Gram (+), non-sporeformer, regular shape

and staining, Anaerobes

Staphylococci Genus General Characteristics Coagulase-negative staphylococcus
• Gram-positive
Frequently involved in nosocomial and opportunistic infections
• Spherical cells arranged in irregular clusters (Grapelike)
• Facultative anaerobe • Presence can indicate contamination, Seeing an increase due to
prosthetic devices, catheters and immunocompromised
• Catalase (+)
• Staphylococcus epidermidis – lives on skin and mucous
• Oxidase (-)
membranes; endocarditis, bacteremia, UTI
• Glucose fermentation
• Staphylococcus hominis – lives around apocrine sweat glands
• Lack spores and flagella - Nonmotile
• Staphylococcus capitis – live on scalp, face, external ear
• May have capsules (Generally non-encapsulated)
• All 3 may cause wound infections by penetrating through broken skin
• Common inhabitant of the skin and mucous membranes
• Staphylococcus saprophyticus – infrequently lives on skin,
intestine, vagina; UTI

Common Staphylococcus species

Staphylococcus epidermidis Staphylococcus saprophyticus
Coagulase positive • Produces a slime layer that helps adherence • UTIs in young sexually active women due
• Staphylococcus aureus to prosthetics and avoidance of phagocytosis to increased adherence to epithelial cells
• Location lining the urogenital tract
Coagulase negative – Normal skin flora • Urine cultures
– Opportunistic pathogen
• Staphylococcus epidermidis – If present in low amounts, it is still
• Skin/wound infections
• Staphylococcus saprophyticus considered significant
• Endocarditis
• Staphylococcus haemolyticus • Diseases
• UTI
• Staphylococcus hominis – UTI / cystitis
• Exposure
• Staphylococcus capitis – Direct contact – Peritonitis
• Newborns / Elderly – Enopthalmitis
Identification of Staphylococcus – Fomites – Endocaritis
• Catheters - Intravascular – Septic arthritis
Catheter-Related Bloodstream
• Frequently isolated from pus, tissue exudates, Infection
sputum, urine, and blood • Shunts
• Cultivation, catalase, biochemical testing, coagulase • IV needles
• Prosthetics
Gram (+), non-sporeformer, regular shape
and staining, Facultative anaerobes
Staphylococcus aureus
• Gram-positive coccus that grows in clusters
• Grows in large, round, opaque colonies
• Optimum temperature of 37oC
• Facultative anaerobe
• Withstands high salt, extremes in pH (7.5%-10%),
and high temperatures
• Produces many virulence factors
• Considered “normal” biota of the skin in 1/3 of the
population.
Virulence factors of S. aureus
Enzymes:
• Clumping Factor – responsible for adherence to
fibrinogen and fibrin, form clump when mixed with plasma
• Coagulase – coagulates plasma and blood; produced by
97% of human isolates; diagnostic
• Hyaluronidase – hydrolyzes hyaluronic acid to digests
connective tissue allowing spread of infection
• Staphylokinase – digests blood clots
• DNase – digests/degrades DNA
• Lipases – digest oils; enhances colonization by acting on •
lipids present on the surface of the skin.
• Penicillinase – inactivates penicillin
Toxins:
• Hemolysins (α, β, γ, δ) – lyse red blood cells
• Panton-Valentine Leukocidin – lyses neutrophils and
macrophages
• Enterotoxin (A-E) – induce gastrointestinal distress (Heat
stable @ 100o C for 30 minutes & resistant to degradation
by stomach gastric acids)
• Exfoliative toxin – separates the epidermis from the
dermis
• Toxic shock syndrome toxin (TSST) – induces fever,
vomiting, shock, systemic organ damage
Epidemiology and Pathogenesis MRSA
• Present in most environments frequented by humans Methicillin-resistant S. aureus
• Readily isolated from carrier/fomites • Hospital associated
• Carriage rate for healthy adults is 20-60% • Community associated
• Carriage is mostly in anterior nares, skin, nasopharynx, intestine VRSA
• Predisposition to infection include: poor hygiene and nutrition, tissue
injury, preexisting primary infection, diabetes, immunodeficiency • Vancomycin resistant S. aureus
• Increase in community acquired methicillin resistance – MRSA
• Immune evasion
Clinical Concerns and Treatment
– Slime layer biofilm (microcapsule)
• 95% have penicillinase and are resistant to penicillin and
• Evades phagocytosis
ampicillin
– Protein A on cell wall
• MRSA – methicillin-resistant S. aureus – carry multiple
• Binds to Fc part of IgG resistance
• Blocks opsonization/phagocyte – Some strains have resistance to all major drug
• Adhesin proteins groups except vancomycin
– Binds to fibrin/fibrinogen • Abscesses have to be surgically perforated
– Binds to ECM • Systemic infections require intensive lengthy therapy
• laminin
• fibronectin Prevention of Staphylococcal Infections
• collagen •
Universal precautions by healthcare providers to
prevent nosocomial infections
• Hygiene and cleansing
Staphylococcal Disease
Localized cutaneous infections – invade skin through wounds, follicles, or glands
– Folliculitis – superficial inflammation of hair follicle; usually resolved with no complications but can progress
– Furuncle – boil; inflammation of hair follicle or sebaceous gland progresses into abscess or pustule
– Carbuncle – larger and deeper lesion created by aggregation and interconnection of a cluster of furuncles
– Impetigo – bubble-like swellings that can break and peel away; most common in newborns
• Systemic infections
– Osteomyelitis – infection is established in the metaphysis; abscess forms
– Bacteremia – primary origin is bacteria from another infected site or medical devices; endocarditis possible
• Toxigenic disease
– Food intoxication – ingestion of heat stable enterotoxins; gastrointestinal distress. Foods affected include meat, dairy
products, bakery goods with cream fillings, and salads made with eggs and mayonnaise.
