Gram-Negative Rods Related to the Enteric Tract

PATHOGENS BOTH WITHIN & OUTSIDE THE ENTERIC TRACT

Escherichia
Salmonella

PATHOGENS PRIMARILY WITHIN THE ENTERIC TRACT

Shigella
Vibrio
Campylobacter
Helicobacter

PATHOGENS OUTSIDE THE ENTERIC TRACT

Klebsiella
Proteus

Enterobacteriaceae
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).
PATHOGENS BOTH WITHIN & OUTSIDE THE ENTERIC TRACT
Escherichia
Salmonella

Escherichia coli (Intestine bacteria)

E. coli is the most common cause of urinary tract infection and gram-
negative rod sepsis. It is one of the two important causes of neonatal
meningitis and the agent most frequently associated with “traveler’s
diarrhea,” a watery diarrhea. Some strains of E. coli are
enterohemorrhagic and cause bloody diarrhea. Escherichia coli (E.
coli) bacteria normally live in the intestines of people and animals.
Most E. coli are harmless and actually are an important part of a
healthy human intestinal tract.
 Gram-negative, motile
 Facultative anaerobe
  Non-sporulating

Virulence factors include the following:

1) Mucosal interaction:
 Mucosal adherence with pili(colonization factor).
 Ability to invade intestinal epithelial cells.
2) Exotoxin production:
 pore-forming cytotoxin
 cytotoxic necrotizing factor (CNF)
 Heat-labile and stable toxin (LT and ST).
 Shiga-like toxin.
3) Endotoxin: Lipid A portion of lipopolysaccharide (LPS).
4) Iron-binding siderophore: obtains iron from Human transferrin or
lactoferrin.

Classification
 Shiga toxin-producing E. coli (STEC)- Shiga toxin-producing
Escherichia coli (STEC) are food-borne pathogens whose source
is most often the digestive tract of ruminants. Ingestion of
ruminant-derived raw products, such as uncooked meat or raw
milk dairy products, contaminated with STEC may result in a
human infection. STEC infections are most often diagnosed
through laboratory testing of stool (poop) specimens.
 Enterotoxigenic E. coli (ETEC)- Enterotoxigenic Escherichia coli
(E. coli), or ETEC, is an important cause of bacterial diarrheal
illness. Infection with ETEC is the leading cause of travelers'
diarrhea. ETEC is transmitted by food or water contaminated
with animal or human feces. Infection can be prevented by
avoiding or safely preparing foods and beverages that could be
contaminated with the bacteria, as well as washing hands with
soap frequently.

 Enteropathogenic E. coli (EPEC)- Two groups of E. coli are

responsible for enteric disease (Enteropathogenic E. coli [EPEC]
and some Shiga toxin–producing E. coli [STEC]) possess a
cluster of virulence genes located on a chromosomal
pathogenicity island called the locus of enterocyte effacement
(LEE).
 EPEC frequently causes infantile diarrhea (outbreaks) and
occasionally cause sporadic diarrhea in adults.
 Disease is transmitted by fecal-oral exposure to contaminated
surfaces or food products. Person-to-person spread is seen.

 Enteroaggregative E. coli (EAEC)- Enteroaggregative E coli

(EAEC) is associated with a protracted (>14 days) watery
diarrhea occasionally with blood and mucus. The pathogenesis
of diarrhea involves formation of a thick mucus–bacteria
biofilm on the intestinal surface.
 This view of EAEC was dramatically altered by a 2011 German
outbreak.There were a thousand cases of bloody diarrhea and
53 deaths due to hemolytic-uremic syndrome HUS.

 Enteroinvasive E. coli (EIEC)- Enteroinvasive E. coli (EIEC)

strains are rare in both developed and developing countries.
  Pathogenic strains are primarily associated with a few
restricted O serotypes: O124, O143, and O164.
 The strains are closely related by phenotypi and pathogenic
properties to Shigella.
 The bacteria are able to invade and destroy the colonic
epithelium, producing a disease characterized initially by
watery diarrhea.

