A novel strain of ''Escherichia coli'' O104:H4 bacteria caused a serious outbreak of

foodborne illness Foodborne illness (also foodborne disease and food poisoning) is any illness resulting from the spoilage of contaminated food by pathogenic bacteria, viruses, or parasites that contaminate food, as well as prions (the agents of mad cow ...

focused in northern Germany in May through June 2011. The illness was characterized by bloody

diarrhea Diarrhea, also spelled diarrhoea, is the condition of having at least three loose, liquid, or watery bowel movements each day. It often lasts for a few days and can result in dehydration due to fluid loss. Signs of dehydration often begin ...

, with a high frequency of serious complications, including

hemolytic–uremic syndrome Hemolytic–uremic syndrome (HUS) is a group of blood disorders characterized by low red blood cells, acute kidney failure, and low platelets. Initial symptoms typically include bloody diarrhea, fever, vomiting, and weakness. Kidney problems and ...

(HUS), a condition that requires urgent treatment. The outbreak was originally thought to have been caused by an

enterohemorrhagic Shigatoxigenic ''Escherichia coli'' (STEC) and verotoxigenic ''E. coli'' (VTEC) are strains of the bacterium ''Escherichia coli'' that produce Shiga toxin (or verotoxin). Only a minority of the strains cause illness in humans. The ones that do ...

(EHEC) strain of ''

E. coli ''Escherichia coli'' (),Wells, J. C. (2000) Longman Pronunciation Dictionary. Harlow ngland Pearson Education Ltd. also known as ''E. coli'' (), is a Gram-negative, facultative anaerobic, rod-shaped, coliform bacterium of the genus ''Escher ...

'', but it was later shown to have been caused by an enteroaggregative ''E. coli'' (EAEC) strain that had acquired the genes to produce

Shiga toxin Shiga toxins are a family of related toxins with two major groups, Stx1 and Stx2, expressed by genes considered to be part of the genome of lambdoid prophages. The toxins are named after Kiyoshi Shiga, who first described the bacterial ori ...

s, present in

organic Organic may refer to: * Organic, of or relating to an organism, a living entity * Organic, of or relating to an anatomical organ Chemistry * Organic matter, matter that has come from a once-living organism, is capable of decay or is the product o ...

fenugreek Fenugreek (; ''Trigonella foenum-graecum'') is an annual plant in the family Fabaceae, with leaves consisting of three small obovate to oblong leaflets. It is cultivated worldwide as a semiarid crop. Its seeds and leaves are common ingredient ...

sprouts. Epidemiological fieldwork suggested fresh vegetables were the source of infection. The agriculture minister of

Lower Saxony Lower Saxony (german: Niedersachsen ; nds, Neddersassen; stq, Läichsaksen) is a German state (') in northwestern Germany. It is the second-largest state by land area, with , and fourth-largest in population (8 million in 2021) among the 16 ...

identified an

organic farm Organic farming, also known as ecological farming or biological farming,Labelling, article 30 o''Regulation (EU) 2018/848 of the European Parliament and of the Council of 30 May 2018 on organic production and labelling of organic products and re ...

Bienenbüttel Bienenbüttel is a free municipality in the district of Uelzen, in Lower Saxony, Germany. It is situated on the river Ilmenau, approximately north of Uelzen, and southeast of Lüneburg. Bienenbüttel is a part of the Hamburg Metropolitan Region ...

, Lower Saxony, Germany, which produces a variety of sprouted foods, as the likely source of the ''E. coli'' outbreak. The farm was shut down. Although laboratories in Lower Saxony did not detect the bacterium in produce, a laboratory in

North Rhine-Westphalia North Rhine-Westphalia (german: Nordrhein-Westfalen, ; li, Noordrien-Wesfale ; nds, Noordrhien-Westfalen; ksh, Noodrhing-Wäßßfaale), commonly shortened to NRW (), is a state (''Land'') in Western Germany. With more than 18 million inhab ...

later found the outbreak strain in a discarded package of sprouts from the suspect farm. A control investigation confirmed the farm as the source of the outbreak. On 30 June 2011, the German ''Bundesinstitut für Risikobewertung (BfR)'' (Federal Institute for Risk Assessment), an institute of the German

Federal Ministry of Food, Agriculture and Consumer Protection The Federal Ministry of Food and Agriculture (german: Bundesministerium für Ernährung und Landwirtschaft, ), abbreviated BMEL, is a cabinet-level ministry of the Federal Republic of Germany. Its primary headquarters are located in Bonn with ...

