ID Enterobacteriaceae

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Issued by the Standards Unit, Microbiology Services Division, HPA

Bacteriology --- Identification | ID 16 | Issue no: 3.1| Issue date: 21.10.11 | Page: 1 of 17

UK Standards for Microbiology InvestigationsIdentification of Enterobacteriaceae


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Identification of Enterobacteriaceae

Bacteriology --- Identification | ID 16 | Issue no: 3.1 | Issue date: 21.10.11| Page: 2 of 17

UK Standards for Microbiology Investigations | Issued by the Standards Unit, Health Protection Agency

AcknowledgmentsUK Standards for Microbiology Investigations (SMIs) are developed under the auspices of theHealth Protection Agency (HPA) working in partnership with the National Health Service (NHS),Public Health Wales and with the professional organisations whose logos are displayed belowand listed on the websitehttp://www.hpa.org.uk/SMI/Partnerships. SMIs are developed,reviewed and revised by various working groups which are overseen by a steering committee(seehttp://www.hpa.org.uk/SMI/WorkingGroups).

The contributions of many individuals in clinical, specialist and reference laboratories who haveprovided information and comments during the development of this document areacknowledged. We are grateful to the Medical Editors for editing the medical content.

For further information please contact us at:

Standards UnitMicrobiology Services Division

Health Protection Agency61 Colindale AvenueLondon NW9 5EQ

E-mail:[email protected]

Website:http://www.hpa.org.uk/SMI

UK Standards for Microbiology Investigations are produced in association with:

The Royal College ofPathologistsPathology: the science behind the cure
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UK Standards for Microbiology Investigations#: StatusUsers of SMIsThree groups of users have been identified for whom SMIs are especially relevant:

SMIs are primarily intended as a general resource for practising professionals in the fieldoperating in the field of laboratory medicine in the UK. Specialist advice should beobtained where necessary.

SMIs provide clinicians with information about the standard of laboratory services theyshould expect for the investigation of infection in their patients and the documentsprovide information that aids the electronic ordering of appropriate tests from hospitalwards.

SMIs also provide commissioners of healthcare services with the standard ofmicrobiology investigations they should be seeking as part of the clinical and publichealth care package for their population.

Background to SMIsSMIs comprise a collection of recommended algorithms and procedures covering all stages ofthe investigative process in microbiology from the pre-analytical (clinical syndrome) stage tothe analytical (laboratory testing) and post analytical (result interpretation and reporting)stages.

Syndromic algorithms are supported by more detailed documents containing advice on theinvestigation of specific diseases and infections. Guidance notes cover the clinical background,differential diagnosis, and appropriate investigation of particular clinical conditions. Qualityguidance notes describe essential laboratory methodologies which underpin quality, forexample assay validation, quality assurance, and understanding uncertainty of measurement.

Standardisation of the diagnostic process through the application of SMIs helps to assure theequivalence of investigation strategies in different laboratories across the UK and is essentialfor public health interventions, surveillance, and research and development activities. SMIsalign advice on testing strategies with the UK diagnostic and public health agendas.

Involvement of Professional OrganisationsThe development of SMIs is undertaken within the HPA in partnership with the NHS, PublicHealth Wales and with professional organisations.

The list of participating organisations may be found athttp://www.hpa.org.uk/SMI/Partnerships. Inclusion of an organisations logo in an SMI implies

support for the objectives and process of preparing SMIs. Representatives of professionalorganisations are members of the steering committee and working groups which developSMIs, although the views of participants are not necessarily those of the entire organisationthey represent.

SMIs are developed, reviewed and updated through a wide consultation process. The resultingdocuments reflect the majority view of contributors. SMIs are freely available to view athttp://www.hpa.org.uk/SMIas controlled documents in Adobe PDF format.

#UK Standards for Microbiology Investigations were formerly known as National Standard Methods.

Microbiology is used as a generic term to include the two GMC-recognised specialties of Medical Microbiology (which includes Bacteriology,Mycology and Parasitology) and Medical Virology.
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Quality AssuranceThe process for the development of SMIs is certified to ISO 9001:2008.

