INTESTINAL

PATHOGENS
Department of Clinical Microbiology
Medical Faculty
Universitas Brawijaya
 What is Gastroenteritis?

 Inflammation process of the gastrointestinal

tract
 Casused by
 Infection (viruses, bacteria, parasite, fungi)
 Food poisoning/intolerance
 Stress
INFECTION GASTROENTERITIS
Virus •Rotavirus

•Escherichia coli
Gastroenteritis •Salmonella Sp
caused by Bacteria •Shigella
infection dysentriae
•Vibrio cholerae

•Candida
Fungi
albicans
Rotavirus
ROTAVIRUS

 RNA virus
 Family Reoviridae
 Genus Rotavirus
 Virion: 76.5 nm, icosahedral symmetry
 Genom: segmented double stranded RNA
with 11 segmen and 18.5 kb nucleotides
 Transmitted via fecal-oral route
Epidemiology
 Rotaviruses cause life-threatening
gastroenteritis worldwide
 The cause of 40 – 50% acute diarrhea among
children in both developed and developing
countries
 Annually, approximately 2.4 million children
hospitalized with 600,000 death from rotavirus
infection, especially in South East Asia and
Sub-Saharan Africa
Epidemiology
Pathogenesis

 Rotavirus infection can be asymptomatic or

symptomatic depends on viral and host
factors
 Rotavirus infection alters the function of the
small intestinal epithelium → diarrhea
 Generally, the diarrhea considered to be
malabsorptive due to enterocyte
destruction
Pathogenesis
Rotaviruses
The infection
replicate in Malabsorptive
alters the
the non diarrhea due
function of the
dividing to enterocyte
small intestinal
mature destruction
epithelium
enterocyte

Malabsorption
causes the
The undigested
transit of
bolus
undigested
Leads to osmotically
mono- and
osmotic active and
disaccharides,
diarrhea colon unable to
carbohydrates,
absorb
fats and
sufficient water
proteins into the
colon
Microbiological Diagnostics
 Rotavirus identified in stool sample
 ELISA → recognizes the VP6 antigen, the kits
are simple to use, inexpensive and sensitive
 Electron-Microscope → detect virus particle(s)
 PCR → Reverse transcription PCR (RT-PCR)
can identified the whole species and
serotype of human rotavirus → detect virus
genome
Escherichia coli
Escherichia coli
 Gram negative bacilli
 Family Enterobacteriaceae
 Motile, Lactose fermenter bacteria
 Generally resides as normal flora
 Several strains are intestinal pathogen
 Determinants of pathogenicity are
 Surface factor → capsule, fimbriae, outer protein
membrane, lipopolysaccharide
 Enterotoxin
 Verotoxin
 Other factor → ability to penetrate epithelial layer,
hemolisin
Escherichia coli
(Diarrheagenic Escherichia coli)
 Classified based on each virulence
 Enteropathogenic Escherichia coli (EPEC)
 Enterotoxigenic Escherichia coli (ETEC)
 Enterohaemorrhagic Escherichia coli (EHEC)
 Enteroinvasive Escherichia coli (EIEC)
 Enteroaggregative Escherichia coli (EAEC)
 Each group has different mechanism in
causing diarrhea
 Transmitted via fecal-oral route
Epidemiology (EPEC)
 The most important pathogen which infect
children < 2 yo in developing countries
 The prevalence is 5 – 20% diarrhea among
children in developing countries
 Annually, EPEC was reported as the main
cause of death among infant and children
worldwide
 The infected children mostly have
 Cow’s milk intolerance
 Failed to respond to oral rehydration therapy
 Require hospitalization
 Develop persistent diarrhea
Epidemiology
of EPEC
Epidemiology (ETEC)
 Estimated cause 280 – 400 million diarrhea
among children < 5 yo with 300,000 – 500,000
deaths, annually
 Associated with child malnutrition, growth
stunting and cognitive defect
 Among children in developing countries,
several diarrhea episodes in a year usually
caused by ETEC
 Among adult travelers, 30 – 45% have
traveler’s diarrhea caused by ETEC
Epidemiology
ETEC
Epidemiology (EHEC)
 First isolated in 1975 from a woman with
bloody diarrhea
 Also known as E. coli O157:H7
 Mostly, reported in developed countries and
rarely in developing countries
 The biggest outbreak was in Sakai, Japan
with 9451 cases and 12 deaths caused by
consuming raw red radish
Epidemiology (EIEC)
 Found worldwide
 Endemic in developing countries especially
with lack of sanitation
 Generally, cases in Europe are sporadic and
associated with travel history
 EIEC outbreaks were reported in Hungary in
1959 and Czechoslovaky in 1982
 The last reported outbreak was in Italy in
2012
Epidemiology (EAEC)
 EAEC associated with diarrhea cases in
children in both developed and developing
countries
 In Vietnam, EAEC caused diarrhea among
children < 2 yo
 In Scandinavia, diarrhea caused by EAEC
are more common than EPEC
 In Germany, EAEC associated with children’s
diarrhea
Pathogenesis of Gastroenteritis
(EPEC)
 The important cause of diarrhea among
infant, especially in developing countries

