LISTERIA

YERSINIA
PROTEUS

Dr. Klára Megyeri

University of Szeged
Department of Medical Microbiology
2024
The genus Listeria
 Listeria monocytogenes
OCCURRENCE
Wide-spread distribution in nature: soil, vegetation, water, and a variety of mammals, birds, fish, insects,
and other animals
MICROSCOPIC MORPHOLOGY
Gram-positive, peritrichous flagellate, nonencapsulated, nonsporulating rods or coccobacilli
Bacteria move at room temperature but not at 37 °C.
CULTIVATION
Can be cultivated on nutrient agar culture medium,
On blood agar culture medium causes  hemolysis, and CAMP-positive
Listeria is able to grow in a wide pH range, as well as in cold temperatures- a fact that has been
exploited for the selective isolation of this bacterium (”cold enrichment”). Thus, refrigeration of
contaminated food products permits the slow multiplication of the oraganism to an infectious dose!
Listeria monocytogenes is CAMP-positive

CAMP = ChristieAtkinsMunch-Petersen
Pathogenesis
 Three tight barriers:
i. the intestinal,
ii. blood-brain, and
iii. placental barriers are crossed by Listeria.
These events are central for human listeriosis
pathophysiology.

 Listeria is a facultative intracellular pathogen capable

of replicating in epithelial cells and macrophages.
 The virulence factor termed internalin is necessary for the adhesion of the bacteria to
the epithelial, endothelial and immune cells.
 The internalin receptor is E-cadherin belonging to the cadherin superfamily of cell
adhesion molecules.
 Enterocytes take up Listeria bound to E-cadherin by endocytosis.
 Internalin/E-cadherin interaction promotes Listeria entry, transcytosis and cell-to-cell
spread.
 Internalin, therefore, is essential for the bacteria to cross the intestinal, placental and
blood-brain barriers.
 Listeria produces three virulence factors that help it to escape from the phagosome to the
cytoplasm:
(i) a listeriolysin (LLO), (ii and iii) two phospholipase C enzymes.
 LLO belongs to the family of cholesterol-dependent cytolytic toxins, and acts as
multifunctional virulence factor triggering:
• pore formation,
→ cell lysis, tissue destruction
→ bacterial escape from the phagosome or endosome
• binding to lipid rafts
→ modulation of cellular signaling mechanisms
→ broad spectrum cellular effects
• autophagy induction through the AMPK pathway
• histone modifications
→ modulate transcription
• inflammasome assembly
→ IL-1 production 
• mitochondrial fragmentation
 The effects of the two phospholipases:
→ they help the bacterium to translocate from the phagosome and endosome into the
cytoplasm
→ in the cytoplasm, they inhibit the elongation and closure of the autophagosomal
membrane
 LLO pore formation

LLO

1. LLO triggers cell

lysis
2. and 3. LLO helps
bacteria to escape
from the phagosome
1 or endosome
LLO binds to lipid rafts and activates several signaling pathways
•Once within the cytoplasm of the host cell, Listeria quickly
assembles proteins from the host cell to form rocket-like tails
containing F-actin.
•The ActA protein is responsible the actin-based intra- and
intercellular motility of this bacterium.
•The actin tail facilitates intra- and intercellular spread of the
bacterium and invasion through the barriers.
•The infection can thereby become disseminated.
Virulence factors of Listeria involved in adhesion and escape
from the phagosome
Listeria monocytogenes is a ubiquitous environmental saprophytic
microorganism.
It can infect animals; the most common manifestations are: abortion in pregnant
animals or neurological signs reflective of encephalitis in non-pregnant animals.
However, asymptomatic carriage is frequent in animals.
Human disease is uncommon and restricted to several well-defined
populations:
• Pregnant women
• Neonates and the elderly
• Immunocompromised patients

 In general, in healthy people, after consuming massively contaminated (~109 bacteria)

food gastroenteritis of varying severity develops.
 However, in people belonging to the risk group, consumption of significantly less
contaminated food (102-104 bacteria) can even cause sepsis, meningitis, or fetal
infection ending in abortion.
 Pathogenesis of Listeria infections

