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By

Prof. Dr. Asem Shehabi and Dr. Suzan Matar

Enteric BacteriaEnteric Bacteria

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• EnterobacteriaceaeEnterobacteriaceae- E.coli- Klebsiella-Enterobacter species - Proteus-Providencia species- Salmonella and Shigella

• Pseudomonas aeruginosa• Vibrio cholerae • Campylobacter • Helicobacter• Brucella

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Enteric Bacteria Enteric Bacteria (Escherichia, Klebsiella, (Escherichia, Klebsiella, Enterobacter, Proteus, Salmonella, Shigella, Enterobacter, Proteus, Salmonella, Shigella, Yersinia )Yersinia )

• General CharacteristicsGeneral Characteristics: : - Gram - ve bacilli, Gram - ve bacilli, - Facultative anaerobes, Facultative anaerobes, - Intestinal normal flora.. Intestinal normal flora.. - Humans, animals, birds.. Humans, animals, birds.. - Common waste water, natural water, soil, vegetation Common waste water, natural water, soil, vegetation - Lactose fermenters and Lactose non fermentersLactose fermenters and Lactose non fermenters- Catalase +ve & Oxidase –veCatalase +ve & Oxidase –ve

• Opportunistic Pathogens & Obligate Pathogens- Causing all types of human infection, some common - Causing all types of human infection, some common

nosocomial infections. nosocomial infections.

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• Pathogenicity: Pathogenicity: - Various Enterotoxins, Various Enterotoxins, - Endotoxins Endotoxins - Capsule, Capsule, - Flagella, Flagella, - O-H-K-Antigens. Develop specific antibodies following blood infectionsO-H-K-Antigens. Develop specific antibodies following blood infections

• Coliform GroupColiform Group: :

11. . Escherichia coliEscherichia coli: : Common Urinary Tract Infection (40-80%)Common Urinary Tract Infection (40-80%) Single organism, Septicemia, Neonatal Meningitis, Wounds. Single organism, Septicemia, Neonatal Meningitis, Wounds.

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Diarrheagenic E. coli TypesDiarrheagenic E. coli Types

6 major types causing diarrhea: Common types.6 major types causing diarrhea: Common types.

1- Enteropathogenic (EPEC)1- Enteropathogenic (EPEC)

- Numerous strains (mostly infants 1-6 months),Watery diarrhea, Numerous strains (mostly infants 1-6 months),Watery diarrhea, less Vomiting, Chronic cases/ fatal.less Vomiting, Chronic cases/ fatal.

2-Enterotoxigenic (ETEC)2-Enterotoxigenic (ETEC)

- (Heat-labile/stable enterotoxins)/ watery diarrhea, Children more (Heat-labile/stable enterotoxins)/ watery diarrhea, Children more than adults, Traveler’s diarrhea, fecal water contamination than adults, Traveler’s diarrhea, fecal water contamination /vegetables / fresh food, Indicator standard of hygiene,/vegetables / fresh food, Indicator standard of hygiene,

- Self-limited diarrhea and no antibiotics treatment.Self-limited diarrhea and no antibiotics treatment. 3 Enterohaemorrhagic (EHEC):3 Enterohaemorrhagic (EHEC):O157:H7, Verotoxins, Common in O157:H7, Verotoxins, Common in

intestinal Cattle, Contamination Ground meat/Hamburger, Dairy intestinal Cattle, Contamination Ground meat/Hamburger, Dairy products, bloody diarrhea, Haemolytic-uremic syndrome (HUS), fatal products, bloody diarrhea, Haemolytic-uremic syndrome (HUS), fatal

-

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E. coliE. coli Culture Culture –– Red color Red color on MacConkey agaron MacConkey agar indicates Lactose positive & indicates Lactose positive & Gram-stain Gram-stain

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Coli-form BacteriaColi-form Bacteria 2. 2. Klebsiella - Enterobacter species Klebsiella - Enterobacter species : :

UTI, Septicemia, Wounds.. Rare Meningitis.. UTI, Septicemia, Wounds.. Rare Meningitis.. Common Hospitalized patients.. Common Hospitalized patients..

