1. Causative agents of bacterial enteric infections:
Microbiology, Virology, and Immunology Department
Causative agents of bacterial enteric infections:
escherichiosis, klebsiellosis, typhoid fever, paratyphoid, salmonellosis.
Shigella. Causative agents of cholera
Lecturer As.Prof. O.V. Pokryshko

2. Classification of the Enterobacteriaceae
Genera
Escherichia
Shigella
Edwardsiella
Salmonella
Citrobacter
Klebsiella
Enterobacter
Hafnia
Serratia
Proteus
Providencia
Morganella
Yersinia
Erwinia

5. The organism was isolated from feces in 1885 by T. Escherich. E
The organism was isolated from feces in 1885 by T. Escherich. E. coli is a common inhabitant of the large intestine of humans and mammals. It is also found in the guts of birds, reptiles, amphibians, and insects. The bacteria are excreted in great numbers with the feces and are always present in the external environment (soil, water, foodstuffs, and other objects).

6. Escherichia coli.
Morphology. E coli are straight rods measuring in breadth and 1-3 in length. There are motile and non-motile types.

7. Scanning electron micrograph

9. Cultivation.
Colonies of E. coli on meat-peptone agar

10. Colonies of E. coli on Endo's medium

11. Colonies of E. coli on Ploskirev's medium

12. Colonies of E. coli on blood agar

13. Escherichia coli
is highly motile
and will show turbidity throughout the tube.

14. Fermentative properties.
Positive (left) reactions of isolates E. coli in glucose fermentation broth. Note the formation of acid (yellow color) and gas. Observe the bubble in the Durham tube.
“+” -ve test “—” -ve test

15. Indole reaction
A. Salmonella
B. E. coli
is the positive microbe. A B

16. Note the bubble formation. Catalase positive
E. coli
can reduce nitrate to nitrite.

17. Toxin production.
a gluco-lipo-protein complex with which their toxic, antigenic, and immunogenic properties
endotoxins
thermolabile neurotropic exotoxins
haemotoxins
pyrogenic substances,
proteinases,
deoxyribonucleases, urease,
phosphatase
hyaluronidase
aminoacid decarboxylases

18. Antigenic structure.
The antigenic structure of E. coli is characterized by variability and marked individuality. Along with the H- and O-antigens, the presence of other antigens has been shown in some strains, i.e. the surface somatic (membranous, capsular) K-antigens which contain the thermolabile L- and B-antigens and the thermostable A- and M-antigens.
On the basis of antigenic structure an antigenic formula is derived which fully reflects the antigenic properties of the strain For example, one of the most widely spread serotypes is designated 0111 : K58 : H2.

19. Pathogenesis of E. coli diarrheal disease

20. Pathogenesis and diseases in man.
Definite E. coli serogroups are capable of causing various acute intestinal diseases in humans:
the causative agents of colienteritis in children are O-groups-25, -26, -44, -55, -86, -91, -111, -114, -119, -125, -126, -127, -128, -141, -146, and others (they cause diseases in infants of the first months of life and in older infants);
the causative agents of dysentery-like diseases are E. coli of the O-groups-23, -32, -115, -124, -136, -143, -144, -151, and others;
the causative agents of cholera-like diarrhoea are the O-groups-6, -15, -78, -148, and others, they produce thermolabile and thermoresistant enterotoxins.

23. Escherichia coli Virulence Factors
Diarrhea-producing
E. coli
Virulence Factors
Enteroroxigenic E. coli
Heat-labile toxin (LT)
Heat-stable toxin (ST) Colonization factors (fimbriae)
Enterohernorrhagic E. coli
Shiga like toxin (SLT-I)
Shiga like toxin II (SLF-II) Colonisation factors (fimbriae)
Enteroinvasive E. coli
Shiga like toxin II (SLF-II)
Ability to invade epithelial cells
Enteropathogenic E. coli
Adhesin factor for epithelial cells
Urinary trace infections
P- fimbriae
Meningitis
K-1 capsule

24. Enterotoxigenic Escherichia coli.
Enterotoxin-producing E coli, called enterotoxigenic E.coli (ETEC), produce one or both of two different toxins – a heat labile toxin called LT and a heat-stable toxin called ST.

25. Enterohemorrhagic Escherichia coli (EHEC)
is the etiologic agent of hemorrhagic colitis, a disease characterized by severe abdominal cramps and a copious, bloody diarrhea. These organisms are also known to cause a condition termed hemolytic-uremic syndrome (HUS), which is manifested by a hemolytic anemia, thrombocytopenia (decrease in the number of blood platelets), and acute renal failure.