EPEC form
Watery diarrhea,
EPEC adhere to filamentous actin
Effacement of the could be self
mucous cell of the pedestal,
intestine’s microvilli limited or become
intestine sometimes invade
chronic infection
the intestine cells

 The diarrhea duration can be shorten by

antibiotic
Pathogenesis of Gastroenteritis
(ETEC)
 The common cause of traveler’s diarrhea
 An important diarrhea cause in developing
countries
 Human specific colonizing factor lead the
attachment of ETEC to intestine epithelial cells
 Several strains produce heat labile exotoxin (LT)
 It is antigenic
 Controlled by genetic plasmid
 Cross react with Vibrio cholera exotoxin
 Induces antibody neutralization in serum and
probably intestine’s surface of the infected
persons
Pathogenesis of Gastroenteritis
(ETEC)
 Other strains produce heat stable exotoxin (ST)
 Controlled by genetic plasmid
 STa activates guanylate cyclase of the intestine’s
epithelial cells → induce fluid secretion
 STb has a shorter onset and induces a secretion
which not depend on nucleotide cycle
 A lot of ETEC strains produce both STa and LT
which cause more severe diarrhea
Pathogenesis of Gastroenteritis
(EHEC)
 Produces verotoxin (VTEC)
 In US and Canada, VTEC causes diarrhea
outbreak, hemorrhagic colitis and hemolytic
uremic syndrome (HUS)
 Hemorrhagic colitis and HUS are complication
of a mild diarrhea which firstly shown among
preschoolers and adults
 The sources of infection are meat or other
animal products such as milk and hamburger
 Serotipe O157:H7 is the main verotoxin producer
and associated with a lot of outbreak
Pathogenesis of Gastroenteritis
(EIEC)

 Similar with shigellosis

 EIEC strains is a slow lactose fermenter or non-
lactose fermenter and non-motile
 Mostly found among children in developing
countries and travelers
 Causes gastroenteritis by invading the
intestine’s epithelial cells
Pathogenesis of Gastroenteritis
(EAEC)
 Causes acute and chronic diarrhea in
developing countries
 It has a specific attachment pattern to human
cells
 Diagnostic

 Escherichia coli can easily grow on common

Enterobacteriaceae medium
 Pathogenic E. coli infection should be
considered in the absence of true
enteropathogen
 Pathogenic E. coli that ferment lactose can be
isolated using standard procedure for E. coli
 Typing can be used to identify specific
pathotypes of E. coli
 Eosin Methylene Blue Agar
 Commonly used for Escherichia coli isolation

Metallic
Sheen
Salmonella Sp.
Salmonella Sp.
 Gram negative bacilli
 Family Enterobacteriaceae
 Non-lactose fermenter
 It can survive against bile with high
concentration
 Antigen O and H are the main antigen used
for classification
 Pathogenicity is determined by surface
factors, invasion ability, endotoxin and
others such as enterotoxin and cytotoxin
Epidemiology

 Transmitted by fecal-oral route

 Annually, approximately 93.8 million cases
worldwide with 155,000 deaths
Pathogenesis of Gastroenteritis

 Salmonella has various virulence factors i.e.

surface antigen, invasion factor, endotoxin,
cytotoxin and enterotoxin
 Each factor has various role on infection
pathogenesis depend on the serotype and
the host
 Salmonella has different ability to live inside
phagocytic cell
Pathogenesis of Gastroenteritis

 Colon infection occurs within 18 – 24 hours

after bacterial entry
 The most common cause in US is the
typhimurium serotype
 The symptoms are diarrhea, fever and
abdominal pain
 Usually self limited within 2 – 5 days and
mostly does not require medical attention
 In severe cases, which usually among infant
and elderly, it may cause dehydration and
electrolyte imbalance
Diagnostic

 Samples: feces, rectal swab

 Isolation and identification
 Differential medium: MacConkey’s → non-
lactose fermenter
 Selective medium: SS agar, Hectoen enteric
agar, deoxycholate-citrate agar
 Enrichment medium: selenite F, tetrathional
 Final identification → biochemical and
serologic assay
 Bismuth Sulfite Agar
 Commonly used for Salmonella Typhi isolation

