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Aerobic Gram-Negative Bacilli

No
1

Micro.
Escherichia
coli

Disease

Intestinal
pathogens

Extraintestinal
infections

Notes of Disease
Enterotoxigenic
(ETEC): travelers
diarrhea.
Enteroaggregative
(EAEC)
Enteroinvasive
(EIEC): travelers
diarrhea.
Enteropathogenic
(EPEC)
Shiga-toxin producers
(STEC)
[Enterohemorrhagic
(EHEC), verotoxigenic
(VTEC)]
Urinary pathogens:
Uropathogenic E. coli
(UPEC)
Special virulence
factors:
Pili:
+ Type 1 pili.
+ P pili.
The intestine is the
source of UPEC: urinary
tract infections (UTIs)
are usually caused by
intestinal E. coli.
UTIs are usually
endogenous infections.
Flagella.
Once established, they
produce: LPS, hemolysin, CNF.
Lower UTI, cystitis:
Dysuria.
Frequency
(pollakiuria).
Urgency.
Suprapubic pain.
Sometimes hematuria.
Upper UTI,
pyelonephritis:
Fever (>38C).
Chills.
Flank pain.
Nausea / vomiting.

Treatment

Prevention

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Aerobic Gram-Negative Bacilli

Bacteremia.
Meningitis:
Uncommon.
One of the most
common causes of
neonatal meningitis:
The other one is
S.agalactiae.
Special virulence
factor: K1 capsular
polysaccharide.

Shigella

Dysentery

Salmonella

Salmonellosis,
gastroenteritis
Typhoid fever

Diarrhea + leukocytes
in stool + erythrocytes in
stool
Dysentery is caused by
invasive Shigella or
enteroinvasive
Escherichia coli
(EIEC).
Transmission: Fecaloral route.
Colon disease
IP: ~ 3 days (1 7
days)
Low infectious dose
(<200 microorganisms):
+ Fever.
+ Abdominal pain.
+ Vomiting.
+ Diarrhea.
No systemic spread
It is a self-limited
disease.
It appears in epidemic
outbreaks.
It may spread quickly.

Antibiotic therapy is
not essential:
Infection clears
spontaneously in
most individuals.
Benefits of
antimicrobial
therapy:
It can reduce the
risk of person-toperson spread: most
favor antibiotic
therapy for patients
with positive stool
culture.
To decrease the
duration of fever and
diarrhea by about two
days
Options:
Fluoroquinolone (3
days)
3rd generation
cephalosporin (5
days)
Azithromycin (3
days)
TMP-SXT (5 days)

Vaccines are in
development.

Fluoroquinolones
are the most
effective:
But increasing
resistance.
In general, they
should NOT be used

Vaccines
Two vaccines
available against
S. Typhi:
+ Live oral S.
Typhi vaccine
strain TY21a.

The most common


The most severe.
Warning: Typhoid
fever should not be
confused with Typhus.
Caused by typhoidal
Salmonella:
Mainly Salmonella

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Aerobic Gram-Negative Bacilli

Salmonellosis

Yersinia
enterocolitica

Acute enteritis
Syndrome that
mimics acute
appendicitis
Reactive arthritis
or erythema

Typhi.
Others (Salmonella
Paratyphi A, B, C).
Food-borne disease.
Systemic disease:
Severe.
Bacteremia, fever and
abdominal pain.
IP: 10 14 days.
Clinical disease
First week:
+ Rising fever until 40C
+ Constipation
+ Sweating
+ Anorexia
Second and third
weeks:
+ Increasing indifference
(lack of energy) and
alteration of level of
consciousness.
+ Intestinal infection and
still high fever
+ Diarrhea
+ Rose spots
Produced by nontyphoidal Salmonella.
Salmonella Enteritidis
is the most common.
Associated with animal
reservoirs.
IP: 1 2 days.
Nausea and vomiting.
Abdominal cramps.
Diarrhea: Sometimes
bloody.
Fever in about 50% of
the patients.
Self-limited for 3 to 4
days.
Bacteremia.
The most common
form of the infection
Self-limited
Fever and severe
abdominal pain in the
right lower quadrant
It may follow diarrhea

as a first-line
treatment for typhoid
fever in patients from
South Asia.
Ciprofloxacin (5
7 days) can be given
if sensitivity has been
tested.
Ceftriaxone (10
14 days)
Azithromycin (5
days)

+ Parenteral Vi
polysaccharide
conjugated
vaccine.
Disadvantages:
+ Not completely
effective against
S. Typhi: 50
70% protection.
+ Not long time
protection.
+ It does not
provide protection
against S.
Paratyphi.
Sanitation is the
most important.

