MEDICAL MICROBIOLOGY I

Lesson 12
Enterobacteriaceae Part II

Salmonella
Gram negative rods, motile, and facultatively
anaerobic
Oxidase negative, catalase positive, KCN
negative, usually citrate positive and H2S
positive, ferments carbohydrates
Most salmonellae are parasites of man, animals
(pigs, cows, goats, etc) and birds (hens, duck,
etc)
S. typhi and S. paratyphi are parasites of man
only

Salmonella

Salmonella on CLED agar

Pathogenesis and Immunity

After ingestion and passage through the
stomach, salmonellae are able to invade and
replicate in the M (microfold) cells located in
Peyers patches of the terminal portion of the
small intestine
These cells typically transport foreign antigens
to the underlying macrophages for clearance

Pathogenesis and Immunity

Two separate type III secretion systems
mediate the initial invasion into the intestinal
mucosa (Salmonella pathogenicity island 1
[SPI-1] and subsequent systemic disease [SPI2])
Binding to M cells is mediated by speciesspecific fimbriae

Pathogenesis and Immunity

The SPI-1 secretion system then introduces
Salmonella-secreted invasion proteins (Sips or
Ssps) into the M cells, resulting in
rearrangement of the host cell actin with
subsequent membrane ruffling
The ruffled membrane surround and engulf
salmonellae, leading to intracellular replication
in the phagosome with subsequent host cell
death and spread to adjacent epithelial cells
and lymphoid tissue

Pathogenesis and Immunity

The inflammatory response confines the
infection to the GIT, mediates the release of
prostaglandins, and stimulates cAMP and active
fluid secretion
Salmonella species are also protected from
stomach acid and the acid pH of the phagosome
by an acid tolerance response (ATR) gene
Catalase and superoxide dismutase are other
factors that protect the bacteria from
intracellular killing

Epidemiology
Salmonella can colonise virtually all animals
including poultry, reptiles, livestock, rodents,
domestic animals, birds, and humans
Animal-animal spread and the use of
Salmonella-contaminated animal feeds
maintain an animal reservoir
S. typhi and S. paratyphi are highly adapted to
humans and do not cause disease in nonhuman hosts

Epidemiology
Transmission: contaminated food products
(e.g. poultry, eggs, dairy products and foods
prepared on contaminated work surfaces),
faecal-oral route (especially in children)
The infectious dose for S. typhi infections is
low, so person-person spread is common
Large inoculum is required for symptomatic
disease to develop with other Salmonella sp.

Epidemiology
The infectious dose is lower for people at high
risk for disease because of age,
immunosuppression or underlying disease
(e.g. leukaemia, lymphoma, sickle cell
disease), or reduced gastric acidity

Clinical Diseases
1. Enteritis
The most common form of salmonellosis
Symptoms generally appear 6 - 48 hours after
the consumption of contaminated food or
water, with the initial presentation consisting of
nausea, vomiting, and non-bloody diarrhoea
Fever, abdominal cramps, myalgias, and
headache are also common
Symptoms can persist from 2 days to 1 week
before spontaneous resolution

Clinical Diseases
2. Septicaemia
All Salmonella species can cause bacteraemia,
although infections with S. cholerasuis, S.
paratyphi and S. typhi more commonly lead to
bacteraemia phase
The risk of Salmonella bacteraemia is higher in
paediatric and geriatric patients as well as
patients with AIDS
Symptoms: Gram negative bacteraemias; 10%
localised suppurative infections, such as
osteomyelitis, endocarditis, and arthritis

Clinical Diseases
3. Enteric fever
S. typhi produce febrile illness - typhoid fever
Mild: S. paratyphi A, S. schottimuelleri, and S.
hirschfeldii - paratyphoid fever
Bacteria pass through the cell lining the
intestines and are engulfed by macrophages replicated (liver, spleen, and bone marrow)
Symptoms: fever, headache, myalgias, malaise,
and anorexia, persist for a week or longer

Clinical Diseases
4. Asymptomatic colonisation
The species of Salmonella responsible for
causing typhoid and paratyphoid fevers are
maintained by human colonisation
Chronic colonisation for more than 1 year after
symptomatic disease develops in 1 - 5% of
patients, the gall bladder being the reservoir in
most patients

Shigella
Gram negative rods, aerobic and facultatively
anaerobic, non-motile, mostly catalase
negative, oxidase negative and ferment
carbohydrates mostly without gas, citrate and
KCN negative
Shigellae are found in the intestinal tract of
man
They are strict human parasites

Shigella

Shigella Infection

Pathogenesis and Immunity

Shigella cause disease by invading and
replicating in cells lining the colonic mucosa
Structural gene proteins mediate the
adherence of the organisms to the cells as well
as their invasion, intracellular replication, and
cell-cell spread
Shigella species appear unable to attach to
differentiated mucosa cells; rather, they first
attach to and invade the M cells located in
Peyers patches

Pathogenesis and Immunity

The type III secretion system mediates
secretion of four proteins (IpaA, IpaB, IpaC,
IpaD) into epithelial cells and macrophages
Shigella are able to lyse the phagocytic
vacuole and replicate in the host cell
cytoplasm; unlike Salmonella, which replicate
in the vacuole

Pathogenesis and Immunity

With the rearrangement of actin filaments in
the host cells, the bacteria are propelled
through the cytoplasm to adjacent cells, where
cell-cell passage occurs - protected from
immune-mediated clearance
Shigella survive phagocytosis by inducing
apoptosis - release of interleukin-1, resulting
in the attraction of polymorphonuclear
leukocytes into the infected cells - destabilises
the integrity of the intestinal wall

