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What are the Pathotypes of E. coli? – ETEC, EPEC, EHEC, EAEC, EIEC, DAEC

Escherichia coli, commonly referred to as E. coli, is a type of Gram-negative bacterium. It is facultative anaerobic, meaning it can survive in environments with or without oxygen, and has a rod-shaped morphology. E. coli is predominantly found in the lower intestine of warm-blooded organisms, including humans (endotherms).

Human strains of E. coli can be classified into different categories based on their genetic features and clinical outcomes. These categories include commensal microbiota E. coli, enterovirulent E. coli, and extraintestinal pathogenic E. coli (ExPEC).

While E. coli strains are typically part of the normal microbial flora in the human intestine and are considered commensal, they can cause infections under certain circumstances. Infections caused by E. coli are mostly endogenous, meaning the bacteria that are already present as part of the patient’s normal microbial flora can cause infection when the patient’s immune defenses are compromised or when certain conditions, such as trauma or immune suppression, occur.

Although E. coli can cause various infections, such as neonatal meningitis and gastroenteritis, most E. coli infections are opportunistic in nature. This means that the bacteria take advantage of compromised immune defenses or underlying conditions to establish an infection.

It is important to note that not all strains of E. coli are harmful. In fact, many strains are harmless and contribute to the normal functioning of the intestinal microbiota. However, certain pathogenic strains of E. coli can cause severe illnesses, such as urinary tract infections, bloodstream infections, and gastrointestinal infections.

Proper hygiene practices, food safety measures, and appropriate sanitation play key roles in preventing E. coli infections. In cases where infections do occur, treatment typically involves appropriate antimicrobial therapy targeted at the specific strain and supportive care to manage symptoms and complications.

Consulting with a healthcare professional is essential for proper diagnosis, management, and prevention of E. coli infections, particularly in cases where there are underlying health conditions or compromised immune systems.

Escherichia coli as Pathogenic Bacteria

Escherichia coli (E. coli) is a pathogenic bacterium that has significant clinical importance due to its ability to cause a wide range of infections. The effectiveness of E. coli as a pathogen is evident from several key aspects:

  1. Sepsis: E. coli is one of the most common gram-negative rods isolated from patients with sepsis, a severe bloodstream infection. The ability of E. coli to invade the bloodstream and spread throughout the body underscores its pathogenic potential.
  2. Urinary Tract Infections (UTIs): E. coli is a leading cause of both community-acquired and hospital-acquired UTIs. In fact, it is responsible for over 80% of all community-acquired UTIs. The bacterium can ascend from the urethra to the bladder and potentially reach the kidneys, leading to significant urinary tract infections.
  3. Gastroenteritis: E. coli is a prominent cause of gastroenteritis, an inflammation of the gastrointestinal tract. Certain strains of pathogenic E. coli, such as enterotoxigenic E. coli (ETEC) and enterohemorrhagic E. coli (EHEC), can cause diarrhea, abdominal pain, and other symptoms associated with gastroenteritis.

The pathogenic potential of E. coli stems from various virulence factors it possesses, including adhesins that allow it to adhere to host cells, toxins that damage tissues, and mechanisms to evade host immune responses. Additionally, the ability of E. coli to acquire antibiotic resistance genes further complicates treatment options.

What do you means by Pathotypes?

Pathotypes refer to distinct groups or classifications of microorganisms, specifically pathogens, based on their genetic features, virulence factors, and clinical outcomes. In the context of E. coli, pathotypes are different strains or types of the bacteria that have specific characteristics and are associated with causing specific types of diseases or infections.

Each pathotype of E. coli has unique genetic features and virulence factors that contribute to its ability to cause disease and its specific clinical manifestations. For example, enterotoxigenic E. coli (ETEC) produces enterotoxins that lead to watery diarrhea, while enterohemorrhagic E. coli (EHEC) produces Shiga toxins that can cause severe complications such as hemolytic uremic syndrome (HUS).

By categorizing E. coli strains into different pathotypes, it becomes easier to understand their specific roles in causing diseases, their transmission routes, and the appropriate diagnostic and treatment approaches for each pathotype.

