MEDICAL MICROBIOLOGY: ENTEROBACTERIACEAE

DR. MAGDALENA NATIVIDAD (MAR 5, 2018)

FAMILY ENTEROBACTERIACEAE CULTURAL CHARACTERISTICS

MEMBERS " Can grow in ordinary media
v Coliforms (Lactose Fermenters) o Grow on peptone or meat extract media without the
" Normally inhabit the colon addition of sodium chloride or other supplements
" Most abundant among the inhabitants of the intestinal (Non-fastidious)
tract o Primary Isolation from clinical specimens primarily
o Escherichia from stool we use selective or differential media:
o Klebsiella Culture Inhibitory CHO/s pH/H2S LF NLF
o Enterobacter media agents ind
v Non-Lactose Fermenters Eosin Eosin Y Eosin Y Red Colorless
§ Invasive Pathogens Methylene MB MB (E. coli –
" Intestinal pathogens that are NLFs Blue green
metallic
o Salmonella
sheen)
o Shigella
MacConkey Crystal violet Neutral Pink/Red Colorless
o Yersinia agar Bile salts Lactose red
§ Opportunistic pathogens
Deoxycholate Na Neutral Pink Colorless
o Proteus deoxycholate red
citrate agar
o Providencia Na citrate
o Morganella Ferric
o Serratia ammonium
citrate
o Citrobacter
o Edwardsiella
o Cedecea o To isolate specific pathogens, use highly/more
o Kluyvera selective culture media
Culture media Inhibitory CHO/s pH/H2S ind LF NLF
GENERAL CHARACTERISTICS agents
Hektoen Bile salts Xylose Phenol red Yellow Green
" Gram negative bacilli Enteric Agar Lactose or Blue
o Species cannot be distinguished by Gram staining alone (HEA) Sucrose green
" Inhabit the intestinal tract except Yersinia pestis hence the Xylose-Lysine- Bile salts Salicin Bromthymol Yellow Red
term coliforms/enterics Desoxycholate Lactose blue
" Facultative anaerobes agar Sucrose
" Utilize glucose anaerobically (OF, +,+) Salmonella- Bile salts Lactose Neutral red Pink/Red Colorless
" Catalase (+) EXCEPT for Plesiomonas Shigella agar
" Oxidase Negative
o Note that other intestinal pathogens are Gram negative
but Oxidase Positive (such as Vibrio, Campylobacter and
Pseudomonas)
IDENTIFICATION OF SIGNIFICANT ISOLATES
MICROSCOPIC MORPHOLOGY
§ Gram staining: Short gram negative rods
§ Most are motile with peritrichous flagella
o Nonmotile organisms: Klebsiella, Shigella, Yersinia

Page 1 of 11
MEDISINA 2020
REFERENCES: Lecture notes + Potter trans + Jawetz, 27th ed + Mahon, 5th ed + Bailey & Scott’s, 12th ed + Notes from MedTech days
 MEDICAL MICROBIOLOGY: ENTEROBACTERIACEAE
DR. MAGDALENA NATIVIDAD (MAR 5, 2018)

BIOCHEMICAL CHARACTERISTICS oFermentation of glucose (anaerobic)