Encapsulated Encapsulated K. pneumoniae cause K. pneumoniae cause Nosocomial infections and PneumoniaNosocomial infections and Pneumonia

3. 3. Proteus-Providencia speciesProteus-Providencia species::

UTIUTI, , Septicemia, Wounds, Nosocomial Septicemia, Wounds, Nosocomial infection.infection.

Proteus causes renal stones. Urease Proteus causes renal stones. Urease positivepositive

. .

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33 . .Pseudomonas groupPseudomonas group• Pseudomonas species Pseudomonas species , Gram-ve bacilli , Facultative , Gram-ve bacilli , Facultative

anaerobe, oxidase+ve and Lactose-ve.. Found in soil, anaerobe, oxidase+ve and Lactose-ve.. Found in soil, water, plants , animals. . Survive under harsh condition, water, plants , animals. . Survive under harsh condition, including Alcohol used in aseptic procedure. More than 20 including Alcohol used in aseptic procedure. More than 20 pseudomonal species can cause human infections.pseudomonal species can cause human infections.

• P. aeruginosaP. aeruginosa :opportunistic pathogen.. colonize URT &  :opportunistic pathogen.. colonize URT & intestine humans.. Produce blue-green pigmention / intestine humans.. Produce blue-green pigmention / pyocyanin and fluoresceinpyocyanin and fluorescein....release many enzymes. It is release many enzymes. It is the most common species causes a clinically significant the most common species causes a clinically significant infection.. infection.. often causing nosocomial often causing nosocomial infections..serious and often life-threatening infections..serious and often life-threatening diseasesdiseases..wound, blood sepsis, pneumonia, External ear ..wound, blood sepsis, pneumonia, External ear infection..burn cases, Urinary catheters, intravenous [IV] infection..burn cases, Urinary catheters, intravenous [IV] line, endotracheal tubes. line, endotracheal tubes. P. aeruginosaP. aeruginosa .. .. innate innate resistance to many antibiotics.. Develop rapidly resistance resistance to many antibiotics.. Develop rapidly resistance to antimicrobial agents. to antimicrobial agents.

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E. coli-E. coli- Flagella- Fimbriae - Flagella- Fimbriae - PiliPili KlebsiellaKlebsiella pneumoniapneumonia--CapsuleCapsule

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Salmonella groupSalmonella group

• Gram-ve bacilli.. Gram-ve bacilli..

• Facultative anaerobesFacultative anaerobes

• Lactose-non fermentersLactose-non fermenters

• Endotoxin / LPS. Endotoxin / LPS.

• Common in Nature (water and soil), Humans, Animals, Common in Nature (water and soil), Humans, Animals, Birds. They are not part of the normal human flora.Birds. They are not part of the normal human flora.

• O/H Antigens with specific antibodies.O/H Antigens with specific antibodies.

• Pathogenic when ingested causing enteritis, systemic Pathogenic when ingested causing enteritis, systemic infections and enteric fever.infections and enteric fever.

• 1. Nontyphoidal Salmonellosis / 1. Nontyphoidal Salmonellosis / GastroenteritisGastroenteritis /Food-/Food-poisoning poisoning S. entericaS. enterica//enteritidisenteritidis.. 2000 Serotypes.. .. 2000 Serotypes..

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• Zoonotic .. Common Birds, Farm Chickens, Pets, Reptiles.. Zoonotic .. Common Birds, Farm Chickens, Pets, Reptiles.. Contamination fresh food, Chicken, Meat-Eggs, Dairy products.. Contamination fresh food, Chicken, Meat-Eggs, Dairy products.. Large number of Salmonella cells causing diarrheaLarge number of Salmonella cells causing diarrhea

- Food borne disease , Incubation 8-24 h.. - Food borne disease , Incubation 8-24 h..