Different Pathotypes of E. coli

Escherichia coli (E. coli) encompasses various strains, including those responsible for gastroenteritis. These strains are further classified into distinct pathotypes or groups based on their specific characteristics. Here are the key pathotypes of E. coli associated with gastroenteritis:

  1. Enterotoxigenic E. coli (ETEC): ETEC strains are known for producing enterotoxins that lead to diarrheal illness. These toxins affect the small intestine, resulting in watery diarrhea. ETEC is a significant cause of traveler’s diarrhea and is commonly associated with contaminated food or water.
  2. Enteropathogenic E. coli (EPEC): EPEC strains primarily affect infants and young children. They attach to the intestinal lining and cause a characteristic “attaching and effacing” lesion, leading to diarrhea. EPEC infections can be associated with outbreaks in daycare centers and other settings.
  3. Enterohemorrhagic E. coli (EHEC): EHEC, notably the serotype E. coli O157:H7, is well-known for causing severe illnesses. These strains produce Shiga toxins, which can lead to bloody diarrhea, as well as potential complications such as hemolytic uremic syndrome (HUS). EHEC infections are often linked to undercooked ground beef, contaminated produce, and person-to-person transmission.
  4. Enteroaggregative E. coli (EAEC): EAEC strains are characterized by their ability to form aggregative adherence patterns on intestinal epithelial cells. They are associated with persistent or chronic diarrhea, particularly in young children in developing countries. EAEC can cause outbreaks in daycare centers, institutions, and communities.
  5. Enteroinvasive E. coli (EIEC): EIEC strains invade the intestinal epithelium, resulting in an inflammatory response similar to Shigella infection. They are associated with dysentery, causing bloody diarrhea with fever and abdominal pain. EIEC infections are often associated with poor sanitation and inadequate hygiene practices.
  6. Diffusely Adhering E. coli (DAEC): DAEC strains exhibit a diffuse adherence pattern on intestinal cells and are associated with persistent diarrhea, particularly in young children in developing countries. The clinical significance of DAEC in causing diarrhea is still being elucidated.

These pathotypes, collectively referred to as diarrheagenic E. coli, are distinct from the commensal E. coli strains that normally colonize the intestine without causing disease. Only certain serotypes of E. coli expressing specific virulence mechanisms, such as enterotoxins, are capable of causing diarrhea.

Differentiating these pathotypes is based on epidemiological and clinical features, specific virulence determinants, and associations with particular serotypes.

1. Enteropathogenic E. coli (EPEC)

Enteropathogenic E. coli (EPEC) is one of the two groups of E. coli strains associated with enteric diseases, with the other being some Shiga toxin-producing E. coli (STEC). EPEC strains possess a cluster of virulence genes known as the locus of enterocyte effacement (LEE), which is located on a chromosomal pathogenicity island.

Key features of EPEC include:

  1. Disease Presentation: EPEC is a common cause of infantile diarrhea, often associated with outbreaks. Although less common, EPEC can also cause sporadic diarrhea in adults.
  2. Mode of Transmission: The transmission of EPEC occurs through fecal-oral exposure, typically via contaminated surfaces or food products. Person-to-person spread is observed, particularly in settings with poor hygiene practices.
  3. Toxin Production and Invasiveness: Unlike some other pathogenic E. coli strains, EPEC is non-toxigenic and non-invasive. It does not produce specific toxins or invade the host tissues.
  4. Mechanism of Diarrhea: The pathogenesis of EPEC involves the adherence of the bacteria to the intestinal mucosa. This adherence is mediated by a plasmid-encoded bundle-forming pilus, which leads to the formation of cup-like projections called pedestals on the surface of the intestinal epithelial cells. These structures are responsible for the characteristic attaching and effacing (A/E) lesions, which disrupt the brush border of the intestinal epithelium. The disruption of the epithelium leads to increased secretion and watery diarrhea.
  5. Clinical Presentation: EPEC infection can have a rapid onset, with symptoms appearing within a few hours after ingestion. While most EPEC infections resolve after a few days, some cases may lead to persistent diarrhea, requiring hospitalization.

Proper hygiene practices, including handwashing and food safety measures, are crucial for preventing the transmission of EPEC. Adequate sanitation and safe water sources also play important roles in reducing the incidence of EPEC infections.

Management of EPEC-related diarrhea involves rehydration therapy to replace fluids and electrolytes lost through diarrhea. In severe cases, hospitalization and supportive care may be necessary.

2. Enterotoxigenic E. coli (ETEC)

Enterotoxigenic E. coli (ETEC) is a significant cause of bacterial diarrheal disease, particularly in developing countries, where it is estimated to cause around 840 million cases annually. It is also responsible for a considerable proportion of cases (about 30%) of travelers’ diarrhea in individuals visiting these countries.

