GRAM

NEGATIVE ORGANISM
 Gram-Negative Diplococci
Neisseria MeninGitidis Neisseria Gonorrheae

Capsule Encapsulated Insignificant capsule

Ferments maltose and glucose glucose

HACEK Organisms
H- aemophilus spp.
A- ggregatibacter spp.
C- ardiobacterium spp.
E- ikenella corrodens
K- ingella spp.
 GRAM-NEGATIVE RODS
RESPIRATORY SYSTEM
Haemophilus influenzae Bordetella Legionella
type B pertussis pneumophila

Distinct Polyribitol Phosphate Whooping cough Poorly gram

Features/ capsule staining Silver
Characteristics stain
Airconditioning
Culture Medium Enriched chocolate agar Borget-Gengou Charcoal yeast
Agar Regan-Lowe agar
medium
 GRAM-NEGATIVE RODS
GIT and GUT

NON LACTOSE
•  Escherichia coli
FERMENTER
•  Salmonella spp. •  Klebsiella pneumoniae
•  Shigella spp. •  Campylobacter jejuni
•  Proteus mirabilis •  Helicobacter jejuni
•  Pseudomonas
aeruginosa
GRAM-NEGATIVE DIPLOCOCCI
 Case 1
An 18-year-old man presents to the emergency department for an
intractable headache and generalized malaise. His symptoms began 3 days
ago and have progressively worsened. Physical examination is significant
for nuchal rigidity, diffuse petechia, and an inability to extend at the knee
while the hips are flexed at 90°.
A lumbar puncture is performed and cerebral spinal fluid studies
demonstrate an elevated opening pressure, elevated protein, decreased
glucose, and a leukocytosis. Gram stain of the cerebral spinal fluid
demonstrates gram-negative diplococci.
 Neisseria meningitidis
Transmission Reservior & Risk Properties & Virulence Factor Pathogenesis & Presentation
Factor
q  Respirator q  Nasopharynx v  Ferments both MALTOSE and q  MENINGITIS:
y droplets o  penetrates GLUCOSE o  most common cause among aged 2-18 yrs
mucosal v  Oxidase-positive colonies on chocolate o  fever, headache, stiff neck, and increased
q  High epithelium agar level of PMNs in CSF
carriage and enters v  Grows best in high CO2 environment
rate in circulation v  Polysaccharide capsule q  MENINGOCOCCEMIA:
CLOSE o  pharynx → ü  an important virulence factor o  dissemination of meningococci into the
QUARTERS hematogen ü  Provides resistance against bloodstream
:: ous spread phagocytosis o  multiorgan disease
(blood) → v  IgA protease o  consumptive coagulopathy
ü  Military choroid ü  allows oropharynx colonization o  petechial or purpuric rash (purpura
recruits plexus → v  Endotoxin (lipooligosaccharide) fulminans)
ü  Dormitorie meninges ü  analogous to LPS from other
s HUMANS are the gram-negative bacteria q  WATERHOUSE-FRIDERICHSEN
ü  Camps only natural hosts. ü  Causes hemorrhage and sepsis SYNDROME:
ü  No ü  Responsible for petechial rash o  most severe form of meningococcemia
meningoc v  Pili o  adrenal insufficiency to bilateral
occus ü  enables attachment to the hemorrhagic destruction of the adrenal
vaccine nasopharynx glands
 NEISSERIA MENINGITIDIS

Dx & Lab Tests Treatment & Prevention

q Gram-negative, aerobic, v Penicillin

encapsulated, kidney bean-shaped
diplococcus v Ceftriaxone (or cefotaxime): DOC for
q Selective media: prevents growth of the treatment of meningococcal
bacteria using Thayer Martin Agar meningitis and septicemia
ü Vancomycin: inhibits G (+)
ü Colistin and trimethoprim: inhibit v Rifampin/ Ciprofloxacin: prophylaxis
G (-) except Neisseria of close contacts of infected persons
ü Nystatin: inhibits fungi
 Case 2

A 19-year-old male college student presents to the clinic

complaining of a burning sensation with urination as well as
purulent urethral discharge. He admits to rarely using condoms
during sexual intercourse, and does not recall the last time he was
tested for sexually-transmitted infections.
Urinalysis is positive for leukocyte esterase and a Gram stain
shows intracellular diplococci within polymorphonuclear
neutrophils.
 Neisseria gonorrheae
Transmissio Reservior & Risk Properties & Virulence Factor Pathogenesis & Presentation
n Factor
q  Sexually- q  Habitat is the v  Ferments GLUCOSE only q  GONOCOCCAL URETHRITIS
transmitt human genital v  Oxidase-positive ü  urethritis and epididymitis in men
ed tract ü  most common cause of urethritis
v  Pili: q  CERVICAL GONORRHEA
q  Passage q  unprotected Ø  Adherence to epithelial ü  in women, which can progress to pelvic
through sexual cells inflammatory disease (PID)
birth intercourse Ø  Antigenic variation
canal Ø  Antiphagocytic, binds q  Complications of PID
bacteria tightly to host cell §  Sterility
protecting it from §  Ectopic pregnancy
phagocytosis §  Chronic Pelvic Pain
v  Opa proteins: §  Dyspareunia
Ø  promote adherence and §  Peritonitis
invasion into epithelial cells; §  Perihepatitis (Fitz-Hugh-Curtis Syndrome) to
expression results in violin-string adhesions
opaque colonies q  GONOCOCCAL ARTHRITIS
§  the most common cause of septic arthritis in
v  Endotoxin: lipooligosaccharide sexually active individuals
(LOS) q  OPHTHALMIA NEONATORUM
 NEISSERIA GONORRHEAE

