Genus

Salmonella

Typhoid (Enteric Fever)

- S. typhi - S. paratyphi A - S. paratyphi B

Characteristics
- Gram-negative rods - Motile

- Non-sporing rods - All except S. typhi are non-capsulate

- Aerobic and anaerobic respiration

Transmission
- Ingestion of contaminated food or water poultry, eggs, meat, milk and cream
- Person to person via fecal-oral route - Mechanically by flies

Clinical Picture Of Enteric Fever

- Nausia, vomiting, diarrhea - Fever

- Abdominal pain or cramping - Tenderness, Muscle pain,

- Chills

Pathogenesis
- Organism enter intestine, multiply in Peyers patches

Carried to mesentric lymph glands, liver, and spleen

Bacteraemia (antibodies developed in the first week)

Laboratory identification
1-Direct isolation - Blood in first week (blood culture) - Stool in 3rd week 2- Blood Culture in broth at 37 C for 24 h . Subculture on Mac-Conkey show pale yellow colonies in positive cases, . Staining with gram: Gm ve bacilli 3-Biochemical identif. by API Bile tolerant , Oxidase -ve . Non-lactose -fermenters . Fermentation of glucose with acid and gas 4-Serology: Detection of circulating antibodyin 2nd week (Widal test)

Treatment
- S. typhi and S. paratyphi infections Systemic antibiotics based on: susceptibility tests - Chloramphenicol - Ampicillin

- Sulfamethoxazole
- Oral amoxicillin

Prevention
- Interrupting fecal-oral transmission - Eliminating opportunities for transmission via the food chain - Vaccines are available to protect against S. typhi and S. paratyphi (TAB Vaccine)

GENUS SHIGELLA

GENUS SHIGELLA
Contains four species of importance to man) - S. dysenteriae

- S. boydii
- S. flexneri - S. sonnei

Shigellosis
Disease:
Bacillary dysentery Shigella enteritis

Shigella gastroenteritis

Characteristics

Gram-negative rods Non-motile (in contrast to salmonellae) Non-capsulate

Aerobic and anaerobic respiration

Transmission

Fecal-oral route
Contaminated food

Clinical Picture
- Acute abdominal pain or cramping

- Tenesmus (crampy rectal pain)

- Watery diarrhea (blood, mucus, or pus in stool) - Nausea and vomiting - Fever - Dehydration

Pathogenesis

Invasion of ileum and colon causes damage, which results in diarrhea S. dysenteriae produces an exotoxin (Shiga toxin) causing damage to intestinal epithelial cells In fewer instances, the toxin results in damage to glomerular endothelial cells, leading to hemolytic uremic syndrome (HUS)

Laboratory Identification
1- Direct isolation (Stool or vomit) 2- Culture on Mac-Conkey show pale yellow colonies in positive cases, Gm ve bacilli 3-Biochemical identification by: API, bile-tolerant, non lactose -fermenters 4-Serology: serologic tests for O antigens.

Treatment

Antibiotic therapy: Fluoroquinolones, Trimethoprim-sulfamethoxazole Ciprofloxacin Chloramphenicol Antibiotic Susceptibility testing is important Electrolytes (salt and minerals) Intravenous fluids, especially in children

Prevention
- Depends upon interrupting fecal-oral spread - Hand hygiene important - No vaccine available

PROTEUS

Characteristics

Gram-negative rod

Non-fastidious
Facultative anaerobe Likes alkaline pH

Characteristic unpleasant odor

Highly motile, swarms on some media

P. mirabilis and P. vulgaris

Diseases: - Normal habitat is human gut, soil and water - Urinary tract infection (UTI) - Hospital-acquired wound infection - Septicemia - Pneumonia in compromised host Transmission: - Contact spread - Infection often endogenous

Laboratory Identification

Staining: Gm stain (Gm ve bacilli, pleomorphic) Biochemical identification (API): Non Lactose fermenter produces urease P. mirabilis, indole-negative P. vulgaris, indole-positive Serologic : response to Proteus infection not useful diagnostically

Laboratory Identification
P. vulgaris strains OX-19, OX-2 and OX-K share antigens with rickettsiae in the typhus and spotted fever groups and are agglutinated by antibodies produced by patients with these rickettsial infections (Weil-Felix test)

Pathogenesis and virulence factors

Endotoxin

Urease

Treatment and prevention

- Treatment P. vulgaris commonly more resistant to antibacterials than P. mirabilis - Prevention . Good aseptic technique in hospitals . No vaccine available

