GRAM POSITIVE BACTERIA

GRAM (+) VS GRAM (-) BACTERIA

 CASE 1

A group of six children younger than 8 years of age live in a

semitropical country. Each of the children has several crusted
weeping skin lesions of impetigo (pyoderma). The lesions are
predominantly on the arms and faces. Which of the following
microorganisms is a likely cause of the lesions?
STAPHYLOCOCCUS AUREUS
Transmission Predisposing factors Reservoir Virulence factor Laboratory Treatment

• hands • surgical wounds • normal flora of nasal  Protein A  Coagulase positive MSSA
• sneezing • foreign body mucosa or skin  binds Fc component of  β-hemolytic  Nafcillin/oxacillin
• surgical wounds  tampons • 25% of population are IgG, forcing variable  Small yellow colonies MRSA
• contaminated food  surgical packing carriers region to face away on blood agar  Vancomycin (DoC)
a. custards or sutures from bacterium  Ferments mannitol  clindamycin
b. mayonnaise /  inhibits  TMP-SMX
potato salad phagocytosis VRSA
c. canned meats  inhibits  Linezolid (DoC)
complement  quinupristin/dalfopristi
fixation n
 Enterotoxins
 fast acting Gastroenteritis is self-
 heat stable limiting
 Toxic shock syndrome
toxin-1 (TSST-1)
superantigen
 binds MHC II and T-cell
receptor
 results in polyclonal T-
cell activation
 Coagulase
 converts fibrinogen to
fibrin clot
 Exfolatins
 skin-exfoliating toxins
 involved in scalded skin
syndrome
CLINIC AL DISEASE
Gastroenteritis  food poisoning
 salty foods and custards
 nausea/vomiting, abdominal pain, diarrhea 2-6 hours after ingesting toxin
 caused by enterotoxins A-E preformed in food
 symptoms start and end quickly
Infective endocarditis (acute)  fever, malaise, leukocytosis, heart murmur
due to fibrin-platelet mesh
Toxic shock syndrome  desquamating rash
 especially on palms and soles
 fever, hypotension
 multiorgan failure
 caused by TSST-1
Pneumonia  typical, acute, productive, rapid onset
 nosocomial pneumonia
 due to coagulase, cytolysins
 can result in empyema
 pus in the pleural space
Scalded skin syndrome  infants and children
 epidermal peeling
 due to exfoliative toxin
 epidermolytic toxins A and B against desmoglein 1 in stratum granulosum
Impetigo  erythematous papules to bullae
 due to coagulase, exfoliatins
Osteomyelitis  the most common overall cause of osteomyelitis
 also associated with prostheses, neonates

MRSA (methicillin-resistant S. aureus)  important cause of serious nosocomial and community-acquired infections
infection  resistant to β-lactams due to altered penicillin-binding protein
 CASE 2

A 16-year-old bone marrow transplant patient has a central venous

line that has been in place for 2 weeks. He also has a urinary tract
catheter, which has been in place for 2 weeks as well. He develops fever
while his white blood cell count is very low and before the transplant has
engrafted.
 STAPHYLOCOCCUS EPIDERMIDIS

Transmission Predisposing Reservoir Virulence factor Laboratory Treatment

factors
• Autoinfection • Infects catheters • Component of • Produces biofilms • Novobiocin • Vancomycin
Direct contact and prosthetic normal skin flora sensitive
(hands) devices • Coagulase (-)
peritoneal
dialysis
Foley
catheters
IV lines
prosthetic
devices
 CASE 3

A 29-year-old sexually active woman comes in with a chief complaint of

dysuria and urgency. A urinalysis and urine cutlure/gram stain is
performed revealing gram-positive organisms in clusters.
 STAPHYLOCOCCUS SAPROPHYTICUS

• 2nd most common cause of UTIs in sexually active young women

• E. coli is most common
• Laboratory tests
 coagulase negative
 novobiocin resistant
 urease positive
• Treatment: Fluoroquinolones
O
 CASE 1

A 78-year-old man develops a high fever, cough producing a blood-tinged

sputum, and difficulty breathing.
 S. PNEUMONIAE (ALSO KNOWN AS
"PNEUMOCOCCUS")

Transmission Predisposing factors Reservoir Virulence factor Laboratory Treatment

