Yersinia enterocolitica septicemia: clinical and microbiological aspects

Is Regular Probiotic Practice Safe for Management of Sepsis?

For decades, the gut has been thought to play an important role in sepsis pathogenesis. Sepsis is a serious life-threatening, chronic condition of an infection caused by dysregulated host immune response in most of the intensive care unit patients. Probiotics have dual roles in polymicrobial sepsis i.e. probiotics may induce sepsis in many cases and may prevent its prognosis in many cases. Experimental evidence from both pre-clinical and clinical studies have demonstrated that probiotic therapy ameliorates various inflammatory mediators such as tumor necrosis factor, interleukin-10 (IL-10), IL-6, etc., in septicemia. In addition, probiotic use was also found to reduce the severity of pathological conditions associated with irritable bowel disorder and prevent development of endocarditis in septicemia. On contrary, probiotic therapy in neonatal and athymic adult mice fail to provide any beneficial effects on mortality and sepsis-induced inflammation. Importantly, in few clinical trials probiotic use was found to aggravate sepsis by promoting inflammatory cascade rather than suppressing it. This review discusses various studies regarding the beneficial or harmful effects associated with probiotic therapy in sepsis.

Infective Endocarditis by Yersinia Species: A Systematic Review

Yersinia spp. are non-spore-forming Gram-negative bacilli. They comprise only three species known to cause disease in humans, namely Y. pestis, Y. enterocolitica and Y. pseudotuberculosis. Since infective endocarditis (IE) is rarely caused by Yersinia, the management of these infections can be problematic due to the lack of experience. The purpose of this study was to systematically review all published cases of IE by Yersinia species in the literature. A systematic review of PubMed, Scopus and Cochrane Library (through 1 November 2020) for studies providing epidemiological, clinical and microbiological information as well as data on treatment and outcomes of IE caused by Yersinia species was performed. A total of 12 studies, containing data of 12 patients, were included. A prosthetic valve was present in 17% of patients. The mitral valve was the most commonly infected site, followed by the aortic valve. Fever, sepsis and embolic phenomena were common clinical signs, followed by heart failure. Aminoglycosides, cephalosporins and quinolones were the most commonly used antimicrobials. Clinical cure was noted in 83%, while overall mortality was 17%. This systematic review describes IE by Yersinia and provides information on patients’ epidemiology, clinical signs and the related therapeutic strategies and outcomes.

Yersinia enterocolitica Septicemia After Chitterling Ingestion in a Pediatric Patient With Iron Overload Disease: A Case Report

Yersinia enterocolitica is a gram-negative cocobacillus causing a range of illness from self-limited enteritis to invasive disease, including septicemia. It is a particularly virulent pathogen in patients with underlying hemoglobinopathies who are predisposed to iron overload. A substantial risk factor for disease in children and infants is exposure to the household preparation of chitterlings. Early identification of these patients is critical in the pediatric intensive care unit as this cause of septicemia can be missed with the potential for significant morbidity. We report an interesting case of Yersinia septicemia in a patient with iron overload disease from chitterling ingestion managed in the pediatric intensive care unit.

Salmonella, Shigella, and yersinia

Salmonella, Shigella, and Yersinia cause a well-characterized spectrum of disease in humans, ranging from asymptomatic carriage to hemorrhagic colitis and fatal typhoidal fever. These pathogens are responsible for millions of cases of food-borne illness in the United States each year, with substantial costs measured in hospitalizations and lost productivity. In the developing world, illness caused by these pathogens is not only more prevalent but also associated with a greater case-fatality rate. Classic methods for identification rely on selective media and serology, but newer methods based on mass spectrometry and polymerase chain reaction show great promise for routine clinical testing.

