Gram Negative Rods

General Classification
Based on source or site of infection
1. Enteric tract
2. Respiratory tract
3. Animal sources

Enteric tract
E.g., Escherichia, Salmonella ,Shigella, vibrio, Campylobacter ,Klebsiella-
Enterobacter-Serratia group, Proteus-Providencia-Morganella group, Pseudomonas,
Bacteroides

Respiratory tract:
E.g., Hemophilus, Legionella, Bordetella

Animal sources:
E.g., Brucella, Francisella, Pasteurella, Yersinia
 Escherichia coli
v The most common cause of sepsis among negative rods.
v One of the 2 important causes of neonatal meningitis (the other is the group B
streptococci) due to colonization of vagina by these organisms in about 25% of pregnant
women.

Virulence factors:
v Pili
v Capsule
v Endotoxin
v Two exotoxins (enterotoxins).
 Pathogenesis

v E. coli attaches to the surface of jejunum and ileum by Pili

v Bacteria synthesize enterotoxins (exotoxins determined by plasmids), causes
diarrhea.
v The toxins are strikingly cell-specific; Cells of colon are not susceptible due to lack
of receptors for the toxins.

Types of E. Coli :
Ø Enteropathogenic E. coli (EPEC)
Ø Enterotoxigenic E. coli (ETEC)
Ø Enter invasive E. coli (EIEC)
Ø Enterohemorrhagic E. coli (EHEC)
Ø Enteradherent E. coli (EAEC)
q Urinary Tract Infections (UTIs:

v The most common agent for UTI (Cystitis, pyelonephritis): fever, chills, flank
pain.
v Occurs primarily in women.
v Attributed to 3 features which facilitate ascending infection into bladder:
Ø A short urethra
Ø Proximity of the urethra to the anus
Ø Colonization of vagina by members of fecal flora.
v The most frequent cause of nosocomial UTI. (equally in both men and women
and associated with using catheters)

q Systemic infection :
v Capsule and endotoxin play a prominent role.
v Capsular polysaccharide interferes with phagocytosis (Serotype having K1 causes
neonatal meningitis).
v LPS during sepsis causes fever, hypotension and disseminated intravascular
coagulation.
q Treatment:
v Antibiogram for most infections.
v A combination of ampicillin and gentamicin in neonatal meningitis
v Rehydration for diarrhea.

q Prevention
v No passive or active immunization.
v Prompt withdrawal of catheters and intravenous lines
v Caution regarding uncooked food and unpurified water while traveling.
 Shigella

q Important properties

v Non lactose fermenting

v Distinguishable from Salmonella by: no gas, no H2S, non motile.
v Divided into 4 groups based on O antigen: A, B, C and D.
v Having an enterotoxin called Shiga toxin.
 Cont.,

q Disease:

v Shigellosis Only a human disease.

v Transmitted from person to person by asymptomatic carriers (oral fecal transmission)
v 4 F’s – fingers, flies, food, feces
v Food-born outbreaks outnumber water-born outbreaks by 2 to 1.
v In mental hospitals and day-care nurseries
v Children <7 accounts for half of shigella positive stool culture
 Pathogenesis

v Exclusively in gastrointestinal tract

v Bloody diarrhea (dysentery): Invading the mucosa of the distal ileum and colon.
v Local inflammation accompanied by ulceration occurs, but the organisms rarely
penetrate the wall or enter the bloodstream unlike salmonellae.
v Although some have an enterotoxin, invasion is not only due to enterotoxin.
v 4Most invasive species
v S. dysenteriae causes the most severe disease but S. sonnei causes mild disease
but more frequent.
 Clinical findings

Incubation period: 1-4 days

Symptoms:
v Fever, abdominal cramps, followed by diarrhea (watery at first but later
contains blood and mucus).
v It can be mild or severe depending on 2 major factor:
v The species of Shigella and the age of the patient.

v Resolves in 2-3 days but antibiotic can shorten the course.

