Introduction for microbiology

Microbiology is the study of microorganisms, a large and diverse group of microscopic

organisms that exist as single cells or cell clusters; it also includes viruses, which are
microscopic but not cellular. Microorganisms have a tremendous impact on all life and the
physical and chemical makeup of our planet. They are responsible for cycling the chemical
elements essential for life, including carbon, nitrogen, sulfur, hydrogen, and oxygen; more
photosynthesis is carried out by microorganisms than by green plants. Furthermore, there
are 100 million times as many bacteria in the oceans (13 × 1028) as there are stars in the
known universe. The rate of viral infections in the oceans is about 1 × 1023 infections per
second, and these infections remove 20–40% of all bacterial cells each day. It has been
estimated that 5 × 1030 microbial cells exist on earth; excluding cellulose, these cells
constitute about 90% of the biomass of the entire biosphere. Humans also have an
intimate relationship with microorganisms; more than 90% of the cells in our bodies are
microbes. The bacteria present in the average human gut weigh about 1 kg, and a human
adult will excrete his or her own weight in fecal bacteria each year. The number of genes
contained within this gut flora outnumber that contained within our genome 150-fold,
and even in our own genome, 8% of the DNA is derived from remnants of viral genomes.
Definition of Medical
Relating to the treatment of diseases and injuries of or relating to medicine.
Viruses
Viruses lack many of the attributes of cells, including the ability to replicate. Only when it
infects a cell does a virus acquire the key attribute of a living system—reproduction.
Viruses are known to infect all cells, including microbial cells. Recently, viruses
called virophages have been discovered that infect other viruses. Host–virus interactions
tend to be highly specific, and the biologic range of viruses mirrors the diversity of
potential host cells. Further diversity of viruses is exhibited by their broad array of
strategies for replication and survival.
Viral particles are generally small (eg, adenovirus is 90 nm) and consist of a nucleic acid
molecule, either DNA or RNA, enclosed in a protein coat, or capsid (sometimes itself
enclosed by an envelope of lipids, proteins, and carbohydrates). Proteins—frequently
glycoproteins—in the capsid determine the specificity of interaction of a virus with its host
cell. The capsid protects the nucleic acid and facilitates attachment and penetration of the
host cell by the virus. Inside the cell, viral nucleic acid redirects the host’s enzymatic
machinery to functions associated with replication of the virus. In some cases, genetic
information from the virus can be incorporated as DNA into a host chromosome. In other
instances, the viral genetic information can serve as a basis for cellular manufacture and
release of copies of the virus. This process calls for replication of the viral nucleic acid and
production of specific viral proteins. Maturation consists of assembling newly synthesized
nucleic acid and protein subunits into mature viral particles, which are then liberated into
the extracellular environment. Some very small viruses require the assistance of another
virus in the host cell for their duplication. The delta agent, also known as hepatitis D virus,
is too small to code for even a single capsid protein and needs help from hepatitis B virus
for transmission. Viruses are known to infect a wide variety of plant and animal hosts as
well as protists, fungi, and bacteria. However, most viruses are able to infect specific types
of cells of only one host species.
Some viruses are large and complex. For example, Mimi virus, a DNA virus
