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B fragilis

The Bacteroides species are very important anaerobes that cause human infection. They are a large group
of bile-resistant, nonspore forming, slender gram-negative rods that may appear as coccobacilli

Bacteroides species are normal inhabitants of the bowel and other sites. Normal stools contain 1011 B
fragilis organisms per gram (compared with 108/g for facultative anaerobes).Bacteroides species are most
often implicated in intra-abdominal infections, usually under circumstances of disruption of the intestinal
wall as occurs in perforations related to surgery or trauma, acute appendicitis, and diverticulitis. These
infections are often polymicrobialanaerobic cocci, Clostridium species and Eubacterium may also be
found. Both B fragilis and B thetaiotaomicron are implicated in serious intrapelvic infections such as pelvic
inflammatory disease and ovarian abscesses. B fragilis group species are the most common species
recovered in some series of anaerobic bacteremia, and these organisms are associated with very high
mortality. As discussed later in the chapter, B fragilis is capable of elaborating numerous virulence factors
which contribute to its pathogenicity and mortality in the host.

Pathogenesis
The capsular polysaccharides of Bacteroides are important virulence factors. A unique feature of infections
with B fragilis is the ability of the organism to induce abscess formation as the sole infecting organism.
When injected into the rat abdomen, purified capsular polysaccharides from B fragilis cause abscess
formation, whereas those from other bacteria (eg, Streptococcus pneumoniae and E coli) do not. The
mechanism by which the B fragilis capsule induces abscess formation is not well understood.

Bacteroides species have lipopolysaccharides but lack the lipopolysaccharide structures with endotoxic
activityThe lipopolysaccharides of B fragilis are much less toxic than those of other gram-negative bacteria.
Thus, infection caused by Bacteroides does not directly produce the clinical signs of sepsis (eg, fever and
shock) so important in infections due to other gram-negative bacteria. When these clinical signs appear in
Bacteroides infection, they are a result of the inflammatory immune response to the infection.

B fragilis elaborates a number of enzymes important in disease. In addition to proteases and


neuraminidases, there is production of two cytolysins that act together to cause hemolysis of erythrocytes.
An enterotoxin capable of causing diarrhea and whose gene is contained on a pathogenicity island is found
in the majority of isolates that are recovered from blood cultures.

B fragilis produces a superoxide dismutase and can survive in the presence of oxygen for days. When a
facultative anaerobe such as E coli is present at the site of infection, it can consume all available oxygen
and thereby produce an environment in which Bacteroides and other anaerobes can grow

Diagnosis of Anaerobic Infections


Clinical signs suggesting possible infection with anaerobes include the following:

1. Foul-smelling discharge (due to short-chain fatty-acid products of anaerobic metabolism).

2. Infection in proximity to a mucosal surface (anaerobes are part of the normal flora).

3. Gas in tissues (production of CO2 and H2).

4. Negative aerobic cultures.

Diagnosis of anaerobic infection is made by anaerobic culture of properly obtained and transported
specimens .Anaerobes grow most readily on complex media such as trypticase soy agar base, Schaedler
blood agar, brucella agar, brain-heart infusion agar, and otherseach highly supplemented (eg, with
hemin, vitamin K1 , blood). A selective complex medium containing kanamycin is used in parallel.
Kanamycin (like all aminoglycosides) does not inhibit the growth of obligate anaerobes; thus, it permits
them to proliferate without being overshadowed by rapidly growing facultative anaerobes. Cultures are
incubated at 3537C in an anaerobic atmosphere containing CO2.

Colony morphology, pigmentation, and fluorescence are helpful in identifying anaerobes. Biochemical
activities and production of short-chain fatty acids as measured by gas-liquid chromatography are used for
laboratory confirmation.

