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Introduction

Gastrointestinal infections encompass a wide variety of symptom


complexes and recognized infectious agents.
The term gastroenteritis is applied to syndromes of diarrhea or
vomiting that tend to involve non-inflammatory infection in the
upper small bowel or inflammatory infection in the colon.
Other enteric infections and infestations cause predominantly systemic
symptoms.
Infections of the gastrointestinal tract, especially infectious diarrhea,
are among the most common debilitating infectious diseases,
afflicting people of all ages around the world.
prolonged diarrhea is emerging as a major cause of death and serious
morbidity, especially in association with malabsorption and
malnutrition in tropical and developing areas.
Whenever a patient has an enteric illness always check carefully for
history of other illnesses in the family or community. Multiple
illnesses and common exposure may be clues to a food-borne
outbreak or to the causative agent

The frequency, type, and severity of enteric infections are determined by who
you are, where you are, and when you are there.

Who is at risk of acquiring a gastrointestinal infection varies greatly with age,


living conditions, personal and cultural habits, and group exposures.
Although the infant who is being breastfed is relatively protected from
contaminated food and water and probably to some degree by maternal
colostral antibodies and lactoferrin, at weaning there is a great increase in the
risk of diarrheal illness.
Adults, particularly if they live for many years in the same environment, may
become asymptomatic reservoirs of microorganisms that cause diarrhea in the
immunologically untutored child or visitor.
Living conditions often reflect socio-economic conditions, and type of housing,
population density, sanitation facilities, and water sources are major
determinants of environmental exposure to enteric pathogens.

The second epidemiologic determinant of risk for enteric infection is where you are.
The pattern of illnesses and the causative agents vary greatly with climate. For
example, enterotoxigenic and enteropathogenic E. coli cause disease primarily in the
tropics, where the heaviest burden of parasites also occurs.
In contrast, enterohemorrhagic E. coli has been found largely in developed areas such
as Japan, North America, and Europe, and enteroaggregative E. coli is found in
developed and developing areas.
Viral causes of common enteric illnesses have been found among young children in
temperate and tropical climates. Even within the same geographic region, diarrhea
rates are higher in those who live in high density with high social connectedness.
Finally, the third determinant of risk is when you are there. Most enteric illnesses in
temperate climates occur during the winter months. The opposite is true in tropical
countries, where distinct summer peaks of illnesses are common. The role of rainfall
is equally responsible for such outbreaks with broken sewers polluting the drinking
water
However, many community cases of diarrhea remain unexplained.

The family Enterobacteriaceae


Members are gram-negative, nonspore-forming, facultative anaerobes
that ferment glucose and other sugars, reduce nitrate to nitrite, and
produce catalase, but do not produce oxidase.
Most are motile by virtue of peritrichous flagellae.
often referred to as enterics because the principal habitat of many of
these organisms is the lower gastrointestinal tract of various
animals.
Widespread in nature and may be found, for example, in water and soil.
Contain endotoxin in cell wall
Coliforms (Enterobacter spp, E.coli & Klebsiella spp) and enterococcus
spp if found in environment are evidence of contamination with
feacal matter

Grow in media with bile salts


Combinations of chromosomal & plasmid-mediated drug resistance hence
importance of in-vitro susceptibility testing
Antigenic structure.
Cell wall/ Somatic or O antigen- heat stable
Capsular/K antigen- heat labile
Flagella /H antigen
Toxins/Enzymes
Endotoxins- Complex LPS in the cell wall
Exotoxins
Relevance in clinical medicine
Normally non-pathogenic.
In some instances, they even contribute to normal function and nutrition.
Other species cause hospital/community acquired disease
Become pathogenic when they change their habitat.
When the host defense is reduced, act as opportunistic pathogens.

Classification
I.
I.
I.
I.
I.
I.

