SHIGELLA

Enterocolitis caused by Shigella is often called bacillary dysentery. The term dysentery refers to bloody diarrhea.
Important Properties
Shigellae are non–lactose-fermenting, gram-negative rods that can be distinguished from salmonellae by three criteria:
1. they produce no gas from the fermentation of glucose,
2. they do not produce H2S, and
3. they are nonmotile.
All shigellae have O antigens (polysaccharide) in their cell walls, and these antigens are used to divide the genus into
four groups: A, B, C, and D.

Pathogenesis & Epidemiology

Shigellae are the most effective pathogens among the enteric bacteria. They have a very low ID50. Ingestion of as few
as 100 organisms causes disease, whereas at least 105 V. cholerae or Salmonella organisms are required to produce
symptoms. Shigellosis is only a human disease (i.e., there is no animal reservoir). The organism is transmitted by the
fecal–oral route. The four Fs—fingers, flies, food, and feces—are the principal factors in transmission. Foodborne
outbreaks outnumber waterborne outbreaks by 2 to 1. Outbreaks occur in day care nurseries and in mental hospitals,
where fecal–oral transmission is likely to occur. Children younger than 10 years account for approximately half of
Shigella-positive stool cultures. There is no prolonged carrier state with Shigella infections, unlike that seen with S.
typhi infections. Shigellae, which cause disease almost exclusively in the gastrointestinal tract, produce bloody diarrhea
(dysentery) by invading the cells of the mucosa of the distal ileum and colon. Local inflammation accompanied by
ulceration occurs, but the organisms rarely penetrate through the wall or enter the bloodstream, unlike salmonellae.
Although some strains produce an enterotoxin (called Shiga toxin), invasion is the critical factor in pathogenesis. The
evidence for this is that mutants that fail to produce enterotoxin but are invasive can still cause disease, whereas
noninvasive mutants are nonpathogenic. Shiga toxins very similar to those produced by Shigella are produced by
enterohemorrhagic E. coli O157:H7 strains that cause enterocolitis and HUS.

Clinical Findings
After an incubation period of 1 to 4 days, symptoms begin with fever and abdominal cramps, followed by diarrhea,
which may be watery at first but later contains blood and mucus. The disease varies from mild to severe depending on
two major factors:
- the species of Shigella and
- the age of the patient, with young children and elderly people being the most severely affected.
Shigella dysenteriae, which causes the most severe disease, Shigella sonnei, which causes mild disease. The diarrhea
resolves in 2 or 3 days; in severe cases, antibiotics can shorten the course. Serum agglutinins appear after recovery but
are not protective because the organism does not enter the blood. The role of intestinal IgA in protection is uncertain.

Laboratory Diagnosis
Shigellae form non–lactose-fermenting (colorless) colonies on MacConkey’s or EMB agar. On TSI agar, they cause an
alkaline slant and an acid butt, with no gas and no H2S. Shigella appears as clear or green colonies on a media such as
Hektoen enteric (HE) agar, whereas Salmonella appears black as a result of production of H2S. Confirmation of the
organism as Shigella and determination of its group are done by slide agglutination. One important adjunct to
laboratory diagnosis is a methylene blue stain of a fecal sample to determine whether neutrophils are present. If they
are found, an invasive organism such as Shigella, Salmonella, or Campylobacter is involved rather than a toxin-
producing organism such as V. cholerae, E. coli, or Clostridium perfringens. (Certain viruses also cause diarrhea without
neutrophils in the stool.)

Treatment
Fluid and electrolyte replacement. In mild cases, no antibiotics. In severe cases, a fluoroquinolone (e.g., ciprofloxacin) is
the drug, but plasmids conveying multiple drug resistance is high enough that antibiotic sensitivity tests must be
performed. Trimethoprimsulfamethoxazole is an alternative choice. Antiperistaltic drugs are contraindicated in
shigellosis, because they prolong the fever, diarrhea, and excretion of the organism.

Prevention
Is dependent on interruption of fecal–oral transmission by proper sewage disposal, chlorination of water, and personal
hygiene (handwashing by food handlers). There is no vaccine, and prophylactic antibiotics are not recommended.