in the butt produces larger amounts
1. Oxidase Negative
of acid, overcoming the alkaline
2. NO3/NO2 Reduction
effects of peptone degradation;
- All spp. Are (+) except for Pantoea agglomerans and
therefore, the butt remains acidic
Erwinia spp.
(yellow).
- Medium is incorporated with 0.1% KNO3
- Red (ALKALINE)/Yellow (ACID) = K/A
- Positive result: Red azodye
v No fermentation
3. Carbohydrate Utilization Tests
- Alkaline slant/alkaline butt (ALK/ALK or K/K) or
a. Triple Sugar Iron (TSI)
alkaline slant/no change (ALK/no change or
- Contains 0.1 % glucose, 1% lactose, 1%
K/NC)
sucrose (1:10:10)
- Typical reaction for non-members of Family
b. Kligler Iron Agar (KIA)
Enterobacteriaceae
- Contains 0.1 % glucose, 1% lactose (1:10)
RESULTS:
v BOTH:
v A/A
" Contains 2% peptone, Phenol Red (pH ind.)
o H2S (-) – Rapid lactose fermenters (RLFs)
and FeSO4/Ferric Ammonium Citrate (H2S ind.)
" E. coli
" Indicates:
" Klebsiella
o Lactose Fermentation
" Enterobacter
o H2S production
o H2S (+) – Late lactose fermenters (LLFs)
o Gas production
" Citrobacter freundii
REPORTING:
" Proteus spp. (except P. penneri)
" Salmonella arizonae
v K/A
" Nice to know: WHY K/A and not K/K? NLFs
utilize 2 % peptone after 18-24 hours of
incubation
o H2S with gas (+)
" Citrobacter freundii
" Proteus spp. (except P. penneri)
" Salmonella spp. (except S. typhi and S.
gallinarum – No gas prod.; S. paratyphi A –
No H2S)
" Edwardsiella spp.
o H2S (-)
" Anaerogenic E. coli
" Citrobacter koseri
" Shigella
v Lactose (or Sucrose or Both) fermentation " Serratia
- Yellow (ACID)/Yellow (ACID) = A/A " Yersinia
- H2S prod = Blackening of medium " Providencia
- Gas prod = Formation of bubbles or splitting of " Morganella
the medium in the butt or complete
displacement of the medium from the bottom 4. IMViC
of the tube a. Indole
v Glucose fermentation only - Detects
- No lactose (or sucrose in TSI) fermentation tryptophanase
o The acid produced from this - Media:
concentration of glucose is enough to • Tryptophan
change the indicator to yellow initially agar
throughout the medium. • SIM
o However, after about 12 hours, the • Motility
glucose is consumed, and bacteria on Indole Ornithine
the slant utilize the peptones - Reagent Ehrlich’s/Kovac’s
aerobically, producing an alkaline - Positive result: Red ring
reaction, which changes the indicator
to a deep red color.

Page 2 of 11
MEDISINA 2020
REFERENCES: Lecture notes + Potter trans + Jawetz, 27th ed + Mahon, 5th ed + Bailey & Scott’s, 12th ed + Notes from MedTech days
 MEDICAL MICROBIOLOGY: ENTEROBACTERIACEAE
DR. MAGDALENA NATIVIDAD (MAR 5, 2018)
b. Methy Red (MR) 5. Urease
- Detects acid production via Mixed Acid - Determines whether a
Fermentation Pathway microorganism can
- Media: hydrolyze urea,
• MRVP releasing a sufficient
• Clark-Lubb’s Broth amount of ammonia to
- Positive result: Red produce a color change
c. Voges-Proskauer by a pH indicator
- Detects acetylymethylcarbinol production - Media (Phenol red –
from glucose via the Butylene Glycol Pathway pH ind):
- Media: • Christensen’s
• MRVP Urea Agar
• Clark-Lubb’s Broth • Urea broth
- Positive result: Pink/Red - Positive result: Pink/Red/Magenta
• Rapid (2-4 hrs)
o Providencia (except P. stuartii –
Urease neg)
o Proteus
o Morganella
• Slow (18-24 hrs)
o Enterobacter spp.
o Klebsiella spp.
6. Sugar Fermentation Tests
- Determines used to
determine the ability of an
organism to ferment a
specific carbohydrate that is
incorporated in a basal
medium, thereby producing
acid with or without visible
gas.
- Media: Peptone media with
phenol red as indicator
- Positive result: Yellow
- NOTE: ALL Enterobacteriaceae ferment Glucose
7. Enzyme Tests
- DNase
- Lipase
- Gelatinase
- Serratia are the only organisms positive to ALL 3
(Differentiates is from other members of
Enterobacteriaceae)
d. Citrate
- Detects ability to
use Citrate as a
sole source of
carbon
- Media: Simon
Citrate agar
(contains
bromthymol
blue)
- Positive result:
Blue

Page 3 of 11
MEDISINA 2020
REFERENCES: Lecture notes + Potter trans + Jawetz, 27th ed + Mahon, 5th ed + Bailey & Scott’s, 12th ed + Notes from MedTech days
 MEDICAL MICROBIOLOGY: ENTEROBACTERIACEAE
DR. MAGDALENA NATIVIDAD (MAR 5, 2018)

