Transcribed by Jacqueline Heath

11.24.14

Infectious Diseases [11 and 12] Intro to Gram negatives and Enterics, E. coli by
Dr. Boylan
[Boylan] Ok good afternoon, all you gram negative bacteria lovers. So, up to this
point we have covered most of the important gram positive bacteria. If you want to
briefly review, there are only two gram positive cocci and gram positive rods. The
gram positive cocci were the staphylococci and the streptococci. We talked about
aureus and pyogenes and all a few other species in each of those two genera. We dial
then to the gram positive rods. The two major genera were the bacillus and the
clostridium genera. Each of those gram positive rods that form spores. The big
difference is the bacillus are all aerobic and clostridium are all anaerobic. We talked
about tetanus and botulism and c. diff and other infections caused by those bacteria.
And the other gram positive rods are, lets see, corynebacterium causes diphtheria,
listeria causes a food poisoning, and actinomyces. So those are the bacteria that
causes lumpy jaw. So try to remember that category. Write those down in different
columns and try to remember whats in the members of those particular groups.
There are no gram positive spirochetes. There are some gram negative spirochetes.
Well talk about a couple of them later. Dr. Courier will give the next conference in
our course on spirochetes. Shell give some case histories of spirochetal infections.
Syphilis and lyme disease, primarily. So today we are going to get into the gram
negatives.
[1] Introduction to the gram negative bacteria: Enterics, coliforms and E. Coli
[Boylan] Mainly were going to spend some time in the GI tract. Not just today, but in
some lectures coming up by some guest lecturers. I hope to be here next week to
introduce one of our new guest lecturers I mean new for you Dr. Bruce Hannah.
He is a compatriot really of Dr. Tiernos, and Dr. Hannah has two sons who are
recent graduates of our dental school, so maybe hell tell you a little about them and
what theyre doing today. Within the last ten years I think they have both graduated.
He also was in charge of the clinical microbiology lab at Belleview for many years, so
he really knows his stuff too. So hell be coming up next week. I think I should be
here, but Ill be away the following week in Chicago myself. But dont worry, well
take care of things before that. So, the gram negative bacteria. An introduction to
them. Looking first at the bacteria called the enterics and the coliforms, and e. coli.
Well spend a lot of time on e. coli. The enterics, first of all. As their name indicates,
those are bacteria that grow in our enteric tract in our gut. Enterobacteriaceae,
enteracium, enteric, enterotoxin, something to do with our gut. The coliforms
Within that group of enterics, as well see its a major, big group, within the enterics,
there are coliforms, and those are the enterics that are normally residents of our
gut. They are ordinarily found there, even in a healthy person. E. coli is one of the
coliforms. The other enterics that are not coliforms are still gram negative enteric
bacteria, but they are considered to be pathogenic all the time. If they are found in
our gut, these other ones Ill mention later, they must be undergoing some infection

at that time or are harboring a dangerous bacteria, like salmonella, at that time.
Well break them down.
[2] Enterics Introduction to Gram-negative bacteria
[Boylan] Just a little bit about the gram negative bacteria that are of course
ordinarily found in our gut. Some are found in our mouth in dental plaque in our
gingival sulcus, and in a couple weeks Ill tell you about the periodontal bacteria,
which are also gram negative bacteria primarily, the ones that cause periodontal
disease, gram negative anaerobic rods. But lets look first at those found in the
intestine. So we have a microbial flora of the intestinal tract. The small intestine
not too many there, actually. That area in the small intestine is still influenced by the
acidity of the stomach. So of the ones that are there the bacteria that are there
the genera would be the enterococcus and often the lactobacilli are there, near
where the stomach leads into the small intestine. So those that are there can
withstand the low pH. The large intestine thats where we have the most complex
microbiota of our body. The predominant bacteria in the large intestine are
anaerobes strict anaerobes. And the two major genera are shown there. Each
makes up maybe 30, at least 30, percent those two: bacteroides fragilis and
fusobacterium fusiformis. Strict anaerobic bacteria make up the bulk of the
microbiota of the gut. Ordinarily not pathogenic at all, not even enterics really, but
theyre there and members of the gut. Each of those two bacteria, when theyre in
the gut no problem. Once they get, if they get out of the gut, so some perforation in
our intestines, if they get into other sites in the body, they can cause serious
infections too. Gun shot wounds, stabbing. Remember the pope years ago had a
terrible infection previous pope after he was shot because some of those gut
microbiota got into his pleural cavity. So some of those bacteria got out of the site
where they are ordinarily found. Then we have in the large intestine also, facultative
bacteria that can grow with or without oxygen. Most of these are called facultative
anaerobics. There are facultative anaerobes and facultative aerobes. Facultative
anaerobes. This name indicates that they prefer lack of oxygen to grow. Facultative
anaerobes will grow very well with a little bit of oxygen. So they do grow well with
oxygen, essentially. Facultative anaerobes. These facultative bacteria like e. coli.
And they are called the enterics, the ones we are going to talk about, and members
of the family enterobacteriaceae. So the family genus species. Family
enterobacteriaceae, the enterics.
[3] Enterics
[Boylan] The properties of the enterics. They are gram negative, short rods,
facultative anaerobes. Are they spore formers? No. No gram negatives are spore
formers at all just clostridium and bacillus as you know by now. Well talk about
how you differentiate them on the next slide. But lets break down the enterics.
Members of this large family enterobacteriaceae are the coliforms and the
pathogens, as shown here. Coliforms, like e. coli, klebsiella pneumoniae, proteus
vulgaris, and I should say, there are many other coliforms as well. We are going to
restrict ourselves to these because these are some of the ones that do cause
sometimes serious infections in humans, especially e. coli. But the other two well

see can cause some unusual and very often life threatening infections as well.
Klebsiella pneumoniae and proteus vulgaris. Many different serotypes of e. coli, and
well talk about why that is the case. Serotypes how we can identify them using
serological tests that is tests based upon their antigenic makeup. The enterics that
are pathogens, not coliforms, when theyre in the body they are in the gut, thats
where they prefer to grow, but they are not ordinarily there. Salmonella typhi
causes typhoid fever, salmonella enteritidis, food poisoning, shigella dysenteriae,
which causes dysentery, a very serious type of gastroenteritis, or diarrhea. And
yersinia pestis, that causes bubonic plague, a pneumonic plague. Of these listed
here, you think, which does not seem to belong at all, is yersinia pestis. The others
cause most of them cause gastroenteritis in one form or another, and then when
they leave that area of the enteric gut can form other types of infections. But
yersinia pestis why is it included among the enterics? Well because when you
analyze it and look at its biochemical properties and its makeup and the various
biochemical tests you run, it seems to fit in with the others listed here, in that family
enterobacteriaceae. Even though it causes plague. So a little bit about that at the end
of the lecture today as well.
[4] Enterics Differentiation
[Boylan] How do you differentiate the gram negative short rods in the lab? Well you
cant do it by gram stain alone. Theyre all gram negative. They all look pretty much
alike. Not that many are longer than others or more curved than others. So you have
to find other ways to identify them in the lab, to differentiate among them. One of
the couple of ways you do it are listed here. First of all, lactose fermentation.
Among the enterics, one of the big tests you do originally, right off the bat when you
get them in culture in a lab is to see whether or not they ferment lactose. Some of
them ferment lactose, others do not. So thats the first sort of big biochemical test to
put them in different groups. Lactose fermenters and non-lactose fermenters. And
then you grow them on selective or differential medium. Once again, somebody has
a GI infection, a gastroenteritis, you want to identify the potential pathogen. This
bacteria is not going to be the only one present in fecal matter, so you want to try to
separate it from all the others the other coliform, the other bacteria that are there
that you know are not causing the infection. So try to find a medium to grow these
bacteria in the lab that will allow you to grow them and not the other bacteria, or
reduce the growth of the other bacteria. So once again, thats a selective medium.
Select for the growth of some bacteria the ones youre interested in, and suppress
the growth of others that probably are not causing the infection. So, selective
medium to separate what you what from all the other hundreds of genera that may
be present in the gut. Then you use a differential medium, which means of course
that when these bacteria do grow on the selective medium, they do form colonies,
often you can differentiate among them by the appearance of the different colonies
that they form. Are they pink, are they red, colorless, have a metallic sheen, all
different properties. So often you can tell by the type of media you use to grow the
bacteria on, the type of colony they form, you can differentiate thats an e. coli,
thats probably shigella, or maybe its a salmonella, but you can begin to process
right away by the types of colonies they form on selective and differential media.