26. Enteroinvasive Escherichia coli.
The disease produced by the enteroinvasive E. coli (EIEC) is indistinguishable from the dysentery produced by members of the genus Shigella, although the shigellae seem to be more virulent because considerably fewer shigellae are required than EIEC to cause diarrhea. The key virulence factor required by the EIEC is the ability to invade the epithelial

27. Enteropathogenic Escherichia coli (EPEC).
The ability of the EPEC to cause diarrhea. EPEC strains routinely have been considered noninvasive, but data have indicated that such strains can invade epithelial cells in culture. However, EPEC strains do not typically cause a bloody diarrhea, and the significance of cell invasion during infection remains uncertain.

31. Immunity.
In individuals who had suffered from diseases caused by pathogenic E. coli serovars, cross immunity is not produced owing to which re-infection may occur.

32. Laboratory diagnosis.
Tested material: the patients' faeces, throat and nasal discharges, material obtained at autopsy (blood, bile, liver, spleen, lungs, contents of the small and large intestine, pus), water, foodstuffs, and samples of washings from objects and hands of staff of maternity hospitals, hospitals, and dairy kitchens

33. The tested material is inoculated onto solid nutrient media (Endo's, Levin's) and, simultaneously, onto Ploskirev's media. Blood is first inoculated into broth and then subcultured on solid media when development of a septic process is suspected.
The pure culture isolate is identified by its morphological, cultural, biochemical, serological, and biological properties.

34. The corresponding O-group to which an enteropathogenic-serovars belong is determined by means of the agglutination reaction.
Besides, the immunofluorescence method employing type specific labelled sera is also used. It yields a preliminary answer in one to two hours.
In serological diagnosis of colienteritis beginning with the third to fifth day of the disease the indirect haemagglutination reaction is used which excels the agglutination reaction in sensitivity.

35. E. coli by immunofluorescence method

36. Treatment. Patients with colienteritis are prescribed
antibiotics (tetracycline with vitamins C, B1 and B2)
biopreparations (coli autovaccine, coli bacteriophage, colicin, bacterin, lactobacterin, bificol, bifidumbacterin).
Physiological solutions with glucose are injected for controlling toxicosis.

37. Prophylaxis.
To prevent diseases caused by pathogenic serovars of E. coli, special attention is given to early identification of individuals suffering from colienteritis, and also to their hospitalization and effective treatment. Regular examination of personnel is necessary in children's institutions as well as of mothers whose children are suffering from dyspepsia. Considerable importance is assigned to observation of sanitary regulations in children's institutions, infant-feeding centres, maternity hospitals, and children's nurseries. Protection of water and foodstuff's from contamination with faeces, the control of flies, and gradual improvement of standards of hygiene of the population are also particularly important.

38. Sanitary significance of E. coli.
This organism is widely spread in nature. It occurs in soil, water, foodstuff's, and on various objects. For this reason E. coli serves as an indicator of faecal contamination of the external environment.
Detection of E. coli is of great importance in estimating the sanitary index of faecal contamination of water, foodstuff's, soil, beverages, objects, and hand-washings. The degree of contamination of water, soil and foodstuff's is determined by the coli titre or coli index (these terms have been discussed in the chapter concerning the spread of microbes in nature).

39. Salmonella Enteric Fever and Paratyphoid Salmonellae: Salmonella typhi
Salmonella paratyphi A
Salmonella schottmuelleri (S. paratyphi B)

40. Salmonella Morphology.
The morphology of the typhoid and paratyphoid salmonella corresponds with the general characteristics of the Enterobacteriaceae family. Most of the strains are motile and possess flagella, from 8 to 20 in number.

41. Salmonella typhi
Scanning electron micrograph
Gram’s staining

42. Cultivation.
Colonies of S. paratyphi on Ploskirev's medium

43. Colonies of S. typhus on Ploskirev's medium

44. Colonies of Salmonella on Mac-Conkey medium

45. Colonies of Salmonella on CLED medium

46. Colonies of S. typhus on on bismuth-sulphite agar

47. Fermentative properties.

48. Toxin production.
S. typhi contains gluco-lipo-protein complexes. The endotoxin is obtained by extracting the bacterial emulsion with trichloracetic acid. This endotoxin is thermostable, surviving a temperature of 120° C for 30 minutes, and is characterized by a highly specific precipitin reaction and pronounced toxic and antigenic properties. Investigations have shown the presence of exotoxic substances in S. typhi which are inactivated by light, air, and heat (80° C), as well as enterotropic toxin phosphatase, and pyrogenic substances.

