Lecture 1 .Campylobacter& ........................................................... .

helicobacter

CAMPYLOBACTER
Campylobacters cause both diarrheal and systemic diseases and are among the most widespread causes of infection in the world. Campylobacter infection of domesticated animals also is widespread. The classification of bacteria within the family Campylobacteriaceae has changed frequently. Some species previously classified as campylobacters have been reclassified in the genus Helicobacter. The organisms that cause intestinal or systemic illness are discussed in this section. Helicobacter pylori, which causes gastric infection, is discussed in the following lecture. Campylobacter jejuni is the prototype organism in the group and is a very common cause of diarrhea in humans. 1. Campylobacter jejuni & Campylobacter coli Campylobacter jejuni and Campylobacter coli have emerged as common human pathogens, causing mainly enteritis and occasionally systemic infection. C jejuni and C coli cause infections that are clinically indistinguishable, and laboratories generally do not differentiate between the two species. Between 5% and 10% of infections reported to be caused by C jejuni are probably caused by C coli. These bacteria are at least as common as salmonellae and shigellae as a cause of diarrhea; an estimated 2 million cases occur in the United States each year. Morphology & Identification A. Typical Organisms C jejuni and the other campylobacters are gram-negative rods with comma, S, or gull-wing shapes. They are motile, with a single polar flagellum, and do not form spores. B. CULTURE The culture characteristics are most important in the isolation and identification of C jejuni and the other campylobacters. Selective media are needed, and incubation must be in an atmosphere with reduced O2 (5% O2) with added CO2 (10% CO2). A relatively simple way to produce the incubation atmosphere is to place the plates in an anaerobe incubation jar without the catalyst and to produce the gas with a commercially available gas-generating pack or by gas exchange. Incubation of primary plates should be at 42 C. Although C jejuni grows well at 3637 C, incubation at 42 C prevents growth of most of the other bacteria present in feces, thus simplifying the identification of C jejuni. Several selective media are in widespread use. Skirrow's medium contains vancomycin, polymyxin B, and trimethoprim to inhibit growth of other bacteria. Other selective media also contain antimicrobials, including cephalothin or cefoperazone, and inhibitory compounds; because they contain a cephalosporin, they will not grow C fetus and several other campylobacter species. The selective media are suitable for isolation of C jejuni at 42 C; when Skirrow's medium is incubated at 3637 C, other campylobacters may be isolated. The colonies tend to be colorless or
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Lecture 1 .Campylobacter& ........................................................... . helicobacter

gray. They may be watery and spreading or round and convex, and both colony types may appear on one agar plate. C. GROWTH CHARACTERISTICS Because of the selective media and incubation conditions for growth, an abbreviated set of tests is usually all that is necessary for identification. C jejuni and the other campylobacters pathogenic for humans are oxidase- and catalase- positive. Campylobacters do not oxidize or ferment carbohydrates. Gram-stained smears show typical morphology. Nitrate reduction, hydrogen sulfide production, hippurate tests, and antimicrobial susceptibilities can be used for further identification of species. Antigenic Structure & Toxins The campylobacters have lipopolysaccharides with endotoxic activity. Cytopathic extracellular toxins and enterotoxins have been found, but the significance of the toxins in human disease is not well defined. Pathogenesis & Pathology The infection is acquired by the oral route from food, drink, or contact with infected animals or animal products. C jejuni is susceptible to gastric acid, and ingestion of about 104organisms is usually necessary to produce infection. This inoculum is similar to that required for salmonella and shigella infection but less than that for vibrio infection. The organisms multiply in the small intestine, invade the epithelium, and produce inflammation that results in the appearance of red and white blood cells in the stools. Occasionally, the bloodstream is invaded and a clinical picture of enteric fever develops. Localized tissue invasion coupled with the toxic activity appears to be responsible for the enteritis. Clinical Findings Clinical manifestations are acute onset of crampy abdominal pain, profuse diarrhea that may be grossly bloody, headache, malaise, and fever. Usually the illness is self-limited to a period of 58 days, but occasionally it continues longer. C jejuni isolates are usually susceptible to erythromycin, and therapy shortens the duration of fecal shedding of bacteria. Most cases resolve without antimicrobial therapy. Diagnostic Laboratory Tests A. SPECIMENS Diarrheal stool is the usual specimen. Campylobacters from other types of specimens are usually incidental findings or are found in the setting of known outbreaks of disease. B. SMEARS Gram-stained smears of stool may show the typical gull wing-shaped rods. Dark-field or phase contrast microscopy may show the typical darting motility of the organisms.

