San Franciscan chicken

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 Patient History
• A 2 year old male with a very complicated medical history
presented to the UCLA emergency department with fever,
diarrhea, myalgias, rhinorrhea, dehydration, and decreased
activity.
• The patient had a medical history significant for heart
transplant and post-transplant lymphoproliferative disorder.
• He lived with 3 siblings, one of which was sick with similar
diarrheal symptoms.
 Enteric Work-up @ UCLA
Specimen: Fresh stool was collected and sent in a
transport container to the UCLA clinical
microbiology lab for culture.

Workup in the clinical microbiology lab:

1. Stool plated onto:
– Blood agar plate (BAP)
– MacConkey’s agar plate
– Hektoen Enteric (HE) agar plate
– Campy Blood agar plate
2. Resulting colonies analyzed by:
– Colony morphology
– Biochemical tests
– Antibody-based serogrouping tests
3. Findings are reported to attending physicians.
 Stool work-up plates
Sheep Blood agar
• Contains blood and nutrients for growth of many bacteria.
Both Gram-positive and Gram-negative bacteria can grow.

MacConkey agar –
• Contains bile salts and crystal violet, which inhibit the
growth of most Gram-positive bacteria. Bacteria that
ferment lactose appear pink on this agar.

Hektoen Enteric (HE) agar

• HE contains bile salts, lactose, acid fuchsin and bromo
thymol blue indicators. Lactose fermenters produce yellow
– orange colonies. Colonies that produce hydrogen sulfide
(H2S) appear black.
 API 20E by bioMerieux

Principle:
The strip consists of 20 microtubes containing dehydrated substrates. The tests
are inoculated with bacterial suspensions that reconstitutes the media. During
incubation, specific bacterial metabolites are produced that can be detected
via color changes. Based on this information, bacterial identification is often
possible.
 Wellcolex Serogrouping for Salmonella
Antibody conjugated latex agglutination test for rapid serogroup classification of Salmonella spp.
Latex reagent 1:
• Green latex (anti-Salmonella grp. D1 Abs)

• Blue latex (anti-Salmonella grp. C Abs)

• Red latex (anti-Salmonella grp. B Abs)

Latex reagent 2:
• Blue latex (anti-Salmonella grps. E & G Abs)

• Red latex (anti-Vi Abs)

• Green latex (anti-Salmonella grp. A Abs)

 UCLA Patient
Stool microbiology findings for the 2 year-old patient:
1. Black colonies grew on Hectoen-Enteric agar.
2. Biochemical tests on sub-cultured black colonies
indicated the organism was a Salmonella species.
3. Wellcolex serogrouping determined the isolate was a
Salmonella enterica subspecies enterica serogroup B
(Red latex from reagent 1).
4. Antimicrobial susceptibility testing was performed.
Antibiotic Sensitivity MIC in µg/mL
Ampicillin Resistant >32
Ciprofloxacin Susceptible 0.03
Bactrim Susceptible <=1/20
5. Los Angeles County Public Health Laboratory
determined the isolate as a Salmonella enterica
subspecies enterica serotype Heidelberg (part of a
larger US outbreak).
 UCLA Patient

• Before culture completion, the patient was discharged without

antibiotics for presumed viral enteritis.

• Given the patient’s age and complicated medical history, antibiotics

were warranted to ensure full recovery. Antibiotics were prescribed
and the patient improved.
The clinical microbiologist provided an unexpected
diagnosis that resulted in a dramatic change in patient
care.
 Salmonella Heidelberg Outbreak, 2013

• 74% of the 389 infected persons were from California.

• Among 389 persons with available information, 40% reported being
hospitalized.
• 14% of ill persons developed blood infections as a result of their illness.
• Typically, only ~5% of persons ill with Salmonella infections develop
blood infections.
• No deaths were reported.
• Several isolates were multi-drug resistant.
• At least some of the cases were
attributable to Foster Farms Chicken
purchased at Costco in San Francisco, CA.

CDC.gov, 2013
Classification - Salmonella species and
serotypes
Only two species of the genus Salmonella are recognized:
S. enterica – composed of six sub-species (I, II, IIIa, IIIb, IV, VI).
S. bongori – formerly subspecies V (20 serotypes).

6 subspecies of S. enterica.
>2500 serotypes of S. enterica subsp. Enterica.
Treatment for Salmonella Gastroenteritis
• Oral or intravenous rehydration.
• Generally antibiotics are not recommended.
– Agents do not shorten course of illness.
– Antibiotic resistance increasing problem.
– Antibiotics can prolong excretion of Salmonella.
– Exceptions include high risk groups.
• Underlying disease or complicated medical history
• Young children
• Disseminated infection
• Antibiotics
– Objective is to treat or prevent recurrence of bacteremic disease .
– Fluoroquinolones
– Azithromycin
– TMP-SMX
Ian McHardy, Ph.D.

Ian McHardy, PhD is second year CPEP

fellow at UCLA. Dr. McHardy studied
aspects of the human microbiome for his
PhD thesis and postdoctoral fellowship.
His research interests involve linking
bioinformatics with basic and clinical
research to drive improved diagnostics,
disease monitoring, and therapies for
infectious diseases.

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