SEROLOGY VIRULENCE FACTORS

" Based on detection of cell wall v Endotoxin
" Involves: " Aka Lipid A
o O/Somatic Antigen " Important role in the pathogenesis of infection
- Heat stable lipopolysaccharide (endotoxin) " All Enterobacteriacae produce Endotoxin
- Present in Proteus spp. (Used to detect " This elicits release of pyrogens from macrophages
antibody to Rickettsial infections; eg. Weil- inducing fever
Felix) v Capsule
o H/Flagellar Antigen v Exotoxin
- Heat labile o Enterotoxin
- Absent in nonmotile organisms such as, " A common toxin that acts on the small intestines,
Klebsiella, Shigella, Yersinia causing accumulation of fluids and electrolytes in
o K/Capsular Antigen the lumen = Diarrhea
- Present in: o Shiga Toxin
• Klebsiella spp. (Large polysaccharide v Invasiveness
capsule) " Involves intestinal pathogens that are NLFs (Salmonella,
• E. coli – K1 Shigella, Yersinia)
• Salmonella typhi – Vi Ag v Type III Secretion System
" Major virulence factor (Provides mechanisms for the
PATHOGENICITY uptake and release of different metabolites and
" The ability to produce disease compounds)
" Virulence factors are encoded by pathogenicity island " Serves as a transport system (forms a tube between the
- Consists of a cluster of genes in a locus that are bacterial cell and host cell)
under the control of a single promoter " Where different metabolites and compounds are
released or introduced into the cell à injects proteins to
- When the promoter is turned on, all genes will be
other cells
expressed
" Composed of several proteins used by the
microorganism to secrete pathogenic factors in the host
environment.
o If No Type III à avirulent

Page 4 of 11
MEDISINA 2020
REFERENCES: Lecture notes + Potter trans + Jawetz, 27th ed + Mahon, 5th ed + Bailey & Scott’s, 12th ed + Notes from MedTech days
 MEDICAL MICROBIOLOGY: ENTEROBACTERIACEAE
DR. MAGDALENA NATIVIDAD (MAR 5, 2018)
SIGNIFICANT ISOLATES " Most common/important cause of Hospital-inquired
OPPORTUNISTIC GROUP pneumonia
" Includes the following: o Lobar Pneumoniae
o E. coli - May be community/hospital acquired
o Klebsiella - Primary disease produced by Klebsiella
o Enterobacter pneumoniae
o Proteus - Extensive necrotizing consolidation of the
o Providencia lungs
o Morganella - Currant jelly sputum (blackish-reddish in
o Serratia color)
o Citrobacter - Predisposing factor: Alcoholism & People
o Kluyvera with compromised pulmonary functions
o Cedecea cystic pulmonary conditions
o Edwardsiella " May also cause UTI, bacteremia, meningitis (because it is
" Commensals of the intestinal tract (Nonpathogenic) opportunistic)
o Disease produced only when there are alterations in v Other Klebsiella spp.:
the defenses of the host: o K. oxytoca
- Changes in immune status " Produce infections same as K. pneumoniae
(Immunocompromised)
" May also cause bacteremia and UTI
- Patient undergone hospital procedures (eg.
" IMViC (+,-,+,+) – Indole Positive
Catheterization, Insertion of IV needles, use
o K. ozaenae
of respiratory apparatus) that may have been
" May cause chronic atrophic rhinitis
contaminated – Nosocomial infections
characterized by purulent sinus infections
o Infections may be community-acquired
o K. rhinoscleromatis
o Infections found outside the intestines
(extraintestinal) " Produce granulomatous disease of the nose
" Usual type of infections produced: and oropharynx
o UTI (most common cause: E.coli) o K. granulomatis
o Pneumonia " Previously Calymmatobacterium granulomatis
o Septicemia " Causes Granuloma inguinale (Donovanosis)
o Wound Infections - Sexually transmitted or non-sexual,
o Meningitis chronic genital ulcerative disease
o Various GIT Disorders but NOT DIARRHEA except E. - Does not grow in artificial culture media
coli o Diagnosis is made by getting a
sample from the lesion stained
KLEBSIELLA-ENTEROBACTER-SERRATIA GROUP with Giemsa/Wright stain
v Klebsiella pneumoniae o Look for mononuclear cells with
" Aka Friedlander’s bacillus 1-25 bacteria (Donovan bodies)
" Has a similar biochemical characteristic with - Doesn’t manifest with buboe-like
Enterobacter Lymphogranuloma venereum caused by
" A/Ag H2S (-), IMViC (-,-,+,+), Non-motile, Urease positive Chlamydia trachomatis (under the
" Capsule is the most important virulence factor microscope: pus cells, w/o organism)
o Produce mucoid glistening colonies
o (+) Neufeld-Quellung test v Enterobacter (formerly Aerobacter)
" E. cloacae, E. aerogenes, E. sakazaki
" Motile, Urease negative
" May infect any tissue
o Most frequently associated with UTI
COMPARISON OF LACTOSE FERMENTERS
Organism TSI INDOLE MR VP CITRATE UREASE
E. coli A/A + + - - -
K. A/A - - + + +
pneumoniae
Enterobacter A/A - - + + -
spp.