One of the ones we use a lot for the enterics is called MacConkeys medium, and it
has in it some various dyes, some various bio salts, in other words it has selective
agents in it that will allow for the growth of most of the enterics so that you can
more easily pick them out. Because an e. coli infection, uh, the enterics are really
only present at much less than 1%. Even though we hear about e. coli all the time,
its present at a very low percentage of the total population of the enteric bacteria
well less than 1%. So you want to kill the other 98 point whatever percent and hope
you increase the growth of e. coli if its causing infection on selective differential
media. So MacConkeys has some dyes, salts, that allow for the growth of these
enterics and not other bacteria that could be present in the gut. And then you have a
biochemical screen, that is you test these different bacteria in various media to see
whether or not they have a positive or negative response to the test, and well show
you on the next slide uh that will come up a couple slides from now. But
biochemical screen, biochemical testing can be run. A lot of testing can be run to
identify enterics, but I just want to mention four more. Theyll come up in a couple
slides.
[5] Lactose fermenters and non-fermenters: MacConkeys medium
[Boylan] So MacConkeys is a selective and differential medium, as you can see here
on the left side we have one of them on the left side in this media that has a lot of
lactose in it, and so whatever bacteria is on the left side of the plate broke down,
were lactose fermenters, and they formed colonies or showed growth it is sort of a
pinkish red. So lactose fermenters, because of the dyes in the media, when they
grow they incorporate the dye and they have this pink red appearance to them. On
the right there, these bacteria were grown on MacConkeys but they didnt ferment
lactose so yeah they still grew, but they didnt ferment lactose, so they remain
colorless or often just transparent, almost like you can see right through them, but
theyre not pink or red if theyre not lactose fermenters.
[6] Biochemical Screen
[Boylan] Heres an example of a biochemical screen. Once again, you have these
tables of about thirty different tests, and all the enterics across the top, and you
match them up. Basically youre asking the question when you grow these bacteria
in these media, is it a positive or a negative? It is a yes or no response? Yes, no, yes
no. And you get a whole number of different yes no results from the tests that you
run, and that helps you identify the genus and species often of the bacteria. These
are all for yes no tests. They help identify the bacteria very simply by color change
a color change. These are called these four here the IMViC tests shown across
the top there. Four commonly used tests to identify the members of the enteric
group of bacteria. The first one here is called So IMViC standing for Indole, M for
methyl red, Vi for Voges-Proskauer (threw the i in there just to make this
pronounceable), and the c stands for Citrate. In the first test here on the top left, you
have two tubes, and initially they were exactly the same sterile some kind of broth,
and on the left you inject, inoculate one type of bacteria, and on the right another.
And if you see a difference, then you incubate these tubes overnight as you do in all
four cases here, come back the next day and look for a color change, or some color

change that will occur when you add something to the media. So as we did here, on
the left there both of them actually had a little bit of solution, you can see kind of on
the top, that ring, its a solution that has some alcohol in it and some other things,
but the thing is, you can see on one its still yellowish on the left and its red on the
right. The red on the right means its a positive Indole test. So right away you know
indole test positive. What does indole positive test mean? It means that those
bacteria on the right there grew in a medium and they were able to break down the
amino acid tryptophan. Remember tryptophan? They produce this enzyme called
tryptophamase. They break down tryptophan producing indole. When indole is
formed, the reaction in the test tube will be red. If they dont form indole, that means
that they dont break tryptophan, they dont have trypthophamase, and there is no
change to the color of the solution put on top there. So yes, no, the one on the left is
no, the one on the right is yes for positive indole test, they produced indole. Another
one is the M methyl red. Once again, some of these enterics will grow in a medium
rich in carbohydrates, and when they do that they form a lot of acids, like pyruvic
acid, lactic acid. So those with a positive methyl red test are those that grew well and
produced a lot of acids. They fermented the sugars that were in the medium,
creating a low pH, and you add methyl red to them the next day and if it goes red, if
you add a couple drop of methyl red dye and the tube stays red, it is a positive
methyl red test. Those bacteria form a lot of acid on the left methyl red negative test
they did not form a lot of acid. They grew, maybe, but they didnt form enough
acids to change the color of that indicator to form a red color. Ok, so thats the
methyl red test. A third test is the Voges-Proskauer test shown here, and once again
its a simple color test, color change. You inoculate the broth with the bacteria,
incubate them overnight, come back the next morning, take them out of the
incubator, add a reagent, as you do with the indole test, and look for a color change.
And it doesnt show up as well on the slide here, but if its a positive test, once again
you see a red ring around the top. Thats a positive Voges-Proskauer test. The
bacteria in the tube on the left negative voges-proskauer. So, anybody remember
what the component responsible for the positive test is here? We briefly mentioned
it when we, way back in the microbiology course, talked about bacteria that have
mixed fermentations, and during one pathway fermentation reacts pathway, one of
the intermediates in the pathway was something called acetoin. So- the point being
here, some enterics will carry out this metabolic pathway and acetoin will be formed
during that pathway. Other enterics will not carry out that pathway, theyll never
produce acetoin, which is the key component of this test, they would be negative.
And the fourth IMViC test, shown here on the right, is citrate. Citrate utilization. This
is kind of an interesting test, its a little bit different from the others we talked about
where often the other tests are indicated by, show a color because of a lower pH or a
pH in the acidic range. But the citrate test is shown here, you have two tubes, and
these tubes, I think Dr. Succine might have mentioned it one time its a media you
make in the lab, agar medium, you know an agar medium usually used on petri
plates, and that solidifies a nice flat plate. Well these tubes here, before we talk
about the test, is they made the media up, it had agar in it, they sterilized it, while it
was still hot they put the media in a test tube, and then as it cools you put the tube at
a 45 degree angle. And then when it solidifies its a nice long slant of solid medium,

and then you can streak your bacteria on this slant, and thats what happened here.
If you look at the top of this tube here, you can see its kind of clear, but maybe about
halfway up the tube its a slant. Very thick but at the bottom, and then you get
thinner as you go up. But anyhow, thats a slant, solid medium. In this medium,
there is a bacteria. The only source of carbon for the bacteria to grow on is citrate,
so in other words they dont use any amino acids in this medium, they dont get any
other sugars like glucose, sucrose, any sugar at all. Only citrate, or only citric acid.
Some of the enterics will grow with citrate, others will not. Thats they key once
again, yes or no. And as it turns out that the actual color of the medium when you
make it up, the citrate medium, is green. Ill tell you, the dye in the medium is called
Brom thymol blue. That color indicator is green at neutral pH. However, if bacteria
will grow on the citrate in the medium in the tube, they will actually raise the pH a
little bit- become slightly alkaline when citrate is broken down. When that happens,
that green color, brom thymol blue at neutral pH, becomes blue. So a positive test
means citrate was used, pH increased slightly to alkaline pH, changing the color of
the dye from green to blue, and the blue is a positive test. So those are just examples
of four fairly simple tests to run. You just have to inoculate the tubes, stick them in
the incubator, come back the next day, sometimes you can just look at them like the
two on the right. The first and the third you have to add some reagent to them, but
within seconds you know. So the IMViC tests. For e. coli, we know the IMViC tests
would be listed as positive, positive, negative, negative. E. coli would produce indole
and it would create a very acidic pH in the medium, but it would not be positive
form the voges-proskauer test, meaning it wouldnt produce acetoin, and it is unable
to grow with citrate as the sole source of carbon. Other enterics that look just like e.
coli, you run these tests you get different patterns. Theres another one we often
confused with e. coli that is found a lot in nature, but we run these IMViC tests we
can easily distinguish it from e. coli because this other one is negative, negative,
positive, positive. Just the opposite four results from e. coli. Some are plus, minus,
plus minus. You get the idea. But this is one of the ways we help identify these
enterics. Not by the gram stain alone impossible. But we run some biochemical
tests, these are four we can use.
[7] Serological tests
[Boylan] Ok, how about another way to differentiate among the enterics - E. coli and
others. We can run various serological tests based upon the antigens present on the
surface of the bacteria. The antigens present. We are going to mention just three
types of antigens that we use in the lab to identify enterics. First, these tests we are
going to use to identify these enterics serologically are all called agglutination tests.
Meaning that if these bacteria we are going to study are positive for these tests, they
will agglutinate they will form big globs of each other and then settle to the bottom
of the test tube. So agglutination if they are positive. Why would they be positive?
Well lets look first at the top one of the antigens the o antigen. So these
agglutionation, these serological tests, are based upon either the o antigens, the k
antigens, or the h antigens. And with just looking at these three types of antigens,
these enterics can have, there are probably thousands of different serotypes. But
they are very very useful in identifying the bacteria, and its very important to that

