Klebsiella spp. are inhabitants of the nasopharynx and gastrointestinal tract.

K. oxytoca carry a heatlabile cytotoxin, which has been isolated from patients who have developed a self-limiting
antibiotic-associated hemorrhagic colitis.
Klebsiella pneumoniae -prowls hospitals , causing sepsis ( second most common after Escherichia coli )
-encapsulated (0 antigen) but is nonmotile (no H antigen)
-causes urinary tract infections
- Klebsiella pneumoniae classically looks like red currant jelly, which is the color of the 0 antigen capsule
-K1 capsular–containing K. pneumoniae organisms are increasingly isolated from community-acquired pyogenic
liver abscess
-resistant to ampicillin

Hafnia - formerly Enterobacter hafniae

-motile non–lactose fermenter
-composed of one species, H. alvei
-two distinct biotypes are recognized:
H. alvei – linked to gastroenteritis and is occasionally isolated from stool cultures
H. alvei biotype 1- grows in the beer wort of breweries and has not been isolated clinically
*delayed positive citrate reaction is a major characteristic of Hafnia

Proteus, Morganella, Providencia

-ability to deaminate the amino acid phenylalanine
-do not ferment lactose
-motile, non–lactose fermenters capable of deaminating phenylalanine

*Proteus spp. -“swarming” appearance on culture media (result of a tightly regulated cycle of differentiation from
standard vegetative cells (swimmers) to hyperflagellated, elongated, polyploid cells (swarmers) capable of
coordinated surface movement)
-has a distinct odor that is often referred to as a “chocolate cake” or burnt chocolate” smell
-urinary tract infections (Examination of the urine will reveal an alkaline pH, which is due to Proteus' ability to split urea
into NH3 and C02)
*urease activity of P. mirabilis can lead to struvite kidney stones (calculi)
*P. mirabilis and P. vulgaris- hydrolyze urea and produce H2S
P. mirabilis P. vulgaris
Indole - +
Ornithine + -
* P. vulgaris ferments sucrose and gives an acid/acid reaction in triple sugar iron (TSI) agar
* P. penneri can also swarm on nonselective media
-has been isolated from patients with diarrhea

Morganella - normal inhabitants of the gastrointestinal tract

-has only one species, M. morganii
- two subspecies: M. morganii subsp. morganii and M. morganii subsp. Sibonii
- M. morganii is a documented cause of UTI
-motile, does not swarm
- deaminase positive and urease positive

Providencia spp. - most commonly associated with urinary tract infections and the feces of children with diarrhea
- consists of five species: P. alcalifaciens, P. stuartii, P. rettgeri, P. rustigianii, and P. heimbachae. P. rettgeri
- implicated in diarrheal disease among travelers
- P. stuartii has been implicated in outbreaks in burn units
Enterobacter - highly motile gram-negative rod is part of the normal flora of the intestinal tract
-It is occasionally responsible for hospital-acquired infections

Edwardsiella
-E. tarda is the only recognizedhuman pathogen
-negative for urea and positive for lysine decarboxylase, H2S, and indole and do not grow on Simmons citrate
-E. tarda is an opportunist, causing bacteremia and wound infections
-typically associated with water harboring fish or turtles

Serratia spp. are known for colonization and the cause of pathogenic infections in health care settings
-motile, slow lactose fermenters, DNAse, and orthonitrophenyl galactoside (ONPG) positive
- red pigment (prodogiosin) produced by S. marcescens typically is the key to identification

Erwinia and Pectobacterium spp. -are plant pathogens

-grow poorly at 37° C and fail to grow on selective media, such as EMB and MAC

Citrobacter
-inhabitants of the GI tract and are associated with hospital-acquired infections, most frequently UTIs. The
three species most often isolated are C. freundii,
C. koseri, and C. braakii. C. freundii
-hydrolyze urea slowly and ferment lactose, producing colonies on MAC agar that resemble those of E. coli
-grow on Simmons citrate medium, positive MR
MOT: person to person
-C. freundii can be isolated in diarrheal stool cultures
-has been associated with infectious diseases acquired in hospital settings; UTIs, pneumonias, and intra
abdominal abscesses
-associated with endocarditis in intravenous drug abusers
-C. freundii produce H2S and some strains (50%) fail to ferment lactose, the colony morphology of C.
freundii on primary selective media can be mistaken for Salmonella when isolated from stool cultures
-hydrolyze urea, but all fail to decarboxylate lysine
*Salmonella fails to hydrolyze urea, and most isolates decarboxylate lysine
-C. freundii may harbor inducible AmpC genes that encode resistance to ampicillin and first-generation
cephalosporins

