Enterobacteriaceae

Dr Ömer Küçükbasmacı
 Enterobacteriaceae
• The largest, most heterogeneous collection of
medically important gram-negative rods
• >40 genera and 150 species
• Fewer than 20 species are responsible for
more than 95% of the infections
• Ubiquitous organisms, found worldwide in
soil, water, and vegetation
 Enterobacteriaceae
• part of the normal intestinal flora
• 30% to 35% of all septicemias, more than 70%
of urinary tract infections (UTIs), and many
intestinal infections
• Salmonella typhi, Shigella species, Yersinia
pestis
• Escherichia coli, Klebsiella pneumoniae,
Proteus mirabilis
 Enterobacteriaceae
• become pathogenic when they acquire
virulence factor
• can originate from an animal
• or from a human carrier
• or through the endogenous spread of
organisms
Sites of infections with common members of the Enterobacteriaceae listed in order of prevalence
 Enterobacteriaceae
• moderately sized (0.3-1.0 × 1.0-6.0 μm)
• gram-negative rods
• either nonmotile or motile with peritrichous
flagella
• do not form spores
• facultative anaerobes
• have simple nutritional requirements
Gram stain of Salmonella typhi from a positive blood culture.
Note the intense staining at the ends of the bacteria.
This "bipolar staining" is characteristic of the Enterobacteriaceae
 Enterobacteriaceae
• ferment glucose, reduce nitrate
• catalase positive and oxidase negative
• the ability to ferment lactose Escherichia,
Klebsiella, Enterobacter, Citrobacter, and
Serratia spp
• do not ferment lactose Proteus, Salmonella,
Shigella, and Yersinia spp.
• Some have prominent capsules
Lactose fermentation
 Enterobacteriaceae
• Resistance to bile salts
• Some have capsules

Common Medically Important Enterobacteriaceae

• Citrobacter freundii, Citrobacter koseri
• Enterobacter aerogenes, Enterobacter cloacae
• Escherichia coli
• Klebsiella pneumoniae, Klebsiella oxytoca
• Morganella morganii
• Proteus mirabilis, Proteus vulgaris
• Salmonella enterica
• Serratia marcescens
• Shigella sonnei, Shigella flexneri
• Yersinia pestis, Yersinia enterocolitica, Yersinia pseudotuberculosis
 Enterobacteriaceae
• LPS: Consists of three components:

the outermost somatic O polysaccharide

a core polysaccharide common to all

Enterobacteriaceae (enterobacterial common
antigen)

lipid A
 Enterobacteriaceae
• serologic classification
 O polysaccharides
 capsular K antigens
(type-specific
polysaccharides)
 the flagellar H proteins

Antigenic structure of Enterobacteriaceae

 Enterobacteriaceae
• Common Virulence Factors Associated with
Enterobacteriaceae
 Endotoxin
 Capsule
 Antigenic phase variation
 Type III secretion systems
 Sequestration of growth factors
 Resistance to serum killing
 Antimicrobial resistance
 Escherichia coli
• five species
• sepsis, UTIs, meningitis, gastroenteritis
• Gram-negative, facultative anaerobic rods
• Fermenter; oxidase negative
• Outer membrane makes the organisms susceptible
to drying
• Lipopolysaccharide consists of outer somatic O
polysaccharide, core polysaccharide (common
antigen), and lipid A (endotoxin)
Specialized Virulence Factors Associated with
Escherichia coli Adhesins and Exotoxins
 Escherichia coli
• the most common gram-negative rods isolated
from patients with sepsis
• responsible for causing more than 80% of all
community-acquired UTIs
• gastroenteritis in developing countries
• Most infections are endogenous
 Escherichia coli