NHS Evidence has accredited the process used by the HPA to produce SMIs. Accreditation isvalid for three years from July 2011. The accreditation is applicable to all guidance producedsince October 2009 using the processes described in the HPAs Standard Operating Procedure

SW3026 (2009) version 6.SMIs represent a good standard of practice to which all clinical and public health microbiologylaboratories in the UK are expected to work. SMIs are well referenced and represent neitherminimum standards of practice nor the highest level of complex laboratory investigationpossible. In using SMIs, laboratories should take account of local requirements and undertakeadditional investigations where appropriate. SMIs help laboratories to meet accreditationrequirements by promoting high quality practices which are auditable. SMIs also provide areference point for method development. SMIs should be used in conjunction with other SMIs.

UK microbiology laboratories that do not use SMIs should be able to demonstrate at leastequivalence in their testing methodologies.

The performance of SMIs depends on well trained staff and the quality of reagents andequipment used. Laboratories should ensure that all commercial and in-house tests have beenvalidated and shown to be fit for purpose. Laboratories should participate in external qualityassessment schemes and undertake relevant internal quality control procedures.

Whilst every care has been taken in the preparation of SMIs, the HPA, its successororganisation(s) and any supporting organisation, shall, to the greatest extent possible underany applicable law, exclude liability for all losses, costs, claims, damages or expenses arising outof or connected with the use of an SMI or any information contained therein. If alterations aremade to an SMI, it must be made clear where and by whom such changes have been made.

SMIs are the copyright of the HPA which should be acknowledged where appropriate.

Microbial taxonomy is up to date at the time of full review.

Equality and Information GovernanceAn Equality Impact Assessment on SMIs is available athttp://www.hpa.org.uk/SMI.

The HPA is a Caldicott compliant organisation. It seeks to take every possible precaution toprevent unauthorised disclosure of patient details and to ensure that patient-related recordsare kept under secure conditions.

Suggested citation for this document:Health Protection Agency. (2011). Identification of Enterobacteriaceae. UK Standards for

Microbiology Investigations. ID 16 Issue 3.1.http://www.hpa.org.uk/SMI/pdf.
http://www.hpa.org.uk/SMIhttp://www.hpa.org.uk/SMIhttp://www.hpa.org.uk/SMIhttp://www.hpa.org.uk/SMI/pdfhttp://www.hpa.org.uk/SMI/pdfhttp://www.hpa.org.uk/SMI/pdfhttp://www.hpa.org.uk/SMI/pdfhttp://www.hpa.org.uk/SMIhttp://www.hpa.org.uk/SMI


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ContentsACKNOWLEDGMENTS ............................................................................................................ 2UK STANDARDS FOR MICROBIOLOGY INVESTIGATIONS: STATUS ............ ............ ......... ............ ..... 3AMENDMENT TABLE ............................................................................................................... 6SCOPE OF DOCUMENT ........................................................................................................... 7INTRODUCTION ..................................................................................................................... 7TECHNICAL INFORMATION/LIMITATIONS ................................................................................... 91 SAFETY CONSIDERATIONS .......................................................................................... 102 TARGET ORGANISMS ................................................................................................. 103 IDENTIFICATION ....................................................................................................... 114 IDENTIFICATION OF ENTEROBACTERIACEAE FLOWCHART .............................................. 135 REPORTING .............................................................................................................. 146 REFERRALS ............................................................................................................... 16REFERENCES ........................................................................................................................ 17


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Amendment TableEach SMI method has an individual record of amendments. The current amendments are listedon this page. The amendment history is available [email protected].

New or revised documents should be controlled within the laboratory in accordance with thelocal quality management system.

Amendment No/Date. 4/21.10.11

Issue no. discarded. 3

Insert Issue no. 3.1

Section(s) involved. Amendment.Whole document. Document presented in a new format .

References.

Some references updated.

