ENTEROBACTERIACEAE

 They are commonly present in large

intestine
 Facultative anaerobic
 Non-sporing, Non-Acid fast (blue stain),
Gram-negative (pink stain) bacilli.
 A complex family of organisms, some are
non-pathogenic, a few are highly Basic Classification
pathogenic I- Lactose fermenters: (coliforms)
o Some commensals turn out to be E.coli, Escherichia, Klebsiella
pathogenic in catheterization. II- Late Lactose Fermenters: Shigella
 They are motile (have flagella), except for sonnei
Shigella and Klebsiella. III- Non-lactose fermenters: Salmonella,
 They are non-capsulated except Shigella
Klebsiella.
Taxonomical Classification
 They are non-fastidious (do not require
 Tribe I- Escherichia
any special conditions or substances for
o Genus 1- Escherichia
growth).
o Genus 2 Shigella
 They grow on bile-containing media
 Tribe II- Edwardsiella
(MacConkey agar).
o Genus Edwardsiella
o Lactose fermenting organisms
 Tribe III- Salmonelleae
appear as pink colonies
 Tribe IV- Citrobactereae
(CiKleEEn- Citrobacter,
 Tribe V: Klebsiella
Klebsiella, E. coli, Enterobacter).
o Genus 1- Klebsiella
o Non-lactose fermenting
o Genus 2- Enterobacter
organisms appear as colorless
o Genus 3- Hafnia
colonies (SalShiProY-
o Genus 4- Serratia
Salmonella, Shigella, Proteus,
o Genus 5- Pantoea
Yersinia)
o Genus 6- Cronobacter
 Tribe VI: Proteae
o Genus 1- Proteus
o Genus 2- Morganella
o Genus 3- Providencia
 Tribe VII- Yersinieae
 o Genus 1- Yersinia  It may contain capsule
 On MacConkey medium, it produces
Highly Pathogenic Enterobacteriaceae
bright pink, lactose fermenting colonies.
 Salmonella
 Many pathogenic strains are hemolytic
 Shigella
on blood agar.
 Escherichia coli
 Biochemical characteristic:
o EPEC
o Fermenters of glucose, mannitol,
o EIEC
maltose with gas
o EHEC
o IMViC reaction: (++--)
o ETEC
 I for Indole test, M for
o EAEC/DEAC
Methyl Red test, V for
Escherichia coli Voges-Proskauer test, and
 It is commonly isolated from colon biota C for Citrate test
that is used as a primary marker of fecal o Urease negative
contamination in water quality testing.  Virulence factors :
 Morphology: Gram-negative straight rods o Two types of virulence factors in
 1-3 X 0.4-0.7 microns E.coli: surface antigens and toxins
 It appear in singles or in pairs o The somatic lipopolysaccharide
 It is motile with peritrichous flagella. surface O antigen has endotoxic
 Very few strains are non-motile activity and protects from
 It is non-spore forming and non-acid fast phagocytosis and bactericidal
effects of complement.
o Fimbriae are present in large
numbers, promoting virulence
o It produces 2 kinds of exotoxins:
hemolysins and enterotoxins.
 Antigenic structure
o Somatic O 170
 Aerobic/Facultative anaerobic o Capsular K 100
 It grows between 10-40 °C optimal at 37 o Flagella H 75
°C. o Virulence factors
 It grows on simple medium.  O Endotoxic activity
 It produces large grayish, thick white,  K protects against the
moist, smooth, opaque colonies. phagocytosis
  Fimbriae promote virulence  Gastroenteritis - there are several distinct
(important in UTI) types of E. coli that are involved in
different types of gastroenteritis:
E.coli toxins
o Enterotoxigenic E.coli (ETEC)
 It causes a movement of water and ions
o Enteroinvasive E.coli (EIEC)
from the tissues to the bowel resulting in
o Enteropathogenic E.coli (EPEC)
watery diarrhea.
o Enteroaggregative E.coli (EAEC)
 There are two types of enterotoxin:
o Enterohemorrhagic E.coli (EHEC)
o LT - is heat labile and binds to
 Leading cause of urinary tract infections
specific gangliosides on the
which can lead to acute cystitis (bladder
epithelial cells of the small
infection) and pyelonephritis (kidney
intestine where it ADP-ribosylates
infection).
Gs which stimulates adenylate
 Mostly ascending UTI
cyclase to increase production of
 Pyogenic infections Intraabdominal
cAMP.
infections
o ST - A and B fragments
 Peritonitis, abscess, septicemia
 ST A Acts by activation of
 Produces drug resistant infections
cyclic guano sine
monophosphate (Cyclic EPEC
GMP).  Enteropathogenic E.coli
 Cyclic GMP causes fluid  It causes diarrheal disease in children,
accumulation in Intestine. infantile enteritis
 Both enterotoxins are composed of five  EPEC 026/011
beta subunits (for binding), and 1 alpha  It is the first diarrheagenic E.coli
subunit (has toxic enzymatic activity). described.
 Verotoxins- acts like shigella dysentery  It produces verocytotoxin.
toxin.
 It involves upper part of intestine
E.coli infections o Brush border of intestine is lost