Key characteristics of ETEC include:

  1. Disease Presentation: ETEC typically causes acute watery diarrhea in both infants and adults. The diarrheal illness is characterized by a sudden onset and is non-bloody in nature.
  2. Mode of Transmission: ETEC infections are primarily acquired through the consumption of food or water that has been contaminated with fecal matter. Person-to-person spread is not common for ETEC.
  3. Common Serotypes: Several E. coli serotypes are commonly associated with ETEC, including O6, O8, O15, O25, O27, O153, O159, and others. These serotypes help in identifying and characterizing specific strains of ETEC.
  4. Toxin Production: ETEC is referred to as “enterotoxigenic” because it produces two classes of enterotoxins. These include heat-stable toxins (STa and STb) and heat-labile toxins (LT-I and LT-II). The heat-stable toxin STa, in particular, is associated with human disease and is found in the majority (75-80%) of ETEC strains.
  5. Pathogenesis: The pathogenesis of ETEC involves the attachment of the bacteria to the intestinal mucosa, which is mediated by fimbrial proteins called CFA (colonization factor antigens). Along with attachment, the production and release of enterotoxins contribute to the development of symptoms.
  6. Clinical Presentation: Following an incubation period of 1-2 days, secretory diarrhea develops, characterized by watery, non-bloody stools, abdominal cramps, and occasionally, nausea and vomiting. The symptoms resemble those of cholera but are typically milder. However, in vulnerable populations such as malnourished individuals and those with underlying diseases, particularly children and the elderly, the mortality rate can be higher.
  7. Diagnosis: The diagnosis of ETEC infection involves the detection of toxins produced by the bacteria. This can be done using various in vitro and in vivo methods to identify the presence of heat-stable and heat-labile toxins.

Proper hygiene practices, safe food and water consumption, and improved sanitation are important measures to prevent the transmission of ETEC. Rehydration therapy is essential for managing ETEC-related diarrhea, particularly in individuals at higher risk of complications.

3. Enteroaggregative E. coli (EAEC)

Enteroaggregative E. coli (EAEC) is a diverse group of strains characterized by their ability to autoagglutinate and adhere to the epithelium of the small intestine and, in some cases, the colon. The term “enteroaggregative” refers to their distinct pattern of adhering to HEP-2 cells in a stacked-brick arrangement.

Key features of EAEC include:

  1. Heterogeneity and Unclear Prevalence: EAEC strains represent a diverse collection, and their prevalence in causing disease is not clearly established due to the lack of a single molecular marker for identification. The genes encoding adhesins, toxins (including Shiga toxin), and other virulence factors vary widely among EAEC strains.
  2. Adherence and Colonization: EAEC strains use aggregative adhesion fimbriae I, regulated by the aggR gene, to colonize the intestinal mucosa. This adhesion contributes to the stacked-brick appearance. EAEC also produces the EAST-1 toxin (enteroaggregative heat-stable enterotoxin 1).
  3. Manifestation of Disease: EAEC infections are associated with both persistent and acute diarrhea, particularly in developing countries. They are known to cause chronic diarrhea and growth retardation, particularly in children.
  4. Outbreaks and Strain-Specific Features: Certain EAEC strains have gained attention due to their association with major outbreaks. For instance, the E. coli O104:H4 strain caused a significant outbreak in Germany in 2011. Notably, this strain produces Shiga-like toxin and can lead to hemolytic uremic syndrome (HUS), a severe complication.

Diagnosing EAEC infection can be challenging due to the lack of a definitive molecular marker. Detection and characterization of EAEC strains involve a combination of laboratory methods, including genetic and phenotypic analysis.

Prevention and control of EAEC infections require improved sanitation, access to clean water sources, and hygiene practices. Safe food handling and proper cooking techniques also play crucial roles in reducing the transmission of EAEC.

In cases of EAEC-associated diarrhea, rehydration therapy is essential to manage fluid and electrolyte imbalances. Treatment may also involve antimicrobial therapy in certain cases, although resistance to commonly used antibiotics is a concern.

4. Diffusely-adherent E. coli (DAEC)

Diffusely-adherent E. coli (DAEC) strains have recently been recognized as the sixth class of diarrheagenic E. coli, contributing to gastrointestinal illness. Here’s what you need to know about DAEC:

  1. Heterogeneous Group: DAEC strains represent a diverse and heterogeneous group of E. coli. They are characterized by their ability to adhere to HEp-2 cells in a diffuse pattern, covering the entire surface of the host cell.
  2. Diffuse Adherence Fimbriae: DAEC strains express diffuse adherence fimbriae, which are important for their adherence to host cells. These fimbriae contribute to the pathogenesis of DAEC-related disease.
  3. Age Dependency: DAEC strains are primarily involved in diarrhea among children aged 2-6 years. They have been implicated in causing diarrheal disease in this age group. However, their role in adult diarrhea is less clear. In some cases, DAEC strains can also exist as part of the intestinal microbiota without causing symptoms in both children and adults.
  4. Pathogenesis and Pathogenicity: The exact mechanisms and pathogenicity of DAEC strains are still under investigation. Further research is needed to better understand the virulence factors and specific disease-causing potential of DAEC.
  5. Clinical Presentation: DAEC strains are thought to be capable of causing diarrheal disease, particularly in children. The symptoms associated with DAEC-related diarrhea can vary and may include watery or loose stools, abdominal discomfort, and other gastrointestinal symptoms.