Subacute endocarditis caused by Yersinia enterocolitica: a case report

Yersinia enterocolitica is an unusual cause of septicaemia, usually occurring in immunocompromised hosts. Endocardial involvement is rare and generally presents as acute endocarditis. We describe the case of a 73-y-old woman, apparently without risk factors for endocarditis, admitted to hospital for persistent fever of unknown origin, arthralgia, and weight loss. Y. enterocolitica was isolated from blood and urine cultures, and echocardiography showed a pedunculated vegetation attached to the non-coronary cusp of the aortic valve. Symptoms and fever resolved after 3 days of intravenous cefotaxime plus amikacin, which were continued for the 2 weeks of her hospital stay; this treatment was followed by intravenous ceftriaxone after discharge. We hypothesized that a chemotherapy course administered 2 months previously for breast cancer might have been a predisposing factor for the Y. enterocolitica valvular infection and that immune system recovery contributed to mitigate the clinical presentation as subacute endocarditis.

Quantification of Yersinia enterocolitica in raw milk using qPCR

This report describes a new, sensitive and specific protocol for rapid detection and quantification of Yersinia enterocolitica in artificially contaminated raw milk samples. The new method is based on an optimized real-time PCR protocol with a TaqMan probe. The primers and probe are based on the chromosomal ail gene. This method was successful for both intended uses: (1) direct detection and quantification of Y. enterocolitica in artificially and naturally contaminated raw milk samples and (2) characterization of growth potential of different serotypes of Y. enterocolitica in raw milk at the most commonly used storage temperatures. The recent method eliminates the pre-PCR enrichment step, which makes it possible to quickly assess milk-related consumer exposure to this pathogen.

Characterization of rabbit antibodies for immunochemical detection of Yersinia enterocolitica

Rabbit IgG raised against whole cells of Yersinia enterocolitica O:3, O:9 and against a group of pathogenic Y. enterocolitica strains (serotypes O:3, O:5,27, O:8. and O:9) were prepared. The antibody limiting titers were within the range of 1:9.5 x 10(4)-1:7.5 x 10(5). The immunoblotting analysis of Yersinia lipopolysacchides separated by SDS-PAGE showed that IgG against the single serotype O:3 interacted with high-molar-mass LPS of O:3 whereas other antibodies were bound to low-molar-mass LPS of serotypes O:3, O:5,27, O:9 and strain Y. enterocolitica (CNCTC Y 2/68). IgG against the group of pathogenic serotypes also weakly interacted with low-molar-mass LPS of serotypes O:5, O:6,30, and O:10. The cross-reactivity of the antibodies with Y. pseudotuberculosis Ia and/or Y. rohdei b, d, e, f, i, which was observed by means of dot-blotting procedure using the whole bacterial cells as an antigen, was shown not to be caused by LPS of these bacteria. The prepared antibodies were used in the development of indirect competitive ELISA. At the optimum concentration of the immunoreactants the detection limits were within the range of 3-7 x 10(6) colony-forming units per mL.

Native-valve infective endocarditis caused by Enterobacteriaceae: report on 9 cases and literature review

Although the demographic characteristics of patients who develop infective endocarditis (IE) have changed over the last few decades, Enterobacteriaceae remain rarely responsible. We report the clinical and epidemiological characteristics of 9 patients with native-valve Enterobacteriaceae IE from 6 French medical intensive care units over a 10-y period and have identified 29 additional cases in the literature. Nearly a third of the 38 patients were immunocompromised and/or had previously known valvular heart disease. Salmonella spp. and Yersinia spp. were the most frequently isolated microorganisms reported in the literature. The overall mortality rate was 24% (9/38) and was lower for operated patients (10% (1/10)) compared to those who did not undergo valve surgery (31% (8/26)). Our results confirmed the rarity of native-valve endocarditis caused by Enterobacteriaceae, pathogens frequently responsible for nosocomial and community-acquired bacteraemias. This paradox may be explained by susceptibility to the bactericidal action of serum and the inability of these bacteria to colonize the endocardium.