Dx & Lab Tests Treatment & Prevention

q Kidney bean-shaped , Gram (-) v Ceftriaxone plus Doxycycline

diplococci
q Culture: Specimen on chocolate v Erythromycin ointment or Silver
agar nitrate to prevent ophthalmia
q Selective media: Thayer Martin neonatorum
Agar

q Most common site of

asymptomatic gonococcal infection
in women: ENDOCERVIX
 Comparative Summary
Characteristics N. gonorrhoeae N. meningitidis

Appearance Kidney-bean shaped diplococci

Oxidase test Positive

Polysaccharide capsule No Yes

Fermentation Glucose ("Gonococci") Maltose and Glucose ("MeninGococci")

Transmission Sex Respiratory

Vaccine No (due to rapid antigenic Yes

variation)
β-lactamase production Common Rare

IgA protease production Yes

GRAM (-) BACILLI
 Case 3
A 76-year-old woman presents to the emergency department for altered
mental status. She currently lives in a nursing home and was brought to seek
treatment by her daughter. She was noted to be more confused over the
course of a few days and developed a fever. Her temperature is 101°F
(38.3°C), blood pressure is 133/99 mmHg, pulse is 101/min, and respirations
are 20/min.

Physical examination is notable for being alert and oriented to self but not
time or place and suprapubic abdominal pain. A urinalysis is remarkable for
being leukocyte-esterase positive.
 Escherichia coli
Transmission Reservior & Risk Properties & Virulence Factor Pathogenesis & Presentation
Factor

q  Ascending q  Habitat is human v  Fimbriae (pili): q  DIARRHEA

infection to colon ü  attachment/ colonization factor; causes ü  ETEC:
the urethra q  Colonizes the cystitis and pyelonephritis •  releases LT and ST toxins
(UTI) vagina and •  traveler’s diarrhea (watery)
urethra v  Capsule (K-antigen): causes pneumonia ü  EPEC :
q  During •  Watery diarrhea of long duration
birth v  Siderophore: •  Mostly in infants, often in developing
(neonatal ü  obtains iron from human transferrin or countries
meningitis) lactoferrin •  Flattens villi to prevents absorption
q  Heat Labile and ü  EIEC:
q  Fecal-oral Heat stable v  Adhesins •  Bloody diarrhea
(diarrhea) cause watery v  Flagella (H-antigen) •  with pus in the stool and fever
diarrhea ü  EHEC/STEC:
v  Endotoxins: •  E. coli strain O157:H7 (MC serotype)
q  Shiga like toxin ü  Lipid A portion of lipopolysaccharide (LPS) •  Transmitted via undercooked meat
(SLT) causes ü  Causes septic shock •  secretes shiga-like toxin (verotoxin)
bloody diarrhea v  Shiga-like toxin (SLT / verotoxin) then causes hemorrhagic colitis and
(HUS) ü  inhibits protein synthesis by inactivating hemolytic uremic syndrome
the 60S subunit of eukaryotic cells (E. coli •  Does not ferment sorbitol
O157:H7, STEC, EHEC) •  no fever, no pus in stool
 ESCHERICHIA COLI

Dx & Lab Tests Treatment & Prevention

q Facultative Gram-negative rods v UTI: Ampicillin or Sulfonamides
Beta-hemolytic
v Indole-positive v Meningitis and Sepsis: 3rd
v Lactose-fermenting colonies on generation cephalosporins
EMB or MacConkey’s agar ü Aminoglycosides
v Green metallic sheen on EMB ü Fluoroquinolones
v TSI (Triple Sugar Iron) agar v Rehydration is effective in
shows acid slant and acid butt traveler’s diarrhea
with gas but no H2S
 Case 4
A 6-year-old girl is brought in to the emergency department
for a 2-day history of fever and watery diarrhea. This morning,
the diarrhea contained some blood. She had just traveled to
Bangladesh to visit relatives. According to her family, an uncle
there recently had bloody diarrhea as well.