E. Coli Infection symptoms and Diagnosis

Typically E. coli infection begins with severe stomach cramps and

watery diarrhea, that often turns into bloody within a few days.
 Vomiting
 Nausea
 Headaches
 Little or no Fever

Diagnosis
 Physical examination
 Stool analysis
 Toxin detection -PCR
 Blood test (CBC)
 Creatinine- for kidney function

E. Coli Infection treatment

Treatment depends on the severity of the disease. Patients,
especially healthy adults, often require no treatment. Moreover, for
the acute diarrheal illness, antibiotics have not proven useful. use of
atropine and diphenoxylate (Lomotil), drugs that are commonly
used to control diarrhea, also may increase symptoms and trigger
complications.
In summary, mild infections are treated with the following:
 Rest
 Fluid intake
 Rarely, antibiotics
Antibiotics may shorten symptoms for ETEC, EIEC, and EPEC
Antibiotics may increase risk of HUS in EHEC

Treatment in an Intensive care unit (ICU)

 Intravenous fluids and electrolytes
 trimethoprim/sulfamethoxazole (TMP-SMX) or
fluoroquinolones
 Selection of other antimicrobials must be guided by
antimicrobial susceptibility testing of the patient’s isolate.

Salmonella
There are more than 2500 serotypes of salmonellae. There are three
types of Salmonella infections: enterocolitis, enteric fevers,and
bacteremia with focal lesions.
Four serotypes of salmonellae that cause enteric fever can
beidentified in the clinical laboratory by biochemical and serologic
tests. They are as follows:
 Salmonella Paratyphi A (serogroup A)
 Salmonella Paratyphi B (serogroup B)
  Salmonella Choleraesuis (serogroup C1)
 S Typhi (serogroup D).
Salmonella serotypes Enteritidis and Typhimurium are the two most
common serotypes.

Sources of Infection
The sources of infection are food and drink that have been
contaminated with salmonellae. The following sources are
important:
 Water—Contamination with feces often results in explosive
epidemics
 Milk and other dairy products
 Shellfish—From contaminated water
 Dried or frozen eggs—From infected fowl or contaminated
during processing
 Meats and meat products
 “Recreational” drugs—Marijuana and other drugs
 Animal dyes—Dyes (eg, carmine) used in drugs, foods, and
cosmetics
 Household pets—Turtles, dogs, cats…

Enteric (Typhoid) Fever

Pathogenesis
After the ingestion of contaminated food or water, the Salmonella
bacteria invade the small intestine and enter the bloodstream
temporarily. The bacteria are carried by white blood cells in the liver,
spleen, and bone marrow, where they multiply and reenter the
bloodstream.
Symptoms
 Fever 39° to 40° C
 Headache
 Stomach pain
 Diarrhea
 Red skin rash
 Weakness
 Bradycardia
 myalgia
 spleen and liver become enlarged
 WBC count normal or low.

Diagnosis
 Blood test for culture
 WIDAL test- (demonstration of Salmonella antibodies against
antigens O and H)
 Stool and Urine test for culture
 Differential medium culture
 Nucleic acid amplification test

Incubation period- 10-14 days

Treatment Antimicrobial therapy of invasive Salmonella infections is

with Ampicillin ,trimethoprim–sulfamethoxazole Or a third-
generation cephalosporin.
PATHOGENS PRIMARILY WITHIN THE ENTERIC TRACT
Shigella
non- Enterobacteriaceae pathogens:
Vibrio
Campylobacter
Helicobacter

Shigella
Shigella is a genus of bacteria that is Gram-negative, facultative
anaerobic, non-spore-forming, nonmotile, rod-shaped, and
genetically closely related to E. coli. Shigella does not ferment lactose
and does not produce H2S.These properties can be used to
distinguish Shigella from Escherichia coli (lactose fermenter) and
Salmonella (non-lactose fermenter, produces H2S).
Shigella species are classified by three serogroups and one serotype:
Serogroup A: S. dysenteriae (15 serotypes)
Serogroup B: S. flexneri (9 serotypes)
Serogroup C: S. boydii (19 serotypes)
Serogroup D: S. sonnei (one serotype)

Shigellosis
Shigellosis is an infectious disease caused by various species of
Shigella. People infected with Shigella develop diarrhea, fever and
stomach cramps starting a day or two after they are exposed to the
bacterium. The diarrhea is often bloody. Shigellosis usually resolves
in 5 to 7 days, but in some persons, especially young children and the
elderly, the diarrhea can be so severe that the patient needs to be
hospitalized.

