Bacteria that infect the GIT

2 forms of gastro-enteritis:
A/ vomiting predominent:
1- Staphylococcus aureus:
• projectile vomiting,with diary producs usually.
2-Bacillus cereus:
with rice
2 syndromes: vomiting predominent(toxin is a
superantigen), diarrhea predominent(cholera-like toxin)
B/Diarrhea predominent:
watery or bloody diarrhea
• watery diarrhea differential diagnosis:
1-Enterotoxigenic Escherichia coli:
• usually with history of travel
2-Vibrio cholerae:
• massive watery diarrhea with loss of skin elasticity,sunken
eyes,history of endemicity
3-Clostridium difficil:
• antibiotic assosiated diarrhea
4- Clostridium perfringens:
with feasts , meat
5- Salmonella( typhimorium& enteritidis):
• with egg & poltury
6- Listeria monocytogenes:
• with ice cream, hotdog, cheese
• mainly in children,pregnant ladies, elderly

(other minor causes: entero-pathogenic E.coli :causes watery diarrhea in

infants”remember that Rota virus is the most common cause of diarrhea in
infants” ,entero-aggregative E.coli: chronic diarrhea )
• Bloody diarrhea differential diagnosis:
1-Enterohemorrhagic Escherichia coli(O157):
• outbreak with undercooked hamburger,or animal contact
• complicated by HUS(hemolytic uremic syndrome)
2- Shigella(flexneri in developing countries):
• begins with fever,abdomenal cramps,watery then bloody diarrhea
• small outbreak
• complicated by HUS, Reiter syndrome.
3-Campylobacter jejuni:
• with raw milk,poultry,domestic animals
• complicated by Guillian Barre syndrome, Reiter syndrome
• start with watery then bloody diarrhea
4-Clostridium difficile:
can cause watery diarrhea or watery diarrhea followed by
bloody diarrhea

(other minor causes:enteroinvasive E.coli, Yersenia enterocolitica which also

causes pseudo-appendesitis or mesenteric adenitis)
 Mechanism of action of different
enterotoxins:
Staphylococcus aureus:
• A superantigen that stimulate the release of inflammatory
mediators( IL-2 from helper T cells, & IL-1, TNF from
macrophages).
• it is heat stable.
Bacellus cereus: 2 toxins
• 1-superantigen 2- cholera like toxin(ADP-ribosylates Gs ,which
increase the level of cAMP which increase Cl- permeability which
lead to secretory diarrhea)
Clostridium perfringens:
• superantigen
Clostridium difficle:
• two toxins: Enterotoxin (toxin A) that causes fluid accumulation
leading to watery diarrhoea and damages the mucosa of the large
bowel. Cytotoxin (toxin B) that causes cytoskeletal changes and
then kills mucosal cells resulting in pseudomembrane formation
Enterotoxigenic E.coli:
• 1-heat labile toxin: like cholera toxin (write its mechanism)
• 2- heat stable toxin: stimulate guanylate cyclase
Enterohemorrhagic E.coli:(also Shigella dysentry):
• shiga toxin: removes an adenine from 28S rRNA stopping proten
synthesis
Vibrio cholerae:(cholera toxin ,see bacillus cereus 2nd toxin)
• Drugs for :
• S. aureus food poisoning : ………………
• Brucellosis : ……………………………….
• Hemolytic-Uremic syndrome : ………………..
• Pseudomembranous colitis : …………………………….
• H.pylori peptic ulcer: ..................................
• Drugs for :
• S. aureus food poisoning : no drug
• Brucellosis : doxycycline + streptomycin(or rifampicin)
• Hemolytic-Uremic syndrome : no drug
• Pseudomembranous colitis : oral vancomycin then
metronidazole
• H.pylori peptic ulcer: Triple therapy= CAP= clarythromycn
+ amoxicillin + PPI(proton pump inhibitor)
quadriple therapy=
PPI+MTB(metronidazole+teracycline+bismuth)
• A man receiving immunosuppresive drugs for cancer developed sepsis
after swimming in sea. It is most likely caused by ?
………………….
• A man receiving immunosuppresive drugs for cancer
developed sepsis after swimming in sea. It is most likely
caused by ?
vibrio vulnificus
• A Young man with sickle cell anemia developed
osteomyelitis. Causative agent is ?
……………………..
• A Young man with sickle cell anemia developed
osteomyelitis. Causative agent is ?
Salmonella typhi
• A man with fever and gastrointestinal infection has a low
WBC count. It is most likely to be ?
….............................
• A man with fever and gastrointestinal infection has a low
WBC count. It is most likely to be ?
Typhoid fever
• Khalid is from Khartoum developed shigellary dysentery.
The strain responsible for is ?
…………………….
• Khalid is from Khartoum developed shigellary dysentery.
The strain responsible for is ?
S. Flexneri
(the most common strain in Sudan and 3rd world)
• Which antibiotic is the best for a 7 yrs old child with E.coli
O157:H7 infection who developed hemolytic-uremic
syndrome ?
……………………..
• Which antibiotic is the best for a 7 yrs old child with E.coli
O157:H7 infection who developed hemolytic-uremic
syndrome ?
No antibiotics
• Double zone of hemolysis is characteristic (& diagnostic)
for ?
……………………………..
• Double zone of hemolysis is characteristic (& diagnostic)
for ?
Clostridium perfringens

