157 has decreased by 28%. We summarized data on D+HUS cases, defined as HUS in children <18 years, reported to FoodNet during 2006–2014. We examined changes in incidence rates using US census data. Population density was defined by the United States Department of Agriculture Rural-Urban continuum codes. During 2006–2014, 719 D+HUS patients were reported, resulting in 13 (1.8%) deaths. The average annual incidence was 0.72 cases/100,000 children which varied by site (range: 0.39–1.28). Incidence was 5-fold greater among patients aged 1–3 years (2.34) than in other age groups (0.44). Incidence rates/100,000 children (IR) were highest among females (0.81) and non-Hispanics (0.70). IRs were higher in rural counties (1.15) than in urban counties (0.64). Comparing 2006–2008 with 2012–2014, average incidence decreased by 19%, from 0.81 to 0.66, with the greatest decreases found in children aged 1–3 years (35%, P = 0.04). No laboratory testing was performed for 10 (1%) cases. The proportion of cases with laboratory evidence of STEC infection increased 15 percentage points, from 69% in 2006–2008 to 84% in 2012–2014. In total, 537 (75%) D+HUS patients had laboratory evidence of STEC infection, 432 (80%) were culture-confirmed; the most common serogroups were O157 (94%), O111 (1.4%) and O121 (1.2%). During 2006–2014 cases of D+HUS decreased and showed marked demographic and geographic differences. The increased number of D+HUS cases with laboratory evidence of STEC is likely in part due to improvements in testing and adherence to guidelines. Prevention strategies for STEC and D+HUS should focus on young children, particularly in rural areas. All authors: No reported disclosures.

OBJECTIVE:To assess the clinical spectrum of postdiarrheal hemolytic uremic syndrome (D(+)HUS) hospitalizations and sought predictors of in-hospital death to help identify children at risk of poor outcomes.STUDY DESIGN:We assessed clinical variables collected through population-based surveillance of D(+)HUS in children <18 years old hospitalized in 10 states during 1997-2012 as predictors of in-hospital death by using tree modeling.RESULTS:We identified 770 cases. Of children with information available, 56.5% (430 of 761) required dialysis, 92.6% (698 of 754) required a transfusion, and 2.9% (22 of 770) died; few had a persistent dialysis requirement (52 [7.3%] of 716) at discharge. The tree model partitioned children into 5 groups on the basis of 3 predictors (highest leukocyte count and lowest hematocrit value during the 7 days before to 3 days after the diagnosis of hemolytic uremic syndrome, and presence of respiratory tract infection [RTI] within 3 weeks before diagnosis). Patients with greater leukocyte or hematocrit values or a recent RTI had a greater probability of in-hospital death. The largest group identified (n = 533) had none of these factors and had the lowest odds of death. Many children with RTI had recent antibiotic treatment for nondiarrheal indications.CONCLUSION:Most children with D(+)HUS have good hospitalization outcomes. Our findings support previous reports of increased leukocyte count and hematocrit as predictors of death. Recent RTI could be an additional predictor, or a marker of other factors such as antibiotic exposure, that may warrant further study.

BACKGROUND:Postdiarrheal hemolytic uremic syndrome (HUS) is the most common cause of acute kidney failure among US children. The Foodborne Diseases Active Surveillance Network (FoodNet) conducts population-based surveillance of pediatric HUS to measure the incidence of disease and to validate surveillance trends in associated Shiga toxin-producing Escherichia coli (STEC) O157 infection.METHODS:We report the incidence of pediatric HUS, which is defined as HUS in children <18 years. We compare the results from provider-based surveillance and hospital discharge data review and examine the impact of different case definitions on the findings of the surveillance system.RESULTS:During 2000-2007, 627 pediatric HUS cases were reported. Fifty-two percent of cases were classified as confirmed (diarrhea, anemia, microangiopathic changes, low platelet count, and acute renal impairment). The average annual crude incidence rate for all reported cases of pediatric HUS was 0.78 per 100,000 children <18 years. Regardless of the case definition used, the year-to-year pattern of incidence appeared similar. More cases were captured by provider-based surveillance (76%) than by hospital discharge data review (68%); only 49% were identified by both methods.CONCLUSIONS:The overall incidence of pediatric HUS was affected by key characteristics of the surveillance system, including the method of ascertainment and the case definitions. However, year-to-year patterns were similar for all methods examined, suggesting that several approaches to HUS surveillance can be used to track trends.

OBJECTIVE To describe pathogens identified through routine clinical practice and factors associated with identifying Shiga toxin-producing Escherichia coli (STEC) infection in patients with postdiarrheal hemolytic uremic syndrome (DHUS). DESIGN Population-based active surveillance. SETTING Hospitals in the FoodNet surveillance areas from 2000 through 2010. PARTICIPANTS Children younger than 18 years with DHUS. MAIN EXPOSURES Testing for STEC and demographic and clinical characteristics. MAIN OUTCOME MEASURES Percentage of patients with evidence of infection with likely HUS-causing agents and associations between exposures and evidence of STEC infection. RESULTS Of 617 patients, 436 (70.7%) had evidence of infection with likely HUS-causing agents: STEC O157 (401 patients), non-O157 STEC (21 patients), O157 and non-O157 STEC (1 patient), Streptococcus pneumoniae (11 patients), and other pathogens (2 patients). Among patients without microbiological evidence of STEC, 76.9% of those tested had serologic evidence of STEC infection. Children more likely to have evidence of STEC infections included those patients tested for STEC less than 4 days after diarrhea onset, 12 months or older (71.6% vs 27.8% if <12 months of age), with infections as part of an outbreak (94.3% vs 67.3%), with bloody diarrhea (77.2% vs 40.4%), with onset during June through September (76.9% vs 60.1%), with a leukocyte count greater than 18 000/μL (to convert to ×10(9)/L, multiply by 0.001) (75.7% vs 65.3%), or with only moderate anemia (hemoglobin 7.0 g/dL [to convert to grams per liter, multiply by 10] or hematocrit greater than 20% [to convert to a proportion of 1, multiply by 0.01]) (75.1% vs 66.3%). However, many of these associations were weaker among children with thorough STEC testing. CONCLUSIONS Early stool collection for E coli O157 culture and Shiga toxin testing of all children with possible bacterial enteric infection will increase detection of STEC strains causing HUS. In the absence of microbiological evidence of STEC, serologic testing should be performed.