– Staphylococcal scalded skin syndrome – toxin induces bright red flush, blisters, then desquamation of the epidermis
– Toxic shock syndrome – toxemia leading to shock and organ failure; Associated with tampon use
 General Characteristics of
Streptococci (Genus)
• Gram-positive spherical/ovoid cocci arranged in
long chains; commonly in pairs
• Non-spore-forming, nonmotile
• Can form capsules and slime layers
• Facultative anaerobes
• Do not form catalase, but have a peroxidase
system
• Most parasitic forms are fastidious and require
enriched media
• Small, nonpigmented colonies
• Sensitive to drying, heat, and disinfectants
Classification of Streptococci
• Lancefield classification system based on
cell wall Ag – 17 groups (A, B, C,….)
• Another classification system is based on
hemolysis
b-hemolysis – A, B, C, G and some D strains (
S.Pyogenes and S, Agalactiae)
a – hemolysis – S. pneumoniae and viridans
Identification of Streptococci
• Cultivation and diagnosis ensure proper
treatment to prevent possible complications
• Culture using bacitracin disc test, CAMP test,
Esculin hydrolysis
• Rapid diagnostic tests based on monoclonal
antibodies that react with C-carbohydrates:
Human Streptococcal Pathogens
• S. pyogenes
• S. agalactiae
• Viridans streptococci
• S. pneumoniae
• Enterococcus faecalis
b-hemolytic Streptococcus pyogenes ( Group A)
• Most serious streptococcal pathogen
• Strict parasite
• Inhabits throat, nasopharynx, occasionally skin
Virulence Factors of S. pyogenes
Produces surface antigens:
C-carbohydrates – protect against lysozyme
Fimbriae – adherence
M-protein – contributes to resistance to phagocytosis
Hyaluronic acid capsule – provokes no immune response
C5a protease hinders complement & neutrophil response
Extracellular toxins:
Streptolysins – hemolysins; streptolysin O (SLO) and
streptolysin S (SLS) – both cause cell and tissue injury
Erythrogenic (pyrogenic) Exotoxin – Spe A, B & C; associated
with streptococcal toxic shock syndrome and scarlet fever
Superantigens – strong monocyte and lymphocyte stimulants;
cause the release of tissue necrotic factor
Streptokinase – digests fibrin clots
Hyaluronidase – breaks down Hyaluronic Acid
DNase – hydrolyzes DNA
Epidemiology and Pathogenesis
• Humans only reservoir
• Inapparent carriers
• Transmission – contact, droplets, food, fomites
• Portal of entry generally skin or pharynx
• Children predominant group affected for cutaneous and
throat infections
• Systemic infections and progressive sequelae possible if
untreated
Scope of Clinical Disease
• Impetigo (pyoderma) – superficial lesions that break and
form highly contagious crust; often occurs in epidemics in
school children; also associated with insect bites, poor hygiene,
and crowded living conditions
• Erysipelas – pathogen enters through a break in the skin and
eventually spreads to the dermis and subcutaneous tissues;
can remain superficial or become systemic
• Necrotizing fasciitis – extensive, spreading necrosis
• Streptococcal pharyngitis – strep throat
• Cellulitis
• Puerperal Fever – Affecting post-partum women
• Scarlet fever – Characterized by exudative
pharyngitis, fever and bright-red exanthem
• Septicemia
• Pneumonia
• Streptococcal toxic shock syndrome –
Characterized by shock, bacteremia,
respiratory failure
Long-Term Complications of Group A Infections
• Rheumatic fever – follows overt or subclinical
pharyngitis in children; carditis with extensive
valve damage possible, arthritis, chorea, fever
• Acute glomerulonephritis – nephritis, increased
blood pressure, occasionally heart failure; can
become chronic leading to kidney failure
Treatment and Prevention
• Groups A and B are treated with
penicillin
• Long-term penicillin prophylaxis for
people with a history of rheumatic
fever or recurrent strep throat
• Enterococcal treatment usually
requires combined therapy
 a-Hemolytic Streptococci:
Group B: Streptococcus agalactiae (b) Viridans Group
• Large complex group
• b-hemolytic – Streptococcus mutans, S.
