GIT Module Normal Flora of GIT & Bacterial infections of GIT

BY

Dr Khine Swe Swe-Han

FC Path ( micro) SA M.Med (micro), SA DTMH ( Wits unive) SA PDIC (Stellenbosch univ) SA MB,BS ( Yangon, Myanmar) Pathologist , Consultant/ lecturer, Medical Microbiology Dept IALCH Academic complex,NHLS/UKZN

Lecture : Bacterial infections of GIT 11/8/11 08h00 10h00 - L2

Introduction
Lectures based on Normal flora of the gastro-intestinal tract Micro-organisms- bacteria causing diseases
Escherichia coli ( EPEC, ETEC, EAEC, EHEC or VTEC,EIEC) Vibrio Shigella Helicobacter pylori/ Campylobacter/Yersinnia
Epidemiology Virulence factors Pathogenesis Laboratory diagnosis Treatment & Prevention

Normal flora of GIT

AT Birth Breast fed children Bottle-fed children Adults Oesophagus Stomach Duodenum to rectum Sterile Large numbers of lactic acid streptococci/lactobacilli Mixed flora of gram-negative bacilli/less lactobacilli Small numbers Microorganisms arriving with saliva and food Small numbers microorganisms arriving with saliva and food 103- 1011 org/g 96-99% consists of anaerobes( e.g bacteroides, fusobacterium, lactobacilli, clostridia, peptostreptococci 1-4% - consists of facultative anaerobes ( coliforms, enterococci, proteus, candida)

Escherichia coli
Normal flora of the intestine Some strains have virulent factors can become pathogenic in the intestine
Infections of the small intestine

can cause various types of diarrhoea; Enteropathogenic E.coli ( EPEC) Enterotoxigenic E.coli ( ETEC) Enterohaemorrhagic E.coli( EHEC) Enteroadhesive E.coli( EAEC) Enteroinvasive E.coli ( EIEC)

Enteropathogenic E.coli ( EPEC)

Cause of infantile diarrhoea Certain serotypes that do not produce LT,ST/VT
Not entero-invasive Adhere to the enteric mucosa Loss of microvilli( effacement) Formation of cup-like structures and occasionally cell invasion Commonly cause watery diarrhoea in young children

Enteroinvasive ( EIEC)
Cause of dysentery Resistant to gastric acid and bile Pass rapidly into the large intestine Multiply, passing through the overlying mucous layer ( bacteria attach to the intestinal mucosal cells) Invade the cells by induced endocytosis Lyse the vacuole, multiply in the cytoplasm, rupture the cell Then invade neighbouring cells Spread and lead to tissue destruction and inflammation

Enterotoxigenic E.coli ( ETEC)

Cause of traveler's diarrhoea Produce enterotoxins ( labile toxin LT and stable toxin ST) LT is under the control of plasmid
Its subunit B attaches to the GMI ganglioside at the brush border of SI mucosal epi cells and facilitate the entry of subunit A into the cell. Subunit A activates adenyl cyclase and markedly increases the cyclic AMP which results in intense and prolonged hypersecretion of water and chlorides and inhibit the absorption of sodium. The gut lumen distended with fluid hypermotility and diarrhoea ensues.

ST
Also acts in the similar way and stimulates fluid secretion.

Enterohaemorrhagic E.coli( EHEC/VTEC)

Verotoxin producing E.coli ( 0157H7)
Associated with haemorrhagic colitis and the haemolytic ureamic syndrome haemorrhagic colitis
Grossly bloody diarrhoea Usually in the absence of pyrexia And preceded by abdominal pain and diarrhoea.

haemolytic ureamic syndrome- characterized by

Acute renal failure Micro-angiopathic haemolytic anaemia Thrombocytopenia

Enteroadhesive E.coli( EAEC)

Mild diarrhoea Adheres to the intestinal mucosa and causes acute and chronic mild diarrhoea

