Enterobacteriaceae

Enterobacteriaceae
Small gram-negative rods (2-5 by 0.5 microns) Most motile with peritrichous flagella Shigella and Klebsiella are nonmotile Oxidase-negative facultative anaerobes Reduce nitrate Ferment glucose and other carbohydrates Lactose fermenting strains (e.g. Escherichia, Klebsiella, Enterobacter) Non-lactose fermenting (e.g. Salmonella, Shigella, and Yersinia) Many genera Escherichia, Salmonella, Shigella, Klebsiella, Proteus, Enterobacter, Yersinia, etc. Some strains opportunistic pathogens Some strains true pathogens

Salmonella, Shigella, Yersinia, some strains of E. coli

Enterobacteriaceae
Opportunistic pathogens Escherichia coli Klebsiella pneumoniae Enterobacter aerogenes Serratia marcescens Proteus spp. Providencia spp. Citrobacter spp.
Obligate pathogens

Meningitis Pneumonia

Sepsis

Diarrhea

UTI

Salmonella spp. Shigella spp. Yersinia spp. Some E. coli strains

Enterobacteriaceae is characterized biochemically by the ability to reduce nitrates to nitrites and to ferment glucose. Cytochrome oxidase-negative. Enterobacteriaceae species differ in their ability to ferment lactose. Some ferment lactose rapidly, some does it slowly and the others (e.g., Salmonella and Shigella) do not ferment lactose at all. Some Enterobacteriaceae pathogens (e.g., Salmonella and Shigella) are resistant to bile salts, and this property can be used to select them from commensal organisms that are inhibited by bile salts.

Antigenic Structure
O antigens
O-specific polysaccharides located in LPS. Heat-stable and resistant to alcohol. A single organism may carry several O antigens.
(Core polysaccharide of LPS: enterobacterial common antigen, ECA.)

K antigens
External to O antigens in some strains. Mostly are capsular antigens (polysaccharides). K antigens of Klebsiella can be identified by capsular swelling test.

H antigen
Flagellin. Heat-labile and denatured by alcohol. May be absent or undergo phase variation in different species.

ECA

Toll-like receptor 4 (TLR-4)

Pathogenesis of sepsis caused by gram-negative bacteria

Pathophysiological effects of LPS

Activation of complement, release of cytokines, fever, leukocytosis, thrombocytopenia, impaired organ perfusion and acidosis, disseminated intravascular coagulation (DIC), hypotension, shock and death, premature labor and abortion.

EXOTOXIN

ENDOTOXIN

1. Released from the cell before 1. Integral part of cell wall or after lysis 2. Protein 3. Heat labile 4. Antigenic and immunogenic 5. Toxoids can be produced 6. Specific in effect on host 7. Produced by gram-positive and gram-negative organisms 2. Endotoxin is LPS; Lipid A is toxic component 3. Heat stable 4. Antigenic; ??immunogenicity 5. Toxoids cannot be produced 6. Many effects on host 7. Produced by gram-negative organisms only

Escherichia

10

Biological properties
Shape and structure
Motile pili microcapsule (pathogenic)

11

Biological properties
Chemical reaction
carbohydrate fermentation, produce gas and acid lactose fermentation positive IMViC ++--

12

Biological properties
Antigenic structure
OHK antigenic formula: OKH ---O111: K58: H2

13

Escherichia coli
Serology of E.coli: According to the cell wall (O antigen) over 160 types recognized. According to the flagellar (H antigen) 55 types. Making over 8000 possible O-H seotypes. Some E.coli types are capsulated

Pathogenesis
Normal flora Molecular biology and gene engineer Extraintestinal infection
urinary tract infection: cystitis, pyelonephritis septicemia neonatal meningitis peritonitis

Intestinal tract infection:

ETEC, EIEC, EPEC, EHEC, EAggEC
15

Escherichia coli
Pathogenesis and clinical diseases Sepsis
For people with inadequate host defenses, e.g. the newborns. Usually originates from UT or GI infections. Some infections may be endogenous.

Meningitis
E. coli (particularly K1 strains) and S. agalactiae are the leading causes of meningitis in infants.

Bacteremia

Escherichia coli
Pathogenesis and clinical diseases Urinary tract infection
E. coli is the most common cause of urinary tract infection. Community- vs. hospital-acquired UT infection Most infections originate from colon; the bacteria contaminate the urethra, ascend into the bladder, and may migrate into the kidney or prostate. Symptoms: urinary frequency, dysuria, hematuria, and pyuria. Can result in bacteremia and sepsis. Uropathogenic E. coli strains produce P (Pyelonephritisassociated) pili, which is associated with renal colonization and may induce protective immunity, and hemolysin HlyA.