 Neonatal meningitis - is the leading o Intimacin - EPEC adhesion factor.

cause of neonatal meningitis and  It is frequent in summer months. Poor

septicemia with a high mortality rate. hygiene predisposes, and diarrheal
o Usually caused by strains with the outbreaks caused by this occur in
K1 capsular antigen. institutions (hospital nurseries, daycare
centers).
 The illness is characterized by low-grade  Adhesive factors: Fimbriae-specific
fever, malaise, and vomiting, with receptor in the intestinal epithelium CFA
persistent watery diarrhea—typically in  Mortality in children: < 5 years
children younger than 2 years of age.  Lab DX
o The stool typically contains large o Demonstration of enterotoxin LT
amounts of mucus, but apparent and ST
blood is not present. o Tissue culture test
 Lab DX o ELISA (enzyme-linked
o Polyvalent antisera immunoassay) test
o Testing of sero-groups with o Passive agglutination test
polyvalent and monovalent sera o Animal experiments in rabbit ileal
o Adherence to human epithelial-2 loop test
(HEp-2) cell cultures
EIEC
ETEC  Enteroinvasive E.coli
 Enterotoxigenic E.coli  It resembles Shigella genetically and
 ETEC strains are associated with phenotypically
diarrhea in adults and especially children,  It is non-lactose fermenter (colorless
living in tropical and subtropical climates, colonies) and non-motile (no flagella).
particularly in developing countries.  They invade the intestinal epithelium.
 ETEC diarrhea is the most common  They penetrate HeLa cells in tissue
cause of diarrheal disease in travelers culture.
(Traveler's diarrhea).  May produce mild diarrhea to frank
 Water contamination is a predisposing dysentery.
factor (poor hygiene, inadequate  Some are non-motile strains, with
sanitation, food contamination) of clinically mild diarrhea.
disease transmission.  Lab DX
 It produces heat stable toxins (ST) or o Sereny test- positive in animal
heat labile toxins (LT). rabbit (eyes).
 It adheres to epithelium of small intestine. o ELISA test
It presents with nausea, vomiting and
EHEC
loose stool
 Enterohemorrhagic E.coli
 HL-like cholera toxin- causes
 It produces verocytotoxin or Shiga-like
accumulation of fluids
toxins.
 It presents with mild diarrhea, which can DAEC
lead to fatal hemorrhagic colitis and  Diffusely adherent E.coli
hemolytic uremic syndrome (HUS).  They are closely associated with cystitis
 It is present in human and animal feces. in children, and acute pyelonephritis in
Hemorrhagic complication with 0157 in pregnant women.
Japan and USA.  Also associated with chronic or recurring
 Proper cooking in salads, vegetables, UTIs.
and radish is recommended.  They have been associated with pediatric
 The primary target for VT appears to be diarrheal disease.
vascular endothelial cells.
Klebsiella, Enterobacter, Serratia & Hafnia
o This may contribute to HUS with sp.
characteristic renal lesion is  They are usually found in intestinal tract.
capillary micro angiopathy.  They have wide variety of infections,
 The typical EHEC serotype is 0157; H7 primarily pneumonia, wound, and UTI
 The disease may manifest as food  General characteristics:
poisoning occurs due to contamination of o Some species are non-motile
feces of humans or animals. o Simmons citrate positive
 Lab DX o H2S negative
o Stool culture o Phenylalanine deaminase
o DNA detection methods negative
o Cytotoxic effects on Vero cells o Some weakly urease positive
o Detection with monovalent sera o MR negative; VP positive
O157/H7
Klebsiella species
EAEC  Usually found in GI tract
 Enteroaggregative E.coli  Four major species
 They appear aggregated in s-stacked  K. pneumoniae is mostly commonly
brick formation in Hep-2 cells. isolated species.
 They produce persistent diarrhea. o Possesses a polysaccharide
 They produce weight heat-stable capsule, which protects against
enterotoxin called low-molecular heat phagocytosis and antibiotics. It
stable enterotoxin. makes the colonies moist and
mucoid.
o Has a distinctive "yeasty" odor
 o Frequent cause of nosocomial  In recent years, Klebsiellae have become
pneumonia. important pathogens in nosocomial
infections (acquired while receiving
Klebsiella
healthcare in hospital).
 A genus of non-motile, Gram-negative,
 NF of GI tract, but potential pathogen in
oxidase-negative, rod-shaped bacteria
other areas.
with a prominent polysaccharide-based
 TSI A/A + gas
capsule.
 LIA K/K
 It is named after the German
 Urea +
microbiologist Edwin Kleb's (1834-
1913).  Citrate +

