Understanding Causes and Risk Factors of Escherichia


Escherichia coli Bloodstream infection (BSI) is referred to the condition in which E.coli bacteria are seen to be present in the blood which causes disruption of the normal functioning of the body. The E.coli is seen to be life-threatening bacteria which are also seen to be often related with urinary tract infection. The bacteria are seen to cause different infection in humans such as intra-abdominal infections, meningitis, pneumonia and others. In the UK, it is seen that most of the health professionals and patients are not well aware of the causes and risk factors of the disease that has resulted to lack understanding regarding the way activities and strategies are to be maintained to prevent the disease. Moreover, the existing studies available regarding the cause and risk factors related top E.coli infection was not effective to understand the spread of the infection. Thus, this proposal is being developed to highlight the key causes and risks factors related to Escherichia coli Bloodstream infection so that health professionals can understand the agents that are causing the spread of the infection and the strategies they are to take to control or prevent the disease. The study will be executed by using positivism research philosophy because it would lead the researchers to identify the causes and risk factors related to E.coli BSI through logical thinking by analysing scientific facts and data. The study will be undertaken by using a deductive approach and the observation research design will be used. The data collection will be done through inclusion and exclusion criteria according to which the studies executed 2008 to 2018 will be included that are fully accessible and written in English. The ethical considerations will be fulfilled by properly referencing the authors from whom the information will be taken.


Bloodstream infections or septecmia is the condition in which bacteria or fungus enters the blood stream from elsewhere in the body like skin or lung (Viscoli, 2016) elicits or may later elicit an inflammatory response that is characterised by altering laboratory, haemodynamics or clinical parameters. The symptoms include high fever, rapid heart rate, increased and faster breathing and others (Cortese et al. 2016). The symptoms that are reflected as the disease progress are inability and confusion to think, vomiting and nausea, reduce volume of urine, inadequate flow of blood and others (Chen et al. 2017). Escherichia coli (E.coli) is the leading gram-negative bacteria organism that causes blood stream infection (BSI) (Tumberallo et al 2010). The Public Health England data capture system shows that there is an increase in gram-negative bloodstream infection and increased antimicrobial resistance seen in gram-negative bacteria. E.coli is one of the predominant gram-negative bacteria that is causing gram-negative Escherichia coli Bloodstream infection among individuals in the UK and leading them to death. This is evident from the study of Abernethy et al. (2015) where it was informed that from 1st July 2011 to 30th June 2012 5220 deaths out of 28616 patients affected by E.coli bloodstream infection was reported.


Background of the Study

Escherichia coli (E. coli) Bloodstream infection (BSI) is the health disorder in which bacteria is seen to be present in the bloodstream that adversely affects the normal functioning of the body (Doumith et al. 2015). The E.coli bacteria inhabits the digestive tracts of humans and they causes common bacterial infections such as urinary tract infection, bacteremia, cholecystitis, bloodstream infection and others (Hwang et al. 2017). The E.coli bloodstream infection are of tow types which are primary BSI and secondary BSI. The primary bloodsteam infection is referred to the condition in which the organisms identified in the blood at one site is not present at the other site. However, the secondary bloodstream infection is the one when the primary infection site does not require a culture and the bllod isolated is a logical pathogen for the site (Harris et al. 2017). In 2015-16, the NHS has reported nearly 38,000 cases of E.coli BSI which is 18% more than the reported number of cases in 2012-13 (publichealthmatters.blog.gov.uk, 2016). Moreover, the increased rates of E.coli BSI from 2009 to 2015 (www.hps.scot.nhs.uk, 2018) highlights that appropriate preventive measures are still not taken on a wider basis so that effective control over the spread of the disease can be attained.

The increased incidence of E.coli Bloodstream Infection (BSI) has become an issue becausemany individuals are seen to be adversely affected as a result of the disease which is interfering with proper functioning of their body. As asserted by Doumith et al. (2015), the presence of BSI leads individuals to experience abdominal pain, septicaemia, sepsis and others. This leads to disrupt the normal functioning of the body making the patients experience health issues. As argued by Wang et al. (2016), the presence of bloodstream infection in the body allows the microorganisms to affect any part of the body. This is because the toxins of the microorganisms are circulated through the blood to all parts. Therefore, E.coli Bloodstream Infection (BSI) is an issue because it may result individuals to face deteriorated health condition if not managed or prevented at the right time.