Page 5 of 11
MEDISINA 2020
REFERENCES: Lecture notes + Potter trans + Jawetz, 27th ed + Mahon, 5th ed + Bailey & Scott’s, 12th ed + Notes from MedTech days
 MEDICAL MICROBIOLOGY: ENTEROBACTERIACEAE
DR. MAGDALENA NATIVIDAD (MAR 5, 2018)
v Serratia o Produce H2S and swarming on non-selective media
" (+) DNase, Lipase, Gelatinase (eg. BAP; When agar is touched with a wire à
" Major entities in nosocomial infections incubated in 18-24 hours à Growth spreads/swarms on
" S. marcescens the entire surface of the plate)
- Most common isolated species
- Produces red pigment (prodigiosin) in MaC

o Antigenically crossreacts with Ricketssiae

" Weil-Felix test
- Developed to diagnose Rickettsia
infection where Proteus antigens (OX2,
PROTEEAE GROUP OX19, OXK) are used
" Includes the following: - Obsolete because infections with
o Proteus Proteus spp. may cause positive results
• P. vulgaris (Indole Pos) and not all Rickettsia spp. exhibit these
• P. mirabilis (Indole Neg) antigens
o Morganella – M. morganii CITROBACTER
o Providencia
• P. rettgeri " Formerly Bethesda-Ballerup group
• P. stuarti " Majority of the isolates are from the urinary tract and
• P. alkalifaciens neonatal infections
" Important test: Urease Test " Formerly may be nonpathogenic (more frequent), opportunist
or true intestinal pathogen
- Urease hydrolyzes urea to form ammonia, water,
and CO2. TRUE INTESTINAL PATHOGENS
- Urease (+)
Escherichia coli
• Proteus spp.
" Most abundant aerobic flora of the colon but NOT the MOST
• Morganella
ABUNDANT FLORA
• Providencia rettgeri
o Anaerobes (Bacteroides) are the most abundant flora
- Urease (-) of the colon (90%)
• P. stuarti o Aerobes are 10%
• P. alkalifaciens " Index for fecal pollution of water (Easiest to detect)
" Majority: Causes UTI o Other organisms used: Enterococcus fecalis,
Clostridium perfringens
v Proteus spp. " Specialized virulence factors:
o H2S producer (Blackening of TSI) o Adhesins
o Proteus mirabilis - Responsible for attachment to epithelial
" Most commonly encountered species surfaces (Pili/Fimbriae)
" 2nd most common cause of UTI - Colonization factor Antigens CFA/I, CFA/II and
• Characterized by alkaline urine CFA/III – ETEC
• Promotes precipitation of Ca and Mg - Aggregative adherence fimbriae AAF/I and
salts and results in the formation of AAF/II – EAEC
urinary calculi/stones (aka Staghorn - Bundle forming pili (Bfp) – EPEC, EHEC
urinary calculi)
- Intimin – EHEC
• Alkaline pH may also cause damage to - P pili – EIEC
the renal epithelial cells

Page 6 of 11
MEDISINA 2020
REFERENCES: Lecture notes + Potter trans + Jawetz, 27th ed + Mahon, 5th ed + Bailey & Scott’s, 12th ed + Notes from MedTech days
 MEDICAL MICROBIOLOGY: ENTEROBACTERIACEAE
DR. MAGDALENA NATIVIDAD (MAR 5, 2018)
- Ipa protein – Uropathogens
- Dr fimbriae – Uropathogens