Black Jet
Colony
Shigella
Shigella
 Major cause of bacillary dysentery
 Non-motile, Gram negative bacilli
 Non-lactose or slow lactose fermenter
 Genetically indistinguishable from E. coli
 DNA homology study showed Shigella and
Escherichia are similar → based on the
clinical importance of bacillary dysentery,
they are still divided in two different genus
 Has 4 serogroups, A – D, with Serogroup A,
S. dysentriae has the highest pathogenicity
 Pathogenicity is determined by surface
factors, invasion ability and toxin
Epidemiology
 Transmitted via fecal-oral route
 The main cause of bacillary dysentery
 Mostly found among children age 1 – 10 yo
 In US, approximately 15% diarrhea cases
among children caused by Shigella
Pathogenesis
 Highly contagious with low infective dose <
200 organisms
 Various symptoms from asymptomatic to
severe dysentery with fever, chills, seizure,
abdominal cramps, tenesmus and bloody
diarrhea
 Shigella multiplies in small intestine until
108/ml → fever, abdominal cramps → in 1 –
3 days can be isolated in colon
 Rarely penetrates intestinal wall and spread
to the other parts of the body
Diagnostic Shigella

 Samples: feces, tissue, rectal swab

 Isolation and identification
 Differential medium: MacConkey’s → non-
lactose fermenter
 Selective medium: SS agar
 Inoculated on TSI agar → showed alkali on
slant, acid on butt without producing gas nor
H2 S
 Final identification → biochemical and
serologic assay
Vibrio cholera
Vibrio cholerae
 Family Vibrionaceae
 Genus Vibrio
 Gram-negative curved or straight bacilli
 Has polar flagellum → darting movement
 Facultative anaerob and grows well at 18 –
37oC with pH 7, but can also grow on pH 9.5
 Sucrose fermenter → produce acid →
yellowish colony on TCBS medium
Vibrio cholerae
 The pathogenicity are determined by
enterotoxin (cholera-toxin), adherence
factor, motility and mucinase
 Based on antigen O, classified into 6
serogroups, OI – OVI
 El tor and classical biotypes are member of
group OI → differentiated by biochemicql
assay (Voges Proskauer), chicken eritrocyte
agglutination, sensitivity against polimiksin B
50IU, and phage group IV
Epidemiology
 Transmitted via fecal-oral route
 El tor and classical biotypes caused
outbreaks in several countries
 In 1947, caused 33,000 cases with 20,000
deaths in Egypt
 Pandemic occurred between 1960 and
1970 with 171,329 cases in 60 countries
 In 2015, WHO reported 172,454 cholera
cases and lead to the death of 1302
patients
Epidemiology
 Cholera can be easily spread due to the
vast development of the modes of
transportation
Pathogenesis
 Vibrio cholerae produce enterotoxin
(Choleragen)
 Produce by living bacteria
 Consists of 98% protein, 1% carbohydrate, 1%
lipid
 Divided into 2 subunit, A and B
 Pathogenesis

Fluid and
Activate A1 Increase Increase
Inhibit turn off electrolyte
Subunit A peptide by adenylate intracellular
mechanism of secreted into
enters host cell reducing cyclase cAMP
GTP intestinal
disulfide bond activity concentration
lumen
Diagnostic Vibrio cholera

 Samples: vomit, feces, rectal swab

 Isolation and identification
 The specimen is inoculated into transport medium
such as Amies, Carry Blair or modified Stuart’s or
Alkali Peptone Water pH 8.5 which also an
enrichment media
 Selective medium: Thiosulfate Citrate Bile salt
Sucrose (TCBS)
 Non-selective medium: MacConkey’s, Nutrient
agar
 Final identification → biochemical and serologic
assay
Vibrio cholerae
(TCBS)
RISK FACTORS OF THE
GASTROENTERITIS
 Infants and children
 Poor hygiene and sanitation
 Lack of clean water facilities
 Poor hand hygiene
 Consuming raw or improperly cooked meals
 Poor waste management
PREVENTION
 Regardless of the etiology, gastroenteritis can
be prevented by
 Improve hygiene and sanitation
 Properly cooked meals and drinking water
 Keep flies away from foods and drinks
 Improve hand hygiene
 Improve clean water facilities
 Improve waste management
PREVENTION
 Rotavirus vaccine
 Two vaccines currently licensed for use in infants
 RV5 (RotaTeq®)→ contains five reassortant
rotavirus developed from human and bovine
rotavirus strains
 RV1 (Rotarix®)→ contains one strain of live
attenuated human rotavirus
 Both vaccines are given orally and give up to
95% protection against severe rotavirus disease,
70% against any rotavirus disease
Thank you