Enterobacteriaceae:

SALMONELLOSIS AND TYPHOID

Dr John Egbagba
Enterobacteriaceae

• The largest, most heterogeneous collection of medically

important gram-negative rods
• >40 genera and 150 species
• Fewer than 20 species are responsible for more than 95% of
the infections
• Ubiquitous organisms, found worldwide in soil, water, and
vegetation
Enterobacteriaceae

• part of the normal intestinal flora

• 30% to 35% of all septicemias, more than 70% of urinary
tract infections (UTIs), and many intestinal infections
• Salmonella typhi, Shigella species, Yersinia pestis
• Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis
Enterobacteriaceae

• become pathogenic when they acquire virulence factor

• can originate from an animal
• or from a human carrier
• or through the endogenous spread of organisms
Enterobacteriaceae Meningitis

Opportunistic pathogens Pneumonia

Escherichia coli
Klebsiella pneumoniae Sepsis
Enterobacter aerogenes
Serratia marcescens
Diarrhea
Proteus spp.
Providencia spp.
Citrobacter spp. UTI

Obligate pathogens
Salmonella spp.
Shigella spp.
Yersinia spp.
Some E. coli strains
Enterobacteriaceae

• moderately sized (0.3-1.0 × 1.0-6.0 μm)

• gram-negative rods
• either nonmotile or motile with peritrichous flagella
• do not form spores
• facultative anaerobes
• have simple nutritional requirements
Enterobacteriaceae. 4 Specific
Characteristics
• ferment glucose.
• Reduce nitrate to nitrite
• catalase positive and
• oxidase negative.

• the ability to ferment lactose Escherichia, Klebsiella,

Enterobacter, Citrobacter, and Serratia spp
• do not ferment lactose Proteus, Salmonella, Shigella, and
Yersinia spp.
• Some have prominent capsules, e.g Klebesiella
Lactose fermentation
 Enterobacteriaceae
• Resistance to bile salts

Common Medically Important Enterobacteriaceae

• Citrobacter freundii, Citrobacter koseri
• Enterobacter aerogenes, Enterobacter cloacae
• Escherichia coli
• Klebsiella pneumoniae, Klebsiella oxytoca
• Morganella morganii
• Proteus mirabilis, Proteus vulgaris
• Salmonella enterica
• Serratia marcescens
• Shigella sonnei, Shigella flexneri
• Yersinia pestis, Yersinia enterocolitica, Yersinia pseudotuberculosis
Enterobacteriaceae: Cell wall

• LPS: Consists of three components:

the outermost somatic O polysaccharide

a core polysaccharide common to all Enterobacteriaceae
(enterobacterial common antigen)

lipid A
Enterobacteriaceae

• serologic classification
 O polysaccharides
 capsular K antigens (type-
specific polysaccharides)
 the flagellar H proteins

Antigenic structure of Enterobacteriaceae

Enterobacteriaceae

•Common Virulence Factors Associated

with Enterobacteriaceae
 Endotoxin
 Capsule
 Antigenic phase variation
 Type III secretion systems
 Sequestration of growth factors
 Resistance to serum killing
 Antimicrobial resistance
 Salmonella
• Has 2 Species;
Salmonella enterica and Salmonella bongori
There are six subspecies of S enterica , i.e
enterica ,
salamae , arizonae ,diarizonae , houtenae,indica
• Salmonella specie have been subdivided into more
than 2500 unique serotypes , for example;
• S. enterica subspecies enterica serotype
Typhimurium or S.Typhimurium
 Salmonella
• Physiology and Structure
 Gram-negative, facultative anaerobic rods
 Fermenter; oxidase negative
 Outer membrane makes the organisms susceptible to
drying
 Lipopolysaccharide consists of outer somatic O
polysaccharide, core polysaccharide (common antigen),
and lipid A (endotoxin)
 More than 2500 O serotypes (commonly referred to as
individual Salmonella species)
 Salmonella

•Transmitted by the fecal-oral routed

•Salmonellosis may present as one of several syndromes

including gastroenteritis, enteric (typhoid) fever or
septicemia.