49. Antigenic structure.
S. typhi possesses a flagella H-antigen and thermostable somatic O- and Vi-antigens. All three antigens give rise to the production of specific antibodies in the body, i. e. H-, O-, and Vi-agglutinins. H-agglutinins bring about a large-flocculent agglutination, while 0- and Vi-agglutinins produce fine-granular agglutination.

51. Classification.
The salmonellae of typhoid fever and paratyphoids together with the causative agents of toxinfections have been included in the genus Salmonella (named after the bacteriologist D. Salmon) on the basis of their antigenic structure and other properties. At present, about 2000 species and types of this genus are known.
F. Kauffmann and P. White classified the typhoid-paratyphoid salmonellae into a number of groups according to antigenic structure and determined 65 somatic O-antigens. For instance, S. typhi (group D) contains three different O-antigens — 9, 12, and Vi. S. paratyphi A alone constitutes group A, and S. schottmuelleri belongs to group B.

52. Pathogenesis and diseases in man.
The causative agent is primarily located in the intestinal tract. Infection takes place through the mouth (digestive stage).
Cyclic recurrences and development of certain pathophysiological changes characterize the pathogenesis of typhoid fever and paratyphoids.
There is a certain time interval after the salmonellae penetrate into the intestine, during which inflammatory processes develop in the isolated follicles and Peyer's patches of the lower region of the small intestine (invasive stage).

53. As a result of deterioration of the defence mechanism of the lymphatic apparatus in the small intestine the organisms enter the blood (bacteriemia stage). Here they are partially destroyed by the bactericidal substances contained in the blood, with endotoxin formation.
During bacteraemia typhoid salmonellae invade the patient's body, penetrating into the lymph nodes, spleen, bone marrow, liver, and other organs (parenchymal diffusion stage). This period coincides with the early symptoms of the disease and lasts for a week.

54. During the second week of the disease endotoxins accumulate in Peyer's patches, are absorbed by the blood, and cause intoxication. The general clinical picture of the disease is characterized by status typhosus, disturbances of thermoregulation, activity of the central and vegetative nervous systems, cardiovascular activity, etc.

55. On the third week of the disease a large number of typhoid bacteria enter the intestine from the bile ducts and Lieberkuhn's glands. Some of these bacteria are excreted in the faeces, while others reenter the Peyer's patches and solitary follicles, which had been previously sensitized by the salmonellae in the initial stage. This results in the development of hyperergia and ulcerative processes. Lesions are most pronounced in Peyer's patches and solitary follicles and may be followed by perforation of the intestine and peritonitis (excretory and allergic stage).

56. The typhoid-paratyphoid salmonellae together with products of their metabolism induce antibody production and promote phagocytosis. These processes reach their peak on the fifth-sixth week of the disease and eventually lead to recovery from the disease.
Clinical recovery (recovery stage) does not coincide with the elimination of the pathogenic bacteria from the body. The majority of convalescents become carriers during the first weeks following recovery, and 3-5 per cent of the cases continue to excrete the organisms for many months and years after the attack and, sometimes, for life.

57. Inflammatory processes in the gall bladder (cholecystitis) and liver are the main causes of a carrier state since these organs serve as favourable media for the bacteria, where the latter multiply and live for long periods. Besides this, typhoid-paratyphoid salmonellae may affect the kidneys and urinary bladder, giving rise to pyelitis and cystitis. In such lesions the organisms are excreted in the urine.

58. Immunity.
Immunity acquired after typhoid fever and paratyphoids is relatively stable but relapses and reinfections sometimes occur.
Antibiotics, used as therapeutic agents, inhibit the immunogenic activity of the pathogens, which change rapidly and lose their O- and Vi-antigens.

59. Laboratory diagnosis.
The present laboratory diagnosis of typhoid fever and paratyphoids is based on the pathogenesis of these diseases.
1. Isolation of haemoculture. Bacteraemia appears during the first days of the infection. Thus, for culture isolation ml of blood (15-20 ml during the second week of the disease and ml during the third week) are inoculated into 100, 150 and 200 ml of 10 per cent bile broth, after which cultures are incubated at 37° C and on the second day subcultured onto one of the differential media (Ploskirev's, Endo's, Levin’s) or common meat-peptone agar.

60. The isolated culture is identified by inoculation into a series of differential media and by the agglutination reaction. The latter is performed by the glass-slide method using monoreceptor sera or by the test-tube method using purified specific sera.