• respiratory droplets • influenza or • upper respiratory • Encapsulated • Diplococci Pneumonia

• not easily measles tract  polysacchari • α-hemolytic • macrolides
transmitted • CHF de capsule • Optochin sensitive Meningitis (adult)
• COPD responsible • Cannot grow in bile • ceftriaxone
• alcoholism for virulence • Positive quellung • cefotaxime
• asplenia reaction • vancomycin
• sickle cell anemia • pneumolysin O if resistant
 damages Otitis media and
respiratory sinusitis (children)
epithelium • amoxicillin
• erythromyci
• peptidoglycan and n if allergic
teichoic acids Vaccine
 cause adult
virulence in  pneumococ
meningitis cal
polysacchari
de vaccine
(PPV)
pediatric
 pneumococ
cal capsular
vaccine
(PCV)
CLINIC AL DISEASE
Meningitis (adult)  most common cause in adults
 ↑ PMNs, ↓ glucose, ↑ protein in CSF

Otitis media (children)  most common cause

 The most common cause of Pneumonia  most common cause of typical pneumonia
meningitis and community-acquired  especially common in senior citizens
pneumonia in adults  rust-colored sputum

 "The most common cause of MOPS 4 histologic stages of lobar pneumonia

is Most sensitive to OPtochin" Congestion
 "MOPS"  fluid extravasation into alveolar space
 contains mostly bacteria
 dilation of alveolar capillaries
For reference, note that the most Red hepatization
 RBCs in alveoli
common causes of acute otitis media,  red and firm without air
sinusitis, and bacterial conjunctivitis are Gray hepatization
 S. pneumoniae  fibrinous material in alveoli
 pale and firm
 nontypeable H. influenza Complete resolution
 Moraxella catarrhalis  enzymatic digestion of exudate

Sinusitis (children)  most common cause

 CASE 2

A 7y/o female with high fever, sore throat developed diffuse finely papular
erythematous rash that feels like sand and paper, hyperpigmentation of
armpits and strawberry tongue.
 S. PYOGENES (GROUP A STREP, OR "GAS")

Transmission Predisposing factors Reservoir Virulence factor Laboratory Treatment

• Direct contact • Throat  M protein  Rapid strep test is ELISA DOC is Penicillin G
• Respiratory droplets • Skin  main virulence factor based
 inhibits phagocytosis  misses 25% of
 inhibits complement infections → Macrolides
activation culture all  if penicillin allergy
 mediates bacterial negative tests
attachment  ASO (anti-streptolysin
 antigenic O) titer detects recent
 antibodies to M infection
protein can give  >200 indicates
rise to rheumatic rheumatic fever
fever  Bacitracin sensitive
 anti-DNase  β-hemolytic
 antibody for the skin  PYR (pyrrolidonyl
infection arylamidase) positive
 stays elevated for longer -
useful for diagnosis

 streptolysin O
 immunogenic
 lyses erythrocytes and
PMNs
 ASO titer reveals the
presence of this antigen
 Erythrogenic toxin:
produces scarlet fever
 Pyogenic pharyngitis  acute onset sore throat, fever, malaise, and headache
 "exudative tonsillitis"
CLINICAL o however, 70% of exudative tonsilitis is caused by
viruses
PRESENTATION o don't assume GAS solely based on finding of
exudative tonsilitis
G A S I S P YO G E N I C ,  tonsillar abscesses
TOX I G E N I C , A N D  tender anterior cervical lymph nodes
IMMUNOGENIC  cellulitis
 impetigo
 honey-crusted lesions

Toxigenic  scarlet fever

 sandpaper rash sparing palms and soles
 strawberry tongue
 toxic shock syndrome
Immunogenic
Rheumatic fever Post-streptococcal glomerulonephritis (PSGN)
 antibodies to heart tissue  immune deposits in glomeruli
 type II hypersensitivity  type III hypersensitivity
 symptoms include  associated with M12 serotype
 subcutaneous plaques  occurs following either pharyngitis or impetigo
 polyarthritis "PHaryngitis can result in rheumatic PHever and nePHritis"
 erythema marginatum
 chorea
 carditis
 occurs following pharyngitis
 does NOT occur following skin infection
(impetigo)
 CASE 3