, announced that seeds of organic

imported from

Egypt Egypt ( ar, مصر , ), officially the Arab Republic of Egypt, is a transcontinental country spanning the northeast corner of Africa and southwest corner of Asia via a land bridge formed by the Sinai Peninsula. It is bordered by the Med ...

were likely the source of the outbreak. In all, 3,950 people were affected and 53 died, 51 of whom were in Germany. 800 people suffered hemolytic–uremic syndrome (HUS), which can lead to kidney failure.New insight from whole-genome sequencing of Europe's 2011 ''E. coli'' outbreaks
Biotechnology, 6 February 2012. A handful of cases were reported in several other countries including Switzerland,

Poland Poland, officially the Republic of Poland, , is a country in Central Europe. Poland is divided into Voivodeships of Poland, sixteen voivodeships and is the fifth most populous member state of the European Union (EU), with over 38 mill ...

, the

Netherlands ) , anthem = ( en, "William of Nassau") , image_map = , map_caption = , subdivision_type = Sovereign state , subdivision_name = Kingdom of the Netherlands , established_title = Before independence , established_date = Spanish Netherl ...

, Sweden,

Denmark ) , song = ( en, "King Christian stood by the lofty mast") , song_type = National and royal anthem , image_map = EU-Denmark.svg , map_caption = , subdivision_type = Sovereign state , subdivision_name = Kingdom of Denmark , establishe ...

, the UK, Canada and the USA. Essentially all affected people had been in Germany or France shortly before becoming ill. Initially, German officials made incorrect statements on the likely origin and strain of ''

Escherichia coli ''Escherichia coli'' (),Wells, J. C. (2000) Longman Pronunciation Dictionary. Harlow ngland Pearson Education Ltd. also known as ''E. coli'' (), is a Gram-negative, facultative anaerobic, rod-shaped, coliform bacterium of the genus '' Esc ...

''. The German health authorities, without results of ongoing tests, incorrectly linked the O104 serotype to

cucumber Cucumber (''Cucumis sativus'') is a widely-cultivated creeping vine plant in the Cucurbitaceae family that bears usually cylindrical fruits, which are used as culinary vegetables. Later, they recognised that Spanish

greenhouse A greenhouse (also called a glasshouse, or, if with sufficient heating, a hothouse) is a structure with walls and roof made chiefly of transparent material, such as glass, in which plants requiring regulated climatic conditions are grown.These ...

s were not the source of the ''E. coli'' and cucumber

sample Sample or samples may refer to: Base meaning * Sample (statistics), a subset of a population – complete data set * Sample (signal), a digital discrete sample of a continuous analog signal * Sample (material), a specimen or small quantity of so ...

s did not contain the specific ''E. coli'' variant causing the outbreak. Spain consequently expressed anger about having its produce linked with the deadly ''E. coli'' outbreak, which cost Spanish exporters US$200 million per week. Russia banned the import of all fresh vegetables from the European Union from early June until 22 June 2011.

Background

Enterohemorrhagic ''E. coli'' has been linked to foodborne outbreaks of bloody diarrhea and hemolytic–uremic syndrome around the world since at least the early 1980s. The majority of disease has been attributed to ''E. coli'' with the

serotype A serotype or serovar is a distinct variation within a species of bacteria or virus or among immune cells of different individuals. These microorganisms, viruses, or cells are classified together based on their surface antigens, allowing the e ...

