Chapter 16 -

Enterobacteriaceae

MLAB 2434 Clinical Microbiology

Cecile Sanders & Keri Brophy-Martinez
Chapter 16 - Enterics

Family Enterobacteriaceae often

referred to as enterics
Four major features:
All ferment glucose (dextrose)
All reduce nitrates to nitrites
All are oxidase negative
All except Klebsiella, Shigella and
Yersinia are motile
 Microscopic and Colony
Morphology
Gram negative bacilli or coccobacilli
Non-spore forming

Colony morphology on BAP or CA of

little value, as they look the same,
except for Klebsiella
Selective and differential media are
used for initial colony evaluation
(ex. MacConkey, HE, XLD agars)
 Classification of Enterics

Due to the very large number of

organisms in the Family
Enterobacteriaceae (see Table 16-
11), species are grouped into Tribes,
which have similar characteristics
(Table 16-1, page 466)
Within each Tribe, species are
further subgrouped under genera
Virulence and Antigenic
Factors of Enterics
Ability to colonize, adhere, produce
various toxins and invade tissues
Some possess plasmids that may mediate
resistance to antibiotics
Many enterics possess antigens that can
be used to identify groups
O antigen somatic, heat-stable antigen
located in the cell wall
H antigen flagellar, heat labile antigen
K antigen capsular, heat-labile antigen
Clinical Significance of
Enterics
Enterics are ubiquitous in nature
Except for few, most are present in
the intestinal tract of animals and
humans as commensal flora;
therefore, they are sometimes call
fecal coliforms
Some live in water, soil and sewage
Clinical Significance of
Enterics (contd)
Based on clinical infections
produced, enterics are divided into
two categories:
Opportunistic pathogens normally
part of the usual intestinal flora
that may produce infection outside
the intestine
Primary intestinal pathogens
Salmonella, Shigella, and Yersinia sp.
Escherichia coli

Most significant species in the

genus
Important potential pathogen in
humans
Common isolate from colon flora
Escherichia coli (contd)

Characteristics
Dry, pink (lactose positive) colony
with surrounding pink area on
MacConkey
Escherichia coli (contd)

Ferments glucose, lactose,

trehalose, & xylose
Positive indole and methyl red tests
Does NOT produce H2S or
phenylalanine deaminase
Simmons citrate negative
Usually motile
Voges-Proskauer test negative
Escherichia coli (contd)

Infections
Wide range including meningitis,
gastrointestinal, urinary tract,
wound, and bacteremia
Gastrointestinal Infections
Enteropathogenic (EPEC) primarily in
infants and children; outbreaks in
hospital nurseries and day care
centers; stool has mucous but not
blood; identified by serotyping
Escherichia coli (contd)
Enterotoxigenic (ETEC) travelers
diarrhea; watery diarrhea without
blood; self-limiting; usually not
identified, other than patient history
and lactose-positive organisms cultured
on differential media
Enteroinvasive (EIEC) produce
dysentery with bowel penetration,
invasion and destruction of intestinal
mucosa; watery diarrhea with blood; do
NOT ferment lactose; identified via
DNA probes
Escherichia coli (contd)

Enterohemorrhagic (EHEC serotype

0157:H7) associated with
hemorrhagic diarrhea and hemolytic-
uremic syndrome (HUS), which includes
low platelet count, hemolytic anemia,
and kidney failure; potentially fatal,
especially in young children;
undercooked hamburger, unpasteurized
milk and apple cider have spread the
infection; does NOT ferment sucrose;
identified by serotyping
Escherichia coli (contd)
Enteroaggregative (EaggEC) cause
diarrhea by adhering to the mucosal
surface of the intestine; watery
diarrhea; symptoms may persist for
over two weeks
Urinary Tract Infections
E. coli is most common cause of UTI
and kidney infection in humans
Usually originate in the large instestine
Able to adhere to epithelial cells in the
urinary tract
Escherichia coli (contd)