Incidence of Enterobacteriaceae associated with bacteremia

 Escherichia coli
• Diseases
– Bacteremia (most commonly isolated gram-negative rod)
– Urinary tract infection (most common cause of bacterial UTIs);
limited to bladder (cystitis) or can spread to kidneys
(pyelonephritis) or prostate (prostatitis)
– At least five different pathogenic groups cause gastroenteritis
(EPEC, ETEC, EHEC, EIEC, EAEC); most cause diseases in
developing countries, although EHEC is an important cause of
hemorrhagic colitis (HC) and hemolytic uremic syndrome (HUS)
– Neonatal meningitis (usually with strains carrying the K1
capsular antigen)
– Intraabdominal infections (associated with intestinal
perforation)
– Most infections are endogenous
 Escherichia coli
• Neonatal Meningitis: E. coli and group B streptococci
• Gastroenteritis
 enteropathogenic (EPEC)
 enterotoxigenic (ETEC)
 enterohemorrhagic (EHEC)
 enteroinvasive (EIEC)
 enteroaggregative (EAEC) E. coli
 Escherichia coli
• ETEC: Traveler's diarrhea; infant diarrhea in
developing countries; watery diarrhea,
vomiting, cramps, nausea, low-grade fever
 Plasmid-mediated, heat-stable and/or heat-labile
enterotoxins that stimulate hypersecretion of
fluids and electrolytes
 LT-1 similar to cholera toxin cAMP GM 1 gangliosid
 Enhanced secretion of chloride and dec
absorption of sodium and chloride
 STa cGMP
 Escherichia coli
• EPEC: Infant diarrhea in underdeveloped
countries; watery diarrhea and vomiting,
nonbloody stools, per to per spread occurs
 Person to person spread
 Plasmid-mediated A/E histopathology with
disruption of normal microvillus
 Nonfimbrial adhesin, no LT or ST
 Moderately invasive
 Escherichia coli
• EAEC: Infant diarrhea in underdeveloped
countries; traveler's diarrhea, persistent or
chronic diarrhea
Plasmid-mediated aggregative adherence of rods
Enteroaggregative heat stable toxin (EAST)
 Escherichia coli
• EHEC: Initial watery diarrhea, followed by
grossly bloody diarrhea (hemorrhagic colitis)
with abdominal cramps; little or no fever; may
progress to hemolytic uremic syndrome (HUS)
Mediated by cytotoxic Shiga toxins, which disrupt
protein synthesis; lesions with destruction of
intestinal microvillus resulting in decreased
absorption, bacteriophage mediated
 Escherichia coli
• EIEC: Disease in underdeveloped countries;
fever, cramping, watery diarrhea; may
progress to dysentery with scant, bloody
stools, fever, severe inflammation
Plasmid-mediated invasion and destruction of
epithelial cells
Sereny test positive
 Escherichia coli-UTI
• Colon contaminate urethra
ascend into bladder and may migrate to
kidney or prostate
• UTIs: adhesins (primarily P pili, AAF/I, AAF/III,
Dr) and hemolysin HlyA
 Escherichia coli-Neonatal
Meningitis

• E.coli and group B streptococci major CNS

pathogens
• K1 capsular antigen
• Commonly present in the GIS
 Escherichia coli-Septicemia

