Enterobactericeae

Members of the Family ESCHERICHIA KLEBSIELLA ENTEROBACTER SALMONELLA SHIGELLA YERSINIA PROTEUS MORGANELLA CITROBACTER CEDECEA Coliforms (Lactose fermenters)

Intestinal pathogens PROVIDENCIA SERRATIA EDWARDSIELLA KLUYVERA Non Lactose Fermenters - produce colorless colonies

VIRULENCE FACTORS Endotoxin all gm (-) Capsule antiphagocytic K1 Ag E. coli Vi Ag S. typhi facultative intracellular parasite Exotoxins invade GI wall Enterotoxin Shiga toxin Invasiveness Has type III secretion system Enterobactericeae is divided clinically into: A. Opportunistic group B. True intestinal pathogens OPPORTUNISTIC GROUP: E. coli (most) Klebsiella Proteus Providencia Serratia Citrobacter Cedecea Edwardsiella Enterobacter Morganella Kluyvera

K. granulomatis granuloma inguinale (donovanosis) chronic genital ulcerative disease does not grow in artificial culture media Giemsa or Wright stain 1 to 25 bacteria per mononuclear cell Different from LGV caused by Chlamydia I M V C Pneumonia - - + + Oxytoca + - + + Enterobacter - - + + E. coli + + - 2. ENTEROBACTER (formerly Aerobacter) E. cloacae, E. aerogenes, E. sakazaki motile, no urease any tissue may be infected - most frequently associated w/ UTI E. cloacae common species Other: Aerogenes, gergoviae, sakazaki 3. SERRATIA DNAse, lipase, gelatinase major entities in nosocomial infections S. marcescens produces red pigment (prodigiosin) o common specie

General Characteristics: Gram negative bacilli Facultative anaerobes Most are motile with peritrichous flagella except: Klebsiella, Shigella and Yersinia OXIDASE NEGATIVE Primary isolation: to isolate from vibrios specimen differential media: a. Eosin Methylene blue agar (EMB) b. Mac Conkey agar c. Desoxycholate citrate agar highly selective media: allows growth of salmonella & shigella a. Hektoen enteric agar b. XLD (xylose-lysine desoxycholate) agar c. Salmonella-Shigella agar Species differentiation is done by: a. Biochemical tests: all are (+) for glucose TSI (triple sugar iron) IMViC Oxidase negative Urease All ferment glucose Sugar fermentation Enzyme tests b. Serologic typing using specific antisera; expensive (3) Antigens: O - somatic polysaccharide (LPS) H - flagellar K - envelope or capsular Ag Serologic tests are useful for Salmonella, Shigella and E. coli

commensals of the large intestines. disease produced only when there are alterations in the defenses of the host infections found outside the intestines can infect any tissue of the body harmless inside the intestines community-acquired or nosocomial infections usual type of infections produced: UTI wound infection pneumonia meningitis septicemia various GIT disorders

II. PROTEEAE

3 GENERA: PROTEUS MORGANELLA PROVIDENCIA -

OPPORTUNISTIC MEMBERS

I. Klebsiella-Enterobacter-Serratia group
1. KLEBSIELLA PNEUMONIAE - Friedlander's bacillus - encapsulated (the virulence factor), non-motile, urease positive UREASE break down Urea Co2 + NH3 - lobar pneumonia a primary type pneumonia - extensive necrotizing consolidation of the lungs - currant jelly sputum - alcoholics, compromised pulmonary function - UTI, bacteremia Other Klebsiellae K. oxytoca - same infections as K. pneumoniae K. ozaenae chronic atrophic rhinitis K. rhinoscleromatis granulomatous disease of the nose K. granulomatis previously Calymmatobacterium granulomatis -

PROTEUS o Exhibit swarming phenomenon on selective media o Cross react with rickettsia o Proteus antigens has OX2, Ox19, OXK Agglutinate antibodies against rickettsia To test rickettsia, use WEIL-FELIX test -majority: cause UTI -urease positive -Proteus mirabilis most common species o #2 cause of UTI P. mirabilis o #1 cause of UTI E.coli -UTI char. by an alkaline pH of urine, which causes: o a precipitation of calcium and magnesium salts from the urine and results in the formation of urinary calculi. o damage to the renal epithelial cells