" Extraintestinal Infections:

o UTI
- Most common cause in humans (Acute or
Chronic)
- Uncomplicated Cystitis
• Caused by uropathogenic strains (via
hemolysis)
• Ascending infection
- Complicated Pyelonephritis
• Caused by non-pathogenic strains via
hematogenous route (via P. fimbriae) v Enterotoxigenic E. coli (ETEC)
o Neonatal meningitis " Site of action: SI
- Via K1/C Ag (Pathogens with capsule are usual " Primary cause of Traveler’s diarrhea, Infant diarrhea
causes of meningitis) in developing countries, watery diarrhea, vomiting,
- Acquired via vaginal sepsis or prolonged cramps, nausea, low grade fever.
delivery o Non-bloody, Non-invasive = Watery stool
- 3 main causes: " Plasmid (+) LT and ST toxin ; Plasmid-mediated, heat
• Streptococcus agalactiae stable and/or Heat labile enterotoxins that stimulate
• Listeria monocytogenes Hypersecretion of fluids and electrolytes
• Escherichia coli
o Nosocomial infections
- Causes pneumonia, wound infections,
septicemia/bactermia, endotoxic shock
o Most common cause of Gram negative sepsis

PATHOGENESIS:
v Plasmid
" Carries virulence factors that enable them to produce
intestinal disease
" Most have plasmids except EHEC
o In EHEC, virulence factors are carried by a
bacteriophage (Phage-coated toxin) • Heat Labile Toxin
- Activates adenylyl cyclase to increase
v Enteropathogenic E. coli (EPEC) secretion of cAMP
" Site of action: SI - Subunits:
" Causes the 2nd most common cause of Infantile § A = Toxic
Diarrhea in underdeveloped countries (#1: Rotavirus) § B = For binding/attachment to
o Watery diarrhea and Vomiting receptor
o Non-bloody stools - ATP à Inc cAMP:
o Non-invasive § Inhibition of Na reab
" Plasmid mediated, Attachment / Effacement (less § Inc secretion of Cl, K, etc
surface area for absorption) or A/E Histopathology § Draw water into the lumen of
with disruption of Normal Microvillus structure intestine
resulting in malabsorption and diarrhea. § NON-BLOODY STOOL
o The bacterium attaches to the surface of the § Usually self-limited
intestinal cells and causes effacement of the • Heat Stable Toxin
microvilli à release toxins via Type III secretion - Activates guanylate cyclase to increase
system. Diarrhea mainly due to malabsorption secretion of cGMP
because of the flattening of microvilli; Has BFP / - GTP à Inc cGMP
Bundle Forming Pilus that causes aggregation of - Same mechanism as LT
the bacteria.
v Enteropathogenic E. coli (EHEC)
" Deadly E. coli
o Only E. coli that does not ferment sorbitol

Page 7 of 11
MEDISINA 2020
REFERENCES: Lecture notes + Potter trans + Jawetz, 27th ed + Mahon, 5th ed + Bailey & Scott’s, 12th ed + Notes from MedTech days
 MEDICAL MICROBIOLOGY: ENTEROBACTERIACEAE
DR. MAGDALENA NATIVIDAD (MAR 5, 2018)
" Site of action: LI
" Causes INTIALLY watery diarrhea, followed by Grossly
Bloody diarrhea (Hemorrhagic colitis) with abdominal
cramps, little or no fever
o May progress to Hemolytic Uremic Syndrome
(HUS, which is the cause of death)
" Phage-Mediated by Cytotoxic Shiga-like toxins (Stx-1 &
Stx-2) (similar to that of Shigella), which disrupt
protein synthesis; A/E lesions with destruction of
Intestinal Microvillus resulting in decreased absorption.
o Transmission: Hamburger (found in the feces of
cattle)
o Why not steak? When feces contaminates the
meat and people buy the meat as ground beef
(hamburger), it is not usually washed. Grinding
the beef increases surface area of the organism
for ground beef instead of meat as a chunk
(steak).
o IDENTIFICATION: Serotyping O157:H7 (O
Antigen) Flagellar Antigen 7.
o Characteristic: Inability to ferment sorbitol
(colorless on MCA), grown on MacConkey with
Sorbitol instead of lactose, most E.coli will
ferment Sorbitol (pink colonies).
- Kidney is particularly susceptible
o Ischemic necrosis of the bowel, brain,
eye, or virtually any organ can occur
o Death due to uremia (Kidney Failure)
v Enteroinvasive E. coli (EIEC)
" Site of action: LI
" Causes disease in underdeveloped countries; fever,
cramping, watery diarrhea, initially watery diarrhea
may progress to Dysentery with Scanty stool
containing blood and mucus
" Plasmid mediated INVASION and destruction of
epithelial cells lining the colon (Site of invasion)
causing Ulcer formation.
o Lining invasion only
o Scanty stool with blood and mucus (Similar to
Shigella)
o Enters enterocyte (M cell) à enclosed in a
phagosome à lyses phagosome (escapes killing)
à organism invades another cell via actin by
pushing it à cell to cell invasion à death of cell
à ulceration
o S/S: Tenesmus (pain in bowel movement)