infecting Acanthamoeba, a free-living soil ameba, has a diameter of 400–500 nm and a
genome that encodes 979 proteins, including the first four aminoacyl tRNA synthetases
ever found outside of cellular organisms and enzymes for polysaccharide biosynthesis. An
even larger marine virus has recently been discovered (Mega virus); its genome
(1,259,197-bp) encodes 1120 putative proteins and is larger than that of some bacteria.
Because of their large size, these viruses resemble bacteria when observed in stained
preparations by light microscopy; however, they do not undergo cell division or contain
ribosomes.
A number of transmissible plant diseases are caused by viroid’s—small, single-stranded,
covalently closed circular RNA molecules existing as highly base-paired rod like structures.
They range in size from 246 to 375 nucleotides in length. The extracellular form of the
viroid is naked RNA—there is no capsid of any kind. The RNA molecule contains no
protein-encoding genes, and the viroid is therefore totally dependent on host functions
for its replication. Viroid RNA is replicated by the DNA-dependent RNA polymerase of the
plant host; preemption of this enzyme may contribute to viroid pathogenicity.
The RNAs of viroid’s have been shown to contain inverted repeated base sequences at
their 3′ and 5′ ends, a characteristic of transposable elements and retroviruses. Thus, it is
likely that they have evolved from transposable elements or retroviruses by the deletion
of internal sequences.
Prions
A number of remarkable discoveries in the past three decades have led to the molecular
and genetic characterization of the transmissible agent causing scrapie, a degenerative
central nervous system disease of sheep. Studies have identified a scrapie-specific protein
in preparations from scrapie-infected brains of sheep that is capable of reproducing the
symptoms of scrapie in previously uninfected sheep. Attempts to identify additional
components, such as nucleic acid, have been unsuccessful. To distinguish this agent from
viruses and viroid’s, the term prion was introduced to emphasize its proteinaceous and
infectious nature. The cellular form of the prion protein (PrPc) is encoded by the host’s
chromosomal DNA. PrPc is a sialo glycoprotein with a molecular mass of 33,000–35,000 Da
and a high content of α-helical secondary structure that is sensitive to proteases and
soluble in detergent. PrPc is expressed on the surface of neurons via a
glycosylphosphatidylinositol anchor in both infected and uninfected brains. A
conformational change occurs in the prion protein, changing it from its normal or cellular
form PrPc to the disease-causing conformation. When PrPSc is present in an individual
(owing to spontaneous conformational conversion or to infection), it is capable of
recruiting PrPc and converting it to the disease form. Thus, prions replicate using the
PrPc substrate that is present in the host.
There are additional prion diseases of importance. Kuru, Creutzfeldt-Jakob disease (CJD),
Gerstmann-Sträussler-Scheinker disease, and fatal familial insomnia affect humans.
Bovine spongiform encephalopathy, which is thought to result from the ingestion of feeds
and bone meal prepared from rendered sheep offal, has been responsible for the deaths
of more than 184,000 cattle in Great Britain since its discovery in 1985. A new variant of
CJD has been associated with human ingestion of prion-infected beef in the United
Kingdom and France. A common feature of all of these diseases is the conversion of a
host-encoded sialo glycoprotein to a protease-resistant form as a consequence of
infection.
Human prion diseases are unique in that they manifest as sporadic, genetic, and infectious
diseases. The study of prion biology is an important emerging area of biomedical
investigation, and much remains to be learned.

