ENTEROBACTERIACEAE

Dorothy Claire M. Gonzales lpu-batangas

Enterobacteriaceae
Family Enterobacteriaceae often referred to as ENTERICS
General characteristics:
Gram-negative bacilli or coccobacilli
Non-spore forming
Facultative anaerobes
Ferment glucose
Reduce nitrates to nitrites (as part of their energy-generating
processes)
Oxidase-negative (except for Plesiomonas sp.)

All except Klebsiella, Shigella and Yersinia are motile (peritrichous

flagella)
Epidemiology
Enterics are ubiquitous in nature
Most are present in the GI tract of animals and humans as
commensal flora; therefore, they are sometimes called fecal
coliforms
Some live in water, soil and sewage
As their reservoirs vary, so do their MOT to humans
Patients own bacterial strains establish infection in a normally sterile
site
Ingestion of contaminated food or water
Insect vector/flea bite (Y. pestis)
Clinical Significance
Associated with many clinical infections, including abscesses, pneumonia,
meningitis, septicemia, and urinary tract infections.
Based on clinical infections produced, enterics are divided into two
categories:
Opportunistic pathogens normally part of the usual intestinal flora that may
produce infection outside the intestine
Primary intestinal pathogens Salmonella, Shigella, and Yersinia spp.
Commonly associated with human infections include E. coli, Klebsiella spp.,
Proteus spp., Enterobacter spp., Salmonella spp., Shigella spp., Serratia
spp., Citrobacter spp., and Providencia spp.
Virulence and Antigenic Factors
Ability to colonize, adhere, produce various toxins and invade
tissues
Endotoxins responsible for much of the morbidity and
mortality resulting from infections
Lipopolysaccharides - elicit fever, chills, hypotension,
granulocytosis, thrombocytopenia, DIC, and activation of both
classic and alternate complement pathways.
Endotoxic shock - endotoxin reacts with macrophages,
leukocytes, platelets, complement, and other serum proteins
resulting in pooling of blood & increased peripheral
vasoconstriction, and diminution in cardiac output.
Some possess plasmids that may mediate resistance to
antibiotics
 Many enterics possess antigens that can be used to identify
groups
O antigen somatic, heat-stable antigen located in the cell wall
H antigen flagellar, heat labile antigen
only flagellated organisms, such as Escherichia and Salmonella have H
antigen.
K antigen capsular, heat-labile antigen
K for Kapsel, German for capsule
Prominent in heavily encapsulated species such as Klebsiella
K antigen is identified by the quellung (capsular swelling) reaction
K1 antigen - associated with a high percentage of strains of E. coli causing
neonatal meningitis
Vi (virulence) antigen Salmonella serotype typhi; interfere with
intracellular killing of this organism

Other surface antigens:

Fimbriae mediate adherence of organism to mucosal surfaces
Genera included in this group are:

Budvicia
Buttiauxella
Cedecea
Citrobacter
Edwardsiella
Enterobacter
Escherichia
Ewingella
Hafnia
Klebsiella
Kluyvera
Leclercia
Leminorella
Moellerella
Morganella
Obesumbacterium
Pragia
Pantoea
Photorhabdus
Proteus
Providencia
Rahnella
Salmonella
Serratia
Shigella
Tatumella
Trabulsiella
Xenorhabdus
Yersinia
Yokenella
 Laboratory Diagnosis of Enterics
Collection and Handling
If not processed quickly, should be collected and transported in Cary-Blair, Amies,
or Stuart media
Isolation and Identification
Site of origin must be considered
Enterics from sterile body sites are highly significant
Routinely cultured from stool
 Laboratory Diagnosis of Enterics
Media for Isolation and Identification of Enterics
Most labs use BAP, CA and a selective/differential medium such as MacConkey
On MacConkey, lactose positive are pink; lactose negative are clear and colorless

MacConkey Agar
 Laboratory Diagnosis of Enterics
For stools, highly selective media, such as Hektoen Enteric (HE), XLD, or SS is
used along with MacConkey agar
Identification
Most labs use a miniaturized or automated commercial identification system,
rather than multiple tubes inoculated manually
All enterics are
Oxidase negative
Ferment glucose
Reduce nitrates to nitrites
 Laboratory Diagnosis of Enterics
Common Biochemical Tests
Lactose fermentation and utilization of carbohydrates
Triple Sugar Iron (TSI) - carbohydrate fermentation test
ONPG (Orthonitrophenyl-beta-galactopyranoside)
rapid test to detect slow lactose fermenters
(+) yellow color
(-) no color change
Glucose metabolism
Methyl red
(+) 4.5 pH and below
(-) pH exceeds 4.5
Voges-Proskauer
(+) formation of pink to cherry red color
Triple Sugar Iron Agar (TSI) Test
Results
ONPG Test Results Methyl Red Test Results

P. Vulgaris (Left): ONPG Negative

E. Coli (Right): ONPG Positive

Voges-Proskauer Test Results

A B
(A) E. coli: VP Negative
(B) E. aerogenes: VP Positive
Laboratory
Common Biochemical
Diagnosis Tests Miscellaneous
of Enterics Reactions
Indole
Citrate utilization
Urease production
Motility
Phenylalanine deaminase
Decarboxylase tests
 Laboratory
Diagnosis
of Enterics
INDOLE
Citrate utilization
Urease production
Motility
Phenylalanine
deaminase
Decarboxylase tests