Immunity in Anaerobic Infections


Many anaerobes (including Bacteroides, Propionibacterium, and Fusobacterium species) produce serum-
independent chemotactic factors that attract polymorphonuclear cells. The capsule of B fragilis is both
antiphagocytic and inhibitory to complement-mediated bactericidal action. Bacteroides species are
optimally phagocytosed by polymorphonuclear cells when the organisms are opsonized by both antibody
and complement. Both animals and humans produce antibodies against Bacteroides antigens, including the
capsular material. Passive transfer of antibodies from an immune animal to a nonimmune animal is
protective against Bacteroides bacteremia but does not prevent abdominal abscess formation; in the rat
model of infection, it is a T cell-dependent immune response that prevents abscess formation. Passive
transfer of immune spleen cells or a low-molecular-weight cell-free factor prevents abdominal abscess
formation in the rat model.

Treatment of Anaerobic Infections


Treatment of mixed anaerobic infections is by surgical drainage (under most circumstances) plus
antimicrobial therapy.

The B fragilis group of organisms found in abdominal and other infections universally produces -
lactamase, as do many of the P bivia and P disiens strains found in genital tract infections in women.
Fortunately these -lactamases are inhibited by -lactam- -lactamase inhibitor combinations such as
ampicillin/sulbactam. Therapy with antimicrobials (other than penicillin G) is necessary to treat infections
with these organisms. At least two-thirds of the P melaninogenica strains from pulmonary and
oropharyngeal infections also produce -lactamase.
The most active drugs for treatment of anaerobic infections are clindamycin and metronidazole although
clindamycin resistance among the B fragilis group has increased in the last decade. Clindamycin is
preferred for infections above the diaphragm. Relatively few anaerobes are resistant to clindamycin and
few, if any, are resistant to metronidazole. Alternative drugs include cefoxitin, cefotetan, some of the other
newer cephalosporins, and piperacillin, but these drugs are not as active as clindamycin and
metronidazole. The carbapenem antibiotics, ertapenem, imipenem, meropenem, and doripenem, have
good activity against many anaerobes and resistance is still uncommon. Tigecycline, an agent that has FDA
approval for the treatment of skin and soft tissue, and intra-abdominal infections, has good in vitro activity
against a variety of anaerobe species including the B fragilis group. Penicillin G remains the drug of choice
for treatment of anaerobic infections that do not involve -lactamase-producing Bacteroides and
Prevotella species.

E coli
The Enterobacteriaceae are a large, heterogeneous group of gram-negative rods whose natural habitat is
the intestinal tract of humans and animals. The family includes many genera (Escherichia, Shigella,
Salmonella, Enterobacter, Klebsiella, Serratia, Proteus, and others). Some enteric organisms, eg, Escherichia
coli, are part of the normal flora and incidentally cause disease, while others, the salmonellae and
shigellae, are regularly pathogenic for humans. The Enterobacteriaceae are facultative anaerobes or
aerobes, ferment a wide range of carbohydrates, possess a complex antigenic structure, and produce a
variety of toxins and other virulence factors. Enterobacteriaceae, enteric gram-negative rods, and enteric
bacteria are the terms used in this chapter, but these bacteria may also be called coliforms.

The family Enterobacteriaceae have the following characteristics: They are gram-negative rods, either
motile with peritrichous flagella or nonmotile; they grow on peptone or meat extract media without the
addition of sodium chloride or other supplements; grow well on MacConkey agar; grow aerobically and
anaerobically (are facultative anaerobes); ferment rather than oxidize glucose, often with gas production;
are catalase-positive, oxidase-negative, and reduce nitrate to nitrite; and have a 3959% G + C DNA
content. Examples of biochemical tests used to differentiate the species of Enterobacteriaceae are
presented in Table 171. There are many others in addition to the ones listed. In the United States,
commercially prepared kits or automated systems are used to a large extent for this purpose

Culture
E coli and most of the other enteric bacteria form circular, convex, smooth colonies with distinct edges.
Enterobacter colonies are similar but somewhat more mucoid. Some strains of E coli produce hemolysis on
blood agar.