Tribe : Escherichieae
Genera: Escherichia/ Shigella
Tribe : Klebsielleae
Klebsiella/ Enterobacter/ Edwardsiella/ Hafnia/ Serratia
Tribe : Salmonelleae
Salmonella/ Arizona/ Citrobacter
Tribe : Proteae
Proteus/ Providencia/ Morganella
Tribe : Yersineae
Yersinia/ Pasteurella
Tribe: Erwinieae
Erwinia/ Pectobacterium

Contamination indicators
Fecal contamination is a common pollutant in open water and a
potential source of serious disease-causing organisms.
Certain members of Enterobacteriaceae,such as Escherichia coli,
Klebsiella pneumoniae, and Enterobacter aerogenes, are able to
ferment lactose rapidly and produce large amounts of acid and
gas.
These organisms, called coliforms, are used as the indicator
species when testing water for fecal contamination because
they are relatively abundant in feces and easy to detect.
Once fecal contamination is confirmed by the
presence of
coliforms, any non-coliforms also present in the sample can be
tested and identified as pathogenic or otherwise.

ESCHERICHIA(1)
E. coli is the type species of the genus Escherichia, which in turn is the
type genus of the family Enterobacteriaceae
E. coli is both the most common species of facultative anaerobe found
in the human gastrointestinal tract and the most commonly
encountered pathogen from the enterobacterial family
E. coli is usually distinguished from other members of the family by the
ability of most strains to ferment lactose and other sugars and to
produce indole from tryptophan. In addition, most strains are motile
most strains of E. coli reside harmlessly in the lumen of the colon and
seem to be poorly adapted to cause disease in healthy individuals
Pathogenic strains differ from commensal organisms in that they
produce virulence factors specific for each pathotype, which may be
encoded by bacteriophages, on plasmids
E. coli is the most common cause of UTIs, is a leading cause of
neonatal meningitis, and can cause a wide variety of other
extraintestinal infections, such as nosocomial pneumonia,
peritonitis, cellulitis, osteomyelitis, and infectious arthritis.

ESCHERICHIA(2)
Strains of E. coli isolated from the urine or blood of patients with UTIs
(termed uropathogenic E. coli ) differ from those cultured from the feces
of healthy individuals and from those that cause diarrhea
E. coli is one of the leading causes of neonatal bacteremia, sepsis,and
meningitis, historically second only to Streptococcus agalactiae
Biochemically, diarrheagenic E. coli are not distinct from the nonpathogenic E. coli present normally in the intestine.
E. coli strains that cause illness can only be differentiated from normal flora
strains by the demonstration of a virulence property.
This always presented a problem for the routine clinical bacteriology
laboratory because demonstration of E. coli virulence properties or E.
coli pathotypes requires methodology generally available only in
research and reference laboratories
Complete serotyping of E. coli strains requires a determination of both the
O and H antigen types. There are approximately 164 O groups and 57 H
groups

Clinical manifestations
Extra-intestinal infections community & hospital acquired
Urinary tract infections (UTI)
Community acquired - usually in females
Nosocomial - indwelling urinary catheters
wound infections (trauma/ burns)
Intra-abdominal abscesses
Neonatal meningitis & sepsis colonization of mothers vagina
bacteremia/ septicemia
Gastroenteritis enterotoxigenic or invasive
ETEC - Travelers diarrhea, diarrhea in children
EPEC childhood & adult diarrhea
EIEC dysentry

Enterotoxigenic E. coli
ETEC strains are a common and important cause of childhood diarrhea
throughout the developing world and a leading cause of diarrhea in
travelers who visit these countries.