• May be originated from UT or GIS

• Mortality is high
 Salmonella
• Salmonella enterica and Salmonella bongori
• S. enterica is subdivided into six subspecies, S.
enterica subsp. enterica
• the two species have been subdivided into
more than 2500 unique serotypes
• S. enterica subspecies enterica serotype
Typhimurium or S.Typhimurium
 Salmonella
• Physiology and Structure
 Gram-negative, facultative anaerobic rods
 Fermenter; oxidase negative
 Outer membrane makes the organisms
susceptible to drying
 Lipopolysaccharide consists of outer somatic O
polysaccharide, core polysaccharide (common
antigen), and lipid A (endotoxin)
 More than 2500 O serotypes (commonly referred
to as individual Salmonella species)
• Enrichment broth:Tetrathionat, GN, selenit
broth
• Selective media: Mac Conkey, SS agar,
Hektoen Enteric Agar, Bismuth sulfide agar
• Human ( Typhi, paratyphi)
• Citrate (-)
• Vi antigen positive
• Gas from glucose negative
 Salmonella
• Tolerant to acids in phagocytic vesicles
• Can survive in macrophages and spread from
the intestine to other body sites (particularly
true of S. typhi)
• Endotoxin
 Salmonella-Epidemiology
• Most infections are acquired by eating contaminated
food products
• Direct fecal-oral spread in children
• S. typhi and S. paratyphi are strict human pathogens
• Individuals at risk for infection include those who eat
improperly cooked poultry or eggs, patients with
reduced gastric acid levels, and
immunocompromised patients
• Infections occur worldwide, particularly in the warm
months of the year
• Nontyphoid Salmonella %98
 Clinical Manifestations
• Gastroenteritis
• Enteric fever
• Bacteremia and vascular infections
• Localized infections
• Carrier state
 Gastroenteritis
• Incubation 6-48 hours
• Watery diarrhea, nausea, vomiting
• Fever
• Neutrophil in stool
• Self limited 3-7 days
• Mortality very low
 Salmonella-Diseases
• Asymptomatic colonization (primarily with S.
typhi and S. paratyphi)
• Enteric fever (also called typhoid fever [S.
typhi] or paratyphoid fever [S. paratyphi])
• Incubation 5-21 days
• Fever, relative bradycardia, leukopenia,
anemia, constipation, SM, rose spots
• Neuropsychiatric manifestations
• Mortality rate was 10-15% in preantibiotic era
 Localized Infections
• Septic artritis
• Osteomyelitis
• Meningitis
• Abscess (splenic, hepatic)
 Salmonella-Diseases
• Bacteremia (most commonly seen with S.
typhi, S. paratyphi, S. choleraesuis, and S.
enteritidis, S.dublin)
• Carrier state S.typhi %1-4, nontyphi
Salmonella %0.2-0.6, no symptoms
• What New York did about Typhoid Mary
• By wildnewyork Mary Mallon was born in Irelend in 1869 and came to
America at 16, working as a cook for wealthy families in Boston and New
York. In the early 1900s, several family members came down with
typhoid—a potentially deadly bacterial infection spread through food
when a carrier doesn’t wash his or her hands after using the bathroom.
• Eventually a New York City typhoid researcher identified Mary as the
source of all the infections. She denied having typhoid, but tests proved
otherwise, and city health officials forced her into quarantine in a city
hospital at North Brother Island in the East River.
• A New York newspaper illustrates her plight in 1909.
• After leaving quarantine and promising not to handle food, she went back
to work as a cook, promptly infecting more people. Eventually she was
brought back to the island, where she lived out her life. Mary died in 1938,
a celebrity for being a healthy carrier of a lethal bacteria.
• Timeline:
1869- Mary Mallon born, Country Tyrone, Irleand
1883- Like many Irish women poverty forces Mallon to emigrate to the United
States
1900- 1906 Mallon works as a cook in New York City. At her places of employment
(private homes), Mallon unknowingly
infects two dozen people with typhoid.
1901- Manhattan. Member's of Mallon's employer's family and her coworkers
develop fevers and diarrhea. One laundress
dies.
1906- Long Island. Within two weeks of hiring Mallon as a cook, fourteen of
twenty family members are ill with typhoid.
Mallon quickly leaves the position. She is eventually identified by George Soper as
a healthy carrier.
1908-1911 Mallon is quaratined on North Brother Island at Riverside Hospital. She
is released after some media attention
and after she gives her promise not to work in the food industry.
1915- Mallon returns to working as a cook. Using the pseudonym "Mary Brown"
she is hired at the Sloan Maternity
Hospital in New York. Twenty-five people are infected, two die. Mallon is returned
to quarantine on North Brother
Island.
1915-1938 Mallon remains in quarantine for the rest of her life. She has her own
cottage, makes her own meals, is occasionally interviewed by reporters and works
as a lab assistant for a time.
1938, November 11th: Mallon dies of pneumonia. An autopsy reveals live typhoid
bacteria in her bladder.
 Diagnosis
• Culture
• Stool, urine ,blood, rose spots, bone marrow
• Selective media
• Typhoid fever 1.week blood culture
≥3. week stool culture
 Diagnosis
• Gruber Widal
Anti-O Ab
Anti-H Ab
Anti-Vi Ab (Long term carriers)
 Therapy
• Replacement
• Quinolones, ampicillin, Co-trimoxazole
• Cephalosporin 1., 2. Gen and aminoglycosides
are ineffective
• Oral attenue and Vi parenteral vaccines
available
 Shigella
• S. dysenteriae, Shigella flexneri, Shigella
boydii, and Shigella sonnei
• S. sonnei is the most common cause of
shigellosis in the industrial world
• S. flexneri is the most common cause in
developing countries
• They are very much like Escherichia
 Shigella
• Nonmotile
• Noncapsulated
• H2S negative
 Shigella
O antigen Ornithin Lactose
decarboxylase

