Escherichia (E.) coli inhabits the pig's microbiota, and some strains can cause a range of diseases when carrying specific virulence factors. Although molecular diagnostics are used to detect these virulence factors, the strength of their detection with clinical disease remains incompletely quantified under field conditions. This systematic review and meta-analysis aimed to estimate the prevalence ratio (PR) of E. coli virulence factor detection in isolates from clinically affected (i.e., enteric disease characterized by diarrhea) versus non-affected pigs. The search was conducted in February 2025 using PubMed and CAB Abstracts to identify articles reporting PCR-based detection of E. coli virulence factors in isolates from pigs with and without clinical signs (i.e., diarrhea). Meta-analyses of each virulence factor detected in two or more studies were conducted using a random-effect model. From 2575 records initially identified, 31 studies met the inclusion criteria, spanning data from 22 countries, with studies from 1998 to 2024. Eighteen virulence factors were analyzed by age category, of which seven were detected more frequently in clinically affected pigs. The F18 (PR = 2.24, 95 % CI = 1.13-4.46), STb (PR = 1.53, 95 % CI = 1.11-2.11), Stx1 (PR = 1.72, 95 % CI = 1.26-2.35), and Stx2 (PR = 1.76, 95 % CI = 1.16-2.67) had a higher frequency of detection in clinically affected pigs over all age categories. When investigating only suckling piglets, F4 (PR = 5.29, 95 % CI = 1.84-15.19), F18 (PR = 2.44, 95 % CI = 1.3-4.6), AIDA (PR = 5.32, 95 % CI = 1.45-19.51), EAST1 (PR = 1.53, 95 % CI = 1.03-2.28), STb (PR = 2.04, 95 % CI = 1.26-3.32) were detected more frequently in clinically affected piglets. The Stx2 was also more frequently detected in clinically affected pigs in the nursery phase (PR = 2.90, 95 % CI = 1.30-6.48). High heterogeneity was present in most analyses, highlighting variability in detection patterns across studies. Several traditionally tested virulence factors, such as F5, F6, and Stx2e, did not show differences between clinically affected and non-affected pigs. These findings support the role of molecular diagnostics in the characterization of pathogenic E. coli and underscore the importance of interpreting virulence factors results in conjunction with clinical signs for a more accurate diagnostic.
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