E coli typically produces positive tests for indole, lysine decarboxylase, and mannitol fermentation and
produces gas from glucose. An isolate from urine can be quickly identified as E coli by its hemolysis on
blood agar.

Pathogenesis
1. Urinary tract infectionE coli is the most common cause of urinary tract infection and accounts for
approximately 90% of first urinary tract infections in young women. The symptoms and signs include
urinary frequency, dysuria, hematuria, and pyuria. Flank pain is associated with upper tract infection. None
of these symptoms or signs is specific for E coli infection. Urinary tract infection can result in bacteremia
with clinical signs of sepsis.

Most of the urinary tract infections that involve the bladder or kidney in an otherwise healthy host are
caused by a small number of O antigen types that have specifically elaborated virulence factors that
facilitate colonization and subsequent clinical infections. These organisms are designated as uropathogenic
E coli. Typically these organisms produce hemolysin, which is cytotoxic and facilitates tissue invasion

2. E coli-associated diarrheal diseasesE coli that cause diarrhea are extremely common worldwide.
These E coli are classified by the characteristics of their virulence properties (see below), and each group
causes disease by a different mechanism. The small or large bowel epithelial cell adherence properties are
encoded by genes on plasmids. Similarly, the toxins often are plasmid- or phage-mediated.

Enteropathogenic E coli (EPEC) is an important cause of diarrhea in infants, especially in developing


countries. EPEC adhere to the mucosal cells of the small bowel. Chromosomally mediated factors promote
tight adherence. There is loss of microvilli (effacement), formation of filamentous actin pedestals or cup-
like structures, and, occasionally, entry of the EPEC into the mucosal cells. Characteristic lesions can be
seen on electron micrographs of small bowel biopsy lesions. The result of EPEC infection is watery diarrhea,
which is usually self-limited but can be chronic. EPEC diarrhea has been associated with multiple specific
serotypes of E coli; strains are identified by O antigen and occasionally by H antigen typing. A two-stage
infection model using HEp-2 cells also can be performed. Tests to identify EPEC are performed in reference
laboratories. The duration of the EPEC diarrhea can be shortened and the chronic diarrhea cured by
antibiotic treatment.

Enterotoxigenic E coli (ETEC) is a common cause of "traveler's diarrhea" and a very important cause of
diarrhea in infants in developing countries. ETEC colonization factors specific for humans promote
adherence of ETEC to epithelial cells of the small bowel. Some strains of ETEC produce a heat-labile
exotoxin (LT) (MW 80,000) that is under the genetic control of a plasmid. Its subunit B attaches to the GM 1
ganglioside at the brush border of epithelial cells of the small intestine and facilitates the entry of subunit
A (MW 26,000) into the cell, where the latter activates adenylyl cyclase. This markedly increases the local
concentration of cyclic adenosine monophosphate (cAMP), which results in intense and prolonged
hypersecretion of water and chlorides and inhibits the reabsorption of sodium. The gut lumen is distended
with fluid, and hypermotility and diarrhea ensue, lasting for several days. LT is antigenic and cross-reacts
with the enterotoxin of Vibrio cholerae. LT stimulates the production of neutralizing antibodies in the
serum (and perhaps on the gut surface) of persons previously infected with enterotoxigenic E coli.

Some strains of ETEC produce the heat-stable enterotoxin STa (MW 15004000), which is under the
genetic control of a heterogeneous group of plasmids. STa activates guanylyl cyclase in enteric epithelial
cells and stimulates fluid secretion. Many STa-positive strains also produce LT. The strains with both toxins
produce a more severe diarrhea.

The plasmids carrying the genes for enterotoxins (LT, ST) also may carry genes for the colonization factors
that facilitate the attachment of E coli strains to intestinal epithelium. Recognized colonization factors
occur with particular frequency in some serotypes.

