Escherichia coli

 Is part of the normal flora of the colon

 Can be pathogenic both within and outside of GI tract
 May be motile or nonmotile in different strain (strain is a genetic variant or subtype of a
microorganism)
 The differences in the degree of virulence of various E. coli strains is correlated with the
acquisition of plasmids, integrated prophages, and pathogenicity islands.
 Most strains can ferment lactose (Lac +)
 E. coli produces both acid and gas during fermentation of carbohydrates

1. Structure and physiology

 They are all facultative anaerobes
 They all lack cytochrome c oxidase (oxidase negative)
 Typing strains is based on differences in three structural antigens: O, H, K.
 The O antigens (somatic or cell wall antigens) are found on the polysaccharide portion of
the LPS. These antigens are heat stable and may be shared among different
Enterobacteriaceae genera. It is commonly used to serologically type many of the
enteric gram-negative rods.
 The H antigens are associated with flagella.
 The K antigens are located within the polysaccharide capsules.
 There are many serologically distinct O, H and K antigens, and specific serotype are associated
with particular diseases. Ex: E. coli O157:H7 causes a severe form of hemorrhagic colitis.

2. Clinical significance: intestinal disease

 Transmission: fecal oral route
 5 types of intestinal infections that differ in pathogenic mechanisms:
 Enterotoxigenic E. coli (ETEC): are commonly cause of traveler’s diarrhea. ETEC colonize
the small intestine (pili facilitate the binding of the organisms to the intestinal mucosa).
In a process mediated by enterotoxin, it causes prolonged hypersecretion of chloride
ions and water by the intestinal mucosal cells, while inhibiting the reabsorption of
sodium, resulting in significance watery diarrhea. Enterotoxin include a heat-stable toxin
(ST) that work by causing an elevation in cellular cGMP levels, whereas a heat-labile
toxin (LT) causes elevates cAMP.
 Enteropathogenic E. coli (EPEC): cause diarrhea in infants, especially in locations with
poor sanitation. The new born becomes infected perinatally. The EPEC attach to
mucosal cells in the small intestine by use of bundle-forming pili (BfpA). Characteristic
lesion in the small intestine called attaching and effacing lesion (A/E), in addition to
destruction of the microvilli, are caused by injection of effector proteins into the host
cell by way of a type III secretion system (T3SS). EPEC are not invasive and do not cause
bloody diarrhea. Toxin are not elaborated by EPEC strains.
 Enterohemorrhagic E. coli (EHEC): bind to cells in large intestine via BfpA, produce A/E
lesions. EHEC produce one of two exotoxins (Shiga-like toxins 1 or 2), resulting in a
 severe form of copious, bloody diarrhea (hemorrhagic colitis) in the absence of mucosal
invasion or inflammation. Serotype O157:H7 is the most common strain that produce
Shiga-like toxins, and also associated with a potential life-threatening, acute renal failure
(hemolytic uremic syndrome, or HUS). Characterized by fever, acute renal failure,
microangiopathic hemolytic anemia and thrombocytopenia in children younger than
ages 5 to 10 years.
 Enteroinvasive E. coli (EIEC): cause a dysentery-like syndrome with fever and bloody
stools. Plasmid-encoded virulence factors are nearly identical to those of shigella
species. These virulence factors allow the invasion of epithelial cell (Ipa) and
intercellular spread by use of actin-based motility. EIEC strains produce a hemolysin
(HIyA). EIEC strains often don’t ferment lactose.
 Enteroaggregative E. coli (EAEC): cause traveler’s diarrhea and persistence diarrhea in
young children. Adherence to the small intestine is mediated by aggregative adherence
fimbriae. It produces a heat-stable toxin that is plasmid-encoded. When EAEC strains
acquired the phage-encoded gene to produce Shiga-like toxin 2 and it capable of tight
adherence to the small intestine, which result in HUS.