Most important

 Microorganisms are a large and diverse group of microorganisms existing as single

cells or clusters; they also include viruses, which are microscopic but not cellular.
 A virus consists of a nucleic acid molecule, either DNA or RNA, enclosed in a protein
coat, or capsid, sometimes enclosed by an envelope composed of lipids, proteins,
and carbohydrates.
 A prion is an infectious protein, which is capable of causing chronic neurologic
diseases.
Bacteria
Las bacterias son microorganismos procariotas que presentan un tamaño de unos
pocos micrómetros (por lo general entre 0,5 y 5 μm de longitud) y diversas formas,
incluyendo filamentos, esferas (cocos), barras (bacilos), sacacorchos (vibrios) y hélices
(espirilos). Las bacterias son células procariotas, por lo que, a diferencia de las células
eucariotas (de animales, plantas, hongos, etc.), no tienen el núcleo definido ni presentan,
en general, orgánulos membranosos internos. Generalmente poseen una pared celular y
esta se compone de peptidoglicano. Muchas bacterias disponen de flagelos o de otros
sistemas de desplazamiento y son móviles. Del estudio de las bacterias se encarga
la bacteriología, una rama de la microbiología.
Aunque el término bacteria incluía tradicionalmente a todos los procariotas, actualmente
la taxonomía y la nomenclatura científica los divide en dos grupos. Estos dominios
evolutivos se denominan Bacteria y Archaea(arqueas). La división se justifica en las
grandes diferencias que presentan ambos grupos a nivel bioquímico y genético. La
presencia frecuente de pared de peptidoglicano junto con su composición en lípidos de
membrana son la principal diferencia que presentan frente a las arqueas.
Las bacterias son los organismos más abundantes del planeta. Son ubicuas, se encuentran
en todos los hábitats terrestres y acuáticos; crecen hasta en los más extremos como en los
manantiales de aguas calientes y ácidas, en desechos radioactivos, en las profundidades
tanto del mar como de la corteza terrestre. Algunas bacterias pueden incluso sobrevivir en
las condiciones extremas del espacio exterior. Se estima que se pueden encontrar en
torno a 40 millones de células bacterianas en un gramo de tierra y un millón de células
bacterianas en un mililitro de agua dulce. En total, se calcula que hay aproximadamente
5×1030 bacterias en el mundo.
Las bacterias son imprescindibles para el reciclaje de los elementos, pues muchos pasos
importantes de los ciclos biogeoquímicos dependen de estas. Como ejemplo cabe citar
la fijación del nitrógeno atmosférico. Sin embargo, solamente la mitad de
los filos conocidos de bacterias tienen especies que se pueden cultivar en el laboratorio,
por lo que una gran parte (se supone que cerca del 90 %) de las especies de bacterias
existentes todavía no ha sido descrita.
En el cuerpo humano hay aproximadamente diez veces más células bacterianas que
células humanas, con una gran cantidad de bacterias en la piel y en el tracto digestivo.
Aunque el efecto protector del sistema inmunológico hace que la gran mayoría de estas
bacterias sea inofensiva o beneficiosa, algunas bacterias patógenas pueden causar
enfermedades infecciosas, incluyendo cólera, difteria, escarlatina, lepra, sífilis, tifus, etc.
Pathogenesis of Bacterial
The pathogenesis of bacterial infection includes initiation of the infectious process and the
mechanisms that lead to the development of signs and symptoms of disease. The
biochemical, structural, and genetic factors that play important roles in bacterial
pathogenesis are introduced in this chapter and may be revisited in the organism-specific
sections. Characteristics of bacteria that are pathogens include transmissibility, adherence
to host cells, persistence, invasion of host cells and tissues, toxigenicity, and the ability to
evade or survive the host’s immune system. Resistance to antimicrobials and disinfectants
can also contribute to virulence, or an organism’s capacity to cause disease. Many
infections caused by bacteria that are commonly considered to be pathogens are in
apparent or asymptomatic. Disease occurs if the bacteria or immunologic reactions to
their presence cause sufficient harm to the person.
Humans and animals have abundant normal microbiota that usually do not produce
disease but achieve a balance that ensures the survival, growth, and propagation of both
the bacteria and the host. Some bacteria that are important causes of disease are cultured
commonly with the normal microbiota (eg, Streptococcus pneumoniae, Staphylococcus
aureus). Sometimes bacteria that are clearly pathogens (eg, Salmonella serotype Typhi)
are present, but infection remains latent or subclinical, and the host is a “carrier” of the
bacteria.
It can be difficult to show that a specific bacterial species is the cause of a particular
disease. In 1884, Robert Koch proposed a series of postulates that have been applied
broadly to link many specific bacterial species with particular diseases. Koch’s
postulates are summarized in.
Koch’s postulates have remained a mainstay of microbiology; however, since the late 19th
century, many microorganisms that do not meet the criteria of the postulates have been
shown to cause disease. For example, Treponema pallidum (syphilis) and Mycobacterium
leprae(leprosy) cannot be grown in vitro; however, there are animal models of infection
with these agents. In another example, there is no animal model of Neisseria
gonorrhoeae (gonorrhea) infection even though the bacteria can readily be cultured in
vitro; experimental infection in humans has been produced that substitutes for an animal
model.

