ESCHERICHIA COLI

E.coli species : famili Enterobacteriaceae falkutative anaerob, basil gram negatif, biasanya mengfermentasi laktosa. Kebanyakan E.coli feses mrp organisme nonpatogen, penyebab penting infeksi enteric jg UTI, neonatus sepsis, meningitis. Immunocompromise & pasien dengan alat iv bakterimia, sepsis. 5 grup besar E.coli diarrheagenic berdasarkan klinis, biokimia, molekuler-genetik: ETEC : Enterotoxigenic E.coli EIEC : Enteroinvasive E.coli EPEC : Enteropathogenic E.coli STEC : Shiga toxin-producing E.coli / EHEC : Enterohemorrhagic E.coli / VTEC : Verotoxin producing E.coli EAEC : Enteroaggregative E.coli

Mungkin merupakan patogen DAEC : Diffusely Adherent E.coli E.coli merupakan flora normal feses, E.coli diarrheagenic mempunyai karakteristik virulensi organisme melekat pada reseptor glikoprotein/ glikolipid memproduksi substansi tertentu yg menyebabkan perlukaan/gangguan fungsi sel saluran cerna. Genetik virulensi dan resistensi antibiotik dibawa oleh transfeable plasmids, pathogenicity islands, or bacteriophages. Kebanyakan strain E.coli (kecuali STEC, mgkn beberapa EPEC) harus dalam jumlah banyak untuk dpt menyebabkan kesakitan.
E.coli Resiko populasi >1 th, travelers >1 th Karakteristik diare Cairan Darah Durasi +++ + ++ Disentri dg demam +++ Afebril hemorrhagic colitis , HUS Akut Akut Faktor virulensi utama Faktor adherence Toxin Colonization factor antigens (CFA I, II, IV) Invasi plasmid antigen (Ipa ABCD) A/E lesion, intimin/Tir, EspABD BFP A/E lesion Heat-labile enterotoxin (LT) Heat-stable enterotoxin (ST) Shigella enterotoxins diagnosis Target gen utk PCR LT, ST IpaH / IAL

ETEC EIEC

EPEC STEC

<2 th, t.u bayi <6 bln 6 bln-10 th Orang tua

+++ +

Akut/ persisten Akut

EspF Shiga toxins (Stx1, Stx2, & variant Stx2)

Eae, BfpA Eae, Stx1, Stx2

EAEC

<1 th, travelers

+++

Akut/ persisten

Aggregative adherence fimbria (AAF)

ShET1, EAST1, Pet

AggR or AA plasmid

PCR, polymerase chain reaction; ETEC, enterotoxigenic E. coli; EIEC, enteroinvasive E. coli;EPEC, enteropathogenic E. coli; STEC, Shiga toxinproducing E. coli;EAEC, enteroaggregative E. coli. ETEC (Enteropatogenic E.coli) ETEC mrp organisme utama penyebab diare pada bayi dan traveler (20-30%) pada negara berkembang. Gejala utama : diare cair, tidak berlendir, tidak berdarah, nyeri abdomen, mual, muntah, demam ringan/ tidak. Biasanya self-limited dalam 3-5 hari, tapi bisa > 1 mgg. Tidak ada kerusakan struktural mukosa GIT. Diare karena o Kolonisasi pada usus halus memerlukan fimbrial CFAs (colonization factor antigens), utk memperantai adhesi pada epitel intestinal. Faktor kolonisasi yg paling umum : CFA/I, CFA/II, and CFA/IV (CFA dibentuk pada antigen permukaan E.coli, mempunyai kombinasi berbeda2) dan 1

Enterotoxin (mensekresi heat-labile enterotoxin LT atau heat-stable enterotoxin ST, beberapa strain dapat memproduksi ke2nya) LT : molekul besar dengan 5 reseptor-binding (B) subunit & 1 enzimatik aktif (A) subunit secara struktur, fungsi, & imunologi berhubungan dengan toxin kolera yg diproduksi oleh vibrio cholerae. Menstimuli adenylate cyclase peningkatan cAMP. ST : molekul kecil berhubungan dengan LT atau toxin cholera Menstimuli guanylate cyclase peningkatan cGMP