(+) deep red color

 Laboratory
Diagnosis
of Enterics
Indole
CITRATE
UTILIZATION
Urease production
Motility
Phenylalanine
deaminase
Decarboxylase tests

(-) Green (+) Blue

 Laboratory
Diagnosis
of Enterics
Indole
Citrate utilization
UREASE
PRODUCTION
Motility
Phenylalanine
deaminase
Decarboxylase tests
 Laboratory
Diagnosis
of Enterics
Indole
Citrate utilization
Urease production
MOTILITY
Phenylalanine
deaminase
Decarboxylase tests
 Laboratory
Diagnosis
of Enterics
Indole
Citrate utilization
Urease production
Motility
PHENYLALANINE
DEAMINASE
Decarboxylase tests

(+) dark green color after

addition of ferric chloride
Laboratory
Diagnosis
of Enterics
Indole
Citrate utilization
Urease production
Motility
Phenylalanine
deaminase
DECARBOXYLASE
TESTS

(+) purple color (-) yellow color

Amino acids: lysine, arginine, ornithine

MALONATE TEST SULFUR REDUCTION IN SIM
RESULT MEDIUM

Malonate broth inoculated with

Enterobacter aerogenes (+) on
the left and Escherichia coli (-) in
the center. An uninoculated
control is on the right.
On the left is Escherichia coli
(H2Snegative);
on the right is Proteus mirabilis
(H2Spositive).
 Screening Stools for Pathogens
Because stools have numerous microbial flora, efficient screening methods
must be used to recover any pathogens
Enteric pathogens include Salmonella, Shigella, Aeromonas, Campylobacter,
Yersinia, Vibrio, and E. coli 0157:H7
Most labs screen for Salmonella, Shigella, and Campylobacter; many screen
for E. coli 0157:H7
Fecal pathogens are generally lactose-negative (although Proteus,
Providencia, Serratia, Citrobacter and Pseudomonas are also lactose-
negative)
Escherichia
Animal and human intestinal pathogens
Consists of five species:
E. coli - Most significant species in the genus
E. fergusonii
E. hermanii
E. vulneris
E. blattae
Escherichia coli
Recognized as harmless commensal and also as a
versatile pathogen Hemolytic uremic syndrome
(HUS)
Causes a broad spectrum of diseases in humans Serious life-threatening
complication, seen in 10-15%
enteric illness of children with EHEC diarrhea.
urinary tract infection (UTI) Important manifestations: (i)
macroangiopathic hemolytic
neonatal sepsis & neonatal meningitis anemia, (ii) thrombocytopenia,
and (iii) renal insufficiency.
Hemolytic uremic syndrome (HUS) - serious complication Typically develops in the 2ndnd

of enteric infection with certain E. coli strains. week of illness, after recovery
from diarrhea.
Presents with anemia,
weakness, irritability, and
oliguria or anuria.
Chronic renal failure may
develop in 10% of patients
with HUS.
Mortality rate nearly 3-5%.
Stool culture for EHEC is
always negative in patients
Escherichia coli
Morphology
Gram-negative bacilli arranged singly or in pairs
Motile (peritrichous flagella)
Some strains are nonmotile. Some strains of E. coli may be fimbriated. The
fimbriae are of type I (hemagglutinating and mannose-sensitive) and are
present in both motile and nonmotile strains.
Some strains isolated from extraintestinal infections possess polysaccharide
capsule. They do not form any spores.
Escherichia coli
Culture
An aerobe and a facultative anaerobe
Grows at a temperature range of 1040C
(optimum 37C) and a pH of 7.2

Colony Morphology
Nutrient agar: Circular, smooth, greyish-white,
moist, having entire edge with butyrous
consistency
 E. coli

MacConkey medium:
bright pink flat colonies due
BAP: produce beta-hemolytic colonies
to lactose fermentation.
E. Coli on EMB produces a
characteristic green metallic
sheen
 Escherichia coli
BIOCHEMICAL REACTIONS
1. Forms lactose fermenting pink colonies on
MacConkey medium.
2. Produce a zone of hemolysis around colonies on
blood agar.
3. Mostly motile (except EIEC).
4. Ferments lactose, glucose, and other sugars with
production of acid and gas (except sucrose). (IMViC reaction )

5. IMViC reaction (+ + - -)
6. Oxidase negative
Oxidase Test:
o Positive results with this test should appear within 20
seconds. The dark blue is a positive result (left
square).
o No color change is a negative result (right square).
Escherichia coli
CLINICAL SIGNIFICANCE
E. coli is an invasive bacterium.
It colonizes the human intestine and, under specific conditions, directly
invades the intestinal mucosa or produces toxins to cause intestinal
infections.
Enter the blood stream and cause septicemia, meningitis, and other
systemic manifestations
Directly invade urinary tract causing UTIs or cause intra-abdominal
infections