S.dysentariae A - -

S.flexneri B -- -

S.boydii C - -

S.sonnei D + -
Late+
• Shigella 10-100
• C.jejuni 102-106
• Salmonella 105
• E.coli 108
• V.cholerae 108
• G.lamblia 10-100 cysts
• E.histolytica 10-100 cysts
• C.parvum 1-1000 cysts
 Shigella-Pathogenesis
• Endotoxin and genes for adherence, invasion,
and intracellular replication
• Permeability barrier of outer membrane
• Exotoxin (Shiga toxin) is produced by S.
dysenteriae; disrupts protein synthesis and
produces endothelial damage
• Hemolytic colitis (HC) and hemolytic uremic
syndrome (HUS) associated with Shigella
 Shigella-Epidemiology
• Humans are only reservoir for these bacteria
• Disease spread person to person by fecal-oral route
• Patients at highest risk for disease are young children
in daycare centers, nurseries, male homosexuals
• Relatively few organisms can produce disease (highly
infectious)
• Disease occurs worldwide with no seasonal incidence
 Shigella-Diseases
• Gastroenteritis (shigellosis)
• Most common form is an initial watery diarrhea
progressing within 1 to 2 days to abdominal cramps
and tenesmus (with or without bloody stools)
• Asymptomatic carriage develops in a small number
of patients (reservoir for future infections)
• A severe form of disease is caused by S. dysenteriae
(bacterial dysentery)
 Shigella-Diseases
• Bloody diarrhae containing mucus,
• Shigatoxin-an exotoxin B unit binds to host cell
glycolipids and A cleaves the 28S rRNA ,
preventing the protein synthesis
• Shigatoxin can mediate the damage to the
glomeruşar endothelial calls, resulting in renal
failure (HUS).
 Shigella-Treatment, Prevention, and
Control
• Antibiotic therapy shortens the course of
symptomatic disease and fecal shedding
• Treatment should be guided by in vitro susceptibility
tests
• Empiric therapy can be initiated with a
fluoroquinolone or trimethoprim-sulfamethoxazole
• Appropriate infection control measures should be
instituted to prevent spread of the organism
 Yersinia
• 11 species
• Y. pestis, Yersinia enterocolitica, Yersinia
pseudotuberculosis
• Y. pestis is covered with a protein capsule
• Some species (e.g., Y. enterocolitica) can grow
at cold temperatures
 Yersinia
• Y. pestis systemic disease with a high mortality
• Y. enterocolitica and Y. Pseudotuberculosis
• Capsule on Y. pestis is antiphagocytic
• Y. pestis is also resistant to serum killing
• Yersinia with genes for adherence, cytotoxic
activity, inhibition of phagocytic migration and
engulfment, and inhibition of platelet
aggregation
 Yersinia
• Y. pestis is a zoonotic infection with humans the
accidental host; natural reservoirs include rats,
squirrels, rabbits, and domestic animals
• Disease is spread by flea bites or direct contact with
infected tissues or person to person by inhalation of
infectious aerosols from a patient with pulmonary
disease
• Other Yersinia infections are spread through
exposure to contaminated food products or blood
products (Y. enterocolitica)
• Colonization with other Yersinia species can occur
 Yersinia
• Y. pestis causes bubonic plague (most common) and
pulmonary plague, both having a high mortality rate
• Other Yersinia species cause gastroenteritis (acute
watery diarrhea or chronic diarrhea) and transfusion-
related sepsis
• Enteric disease in children may manifest as enlarge
mesenteric lymph nodes and mimic acute
appendicitis
 Yersinia
• All Yersinia infections are zoonotic
• Urban plague, sylvatic plague
• Bubonic plague, pneumonic plague
•
 Yersinia
• Y. pestis infections are treated with streptomycin;
tetracyclines, chloramphenicol , or trimethoprim-
sulfamethoxazole can be administered as alternative therapy
• Enteric infections with other Yersinia species are usually self-
limited. If antibiotic therapy is indicated, most organisms are
susceptible to broad-spectrum cephalosporins,
aminoglycosides, chloramphenicol , tetracyclines, and
trimethoprim-sulfamethoxazole
• Plague is controlled by reduction of the rodent population and
vaccination of individuals at risk
• Other Yersinia infections are controlled by the proper
preparation of food products
 Klebsiella
• K. pneumoniae and Klebsiella oxytoca
• Klebsiella rhinoscleromatis (causes a
granulomatous disease of the nose)
• Klebsiella ozaenae (causes chronic atrophic
rhinitis)
• K. granulomatis is the etiologic agent of
granuloma inguinale
Klebsiaella granulomatis
 Proteus
• P. mirabilis
• P.vulgaris
ENTEROBACTER, CITROBACTER, MORGANELLA,
SERRATIA
• Primary infections are rare
• Citrobacter koseri has a predilection for
causing meningitis and brain abscesses in
neonates
• Resistance is a particularly serious problem
with Enterobacter species
 Laboratory Diagnosis
• Grow readily on culture media
• Selective media (e.g., MacConkey agar, eosin-
methylene blue [EMB] agar
• Cold enrichment Y. enterocolitica
• Biochemical identification
• Serologic testing such as E. coli O157 : H7 or Y.
enterocolitica O8
• Az sayıda bol dışkı İB V.cholerae, ETEC,
Shigella, Giardia
• Çok sayıda az miktarda dışkı KB Shigella,
Salmonella, Campylobacter, Entamoeba
histolytica
• Tenezm, acil dışkılama, dizanteri kolit Shigella,
Salmonella, Campylobacter, Entamoeba
histolytica