• Regularly resides in human vagina, pharynx, and large oralis, S. salivarus, S.
sanguis, S. milleri, S. mitis
intestine
• Can be transferred to infant during delivery and cause severe
infection • Most numerous and widespread
– Most prevalent cause of neonatal pneumonia, sepsis,
residents of the gums and teeth,
oral cavity, and also found in
and meningitis nasopharynx, genital tract, skin
– Pregnant women should be screened and treated
• Not very invasive; dental or
• Wound and skin infections and endocarditis in debilitated surgical procedures facilitate
people entrance
• Bacteremia, meningitis, abdominal
Group D Enterococci and Groups C and G Streptococci infection, tooth abscesses
• Most serious infection – subacute
• Group D (b ) : endocarditis – Blood-borne bacteria settle
– Enterococcus faecalis, E. faecium, E. durans and grow on heart lining or valves
– Normal colonists of human large intestine • Persons with preexisting heart disease are
– Cause opportunistic urinary, wound, and skin at high risk
infections, particularly in debilitated persons • Colonization of heart by forming biofilms
• Groups C and G (b ) :
Streptococcus mutans produce slime layers that
– Common animal flora, frequently isolated from adhere to teeth, basis for plaque
upper respiratory; pharyngitis,
glomerulonephritis, bacteremia Involved in dental caries
Persons with preexisting heart conditions should
receive prophylactic antibiotics before surgery or
dental procedures
a-Hemolytic Streptococcus pneumoniae
• Causes 60-70% of all bacterial
pneumonias (Majority)
• Small, lancet-shaped cells arranged in
pairs and short chains
• Culture requires blood or chocolate
agar & growth improved by 5-10% CO2
• Lack catalase and peroxidases –
cultures die in O2
• All pathogenic strains form large capsules – major
virulence factor
• Specific soluble substance (SSS) varies among
types
• 90 different capsular types have been identified
• Causes pneumonia and otitis media
Epidemiology and Pathology
• 5-50% of all people carry it as normal flora in the nasopharynx;
infections are usually endogenous
• Very delicate, does not survive long outside of its habitat
• Young children, elderly, immune compromised, those with other
lung diseases or viral infections, persons living in close quarters
are predisposed to pneumonia
• Pneumonia occurs when cells are aspirated into the lungs of
susceptible individuals
• Pneumococci multiply and induce an overwhelming inflammatory
response
• Gains access to middle ear by way of eustachian tube
Treatment and Prevention Cultivation and Diagnosis
• Traditionally treated with penicillin G
or V • Gram stain of specimen –
• Increased drug resistance presumptive identification
• Two vaccines available for high risk • Quellung test or capsular
individuals: swelling reaction (upon
– Capsular antigen vaccine for binding of homologous
older adults and other high antibody)
risk individuals – effective 5 • α-hemolytic; optochin
years sensitivity, bile solubility,
– Conjugate vaccine for inulin fermentation
children 2 to 23 months
 General Characteristics of the Genus Bacillus
• Gram-positive, endospore-forming, motile rods
• Mostly saprobic
• Aerobic and catalase positive
• Versatile in degrading complex macromolecules
• Source of antibiotics
• Primary habitat is soil
• 2 species of medical importance:
– Bacillus anthracis
– Bacillus cereus
• 3 types of anthrax:
• Treated with penicillin, tetracycline, or
• Vaccines
Bacillus anthracis
• Large, block-shaped rods
• Central spores that develop under all conditions except in
the living body
• Primarily a disease of herbivores
• B. antracis spread via lymphatics into bloodstream
• Virulence factors :
- Protective antigen (PA) : binds to cell receptor, forms a
membrane channel, mediates entry of EF & LF
- Edema Factor (EF) : Adenylate cyclase with PA forms
edema toxin
- Lethal factor ( LF) : Together with PA forms lethal toxin
– Cutaneous – spores enter through skin,
black sore- eschar; least dangerous
– Pulmonary –inhalation of spores
– Gastrointestinal – ingested spores
Control and Treatment
ciprofloxacin
– Live spores and toxoid to protect
livestock
– Purified toxoid; for high risk
occupations and military personnel;
toxoid 6 inoculations over 1.5 years;
annual boosters
Bacillus cereus
• Common airborne and dustborne; usual
methods of disinfection and antisepsis are
ineffective
• Grows in foods, spores survive cooking and
reheating
• Ingestion of toxin-containing food causes
nausea, vomiting, abdominal cramps, and
diarrhea; 24-hour duration
• No treatment
• Increasingly reported in immunosuppressed
• Cause Food poisoning :
Emetic type : associated with fried rice,
- Manifested by nausea, vomiting, abdominal
cramps, self- limiting, recovery within 24 hours
Diarrheal type : associated with meat dishes and
sauces
- Manifested by profuse diarrhea with
abdominal pain and cramps
 The Genus Clostridium
• Gram-positive, spore-forming rods
• Anaerobic and catalase negative
• Natural Habitat is the soil or the intestinal
tract
• 4 medically important :
- C. botulinum
- C. difficile
- C.perfringens
- C. tetani
Clostridium tetani
• Common resident of soil and GI tracts of
animals
• Causes tetanus or lockjaw, a
neuromuscular disease
• Most commonly among geriatric patients
and IV drug abusers; neonates in
developing countries
• Spores usually enter through accidental puncture
wounds, burns, umbilical stumps, frostbite, and
crushed body parts
• Anaerobic environment is required for vegetative cells
to grow and release toxin
Pathology
• Tetanospasmin – neurotoxin causes paralysis by
binding to motor nerve endings; blocking the release
of neurotransmitter for muscular contraction inhibition;
muscles contract uncontrollably
• Death most often due to paralysis of respiratory muscles