61. 2. Serological method. Sufficient number of agglutinins accumulate in the blood on the second week of the disease, and they are detected by the Widal reaction. Diagnostic typhoid and paratyphoid A and B suspensions are employed in this reaction. The fact that individuals treated with antibiotics may yield a low titre reaction must be taken into consideration. The reaction is valued positive in patient's serum in dilution 1 : 200 and higher.
The Widal reaction may be positive not only in patients but also in those who had suffered the disease in the past and in vaccinated individuals. For this reason diagnostic suspensions of O- and H-antigens are employed in this reaction. The sera of vaccinated people and convalescents contain H-agglutinins for a long time, while the sera of patients contain O-agglutinins at the height of the disease.

62. In typhoid fever and paratyphoids the agglutination reaction may sometimes be of a group character since the patient's serum contains agglutinins not only to specific but also to group antigens which occur in other bacteria. In such cases the patient's blood must be sampled again in 5-6 days and the Widal reaction repeated. Increase of the agglutinin titre makes laboratory diagnosis easier. In cases when the serum titre shows an equal rise with several antigens, 0-, H-, and Vi-agglutinins are detected separately.

63. 3. A pure culture is isolated from faeces and urine during the first, second, and third weeks of the disease. The test material is inoculated into bile broth, Muller's medium, Ploskirev's medium, or bismuth sulphite agar.
Isolation and identification of the pure culture are performed in the same way as in blood examination.
Selective media are recommended for isolation of the typhoid-paratyphoid organisms from water, sewage, milk, and faeces of healthy individuals. These media slightly inhibit the growth of pathogenic strains of typhoid-paratyphoid organisms and greatly suppress the-growth of saprophytic microflora.

64. A reaction for the detection of a rise in the phage titre is employed in typhoid fever and paratyphoid diagnosis. This reaction is based on the fact that the specific (indicator) phage multiplies only when it is in contact with homologous salmonellae. An increase in the number of phage corpuscles in the test tube as compared to the control tube is indicative of the presence of organisms homologous to the phage used. This reaction is highly sensitive and specific and permits to reveal the presence of the salmonellae in various substrates in hours without the necessity of isolating the organisms in a pure culture. The reaction is valued positive if the increase in the number of corpuscles in the tube containing the test specimen is not less than 5-10 times that in the control tube.

65. Treatment.
chloramphenicol, oxytetracycline, and nitrofuran preparations
general non-specific treatment (dietetic and symptomatic)

66. Prophylaxis. timely diagnosis
hospitalization of patients, disinfection of the sources, and identification
treatment of carriers
disinfection of water, safeguarding water supplies from pollution, systematic and thorough cleaning of inhabited areas, fly control, and protection of foodstuff's and water from flies
Washing of hands before meals and after using the toilet is necessary
regular examination of personnel in food-processing factories for identification of carriers is also extremely important.
several varieties of vaccines are prepared: typhoid vaccine (monovaccine), typhoid and paratyphoid B vaccine (divaccine).

67. Shigella
a. Slender, gram-negative rod; non lactose-fermenting (except for S. sonnei)
b. In contrast to E. coli: no H2S production, no lysine decarboxylation, no acetate utilization
c. Invasive (key to pathogenesis)
d. In contrast to Salmonella: non-motile; no gas from glucose fermentation; no H2S production
e. Toxin production limited to a few strains

68. f. All have O antigens-four groups (A-D)
g. Differentiating species ( S. dysenteriae - no mannitol fermentation; S. boydii - C antigen group; S. flexneri - B antigen group; S. sonnei-orniltine decarbexylase production) h. Specimens
i. Rectal swab from colonic ulcer is best for culture.
j. Fecal specimen - must be immediately innoculated onto transport media or culture media. k. Sensitive to acids present in feces.

69. Morphology.
Morphologically dysentery bacilli correspond to the organisms of the family Enterobacteriaceae. Dysentery bacilli have no flagella and this is one of the differential characters between these organisms and bacteria of the coli-typhoid-paratyphoid group.

70. Dysentery bacilli
Intracellular Shigella

71. Colonies of dysentery bacilli on Ploskirev's medium
Cultivation.
Colonies of dysentery bacilli on Ploskirev's medium

72. Colonies of Salmonella on Mac-Conkey medium

73. Fermentative properties.
None of the species of dysentery bacilli liquefy gelatin nor produce hydrogen sulphide. They ferment glucose, with acid formation, with the exception of the Newcastle subspecies which sometimes produce both acid and gas during this reaction. With the exception of the Sonne bacilli, none of them ferment lactose.

