Case definitions of hemolytic uremic syndrome following Escherichia coli O157:H7 infection vary in validity

Gillian A.M. Tarr, Hanna N. Oltean, Amanda I. Phipps, Peter Rabinowitz, Phillip I. Tarr

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


Background: Multiple case definitions for post-diarrheal hemolytic uremic syndrome (D+ HUS) associated with Shiga toxin-producing Escherichia coli (STEC) are used across public health, research, and clinical practice. Methods: To identify a single definition of D+ HUS for standardized use, we evaluated the comparability and validity of four common, heterogeneous definitions: the Council of State and Territorial Epidemiologists (CSTE) definition, hematology-focused and age-focused definitions from the literature, and hospital diagnosis. We reviewed medical records from 471 hospitalized E. coli O157:H7 cases reported in Washington State, 2005–2014. We assessed 1) reliability across definitions, 2) comparability of temporal trends, and 3) sensitivity and specificity using an omnibus reference standard, developed using a combination of definition agreement and clinical outcomes. With the standard, we classified cases as definite, borderline, or unlikely/not post-diarrheal D+ HUS. Results: Reliability was highest between the age-focused definition and hospital diagnosis (κ = 0.84), and temporal trends were largely comparable across definitions. For definite D+ HUS cases, the age-focused definition had the highest overall validity [100% sensitivity, 95% confidence interval (CI): 94%, 100%; 96% specificity, 95% CI: 94%, 98%]. The CSTE definition had low specificity (75%, 95% CI: 70%, 79%). Conclusions: In this review, the CSTE definition overestimated the burden of D+ HUS, and the age-focused definition provided the best overall reliability and validity to define post-diarrheal D+ HUS. Disease monitoring and research activities should consider using the age-focused D+ HUS definition.

Original languageEnglish
Pages (from-to)1121-1127
Number of pages7
JournalInternational Journal of Medical Microbiology
Issue number8
StatePublished - Dec 2018


  • E. coli O157:H7
  • Hemolytic uremic syndrome
  • Shiga toxin-producing Escherichia coli
  • Surveillance


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