Lecture 1 .Campylobacter& ........................................................... . helicobacter

C. CULTURE Culture on the selective media described above is the definitive test to diagnose C jejuni enteritis. If another species of campylobacter is suspected, medium without a cephalosporin should be used and incubated at 36 37 C. Epidemiology & Control Campylobacter enteritis resembles other acute bacterial diarrheas, particularly shigella dysentery. The source of infection may be food (eg, milk, undercooked fowl) or contact with infected animals or humans and their excreta. Outbreaks arising from a common source, eg, unpasteurized milk may require public health control measures.

2. Campylobacter fetus
Campylobacter fetus subspecies fetus is an opportunistic pathogen that causes systemic infections in immunocompromised patients. It may occasionally cause diarrhea. The gastrointestinal tract may be the portal of entry when C fetus causes bacteremia and systemic infection. C fetus has several surface array proteins (S protein, MW 100,000149,000) which form a capsule-like structure on the surface of the organism (as compared with the polysaccharide capsules of pathogens such as Neisseria meningitidis and Streptococcus pneumoniae). 3. Other Campylobacters Campylobacter species other than C jejuni are encountered infrequently. This is partially due to the standard methods used for isolation of campylobacters from stool specimens: incubation at 42 C and use of medium containing a cephalosporin. Campylobacter lari is often found in seagulls and occasionally causes diarrhea in humans. Campylobacter upsaliensis from dogs occasionally causes diarrhea in humans. Helicobacter fennelliae and Helicobacter cinaedi can cause either diarrheal or extraintestinal disease. The arcobacter species are uncommon enteric pathogens.

HELICOBACTER PYLORI
Helicobacter pylori is a spiral-shaped gram-negative rod. H pylori is associated with gastritis, duodenal (peptic) ulcer disease, gastric ulcers, and gastric carcinoma. Other helicobacter species that infect the gastric mucosa exist but are rare. Morphology & Identification A. TYPICAL ORGANISMS H pylori has many characteristics in common with campylobacters. It has multiple flagella at one pole and is actively motile.

Lecture 1 .Campylobacter& ........................................................... . helicobacter

B. CULTURE Culture sensitivity can be limited by prior therapy, contamination with other mucosal bacteria, and other factors. H pylori grows in 36 days when incubated at 37 C in a microaerophilic environment, as for C jejuni. The media for primary isolation include Skirrow's medium with vancomycin, polymyxin B, and trimethoprim, chocolate medium, and other selective media with antibiotics (eg, vancomycin, nalidixic acid, amphotericin). The colonies are translucent and 12 mm in diameter. C. GROWTH CHARACTERISTICS H pylori is oxidase-positive and catalase-positive, has a characteristic morphology, is motile, and is a strong producer of urease. Pathogenesis & Pathology H pylori grows optimally at a pH of 6.07.0 and would be killed or not grow at the pH within the gastric lumen. Gastric mucus is relatively impermeable to acid and has a strong buffering capacity. On the lumen side of the mucus, the pH is low (1.02.0) while on the epithelial side the pH is about 7.4. H pylori is found deep in the mucous layer near the epithelial surface where physiologic pH is present. H pylori also produces a protease that modifies the gastric mucus and further reduces the ability of acid to diffuse through the mucus. H pylori produces potent urease activity, which yields production of ammonia and further buffering of acid. H pylori is quite motile, even in mucus, and is able to find its way to the epithelial surface. In human volunteers, ingestion of H pylori resulted in development of gastritis and hypochlorhydria. There is a strong association between the presence of H pylori infection and duodenal ulceration. Antimicrobial therapy results in clearing of H pylori and improvement of gastritis and duodenal ulcer disease. The mechanisms by which H pylori causes mucosal inflammation and damage are not well defined but probably involve both bacterial and host factors. The bacteria invade the epithelial cell surface to a limited degree. Toxins and lipopolysaccharide may damage the mucosal cells, and the ammonia produced by the urease activity may directly damage the cells also. Histologically, gastritis is characterized by chronic and active inflammation. Polymorphonuclear and mononuclear cell infiltrates are seen within the epithelium and lamina propria. Vacuoles within cells are often pronounced. Destruction of the epithelium is common, and glandular atrophy may occur. H pylori thus may be a major risk factor for gastric cancer. Clinical Findings Acute infection can yield an upper gastrointestinal illness with nausea and pain; vomiting and fever may be present also. The acute symptoms may last for less than 1 week or as long as 2 weeks. Once colonized, the H pylori infection persists for years and perhaps decades or even a lifetime. About 90% of patients with duodenal ulcers and 5080% of those with gastric ulcers have H pylori infection. H pylori also may have a role in gastric carcinoma and lymphoma.
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Lecture 1 .Campylobacter& ........................................................... . helicobacter