Septicemia & Meningitis

E. coli is one of the most common causes of
septicemia and meningitis among neonates;
acquired in the birth canal before or during
delivery
E. coli also causes bacteremia in adults,
primarily from a genitourinary tract infection
or a gastrointestinal source
Escherichia hermannii yellow pigmented;
isolated from CSF, wounds and blood
Escherichia vulneris - wounds
Klebsiella, Enterobacter,
Serratia & Hafnia sp.
Usually found in intestinal tract
Wide variety of infections, primarily
pneumonia, wound, and UTI
General characteristics:
Some species are non-motile
Simmons citrate positive
H2S negative
Phenylalanine deaminase negative
Some weakly urease positive
MR negative; VP positive
Klebsiella species

Usually found in GI tract

Four major species
K. pneumoniae is mostly commonly isolated
species
Possesses a polysaccharide capsule, which
protects against phagocytosis and
antibiotics AND makes the colonies moist
and mucoid
Has a distinctive yeasty odor
Frequent cause of nosocomial pneumonia
Klebsiella species (contd)

Significant biochemical reactions

Lactose positive
Most are urease positive
Non-motile
Enterobacter species

Comprised of 12 species; E. cloacae

and E. aerogenes are most common
Isolated from wounds, urine, blood
and CSF
Major characteristics
Colonies resemble Klebsiella
Motile
MR negative; VP positive
Enterobacter species
(contd)
Serratia species

Seven species, but S. marcescens is

the only one clinically important
Frequently found in nosocomial
infections of urinary or respiratory
tracts
Implicated in bacteremic outbreaks
in nurseries, cardiac surgery, and
burn units
Fairly resistant to antibiotics
Serratia species (contd)

Major characteristics
Ferments lactose slowly
Produce characteristic pink pigment,
especially when cultures are left at
room temperature

S. marscens on
nutrient agar
Hafnia species

Hafnia alvei is only species

Has been isolated from many
anatomical sites in humans and the
environment
Occasionally isolated from stools

Delayed citrate reaction is major

characteristic
Proteus, Morganella &
Providencia species
All are normal intestinal flora
Opportunistic pathogens

Deaminate phenylalanine

All are lactose negative

Proteus species

P. mirabilis and P. vulgaris are widely

recognized human pathogens
Isolated from urine, wounds, and ear and
bacteremic infections
Both produce swarming colonies on non-
selective media and have a distinctive
burned chocolate odor
Both are strongly urease positive
Both are phenylalanine deaminase positive
Proteus species (contd)

A exhibits characteristic swarming

B shows urease positive on right
Morganella species

Morganella morganii is only species

Documented cause of UTI

Isolated from other anatomical

sites
Urease positive

Phenylalanine deaminase positive

Providencia species

Providencia rettgeri is pathogen of

urinary tract and has caused
nosocomial outbreaks
Providenicia stuartii can cause
nosocomial outbreaks in burn units
and has been isolated from urine
Both are phenylalanine deaminase
positive
Citrobacter species

Citrobacter freundii associated

with nosocomial infections (UTI,
pneumonias, and intraabdominal
abscesses)
Ferments lactose and hydrolyzes
urea slowly
Resembles Salmonella sp.
Salmonella

Produce significant infections in

humans and certain animals
On differential selective agar,
produces clear, colorless, non-
lactose fermenting colonies with
black centers (if media contains
indicator for hydrogen sulfide)
Salmonella (contd)

Salmonella on MacConkey
Salmonella (contd)

Lactose negative
Negative for indole, VP,
phenylalanine deaminase, and urease
Most produce H2S
Do not grow in potassium cyanide
Large and complex group of
organisms; grouped by O, H, and Vi
(for virulence) antigens
Salmonella (contd)

Clinical Infections
Acute gastroenteritis or food poisoning
Source = handling pets, insufficiently cooked
eggs and chicken, and contaminated cooking
utensils
Occurs 8 to 36 hours after ingestion
Requires a high microbial load for infection
Self-limiting in health individuals (antibiotics
and antidiarrheal agents may prolong
symptoms)
Salmonella (contd)