ENTEROBACTERIACEAE
Lactose Fermenter

* E. coli * Klebsiella * Citrobacter

ESCHERICHIA COLI (E. coli)

Characteristics
- Gram-negative rod
- Motile - With or without capsule - Non-fastidious - Facultative anaerobe - Capable of growth at 44C

Diseases
- Urinary tract infection - Diarrheal diseases - Neonatal meningitis

Transmission
Normal habitat : - Gut of man and animals - Colonize lower end of urethra and vagina Spread by: - Contact - Ingestion (fecal-oral route) - Endogenous

Pathogenesis and Virulence factors

- Endotoxin: present in all strains - Adhesins (pili): associated with urinary tract infection - Colonization factors: (e.g. CFA I, II and III) associated with gastrointestinal tract infection - K1 capsular type: associated with neonatal meningitis - Enterotoxins associated with diarrheal disease: ETEC (enterotoxigenic E. coli) EIEC (enteroinvasive E. coli) EHEC (enterohemorrhagic E. coli)

Laboratory Identification
- Gram staining: gram ve bacilli - Culture: Mac Conkeys media Lactose fermenter - Biochemical reaction: API for full identification

Treatment and prevention

- Antibacterial agents determined by susceptibility testing - Specific treatment of diarrheal disease usually not required

- No currently available vaccine

Klebsiella

Characteristics
- Normal habitat is gut of man and animals and moist

inanimate environments - Gram-negative rods, sometimes

- Capsulate (usual for Klebsiella)

- Non-fastidious growth requirements - Capable of aerobic and anaerobic

Diseases
- Upper respiratory tract infection - Urinary tracts infection - Opportunist infections in hospitalized host

Transmission
- Infection may be endogenous
- Contact spread - Hospital-acquired infection

Pathogenesis And Virulence Factors

- Endotoxin - Fimbriae - Capsules

Laboratory Identification
- Gram staining: Gm ve bacilli - Culture: Grow readily on routine laboratory media - Biochemical reactions: (API) - Lactose-fermenting - Bile-tolerant organisms - Oxidase negative - Serology: Detection of circulating antibody techniques

Treatment and prevention

- Antibiotic determined by susceptibility tests

* Prevention:
- Aseptic techniques

- Hand washing in hospitals

PSEUDOMONAS AERUGINOSA

Characteristics
- Aerobic Gram-negative rod - Motile by means of polar flagella

Diseases

Skin and burns infections Pneumonia in intubated patients Urinary tract infections Septicemia Osteomyelitis Endocarditis

Transmission Contact spread, directly or indirectly from these environmental sites

Pathogenesis and virulence factors

- Endotoxin and exotoxin A

- Extracellular polysaccharide capsule

- Pigments may have a role in pathogenicity

Laboratory Identification
- Gram Staining: Gm ve bacilli

- Culture:
- Grows readily on Mac Conkey - Produces : . Irregular iridescent colonies . Characteristic smell - Most strains produce: . Blue-green pigment (pyocyanin) . Yellow-green pigment (pyoverdin)

- Biochemical tests: (API) - Serology: Detection of circulating antibody

Treatment and prevention

- Combination antimicrobial chemotherapy based on susceptibility testing - Aminoglycoside and beta-lactam antibiotic * Prevention - Avoidance of: unnecessary or prolonged broad spectrum antibiotic treatment and prophylaxis

Genera Of Curved Gram-Negative Rods

Genera of Curved Gram-Negative Rods

- Vibrio
- Campylobacter - Helicobacter

GENUS VIBRIO V. cholerae

Characteristics Curved Gram-negative rods

Highly motile Facultatively anaerobic

NaCl tolerant; some salt-requiring

V. cholerae

Diseases
* Organism: V. cholerae, V. parahaemolyticus * Diseases: - Cholera - Diarrheal disease

* Transmission: Contaminated water or food

Clinical Picture

Cholera: Sudden onset of watery diarrhea (rice water stool) Diarrhea has a "fishy" odor Abdominal cramps

Nausea
Vomiting Rapid dehydration collapse and shock, death within 2 days
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Pathogenesis
- Mucinase - Adhesins - Enterotoxin

- V. parahaemolyticus produces cytotoxin

Laboratory Identification
Staining: simple microscopic examination of stool for
detection of vibrios

Culture: - alkaline peptone

- thiosulfate citrate bile salts sucrose (TCBS) medium (yellow or green colonies)