Escherichia coli
Pathogenesis and clinical diseases
EAST & PET

Gastroenteritis (Diarrhea)
Caused by various virotypes: Enterotoxigenic E. coli Enteropathogenic E. coli Enterohemorrhagic E. coli Enteroinvasive E. coli Enteroaggregative E. coli
Table 30-2

Pathogenic strains
1. 2. 3. 4. 5. EPEC ( Enteropathogenic ) ETEC ( Enterotoxigenic ) EIEC ( Enteroinvasive ) EHEC( Enterohaemorrhagic ) EAEC ( Enteroadherent )

Escherichia coli
Pathogenesis and clinical diseases
Enterotoxigenic E. coli (ETEC): major causal agent of Traveler's diarrhea. These strains express: a) Heat-labile (LT-1) enterotoxins: an A-B toxin. Subunit A causes intense and prolonged hyper secretion of chloride ions and inhibits the reabsorption of sodium and chloride. The gut lumen is distended with fluid, and hypermotility and secretory diarrhea occur, lasting for several days. It stimulates the production of neutralizing antibodies, and cross-reacts with the enterotoxin of Vibrio cholerae. b) Heat-stable (STa) enterotoxin: also stimulates fluid secretion; poorly immunogenic; short onset. c) Colonization factors (CFAs): facilitate the attachment of E. coli strains to intestinal epithelium. Usually are pili in nature.

Enterotoxigenic E. coli (ETEC)

Produced Enterotoxin. Plasmid mediated enterotoxin production. There are 2 kind of Toxins : Lt ( Labile toxin ) St ( Stable toxin)

Lt ( Labile toxin )
Big Molecule. Antigenic. Cross reaction with Cholera toxin. Activate Adenylate cyclase enzyme Cascade reaction-end product cyclic -5AMP ( Adenosine Mono Phosphate ) Profuse watery diarrhea. DehydrationElectrolyte and Acid-Base derangementmetabolic acidosis renal failure death.

Stable toxin (St)

Smaller molecule Non Antigenic. Activate Guanylate cyclase enzyme systemcascade reactionend product cyclic 5 GMP (Guadenosin Mono Phosphate ) Low quality energy resouces mild diarrhea.

Enteropathogenic E coli (EPEC)

Causes infant diarrhea in poor countries. Attachment to immature intestinal mucosal cells Destruction of mucosal villi Watery diarrhea results from malabsorption due to microvilli destruction. Spread by personto-person contact Causing diarrhea followed by fever and icteric Fatal infection especially on neglected labor.

Enteroinvasive Escherichia coli (EIEC)

Site of infection mucosal cells layer of Colon. Shigella like infection. Closely related to Shigella in pathogenic properties. Shiga like toxin toxic to colonic mucosal cells- necrosisulcersbleeding ( Blooded diarrhea), fever tenesmus ani ( Trias Bacillar Dysentery)

Escherichia coli
Pathogenesis and clinical diseases Enterohemorrhagic E. coli (EHEC)
The most common strains producing disease in developed countries. These strains are associated with hemorrhagic colitis and hemolytic uremic syndrome (HUS: acute renal failure, microangiopathic hemolytic anemia and thrombocytopenia; 5-10% infected children). Serotpe O157:H7 is most commonly isolated. Cattle is a reservoir, and hamburger, unpasteurized milk, fruit juices, and uncooked vegetables are common sources of human infection. Induces A/E lesions on enterocytes. Diarrhea and HUS may be associated with the Shiga toxins, which are A-B toxins that bind to 28S rRNA and disrupt protein synthesis.

Enteroadherent E coli
Multilayer colonization on intestinal mucose. Biofilm formation Inhibit water and nutrition absorbtion. Malabsorbtion syndrome. Enteroaggregative E. coli (EAEC): causes chronic diarrhea and growth retardation in infants in developing countries.

Other opportunistic Enterobacteriaceae

Klebsiella
K. pneumoniae and K. oxytoca are the most commonly isolated. Can cause community-acquired primary lobar pneumonia (frequently involves necrotic destruction of alveolar space), and infections of wound, soft tissue, and urinary tract. Risk factors for pneumonia: alcoholism; compromised pulmonary function. *In Taiwan: liver abscess is commonly seen in infection by K. pneumoniae. K. granulomatis may cuase granuloma inguinale, a sexually transmitted disease, in some countries. K. rhinoscleromatis: granulomatous disease of the nose. K. ozaenae: chronic atrophic rhinitis.

Proteus
Most common isolates: P. mirabilis. Cause urinary tract infections and bacteremia. Produce urease, making the urine of the patients of UT infection with Proteus alkaline, promoting stone formation by precipitating Mg and Ca.