that often during some epidemics or outbreaks of these. What enteric is it? Oh its an
e. coli. But which e. coli is it? Well lets not just identify it biochemically, but
serologically as well. Maybe we can track down the source of the infection. So
serological identification tests are very very important often, especially when there
are outbreaks of these e. coli diseases well talk about. So the o antigen is found in
the LPS, or endotoxin, same thing. Whats the real name of this particular
component? LPS what does LPS stand for? Lipopolysaccharide. Here it is on the
upper right here, the gram negative cell wall, and you can see on top the o antigens
there. Remember the LPS has the lipid part, the toxi (?) part, and it has two different
polysaccharide parts: the core, but then the o antigens that stick up like whiskers on
the surface of the bacterial cells. And thats what our immune systems see when
they come in contact with these bacteria. They see the carbohydrates and the o
antigen. And the o antigens vary, there can be variations dependent upon the sugars
in them, and how they link to each other, and the side groups on these sugars. So o
antigens are the polysaccharide antigens found on the outer surface of the gram
negative cell wall, in the outer membrane up on the top there. They are repeats, 3 or
4 sugars, those same 3 or 4 sugars again, and again and again kind of like if you had
4 different types of ice cream on your cone, chocolate, vanilla, strawberry, pistachio,
chocolate, they repeat over and over again. Those are the o antigens. Every bacteria
have different types of ice creams, different types of sugars in their o antigen.
Oligosaccharide units. K antigens are found in the capsule. Polysaccharides of the
capsule. Remember we know about the pneumococcus can have over 80 different
antigenic types. Its not an enteric of course, but based on the capsular composition,
different sugars and combinations of them. And finally the third type of antigen we
can look at to identify these bacteria serologically, is the h antigen. The h antigen.
And those are found in the flagella of the bacteria. So the point I want to make is
only those bacteria that are motile, only those enterics that are motile, that are
flagellated, will have an h antigen. An example I want to show is this e. coli O157:H7.
Thats the one you read about a lot in the news lately. Thats the one that can cause
so many cases of gastroenteritis, and well talk about it more later. In the news
lately, outbreaks of severe bloody diarrhea. But why is it called O157:H7? Because of
the antigens. The O antigen it has is 157. Im not sure what those sugars are, but it
means its O antigen it has a combination of sugars, 3 or 4 repeated over and over
again, that are identified as 157. Another e. coli might be O122 or 65 or whatever.
But once again, it refers to those O antigens. And the H7 means that the flagella
antigen it has, so it must be a mobile bacteria, the flagellar antigen, is called H7. So
once again, the first two, the O antigen and K antigen are polysaccharides, or sugars,
whereas the H antigen is a protein, and its found in the flagella. We know the
flagella are made up of protein. And even within the flagella, there can be different
types of amino acids, different types of flagellar proteins. At least 7. So thats how it
gets a specific fingerprint classification. O157:H7. One other one I just, when we got
this out, I did eliminate from that discussion, so you can forget about the Vi antigen.
I didnt follow up, I cut that out on my slides on salmonella. But there are other
antigens as well. So serological tests. We have all these different antigenshundreds, if not thousands. We have the antibodies stockpiled in our refrigerators.
We have antibodies against O157:H7. So you add the bacteria, add the antiserum,

and see if it agglutinates. If the antibody against O157:H7 agglutinates the bacteria.
If it does, that identifies it as such, that particular strain. We have antibodies against
O and H and K serotypes of all these different bacteria. We can identify them very
specifically, much more specifically the strains of these bacteria, the strains or
serotypes, than simple biochemical tests. Very powerful types of identification tools,
these tests.
[8] LPS
[Boylan] In the bacteria we find the LPS, one of the most interesting biological
molecules that we know about, lipopolysaccharide. I found something in a book
recently, you can read this over later, but look at all the effects of having LPS
produced by these gram negative bacteria during the course of a gram negative
infection. LPS, that outer membrane component of the gram negatives, can induce
macrophages to do a number of things. So macrophages ingest these gram negative
bacteria causing infection, and the LPS in the bacteria or even by itself, can induce
macrophages to produce inflammatory cytokines, like interleukin 1, tissue necrosis
factor alpha, and some others as well. So cytokines help stimulate our acquired
immune system to come into play and help fight off the infection. But also, the fever.
Weve mentioned a few times that the fever induced by LPS is caused by the lipid
portion, lipopolysaccharide, remember lipid A. Lipid A causes a fever. What happens
is that our macrophages ingest the gram negative bacteria and the LPS inside the
macrophages induce the macrophages to produce the cytokines, especially
interleukin 1. I have two others listed here, there are others, but interleukin 1 I want
to focus on that. Cause thats the one that these activated macrophages ingesting the
bacteria, LPS induces interleukin 1, that gets out into the blood stream, and it goes
to our hypothalamus. And they hypothalamushow do we get fever? The
hypothalamus is kind of the thermostat of the brain. It regulates our body
temperature, and Interleukin 1 is that one that convinces the hypothalamus that it
should elevate the body temperature up to where we have a fever. A fever, as you
know, helps us fight off the infection. We dont want to have a big increase, but even
a couple degrees, 3 degrees, we are responding to the infection. The infectious
agent. The fever is helping us fight off the infection. It slows down the growth of the
bacteria at elevated temperature. At the same time, the fever stimulates our immune
system, our cellular immunity especially comes into play and even our acquired
immunity, humoral immunity, to produce antibodies. So it stimulates our immune
system to help fight off the infection. But fever can also cause hypotension, a low
blood pressure, vasodilation, it increases the permeability of the vessels, thats not
good. It can cause coagulation, DIC dissemination intravascular coagulation, which
clots form in the blood, especially peripheral circulation, fingers, toes. Thats going
to interrupt the flow of blood in those sites, so the sites become necrotic.
Coagulation of the blood, fibrin clots. And even endotoxic shock. If we have an
overwhelming gram negative infection especially, shock can lead to shut down of
our essential organs the liver, the pancreas, the lung, everything shuts down when
theres a lot of LPS. So these are very important molecules that have a lot of different
effects. Most of them are not good for us, of course, as you see here. Well, fever
would be, fever is good, helps us, unless its an excessive fever, but if its a prolonged

gram negative infection, lower blood pressured, hypotension, coagulation, shock,

can be the agent responsible for the death of the people who have these gram
negative infections well talk about.
[9] E. Coli the colon bacillus
[Boylan] Lets look at e. coli. Its called the colon bacillus. Its found in the colon. I
guess thats the name it deserves. Maybe it doesnt appreciate it, but thats how it
got its name. Coli its found in the colon, the large intestine. The general properties,
well weve already gone through those. The things that distinguish it we know now
that its a small gram negative rod, IMViC tests, we know the results of those tests on
e. coli. Its called the colon bacillus because of all these bacteria we are talking about
that are in the gut, the coliforms and others, e. coli should only be found in the gut. It
should not be found what we call outside the gut, or free living, out there in nature.
It shouldnt be found in streams or vegetation or soil. It really shouldnt be, and if it
is found there, that means one thing that material has been fecally contaminated.
Many other coliforms that look very much like e. coli we find them free living. They
can survive outside the gut for a long time in soil, streams, etc. But not e. coli. So if e.
coli is present in your drinking water or your pools or oceans after a storm, that
means that water has somehow been fecally contaminated. So you look for e. coli
when you tests these waters oceans, streams, lakes, whatever, if they may be
fecally contaminated, you look for e. coli. The colon bacillus, because that should
only be found, whether its human waste or animal waste, its from some animals of
waste. Its the one thats used for water tests. There are over 700 different
serotypes based upon primarily its O antigens, but also its K I think. There are 4
principle types of infections caused by e. coli: urinary tract infections, bacteremia
leading to sepsis, neonatal meningitis, and intestinal (diarrheal) diseases, also
known as gastroenteritis. So here we see the gram negative rods, short rods there,
red color. And we see that most of these e. coli have a lot of pili all over the surface
often, the pili, thats what helps them adhere to our tissues. Sometimes tenaciously
to our tissues. The pili make them look ugly, but they are able to adhere and not be
voided from our system they stick so well.
[10] E. coli- virulence factors
[Boylan] So this is another key, very important point right here I think. We talk
about e. coli and it is a member of our gut. Microbiota, all of us. Why is it that it can
cause so many different types of infection, as was on the previous slide? A harmless
bacteria, what gives it the ability to do so many terrible things if we come in contact
with them? Well, it comes down to what we see here. We have many different
serotypes of e. coli. The ones we have in our gut are harmless to us our body is
used to them, but these other serotypes of e. coli are a result of the particular
plasmids they have or the particular bacteriophage genes they harbor. In contrast to
the chromosomal genes, pretty much the same in all e. coli. What makes them non
pathogenic, causing gastroenteritis, or sepsis, or urinary tract infections, depends
upon the serotype of e. coli youre looking at. And these different serotypes, once
again, are based upon the genes in their plasmids or bacteriophage genes they
harbor. Lets go back to bacteriophage genes for a second. Remember what type of