Biochemical kits: (API)

Serology: Detection of circulating antibody

Treatment
- Fluid replacement (oral rehydration therapy: ORT) - Antibiotics - Tetracycline - Chloromphinicol - Streptomycine

Prevention & Prophylaxis

Prevention
- water supply (Chlorinated) - Adequate sewage disposal - Adequate cooking of sea food

Prophylaxis
- Cases isolation - Heat killed vaccination with (Kolls vaccine)

GENUS CAMPYLOBACTER

GENUS CAMPYLOBACTER

primarily pathogens of animals several species also infectious species in man 1- Campylobacter jejuni 2- Campylobacter coli

Characteristics:
- Slender - Curved Gram-negative rods - Motile - Microaerophiles

Diseases
- C. jejuni is a major cause of bacterial gastroenteritis - C. coli also causes gastroenteritis - Diarrhea, septicemia

Transmission
- Animal reservoir

- Contaminated food and milk

- Person to person spread rare

Pathogenesis
- Cytotoxin
- Invasion (local destruction of gut mucosa)

Laboratory Identification
Require enriched media and moist microaerophilic environment (10 % O2) for growth. Incubation at 42C for 24-72 h. Colonies resemble water Full identification by biochemical tests

Treatment
- No specific treatment necessary for diarrhea - Erythromycin for invasive disease.

Prevention:
- Good food hygiene - No vaccine

HELICOBACTER PYLORI

Helicobacter pylori
Characteristics: - Slender - Curved Gram-negative rods

- Motile
- Microaerophiles

Diseases Of Helicobacter pylori

- Gastritis and duodenal ulcers - Gastrointestinal tract infections - Gastric carcinoma

Transmission:
- Person-to-person transmission (fecal-oral) likely - Infections observed in multiple family members

Pathogenesis
- Little known - Both bacterial and host factors involved

- Protease affects gastric mucosa

- Urease produces ammonia and buffers stomach acid - Some invasion of intestinal epithelium

Laboratory Identification
- Culture: - Eenriched media - Moist microaerophilic (10% O2) for growth - Biochemical tests: Differentiated from Campylobacter by tests such as nitrate reduction (C. jejuni, positive; H. pylori, negative) and urease (C. jejuni, negative; H. pylori, positive) - Serology: Detection of circulating antibody

Treatment
- Clarithromycin - Metronidazole - Tetracycline

GRAM-NEGATIVE NON-SPORE-FORMING ANAEROBES

Bacteroides (Fusobacterium)
B. Fragilis
The most important non-sporing anaerobe causing infection

Characteristics

- Gram-negative anaerobic rods or coccobacilli - Capable only of anaerobic respiration

- Non-spore forming
- non-motile

Diseases
Intra-abdominal sepsis Liver abscesses Aspiration pneumonia Brain abscesses Wound infections

Transmission
- Endogenous infection - Arising from contamination by gut contents or feces is most common route of acquisition

Pathogenesis
- Polysaccharide capsule production - Enzymes

Prevention
- Use of prophylactic antibiotics important in abdominal surgery

Laboratory Identification

Grows on blood agar incubated anaerobically Cultures have a foul odor Biochemical tests, API

Treatment

Metronidazole

PLEOMORPHIC GRAM-NEGATIVE RODS

* Pleomorphic bacteria (different shapes) - HAEMOPHILUS

- BORDETELLA
- BRUCELLA

GENUS HAEMOPHILUS
- The genus contains many species: - These are of medical importance 1- H. influenzae

2- H. ducreyi
3- H. aegyptius

HAEMOPHILUS INFLUENZAE H. influenzae

Characteristics - Small Gram-negative rods (coccobacillary)
- Non-motile - Fastidious, capnophilic, facultative anaerobe

- May be capsulate
- Six antigenically distinct capsular types recognized (a-f). Type b has been most frequently in disease

Diseases
- Capsular type b H. influenzae causes meningitis, osteomyelitis, epiglottitis, otitis - Non-capsulate strains associated with acute exacerbations of chronic bronchitis

Transmission
- Normal habitat is upper respiratory tract in humans
- Transmitted from person to person by airborne route

Laboratory Identification

Grows on blood containing enriched media Requires both hematin (X factor) and NADP (V factor) for growth (other species require one factor only). Capsulate organisms can be agglutinated by specific antisera and detected directly (e.g. by latex agglutination)

Pathogenesis

Polysaccharide capsule
Outer membrane proteins Endotoxin

Treatment
- Ampicillin (or amoxicillin) may be used if isolates are susceptible - Third generation cephalosporin (e.g. cefotaxime or ceftriaxone) are usual alternatives.