Salmonella -gram-negative, facultatively anaerobic bacilli that morphologically resemble other enteric
bacteria
-facultative anaerobic, motile gram-negative rods
-Identification is primarily based on the ability of the organism to use citrate as the sole carbon source and lysine as
a nitrogen source in combination with hydrogen sulfide (H 2S) production.
-MAC, salmonellae produce clear, colorless, non–lactose fermenting colonies; colonies with black centers are
seen if the media
-HE or XLD contain indicators for H2S production
-do not ferment lactose, negative for indole, the Voges-Proskauer test, phenylalanine
deaminase, and urease
-Most produce H2S; a major exception is Salmonella Paratyphi A, which does not produce H2S
-do not grow in medium containing potassium cyanide
-comprised of two primary species, S. enterica (human pathogen) and S. bongori (animal pathogen
*S. enterica are six subspecies:
S. entericasubsp. enterica (also called subspecies I),
S. enterica subsp.salamae (subspecies II),
S. enterica subsp. arizonae (subspeciesIIIa),
S. enterica subsp. diarizonae (subspecies IIIb),
S. enterica subsp. houtenae (subspecies IV)
S. enterica subsp. Indica (subspecies VI)
Salmonella serotype Typhi, Salmonella serotype Choleraesuis,
and Salmonella serotype Paratyphi

Virulence Factors
-role of fimbriae in adherence in initiating intestinal infection
-ability to traverse intestinal mucosa
-Enterotoxin produced by certain Salmonella strains that cause gastroenteritis

Antigenic Structures
-somatic O antigens and flagellar H antigens are the primary antigenic structures used in serologic grouping
-serologic identification of the Vi antigen is important in identifying Salmonella serotype Typhi
- heat-stable O antigen (lipopolysaccharidelocated in the outer membrane of the cell wall)
-H antigens (flagellar antigen proteins are heat labile) occur in one of two phases:
*phase 1, the specific phase
-Phase 1 flagellar antigens occur only in a few serotypes and determine the immunologic identity of the
particular serotype
-Phase 1 antigens agglutinate only with homologous antisera
*phase 2, the nonspecific phase
-Phase 2 flagellar antigens occur among several strains
-Shared by numerous serotypes, phase 2 antigens react with heterologous antisera

*heat-labile Vi (from the term virulence) antigen is a surface polysaccharide capsular antigen found in
Salmonella serotype Typhi and a few strains of Salmonella serotype Choleraesuis
-preventing phagocytosis of the organism
-Vi antigen often blocks the O antigen during serologic typing but may be removed by heating

Clinical Infections
In humans, salmonellosis may occur in several forms, as follows:
*Acute gastroenteritis or food poisoning characterized by vomiting and diarrhea
*Typhoid fever, the most severe form of enteric fever, caused by Salmonella serotype Typhi, and enteric fevers
caused by other Salmonella serotypes (e.g., Salmonella Paratyphi and Choleraesuis)
*Nontyphoidal bacteremia
*Carrier state following Salmonella infection

MOT: ingesting the organisms in food, water, and milk contaminated with human or animal excreta
*With the exception of Salmonella Typhi and Salmonella Paratyphi, salmonellae organisms infect various
animals that serve as reservoirs and sources of human infections

Gastroenteritis- One of the most common forms of “food poisoning,”

-Salmonella strains associated with gastroenteritis are usually strains found in animals; most such strains in the
United States are members of S. enterica subsp. Enterica
-Salmonella gastroenteritis occurs when a sufficient number of organisms contaminate food that is maintained
under inadequate refrigeration, allowing growth and multiplication of the organisms
-infective dose necessary to initiate the disease, 106 bacteria

Enteric Fevers
The clinical features of enteric fevers include:
• Prolonged fever
• Bacteremia
• Involvement of the reticuloendothelial system, particularly the liver, spleen, intestines, and mesentery
• Dissemination to multiple organs

-Enteric fever caused by Salmonella Typhi is known as typhoid fever, a febrile disease that results from the
ingestion of food contaminated with the organisms originating from infected individuals or carriers
*Salmonella Typhi does not have a known animal reservoir; humans are the only known source of infection
-“Rose spots” (blanching, rose-colored papules around the umbilical region) appear during the second week of
fever
*paratyphoid fevers, which may be due to Salmonella serotypes Paratyphi A, B, and C and Salmonella
serotype Choleraesuis.
-The clinical manifestations of paratyphoid fevers are similar to typhoid fever but are less severe, and the
fatality rate is lower