On physical exam, she is febrile, has hyperactive bowel

sounds, and abdominal tenderness to palpation. A stool culture
and Gram stain reveals lactose-fermenting, gram (-) rods. She
is admitted for immediate rehydration and treatment.
 Shigella dysenteriae
Transmission Reservior & Risk Factor Properties & Virulence Factor Pathogenesis & Presentation

q Fecal-oral q Human colon v No H2S production q Invades submucosa of intestinal

route 4Fs: v Non-lactose fermenter tract (distal ileum and colon), but
ü  Food q Risk factors v Produce no gas from the not the lamina propria then causes
ü  Fingers ü  ingestion of fermentation of glucose local inflammation with ulceration
ü  Feces contaminat to bleeding
ü  Flies ed or v Shigella has a low infective dose
uncooked (200 bacilli) to highly infectious q BACILLARY DYSENTERY
food/water vs Salmonella with an infective ü  Incubation period: 1-4 days
ü  Travel dose of 105-108 ü  Fever and abdominal cramps
ü  Poor then diarrhea (initially watery
hygiene v  Invasion of M cells is key to then bloody)
ü  crowding pathogenicity ü  Diarrhea frequently resolves in
v Shiga toxin: 2 or 3 days
ü  inactivates the 60S
ribosome, inhibiting protein q Febrile seizure as complication
synthesis and killing q Shigella is more toxic and invasive
intestinal epithelial cells than Salmonella
ü  protein synthesis inhibitor of
EUKARYOTES
 SHIGELLA DYSENTERIAE

Dx & Lab Tests Treatment & Prevention

q Gram-negative non-motile rods, v Fluoroquinolones (Ciprofloxacin)
have O antigens - in severe cases
q Cultured in XLD (xylose lysine
deoxycholate) medium v Fluid and electrolyte
replacement
 Case 5
A 4-year-old girl presents to her pediatrician for diarrhea and
fever. She recently flew back from India, where she spent a
summer with her grandparents. She has had a low-grade
fever since 3 days prior and had constipation followed by non-
bloody diarrhea.

On physical exam, she has a low grade fever, abdominal

tenderness to palpation, and a faint pink macular rash on her
trunk and upper arms. She is started on antibiotics.
 Salmonella spp.
Transmission Reservior & Risk Factor Properties & Virulence Factor
q S. typhi is q S. typhi is found v Produces H2S
transmitted via only in humans v Non-lactose fermenter
fecal-oral route (colon) v Motile (H-antigen) Capsule
(called the Vi antigen): protects
q S. enteritidis is from intracellular killing
found in enteric v Siderophores
tract of humans
and animals e.g.,
chickens and
domestic livestock
Course of the typhoid fever
 Spectrum of the disease
ENTEROCOLITIS TYPHOID FEVER SEPTICEMIA
S. enteritidis/ S. typhi S. choleraesuis
S. typhimurium

q Invasion of the epithelial v Due to Vi capsular antigen q Bacteremia results in the

and subepithelial tissue of v Organisms enter, multiply in seeding of many organs with
small and large intestines Peyer’s patches, and then osteomyelitis, pneumonia,
q Infectious dose is HIGH spread to RES meningitis as the MC
q Gastrectomy or use of v Predilection for invasion of sequelae
antacids lowers infectious the gallbladder lead to q Commonly seen in patients
dose significantly chronic carrier state with sickle cell anemia or
q Incubation period: 12-48hr v Incubation period: 5-21days cancer
q Nausea/vomiting then q Fever but with little or no
abdominal pain and enterocolitis to focal
nonbloody diarrhea symptoms associated with
affected organ (frequently
bone, lung, or meninges)
 Salmonella spp.
Dx & Lab Tests Treatment & Prevention
q Facultative Gram-negative rods Empirical Treatment:
ü  Ceftriaxone(2g/d IV) 10-14 days
q WIDAL TEST: detects antibodies in ü  Azithromycin (1g/d PO) 5 days
patient’s serum Fully Susceptible Tx:
q XLD (xylose lysine deoxycholate) ü  Ciprofloxacin 500mg BID 5-7 days(optimal tx)
medium ü  Chloramphenicol 25mkd TID 14-21 days
q Specimen Culture timing (BUS)
ü  1st week: Blood v  In the Philippines, first line drugs for typhoid:
ü  2nd week: Urine ü  Amoxicillin
ü  3rd week: Stool ü  Chloramphenicol
ü  TMP-SMX
ü  Vaccines for S. typhi
o  Oral: live attenuated S. typhi
o  IM: Vi Capsular polysaccharide
 Case 6

A 40-year-old man presents to a local emergency room. He is

currently on a medical mission in India. He reports sudden-
onset nausea, vomiting, and copious amounts of watery
diarrhea. His blood pressure is 93/65 mmHg and pulse is 114/
min.
On physical exam, he has sunken eyes, decreased skin
turgor, and dry mucous membranes. He is given intravenous
rehydration with the goal of rapid rehydration.
 Vibrio spp.
Transmission Reservior & Risk Factor Properties & Virulence Factor Pathogenesis & Presentation

q V. cholerae: q V. cholerae: v Oxidase-positive q CHOLERA:

ü  Fecal-oral ü  human v Non-lactose fermenter ü  severe diarrhea with rice water
route colon only v V. parahaemolyticus: stools or pea soup (no pus in
q V. halophilic stools)
parahemolyticus q  V. ü  Washer woman’s hands sign to
: parahemolytic v Motile (H-antigen): Shooting wirnkled skin due to loss of skin
ü  Contaminat us and V. star / fast darting motility turgor due to dehydration
ed raw vulnificus:
seafood ü  saltwater v Choleragen (enterotoxin): q PARAHEMOLYTICUS&VULNIFICUS:
q V. vulnificus: like LT of E. coli, acts by ADP GASTROENTERITIS
ü  Trauma to ribosylation; inc. cAMP, ü  Generally self-limited with an
skin, leads to secretion of explosive onset of watery
especially in electrolytes from the diarrhea and nausea, vomiting,
shellfish intestinal epithelium leads to abdominal cramps, headache,
handlers, or secretory diarrhea low-grade fever
by ingestion
of raw
shellfish
 Vibrio spp.
Dx & Lab Tests Treatment & Prevention

q Comma-shaped gram-negative v Tetracycline or Azithromycin

rods with a single polar flagellum shortens duration
v  Fluid and electrolyte
q Grows as flat yellow colonies on replacement
selective media: Thiosulfate-
citrate-bile-salts-sucrose (TCBS) v V. parahemolyticus and V.
agar vulnificus infection:
ü Minocycline plus
Fluoroquinolone or
Cefotaxime
 Case 7
A 53-year-old woman presents to an urgent care clinic for
diarrhea and abdominal cramping for the past 2 days. She
reports having a subjective fever with nausea and frequent
watery diarrhea that is occasionally bloody. She recently went
on a backpacking trip throughout Southeast Asia and returned 5
days ago.
On physical exam, she has dry mucous membranes and her
abdomen is soft, nontender, and nondistended. She is started
on intravenous hydration and a stool culture is sent. Given her
recent travel history, she is started on appropriate antibiotics.
 Campylobacter jejuni
Transmission Reservior & Risk Factor Properties & Virulence Factor Pathogenesis & Presentation

q Uncooked q Zoonotic: wild v Microaerophilic q GASTROENTERITIS

meat and domestic v Oxidase-positive ü  Most common cause of bacterial
(especially animal and v Catalase-positiv gastroenteritis
poultry) poultry; ü  Usually caused by ingestion of
q Unpasteurize undercooked v Motile (H-antigen) undercooked chicken
d milk chicken ü  Watery, foul-smelling diarrhea
q Fecal-oral v Invasive: invades the mucosa followed by bloody stools
of the colon but does not accompanied by fever and severe
penetrate, therefore, sepsis abdominal pain
rarely occurs then produces ü  May mimic ulcerative colitis
histologic damage to the
mucosal surfaces of the Associated with:
jejunum q GUILLAIN-BARRE SYNDROME
ü  Antigenic cross-reactivity
v Enterotoxin: similar to cholera between oligosaccharides in
toxin and the LT of E. coli bacterial capsule and
v Cytotoxins: destroy mucosal glycosphingolipids on surface of
cells neural tissues
 Campylobacter jejuni
Dx & Lab Tests Treatment & Prevention

q Motile, curved/comma- or S- shaped v Symptomatic treatment only

gram-negative rods with a single v Erythromycin - for severe disease
polar flagellum v Fluoroquinolone

q Selective media with antibiotic at

42oC:
ü Skirrow’s agar
ü Campy’s agar

q Optimum temperature is 42oC

 Case 8
A 54-year-old man presents to his primary care physician for
an annual checkup. He reports having intermittent epigastric
discomfort. He reports that the symptoms often improve after
eating and that he has some bloating after big meals. He
denies any fevers, chills, nausea or vomiting. He also denies
having any blood in his stools.
His physical exam is unremarkable. A urea breath test is
arranged and the results are positive. He is started on triple
therapy for eradication of the infection.
 Helicobacter pylori
Transmission Reservior & Risk Properties & Virulence Factor Pathogenesis & Presentation
Factor

q ingesti q stomach v Microaerophilic q PEPTIC ULCER DISEASE

on v Oxidase-positive ü most common cause of
v Catalase-positive duodenal ulcers and
v Urease-positive chronic gastritis
ü second leading cause of
“Triple Positive” gastric ulcer

q Urease: produces ammonia; q Disease Associations:
makes the environment alkaline ü GASTRIC CARCINOMA
then helps H. pylori survive in ü MALT LYMPHOMA
acidic mucosa