E. coli causes (a) urinary tract infections, (b) gastroenteritis, (c) septicemia,
(d) neonatal meningitis, and (e) other infections.
Urinary Tract Infections
E. coli is the most common bacteria responsible for causing more than
80% of all community-acquired UTI
E. coli cause a wide range of UTIs, including uncomplicated urethritis or
cystitis, symptomatic cystitis, pyelonephritis, acute prostatitis, prostatic
abscess, or urosepsis.
Uncomplicated cystitis occurs primarily in sexually active females who are
colonized by uropathogenic strains of E. coli.
Subsequently, the periurethral region is colonized by E. coli due to fecal
contamination, and the bacteria reach the urinary bladder during sexual
intercourse.
GASTROENTERITIS
TRANSMISSION
ETEC (travelers' diarrhea)
diffusely adherent E. coli
Fecal/oral
EPEC (second most common
infantile diarrhea)
enteropathogenic E. coli
Fecal/oral
EIEC
enteroinvasive E. coli
Fecal/oral
EHEC (VTEC}-0157:H7 most
common
enterohemorrhagic E. coli
Bovine feces, petting zoos
EAEC
enteroaggregative E. coli
Fecal/oral
DAEC
diffusely adherent E. coli
Fecal/oral
CLINICAL CLUES TREATMENT
Sudden onset of watery diarrhea without blood, Rehydration, TMP/
mucus, or fecal leukocytes. SMX may shorten
Vomiting may be present, but most patients symptoms
typically have no fever.
self-limiting condition; persists for less than 5 days
Non inflammatory diarrhea in babies in developing Beta-lactams
countries
Diarrhea and dysentery, similar to shigellosis;
Cause watery diarrhea, dysentery, fever, vomiting,
painful abdominal cramps, and tenesmus;
Stools often contain blood and leukocytes
No fever, no PMNs, blood in stool, nonfermenters of Antibiotics risk of
sorbitol; HUS
May progress to hemorrhagic colitis and HUS; most
common in children <5 years
important cause of food-borne illness, particularly in
developed countries
common microbiological flora of the intestine of
cattle
Watery diarrhea, vomiting, low-grade fever
Infants and children in developing world
Infants to 5 years; noninflammatory diarrhea
SEPTICEMIA
Caused by invasion of blood stream by E. coli

Caused by E. coli strains associated with UTIs or intra-abdominal infections, such as

peritonitis and abscesses following intestinal perforation.

Mortality is high for patients with immunocompromised status, or for patients in whom the
primary infection is in the abdomen or CNS.

NEONATAL MENINGITIS
E. coli is an important cause of meningitis in neonates.

Caused by E. coli strains that possess the KI capsular antigen, which are commonly present
in the gastrointestinal tracts of pregnant women and newborn infants.

In adults, it occurs following neurosurgical procedures, CNS trauma, or complicating

Strongyloides stercoralis hyperinfection involving the CNS.
TREATMENT
Community-acquired infections usually sensitive to commonly used antibiotics
except penicillins.
Hospital-acquired E. coli isolates - show multidrug resistance; Majority of
infections are best treated based on antibiotics susceptibility results.
Treatment of bacterial gastroenteritis is primarily supportive.
Meningitis and pneumonia - Third-generation cephalosporins, such as ceftriaxone
are recommended

PREVENTION & CONTROL The analysis of water used

Availability of safe drinking water for human consumption and
proper food hygiene recreational use is routinely
performed for safety. Water
sanitary disposal of excreta
sources are regularly tested
Cooking ground beef thoroughly for the presence of
(hemorrhagic colitis caused by E. coli O157:H7) Escherichia coli to
determine the quality and
safety of municipal water
supplies
Edwardsiella
Differs from Escherichia by its ability to prodyce H2S
Genus includes E. tarda, the only pathogenic sp. for humans
Inhabits intestines of snakes and other cold-blooded animals
The name tarda refers to slow or weak fermentation of sugars by the
bacteria.
Edwardsiella tarda
Gram-negative bacillus
Non-capsulated
Motile
Has weak fermentative powers

CLINICAL SIGNIFICANCE
An occasional human pathogen isolated from wounds, blood, and CSF in cases of
fatal meningitis
Also isolated from stool of normal healthy people and that of patients with
diarrhea.
Pathogenic role of the bacteria in causation of diarrhea is yet to be established
Edwardsiella tarda
BIOCHEMICAL REACTIONS
Ferments only glucose and maltose with production of acid and some gas
Indole, H2S, and citrate positive
Decarboxylates lysine and ornithine
Citrobacter
Normal inhabitant of the intestine of humans.
Genus Citrobacter consists of three species, namely:
Citrobacter freundii,
Citrobacter amalonaticus, and
Citrobacter koseri (formerly C. diversus).
Show extensive antigenic sharing with salmonellae, hence may be mistaken
for salmonellae.
Certain strains possess a Vi antigen, closely related to the antigen of
Salmonella Typhi and Salmonella Paratyphi.
Citrobacter
CLINICAL SIGNIFICANCE
Citrobacter spp. may cause infections of the urinary tract, gall bladder, and
middle ear and meninges.
Transmission is typically person to person.
C. koseri may occasionally cause meningitis in neonates.
C. freundii associated with nosocomial infections (UTI, pneumonias, and
intraabdominal abscesses)
C. freundii may harbor inducible AmpCgenes that encode resistance to ampicillin
and first gen. cephalosporins.
Citrobacter
CULTURE
They grow well on nutrient agar and other
ordinary media producing smooth and convex
non-pigmented colonies.
On MacConkey: Late LF, producing pale
colonies.
XLD: Red, yellow, or colorless colonies, with or
without black centers

