Bakteri, Virus dan Penyakit

Gastrointestinal (2)
Bagian Mikrobiologi
FK Undip

General Objectives
To explain bacterial involvement in Gastrointestinal
diseases
Specific Objectives
To explain bacterial involvement in :
- Peptic ulcer
- Diarrhea
- Food intoxication
- Enteric fever
- Pancreatitis
- Peritonitis
- Appendicitis
- Colitis
To explain treatment involving bacteria in GI diseases
Prebiotic, probiotic, faecal transplantation
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Bacterial Food Borne Intoxication

Staphylococcus aureus
Bacillus cereus
C.perfringens
Clostridium botulinum

Staphylococcus aureus
Pathogenesis
dirty hands, coughing, sneezing into ready to eat foods the
organism multiplies enterotoxin production on the food
The toxin is heat-stable (resists autoclaving)
Commonly contaminated food : meat products, poultry, egg
products, mayonnaise-based salads, cream-filled pastries, dairy
products
Bacteria resist higher salt levels can also live in cured foods

Short incubation: 0,5 - 6 hours

Duration of symptoms : < 24 hours severe nausea and
vomiting, abdominal pain, watery diarrhea
Diagnosis : detection of toxins/ organisms

C.perfringens
eating food contaminated by C.perfringens
releases toxin in intestine diarrhea (mild),
intestinal damage and death (severe)
onset : 6 to 24 hours watery diarrhea,
abdominal cramps, abdominal distention, severe
diarrhea, dehydration, and shock
Diagnosis : local outbreak Isolation of C.
perfringens, detection of toxin
5

Bacillus cereus
Emetic form :

Toxin : preformed, heat-stable enterotoxin

Short incubation : 1-6 hours S. aureus food poisoning
Nausea, vomiting, abdominal cramps
Commonly contaminated food : fried rice held in warm
temperatures for hours

Diarrheal form :

Toxin: heat-labile enterotoxin intestinal fluid secretion

Long incubation : 8-16 hours
Abdominal cramps and watery diarrhea C.perfringens
Meat / vegetable-containing foods after cooking

Usually symptoms lasts < 24hours

Diagnosis confirmed by the isolation of > 105 B. cereus organisms per
gram from epidemiologically implicated food
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Treatment and Prevention

Treatment :
Rehydration
Symptomatic

Prevention : food hygiene

Before and afer cooking
The left over food should be refrigerated promptly and
preheated before eating

C. botulinum
Gram positive, spore forming, anaerobic
Produce botulinum toxin (exotoxin, preformed toxin)
botulism
binds to receptors on
peripheral nerves
Respiratory
flaccid
inhibits nerve impulses
failure
paralysis
Cardiac failure
Small dosage : antiwrinkle treatment
botox (botulinum toxin) injection
Commonly contaminated food : canned food, home-packaged
honey
Toxin is heat-labile can be prevented by adequate heating
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Pancreatitis
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Pancreatitis
inflammatory process in which pancreatic enzymes autodigest
the gland
may heal spontaneously, but can also recur intermittently
causing functional and morphologic loss of the gland affect
the endocrine and exocrine function of pancreas
mostly from non-infectious cause (alcoholism, gall stone)
Clinical spectrum : mild to live threatening disease
Infection causes < 5%, but mortality may up to 100% without
extensive surgical debridement or drainage of the infected
area
Bacteria : Salmonella, Campylobacter, M. pneumoniae, M. tuberculosis
Virus : mumps virus, coxsackievirus, cytomegalovirus (CMV), EpsteinBarr virus (EBV), varicella-zoster virus (VZV),

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 Specimen for microbiology tests:

fluid obtained by percutaneous CT-guided needle
aspiration of cysts or areas of fluid collection or necrosis
Gram and culture
Blood cultures

Treament :
Supportive : fluid resuscitation, analgetic, acid blocker
Antibiotics for pancreatic necrosis :
Should be able tp penetrate pancreatic necrosis (carbapenems,
quinolones, and metronidazole useful in delaying intervention
decreasing morbidity and mortality.