- Mild-severe watery-bloody diarrhea, Vomiting, FeverMild-severe watery-bloody diarrhea, Vomiting, Fever

- Self-Limiting in healthy personsSelf-Limiting in healthy persons

- Rarely Septicemia - Meningitis Infant / young Children.. Rarely Septicemia - Meningitis Infant / young Children.. Immunocompromised patients. Immunocompromised patients.

- Human healthy carriers.. Short periods..animals long period crriers Human healthy carriers.. Short periods..animals long period crriers

Lab DiagnosisLab Diagnosis

Culture Feces or Food.. Prevention and Control , Sanitation & Culture Feces or Food.. Prevention and Control , Sanitation & hygiene in restaurants & slaughter houses and food-handlershygiene in restaurants & slaughter houses and food-handlers

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Salmonella/ FlagellaSalmonella/ Flagella

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Hektoen–Enteric agar: Hektoen–Enteric agar: SalmonellaSalmonella transparent colonies, +H transparent colonies, +H22s s

Lactose-ve. Lactose-ve. Shigella Shigella : transparent,lactose-ve : transparent,lactose-ve

E. coli E. coli : orange colonies, Lactose: orange colonies, Lactose-ve-ve

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SS agar for Salmonella & Shigella Salmonella..Transparent colonies+H2s.. Ohers fecal flora will be inhibited to 98%

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Typhoidal SalmonellaTyphoidal Salmonella

• 2- 2- Typhoidal SalmonellaTyphoidal Salmonella:: (Human Enteric Fever) (Human Enteric Fever)- Salmonella enterica /typhi & paratyphi Salmonella enterica /typhi & paratyphi A, B, CA, B, C- Few cells Invasive, Only infect human, Fecal-OralFew cells Invasive, Only infect human, Fecal-Oral- Water , Food.. Incubation:1-3 WeeksWater , Food.. Incubation:1-3 Weeks- High continuous fever, Bloody Diarrhea and constipation, Septicemia, High continuous fever, Bloody Diarrhea and constipation, Septicemia,

Meningitis, osteomyelitis, Hepatosplenomegaly, Intestinal Meningitis, osteomyelitis, Hepatosplenomegaly, Intestinal perforation.perforation.

- Healthy Carriers: Gallbladder, Intestine, Short period or Life Long .Healthy Carriers: Gallbladder, Intestine, Short period or Life Long .- Human Healthy Carriers ..mostly women, Gallbladder (1-3%) - Human Healthy Carriers ..mostly women, Gallbladder (1-3%)

• Lab DiagnosisLab Diagnosis:: Culture Feces, blood, Urine, CSF, Bone marrow, Culture Feces, blood, Urine, CSF, Bone marrow, Selective Media: S-S AgarSelective Media: S-S Agar, , Hektoen-enteric.Hektoen-enteric.

• Serological Serological Widal Test Widal Test for detection of specific antibodies against O for detection of specific antibodies against O & H antigens (Titer > 160)& H antigens (Titer > 160)

Antibiotics, Human vaccine is available.. Antibiotics, Human vaccine is available..

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Shigella groupShigella group Common serotypes: Common serotypes: S. S. SonneiSonnei, , S.boydiiS.boydii, , S. dysenteriae S. dysenteriae - Gram -ve, Lactose-ve , Susceptible to dryness, acid, Low-High - Gram -ve, Lactose-ve , Susceptible to dryness, acid, Low-High

TemperatureTemperature- Fecal-Oral infection. Water, fresh Vegetations,- Fecal-Oral infection. Water, fresh Vegetations, - Few serotypes.. Infect only humans. Incubation 1-2 Days- Few serotypes.. Infect only humans. Incubation 1-2 Days• Pathogenicity:Pathogenicity: - Endo/Enterotoxins released intestine.. Purulent-Bloody-Diarrhea.. Endo/Enterotoxins released intestine.. Purulent-Bloody-Diarrhea..

