Gram-Negative Bacilli 1

Table of Contents
A. Gram-Negative Bacilli B. Escherichia coli (E. coli) C. Klebsiella species D. Proteus species E. Providentia, Serratia, Citrobacter, Acinetobacter spp. etc. F. Pseudomonas species

G. Burkholderia H. Acinetobacter I. Further Reading

Gram-Negative Bacilli
What is one of the main differences morphologically, between Gram- negative and Grampositive bacteria?

This relates to the cell wall. In Gram-positive bacteria such as Staphylococcus aureus, peptidoglycan with teichoic acid polymers comprise much of the cell wall. In Gram-negative bacteria, there is much less peptidoglycan but lipopolysaccharide with endotoxin, is a key feature.

What is the natural habitat of Enterobacteriaceae(coliforms)? The correct answer is: They are found worldwide in soil, water and vegetation and are part of the normal intestinal flora of most animals including humans and are the largest most heterogenous collection of medically important Gram-negative bacilli.

List the most important Enterobacteriaceae that cause human infections. 1. Escherichia coli (E. coli) 2. Klebsiella species (spp.) 3. Proteus spp 4. Salmonella spp., Shigella spp. (See Gram-negative bacilli 2 notes) 5. Miscellaneous collection of relatively small numbers of other Gram -negative bacilli, e.g. providentia, Serratia marcescens, citrobacter, acinetobacter.

Escherichia coli (E. coli)

How is E. coli identified within the microbiology laboratory? The correct answer is: E. coli appears as lactose fermenting colonies on MacConkey agar.

Is E. coli found as part of the body's normal flora?

a)

Yes

That's right. E. coli is present in large numbers within the colon (greater than all the other normal commensals of the colon, with the exception of Bacteroidesspp. and is normally non-pathogenic within the colon. In hospitalised patients, E. coli may colonise the skin and respiratory tract. There are pathogenic E. coli which can cause intestinal infection (See later). What are the important infections caused by E. coli?

These include:
1. Urinary Tract Infection (UTI).

E. coli is the commonest cause of UTI. These bacteria enter the bladder by travelling up the urethra. In a small proportion of cases (under 10%), E. coli are said to reach the bladder via the bloodstream. Certain serotypes are more commonly associated with UTI than others. These are called "Urinary E. coli types." Examples are 01, 02, 04, etc. (0 stands for somatic antigen). E. coli is able to adhere to the urinary epithelium via special adhesins called pili.
2. Appendicitis, appendicular abscess 3. Acute cholecystitis (inflammation of the gall bladder) and peritonitis 4. Post-operative wound infections in particular abdominal operations 5. Blood stream infection, one of the commonest 6. Septic shock - more commonly called endotoxic shock 7. Sub phrenic abscess, liver abscess 8. Neonatal meningitis 9. Pneumonia acquired in hospital environment such as the intensive care unit 10. Gastroenteritis

How can the strains of E. coli that can cause gastroenteritis be subdivided?

The strains of E. coli that cause gastroenteritis are subdivided into 5 groups:

enterotoxigenic enteroinvasive enteropathogenic enterohaemorrhagic / verocytoxin-producing (VTEC) enteroaggregative

Which groups cause the most severe diarrhoeal disease?

The most noteworthy diarrhoeal diseases include traveller's diarrhoea (enterotoxigenic) and VTEC (E. coli 0157/ enterohaemorrhagic E. coli). The severity of the disease caused by E. coli 0157 (there are other types apart from 0157) ranges from mild uncomplicated diarrhoea to haemorrhagic colitis with severe abdominal pain, bloody diarrhoea and little or no fever. Haemolytic uraemic syndrome is also associated with this organism (acute renal failure, thrombocytopenia, and microangiopathic haemolytic anaemia) in children. It is a complication in 10% of children younger than 10 years. Most cases of epidemic and endemic disease have been attributed to the consumption of undercooked ground beef but it may also be acquired by children accessing open farms without adequate hygiene measures.

Klebsiella species
Describe the basic microbiological features of the genus Klebsiella? The correct answer is: Lactose-fermenting Gram-negative bacillus with a capsule. They are nonmotile. The two main species are K. pneumoniae and K oxytoca.

What is the normal habitat of Klebsiella species?

They are a normal inhabitant of the GIT and cause no disease within the intestinal tract, they are not a cause of diarrhoea and gastroenteritis.
What infections do they cause?

These include:

Urinary tract infection Infections within the abdomen including appendicitis, cholecystitis, peritonitis Post-operative surgical site (wound) infection Bloodstream infection Hospital-acquired pneumonia (rarely community-acquired) especially in the ICU

What is the name of the most common member of the genus Klebsiella and which infection is it associated with?