Nutrient Agar
C. diversus on MAC C. freundii on XLD
Citrobacter
BIOCHEM REACTIONS
Citrobacter spp. are motile,
H2S positive,
MR positive,
citrate positive, and
indole variable
Do not decarboxylate lysine, but most strains decarboxylate ornithine.
Ferments lactose late or do not ferment at all.
 Important properties used for differentiation of Citrobacter species

Properties C. freundii C. koseri C. amalonaticus

Indole - + +

H2S production + - -

Acid from salicin - + +

Acid from
- + -
malonate
Acid from
- + -
adonitol
Klebsiella
Based on DNA
Named after Edwin Klebs, who demonstrated the
homology, they have
bacteria for the first time.
been divided into seven
Members of the genus Klebsiella are Gram- species, namely:
negative, rodshaped, nonmotile bacteria, with a Klebsiella pneumoniae
prominent polysaccharide capsule.
Klebsiella ozaenae
Emerge as important agents of nosocomial
Klebsiella
infections
rhinoscleromatis
K. pneumoniae is the most important species of Klebsiella oxytoca
the group to cause infections in humans.
Klebsiella planticola
K. oxytoca and K. rhinoscleromatis have also been Klebsiella terrigena
occasionally associated with human infections.
Klebsiella ornithinolytica
Klebsiella pneumoniae
Friedlanders bacillus
First isolated by Friedlander in 1883, from fatal
cases of pneumonia Quellung (capsular swelling) reaction
Gram-negative, short and straight rods, arranged
singly or in pairs
Nonmotile and non-spore forming
Freshly isolated strains show a well-defined
polysaccharide capsule.
Capsule can be demonstrated by India ink
preparation and Quellungs reaction
Accumulation of extracellular polysaccharides as a
loose slime gives mucoid appearance to Klebsiella
colonies.
Klebsiella pneumoniae
BIOCHEM REACTIONS
lactose-fermenting, urease- positive, and indole-negative organisms;
however, some strains of K. pneumoniae and K. oxytoca are exceptions.
They do not produce hydrogen sulphide, and they are both VP and MR tests
positive.
Klebsiella pneumoniae
CULTURE
grow well on ordinary media, such as nutrient agar and MacConkey agar at
37C, forming large, dome-shaped, mucoid colonies.
MAC: produce lactose-fermenting, mucoid colonies

Klebsiella on MAC
Klebsiella pneumoniae
CLINICAL SIGNIFICANCE
Klebsielleae organisms cause a variety of clinical syndromes in humans. These
are:
a. community-acquired pneumonia - serious condition with a rapid onset and often
fatal outcome despite early and appropriate antimicrobial treatment
b. UTI - common problem in patients with indwelling catheters
c. nosocomial infections - UTI, pneumonia, bacteremia, wound infection, cholecystitis,
and catheter-associated bacteriuria; Other rare nosocomial infections include
cholangitis, meningitis, endocarditis, and bacterial endophthalmitis.
d. Bacteremia and sepsis
In neonatal units, outbreaks of infection caused by extended-spectrum beta-lactamase (ESBL)-
producing Klebsiella strains present a more serious problem and may be associated with high
mortality.
ESBL strains of Klebsiella show the following features: (a) these are highly virulent, (b) they
possess capsular type K55 antigen, and (c) they have an extraordinary ability to spread.
 Diagnosis of K. pneumoniae infection is made by isolation of bacteria from
clinical specimens obtained from possible sites (e.g., wounds, peripheral or
central intravenous access sites, urinary catheters, respiratory support
equipment) and by culture.
Klebsiella organisms may also be isolated from urine, blood, pleural fluid,
and wounds.
Klebsiella ozaenae
Causes Ozena, a chronic atrophic rhinitis characterized by necrosis of nasal
mucosa and mucopurulent nasal discharge
often occurs in elderly persons
Trimethoprim and sulfamethoxazole are used for treatment of ozena.
Klebsiella oxytoca
rarely isolated from clinical specimens
associated with neonatal bacteremia, especially among premature infants
and in neonatal intensive care units
Important properties used for differentiation of Klebsiella species
Enterobacter
genus Enterobacter includes 12 species
Enterobacter cloacae and Enterobacter aerogenes, followed by Enterobacter
sakazakii are the most frequently isolated species causing human infections
(nosocomial infections).
Other species rarely associated with human infections include: Enterobacter
asburiae, Enterobacter gergoviae, Enterobacter taylorae, and Enterobacter
hormaechei.

