Gastrointestinal

Infections & Food

Poisoning
MLAB 2434 Microbiology
Keri Brophy-Martinez

General Concepts

A complete history should be taken

Foods eaten recently
Exposure to ill patients
Recent travel
Medicinal history
Any underlying illnesses

Diarrhea may be caused by viruses, bacteria,

parasites, food poisoning and non-infectious
processes
Usually acquired by ingesting contaminated food
or beverage

Anatomy of GI Tract
Organisms must be able to survive
gastric acids in order to reach the
small bowel
In small bowel, motility (peristalsis)
is major host defense. Organisms
can not adhere to intestinal wall
Generally, a large dose of organisms
is needed to cause disease

Normal GI Flora

Stomach contains few organisms

Upper part of small bowel contains small
numbers of Enterococcus sp, lactobacilli,
and diphtheroids, along with Candida
albicans in 20-40% of individuals
Colon contains large numbers of
anaerobes and facultative aerobes in
1000:1 ratio
Colon

produces IgA
Pathogens would have to compete with
normal flora

Risk Factors

Number of Ingested Organisms

Median

infectious dose (ID50)

The number of ingested organisms that

must be ingested to cause a diarrheal
illness in 50% of exposed individuals

Achlorhydria
Inadequate

stomach acidity

Reduction in normal flora

Use

of antibiotics

Diagnosing Cause of
Diarrhea

History
Travel to endemic areas of world
Recreational activities
Exposure to ill patients
Food
Detailed history of food eaten 3 days
prior to onset of symptoms

Diagnosing Cause of
Diarrhea

Physical Exam
Dehydration
Toxic megacolon
Increase in heart rate or decrease in blood
pressure after standing upright
Laboratory Diagnosis
CBC
Fecal WBC
Stool Culture
O &P
Electrolyte panel

Enterotoxin-Mediated
Diarrhea

Symptoms
Rapid

onset of diarrhea

Less than 12 hours

Lack

fever
Absence of blood or pus
Point to enterotoxin mediated illness
Large

number of watery stools

Sometimes >20 per day

Enterotoxin-Mediated
Diarrhea

Pathogens
ETEC
V.

cholerae
S. aureus
C. perfringens
B. cereus
Other types
Viral and parasitic can be similar but
symptoms longer lasting

Invasive Diarrhea

Invasion of the bowel mucosal surface

Symptoms
Fecal leukocytes
RBCs
Sometimes fever
Organisms
Salmonella spp.
Campylobacter spp.
Shigella spp.
E. coli
E. histolitica

Common Bacterial Agents

Causing Diarrhea

Common Bacterial Agents

Causing Diarrhea

Campylobacter jejuni
Most

common cause of bacterial diarrhea

in the world
Inadequately cooked poultry, untreated
water, unpasteurized milk, and exposure
to animals with diarrhea
Self-limiting, antibiotics not needed
Manifests with fever, diarrhea and
abdominal cramping

Campylobacter jejuni:
Fast facts
Grows best at 42 degrees C
Microaerophilic conditions
Capnophilic conditions
Campy plate
Gram-negative curved rods, seagull
wings

Common Bacterial Agents

Causing Diarrhea (contd)

Salmonella species
Gastroenteritis

and Food Poisoning

Contracted by eating undercooked

meat, poultry, eggs, and contaminated
dairy products
Nausea, vomiting, and diarrhea 6-48
hours after ingestion
Usually self-limiting; antibiotics
discouraged because they can induce
carrier state

Common Bacterial Agents

Causing Diarrhea (contd)

Salmonella species (contd)

Enteric

Fever

Typhoid fever is most severe

Contaminated food and water
Organisms invade small bowel & colonic tissue
Live and reproduce in monocytes
Can invade gall bladder and produce carrier
state
Symptoms include headache, fever, malaise and
abdominal tenderness

Salmonella species
Fast Facts

Requires a high microbial load for infection

Culture
Look for LN on MAC
Look for blue green colonies with blk
centers on HE
Look for red colonies with blk centers on
XLD
Fecal wbc lab test
See rbcs and wbcs in stool

Salmonella

Common Bacterial Agents

Causing Diarrhea (contd)

Shigella species
Diarrhea

may have blood and pus

Symptoms appear 12-50 hours after
exposure
Most communicable of the diarrheal
bacteria
Symptoms include: fever, malaise, fatigue
and anorexia

Shigella species
Fast Facts
Requires a low microbial load
Fecal WBC lab test

Observe

blood, WBCs, pus

Culture
Colorless

colonies(NLF) on MAC
Blue green colonies of HE
Red/colorless on XLD

Shigella

Common Bacterial Agents

Causing Diarrhea (contd)

Diarrheogenic Escherichia coli

ETEC: Enterotoxigenic
Cause of travelers diarrhea
EIEC: Enteroinvasive
EPEC: Enteropathogenic
Diarrhea outbreaks in infants in hospital setting
EHEC: Enterohemorrhagic
E. coli 0157:H7
Presence of shiga-like toxin
Associated with HUS
EAEC: Enteroaggregative
Chronic diarrhea in HIV patients, travelers, & children
in poor countries