Care in the selection and consumption of foods potentially contaminated with ETEC is highly
recommended to help prevent traveler's diarrhea. Antimicrobial prophylaxis can be effective but may
result in increased antibiotic resistance in the bacteria and probably should not be uniformly
recommended. Once diarrhea develops, antibiotic treatment effectively shortens the duration of disease.

Shiga toxin producing E coli (STEC) are named for the cytotoxic toxins they produce. There are at least two
antigenic forms of the toxin referred to as Shiga-like toxin 1 and Shiga-like toxin 2. STEC has been
associated with hemorrhagic colitis, a severe form of diarrhea, and with hemolytic uremic syndrome, a
disease resulting in acute renal failure, microangiopathic hemolytic anemia, and thrombocytopenia. The
Shiga-like toxins have many properties that are similar to the Shiga toxin produced by some strains of
Shigella dysenteriae type 1; however, the two toxins are antigenically and genetically distinct. Many cases
of hemorrhagic colitis and its associated complications can be prevented by thoroughly cooking ground
beef.

Enteroinvasive E coli (EIEC) produces a disease very similar to shigellosis. The disease occurs most
commonly in children in developing countries and in travelers to these countries. Like Shigella, EIEC strains
are non-lactose or late lactose fermenters and are nonmotile. EIEC produce disease by invading intestinal
mucosal epithelial cells.

Enteroaggregative E coli (EAEC) causes acute and chronic diarrhea (>14 days in duration) in persons in
developing countries. These organisms also are the cause of food-borne illnesses in industrialized
countries. They are characterized by their specific patterns of adherence to human cells. EAEC produce ST-
like toxin and a hemolysin.

3. SepsisWhen normal host defenses are inadequate, E coli may reach the bloodstream and cause sepsis.
Newborns may be highly susceptible to E coli sepsis because they lack IgM antibodies. Sepsis may occur
secondary to urinary tract infection.

4. MeningitisE coli and group B streptococci are the leading causes of meningitis in infants.
Approximately 75% of E coli from meningitis cases have the K1 antigen. This antigen cross-reacts with the
group B capsular polysaccharide of N meningitidis. The mechanism of virulence associated with the K1
antigen is not understood.

Diagnostic Laboratory Tests


Specimens
Specimens include urine, blood, pus, spinal fluid, sputum, or other material, as indicated by the localization
of the disease process.

Smears

The Enterobacteriaceae resemble each other morphologically. The presence of large capsules is suggestive
of Klebsiella.

Culture

Specimens are plated on both blood agar and differential media. With differential media, rapid preliminary
identification of gram-negative enteric bacteria is often possible (see Chapter 47).

Immunity

Specific antibodies develop in systemic infections, but it is uncertain whether significant immunity to the
organisms follows.

Treatment
No single specific therapy is available. The sulfonamides, ampicillin, cephalosporins, fluoroquinolones, and
aminoglycosides have marked antibacterial effects against the enterics, but variation in susceptibility is
great, and laboratory tests for antibiotic susceptibility are essential. Multiple drug resistance is common
and is under the control of transmissible plasmids.

Certain conditions predisposing to infection by these organisms require surgical correction, eg, relief of
urinary tract obstruction, closure of a perforation in an abdominal organ, or resection of a bronchiectatic
portion of lung.

Treatment of gram-negative bacteremia and impending septic shock requires rapid institution of
antimicrobial therapy, restoration of fluid and electrolyte balance, and treatment of disseminated
intravascular coagulation.

Various means have been proposed for the prevention of traveler's diarrhea, including daily ingestion of
bismuth subsalicylate suspension (bismuth subsalicylate can inactivate E coli enterotoxin in vitro) and
regular doses of tetracyclines or other antimicrobial drugs for limited periods. Because none of these
methods are entirely successful or lacking in adverse effects, it is widely recommended that caution be
observed in regard to food and drink in areas where environmental sanitation is poor and that early and
brief treatment (eg, with ciprofloxacin or trimethoprim-sulfamethoxazole) be substituted for prophylaxis

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