The exact source through the E.coli infects the bloodstream cannot be determined in most cases (Bookstaver et al. 2017). However, there are various causes that lead to the development of E.coli BSI such as infection, surgery, inappropriate use of medical devices and others. As mentioned by Abernethy et al. (2017), urinary tract infection leads to development of E.coli BSI. This is because untreated urinary tract infection (UTI) results the E.coli bacteria to travel up the bladder from the ureters to the kidney where they multiply and reach the bloodstream through the damaged blood vessels in the kidney. As argued by Vincent et al. (2015), pneumonia spreads from lungs to the bloodstream that leads to cause E.coli bloodstream infection. The exact mechanism is still unknown but a toxin named as EXoS in the mouse model is seen to act in spreading of the infection into the bloodstream to cause bacteraemia where patient presents with pneumonia. The infection in the abdominal area caused by the E.coli bacteria is also regarded as potential cause for rise of bloodstream infection.

The study of Suzuki et al. (2016) informs that the rise of E.coli bloodstream infection in haemodialysis patient is 26 times higher in comparison to general individuals. The key risk factor that causes the rise of the bloodstream infection through this case is the use of central venous catheters. This is because the catheters are often handled in an improper manner which leads to the contamination of the equipment by E.coli present in the environment leading to rise of bloodstream infection. As asserted by Kritikos and Manuel (2016), the prolonged surgical interventions involved in organ transplantation leads to E.coli bloodstream infection.

The sepsis is caused by response of the body to an infection present in the bloodstream resulting in a potentially life-threatening condition as it creates posioning of the blood (Paulsen et al. 2015). The development of sepsis as a result of Escherichia coli (E. coli) Bloodstream infection may result in organ failure if the disease remains untreated (Chang et al. 2015). The toxins, when released in increased amount in the blood as a result of bloodstream infection, restrict the proper flow of blood that results to reduce the blood pressure. This sudden drop in blood pressure causes to shock to the body that results in organ or tissues damage (Duan et al. 2016).

Health care professionals are expected to provide holistic care to the patients with importance to patient’s wellbeing, (Lowe, et al, 2012, Robson et al 2008). With the lack of knowledge on the causes and risk factors of E.coli BSI, Health care professionals are not attaining this. There are certain preventive measures that can be taken to reduce the incidence of Escherichia coli (E. coli) Bloodstream infection like maintaining aseptic technique, good hand hygiene, providing adequate hydrations, etc. But, new interventions has to be innovatively brought into light to prevent and show evidence that the rates can be reduced by tackling conditions that can cause or put patients into risk to develop E.coli BSI(Giannella et al. 2018).

A literature review focusing on risk factors of E.coli blood stream infection was conducted via electronic databases like Medline, CINHAL, PubMed, Google Scholar, Cochrane, Ovid, Science Direct, ProQuest. The search focused on the materials based on E.coli infection in both acute and community settings. The following search terms were used, “Eschericia coli infection*” or “E.coli infection* or “Blood stream infection*” AND healthcare associated infection*” , e.coli bacteraemia, population, risk factors and causes of gram negative organism, gram negative blood stream infection, E.coli BSI. Further searches were done through, department of health website, PHE website, using the reference list from the selected article, and by accessing hospital library. This initial search highlighted that there is a number of studies that have looked at risk factors and causes, behavioural interventions and seasonal variations, aspects of increase in rate, population and sex. A study to identify the risk factors at the earliest might help to reduce the burden of E.coli BSI.