Amendment No/Date. 3/28.09.10

Issue no. discarded. 2

Insert Issue no. 3

Section(s) involved. Amendment.Introduction

.

Hydrogen sulphide production for SalmonellaParatyphiA and S. Typhi corrected

.

Principles of identification.Additional text to cover acceptance of commercialidentification system.

Flowchart.Updated in last box to state presumptive (locallyconfirmed) E. coliO157.

Notification to HPA.Heading and text amended in light of the new HealthProtection Regulations 2010.

References. References reviewed and updated.
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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Scope of DocumentThis SMI describes the identification of members of the family Enterobacteriaceae. There are alarge number of species included in the family. In diagnostic clinical microbiology laboratoriesit is usual to attempt identification by use of biochemical tests. The level of identificationdepends on the site of infection, the immune status of the host and the need forepidemiological surveillance.

Because of the large number of species involved, this SMI will concentrate on the mostcommon genera and species isolated from clinical specimens. The identification ofEnterobacteriaceae can be simplified by taking advantage of the fact that three speciescomprise 80-95% of all isolates in the clinical setting. These are Esherichia coli, Klebsiellapneumoniaeand Proteus mirabilis

1. The other species can be easily identified usingbiochemical tests.

This SMI should be used in conjunction with other SMIs.

IntroductionTaxonomyThe nomenclature of the Enterobacteriaceae is complicated and has been based onbiochemical and antigenic characteristics. Recently, the application of new technologies suchas DNA hybridisation has resulted in numerous changes in classification of theEnterobacteriaceae. In 1972 there were 26 recognised species, now there are in excess of1701.CharacteristicsMembers of the Enterobacteriaceae are Gram negative, straight rods, some of which are

motile. Most species grow well at 37C, although some species grow better at 25-30C. Theyare facultatively anaerobic, oxidase negative and catalase positive (except Shigella dysenteriaetype 1). They are distributed worldwide and may be found in soil, water, plants and animals.

Common genera of the family EnterobacteriaceaeCitrobacter speciesThere are 11 species of which 9 have been recovered from clinical material. They may befound in the faeces of humans and animals as part of the normal flora and grow readily onordinary media. Colonies are generally smooth and moist although mucoid or rough strainsoccur. Some strains of Citrobacterresemble Salmonellaspecies biochemically and agglutinate

with Salmonellapolyvalent antisera, which may lead to misidentification.Enterobacter speciesThere are eleven species, but only eight have been isolated from clinical material (see section2). They grow readily on ordinary agar, ferment glucose with the production of acid and gas,and are motile by peritrichous flagella. Some strains with a K antigen possess a capsule.

Escherichia speciesThere are 6 species, of which four are known to cause human disease (see section 2). Themost commonly isolated is Escherichia coli, which contains numerous serotypes, some ofwhich are associated with specific diseases.

A number of strains of E. colimay produce enterotoxins or other virulence factors, includingthose associated with invasiveness. Some strains are capsulated with a K antigen.


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For more information on the identification of E. coliO157, refer toID 22 - Identification ofEscherichia coliO157.

Hafnia alveiThe genus Hafniacontains a single species, H. alvei. It grows readily on ordinary media and isgenerally motile. Motility is more pronounced at 30C than 37C2. H. alveican resemble non

motile salmonella biochemically, and can agglutinate in polyvalent salmonella antisera.Klebsiella speciesThe genus Klebsiellacontains 5 species and 4 subspecies. Four species, previously namedKlebsiella pneumoniae, Klebsiella ozaenae, Klebsiella rhinoscleromatisand Klebsiella aerogenesare now classed as subspecies of K. pneumoniae. K. pneumoniaesubspecies aerogenesis themost frequently isolated species. All grow readily on ordinary media, are non-motile and arecapsulated.

Morganella morganiiThe genus Morganellacontains a single species, Morganella morganii, which isdivided into 2sub species. It is motile with peritrichous flagella, but some strains do not form flagella above30C. M. morganiican resemble non motile salmonella biochemically, and can agglutinate inpolyvalent salmonella antisera.