Gram-negative bacilli
Aerobic and facultatively anaerobic
Enterobacter
CULTURE
Sheep blood agar: produces large,
gray, and dry or mucoid colonies
MAC: lactose-fermenting pink
colonies, may be mucoid

Enterobacter cloacae on MAC

Enterobacter
BIOCHEMICAL REACTIONS
ferment glucose with production of acid.
Motile
Urease negative
ornithine decarboxylase-positive
Enterobacter
CLINICAL SIGNIFICANCE
opportunistic pathogens
rarely cause disease in otherwise healthy people
Cause frequent and severe nosocomial infections, such as UTIs, lower respiratory
tract infections, skin and soft tissue infections, bacteremia, endocarditis,
intraabdominal infections, septic arthritis, and osteomyelitis.
These infections are associated with:
prolonged hospitalization,
use of a variety of different surgical and nonsurgical procedures, and
use of recent and expensive antimicrobial agents.
Enterobacter
infection management is complicated by multiple antibiotic resistances shown by
the bacteria.
The sources of infection may be endogenous or exogenous.
endogenous sources - originate from the skin, gastrointestinal tract, or urinary tract
colonized by the bacteria.
Exogenous sources - hands of medical personnel, intravenous solutions, endoscopes,
blood products, devices for monitoring intraarterial pressure, and stethoscopes

TREATMENT
Carbapenems, fourth-generation cephalosporins, aminoglycosides, new
quinolones, and trimethoprimsulfamethoxazole (TMPSMX) are the most
frequently used antibiotics against Enterobacter infections
Hafnia alvei
the only species of the genus Hafnia
found in human and animal feces, sewage, soil, and water

CLINICAL SIGNIFICANCE
bacteria have been isolated from abscesses, wounds, sputum, urine, blood, and
from other sites, but often with other bacteria.
The pathogenic role of H. alvei is yet to be established
Hafnia alvei
BIOCHEMICAL REACTIONS
motile
does not ferment lactose, raffinose, sucrose,
adonitol, dulcitol, and inositol.
indole and MR negative
VP and citrate positive.

Biochemical reactions are better read on

incubation at 22C than at 37C

Hafnia alvei on MAC

Serratia
Gram-negative bacteria
Serratia marcescens is the only pathogenic species causing human
infection.
Serratia marcescens
The species name marcescens is derived from the Latin word meaning
decaying due to fast-deteriorating nature of the bloody pigment produced
by the bacteria
Opportunistic pathogen
Some strains typically produce a nondiffusible pigment called
PRODIGIOSIN, which varies in color from dark red to pink or magenta,
depending on the age of the colonies
Usually grows on starchy foodstuffs, where the production of pigmented
colonies is easily mistaken for drops of blood
pleomorphic with minute coccobacillary and normal bacillary forms.
Serratia marcescens ONPG Test Results

BIOCHEMICAL REACTIONS
motile
slow LF
DNase and ONPG positive

DNase (+) DNase (-)

Serratia marcescens
CULTURE
MAC: Late LF, may be red pigmented,
especially if plate is left at 25C

S. marcescens on
nutrient agar
Serratia marcescens
CLINICAL SIGNIFICANCE
usually colonizes the respiratory and urinary tracts of adult patients
responsible for nearly 2% of nosocomial infections of the urinary tract, lower
respiratory tract, surgical wounds, blood, and skin and soft tissues of these
patients.
Associated with outbreaks of meningitis, wound infections, and arthritis in
pediatric wards, and in the intensive care units
also causes endocarditis and osteomyelitis in people addicted to intravenous
drugs, such as heroin
TREATMENT
S. marcescens is sensitive to amikacin and quinolones but is resistant to
gentamicin and tobramycin
Naturally resistant to ampicillin, macrolides, and first-generation cephalosporins
Proteus
The name Proteus (after the Greek god Proteus who could assume any shape) refers to
their property of pleomorphism
Opportunistic pathogens, responsible for urinary and hospital-acquired infections
widely distributed as saprophytes in nature
commonly found in sewage, in manure soil, in human and animal feces, and in decomposing
animal products
most commonly found as part of normal human intestinal flora, along with E. coli and
Klebsiella species

Gram-negative and noncapsulated coccobacilli arranged as single, in pairs, or in short chains

Many of them form long, curved, and filamentous forms in young cultures.
Most of them, with few exceptions, are motile due to the presence of peritrichous flagella.
They are fimbriated.
Proteus
Genus Proteus has four species:
1. Proteus mirabilis most important, causes 90% of Proteus infections, associated with
community-acquired urinary tract and wound infection.
2. Proteus vulgaris
3. Proteus penneri, and
4. Proteus myxofaciens