P. vulgaris, P. mirabilis M. morgani P. rettgeri, P. stuarti, P. alkalifaciens *last 2 = (-) urease

Prepared by: EGBII

III. CITROBACTER
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IV. OTHER ORGANISMS have been isolated from a variety of opportunistic infections True intestinal pathogens

(formerly Bethesda-Ballerup group) -majority of the isolates are from the urinary tract, neonatal infections

pneumonia, wound infection, septicemia/bacteremia, endotoxic shock most common cause of gram negative sepsis o Site of Action SI
Usually non toxin, non invasive no blood in stool

Enteroinvasive E. coli (EIEC) can also cause dysentery

LI

Organism Enteropathogenic E. coli (EPEC) #2 cause of infantile diarrhea #1 is the rotavirus

Disease .Infant diarrhea in underdeveloped countries; .watery diarrhea and .vomiting, .nonbloody stools

Pathogenesis Plasmid-mediated A/E histopathology with disruption of normal microvillus (for absorption) structure resulting in malabsorption and diarrhea uses: for adherence/ ephasement to increase surface area absorption Plasmid-mediated, heat-stable and/or heat-labile enterotoxins that stimulate hypersecretion of fluids and electrolytes ST activates Guanylate cyclase form of cGMP LT activates enzyme to form cAMP Adenyl cyclase >Mediated by cytotoxic Shiga like toxins (Stx-1, Stx-2), which disrupt protein synthesis; contains .A subunit .B subunit bind to surface receptor BOTH (-) protein synthesis by binding w/ 60s ribosome >A/E lesions with destruction of intestinal microvillus resulting in decreased absorption

.Disease in underdeveloped countries; .fever, cramping, .watery diarrhea; .may progress to dysentery with scant, bloody stools .Infant diarrhea in underdeveloped countries; .traveler's diarrhea; .persistent watery diarrhea with vomiting, .dehydration, and .low-grade fever

Plasmid-mediated invasion and destruction of epithelial cells lining colon can cause ulceration bu not penetrate the lining of the colon Plasmid-mediated aggregative adherence of rods ("stacked bricks") with shortening of microvilli, mononuclear infiltration, and hemorrhage; decreased fluid absorption

Escherichia coli

Specialized Virulence Factors Adhesins Colonization factor antigens CFA/I, CFA/II, and CFA/III Aggregative adherence fimbriae AAF/I and AAF/II Bundle-forming pili (Bfp) Intimin P pili Ipa protein Dr fimbriae Exotoxins Heat-labile toxins - LT-I and LT-II activates adenyl cyclase Heat-stable toxins - STa and STb Activates guanylate cyclase Shiga toxins - Stx-1 and Stx-2 Hemolysin - HlyA Virulence factors produced by ETEC LT (+) adenyl cyclase cAMP ST (+) guanyl cyclase cGMP *BOTH inhibit Na reabsorption secretion of electrolytes (Na, P, etc) & draw H2O together leading to diarrhea

Enteroaggregativ e E. coli (EAEC)

SI

Enterotoxigenic E. coli (ETEC) Can be detected thru serotype by detecting >O 157; H7 >do not ferment SORBITOL

SI
(+) toxin but non invasive

.Traveler's diarrhea . infant diarrhea in developing countries; .watery diarrhea, .vomiting, .cramps, nausea, .low-grade fever no blood in stool

2. SHIGELLA
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Four species: All can cause bacillary dysentery S. dysenteriae (shiga bacillus) S. flexneri S. boydii S. sonnei S. dysenteriae most severe disease S. sonnei - most common in industrial world S. flexneri most common in developing countries -

Group A Group B Group C Group D

1. ESCHERICHIA COLI

Can be used in synthesis of vitamin B complex & vit. K may be nonpathogenic, opportunist or true intestinal pathogen most abundant aerobic flora of the colon index for fecal pollution of water index means that the water is contaminated by certain bacteria Other than E.coli that can contaminate? E. fecalis extraintestinal infections: UTI - most common cause of UTI in man o uncomplicated cystitis: uropathogenic strains (hemolysin) o complicated (pyelonephritis): non-uropathogenic strains (P fimbriae) neonatal meningitis: K1 antigen (capsular) nosocomial infections:

Enterohemorrhag ic E. coli (EHEC) deadly form of E.coli found in uncooked hamburger also considered as most important E.coli

LI

.Initial watery diarrhea, followed by grossly bloody diarrhea (hemorrhagic colitis) with abdominal cramps; .little or no fever; may progress to hemolytic uremic syndrome (HUS) caused by shigella, w/c produce shigella like toxin

Primarily a human pathogen. Does not infect animals. Infection is usually confined in the GIT Usually no bacteremia.