Proteus speciesThere are 4 species of Proteus, of which 3 cause disease (see section 2). All strains are ureasepositive and motile. They may swarm on blood agar, producing concentric zones or an evenfilm. They are resistant to polymyxin B and colistin. Proteusspecies can resemble non motilesalmonella biochemically, and can agglutinate in polyvalent salmonella antisera.

Providencia speciesThe genus Providenciawas originally established for organisms similar to Proteus species that

were urease negative. There are 5 species within the genus, of which 3 cause disease (seesection 2). All are motile, but do not swarm. They are resistant to polymyxin B and colistin.

Salmonella speciesSerotypes of Salmonellaand Arizonaare now considered to belong to two species, SalmonellaBongori, (formerly subspecies V) and Salmonella Enterica, which comprises six subspecies:

I = enterica, II = salamae, IIIa = arizonae, IIIb = diarizonae, IV = houtenae, and VI = indica. Mostserotypes are motile; all except Salmonella Typhiproduce gas from glucose. Most producehydrogen sulphide. However, Salmonella ParatyphiA is normally hydrogen sulphide negativeand S. Typhiis a weak producer.

For more information on serotyping of Salmonellaspecies, refer toID 24 - Identification ofSalmonellaspecies.

Serratia speciesThe genus Serratiacontains 10 species (but only 2 are commonly isolated from clinicalmaterial) and 2 subspecies. They are Serratia liquefaciensand Serratia marcescens, the latteroften producing a red pigment when grown at 20C. Most of the species are motile. Membersof the genus characteristically produce three enzymes lipase, DNase and gelatinase. They arealso resistant to polymyxin B and colistin and this resistance may be heterogeneous, leading toa target-zone appearance.

Shigella speciesThere are 4 species, Shigella dysenteriae, Shigella flexneri, Shigella boydiiand Shigella sonnei.All are non-motile. Shigella species are highly infective, particularly S. dysenteriae

4,5.
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For more information on the identification of Shigellaspecies, refer toID 20 - Identification ofShigella species.

Yersinia speciesThe genus Yersiniacontains eleven species, 3 of which (Yersinia pestis, Yersinia enterocoliticaand Yersinia pseudotuberculosis) are known pathogens of man and animals

3. All members of

the genus grow readily on ordinary media.Y. pestisis not fastidious but, after incubation for 24 hr on blood agar, colonies are usuallymuch smaller than those of other Enterobacteriaceae. Y. pestisis always non motile. The otherspecies are non motile at 37C but motile at 30C.

For more information on the identification of Yersinia species, refer toID 21 - Identification ofYersiniaSpecies from Faeces.

Other genera of the family Enterobacteriaceae7-10.Other genera of the family reported to have caused infection are listed in section 2.

Principles of IdentificationColonial morphology, Grams stain, oxidase and the use of several biochemical tests identifyisolates from clinical material. Enteric pathogens such as Salmonellaspecies should beidentified biochemically and typed serologically. Hafnia, Morganellaand Proteusspecies canresemble non motile salmonella biochemically, and can agglutinate in polyvalent salmonellaantisera. Because of the diversity of biochemical activities, all the reactions of every species arenot described in this SMI. Therefore only a few screening tests are included together withresults for the more common genera and species.

If further identification or confirmation is required, isolates should be sent to the ReferenceLaboratory.

Careful consideration should be given to isolates that give an unusual identification. Allevidence including growth characteristics, cultural morphology and serology should beconsidered before accepting commercial identification system results.

Technical Information/LimitationsN/A
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1 Safety Considerations4-14All S. Typhi, S. ParatyphiA, B and C, S. dysenteriaetype 1, E. coliO157, Salmonella sendaiandSalmonella cholera-suis, and Yersinia pestisare Hazard Group 3 organisms and suspectedisolates must be handled in a containment level 3 room.

Refer to current guidance on the safe handling of all organisms documented in this SMI.Laboratory procedures that give rise to infectious aerosols must be conducted in amicrobiological safety cabinet.

