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The frequency, type, and severity of enteric infections are determined by who
you are, where you are, and when you are there.
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.
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.
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.
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.
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
Escherichia coli
Klebsiella
Shigella
Salmonella
Serratia
Enterobacter
Proteus
Yersinia
E.coli on MacConkey
TSI
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
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