ETEC infections are acquired through ingestion of heavily contaminated


water or food and thus result from a failure of sanitation.
Infections caused by ETEC range from asymptomatic carriage to severe
cholera-like illness.
The predominant symptom is watery
accompanied by nausea and cramps.

diarrhea,

which

may

be

Vomiting, severe cramps, and fever are not prominent, and the stool
does not contain blood, mucus, or fecal leukocytes.
The incubation period ranges from a few hours to 2 days, and symptoms
usually last less than 5 days

Enterotoxigenic E. coli
The diversity of colonization factors that may be expressed by
ETEC strains is thought to be a major factor that allows
children in developing countries to have multiple bouts of
ETEC diarrhea.
Adults in developing countries are protected from illness after
repeated exposure to multiple ETEC strains during their
lifetime, whereas travelers to such countries are susceptible.
ETEC strains may express either or both of two enterotoxins,
known as heat-labile enterotoxin and heat-stable enterotoxin,
that are responsible for the secretory diarrhea seen in
symptomatic patients.
Heat-labile enterotoxin is closely related to cholera toxin, and
has an identical mechanism of action

DX of ETEC
The diagnosis of ETEC infection is not usually confirmed because it rests on
detection of the genes encoding heat-labile enterotoxin and heat-stable
enterotoxin by PCR or DNA probes or on assays for the biologic activity of
these toxins.
Prevention: Travelers to endemic areas can reduce the risk of ETEC infection
by strict adherence to advice regarding the ingestion of safe food and
water.
To avoid travelers diarrhea,drink only bottled beverages, avoid ice, meat and
vegetables that are not served steaming hot, and shun fruit that cannot be
peeled. Dry packaged or canned foods carry no risk.

Treatment of all diarrheal disease rests first and foremost on


providing adequate fluid replacement via the oral or, if
necessary,parenteral route.
Prompt therapy with an antimotility agent such as loperamide can
reduce symptoms.
These medications can be provided to travelers for use should diarrhea
develop during a trip to an endemic country. Combination therapy
with a fluoroquinolone and loperamide. azithromycin and rifaximin

Enteropathogenic E. coli (EPEC)


Enteropathogenic E. coli (EPEC) strains are defined by the characteristic attaching and effacing
effect that they elicit on interaction with epithelial cells and by the fact that they do not
produce Shiga toxins.
Typical EPEC strains carry a large EPEC adherence factor plasmid that encodes bundle-forming pili
(BFP) and the ability to form microcolonies on tissue culture cells, a pattern called localized
adherence
EPEC infections appear to be acquired principally by person-to-person spread and hospitals
continue to be a source of Infections
INFECTIONS caused by EPEC are difficult to differentiate from those with other causes; symptoms
include watery diarrhea sometimes accompanied by low-grade fever and vomiting.
However, EPEC infection may be severe, vomiting may make oral rehydration difficult, and lifethreatening dehydration may ensue.
Furthermore, disease caused by EPEC may be protracted, resulting in weight loss, malnutrition,
and death.
Breast milk contains factors found in both the lipid and the immunoglobulin fractions that inhibit
EPEC adherence,
Treatment of EPEC infection rests first on fluid replacement, which may require parenteral routes
of administration in children who have profuse vomiting. Mild EPEC illness does not require
antimicrobial therapy, but antibiotics can shorten the duration of illness in those with more
severe disease. Unfortunately, strains of EPEC are often resistant to multiple antibiotics
There is at present no vaccine to prevent EPEC.

Enterohemorrhagic E. coli (1)


EHEC serotype O157:H7, are responsible for larger outbreaks of infection,
have higher rates of complications, and seem to be more pathogenic than
non-EHEC STEC strains.
reservoir of EHEC strains is the gut of herbivorous mammals, these strains can
survive for long periods in the environment even at very low pH and can
proliferate in vegetables and other foods and beverages.
Outbreaks are often linked to the consumption of undercooked ground beef or
from produce, but can arise from a wide variety of other food sources,
drinking and recreational water, or petting zoos and by direct person-to
person contact.
Infectious dose of EHEC strains, is as low as less than 100 organisms,
EHEC infections are manifest by the onset of severe abdominal cramping,
which may progress to watery and bloody diarrhoea
The principal virulence factors are a group of related cytotoxins called Shiga
toxins. identical to the toxin produced by Shigella dysenteriae type 1, and
shares a high degree of sequence similarity and identical functional features.
Shiga toxins are encoded on temperate bacteriophages harbored by stressed
cells e.g.due exposure to certain antibiotics.