Shigellaspecies and E. coliO157are highly infective, and as few as 10 organisms are requiredfor an infective dose. They have been reported as a cause of laboratory acquired infection.

The above guidance should be supplemented with local COSHH and risk assessments.

Compliance with postal and transport regulations is essential.

2 Target OrganismsEnterobacteriaceae reported to have caused human infections7-9Species SubspeciesCedecea davisae, lapagei, neteri, sp 3, sp 5

Citrobacter amalonaticus, braakii, farmeri, freundii, koseri, rodentium, sedlakii, werkmanii, youngae

Edwardsiella hoshinae, ictaluri, tarda

Enterobacter aerogenes, amnigenus, asburiae, cloacae, gergoviae, hormaechei, sakazakii, taylorae

Escherichia coli, fergusonii, hermanii, vulneris

Ewingella americana

Hafnia alvei

Klebsiella oxytoca, pneumoniae subspecies aerogenes, ozaenae, pneumoniae, and rhinoscleromatis

Kluyvera ascorbata, cryocrescens, georgiana

Leclercia adecarboxylata

Morganella morganii

Pantoea agglomerans, dispersa

Photorhabdus luminescens

Proteus mirabilis, penneri, vulgaris

Providencia alcalifaciens, rettgeri, stuartii

Rahnella aquatilis

Salmonella enterica (>2000 serotypes)

Serratia fonticola, grimesii, liquefaciens, marcescens, odorifera, plymuthica, proteamaculans, rubidaea

Shigella boydii, dysenteriae, flexneri, sonnei

Tatumella ptyseos

Yersinia aldovae, bercovieri, enterocolitica, intermedia, frederiksenii, kristensenii, mollaretti, pestis,pseudotuberculosis, rohdei

Yokenella regensburgei

Other genera and species of the Enterobacteriaceae may rarely be associated with human disease.


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3 Identification3.1 Microscopic AppearanceGram stain (TP 39 - Staining Procedures)Gram negative rods, some may show bipolar staining (eg Yersiniaspecies).3.2 Primary Isolation MediaBlood agar (BA): 16-24 hr incubation in 5-10% CO2 at 35-37C.

MacConkey (MAC) agar: 16---24 hr incubation in air at 35-37C.

Cystine-lactose-electrolyte deficient (CLED) agar with bromothymol blue (CLED B) or Andradesindicator (CLED A): 16---24 hr incubation in air at 35-37C.

Selective enteric media, incubation in air at 35-37C for 16---24 hr:

Desoxycholate citrate agar (DCA).

Xylose-lysine-desoxycholate agar (XLD).Cefixime-tellurite-sorbitol-MacConkey (CT-SMAC) agar.

Thiosulphate-citrate-bile salt (TCBS) agar.

Cefsulodin-Irgasan (triclosan)-novobiocin (CIN) agar incubated in air at 32C for 24---48 hr.

Chromogenic media incubated in air at 35-37C for 16-24 hr.

3.3 Colonial AppearanceBA---Gram negative rods 2-3 mm diameter, low, convex, grey, smooth or mucoid, may behaemolytic or swarming.

MAC---Gram negative rods may appear pink (lactose fermenting) or colourless (lactose nonfermenting) size and shape vary with individual species.

CLED B---Gram negative rods may appear yellow (lactose fermenting) or blue (lactose nonfermenting) size and shape vary with individual species.

CLED A-Gram negative rods may appear pink (lactose fermenting) or green translucent(lactose non fermenting) size and shape vary with individual species.

DCA---Gram negative rods may appear pink (lactose fermenting) or colourless (lactose nonfermenting) and may have black centre (H2S producers).

XLD---Gram negative rods may appear yellow (xylose, lactose or sucrose fermenting) or pink(non fermenting) and may have black centre (H2S producers).CT-SMAC---Gram negative rods may appear pink (sorbitol fermenting) or colourless (sorbitolnon fermenting).