74. Shigellae Biochemical Properties
Subgroup
Fermentation of carbohydrates
Indole production
Catalase
lactose
glucose
mannite
succrose
S. dysenteriae – A – +
S. fiexneri – B
S. boydii – C
S. sonnei – D
+ slowly
slowly

75. Test for determination of motility and producing hydrogen sulphide
S. flexneri – nonmotile, no produce hydrogen sulphide;
Enterobacter cloacea – motile, no produce hydrogen sulphide;
3. Proteus mirabilis – motile, produce hydrogen sulphide.

76. Toxin production.
S. dysenteriae produce thermolabile exotoxin which displays marked tropism to the nervous system and intestinal mucous membrane. This toxin may be found in old meat broth cultures, lysates of a 24-hour-old agar culture, and in desiccated bacterial cells.
An intravenous injection of small doses of the exotoxin is fatal to rabbits and white mice. Such an injection produces diarrhoea, paralysis of the hind limbs, and collapse.

77. The dysentery exotoxin causes the production of a corresponding antitoxin. The remaining types of dysentery bacilli produce no soluble toxins. They contain endotoxins, which are of a gluco-lipo-protein nature, and occur in the smooth but not in the rough variants.
Thermolabile substances exerting a neurotropic effect were revealed in some S. sonnei strains. They were extracted from old cultures by treating the latter with trichloracetic acid.

78. Antigenic structure.
Dysentery bacilli are subdivided into 4 subgroups within which serovars may be distinguished. The antigenic structure of shigellae is associated with somatic O-antigens and surface K-antigens.

79. Antigens Subgroup Species and serotype Subse-rotypes Antigenic formula
Type antigen
Group antigens
A. Does not ferment mannite
S.dysenteria
1-12
B. Ferments mannite as a rule
S. flexneri , 2, 3, 4, 5,
6, X variant Y variant
1a, 1b, 2a, 2b,
3a, 3b, 4a, 4b
I, II, III, IV, V, VI
2, 3, 4, 6, 7, 8
C. Ferments mannite as a rule
S. boydii,
D. Ferments mannite, slowly lactose and saccharose
S. sonnei

80. Classification.
Dysentery bacilli are differentiated on the basis of the whole complex of antigenic and biochemical properties. S. sonnei have four fermentative types which differ in the activity of ramnose and xylose and in sensitivity to phages and colicins.

81. Epidemiology and Pathogenesis of Shigellosis.
Humans seem to be the only natural hosts for the shigellae, becoming infected after the ingestion of contaminated food or water. Unlike Salmonella, the shigellae remain localized in the intestinal epithelial cells, and the debilitating effects of shigellosis are mostly attributed to the loss of fluids, electrolytes, and nutrients and to the ulceration that occurs in the colon wall.

82. of shigellosis in humans
Pathogenesis
of shigellosis in humans

83. Shigella dysenteriae type 1 secreted one or more exotoxins (called Shiga toxins), which would cause death when injected into experimental animals and fluid accumulation when placed in ligated segments of rabbit ileum.
The mechanism whereby Shiga toxin causes fluid secretion is thought to occur by blocking fluid absorption in the intestine. In this model, Shiga toxin kills absorptive epithelial cells, and the diarrhea results from an inhibition of absorption rather than from active secretion.

84. To cause intestinal disease, shigellae must invade the epithelial cells lining of the intestine. After escaping from the phagocytic vacuole, they multiply within the epithelial cells. Thus, Shigella virulence requires that the organisms invade epithelial cells, multiply intracellularly, and spread from cell to cell by way of finger-like projections to expand the focus of infection, leading to ulceration and destruction of the epithelial layer of the colon.

85. Gross pathology of shigellosis

86. Histopathology of acute colitis following peroral infection with shigellae.

87. Immunity.
Immunity acquired after dysentery is specific and type-specific but relatively weak and of a short duration. For this reason the disease may recur many times and, in some cases, may become chronic. This is probably explained by the fact that Shigella organisms share an antigen with human tissues.

88. Laboratory diagnosis.
Reliable results of laboratory examination depend, to a large extent, on correct sampling of stool specimens and its immediate inoculation onto a selective differential medium. The procedure should be carried out at the patient's bedside, and the plate sent to the laboratory.

89. Rules the correct procedure of material collection :
carry out bacteriological examination of faeces before aetiotropic therapy has been initiated;
collect faecal samples (mucus, mucosal admixtures) from the bedpan and with swabs (loops) directly from the rectum (the presence in the bedpan of even the traces of disin­fectants affects the results of examination);
inoculate without delay the collected material onto enrichment media, place them into an incubator or store them in preserving medium in the cold;
send the material to the laboratory as soon as possible.