HUS
EHEC primary cause of HUS and the leading cause of renal insufficiency in
children, occur in 5% to 10% of individuals EHEC outbreaks.
Children younger than the age of 5 and the elderly are most affected.
HUS is a hemolytic anemia and the kidneys are the most VULNERABLE
TARGET ORGAN. The brain (strokes), eyes (blindness),and colon
(ischemic bowel) are other organs commonly affected

Strains that produce Shiga toxins (also called verotoxins) can cause
diseases of varying severity, including watery diarrhea, bloody diarrhea,
hemorrhagic colitis, hemolytic-uremic syndrome (HUS), and death.

HUS carries a 12% risk of death or end-stage renal disease, and 25% of
survivors experience long-term renal sequelae such as hypertension,
proteinuria, and renal insufficiency.

Enterohemorrhagic E. coli (2)


The diagnosis of infection with STEC is vital because of the importance of recognizing
potential outbreaks and of taking action to prevent further infections. STEC
The laboratory should be notified that STEC infection is suspected because many
laboratories do not routinely test for these strains. Sorbitol-MacConkey agar plates
can be used to detect O157:H7 colonies confirmatory testing using immunoassays
for Shiga toxin or PCR to detect stx genes.
Treatment of EHEC infection is entirely supportive. Antibiotics are currently
contraindicated because they can induce the expression and release of Shiga
toxins and their use is associated with a higher risk of HUS in children.
Alternative treatment modalities, including soluble toxin receptors and humanized
monoclonal antitoxin antibodies.
The risk of STEC infection can be reduced by following safe practices in food handling
and preparation and in other areas of hygiene.
Ground beef should be cooked to 155 F (68.3 C), prevent cross-contamination
between uncooked meat and foods to be served without further cooking,
unpasteurized juices and milk should be avoided, prevent infants and children who
are not toilet trained from defecating in public swimming areas, and hands should
be washed after touching animals in farms and petting zoos.
Vaccine development underway. Such vaccines and other preventive strategies may
be targeted either to cattle or humans.

Enteroaggregative E. coli
Enteroaggregative E. coli (EAEC) may be considered a true emerging
infection, and are defined by their aggregative pattern of adherence to
tissue culture cells
Form two-dimensional clusters when they adhere to cells in vitro, to glass
slides, to plastic, or to the intestinal mucosa.
isolated with increased frequency from children with acute diarrhea in
both developing and developed countries.
Enteroaggregative heat-stable enterotoxin (EAST) is similar to heat-stable
enterotoxin and seems to act by a similar mechanism,
A diagnosis of EAEC infection can be suspected in the appropriate setting
(acute diarrhea in children or recent travelers, persistent diarrhea in
children or human immunodeficiency virusinfected patients), but
confirmation requires performing tissue culture adhesion assays
General methods for preventing other E. coli enteric infections would be
effective for EAEC as well

Enteroinvasive E. coli
Enteroinvasive E. coli (EIEC) strains are very similar to Shigella
strains in terms of clinical features and pathogenesis
Unlike most E. coli organisms, both EIEC and Shigella strains are
usually non-motile, cannot ferment lactose, and, because of a
chromosomal deletion, are lysine decarboxylase negative.
They are differentiated from Shigella principally by the fact that
EIEC strains ferment glucose and xylose.
Like Shigella, EIEC can cause watery diarrhea, which may
progress to dysentery characterized by severe abdominal
cramps, fever, tenesmus, and frequent passage of smallvolume stools that may contain mucus and blood.