(bacillary dysentery) with abdominal pain, fever, not invasive. No (bacillary dysentery) with abdominal pain, fever, not invasive. No chronic or healthy carrierschronic or healthy carriers

• S. dysenteriae (Shiga type toxins)S. dysenteriae (Shiga type toxins)- Enterotoxin /Neurocytotoxin, Severe intestinal Necrosis, Fever, - Enterotoxin /Neurocytotoxin, Severe intestinal Necrosis, Fever,

Severe Severe Purulent-Bloody-DiarrheaPurulent-Bloody-Diarrhea, , Abdominal Cramps, CNS. Abdominal Cramps, CNS. Rare Septicemia.. Can be fatal without treatment. Rare Septicemia.. Can be fatal without treatment.

Lab Diagnosis:Lab Diagnosis: Rapid culture Feces/rectal swabs on S-S Agar, Hektoen –Enteric Rapid culture Feces/rectal swabs on S-S Agar, Hektoen –Enteric

Agar.. Recommended Antimicrobials Treatment.. Control Sanitation Agar.. Recommended Antimicrobials Treatment.. Control Sanitation & hygiene food .. Foodhandlers & hygiene food .. Foodhandlers

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Vibrio choleraeVibrio cholerae • Gram-ve Vibrios ’comma shaped’ Gram-ve Vibrios ’comma shaped’ , , motile.motile.- Lactose-ve,Lactose-ve, oxidase positiveoxidase positive, , - Aerobic Growth and aAerobic Growth and alkaline medium (pH >8-9).. lkaline medium (pH >8-9).. - Water.. Fresh Food.. Water.. Fresh Food.. Reservoir contaminated waterReservoir contaminated water. Salt tolerant.. Salt tolerant.• Endemic In India/Bangladish but epidemic Disease, causing Endemic In India/Bangladish but epidemic Disease, causing human Outbreaks.human Outbreaks.. .

Asymptomatic/symptomatic person Asymptomatic/symptomatic person • V. cholerae-01V. cholerae-01: Type El-Tor.. : Type El-Tor.. - Only Human, Fecal-oral infection.. Raw Sea/ Fresh Foods, Only Human, Fecal-oral infection.. Raw Sea/ Fresh Foods, - Small Intestine Infect. Small Intestine Infect. - Cholera toxin- enterotoxin, Incubation 8-48 h, Heat labile toxinCholera toxin- enterotoxin, Incubation 8-48 h, Heat labile toxin- Severe water diarrhea (rice water stool), Severe dehydration, Blood acidosis, Severe water diarrhea (rice water stool), Severe dehydration, Blood acidosis,

Shock, Death within hours. No invasion.Shock, Death within hours. No invasion.• Lab Diagnosis: Lab Diagnosis: Feces Culture.. Selective TCBS agar.Feces Culture.. Selective TCBS agar.• Treatment:Treatment: Rapid replacement fluids & electrolytes.. Antibiotic.. Rapid replacement fluids & electrolytes.. Antibiotic..

Public Heath sanitation measurements. Human Vaccine. Public Heath sanitation measurements. Human Vaccine.

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Cholera

2020

TCBS agar for isolation of V. cholerae

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Brucella speciesBrucella speciesBrucellosis/Malta FeverBrucellosis/Malta Fever

- Gram-ve coccobacilli, Microaerophilic..Gram-ve coccobacilli, Microaerophilic.. Endotoxins Endotoxins ..Highly infectious ..Highly infectious - Primarily pathogens of animals (Zoonosis), Localized Infection in animal Primarily pathogens of animals (Zoonosis), Localized Infection in animal

reproductive Organs, Sepsis ..Abortions. reproductive Organs, Sepsis ..Abortions. • B. abortusB. abortus (Cattle), (Cattle), B. melitensisB. melitensis (Goats/Sheep). (Goats/Sheep). - Rare other species in Jordan & Arab countries.- Rare other species in Jordan & Arab countries.• Transmitted to HumansTransmitted to Humans: : The bacteria are transmitted from animals to humans by ingestion The bacteria are transmitted from animals to humans by ingestion

infected food products (Dairy ), direct contact with an infected animal, infected food products (Dairy ), direct contact with an infected animal, inhalation of aerosols. inhalation of aerosols. 