v Serum agglutinins appear after recovery but are not protective because the
organism does not enter the blood.
 Treatment
4 The main treatment:

v Fluid and electrolyte replacement.

v No antibiotic in mild cases
v Antibiogram test: Trimethoprim - sulfamethoxazole or ampicillin.
v Antiperistaltic drugs are contraindicated as they prolong the fever, diarrhea an
excretion.
 v47Prevention

v Interruption of fecal-oral transmission by proper sewage disposal,

v Chlorination of water and personal hygiene.
v No vaccine
v Antibiotic prophylactic is not recommended.
 Salmonella
q Important properties

v Not ferment lactose

v Produce H2S, Gas, motile

q Naming the salmonella

Ø S. typhi
Ø S. Para typhi (A, B, C…)
Ø S. typhimurium
Ø S. Choleraesuis
Ø S. enteritidis (1500 serotypes)
Ø

5
 Diseases

ü Enterocolitis (S. typhimurium) –

ü Enteric fever (typhoid fever);(S. typhi and S. paratyphi)
ü Septicemia with metastatic abscesses (S. choleraesuis)

q Enterocolitis

v An invasion of the epithelial and subepithelial tissue of the small and large intestines.
v Penetration both through and between the mucosal cells: Inflammation and diarrhea.
v PMN response limits the infection to the gut and the adjacent mesenteric lymph nodes.
v The dose of Salmonella required: at least 100,000 while for Shigella: 100 organisms.
q Typhoid (Enteric fevers):

v Infection begins in the small intestine but few gastrointestinal symptoms occur.
v The organisms multiply in the mononuclear phagocytes of peyer’s patches,
then spread to the phagocytes of the liver, gallbladder and spleen leading to
bacteremia and then fever.
q Septicemia:

v Accounts for only about 5-10% of Salmonella infections and occurs in:

Ø More common in patients with chronic disease or children with

enterocolitis.

v It leads to seeding of many organs, with osteomyelitis, pneumonia, and

meningitis as most common sequela.
 Clinical findings

q Enterocolitis

v Incubation period: 6-48 hours

v Symptoms: Nausea, Vomiting, Abdominal pain and diarrhea with or without
blood
v The disease is self-limited.
v Treatment only in the very young and very old.
v S. typhimurium: the most common cause of enterocolitis.
 Clinical findings

q Typhoid or Enteric fever:

v Typhoid or Enteric fever caused by S. typhi and S. paratyphi (A, B and C).

v The illness is slow, with fever and constipation rather than vomiting and diarrhea.

v After the first week, bacteremia becomes sustained.

v High fever, tender abdomen, and enlarged spleen occur.

q Enterocolitis

v Rose spot (rose-colored papules) on the abdomen are associated with typhoid
fever but occur only rarely.

v The disease begins to resolve by the third week but intestinal hemorrhage or
perforation can occur.

v 3% of typhoid fever patients become chronic carriers.

v The carrier rate is higher among women.

q Septicemia

v S. Choleraesuis: most often cause septicemia.

Symptoms:
v Fever
v Little or no enterocolitis
v Focal symptoms: bone, lung, or meninges.
 59Transmission of salmonella

The epidemiology of Salmonella infections:

v Ingestion of food and water contaminated by human and animal wastes.

v S. typhi, transmitted only by humans, but other species have a significant

animal reservoir.

v Human sources are either persons who temporarily excrete the organism
during or shortly after enterocolitis or chronic carriers who excrete the
organism for years.
 Cont.,

v The most frequent animal source is poultry and eggs, but meat products
that are inadequately cooked have been implicated as well.

v Dogs and other pets including turtles are additional sources.