Prevention: Because Listeria is ubiquitous and most infections are sporadic, prevention and control are
difficult. However, high-risk individuals (e.g., pregnant women, immunocompromised persons, the elderly)
should avoid eating raw or partially cooked foods of animal origin, soft cheeses, and unwashed raw
vegetables.
Pathogenesis of listeriosis

SEPTICEMIA
 Clinical forms of listeriosis
1. Listeria gastroenteritis
•Gastroenteritis with fever
•Food-borne, non-invasive diarrhea
•Incubation period: 1-2 days
•Diarrhea period: 1-3 days
•The possibility of a manifest diarrhea increases with the size of Listeria
inoculum
•Patients present with fever, muscle aches, nausea, diarrhea, headache,
stiff neck, confusion, loss of balance, or convulsions.
2. Listeriosis in pregancy
•Listeria can colonize and proliferate asymptomatically in the GI tract,
vagina and uterus.
•Pregnancy (especially in the 3rd trimester) leads to immunosuppression,
which in turn may lead to manifest disease. Thus, if the mother becomes
symptomatic, it is usually in the third trimester.
•The infection is usually mild; symptoms include fever, myalgias,
arthralgias and headache, but sometimes CNS infection may arise.
•Miscarriage, stillbirth and preterm labor are complications of this
infection.
 3. CNS listeriosis
Listeria has a predilection for the brain parenchyma, especially the brain
stem, and the meninges.
Clinical manifestations:
•Meningitis,
•Ventriculitis (IV. ventricle),
•Cervical myelitis,
•Abscesses (in 10% of the cases), located in the thalamusban and brain
stem; has a high mortality rate
Clinical symptoms:
•Mental status changes are common
•Focal and generalized seizures (in 25% of cases)
•Cranial nerve palsies
•Stroke-like symptoms
•Tremor, myoconus, ataxia
•Stiff neck may not be present
 4. Neonatal listeriosis

EARLY-ONSET LATE-ONSET

Mode of infection in utero postpartum

Symptoms in fever, headache and myalgia a few days before asymptomatic

mother delivery
Time of delivery Often preterm term

Mean time of 1,5 d after birth 14 d after birth

onset
Clinical picture sepsis Nonspecific illness

Other Chorioamnionitis, Respiratory distress Meningitis

manifestations syndrome, Pneumonia, Meningitis, Myocarditis
Granulomatosis infantiseptica
Granulomatosis infantiseptica: widely disseminated granulomas and abscesses;
affected organs: liver, skin, placenta and also brain, adrenal glands, spleen,
kidney, lungs and GI tract

Stillborn with generalized Listeria monocytogenes infection, a clinical

condition also known as granulomatosis infantiseptica and characterized by
the presence of disseminated pyogranulomatous lesion on the body surface
(A) and internal organs (B, liver of the infant)

A. B.
5. Focal infections
Most of these focal infections tend to occur in immunocompromised patients.

●Skin or eye infections as a result of direct inoculation are a rare occurrence in

veterinarians, farmers, and laboratory workers.
●Cholecystitis can result from hematogenous seeding, and acute hepatitis
simulating viral hepatitis can be seen in patients with disseminated infection.
●Peritonitis can occur in patients treated with continuous ambulatory peritoneal
dialysis and those with cirrhosis.
●Other complications include Parinaud oculoglandular syndrome (conjunctivitis,
lymphadenomegaly, fever), lymphadenitis, pneumonia and empyema,
myocarditis, endocarditis (usually with a subacute presentation), septic arthritis,
osteomyelitis, prosthetic joint infection, necrotizing fasciitis, arteritis,
prosthetic graft infection, and biliary tract infection.
Diagnosis
Samples: liquor, blood, pus
Methods:
cultivation, identification by MALDI-TOF, determination of the antibiotic
susceptibility
rtPCR (can be multiplex)

QIAstatDx ME panel
Therapy:
Preferred Abx:
Ampicillin+aminoglycosides (gentamicin)