• Pathogenicity: Pathogenicity: Enter through GI, skin abrasions, eye, inhalation/DropletsEnter through GI, skin abrasions, eye, inhalation/Droplets Intracellular (macrophages), Incubation:1-6 Weeks.. Intermittent fever, Intracellular (macrophages), Incubation:1-6 Weeks.. Intermittent fever,

headaches, fatigue, joint and bone pain, GI Symptoms, Sweats, headaches, fatigue, joint and bone pain, GI Symptoms, Sweats, septicemia, meningitis, chronic disease with complication on CNSsepticemia, meningitis, chronic disease with complication on CNS

• Lab DiagnosisLab Diagnosis: : Blood, CSF, Bone marrow cultures, Brucella ..1-4 weeks Blood, CSF, Bone marrow cultures, Brucella ..1-4 weeks culture incubation. agglutination Test. Specific Antibodies (IgM and culture incubation. agglutination Test. Specific Antibodies (IgM and IgG)..IgG)..Treatment: Treatment: 6-8 Weeks with Antimicrobial drugs 6-8 Weeks with Antimicrobial drugs

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Campylobacter SpeciesCampylobacter Species

• Many species.. Most human infection Many species.. Most human infection C. jejuni, C. C. jejuni, C. infantis infantis

• Microaerophilic.. Microaerophilic.. Optimal Growth 42 C Optimal Growth 42 C , Gram-negative thin- , Gram-negative thin- curved, Motile Bacilli/Bipolar flagella , Grow slowly over 3-6 days curved, Motile Bacilli/Bipolar flagella , Grow slowly over 3-6 days in vitro culture…This bacterium became important enteric pathogen in vitro culture…This bacterium became important enteric pathogen since 1976.. Widely spread in small animals, dogs, cats, birds. since 1976.. Widely spread in small animals, dogs, cats, birds. It is primarily an animal pathogen causing It is primarily an animal pathogen causing abortion and abortion and enteritis in enteritis in sheep and cattle.sheep and cattle.

- - Human illness Human illness usually occurs 2-5 days after ingestion of the usually occurs 2-5 days after ingestion of the contaminated Chicken meat, Milk, fresh food , water.contaminated Chicken meat, Milk, fresh food , water.

- Multiply in the small intestine invade the epithelium produce mild inflammation cause bloody-watery/ mild-moderate.. Few mild-moderate.. Few fecal fecal leukocytes in feces..causes occasionally blood sepsis in children in feces..causes occasionally blood sepsis in children

- Other symptoms often present are fever, abdominal pain, nausea, Other symptoms often present are fever, abdominal pain, nausea, headache and muscle pain.. Infection may be associated with arthritis headache and muscle pain.. Infection may be associated with arthritis

- Diagnosis:Diagnosis: Stool culture .. Stool culture .. Selective Campylobacter Media Selective Campylobacter Media including including 3 antibiotics/ biochemical tests.. Or direct detection of bacteria by 3 antibiotics/ biochemical tests.. Or direct detection of bacteria by PCR.PCR.