bacteriophages survive in as part of the bacterial chromosome, whether theyre lytic

or temperate? We talked about the two types way back then. Temperate, right? So
some bacteriophages, these that are DNA-phages, theyre viruses that infect
bacteria, and often when they infect them, they become part of the bacterial
chromosome. They inject their DNA into the chromosome of the bacteria. So when
they are like that, well heres a bacteria chromosome that has a relatively small
piece of bacteriophage genome its carrying, that particular piece of DNA from the
phage is called the prophage. The prophage is the DNA of the phage when its
integrated into the bacterial chromosome. (?) So okay heres this prophage in the
chromosome, and most of its genes are involved with prophage replication later on,
its living there and part of the chromosome for a long time perhaps, maybe
generation after generation, but sooner or later, these prophage genes say Ive had
enough of this, I want to break free and I want to produce more and more
bacteriophage progeny, right? So the thing is, most of the genes in the prophage are
involved with replication of the phage. But there are also a few cases where these
prophage have some extra genes they carry around with them, and the genes code
for toxins. They code for toxins, they code for invasins. They code for other things
that make the bacteria pathogenic. So these e. coli, if they didnt have the prophage,
they would be non-pathogenic if it didnt have plasmids either. But if they have
certain prophage, some of them carry genes, and when the prophage in the
chromosome are activately encoding toxins, enzymes that make the bacteria, e. coli,
pathogenic. Same thing with plasmids. If the e. coli harbor certain plasmids, as well
see, those plasmids have the genes to make them stick better, to make them more
toxic, etc., invade better, thats where theyre found. So thats why we have so many
e. coli, a commensurate harmless member of our gut bacteria, can turn out to be
pathogenic. It has genes from these two sources. What are the virulence factors of e.
coli? Of course most of the enterics have some or all of them. The pili, also known as
the fimbriae, enterotoxins, the toxins they produce while they are living in the gut
that act in our gut tissue, invasive factors help them spread, endotoxins, we saw how
that can contribute to infections in the previous slide, a capsule, anti-phagocytic, and
one other component many of these enterics have is called the siderophore, or
siderophores. These are proteins in their cell membrane that are called iron
chelating compounds. What these do, the siderophores, is any available iron that
may be available in their environment they want to grasp it, they want to use it.
There are very very low concentrations of iron in our tissue where the e. coli and
other bacteria replicate. But whatever they have access to, they want it. They need
iron to grow. These e. coli and other enterics they need iron to grow. And so the
advantage would be to have these siderophores to latch on to or bind to iron and
then use it for their own purposes. So it is a very good virulence factor as well
[Student] Can it cause iron deficiency?
[Boylan] Its not a major cause of that I dont think. Maybe over the course of an
overwhelming infection, but we dont need that much either, but for bacteria it is
essential. So I dont think it causes, Im not sure if its involved with iron deficiency
anemia or anything like that, but theoretically if its a massive infection it could. But
thats not usually the case. Well talk about the infections it does cause.

[11] E. coli and UTIs

[Boylan] Ok, lets talk about e. coli and urinary tract infections. E. coli is the most
common cause of UTIs, right off the bat. And it causes UTIs that is, infections of
the urethra, the bladder, the ureters, and even the kidney, by the ascending route.
The ascending route in other words, it enters through the urethral opening and
makes its way up to the bladder and further up possibly to the kidney. What do we
mean by ascending thats the way we get these infections, as opposed to say the
blood bourne route. So these UTIs are not usually a result of bacteria being in the
blood getting to these sites, but the ascending route, going up through the urethra
and progressing to it. So the source what do you think the source of these e. coli
that cause urinary tract infections is? Some outside exogenous source, or our own
endogenous bacteria? Its our own bacteria. So with urinary tract infections, the
principle is its almost always caused by our own e. coli. What does that mean? That
means that urethral openings become contaminated with e. coli from our fecal, from
our anal opening, shall we say. And also, this is why women have a much higher
percentage of UTIs than males. The bacteria dont have that far to go, maybe an
inch, inch and a half. Whereas in men, its 8 inches or something like that. So women
have more urinary tract infections. And it is a result, most of the time, of infection by
their own e. coli that contaminates the urethral opening. So serotypes causing them
are their own endogenous serotypes.
[Student] Theyre not always endogenous, though, right? Because sometimes you
can be in a lake and there can be e. coli there
[Boylan] Yeah, I mean, you might be swimming in fecally contaminated water.
[Student] So not always
[Boylan] No I wouldnt say always, but the odds of a much more generous dose of e.
coli come from the gut, I think, you know, a larger dose than if youre swimming. But
it could happen, I dont want to say it always happens that way. It could happen.
Thats often how males get it too, from fecally contaminated water, but ordinarily, it
is more common in females. Its going to cause an infection, entering through the
urethra, getting to the bladder. And a bladder infection is called cystitis, and that
means e. coli can crawl up the ureters to get to the kidney to cause pyelonephritis,
which is a very serious infection. Hopefully it never gets that far. How do they do it?
You have urine being released from the bladder, youre voiding, and youd think
youd be able to rinse out these e. coli before they get a chance to go up that far. But
these e. coli often have what are called P fimbriae, those fimbriae we saw on the
previous slide, the e. coli are coated with pili, or fimbriae, and somehow it helps
them stick to the epithelial cells in the genital tract, urinary tract, and climb up, or
hold on. And eventually over a period of time it could go up to the kidney and cause
pyelonephritis, and that can lead to obstruction of the kidney, and thats when its
very serious. So urinary tract infections, you have burning sensation upon urination,
you have to go more frequently, and you feel a bit feverish sometimes as well, so you
know when theyre coming on ordinarily, these infections.
[12] E. coli bacteremia and sepsis

[Boylan] E. coli bacteremia and sepsis. The most common cause also of bacteremia.
So we spent a lot of time previously talking about staph aureus and all that it can do.
E. coli is another one. Its a part of our endogenous bacteria. Its there. It gets out of
the site where its ordinarily found to cause a lot of these infections. Septicemia,
septic shock, can be a rapidly overwhelming infection if they get inside the blood
stream and multiply. Endogenous infection, once again, caused by our own strains.
UTIs cause pyelonephritis. Iatrogenic many times IV lines and catheters as shown
there in the picture on the right can be introduced if they are contaminated and they
get into the blood stream, they can cause these infections. At risk, often these types
of infections occur in people who are hospitalized. I mean, anybody can get it. But
whos at risk? Its a nosocomial infection, usually, because of catheters, endoscopy
that are contaminated with e. coli bacteria from a patients own body, they can cause
bacteremia, sepsis, shock, and death. So bacteremia, as you know, bacteria in the
blood stream. Septicemia, an overwhelming blood infection, also known as sepsis if
it really gets out of hand.
[13] E. coli Neonatal meningitis
[Boylan] Heres an interesting one. Well take a break after this one. E. coli
meningitis in a newborn. Why would a strain of e. coli from a mother cause a serious
life threatening infection like meningitis in a newborn? This is e. coli. A newborn the
first three months of life is most susceptible to this type of meningitis. You see the
brain, spinal cord meninges around these organs, infected. The main virulence
factor of the e. coli causing this is a capsule. Anti-phagocytic capsule. It is an unusual
composition of this capsule. Its called a K1 capsule. Remember that. K1 capsule. And
it is composed of something that is not foreign to our body. In other words, our
immune system, we saw this once before, our immune system, it responds to foreign
invaders. It recognizes something in our body that shouldnt be there. It does not
recognize the material, in this particular in this capsule, of these e. coli, as foreign, so
it doesnt try to destroy the bacteria. It lets them go. It tastes them, but it doesnt
gobble them up. What is this component? It is sialic acid. And the capsule is made up
of pure sialic acid monomers that form a large polymer of capsule. So even as a
fetus, as the child is developing, sialic acid is a part of our normal tissues. It is
especially found in our nerve tissue as were developing in utero. So in other words
our immune system is recognizing this material as self, so it doesnt respond to it or
try to knock it out, or neutralize it, destroy it. So when the child is born, its infected
with e. coli maybe from its mother, and this e. coli strain has this particular capsule,
and it doesnt try to destroy it. It says ok, this is normal human material. And so
thats why its not destroyed and can go on to cause meningitis. Thats why we have
the infection. Alright lets take a break and then well have some more to say about e.
coli and a couple other coliforms and enterics.
[14] E. Coli gastroenteritis
[Boylan] And if you see some other students later, and they ask you what was that
lecture on this afternoon, you say that lecture was full of feces, full of feces. I will
not take it personally, ok? Put it that way. Ok lets get to the other main infection
caused by e. coli diarrhea. Gastroenteritis. Transmission: fecal-oral route. E. coli