Modern-day microbial genetics has opened new frontiers to study pathogenic bacteria
and differentiate them from nonpathogens. Molecular cloning has allowed investigators
to isolate and modify specific virulence genes and study them with models of infection.
The ability to study genes associated with virulence has led to a proposed form
of molecular Koch’s postulates.
Some pathogens are difficult or impossible to grow in culture, and for that reason, it is not
possible with Koch’s postulates or the molecular Koch’s postulates to establish the cause
of their associated diseases. The polymerase chain reaction is used to amplify
microorganism-specific nucleic acid sequences from host tissues or fluids. The sequences
are used to identify the infecting organisms. The molecular guidelines for establishing
microbial disease causation are listed in Table 9-1. This approach has been used to
establish the causes of several diseases, including Whipple disease (Tropheryma whipplei),
bacillary angiomatosis (Bartonella henselae), human monocytic ehrlichiosis (Ehrlichia
chaffeensis), hantavirus pulmonary syndrome (Sin Nombre virus), and Kaposi sarcoma
(human herpesvirus 8).
Analysis of infection and disease through the application of principles such as Koch’s
postulates leads to classification of bacteria as pathogens, opportunistic pathogens, or
nonpathogens. Some bacterial species are always considered to be pathogens, and their
presence is abnormal; examples include Mycobacterium tuberculosis (tuberculosis)
and Yersinia pestis (plague). Such bacteria readily meet the criteria of Koch’s postulates.
Other species are commonly part of the normal microbiota of humans (and animals) but
also can frequently cause disease. For example, E coli is part of the gastrointestinal
microbiota of normal humans but is also a common cause of urinary tract infections,
traveler’s diarrhea, and other diseases. Strains of E coli that cause disease are
differentiated from those that do not by determining (1) whether they are virulent in
animals or in vitro models of infection and (2) whether they have a genetic makeup that is
significantly associated with production of disease. Other bacteria
(eg, Pseudomonas species, Stenotrophomonas maltophilia, and many yeasts and molds)
only cause disease in immunosuppressed and debilitated persons and are opportunistic
pathogens.

TRANSMISSION OF INFECTION

Bacteria (and other microorganisms) can adapt to a variety of environments that include
external sources such as soil, water, and organic matter or internal milieu as found within
insect vectors, animals, and humans, where they normally reside and subsist. In doing so,
the bacteria ensure their survival and enhance the possibility of transmission. By
producing asymptomatic infection or mild disease rather than death of the host,
microorganisms that normally live in people enhance the possibility of transmission from
one person to another.
Some bacteria that commonly cause disease in humans exist primarily in animals and
incidentally infect humans. For example, Salmonella and Campylobacter species typically
infect animals and are transmitted in food products to humans. Other bacteria produce
infection of humans that is inadvertent, a mistake in the normal life cycle of the organism;
the organisms have not adapted to humans, and the disease they produce may be severe.
For example, Y pestis (plague) has a well-established life cycle in rodents and rodent fleas,
and transmission by the fleas to humans is inadvertent; Bacillus anthracis (anthrax) lives in
the environment, occasionally infects animals, and is transmitted to humans by products
such as raw hair from infected animals. The Clostridium species are ubiquitous in the
environment and are transmitted to humans by ingestion (eg, Clostridium
perfringensgastroenteritis and Clostridium botulinum [botulism]) or when wounds are
contaminated by soil (eg, C perfringens [gas gangrene] and Clostridium tetani [tetanus]).
Both B anthracisand the Clostridium species elaborate spores to protect the organisms’
nucleic acid from harsh environmental factors such as ultraviolet light, desiccation,
chemical detergents, and pH extremes. These spores ensure survival in external
environments including foods ingested by humans. After being ingested or inoculated, the
spores germinate into the vegetative, metabolically active form of the pathogen.
Many bacteria are transmitted from one person to another on hands. A person with
Saureus carriage in the anterior nares may rub his nose, pick up the staphylococci on the
hands, and spread the bacteria to other parts of the body or to another person, where
infection results. Many opportunistic pathogens that cause nosocomial infections are
transmitted from one patient to another on the hands of hospital personnel. Handwashing
is thus an important component of infection control.
The most frequent portals of entry of pathogenic bacteria into the body are the sites
where mucous membranes meet with the skin, which are the respiratory (upper and
lower airways), gastrointestinal (primarily mouth), genital, and urinary tracts. Abnormal
areas of mucous membranes and skin (eg, cuts, burns, and other injuries) are also
frequent sites of entry. Normal skin and mucous membranes provide the primary defense
against infection. To cause disease, pathogens must overcome these barriers.