A preterm (33-week) infant girl is born at home to a16-year-old mom

after 22 hours of labor after the rupture of the membranes. A friend
helped the mother deliver the baby. The now 4 day old infant now shows
signs of sepsis.
 STREPTOCOCCUS AGALACTIAE (GROUP B
STREPTOCOCCI)

Transmission Diseases Reservoir Virulence factor Laboratory Treatment

Perinatal Neonatal Vagina : 15-20% Capsule is Bacitracin Ampicillin

 increased risk septicemia of women are pathogenic resistant with
with prolonged carriers lipotechoic acid of β-hemolytic aminoglycoside or
labor after Neonatal GI tract cell wall - repels Hydrolyze cephalosporin
rupture of meningitis cationic hippurate
membranes antibicrobial CAMP test Prophylaxis
Neonatal peptides (innate positive during high-risk
• GBS screening pneumonia immune system) deliveries
@35-37 wks intrapartum
AOG Neonatal ampicillin for
osteomyelitis mom after
week 35
Causes of Neonatal
meningitis:
 GBS
 E. coli
 L.
monocytogenes
SUMMARY
SUMMARY
SUMMARY
GOD BLESS
 CASE 1

A 35-year-old woman presents to the emergency room for an ulcer on

her arm. She reports that she recently completed a travel program in
Africa, where she worked on the farms in exchange for room and board.
She reports coming into contact with farm animals every day. She said
she accidentally cut her left forearm on some wooden post a few days
ago.
Yesterday, she noticed a painless but pruritic lesion. On physical exam,
there is a 4-mm papule with a dusky-looking central vesicle and
surrounding edema. There is also axillary lymphadenopathy. She is
started on antibiotics.
 BACILLUS ANTHRACIS
Transmission Risk factors & Reservoir Virulence factor Laboratory Treatment
Epidemiology

 inhalation of  intravenous drug • Sheep Anthrax toxin composed Microscopy:  antibiotics should
spores use (e.g., heroin) • Goat of 3 components:  “medusa head” be given in the
 introduction of  occupational • Cattle  Protective antigen appearance prodromal phase of
spores into a skin exposure to  binds cell surface and  box-car shaped rods the disease
break unvaccinated mediates entry of  cutaneous anthrax
 ingestion of animals edema and lethal treated with 1
spores  occupational factor antibiotic
exposure to animal  Edema factor  systemic anthrax
hides  binds calmodulin and treated with 2
 only bacteria w/ a  bioterrorism performs the same antibiotics
polypeptide capsule function as adenylate  ciprofloxacin or
(poly-D-glutamate) cyclase, ↑ cAMP and doxycycline
resulting in
Types:  black eschar’s
 Cutaneous anthrax : edematous
most common borders
 Pulmonary anthrax :  vasodilation
“woolsorter’s and
disease” hypotension
 Gastrointestinal  Lethal factor
anthrax  cleaves the MAPKK,
inhibiting this
signaling pathway,
and resulting in
macrophage
apoptosis
 CASE 2

A 25-year-old medical student goes to an urgent care clinic for vomiting and
non bloody diarrhea. He is on a tight budget and has recently been relying on
buying bulk amounts of rice and making fried rice. He makes a batch every
Monday, and reheats it throughout the week.
He finished off his last batch for lunch around 3 hours ago and admits that he
had accidentally left that portion out overnight. He reports feeling nauseous.
On physical exam, he is afebrile, has hyperactive bowel sounds, and
abdominal tenderness. His physician reassures him that this disease is likely self-
limited and suggests that he vary his diet.
 BACILLUS CEREUS
Transmission Risk factor Virulence factor Diseases Laboratory Treatment

ingestion of spores or  ingestion of (fried) Spores Emetic type • spore-forming rod; self-limited
toxin rice or pasta  are heat resistant associated with MOTILE
 poor practices of and thus can reheated rice
handling and survive cooking and pasta
storing food rice especially seen within 1-5 hours
with reheated rice, after exposure
as spores Diarrheal type
germinate and associated with
produces meats and
enterotoxin sauces within 8-
18 hours after
 produces “emetic exposure
toxin” cereulide:
causes emetic type

Differential diagnosis
Giardiasis
distinguishing factors:
patients often report bloating and foul-smelling fatty watery diarrhea and have a
history of swimming in or drinking river/lake water
typically patients do not vomit
 CASE 3