VIBRIO
Vibrio cholerae causes cholera. Vibrio parahaemolyticus causes diarrhea associated with eating raw or improperly
cooked seafood. Vibrio vulnificus causes cellulitis and sepsis.
Important Properties
Vibrios are curved, comma-shaped, gram-negative rods. V. cholerae is divided into two groups according to the nature
of its O cell wall antigen. Members of the O1 group cause epidemic disease, whereas non-O1 organisms either cause
sporadic disease or are nonpathogens. The O1 organisms have two biotypes, called classic and El Tor, and three
serotypes, called Ogawa, Inaba, and Hikojima. (Biotypes are based on differences in biochemical reactions, whereas
serotypes are based on antigenic differences.) These features are used to characterize isolates in epidemiologic
investigations. Serogroup O139 organisms, which caused a major epidemic in 1992, are identified by their reaction to
antisera to the O139 polysaccharide antigens (O antigen).
Vibrio parahaemolyticus and V. vulnificus are marine organisms; they live primarily in the ocean, especially in warm salt
water. They are halophilic (i.e., they require a high NaCl concentration to grow).

1. Vibrio cholerae
Pathogenesis
Vibrio cholerae is transmitted by fecal contamination of water and food, primarily from human sources. Human
carriers are asymptomatic. The main animal reservoirs are marine shellfish, such as shrimp and oysters. Ingestion of
these without adequate cooking can transmit the disease. The pathogenesis of cholera is dependent on colonization of
the small intestine by the organism and secretion of enterotoxin. For colonization to occur, large numbers of bacteria
must be ingested because the organism is particularly sensitive to stomach acid. Persons with little/no stomach acid,
such as those taking antacids or those who have had gastrectomy, are much more susceptible.
Adherence to the cells of the brush border of the gut, which is a requirement for colonization, is related to secretion of
the bacterial enzyme, mucinase, which dissolves the protective glycoprotein coating over the intestinal cells. After
adhering, the organism multiplies and secretes an enterotoxin called choleragen (cholera toxin). This exotoxin can
reproduce the symptoms of cholera even in the absence of the Vibrio organisms. Choleragen consists of an A (active)
subunit and a B (binding) subunit. The B subunit, which is a pentamer composed of five identical proteins, binds to a
ganglioside receptor on the surface of the enterocyte. The A subunit is inserted into the cytosol, where it catalyzes the
addition of ADP-ribose to the Gs protein (Gs is the stimulatory G protein). This locks the Gs protein in the “on”
position, which causes the persistent /activation of adenylate cyclase resulting an overproduction of cyclic AMP that
activates AMP-dependent protein kinase, an enzyme that phosphorylates ion transporters in the cell membrane,
resulting in the loss of water and ions from the cell. The watery efflux enters the lumen of the gut, resulting in a
massive watery diarrhea that contains neither neutrophils nor red blood cells.
Morbidity and death are due to dehydration and electrolyte imbalance. However, if treatment is instituted promptly,
the disease runs a self-limited course in up to 7 days. Non-O1 V. cholerae is an occasional cause of diarrhea associated
with eating shellfish obtained from the coastal waters.

Clinical Findings
Watery diarrhea in large volumes is the hallmark of cholera. There are no red blood cells or white blood cells in the
stool. Rice-water stool is the term often applied to the nonbloody effluent. There is no abdominal pain, only
dehydration. The loss of fluid and electrolytes leads to cardiac and renal failure. Acidosis and hypokalemia also occur as
a result of loss of bicarbonate and potassium in the stool. The mortality rate without treatment is 40%.

Laboratory Diagnosis
Most of the Vibrio species require salt for growth and therefore specialized media, such as thiosulfate citrate bile salts
sucrose (TCBS) agar or tellurite-taurocholategelatin are used. Most of the Vibrio species will grow on blood agar and
may appear β-hemolytic, but poor growth is seen on MacConkey agar. Vibrio cholerae appear as yellow colonies, and
V. parahaemolyticus and V. vulnificus appear as green colonies on TCBS agar.
For diagnosis of sporadic cases in this country, a culture of the diarrhea stool containing V. cholerae will show colorless
colonies on MacConkey’s agar because lactose is fermented slowly. The organism is oxidase-positive, which
distinguishes it from members of the Enterobacteriaceae. On TSI agar, an acid slant and an acid butt without gas or H2S
are seen because the organism ferments sucrose. A presumptive diagnosis of V. cholerae can be confirmed by
agglutination of the organism by polyvalent O1 or non-O1 antiserum.

Treatment
Treatment consists of prompt, adequate replacement of water and electrolytes orally or intravenously. Glucose is
added to the solution to enhance the uptake of water and electrolytes. Antibiotics such as tetracycline are not
necessary, but they do shorten the duration of symptoms and reduce the time of excretion of the organisms.