Antimicrobials
should NOT be used
routinely to treat
uncomplicated nontyphoidal Salmonella
gastroenteritis.
Options (3 to 7 days
treatment):
Fluoroquinolone
TMP-SXT
Amoxicillin
3rd generation
cephalosporin if iv.
therapy is required

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Aerobic Gram-Negative Bacilli

nodosum
5

Yersinia
pseudotuberculosis

Yersinia pestis

Acute enteritis
Syndrome that
mimics acute
appendicitis
Plague

Similar to Y.
enterocolitica.
Plague has been one of
the diseases that has
killed more people in the
history.
Zoonosis in rodents:
Transmitted to humans
by a vector: Flea
(Xenopsilla cheopis)
IP: 2 7 days.
Bubonic plague:
+ Acquired by cutaneous
inoculation after a bite.
+ Fever.
+ Painful bubo
(inflamed lymph node).
Bacteremia and death
in 50 75% of patients
if untreated.
Pneumonic plague:
+ Secondary (after
bubonic plague).
+ Primary pneumonic
plague: Acquired by
inhalation.
Fever, malaise.
Respiratory clinical
findings:
+ Cough.
+ Productive sputum.
+ Dyspnea.
+ Cyanosis.
100% of patients die
after 2 3 days if
untreated.
Currently, pneumonic
plague is still fatal if
appropriate treatment is
delayed.
Septicemic plague:
Bacteremia without a
preceding bubo.
Difficult to diagnose.
Febrile and extremely

Preferred choices:
Streptomycin.
Gentamycin.
Alternative choices:
Doxycycline.
Ciprofloxacin.
Chloramphenicol.

Two types of
plague vaccine
have been
available.
+ Killed wholecell vaccine
(KWC): Not
effective against
respiratory
exposures.
+ Live attenuated
vaccine (LWC)

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Aerobic Gram-Negative Bacilli

ill.
Systemic symptoms.
Very high mortality.

Vibrio
cholerae

Cholera

Cholera produces the


most dramatic watery
diarrhea known.
Voluminous bowel
movements.
Intense dehydration
and electrolyte
imbalance.
NON-invasive disease:
No inflammation, No
mucosal injury.
IP ~ 2 days (12h 72h)
Food-borne disease,
transmitted by the fecaloral route.
Clinical disease:
Diarrhea.
Severe dehydration.
Vomiting.
NO fever.
Very high mortality.

Gastroenteritis

IP: 12 24 hours.
Self-limited.
Diarrhea.
Moderate cramps or
vomiting.
Fever is uncommon.

Vibrio parahaemolyticus

Antimicrobial
therapy plays a
secondary role:
+ Duration of
diarrhea is shorter (~
50%).
+ Less fluid loss.
+ It reduces the
duration of Vibrio
excretion to about
one day.
Tetracyclines is
greatest clinical
experience:
Single dose
doxycycline has been
shown to be as
effective as multiple
doses of tetracycline.
In regions where
tetracycline
resistance is
common,
fluoroquinolones and
macrolides
(azithromycin) are
alternative agents.
TMP-SXT.
Single dose
azithromycin is the
preferred therapy

Pre-exposure
prophylaxis
(vaccination):
Two available
vaccines:
+ WC-rBS
(Dukoral).
+ Modified WConly vaccines
(mORCVAX and
Shanchol).
Post-exposure
prophylaxis: not
generally
accepted.

Wound infections
Bacteremia
9

Aeromonas

Wound infections

Individuals with
underlying liver disease
From a traumatic
injury:
Exposed to
contaminated water
Severe

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Aerobic Gram-Negative Bacilli

Enteritis

Systemic disease
10

Plesiomonas

Intestinal
infection

11

Pseudomonas
aeruginosa

Typical
opportunistic and
nosocomial
pathogen, mainly
in ICUs

12

Acinetobacter
baumannii

Similar to P.
aeruginosa

Burkholderia
pseudomallei

Melioidosis

13

Associated to the use of


medicinal leeches
Diarrhea.
But it is a common
isolate in stool from
asymptomatic
individuals.
Self-limited.
Opportunistic.
Patients with liver
disease.

Respiratory infections:
Pneumonia.
Burns.
UTI
Skin, nails, wounds
Eye
Ear

Most infections are


asymptomatic.
IP: 1 21 days (~9
days).
Pneumonia:

Beta-lactams:
Carbapenems except ertapenem.
Piperacillin
Tazobactam.
Ticarcillin
Clavulanate.
Ceftazidime.
Monobactams
(aztreonam).
Cefepime.
Aminoglycosides
Fluoroquinolones
Colistin
Beta-lactams:
Carbapenems
Except ertapenem
Sulbactam
Piperacillin
Tazobactam
Ticarcillin
Clavulanate
Ceftazidime
Cefepime
Aminoglycosides
Fluoroquinolones
Some tetracyclins
(minocyclin)
Tigecyclin
Rifampin
Polymyxins (B, E)
Melioidosis should
always be treated
with antimicrobials.
It is intrinsically
resistant to many

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Aerobic Gram-Negative Bacilli

The most common


clinical presentation
(~50% of cases).
Acute: Similar to other
bacterial pneumonias.
Subacute or chronic
presentation: Similar to
tuberculosis pneumonia
(cough, purulent sputum
production, hemoptysis,
and night sweats).
Skin ulcers or
abscesses.
Bacteremia: Abscesses
in internal organs.

antimicrobials.
Initial intensive
therapy:
- At least 2 weeks of
intravenous therapy:
+ Ceftazidime OR
+ Meropenem OR
+ Imipenem
WITH or
WITHOUT TMPSXT
Followed by
eradication therapy:
TMP-SXT
WITH or
WITHOUT
Doxycycline

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