A 20-year-old college student presents to the emergency room

after stepping on a piece of a rusted nail outside of his dorm. He
reports that he has had all the appropriate childhood vaccinations
but has had nothing since his last set of boosters at 10 years of
age.
His vital signs are within normal limits. Aside from erythema
surrounding his left sole at the site of trauma, his physical exam is
within normal limits. After cleaning the wound site, he is given the
appropriate post-exposure prophylaxis.
 CLOSTRIDIUM TETANI
Transmission Risk factor Virulence factor Diseases Laboratory Treatment

 direct contact in  lack of vaccination  Motile: Flagella (so  Trismus (lockjaw) Microscopy Tetanus antitoxin
contaminated soil  trauma H antigen-positive)  Risus sardonicus  drumstick, tennis Indication: patients with
 chronic wounds  Raised racket, or lollipop contaminated or dirty
 lack of immunity in  Tetanospasmin, an eyebrows shape wounds
mothers exotoxin  grin
 A protease  Opisthotonos Benzodiazepine
that cleaves  spinal muscle Indications: muscle
SNARE spasms spasms
proteins  causes
(synaptobrevin backward Booster vaccine
2), which arching of head Indication: patients with
blocks the and spine
release of  Rigid abdominal > 10 years from last
inhibitory muscles dose
neurotransmit
ters (glycine  Neonatal tetanus < 3 or uncertain number
and GABA) • neonates who of tetanus vaccine doses
causes are born to
paralysis unvaccinated
mothers
• inability to suck
or cry after day
2 of life
• foul-smelling
and
erythematous
umbilical stump
in neonates
 CASE 4

A 40-year-old man presents to the emergency room for blurry vision. He

reports that the blurry and double vision started this morning along with nausea
and vomiting. He also reports feeling weak in his arms. Upon further questioning,
he recently ate a can of beans from his aunt in Alaska, where they run their own
food storage business.
On physical exam, there is bilateral ptosis and facial weakness. There is also
bilateral upper arm weakness with absent deep tendon reflexes. His mental
status is intact. His physician immediately administers antitoxin treatment for the
disease.
 CLOSTRIDIUM BOTULINUM
Transmission Risk factor Virulence factor Diseases Laboratory Treatment

• ingestion of spore o ingestion of old or Motile: Flagella Infantile botulism Thioglycollate equine-derived
• ingestion of expired bottles or (so H antigen-  poor feeding and enriched agar heptavalent
preformed toxins cans of food or positive) diminished suck antitoxin
• direct wound honey  4 D’s  indication:
contamination o wound heat-labile Diplopia patients > 1
• inhalation (rare) contamination exotoxin Dysarthria years of age
o intravenous drug  irreversibly inhibits Dysphagia bivalent human-
use acetylcholine Dyspnea derived antitoxin
release at the autonomic nervous (BabyBIG)
neuromuscular system dysfunction  indication:
junction by  dry mouth patients < 1
cleaving SNARE  postural years of age
proteins hypotension
 ingestion of descending
exotoxin causes symmetric muscle
adult botulism weakness and
flaccid paralysis
absent deep tendon
reflexes
 CASE 5

A 45-year-old man presents to the emergency room after stepping on

a nail resulting in a puncture wound on his right foot. He was given a
tetanus booster and he left against medical advice refusing antibiotics.
Two days later, he returned to the emergency room for increasing pain in
his right foot.
Physical exam reveals dark purple and black discoloration of the right
sole with multiple ruptured bullae oozing serous drainage. On palpation,
there is soft tissue crepitus. A wound culture is sent, which shows gram-
positive bacilli. He is started on the appropriate antibiotics immediately.
 CLOSTRIDIUM PERFRINGENS

Transmission Risk factor Virulence factor Diseases Laboratory Treatment

gas gangrene Gas gangrene  Alpha  Food  Wound Penicillin

(exotoxin- traumati exotoxins poisoning culture & Clindamycin
mediated) c open  causes watery Gram stain ( if allergic to
necrotizi wounds myonecrosis diarrhea Gram(+) bacilli penicillin)
ng soft previous or gas nausea w/o
tissue surgery gangrene  Gas gangrene polymorphon
infection diabetes erythema uclear cells
food mellitus  heat-labile with “stormy
poisoning alcoholis enterotoxin purple- fermentation”
(enterotoxin- m • causes black in milk media
mediated) frostbite food discolorat double zone
immuno poisoni ion of of hemolysis
suppress ng affected on blood agar
ion limb
 CASE 6