• Double zone of hemolysis means that organism is

both alpha & beta hemolytic
• Which of the following pairs of (organism-site of
infections) is LEAST correct ?

1) Shigella – colon
2) Salmonella typhimerium – small intestine
3) H. pylori – stomach
4) V. cholerae – small intestine
5) ETEC – large intestine
• Which of the following pairs of (organism-site of
infections) is LEAST correct ?

1) Shigella – colon
2) Salmonella typhimerium – small intestine
3) H. pylori – stomach
4) V. cholerae – small intestine
5) ETEC – large intestine
• Which of the following has the least similar reservoir ?

1) Salmonella typhymerium & cambylobacter jejuni

2) Salmonella typhi & shigella dysentry
3) E. coli O157: H7 & S. aureus
4) Bacillus cereus & clostridium botulinum
5) ETEC & EAEC
• Which of the following has the least similar reservoir ?

1) Salmonella typhymerium & cambylobacter jejuni(in animals)

2) Salmonella typhi & shigella dysentry(in humans)
3) E. coli O157: H7 & S. aureus(O157in animals, S.aureus
in humans)
4) Bacillus cereus & clostridium botulinum(in contaminated
food )
5) ETEC & EAEC(in humans)
• An 18 yrs old student that developed diarrhea with 8 to 10
stools aday. She was healthy 2 days earlier and had no
known immune deficits . The stool contained neither blood
nor pus cells. The diarrhea is most likely due to :

1) A protein synthesis inhibitor toxin

2) An ADP-ribosylating toxin
• An 18 yrs old student that developed diarrhea with 8 to 10
stools aday. She was healthy 2 days earlier and had no
known immune deficits . The stool contained neither blood
nor pus cells. The diarrhea is most likely due to :

1) A protein synthesis inhibitor toxin(shiga toxin but no

blood here)
2) An ADP-ribosylating toxin (enterotoxigenic E.coli)
• Regarding typhoid fever, which of the following is true ?

A. Blood culture is sensitive investigation at least 5 days

after commencement of antibiotics
B. The bacteria can be isolated from rose-spots even after
administration of antibiotics
C. Widal test is used to measure precipitating antibodies
D. Urine culture are more sensetive than stool cultures
E. Quinolones are not recommended for treatment
• Regarding typhoid fever, which of the following is true ?

A. Blood culture is sensitive investigation at least 5 days

after commencement of antibiotics
B. The bacteria can be isolated from rose-spots even after
administration of antibiotics
C. Widal test is used to measure precipitating antibodies
D. Urine culture are more sensetive than stool cultures
E. Quinolones are not recommended for treatment
 Which of the following is true abou H. pylori :

A. Ag detection in stool is not used for diagnosis

B. Antibody testing (serology) is used for assessing
eradication of infection
C. Transmission is only faeco-oral
D. It is not cultured because it is microaerophilic
E. xxxxxxxxxxxxxx
 Which of the following is true abou H. pylori :
A. Ag detection in stool is not used for diagnosis
B. Antibody testing (serology) is used for assessing eradication of infection
C. Transmission is only faeco-oral
D. It is not cultured because it is microaerophilic
E. xxxxxxxxxxxxxx
all the answers are wrong except the missed one, why ??
F. Antigen in stool is diagnostic (non invasive , alternative to endoscopy)
G. serology remains +ve for 1 year so it is not indicative of treatment
H. Transmission is unknown, yet feco-oral is one of the routes not only
I. It is culturable
• 5 yrs boy, lethargy, oliguria , high blood urea and creatinine. he had bloody
diarrhea 6 days ago.

