Bacteria are single-celled microorganisms that lack a nuclear membrane, are metabolically active and divide by binary fission. Medically they are a major cause of disease. Superficially, bacteria appear to be relatively simple forms of life; in fact, they are sophisticated and highly adaptable. Many bacteria multiply at rapid rates, and different species can utilize an enormous variety of hydrocarbon substrates, including phenol, rubber, and petroleum. These organisms exist widely in both parasitic and free-living forms. Because they are ubiquitous and have a remarkable capacity to adapt to changing environments by selection of spontaneous mutants, the importance of bacteria in every field of medicine cannot be overstated.

The discipline of bacteriology evolved from the need of physicians to test and apply the germ theory of disease and from economic concerns relating to the spoilage of foods and wine. The initial advances in pathogenic bacteriology were derived from the identification and characterization of bacteria associated with specific diseases. During this period, great emphasis was placed on applying Koch's postulates to test proposed cause-and-effect relationships between bacteria and specific diseases. Today, most bacterial diseases of humans and their etiologic agents have been identified, although important variants continue to evolve and sometimes emerge, e.g., Legionnaire's Disease, tuberculosis and toxic shock syndrome.

Major advances in bacteriology over the last century resulted in the development of many effective vaccines (e.g., pneumococcal polysaccharide vaccine, diphtheria toxoid, and tetanus toxoid) as well as of other vaccines (e.g., cholera, typhoid, and plague vaccines) that are less effective or have side effects. Another major advance was the discovery of antibiotics. These antimicrobial substances have not eradicated bacterial diseases, but they are powerful therapeutic tools. Their efficacy is reduced by the emergence of antibiotic resistant bacteria (now an important medical management problem) In reality, improvements in sanitation and water purification have a greater effect on the incidence of bacterial infections in a community than does the availability of antibiotics or bacterial vaccines. Nevertheless, many and serious bacterial diseases remain.

Most diseases now known to have a bacteriologic etiology have been recognized for hundreds of years. Some were described as contagious in the writings of the ancient Chinese, centuries prior to the first descriptions of bacteria by Anton van Leeuwenhoek in 1677. There remain a few diseases (such as chronic ulcerative colitis) that are thought by some investigators to be caused by bacteria but for which no pathogen has been identified. Occasionally, a previously unrecognized diseases is associated with a new group of bacteria. An example is Legionnaire's disease, an acute respiratory infection caused by the previously unrecognized genus, Legionella. Also, a newly recognized pathogen, Helicobacter, plays an important role in peptic disease. Another important example, in understanding the etiologies of venereal diseases, was the association of at least 50 percent of the cases of urethritis in male patients with Ureaplasma urealyticum or Chlamydia trachomatis.

Recombinant bacteria produced by genetic engineering are enormously useful in bacteriologic research and are being employed to manufacture scarce biomolecules (e.g. interferons) needed for research and patient care. The antibiotic resistance genes, while a problem to the physician, paradoxically are indispensable markers in performing genetic engineering. Genetic probes and the polymerase chain reaction (PCR) are useful in the rapid identification of microbial pathogens in patient specimens. Genetic manipulation of pathogenic bacteria continues to be indispensable in defining virulence mechanisms. As more protective protein antigens are identified, cloned, and sequenced, recombinant bacterial vaccines will be constructed that should be much better than the ones presently available. In this regard, a recombinant-based and safer pertussis vaccine is already available in some European countries. Also, direct DNA vaccines hold considerable promise.

In developed countries, 90 percent of documented infections in hospitalized patients are caused by bacteria. These cases probably reflect only a small percentage of the actual number of bacterial infections occurring in the general population, and usually represent the most severe cases. In developing countries, a variety of bacterial infections often exert a devastating effect on the health of the inhabitants. Malnutrition, parasitic infections, and poor sanitation are a few of the factors contributing to the increased susceptibility of these individuals to bacterial pathogens. The World Health Organization has estimated that each year, 3 million people die of tuberculosis, 0.5 million die of pertussis, and 25,000 die of typhoid. Diarrheal diseases, many of which are bacterial, are the second leading cause of death in the world (after cardiovascular diseases), killing 5 million people annually.

Many bacterial diseases can be viewed as a failure of the bacterium to adapt, since a well-adapted parasite ideally thrives in its host without causing significant damage. Relatively nonvirulent (i.e., well-adapted) microorganisms can cause disease under special conditions - for example, if they are present in unusually large numbers, if the host's defenses are impaired, (e.g., AIDS and chemotherapy) or if anaerobic conditions exist. Pathogenic bacteria constitute only a small proportion of bacterial species; many nonpathogenic bacteria are beneficial to humans (i.e. intestinal flora produce vitamin K) and participate in essential processes such as nitrogen fixation, waste breakdown, food production, drug preparation, and environmental bioremediation. This textbook emphasizes bacteria that have direct medical relevance.

In recent years, medical scientists have concentrated on the study of pathogenic mechanisms and host defenses. Understanding host-parasite relationships involving specific pathogens requires familiarity with the fundamental characteristics of the bacterium, the host, and their interactions. Therefore, this section first presents with the basic concepts of the immune response, bacterial structure, taxonomy, metabolism, and genetics. Subsequent chapters emphasize normal relationships among bacteria on external surfaces; mechanisms by which microorganisms damage the host; host defense mechanisms; source and distribution of pathogens (epidemiology); principles of diagnosis; and mechanisms of action of antimicrobial drugs. These chapters provide the basis for the next chapters devoted to specific bacterial pathogens and the diseases they cause. The bacteria in these chapters are grouped on the basis of physical, chemical, and biologic characteristics. These similarities do not necessarily indicate that their diseases are similar; widely divergent diseases may be caused by bacteria in the same group.

Charles P. Davis

Gail Woods

David Niesel