Gap in the Literature

The gap in the literature is that proper studies are still not framed to collectively identify the risk factors and causes of E.coli bloodstream infection. Further, the literatures still now analysed do not inform in details about the strategies to be implemented and the way they are to be implemented to reduce the incidence of E.coli infection among the adult patients. Thus, it is unable to understand which of the key risk factors related to BSI Escherichia coli infection that actually makes people develop the infection in comparison to the population that does not develop infection even though they are exposed to the causes and risk factors. Further, this gap also does not allow determining the impact of intervention in reducing the incidence of BSI Escherichia coli infection. Thus, this study is significant as it is going to create awareness among the individuals as well as health professionals to understand the actual reasons behind the raised incidence of the disease which they require to control to lower its prevalence among infected people.

Research Rationale

In the UK, there are increased incidences of Escherichia coli Bloodstream infection among individuals. The health statistics provided by the UK government in 2015-2016 indicates that there is a rise of 18% when compared to the data obtained in 2012-2013 (www.gov.uk, 2017). Moreover, it is reported that 3.5% patients who stayed more than 2 days in the ICUs in 2008-2012 were reported to be affected by E.coli bloodstream bacteria. The data also revealed that nearly 4505 deaths occurs due to direct E.coli bloodstream infection among patients each year with 1.26 million deaths occurring in ICUs each year affected by E.cli bloodstream infection due to their extened stay in the hospital (ecdc.europa.eu, 2018). The Improvement.nhs.uk, 2018 sheds light on the NHS Trust which stands with high rates of E.coli BSIs (improvement.nhs.uk, 2018). These figures indicate that E.coli BSI one of the prominent condition within the UK that needs to be taken into consideration very seriously so that it can be controlled and prevented in a more strategic manner.

In study of Wilson et al. (2011) it is informed that 23% of the blood stream infection in England was caused by E.coli bacteria as reported from 2004 to 2008. In between 2004 to 2008, it is reported in the study that the E.coli bloodstream infection was raised by 33%. This data informs that proper measures were not taken due to which the rise of the bacteraemia could not be controlled and relapsed at a steady rate in England. The study of Marschall et al. (2012), informed that most of the individuals affected by E.coli bloodstream infection had history of urogential surgery (28%), prostatic plasia (19%), pyelonephritis (67%) and other medical conditions. This indicates that the individuals facing urinary tract infection are prone to E.coli infection. It has raised E.coli bloodstream infection to be vital issue which has to be analysed to understand the causes and risk factors related to the disease so that better control activities can be taken in case of the patients to avoid them from getting infected by E.coli.

The E.coli bloodstream infection has presently became an issues as in the study of Abernethy et al. (2015) it is informed that out of 5220 deaths, 28616 deaths was caused by E.coli bloodstream infection in between 1July 2011 to 30th June 2012. This indicates that E.coli bloodstream infection is fatal in nature and the causes and risk factors required to be understood so that such consequences of death can be avoided. Thus, discussion regarding the causes and risk factors of the E.coli Bloodstream Infection (BSI) is required to be discussed so that proper awareness regarding the disease can be informed among health professionals and individuals. This would also help in developing better strategies to prevent the spread of the infection. Therefore, this study is going to shed light on the causes and risk factors of E.coli Bloodstream Infection (BSI) among adult patients.

Research Aim

The aim of the study is to execute a systematic review of the evidence published in relation to risk factors related to the E.coli Bloodstream Infection (BSI) among patients and way to reduce the infection.

Research Objective

To identify and analyse the quality of evidence and summarise the findings which reports risk factor associated with the rise of E.coli Bloodstream infection.

Research Questions

What are the risk factors related to Escherichia coli (E. coli) Bloodstream infection (BSI) among adult patients and the way it can be reduced?


Independent variable: Exposure of Escherichia coli (E. coli) Bloodstream infection (BSI) among adult patients

Dependent variable: Outcome of the health intervention provided for risk factors related to Escherichia coli (E. coli) Bloodstream infection (BSI) among adult patients



Research Paradigm

Research Philosophy

The positivism research philosophy will be used in executing the study. As mentioned by Ryan (2018), positivism philosophical perspective recognises and applies any data through scientific verification to reach a proper decision. Thus, this perspective is usually applied to solve raised research problems as it avoids error in studies. As criticised by Ryan and Rutty (2018), interpretive perspective is seen to oppose positivist perspective and informs that all the decision to be taken through realistic thinking of the researcher. Thus, the information developed through this perspective is not taken logically. This is evident as the research to develop information through this perspective does not evaluate data by linking them with previous literary facts. The positivism perspective is seen to be appropriate for studies that need a structural and quantitative approach for resolving the raised research problem (Williams et al. 2017). This is because the positivism philosophy helps the researchers to develop observable and quantifiable data. Thus, in this study, the research problem will be resolved by taking a quantitative approach and therefore this perspective will be appropriate to be used for the study.