Treatment and Prevention
• Treatment aimed at deterring degree of toxemia
and infection and maintaining homeostasis
• Antitoxin therapy with human tetanus immune
globulin; inactivates circulating toxin but does not
counteract that which is already bound
• Control infection with penicillin or tetracycline;
and muscle relaxants
• Vaccine available; booster needed every 10 years
Clostridium difficile
• Pseudomembranous Colitis
Diarrhea (watery/bloody), with abdominal cramps,
leukocytosis, fever. Associated with Toxin A (enterotoxin ),
Toxin B ( cytotoxin)
• Antibiotic- associated colitis
Administration of antibiotics lead to mild diarrhea, less severe
Clostridium Perfringens
• Clostridium perfringens most frequent
clostridia involved in soft tissue and wound
infections – myonecrosis
• Spores found in soil, human skin, intestine,
and vagina
• Predisposing factors – surgical incisions,
compound fractures, diabetic ulcers, septic
abortions, puncture wounds, gunshot wounds
• Gas gangrene : Spores germinate at low
oxidation reduction potential, vegetative cells
multiply, ferment carbohydrates, produce
gas, the distention of tissue and interference
with blood, together with necrotizing toxin and
hyaluronidase, favor spread of infection
Virulence Factors ( C. Perfringens)
– Alpha toxin : a lecithinase
– Collagenase
– Hyaluronidase
– DNase
Pathology
• Not highly invasive; requires damaged and
• Infant botulism – caused by ingested spores that germinate and release toxin;
dead tissue and anaerobic conditions
• Conditions stimulate spore germination,
vegetative growth and release of exotoxins, •
and other virulence factors
• Fermentation of muscle carbohydrates results •
in the formation of gas and further tissue • Practice proper methods of preserving and handling canned foods; addition of
destruction
Clostridial Gastroenteritis
• Caused by Clostridrium perfringens
• Spores contaminate food that has not been cooked thoroughly
enough to destroy spores
• Spores germinate and multiply (especially if unrefrigerated)
• When consumed, toxin is produced in the intestine; acts on
epithelial cells, acute abdominal pain, diarrhea, and nausea
• Rapid recovery
C. Perfringens Diagnostic test
• Inoculated specimens into :
- Chopped meat – glucose medium
- thioglycolate medium
- blood agar
• Plates incubated anaerobically
• A clot torn by gas is suggestive of C. perfringens
Clostridium Botulinum
• Botulism – intoxication associated with inadequate food preservation
• Clostridium botulinum – spore-forming anaerobe; commonly inhabits soil and
water. 7 antigenic varieties of toxin (A-E), type A,B,E,F cause most illness.
Pathogenesis
• Spores are present on food when gathered and processed
• If reliable temperature and pressure are not achieved air will be evacuated but
spores will remain
• Anaerobic conditions favor spore germination and vegetative growth
• Potent toxin, botulin, is released
• Botulin toxin is carried to neuromuscular junctions and blocks the
release of acetylcholine, necessary for muscle contraction to occur
• Double or blurred vision, difficulty swallowing, neuromuscular symptoms
Infant and Wound Botulism
flaccid paralysis
Wound botulism – spores enter wound and cause food poisoning symptoms
Treatment and Prevention
Administer trivalent (A,B, E) antitoxin, cardiac and respiratory support
preservatives

Aerobic Gram-Negative Non-
enteric Bacilli
• Large, diverse group of non-spore-forming bacteria
• Wide range of habitats – large intestines (enteric), zoonotic,
respiratory, soil, water
• Most are not medically important; some are true pathogens,
some are opportunists
• All have outer membrane lipopolysaccharide of the cell wall –
endotoxin
• Pseudomonas and Burkholderia – opportunistic
pathogens
• Bordetella and Legionella – mainly human pathogens
Pseudomonads (Genus)
• Small gram-negative rods with a single polar flagellum
• Free living
– Primarily in soil, sea water, and fresh water; also
colonize plants and animals
• Important decomposers and bioremediators
• Frequent contaminants in homes and clinical settings
• Use aerobic respiration; do not ferment carbohydrates
• Produce oxidase and catalase
• Many produce water soluble pigments
Pseudomonas aeruginosa Burkholderia (Genus)
• Present in small numbers in normal intestinal flora • Similar to pseudomonads
• Resistant to soaps, dyes, quaternary ammonium disinfectants, • Wide variety of habitats in soil, water, and related
drugs, drying environments
• Frequent contaminant of ventilators, IV solutions, anesthesia • Obligate aerobes; do not ferment sugars
equipment
• Motile, oxidase positive
• Opportunistic pathogen
• Opportunistic
• Pigment produced :
pyocyanin - nonfluorescent bluish pigment
pyoverdin - fluorescent greenish pigment Burkholderia pseudomallei
• causes melioidosis (Whitmore's disease)
pyorubin - dark red pigment
pyomelanin - black pigment may manifest itself as acute, subacute, or
chronic infection
• Pili (fimbriae) - extend from the cell surface and • Short incubation period (2-3days)
promote attachment to host epithelial cells • Most common form of melioidosis is
• Exopolysaccharide pulmonary infection (peumonitis)
• Lipopolysaccharide - plays a direct role in causing • High mortality if untreated
fever, shock, oliguria, leukocytosis and leukopenia,
disseminated intravascular coagulation, and adult Burkholderia mallei
respiratory distress syndrome. • causes glanders, a disease of horses, mules, and
• extracellular enzymes - including elastases, donkeys
• transmissible to humans
proteases, and 2 hemolysins (a heat-labile
• begins as an ulcer of the skin or mucous
phospholipase C and a heat- stable glycolipid)
• exotoxin A - causes tissue necrosis membranes
• Common cause of nosocomial infections in hosts followed by lymphangitis and sepsis.