O157:H7; however, over 100 ''E. coli'' serotypes have been associated with human diarrheal disease. In the five years before the outbreak (2006 to 2010) Germany experienced an

average In ordinary language, an average is a single number taken as representative of a list of numbers, usually the sum of the numbers divided by how many numbers are in the list (the arithmetic mean). For example, the average of the numbers 2, 3, 4, 7, ...

of 218 cases of EHEC gastroenteritis and 13 cases of hemolytic–uremic syndrome each year. According to the German National Reference Centre for ''Salmonella'' and Other Enteric Pathogens, the most common serotypes in those years were O157, O26, O103, and O91. Serotype O104 was relatively rare in Europe in the years preceding the outbreak, with just 11 reported cases in the EU and Norway between 2004 and 2009.

Outbreak

Cases

Cases began as early as 1 May 2011 with a man in Aachen reporting bloody diarrhea. Cases then rapidly increased, with over 100 cases of EHEC gastroenteritis and/or HUS were being reported each day by 16 May. The outbreak centered on the five northern German states of Hamburg, Schleswig-Holstein, Bremen, Lower Saxony, and Mecklenburg-Western Pomerania. Cases would eventually be reported in all 16 German states; however most cases outside of the northern states were linked to travel in northern Germany. Additionally, a small number of cases were reported from other countries, although most of those ill had previously travelled to Germany. The most substantial outbreak outside of Germany was in Bordeaux, France where 15 cases of EHEC gastroenteritis were associated with the same strain of ''E. coli'' which caused the outbreak in Germany. The French cases had not previously travelled to Germany, suggesting they acquired the bacteria from contaminated sprouts grown in France. Cases of EHEC HUS and gastroenteritis peaked on 21 and 22 May respectively. Cases then slowly decreased over the following month, with cases reported throughout the month of June and ending during July 2011. German authorities deemed the outbreak over in early July 2011. The outbreak disproportionately affected adults and the elderly. 88% of hemolytic–uremic syndrome patients were over 17 years of age, and the median age of hemolytic–uremic syndrome patients was 42 years. The median age of patients who died of gastroenteritis was 82 years, while the median age of patients who died from hemolytic–uremic syndrome was 74 years. Most or all victims were believed to have become infected in Germany or France. Confirmed cases are listed below according to their location when diagnosed.

Source investigation

The investigation into the cause of the outbreak officially began with the notification of the

Robert Koch Institute The Robert Koch Institute (RKI) is a German federal government agency and research institute responsible for disease control and prevention. It is located in Berlin and Wernigerode. As an upper federal agency, it is subordinate to the Feder ...

on 19 May concerning three cases of HUS in children in Hamburg. On 26 May, German health officials hastily and prematurely announced that cucumbers from Spain were identified as a source of the ''E. coli'' outbreak in Germany, when in fact the source were Egyptian sprouts. On 27 May 2011, German officials issued an alert distributed to nearby countries, identifying organic cucumbers from Spain and withdrawing them from the market. The European Commission on 27 May said the two Spanish greenhouses suspected to be the sources had been closed, and were being investigated. The investigation included analyzing soil and water samples from the greenhouses in question, located in the

Andalusia Andalusia (, ; es, Andalucía ) is the southernmost autonomous community in Peninsular Spain. It is the most populous and the second-largest autonomous community in the country. It is officially recognised as a "historical nationality". The ...

region, with results expected by 1 June. Cucumber samples from the Andalusian greenhouses did not show ''E. coli'' contamination, but cross-contamination during

transport in Germany As a densely populated country in a central location in Europe and with a developed economy, Germany has a dense transport infrastructure. One of the first limited-access highway systems in the world to have been built, the extensive German ...

and distribution in

Hamburg Hamburg (, ; nds, label=Hamburg German, Low Saxon, Hamborg ), officially the Free and Hanseatic City of Hamburg (german: Freie und Hansestadt Hamburg; nds, label=Low Saxon, Friee un Hansestadt Hamborg),. is the List of cities in Germany by popul ...