 Frequent human pathogens, Klebsiella  MR-, VP+

organisms can lead to a wide range of  Motility -

disease states, notably pneumonia,  Virulence factors:

urinary tract infections, septicaemia, and o Capsule

soft tissue infections. o Adhesins

 The genus was originally divided into 3 o Iron capturing ability

main species based on biochemical o Clinical significance

reactions.  Causes pneumonia, mostly

in immunocompromised
 Today, 7 species with demonstrated
similarities in DNA homology are known. hosts.

These are:  Permanent lung

o Klebsiella pneumonia damage is a

o Klebsiella ozaenae frequent occurrence

o Klebsiella rhinoscleromatis, (rare in other types

Klebsiella oxytoca of bacterial

o Klebsiella planticola pneumonia).

o Klebsiella terrigena  A major cause of

o Klebsiella ornithinolytica nosocomial infections such

 K. pneumoniae is the most medically as septicemia and

important species of the group. meningitis.

 K. oxytoca and K. rhinoscleromatis have Enterobacter species

also been demonstrated in human  Comprised of 12 species; E. cloacae and
clinical specimens. E. aerogenes are most common.
  Isolated from wounds, urine, blood and Other Enterobacteriaceae
CSF.  Proteus, Providencia, and Morganella
 Major characteristics o All part of the NF (normal flora) of
o Colonies resemble Klebsiella the GI tract (except Providencia).
o Motile o All motile, with Proteus swarming
o MR negative; VP positive o PA positive
o Lysine deamination positive (LIA
Serratia species
R/A)
 Seven species, but S. marcescens is the
o Urea positive for most, strongly
only one clinically important,
positive for Proteus
 Frequently found in nosocomial
o TSI variable (know the reactions
infections of urinary or respiratory tracts.
for each in the lab!)
 Implicated in bacteremic outbreaks in
o Indole -, only Proteus mirabilis is –
nurseries, cardiac surgery, and burn
o All are lactose negative
units.
o Opportunistic pathogens
 Fairly resistant to antibiotics.
 Major characteristics Proteus species

o Ferments lactose slowly  P. mirabilis and P. vulgaris are widely

o Produce characteristic pink recognized human pathogens
pigment, especially when cultures o Isolated from urine, wounds, and
are left at room temperature ear and bacteremic infections
o Both produce swarming colonies
S. marscescens on nutrient agar:
on non-selective media and have
a distinctive "burned chocolate"
odor
o Both are strongly urease positive
o Both are phenylalanine
deaminase positive

Hafnia species  A exhibits characteristic “swarming”; B

 Hafnia alvei is only species. shows urease positive on right

 Has been isolated from many anatomical

sites in humans and the environment.
 Occasionally isolated from stools.
 Delayed citrate reaction is a major
characteristic.
 Morganella species o Overt pathogens because they
 Morganella morganii is the only frequently cause disease in
species. humans
 Documented cause of UTI o Often implicated as the cause of

 Isolated from other anatomical sites. severe infections in patients with

 Urease positive AIDS

 Phenylalanine deaminase positive o Causes typhoid fever (enteric

fever), bacteremia, and
Providencia species
enterocolitis
 Providencia rettgeri is pathogen of
Typhoid fever
urinary tract and has caused nosocomial
outbreaks.  Large number of organisms must be