Comparison of culture, multiplex, and 5' nuclease polymerase chain reaction assays for the rapid detection of Yersinia enterocolitica in swine and pork products

Bacteriological culture was compared with multiplex and fluorogenic (TaqMan) polymerase chain reaction (PCR) assays for the detection of attachment invasion locus (ail)-bearing Yersinia enterocolitica in market weight swine, chitterlings, and ground pork. The TaqMan assay detected 1 pg of purified Y. enterocolitica DNA, whereas conventional gel-based PCR detected I ng of the same. The presence of ail-bearing Y. enterocolitica was tested in pork and feces artificially inoculated with Y. enterocolitica strain NADC 5561. The sensitivity limits of culture, multiplex, and TaqMan PCR assays were 4 x 10(3), 4 x 10(2), and 0.4 CFU/g, respectively, for the artificially inoculated pork. The sensitivity limits were 4 x 10(2), 4 x 10(2), and 0.4 CFU/g, respectively, for feces after a 48-h enrichment in a Yersinia selective broth. By the culture method, Y. enterocolitica was not detected in any of the swine specimens (n = 2,403) examined. By contrast, it was detected in 48 (2%) of the swine samples screened using the multiplex PCR and in 656 (27.2%) of these samples using the TaqMan assay. Using the culture method, Y. enterocolitica was detected in 8% of chitterling samples (n = 350) and in none of the ground pork samples (n = 350). It was identified in 27% of the chitterling samples using multiplex PCR and in 79% of these samples using the TaqMan assay. Ten percent of the ground pork samples contained Y. enterocolitica, as determined by the multiplex PCR, and 38% based on the TaqMan assay. The results suggest that pork products harbor more ail-bearing Y. enterocolitica than selected organs of freshly slaughtered hogs and that the TaqMan assay is more sensitive than either the multiplex PCR or traditional culture methods.

Yersinia enterocolitica: the charisma continues

Yersinia enterocolitica, a gram-negative coccobacillus, comprises a heterogeneous group of bacterial strains recovered from animal and environmental reservoirs. The majority of human pathogenic strains are found among distinct serogroups (e.g. O:3, O:5,27, O:8, O:9) and contain both chromosome- and plasmid (60 to 75 kb)-mediated virulence factors that are absent in "avirulent" strains. While Y. enterocolitica is primarily a gastrointestinal tract pathogen, it may produce extraintestinal infections in hosts with underlying predisposing factors. Postinfection sequelae include arthritis and erythema nodosum, which are seen mainly in Europe among patients with serogroups O:3 and O:9 infection and HLA-B27 antigen. Y. enterocolitica is acquired through the oral route and is epidemiologically linked to porcine sources. Bacteremia is prominent in the setting of immunosuppression or in patients with iron overload or those being treated with desferrioxamine. metastatic foci following bacteremia are common and often involve the liver and spleen. Of particular concern is blood transfusion-related bacteremia. Evidence has accumulated substantiating the role of Y. enterocolitica as a food-borne pathogen that has caused six major outbreaks in the United States. The diagnosis of Y. enterocolitica gastroenteritis is best achieved through isolation of the bacterium on routine or selective bacteriologic media. When necessary, serogrouping, biogrouping, and assessment for plasmid-encoded virulence traits may aid in distinguishing virulent from "avirulent" strains. Epidemiologically, outside of identified food-borne outbreaks, the source (reservoir) of Y. enterocolitica in sporadic cases is speculative. Therefore, prevention and control measures are difficult to institute.

Contribution of urease to acid tolerance in Yersinia enterocolitica

The stomach serves as a barrier to enteric infection because of the antibacterial effect of the hydrochloric acid in gastric juice. In this study, we tested the ability of the enteric pathogen Yersinia enterocolitica to tolerate a pH range of 2.0 to 6.0 and found that under the conditions of a normal human fasting stomach (pH < 3 and a gastric emptying time of 2 h), Y. enterocolitica is highly acid resistant, showing approximately 85% survival. The resistance of Y. enterocolitica to acid in vitro depended on the bacterial growth phase and the concentration of urea in the medium, being maximal during stationary phase in the presence of at least 0.3 mM urea. Urease-negative mutants of Y. enterocolitica were constructed by disrupting the urease gene complex of a virulent strain of serogroup O9. Compared with the wild type, these mutants showed an approximately 1,000-fold decrease in the ability to tolerate acid in vitro (< 0.08% survival) and a 10-fold reduction in viability after passage through the stomachs of mice. Complementation of the disrupted urease genes in trans restored the ability of urease-negative mutants to tolerate low pH in vitro and gastric acidity to approximately wild-type levels. These findings indicate that urease is responsible for acid resistance in Y. enterocolitica and suggest that urease contributes to the virulence of Y. enterocolitica by enhancing the likelihood of bacterial survival during passage through the stomach.