3. Clinical significance: extraintestinal disease

 It frequently causes by patience’s own flora.
 Urinary tract infection: uncomplicated cystitis is caused by uropathogenic strains of E. coli,
characterized by P fimbriae (an adherence factor) and, commonly, hemolysin, colicin V, and
resistance to the bactericidal activity of serum compliment. Complicates UTI (pyelonephritis)
may occur in settings of obstructed urinary flow, which may be caused by nonuropathogenic
strains.
 Neonatal meningitis: E. coli is a major cause of this disease occurring within the first month
of life.
 Nosocomial infections

4. Laboratory identification
 Intestinal disease: because E. coli is normally part of the intestinal flora, detection in stool
cultures of disease-causing strains is generally difficult. EIEC strains may be detected on media
such as Mac Conkey agar. EHEC ferment sorbitol slowly, and may be detected on Mac Conkey
agar.
 Extraintestinal disease: specimen may be cultured on Mac Conkey agar.

5. Prevention and treatment

 Maintenance of fluid and electrolyte balance.
 Care in selection, preparation and consumption of food and water
 Antibiotic sensitivity testing of isolates is necessary to determine the appropriate choice of drugs
Gram (-) rods  Short rods
 Facultative anaerobe
Escherichia  Ferment glucose
 Most strains ferment lactose
 Catalase positive
species  Oxidase negative
 Culture on Mac Conkey agar