In summary
Enterotoxigenic E. coli (ETEC) strains are important causes of
diarrhea among children living in developing countries and among
international visitors to the areas (travelers diarrhea).
Enteroinvasive E. coli (EIEC) strains have been identified in patients
with dysenteric
illness clinically indistinguishable from that
produced by Shigella strains.
Enterohemorrhagic E. coli (EHEC) or Shiga toxin producing E. coli
(STEC) strains cause colitis with dysentery and produce hemolytic
uremic syndrome primarily in children. While the most common
serotype of STEC is O157:H7, many other serotypes of
shigatoxigenic E. coli can cause illness.
Our food supply is currently an important source of STEC infection.
E. coli strains showing enteroaggregative attachment to epithelial
cells and referred to as enteroaggregative E. coli (EAEC) cause
persistent diarrhea in infants living in developing countries, AIDSassociated diarrhea and travelers diarrhea.

Lab diagnosis
Specimens inoculated into 2 media BA and MacConkey/ EMB
Lactose fermentation: LF-colored/pink, NLF- colorless colonies
Biochemical tests:
Triple Sugar Iron (TSI) - Slant, butt, gas, H2S
Urease test
Oxidase test
Serology tests identification of somatic and flagellar antigens e.g. Salmonella,
Shigella
Typing for species identification e.g.bacteriophage typing

Lactose fermenters (LF)

Non- lactose fermenters (NLF)

Escherichia coli
Klebsiella

Shigella
Salmonella

Serratia
Enterobacter

Proteus
Yersinia

E.coli on MacConkey

TSI

Bacteriuria and UTI


Bacteriuria is a frequently used term and literally means bacteria in the urine.
The probability of the presence of infected urine in the bladder can be ascertained
by quantifying the numbers of bacteria in voided urine or in urine obtained via
urethral catheterization.
Significant bacteriuria is a term that has been used to describe the numbers of
bacteria in voided urine that usually exceed
the numbers caused by
contamination from the anterior urethra (i.e., =105 bacteria/mL).
The implication is that in the presence of at least 10 5 bacteria/mL of urine,
infection must be seriously considered. Asymptomatic bacteriuria refers to
significant bacteriuria in a patient without symptoms.
Urinary tract infection may involve only the lower urinary tract or both the upper
and lower tracts.
The term cystitis has been used to describe the syndrome involving dysuria,
frequency, urgency, and occasionally suprapubic tenderness.
However, these symptoms may be related to lower tract inflammation without
bacterial infection and can be caused by urethritis (e.g., gonorrhea or
chlamydial urethritis)
The term urosepsis is commonly used to describe the sepsis syndrome caused
by urinary tract infection.

UTI in Children
The problem of UTI spans all age groups, beginning with neonates.
The frequency of urinary tract infection in infants is about 1% to 2%.It is much more
common in boys during the first 3 months and thereafter occurs more often in girls.
Bacteremia is common in association with UTI in male newborns. Most studies have
found that a lack of circumcision predisposes to UTIs in infants and young boys

UTI in Women
The fact that UTI is much more common in women than in men gives support to the
importance of the ascending route of infection.
The female urethra is short and is in proximity to the warm, moist, vulvar and perianal
areas, making contamination likely

Up to 40% to 50% of the female population will experience a symptomatic UTI at


some time during their life
Frequent sexual intercourse, diaphragm use, especially with a spermicide,lack of
urination after intercourse, and a history of recurrent infections are risk factors for
urinary infection in women.
Most women with an acute onset of frequency, urgency, or dysuria, or all of these,
have UTI with 105 or more bacteria/mL of urine

UTI in elderly
At least 10% of men and 20% of women older than 65 years have asymptomatic
bacteriuria
Possible reasons for the high frequency of UTIs in older patients include obstructive
uropathy from the prostate and loss of the bactericidal activity of prostatic secretions
in men, poor emptying of the bladder because of prolapse in women, soiling of the
perineum from fecal incontinence in demented women, and neuromuscular diseases
and increased instrumentation and bladder catheter usage in both genders