90. Bacteriological examination.
Faecal samples are streaked onto plates with Ploskirev's medium and onto a selenite medium containing phenol derivatives, beta-galactosides, which retard the growth of the attendant flora, in particular E. coli. The inoculated cultures are placed into a 37 °C incubator for 1S-24 hrs. The nature of tile colonies is examined on the second day.
Colourless lactose-negative colonies are subcultured to Olkenitsky's medium or to an agar slant to enrich for pure cultures. On the third day, examine the nature of the growth on Olkenitsky's medium for changes in the colour of the medium column without gas formation. Subculture the material to Hiss' media with malonate, arabinose, rhamnose, xylose, dulcite, salicine, and phenylalanine. Read the re­sults indicative of biochemical activity on the following day. Shigellae ferment carbohydrates with the formation of acid

91. To determine the species of Shigellae, one can employ the following tests:
1.The agglutination test is performed first with a mixture of sera containing those species, and variants of Shigellae that are prevalent in a given area, and then the slide agglutination test with monoreceptor species sera.
2. The coagglutination test which allows to determine the specificity of the causative agent by a positive reaction with protein A of staphylococci coated with specific antibodies. On a suspected colony put a drop of specific sensitized protein A of Staphylococcus aureus, then rock the dish and 15 min later examine it microscopically for the appearance of the agglutinate (these tests may also be carried out on the second day of the investigation with the material from lactose-negative colonies).
3. Direct and indirect immunofluorescence test.

92. IFT: Salmonella enterica serovar Typhimurium inside (green) and on the surface (blue) of human intestinal epithelial cells. Actin is labelled in red.

93. 4. The indirect haemagglutination (IHA) test with erythrocyte diagnosticums with the titre of 1:160 and higher is performed. The test. is repeated after at least seven days. Diagnostically important is a four-fold rise in the anti­body litre, which can be elicited from the 10th-12th day of the disease. To distinguish between patients with subclinical forms of the disease and Shigella carriers, identify immunoglobulins of the G class.
5. ELISA. For the epidemiological purpose the phagovar and colicinovar of Shigellae are also identified.
6. To determine whether the isolated cultures belong to the genus Shigella, perform the keratoconjunctival test on guinea pigs. In contrast to causal organisms of other intestinal infections, the dysentery Shigellae cause marked keratitis.

94. 7. An allergic test consisting in intracutaneous injection of 0
7. An allergic test consisting in intracutaneous injection of 0.1 ml of dysenterin is applied in the diagnosis of dysentery in adults and children. Hyperaemia and a papule 2 to 3.5 cm in diameter develop at the site of the injection in 24 hours in a person who has dysentery. The test is strictly specific.
8. An allergy intracutaneous test with Tsuverkalov's dysenterine is of supplementary significance. It becomes positive in dysentery patients beginning with the fourth day of the disease. The result is read in 24 hrs by the size of the formed papula. The test is consid­ered markedly positive in the presence of oedema and skin hyperaemia 35 mm or more in diameter, moderately positive if this diameter is mm, doubtful if there is no papula and the diameter of skin hyperaemia measures mm, and negative if the hyperaemic area is less than 10 mm.
9. The nature of the isolated culture may be determined in some cases by its lysis by a polyvalent dysentery phage

95. Treatment of Shigellosis
Intravenous replacement of fluids and electrolytes;
antibiotic therapy (ampicillin frequently is not effective, and alternative therapies include sulfamethoxazole / trimethoprim and, the quinolone antibiotics such as nalidixic acid and ciprofloxacin)

96. Dysentery control is ensured by a complex of general and specific measures; (1) early and a completely effective clinical, epidemiological, and laboratory diagnosis; (2) hospitalization of patients or their isolation at home with observance of the required regimen; (3) thorough disinfection of sources of the disease; (4) adequate treatment of patients with highly effective antibiotics and use of chemotherapy and immunotherapy; (5) control of disease centres with employment of prophylaxis measures; (6) surveillance over foci and the application of prophylactic measures there; (7) treatment with a phage of all persons who were in contact with the sick individuals; (8) observance of sanitary and hygienic regimens in children's institutions, at home and at places of work, in food industry establishments, at catering establishments, in food stores.

97. Vibrio Cholerae
Morphology. Cholera vibrios are shaped like a comma or a curved rod measuring 1-5 mcm in length and 0.3 mcm in breadth
They are very actively motile, monotrichous, nonsporeforming, noncapsulated, and Gram-negative.