• Shiga-like Toxin (STx)

v Enteroaggregative E. coli (EAEC)
- The A subunit = toxic portion; binds to the 28s RNA
" Site of action: SI
@ 60S subunit à induces depuration/removal of a
" Causes infant diarrhea in underdeveloped countries,
specific adenine residue in ribosomal RNA à Leads
traveler’s diarrhea, persistant water diarrhea with
to cessation of protein synthesis and death of the
vomiting.
endothelial cell.
o S/S: Dehydration and low-grade fever
- Target: Endothelial cells. The altered surface of
" Plasmid mediated Aggregative adherence of Rods
the intoxicated endothelial cell serves as a nidus
(Stacked bricks) with shortening of microvilli à
for activation of the coagulation cascade à
decreased fluid absorption à decrease fluid
formation of microthrombi à causes distal
absorption à formation of biofilm à release of
ischemic necrosis, platelet consumption, and red
cytotoxins and enterotoxins à mononuclear
cell fragmentation—the hallmarks of the
infiltration and hemorrhage
hemolytic-uremic syndrome
o The kidney is particularly susceptible for
ischemic necrosis d/t microthrombi
• STEC
" Hemolytic Uremic Syndrome
- Microangiopathic hemolytic anemia
- Results from Shiga toxin-induced damage to
endothelial cells
o Leading to activation of coagulation in
the microvasculature

