It is a well-known observation and a long-standing hypothesis that pathogen genome dynamics are important in infectious disease processes. Recent achievements in large-scale genome sequencing, comparative genomics and molecular epidemiology help to unravel current challenges of E. coli pathogenomics, i.e. to gain insights into the in vivo relevance of genome dynamics. Data from comparative genomics support the hypothesis of widespread involvement of horizontal gene transfer in the evolution of E. coli, leading to the presence of distinct and variable 'genomic islands' within the conserved 'chromosomal backbone' in several bacterial lineages. Extensive gene acquisition and loss provide different lineages with distinct metabolic, pathogenic and other capabilities. Not only mobile genetic modules but also point mutations facilitate rapid adaptation of E. coli to changing environmental conditions and hence extend the spectrum of sites that can be infected. We report on recent research efforts to analyze pathoadaptive and other genomic alterations of the E. coli genome that affect disease severity and may have consequences for diagnostics and treatment of E. coli infections.