PATHOGENIC E.

coli

INTRODUCTION
E. coli is usually considered to be an
opportunistic pathogen which constitutes a
large portion of the normal intestinal flora of
humans
This organism can, however, contaminate,
colonize, and subsequently cause infection of
extraintestinal sites and is a major cause of
septicemia, peritonitis, abscesses, meningitis,
and urinary tract infections in humans

Humans are thought to be the principal if not the only

reservoir of toxigenic and invasive strains of E. coli,
contaminating foods via contact with food or via contact of
processing equipment with water contaminated by human
feces
In contrast, animals are reservoirs of the hemorrhagic strain
(O157:H7); hence, foods of animal origin may become
contaminated via slaughter procedures or post-processing
recontamination
However, when E. coli is isolated from foods, pathogenic
serotypes are usually absent or represent a very low
percentage of the total isolates

Morphology
usually motile, produce peritrichous flagella
some produce polysaccharide capsules
grow well on non-selective media, forming
smooth, colourless colonies 2-3 mm in
diameter in 18h on nutrient agar
temperature (15-45)

Colonies on selective media

blue and violet
colonies on EMB
agar
red colonies on
MacConkey agar

Biochemical reaction
aerobic or anaerobic --can grow in the
presence or absence of O2.
typically oxidase-negative
most strains ferment lactose & glucose with
the production of acid and gas
IMViC reaction : + + - -

Many strains
Serotypes:
Antibody antigen rxn

O antigen
Somatic (on LPS)
171 antigens

H antigen
Flagella
56 antigens

K antigen
Capsule and or
fimbrial antigen
80 antigens

18th O antigen

O18ac:H7:K1
1st K antigen

7th H antigen

Diseases caused by E. coli

E. coli is responsible for three types of
infections in humans:
urinary tract infections (UTI),
neonatal meningitis,
intestinal diseases (gastroenteritis).

the virulence factors of pathogenic strains of E. coli

Fimbriae (Pili)
Hemolysins
Toxin and other virulence
Siderophores
plasmids
Flagella
Toxins
Thermolabile toxin (LT)
Endotoxin LPS
Thermostable toxin (ST)
Capsules
K antigens
Found alone or together
LPS
Both are plasmid borne
Antigenic variation
Drug resistance plasmids

Uropathogenic E. coli UPEC

Most common form of extraintestinal E. coli
infection
Acute symptomatic UTI
12% of all men
10-20% of women
100,000 patients hospitalized for renal infections

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Urovirulence Factors
Adherence
Fimbriae
Capsule

Hemolysis
a
b

Aerobactin
Siderophore

K antigens
Resist phagocytosis
Resist complement proteins

Endotoxin

Neonatal Meningitis E. coli NMEC

Meningitis in an infection of the fluid and membranes that cover the brain and
spinal cord
Bacteria
Viruses
Fungi
E. coli incites between 1/4 and 1/3 of meningitis cases in newborns
Less than 2% of cases of meningitis at all other ages
Approximately 1 out of 5 newborns with E. coli meningitis dies
Survivors frequently sustain permanent brain damage
The majority of cases occur in premature babies
K-1
80% of NMEC E. coli strains produce K-1 capsular antigens
O18ac:H7:K1
Inhibits phagocytosis
Siderophore production
Sequesters Fe
Endotoxin
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Diarrhegenic E. coli
The most highly conserved feature of diarrheagenic E. coli
strains is their ability to colonize the intestinal mucosal
surface despite peristalsis and competition for nutrients by
the indigenous flora of the gut (including other E. coli strains)
diarrheagenic E. coli strains possess specific fimbrial antigens
that enhance their intestinal colonizing ability and allow
adherence to the small bowel mucosa, a site that is not
normally colonized
Five classes (virotypes) of E. coli that cause diarrheal diseases
are now recognized: enterotoxigenic E. coli (ETEC),
enteroinvasive E. coli (EIEC), enterohemorrhagic E. coli
(EHEC), enteropathogenic E. coli (EPEC), enteroaggregative E.
coli (EAggEC).

Three general paradigms have been described by which

E. coli may cause diarrhea:

enterotoxin production (ETEC and EAEC)

invasion (EIEC)
intimate adherence with membrane signalling
(EPEC and EHEC).