Enterobacter, Citrobacter, Morganella, Serratia

Opportunistic pathogens causing nosocomial infections in neonates and immunocompromised patients. These genera, particularly Enterobacter, are resistant to multiple antibiotics.

Yersinia
Y. pestis: plague ("black death") Y. pseudotuberculosis and Y. enterocolitica: gastroenteritis

Grows more rapidly in media containing blood or tissue fluids and fastest at 30 oC. Some species (e.g. Y. enterocolitica) can grow in refrigerated food.

Pathogenesis
The Yersinia pathogens are able to resist phagocytic killing by secreting proteins into the phagocyte and result in inhibition of killing by phagocyte, apoptosis of macrophage, and suppression of cytokine production. Y. pestis produces a protein capsule (Fraction 1), and Pla (plasminogen activator protease) that degrades C3b and C5a, and fibrin clot (enhances spread of bacteria into blood stream).

Yersinia pestis
Causes zoonotic infections; humans are accidental hosts. Three major pandemics have occurred in 541 AD, 1320s and 1860s. Two forms of infections: Urban plague Rats as natural reservoirs. Spread among rats or between rats and humans by infected flea. Can be eliminated by effective control of rats and better hygiene. Sylvatic plague: infections of rodents and domestic cats. Y. pestis are widely distributed in mammalian reservoirs and flea vectors and produces fatal infections in animal reservoirs. Human infections are acquired by contacting the reservoir population.

Yersinia pestis
Pathogenesis
Bubonic plague

Y. pestis enters a flea when it feeds on an infected animal the bacteria multiply in the gut of the flea flea becomes hungry and bites ferociously Y. pestis passes from the flea into the bite wound the bacteria are phagocytised, but can multiply intracellularly or extracellularly reach the lymphatics, and an intense hemorrhagic inflammation develops in the enlarged lymph nodes, which may undergo necrosis Y. pestis may reach the bloodstream and become widely disseminated. Hemorrhagic and necrotic lesions may develop in all organs.
Primary pneumonic plague

Results from inhalation of infective droplets (usually from a coughing patient), with hemorrhagic consolidation of the lung, sepsis and death.

Yersinia pestis
Clinical Diseases
Bubonic plague Incubation period: 2-7 days. High fever and painful lymphoadenopathy with greatly enlarged, tender lymph nodes (buboes) in the groin and axilla sepsis (early stage: vomiting and diarrhea; late stage: hypotension, renal and cardiac failure; terminal stage: pneumonia and meningitis). Mortality: 75% if untreated. Pneumonic plague Incubation time: 2-3 days. Fever and malaise, pulmonary signs develop within 1 day. Patients are highly infectious. Mortality: 90% if untreated.

Yersinia pestis
Treatment
Patients have to be promptly treated with antibiotics (drug of choice: streptomycin).

Epidemiology and control

Plague is an infection of wild rodents that still occurs in many parts of the world (enzootic areas: India, Southeast Asia, Africa, and North and South America). Control of plague requires surveys of infected animals, vectors, and human contacts, and by destruction of infected animals. All patients with suspected plague should be isolated. Contacts of patients with suspected pneumonic plague should receive tetracycline as chemoprophylaxis.

Salmonella
Epidemiology
S. Typhi and S. Paratyphi are primarily infective for humans. Other salmonellae are chiefly pathogenic in animals (poultry, pigs, rodents, cattle, pets etc.) that constitute the reservoir for human infection. Humans usually become infected by ingestion of contaminated food or drink (mean infective dose: 106-108, but that of S. typhi is lower). In children, infections can result from direct fecal-oral spread. The most common sources of human infections: poultry, eggs, dairy products, and foods prepared on contaminated work surfaces. However, the major source of infection for enteric fever is the carriers (convalescent or healthy permanent).

Salmonella
Salmonella spp. do not ferment lactose. Most species of Salmonella are motile with peritrichous flagella. Some Salmonellae have capsular antigens; that of S. Typhi is referred to as Vi antigen. Groups and species of Salmonella are identified by serologic analysis of O and H antigens (> 2,500 serotypes). Classification of salmonellae is traditionally based on serogrouping and serotyping (e.g. S. typhimurium, which is reclassified as S. enterica together with most human pathogens by analysis of DNA homology). The correct name for S. typhi is S. enterica, serovar. Typhi or S. Typhi. They can be identified by biochemical tests and serogrouping, with follow-up serotyping confirmation.

Salmonella
Pathogenesis and Immunity Invasion
Acid tolerance response (ATR) gene protects the organism from gastric acid. The bacteria invade into (by inducing membrane ruffling) and multiply in the M cells of the small intestine. Inflammatory response confines the infection to the GI tract.