lives in our gut, contaminates our hand, after going to the bathroom, we
contaminate food or water we touch. Food handlers have to be very careful
especially not to transmit it. And a big difference between this and the others I just
talked about is this comes from an exogenous source. Generally gastroenteritis is
not caused by our own e. coli in our gut. We pick it up from some outside source
contaminated water, vegetables, water, meats, almost anything, a lot of plants
sometimes. Spinach, well see, crops grown in large fields, irrigation water irrigating
them and if that water is contaminated with feces from somebody else, often from
some farm animal, we then if we then eat that spinach without washing it
thoroughly, that can also lead to these types of gastroenteritis. So weve seen a lot of
that lately. The contaminated water used for irrigation of many types of plants we
eat. We are going to talk about two types of e. coli that cause gastroenteritis. Youre
in luck, because I used to talk about four. But there are so many of these bacteria
coming up that cause gastroenteritis of one form or another that I think just two e.
coli is enough. The first one is called ETEC. These are the enterotoxigenic e. coli. So
EC always means e. coli, the ET stands for enterotoxigenic. These are the e. coli that
elaborate a pretty potent toxin that results in the infection. These e. coli ordinarily
cause their damage in the small intestine the small colon, rather than the large.
And the factors that play a role in the infection cause by ETEC are the colonization
factors, called CFAI and CFAII, colonization factor AI and colonization factor AII.
These are both pili, so thats what helps these bacteria adhere, and both of the genes
for those two types of pili are found on plasmids. And there are two enterotoxins
they may produce as well, usually its one or the other, but these enterotoxins, the
genes for them are also found on plasmids. So these e. coli, the plasmids they harbor
carry the genes for either adherence or toxigenicity. Once again, not chromosomal,
not on the prophage.
[15] untitled slide
[Boylan] Heres the way were probably most familiar. We go away on vacation, and
we go away to certain countries, most any country. Were exposed to some
contaminated food or water with e. coli that comes from somebody else humans,
cattle, other animals. How do the enterotoxic e. coli make us sick? Is basically what
Im trying to show on this slide. Up on the upper left there, youll see an e. coli with
its pili, and it is in our gut, and its going to stick to our epithelial cells, our brush
border, the microvilli of our epithelial cells in our gut, and then its going to
elaborate the enterotoxin. The enterotoxin gets into the cell, gets to the cell
membrane of these cells. And remember, this is happening with probably millions of
our gut cells that are infected. And the enterotoxin, what it does, is stimulate the
enzyme adenyl cyclase, which is shown down below there. Adenyl cyclase. So the
two toxins are LT or ST. LT means that toxin is heat labile, the ST toxin means that
that toxin is heat stable. So LT, the toxicity much more lost with just a little bit of
heat. Whereas even at high temperatures, ST can still be effective. They both act the
samewell, they act the same way, but its the LT, the heat labile toxin, that when
these e. coli elaborate, this toxin, this enterotoxin, it stimulates adenyl cyclase. As a
result of that adenyl cyclase, that enzyme in our membranes, sometimes in our
cytoplasm, when it is activated, it builds up the levels of cyclic AMP. Thats the key.

Cylic AMP. We have very small quantities of cyclic AMP floating around in our cells.
Its essential for our growth of our cells and should be maintained at a certain low
level. But when the level of cyclic AMP is increased, it can lead to dire consequences
of these cells, as well see. So its stimulation of the enzyme adenyl cyclase, leading
to the production of more cyclic AMP in our cells, what happens next? The enzyme
cyclic AMP, you can see what happens here, on the top right of the slide. (?) You can
see, the overall result is- look whats being lost from these cells as a result of cyclic
AMP being built up. You lose water, not just water, but chloride ions, sodium,
potassium, and bicarbonate ions are lost from these cells as a result of stimulation
by the cells of enterotoxin, cyclic AMP, increases cyclic AMP levels. So water is lost,
all these electrolytes are lost, the gut fills up with fluids, we have diarrhea. We have
gastroenteritis. And thats what flows from the body of this guy here for example.
And also, hes vomiting to try to get rid of this your body is trying to get rid of the
toxin from both sides, from your mouth and rear. So diarrhea as well as vomiting
occur. Its your body responding to this toxin and its consequences. The other one,
the ST, does the same thing only it stimulates guanyl cyclase. So LT stimulates
adenyl cyclase, ST stimulates guanyl cyclase, but they both lead to increase of cAMP
or gAMP, and that leads to loss of electrolytes, loss of ions, loss of salts, and water.
So its not just the water, its the loss of salts. They call it an electrolyte imbalance.
The electrolytes our cells need to survive are lost as well. The incubation period is
about three days or so. Two or three days after you eat the food or drink the water,
youre gonna get sick, and then you can be sick for three or four days, really. Just
enough to ruin your vacation if youre on a week vacation. So hypersecretion of
water and electrolytes chloride, sodium, potassium, bicarbonate. Its called
travelers diarrhea, because you get it often when youre in other countries. Mild to
explosive watery diarrhea, nausea, and vomiting. I want to point out here this
diarrhea is watery, no blood. As a result of the ETEC strain were talking about here
causing this. And depending upon what country you visit, it is also known as
Montezumas revenge, you know, I think thats mexico I guess. Dehli belly in New
Dehli. Casablanca crud. There are so many beautiful names given to this disease. I
think when Mexicans come here and go to San Francisco and get sick, they are
exposed to these new e. coli from some people, they call it the San Francisco Fire. I
used to say, when I didnt have these other terms written out, I used to say
Montezumas revenge and Dehli belly. I remember looking at a students notes one
time, he had Dehli spelled Deli, so I thought, no, it doesnt come from being at a
delicatessen. Dehli belly means from New Dehli, India. Once again, it happens
worldwide. Outside strains of e. coli.
[16] Enterohemorragic E. coli EHEC (aka STEC)
[Boylan] The other one of e. coli, EHEC, enterohemorrhagic e. coli. This can be much
more dangerous in the long run than ETEC. Its an infection not of the small
intestine, but the large intestine. And here is our friend again the e. coli O157:H7,
most frequently found to cause it. The toxins here destroy mucosal cells in the
lumen of the large intestine. They destroy the cells. So here its not just loss of water,
its destroying the cells. And there will be bleeding as well. So youre going to have
bloody diarrhea. Thats why I wanted to give these two examples of different types

of diarrhea one watery the toxin, this one actually destroys the cells in the gut.
Copious bloody diarrhea, abdominal cramps, usually no fever and no inflammation.
So there are some unusual features of this one. This is the one you read about a
couple of times every year, oftentimes because of contaminated water reaching
plants and other things that we eat or fecally contaminated food from cattle or
animals. At risk: children and the elderly. The first case of this was found maybe 15
years or so ago now in a fast food restaurant in Washington. A jack in the box, I think
it was called, but many many people came down with this unusual bloody diarrhea
after eating hamburgers there, but the hamburgers were undercooked. They came
from cattle who themselves were carriers of this particular strain of e. coli, O157:H7.
They got sick, and actually some elderly people died from it. So you can see, it can be
quite serious infection.
[17] EHEC contd
[Boylan] Primary reservoir is cattle. Transmission: fecal-oral route, as most of these
gastroenteritis infections are. Undercooked hamburgers, unpasteurized milk from
cattle, contaminated well water, and apple cider. So just think of cattle fecal matter
getting to a well water, getting to manure from cattle in these fields, it can get
rained on, it can wash the manure all over the field and anyplace down the hill from
there. And what happened a few years ago but also apple cider. Why apple cider?
Oftentimes they pasteurize it but they dont really heat it well enough to kill the
bacteria. Well, what happned was, there was a fair in upper New York state, and
they served apple cider there. And a number of children especially for some reason,
some adults too, got very sick and had EHEC infections. And they found out the
apple cider had not been pasteurized, or not adequately pasteurized to kill the
bacteria, but what happened, the apple cider. When you use apples for apple cider,
you use the apples that fall to the ground from the tree. If you want to sell nice
pristine apples, you want to pick them. Ive done that one day in my life, thats the
hardest job Ive ever had. To pick apples from a tree and try to make enough money
to make it worthwhile. It didnt work out. So I did it just once. But I know not to pick
the apples that fall to the ground, because theyre bruised. So were gonna take those
bruised apples and use those to make apple cider. But they also had cattle roaming
there in the apple orchards as well, defecating, and so the apples that were lying on
the ground were contaminated with feces. They used them for apple cider, they
were not pasteurized. I dont know if pasteurization would really kill this bacteria,
but they werent adequately the cider wasnt heated enough to kill the bacteria, so
another outbreak of gastroenteritis caused by this bacterium. The exotoxins they
produce are shiga-like toxins. You dont know what that means yet, but we will later.
Shiga-like toxins mean the toxins these EHEC strains produce are those toxins that
are like the ones found in the genus shigella, which is coming up after a few more
slides. So these are very potent toxins. Much more so than the LT and ST we saw
before. Shigella. These are toxins these e. coli derive from their gram negative
enteric friends the enterics. Somehow or other these toxins from the shigella
bacteria, which cause dysentery, those toxins in shigella were transferred to the e.
coli. They picked them up, and now they produce these potent toxins just like the
ones in the bacteria that cause dysentery. They are encoded by phage, not plasmids,