98. Gram’s stain
Scanning electron
micrograph V. cholerae

100. Colonies of V. cholerae on bismuth-sulphit-agar
Cultivation.
Colonies of V. cholerae on bismuth-sulphit-agar

101. Colonies of V. cholerae on blood agar

102. Fermentative properties.
The cholera vibrio liquefies coagulated serum and gelatin; it forms indole and ammonia, reduces nitrates to nitrites, breaks down urea, ferments glucose, levulose, galactose, maltose, saccharose, mannose, mannite, starch, and glycerine (slowly) with acid formation but does not ferment lactose in the first 48 hours, and always coagulates milk. The cholera vibrio possesses lysin and ornithine decarboxylases and oxidase activity. B. Heiberg differentiated vibrios into biochemical types according to their property of fermenting mannose, arabinose, and saccharose.

103. Sheep erythrocyte hemolysis Lysis by specific O-1 subgroup phages
Vibrio
Fermentation
within 24 hrs
Sheep erythrocyte hemolysis
Lysis by specific O-1 subgroup phages
Agglutination by O-1 cholera serum
Sensitivity to polymixin B
sacharose
mannose
arabinose
Vibrio cholerae biovar cholerae A – +
Vibrio cholerae biovar El Tor
Vibrio cholerae biovar Proteus
Vibrio cholerae biovar albensis А

104. Toxin production.
an exotoxin (cholerogen) which is marked by an enterotoxic effect
the endotoxin also exerts a powerful toxic effect fibrinolysin
hyaluronidase
collagenase
mucinase
lecithinase
neuraminidase
proteinases

105. Mechanism of action of cholera enterotoxin according to Finkelstein
Mechanism of action of cholera enterotoxin according to Finkelstein. Cholera toxin approaches target cell surface. B subunits bind to oligosaccharide of GM1 ganglioside. Conformational alteration of holotoxin occurs, allowing the presentation of the A subunit to cell surface. The A subunit enters the cell. The disulfide bond of the A subunit is reduced by intracellular glutathione, freeing A1 and A2. NAD is hydrolyzed by A1, yielding ADP-ribose and nicotinamide. One of the G proteins of adenylate cyclase is ADP-ribosylated, inhibiting the action of GTPase and locking adenylate cyclase in the "on" mode.

106. Cholera toxin activates the adenylate cyclase enzyme in cells of the intestinal mucosa leading to increased levels of intracellular cAMP, and the secretion of H20, Na+, K+, Cl-, and HCO3- into the lumen of the small intestine.

107. Antigenic Determinants of Vibrio cholerae

108. Pathogenesis and diseases in man.
Cholera is undoubtedly the most dramatic of the water-borne diseases. The cholera vibrios are transmitted from sick persons and carriers by food, water, flies, and contaminated hands.

110. Cholera is characterized by a short incubation period of several hours to up to 6 days (in a disease caused by the El Tor vibrio it lasts three to five days), and the disease symptoms include general weakness, vomiting, and a frequent loose stool. The stools resemble rice-water and contain enormous numbers of torn-off intestinal epithelial cells and cholera vibrios. The major symptom of cholera is a severe diarrhea in which a patient may lose as much as 10 to 20 L or more of liquid per day. Death, which may occur in as many as 60% of untreated patients, results from severe dehydration and loss of electrolytes.

111. Phases in the development of the disease:
1. Cholera enteritis (choleric diarrhoea) which lasts 1 or 2 days. In some cases the infectious process terminates in this period and the patient recovers.
2. Cholera gastroenteritis is the second phase of the disease. Profuse diarrhoea and continuous vomiting lead to dehydration of the patient's body and this results in lowering of body temperature, decrease in the amount of urine excreted, drastic decrease in the number of mineral and protein substance, and the appearance of convulsions. The presence of cholera vibrios is revealed guite frequently in the vomit and particularly in the stools which have the appearance of rice water.

112. 3. Cholera algid which is characterized by severe symptoms
3. Cholera algid which is characterized by severe symptoms. The skin becomes wrinkled due to the loss of water, cyanosis appears, and the voice becomes husky and is sometimes lost completely. The body temperature falls to ° C. As a result of blood concentration cardiac activity is drastically weakened and urination is suppressed.

114. Immunity
acquired after cholera is high-grade but of short duration and is of an anti-infectious (antibacterial and antitoxic) character. It is associated mainly with the presence of antibodies (lysins, agglutinins, and opsonins). The cholera vibrios rapidly undergo lysis under the influence of immune sera which contain bacteriolysins.