P. vulgaris and P. penneri are usually associated with hospital-acquired

infections. They are isolated from patients with chronic debilitating diseases
and from those who are immunocompromised.
Proteus
CULTURE
Aerobic bacteria, which grow well on ordinary media,
such as nutrient agar.
Emit a characteristic chocolate cake or burnt
chocolate smell
Swarming: P. mirabilis and P. vulgaris typically spread
or swarm on surface of the medium. They spread on
the surface of the plate in successive waves to form a
thin filmy layer in concentric circles.
Swarming does not occur on MacConkey medium, on
which Proteus produces colorless nonlactose-
fermenting colonies
bile salts present in the MacConkey medium inhibit Swarming of Proteus on
the swarming blood agar
Proteus
BIOCHEMICAL REACTIONS
ferment glucose with production of acid only
urease and PPA positive
do not ferment lactose, mannitol, mannose, inositol, adonitol, dulcitol, sorbitol,
raffinose, and arabinose
reduce nitrate to nitrite but do not utilize malonate
do not decarboxylate amino acids, such as lysine or arginine
show variable reactions in the production of hydrogen sulfide and indole.
P. mirabilis is indole negative, while P. vulgaris is indole positive.
Proteus
CLINICAL SIGNIFICANCE
Patients with multiple antibiotic treatments, urinary tract obstruction, or infection
developing after catheterization or instrumentation frequently become infected with
Proteus spp.
Proteus species cause:
a) urinary tract infections - most common clinical manifestation of Proteus infections
b) hospital-acquired infections - usually transmitted from attending doctors or other healthcare
workers and are caused by interruption of the closed sterile system by hospital staff
c) other miscellaneous infections:
wound infections
infection of the umbilical stump in neonates, which often leads to sepsis neonatorum, bacteremia, and
meningitis
nonclostridial anaerobic myonecrosis, a condition which involves subcutaneous tissue, fascia, and
muscle
Gram-negative endotoxin-induced sepsis, resulting in systemic inflammatory response syndrome
Proteus
TREATMENT
The choice of a specific antimicrobial agent depends on antibiotics susceptibility
patterns of isolated strains.
P. mirabilis is susceptible to nearly all antimicrobials except tetracycline.
P. vulgaris and P. penneri are sensitive to trimethoprim and sulfamethoxazole,
quinolones, imipenem, aminoglycosides, and fourth-generation cephalosporins.
They are resistant to ampicillin and first-generation cephalosporins.

PREVENTION
Hand washing holds the key to prevent transmission from patient to patient via
medical personnel.
Morganella
The genus Morganella has only one species, Morganella morganii with two
subspecies, morganii and sibonii

Morganella morganii
small, Gram-negative, motile bacilli
do not produce swarming on the solid media
facultative anaerobes
nonencapsulated
Morganella morganii
BIOCHEMICAL REACTIONS
oxidase negative
catalase and indole positive
ferments glucose and mannose, but not lactose
decarboxylate ornithine
hydrolyze urease
reduce nitrates
do not liquefy gelatin
do not produce hydrogen sulfide

M. morganii on nutrient agar

Morganella morganii
CLINICAL SIGNIFICANCE
commonly found in human and animal feces and rarely causes severe invasive
diseases
opportunistic pathogen in patients who are hospitalized, particularly those on
prolonged
antibiotic therapy
causes UTIs, which are often associated with an alkaline urine pH
occasionally reported to cause sepsis, pneumonia, wound infections, pericarditis,
chorioamnionitis, endophthalmitis, empyema, spontaneous bacterial peritonitis,
and CNS infections
Morganella morganii
TREATMENT
Nosocomial M. morganii strains are usually susceptible to cefepime, imipenem,
meropenem, piperacillin, aminoglycosides, and fluoroquinolones.
These have also shown resistance to ceftazidime and other third-generation
cephalosporins.
ESBL-producing strains of M. morganii have been reported recently.
Providencia
Gram-negative, motile bacilli but do not show swarming on solid media
produce a fruity smell
consists of five species:
1. Providencia stuartii
2. Providencia rettgeri
3. Providencia alcalifaciens
4. Providencia rustigianii
5. Providencia heimbachae
Providencia
CLINICAL SIGNIFICANCE
isolated from urine, stool, and blood, as well as from the throat, perineum,
axilla, and wounds from humans
Most commonly associated with urinary tract infections and the feces of
children with diarrhea
P. alcalifaciens, P. rettgeri, and P. stuartii also may cause invasive diarrhea.
These species are emerging as important causes of travelers diarrhea in
adults.
May be associated with nosocomial outbreaks
No clear clinical association exists when these organisms are isolated
Providencia
CULTURE
On DCA form yellow to orange
colonies
MAC: NLF