• Inhalation of the organisms may lead to primary
with burns, neoplastic disease, cystic fibrosis
pneumonia.
— blue-green pus
• Can be fatal
• Complications include pneumonia, UTI, abscesses,
otitis, and corneal disease
• Endocarditis, meningitis, bronchopneumonia
• Multidrug resistant
• Hemorrhagic necrosis of skin (ecthyma
gangrenosum) occurs often in sepsis
 Escherichia coli: The Most • Enteroaggregative E. coli (EAEC) causes acute and chronic diarrhea
Enterobacteriaceae Family Prevalent Enteric Bacillus — quite heterogeneous
• Enterics • Enterohemorrhagic E. coli (EHEC) also known as Shiga toxin-
• Large family of small, non-spore-forming gram- • Most common aerobic and non-fastidious producing E coli (STEC) 0157:H7 strain, causes hemorrhagic
negative rods bacterium in gut syndrome and kidney damage
• Many members inhabit soil, water, decaying matter, • 150 strains — 2 antigenic form
and are common occupants of large bowel of animals • Some have developed virulence through • Shiga-like toxin 1
including humans plasmid transfer, others are opportunists • Shiga-like toxin 2
• Most frequent cause of diarrhea through enterotoxins • Causes —70% of traveler's diarrhea — associated with hemorrhagic colitis
Enterics, along with Pseudomonas sp., account for • Causes 50-80% UTI
almost 50% of nosocomial infections • Coliform count — indicator of fecal
• Either motile with peritrichous flagella or nonmotile contamination in water
• Facultative anaerobic or aerobes
Urinary tract infection (by E. coli)
• Catalase positive
• most common cause of first urinary tract
• oxidase negative - no cytochrome oxidase
infections in young women
members of family commonly associated with human
• symptoms and signs include urinary frequency,
disease:
dysuria, hematuria, and pyuria.
- Escherichia
• Flank pain is associated with upper tract infection.
- Salmonella
• Caused by uropathogenic E coli.
- Shigella
• Typically produce hemolysin (cytotoxic) and
- Yersinia
facilitates tissue invasion.
- Klebsiella
• Strains that cause pyelonephritis express K
- Serratia
antigen and elaborate a specific type of pilus, P
- Proteus
fimbriae, which binds to the P blood group
antigen.
Antigenic Structures
and Virulence Factors
Complex surface antigens contribute to Diarrheal disease by E. coli
pathogenicity and trigger immune response: • Enterotoxigenic E. coli (E TEC) causes severe diarrhea
due to heat- labile toxin and heat-stable toxin —
• O— most external part of the cell wall stimulate secretion and fluid loss; also has fimbriae
lipopolysaccharide; resistant to heat and — Also known as traveler's diarrhea
alcohol — Important cause of diarrhea in infants
• K— external to O antigen; capsule and/or • Enteroinvasive E. coli (EIEC) causes inflammatory
fimbrial antigen; not present in all disease of the large intestine by invading intestinal
Enterobacteriaceae; some are protein some are mucosal epithelia cells
polysaccharides • Enteropathogenic E. coli (EPEC) linked to wasting, form
• H — flagellar Ag; can denatured or removed by infantile diarrhea
heat or alcohol — 2 important factors involved
• Endotoxin • plasmid EPEC adherence factor (EAF)
• Exotoxins • chromosomal locus of enterocyte effacement (LEE)
— severe, watery diarrhea; vomiting; and fever
Opportunistic Coliforms Noncoliform Lactose-Negative Enterics Shigella sp Pathogenesis
Klebsiella pneumoniae — normal inhabitant of
respiratory tract, has large capsule • Proteus sp. (opportunistic pathogen) 1. invasion of the mucosal epithelial cells by induced
extensive hemorrhagic necrotizing consolidation — Proteus mirabilis phagocytosis, escape from the phagocytic vacuole,
of the lung (nosocomial pneumonia) — Proteus vulgaris multiplication and spread within the epithelial cell cytoplasm
meningitis, bacteremia, wound infections, and • Rapid motility, facultative anaerobe, then passage to adjacent cells
UTI • Cause infections in humans only when the bacteria leave the 2. Microabscesses in the wall of the large intestine and terminal
• 2 important subspecies intestinal tract (normal flora in GIT) ileum lead to necrosis of the mucous membrane, superficial
-K. pneumoniae subspecies ozaenae • found in urinary tract infections (P mirabilis) ulceration, bleeding, and formation of a "pseudomembrane"
• Progressive atrophy of mucous membranes — produce urease, resulting in rapid hydrolysis of urea with on the ulcerated area.
-K. pneumoniae subspecies rhinoscleromatis liberation of ammonia 3. "Pseudomembrane" on the ulcerated area consists of fibrin,
• destructive granuloma of the nose and pharynx — Thus, urine becomes alkaline,promoting stone formation and leukocytes, cell debris, a necrotic mucous membrane, and
• Enterobacter sp. making acidification virtually impossible bacteria.
cause the majority of Enterobacter infections by • Produce bacteraemia, pneumonia, and focal lesions in debilitated 4. As the process subsides, granulation tissue fills the ulcers,
— Enterobacter cloacae patients or those receiving contaminated intravenous infusions. and scar tissue forms.