END
E. Coli, is a gram-negative rod-shaped bacteria named after Dr. Escherich Theodor,
who discovered it in feces, thus concluding that it colonizes the colon.
Alright, now E. Coli is gram-negative because its cell wall has a thin peptidoglycan
layer so it cannot retain the crystal violet stain, but instead, it stains pink with
Safranin dye used during Gram staining.
So it looks like a little pink rod under the microscope.
Also, E. Coli is a catalase positive bacteria, and that means it produces an
enzyme called catalase.
This can be tested by adding a few drops of hydrogen peroxide to a colony of bacteria,
and catalase makes hydrogen peroxide dissociate into water and oxygen, making
the mixture foam.
E. Coli is also a lactose fermenter, because it can produce an enzyme called beta B-
galactosidase that cleaves lactose into glucose and galactose monomers.
To test this, E. Coli can be cultivated on lactose-containing media such as
Phenol lactose, and as it ferments it, the fermentation results in the production
of acids that turn the red of phenol to yellow.
It is also a facultative anaerobe, meaning it lives in environments with or without
oxygen.
Now, taking a closer look to this bacteria, E. Coli is encapsulated, meaning it's covered
by a polysaccharide layer called a capsule.
E. Coli is a motile bacteria, because it has helical whip-like threads called flagella that it
can use to move around.
When E coli is cultivated on eosin methylene blue agar, it grows into black colonies with
a greenish-black metallic sheen.
Alright, most of E. Coli are harmless, and they can peacefully colonize the human gut
without causing any trouble.
However, some strains of E. Coli are pathogenic, meaning they can cause illness. It
starts with this bacteria using little thread-like extensions called fimbriae to attach to
the host cell surface.
E coli has many different strains that can do that, and they cause different diseases.
These strains can be classified by two systems.
The first system uses serotypes, and it groups E. Coli strains based on their antigens.
Antigens are elements that the host’s immunity considers foreign and mount an immune
reaction as a response.
So, bacteria within a given serotype, trigger a similar immune response.
Alright, E. Coli has a number of antigens, and among them we have somatic antigens
located just on the cell membrane, and these ones are abridged with the letter “O”.
There are also capsular – “K” antigens located on the capsule, fimbrial – “F” antigens
located on the fimbria, and flagellar – “H” antigens located on the bacterial flagella.
Usually after this letter that tells on what part of the bacteria where the antigen is found,
it follows a designation number in case there are more antigens of the same kind, such
as K1, K2, and so forth… E. Coli antigens, influence its power to cause diseases, so
that’s why they can alternatively be referred to as virulence factors.
For example, E. Coli with capsular antigen one, or K1, are the ones that cause neonatal
meningitis, while an E. Coli that has an O157, and an H7 – designated as O157:H7, is
associated with hemorrhagic colitis, hemolytic uremic syndrome and diarrheal
outbreaks.
Other E. Coli serotypes include E. Coli SE15, E. Coli F11, E. Coli O25:H and so on…
but in fact, these serotypes are so numerous and they can go up to 200 serotypes.
Thankfully, there’s a much simpler classification, and that is based on pathotypes.
A pathotype is a group of organisms of the same species, that cause disease in the
same way - meaning they use the same virulence factors.
And there are 5 E.Coli pathotypes: Shiga-like toxin-producing E.Coli, or STEC for
short, enterotoxigenic E. Coli or ETEC, enteroinvasive E. Coli, or EIEC,
enteropathogenic E. Coli, or EPEC, and uropathogenic E. coli or UPEC/
So first, Shiga-like toxin-producing E. Coli, or STEC is called that because it makes a
toxin similar to the one called Shiga toxin produced by Shigella.
STEC attaches to the host’s intestinal cells, and then start releasing toxins that cause
injury to intestinal epithelium and underlying blood vessels, resulting in inflammation.
This makes fluid and blood leak into the intestinal lumen, resulting in bloody diarrhea.
That’s why some people refer to it as enterohemorrhagic E. Coli, or EHEC.
But STECs can also affect the urinary tract, causing hemolytic uremic syndrome or
HUS. Hemolytic uremic syndrome usually develops after STEC have released their
toxin into the bloodstream.
From the bloodstream, the toxin can get to the kidneys, and bind to the endothelial cells
lining the glomerulus, making them die by apoptosis, or programmed cell death.
Consequently, a dead endothelial cell leaves a gap in the capillary wall, and as more
gaps keep forming, it results in holes big enough to allow large molecules such as
proteins to start leaking out of the capillaries, resulting in proteinuria.
The destruction of endothelial cells triggers an inflammatory process in which
inflammatory molecules such as cytokines and chemokines are released.
Cytokines and chemokines activate blood platelets and initiate the clot formation.
As these platelets are used to form these clots their number in the blood decreases
resulting in low platelets or thrombocytopenia.
Also these clots can be big enough to obstruct small arterioles.
So, as red blood cells force to pass through obstructed micro-vessels, they can get
sliced into fragments called schistocytes in this process known
as microangiopathic hemolysis.
So, as more red blood cells get destroyed in the process, their number reduces, which
can cause anemia.