Research Approach

The study will be conducted by using systematic review as the research approach. As mentioned by Saunders et al. (2018), systematic review are reffered to the process in which a literature is reviewed by using systematic methods such as crtical appraisal research studies, secondary data and the data are synthesised qualitatively or quantitatively. This nature of approach is used for providing a complete as well as exhaustive summary of present evidence that are available and relevant to the identified research question in the study. The benefit of using systematic review is that it uses scientific methods in finding and selecting studies which reduces bias as well as helps to produce accurate and reliable conclusions related to the study. (Refer to Appendix 1)

Research Design

The observational research design with qualitative focus will be used in executing study. The observational research design helps in identifying the casual association present between exposure and health outcome related to a disease. This is because as per this design the researcher observes the ongoing behaviour of the subjects under certain conditions. The observational research design does not include the manipulation of the information due to the perspective of the researcher. This is because this nature of research studies relies on developing information by analysing the ecological or natural events. Thus, using this nature of review creates greater validity of the study and provides better insight and explanations of the raised problems (wiki.joannabriggs.org, 2018). Therefore, this study will be executed by using a qualitative focus. (Refer to Appendix 2)

Research Type

The cohort and case control studies are seen to be frequently used in medical research. The cohort studies are type of medical research which is implemented for investigating the cause related with teh spread of the disease and establishing links between the risk and health outcomes. In this nature of study, a group of people is chosen for executing the study (Theilacker et al. 2015). However, the case control studies are referred to be retrospective and they are designed for helping the research identify if an exposure of infection or disease is related with an health outcome. In this form of study, two separate groups are defined at the start that is one with the disease and another without the disease (Lambregts et al. 2019). In this research, the cohort study will be used as the risk factors related to exposure to E.coli BSI is to be determined.

Data Collection Method

The PEO framework will be used to develop the research question regarding the study. The PEO is stands for population, exposure and outcome and it is widely used for executing qualitative studies (Moser et al. 2015).

Data Collection Method Data Collection Method

The data will be collected by using inclusion and exclusion criteria. The inclusion criteria refer to the factors that the subject needs to have for including them in the study. The exclusion criteria are the factors which if possessed by the subjects are excluded from the study (Shin et al. 2015). In the mentioned study, the exclusion criteria will include papers that are not fully accessible, not written in English, published before 2008, not related to patients suffering from Escherichia coli (E. coli) Bloodstream infection and are non-academic. This is to ensure that findings from most current researches are included in the study. Moreover, since the researcher is unable to understand any other language except English and thus paper written in other languages are excluded as the researcher cannot derive proper information from them. The non-academic journals include newspaper articles, commercial journals and websites which often include improper and wrong data and thus they are not be included in the study. The inclusion criteria will include journals which are written in English, published after 2008, are fully accessible and are academic papers. The academic papers are to be used as they provide valid information with proper proof ensuring error free collection of data. The papers which are published within 10 years are selected so that most current information regarding the study can be identified to resolve the raised research problem. The searching is limited to papers that are written in English so that it is easier to understand and derive information for the purpose of the study as the researcher is knowledge only about English and could not understand or read other languages.

erive information for the purpose erive information for the purpose

Data Analysis

The systematic review research guide developed by the Joanna Briggs Institute will be used for critically appraising the chosen articles for the study. In this process, initially the articles that are considered for the study would be analysed to extract the data required to resolve the raised research question in the study. The inclusion and exclusion of the articles to be considered for the study are to be based on the inclusion and exclusion criteria mentioned in the study. The quality of the study would be assessed by using PRISMA tool which is being used for critical analysis of studies. The PRISMA tool is the evidance-based minimum set of items that are to be reported in the meta-analysis and systematic review of articles (Lewis et al. 2019). The data is to be pooled for analysis according to the themes developed so that strcture representation of the findings can be made.The results are then to be critically analysed and discussed to resolve the raised question in the study.