— Enterobacter aerogenes
— Enterobacter sakazakii Shigellosis and Bacillary Dysentery
• cause a broad range of hospital-acquired infections Shigella sp
such as • Shigella dysenteriae type 1 (Shiga bacillus)
— pneumonia — S. dysenteriae
produces a heat-labile exotoxin that affects both the
— urinary tract infections — S. flexneri
gut and the CNS (lead to meningismus,coma)
— wound and device infections — S. boydii
• produces diarrhea by the same mechanism as
• Most strains possess a chromosomal beta-lactamase — S. sonnei
does the E coli Shiga-like toxin
• Gram-negative rod ( coccobacilli)
called ampC, which renders them intrinsically resistant • • short incubation period (1—2 days) followed by
to ampicillin • Non-motile, Non-encapsulated, Non-lactose
a sudden onset
• Serratia marcescens fermenter (but glucose fermenter)
• Abdominal pain
• • Colourless on MacConkey/DCA agar
Common opportunistic pathogen in hospitalized • Each bowel movement is accompanied by
patients • Facultative intracellular pathogens
straining and tenesmus (rectal-spasm
• • Facultative anaerobes but grow best aerobically
causes • Fever
— Pneumonia • Human parasites • Watery diarrhea
— Bacteremia • infection from faecal-oral transmission from infected • Less liquid but often contain mucus and blood
— Endocarditis humans lead to dehydration, acidosis, and even death (in
especially in narcotics addicts and hospitalized • highly communicable with low infective dose (103) children)
patients organisms (105— 108 for salmonellae & vibrios)
• produces a red pigment (prodigiosin) • high rate of secondary household transmission
• Citrobacter sp. — opportunistic UTI and • Limited to the gastrointestinal tract infection
bacteremia bloodstream invasion is quite rare
• Providencia species — cause urinary tract • Produce both
infections — endotoxin (from toxic lipopolysaccharide)
— Providencia rettgeri, — exotoxin (Shiga toxin — a neurotoxin)
— Providencia alcalifaciens
— Providencia stuartii
• normal intestinal flora

Salmonella
• motile with peritrichous flagella
• Not ferment lactose or sucrose
• survive freezing in water (ice) for long periods
• Resistant to chemicals — bile and dyes
• Salmonella typhi— most serious pathogen of the
genus, cause of typhoid fever; human host
• S. enteritidis — includes 1,700 different serotypes
based on variation on O, H, and VI
• S. typhimurium
Typhoid Fever
• Bacillus enters with ingestion of contaminated
food or water
• From small intestine it enter the lymphatics and • short, pleomorphic gram-negative rods that can
then the bloodstream.
• Then carried by the blood to many organs
occasionally spread by close personal contact
• Asymptomatic carriers; some chronic carriers
shed bacilli from gallbladder
• Bacilli adhere to small intestine, cause invasive • 3 medical important species
diarrhea that leads to septicemia
• incubation period of 10—14 days
Typhoid
Symptoms
— Fever (high plateau)
— Malaise
— Headache
— Constipation
—Bradycardia
—Myalgia
• principal lesions are hyperplasia and necrosis
of lymphoid tissue (eg, Peyer's patches)
• Hepatitis (focal necrosis of the liver)
• inflammation of the gallbladder, periosteum,
lungs
• 2 vaccines for temporary protection
Salmonellosis
• Known as non-typhoidal Salmonella (> 2000
serotypes)
• Salmonella typhimurium
• Salmonella enteritidis
• Transmitted via ingestion of contaminated
food (esp. poultry, egg yolk) - Raw or
undercooked eggs that have been infected in
the hen's ovaries
• Most common in children < 4 years old (esp. in
the first few months of life)
• Symptoms usually appear 48 hours after
ingestion of contaminated food/water
• Fever 38-39'C, diarrhea & abdominal cramps
Yersinia
exhibit bipolar staining
• catalase positive, oxidase negative, and
microaerophilic or facultatively anaerobic
• Most have animals as their natural hosts, but they• Hemorrhagic
can produce serious disease in humans
Y. pestis — cause plague
Y. pseudotuberculosis
Y. enterocolitica — causes human diarrheal
diseases
Yersinia pestis and Plague
• Plague is an infection of wild rodents
transmitted from one rodent to another and
occasionally from rodents to humans by the
bites of fleas
• In history, it produced pandemics of "black
death" with millions of fatalities
• Can also be transmitted by aerosol
(pneumonic plague)
• cause high severity & mortality associated
- Potential biological weapon
• Nonmotile & facultative anaerobe
Yersinia pestis
3 pathogenic species produce antigens and toxins Haemophilus influenzae Virulence factors
• V and W antigens • capsular polysaccharides (a-f)
type b is a polyribitol ribose phosphate (PRP)
• plasmids pPCP1
— major
— contains genes that yield plasminogen-activating
• somatic antigens
protease that has temperature dependent coagulase
• Lipooligosaccharides (endotoxins)
activity and fibrinolytic activity
• Do not produce exotoxin
Pathogenesis Y. pestis • Can also cause bacterial otitis media and
• Fleas bit human, then Y. pestis enter wound. acute sinusitis
• It killed by the polymorphonuclear cells but multiply in • Can be prevented by Haemophilus b
the macrophages at 37C, thus they can produce the conjugate vaccine (to children)
antiphagocytic protein and subsequently are able to
resist phagocytosis.
• Then reach lymphatics, and an intense hemorrhagic Haemophilus ducreyi
inflammation develops > enlarged lymph nodes > • sexually transmitted disease
necrosis > become fluctuant — causes chancroid (soft chancre)
• Then reach the bloodstream > become widely • consists of a ragged ulcer on the
disseminated. genitalia, with marked swelling and
tenderness.