 diagnosis: ....................................................
 Causative agents (D.D) :
……………………………………………..
……………….…………………………….
 tests for condition diagnosis :
……………………………………………..
……………………………………………..
 Name a test to identify causative agent :
………………………………………………
 Treatment : ……………………………………..
• 5 yrs boy, lethargy, oliguria , high blood urea and creatinine. he had bloody
diarrhea 6 days ago.
 diagnosis: hemolytic uremic syndrome (HUS)
 Causative agents (D.D) :
Vero-toxigenic(=enterohemorrhagic) E.coli O157:H7
Shigella dysentery serotype Shiga
(some times enteropathogenic E.coli & varicella virus)
 tests for condition diagnosis : 1) blood film : segmented RBCs (schistocytes)
2) CBC : low platelet count
 Name a test to identify causative agent : sorbitol McConkey agar for E.coli
(EHEC O157:H7 is a non sorbitol fermenter)
 Treatment : no antibiotic , only rehydration + renal dialysis
• A 16 yrs old girl presented with a history of fever, severe abdominal pain and
bloody diarrhea. She used to eat a lot of unpasteurized yogurt. She reported
that diarrhea started watery and foul-smelling 4 days ago before becoming
bloody.
Lab : Gram –ve curved rods in stool with PMNs
The following is true about this patient ?

1) Causative agent is ETEC

2) Causative agent is a retrovirus
3) xxxxxxxxxxxxxxxxxxxxxxx
4) Can present with neurological manifestations
5) xxxxxxxxxxxxxxxxxxxxxxx
• A 16 yrs old girl presented with a history of fever, severe abdominal pain and
bloody diarrhea. She used to eat a lot of unpasteurized yogurt. She reported
that diarrhea started watery and foul-smelling 4 days ago before becoming
bloody.
Lab : Gram –ve curved rods in stool with PMNs
The following is true about this patient ?

1) Causative agent is ETEC(does not cause bloody diarrhea)

2) Causative agent is a retrovirus
3) xxxxxxxxxxxxxxxxxxxxxxx
4) Can present with neurological manifestations( the organism is
Campylobacter)
5) xxxxxxxxxxxxxxxxxxxxxxx
• Bloody diarrhea with mucous and pus cells
1) mention 4 D.D : ……....………………………….
2) Two differentiating tests
…………………………………………………..
3) Name a neurological sequel for one of them
………………………..…………………………
4) Treatment for each : ………………………..
…………………………………………………………………
…………………….
• Bloody diarrhea with mucous and pus cells
1) mention 4 D.D : cambylobacter jeujeni
, shigella , EHEC O157.H7, clostridium difficle
2) Two differentiating tests : Oxidase test / McConkey
(Mention 2 selective media and their colonical morphology
Sorbitol MacConkey agar pale in all cases
MacConkey agar pink in EHEC O157.H7 , pale in the others)
3) Name a neurological sequale for one of them : Guillian-Barre
(after cambylobacter jeujeni)
4) Treatment for each : Cambylobacter : ciprofloxacin /EHEC : none
/ shigella : ciprofloxacin / Clostridium : metronidazole or
vancomycin
• If he develop renal failure mention 2 other clinical features
and what agent was it ? What antibiotic we will use ?
Anemia , thrombocytopenia (as part of HUS) – shigella
dysentery (shiga) , Enterohemorrhagic E.coli O157.H7 - no
antibiotic (you can manage him by dialysis ) .
• A 5 yrs old child brought to pediatric clinic complaining of bloody
diarrhea for 2 days.

 Possible bacterial causes ?

……………………………………………………….
 Stool specimen is collected, describe its possible microscopic
findings :
………………………………………………………..
 Name a selective 2 media for 2 organisms and describe them :
…………………………………………………………
• A 5 yrs old child brought to pediatric clinic complaining of bloody
diarrhea for 2 days.

 Possible bacterial causes ?

cambylobacter , shigella , EHEC , clostridium difficle
 Stool specimen is collected, describe its possible microscopic
findings :
G-ve curved rods/ G-ve rods / G+ve rods
 Name a selective 2 media for 2 organisms and describe them :
Sorbitol McConkey : EHEC is pale / McConkey : shigella is
pale
 If The above patient developed renal failure a week later ..
I. What would be the organism ? ...................................
II. What other findings expected in this case ?
……………………………………………………
III. Causative agent Selective media ? ……………………….
IV. Best antibiotic in this case ?
……………………………………………………….

 If the patient rather got an autoimmune neurologic disease.