TCBS---Gram negative rods may appear yellow (sucrose fermenting) or blue-green (sucrose nonfermenting).

CIN---Gram negative rods, colonies may have deep red centres (mannitol fermenting)surrounded by a translucent border giving the appearance of a bulls eye.

Note: Colonies of Yersiniaspecies may be smaller than those of other Enterobacteriaceae.
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3.4 Test ProceduresOxidase (TP 26 - Oxidase Test).All Enterobacteriaceae are oxidase-negative.

Lactose fermentation exhibits variable results depending on the genus and species.

3.5 Further IdentificationCommercial identification kit.

Serotyping.

3.6 Storage and ReferralSave the pure isolate on a nutrient agar slope for referral to the Reference Laboratory.
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4 Identification of Enterobacteriaceae FlowchartClinical Specimens

Primary isolation plate

BA

CLED B or CLED A, MAC

DCA, XLD, CT-SMAC, TCBS, CIN agar

Carbohydratefermenting

Carbohydratenon fermenting

Further identification ifclinically indicated

OxidasePerformed from non selective

medium

Negative Positive

Possible Pseudomonas speciesor

Pasteurella species(see ID 17 & 13)

Further identificationSerology for possible:

Salmonella / Shigella species (XLD / DCA)E. coli O157 (CT-SMAC) all presumptive (locally confirmed)

E. coli O157 should be sent to the Reference Laboratory Y. enterocolitica (CIN)(see ID 20, 21, 22, 24)

Commercial identification systemor

other biochemical identificationorsend to the Reference Laboratory

The flowchart is for guidance only.


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5 Reporting5.1 Presumptive IdentificationIf appropriate growth characteristics, colonial appearance, Grams stain of pure culture,oxidase and serological results are demonstrated.

5.2 Confirmation of Identification5.3 Medical MicrobiologistInform the medical microbiologist of presumptive and confirmed Y. pestis, S. Typhi,S. Paratyphi, Shigellaspecies, E. coliO157 and Salmonellaspecies (according to localprocedures).

The medical microbiologist should also be informed if the request card bears informationrelating to infection with Y. pestiseg

ulceroglandular/pneumonic syndrome. Septicaemia. travelling, hunting, farming, or veterinary work overseas.

Information relating to cases of:

enterocolitis. Dysentery. Septicaemia. haemolytic-uraemic syndrome. neurological dysfunction or confusional states. (non blanching) rash.

Presumptive or confirmed agents of enteric fever, dysentery, and enterocolitis should also berelayed to the medical microbiologist, especially if the patient has a history of:

recent foreign travel. farming (or visits to farms). veterinary or laboratory work. alcoholism, substance abuse, immunodeficiency or other serious underlying disorder

such as cancer.

Presumptive and confirmed isolates of Enterobacteriaceae from cases of food poisoning andfrom investigations of outbreak situations should additionally be reported to the medicalmicrobiologist.

Follow local protocols for reporting to clinician.

Further biochemical tests and/or molecular methods and/or reference laboratory report.


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5.4 Health Protection Agency15,16From 1 October 2010 provisions relating to diagnostic laboratories come into force. TheNotification Regulations require diagnostic laboratories to notify the Health Protection Agency(HPA) when they identify the causative agents that are listed in Schedule 2 of the Regulations.Notifications must be provided in writing, on paper or electronically, within seven days. Urgentcases should be notified orally and as soon as possible, recommended within 24 hr. Theseshould be followed up by written notification within seven days. For the purposes of theNotification Regulations, the recipient of laboratory notifications is the local HPA office. If acase has already been notified by a registered medical practitioner, the diagnostic laboratory isstill required to notify the case if they identify any evidence of an infection caused by anotifiable causative agent.

Notification under the Health Protection (Notification) Regulations 2010 does not replacevoluntary reporting to the HPA. The vast majority of NHS laboratories voluntarily report a widerange of laboratory diagnoses of causative agents to the HPA and many HPA offices haveagreements with local laboratories for urgent reporting of some infections. This shouldcontinue.