called Stx 1 and 2, the shigella-like toxins. Shigella toxins 1 and 2. Very dangerous,
potent toxins. Well see what effect they have.
[18] Shiga-like toxins
[Boylan] So these toxins, how do they work? They destroy the microvilli of the
intestinal mucosa. Toxins enter the blood, damage the blood vessels, increase
platelet aggregation leading to formation in the bloodstream of thrombi, and they
damage the kidneys primarily due to blockage of blood flow in the kidneys. So
overall, as a result, these toxins lead to often kidney failure.
[19] EHEC contd
[Boylan] Also they can produce hemorrhagic colitis. Colitis inflammation of the
colon with hemorrhaging, bleeding. Abdominal cramps, copious bleeding, diarrhea,
still no fever. So the cramping too. I mean, you have diarrhea, you have vomiting, but
the cramping, the gas thats produced, thats what really really causes a lot of pain.
Thats why people with staph aureus, food bourne infections, and these too, if
theres a lot of gas being formed, cramping can really get you, can lay you low for, in
this case, many hours. In addition to that, it can also lead to hemorrhage uremic
syndrome, the most serious manifestation of EHEC, mostly in children. Potentially
life threatening. The red blood cells are destroyed, so hemolytic, and acute renal
failure. So this is a very, very serious gram negative e. coli infection. Why? Because
the toxins they produce. Where do they get the toxins from? Neighboring enteric
shigella. And it can lead to all these dangerous situations and potentially lethal
outcomes. Colitis of the colon, kidney failure, death. Prevention: thoroughly cooking
ground beef, avoid drinking unpasteurized milk and unpasteurized cider as well I
guess. So in general, once again, its found in cattle primarily, cattle feces that can
contaminate a whole bunch of different things, and eventually get to you through
the food you eat or the cider or water you drink.
[20] EHEC contd
[Boylan] A couple other things. EHEC is now called STEC for shiga toxin producing e.
coli. There is one very useful diagnostic test in the lab to identify EHEC or STEC.
They do not ferment sorbitol. Somebody found that out just a few years ago. Other e.
coli, other strains, can ferment sorbitol. Its another sugar alcohol, you add that to
media, have it be the only carbon source, the only source of energy. Most e. coli can
break down sorbitol. This strain, the EHEC strain, O157:H7, cannot ferment sorbitol.
So you see maybe itll grow on the plate, but it wont change the color, it wont break
it down, change the pH. So thats a key thing to remember about this strain. It really
helps a lot in identifying it. Treatment: fluid therapy, intravenously if necessary. Try
gatorage. Remember youre losing water, losing electrolytes, and with HUS you
might need blood transfusions, kidney dialysis might be necessary. Thats happened
quite often, especially in the very young and very old. Also the
immunocompromised of course. Very serious infections.
[21] Salmonella, Shigella and opportunistic coliforms

[Boylan] Ok lets get out of the e. coli, away from e. coli for a while, and go on to
others. Salmonella and shigealla are indeed enterics, but when they are found in our
gut, it is indication that there is some infection going on, because they are not
coliforms.
[22] Salmonella
[Boylan] Infection caused by salmonella is called salmonellosis. Identification: well,
it is motile. I want you to remember the difference between salmonella and shigella
as far as motility is concerned. These two bacteria have often similar types of
infection sometimes, and you have to run some tests in a lab that will distinguish
between these two genera, salmonella and shigella. Well salmonella are motile,
shigella are non-motile. Biochemical tests: probably the most useful one for
salmonella identification, and helps distinguish it from shigella and other bacteria, is
that these bacteria, the salmonella, produce hydrogen sulfide, H2S, when they grow.
Hydrogen sulfide, when they grow, and they grown on media, you have some
proteins in there, peptides, and as you know there are some amino acids in peptides
that have sulfur in them, like cysteine, methionine, right? So these bacteria, the
salmonella, are able to break down the amino acids that have sulfur in them and
form H2S hydrogen sulfide. Shigella will not do that. And what a salmonella does,
the media they have devised to determine whether or not the bacteria produce H2S,
when they do produce H2S, they form a little blackening the media turns black. So
H2S test, the bacteria grow on the media, if the bacteria produce H2S, it turns black.
Salmonella does this, and its one of the few that do, so its a very important test to
identify that particular gene of salmonella. Thats about all for the biochemical tests.
Antigenically, Kauffmann-White scheme is used to identify salmonella. Over 2000
serotypes, and s. typhi, the one that causes typhoid fever, theres only one serotype.
The other 1999 are all variants of the serotype salmonella enteritidis, the salmonella
that causes food poisoning. And if you read the literature you can be very confused
about the naming of this particular species and this particular genus. Lets stick with
this: typhi, typhoid fever bacterium, one serotype. All the others, salmonella
enteritidis, found in the enteric tract, food poisoning. Salmonella reservoir: (?),
cattle. Theres something unusual to say about the reservoir I believe. Ah, in
addition, the salmonella and shigella are both lactose negative. They are non lactose
fermenters. Salmonella, shigella, non lactose fermenters. Ok. Transmission: fecal
oral route, because again, these grow in the gut. Thats the way theyre transmitted.
Reservoirs: yeah, uh, cattle, sheep, but another unusual reservoir for these bacteria,
the salmonella, are pet turtles. And I mention that for two reasons. We had to
prohibit the we no longer allow pet turtles from other countries to come to the
United States. I dont know what it is, but the kids used to have these pet turtles, and
whether it was the feed they used to use for them, but something in the turtle food
they used, had salmonella bacteria that caused food poisoning, and even typhoid
fever. So pet turtles is one of theand believe it or not, that was a question on
jeopardy years ago. Not that many people got that right. But I guess those of you
who had pets and turtles as a kid, you probably would have known that they are no
longer admitted to this country. Fecal oral route.

[23] Typhoid fever

[Boylan] Lets talk about typhoid fever. We have that one species that causes
typhoid fever and all the other serotypes of the other species cause food poisoninggastroenteritis. Transmission by the five Fs. While most of these GI disturbances are
indeed transmitted by bacteria by the five Fs. What are the five Fs? Well the big one
is feces. I mean, fecal oral transmission. But feces leads to transmission by other
sources. Fs I have for fingers, food, fluids, and flys as well, cause flys often land on
contaminated food and then land on your food. So the five Fs, but all because
whatever material it was, the water, the fluids, the food, was contaminated with the
bacteria salmonella. Incubation period for typhoid fever: 5 to 21 days. So thats quite
a period. Once again depending upon the dose youre exposed to. Symptoms:
typhoid fever is also called enteric fever, meaning its a continuous fever. The fever
stays high all during the course of the infection. Many other infections that have
fevers associated with them, the fever ebbs and flows, there are peaks and valleys
over a period of time. It might be high for a day, low for a couple. High, low. But
thats the thing about typhoid fever: the fever remains high for days or week,
depending upon how long you have it. It invades and replicates in cells of the peyers
patches, the M cells. Inflammation of the small intestine occurs, and you get a
bacteremia. It spreads to many organs. Once again, in contrast to the next thing
were going to discuss, shigella, that causes dysentery, shigella do not invade the
blood stream. Shigella bacteria coming up next do not cause a bacteremia.
Salmonella that cause typhoid fever cause a bacteremia. As a result of that, there are
bacteria in the blood stream, and they are circulating in our blood stream, and they
have a pre-deliction, or a affinity, or a tropism for the organs of our reticulo
endothelial system the RES. Liver, spleen, lungs, other organs as well. And they
adhere to them. Then you have rose spots, hence the name typhoid. Rose spots all
over the body have red, maybe flat red macules, or slightly raised pimple like
papules, all over the body. And thats how it got its name typhoid fever typhoid
means like typhus. We havent discussed typhus, but typhus is an infection where
you have a rash all over your body as well. We knew about typhus since napoleons
time or before, caused by a protozoan. So typhoid fever is a bacterial infection, has
rose spots that look like those of typhus, so typhoid. Fever, lethargy, delirium. Heres
typhoid Mary. Lab diagnosis: well, you can get a sample from anyfrom urine, from
feces, from blood, from biopsies. This bacterium grows all over your body, in all
systems of your body, not just in the gut. Do the H2S test as well, look for gram
negative bacteria. H2S, its going to be lactose negative. Treatment and control: well,
treatment. There are some antibiotics you can use. They had some new ones out
that they use I believe. Actually you can use beta lactams and some of the
ciprofloxacin you can use. Thats unusual that penicillin and some of the beta
lactams can be used to treat typhoid fever. But in those people who have typhoid
fever and its not treated with any antibiotic, it has a mortality rate of about 15%. So
its pretty bad, pretty serious. Carriers. What happens with this bacteria is that many
people can become carriers, well a certain percent, a small percent. Typhoid Mary
was one of the carriers of typhoid fever bacteria, and she lived.I think I told you
this story before. She lived in New York City, 3rd and 33rd, and a couple other places.
I remember one time this slide, or mentioning it to the class, she lived up town, on