q Damages the goblet cells of gastric

mucosa
 Helicobacter pylori
Dx & Lab Tests Treatment & Prevention
q Curved gram-negative rods with a tuft v Triple Therapy:
of polar flagella (lophotrichous) ü Omeprazole
ü Clarithromycin
q EGD with biopsy showing H. Pylori ü Amoxicillin or Metronidazole

q H. pylori stool antigen: to document v Quadruple Therapy:

cure ü Tetracycline
ü Omeprazole
q Confirmatory for eradication of H. ü Metronidazole
pylori ü Bismuth subsalicylate
ü Urease breath test
 Case 9
A 24-year-old woman at 8 weeks of gestation presents to her
obstetrician for increased urinary frequency, dysuria, and
some suprapubic pressure for the past few days. She has a
history of spontaneous abortions.
On physical exam, she has suprapubic tenderness to
palpation and right costovertebral tenderness. A rapid urine
dipstick shows nitrite, leukocyte esterase, and urease
positivity. She is started on an antibiotic that is safe for
pregnant women.
 Proteus
Transmission Reservior & Properties & Virulence Pathogenesis & Presentation
Risk Factor Factor
q  v Urease-positive: q COMPLICATED UTI:
hydrolyzes urea into
NH3 and CO2 ü UTI associated with
v Indole-negative nephrolithiasis
v Non-lactose fermenter ü Urease hydrolyzes urea in the
urine to form ammonia then
v Motile inc, pH resulting to alkaline
v Fimbriae: for adherence urine to struvite stone
v Lipopolysaccharide formation (staghorn calculi;
v Urease production composed of magnesium-
ammonium-phosphate)
 Proteus
Dx & Lab Tests Treatment & Prevention

q Facultative gram-negative rod v Ampicilin TMP-SMX

q Culture: Swarming pattern colonies v Surgery: for large stones

on BAP
 Case 10
A 55-year-old woman presents to the emergency department
with fatigue and abdominal pain. Her symptoms are
associated with dysuria, hematuria, and increased urinary
frequency.
Physical examination is remarkable for bilateral flank pain,
suprapubic tenderness, and costovertebral angle tenderness.
Urine studies are obtained and she is started on empiric
antibiotics.
 Pseudomonas aeruginosa
Transmission Reservior & Risk Factor Properties & Virulence Factor

q  Transmission is via q  Habitat is environmental v  Non-lactose fermenter

ü  water aerosols water sources e.g., v  Oxidase-positive
ü  Aspiration ü  hospital respirators v  Motile (polar flagella)
ü  Fecal ü  humidifiers v  Elastase: causes vascular necrosis and local tissue
contamination destruction
q  Inhabits the skin, upper v  Proteases: destroy antibody and complement
q  Medical devices Hands respiratory tract, and colon v  Pyocyanin: damages the cilia and mucosal cells;
of healthcare workers of about 10% of people generates reactive oxygen species
v  Verdoglobin: from hemoglobin breakdown
q  Endotoxin v  Hemolysins: lyses RBC
v  Antiphagocytic mucopolysaccharide capsule: may
contribute to chronic pneumonia in cystic fibrosis
patients due to biofilm formation
q  Exotoxin A
ü  similar to diphtheria toxin
ü  inhibits protein synthesis by blocking EF2
ü  causes tissue necrosis
ü  Type III secretion system facilitates exotoxin transfer
 Pseudomonas: Pathogenesis & Presentation
q  SKIN AND SOFT TISSUE INFECTIONS q  BONE AND CARTILAGE INFECTIONS
ü  Burn wound infections ü  Puncture wound osteomyelitis
ü  Hot tub folliculitis: spa pools, whirl pools, or ü  Pubic osteomyelitis in IV drug users
inadequately chlorinated swimming pools q  EAR INFECTIONS
and hot tubs ü  Most common cause of:
ü  Skin graft loss due to infection ü  Otitis externa
ü  Green nail syndrome ü  Malignant otitis externa in diabetics
q  PNEUMONIA ü  Chronic suppurative otitis media
ü  Ventilator-associated pneumonia q  GASTROINTESTINAL INFECTIONS
ü  Necrotizing pneumonia (fleur-de-lis pattern) ü  Typhlitis (necrotizing enterocolitis)
ü  High-risk CAP: ü  Shanghai fever (mild form of typhoid)
§  Immunocompromised ü  Peritonitis in peritoneal dialysis patients
§  Broad-spectrum antibiotics
§  Steroid therapy q  URINARY TRACT INFECTONS
§  Structural lung lesions ü  3rd MCC of nosocomial UTIs
o  Bronchiectasis q  SEPSIS
o  Cystic fibrosis ü  Ecthyma gangrenosum (hemorrhagic lesions)
ü  Febrile neutropenia
•  Leukemia or lymphoma post chemo- or radiation
therapy
•  Severe burns
 Pseudomonas
Dx & Lab Tests Treatment & Prevention