Other Abx/Pathogen-specific therapy:

• TMP/SMX, Ampicillin+TMP/SMX
• Carbapenems (meropenem)+ gentamicin

Duration: 21 days
 Yersinia
Gram-negative, non-sporing rods, facultative anaerobs, oxidase-, catalase+, nitrate
reductase+, ferments glucose without the production of gas
Order: Enterobacterales; family: Yersiniaceae
Species of medical importance:
Yersinia pestis (no flagella)
Yersinia enterocolitica (peritrichous flagella at 22-25 C, but no flagella at
37 C)
Yersinia pseudotuberculosis (peritrichous flagella at 22-25 C, but no
flagella at 37 C)
 Virulence factors

•Virulence factors of Yersiniae are encoded by plasmids and

chromosomal genes.
•A 70 kb plasmid (pYV) encodes the main virulence factors of
Yersiniae. This plasmid can be found in every Yersinia species.

•in Yersinia pestis:

+1. 110 kb plasmid, containing the genes responsible for
antiphagocytic protein capsule (Fra) and a toxin which is lethal in
mice and acts by preventing the action of adrenaline.
+2. 9.5 kb plasmid, which contains the gene(s) responsible for
plasminogen aktivator protease (Pla)

-has a role in the invasiveness of Y. pestis
-regulates the expression of Yops, thereby promotes the survival of Y.
pestis in phagocytes
 Effect of Yersinia pestis Pla on the coagulation system

Urokinase
activation

Plasminogen
activation PAI-1
inactivation TAFI degradation
Inactivation
of α-2AP Activation of the VII
Plasmin
coagulation factor

FIBRINOLYSIS COAGULATION

Decrease in
neutrophil
recruitment Increase in Inactivation of TFPI
neutrophil
Inactivation of C3 recruitment
complement component

Pla enhances fibrinolysis by:

• Stimulating conversion of plasminogen to plasmin
• Activating urokinase
• Inducing degradation of thrombin-activated fibrinolysis inhibitor (TAFI)
• Inactivating plasminogen activator inhibitor-1 (PAI-1)
• Inaktivating α2-antiplasmin (α2AP)
Fibrin degradation allows bacterial dissemination and reduces recruitment of neutrophils to the infection foci, which is
also affected by the Pla-mediated cleavage of the C3 complement protein.
Pla favors coagulation by:
• Activating the VII coagulation factor
• Inactivating the anticoagulant tissue factor pathway inhibitor (TFPI)
Fibrin traps bacteria and decreases their dissemination, it also increases leukocyte engagement.
 The 3 main groups of virulence factors encoded by Yersiniae

1. Adhesin/invasin proteins
invasin (inv), Ail, YadA
- YadA binds to fibronectin,
- YadA and Inv bind to integrins in intestinal tissue

these proteins play a role in adherence, invasion and serum resistance
2. Yersinia effectors proteins/Secreted antiphagocytic proteins
11 Yops; THEMPO
they gain access to human cells via the bacterial T3SS
directly attack the host cells
interfere directly with signal transduction of phagocytes
destroy actin filaments
suppress the production of proinflammatory cytokines (TNF-)
inhibit phagocytosis and respiratory burst in macrophages
secretion of Yops occurs only at 37o and in the absence of Ca2+
3. Proteins involved in processing and excretion of the Yops (T3SS=Ysc and
Syc) and Regulatory proteins (Lcr)
The Yop virulon consists of three basic components: the Ysc injectisome, the Yop effectors and the
Yop translocators. The Yop virulon is the core of the Yersinia pathogenicity machinery designed for
close combat with cells of the immune system
Yersiniae inhibit the activity of several signal tansduction pathways in macrophages

YopH (PTPase)