Diagnosis of DAEC infection requires specialized laboratory techniques to identify the presence of diffuse adherence and characterize the strain. Due to the diverse nature of DAEC strains, detection methods may vary.

Prevention measures for DAEC-related infections include practicing good hygiene, such as regular handwashing and safe food handling. Proper sanitation and access to clean water sources also play important roles in reducing the transmission of DAEC.

5. Enteroinvasive E. coli (EIEC)

Enteroinvasive E. coli (EIEC) strains are relatively rare in both developed and developing countries. Here’s what you need to know about EIEC:

  1. Serotypes: Pathogenic EIEC strains are primarily associated with a few specific O serotypes, including O124, O143, and O164. These serotypes help in identifying and characterizing EIEC strains.
  2. Similarities to Shigella: EIEC strains are closely related to Shigella in terms of their phenotypic and pathogenic properties. They share similarities in terms of their ability to invade the intestinal epithelium and cause disease.
  3. Disease Presentation: EIEC is capable of invading and destroying the colonic epithelium, leading to a specific clinical presentation. The initial stage is characterized by watery diarrhea. In a minority of patients, the disease progresses to a dysenteric form, which includes symptoms such as fever, abdominal cramps, and the presence of blood and leukocytes in stool specimens.
  4. Mechanism of Invasion: EIEC strains possess a series of genes located on a plasmid (pInv genes) that enable bacterial invasion into the colonic epithelium. Once inside the host cell, the bacteria lyse the phagocytic vacuole and replicate in the cell cytoplasm. They also have the ability to move within the cytoplasm and invade adjacent epithelial cells, which is regulated by the formation of actin tails, a process similar to that observed with the bacteria Listeria.
  5. Colonic Ulceration: The destructive process caused by EIEC’s invasion of the epithelial cells, coupled with the inflammatory response, can lead to colonic ulceration. This progression of cell destruction and inflammatory infiltration contributes to the pathogenesis of EIEC-induced disease.

Due to the similarities between EIEC and Shigella, laboratory methods are necessary to differentiate between the two. Appropriate diagnostic tests, including microbiological and molecular techniques, can help identify the presence of EIEC and confirm its role in disease.

Prevention measures for EIEC infection involve practicing good hygiene, including proper handwashing and sanitation practices. Ensuring the safety and hygiene of food and water sources is also crucial in reducing the transmission of EIEC.

6. Shiga Toxin–Producing E. coli (STEC/VTEC/EHEC)

Shiga toxin–producing E. coli (STEC), also known as verocytotoxin-producing E. coli (VTEC) or enterohemorrhagic E. coli (EHEC), refers to a group of E. coli strains associated with specific characteristics and clinical manifestations. Here’s what you need to know:

  1. Nomenclature and Characteristics: The nomenclature for this group can be confusing, with different names used interchangeably. All strains within this group share a common feature—they produce Shiga toxin 1 (Stx1) or Shiga toxin 2 (Stx2). Some EHEC strains exhibit characteristics similar to enteropathogenic E. coli (EPEC), such as forming attaching and effacing (A/E) lesions.
  2. Serotypes: The most commonly associated serotype with EHEC is 0157:H7, although other serotypes, such as 026:H11, 06, 055, 091, 0103, 0 111, and 0113, are rarely implicated.
  3. Diagnosis: Diagnosis of STEC disease now relies on the detection of Shiga toxins rather than serotyping the suspected isolates. Laboratory tests are conducted to identify the presence of these toxins in patient samples.
  4. Transmission: Most STEC infections occur during warm months, with children under 5 years being the most affected group. Consumption of undercooked ground beef or other meat products, contaminated water, unpasteurized milk or fruit juices, uncooked vegetables (e.g., spinach), and fruits are common sources of infection. Person-to-person transmission can also occur.
  5. Clinical Presentation: STEC infections can range from mild uncomplicated diarrhea to hemorrhagic colitis, characterized by severe abdominal pain and bloody diarrhea. Severe disease is more commonly associated with the STEC O157:H7 serotype.
  6. Hemolytic Uremic Syndrome (HUS): Approximately 5% to 10% of infected children under 10 years of age can develop HUS, which involves acute renal failure, thrombocytopenia (low platelet count), and microangiopathic hemolytic anemia. HUS can have severe complications and can be fatal in some cases. Long-term renal impairment, hypertension, and central nervous system (CNS) manifestations may occur in a significant proportion of HUS patients.