Vibrio cholerae
Virulent and characteristic of organism
Comma-shaped, curved, facultative anaerobic gram-negative bacillus Found in marine and surface waters Actively motile ( darting motility ) by means of its polar flagellum. Tolerant to alkali and intolerant to acid Mucinase enzymes Cholera toxin

Epidemiology
V.cholerae that can cause cholera include
V.cholerae serogroup O1 V.cholerae O139 Bengal

Other vibrios that can cause diarrhoea includeV.cholerae non-O1 V. parahaemolyticus V.cholerae
3 serotypes Inaba, Ogawa, and Hikojima 2 biotypes - classical and E1 Tor

Epidemiology
Distribution Worldwide and occurs as epidemics & pandemics 6 pandemics originating in the Bengal basin in 19th and early 20th centuries. in 1961 7th pandemic E1 Tor biotype of V cholerae O1 spread from Indonesia to the Far East and then swept back through much of southern Asia. Early in the 1970s Pandemic invaded Africa 1991 It reached South America

Epidemiology:
Fecal-oral route route of transmission and principally water-borne Endemic in areas of poor sanitation (India, Sub-Saharan Africa, Southern Asia) May persist in shellfish or plankton 7 pandemics since 1817: First 6 from Classical biotype and 7th from the El Tor biotype In 1993 Cholera epidemic in Bengal was caused by O139 which may be the cause of the 8th pandemic The recent Cholera epidemic in Haiti occured due to El Tor O1 strains that are predominant in South Asia.

Pathogenesis of cholera
Cholera is caused by V.cholerae serogroup O1 V.cholerae O139 Bengal In faecal contaminated water or food Ingestion Infective dose large numbers ( 108- 109 orgs) Reach the small intestine Invade the mucosal barrier of SI ( active motility and mucinase e/z Attach to the microvilli of the brush border of epi cellsmultiply liberate cholera toxin

Pathogenesis of cholera
Cholera toxin acts ( same as LT of ETEC)
CAUSING profuse watery diarrhoea

Mechanism
LT is under the control of plasmid
Its subunit B attaches to the GMI ganglioside at the brush border of SI mucosal epi cells and facilitate the entry of subunit A into the cell. Subunit A activates adenyl cyclase and markedly increases the cyclic AMP( Adenosine monophosphate) which results in intense and prolonged hypersecretion of water and chlorides and inhibit the absorption of sodium. The gut lumen distended with fluid hypermotility and diarrhoea ensues.

Pathogenesis of cholera ( clinical findings)

Incubation period
1-4 days Sudden onset of nausea, vomitting, profuse watery diarrhoea with mucus flakes ( rice water stool) Severe dehydration , circulatory collapse and even anuria and death. NB: NOT invasive infection and organism do not reach the blood stream.

clinical findings
Consequences of severe dehydration: Intravascular volume depletion Severe metabolic acidosis Hypokalemia Cardiac and renal failure

Lab dx
Specimens Fresh stool, Watery stool and mucus flakes from stool rectal swab Vomitus Strip of blotting paper soaked in watery stool Preservation and Transport media: When there may be delay in transmission of specimen to laboratory, it must be refrigerated at 8c to 10c for 24 hours, else following transport media may be used: E.g. Cary-Blair medium Enrichment media: Alkaline peptone water (pH 8.6) MCCS Smear microscopic examination Culture Serology test Slide agglutination

Procedure for recovery of V.cholera O1 from fecal specimen

Direct enrichment APW ( alkaline peptone water) (6-8 HRS, 35-37 C) TCBS Non selective medium V.cholera O1 polyvalent antisera Ogawa & inaba antisera Optional screening tests string oxidase KIA or TSI Arginine or lysine

Treatment
Rehydration Antibiotics
Tetracycline Ciprofloxacin
Shorten diarrhoeal illness.

Resistant emerged !