Prominent Features of Y. pestis infection • The regional lymph nodes are
and necrotic lesions may develop in all enlarged and painful.
organs; • Requires hemin to grow but
Meningitis pneumonia, NOT nicotinamide
• Serosanguineous pleuropericarditis adenine nucleotide (NAD)
• Differential diagnosis includes
Haemophilus Syphilis
— herpes simplex infection
— lymphogranuloma venereum
• Tiny gram-negative pleomorphic rods
Fastidious, sensitive to drying, temperature extremes,
and disinfectants
• Need 2 factors to growth
— hemin
— nicotinamide adenine nucleotide (NAD)
• 2 important species
Haemophilus influenzae type b
— important human pathogen
— Cause pneumonia in adult and children
— Cause meningitis in children
Haemophilus ducreyi
— Sexually transmitted pathogen, causes chancroid
Genus Neisseria
• Gram-negative, bean-shaped (kidney
shaped),
non-motile diplococci
• None develop flagella or spores
• Strict parasites, do not survive long outside
of
• Aerobic or microaerophilic
• Produce catalase and cytochrome
oxidase
2 primary human pathogens:
— Neisseria gonorrhoeae
— Neisseria meningitidis
Neisseria gonorrhoeae: The
Gonococcus
Causes gonorrhoea, an STD
• Virulence factors:
— Pili (Fimbriae)
• for attachment
• Slows/resist phagocytosis
— Por protein
• Preventing phagosome—lysosome fusion
— Opa Proteins
• Enhance attachment to host cell receptor
— rmp (Protein Ill)
— gonococcal lipopolysaccharide (LOS)
• No long O-antigen side chains and is called a
lipooligosaccharide
- Lip (1-18)
• a surface exposed protein
— Fbp (ferric-binding protein)
— IgA protease — cleaves secretory/inactivate IgA1 Curviform Bacteria
Gonorrhoea
• Males — urethritis, yellowish discharge,
scarring, and infertility
- 10% of males are asymptomatic
• Females — vaginitis, urethritis, salpingitis
(PID) mixed anaerobic abdominal infection,
common cause of sterility and ectopic tubal
pregnancies
- 50% of females are asymptomatic
Gonorrhoea in Newborns
• Known as Gonococcal ophthalmia neonatorum
Infected as they pass through birth canal
• Eye inflammation, blindness
• Prevented by prophylaxis immediately after birth
Neisseria meningitidis: The
Meningococcus
Virulence factors:
— Capsule
— Adhesive fimbriae
— IgA protease
— Endotoxin
12 strains; serotypes A, B, C cause most cases
Epidemiology and Pathogenesis
Prevalent cause of meningitis; sporadic or epidemic
• Human reservoir— nasopharynx; 3-30% of adult
population; higher in institutional settings
• High risk individuals are, children 6 months-3 years, antigen (somatic antigen)
children athose living in close quarters and young - 01 V. cholerae (Classical or El tor biotypes)
adults 10-20 years
• Disease begins when bacteria enter bloodstream,
cross the blood-brain barrier, permeate the
meninges, and grow in the cerebrospinal fluid
• Very rapid onset; neurological symptoms; endotoxin •
causes hemorrhage and shock; can be fatal
• Gram-Negative
• Generally cause enteric diseases
• Vibrio — comma-shaped rods, single
polar flagellum
• Campylobacter— short spirals or
curved rods; one flagellum
• Helicobacter— spirochete with tight
spirals and several polar flagella
Vibrio Cholerae
• El Tor biotype: survives longer, more infectious
• Infects mucous barrier of small intestine,
noninvasive
• Releases cholera toxin that causes electrolyte and
water loss through secretory diarrhea, "rice water
stool"; resulting dehydration leads to muscle,
circulatory, and neurological symptoms
• Rehydrate and treat with Tetracycline
• They are short Gram negative, curved rods
• Comma-shaped bacteria is ingested in food or
water
• All are oxidase positive
• Growth on TCBS (Thiosulfate-citrate-bile salts-
sucrose) Agar
— V. cholerae ferment sucrose yellow colonies
— V. parahaemolyticus & V. vulnificus : not-
ferment sucrose -5 green colonies
Grouped based on the antigenic structure: O
- 0139 V. cholerae
- non-Ol V. cholerae
Causes rice-water stool
• 01 serotype:
— watery diarrhea, dehydration;
— associated with epidemic cholera
• non-01-serotypes:
— Milder diarrhea, fever, nausea, vomiting,
blood in stool
— often associated with traveler's diarrhea
Helicobacter pylori
• A gastric pathogen
Curved cells discovered in
1979 in stomach biopsied
specimens
• Causes 90% of stomach and
duodenal ulcers; apparent
cofactor in stomach cancer
• People with type O blood
have a 1.5-2X higher rate of
ulcers. Motile, even in mucus
• grows optimally at a pH of 6 — 7
• Gastric mucus is relatively
impermeable to acid and has a strong
buffering capacity.
— On the lumen side of the mucus,
the pH is low (1.0—2.0)
— On the epithelial side, the pH is
about 7.4.
• H. pylori is found deep in the
mucous layer near the epithelial
surface where physiologic pH is
present.