Alternatively, if clots obstruct too many arterioles, organs that depend on high blood
flow, like the kidney, may lack blood and die by ischemia.
Now, an ischemic kidney is unable to filter blood. This is how too much of metabolic
wastes such as urea, start accumulating in the blood, leading to uremia.
Then HUS is a combination of hemolytic anemia, when red blood cells are being overly
destroyed, kidney failure due to the destroyed glomerular cells that results in uremia or
high levels of blood urea, and thrombocytopenia, meaning low platelets.
Ok, next up, there’s enterotoxigenic E. Coli or ETEC. After using its fimbriae to attach to
the intestinal mucosa, it starts releasing two types of enterotoxins: heat-
labile enterotoxin, which is easily destroyed by heat, and heat stable enterotoxin which
is not easily destroyed by heat.
Both of these toxins cause intestinal inflammation, which leads to a lot of fluid being
secreted in the intestinal lumen, causing watery diarrhea.
But there’s usually no intestinal wall destruction, and as a result, no bleeding.
In contrast, enteroinvasive E. Coli, or EIEC, attaches to the intestinal epithelium and
then it mechanically destroys and invades the intestinal epithelial cells, and multiplies
intracellularly.
This triggers a widespread destructive inflammatory response in the intestines that may
result in bloody diarrhea
Next up, there’s enteropathogenic E. Coli, or EPEC, and for unknown reasons, this one
almost exclusively causes disease in children under 2 years of age.
EPEC also attaches to the intestinal epithelium and invades the intestinal epithelial
cells.
Then, through an unknown mechanism, it destroys the cell cytoskeleton, which is the
intracellular framework responsible for maintaining the shape of the cell.
This makes the intestinal epithelial cells flatten, which impairs their ability to absorb
water and nutrients, resulting in watery diarrhea.
And lastly, there’s uropathogenic E. coli or UPEC, that causes about 90% of
all community acquired urinary tract infections, or UTIs, and roughly 50% of hospital-
acquired UTIs.
UPEC usually live peacefully in the gastrointestinal tract without causing any harm.
However, if they get out of the colon, like following defecation, and colonize
the perineum, they may ascend from the perineum, up the urethra and reach the urinary
bladder, causing cystitis.
On the urinary epithelium, these bacteria produce alpha- and beta-hemolysins, which
cause lysis of urinary tract cells.
They can also move up the ureters and infect the kidneys, causing pyelonephritis.
Symptoms depend on the disease and the infecting pathotype.
So right off the bat, all pathotypes except for UPEC cause diarrhea, and are associated
with abdominal cramps and vomiting.
With STEC, there’s bloody diarrhea, and there may be a low-grade fever.
If things progress to hemolytic-uremic syndrome, there may be body
swelling, confusion, nausea and vomiting.
In addition to that, there can be paleness of the eyes’ conjunctiva due
to anemia, jaundice that results from buildup of bilirubin that result from hemolysis,
diarrhea and abdominal pain.
With EIEC, there may also be bloody diarrhea, and chills.
With the remaining pathotypes, EPEC, and ETEC, there’s usually non-bloody diarrhea.
EPEC causes severe dehydration in children under 2, and may cause prolonged or
chronic diarrhea, which may lead to malnutrition, or stunted growth.
ETEC causes large amounts of watery diarrhea, and there may also be fever,
and bloating. Finally,
UPEC causes UTI symptoms like dysuria, which is pain during urination, urinary
frequency, and, if the kidney is affected, there may be flank pain.
Now, in general, it’s hard to diagnose an E. Coli serotype or pathotype because it
requires a series of complex tests.
But to diagnose E. Coli in general, Gram-staining can be done on a stool or urine
sample, and cultures on eosin methylene blue agar can be done to confirm the
diagnosis.
HUS can be confirmed by identifying shiga toxin in the blood.
Treatment for diarrhea usually consists of hydration and rest. Antibiotics are not
routinely used, but doxycycline or cotrimoxazole, which is the combination
of Trimethoprim and Sulfamethoxazole can be given in severe cases.
For hemolytic uremic syndrome, supportive care,
including dialysis, corticosteroids, blood transfusions, and plasmapheresis or the
exchange of the affected blood plasma with a new unaffected one from a donor.
UTIs are treated with antibiotics such as cotrimoxazole, nitrofurantoin,
or fluoroquinolones like ciprofloxacin.
Summary
Alright, as a quick recap, Escherichia coli are gram-negative, rod-
shaped, encapsulated, facultative anaerobic, catalase positive, lactose fermenting
bacteria.
Even though some E. Coli might become pathogenic, most of the time they colonize the
gut harmlessly.
The pathogenic E. Coli are classified into four main pathotypes namely; STEC, which
particularly causes hemorrhagic diarrhea, and hemolytic uremic syndrome, ETEC,
which is commonly associated with watery diarrhea, EIEC which causes bloody
diarrhea by mechanically damaging the intestinal epithelium, EPEC which causes
diarrhea in children below 2 years, and finally UPEC which cause most of the UTIs.
E. Coli is usually diagnosed using a gram stain and a microscopic examination followed
by a bacteria culture.
Treatment of diarrhea consists of supportive measures like rehydration, and sometimes
antibiotics are used.
Hemolytic uremic syndrome may require complex treatment measures,
like dialysis, corticosteroids, blood transfusions and plasmapheresis.
UTIs are treated with antibiotics such as cotrimoxazole, nitrofurantoin,
or fluoroquinolones like ciprofloxacin.