Volume Resuscitation and Progression to Organ Failure in Shiga Toxin-Producing Infection in Adults.

UNLABELLED

Shiga toxin-producing infection is associated with dysentery and the hemolytic uremic syndrome, marked by the triad of microangiopathic hemolytic anemia, acute kidney failure, and thrombocytopenia. Descriptions of Shiga toxin-producing outbreaks causing hemolytic uremic syndrome in adults are sparse, and management strategies are largely adapted from pediatric literature where aggressive fluid administration is recommended. However, these may not be ideal for adults.

DESIGN

We present a case series of an Shiga toxin-producing outbreak in U.S. Marine Corps recruits.

SETTING

We review the clinical course, laboratory data, and fluid resuscitation used in hospitalized patients during the 2017 Shiga toxin-producing outbreak at Marine Corps Recruit Depot, San Diego.

PATIENTS

Patients admitted to the hospital for complications from Shiga toxin-producing infection. All were previously healthy men between the ages of 17 and 20 years.

INTERVENTIONS

Isotonic crystalloid fluid resuscitation during the first 72 hours.

MEASUREMENTS AND MAIN RESULTS

Of 244 identified cases of Shiga toxin-producing infection, 30 required hospitalization, 15 progressed to hemolytic uremic syndrome, and five required hemodialysis. Patients were admitted and given aggressive IV fluid hydration. Those who progressed to hemolytic uremic syndrome received on average 8.4 L of isotonic crystalloid over the initial 72 hours, with up to 18% of body weight delivered. The six critically ill patients received a mean 12.2 L in the first 72 hours. Those who did not progress to hemolytic uremic syndrome received a mean 3.0 L of crystalloid. If oligoanuria developed, a net-even fluid balance was maintained. The amount of volume infused was not associated with improved outcomes. The patients with the highest fluid balance totals more often required dialysis than those who received less fluid. One hemolytic uremic syndrome patient developed flash pulmonary edema.

CONCLUSIONS

The aggressive IV hydration protocols (as a percentage of body weight) in the pediatric literature may not be applicable to adults diagnosed with hemolytic uremic syndrome. A more conservative fluid strategy in adults with hemolytic uremic syndrome merits further investigation.