P. stuartii on MAC
Providencia
BIOCHEM REACTIONS
deaminate phenylalanine
only P. rettgeri hydrolyses urea consistently
Providencia
TREATMENT
Antibiotics susceptibility testing is useful for treatment with suitable antibiotics,
because many Providencia species show resistance to multiple antibiotics.
P. stuartii is the most resistant species.
P. alcalifaciens and P. rustigianii are usually susceptible to antibiotics. They
usually are susceptible to fluoroquinolones, aminoglycosides, late-generation
cephalosporins, aztreonam, carbapenems and TMPSMX.
Salmonella
Gram-negative rods (Enterobacteriaceae)
Non-lactose fermenters
Motile
More than 2,400 serotypes of salmonellae Species of Medical Importance
S. enterica subsp. typhi
Salmonellae are named by genus (Salmonella), S. enterica subsp. enteritidis
species (enterica), and subspecies (e.g., typhi or
S. enterica subsp. typhimurium
enteritidis)
S. enterica subsp. choleraesuis
S. enterica subsp. paratyphi
GROUPS S. enterica subsp. Dublin
S. dysenteriae (Group A)
S. flexneri (Group B)
S. boydii (Group C)
S. sonnei (Group D)
Salmonella
CLINICAL SIGNIFICANCE
Cause enterocolitis, enteric fevers such as typhoid fever, and septicemia
with metastatic infections such as osteomyelitis.
S. Typhi causes typhoid fever
S. Paratyphi A, Salmonella Schottmuelleri (formerly S. Paratyphi B), and
Salmonella Hirschfeldii (formerly S. Paratyphi C) cause a mild form of this
disease referred to as paratyphoid fever.
The term enteric fever includes both typhoid and paratyphoid fever caused
by these Salmonella spp.
Widal test
the traditional serologic test used for the diagnosis of typhoid fever.
measures agglutinating antibodies against flagellar (H) and somatic (O) antigens of S. Typhi for typhoid and paratyphoid
bacilli in the patients sera.
Salmonella enterica Subsp. typhi
DISTINGUISHING FEATURES
Gram-negative rods, highly motile with the Vi capsule
Facultative anaerobe, non-lactose fermenting
Produces H2S
Species identification with biochemical reactions
Sensitive to acid
RESERVOIR
Humans only; no animal reservoirs
TRANSMISSION
Fecal-oral route from human carriers (gall bladder)
Decreased stomach acid or impairment of mononuclear cells such as in
sickle cell disease predisposes to Salmonella infections
Salmonella enterica Subsp. typhi
PATHOGENESIS AND DISEASE
Typhoid fever (enteric fever), S. typhi (milder form: paratyphoid fever; S.
paratyphi)
Organism ingested (requires large number if stomach acid is normal)
Infection begins in ileocecal region; constipation common
Host cell membranes "ruffle" from Salmonella contact.
Salmonella reach basolateral side of M cells, then mesenteric lymph nodes
and blood (transient l ' septicemia)
At 1 week: patients have 80% positive blood cultures; 25% have rose spots
(trunk/abdomen)
Liver and spleen are infected with additional release of bacteria to bloodstream
signs of septicemia (mainly fever).
Salmonella enterica Subsp. typhi
S. typhi survives intracellularly and replicates in macrophages; resistant to
macrophage killing due to:
o Decreased fusion of lysosomes with phagosomes
o Defensins (proteins) allow it to withstand oxygen-dependent and oxygen-independent killing.
Released from the macrophages; the Vi capsular antigen (S. typhi only) withstands
complement-mediated killing.
Biliary system (liver, gallbladder) is infected, organisms enter intestinal tract in bile.
By week 3: 85% of stool cultures are positive.
Symptoms: fever, headache, abdominal pain, constipation more commonthan diarrhea
Complications if untreated: necrosis of Peyer patches with perforation
(local endotoxin triggered damage), thrombophlebitis, cholecystitis,
pneumonia, abscess formation, etc.
Salmonella enterica Subsp. typhi
DIAGNOSIS
organisms can be isolated from blood, bone marrow, urine, and tissue
biopsy from the rose spots if present.
TREATMENT
fluoroquinolones or third-generation cephalosporins
PREVENTION
Sanitation
Three vaccines:
1. attenuated oral vaccine of S. typhi strain 2 1 (Ty2 1 a),
2. parenteral heat-killed S. typhi (no longer used in the U.S.), and
3. parenteral ViCPS polysaccharide capsular vaccine
S. enteritidis, S. typhimurium
DISTINGUISHING FEATURES
Facultative gram-negative rods, non-lactose-fermenting on EMB, MacConkey
medium
Produces H2S, motile (unlike Shigella)
Speciated with biochemical reactions and serotyped with 0, H, and Vi antigens
Antibodies to 0, Vi, and H antigens in patient's serum can be detected by
agglutination (Widal test)
RESERVOIR
enteric tracts of humans and domestic animals, e.g., chickens and turtles
TRANSMISSION
Largely through chicken products (raw chicken and eggs) in the kitchen
Reptile pets--snakes, turtles
S. enteritidis, S. typhimurium
PATHOGENESIS
Sensitive to stomach acid (infectious dose 1 05 organisms)
Lowered stomach acidity (antacids or gastrectomy) increases risk.
Endotoxin in cell wall; no exotoxin
Invades the mucosa in the ileocecal region, invasive to lamina propria
inflammation increased PG increased cAMP loose diarrhea; shallow
ulceration
Spread to septicemia not common with S. enterica subsp. enteritidis (the most
common) but may occur with others
S. enteritidis, S. typhimurium
DISEASE(S)
Enterocolitis/ gastroenteritis
Second most common bacterial cause after Campylobacter: 6--48 hour incubation;
nausea; vomiting; only occasionally bloody, loose stools; fever; abdominal pain;
myalgia; headache
Septicemia
S. enterica subsp. choleraesuis, S. enterica subsp. paratyphi, and S. enterica
subsp. dublin
When it occurs, it is usually in very young or elderly.
Endocarditis or arthritis complicates about 10% of cases.
Osteomyelitis
Sickle cell disease predisposes to osteomyelitis. Salmonella is the most common
causal agent of osteomyelitis in sickle cell disease (not trait) patients (>80%).
S. enteritidis, S. typhimurium
DIAGNOSIS
culture on Hektoen agar, H2S production
TREATMENT
For gastroenteritis self-limiting, antibiotics are contraindicated
For invasive disease, ampicillin, third-generation cephalosporins,
fluoroquinolones, or TMP-SMX
PREVENTION
properly cook foods and wash hands, particularly food handlers
Salmonella
CULTURE
aerobic and facultatively anaerobic
grow at an optimum temperature of
37C in a pH of 68
Nonselective solid media:
On nutrient agar and blood agar,
Salmonella spp. produce gray white
moist colonies with smooth convex
surface after 1824 hours of
incubation.
S. typhimurium on nutrient agar
On MacConkey agar, they produce
pale colorless colonies because they do
not ferment lactose.
Salmonella
Selective solid media:
Wilson and Blairs bismuth sulfite
agar - medium of choice for
Salmonella spp.
produce jet black colonies surrounded by
a metallic sheen due to production of
hydrogen sulphide
S. Paratyphi A and other species, which
do not produce H S, form green colonies.
2