Yop E, O, T
(GAP,
Ser/Thr kinase,
cysteine protease) YopP
(cysteine protease)
YopP
(cysteine protease)
Yop proteins – through the inhibition of signaling pathways- exert several biological
effects, including:
• Inhibition of focal adhesion complex formation
• Inhibition of actin polymerization, thereby disorganization of the cytoskeleton leading to
the impairment of phagocytosis
• Apoptotic demise of macrophages
• Modulation of cytokine production
The effects of Yersiniae on the immune system
 Yersinia enterocolitica
Occurrence of Y. enterocolitica
The major animal reservoir for Y. enterocolitica strains that cause human illness is pigs, but
other strains are also found in many other animals including rodents, rabbits, sheep, cattle,
horses, dogs, and cats. In pigs, the bacteria are most likely to be found on the tonsils.
Infection is most often acquired by eating contaminated food, especially raw or
undercooked pork products. The preparation of raw pork intestines (chitterlings) may be
particularly risky. Infants can be infected if their caretakers handle raw chitterlings and then do
not adequately clean their hands before handling the infant or the infant’s toys, bottles, or
pacifiers. Drinking contaminated unpasteurized milk or untreated water can also transmit the
infection. Occasionally Y. enterocolitica infection occurs after contact with infected animals.
On rare occasions, it can be transmitted as a result of the bacterium passing from the stools or
soiled fingers of one person to the mouth of another person. This may happen when basic
hygiene and handwashing habits are inadequate. Rarely, the organism is transmitted through
contaminated blood during a transfusion.
Preventive strategies for Y. enetrocolitica infections include
•Avoidance of eating raw or undercooked pork.
•Consume only pasteurized milk or milk products.
•Hand washing with soap and water before eating and preparing food, after contact with
animals, and after handling raw meat.
 • Y. enterocolitica colonizes the intestinal
tract, particularly the distal small intestine
(terminal ileum) and proximal colon.
Pathogenesis Bacteria attach to and penetrate intestinal
cells, their preferred targets are the M
cells of Peyer’s patches (PP).
• Once internalized, the bacteria are
transported across the epithelial barrier
and expelled from the basolateral side of
the M cell. There, phagocytes internalize
them.
• Internalized bacteria replicate in M and
they are transported within migrating
phagocytes to the mesenteric lymph nodes
(MLNs), blood stream, liver and spleen.
• Once located in PPs, MLNs, the spleen or
liver, Y. enterocolitica replicates in an
extracellular form within micro-abscesses.
• Cases of mesenteric lymphadenitis are
mostly mild.
• Cases of septicemia may be accompanied
by arthritis, meningitis, pneumonia,
osteomyelitis, endocarditis, mycotic
aneurysm; prognosis is worse.
 The pathogenesis of Yersinia enterocolitica infection

Yersinia enterocolitica ingested


Colonization of the small and large intestines

Bacteria multiply in in lymphoid follicles causing RES
hyperplasia

INFLAMMATORY RESPONSE

SYMPTOMS:
Enterocolitis that mimics appendicitis
Mesenteric lymphadenitis, terminal ileitis

COMPLICATIONS:
arthritis,
erythema nodosum,
ankylosing spondylitis
Infections caused by Yersinia enterocolitica:
1. Enterocolitis that mimicks appendicitis
2. Mesenteric lymphadenitis
3. Terminal ileitis
3. Pharyngitis, pneumonia, empyema, lung abscess
4. Reactive complications, (the HLA B27 is associated with increased risk of):
• arthritis,
• erythema nodosum,
• ankylosing spondylitis