Diagnostic Laboratory Tests A. SPECIMENS Gastric biopsy specimens can be used for histologic examination or minced in saline and used for culture. Blood is collected for determination of serum antibodies. B. SMEARS The diagnosis of gastritis and H pylori infection can be made histologically. A gastroscopy procedure with biopsy is required. Routine stains demonstrate gastritis, and Giemsa or special silver stains can show the curved or spiraled organisms. C. CULTURE As above. D. ANTIBODIES Several assays have been developed to detect serum antibodies specific for H pylori . The serum antibodies persist even if the H pylori infection is eradicated, and the role of antibody tests in diagnosing active infection or following therapy is therefore limited. E. SPECIAL TESTS Rapid tests to detect urease activity are widely used for presumptive identification of H pylori in specimens. Gastric biopsy material can be placed onto a urea-containing medium with a color indicator. If H pylori is present, the urease rapidly splits the urea (12 days) and the resulting shift in pH yields a color change in the medium. In vivo tests for urease activity can be done also. 13C- or 14C-labeled urea is ingested by the patient. If H pylori is present, the urease activity generates labeled CO2 that can be detected in the patient's exhaled breath. Detection of H pylori antigen in stool specimens is appropriate as a test of cure for patients with known H pylori infection who have been treated. Immunity Patients infected with H pylori develop an IgM antibody response to the infection. Subsequently, IgG and IgA are produced, and these persist, both systemically and at the mucosa, in high titer in chronically infected persons. Early antimicrobial treatment of H pylori infection blunts the antibody response; such patients are thought to be subject to repeat infection. Treatment Triple therapy with metronidazole and either bismuth subsalicylate or bismuth subcitrate plus either amoxicillin or tetracycline for 14 days eradicates H pylori infection in 7095% of patients. An acidsuppressing agent given for 46 weeks enhances ulcer healing. Proton pump inhibitors directly inhibit H pylori and appear to be potent urease inhibitors. Either 1 week of a proton pump inhibitor plus amoxicillin and clarithromycin or of amoxicillin plus metronidazole also is highly effective.
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Lecture 1 .Campylobacter& ........................................................... . helicobacter

Epidemiology & Control H pylori is present on the gastric mucosa of less than 20% of persons under age 30 but increases in prevalence to 4060% of persons age 60, including persons who are asymptomatic. In developing countries, the prevalence of infection may be 80% or higher in adults. Person-to-person transmission of H pylori is likely because intrafamilial clustering of infection occurs. Acute epidemics of gastritis suggest a common source for H pylori .

Dr. Shama M.J Saadaldin AlShadidi 3rd grade / College of Medicine Mustansiryah University 20/3/2012 Updated 2012
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