Enterotoxigenic E. coli (ETEC)

cause diarrhea in
infants and travelers

pathogenesis of ETEC
involves two steps:
intestinal colonization,
fimbrial adhesins e.g. CFA I, CFAII, K88. K99
non invasive
diarrheagenic enterotoxin(s) -- LT and/or ST toxin
both traits are plasmid-encoded

Enterotoxins
LT
(heatlabile)
toxin
ST
(heatstable)
toxin

heat-labile toxin (LT)

similar to Vibrio cholerae enterotoxin.
LT from E. coli is a protein of approximately
86,000 daltons that consists of one A
polypeptide and five B polypeptides held
together by noncovalent bonds
the B subunit binds the toxin to the target
cells via a specific receptor that has been
identified as Gm1 ganglioside.
The B subunit of LTh (Human) is also
hemagglutinating

heat-labile toxin (LT)

the A subunit is then activated by cleavage of a
peptide bond and internalized
The actived subunit A then catalyzes the ADPribosylation (transfer of ADP-ribose from
nicotinamide adenine dinucleotide [NAD]) of a
regulatory subunit of membrane-bound adenylate
cyclase, the enzyme that converts ATP to cAMP.
This activates the adenylate cyclase, which
produces excess intracellular cAMP, which leads
to hypersecretion of water and electrolytes into
the bowel lumen.

heat-labile toxin (LT)

Two partially cross-reacting antigenic variants
of plasmid-coded LT, designated LTh and LTp,
have been described in E. coli
LTh is associated with E. coli isolates from
humans, and LTp is associated with E. coli
isolates from pigs
The LT family from restricted geographical
region exhibited a segregated pattern of
dissemination that was revealed by a
restriction enzyme site polymorphism

 Separation of ETEC bacteria from target

intestinal epithelial monolayers by
semipermeable filters prevented activation of
adenylate cyclase suggesting that pathogenhost cell contact is required for efficient toxin
delivery

HEAT-STABLE ENTEROTOXINS (ST)

The heat-stable enterotoxins are low-molecularweight, heat-stable, nonantigenic proteins which do
not cause intestinal secretion by activation of
adenylate cyclase
At least two types have been described, one with
biological activity in suckling mice and piglets (STa, or
named as STh, or ST-I) due to stimulation of
particulate intestinal guanylate cyclase and a second
which induces secretion by an unknown mechanism
only in piglets (STb, or known as STp, or ST-II).

heat-stable toxin
ST enterotoxin causes an increase in cyclic GMP
in host cell cytoplasm.
Those termed STa stimulate intestinal guanylate
cyclase, the enzyme that converts guanosine 5'triphosphate (GTP) to cyclic guanosine 5'monophosphate (cGMP). Increased intracellular
cGMP inhibits intestinal fluid uptake.
Those termed STb do not seem to cause diarrhea
by the same mechanism.

HEAT-STABLE ENTEROTOXINS

Generally STs are known to be small peptide toxins consisting

of 18 (STb) or 19 (STa) amino acids.
The different STa (M.W. about 2,000) from different animal
origins are remarkably homogeneous.
The amino acid composition of STa of porcine, bovine, and
human origins were identical and consisted of 10 of the 18
amino acids usually present in proteins.
Six of the 18 amino acids were half-cystines which appear to
be present as three disulfide bonds in the native form of the
toxin. These disulfide bonds are important for toxic activity.

HEAT-STABLE ENTEROTOXINS
STb is a heat-stable enterotoxin which does
not cause intestinal fluid secretion in the
suckling mouse as STa does, but does cause
intestinal fluid secretion in pig intestinal loop
assays.
It is insoluble in methanol, while STa is
methanol-soluble

Laboratory methods for isolation and identification of ETEC

Control
controlled by preventing transmission and
by stressing the importance of breastfeeding of infants
The best treatment is oral fluid and
electrolyte replacement (intravenous in
severe cases).
Antibiotics are not recommended ----antibiotic-resistant pathogenic E coli

Enteroinvasive E. coli (EIEC)