E. coli O157:H7 on MAC and

SMAC

Common Bacterial Agents

Causing Diarrhea (contd)

Vibrio species
Requires

a large microbial load

Utilize TCBS media

Inhibits colonic flora

Differentiates sucrose fermenters from
species of Vibrio that are non-fermenters

Stool

contains no rbcs or wbcs since it is

toxin mediated & non-inflammatory

Common Bacterial Agents

Causing Diarrhea (contd)

Clostridium difficle
Test

for the toxin, culture not performed

Hospital-acquired due to alteration of
normal flora and use of antibiotics
Consists of Toxin A & B

Less Common Agents of GI

Illness
Yersinia enterocolita
Plesiomonas shigelloides
Aeromonas hydrophilia
Listeria monocytogenes

Common Bacterial Agents

Causing Diarrhea (contd)

Many cases of food poisoning

caused by toxins produced by
bacteria
Bacteria

may no longer be alive, but

toxins can cause food poisoning
Example: S. aureus, Clostridium
botulinum, Bacillus cereus

Bacterial Agents Associated

with Food Poisoning
Agent

Source of
Contamination

Toxin

Implicated Foods

S. aureus

Nasal passages of
asymptomatic
carriers

Staphylococcal
enterotoxin

Foods with mayonnaise,

eggs, or dairy products,
canned food, frozen
food, processed meats

Clostridium
botulinum

Soil & water

Botulism
neurotoxin

Mushrooms, salami,
improperly canned foods

Bacillus cereus

Environmental
contaminant

Heat-stable
enterotoxin &
heat-labile
enterotoxin

Grains, especially rice

Common Parasitic Agents

Causing Diarrhea

Parasitic Infections
Giardia lamblia

Ingestion of contaminated water or person-person spread

Nausea, vomiting, flatulence, cramping and diarrhea
Absence of fever and fecal leukocytes

Entamoeba histolytica

Fever, grossly bloody diarrhea

Other rare parasites include:

Cryptosporidium
Cyclospora
Microsporidia
Ascaris
Stronglyloides
Trichuris
And many more

Common Viral Agents

Causing Diarrhea
Hard to diagnosis due to virus size
Require secondary testing such as
cell culture, PCR, EM

Common Viral Agents

Causing Diarrhea

Rotavirus
Primarily

affects children < 5 years

old
Spread by fecal-oral route
Peak incidence from December
through June

Common Viral Agents

Causing Diarrhea

Calicivirus
Norovirus

Spread by fecal-oral route by

contaminated food or water or
environmental fomites, person to
person
Outbreaks on cruise ships
Cause of stomach flu

Laboratory Diagnosis of
Gastrointestinal Pathogens

Specimen Collection and Handling

Collect

with 4 days of onset of

symptoms
Stool should be processed ASAP; NOT
refrigerated
Rectal swabs NOT recommended
Use of preservatives not
recommended unless test ordered is
an O & P

Laboratory Diagnosis of
Gastrointestinal Pathogens
Fecal

Leukocytes

Direct microscopic exam almost

exclusively performed to detect
presence of WBCs and RBCs. Their
presence is due to intestinal wall
bleeding
Differentiates invasive disease from
toxin-mediated illnesses, viral illness
and parasitic infections

+ WBC: Salmonella, Shigella, Yersinia, EIEC,

Campylobacter, Vibrio

Positive Fecal WBC

Interpretation of Cultures
All media plates work together to
determine the presence of a pathogen.
Routine stool cultures include testing for:
Salmonella species, Shigella species,
Aeromonas species, Plesiomonas species,
and Campylobacter jejuni
Less frequently ordered
Yersinia, Vibrio, E. coli 0157:H7

Identification & Reporting of

Isolates

Presumptive identification tests

Oxidase
TSI
Urea
Reporting
If no pathogens found
Report No Salmonella, Shigella, or Campylobacter
isolated
Pathogen Isolated
Identification & quantification
Any amount significant
Additional testing may be indicated

Treatment of Diarrhea

Patients must be watched for dehydration

Antibiotics are NOT effective against viral
pathogens, give supportive care for hydration
Antibiotics may shorten illness by invasive bacteria
or an enterotoxin-mediated process
Antidiarrheal mediations (Lomotil, Pepto-Bismol)
Primarily used with enterotoxin mediated diarrhea
or viral gastroenteritis
Prophylactic therapy not recommended for
travelers
When traveling, Boil it, peel it, cook it, or forget
it!

References

Engelkirk, P., & Duben-Engelkirk, J. (2008). Laboratory

Diagnosis of Infectious Diseases: Essentials of Diagnostic
Microbiology . Baltimore, MD: Lippincott Williams and
Wilkins.
http://www2.cfpc.ca/cfp/2004/Nov/vol50-nov-cme-1.asp?s
type=advanced&
http://www.cdc.gov/rotavirus/index.html
Kiser, K. M., Payne, W. C., & Taff, T. A. (2011). Clinical
Laboratory Microbiology: A Practical Approach . Upper
Saddle River, NJ: Pearson Education.
Mahon, C. R., Lehman, D. C., & Manuselis, G. (2011). Textbook
of Diagnostic Microbiology (4th ed.). Maryland Heights, MO:
Saunders.