Prevention
- All children should be immunized with Hib vaccine. - Rifampicin prophylaxis recommended for close contacts of Haemophilus

HAEMOPHILUS
2- H. ducreyi:
- Disease: Chancroid (soft chancre) - sexually transmitted disease - Genital tract infection - Painful genital ulcers

3- H. aegyptius :
- cause conjunctivitis (pinkeye)

GENUS BORDETELLA

B. pertussis
Characteristics
- Small Gram-negative coccobacilli - Slow growing and fastidious in its growth requirements

Whooping cough (pertussis)

* Clinical picture: (Two phases)
- Cattarrhal phase:
- Rhinorrhoea, mild conjunctival injection, malaise, mild fever, dry nonproductive cough

- Paroxysmal phase:
- Violent cough - Episodes of violent cough are followed by a whoop on inspiration

* Transmission:
- Spread by airborne route from cases

Pathogenesis
- Tracheal cytotoxin - Fimbrial antigen - Endotoxin - Irritation of surface epithelium of trachea and bronchi and interfere with ciliary activity - There is no blood invasion

Laboratory Identification
- Requires enriched medium (e.g. Bordet-Gengou or blood charcoal agar) - Fails to grow on routine blood agar (i.e. 5-7% blood) - Requires 3-7 days incubation in moist atmosphere - Further identification by reaction with specific antisera

Treatment and Prevention

Erythromycin is the drug of choice for cases and close contacts of whooping cough Antibacterial therapy has little effect on clinical cases but reduce infectivity and incidence of superinfection

Prevention:
- Whole cell inactivated vaccine - Administered to young children -Three doses together with diphtheria and tetanus toxoids

Genus Brucella

Genus Brucella
Four species are most often found causing human zoonotic infections - B. abortus from cattle - B. suis from pigs - B. canis from dogs - B. melitensis from goats

Characteristics
- Small Gram-negative coccobacilli - Intracellular pathogens - Some strains slow-growing and fastidious, requiring complex growth media - Growth enhanced by erythritol in placenta of animals (not in man).

Diseases
- Undulant fever (brucellosis)
- Patients frequently present with FUO - Infection become chronic if not adequately treated

* Transmission
Zoonotic infections transmitted to man through: - Consumption of contaminated milk or other unpasteurized dairy products - Direct contact (occupational hazard for veterinarians and farmers)

Pathogenesis
-Virulence associated with ability to survive intracellularly -Especially in bone marrow, liver and spleen

- Thus 'hide' from host defenses

- Erythritol accounts for tropism of organism to placenta and fetus of animals - This is not true in humans

Laboratory Identification
- Isolation from blood cultures by use of biphasic media (Castenada bottles containing broth and agar) - Incubation in CO2 environment (3-5 days) Strains of B. abortus may take up to 4 weeks - Identification is by biochemical - Examination of patient's serum for antibodies

Treatment
- Doxycycline alone or in combination (e.g. with streptomycin or rifampin) - Tetracyclines may not be tolerated during long treatment courses required (combinations with fluoroquinolone or trimethoprim-sulfamethoxazole)

Recrudescence of infection is common

Prevention
* Elimination the disease from domestic animals by:

- Pasteurization of milk

- Vaccination is available for persons at risk

SPIRAL BACTERIA
Three genera of medical importance: - Treponema

- Leptospira - Borrelia

GENUS TREPONEMA

Regularly coiled spirochetes with a longer wavelength than Leptospira Several species and subspecies are important human pathogens; others are members of the normal flora, especially in the mouth T. pallidum and its subspecies pertenue, and T. carateum are the most important sp.

Characteristics
- T. pallidum is too small to visualize by direct

light microscopy

- Films from exudates stained with Giemsa or fontana stains - Direct immunofluorescent staining - Cells are motile by means of flagella

Histology: Treponema pallidum - testis infected rabbit

Diseases
- T. pallidum: syphilis

- T. pertenue and T. carateum: non-sexually transmitted treponematoses, yaws and pinta

Transmission
- T. pallidum is spread by close sexual contact

- Materno-fetal route: congenital syphilis

- Yaws and pinta spread by direct contact from infected skin lesions

Pathogenesis
- T. pallidum unable to grow in artificial media - Disease presents in three stages: . Primary stage: after 4-5 w (chancre) . Secondary phase: 6-12 w - Mucous patches in mouth - Condylomata at anal orifice and vulva