Page 8 of 11
MEDISINA 2020
REFERENCES: Lecture notes + Potter trans + Jawetz, 27th ed + Mahon, 5th ed + Bailey & Scott’s, 12th ed + Notes from MedTech days
 MEDICAL MICROBIOLOGY: ENTEROBACTERIACEAE
DR. MAGDALENA NATIVIDAD (MAR 5, 2018)
v Enterohemorragic E. coli (EHEC) " Prominent:
" Gives Hemolytic Uremic Syndrome (HUS) o Dysentery
" MOT: UNDERCOOKED HAMBURGER! It is found in - inflammation of the intestine esp. the colon
feces of cattle or cows. with accompanying severe abdominal cramps
" Characterized by: and tenesmus, volume of stool is low or in
o Acute renal failure leading to increased Urea squirts + blood and mucus), fever, and
in blood convulsions
o Thombocytopenia causing bleeding
tendencies PATHOGENECITY:
o Microangiopathic Hemolytic Anemia § Invasiveness
- Ulceration of terminal ileum and colon (Blood and
DIAGNOSIS: mucus in stool)
v Non-GIT Infections - Rarely penetrate through the wall or the blood stream
" Differential Media: Lactose Fermenting - Invasion is only in the lining. Does not penetrate the
" Biochemical Tests wall.
v GIT Infections § Shiga toxin
" Differential Identification done in reference labs - Mainly secreted by S. dysenteriae type 1 (real
except: producer)
o EHEC: in culture – use S-MAC (Sorbitol o Other species: produces Shiga-like toxin
containing MacConkey Agar) (other Shigella are antigenically different)
o Via Non sorbitol fermenting à colorless - Encoded by Chromosome genes
colonies
§ Confirmation via Serotype: O157: H7 - Subunits:
(most common) o Subunit B
o Via Immunoassay for toxin production (also Ø For binding to intestinal epithelium M2
for Specialized lab) cells
SHIGELLA o Subunit A1
Ø Inhibits protein synthesis
" Has 4 species (categorized based on their O Ag; All are Ø Binds with 60S ribosomal subunit
known to cause Bacillary dysentery): - It has 3 activities:
o Shigella dysenteriae or Shiga bacillus: Grp A o Enterotoxic
- Gives the most severe form of disease Ø Inhibits adheres to SI receptors and
o Shigella flexneri: Grp B blocks absorption of electrolytes,
- Seen in developing countries glucose, and amino acids from the
o Shigella boydii: Grp C intestinal lumen
o Shigella sonnei: Grp D Ø Quite different from E.coli’s LT (causes
- Most common isolate in the industrial world production cAMP à inhibition of sodium
" Primarily a human pathogen (Does not infect animals) reabsorption and increase secretion of
o Infection is usually confined in the GIT electrolytes)
o Usually no extraintestinal invasion like bacteremia o Cytotoxic
(Blood is not the specimen for diagnosis) o Neurotoxic
" Very low infective dose: 100 bacilli Ø Cause convulsions
o Shigella = 102 cells (Most virulent) - E. coli LT and Vibrio cholera toxin: same mechanism
o S. typhi (Typhoid fever) = 103 cells of action
o Other Salmonella (Gastroenteritis) = 105 cells
o V. cholera = 105cells (Most severe but least virulent) DIAGNOSIS:
" Transmitted by 4F’s § Best sample: Rectal swab
o Fingers § Non-lactose fermenting (Culture – gold standard)
o Flies § TSI : K/A (alkaline slant and acid butt) no gas, no H2S
o Food § Confirmation via serotyping by slide agglutination
o Feces
" No prolonged carrier state until Convalescence stage. TREATMENT
o Unlike Salmonella, forever a carrier (most § Usually self-limited
commonly: Chronic carrier state of 1 year) § Replacement of fluids and electrolytes for diarrhea
" Harbors the R Plasmid § Ciprofloxacin, Ampicillin, Doxycycline, TMP-SMZ (Given to
- Responsible for MDR via Conjugation lessen number of bacteria or shorten duration of illness)
" No vaccine yet