3rd and 33rd, and I hear a big yelp from a couple students because thats where they
were living at that time in an apartment building on 3rd and 33rd. Im sure it
probably wasnt the same building that typhoid Mary lived in. She moved around
New York. She was a cook. She came from Ireland, thats how she made her living.
She was single. Thats all she knew how to do to support herself, and she became a
carrier of the typhoid fever bacteria in her gallbladder. It was said that her
gallbladder was completely covered, infiltrated with typhoid fever bacteria,
salmonella typhi. The thing is she had never been sick with typhoid fever. She
harbored the bacteria, she was a carrier in her gallbladder, but never had typhoid
fever. So there were some outbreaks of typhoid fever in homes where she served as
a cook. A couple people died. She kept moving on though, she would work for a
while and then, oh some people are getting sick in this place where Im working so I
better move on to some other location. She worked in hospitals, she worked in
restaurants, but also private homes. So after a couple of outbreaks of typhoid fever
in the early part of the last century, they tracked her down. And I should say that the
typhoid fever was pretty rampant in New York City at that time, but it wasnt just
that she had it and nobody else did. She had it, but what gained her notoriety was
that when they finally tracked her down, they wanted to bring her back and check
her out, and maybe even quarantine her for a while, she put up a big fight with the
police. Got engaged in a fight, and I think a photographer from the paper was there
and took a picture of that. So she was known as typhoid Mary. So they said, ok, well
look at your gallbladder, it has all this bacteria in it, and we will allow you to go back
and work as a cook if you permit us to remove your gallbladder. And she said no, she
wont do that. She said she was never sick with typhoid fever a day in her life, never
a fever at all. And they said, well ok well let you go under two conditions. One that
you promise never to serve as a cook again in a household and two that you report
back to us every few months. And she said ok. Guess what? She disappeared. She
didnt come back. And she continued to work as a cook, because that was the only
way she could make a living. And so there were a couple more outbreaks of typhoid
fever, they tracked her down again after really a long period because she kept
moving on, and finally she spent the last 20 or so years of her life in quarantine
because she wouldnt allow her gallbladder to be removed. Some island up on the
east river, one of the brothers islands up there near where I guess you get to the
manhattan Bronx border, way up on Roosevelt Island, where she was quarantined
for 20 years or so of her life. And so, that was it. Once again, it wasnt because she
became notoriety because that incident she was involved with, not because she was
the only one. Typhoid fever was prevalent throughout New York City way back in
the early part of the last century and before that. Immunization there are indeed
three vaccines, different types of effectiveness, but its pretty rare. We dont usually
get vaccinations against typhoid fever. Its fairly rare. People that work with these
bacteria in a lab setting routinely would get the vaccinations.
[24] Food poisoning
[Boylan] Food poisoning, gastrogenteritis. There is a very large dose of bacteria
needed. And we are going to see some stories in the paper in the next couple of
weeks caused by this bacterium because the main source of the bacteria are poultry

 chicken and turkeys. Cattle as well. But what happens is food handlers, or
somebody preparing the turkey does not heat the turkey enough or handles the
turkey before heating it, gets the bacteria on his or her fingers, goes to the
bathroom, touches that or other food youre going to serve at thanksgiving dinner,
and the guests all get sick. Youll read about an outbreak of 20 people at that
gathering, or 7 people in a family come down with salmonellosis, and its always the
same thing. They didnt clean the turkey, rinse it, make sure they didnt contaminate
other foods they were working with that day, or didnt go to the bathroom and clean
up properly. Its often very embarrassing to the host or the cook who provided
others with that turkey and also food poisoning. The thing you need is a large dose.
No bacteremia here, as opposed to salmonella typhi. Incubation period is a matter of
a couple days is all. Symptoms, general symptoms of cramping, diarrhea. Recovery
takes a few days. At risk are the usual people with compromised immune systems:
the eldery, young. Avoid eggs and avoid raw uncooked chicken, things like that could
be sources of infection. Undercooked chicken, undercooked turkey, raw eggs,
poultry. Usually, I should say, Im sorry lets go back. You eat the food, within about
two days you get sick, and you have this illness for about two or three more days.
Usually youre ok after that. Wash hands, avoid antacids. Well, avoid antacids. How
could that help to prevent? How do antacids compound the problem? Well you can
see up here that a large dose is needed, maybe thousands and thousands of these
salmonella enteritidis that cause these food bourne infections. Why? Because as
they pass through you eat the food, as the bacteria passes through your stomach,
the pH, the acidity of your stomach, will destroy most of the bacteria so only a few
survive. But enough to pass through and cause the diarrhea. However if you elevate
the pH of the stomach by taking antacids, making it a little more alkaline, then the
bacteria have a greater chance of passing through because it isnt quite as acidic.
Theyre not destroyed by the high concentration of hydrogen. So some people do
that when they feel sick, they take antacids with an upset stomach. Well that can
possibly increase your chances of getting infection by these bacteria. Youre going to
allow the dose of the bacteria to remain fairly large and pass through.
[25] Shigella
[Boylan] Shigella. Dysentery, of those three different species. Lab ID tests: lactose
non-fermenters, non-motile, does not produce hydrogen sulfide. Causes dysentery
bacillary dysentery, as opposed to viral or other types. Maybe more than any other
infection in the history of human kind has this disease affected the outcome of the
world today. Dysentery is an infection only of humans, you dont get it from animals,
but it can spread very rapidly, and in contrast to the previous bacteria we just
discussed, you only need a very very small dose, maybe even under 200. So the key
is a small dose of these bacteria is all you need. They are more resistant to the
acidity of the stomach. The food poisoning caused by salmonella enteritidis you
need thousands of bacteria. So very very infectious bacterium. So only humans.
What I mean by affected history is so many times in the course of battles in
European countries especially in the middle ages and later, whole armies would be
infected with these bacteria. And once they were dysentery is very terrible, its like
EHEC. Remember because thats where EHEC got their toxins from this bacteria,