Enteroinvasive E. coli. Clinically EIEC infections present either with watery diarrhea or a dysentery syndrome, manifested as blood, mucus, and leukocytes in the stools, with fever, systemic toxicity, crampy abdominal pain, tenesmus, and urgency. They resemble bacillary dysentery because they share virulence genes with Shigella. EIEC organisms are mostly described in outbreaks; however, endemic disease occurs in developing countries where these bacteria can be isolated with relatively high frequency. In the developing world, as many as 5% of sporadic diarrhea episodes and 20% of bloody diarrhea cases may be caused by EIEC strains. EIEC organisms cause colonic lesions with ulcerations, hemorrhage, mucosal and submucosal edema, and infiltration by polymorphonuclear leukocytes. EIEC strains behave like shigellae in their capacity to invade gut epithelium and produce a dysentery-like illness. The invasive process involves (1) initial entry into cells, (2) intracellular multiplication, (3) intracellular and intercellular spread, and (4) host cell death. All bacterial genes necessary for entry into the host cell are clustered within a 30 kb region of a large virulence plasmid, also found in Shigella. This region carries genes encoding the entry-mediating proteins, which code for proteins forming a type III secretion apparatus required for secretion of the invasins (IpaA-D and IpgD). IpaB and IpaC have been identified as the primary effector proteins of epithelial cell invasion. The type III secretion apparatus is found in many other pathogenic gram-negative bacteria. It is a system triggered by contact with host cells that bacteria use to transport proteins from their cytoplasm into the host cell plasma membrane and cytoplasm. EIEC organisms encompass a small number of serogroups (028ac, 029, 0124, 0136, 0143, 0144, 0152, 0164, 0167, and some nontypable strains). These serogroups have lipopolysaccharide (LPS) antigens related to Shigella LPS, and, like shigellae, are nonmotile (they lack H or flagellar antigens) and are usually nonlactose fermenting. Enteropathogenic E. coli. EPEC organisms are a major cause of infant acute and persistent diarrhea in developing countries, primarily in children <2 yr of age. In developed countries, EPEC organisms are responsible for occasional outbreaks in daycare centers and pediatric wards. EPEC organisms generally cause acute or protracted disease. In addition to profuse watery, nonbloody diarrhea with mucus, vomiting and low-grade fever are common symptoms. Persistent diarrhea (>14 days) can lead to malnutrition; this is an important outcome of EPEC infection in infants in the developing world. Several studies have shown that breast-feeding is protective against diarrhea due to EPEC. EPEC colonization causes blunting of villi, inflammatory changes, and sloughing of superficial mucosal cells; these lesions are found from the duodenum through the colon. EPEC organisms induce a characteristic attaching and effacing (A/E) histopathologic lesion, which is defined by the intimate attachment of bacteria to the epithelial surface and effacement of host cell microvilli. Factors responsible for the A/E lesion formation are encoded by the locus of enterocyte effacement (LEE), which is a pathogenicity island that contains the genes for (1) the type III secretion system, (2) the translocated intimin receptor (Tir) and intimin, and (3) effector proteins such as the E. colisecreted proteins (EspA-B-D). EPEC pathogenesis involves several stages. The initial adherence of the bacteria to the host's intestinal epithelium in a pattern known as localized adherence is mediated in part by the type IV bundle-forming pilus (BFP) encoded on a plasmid (the EAF plasmid). Next, bacterial proteins are translocated through a type III secretion system needle complex. Filamentous appendages made of EspA form a physical bridge between the bacteria and the host cell for the translocations of bacterial effectors (EspB, EspD, Tir). EspB and EspD form pores in the host's cell membrane. Tir is injected into host cells by way of this