Pathogenesis and Immunity

Pathogenesis and Immunity

S. dysenteriae produce an exotoxin, Shiga toxin
Like the toxin produced by EHEC, the Shiga
toxin has one A subunit and five B subunits
The B subunits bind to a host cell glycolipid
(Gb3) and facilitate transfer of the A subunit
into the cell
The A subunit cleaves 28s rRNA in the 60s
ribosomal subunit, thereby preventing the
binding of aminoacyl-transfer RNA and
disrupting protein synthesis

Epidemiology
4 species consisting of more than 45 O
antigen-based serogroups have been
described: S. dysenteriae, S. flexneri, S. boydii,
and S. sonnei
S. sonnei is the most common cause of
shigellosis in the industrial world, and S.
flexneri is the most common cause in
developing countries

Epidemiology
Shigellosis is primarily a paediatric disease;
70% of all infections occur in children younger
than 15 years
Endemic disease in adults is common in male
homosexuals and in household contacts of
infected children
Epidemic outbreaks of disease occur in
daycare centers, nurseries, and custodial
institutions

Epidemiology
Transmission: faecal-oral routes, primarily by
people with contaminated hands and less
commonly in water or food
Because as few as 200 bacilli can establish
disease, shigellosis spreads rapidly in
communities where sanitary standards and
the level of personal hygiene are low

Clinical Diseases
Symptoms: abdominal cramps, diarrhoea,
fever, and bloody stools
Clinical signs and symptoms of the disease
appear 1 - 3 days after bacilli are ingested
The bacilli initially colonise the small intestine
and begin to multiply within the first 12 hours
Abundant pus, neutrophils, erythrocytes, and
mucus in stool

Clinical Diseases
Infection is generally self-limited, although
antibiotic treatment is recommended to
reduce the risk of secondary spread to family
members and other contacts
Asymptomatic colonisation of the organism in
the colon develops in a small number of
patients and represents a persistent reservoir
for infection

Other Enterobacteriaceae
1. Klebsiella
Members of the genus Klebsiella have a
prominent capsule that is responsible for the
mucoid appearance of isolated colonies and
the enhanced virulence of the organisms in
vivo
K. pneumoniae can cause communityacquired primary lobar pneumonia

Other Enterobacteriaceae
Alcoholics and people with compromised
pulmonary function are at increased risk for
pneumonia because of their inability to clear
aspirated oral secretions from the lower
respiratory tract
Pneumonia due to Klebsiella species
frequently involves necrotic destruction of
alveolar spaces, formation of cavities, and the
production of blood-tinged sputum

Other Enterobacteriaceae
2. Proteus
Infection of the urinary tract with Proteus
mirabilis is the most common disease
produced by this genus
P. mirabilis produces large quantities of
ureases, which splits urea into carbon dioxide
and ammonia
This process raises the urine pH and facilitates
the formation of renal stones

Other Enterobacteriaceae
The increased alkalinity of the urine is also
toxic to uroepithelium
Despite the serologic diversity of these
organisms, infection has not been associated
with any specific serogroup
The pili on P. mirabilis may decrease its
virulence by enhancing the phagocytosis of
the bacilli, unlike E. coli

Laboratory Diagnosis
Specimens: sterile specimens such as CSF and
tissue collected at surgery should be cultured
on blood agar (non-selective media)
Specimens: contaminated specimens such as
sputum and faeces should be cultured on
MacConkey and eosin methylene blue (EMB)
agar
This is to separate lactose fermenting from
non-lactose fermenting strains

Laboratory Diagnosis
Highly selective or organism-specific media are
useful for the recovery of organisms in stool,
whereas abundance of normal flora can
obscure the presence of these important
pathogens
Cold enrichment permits the growth of
Yersinia but inhibits or kills other organisms

Laboratory Diagnosis
Biochemical identification
Triple sugar iron agar, indole, methyl red, VogesPoskauer, citrate, malonate, urease,
pheulalanine deaminase, orthonitrophenyl--Dgalactopyranoside test ( -galactosidase test),
arabinose fermentation

Serologic classification
Serotyping specific pathogenic strains:
usefulness of this procedure is limited

Treatment, Prevention and Control

Antibiotic therapy must be guided by in vitro
susceptibility test results and clinical
experience
Some organisms, such as E. coli and P.
mirabilis are susceptible to many antibiotics,
other can be highly resistant
Susceptible organisms exposed to subtherapeutic concentrations of antibiotics in a
hospital setting can rapidly develop resistance

Treatment, Prevention and Control

Symptomatic relief, but not antibiotic
treatment, is usually recommended for
patients with E. coli or Salmonella
gastroenteritis because antibiotics can prolong
the faecal carriage of these organisms or
increase the risk of secondary complications
(e.g. HUS with EHEC infections in children)

Treatment, Prevention and Control

Avoid risk factors:
The unrestricted use of antibiotics that can select
for resistant bacteria
The performance of procedures that traumatise
mucosal barriers without prophylactic antibiotic
coverage
The use of urinary catheters

Exogenous infection with Enterobacteriaceae

is theoretically easier to control

Treatment, Prevention and Control

These bacteria are ubiquitous in poultry and
eggs
Shigella organisms are predominantly
transmitted in young children, but it is difficult
to interrupt the faecal-hand-mouth
transmission responsible for spreading the
infection in this population
Prevention and control: education and
introduction of appropriate infection-control
procedure (e.g. hand washing, proper disposal
of soiled diapers and linens)

Treatment, Prevention and Control

Vaccination with formalin-killed Yersinia pestis has
proved effective for people at high risk
Chemoprophylaxis with tetracycline has also
proved useful for people in close contact with a
patient with pneumonic plague
Improvement in the live, attenuated S. typhi
vaccines gives significant protection, persist for up
to 5 years
Vaccination with purified Vi antigen (the
polysaccharide) capsular antigen of S. typhi
associated with virulence), are also protective