Yersinia enterocolitica endocarditis: case report and literature review

Endocarditis is a rare manifestation of Yersinia enterocolitica infection. The case of a 45-year-old man who presented with high fever and in whom prosthetic valve Yersinia enterocolitica endocarditis was diagnosed is described. The patient was successfully treated with ceftriaxone plus tobramycin, as proved by negative cultures of the prosthesis removed at the end of therapy. Including the patient reported, only 12 cases of Yersinia enterocolitica endocarditis have been published to date, two of which describe prosthetic cardiac valve endocarditis. The clinical characteristics do not distinguish septicemia from involvement limited to the cardiac valves. Diagnosis, however, has been improved by progress in echocardiography. Prognosis is grave but can be ameliorated if appropriate antimicrobial agents are administered, i.e. the combination of a third-generation cephalosporin plus an aminoglycoside. Fluroquinolones may also constitute an attractive therapeutic alternative.

Yersinia enterocolitica endocarditis on a prosthetic valve

Yersinia entercolitica endocarditis has rarely been described before. This is the first report of prosthetic valve Yersinia enterocolitis endocarditis, complicated by infected brain embolization. The patient, however, completely recovered after 6 weeks of combined therapy with ceftriaxone and gentamicin.

Septicemia due to Yersinia enterocolitica in a hemodialyzed, iron-depleted patient receiving omeprazole and oral iron supplementation

Septicemia occurred in a long-term hemodialysis patient on oral iron supplementation who had been treated for esophageal ulcer by omeprazole, an ulcer-healing drug. Yersinia enterocolitica serotype 0:3 was recovered from blood cultures. A raised intraintestinal pH and an increased intraluminal iron load may have been contributing factors for the enhanced proliferation and generalized infection of Y enterocolitica.

Intestinal symptoms and serological response in patients with complicated and uncomplicated Yersinia enterocolitica infections

Clinical course, serological response and effect of antibiotic treatment were evaluated in 34 patients with uncomplicated enterocolitis and in 27 patients with reactive arthritis (ReA) due to Yersinia enterocolitica. Patients participating in this prospective multicentre trial were randomised to treatment or no treatment with antibiotics. Only 3 (11%) of the patients who later developed ReA asked for medical care because of intestinal symptoms and fever and they all developed arthritis within 2 days after admission to hospital, i.e. before an etiological diagnosis was obtained. Patients with ReA had a history of milder intestinal symptoms than patients with uncomplicated enterocolitis. The peak IgA titer to Y. enterocolitica, as measured by enzyme linked immunosorbent assay, was higher in ReA patients and it was not affected by the presence of HLA-B27 antigen. On the other hand, untreated patients with uncomplicated enterocolitis had the longest duration of IgG antibodies. The duration of IgG antibody response was shortened in uncomplicated enterocolitis patients treated with antibiotics, but not in ReA patients. Treatment did not influence intestinal or ReA symptoms. It is concluded, that patients with uncomplicated enterocolitis due to Y. enterocolitica differ in intestinal symptoms and serological response, compared with patients who develop ReA. These parameters could however not be used to predict the development of arthritis in individual patients.

Yersinia enterocolitica infection with ileal perforation associated with iron overload and deferoxamine therapy

Despite the frequency of gastrointestinal disease caused by Yersinia enterocolitica, intestinal perforation is a rare complication of this infection and to date only eight cases have been reported in the English literature. We describe a case of this unusual condition in a 17-year-old male patient with thalassemia intermedia requiring transfusion, who was also taking deferoxamine. The severity of the clinical picture is probably due to the increased virulence of Yersinia enterocolitica in the presence of deferoxamine and iron.