Survival in macrophages
Salmonellae are facultative intracellular pathogen.

Salmonella
Clinical diseases
1. Enteritis
Incubation period: 6-48 hours. Symptoms: nausea, headache, vomiting, nonbloody profuse diarrhea, with few leukocytes in the stools. Lowgrade fever, abdominal cramp, myalgia, and headache are also common. Episode resolves in 2-7 days. Inflammatory lesions of the small and large intestine are present. Stool cultures remain positive for several weeks after clinical recovery.

Salmonella
Clinical diseases
2. Bacteremia
Most common causal species: S. Choleraesuis, S Typhi

and S. Paratyphi.
Symptoms: like sepsis caused by other gram-negative bacteria. 10% of patients may have localized suppurative infections, e.g., osteomyelitis, endocarditis, arthritis, etc. High risk population: pediatric and geriatric patients; AIDS patients.

Salmonella
Clinical diseases
3. Enteric fever (typhoid fever)
Causal species: S. Typhi, S. Paratyphi A, S. Schttmuelleri, and S. Hirschfeldii. Mouth small intestine lymphatics and bloodstream infect liver, spleen and bone marrow multiply and pass into the blood second and heavier bacteremia onset of clinical illness colonization of gallbladder invasion of the intestine typhoid ulcers and severe illness. Chronic carriers (1%-5% of patients): bacteria persist in the gallbladder and the biliary tract for more than one year.

Symptoms: incubation time: 10-14 days. Gradually increasing fever, malaise, headache, myalgias, and anorexia, which persist for a week or longer. In severe cases: intestinal hemorrhage and perforation. Principal lesions: hyperplasia and necrosis of lymphoid tissue, hepatitis, focal necrosis of the liver, and inflammation of the gallbladder, periosteum, lungs and other organs.

Salmonella
Treatment
Enteric fever and bacteremia require antibiotic treatment: chloramphenicol, ampicillin, trimethoprim-sulfamethoxazole. Surgical drainage of metastatic abscesses may be required. Salmonella enterocolitis needs only supportive therapy (antibiotic treatment may prolong the symptoms and excretion of the salmonellae). Drugs to control hypermotility of the gut should be avoided because it is easy to transform a trivial gastroenteritis into a life-threatening bacteremia by paralyzing the bowel. Chronic carriers of S. Typhi may be cured by antibiotics alone or combined with cholecystectomy.

Salmonella
Prevention and control
Sanitary measures. Carriers must not be allowed to work as food handlers. Strict hygienic precautions for food handling. Vaccines against S. Typhi: Purified Vi antigen Oral, live attenuated vaccine.

Shigella
S. dysenteriae, S. flexneri , S. sonnei , & S. boydii: bacillary dysentery > 45 O serotypes; have no H antigen; do not ferment lactose.

Pathogenesis and Immunity

Shigellosis is primarily a pediatric disease, and is restricted to the GI tract. Mean infective dose: 103. Mouth colon invade M cells and subsequently spread to mucosal epithelial cells cause microabscess in the wall of colon and terminal ileum necrosis of the mucous membrane, superficial ulceration, bleeding, and formation of pseudomembrane. Shiga toxin An A-B toxin inhibiting protein synthesis. Damages intestinal epithelium and glomerular endothelial cells (associated with HUS) .

Destablize the intestinal wall

Activates the invasion genes on the virulence plasmid

M cell

Attracted by the cytokines released by macrophage

Internalized shigellae induce apoptosis of macrophage and release of the bacteria

Shigella
Clinical diseases
Incubation period: 1-3 days Sudden onset of abdominal pain, fever and watery diarrhea number of stools increase, less liquid, often contain mucus and blood, rectal spasms with resulting lower abdominal pain (tenesmus) symptoms subside spontaneously in 2-5 days in adult cases, but loss of water and electrolytes frequently occur in children and the elderly a small number of patients remain chronic carriers. Some cases were accompanied by hemolytic uremic syndrome (HUS).

Shigella
Laboratory diagnosis
Specimens: fresh stool, mucus flecks, and rectal swabs. Large numbers of fecal leukocytes and some RBC may often be seen microscopically. Culture: differential and selective media as used for salmonellae.

Treatment
Antibiotic treatment: chloramphenicol, ampicillin, tetracycline, and trimethoprim-sulfamethoxazole. Drug resistance is common. Opiates should be avoided.

Shigella
Prevention and control
Humans are the only reservoir for shigellae. Transmission of shigellae: water, food, fingers, feces, and flies. Most cases occur in children under 10 years of age. Prevention and control of dysentery: 1. Sanitary control of water, food and milk; sewage disposal; and fly control. 2. Isolation of patients and disinfection of excreta. 3. Detection of subclinical cases and carriers.