 Treatment

q Enterocolitis:

v Self-limited.
v Fluid and electrolyte replacement.
v Antibiotic can select mutants resistant and increase the frequency of
the carrier state.
v Antimicrobial agents are indicated only for neonates or persons with
chronic disease who are at risk of septicemia and disseminated
abscesses.
 Treatment

q Enteric fever and Septicemia:

v Ampicillin or chloramphenicol.
v Ampicillin: in patients who are chronic carriers of S. typhi.
v Cholecystectomy may be necessary to abolish the chronic carrier state.
v Focal abscesses should be drained.
 Prevention

v Public health and personal hygiene measures.

v Proper sewage treatment
v A chlorinated water supply
v Cultures of stool samples from food handlers
v Hand washing
v Pasteurization of milk
v Proper cooking of poultry and meat
v Two vaccine confer protection against S. typhi but no common
Vibrionaceae Curved or “comma-shaped” gram-negative rods

v Against Enterobacteriaceae, they have Monotricus not peritricus flagellum.

v All members live in aqueous material.
v G e n u s Vi b r i o l i v e s i n r i v e r s , s a l t w a t e r s l i k e b e a c h e s .

Vibrio cholerae
Ø Facultative anaerobic
Ø Can tolerate pH=9
Ø Fermenting sucrose
Ø Oxidase positive
Ø Monotricus flagellum
 Epidemiology

q Infects only humans.

Ø Transmitted by fecal contamination of water and food.

q Asymptomatic carriers:
Ø Individuals in the incubation or convalescing (Recovery) period

q Recent pandemic:
Ø 1960s-1970s, over 3 continents (Africa, Europe and Asia)
Ø El Tor biotype/ usually Ogawa serotype.
 Factors predisposing to epidemics

v Poor sanitation
v Malnutrition
v Overcrowding and
v Inadequate medical services.
v Quarantine measures failed to prevent the spread of the disease due
to many asymptomatic carriers.

9
 Pathogenesis

v Colonization (approximately 1 billion organism must be ingested, because

the organism is particularly sensitive to stomach acid.

v Adherence to the cells of brush border of the gut is related to secretion of

mucinase: dissolves the glycoprotein coating over the intestinal cells.
Massive watery diarrhea without inflammatory cells.

v Morbidity and death are due to dehydration and electrolyte imbalance.

v If treatment is instituted promptly, the disease runs a self-limited

course in up to 7 days.
 Clinical findings

v Watery diarrhea in large volumes (the hallmark of cholera) without cells.

v Non-bloody rice-water stool
v No fever
v Symptoms are referable to the dehydration:
v the loss of fluid and electrolytes leads to cardiac and renal failure.
v Acidosis and hypokalemia occur as a result of loss of bicarbonate and
potassium in the stool.
v Mortality rate without treatment is 40%
 Treatment

v Prompt, adequate replacement of water and electrolytes (orally or

intravenously).

v Tetracycline is not necessary but do shorten the duration of symptoms and

reduce the time of excretion of organisms.
 Prevention

v Providing clean water and food supply.

v Vaccine has limited usefulness (50% effective for 3-6 months)
v Tetracycline for prevention is effective in close contacts but
cannot prevent the spread of a major epidemic.
v Prompt detection of carriers is important in limiting outbreaks.
 Psuedomonaceae Gran Negative rods

q Non fermentative (Strict aerobic)

Ø Oxidation of sugars
Ø Cytochrome C oxidase

q Pseudomonas aeroginosa (Piocianic bacillus)

v Growth in soil and water containing only traces of nutrients.

v A remarkable ability to withstand disinfectants (found in soap solutions, in
antiseptics and in detergents).
v Persistent in the hospital environment
v An important role in hospital-acquired infections
 Epidemiology

v Approximately, 10% of people carry it in the normal flora of the colon and
on the skin in moist areas.

v It can colonize the upper respiratory tract of hospitalized patients.

v Its ability to grow in simple aqueous solutions has resulted in contamination

of respiratory therapy and anesthesia equipment's, and even distilled water.
 11An opportunistic pathogen

An opportunistic pathogen. e.g. in those with extensive burns (skin host

defenses are destroyed), those with chronic respiratory disease (such as
cystic fibrosis), immunosuppressed, those with catheters.
10-20% of hospital-acquired infections.
 Clinical finding

v Can cause infections virtually anywhere in the body, but more frequent
in:
Ø Urinary tract infections (UTIs)
Ø Pneumonia
Ø External otitis
Ø Wound infections (especially burns).
v From these sites, the organism can enter the blood, causing sepsis with
mortality rate of over 50%.
 Treatment & Prevention

v Resistant to many antibiotics

v Antibiogram test is essential
v Usually is chosen from penicillin or cephalosporins along with an aminoglycoside.