BACKGROUND Campylobacter is a leading cause of foodborne illness in the United States. Understanding laboratory practices is essential to interpreting incidence and trends in reported campylobacteriosis over time and provides a baseline for evaluating the increasing use of culture-independent diagnostic methods for Campylobacter infection. METHODS The Foodborne Diseases Active Surveillance Network (FoodNet) conducts surveillance for laboratory-confirmed Campylobacter infections. In 2005, FoodNet conducted a survey of clinical laboratories to describe routine practices used for isolation and identification of Campylobacter. A profile was assigned to laboratories based on complete responses to key survey questions that could impact the recovery and isolation of Campylobacter from stool specimens. RESULTS Of 411 laboratories testing on-site for Campylobacter, 97% used only culture methods. Among those responding to the individual questions, nearly all used transport medium (97%) and incubated at 42°C (94%); however, most deviated from existing guidelines in other areas: 68% held specimens in transport medium at room temperature before plating, 51% used Campy blood agar plate medium, 52% read plates at <72 hours of incubation, and 14% batched plates before placing them in a microaerobic environment. In all, there were 106 testing algorithms among 214 laboratories with a complete profile; only 16 laboratories were fully adherent to existing guidelines. CONCLUSIONS Although most laboratories used culture-based methods, procedures differed widely and most did not adhere to existing guidelines, likely resulting in underdiagnosis. Given the availability of new culture-independent testing methods, these data highlight a clear need to develop best practice recommendations for Campylobacter infection diagnostic testing.

BACKGROUNDCyclosporiasis is an enteric disease caused by the parasite Cyclospora cayetanensis. Since the mid-1990 s, the Centers for Disease Control and Prevention has been notified of cases through various reporting and surveillance mechanisms.METHODSWe summarized data regarding laboratory-confirmed cases of Cyclospora infection reported during 1997-2009 via the Foodborne Diseases Active Surveillance Network (FoodNet), which gradually expanded to include 10 sites (Connecticut, Georgia, Maryland, Minnesota, New Mexico, Oregon, Tennessee, and selected counties in California, Colorado, and New York) that represent approximately 15% of the US population. Since 2004, the number of sites has remained constant and data on the international travel history and outbreak status of cases have been collected.RESULTSA total of 370 cases were reported, 70.3% (260) of which were in residents of Connecticut (134 [36.2%]) and Georgia (126 [34.1%]), which on average during this 13-year period accounted for 29.0% of the total FoodNet population under surveillance. Positive stool specimens were collected in all months of the year, with a peak in June and July (208 cases [56.2%]). Approximately half (48.6%) of the 185 cases reported during 2004-2009 were associated with international travel, known outbreaks, or both.CONCLUSIONSThe reported cases were concentrated in time (spring and summer) and place (2 of 10 sites). The extent to which the geographic concentration reflects higher rates of testing, more sensitive testing methods, or higher exposure/infection rates is unknown. Clinicians should include Cyclospora infection in the differential diagnosis of prolonged or relapsing diarrheal illness and explicitly request stool examinations for this parasite.

In 2006, the Centers for Disease Control and Prevention (CDC) sponsored a study with the ten Emerging Infections Program (EIP) states to assess compliance with the 2002 perinatal group B streptococcus (GBS) prevention guidelines. The New York State Department of Health (NYSDOH) is a participating EIP site and supports active surveillance for GBS in fifteen counties surrounding Albany (n=8) and Rochester (n=7). To assess compliance, 749 labor and delivery records were randomly selected for review from 44,882 live births that occurred in 20 hospitals within the EIP surveillance area between 2003 and 2004. All invasive early-onset infant GBS cases that occurred in the surveillance area were also included in the review (n=14). The major findings include: • Over 92% (n=673) of women were screened for GBS colonization at least two days prior to delivery. • Among screened women, 20% were colonized with GBS. • Intrapartum antibiotic prophylaxis (IAP) was administered to 87% (130/150) of women with an indication for treatment. Of these, 32% (n=41) received antibiotics less than 4 hours prior to delivery; however, 49% (n=20) were admitted less than 4 hours prior to delivery. • All of the 14 women who delivered infants with invasive, early-onset GBS were screened prior to delivery. Twelve screened negative and 2 screened positive for GBS colonization. Of the two women who screened positive, one received IAP. Overall compliance with the guidelines appears high. Nevertheless, approximately 9% of women were not screened in the recommended time period and 13% were not treated with IAP when indicated. Perhaps of greater concern is the finding of invasive, early- onset GBS in infants of women who had screened negative for GBS. The seemingly false negative screening results are concerning and warrant further investigation regarding specimen source and testing methods used.