Typhoid and Other Enteric Fevers

Prolonged fever
Bacteremia
Involvement of the RE system,
particularly liver, spleen, intestines, and
mesentery
Dissemination to multiple organs
Occurs more often in tropical and
subtropical countries
Salmonella (contd)

Salmonella Bacteremia
Carrier State
Organisms shed in feces
Gallbladder is the site of organisms
(removal of gallbladder may be the only
solution to carrier state)
Shigella species

Closely related to the Escherichia

All species cause bacillary
dysentery
S. dysenteriae (Group A)

S. flexneri (Group B)

S. boydii (Group C)

S. sonnei (Group D)
Shigella (contd)

Characteristics
Non-motile
Do not produce gas from glucose
Do not hydrolyze urea
Do not produce H2S on TSI
Lysine decarboxylase negative
ONPG positive (delayed lactose +)
Fragile organisms
Possess O and some have K antigens
Shigella (contd)

Clinical Infections
Cause dysentery (bloody stools, mucous,
and numerous WBC)
S. sonnei is most common, followed by S.
flexneri (gay bowel syndrome)
Humans are only known reservoir
Oral-fecal transmission
Fewer than 200 bacilli are needed for
infection in health individuals
Shigella (contd)
Yersinia species

Consists of 11 named species

Yersinia pestis
Causes plague, which is a disease primarily
of rodents; transmitted by fleas
Two forms of plague, bubonic and
pneumonic
Gram-negative, short, plump bacillus,
exhibiting safety-pin or bipolar
staining
Yersinia species
Yersinia enterocolitica
Most common form of Yersinia
Found worldwide
Found in pigs, cats and dogs
Human also infected by ingestion of contaminated
food or water
Some infections result from eating contaminated
market meat and vacuum-packed beef
Is able to survive refrigerator temperatures (can
use cold enrichment to isolate)
Mainly causes acute gastroenteritis with fever
Yersinia species

Yersinia pseudotuberculosis
Pathogen of rodents, particularly
guinea pigs
Septicemia with mesenteric
lymphadenitis, similar to
appendicitis
Motile at 18 to 22 degrees C
Laboratory Diagnosis of
Enterics
Collection and Handling
If not processed quickly, should be
collected and transported in Cary-
Blair, Amies, or Stuart media
Isolation and Identification
Site of origin must be considered
Enterics from sterile body sites are
highly significant
Routinely cultured from stool
Laboratory Diagnosis of
Enterics (contd)
Media for Isolation and
Identification of Enterics
Most labs use BAP, CA and a
selective/differential medium such
as MacConkey
On MacConkey, lactose positive are
pink; lactose negative are clear and
colorless
Laboratory Diagnosis of
Enterics (contd)
For stools, highly selective media,
such as Hektoen Enteric (HE), XLD,
or SS is used along with MacConkey
agar
Identification
Most labs use a miniaturized or
automated commercial identification
system, rather than multiple tubes
inoculated manually
Laboratory Diagnosis of
Enterics (contd)
Identification (contd)
All enterics are
Oxidase negative
Ferment glucose
Reduce nitrates to nitrites
Laboratory Diagnosis of
Enterics (contd)
Common Biochemical Tests
Lactose fermentation and utilization
of carbohydrates
Triple Sugar Iron (TSI)
ONPG
Glucose metabolism
Methyl red
Voges-Proskauer
Laboratory Diagnosis of
Enterics (contd)
Common Biochemical Tests (contd)
Miscellaneous Reactions
Indole
Citrate utilization
Urease production
Motility
Phenylalanine deaminase
Decarboxylase tests
Screening Stools for
Pathogens
Because stools have numerous
microbial flora, efficient screening
methods must be used to recover
any pathogens
Enteric pathogens include
Salmonella, Shigella, Aeromonas,
Campylobacter, Yersinia, Vibrio, and
E. coli 0157:H7
Screening Stools for
Pathogens (contd)
Most labs screen for Salmonella,
Shigella, and Campylobacter; many
screen for E. coli 0157:H7
Fecal pathogens are generally
lactose-negative (although Proteus,
Providencia, Serratia, Citrobacter
and Pseudomonas are also lactose-
negative)