•Zoonosis
Antigenic composition of Salmonella

• O antigen
• H antigen
• Vi antigen

- S. typhi and S. hirschfeldii

- Pathogenicity
- Screening of carriers (titer≥1:10)
- Inhibition of the agglutination of O Ags and the O Abs
The antigenic structures of salmonellae used in
serologic typing
 Pathogenicity
•Virulence factors
• Endotoxin – may play a role in intracellular survival
• Capsule (for S. typhi and some strains of S. paratyphi)
• Adhesions – both fimbrial and non-fimbrial
• Enterotoxin - may be involved in gastroenteritis
• Outer membrane proteins - involved in the ability of Salmonella
to survive inside macrophages
• Flagella – help bacteria to move through intestinal mucous
 Pathogenicity
• Type III secretion systems and effector
molecules – 2 different systems may be
found:
– One type is involved in promoting entry into
intestinal epithelial cells
– The other type is involved in the ability of
Salmonella to survive inside macrophages
 Disease caused by Salmonella

Disease Pathogens

Gastroenteritis S. enteritidis, S. typhimurium,

S. choleraesuis
Septicemia S. choleraesuis, S. typhimurium,
S. enteritidis, S. hirschfeldii
Enteric fever S. typhi, S. paratyphi A,B,C
S. schottmuelleri, S. hirschfeldii
 Salmonellosis; Epidemiology/clinical features

•Salmonellosis, the common salmonella infection, is caused by a

variety of serotypes (S. enteritidis) and is transmitted from
contaminated food (such as poultry and eggs).
•It does not have a human reservoir and usually presents as
gastroenteritis (nausea, vomiting and non-bloody stools).
• Like Shigella they invade the epithelium and do not produce
systemic infection.
•In uncomplicated cases of salmonellosis, which are the vast majority,
antibiotic therapy is not useful.
•S. choleraesuis (seen much less commonly) causes septicemia after
invasion. In this case, antibiotic therapy is required. .
 Gastroenteritis
• The most common form of salmonellosis and
generally requires an 8-48 hour incubation period
and may last from 2-5 days.
• Symptoms include nausea, vomiting and diarrhea
(non-bloody stool). Salmonella enteritidis is the
most common isolate.
• poultry, eggs. no human reservoir
• self-limiting (2 - 5 days)
 Gastroenteritis
• The most common form of salmonellosis (70%)
• Self-limited (2-5 d)
• Not enter into blood

Lab Diagnosis:
• Stool Culture
 Septicemia
• Salmonella septicemia (bacteremia) may be
caused by any species but S. choleraesuis is
common.
• This disease resembles other G- septicemias
and is characterized by a high, remittent fever
with little gastrointestinal involvement.
 Septicemia
• 5-10% of salmonellosis
• Intestinal manifestations: often absent

Lab diagnosis:
- Stool culture
 Typhoid; epidemiology

• It is the severest form of salmonella infections (enteric fever),

caused by Salmonella typhi.
• The organism is transmitted from a human reservoir or in the water
supply (if sanitary conditions are poor) or in contaminated food.
• A carrier state is common; thus one person e.g. a food handler can
cause a lot of spread.
Epidemiology cont.

• What New York did about Typhoid Mary

• Mary Mallon was born in Irelend in 1869 and came to America at 16,
working as a cook for wealthy families in Boston and New York. In the
early 1900s, several family members came down with typhoid—a
potentially deadly bacterial infection spread through food when a carrier
doesn’t wash his or her hands after using the bathroom.
• Eventually a New York City typhoid researcher identified Mary as the
source of all the infections. She denied having typhoid, but tests proved
otherwise, and city health officials forced her into quarantine in a city
hospital at North Brother Island in the East River.
• A New York newspaper illustrates her plight in 1909. 
• After leaving quarantine and promising not to handle food, she went
back to work as a cook, promptly infecting more people. Eventually she
was brought back to the island, where she lived out her life. Mary died in
1938, a celebrity for being a healthy carrier of a lethal bacteria.
 Enteric fever
The pathogenesis of typhoid
 Enteric or typhoid fever
• Enteric or typhoid fever occurs when the bacteria leave the
intestine and multiply within cells of the reticuloendothelial
system.
• The bacteria then re-enter the intestine, causing gastrointestinal
symptoms.
• Typhoid fever has a 10-14 day incubation period and may last
for several weeks.
• Salmonella typhi is the most common species isolated from this
salmonellosis.
• Human reservoir: carrier state common
• Contaminated food: water supply
• Poor sanitary conditions
Implication of the pathogenesis in terms
of collection of clinical samples?
(BSU 123)
 CLINICAL FEATURES