. Tertiary phase: - Chronic granuloma (gummata) in skin, bones, or internal organs - Nervous manifestation - Cardiovascular affection

Laboratory Identification
- T. pallidum cannot be grown in artificial media - Primary stage: Microscopic examination of fluid from primary lesions (Chancer) - Secondary and third stages: Serological identification

Treatment and Prevention

- Penicillin is the treatment of choice for syphilis - Tetracycline to penicillin-allergic patients Prevention - Detection and treatment of cases - Contact tracing - Serologic testing of pregnant women

GENUS LEPTOSPIRA

Two species: - L. interrogans is parasitic - L. biflexa contains free-living species

Within the species interrogans there are several different serogroups responsible for disease in humans and animals

LEPTOSPIRA INTERROGANS
Characteristics Finely coiled spirochetes with hooked ends. Cells 0.1-0.2 m in diameter, up to 20 m in length

Not visible by direct light microscopy unless stained by silver impregnation or immunofluorescent methods
Dark ground (darkfield) microscopy reveals rotational and directional motility by means of periplasmic flagella

Diseases

Leptospirosis or Weil's disease in humans and animals

Transmission
Leptospirosis in humans is a zoonosis, usual hosts being rodents, cattle, sheep, goats Leptospires excreted in urine contaminate food and water Infection occurs by contact through occupation (e.g. sewer workers, farmers) Organisms may penetrate unabraded skin and conjunctiva

Pathogenesis

After initial invasion there is hematogenous spread before the organisms localize in various organs including liver and kidney
Subclinical infection is common in endemic areas

Laboratory Identification

Direct microscopy of blood and urine but difficult to interpret Leptospira can be grown, with difficulty, in special serum-containing media Serologic diagnosis is usual

Treatment and Prevention

- Penicillin - Doxycycline
(in penicillin-allergic patients)

GENUS BORRELIA

Two species are of importance in humans: - B. recurrentis causes relapsing fever - B. burgdorferi causes Lyme disease

Characteristics
- Less finely coiled than the leptospires - Cells 0.2-0.5 m in diameter - stain readily, visible by light microscopy

Laboratory Identification

Microaerophilic Complex nutritional requirements Long growth time (weeks) thus culture is not routinely used for identification B. recurrentis demonstrated in blood smears by staining with Giemsa or acridine orange B. burgdorferi much more difficult to visualize Culture from biopsy material possible Diagnosis usually by serology

Borrelia burgdorferi and Lyme disease

Diseases
- Relapsing fever

- Lyme disease is slowly progressive Characteristic 'bull's eye' skin lesion (erythema chronicum migrans) Joint pains and fatigue

Transmission
- B. recurrentis spread from person to person by lice - Lyme disease is transmitted to humans by ticks

Lyme Disease erythematous rash

Ixodes scapularis, tick vector for Lyme disease. Also known as Ixodes dammini. CDC

Pathogenesis

Little known about pathogenesis of either disease Antigen switching in B. recurrentis presumably allows evasion of host's antibody response

Treatment and Prevention

- Doxycycline - Erythromycin and penicillin

Prevention
avoiding contact with vectors (protective clothing for walkers and forestry workers)

RICKETTSIAE
Characteristics
- Pleomorphic coccobacilli
- They do not stain well with grams stain - These organisms have requirement for coenzyme A, NAD and ATP

- Obligate intracellular parasites

- They need to be grown in cell cultures or experimental animals

Diseases
Typhus; Rocky Mountain, Mediterranean and other spotted fevers; Q fever

Transmission

- Maintained in animal reservoirs transmitted by bites of ticks, fleas, mites, lice - Coxiella burnetii (Q fever) survives drying and is transmitted in aerosols from animals or materials contaminated by infected animals and inhaled

Pathogenesis

Mechanisms unclear

Organisms have a predilection for endothelial cells, giving rise to characteristic primary skin lesion (spotted fevers) and vasculitis
The intracellular habitat is important to the organism's survival in the face of host defenses

Laboratory Identification

Gram-negative pleomorphic coccobacilli

Isolation in laboratory is difficult (carry a high risk of laboratory-acquired infection) Diagnosis of infection based on serology

Treatment and Prevention

- Tetracycline - Fluoroquinolones - Chloramphenicol Prevention: - Avoid contact with vectors - Vaccines available for at-risk groups (veterinarians, farm workers)