1 Prevention

v Removing indwelling catheters promptly

v Taking special care of burned skin
 Spirochetes

v Thin-walled Spiral rods

v Flexible
v Motile
v Having an axial filament under the outer sheath
e.g., 1Treponema, Leptospira, Borreliae.
v S e e n o n l y b y d a r k f i e l d m i c r o s c o p y, s i l v e r i m p r e g n a t i o n , o r
immunofluorescence.
v No growth in bacteriologic media.
v Borreliae- Larger than two others
v Seen by Giemsa’s and other blood stains
v Seen in the standard light microscope
 Treponema pallidum

The bacterial agent of syphilis.

q Transmission and Epidemiology

Ø Transmission from spirochete-containing lesions of the skin or
mucous membranes
Ø From pregnant women to their fetuses.
Ø Blood transfusion during early syphilis
Ø A worldwide STD
Ø The incidence is increasing
 Pathogenesis & Clinical finding

No important toxins or enzymes.

q Primary stage:
Ø Chancre in 2 – 10 weeks (average 21 days).
Ø The ulcer heals spontaneously, but spirochetes spread widely in tissues.
q Secondary stage:
Ø Lesions as maculopapular rash or moist papules on skin and mucous
membranes. Or
Ø organ involvement (meningitis, nephritis, hepatitis.
Ø Secondary lesions are rich in spirochetes and highly infectious but heal
spontaneously.
q Tertiary stage:
Ø One-third of early syphilis cases progress to cure without treatment.
Ø Another third remain latent; i.e. no lesions appear, but positive serologic tests
indicating continuing infections (Asymptomatic).

q In the remainder, the disease progresses to the late, tertiary stage.

Ø Granulomas (gummas), especially of skin and bones, central nervous system
involvement (e.g. tabes, paresis( muscular weakness), or cardiovascular lesions (eg,
aortitis, aneurysm (weakening of artery wall).
Ø In tertiary stage, the treponemes are very rare.
 Immunity

v Immunity to syphilis is incomplete

v Antibodies are produced but not stop the progression of the
disease.
v Patients with early syphilis who have been treated can contract
syphilis again.
v Patients with late syphilis are relatively resistant to reinfection.
 Lab diagnosis

Microscopy:
v Demonstrating spirochetes by darkfield or immunofluorescence
microscopy.
v Nonspecific serologic tests
v Nontreponemal antigens (extracts of normal mammalian tissues. eg.
Cardiolipin from beef heart) react with “reagin” antibodies in serum
samples from patients with syphilis.
v VDRL (Venereal Disease Research Laboratory)
v RPR (Rapid plasma reagin)
 Cont.,

v Antibodies are detectable in the majority of patients at the time the primary lesion
appears.

v Always present in secondary syphilis.

v False-positive reactions occur in infections, such as hepatitis and infectious

mononucleosis and in various autoimmune disease.
 Cont.,

16Specific serologic tests:

v Involving the use of treponemal antigens.

T. pallidum extracted from experimentally infected rabbits reacts in immune fluorescence

or hemaglutination (TPHA) tests with specific antitreponemal antibodies, which arise
within 2-3 weeks of syphilitic infection.
 Treatment & Prevention

Ø Penicillin G (A single injection of benzathin penicillin G).

Ø Tetracycline or erythromycin if given for prolonged periods.

Prevention:
Ø Administration of antibiotic after suspected exposure.
Ø The presence of any sexually transmitted disease makes testing for syphilis
mandatory.
Ø No vaccine is available.