THE INFECTIOUS PROCESS

In the body, most bacteria that cause disease do so first by attaching or adhering to host
cells, usually epithelial cells. After the bacteria have established a primary site of infection,
they multiply and spread directly through tissues or via the lymphatic system to the
bloodstream. This infection (bacteremia) can be transient or persistent. Bacteremia allows
bacteria to spread widely in the body and permits them to reach tissues particularly
suitable for their multiplication.
Pneumococcal pneumonia is an example of the infectious process. S pneumoniae can be
cultured from the nasopharynx of 5–40% of healthy people. Occasionally, pneumococci
from the nasopharynx are aspirated into the lungs; aspiration occurs most commonly in
debilitated people and in settings such as coma when normal gag and cough reflexes are
diminished. Infection develops in the terminal air spaces of the lungs in persons who do
not have protective antibodies against that particular pneumococcal capsular
polysaccharide type. Multiplication of the pneumococci and resultant inflammation lead
to pneumonia. The pneumococci enter the lymphatics of the lung and move to the
bloodstream. Between 10% and 20% of persons with pneumococcal pneumonia have
bacteremia at the time the diagnosis of pneumonia is made. When bacteremia occurs, the
pneumococci can spread to secondary sites of infection (eg, cerebrospinal fluid, heart
valves, and joint spaces). The major complications of pneumococcal pneumonia are
meningitis, septic arthritis, and rarely endocarditis.
The infectious process in cholera involves ingestion of V cholerae, chemotactic attraction
of the bacteria to the gut epithelium, motility of the bacteria by a single polar flagellum,
and penetration of the mucous layer on the intestinal surface. The V cholerae adherence
to the epithelial cell surface is mediated by pili and possibly other adhesins. Production of
cholera toxin results in flow of chloride and water into the lumen of the gut, causing
diarrhea and electrolyte imbalance.

REGULATION OF BACTERIAL VIRULENCE FACTORS

Pathogenic bacteria (and other pathogens) have adapted both to saprophytic or free-living
states, possibly environments outside the body, and to the human host. They have
evolved complex signal transduction systems to regulate the genes important for
virulence. Environmental signals often control the expression of the virulence genes.
Common signals include temperature, iron availability, osmolality, growth phase, pH, and
specific ions (e.g., Ca2+) or nutrient factors. A few examples are presented in the following
paragraphs.
The gene for diphtheria toxin from Corynebacterium diphtheriae is carried on temperate
bacteriophages. Toxin is produced only by strains lysogenized by the phages. Toxin
production is greatly enhanced when C diphtheriae is grown in a medium with low iron.
Expression of virulence genes of B pertussis is enhanced when the bacteria are grown at
37°C and suppressed when they are grown at lower temperatures or in the presence of
high concentrations of magnesium sulfate or nicotinic acid.
The virulence factors of V cholerae are regulated on multiple levels and by many
environmental factors. Expression of the cholera toxin is higher at a pH of 6.0 than at a pH
of 8.5 and higher also at 30°C than at 37°C.
Osmolality and amino acid composition also are important. As many as 20 other genes
of V cholerae are similarly regulated.
Y pestis produces a series of virulence plasmid-encoded proteins. One of these is an
antiphagocytic fraction 1 capsular protein that results in antiphagocytic function. This
protein is expressed maximally at 35–37°C, the host temperature, and minimally at 20–
28°C, the flea temperature at which antiphagocytic activity is not needed. The regulation
of other virulence factors in Yersinia species also is influenced by environmental factors.
Motility of bacteria enables them to spread and multiply in their environmental niches or
in patients. Yersinia enterocolitica and Listeria monocytogenes are common in the
environment where motility is important to them. Presumably, motility is not important in
the pathogenesis of the diseases caused by these bacteria. Y enterocolitica is motile when
grown at 25°C but not when grown at 37°C. Similarly, Listeria is motile when grown at
25°C and not motile or minimally motile when grown at 37°C.

