Methodology

The guideline was developed according to SIGN 50: a guideline developer’s handbook (2019 edition) methodology. A systematic review of the evidence was carried out to address the clinical questions. Included studies were dual appraised using Scottish Intercollegiate Guidelines Network (SIGN) checklists and recommendations were derived using nominal group technique and the SIGN considered judgement process.

Update searches were carried out using the original search strategies. Results were limited by publication year from 2019 to August 2024, in English language only.

No new evidence was identified to update the recommendations.

Question 1: Antibiotics

1. What is the evidence for increased risk of HUS?
2. Does this risk exist for all antibiotic classes?
3. Is the risk equal for all virulence types/serotypes of vero cytotoxin-producing Escherichia coli (VTEC)?

Search terms [Title/Abstract]:

• VTEC OR Escherichia coli OR E. coli OR Verocytotoxin OR Shiga toxin
• AND Haemolytic uraemic syndrome OR HUS
• AND publication date 2010 to present (January 2019)
• AND English language
• AND antibiotic OR antimicrobial

Question 2: Opiate analgesia–generally recommended that this should be avoided.

1. Is there evidence to support this recommendation? Any evidence of harm?
2. Should they be avoided in only certain situations (eg HUS / VTEC / VTEC with colitis)?

Search terms [Title/Abstract]:

• VTEC OR Escherichia coli OR E. coli OR Verocytotoxin OR Shiga toxin
• AND Haemolytic uraemic syndrome OR HUS
• AND publication date 2010 to present (January 2019)
• AND English language
• AND opiate OR opioid OR opiate analgesia OR morphine OR codeine OR oxycodone OR hydrocodone OR hydromorphone OR pethidine OR methodone

Question 3: Earliest clinical signs of HUS/HUS with colitis

1. What are these (in children, in adults)?
2. What are prognostic factors (fever, blood tests, urine tests), and are these independent?

Search terms [Title/Abstract]:

• VTEC OR Escherichia coli OR E. coli OR Verocytotoxin OR Shiga toxin
• AND Haemolytic uraemic syndrome OR HUS
• AND publication date 2010 to present (January 2019)
• AND English language
• AND risk factor OR sign OR clinical sign OR multivariate OR multivariate OR prognostic OR biomarker

Question 4: Recommendations for monitoring for HUS

1. How is HUS monitored in hospitals (for children, for adults)?
2. Does this differ in the community where it is more difficult?
3. Should everyone have bloods done?
4. Should bloods be repeated and if so when?
5. What are the recommendations for monitoring for HUS in confirmed VTEC with colitis, vs confirmed VTEC without colitis.

Search terms [Title/Abstract]:

• VTEC OR Escherichia coli OR E. coli OR Verocytotoxin OR Shiga toxin
• AND Haemolytic uraemic syndrome OR HUS
• AND publication date 2010 to present (January 2019)
• AND English language
• AND volume expansion OR monitoring OR manage OR monitor OR management

Question 5: Preferred management of HUS

1. Is there consensus in the preferred management of HUS?
2. What is done in each of the Health Boards?

Search terms [Title/Abstract]:

• VTEC OR Escherichia coli OR E. coli OR Verocytotoxin OR Shiga toxin
• AND Haemolytic uraemic syndrome OR HUS
• AND publication date 2010 to present (January 2019)
• AND English language
• AND volume expansion OR monitoring OR manage OR monitor OR management

Question 6: Role of eculizimab and plasma exchange in HUS

1. When to apply these?

Search terms [Title/Abstract]:

• VTEC OR Escherichia coli OR E. coli OR Verocytotoxin OR Shiga toxin
• AND Haemolytic uraemic syndrome OR HUS
• AND publication date 2010 to present (January 2019)
• AND English language
• AND eculizimab OR plasma exchange

Question 7: Should the use of antimotility or antidiarrhoeal agents be recommended for treatment of STEC?

Search terms [Title/Abstract]:

• VTEC OR Escherichia coli OR E. coli OR Verocytotoxin OR Shiga toxin
• AND Haemolytic uraemic syndrome OR HUS
• AND publication date 2010 to present (January 2019)
• AND English language
• AND antimotility OR antidiarrhoeal

We wish to express our appreciation to all whose efforts made this guidance possible. In particular, to the members of the Scottish Clinical Expert Working Group for STEC and their constituencies, Public Health Scotland (PHS) Digital Support, Research and Information Service, Healthcare Improvement Scotland (HIS), stakeholders and external reviewers, who contributed to and reviewed the content of this guidance.

The guidance was sent for external feedback to the following identified stakeholders:

• Consultants in Public Health Medicine (Health Protection) Group (CPHM(HP)) now known as the Scottish Health Protection Consultants Group (SHPCG)
• SHPN-Co-ordination Group
• SHPN-Gastrointestinal and Zoonoses (GIZ) group
• SHPN-VTEC AIG Group
• Public Health Scotland on-call consultants
• Scottish Health Protection Nurses Network
• Chief Officers of Environmental Health
• Scottish Microbiology and Virology Network (SMVN)
• Scottish Paediatrics renal and Urology Network and Managed Clinical Network (MCN)
• Haematology
• Infectious Disease
• Primary Care
• Medical Directors

This guidance was published in 2025 and will be considered for review in three years. The review history, and any updates to the guideline in the interim period, will be noted here.