115. Laboratory diagnosis.
A strict regimen is established in the laboratory. Examinations are carried out in accordance with the general rules observed for particularly hazardous diseases.
Test specimens are collected from stools, vomit, organs obtained at autopsy, water, objects contaminated by patient's stools, and, in some cases, from foodstuffs. Certain rules are observed when the material is collected and transported to the laboratory, and examination is made in the following stages.

116. 1. Stool smears stained by a water solution of fuchsin are examined microscopically. In the smears, the cholera vibrios occur in groups similar to shoals of fish.
2. A stool sample is inoculated into 1 per cent peptone water and alkaline agar. After 6 hours incubation at 37°C the cholera vibrios form a thin pellicle in the peptone water, which adheres to the glass. The pellicle smears are Gram stained, and the culture is examined for motility. A slide agglutination reaction is performed with specific agglutinating O-serum diluted in a ratio of 1 in 100.

117. Vibrio cholerae (stool smear)

118. The organisms are then transferred from the peptone water onto alkaline agar for isolation of the pure culture. If the first generation of the vibrios in peptone water is not visible, a drop taken from the surface layer is re-inoculated into another tube of peptone water. In some cases with such re-inoculations, an increase in the number of vibrios is achieved.
The vibrio culture grown on solid media is examined for motility and agglutinable properties. Then it is subcultured on an agar slant to obtain the pure culture.

119. 3. The organism is identified finally by its agglutination reaction with specific O-serum, determination of its fermentative properties (fermentation of mannose, saccharose, and arabinose), and its susceptibility to phagolysis.

120. Colonies of Vibrio cholerae of font varying opacity (increasing from top right, left bottom right)  pseudocoloured to accentuate differences in gray-scale intensity. Of varying opacity (increasing from top left to top right, to bottom left to bottom right) pseudocoloured to accentuate differences in grey-scale intensity. 

121. The following procedures are undertaken for rapid diagnosis: (1) dark field microscopy of the stool; (2) stool culture by the method of tampons incubated for hours in an enrichment medium with repeated dark field microscopy; (3) agglutination reaction by the method of fluorescent antibodies; (4) bacterial diagnosis by isolation of cholera vibrios (the faecal mass is seeded as a thin layer into a dish containing non-inhibiting nutrient agar and grown for 4-5 hours, the vibrio colonies are detected with a stereoscopic microscope, and the culture is tested by the agglutination reaction with O-serum on glass; (5) since neuraminidase is discharged by the cholera vibrios and enters the intestine, a test for this enzyme is considered expedient as a means of early diagnosis (it is demonstrated in per cent of patients, in per cent of vibrio carriers, and occasionally in healthy individuals).

123. Treatment.
antibiotics of the tetracycline group (tetracycline, sigmamycin), amphenicol, and streptomycin are prescribed at first intravenously and then by mouth.
pathogenetic therapy is very important: control of dehydration, hypoproteinaemia, metabolic disorders, and the consequences of toxicosis, acidosis in particular, by infusion of saline (sodium and potassium) solutions, infusion of plasma or dry serum, glucose, the use of warm bath, administration of drugs which improve the tone of the heart and vessels.

124. Prophylaxis.
Cholera patients and vibrio carriers are the source of the disease. Individuals remain carriers of the El Tor vibrio for a lengthy period of time, for several years. Vibrios of this biotype are widely distributed in countries with a low sanitary level. They survive in water reservoirs for a long time and have been found in the bodies of frogs and oysters. Infection may occur from bathing in contaminated water and fishing for and eating shrimps, oysters, and fish infected with El Tor vibrio.The following measures are applied in a cholera focus:

125. 1. detection of the first cases with cholera, careful registration of all sick individuals, immediate information of health protection organs;
2. isolation and hospitalization, according to special rules, of all sick individuals and carriers, observation and laboratory testing of all contacts;
3. concurrent and final disinfection in departments for cholera patients and in the focus;

126. 4. protection of sources of water supply, stricter sanitary control over catering establishments, control of flies; in view of the possibility of El Tor vibrio reproducing in water reservoirs under favourable conditions (temperature, the presence of nutrient substrates) systematic bacteriological control over water reservoirs has become necessary, especially in places of mass rest and recreation of the population in the summer;

127. 5. strict observance of individual hygiene; boiling or proper chlorination of water, decontamination of dishes, hand washing;
6. specific prophylaxis: immunization with the cholera monovaccine containing 8 thousand million microbial bodies per 1 ml or with the cholera anatoxin. Chemoprophylaxis with oral tetracycline is conducted for persons who were in contact with the sick individual or for patients with suspected cholera.