BACTERIAL VIRULENCE FACTORS

1. Adherence Factors

When bacteria enter the body of the host, they must adhere to cells of a tissue surface. If
they did not adhere, they would be swept away by mucus and other fluids that bathe the
tissue surface. Adherence, which is only one step in the infectious process, is followed by
development of microcolonies and subsequent steps in the pathogenesis of infection.
The interactions between bacteria and tissue cell surfaces in the adhesion process are
complex. Several factors play important roles, including surface hydrophobicity and net
surface charge, binding molecules on bacteria (ligands), and host cell receptor
interactions. Bacteria and host cells commonly have net negative surface charges and
therefore repulsive electrostatic forces. These forces are overcome by hydrophobic and
other more specific interactions between bacteria and host cells. In general, the more
hydrophobic the bacterial cell surface, the greater the adherence to the host cell.
Different strains of bacteria within a species may vary widely in their hydrophobic surface
properties and ability to adhere to host cells.
Bacteria also have specific surface molecules that interact with host cells. Many bacteria
have pili, thick rodlike appendages or fimbriae, shorter “hairlike” structures that extend
from the bacterial cell surface and help mediate adherence of the bacteria to host cell
surfaces. For example, some E coli strains have type 1 pili, which adhere to epithelial cell
receptors; adherence can be blocked in vitro by addition of D-mannose to the medium. E
coli organisms that cause urinary tract infections commonly do not have D-mannose–
mediated adherence but have P-pili, which attach to a portion of the P blood group
antigen; the minimal recognition structure is the disaccharide a-D-galactopyranosyl-(1–4)-
β-D-galactopyranoside (GAL–GAL binding adhesin). The E coli that causes diarrheal
diseases have pilus (fimbriae)-mediated adherence to intestinal epithelial cells. The type
of pili and specific molecular mechanisms of adherence appear to be different depending
on the form of the E coli that induce the diarrhea.
Other specific ligand-receptor mechanisms have evolved to promote bacterial adherence
to host cells, illustrating the diverse mechanisms used by bacteria. Group A streptococci
(Streptococcus pyogenes) also have hairlike appendages, termed fimbriaethat extend from
the cell surface. Lipoteichoic acid, protein F, and M protein are found on the fimbriae. The
lipoteichoic acid and protein F cause adherence of the streptococci to buccal epithelial
cells; this adherence is mediated by fibronectin, which acts as the host cell receptor
molecule. M protein acts as an antiphagocytic molecule and is a major virulence factor.
Antibodies that act against the specific bacterial ligands that promote adherence (eg, pili
and lipoteichoic acid) can block adherence to host cells and protect the host from
infection.
After adherence occurs, conformational changes in the host cell ensue that can lead to
cytoskeletal changes allowing organism uptake by the cell. Sometimes, changes in the
adhesin molecule after attachment may trigger activation of virulence genes that promote
invasion or that result in other pathogenic changes as described in the following pages.

2. Invasion of Host Cells and Tissues

Invasion is the term commonly used to describe the entry of bacteria into host cells and
for many disease-causing bacteria, invasion of the host’s epithelium is central to the
infectious process. Some bacteria (eg, Salmonella species) invade tissues through the
junctions between epithelial cells. Other bacteria (eg, Yersinia species, N gonorrhoeae,
and Chlamydia trachomatis) invade specific types of the host’s epithelial cells and may
subsequently enter the tissue. In many infections, the bacteria produce virulence factors
that cause the host cells to engulf (ingest) the bacteria. The host cells play a very active
role in the process.
When inside the host cell, bacteria may remain enclosed in a vacuole composed of the
host cell membrane, or the vacuole membrane may be dissolved and bacteria may be
dispersed in the cytoplasm. Some bacteria (eg, Shigella species) multiply within host cells,
but other bacteria do not.
Toxin production and other virulence properties are generally independent of the ability
of bacteria to invade cells and tissues. For example, C diphtheriae is able to invade the
epithelium of the nasopharynx and cause symptomatic sore throat even when the C
diphtheriae strains are nontoxigenic.
In vitro studies with cells in tissue culture have helped characterize the mechanisms of
invasion for some pathogens; however, the in vitro models have not necessarily provided
a complete picture of the invasion process. Full understanding of the invasion process, as
it occurs in naturally acquired infection, has required study of genetically engineered
mutants and their ability to infect susceptible animals and humans. Thus, understanding
of eukaryotic cell invasion by bacteria requires satisfying much of Koch’s postulates and
the molecular Koch’s postulates. The following paragraphs contain examples of bacterial
invasion of host cells as part of the infectious process.
3. Toxins