q Gram-negative rods, obligate aerobe v Combination of active antibiotics

required
q Culture:
ü Grown on Cetrimide agar v Examples of suitable combinations:
ü greenish, metallic colonies on ü Ceftazidime + Amikacin
blood agar ü Piperacillin + Amikacin
ü with sweet, fruity grape-like odor ü Azlocillin + Ciprofloxacin
ü produces pigments:
•  Pyocyanin (blue)
•  Pyoverdin (green, fluorescent)
 Bacteroids fragilis
Transmission Reservior & Risk Factor Properties & Virulence Factor Pathogenesis & Presentation

q Spreads to q Predomina v Capsular polysaccharide: q Infections commonly due to

blood or nt antiphagocytic and combinations of bacteria in
peritoneum anaerobe anticomplement synergistic pathogenicity
during bowel of the v Succinate: inhibits PMN
trauma, human phagocytosis q ABDOMINAL ABSCESS
perforation, colon v Attachment factors: pili q PERITONITIS
or surgery q PERICARDITIS
v Lipid A does not elicit a q ENDOCARDITIS
strong host inflammatory
response (attenuated) then q CEREBRAL ABSCESS
to LPS with low endotoxic ü Chloramphenicol is ideal
activity because it is lipophilic

v Enterotoxins: causes
diarrhea
 Bacteroids fragilis
Dx & Lab Tests Treatment & Prevention
q Anaerobic, gram-negative rods v Metronidazole – DOC

v Surgical drainage of abscess

v Chloramphenicol is static, but cidal

to the following: No Bf Since
Highschool
ü N. meningitidis
ü B. fragilis
ü S. pneumoniae
ü H. influenzae
 GRAM-NEGATIVE RODS
RESPIRATORY SYSTEM
q Haemophilus influenzae
q Moraxella (Branhamella catarrhalis)
q Legionella pneumophila
q Bordetella pertussis

 Haemophilus influenzae
Transmission Reservior & Risk Factor Properties & Virulence Factor
q via respiratory q Man only (obligate v Requires two factors for growth (both
route human parasite) found in blood):
ü X factor: Hematin
q The non-typable H. ü V factor: NAD+
influenzae (NTHi) strains
colonize the v Satellite growth around S. aureus
nasopharynx in up to colonies
80% of individuals
v Capsule
ü 6 types, a-f
ü Type b is most virulent
ü composed of polyribitol ribose
phosphate Attachment pili

v lgA1 protease
 H. Influenzae: Pathogenesis & Presentation
q ENCAPSULATED H. INFLUENZAE: MENINGITIS: q CELLULITIS
ü  Most serious manifestation of Hib infection ü  Most commonly involves the buccal and
ü  Haemophilus influenzae type B is the one of periorbital regions; usually associated with
the primary causes of meningitis in infants fever
from 3 to 36 months of age
ü  antecedent upper respiratory tract infections q SEPTIC ARTHRITIS in infants
are common
ü  Complications: sensorineural hearing loss (6%), q SEPSIS especially in patients without functioning
mental retardation, seizure, deafness, and spleen
death
q ACUTE EPIGLOTTITIS: q NON-ENCAPSULATED H. INFLUENZAE:
ü  Most common cause is HiB ü  OTITIS MEDIA
ü  Cherry-red epiglottis ü  SINUSITIS CONJUNCTIVITIS
ü  Fever, sore throat, dysphagia, drooling, and ü  COPD EXACERBATIONS
difficulty breathing
ü  Thumb sign on X-ray
q PNEUMONIA:
ü  insidious onset and a history of fever, cough,
and purulent sputum production
 HAEMOPHILUS INFLUENZAE

Dx & Lab Tests Treatment & Prevention

q Gram stain: small gram-negative v Amoxicillin +/− clavulanate:
(coccobacillary) rods ü for mucosal infections (otitis
media, conjunctivitis, bronchitis)
q Positive Quellung test: due to its
capsule, similar to Streptococcus v Ceftriaxone: for meningitis
pneumoniae
v Rifampin: prophylaxis for close
q Fluorescently labeled antibodies contacts
(ELISA and latex particle agglunation)
 Moraxella (Branhamella catarrhalis)

Transmission Reservior & Spectrum of disease Treatment

Risk Factor
q Part of the v OTITIS MEDIA in children v Azithromycin or
normal flora clarithromycin
v SINUSITIS
v BRONCHITIS v Amoxicillin with
v PNEUMONIA clavulanate

v COPD EXACERBATION v Oral second or third

generation
cephalosporin

v TMP-SMX
 Bordetella pertussis
Transmission Reservior & Risk Factor Properties & Virulence Factor

q respiratory q Habitat is upper v Capsule

droplets respiratory tract v Beta-lactamase

v Filamentous hemagglutinin (FHA):