 Providencia stuartii can cause ingested because they are susceptible to

stomach acidity.
nosocomial outbreaks in burn units and
has been isolated from urine.  Bacteria proliferate in the Peyer's
patches and becomes infiltrated with
 Both are phenylalanine deaminase
positive. inflammatory cells.
 The organism travel through the
Citrobacter species
lymphatic and blood circulation and
 Citrobacter freundii is associated with become disseminated to many parts of
nosocomial infections (UTI, pneumonias, the body including the bladder, liver,
and intraabdominal abscesses) spleen and kidneys.
 Ferments lactose and hydrolyzes urea  After an incubation of approx. 2 weeks,
slowly fever rises to a high plateau, and may
 Resembles Salmonella sp. stay high for 4-8 weeks in untreated
Salmonellae cases.

 Consists of more than 2400 serologic  Carriers usually shed the bacteria in the

types based on the O, H and Vi antigens stool.

 Motile bacteria  Infection results in some degree of

 Do not ferment lactose or sucrose immunity after recovery.

 Produce H2S (hydrogen sulfide)  IgA in the intestinal mucosa may prevent

 Resistant to chemicals such as sodium attachment of the organisms.

deoxycholate, brilliant green and sodium  Serum antibodies against the O and Vi

tetrathionate antigens are generally associated with

 Salmonella infections resistance.

 Bacteremia  Multidrug-resistance (MDR) is a problem
 With focal lesions is most often seen after with Salmonella because of the use of
infection with S. choleraesuis but can antibiotics as growth promoters in food
occur following infection with virtually any animals.
serotype.  Eradication in chronic carriers frequently
 Elderly, debilitated and with chronic requires long-term ampicillin together
underlying diseases, and children with with cholecystectomy.
enterocolitis are the most susceptible.  Available vaccines are primarily used
 Blood cultures are positive during high during outbreaks of Salmonella.
fever.
Prevention
 Diarrhea usually does not occur.
 Relies on proper methods of sewage
 Organism is rarely isolated from the
disposal, maintenance of unpolluted
stool.
water supplies, proper handling of food
Enterocolitis supplies of animal origin, proper cooking
 The most common manifestation of of foods, proper health control of public
infection with Salmonellae. eating places and identification and

 S. typhimurium and S. enteritidis are the treatment of carriers.

most commonly isolated. Shigella

 Manifested as diarrhea, fever, nausea,  4 serogroups:
vomiting and headache that occurs 8-48 o Serogroup A: S. dysenteriae (12
hours after ingestion of the organisms. serotypes)
 Fever is low grade, inflammation of the o Serogroup B: S. flexneri (6
intestine is common. serotypes)
 Illness usually resolves on its own within o Serogroup C: S. boydii (23
4-7 days. serotypes)
 Stool cultures may remain positive for o Serogroup D: S. sonnei (1
several weeks after recovery. serotype)

Treatment  Shigellosis MOT occurs person to person

via the 5 F's (friends, flies fingers, feces
 A fluoroquinolone is the empiric drug of
and food) and contaminated water.
choice for typhoid fever.
 Amphetamine (Amp), Trimethoprim  They are naturally found only in the

Sulfamethoxazole (tmp-sxt), and third intestinal tracts of humans and some

non-human primates.
gen Cephalosporins may be effective.
 Gram negative, slender rods often  Causes hemorrhagic septicemia in
coccobacillary in early cultures. several commercially important fish
 Non-motile because they lack flagella. species.
 Facultative anaerobes.  The organism has been isolated from
 Do not ferment lactose. turtles, lizards, snakes, alligators,
 Ferments glucose and other crayfish, birds and mammals, from lakes,
carbohydrates with acid but no gas. rivers and sewage water.

 Colonies on blood agar plate (BAP) are  Motile, gram negative rods that produce
convex and transparent. H2S.