Toxins produced by bacteria are generally classified into two groups: endotoxin, which is
present in the outer membrane of gram-negative rods, and toxins that are secreted, such
as enterotoxins and exotoxins. Enterotoxins and exotoxins are often classified by
mechanisms of action and the impact on host cells and they are discussed in more detail
below.
A. Exotoxins

Many gram-positive and gram-negative bacteria produce exotoxins of considerable

medical importance. Some of these toxins have had major roles in world history. For
example, tetanus caused by the toxin of C tetani killed as many as 50,000 soldiers of the
Axis powers in World War II; the Allied forces, however, immunized military personnel
against tetanus, and very few died of that disease. Vaccines have been developed for
some of the exotoxin-mediated diseases and continue to be important in the prevention
of disease. These vaccines—called toxoids—are made from exotoxins, which are modified
so that they are no longer toxic. Many exotoxins consist of A and B subunits (often
referred to as binary toxins or type III toxins). The B subunit generally mediates adherence
of the toxin complex to a host cell and aids entrance of the exotoxin into the host cell. The
A subunit provides the toxic activity. Examples of some pathogenetic mechanisms
associated with exotoxins are given below. Other toxins of specific bacteria are discussed
in the chapters covering those bacteria.
Type II toxins are proteins that typically affect cell membranes facilitating invasion by the
pathogen secreting them (see also Tissue-Degrading Enzymes later in the chapter).
B. Exotoxins Associated with Diarrheal Diseases and Food Poisoning
Exotoxins associated with diarrheal diseases are frequently called enterotoxins and many
belong to the type III toxin family. Characteristics of some important enterotoxins are
discussed as follows.
C. Lipopolysaccharides of Gram-Negative Bacteria

The LPS (endotoxin) of gram-negative bacteria are bacterial cell wall components that are
often liberated when the bacteria lyse. The substances are heat stable, have MWs
between 3000 and 5000 (lip oligosaccharides, LOS), and several
million (lipopolysaccharides)can be extracted (eg, with phenol-water). They have three
main regions. The lipid A domain is the region recognized by the immune system and is
the component that is responsible for cytokine stimulation (see below). The other two
components are an oligosaccharide core and an outermost O-antigen polysaccharide.
The pathophysiologic effects of LPS are similar regardless of their bacterial origin except
for those of Bacteroides species, which have a different structure and are less toxic. LPS in
the bloodstream is initially bound to circulating proteins, which then interact with
receptors on macrophages, neutrophils, and other cells of the reticuloendothelial system.
Proinflammatory cytokines such as IL-1, IL-6, IL-8, TNF-a, and other cytokines are released,
and the complement and coagulation cascades are activated. The following can be
observed clinically or experimentally: fever, leukopenia, and hypoglycemia; hypotension
and shock resulting in impaired perfusion of essential organs (eg, brain, heart, kidney);
intravascular coagulation; and death from massive organ dysfunction.
4. Enzymes

Many species of bacteria produce enzymes that are not intrinsically toxic but do play
important roles in the infectious process.
Resumen
 Animals and humans are colonized with abundant microbiota, normal commensals
that do not cause disease and are protective to the host.
 Virulent bacteria cause disease through the elaboration of factors that facilitate
adherence, persistence, invasion, and toxigenicity.
 Genes that encode virulence factors may be carried on mobile genetic elements
such as plasmids or bacteriophages or are found on large pathogenicity islands on
bacterial chromosomes.
 Pili and fimbriae are rod like or hair like structures, respectively, that facilitate
attachment to host cells.
  Invasion of host cells is a complex mechanism that involves elaboration of proteins
that facilitate entry.
 Bacterial toxins may be extracellular (exotoxins) or are a component of the
bacterial cell membrane (endotoxin, LPS) and are among the most powerful toxins
in nature (eg, botulinum toxin).
 Other mechanisms important to bacterial survival and virulence include tissue-
degrading enzymes, antiphagocytic factors, IgA proteases, antigenic heterogeneity,
and the ability to chelate iron.
 There are at least seven known bacterial secretion systems, protein complexes, or
channels that ensure transport of structural and toxigenic proteins through the
bacterial cell after translation.
EPIDEMOLOGY
La epidemiología, palabra derivada del griego epi (sobre) demos (pueblo) y logos (ciencia),
es una disciplina científica en el área de la biología y medicina que estudia
la distribución, frecuencia, factores determinantes, predicciones y control de los factores
relacionados con la salud y las enfermedades existentes en poblaciones humanas
definidas. Más sencillamente Rich la describió acertadamente en 1979 como la ciencia que
estudia la dinámica de salud en las poblaciones.