Therapy:
 Most cases of Yersinia enterocolitis do not merit treatment and no clinical
benefit of treatment has been documented.
 For adults with severe illness and/or underlying immunosuppression antibiotic
treatment is recommended with:
• fluoroquinolones (ciprofloxacin), TMP/SMX, tetracyclines (Doxycyclin)
 Antibiotics are warranted for treatment of patients with bacteremia or sepsis
with:
• a third-generation cephalosporin such as ceftriaxone combined with gentamicin
 Yersinia pseudotuberculosis
Occurrence of Y. pseudotuberculosis
 Y. pseudotuberculosis occurs mainly in rodents, birds, and sporadically in a wide
variety of domestic, wild, and zoo animals.
 In animals, it causes acute septicemia with fever, intestinal inflammation, diarrhea,
or chronic disease associated with the formation of inflammatory-necrotic foci
resembling tuberculosis in the intestine, mesenteric lymph nodes, and various
internal organs.
 It can also be detected from soil, natural waters, milk, meat, the surface of tubers
and vegetables stored in a refrigerator (beets, potatoes, onions, etc.).
 Occurs cumulatively in the environment of sick animals in humans.
Epidemiology
• The infection usually derives from wild rodents, birds, or other animals that carry
or excrete bacteria, through the consumption of food and drinking water
contaminated with feces containing the pathogen.
• However, infection can occur through skin injuries, as well.
• The infection can also be transmitted by arthropods if they have sucked blood from
previously infected animals.
 Infections caused by Yersinia pseudotuberculosis
Pathogenesis
 The pathogen enters the body through the epithelial cells and Peyer’s patches in
the terminal ileum and proximal colon.
 Ms phagocytose Y. pseudotuberculosis.
 In Ms, the bacterium survives, multiplies, and enters the mesenteric lymph
nodes, lymphatics, and bloodstream.
 Infection results in the formation of necrotic foci in Peyer's patches and
ascending colon.
 Cases of mesenteric lymphadenitis are mostly mild.
 The prognosis of cases with septicemia is worse; in immunosuppressed patients,
mortality may be as high as 27%.
Human forms:
1. Benign form: It manifests as mesenteric lymphadenitis in the lymph nodes of the
ileocecal region. Abdominal pain is a characteristic feature, and the symptoms
mimic appendicitis. Diarrhea is often absent.
2. Septic form: more severe symptoms, metastatic abscesses
Therapy: trimethoprim-sulfamethoxazole, ciprofoxacin, ofloxacin, tetracyclines
(Doxycycline), aminoglycosides, ceftriaxone
Yersinia pestis is the causative agent of plague="black plague"
Shibasaburo Kitasato Alexandre Yersin (1863-1943)
 Pathogenicity of Yersinia pestis

1. Infection via inoculation

Pustula at the site of the bite of the flea, lymphadenitis
(haemorrhagic inflammation), fever,
Bacteriaemia  inflammation in lymphoid organs, spleen,
liver, brain, kidneys and lungs.

2. Infection via inhalation

Fulminant haemorrhagic pneumonia, pleuritis, skin
eruptions
Pathogenicity of Yersinia pestis
BUBONIC PLAGUE PNEUMONIC PLAGUE

1. Entry
4. Kórokozó kijutása
3. Exit
(highly contagious)

3. Diesease: 2. Disease:
Buboes (black, hemorrhagic Pneumonia
lymph nodes) Sepsis
Pneumonia (usually 100% mortality)
Sepsis
(internal organ hemorrhage)

2. Spread: lymphatic and

systemic

1. Entry: bite of infected

flea
 VECTOR
Rat flea (Xenopsylla cheopis)

RESERVOIR
Black rat (Rattus rattus) Prairie dog

Brown rat (Rattus norvegicus)

Y. pestis infection can cause the following clinical syndromes:

Bubonic plague
Primary septicemic plague
Primary pneumonic plague
Plague meningitis
Plague pharyngitis
Pestis minor
Subclinical infection
 Bubonic plague