Drainage of infected pseudocysts or areas of necrosis

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Peritonitis (and
intraabdominal sepsis)
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- Peritoneum : sterile, but in constant danger of

contamination by bacteria discharged through perforation
of the gut (from trauma/ infection/ spontaneus
translocation)
- Types of peritonitis :
- Primary / Spontaneus peritonitis
- Secondary peritonitis

- Can be localized (intraabdominal abscess) or

generalized (peritonitis)
- Without proper treatment life threatening
- Microbiology diagnostic :
- Specimen : peritoneal fluid with leukocyte count > 250/LPF,
aspirate from abscess
- Tests : Gram staining, aerobic and aerobic cultures
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Primary Peritonitis

Secondary Peritonitis

- From intestinal perforation

= spontaneus peritonitis
- bacteria translocate from intestine
caused by trauma or infection
to mesenteric lymphnodes
- Can also be from
- Usually in patient with ascites
hematogenous spread, i.e.
from cirrhosis hepatis
M. tuberculosis
- 50% by E.coli
- 25% by other aerobic Gram-neg
bacilli
- 19% by Streptococcus sp (78%
viridans group)
-anaerob rare (O2 content is
in previously healthy peritoneum)
-92% monomicrobial
-

90% by B.fragilis (anaerob) +

facultative anaerob (e.g, E.coli)
polymicrobial infection

ction

Empiric AB : cefotaxime or ofloxacin Empiric AB : metronidazole +

gentamicin

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Bacterioides fragilis
Comprising only 0,5% of gut flora, but causing
90% infection related to GI tract (peritonitis,
sepsis subcutaneus abscess)
Virulence factor : capsular polysacharide
escape phagocytosis, abscess formation
Gram negative bacilli, anaerobic
Easily grow in simple liquid media (nutrient broth,
thioglycollate, etc)
Selective solid agar : Bacterioides bile esculin agar

Susceptible to : metronidazole, tygecyclin,

lactam+ lactamase inhibitors, carbapenem,
cefoxitin

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Appendicitis

16

blockage in
appendix

bacteria
multiply
rapidly

appendix
inflamed,
swolllen, pus
production

rupture.
Peritoneal
abscess/
peritonitis

Bacteria involved : mixtures of aerobes and anaerobes

- Anaerob : B. fragilis, Clostridium spp, Prevotella spp,
- Aerob : E. coli, Klebsiella spp, P. mirabilis, P. aeruginosa,
streptococci, enterococci
Treatment : combination of agents :
- For anaerobes : metronidazole, clindamycin, carbapenem
betalactam+betalactamase inhibitor
- Gram-neg bacilli : ciprofloxacin, gentamicin,
betalactam+betalactamase inhibitor
- Streptococcus, enterococcus : betalactam+betalactamase
inhibitor, carbapenem
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Cholangitis
Liver Abscess
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Liver abscess
Three major forms of liver abscess, :
80% : pyogenic abscess, mostly polymicrobial
10% : Amoebic abscess due to Entamoeba
histolytica accounts for 10% of cases [2]
< 10%: Fungal abscess, mostly due to Candida species,

19

20

Cholangitis
= infection of the biliary tract with the potential to cause
significant morbidity and mortality
Patogenesis :
Obstruction :
- Choledocolithiasis
- cancer

Bacterial
overgrowth

Surgery on
biliary tree

Bacterial
infection

Cholangitis

Clinical presentation :
Mild cholangitis : triad of fever, jaundice, and right upper quadrant pain
Severe/ toxic cholangitis : pentad of fever, jaundice, right upper quadrant pain
septic shock and mental confusion

21

Microbiology consideration
Microbiology diagnostic :
Blood culture : positive in 50%
Bile aspirate culture : positive in almost all

Most common etiologies :

Aerobes : E. coli, Klebsiella and Enterococcus sp
Anaerobes : B. fragilis, C. perfringens

Treatment
Empiric AB should cover aerobes and anaerobes, and able to
reach high concentration in the biliary system
Single regimens : piperacillin-tazobactam, ticarcillin-clavulanate,
mezlocillin, imipenem, or meropenem
Combined regimens : cefalosporins + metronidazole
In severe/ toxic cholangitis, intrabiliary pressure is high due to
obstruction AB can not penetrate emergency biliary
drainage is required
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Colitis
23

Colitis
Inflammation of the colon that can be caused by
infection, hypersensitivity to various allergens,
ischemia, vasculitis, or several drugs
Bacteria causing colitis :

Salmonella
Yersenia enterocoltica
Campylobacter
C. difficile causes pseudomembranous colitis
Shigella sp

Microbiology diagnosis : feces cultures

Therapy :
Antibiotic not always beneficial
Probiotic
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Clostridium difficile
Anaerobic spore-forming bacillus
Ubiquitous in nature : in soil, river, lake, sea, and swimming
pool water as well as from farm animals, dogs, and cats1