Fatal Yersinia enterocolitica (serotype 0:5,27) sepsis after blood transfusion

Septicemia is a rare complication of blood transfusion. This is probably primarily due to the use of sealed disposable containers for blood collection and the storage of red cell-containing components at 4 degrees C. However, despite these measures, septicemia due to blood transfusion continues to occur. We report here a fatal case of Yersinia enterocolitica septicemia due to a contaminated unit of red cells which was collected from an apparently healthy, asymptomatic blood donor. The organism grows at cold temperature and multiplies during storage of red blood cell-containing components. Contaminated components do not show any visible abnormalities. The possibility of transfusion-transmitted Y. enterocolitica should be considered in patients who have symptoms of sepsis or shock following transfusion.

Yersinia enterocolitica biotype 2 serotype O9 septicaemia in a previously fit man, raw goats' milk having been the apparent vehicle of infection: a cautionary tale

A previously fit 66-year-old man presented with a 2 weeks' history of malaise, fever and vomiting which led to a septicaemic illness. Yersinia enterocolitica biotype 2 serotype O9 was isolated from the patient's blood and from raw goats' milk remaining in a bottle after the patient had consumed some of the contents. He also produced antibodies to this serotype. Careful history taking, however, revealed that the bottle of milk had been purchased after the patient became ill. Milk from the same bottle was consumed by his wife who neither became ill nor seroconverted. Furthermore, the organism was not isolated from further samples from the same supplier. The milk consumed by the patient was probably contaminated by him so that initial enthusiasm in attributing his infection to the consumption of raw goats' milk is not supported by the facts. This case illustrates some of the pitfalls of trying to determine the vehicle of infection in a single case.

Yersinia enterocolitica in donor blood: a case report and review

Routine sterility control of a unit of leukocyte-depleted erythrocyte concentrate yielded growth of Yersinia enterocolitica serotype O:3. Plasma of the donor showed a high titer of agglutinins against the homologous organism. Although the donor was apparently well at the time of donation, he had a history of protracted terminal ileitis treated by surgery. The recipient of the contaminated blood was taking broad-spectrum antibiotics and did not experience any adverse effect. Fourteen other cases of transfusion-associated yersiniosis have been reported.

Yersinia infections in surgical practice

This article reviews the clinical manifestations of Yersinia bacteria emphasizing their recent rise in incidence and describing how Yersinia infection presents to the general surgeon. Geographical variations, patterns of disease, pathogenicity and the problems in diagnosis and management are discussed. This common but often unrecognized infection is usually self-limiting but the very young, the very old and the immunocompromised are at greater risk and prompt treatment is required to save lives.

Comparison of bacteria with and without plasmid-encoded proteins as antigens for measurement of immunoglobulin M, G, and A antibodies to Yersinia enterocolitica by enzyme-linked immunosorbent assay

Yersinia enterocolitica serovar O:3 bacteria with and without plasmid-encoded proteins were compared as antigens in an enzyme-linked immunosorbent assay. Good correlations between the two antigen preparations were obtained for immunoglobulin M (IgM), IgG, and IgA antibodies of patients with yersiniosis. For routine diagnostic purposes, these antigens are considered equal.

Association of persisting IgA response with yersinia triggered reactive arthritis: a study on 104 patients

Twelve to 16 months after Yersinia enterocolitica O:3 enteritis 33 (85%) of the 39 patients who developed reactive arthritis as a postinfection complication had IgA class and 28 (72%) had IgG class anti-yersinia antibodies. In contrast, 7 (32%) of the 22 patients who did not develop arthritis were positive in the IgA test and 11 (50%) positive in the IgG test. The results were about the same when the material was divided into cases with diagnosis of yersiniosis verified by stool culture or by serology. These results confirm the value of enzyme linked immunosorbent assay (ELISA) in the diagnosis of yersiniosis, particularly in cases with postinfection complications when the stool isolations remain negative.