conduit. Tir moves to the surface of host cells where it is bound by a bacterial outer membrane protein intimin, which is encoded by the eae gene. Intimin-Tir binding triggers polymerization of actin and other cytoskeletal components at the site of attachment. The result of these cytoskeletal changes is intimate bacterial attachment to the host cell, enterocyte effacement, and pedestal formation. Other bacterial effectors include a mitochondrial-associated protein (Map) with membrane-potential disrupting activity and EspF, a protein that disrupts the intestinal barrier function and induces host cell death. Some serogroups are associated with localized adherence and are EAF probe positive (055, 086, 0111, 0119, 0125, 0126, 0127, 0128ab, and 0142), whereas others (atypical EPEC) are nonadherent or diffusely adherent to HEp-2 cells and are usually EAF probe negative (018, 044, 0112, and 0114). There is more evidence that EPEC organisms with localized adherence are true enteropathogens, although, as noted above, evidence is mounting that at least some of the atypical EPEC organisms are also pathogens. Shiga ToxinProducing E. coli. STEC organisms have been shown to cause a wide spectrum of diseases. STEC infections may be asymptomatic. Patients develop intestinal symptoms ranging from mild diarrhea to severe hemorrhagic colitis. The gastrointestinal illness is characterized by abdominal pain with diarrhea that is initially watery but within a few days becomes blood streaked or grossly bloody. Although this pattern resembles that of shigellosis or EIEC disease, it differs in that fever is an uncommon manifestation. Most individuals infected with STEC recover from the infection without further complication. However, 510% of children go on within a few days to develop systemic complications such as hemolytic-uremic syndrome (HUS), characterized by acute renal failure, thrombocytopenia, and hemolytic anemia (see Chapter 518 ). Very young children are not a target group of STEC; rather, severe and complicated illness occurs most often among children from 6 mo to 10 yr of age. The elderly may also develop HUS or thrombotic thrombocytopenic purpura. STEC organisms are transmitted person to person as well as by food and water; ingestion of a low number of these organisms is sufficient to cause disease. Poorly cooked hamburger is a common cause of food-borne outbreaks, although many other foods (apple cider, lettuce, mayonnaise, salami, dry fermented sausage, unpasteurized dairy products) have also been incriminated. Most outbreaks of STEC-associated diarrhea in the Northern hemisphere have been attributed to strains of serotype 0157 : H7, and many other serotypes have been associated with outbreaks and sporadic cases of severe disease. STEC organisms affect the colon most severely. STEC organisms adhere to intestinal cells, and most strains that affect humans produce attaching-effacing lesions like those seen with EPEC. Most STEC strains also carry a large plasmid encoding proteins such as enterohemolysin (EhyA), an extracellular serine protease (EspP), and a STEC autoagglutinating adhesin (Saa), which may be accessory virulence factors. These organisms cause edema, fibrin deposits, hemorrhage in the submucosa, mucosal ulceration, neutrophil infiltration, and microvascular thrombi. Pseudomembranous colitis may be seen. Shiga toxins are considered to be the key virulence factor of STEC. There are 2 major toxin types, Stx1 and Stx2. Some STEC organisms produce only Stx1 and others only Stx2, but most STEC organisms produce both toxins. There are strains that produce multiple toxin variants. Stx1 is essentially identical to Shiga toxin, the protein synthesisinhibiting exotoxin of Shigella dysenteriae serotype 1, whereas Stx2 and variants of Stx2 are more distantly related. Each toxin is composed of a single A subunit noncovalently associated with a pentamer composed of identical B subunits. The B subunits bind to globotriaosylceramide (Gb3), a glycosphingolipid receptor on host cells. The A subunit is taken up by endocytosis. The toxin target is the 28S recombinant RNA, which is depurinated by the toxin at a specific adenine residue, causing protein synthesis to cease and affected cells to die. These toxins are carried on bacteriophages that are normally inactive when inserted into the bacterial chromosome; when the phages are induced to replicate (e.g., by the stress induced by many antibiotics), they cause lysis of the bacteria and release of large amounts of toxin. The toxin enters the systemic circulation after translocation across the intestinal epithelium and damages vascular endothelial cells. This causes activation of the coagulation cascade, formation of microthrombi, intravascular hemolysis, and ischemia. STEC organisms induce proinflammatory cytokines. Clinical outcome of STEC infection depends on the stx genotype of the infecting strain. The Stx2 genotype is associated with a higher risk for causing HUS. The most common STEC serotypes are E. coli O157 : H7, E. coli 0111 : NM, and E. coli 026 : H11, although several hundred other STEC serotypes have also been described. Enteroaggregative E. coli.