1935 - First described by Hall and O'Toole2

Known colonizer of neonates (50% to 60%)

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1978 - recognized as cause of antimicrobialassociated pseudomembranous colitis

Now regarded as most common cause of
antimicrobial-associated diarrhea (20-30% of cases)

1. Brazier JS, al Saif. J Med Microbiol 1996; 45: 133-7

2. Hall I; O'Toole E. Am J Dis Child 1935; 49: 390
3. Larson HE et al. Lancet 1978; 8073: 10631066.

Pathogenesis (1)
Fecal oral transmission
Survive gastric acidity
Small intestine : spores
germinate into vegetative
forms
Large intestine : normal
flora predominant and
overgrowth with
consumption of broad
spectrum AB
26 Diagram: Sunenshine et al Clev Clin J Med 2006 73(2) 187-197

Pathogenesis (2)
C. difficile can
produce 3 toxins
Toxin A
enterotoxin
Toxin B cytotoxin
Binary toxin

Toxins cause the

disease
Some strains only
produce one toxin
(A-, B+)
Diagram: Sunenshine, et al. Clev Clin J Med 2006 73: 187-197

27 1.Geric B, et al. J Med Micro 2004;53:887-94

C.difficile associated disease (CDAD)/

Antibiotic associated diarrhoea (AAD)
Common symptoms : watery diarrhea (sometimes
with blood or pus), fever, loss of appetite, nausea,
and abdominal pain.
Complications : pseudomembranous colitis, toxic
megacolon, perforations of the colon, sepsis,
(sometimes) death.

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Healthy
colon

Pseudomembranous
colitis

CDAD : Risk Factors

Increasing age1
Exposure to antimicrobials :
Clindamycin, cephalosporine,
penicillin,fluoroquinolones
The risk doubles with >3 days of antibiotic
therapy

Length of stay in hospital2

Immune response: antitoxin A IgG/IgA
underlying gastrointestinal diseases
GI procedures or GI surgery

PPI/H2 blockers?
29

1.Brown E et al. Infect Control Hosp Epi 1990;11: 283-90

2. Johnson S, et al Lancet 1990;336:97-100
3. M. Delmee Clin Microbiol Infect 2001; 7: 411-416

C. difficile : Laboratory Tests

Stool culture: Most sensitive
Requiring 2-3 days for growth
Unable to distinguish between the presence of toxinpositive or toxin-negative strains

Cell cytotoxin test most specific

Enzyme immunoassay (EIA) most common
May detect Toxin A only or Toxin A and B

PCR detect A, B, and Binary toxin

30

Treatment
Initial Course of Antibiotics

At least 10 days
Metronidazole (mild/moderate disease)
Oral vancomycin (severe disease)1

Treatment of Recurrence

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Longer course of metronidazole

Vancomycin with a taper
Rifaximin
Nitazoxanide
Vancomycin and rifaximin2
Fecal transplantation

1. Zar FA, et al. CID 2007; 45: 302-7

2. Johnson S, et al. CID 2007; 44: 846-8

Transmission of C.
difficile
shed in feces contaminate high
contact surfaces such commodes,
thermometers, bed-side tables, etc.
Spores resist alcohol
often spread among patients on the hands
of health care workers
Surface desinfection and hand hygiene with
alcohol based substance is insufficient
water and soap is more effective

32

How can CDAD be prevented in our

facility?
Use antibiotics judiciously
Use Contact Precautions for patients with CDAD:
place the patients in private rooms or place in rooms (cohorted)
with other patients with C. difficile-associated disease.
Use gloves when entering patients rooms and during patient
care.
Use gowns if soiling of clothes is likely.
Dedicate equipments if possible, or disinfect them between
patients.
Precautions should be continued until diarrhea has ceased.
Wash hands with SOAP and WATER before and after caring for
patients.