are not discounted; in fact, the most probable cause is cross-contamination inside Germany. The

advises against eating raw tomatoes, cucumbers, and lettuces in Germany to prevent further cases. On 31 May, an EU official said the transport chain was so long, the cucumbers from Spain could have been contaminated at any point along the transit route. Spanish officials said before, there was no proof that the outbreak originated in Spain; Spanish Secretary of State for European Affairs

Diego López Garrido Diego López Garrido (born 8 September 1947) is a Spanish politician, university professor and Secretary of State for the European Union in the Spanish Ministry of Foreign Affairs and Cooperation, He was also Minister of the Spanish government. B ...

said, "you can't attribute the origin of this sickness to Spain." On Tuesday 31 May, lab tests showed two of the four cucumbers examined did contain toxin-producing ''E. coli'' strains, but not the O104 strain found in patients. The bacteria in the other two cucumbers have not yet been identified.

Genomic sequencing DNA sequencing is the process of determining the nucleic acid sequence – the order of nucleotides in DNA. It includes any method or technology that is used to determine the order of the four bases: adenine, guanine, cytosine, and thymine. The ...

by BGI Shenzhen confirm a 2001 finding that the O104:H4 serotype has some enteroaggregative ''E. coli'' (EAEC or EAggEC) properties, presumably acquired by

horizontal gene transfer Horizontal gene transfer (HGT) or lateral gene transfer (LGT) is the movement of genetic material between unicellular and/or multicellular organisms other than by the ("vertical") transmission of DNA from parent to offspring ( reproduction). ...

. The only previous documented case of EHEC O104:H4 was in

South Korea South Korea, officially the Republic of Korea (ROK), is a country in East Asia, constituting the southern part of the Korea, Korean Peninsula and sharing a Korean Demilitarized Zone, land border with North Korea. Its western border is formed ...

in 2005, and researchers pointed at contaminated

hamburger A hamburger, or simply burger, is a food consisting of fillings—usually a patty of ground meat, typically Ground beef, beef—placed inside a sliced bun or bread roll. Hamburgers are often served with cheese, lettuce, tomato, onion, pickles ...

s as a possible cause. On 4 June, German and EU officials had allegedly been examining data that indicated an open catering event at a restaurant in

Lübeck Lübeck (; Low German also ), officially the Hanseatic City of Lübeck (german: Hansestadt Lübeck), is a city in Northern Germany. With around 217,000 inhabitants, Lübeck is the second-largest city on the German Baltic coast and in the stat ...

, Germany, was a possible starting point of the ongoing deadly ''E. coli'' outbreak in Europe. German hospitals were nearly overwhelmed by the number of ''E. coli'' victims. A spokesman for the agriculture ministry in

, warned people on 5 June to stop eating local

bean sprouts Sprouting is the natural process by which seeds or spores germinate and put out shoots, and already established plants produce new leaves or buds, or other structures experience further growth. In the field of nutrition, the term signifies ...

, as they had become the latest suspected cause of the ''E. coli'' outbreak. A farm in Bienenbuettel, Lower Saxony, was announced as the probable source, but on 6 June, officials said this could not be substantiated by tests. Of the 40 samples from the farm that were being examined, 23 had tested negative. But on 10 June, the head of the Robert Koch Institute confirmed the sprouts were the source of the outbreak, and people who ate the sprouts were nine times more likely to have bloody diarrhea. The

WHO Who or WHO may refer to: * Who (pronoun), an interrogative or relative pronoun * Who?, one of the Five Ws in journalism * World Health Organization Arts and entertainment Fictional characters * Who, a creature in the Dr. Seuss book ''Horton Hear ...

have confirmed on 10 June this statement on the update 13 of the EHEC outbreak. According to the head of the national ''E. coli'' lab at the German Federal Institute for Risk Assessment, the strain responsible for the outbreak has been circulating in Germany for 10 years, and in humans not cattle. He said it is likely to have gotten into food via human feces. A joint risk-assessment by

EFSA The European Food Safety Authority (EFSA) is the agency of the European Union (EU) that provides independent scientific advice and communicates on existing and emerging risks associated with the food chain. EFSA was established in February 2002, ...