EAEC organisms are associated with acute and persistent pediatric diarrhea in developing countries, most prominently in children >12 mo of age. EAEC organisms are etiologic agents in AIDS-associated chronic diarrhea and traveler's diarrhea. EAEC typical illness is manifested by watery, mucoid, secretory diarrhea with low-grade fever and little or no vomiting. One third of patients have grossly bloody stools. The watery diarrhea may persist for weeks. EAEC organisms have been associated with growth retardation in infants and malnutrition in the developing world. EAEC organisms form a characteristic mucous biofilm on the intestinal mucosa and induce shortening of the villi, hemorrhagic necrosis, and inflammatory responses. The proposed model of pathogenesis of EAEC involves three phases: adherence to the intestinal mucosa by way of the aggregative adherence fimbriae (AAF); enhanced mucus production; and production of toxins and inflammation that result in damage of the mucosa and intestinal secretion. Diarrhea caused by EAEC is predominantly secretory. The intestinal inflammatory response (elevated fecal lactoferrin, interleukin 8 [IL-8] and IL-1) may be related to growth impairment and malnutrition. Putative EAEC virulence factors include aggregative adherence fimbriae (AAF-I, AAF-II, and AAF-III), hemolysins, various outer membrane and secreted proteins (dispersin), and several toxins: an oligomeric enterotoxin called Shigella enterotoxin 1 (ShET1); an enteroaggregative E. coli heat-stable toxin 1 (EAST1), homologous to the Enterotoxigenic E. coli heat-stable toxin; and an autotransporter toxin called Pet. A transcriptional activator called AggR controls expression of plasmid-borne and chromosomal virulence factors. Identification of AggR or members of the AggR regulaton may identify typical pathogenic EAEC strains. Strains of E. coli categorized as EAEC belong to a diverse range and combination of O and H serotypes. Definition of these pathogens is in flux. The original diagnostic criteria (HEp2 cell adherence pattern) identified many strains that are probably not true pathogens; genetic criteria appear to more reliably define true pathogens. DIAGNOSIS. The clinical features of illness are seldom distinctive enough to allow confident diagnosis, and routine laboratory studies are of very limited value. Diagnosis currently depends primarily on laboratory studies that are not readily available. Practical, nonDNA-dependent methods for routine diagnosis of diarrheagenic E. coli have been developed primarily for STEC. Serotype O157 : H7 is suggested by isolation of an E. coli that fails to ferment sorbitol on MacConkey sorbitol medium; latex agglutination confirms that the organism contains O157 LPS. Other STEC organisms can be detected in routine hospital laboratories using commercially available enzyme immunoassay or latex agglutination to detect Shiga toxins. The diagnosis of other diarrheagenic E. coli infection is typically made based on tissue culture (e.g., HEp2 cell assays for EPEC and EAEC), or identification of specific virulence factors of the bacteria by phenotype (e.g., toxins) or genotype. DNA probes for genes encoding the various virulence traits are the best diagnostic tests, but are currently available only as a research tool. Therefore, suspected organisms should be forwarded to reference or research laboratories for definitive evaluation. Such efforts are seldom necessary, but they may be helpful for correct diagnosis when a child has severe or life-threatening complications, persistent diarrhea, or for outbreak investigation. Polymerase chain reaction and DNA probes for genes encoding the various virulence factors are now available for the major diarrheagenic E. coli strains. Typical targets include LT and ST for ETEC; IpaH or IaL for EIEC; Eae and BfpA for EPEC; Eae, Stx1, and Stx2 for STEC; and AggR or the AA plasmid for EAEC. Other laboratory data are at best nonspecific indicators of etiology. Fecal leukocyte examination of the stool is frequently positive with EIEC but negative with other diarrheagenic E. coli. With EIEC and STEC there may be an elevated polymorphonuclear leukocyte count with a left shift. Fecal lactoferrin, IL-8, and IL-1 can be used as inflammatory markers. Electrolyte changes are nonspecific, reflecting only fluid loss. TREATMENT. The cornerstone of management is appropriate fluid and electrolyte therapy (see Chapters 55 and 337 ). In general, this therapy should include oral replacement and maintenance with rehydration solutions such as those specified by the World Health Organization. Pedialyte and other readily available oral rehydration solutions are acceptable alternatives. After refeeding, continued supplementation with oral rehydration fluids is appropriate to prevent recurrence of dehydration. Early refeeding (within 812 hr of initiation of rehydration) with breast milk or infant formula should be encouraged. Prolonged withholding of feeding frequently leads to chronic diarrhea and malnutrition.

Specific antimicrobial therapy of diarrheagenic E. coli is problematic because of the difficulty of making an accurate diagnosis of these pathogens and the unpredictability of antibiotic susceptibilities. ETEC organisms respond to antimicrobial agents such as trimethoprim-sulfamethoxazole (TMP-SMZ) when the E. coli strains are susceptible. However, other than for a child recently returning from travel in the developing world, empirical treatment of severe watery diarrhea with antibiotics is seldom appropriate. EIEC infections may be treated before the availability of culture results because the clinician suspects shigellosis and has begun empirical therapy. If the organisms are susceptible, TMP-SMZ is an appropriate choice. Although treatment of EPEC infection with TMP-SMZ intravenously or orally for 5 days is effective in speeding resolution, the lack of a rapid diagnostic test makes treatment decisions difficult. Ciprofloxacin or rifaximin are useful for EAEC traveler's diarrhea; pediatric data are sparse. STEC organisms represent a particularly difficult therapeutic dilemma; antibiotic treatment can induce toxin production and phage-mediated bacterial lysis with toxin release. Current data suggest that antibiotics should not be given for STEC infection because they may increase the risk for HUS (see Chapter 518 ). PREVENTION. In the developing world, prevention of disease caused by diarrheagenic E. coli is probably best done by maintaining prolonged breast-feeding, paying careful attention to personal hygiene, and following proper food- and water-handling procedures. People traveling to these places can be best protected by consuming only processed water, bottled beverages, breads, fruit juices, fruits that can be peeled, or foods that are served steaming hot. Prophylactic antibiotic therapy, although effective in adult travelers, has not been studied in children and is not recommended. Public health measures, including sewage disposal and food-handling practices, have made pathogens that require large inocula to produce illness relatively uncommon in industrialized countries. Food-borne outbreaks of STEC are a problem for which no adequate solution has been found. During the occasional hospital outbreak of EPEC disease, attention to enteric isolation precautions and cohorting may be critical. The nature of protective immunity is not fully understood, and no vaccines are available for clinical use. There are several vaccine candidates based on bacterial toxins or colonization factors that are being studied. Email to Colleague Print Version Copyright 2008 Elsevier Inc. All rights reserved. - www.mdconsult.com