Stage 1 (1ST WEEK) End of 1ST WEEK

• Slowly rising (stepladder fashion) of • Rose spots may appear

temperature for 4-5 days on the upper abdomen &
• Abdominal pain & myalgia on the back of sparse
• Malaise • Cough
• Splenomegaly
• Headache
• Abdominal distension with
• Constipation tenderness
• Relative bradycardia • Diarrhea

Stage 2 (2ND WEEK)

• Signs and symptoms of 1st week progress

 Stage 3 (3RD WEEK)

• Febrile become toxic & anorexic

• Significant weight loss
• Typhoid state (Apathy, confusion & psychosis)
• High risk (5-10%) of hemorrhage and perforation may cause death

Stage 4 (4TH WEEK)

Recovery period

Some survivors become asymptomatic S typhi carriers and have the potential
to transmit the bacteria indefinitely.
 Laboratory Diagnosis of
Typhoid Fever
• 1 Isolation of Bacilli. A Gold standard
• 2 Diagnosis for presence of
Antibodies,
• Positive Blood culture – A gold
standard
• Isolation from Feces and Urine ?
• Detection of Antibodies
Inconclusive.
• Newer methods: 38
 Diagnosis
• Specimens

a) Enteric fever: blood, bone marrow, stool, urine.

b) Food poisoning: stool, vomitus, suspected food.
c) Septicemia: blood.
• Culture and identification
• Widal test
• Isolation from stool requires enrichment broth.
• Enrichment broth:Tetrathionate broth, Gram negative broth,
selenit F broth
• Selective media: SS agar, Hektoen Enteric Agar, Bismuth sulfide
agar and Deoxycholate citrate agar

• On MacConkey medium appear

Colorless ( NLF )
Selective Medium - Produce Jet black colonies as
H2 S produced by Salmonella typhi
 Widal test
A quantitative agglutination test for typhoid and
paratyphoid, in which detects a patient’s
antibodies to the specific O antigen of S. typhi
and H antigens of S. typhi, S. paratyphi A, S.
schottmuelleri and S. hirschfeldii
How to interpret the results of Widal test?

• Consider the manifestaton, course, history,

and local epidemiological conditions
How to interpret the results of Widal test?

TO<1:80,TH<1:160, PH<1:80 Normal value

TO≥1:80 & TH≥1:160 or Typhoid fever
TO≥1:80 & PH≥1:80 Paratyphoid fever
How to interpret the results of Widal test?
• Dynamic observation
-antibody titer give a rise gradually
-titer of convalescence serum≥4 times than that of
early specimen
 Typhoid -Therapy
• Antibiotics
• essential
• Vaccines
Vi (capsular) antigen :protective
 Antibiotic
Resistance in many
Chloramphenicol (500mg qid) areas of the world
Ampicillin ( 750mg qid)
Co-trimoxazole ( 2 tablets/ iv
bds)
Fluoroquinolone (Drug of choice) – ciprofloxacin (500mg bds)
3rd generation cephalosporin – ceftriaxone, cefotaxime (alternative)
Azithromycin ( 500mg once daily) alternative when fluoroquinolone
resistant is present

Treatment should be continued for 14 days

•Chronic carriers are formerly treated for 4 weeks with ciprofloxacin but
may require an alternative agent and duration, as guided by antimicrobial
sensitivity testing.
•Cholecystectomy may be necessary.
 How to prevent salmonellosis
 Don’t eat raw or undercooked food
 Cross-contamination of foods should be avoided
 Do not prepare food or pour water if you are
infected with the bacteria
 How to prevent salmonellosis
 Wash hands, kitchen surfaces, and utensils with
soap and water after they have come in contact
with raw meat or poultry

 Wash hands after contact with animal feces

 Avoid direct/indirect contact between reptiles

and infants