Epidemiology is concerned with the identification, measurement, and analysis of factors

that may be associated with differences in the health status of populations. The goal of
such investigations is to modify these factors to improve the health status of
individuals. Classical epidemiology is focused on populations, seeks to identify risk factors,
and has been described as the “basic science” of public health Therefore, some familiarity
with epidemiologic methods is essential to the understanding of public and global health.
The public health approach can be illustrated by the epidemiologic triad as applied to
malaria:
According to this model, disease arises through interactions between a host, environment,
and agent. In the case of many infectious diseases, a vector through which the agent is
transmitted is also relevant. This model allows opportunities for the interruption of
disease transmission to be clarified. For example, in the case of malaria, opportunities
might include the use of insecticide-treated bed-nets for the host, reduced areas of
standing water in the environment, destruction of the Anopheles mosquito vector through
pesticides, and chemoprophylaxis targeted at the plasmodium.
Note that the public health model takes a very broad view of what constitutes a risk factor
for disease. Whereas a traditional biomedical paradigm tends to focus on a small number
of causes for a disease, such as a specific microorganism, public health considers more
diverse social, economic, and environmental factors as playing a potentially causative role
in disease development, each offering an opportunity for intervention.
Indeed, there are potentially an infinite number of causative factors, each acting at
various points along a timeline as shown in the next figure, which depicts two such factors
for simplicity. For each factor, there is an induction period between when that factor acts
and when the disease is initiated. After disease initiation, there follows a latent
period corresponding to a preclinical phase before the disease is recognized. Preventive
strategies can be placed into three groups based on this chronology. The preferred
approach is always primary prevention because interventions are made prior to disease
initiation, such as vaccination to confer immunity to measles. Screening is by definition a
form of secondary prevention as it attempts to identify asymptomatic individuals with
disease with the intent of improving treatment outcomes through earlier intervention.
Lastly, tertiary prevention does not alter the full manifestation of a disease but seeks to
limit the long-term sequelae. Such measures might include physical and occupational
therapy following a stroke resulting in hemiplegia.

Although the distinction between epidemiology and biostatistics is not always apparent,
biostatistics has a relatively greater emphasis on data gathering and analysis. Accordingly,
this field provides a variety of measures used to quantify both disease outcomes
(morbidity) and death (mortality). Further, biostatistics offers methods to examine the
relationships between variables, especially whether such relationships could have arisen
purely as a result of chance, a procedure known as statistical inference.
SUMMARY
Epidemiology is often described as the basic science of public health, and some familiarity
with this field is essential to the understanding of causes of disease in global health and to
guide preventive strategies. Biostatistics provides important measures of morbidity and
mortality that serve as indicators of the overall health status of populations and countries.
However, a variety of different techniques are needed, such as stratification and survival
analysis, to provide greater insight when comparisons are made.
Several study designs are available, each with advantages, disadvantages, and practical
limitations. When a disease association is reported by a study, it is important to first
address the roles of chance, bias, and confounding as potential explanations. If these
three factors are not felt to account for the association, in whole or in part, the
association is considered valid. Additional criteria are applied to determine if the
association is causal.
Epidemiology has important applications in the management of infectious disease and the
early detection of disease through screening and surveillance. Because primary prevention
of disease is always preferred, epidemiology and biostatistics provide very powerful tools
in global health.
Cybergrafia
 https://es.wikipedia.org/wiki/Bacteria
 https://www.merriam-webster.com/dictionary/medical
 http://aplicacionesbiblioteca.udea.edu.co:2351/book.aspx?bookid=1551
 https://es.wikipedia.org/wiki/Epidemiolog%C3%ADa
 https://www.eupati.eu/es/farmacoepidemiologia-es/conceptos-epidemiologicos-
incidencia-y-prevalencia/
 http://aplicacionesbiblioteca.udea.edu.co:2351/content.aspx?sectionid=4679690
4&bookid=710&Resultclick=2#57931606