An 89-year-old man with a past medical history of gastritis presents to

the hospital for dehydration and watery diarrhea. He started having
diarrhea and some weakness about 2 days ago and had not been able to
keep up with his fluid intake. He has been taking omeprazole for over 30
years and was recently treated with clindamycin for a soft tissue
infection. On laboratory evaluation, he has a marked leukocytosis. He is
started on oral vancomycin.
 CLOSTRIDIUM DIFFICILE
Transmission Risk factor Virulence factor Diseases Laboratory Treatment

• Fecal-oral: recent antibiotics toxin A is an pseudomembranou diagnostic tests of Metronidazole

ingestion of use enterotoxin that s colitis and the stool  alternative if
endospores  clindamycin binds to the diarrhea  polymerase vancomycin or
• Hands of hospital  ampicillin intestinal brush  characterized chain fidaxomicin are
personnel are  cephalospori border by yellow- reaction for not available
important ns toxin B is a white plaques the  addition to
intermediaries  fluoroquinol cytotoxin and in intestinal organism vancomycin if
ones depolymerizes mucosa  detection of patients are
proton-pump actin, disrupting antigen refractory to
inhibitors the cytoskeleton  + fecal monotherapy
recent leukocytes
hospitalization Motile: Flagella (so
advanced age H-antigen-positive) Vancomycin
 resistant to
metronidazole
 severe cases
 CASE 7

A 4-year-old girl presents to the emergency room for a fever and sore
throat. She recently visited Thailand for 2 months with her parents and
had just flown back a couple of days ago. Her parents report that she has
not had any of her recommended immunizations, as they have traveled
all over the world.
On physical exam, there is a grayish-white membrane covering her soft
palate. When irritated by a tongue depressor, the membrane oozes with
blood. She also has marked cervical lymphadenopathy and edema of the
neck. She is immediately admitted for monitoring, antibiotics, and
antitoxin.
 CORYNEBACTERIUM DIPHTHERIAE
Transmission Reservoir Virulence factor Disease Laboratory Treatment
Manifestations

• Respiratory Throat diphtheria Pseudomembran Bacterial culture  Erythromycin

droplets exotoxin ous pharyngitis gram-positive  Penicillin G
inactivates gray or rods with blue  Vaccine DPT
elongation bluish white and red granules
factor (EF-2) via membrane (metachromicall
ADP-ribosylation seen on y) seen on
soft palate, culture
Exotoxin is tonsils, or • cysteine-
encoded by β- back of the tellurite
prophage throat agar
bleeds (appears as
easily if black
irritated colonies)
develops 2- • Löffler
3 days after medium
symptoms positive Elek test
severe cervical for diphtheria
lymphadenopath toxin
y : “bull neck”
myocarditis
 CASE 8

A 73-year-old woman is brought to the emergency room by family

members due to intense headache, subjective fever, and altered mental
status. She currently lives in an independent living facility and enjoys
eating charcuterie and cheese plates.
On physical exam, she is oriented to person and place, but not time, a
change from her mental baseline, and found to have nuchal rigidity. A
lumbar puncture is done and the cerebral spinal fluid is sent for studies.
In the meantime, she is started empirically on ceftriaxone, vancomycin,
and ampicillin.
 LISTERIA MONOCYTOGENES
Transmission Reservoir Virulence factor Disease Laboratory Treatment
Manifestations

ingestion of Colonizes GI and The only gram Clinical Syndrome: Cerebrospinal  Ampicillin: 1st
unpasteurized female GUT positive bacteria  amnionitis fluid (CSF) studies line
dairy products or that produces LPS  septicemia  neutrophil-  trimethoprim-
cold deli meats  spontaneous dominant sulfamethoxazol
transplacental abortion pleocytosis e: 2nd line
vertical  granulomatosis  elevated
transmission infantiseptica protein
vaginal  gastroenteritis  low or
transmission (immunocompete normal
during birth to nt patients) glucose
neonate  meningitis  gram-
• neonates positive or
• immunocom gram-
promised variable
patients rods
 positive
culture
Blood culture:
tumbling motility
in broth at 22°C
GOD BLESS