Bacteremia
Salmonella bacteremia, with and without extraintestinal foci of infection caused by nontyphoidal Salmonella, is
characterized primarily by prolonged fever and intermittent bacteremia
*serotypes most commonly associated with bacteremia are Typhimurium, Paratyphi, and Choleraesuis
Salmonella
infection has been observed among two different groups:
(1) young children, who experience fever and gastroenteritis with brief episodes of bacteremia
(2) adults, who experience transient bacteremia during episodes of gastroenteritis or develop symptoms of
septicemia without gastroenteritis
*Patients with sickle-cell anemia are particularly prone to Salmonella osteomyelitis (bone infection)

Carrier State
Individuals who recover from infection may harbor the organisms in the gallbladder, which becomes the site of
chronic carriage
-carrier state may be terminated by antimicrobial therapy if gallbladder infection is not evident. Otherwise,
cholecystectomy has been the only solution to the chronic state of enteric carriers.

Gastroenteritis and diarrhea caused by a wide variety of serotypes that produce infections limited to the mucosa and
submucosa of the gastrointestinal tract. S. serotype Typhimurium and S. serotype Enteritidis are the serotypes most
commonly associated with Salmonella gastroenteritis in the United States.
• Bacteremia and extraintestinal infections occur by spread from the gastrointestinal tract. These infections usually
involve S. Choleraesuis or S. dublin, although any serotype may cause these
infections.
• Enteric fever (typhoid fever, or typhoid) is characterized by prolonged fever and multisystem involvement, including
blood, lymph nodes, liver, and spleen. This life-threatening infection is most frequently caused by S. serotype Typhi;
more rarely, S. serotypes Paratyphi A, B or C.

Shigella
-nonmotile; lysine decarboxylase–negative; citrate-, malonate-, and H2S-negative; non–lactose fermenting; gram-
negative rods that grow well on MacConkey agar
-urease neg
-4 subgroups:
S. dysenteriae (group A), S. flexneri (group B), S. boydii(group C), and S. sonnei (group D)
*Serotyping is based on the somatic LPS O antigen
-shigellosis or bacillary dysentery
*all Shigella spp. can cause bacillary dysentery
-named after the Japanese microbiologist Kiyoshi Shiga
Shigella dysenteriae, caused the enteric disease bacillary dysentery
-characterized by the presence of blood, mucus, and pus in the stool
-Except for certain types of S. flexneri, they do not produce gas from glucose
-In contrast to Escherichia spp., Shigella spp. do not use acetate or mucate as a source of carbon
-S. sonnei is uniquein its ability to decarboxylate ornithine
-slowly ferments lactose, producing a “delayed” positive fermentation of lactose with the formation of pink
colonies on MAC agar only after 48 hours of incubation
-ONPG-positive
-clear, non–lactose-fermenting colonies
-susceptible to thevarious effects of physical and chemical agents, such as disinfectants and high
concentrations of acids and bile

Antigenic Structures
*All Shigella spp. possess O antigens, and certain strains can possess K antigens
*S. sonnei has only one serotype

Clinical Infections
MOT: direct person-to-person contact, fecal-oral route
-less than 100 bacilli are needed to initiate the disease
-Bloody stools containing mucus and numerous leukocytes follow the watery diarrhea, as the organisms invade
the colonic tissues and cause an inflammatory reaction
*dysentery caused by S. dysenteriae type 1- Bloody diarrhea, extremely painful bowel movements, which
contain predominantly mucus and blood, ileus, an obstruction of the intestines, with marked abdominal dilation,
possibly leading to toxic megacolon
-HUS
-effects of shigella toxin have been implicated as the mechanism responsible for the signs of disease
-Patients develop diarrhea because the inflamed colon, damaged by the Shiga toxin, is unable to reabsorb
fluids and electrolytes

Shiga Toxin
-same toxin as in EHEC and EIEC, same mechanism

Yersinia
-gram-negative; catalase-, oxidase-, and indole-positive, non–lactose fermenting; facultative anaerobes capable of
growth at temperatures ranging from 4° to 43°C
-unusual bipolar staining
*Based on the composition of the LPS in the outer membrane, colonies may present with
either a rough form lacking the O-specific polysaccharide chain (Y. pestis) or a smooth form containing the lipid A-
oligosaccharide core and the complete O-polysaccharide (Y. pseudotuberculosis and Y. enterocolitica)
-Yersinia pestis-a select agent
- generate aerosols and should be handled using Biosafety Level 3 (BSL-3)
*Y. pestis resembles a closed safety pin when it is stained with methylene blue or Wayson stain; this is a key
characteristic for rapid diagnosis of plague
*Y. pestis grows best at 25° to 30°C. Colonies of Y. pestis are pinpoint at 24 hours but resemble those of other
Enterobacteriaceae after 48 hours
*However, because most Aeromonas spp. produce similar colonies on CIN agar, it is important to perform an
oxidase test to verify that the organisms are Yersinia spp. (oxidase negative)
* Colonies of Y. pestis on 5% sheep blood agar are pinpoint at 24 hours but exhibit a rough, cauliflower appearance
at 48 hours
*Broth cultures of Y. pestis exhibit a characteristic “stalactite pattern” in which clumps of cells adhere to one side of
the tube