Prompt medical attention is necessary if STEC infection is suspected, especially in young children or individuals experiencing severe symptoms. Treatment focuses on supportive care, including rehydration therapy. Antibiotics are generally not recommended as they may increase the risk of complications, particularly HUS.

Prevention measures involve safe food handling practices, thorough cooking of meat, pasteurization of milk and juice, and maintaining proper hygiene. Public health efforts are crucial to reduce the incidence and impact of STEC infections, especially in high-risk populations.


What are the pathotypes of E. coli?

E. coli has several pathotypes, including enterotoxigenic E. coli (ETEC), enteropathogenic E. coli (EPEC), enterohemorrhagic E. coli (EHEC), enteroaggregative E. coli (EAEC), enteroinvasive E. coli (EIEC), and diffusely adherent E. coli (DAEC).

What is the difference between ETEC and EPEC?

ETEC strains cause acute watery diarrhea and are primarily transmitted through the consumption of contaminated food or water. On the other hand, EPEC strains cause infantile diarrhea and can be transmitted through person-to-person contact or exposure to contaminated surfaces.

What is unique about EHEC?

EHEC, such as the serotype O157:H7, is notorious for causing severe foodborne illnesses. It produces Shiga toxins, which can lead to complications like hemolytic uremic syndrome (HUS). EHEC infections are commonly associated with the consumption of undercooked ground beef or contaminated produce.

What distinguishes EAEC from other pathotypes?

EAEC strains form a “stacked-brick” arrangement when adhering to host cells. They are a diverse group and their prevalence is not clearly established. EAEC can cause persistent and acute diarrhea, particularly in developing countries.

How does EIEC differ from other E. coli pathotypes?

EIEC strains closely resemble Shigella in terms of their pathogenic properties. They invade and destroy the colonic epithelium, leading to symptoms similar to Shigella infections, such as watery diarrhea progressing to dysentery.

What is the main characteristic of DAEC?

DAEC strains exhibit diffuse adherence, covering the entire surface of host cells. They are primarily associated with diarrhea in children aged 2-6 years, although their exact role in adult diarrhea is less clear.

Are there specific virulence factors associated with each pathotype?

Yes, each pathotype has unique virulence factors. For example, ETEC produces heat-stable and heat-labile enterotoxins, while EPEC forms attaching and effacing lesions on the intestinal epithelium. EHEC produces Shiga toxins, and EAEC expresses aggregative adherence fimbriae.

How are these pathotypes transmitted?

Transmission routes vary among the pathotypes. ETEC and EAEC are primarily transmitted through the ingestion of contaminated food or water. EPEC and EIEC can be spread through person-to-person contact or exposure to contaminated surfaces. EHEC infections commonly occur through the consumption of undercooked meat or contaminated produce.

Which pathotype is associated with hemolytic uremic syndrome (HUS)?

HUS is primarily associated with EHEC infections, especially the serotype O157:H7. The production of Shiga toxins by EHEC strains can lead to the development of HUS, a severe complication characterized by acute renal failure, thrombocytopenia, and microangiopathic hemolytic anemia.

How are these pathotypes diagnosed?

Diagnosis involves various laboratory techniques, including detection of specific virulence factors or genetic markers, serotyping, and molecular testing. The choice of diagnostic method depends on the suspected pathotype and available resources.


  • Murray, P. R., Rosenthal, K. S., & Pfaller, M. A. (2013). Medical microbiology. Philadelphia: Elsevier/Saunders
  • Parija S.C. (2012). Textbook of Microbiology & Immunology.(2 ed.). India: Elsevier India.
  • Sastry A.S. & Bhat S.K. (2016). Essentials of Medical Microbiology. New Delhi : Jaypee Brothers Medical Publishers.
  • Scaletsky IC, Fabbricotti SH, Carvalho RL, Nunes CR, Maranhão HS, Morais MB, Fagundes-Neto U. Diffusely adherent Escherichia coli as a cause of acute diarrhea in young children in Northeast Brazil: a case-control study. J Clin Microbiol. 2002 Feb;40(2):645-8. doi: 10.1128/JCM.40.2.645-648.2002. PMID: 11825986; PMCID: PMC153384.

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