The most common species is K. pneumoniae, which can cause lower respiratory tract infection.

Proteus species
How are Proteus species identified within the microbiology laboratory? The correct answer is: Gram-negative highly motile bacilli. They produce characteristic "swarming" on blood and nutrient agar but not on media containing bile salts such as MacConkey agar. They have a fishy smell. Proteus mirabilis is most commonly responsible for infections, which are similar to those caused by Klebsiella spp.

What feature facilitates Proteus spp. to cause urinary tract infections? The correct answer is: Proteus spp. possess the enzyme urease which splits urea in urine into ammonia. This makes the urine alkaline and this alkalinity predisposes to the deposition of phosphate stones which in turn increases the chances of infection by retention of residual urine.

Providentia, Serratia, Citrobacter, Acinetobacter spp. etc.

What do these Gram-negative bacilli have in common? The correct answer is: These Gram-negative bacilli are present in the normal intestine in small numbers. These are all examples of "Opportunistic Pathogens" (see appropriate notes). They produce infections e.g. blood strem infections only in "patients at risk," usually in hospitalised patients but they may be very antibiotic resistant.

Pseudomonas species
What is most common pseudomonad associated with infection in humans?

The most common pseudomonad associated with human infection is Pseudomonas aeruginosa (pyocyaneae) which may be found as part of the normal flora of the gastrointestinal tract. This Gram-negative organism produces two distinct pigments pyocyanin and fluorescein. Other species have been identified which are pathogenic to man. This is an example of an "Opportunistic Pathogen".
What requirements do these bacteria have to survive? The correct answer is: Very little, i.e. moisture e.g. water and they can thrive even in disinfectants. This partly explains the success of this bacterium as a pathogen in a variety of settings such as the ICU. What contributes to the pathogenicity of Pseudomonas species?

The virulence (and pathogenicity) of Pseudomonas species is due to the production of the following virulence factors:

Adhesins : to attach to host cells Polysaccharide capsule : protects the organism from phagocytosis Endotoxin : lipopolysaccharide endotoxin Exotoxin A : blocks protein synthesis in eukaryotic cells Exoenzyme S : extracellular toxin which inhibits protein synthesis Elastase: degrades elastin, resulting in lung parenchymal damage and haemorrhagic lesions (ecthyma gangrenosum)

What infections do they cause?

In non-hospitalised patients pseudomonas may cause chronic otitis externa. In certain at risk hospital patients the following infections may occur:
1. Infections in burns. 2. Pulmonary infections in particular those patients on assisted ventilation with a tracheostomy. Also causes chronic infection in cystic fibrosis. 3. Wound sepsis. 4. UTI. 5. Eye infections. How are Pseudomonas species identified within the microbiology laboratory? Pseudomonads have simple nutritional requirements and they grow easily on common isolation media such as nutrient, blood or MacConkey agar. Aerobic incubation is essential: these bacteria are not facultative and therefore do not grow anaerobically.

Why are these infections difficult to treat? he correct answer is: Pseudomonads are intrinsically resistant to most agents e.g. many penicillins and cephalosporins, and coupled to the status of the infected patients,which may be compromised e.g. organ support in the ICU this makes infections involving Pseudomonas difficult to treat. What measures are used to control and prevent these infections?

Effective infection control practices should concentrate on preventing the contamination of sterile equipment such as respiratory therapy and dialysis machines and preventing the cross contamination of patients by medical personnel by strict adherence to hand-hygiene recommendations. The inappropriate use of broad-spectrum antibiotics should also be avoided because such use can suppress the normal microbial flora and permit the overgrowth of these bacteria which are intrinsically resistant.

Burkholderia
How were these species previously classified and where do they colonise? The correct answer is: Burkholderia cepacia was previously regarded as a member of the genus Pseudomonas but is now considered to be a separate genus. They are adaptable bacteria originally described as causing soft rot in onions. What is referred to as B. cepacia consists of nine phenotypically similar but genetically distinct species. Like P. aeruginosa, B. cepacia can colonise a variety of moist environmental surfaces

What type of infection do they cause? The correct answer is: Infections caused by this organism include respiratory tract infections in patients with cystic fibrosis or chronic granulomatous disease, and occasionally the following: urinary tract infections in catheterised patients, blood stream infections particularly in patients with contaminated intravascular catheters, and other opportunistic infections. What is the significance of these bacteria? The correct answer is: These are opportunist pathogens that cause infections such as ventilatorassociated pneumonia, bloodstream infection and systemic sepsis in the ICU patient. Some strains have evolved to be become highly antibiotic-resistant with few if any options available for therapy. Outbreaks caused by these strains have been well described, particularly in ICUs and can be difficult to eradicate.