After a flea initially ingests Y. pestis, the organisms elaborate a coagulase that clots
ingested blood in the proventriculus (an organ between the esophagus and stomach) of the
flea, thus blocking passage of the next blood meal into the flea's stomach. Fleas with this
blockage regurgitate Y. pestis into the bite wound while attempting to feed. Between
25,000 and 100,000 Y. pestis organisms are inoculated into the skin via the bite of an
infected flea.
A papule, vesicle, pustule, or furuncle may occur at the site of the fleabite but is noted in
less than 10% of patients. The organisms migrate through the cutaneous lymphatics to
regional lymph nodes.
Once in the lymph nodes, they are phagocytized by polymorphonuclear leukocytes (PMNs)
and mononuclear phagocytes. Organisms that are phagocytosed by PMNs generally are
destroyed, whereas those phagocytosed by mononuclear cells proliferate
intracellularly and develop resistance to further phagocytosis. These organisms are
released when cell lysis occurs. Initially, a thick, proteinaceous exudate that includes
plague bacilli, PMNs, lymphocytes, and fewer macrophages can be found in affected
nodes. Subsequently, the exudative pattern gives way to lakes of hemorrhagic necrosis,
which obliterate the underlying lymph node architecture. A ground-glass amphophilic
material that represents masses of bacilli may be present. The inflammatory process creates
swollen painful buboes and surrounding edematous tissues that are characteristic of
bubonic plague. The organisms often enter the bloodstream, causing hemorrhagic lesions
in other lymph nodes and in organs throughout the body (initially the liver and spleen).
Septicemia, disseminated intravascular coagulation (DIC), and shock can ensue.
Unless treated promptly with appropriate antibiotic therapy, death usually results from
overwhelming sepsis.
Bubonic plague
 Pneumonic plague

Y. pestis can enter the lungs either through direct inhalation (primary
pneumonic plague) or through hematogenous spread as a complication of
bubonic or septicemic plague (secondary pneumonic plague). Primary
pneumonic plague is acquired naturally by inhaling respiratory droplets from
infected humans or animals. The infectious dose by inhalation is estimated to
be 100 to 500 organisms.
Features of pneumonic plague include the following:
• Marked intra-alveolar edema and congestion of the lungs
• Tracheal and bronchial mucosal hemorrhages
• Fibrinous pleuritis and subpleural hemorrhages overlying areas of
exudative pneumonia
• Involvement of hilar lymph nodes
• Organisms often enter the bloodstream and cause multiorgan involvement,
DIC, and shock
• In the absence of early antibiotic therapy (ie, within the first 24 hours),
death occurs from overwhelming sepsis (usually within several days after
illness onset). Without therapy, mortality approaches 100%.
 Septicemic plague
Primary septicemic plague is defined as systemic toxicity caused by Y. pestis infection but
without apparent preceding lymph node involvement. Secondary septicemic plague occurs
commonly with either bubonic or primary pneumonic plague.
Septicemic plague causes sepsis syndrome with multiorgan involvement, DIC, and shock.
In the late stages of infection, high-density bacteremia often occurs, leading to identification of
organisms on peripheral blood smears. Spleen, liver, kidneys, skin, and brain are the most
commonly affected organs. Meningitis can occur and is characterized by a thick, yellow,
fibrinous-purulent exudate. Foci of necrosis with hemorrhage are common, as are characteristic
lesions of DIC (such as fibrin thrombi in glomerular capillaries or purpuric skin lesions).
Y. pestis may persist in necrotic tissues after antibiotic treatment, despite negative blood
cultures. Presumably, Y. pestis becomes trapped in hypoperfused tissues and is able to
persist because of: (i) inadequate delivery of antibiotics to affected areas and (ii) the ability of
the organisms to overcome local host defenses
 Laboratory diagnosis/Clinical specimens
Bubo aspirate:
—Sterile saline flush (1.0 mL saline in 10 mL syringe with 20-guage needle) may be needed to obtain
adequate material for culture
—Transport capped, taped syringe without needle (or contents of syringe in sterile container) at room
temperature (22°C-28°C) for immediate processing.
—Refrigerate (2°C-8°C) if processing will be delayed
—Order culture, Gram stain, and Giemsa, Wright’s, or Wayson stain
Tissues:
—Place in sterile containers with 1-2 drops sterile nonbacteriostatic normal saline to keep moist
—Transport at room temperature to laboratory for immediate processing
—Use same specimen handling conditions and test orders as described for bubo aspirates
—Swabs of tissue are not recommended
Sputum:
—May be collected for culture/direct examination
—Transport at room temperature (22°C-28°C) if transport <2 hr; If transport expected to be 2-24 hr,
refrigerate (2°C-8°C)
—Order culture, Gram stain, and Giemsa, Wright’s, or Wayson stain
Bronchial wash (>1.0 mL):
—Bronchoscopy may be indicated in certain situations where sputum specimens are negative
—Use same specimen handling conditions and test orders as described for sputum specimens
Blood:
—Hold at ambient temperature until placed into incubator or blood culture instrument
—DO NOT REFRIGERATE
—Follow established laboratory protocol for processing blood cultures
—If high suspicion of plague, order additional blood or broth culture (general nutrient broth) for incubation
at room temperature (22°C-28°C), the optimal growth temperature range for Y pestis.
Serum:
—An acute-phase serum sample may be collected and stored at 4°C until plague can be ruled out
Yersinia pestis is a small coccobacillus, which
frequently shows strong bipolar staining conferring
safety-pin appearance under the microscope.
Yersinia pestis in blood sample taken from a patient with
septicemic plague
 Laboratory identification of Yersinia pestis