 The 4 serogroups can be differentiated  Ferment glucose with gas.

by: mannitol, lactose, and indole.  Do not ferment lactose, sucrose or most
 Responsible for bacillary dysentery or other sugars.
shigellosis.  Majority are positive for IND, MR,
 Disease severity is dependent on the Lys/Orn decarboxylases.
serotype with S. dysenteriae causing the  Negative for VP, Cit, Urease, PAD, Gel
most severe infection. and arginine dihydrolase assays.
 The disease is caused by the endotoxin  Organisms resemble Salmonella
LPS and also an exotoxin (shiga toxin) morphologically.
produced by S. dysenteriae.  In humans, intestinal tract is the site of
 Disease is highly infectious, ingestion of localization (80% of cases are associated
<1,000 organisms can result to disease. with GIT disease).
 Treatment and Prevention  Also known to cause wound infections
o Cip, Amp, Tmp-sxt, Te, C if such as fish hook injuries, osteomyelitis,
necessary peritonitis, myonecrosis, cholecystitis
o Prevention is dependent on and sepsis.
sanitary food and water supplies,  Occasionally isolated in human
appropriate sewage disposal, infections in stool, blood, urine CSF
disinfection of feces, fly control, peritoneal fluid, bile.
isolation of patients.
Yersinia species
o Subclinical cases and carriers
 Facultatively anaerobic or
should be identified and treated.
microaerophilic.
Edwardsiella tarda  Short, ovoid to rod-shaped GNB.
 Primarily found in freshwater fish.  Non-motile at 37 °C, some motile below
30 °C.
 Not found in the intestinal tract of humans Yersinia pestis virulence factors
or animals.  LPS
 Exhibits a bipolar "safety-pin  Fraction I (FI), a heat-labile envelope
appearance" with Wayson, Wright's or protein, produced mainly at 37°C, this is
Giemsa stain but not on Gram's stain. the main antigen responsible for both
virulence and immunity.
 V-W antigen system.
 Exotoxin leads to hemoconcentration
and shock.
 Coagulase produced at 28 °C.
 Y. enterocolitica and Y.
 Bacteriocin kills some bacteria.
pseudotuberculosis cause enterocolitis
 Serum samples may be tested for
and mesenteric adenitis.
specific antibodies, antibody titer of >16
 Produce a large number of virulence
is presumptive evidence for infection.
factors.
 2-fold rise in titer in acute and
 Ferments mannitol and glucose but not
convalescent serum confirms diagnosis
lactose.
of plague.
 PYR, MR and catalase positive, citrate
Bubonic plague
negative.
 Urease negative.  Humans develop plague after the bite of
an infected flea, direct contact with an
 Growth is relatively slow on blood and
infected animal (rat or ground squirrel) or
McConkey agar.
via inhalation of contaminated aerosols.
 Best growth is obtained at 25- 28 °C.
 Robust production of a capsule at 37 °C
 The peripheral growth around the central
allows many organisms to escape
portion contains capsular material that
destruction and travel via the lymphatics
forms strings when scooped up with a
to the lymph node.
loop.
 The lymph nodes swell up to 4 cm in
 Colonies on BAP resemble fried eggs.
diameter and forms "buboes".
 Pneumonic plague  BAP, MacConkey (MC), Hektoen enteric
 When the buboes burst, pneumonic agar, xylose lysine deoxycholate (XLD)
plague ensues, releasing the organism agar can be used.
into the blood circulation or via inhalation  Cefsulodin-Irgasan-Novobiocin (CIN)
of contaminated aerosols. agar is specifically designed for Y.
 The lungs become filled with fluid, enterocolitica, colonies looks like a
sputum is bloody and frothy, patient has target with a red center and a clear edge
great difficulty breathing. "cold enrichment".
 Drug of choice is Streptomycin.
 C and Te are also effective.

 Species produce urease rapidly.

 Motile at room temperature 25 °C but not
Yersinia enterocolitica, Y. at 37 °C.
pseudotuberculosis  Y. enterocolitica has more than 50
 Found in the feces and lymph nodes of serotypes.
both healthy and sick animals.  Y. pseudotuberculosis has at least 6
 The MOT is by ingestion of food or water serotypes.
contaminated with animal feces.  Y. enterocolitica is positive for ornithine
 Person to person transmission is rare. decarboxylase and ferments sucrose.
 Fever, abdominal pain and bloody  Y. pseudotuberculosis is negative for
diarrhea are typical symptoms that both.
appear in 5-10 days.
 Multiplication in the gut (esp. ileum) leads
to inflammation, ulceration and
appearance of blood in the stool.
 Yersinia spp. can multiply in high
numbers.
 Stool samples and rectal swabs are
collected.