Cefsulodin-irgasan-novobiocin (CIN) agar is a selective medium specifically used for the isolation of Y.
enterocolitica from gastrointestinal specimens
-should be incubated 48 hours at room temperature to allow for the development of typical “bull’s-eye” colonies
-Y. enterocolitica produces bull’s-eye colonies (dark red or burgundy centers surrounded by a translucent border;
on CIN agar at 48 hours

Y. pestis is the causative agent of plague, a disease primarily of rodents transmitted to humans by fleas
In humans, plague can occur in three forms:
the bubonic, or glandular, form;- most common, usually results from the bite of an infected flea
-high fever with painful regional lymph nodes known as buboes (swollen lymph nodes) begin to appear
-
the septicemic form;- occurs secondary to bubonic plague when organisms proliferate in the bloodstream
the pneumonic form. - occurs secondary to bubonic plague when organisms proliferate in the respiratory tract
-pneumonic plague – if bacteria are inhaled
- gram-negative, short, plump bacillus
- methylene blue or Wayson stain, it shows intense staining at each end of the bacillus, referred to as bipolar
staining, which gives it a “safety-pin” appearance
- preferential growth temperature of 25° C to 30° C
- class A bioterrorism agent
VF: Multiple factors play a role in the pathogenesis of this highly virulent
organism. These include the ability to adapt for intracellular survival and production of an antiphagocytic
capsule, exotoxins, endotoxins, coagulase, and fibrinolysin

Y. pseudotuberculosis and Y. enterocolitica have caused sporadic cases of

mesenteric lymphadenitis in humans

Y. enterocolitica produces an infection that mimics appendicitis

MOT: contact with household pets
- Y. enterocolitica sepsis associated with the transfusion of contaminated packed red blood cells has been
reported
Y. enterocolitica infections manifest in several forms: an acute enteritis, an appendicitis-like syndrome, arthritis,
and erythema nodosum
* Acute enteritis, the most common form of the infection, is characterized by acute gastroenteritis with fever
accompanied by headaches, abdominal pain, nausea, and diarrhea.Stools may contain blood
-This pain is often most severe in the right lower quadrant of the abdomen , and therefore patients may appear
to have appendicitis
* Erythema nodosum is an inflammatory reaction caused by Y. enterocolitica characterized by tender, red
nodules that may be accompanied by itching and burning
- gram-negative coccobacilli with bipolar staining
- Y. enterocolitica grows better with cold enrichment, and motility is clearly noted at 25° C but not at 35° C
- Cefsulodin-irgasan-novobiocin (CIN) agar, a selective medium to detect the presence of Y. enterocolitica,
incorporates cefsulodin, irgasan, novobiocin, bile salts, and crystal violet as inhibitory agents
VF: Various factors encoded on a virulence plasmid allow the organism to attach to and invade the intestinal mucosa
and spread to lymphatic tissue.

Yersinia pseudotuberculosis, similar to Y. pestis, is a pathogen primarily of rodents, particularly guinea pigs
- disease characterized by caseous swellings called pseudotubercles.
- typical-looking plague bacillus.
-It can be differentiated from Y. pestis by its motility at 18° C to 22° C, production of urease, and ability to
ferment rhamnose

Serratia spp.- are known for colonization and the cause of pathagenic infections in health care settings
-motile, slow lactose fermenters, DNAse, and orthonitrophenyl galactoside (ONPG) positive
-capable of survival under very harsh environmental conditions and is resistant to many disinfectants
-red pigment (prodogiosin) produced by S. marcescens typically is the key to identification
-Serratia spp. are resistant to ampicillin and first-generation cephalosporins because of the presence of an
inducible, chromosomal AmpC β-lactamase
-S. marcescens, S. rubidaea, and S. plymuthica often produce a characteristic pink-to-red pigment, prodigiosin

-S. odorifera -emits a dirty, musty odor resembling that of rotten potatoes
- contains two biogroups
S. odorifera biogroup 1 is isolated predominantly from the respiratory tract and is positive for sucrose, raffinose,
and ornithine
S. odorifera biogroup 2 is negative for sucrose, raffinose, and ornithine and has been isolated from blood and
CSF