(Note: The Health Protection Legislation Guidance (2010) includes reporting of HIV & STIs,HCAIs and CJD under Notification Duties of Registered Medical Practitioners: it is not notedunder Notification Duties of Diagnostic Laboratories).

Other arrangements exist in Scotland17 and Wales18.

Notify all isolates of the following:E. coli(presumptive [locally-confirmed] VTEC O157 and other possible VTEC strains)

Salmonellaspecies

Shigellaspecies

Yersinia pestisUrgent oral notification to the Health Protection Unit within 24 hr of identification islikely to be necessary to protect human health when presumptive identification is madeof the following:S. Typhior S. Paratyphi

Salmonellaspecies if a suspected outbreak or a case in a food handler or closed communitysuch as a care home

Shigellaspecies other than S. sonnei

S. sonneiif a suspected outbreak or a case in a food handler or closed community such as a

care homeE. coliO157 when presumptive (locally confirmed) at the diagnostic laboratory

Other verocytotoxigenic E. coliO157

Yersinia pestis

Confirmatory and typing results should be forwarded to the Health Protection Unit assoon as they are available to expedite appropriate health protection interventions.5.5 Infection Control TeamInform the infection control team of presumptive and confirmed isolates of E. coliO157,

Yersinia, Salmonellaand Shigellaspecies.


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6 Referrals6.1 Reference LaboratoryFor information on the tests offered, turn around times, transport procedure and the otherrequirements of the reference laboratory refer to:http://www.hpa.org.uk/Centre for

Infections/lep/default.htmLaboratory of Enteric PathogensMicrobiology Services DivisionHealth Protection Agency61 Colindale AvenueLondonNW9 5HT

Contact Microbiology Services Division main switchboard: Tel. +44 (0) 20 8200 6173
http://www.hpa.org.uk/cfi/lep/default.htmhttp://www.hpa.org.uk/cfi/lep/default.htmhttp://www.hpa.org.uk/cfi/lep/default.htmhttp://www.hpa.org.uk/cfi/lep/default.htmhttp://www.hpa.org.uk/cfi/lep/default.htm


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References1. Hong Nhung P, Ohkusu K, Mishima N, Noda M, Monir Shah M, Sun X, et al. Phylogeny and species

identification of the family Enterobacteriaceae based on dnaJ sequences. Diagnostic Microbiology andInfectious Disease 2007;58:153-61.

2. Winstanley TG, Limb DI, Wheat PF, Nicol CD. Multipoint identification of Enterobacteriaceae: report ofthe British Society for Microbial Technology collaborative study. J Clin Pathol 1993;46:637-41.

3. Gray LD. Escherichia, Salmonella, Shigella and Yersinia. In: Murray PR, Baron EJ, Pfaller MA, Tenover FC,Yolken RH, editors. Manual of Clinical Microbiology. 6th ed. Washington D.C.: American Society forMicrobiology; 1995. p. 450-6.

4. Advisory Committee on Dangerous Pathogens. The Approved List of Biological Agents. Her Majesty'sStationery Office. Norwich. 2004. p. 1-21

5. Infections at work: Controlling the risks. Her Majesty's Stationery Office; 2003.

6. Advisory Committee on Dangerous Pathogens. Biological agents: Managing the risks in laboratories andhealthcare premises. HSE. 2005.

7. Control of Substances Hazardous to Health Regulations. The control of susbstances hazardous to healthregulations 2002. 5th ed. HSE Books; 2002.

8. Health and Safety Executive. Five Steps to Risk Assessment: A Step by Step Guide to a Safer and HealthierWorkplace. HSE Books. 2002.

9. Health and Safety Executive. A Guide to Risk Assessment Requirements: Common Provisions in Healthand Safety Law. HSE Books. 2002.

10. British Standards Institution (BSI). BS EN12469 - Biotechnology - performance criteria for microbiologicalsafety cabinets. 2000.

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ID Enterobacteriaceae