the shigella toxins, the shiga toxins. So these toxins are shiga toxins. In e. coli theyre
shiga-like toxins, but e. coli, this is where they got them from. They cause cramping
and pain, and diarrhea, and vomiting, and what happens and once again, bacteria
only of humans, but these soldiers fighting these battles would go to streams to
defecate there, bathe there, use the stream water to wash their food, and they would
get the infection. And the invading army would see an army that was on the ground,
writhing in pain, unable to defend themselves, hoping they would shoot them
actually, they were in such pain. And so many times, poor sanitary conditions, as you
would find in the course of these battles, would lead to contamination of water that
would find its way eventually. They didnt know about bacteria in those days. So
many battles, the outcome was changed because of illnesses among the soldiers
fighting the battle on one side. Ok, so incubation a couple days. But when youre
sick with this dysentery, its very serious and very incapacitating. Invasion of lamina
propria, ulcers produced, severe and bloody. So, as with the STEC we saw we e. coli,
these are the same way. They damage the epithelial cells, the microvilli, and cause
bleeding and consequent symptoms of serious GI infections. I want to throw in a
couple others now.
[26] Other coliforms: UTI urinary tract infections
[Boylan] Getting back to coliforms. We talked about a couple pathogens salmonella
and shigella. Here are some bacteria once again that are coliforms, that are part of
our normal microbiotia, not ordinarily causing infections. Here are some that cause
urinary tract infections. They are opportunists. They take advantage of some other
malady or some other infection or condition in the body to cause these UTIs.
Serratia marcescens. This is the one that causes nosocomial infections. We used to
work with this one in the lab all the time because it forms this red pigment. When
you grow this bacterium at room temperatures in the lab, it forms a red pigment.
When you put the plate of these bacteria in the incubator and grow it at, say, 37
degrees, our body temperature, it does not produce the pigment. It loses the ability
to produce the red pigment. So it was a test where you could see a bacteria could
change a property they have based upon environmental conditions. Environment
changes, temperature changes. At a low temperature they produce the pigment,
elevate the temperature, something happens to the enzymes involved in pigment
production, temperature rises, and they no longer can produce it. Bring the
temperature back down to 20 degrees or room temperature, and it forms the red
pigment. So it never changes its genotype, but change the temperature, change the
property it has based upon the condition. And actually in the old days, even in the
labs, micro labs, students who took microbiology, the used to give them some
serratia marcescens after it grew for a while at room temperature, and you could
see in a while it got in the blood stream, you could see the blood vessels would be
redder as a result of these bacteria. Of course after a while they would lose the
pigmentation, but if you give somebody this bacteria, if you inject them in them or
you have them eat them, some would get in the blood stream and you would see it,
especially in the gingiva. Of course that was never a good idea, and we dont do that
anymore. Proteus vulgaris and proteus mirabilis- these are bacteria that are
swarmers. They are so motile, members of the genus proteus, that they put a little

drop on the center of a petri plate, and within a matter of hours you will see they
swarm over the whole plate. They are tremendously fast spreaders. They swarm.
Extreme motility. And you put a little drop on the center of a plate, the next day you
will see that plate is coated completely with these bacteria. They are swarmers. Why
are we concerned about them? Well they can produce the enzyme urease. Urease
that breaks down uric acid, which is found in urine, and when they do this so lets
say these bacteria, they can find their way sometimes to the blood and get into the
kidney, and when they grow there, they elevate the pH of urine flowing through the
kidney, and you know the pH of urine is slightly acidic, and when its acidic,
everythings fine. But when these bacteria grow there and produce the enzyme
urease, that breaks down uric acid, the pH goes up. The pH rises above what its
supposed to be in urine in the kidney. As a result of that elevation in pH, you get
kidney stones or renal stones. So there are certain salts like magnesium, calcium
that with an elevated pH start to precipitate out of your urine and form these so
called stones, that block the transmission of urine through the kidney. Very painful.
Those are caused by bacteria, often. Dr. Tierno will talk about the Weil-Felix story
later on, its a cross reaction story. Some components of the cell wall of this
bacterium cross react with typhus protozoa. TyphusI think its typhus. Hell tell
you the story of Weil-Felix and world war II story and how this one test called the
Weil-Felix test actually saved the people in a village from being taken over by the
nazis. But thats for him. Ill let him tell that. But refer back to proteus. Its a
component in the cell wall of proteus that cross reacts with this other microbe hell
talk about. So kidney stones, renal stones, elevation of pH, urease breaking down
uric acid, pH goes up.
[27] Other coliform pneumonia
[Boylan] This one youre going to hear a lot more about over the next couple years,
because were hearing more about it now and the danger it poses to us, all of us,
worldwide. And its klebsiella pneumoniae, k. pneumoniae, shown under klebsiella
pneumoniae. It can be a primary or secondary infection. People with impaired
pulmonary function, pneumonias, and sepsis, especially. So the top part, that part,
we always knew about above the red. Could cause pneumonia and sepsis in
alcoholics, chronic obstructive pulmonary disease, it comes with a fever and a
cough. You get these lung infections, they cough up the sputum, very productive
cough, looks like currant jelly sputum. So thats a characteristic of this particular
infection. Pneumonia. The bacteria reside in the gut, but every now and then fecal
oral transmission, they can get sometimes in the lungs, especially in people who are
immunocompromised and have those conditions shown there. And its luxuriant
capsule it produces, its a very large capsule that is its main virulence factor.
Attentionattention. New superbug strain recently emerged. Called klebsiella
peumoniae NDM1-Kp. Ok, lets talk a little bit more about it first. It has a plasmid
gene called NDM1. That gene codes foroh I had it written down hereNew
Dehliok. You have the slides? You know its on the bottom, maybe underneath the
slides, it shows something? It doesnt?
[student] New Dehli Motila beta lactamase

[Boylan] New Dehli protenaseNew Dehli beta lactamase. This bug is becoming
resistant to almost every drug we have out there on the market. Phenomenally
resistant. And it is spreading among (?) throughout the world, and a very interesting
story, it may have even been first diagnosed here at Langone medical center maybe
8 or so years ago. This particular strain is very very virulent, deadly, and spreading,
and resistant to many antibiotics. That combination of properties makes it very
serious. We have to monitor it very carefully. So klebsiella pneumoniae, New Dehli
Metalo-beta lactamase 1. Klebsiella pneumoniae. Its a gene on a plasmid that is
transmitted among not only this bacterium but other gram negative bacterium
other enterics as well. Spreading rapidly. Even the last resort drugs like vancomycin
and others. I wanted you to be aware of this particular bacteria, klebsiella
pneumonia, not just for what we have always known its able to do on the top of the
slide, but also this new superbug. Some other bacteria are given the name super bug
because they are resistant to one or two antibiotics. This one is pan resistant, even
those we use. There used to be many drugs to treat infection caused by this
bacterium, but now they are useless. So keep your eye on this one because it is
spreading worldwide. And finally, one more.
[28] Enteric infections treatments
[Boylan] Ok, so treatments. Some antibiotics are shown here. But for these GI
infections, cook all meat thoroughly, consume only pasteurized milk and juices,
pasteurized thoroughly. Wash hands carefully and frequently. If its gastroenteritis,
you want to replace fluids, electrolytes with Gatorade, pedialyte for kids. Often
better than using some antibiotic because you want to replenish the fluids that are
being lost to restore the health of the patient.
[29] Yersinia pestis an enteric organism with a different type of infection
[Boylan] And finally, this other one which I didnt think should be included among
these but is, its an enteric because of the biochemical and serological properties it
has, is the bacterium that causes bubonic plague. Bubonic plague, dysentery,
cholera, three of the major scouragers of mankind. I mentioned this briefly in the
last conference we had on bioterrorism and bioweapons that we use, and this is one
of the ones were concerned about being used as a bioweapon by terrorists because
of the deadly disease it can cause bubonic plague. The black death. May be
responsible for the deaths of a third of the European population in the 13th century.
There have been three really serious outbreaks, epidemics, not quite pandemics, but
epidemics of the plague in Europe that wiped out a third to maybe more of the
population. Terrible history. Its called the black death because it causes
hemorrhaging and the skin and all the blood vessels hemorrhage and die, they turn
black. It comes from animals primarily. The carrier of the reservoir of this bacteria
in the middle ages and even today was the rat, although there are some other
animals like prairie dogs in the US can carry it and be a reservoir. (?) Urban plague
and sylvatic plague. Sylvatic plague refers to the plague out there in the woods
sylvatic. Urban plague is when humans and cities begin to get the plague. And the
fleas are of course the vectors for the bubonic plague. Pneumonic plague is when the
plague proceeds. Its called bubonic plague because these bacteria infect our lymph

nodes, and our lymph nodes begin to swell, particularly in the axillae and the groin
area, and the swollen lymph nodes are called buboes. So its called bubonic plague
because of these swollen lymph nodes. If youre bitten by a flea in the leg, itll be
your groin, and if youre bitten by a flea in your arm itll be your axilla, your armpits.
So thats the essentials of it. And the protein capsule is anti-phagocytic. Pneumonic
plague, once it gets to the lungs, youre gonna die, and pneumonic plague, if you get
exposed to someone who coughs up these bacteria, and it goes from their lungs to
your lungs, yersinia pestis bacteria, its going to be fatal. This is the fatal form of the
plague pneumonic plague, when it gets to the lungs. And it happened in many
cases, many people who died in the middle ages and more recently as well from this,
were exposed to the bacteria in this way. They inhaled it from patients who had
pneumonia and within hours they were gone. Believe it or not this is one of the
enterics. It likes to grow in our gut too. Ok I guess thats about it. If youre not
completely dead Ill go on. Thats enough. Weve covered everything.