Pathogenicity invasiveness o ulceration of the terminal ileum and colon (blood and mucus in stool) o rarely penetrate through wall or the blood stream SHIGA TOXIN caused by S. dysenteriae type 1 With 2 subunits: o Subunit B for binding to intestinal epithelium o Subunit A1 inhibits protein synthesis: binds with 60S ribosomal subunit Always toxic! EFFECTS: enterotoxic; cytoxic; neurotoxic Other species: produce shiga-like toxin

Prepared by: EGBII

Very low infective dose: 100 bacilli 1000 bacilli = salmonella 100,000 bacilli = other salmonella 10 bacilli = V.cholera Most severe diarrhea Most virulent Transmitted by 4 Fs Fingers, flies, food and feces No prolonged carrier state Prominent s/s: painful passage of bloody, mucoid stools with cramping (dysentery); tenesmus with squirts or scant diarhhea fever, convulsions Non-lactose fermenting TSI: K/A (alkaline slant & acid butt), no gas, no H2S Confirmation: serotyping by slide agglutination

Ingestion ---- intestine---- early blood stream invasion ----- seeding in many organs: osteomyelitis, pneumonia, meningitis Intestinal symptoms usually absent

Lab Dx

c. Enteric fever: TYPHOID & PARATYPHOID FEVER o Vi Ag antipahgocytic most important antiphagocytic o Severe life-threatening o Incubation period: 10-14 days o intestines lymphoid tissues bacteremia affects various organs + intestines o Manifestations: fever, malaise, headache, constipation, bradycardia, myalgia, hepatomegaly, splenomegaly, Rose spots in abdomen and chest (rare) constipation early manifestation diarrhea late manifestation occurs in 2nd week Pathognomonig sign: rose spots chronic carrier state: gallbladder* o may be carrier for life until if gallbladder is removed Laboratory diagnosis -Lab D: Enteric fever 1. BEST: culture from blood or bonemarrow a. specimen: 1st and 2nd wk blood only after 2nd week stool or urine S. typhi: Non-lactose fermenter TSI: K/A; no gas; with H S (small amount) 2. 3. Widal Test obsolete (O and H antibodies) Typhi Dot specific IgG and IgM
2

M.O.T.

source: feces of animals may also be person-to-person

Manifestations: bloody diarrhea mimics appendicitis Lab Dx: made only by culture of the organism; requires cold enrichment o Yersinia will grow & other bacteria will be inhibited o Put in ref for 24 hours

Remember!

Treatment: Usually self-limited Replacement of fluids and electrolytes Ciprofloxacin, ampicillin, doxycycline, TM-SM

Shigellosis: No animal source Usually no bacteremia No prolonged carrier state Typhoid fever: No animal source With bacteremia With chronic carrier state

3. SALMONELLA

Single species: Salmonella enterica other previous spp. - serotypes Transmission: fecal-oral Most serotypes: animal sources (poultry, pigs, rodents, cattle, pets (turtles, parrot), etc. Typhi, paratyphi and cholerasuis : human source only

3 clinical entities: a. Enterocolitis most common manifestation most common serotype: typhimurium incubation period: 8-48 hrs - nausea, headache, vomiting and profuse diarrhea - often self-limited - infection limited to the gut - Infectious Disease: 105 cells/mm NOT given antibiotic Natatangi! (-) bloody stool b. Septicemia occurs in one of 2 settings: o chronic disease: e.g., sickle cell anemia, cancer o a patient with enterocolitis

Treatment For Enteric fever: TYPHOID & PARATYPHOID FEVER drug of choice: ceftriaxone or ciprofloxacin before o AMPICILLIN/ CHLORAMPENICOL must 1st use Prevention: Vaccine (50-80% protection) a. IM contains Vi polysaccharide capsule a. Vi impt.virulent factor of S.typhi b. Typhi facultative intracellular parasite b. oral live attenuated S. typhi

4. YERSINIA ENTEROCOLITICA

cause Yersiniosis zoonotic majority of human infections come from Northern Europe (cold countries) o grows better at room temperature may harm R Factor wc can cause antibiotic resistance before giving drugs must do susceptibility testing

Prepared by: EGBII