I. Name it ? …………………………………..
II. Causative agent ? …………………………….
 If The above patient developed renal failure a week later ..
I. What would be the organism ? EHEC (E.coli O157:H7)
II. What other findings expected in this case ? Thrombocytopenia &
schistocytes in blood film
III. Causative agent’s Selective media ? sorbitol McConkey agar
IV. Best antibiotic in this case ? No antibiotic (kidneys are shut off)

 If the patient rather got an autoimmune neurologic disease.

I. Name it ? Guillian-Barre syndrome
II. Causative agent ? Campylobacter jejuni
• Outbreak of watery diarrhea in a camp , skin turgor was reduced
• diagnosis
• Serogroups

• how can you differentiate between biogoups

• 2 drugs predispose to this infection

• incubation period
• 2 drugs for pregnant woman and children
• vaccine
• pathogenesis
• lab
• Outbreak of watery diarrhea in a
camp , skin turgor was reduced
• diagnosis cholera
• Serogroups serogroup O1 (inaba,
ogawa, hikojima) , non O1
(serogroup O139)
• how can you differentiate between
biogoups

• mode of transmission: fecal- oral

rout
• 2 drugs predispose to this infection
• Omeprazole , cimetidine (anti acid as general )
• incubation period 1-2 days
• 2 drugs for pregnant woman and children erythromycin and
furazolidine
• vaccine there is live attenuated vaccine( also a killed vaccine)
pathogenesis Transmission is feco-oral with high infecting dose
(bacteria is acid labile ) ,
in the small intestine it produce mucinase and cholera toxin (which is
lysogenized) which attach to GM1 receptors ,
In the enterocyte this toxin ADP-ribosylates Gs ,which increase the
level of cAMP which increase Cl- permeability which lead to
secretory diarrhea
• lab
1.specimen: stool ( anotectal swab for children)
specimen transported in : alkaline peptone water or Carryblair transport media
2.culture:
*TCBS (Thiosulfate citrate bile salt sucrose agar) selective medium, the
medium is green, colonies are yellow
*alkaline peptone water
3. Microscopy:
gram negative, comma shaped bacilli with polar filament(highly motile)
4.Biochemical tests:
oxidase test... positive
motility test.... positive
NOTE: in epidemics, tests are applied to water to know if it is contaminated or
not
TCBS
• 70 year old woman in the ICU for pneumonia she has a ventilator then she develops diarrhea,

fever, stool analysis reveal blood and pus

• Causative organism for the diarrhea

……………………

• Pathogenesis

……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………………..

• Most important test for diagnosis

……………………………………………………………………………….

• Management .......................................

• complications ...............................
• 70 year old woman in the ICU for pneumonia she has a ventilator then she develops diarrhea fever
stool analysis reveal blood and pus

• Causative organism for the diarrhea

Clostridium difficile

• Pathogenesis use of broad spectrum antibiotic lead to disturbance in the gut normal flora and
increase in Cl. Difficile which secretes two toxins: Enterotoxin (toxin A) that causes fluid
accumulation leading to watery diarrhoea and damages the mucosa of the large bowel.
Cytotoxin (toxin B) that causes cytoskeletal changes and then kills mucosal cells resulting in
pseudomembrane formation

• Most important test for diagnosis

toxin detection in stool via ELISA or PCR or in vitro cytotoxicity test

• (other tests include: endoscopy to visualize the pseudomembrane, histopathology)

• Management stop the antibiotic , rehydration,
metronidazole or oral vancomycin (or
fidaxomycin )

• antibiotics mostly associated with the disease:clindamycin,

ciprofloxacin,3rd generation cephalosporins

• complications include:dehydration,colon perforation, peritonitis, sepsis, toxic

megacolon
 vaccines:
– 1/TAB
(TYPHI ,Parat
yphi A,B):It’s a
killed vaccine
– 2/type 21
a:Live
attenuated
strain of
salmonella
typhi
– 3/ capsular
polysaccharid
es vaacine:
Made from
purified vi
capsular
• also ferment
manitol
• Brucella can be
transmitted by
consumption of
raw milk, contact
with
animal,inhalation
of aerosoles.
• lab also includes:
biochmical
test:sensitivity to
dye(thionine,basic
fuchsin)
• red agar=basic fuchsin
• blue agar=thionin
• B.melitensis grows in both
• B.abortus grows in basic
fuchsin only
• B.suis grows in thionin only
• complications of brucellosis:
osteomylitis,orchitis,pyeloneph
ritis,meningitis,
endocarditis,etc
• toxin is ingested with food, it is a superantigen