Prevention
Mainly by public health measures that ensure a clean water and food supply. There are two oral vaccines.
1. One, called Dukoral, contains killed whole cells of the O-1 strain plus recombinant cholera toxin subunit B.
Antibodies induced by the vaccine prevent ingested V. cholerae from attaching to the intestinal mucosa and
neutralize any cholera toxin that is produced.
2. The second vaccine is a killed whole cell vaccine called Shanchol. It contains both O-1 and O-159 strains and
was reported to be very effective in field trials in 2014. The injectable killed vaccine is no longer in use.
The use of tetracycline for prevention is effective in close contacts but does not prevent the spread of a major
epidemic. Prompt detection of carriers is important in limiting outbreaks.
2. Vibrio parahaemolyticus
Vibrio parahaemolyticus is a marine organism transmitted by ingestion of raw or undercooked seafood, especially
shellfish such as oysters. It is a major cause of diarrhea in Japan, where raw fish is eaten in large quantities, several
outbreaks have occurred aboard cruise ships in the Caribbean. Enterotoxin similar to choleragen is secreted and limited
invasion sometimes occurs. The clinical picture caused by V. parahaemolyticus varies from mild to quite severe watery
diarrhea, nausea and vomiting, abdominal cramps, and fever. The illness is selflimited, lasting about 3 days. Vibrio
parahaemolyticus is distinguished from V. cholerae mainly on the basis of growth in NaCl: V. parahaemolyticus grows in
8% NaCl solution (as befits a marine organism). Disease can be prevented by proper refrigeration and cooking of
seafood.

3. Vibrio vulnificus
Vibrio vulnificus is also a marine organism (i.e., it is found in warm salt waters such as the Caribbean Sea). It causes
severe skin and soft tissue infections (cellulitis), especially in shellfish handlers, who often sustain skin wounds. It can
also cause a rapidly fatal septicemia in immunocompromised people who have eaten raw shellfish containing the
organism. Hemorrhagic bullae in the skin often occur in patients with sepsis caused by V. vulnificus. Chronic liver
disease (e.g., cirrhosis) predisposes to severe infections. The recommended treatment is doxycycline.

CAMPYLOBACTER
Enterocolitis especially in children. C. jejuni infection is a common factor to Guillain-Barre syndrome. Other
Campylobacter species are rare causes of systemic infection, particularly bacteremia.

Important Properties
Campylobacters are curved, gram-negative rods that appear either comma- or S-shaped. They are microaerophilic,
growing best in 5% oxygen rather than in the 20% present in the atmosphere. C. jejuni grows well at 42°C, whereas
Campylobacter intestinalis (Also known as Campylobacter fetus subsp. fetus) does not—an observation that is useful in
microbiologic diagnosis.

Pathogenesis & Epidemiology

Domestic animals such as cattle, chickens, and dogs serve as a source of the organisms for humans. Transmission is
usually fecal–oral. Food and water contaminated with animal feces are the major sources of human infection. Foods,
such as poultry, meat, and unpasteurized milk, are commonly involved. Puppies with diarrhea are a common source for
children. Human-to-human transmission occurs is less common than animal-to-human transmission. Campylobacter
jejuni is the leading cause of diarrhea associated with consumption of unpasteurized milk. Inflammation of the
intestinal mucosa occurs, accompanied by blood in stools. Systemic infections (e.g., bacteremia) occur in neonates or
debilitated adults.

Clinical Findings
Enterocolitis begins as watery, foul-smelling diarrhea followed by bloody stools accompanied by fever and severe
abdominal pain. Systemic infections, most commonly bacteremia, are caused by C. intestinalis. The symptoms of
bacteremia is fever and malaise. Gastrointestinal infection with C. jejuni is associated with Guillain-Barre syndrome, the
most common cause of acute neuromuscular paralysis. Guillain-Barre syndrome is an autoimmune disease attributed
to the formation of antibodies against C. jejuni that cross-react with antigens on neurons. Infection with
Campylobacter is also associated with two other autoimmune diseases: reactive arthritis and Reiter’s syndrome.

Laboratory Diagnosis
If the patient has diarrhea, a stool specimen is cultured on a blood agar plate containing antibiotics. Campylobacter are
more fastidious and specimens should be transported to the laboratory in transport media such as Cary-Blair. Selective
media such as campy blood agar or Skirrow medium containing antibiotics suc as vancomycin, trimethoprim,
cephalothin, polymyxin, and amphotericin B that inhibit most other fecal flora.
The plate is incubated at 42°C in a microaerophilic atmosphere containing 5% oxygen and 10% carbon dioxide, which
favors the growth of C. jejuni. It is identified by failure to grow at 25°C, oxidase positive, and sensitivity to nalidixic
acid. Unlike Shigella and Salmonella, lactose fermentation is not used as a distinguishing feature. If bacteremia is
suspected, a blood culture incubated under standard temperature will reveal the growth of the characteristically
comma- or S-shaped, motile with amphitrichous flagella, gram-negative rods. Identification of the organism as C.
intestinalis is confirmed by its failure to grow at 42°C, its ability to grow at 25°C, and it is resistant to nalidixic acid.