Treatment
Shigellosis can usually be treated with antibiotics. The antibiotics
commonly used are ampicillin, trimethoprim/sulfamethoxazole
(also known as Bactrim or Septra), nalidixic acid and the
fluoroquinolone, ciprofloxacin.

Reiter's syndrome
Persons with diarrhea usually recover completely, although it may be
several months before their bowel habits are entirely normal. About
3% of persons who are infected with Shigella flexneri may
subsequently develop pains in their joints, irritation of the eyes, and
painful urination. This condition is called Reiter's syndrome. It can
last for months or years, and can lead to chronic arthritis which is
difficult to treat.

Hemolytic Uremic Syndrome (HUS)

Hemolytic uremic syndrome (HUS) can occur after S. dysenteriae
type 1 infection.

VIBRIO
curved, comma-shaped, gram-negative rods
V. cholerae, the major pathogen in this genus, is the cause of cholera
  V. cholerae is transmitted by fecal contamination of water and
food, primarily from human sources.
 The main animal reservoirs are marine shellfish, such as shrimp
and oysters.
The pathogenesis of cholera is dependent on colonization of the
small intestine by the organism and secretion of enterotoxin-
cholera toxin.
Treatment - consists of prompt, adequate
replacement of water and electrolytes,
either orally or intravenously. Antibiotics
such as tetracycline are not necessary,
but they do shorten the duration of symptoms
and reduce the time of excretion of the
organisms.

CAMPYLOBACTER
 Campylobacters are curved, gram-negative rods that appear
either comma- or S -shaped.
 Domestic animals such as cattle, chickens, and dogs serve as a
source of the organisms for humans. Transmission is usually
fecal–oral. Food and water,contaminated with animal feces are
the major sources of human infection

It has one pathogen C.jejuni and it causes bloody

diarrhea,dysentery,abdominal pain and thus is caused by damage
of the gut epithelium by C.jejuni and this pathogen also causes
autoimmune disease Guillain-barre syndrome

Treatment
Erythromycin or ciprofloxacin is used successfully in C. jejuni
enterocolitis.

HELICOBACTER
urease-positive curved gram-negative rods, microaerophilic, spiral
(helical) bacterium usually found in the stomach.
H.pylori infection is one of the most common worldwide human
infections.
Is associated with a number of important upper GI conditions:
 Chronic gastritis
 Peptic ulcer disease
 Gastric malignancy

Symptoms
 Abdominal pain
 Mild nausea
 Irritable bowel syndrome
 Anemia
 Gastric reflux
Treatment
In gastritis we use clarithromycin,amoxicillin
In peptic ulcer we use metronidazole
PATHOGENS OUTSIDE THE ENTERIC TRACT
Klebsiella
Proteus

Klebsiella
Klebsiellae are nonmotile, rod-shaped, gram-negative bacteria with
a prominent polysaccharide capsule. Members of the Klebsiella
genus typically express 2 types of antigens on their cell surface.
 lipopolysaccharide (O antigen);
 capsular polysaccharide (K antigen).
Both of these antigens contribute to pathogenicity.
Three species in the genus Klebsiella are associated with illness in
humans:
 Klebsiella pneumoniae
 Klebsiella oxytoca
 Klebsiella granulomatis.
Klebsiella organisms can lead to a wide range of disease states,
notably pneumonia, urinary tract infections, sepsis, meningitis,
diarrhea, peritonitis and soft tissue infections,wound infection,uti
infection.
Treatment – we use carbapenems

Proteus
Proteus species are part of the Enterobacteriaceae family of gram-
negative “swarming” bacilli. Proteus species are most commonly
found in the human intestinal tract as part of normal human
intestinal flora. Three species are important pathogens:
 Proteus mirabilis
 Proteus vulgaris
 Proteus panneri
It causes uti infections,kidney stones
Treatment
We use ampicillin and cephalosporins