ü  pili rod that extends from the surface of B. pertussis,
enabling the bacteria to bind to ciliated epithelial
cells of the bronchi
Virulence ü  mediates attachment
q Filamentous v  Pertussis toxin:
hemagglutinin: ü  causes ADP ribosylation
ü  allows binding to ü  activates G proteins that increases cAMP resulting in:
ciliated epithelial o  Inc. sensitivity to histamine
cells o  Inc. insulin release
q Tracheal cytotoxin: o  Inc. number of lymphocytes in blood
ü  kills ciliated v  Extra-cytoplasmic adenylate cyclase:
epithelial cells ü  “weakens” neutrophils lymphocytes and monocytes
ü  paralyze cilia ü  inhibits phagocytosis
ü  causes whooping
 Bordetella pertusis: Pathogenesis & Presentation
q WHOOPING COUGH q Paroxysmal phase
ü  “Tuspirina” ü  2-4 weeks
ü  paroxysmal pattern of hacking coughs, ü  Whoop (burst of non-productive
accompanied by production of copious coughs)
amounts of mucus, that end with an ü  Increased number of lymphocytes in
inspiratory “whoop” blood smear
ü  Antibiotics ineffective during this
q Incubation Period stage
ü  7-10 days
q Convalescent stage
q Catarrhal phase ü  3-4 weeks (or longer)
ü  1-2 weeks ü  Diminished paroxysmal cough
ü  rhinorrhea, malaise, fever, sneezing, ü  Development of secondary
anorexia complications (pneumonia, seizure,
ü  patient is highly contagious encephalopathy)
ü  Antibiotics most effective
 BORDETELLA PERTUSSIS

Dx & Lab Tests Treatment & Prevention

q Small gram-negative rods v Erythromycin (most effective when given

in catarrhal stage)
q Culture:
ü  Bordet-Gengou agar: potato extract v Vaccine: DaPT (Given routinely at ages 2, 4,
ü  Regan-Lowe charcoal medium: 6, 15 mos and between 4-6yo.)
charcoal, blood, and antibiotic
v Pertussis vaccination during pregnancy is
safe

v Treat household contacts with

erythromycin.
 Legionella pneumophila
Transmission Reservior & Risk Factor Properties & Virulence Factor
q No person-to- q Ubiquitous in man and v Growth depends on the presence of L-cysteine and iron
person natural water in special media (charcoal yeast extract agar)
transmission environments:
PREDISPOSING ü  air conditioning v Optimal growth temperature is 28-40°C; organisms are
FACTORS: systems dormant below 20°C and are killed at temperatures
ü  Old age ü  cooling towers above 60°C.
ü  Smoking v Facultative intracellular parasite
ü  High q Freshwater amoebae ü  inhibits macrophage phagolysosome fusion
alcohol appear to be the natural ü  cell-mediated immunity is important
intake reservoir for the organisms. v Cu-Zn superoxide dismutase and catalase-peroxidase
ü  Immunosu ü  protects bacteria from macrophage superoxide and
ppression hydroperoxide oxidative burst
v Pili and flagella
ü  promote attachment and invasion
v Secretion of protein toxins
ü  like RNAase, phospholipase A and phospholipase C
v Cytotoxins: kill hamster ovary cells
 L. Pneumophila: Pathogenesis & Presentation

q PONTIAC FEVER q ATYPICAL PNEUMONIA

ü mild flu-like illness o  Accompanied by
ü headache, fever, muscle aches ü confusion
and fatigue ü nonbloody diarrhea
ü self-limiting: recovery in a week ü Hyponatremia
is common ü Proteinuria
ü hematuria
 LEGIONELLA PNEUMOPHILA

Dx & Lab Tests Treatment & Prevention

q Aerobic, motile, and nutritionally fastidious v Azithromycin
pleomorphic poorly gram-negative rods; v Levofloxacin
visualized with silver stain v Doxycycline

v PREVENTION:
ü  Reducing cigarette and alcohol
consumption
ü  Eliminating aerosols from water
sources
ü  High temperatures and
hyperchlorination in hospital water
supply
 Klebsiella pneumoniae
Transmission Reservior & Properties & Virulence Pathogenesis & Presentation
Risk Factor Factor
q Aspiration or q Habitat Is the v Urease-positive q NECROTIZING PNEUMONIA
inhalation upper v Indole-negative ü Friedlander’s Pneumonia
respiratory ü **vs E. coli which ü Most common cause in
q Ascending and GIT is indole- alcoholics
spread of positive** ü Usually nosocomial
fecal flora ü Thick, bloody sputum
(currant jelly sputum)

q URINARY TRACT INFECTIONS

q SEPSIS
ü Second to E. coli as the
common cause of sepsis
 KLEBSIELLA PNEUMONIAE