Treatment
Erythromycin or ciprofloxacin is used in C.jejuni enterocolitis. C. intestinalis bacteremia is an aminoglycoside.

Prevention
There is no vaccine. Proper sewage disposal and personal hygiene (handwashing) are important.
HELICOBACTER
Helicobacter pylori causes gastritis and peptic ulcers. Infection with H. pylori is a risk factor for gastric carcinoma and is
linked to mucosal-associated lymphoid tissue (MALT) lymphomas.
Important Properties
Helicobacters are curved gram-negative rods but are lophotrichous in flagellar arrangement and biochemically are
strongly urease-positive, whereas Campylobacters are urease-negative.

Pathogenesis & Epidemiology

Helicobacter pylori attaches to the mucus-secreting cells of the gastric mucosa. The production of large amounts of
ammonia from urea by the organism’s urease, coupled with an inflammatory response, leads to damage to the
mucosa. Loss of the protective mucus coating predisposes to gastritis and peptic ulcer. The ammonia also neutralizes
stomach acid, allowing the organism to survive. Helicobacter pylori also has oxidase, catalase, mucinase,
phospholipase enzymes, and vacuolating cytotoxin, which aid in the virulence and pathogenesis of the organism.
Epidemiologically, most patients with these diseases show H. pylori in biopsy specimens of the gastric epithelium. The
natural habitat of H. pylori is the human stomach, and it is probably acquired by ingestion. However, it has not been
isolated from stool, food, water, or animals. Person to-person transmission occurs because there is clustering of
infection within families. The rate of infection with H. pylori in developing countries is very high—a finding that is in
accord with the high rate of gastric carcinoma in those countries. MALT lymphomas are B-cell tumors located typically
in the stomach, but they occur elsewhere as well. Helicobacter pylori is often found in the MALT lesion, and the chronic
inflammation induced by the organism is thought to stimulate B-cell proliferation and eventually a B-cell lymphoma.
Antibiotic treatment directed against the organism often causes the tumor to regress.

Clinical Findings
Gastritis and peptic ulcer are characterized by recurrent pain in the upper abdomen, frequently accompanied by
bleeding into the gastrointestinal tract. No bacteremia or disseminated disease occurs.

Laboratory Diagnosis
The organism can be seen on Gram-stained smears of biopsy specimens of the gastric mucosa. It can be cultured on the
same media as Campylobacters. The most rapid test to detect H. pylori urease production is the basis for a noninvasive
diagnostic test called the “urea breath” test. In this test, radiolabeled urea is ingested. If the organism is present,
urease will cleave the ingested urea, radiolabeled CO2 is evolved, and the radioactivity is detected in the breath.
Serology, a test for Helicobacter antigen in the stool via a commercial polyclonal enzyme immunoassay is highly
sensitive and specific, while also inexpensive and easy to perform. can be used for diagnosis whereby H. pylori
stimulates a humoral immune response (IgM early in infection; IgG and IgA later in infection and persisting), but it
cannot distinguish between past and present infections. The presence of IgG antibodies in the patient’s serum can also
be used as evidence of infection. Microscopy is both extremely sensitive and specific for diagnosis of H. pylori in gastric
biopsy specimens when stained with Warthin-Starry silver stain, hematoxylin-eosin, or Gram stain. Culture is a more
challenging and time-consuming way to diagnose H. pylori, because it must be grown in a microaerophilic atmosphere
on an enriched medium containing charcoal, blood, and hemin.

Treatment & Prevention

This therapy includes:
(1) acid suppression, usually with a proton pump inhibitor,
(2) one or more antibiotics,
(3) occasional additive therapy with bismuth.
To use antibiotics to eliminate Helicobacter plus a drug to reduce gastric acidity. A combination of two antibiotics is
used because resistance, especially to metronidazole, has emerged. Treatment of duodenal ulcers with antibiotics (e.g.,
amoxicillin and metronidazole) and bismuth salts (Pepto-Bismol) results in a greatly decreased recurrence rate.
Tetracycline can be used instead of amoxicillin. There is no vaccine or other specific preventive measure.