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Flagella of Flagella of Helicobacter pyloriHelicobacter pylori & & Campylobacter jejuniCampylobacter jejuni , Modified G-stain , Modified G-stain

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Helicobacter SpeciesHelicobacter Species • Helicobacter pyloriHelicobacter pylori - Spiral shaped bacterium with multiple flagella.Spiral shaped bacterium with multiple flagella.- Lives in the mucus lining stomach & duodenum Lives in the mucus lining stomach & duodenum

causes chronic inflammation..causes chronic inflammation..Gastritis/UlcersGastritis/Ulcers- Only pathogenic in humanOnly pathogenic in human• Release urease, converted urea into Release urease, converted urea into

COCO22/bicarbonate & ammonia /bicarbonate & ammonia neutralize neutralize stomach acidity and protects colonizing stomach acidity and protects colonizing . .

• H.pyloriH.pylori - Found worldwide, up to 10% of children - 80% Found worldwide, up to 10% of children - 80%

of adults can have evidence of an of adults can have evidence of an H. pyloriH. pylori colonization/ mild infection - usually without colonization/ mild infection - usually without having any clinical signs or symptoms..having any clinical signs or symptoms..

• Transmission route..Transmission route..- Close personal contact.- Close personal contact.

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Helicobacter Species-2Helicobacter Species-2

• Common symptomsCommon symptoms: : - Gastritis /Peptic ulcer..Gastritis /Peptic ulcer..Painful sores or ulcers in Painful sores or ulcers in

Stomach or duodenum...Stomach or duodenum...Duodenal ulcers , Nausea, Duodenal ulcers , Nausea, Vomiting.Vomiting.

• Persistence of ulcers Persistence of ulcers increased risk of stomach increased risk of stomach cancer cancer and Lymphoma.and Lymphoma.

• H. pyloriH. pylori can be successfully eradicated (95%) using a can be successfully eradicated (95%) using a combination of certain antibiotics and medicines that suppress combination of certain antibiotics and medicines that suppress stomach acid production. Common Re-occurrence within few stomach acid production. Common Re-occurrence within few weeks - months. No vaccineweeks - months. No vaccine

• Diagnosis: Diagnosis: - Urea Breath test, Culture biopsy stomach .. Selective Medium - Urea Breath test, Culture biopsy stomach .. Selective Medium

with 3 antibiotics.. Incubation 37C, 4-6 days.with 3 antibiotics.. Incubation 37C, 4-6 days.- Serological test: - Serological test: H. pyloriH. pylori antibodies antibodies not significant for not significant for

clinical diagnosis alone.clinical diagnosis alone.

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Acinetobacter groupAcinetobacter group- Many species.. Pleomorphic aerobic gram-negative bacillus, aerobicMany species.. Pleomorphic aerobic gram-negative bacillus, aerobic

- Catalase +, Oxidase-ve, lactose-ve.. Commonly found in water, Catalase +, Oxidase-ve, lactose-ve.. Commonly found in water, moist hospital environment ..contaminate irrigating solutions and moist hospital environment ..contaminate irrigating solutions and intravenous solutions and respiratory equipments, catheters intravenous solutions and respiratory equipments, catheters

- Asymptomatic skin carriage, nasopharyngeal carriageAsymptomatic skin carriage, nasopharyngeal carriage

- Commensal, low virulence .. Commensal, low virulence .. Opportunistic pathogenOpportunistic pathogen

A. baumanniiA. baumannii  : : Common species, often represent colonization rather than infectionCommon species, often represent colonization rather than infection Found in skin, urine, wound & sputum hospitalized patientsFound in skin, urine, wound & sputum hospitalized patients..

-Nosocomial infections:Nosocomial infections: in Immunodeficient patients & others ICUs- in Immunodeficient patients & others ICUs-Patients . Patients . Infections: Infections: Pneumonia, Bloodstream Wound, Meningitis .. Pneumonia, Bloodstream Wound, Meningitis .. Develop rapidly resistance to most used antibiotics .. Multidrug-Develop rapidly resistance to most used antibiotics .. Multidrug-resistant resistant  A baumanniiA baumannii    is a new emerging pathogen in hospitals is a new emerging pathogen in hospitals worldwide with high mortalityworldwide with high mortality..