Dx & Lab Tests Treatment & Prevention

q Facultative gram-negative rods v Culture-guided treatment

with large polysaccharide
capsule v Cephalosporins +/-
Aminoglycosides
q Extended spectrum beta-
lactamase (ESBL) activity in
drug-resistant strains
Gram (-) ZOONOTIC
Yersinia pestis
Brucella spp.
Francisella tularensis
Pasteurella multocida
 Yersinia pestis
Transmission Reservior & Risk Factor Properties & Virulence Factor Pathogenesis & Presentation

q Flea bite q Wild rodents v Fraction 1 (F1): this capsular q  BUBONIC PLAGUE:
q Contact q City rats antigen is antiphagocytic ü  Regional lymph nodes (usually
with q Squirrels and groin) swell, and become red,
infected prairie dogs in the v V and W proteins hot and tender (called a bubo)
animal US ü  high fever
tissue v Non-motile ü  conjunctivitis
q Inhaled q SEPTICEMIC PLAGUE
aerosolized v Requires calcium at 37oC. If ü  bacteria survive in
organisms: VIRULENCE insufficient calcium, Y. pestis macrophages, and spread to
human to alters its metabolism and blood and organs
human q Pesticin: kills protein production. This trait ü  death occurs in 75% in
transmissio other bacteria assists with its intracellular state untreated
n occurs (including E. coli) v The bacteria elaborate a q SEPTICEMIC PLAGUE
during lipopolysaccharide endotoxin, ü  bacteria survive in
epidemics q Intracellular coagulase, and a fibrinolysin, macrophages, and spread to
murine toxin: which are the principal factors blood and organs
lethal to mice in the pathogenesis of plague. ü  death occurs in 75% in
untreated
 YERSINIA PESTIS

Dx & Lab Tests Treatment & Prevention

q Gram-negative rods with v Streptomycin or Gentamicin

bipolar staining: (closed v Doxycycline
safety pin appearance)
q Blood culture
q Culture bubo aspirate
q Serology
 Pasteurella multocida
Transmission Reservior & Properties & Virulence Pathogenesis & Presentation
Risk Factor Factor

q Bite from q Part of v Facultative q WOUND INFECTIONS

dog or cat the anaerobe (following dog or cat
normal v Capsule bites): may progress
flora of v Non motile to infection of nearby
domestic bones and joints
and wild
animals
 PASTEURELLA MULTOCIDA

Dx & Lab Tests Treatment & Prevention

q Short encapsulated gram- v Penicillin G

negative rod that exhibits v Doxycycline
bipolar staining v Third generation
q Buttery colonies with musty cephalosporin
odor due to indole production
 Francisella tularensis
Transmission Reservior & Risk Factor Properties & Virulence Factor Pathogenesis & Presentation

q Bite of tick (e.g. q Rabbits and v Obligate aerobe q TULAREMIA

Dermacentor), squirrels v Requires cysteine ü  Ulceroglandular: at the site of
deerfly or v Capsule antiphagocytic tick bite or direct contact with
infected q Ticks can serve v Non-motile contaminated rabbit, an ulcer
animals as a reservoir develops, with swelling of focal
q Direct contact lymph nodes
with infected q Pneumonia: inhalation, or through
animal tissue the blood
(usually rabbit)
q Inhaled q Oculoglandular: direct inoculation
aerosolized into eyes
organisms
q Ingestion of q Typhoidal: ingestion results in
contaminated gastrointestinal symptoms
meat or water (abdominal pain) and fever
q Easily
transmitted to
lab personnel
 Francisella tularensis
Dx & Lab Tests Treatment & Prevention

q Culture (but very dangerous due v Streptomycin (DOC)

to its high infectivity, requires
addition of cysteine to blood agar v Gentamicin
media v Doxycycline

q Skin test v Attenuated vaccine: only for high-

risk individuals
q Measure rise in IgG antibody titer
(IgM is not very good)
 Brucella
Transmission Reservior & Risk Factor Properties & Virulence Factor Pathogenesis & Presentation

q Direct contact q Brucella v Obligate aerobes q BRUCELLOSIS:

with meltitensis ü  Undulating fever (fever peaks
contaminated (highest v Non-motile Tropism for in the evening, and returns to
livestock or pathogenicity): erythritol, a sugar found in normal by morning)
aborted Goat animal placentas ü  Weakness
placentas ü  Loss of appetite
q Brucella
q Ingestion of abortus: Cattle
infected/ q Includes ABORTIONS in animals
contaminated/
unpasteurized q Brucella suis:
dairy products pig

q Aerozolization in
laboratory or q Brucella canis:
possibly due to Dogs
bioterrorism
 Brucella
Dx & Lab Tests Treatment & Prevention

q Aerobic gram-negative v Pasteurization of milk

coccobacilli
v Treat with combination of
q Culture blood, bone marrow doxyxycline and one other
(best yield), liver, or lymph drug:
nodes ü Gentamicin
ü Streptomycin
ü Rifampin