ECDC The European Centre for Disease Prevention and Control (ECDC) is an agency of the European Union (EU) whose mission is to strengthen Europe's defences against infectious diseases. It covers a wide spectrum of activities, such as: surveillance, ...

, issued 29 June 2011, made a connection between the German outbreak and a HUS outbreak in the

Bordeaux Bordeaux ( , ; Gascon oc, Bordèu ; eu, Bordele; it, Bordò; es, Burdeos) is a port city on the river Garonne in the Gironde department, Southwestern France. It is the capital of the Nouvelle-Aquitaine region, as well as the prefecture ...

area of France, first reported on 24 June, in which infection with ''E. coli'' O104:H4 has been confirmed in several patients. The assessment implicated

seeds imported from

in 2009 and 2010, from which sprouts were grown, as a common source of both outbreaks, but cautioned, "there is still much uncertainty about whether this is truly the common cause of the infections", as tests on the seeds had not yet found any ''E. coli'' bacteria of the O104:H4 strain. The potentially contaminated seeds were widely distributed in Europe. Egypt, for its part, steadfastly denied it may have been the source of deadly ''E. coli'' strain, with the Minister of Agriculture calling speculations to that effect "sheer lies". Using epidemiological methods the outbreaks in 2011 were traced to a shipment of seeds from Egypt that arrived in Germany in December 2009.

International response

European Union

On 22 May, Health Commissioner

John Dalli John Dalli (born 5 October 1948) is a Maltese former politician who served as Cabinet Minister in various Maltese governments between 1987 and 2010. He was European Commissioner for Health and Consumer Policy between 2010 and 2012. Maltese pol ...

of the

European Commission The European Commission (EC) is the executive of the European Union (EU). It operates as a cabinet government, with 27 members of the Commission (informally known as "Commissioners") headed by a President. It includes an administrative body ...

declared the issue to be an 'absolute priority', saying the commission is working with member states, particularly Germany, to identify the source of the outbreak.''Escherichia coli'' outbreak in Germany: Shiga toxin-Producing ''Escherichia coli'' (STEC)

Speaking again on 1 June, Commissioner Dalli noted the outbreaks have been limited in origin to the greater Hamburg area and declared any product ban would be disproportionate. He also said he is working with Agriculture Commissioner

Dacian Cioloş Dacian, Geto-Dacian, Daco-Getic or Daco-Getian () often refers to something of or relating to: * Dacia (disambiguation) * Dacians * Dacian language Dacian may also refer to: * Dacian archaeology * Dacian art * Dacia in art * Dacian culture * D ...

"to address the hardship faced by this group of our citizens that has also been hit hard by the ''E. coli'' outbreak". He also said, "In the future, we need to see how the timing of the alerts can be closer to the actual scientific basis and proof." By 7 June, EU Ministers held an emergency meeting in

Luxembourg Luxembourg ( ; lb, Lëtzebuerg ; french: link=no, Luxembourg; german: link=no, Luxemburg), officially the Grand Duchy of Luxembourg, ; french: link=no, Grand-Duché de Luxembourg ; german: link=no, Großherzogtum Luxemburg is a small land ...

to discuss the growing crisis, which had left 23 people dead, and more than 2,000 ill so far. Germany's Federal Agriculture Minister,

Ilse Aigner Ilse Aigner (born 7 December 1964) is a German politician and member of the Christian Social Union of Bavaria (CSU). Aigner was born in Feldkirchen-Westerham, Bavaria, and entered Angela Merkel's grand coalition cabinet as Federal Minister of ...