Ethical Consideration

The ethical issues that are to be considered in executing primary studies include informed consent, beneficence, respect for autonomy and confidentiality and respect for privacy.

Informed Consent:

The researchers of the articles are to be informed about the way the articles are to be used in the study. They are to be contacted to take initial consent regarding the articles to be able to be used in executing the study. This is because the Data Protection Act 1998 refers that no information is to be used without prior permission from the owner (www.legislation.gov.uk, 1998). In case, where the researchers cannot be contacted the information taken from the papers are to be properly referenced. The research articles to be used are to be initially analysed to ensure that during their execution the ethical considerations are properly abided.


In order to ensure beneficence, the personal information of the researchers as well as the participants they have used in their studies are not to be revealed. Further, it is to be ensured that the data informed by the researchers are properly analysed and interpreted so that no wring concept regarding them is raised as it may harm them.

Respect for Confidentiality and Autonomy:

The information about the researchers is to be stored in a secured way so that the confidentiality is maintained. The researchers are freely to avoid use of their papers for the study and they are not to be forced for providing their consent in order to maintain autonomy.

Respect for privacy:

The title of the key author is to be used without informing their name while referencing the work used in the study. This is to be done so that the privacy of the researchers is ensured.

The identified papers are to be present in the results under the themes developed in relation to the topic of discussion for the study. The content with the paper are to be analysed and the statistical data are to be informed under specific themes in the study. The research is to be used in such a way so that they are relevant for the patient care which means that the study should be developed in such a way so that the results found can be implemented to improve the conditions of the patients. The results developed are required to have practical or theoretical value as well as need to be able to contribute to the scientific knowledge required by the health professionals in managing disease. At the present, there is lack of proper and collective information about the key causes and risk factors related to Escherichia coli (E. coli) Bloodstream infection (Bou-Antoun et al. 2016). Thus, this study will be executed to inform about the basis on which the strategies to prevent Escherichia coli (E. coli) Bloodstream infection are to be developed by identifying risk factors.

The search results will be illustrated in descriptive form on the basis of the themes developed. The presentation of results on the basis of the themes helps in systematic presentation of information. This is because thematic analysis put emphasis on identifying, recording and analysing the pattern presents within the data collected (Stewart et al. 2015). Further, the results to be developed are to be checked by another researcher to ensure that they are not manipulated by the feelings and thoughts of the researcher (Moher et al. 2015).

Discussion and Limitations

The study is going to inform in details about the causes and risk factors related to Escherichia coli (E. coli) Bloodstream infection that are causing patients to suffer from the disease. The limitation of the study will be cost as no enough finances can be gathered in executing the study in a proper manner. Moreover, the lack of access to main potential papers and journals will act as a limitation for the study as proper and detailed information to conduct the study in an enriched manner cannot be achieved. The time limitation would be managed by develop timetable for work where the activities to be conducted in the study would be schedules properly.

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Research Approch

Moreover, it helps to sumarise data from wide number of studies which helps the researcher to read and understand the facts properly and present them in an appropriate manner in the study (Patterson et al. 2016). However, the disadvantage to be faced while using systematic review is that researchers may find it hard to compile findings as each of the researcher in their studies have carried out the studies in different way (Rudmik and Soler, 2015). Thus, the researcher in this study while using systematic review required to be concerned in appropriately compling all the findgs from different studies to ensure validity of results.

Research Design

The MOOSE checklist will be used in the study as it would help to examine data from different independent studies related to the similar topic to understand the information required to solve the raised research problem (Vandenbroucke, 2009). The cross-sectional study design will be used in executing the study as it provides a glance of the variables related to the disease as well as the incidence rate of the disease within a defined population at a particular time (wiki.joannabriggs.org, 2018). Since this form of design provides ability to develop relationship between variables and disease thus it will be used as it can be understood the way identified causes are causing E.coli BSI among patients.

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