Environmental cleaning and disinfection strategy:

Use hypochlorite-based disinfectant for environmental surface
disinfection

33

Other bacteria are identified as a potential

cause of AAD :
Staphylococcus aureus.
Drug-resistant Salmonella spp
Clostridium perfringens.
Pseudomonas aeruginosa.
Candida spp

34

Viral gastroenteritis
35

3 Groups of Viruses found

in the gut
Associated with
gastroenteritis

Enterovirus &
Found in the gut as
others, not
opportunistic
normally associated infection
with gastroenteritis

Rotaviruses

Polio

CMV

Adenoviruses 40 41

Coxsackie A

HSV

Caliciviruses

Coxsackie B

VZV

Norwalk like viruses or Echo

SRSV
Astroviruses

Enteroviruses 68-71

SRV

Hepatitis A

Coronaviruses

Hepatitis E

Toroviruses

Adenoviruses 1-39
Reoviruses

36

HIV

Viral Gastroenteritis
responsible for up to 3/4 of all infective diarrhoeas.
the second most common viral illness after upper
respiratory tract infection a major killer of infants who are
undernourished.

37

Rotaviruses
Adenoviruses Enteric adenoviruses
Caliciviruses
Astroviruses
SRV (Small Round Viruses)
Coronaviruses
Noroviruses

Rotaviruses
7 groups and many serotypes
Unenveloped
Virus is stable in the environment
(months)
Relatively resistant to handwashing
agents
Susceptible to disinfection with 95%
ethanol, Lysol, formalin

38

http://www.bovilis.com/diseases/ncd/pathogenesis.asp

Pathogenesis
lactase
water
Undigested
milk
Acid

gas

water

39

Shortenedandfused
villi

Clinical features
Incubation period <4 days, high fever
Nausea, vomiting
Diarrhea (3-9 days)
usually watery (no blood/ leukocytes),
acid (pH<6 ) perianal irritation
longer in malnourished and immune
deficient individuals
dehidration is the main contributor to
mortality

40

Microbiology Diagnosis
Antigen detection in stool (ELISA, LA (Group A
rotavirus), immunochromatographic assay (rapid test)
Eletron microscopy
Culture- Group A rotaviruses can be cultured in monkey
kidney cells
Serology for epidemiologic studies

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Treatment and Prevention

Treatment

Prevention

43

Supportive : oral/ IV rehydration

Zink : restore intestinal villi
Antibiotic
Probiotic : restore normal flora

Hand hygiene and disinfection of surfaces

Vaccine with live attenuated virus

Probiotic, Immunobiotic,
Immunoprobiotic, Faecal
transplantation
44

Probiotic Immunobiotic - Immunoprobiotic

Elie Metchnikoff ( Nobel Prize for Physiology &

Medicine in 1908) Innate or Cell Mediated
Immunity
there are many useful microbes, amongst
which the lactic bacilli have an honorable
place

45

Probiotic (general definitions)

From the Greek meaning for live eventually
assigned to Metchnikoffs honorable lactic
bacilli .
Live enterolactobacilli administered in
adequate amounts able to confer health effects
on the host by improving its intestinal microbial
balance.
Today, Lactobacillus reuteri is one of only few
enterolactobacillus have been tested for
probiotic safety and efficacy when
administered orally to their respective hosts
46

Immunobiotic ( Clancy, 2003)

Probiotics shown to confer health beneficial by
guarding and modulating hosts mucosal
immune system and/ or promoting specific
antibiotic substances against harmful
bacteria-viruses and fungi

47

Immunoprobiotic (Dobrogosz, 2005)

= Immunobiotic which confer additional
benefits, such as
production of vit. B as biotin, niacin,
pyridoxine & folic acid.
Produce conjugated linoleic acid (CLA),
recognized as a cancer inhibitor
antioxidant anti-hypercholesterolemic /
atherosclerosis inhibitor
Protecting against the negative effects
of radiation and toxic pollution
48

Choosing a high quality probiotic

supplement

49

Number of the organism (at least 1 billion

organism/gram )
Type of the organism
Single strain (strongly prefered) or multiple
strain
Base of product
diary (Pasteurization: milk; fermented: yoghurt,
kefir) or non dairy product (rice)
Form of product
powdered (highly recommended)
encapsulated in liquid form

Prebiotic
non-digestible food ingredients that stimulate growth and/or
activity of bacteria in GI tract that beneficial to health

potential benefit on :
on calcium and other mineral absorption
immune system effectiveness
bowel pH
reduction of colorectal cancer risk
inflammatory bowel disorders (Crohn's disease and ulcerative
colitis)
Hypertension
intestinal regularity

50

Faecal transplantation / Faecal microbiota

transplant (FMT)/ stool transplant
= transplantation of fecal bacteria from a
healthy individual into a recipient, through
infusion of stool (enema, orogastric tube) or
orally (in capsule)
has been succesfully applied in CDAD, colitis,
chronic constipation, irritable bowel syndrom
cases

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