Prevention & control

Epidemiology important Carrier state seldom exceed 3-4 weeks chronic carrier rare Vibrio survive in water up to 3 weeks Source contaminated water, food, flies( from person to person) Isolation , disinfection of excreta, contact follow up Vaccine Endemic area Only valid for 6 months

Shigellosis ( bacillary dysentery)

Natural habitat Limited to the intestinal tracts of humans & other primate Coliform and a true pathogen Produce bacillary dysentery Non-motile and encapsulated Endotoxin ( LPS)( somatic o antigen) Heat labile exotoxin- enterotoxin & neurotoxin

Pathogenesis
Aetiology agents Shigella dysenteriae ( severe) Shigella flexneri Shigella boydii Shigella sonnei Contaminated with food and water Incubation period 1-2 days Infective dose -103 organisms ( highly communicable) Always limited to the GIT Bloodstream invasion quite rare

Pathogenesis
Invade the colonic mucosa by induced phagocytosis Spread within the epithe cell cytoplasm and passage to adjacent cells. Microabscesses
In the wall of the LI & terminal ileum leads to necrosis of the mucous mem, superficial ulceration, bleeding, and formation of a pseudomembrane on the ulcerated area
Dysentery

Pathogenesis ( action of toxins )

Endotoxin ( LPS) Autolysis Contribute to the irritation of the bowel wall. Shigella dysenteriae type 1 Produce a heat labile exotoxin Acts as both enterotoxin and neurotoxin ( gut & CNS) Enterotoxin produces early non-bloody , voluminous diarrhoea ( early) Invasion to large intestine, dysentery with blood and pus in the stool ( later) Inhibit the sugar and amino acid absorption in the small intestine. Neurotoxin fatal CNS reactions. ( meningism and coma)

Clinical manifestation
Sudden onset of abdominal pain, fever, watery diarrhoea Later As involves the ileum ,colon ( stool increase, less liquid , often contain blood & mucous Each bowel movement is accompanied by Straining, tenesmus( rectal spasms), lower abdominal pain. of the adult cases subside spontaneously in 2-5 days . In children & elderly loss of water & elect- dehydration , acidosis and even death On recovery
Shed shigella bacilli for only short time Remain chronic carrier- recurrent infection

Lab diagnosis
Specimens
Fresh stool

MCCS
M/C Culture Serology

Treatment
Ampicillin, tetracycline ,cotrimoxazole , chloramphenicol and ciprofloxacine , nalidixic acid Drug resistant emerged
Transmitted by plamids.

Opioids should be avoided.

Epidemiology and prevention & control of Shigella

Transmitted by
Food, fingers, feces, and flies From person to person Spread widely

Humans main host

Directed at eliminating the organisms from this reservoir by
Sanitary control Fly control Isolation of patients and disinfection of excreta Detection of subclinical cases and carriers ( food handlers)

Campylobacters
Known mainly as pathogens for various animals
Sepsis, abortion, enteritis

Campylobacter jejuni
Common cause of diarrhoea in humans Mainly enteritis Occasionally systemic invasion Gram negatic rod with comma,S , gull-wing shapes Motile Endotoxin ( LPS) Cytopathic extracellular toxins, enterotoxin

Pathogenesis
Acquired by Oral route ( contaminated food, drinks, contact with infected animals, or anal-genital-oral sexual activity. Susceptible to gastric acid Infective dose - 104 Multiply in the small intestine invade the epithelium cell & produce inflammation
Localised enteritis The jejunum and the ileum are the first site to become colonised Infection extends distally to affect the terminal ileum and usually the colon & rectum. Red and wbc in the stools If invade to blood stram clinical pictures of enteric fever

Clinical manifestation
Acute onset of crampy abdominal pain Profuse diarrhoea ( may be grossly bloody) Head ache, malaise, fever Usually self-limited ( 5-8 days)

Lab diagnosis
Specimens MCCS
Smear m/c Culture

Treatment, control
Erythromycin ( to reduce the fecal shedding )
Severe (accompanying fevers, blood in stools) or prolonged cases may require ciprofloxacin, erythromycin, azithromycin or norfloxacin. The drug of choice is usually erythromycin. About 90% of cases respond to ciprofloxacin treatment. Fluid and electrolyte replacement may be required for serious cases. Public health control measures