, repeated her warnings to EU consumers to avoid eating any bean sprouts, cucumbers, tomatoes, and

salad A salad is a dish consisting of mixed, mostly natural ingredients with at least one raw ingredient. They are typically served at room temperature or chilled, though some can be served warm. Condiments and salad dressings, which exist in a v ...

s. The United States

Center for Disease Control The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States. It is a United States federal agency, under the Department of Health and Human Services, and is headquartered in Atlanta, Georgi ...

and the

United States Department of Agriculture The United States Department of Agriculture (USDA) is the federal executive department responsible for developing and executing federal laws related to farming, forestry, rural economic development, and food. It aims to meet the needs of com ...

has long been concerned regarding risks involving the ''E. coli'' risk in raw bean sprout production.

EU member states

Apart from the German government, which warned against the consumption of all raw cucumbers, tomatoes, and lettuce, several countries implemented restrictions or bans on the import of produce.

Non-EU European nations

Many other European countries took restrictive actions or lost sales of produce, including Albania, Croatia, and Russia. The ban on EU vegetables was lifted on 10 June, but stiff safety measures remained in place.

Middle East

Many countries took restrictive action. Egypt was a focus of the epidemiological investigation because the fenugreek seeds were imported into Germany from Egypt. Egypt's Minister of Health Ashraf Hatem denied his nation had any patients infected with the new ''E. coli'' strain, due to the strict precautions brought in to test overseas tourists entering the country on 2 June. Responding to claims that Egyptian fenugreek seeds were the cause of the ''E. coli'' outbreak, Egyptian Minister of Agriculture Ayman Abu-Hadid told the Egyptian press the problem had nothing to do with Egypt and instead asserted, "Israel is waging a commercial war against Egyptian exports."

North America

Canada and the United States reported cases of ''E. coli'' infection that had been acquired in Europe. On 2 June, Canada brought in stricter anti ''E. coli''-related food inspections, and by 3 June the

Public Health Agency of Canada The Public Health Agency of Canada (PHAC; french: Agence de la santé publique du Canada, ASPC) is an agency of the Government of Canada that is responsible for public health, emergency preparedness and response, and infectious and chronic disea ...

said no Canadians had been reported sick with the strain as of that date. The Canadian government also brought in heavier import and hygiene restrictions on EU cucumbers, lettuces, and tomatoes. The

and the

Food and Drug Administration The United States Food and Drug Administration (FDA or US FDA) is a federal agency of the Department of Health and Human Services. The FDA is responsible for protecting and promoting public health through the control and supervision of food ...

(FDA) stated that emerging strains of ''E. coli'' are a significant problem, but regulatory bodies in the US have concentrated on the more infamous ''E. coli'' O157 serotype. The FDA noted nearly all of America's fresh produce is grown in the US and areas of Central America, and the EU has not been a significant source of fresh produce for the US.

Other countries

Other countries, including Nigeria, Hong Kong, and Thailand, expressed concern regarding imported produce.

Economics

By 1 June, Italian, Austrian, and French cucumber sales had begun to decline sharply, but the Austrian Health Ministry official, Dr. Pamela Rendi-Wagner, claimed Austrian customers were still safe. On 3 June, the governments of Spain, Portugal, and Germany said they would formally request EU agricultural aid for farmers affected by the outbreak. That day, Russia also set up plans for new imports of cucumbers from Ukraine, Azerbaijan, Egypt, and Turkey. By 7 June, the EU's farmers had reported they had lost millions of dollars in exports during the outbreak, with Fepex, Spain's fruit and vegetable industry group, saying its growers had $256,000,000 in turnover. French, Swiss, Bulgarian, German, Dutch, Belgian, and Portuguese producers have also been similarly affected. That day, the EU proposed issuing £135,000,000 in agricultural compensation to its farmers. The EU agriculture commissioner said the EU's farmers could get back up to 30% of the cost of vegetables they were unable to sell. The EU's health commissioner, John Dalli, had formally criticised Germany earlier that day for rushing out "premature conclusions" about the source of an outbreak, and only helped to spread alarm among the public and farmers and untimely leading to the damaging the EU's agriculture sector. John Dalli also told the EU parliament in Strasbourg that claims had to be scientifically sound, unbiased, and fool-proof in nature before it was publicised in future. Spain then rejected a €150,000,000/£135,000,000 the

's compensation deal for their farmers who were hit by the ''E. coli'' outbreak, on 8 June, saying it was too small. France, European Union's largest agricultural grower, said it would support the plan to compensate producers hurt by the outbreak, according to the French Agriculture Minister

Bruno Le Maire Bruno Le Maire (; born 15 April 1969) is a French politician and former diplomat who has served as Minister of the Economy and Finance since 2017 under President Emmanuel Macron. A former member of The Republicans (LR), which he left in 2017 to ...