Page 9 of 11
MEDISINA 2020
REFERENCES: Lecture notes + Potter trans + Jawetz, 27th ed + Mahon, 5th ed + Bailey & Scott’s, 12th ed + Notes from MedTech days
 MEDICAL MICROBIOLOGY: ENTEROBACTERIACEAE
DR. MAGDALENA NATIVIDAD (MAR 5, 2018)
Profuse diarrhea (No gross blood and mucus,
o
Microscopic RBCS and pus cells may be seen)
" Often Self-limiting
o Give Fluid and Electrolyte replacement
o NOT RECOMMENDED TO GIVE ANTIBIOTICS unless
patient is immunocompromised
o Clinical symptoms and excretion of salmonellae
may be prolonged by anti-microbial therapy
v Septicemia
" All serovars of Salmonella enterica
" Predisposing factor: extremes of age,
immunocompromised
" Occurs in one of 2 settings:
o Chronic disease (eg. sickle cell anemia, cancer)
o A patient with Enterocolitis
" Transmission: Ingestion (fecal-oral route) à once
reached intestines, it invades intestine wall à early
blood stream invasion à seeding in many organs
SALMONELLA o In case of septicemia, immediately leaves the
intestine and goes to the blood = absence of
" Single species: Salmonella enterica INTESTINAL SYMPTOMS
o Other previous species are now known to be " Manifestation:
serotypes/serovars (S. typhi & S. paratyphi) o Osteomyelitis (prominent)
" MOT: Fecal-oral route o Pneumonia
o Important sources of most serotypes: Animals o Meningitis
(poultry, pigs, rodents, cattles, and pets such as turtles o Intestinal symptoms usually absent (usually no
& parrots diarrhea)
o Human sources only: v Enteric Fever (Typhoid and Paratyphoid Fever)
§ S. Typhi (Typhoid) " Typhoid – caused by S. Typhi
§ S. Paratyphi (Paratyphoid) " Paratyphoid (milder form)
§ S. Cholerasuis (Septicemia) o S. Paratyphi A
o S. Schottmuelleri (formerly Paratyphi B)
PATHOGENESIS: o S. Hirschfeldii (formerly Paratyphi C)
" Pathogenecity Islands o Paratyphoid is MILDER than Typhoid
o PAI I – encodes the following: " Virulence Factor: Vi Ag
§ A (Salmonella secreted invasion proteins/Ssps) - Capsular antigen
§ B (Type III Secretion system) - Antiphagocytic (Allows the organism to survive
o PAI II – encodes the following: inside phagocytes = Facultative intracellular
§ A (Genes for evasion of the host’s immune
parasite)
response)
- Causes resistance to lysosomal enzymes
§ B (Type III Secretion system)
" Causes severe life threatening disease
" Enter enterocytes à engulfed by macrophages à macrophage
" Incubation Period : 10-14 days
survives à macrophage will bring the organism to the lymph
node à brought to liver and intestines à breach intestinal lining
" Transmission: Ingestion à Intestines à lymphoid
à go to the lymphatics à blood tissues (Peyer’s patches) à blood causing bacteremia
à various tissues like liver and spleen then to
3 DISTINCT CLINICAL/DISEASE ENTITIES: Gallbladder to the bile à goes back to the intestines
v Salmonella Gastroenteritis/Enterecolitis/ Salmonellosis o First few weeks: Constipation rather than
" Most common form Diarrhea
" Due to Animal acquired salmonella o It goes back to the intestines after 2nd week of
" Most common serotype: Typhimurium (but it can be Illness à Diarrhea
caused by any serotype) " S/S: Fever, malaise, headache, constipation,
" Incubation period: 8-48 hrs bradycardia, myalgia, hepatomegaly, splenomegaly,
" S/S: Rose spots in abdomen and chest (rare; suggestive of
o Nausea Typhoid)
o Headache " Chronic carrier state (1-5% of patients): organisms are
o Vomiting found in gallbladder (Typhoid Mary)
o Detection: Stool exam / culture (person may be
asymptomatic)

Page 10 of 11
MEDISINA 2020
REFERENCES: Lecture notes + Potter trans + Jawetz, 27th ed + Mahon, 5th ed + Bailey & Scott’s, 12th ed + Notes from MedTech days
 MEDICAL MICROBIOLOGY: ENTEROBACTERIACEAE
DR. MAGDALENA NATIVIDAD (MAR 5, 2018)
" COMPLICATION (if left untreated): intestinal DIAGNOSIS:
perforation, cholecystitis " Culture (Cold enrichment at -4oC)
" DIAGNOSIS: o Refrigerate stool for 24 hours before inoculating in
o Culture (Gold standard) from Blood or Bone the plate to allow multiplication and inhibition of
Marrow normal flora
§ Sample collection:
- Blood (10-14 days) TREATMENT:
- Stool/Urine (After 2 weeks) " Replacement of fluids & electrolytes
§ BM is better than blood " Via susceptibility testing for choosing antibiotics
o Widal Test
- Obsolete (O & H Abs)
- S. Typhi cross-reacts with other
Salmonella. Those living in an endemic
area may give positive results.
o Typhi Dot
- Specific IgG and IgM

" DOC: Ceftriazone/Ciprofloxacin

" Prevention:
o Vaccine (50-80% protection; only for 1 year)
o IM – contains Vi Ag polysaccharide capsule
o Oral – Live attenuated S. Typhi (best; enhances
production of secretory IgA in the intestines)

YERSINIA
" Involves the following organisms:
o Y. enterocolitica
- Causes intestinal disease (Yersiniosis)
- Zoonotic
- More common in Northern Europe (Grows
better in cold temperatures); May still be
present here in the Philippines
- Usually misdiagnosed because it does not
grow well at 37oC (Grows better at 22oC)
- S/S: Bloody diarrhea and may mimic
appendicitis
o Y. pseudotuberculosis – may also cause intestinal
disease
o Y. pestis – Important cause of bubonic plague

Page 11 of 11
MEDISINA 2020
REFERENCES: Lecture notes + Potter trans + Jawetz, 27th ed + Mahon, 5th ed + Bailey & Scott’s, 12th ed + Notes from MedTech days