Helicobacter pylori
Spiral shaped gram negative rod Actively motile Strong producer of urease Not grow in gastric lumen ( PH 1.0-2.0) Epithelium surface side ( grows at PH 6.0-7.0) Associated with Antral gastritis Duodenal (peptic) ulcer Gastric ulcer and Gastric adenocarcinoma Gastric lymphoma

Pathogenesis
Produce : ( virulent factors) protease Modifies the gastric mucus and reduce the ability of acid to diffuse through the mucus. Urease Production of ammonia and further buffering of acid Ammonia may directly damage the cell also. Motile ( quite motile ,even in the mucus ) To find its way to the epithelial surface. Adhesins- highly affinity for epithelial cell receptors Mucosal inflammation & damage are not well defined. Invade the epithelial cell surface to a limited degree. Toxins & LPS Cytotoxin Damage the mucosal cells

Clinical manifestation
Asymptomatic Sign and symptoms of gastritis , DU. DU 90% of pts ( associated with DU have H.pylori infection ) 10% -related to drugs GU Uncertain Chronic and active gastritis Destruction of epithelium cells Glandular atrophy Associated with carcinoma.
H.pylori type 1carcinogen

Gastric lymphoma

Lab dx
Specimens Gastric biopsy ( endoscopy ) Histology

Mince in saline for culture

Blood Serum antibodies Culture Antibodies ( IgG,IgA) Special tests RAPID test to detect the urease activity
In vitro test In vivo test
C13 or C14 Labeled urea breath test

Treatment
Triple therapy Metronidazole + either bismuth subsalicylate or bismuth subcitrate+ either amoxicillin or tetracycline x 14 days 80% + eradicate Metroniazole + omeprazole+ clarithromycin x 1 week 90%+ eradicate

Epidemiology & control

H pylori < 20% of persons <30 years old Increase 40-60% of persons age 60( asymptomatic ) Developing countries 80% in adults Person to person transmission Once acquired the infection, persists for years or for life. Infection associated with Socioeconomic status Hygiene Water supply/sanitation Crowding in households Gastroenterologist/endoscopy nurse

Transmission
Faecal oral Oral-oral Via endoscope

Prevention
Difficult and improve living condition

Yersinia enterocolitica
Gram negative rod Found in the intestinal tract of animals Cause disease in animals and may transmit to humans Person to person rare Produce heat stable enterotoxin
Role not well defined

Pathogenesis
Ingestion of material ;contaminated food, water, fomites Infective dose -108-109 Incubation period 5-10 days Multiply in the gut mucosa( ileum) Inflammation & ulceration leucocytes in stool Extend to mesenteric lymph nodes and rarely to bacteremia. C/F Early symptoms Fever, abdo pain, diarrhoea ( watery to bloody) Abdo pain severe at Rt lower quadrant suggesting appendicitis One -2 weeks after onset Arthralgia, arthritis, erythema nodosum, - suggesting immunologic reaction to infection Rarely Pneumonia, meningitis, sepsis In most cases self limited.

Lab dx
Specimens
Stool, blood, material obtained at surgical exploration

MCCS
m/c Culture

Serology
Cross reaction to others

Treatment
Diarrhoea
Self limited Antibiotic
Benefits unknown Tetracycline, aminoglycosides, chloramphenicol, ciprofloxacin, cotromoxazole

Prevention & control

Source Sanitation- precaution Farm & domestic animals

References
Geo.F.Brooks, Janet S.Butel ,L.Nicholas Ornston ;Jawetz, Melnick & Adelberg s ; Medical Microbiology http://www.springerimages.com/Images/MedicineAndPu blicHealth/2-AID07E3-04-038 http://en.bestpicturesof.com/pictures%20of%20e%20coli %20gram%20stain http://totallyfreeimages.com/118304/Yersinia-pestis,Gram-negative-bacillus,-1000x-Magnification.

END
11/08/2011 BY Dr KSS/Han