Salmonella typhimurium on BSA

Salmonella enterica on XLD agar

XLD produce pink colonies with black centers

as a result of H2S production.
- H2S-negative Salmonella serotypes produce
red colonies without black centers.
SALMONELLA ENTERITIDIS ON SS AGAR
Presence of black colonies due to reaction of H2S
(fromsulfur reduction) and ferric citrate in the
medium
Biochemical reactions of common
Salmonella spp.
Shigella
DISTINGUISHING FEATURES
Gram-negative rods, nonmotile
Identified by biochemical reactions or by serology with anti-0 antibody in
agglutination test
RESERVOIR - human colon only (no animal carriers)
TRANSMISSION - fecal-oral spread, person to person
PATHOGENESIS
Endotoxin triggers inflammation.
Shiga toxin:
Produced by S. dysenteriae, type 1
Three activities: neurotoxic, cytotoxic, enterotoxic
CULTURE
Mac: NLF; S. sonnei
produces flat colonies with
jagged edges
HE: Green
XLD: Colorless

SALMONELLA TYPHI ON SALMONELLA-

SHIGELLA AGAR
Note the absence of black in the colonies
due to weak (or lack of) sulfur reduction to
H2S.

S. sonnei on MAC
Shigella
DISEASE(S)
Enterocolitis/shigellosis (most severe form is dysentery)
Few organisms required to start infection ( 1-10) (extremely acid resistant)
1-4 day incubation
Organisms invade, producing bloody diarrhea.
Fever (generally > 10 l.0F); lower abdominal cramps; tenesmus; diarrhea first
watery, then bloody; invasive but rarely causes septicemia; shallow ulcers
Severity depends on the age of patient and the strain; S. dysenteriae type 1 with
toxin most severe
Shigella
TREATMENT
Mild cases: fluid and electrolyte replacement only
Severe cases: antibiotics
Resistance is mediated by plasmid-encoded enzymes.
Many strains are ampicillin resistant.
PREVENTION
proper sanitation (sewage, clean drinking water, hand washing)
Yersinia
GENUS FEATURES
Gram-negative rods
Enterobacteriaceae
SPECIES OF MEDICAL IMPORTANCE
Yersinia pestis
Yersinia enterocolitica
Yersinia pestis
Small gram-negative rods with bipolar staining
Facultative intracellular parasite
Coagulase positive

RESERVOIR
Zoonosis
U.S. desert southwest: rodents (e.g., prairie dogs, chipmunks, squirrels)
Potential biowarfare agent
TRANSMISSION
Wild rodents flea bite ---7 sylvatic plague
Human-to-human transmission by respiratory droplets
Yersinia pestis
DISEASES
Bubonic plague
Flea bites infected animal and then later uninfected human
Symptoms
Rapidly increasing fever
Regional buboes
Conjunctivitis
Leads to septicemia and death if untreated
Pneumonic plague
Arises from septic pulmonary emboli in bubonic plague or inhalation of organisms from
infected individual
Highly contagious!
Yersinia pestis
DIAGNOSIS
Clinical specimens and cultures are hazardous.
Serodiagnosis or direct immunofluorescence
"Safety pin'' staining
TREATMENT - aminoglycosides
PREVENTION
Animal control; avoid sick and dead animals.
Killed vaccine (military)
Yersinia enterocolitica
Motile at 25.0C, nonmotile at 37.0C
Cold growth

RESERVOIR zoonotic

TRANSMISSION
Unpasteurized milk, pork
Prominent in northern climates (Michigan, Scandinavia)
Yersinia enterocolitica
DISEASE(S)
Enterocolitis
Presentations may vary with age
Very young: febrile diarrhea (blood and pus)
Older kids/young adults: pseudoappendicitis (also caused by Yersinia pseudo
tuberculosis)
Adults: enterocolitis with postinfective sequelae like reactive arthritis
Blood transfusion - associated infections

TREATMENT
Usually supportive care
For immunocompromised: fluoroquinolones or third-generation cephalosporins
Yersinia
CULTURE
Mac: NLF; may be colorless to peach
HE: Salmon
XLD: Yellow or colorless

Y. enterocolitica on MAC

Y. enterocolitica on XLD
Y. enterocolitica on CIN (white arrowhead)

Bulls eye (arrow) colony of Y.

enterocolitica on CIN agar