Shigella-like E coli strains
dysentery-like diarrhea (mucous, blood), severe
inflammation, fever
nonfimbrial adhesins, possibly outer membrane
protein
invasive (penetrate and multiply within epithelial
cells)
does not produce shiga toxin
Plasmid encoding a gene for a K surface antigen
Attach and invade mucosal cells

Cellular pathogenesis of invasive E coli

EIEC cells invade intestinal epithelial cells, lyse the phagosomal vacuole, spread
through the cytoplasm and infect adjacent cell

 Sereny test -- Invasive E coli, like Shigella,

causes a rapid keratoconjunctivitis when
placed on the conjunctiva of the guinea pig
eye.
Virulent Sereny test-positive isolates carry a
large (usually 140-megadalton) plasmid
responsible for this property.

Enteropathogenic E. coli (EPEC)

non fimbrial adhesin (intimin)
moderately invasive (not as invasive as
Shigella or EIEC) "attaching and effacing"
does not produce LT or ST; some reports of
shiga-like toxin
usually infantile diarrhea; watery diarrhea
similar to ETEC, some inflammation, no
fever; symptoms probably result mainly
from invasion rather than toxigenesis

Enterohemorrhagic E. coli (EHEC)

represented by a single strain (serotype O157:H7)

adhesins not characterized, probably fimbriae
moderately invasive
produces shiga toxin but not LT or ST
copious bloody discharge (hemorrhagic colitis), intense
inflammatory response, may be complicated by hemolytic
uremia
pediatric diarrhea caused by this strain can be fatal due
to acute kidney failure (hemolytic uremic syndrome
[HUS]).

E. coli 015:H7
157th somatic O antigen
7th flagellar H antigen
Hemorrhagic colitis
Abdominal cramps, blood stools, with minor or
no fever

Post diarrheal hemolytic ureamic syndrome

Acute renal injury
Thrombocytopenia
An abnormal decrease in the number of
platelets in circulatory blood.

Microangiopathic hemolytic anemia

The fragmentation of red blood cells because of
narrowing or obstruction of small blood vessels.

Enterohemorrhagic E. coli
EHEC

Among the most dangerous enteric pathogens

The Lancet 1998 352:1207-1212

36

Reservoir
Healthy cattle are the major reservoir for
human infection
Deer, sheep, goats, horses, dogs, birds and flies

Bacterial cells can survive in manure and

water troughs
Infection is more common during the summer
in both the northern and southern
hemisphere

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 Transmitted via food

Ground beef
Raw milk
Lamb meat
Venison jerky
Salami and other fermented dried meat products
Lettuce, spinach, alfalfa sprouts
Unpasteurized apple cider

Transmitted via water

Drinking and swimming in unchlorinated water

Direct person to person contact

Diaper changing
Improper sanitation
Day care & chronic adult care facilities

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Clinical Features

Average interval between

exposure & illness is 3
days
Most patients recover with
7 days
70% of patients report
bloody stools
30-60% of patients report
vomiting
Approx 5% of patients
develop HUS

The Lancet 1998 352:1207-1212

Sequelae
A condition following as a
consequence of a disease.
Proteinuria
Excess protein in the urine.

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Identification
MacConkey agar (SMAC)
Does not ferment sorbitol rapidly
Forms colorless colonies on sorbitol containing
MacConkey agar

Serology
Colorless colonies on SMAC are screened for the
0157 antigen

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Shiga Toxins
Exotoxin
Very similar to toxin produced by Shigella dysenteriae
Inhibits protein synthesis in host cell
A subunit inactivates the 60S ribosomal subunit

Shiga toxin producing E. coli (STEC)

Verotoxins

Most OH157 strains produce Shiga toxin 2

25% produce Shiga toxin 1
Identical to Shigella toxin

A B exotoxin
A subunit exists on a temperate bacteriophage

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Virulence Factors
Virulence plasmid (pO157)
Encodes a hemolysin
O157 strains can use iron from blood released into
the intestine

Locus of enterocyte effacement

Adhesion proteins

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Enteroaggregative E. coli (EAggEC)

adhesins not characterized

non invasive
produce ST-like heat-labile plasmidencoded toxin (EAST) and a hemolysin
persistent diarrhea in young children
without inflammation, no fever