Cultivation
• Bloodagar, chocolate agar, MacConkey culture media
Identification by using
• automatic biochemical identification system (non-motile,
catalase: +, oxidase:-, urease: -, indol: -)
• MALDI-TOF MS identification system
• (by using specific bacterophages)
A preliminary examination of the sample can be performed
using the immunofluorescence method.

If the culture is negative and plague remains suspected, the antibody

level and seroconversion can be determined using a serological
method (ELISA).
NAT: PCR (amplification of Pla and Caf1 genes), hybridization
method
 Laboratory diagnosis of plague
Detection of F1 antigen Detection of Y. pestis DNA Y. pestis izolálása

Minta
1. Cultivation
(on CIN CM)
Pestis gyanús
beteg F1 ICA Real-time PCR pla, caf1 PCR pla, caf1, inv
2. Identification
• Biochemical
tests
Algorithm used in molecular diagnosis
• MALDI-TOF
uncertain
results 3. Confirmation
• Biochemical
tests
• MALDI-TOF

repeats

cefsulodin–irgasan–novobiocin (CIN); plazminogen activator (Pla); capsular antigen Caf1; invasin (Inv)
Therapy:
 Aminoglycosides:
• Streptomycin, im
• Gentamycin, im or iv

 Fluoroquinolones:
• Levofloxacine, iv or po
• Ciprofloxacine, iv or po
• Moxifloxacin, iv or po

 Tetracyclines:
• Doxycyclin, iv or po
 Plague cases reported in the period 2013-2018

• Plague cases have been reported from 20 countries in the last 15 years
• Democratic Republic of Congo, Madagascar, Peru, Mongolia, United States
of America
• Plague epidemic 2017/Madagascar
• 2348 cases and 202 deaths: 1791 pneumonic plague,
341 bubonic plague, 1 septicaemic plague, 215
unspecified cases.
• Nine countries and overseas territories in the African
region (Comoros, Ethiopia, Kenya, Mauritius,
Mozambique, La Réunion (France), Seychelles, South
Africa, and Tanzania) had been identified as priority
countries for plague preparedness and readiness by
virtue of their trade and travel links to Madagascar.
The life cycle of Yersinia pestis in the USA
 Lifestyles and pathogenesis of the human pathogenic
Yersinia species

Lung

Oral uptake Pneumonic

Respiratory
plague
droplets

Blood

Lymph node

Bubonic plague
M cell
small intestine

Bite of
Peyer’s patch M infected flea
Lymph node
Mesenteric
lymph node

Lokalized Flea
infection (liver, Rodent
spleen)
Systemic infection
(rare event)

• The enteropathogenic Yersinia species (Y. enterocolitica and Y. pseudotuberculosis) are associated with meat (mainly pork) and
lettuce/vegetables. They are ingested via contaminated food and enter the lymphatic system through the M cells in the small intestine.
• The main reservoirs of Y. pestis are rodents. Transmission of the bacteria to humans occurs through the bite of an infected flea resulting in
bubonic plague. Pneumonic plague is developed when Y. pestis reaches the lung and is transmitted via respiratory droplets.
 Proteus, Morganella, Providencia