. Ministers from both EU and Russia were scheduled to meet on 8 June over Russia's earlier decision to ban all its vegetable imports from the EU. On 8 June, the EU's ''E. coli'' O104:H4 outbreak was estimated to have cost $2,840,000,000 in human losses (such as sick leave), regardless of material losses (such as dumped cucumbers). Consumers across Europe were shunning fruit and vegetables ''en masse'' by 8 June, as the German government's edict against eating raw cucumbers, tomatoes, lettuce and sprouts remained on. EU farmers claimed to have losses up to C$417,000,000 a week as ripe vegetables rotted in their fields and warehouses.CTV Edmonton – Cucumbers suspected again in European ''E. coli'' outbreak – CTV News
/ref> On 8 June, The EU Farm Commissioner Dacian Ciolos said the EU had increased its offer of compensation to farmers for the losses caused by ''E. coli'' outbreak to C$210,000,000.

Cause

The outbreak was caused by a strain of ''E. coli'' of the serotype O104:H4, that was unusual for having characteristics of both enteroaggregative ''E. coli'' and enterohemorrhagic ''E. coli''. The strain has a number of virulence genes typical of enteroaggregative ''E. coli'', including ''attA'', ''aggR'', ''aap'', ''aggA'', and ''aggC'', in addition to the

variant 2. All bacteria isolated from patients in this outbreak were resistant to

beta-lactam A beta-lactam (β-lactam) ring is a four-membered lactam. A ''lactam'' is a cyclic amide, and ''beta''-lactams are named so because the nitrogen atom is attached to the β-carbon atom relative to the carbonyl. The simplest β-lactam possible i ...

antibiotics, third-generation

cephalosporin The cephalosporins (sg. ) are a class of β-lactam antibiotics originally derived from the fungus '' Acremonium'', which was previously known as ''Cephalosporium''. Together with cephamycins, they constitute a subgroup of β-lactam antibioti ...

s, and partially resistant to

nalidixic acid Nalidixic acid (tradenames Nevigramon, NegGram, Wintomylon and WIN 18,320) is the first of the synthetic quinolone antibiotics. In a technical sense, it is a naphthyridone, not a quinolone: its ring structure is a 1,8-naphthyridine nucleus that ...

, but susceptible to

carbapenem Carbapenems are a class of very effective antibiotic agents most commonly used for the treatment of severe bacterial infections. This class of antibiotics is usually reserved for known or suspected multidrug-resistant (MDR) bacterial infections. S ...

s and

ciprofloxacin Ciprofloxacin is a fluoroquinolone antibiotic used to treat a number of bacterial infections. This includes bone and joint infections, intra abdominal infections, certain types of infectious diarrhea, respiratory tract infections, skin infec ...

References

{{DEFAULTSORT:E. coli O104:H4 outbreak, 2011 Germany 2011 disease outbreaks 2011 in Denmark 2011 in Germany 2011 in Poland 2011 in Sweden 2011 in Switzerland 2011 in the Netherlands 2011 in the United Kingdom 2011 Disease outbreaks in Denmark Health disasters in Poland Disease outbreaks in the United Kingdom Disease outbreaks in Germany Food safety in the European Union May 2011 events in Europe June 2011 events in Europe May 2011 events in Germany June 2011 events in Germany May 2011 events in the United Kingdom June 2011 events in the United Kingdom 2011 disasters in Europe Health disasters in Sweden Health disasters in Switzerland Health disasters in the Netherlands Health disasters in the United Kingdom Health disasters in Germany