Gram-negative rods, peritrichous flagellae.

order: Enterobacterales; family: Morganellaceae
Species:
Proteus vulgaris
Proteus mirabilis
Proteus penneri
Morganella morganii
Providencia rettgeri
Providencia stuartii

Proteus= greek sea god capable of changing the shape

 Virulence factors of Morganellaceae

Virulence factors Contribution to the pathogenesis

Fimbriae Adherence of bacteria to human tissues
Flagellae Swarming, Movement of bacteria in the urinary tract
Urease pH elevationstone-formation
Aminoacid deaminase Production of -keto acids acting as siderophores
Hemolysines Cytotoxicity
Invasiveness Penetration of bacteria into human host cells
Exopolysaccharide Formation of biofilm and stone
LPS Immunmodulatory effect
Proteus / Swarming
 Proteus / Swarming phenomenon

1,5-2,0 m Length 10-80 m

4-10 Flagellae 103-104
1-2 Nucleoids Polyploid
Swimming Motility behavior Swarming
Ammonia increases the pH and thereby facilitates stone formation in
the urinary tract

The increase in pH due to ammonia release can reach values above 9.0, causing the
previously soluble urinary salts to precipitate forming crystals, that block the urine
flux and causing tissue injury, such as struvite ((MgNH4PO4).6H2O) and hydroxy-
apatite carbonate ([Ca10(PO4CO3OH)6].OH)
The Proteus group bacteria form intraluminal clusters and lead to
urothelial damage, mineral deposition and stone formation in the
urinary tract
Virulence factors produced by Proteus and possible
sites of action during infection in the urinary tract
Diseases caused by Proteus
• Urinary tract infections (cystitis, pyelitis, pyelonephritis)
• Urinary tract stone
• Pneumonia
• Sepsis, metastatic foci
• Nosocomial infections
Diseases caused by Providencia
• Urinary tract infections
• Infection of other organs: wound infections, skin and soft tissue
infections, pneumonia, meningitis, biliary tract infections
Diseases caused by Morganella
• Urinary tract infections
• Infection of other organs: wound infections, skin and soft tissue
infections, pneumonia, meningitis, biliary tract infections
Therapy:

Morganellaceae members are sensitive to:

Cephalosporins:
– III. generation: ceftriaxion, ceftazidime-avibactam, cefpodoxim, cefdinir
– IV. generation: cefepim
– V. generation: ceftolozane-tazobactam
Ureidopenicillins: piperacillin-tazobactam
Monobactam: aztreonam
Carbapenems: ertapenem, meropenem
Fosfomycin
Gentamycin/Tobramycin/Amikacin protein synthesis inhibitors
Antibiotic resistance of Proteus group bacteria:
• Occurrence of ESBL producing MDR strains is rare
• Occurrence of carbapenemase-producing strains is rare
• Cefalexin, aminopenicillin (ampicillin), fluoroquinolone,
polymyxin, tetracycline and nitrofurantoin resistances are frequent
Therapy:

Uncomplicated UTIs/pyelonephritis:
– Oral III. generation cephalosporins (ceftazidime-avibactam) or
– Piperacillin/tazobactam or
– Aztreonam or
– Gentamycin
– for 7-14 days
For hospitalized patients with urosepsis:
– IV. generation cephalosporin: Cefepim
– V. generation cephalosporin: Ceftolozane-tazobactam
– Carbapenem: Ertapenem, if history of ESBL
– Amikacin
 Diagnosis/Biochemical tests

Species Urease Citrate Indol Sucrose H2S PDA GG

P. vulgaris + v + + + + v

P. mirabilis + v ‒ ‒ + + +

M. morganiii + ‒ + ‒ ‒ + v

P. rettgeri + + + + ‒ v v

P. stuartii ‒ + + + ‒ + ‒

Every species is oxidase-negative

PDA= phenylalanine-deaminase
GG = glucose metabolism with gas production
v= variable (different strains give different results