• Produces a protease
— modifies the gastric mucus
— further reduces the ability of acid to
diffuse through the mucus
• Produces urease which converts
urea into ammonium and
bicarbonate
Acid-fast Bacteria
• Acid fast organisms like Mycobacterium contain
large amounts of waxy lipid substances within
their cell walls called mycolic acids.
• These acids resist staining by ordinary methods
such as a Gram stain.
• But M. tuberculosis can be stained by acid-fast
stain with long time heating.
• It can also be used to stain a few other bacteria,
such as Nocardia.
Mycobacteria: Acid-Fast Bacilli
• Acid-fast staining
• Strict aerobes
• Produce catalase
• Possess mycolic acids and a unique type
of peptidoglycan
• Do not form capsules, flagella, or spores
• Grow slowly
Mycobacterium tuberculosis
• causes tuberculosis and is a very important
pathogen of humans.
Mycobacterium leprae
• causes leprosy.
Mycobacterium avium-intracellulare (M.
avium complex) and other nontuberculous
(NTM) mycobacteria
• frequently infect patients with AIDS
• opportunistic pathogens in other
immunocompromised persons
Mycobacterium tuberculosis
• nutrition, debilitation of the immune
Thin and straight rod
• system, poor access to medical care,
Gram Positive
• intracellular pathogen that is able to establish lifelong
infection
• Produces no exotoxins or enzymes that contribute
to infectiousness
• Virulence factors — contain complex waxes and
cord factor that prevent destruction by lysosomes
or macrophages
• Humans and guinea pigs are highly susceptible,
but fowl and cattle are resistant.
• Infectious dose 10 cells
Pathogenesis of M. tuberculosis
1. Enters the respiratory airways, and infectious particles
penetrate to the alveoli where they are phagocytized by
alveolar macrophages.
2. It prevents fusion of the phagosome with lysosomes
by blocking the specific bridging molecule, early
endosomal autoantigen 1 [EEA1]
3. Phagosome is able to fuse with other intracellular vesicles,
permitting access to nutrients and facilitating
intravacuole replication.
4. Phagocytized bacteria are also able to evade macrophage
killing mediated by reactive nitrogen intermediates formed
between nitric oxide and superoxide anions by
catalytically catabolizing the oxidants that are formed.
5. Then it begin to multiply within macrophages.
In this state, the bacteria are able to evade the immune
system and replicate
Epidemiology of Tuberculosis Diagnosis
• Predisposing factors include inadequate
• Tuberculin testing
• X-rays
• Direct identification of acid-fast bacilli in
lung damage, and genetics
specimen
• Estimate 1/3rd of world population
• Cultural isolation and biochemical testing
carry tubercle bacillus.
• The number of tuberculosis (T B) cases
Prevention of TB
in the Malaysia rose by 6% to 25,739 in
2016 compared with 24,220 cases in
Vaccine based on attenuated (weakened)
2015.
Bacilli Calmette-Guerin strain of live Mycobacterium
• Bacillus very resistant; transmitted by
bovis is used
airborne respiratory droplets
Course of Infection and Disease
• 5% to 10% of infected people develop
clinical disease
• Untreated, the disease progresses slowly;
majority of TB cases contained in lungs
• The bacilli will reach to the cervical
glands.
• Also, the organism may reach to the
mesenteric lymph nodes causing
lymphadenitis.
• From the lymph glands the bacilli may
reach to many organs causing generalized
miliary tuberculosis.
Mantoux test
• Also known as Tuberculin test
• Local intradermal injection of purified
protein derivative (PPD);
• Look for red wheal to form in 48-72
hours — induration;
• Established guidelines to indicate
interpretation of result based on size
of wheal and specific population
factors
 Gram (+), non-sporeformer, Irregular shape
and staining, Acid Fast
Mycobacterium leprae:
• Hansen's bacillus/Hansen's Disease
— described by Hansen in 1873
• Strict parasite — has not been grown on
artificial media or tissue culture, but can be grown
in the mouse footpad or in the armadillo
• Slowest growing of all species
• Multiplies within host cells in large packets called
globi
• Virulence factor — O-diphenoloxidase enzyme
• The optimum temperature for growth is
30c.
• It is lower than body temperature That is
why it grows preferentially in the skin
and superficial nerves.
• Causes leprosy, a chronic disease that
begins in the skin and mucous
membranes and progresses
into nerves
Epidemiology and Transmission
of Leprosy
• Endemic regions throughout the world
• Infection is acquired by prolonged
contact with patients with lepromatous
leprosy, who discharge
• M. leprae in larqe numbers in nasal
secretions and from skin lesions.
• Not highly virulent; appears that health and
living conditions influence susceptibility and
the course of the disease
• May be associated with specific genetic
marker .
Course of Infection and Disease Infections by Non-Tuberculosis
• Macrophages phagocytize the bacilli, but a Mycobacteria (NTM)
weakened macrophage or slow T cell
response may not kill bacillus • M. avium complex — third most common cause of
• Incubation from several months - 20 years; if
death in AIDS patients
untreated, bacilli grow slowly in the skin
macrophages and Schwann cells of • M. kansaii— pulmonary infections in adult white
peripheral nerves males with emphysema or bronchitis
• 3 forms: • M. marinum — water inhabitant; lesions develop
— Tuberculoid : asymmetrical, shallow lesions, after scraping on swimming pool concrete
damage nerves, results in local loss of pain
• M. scrofulaceum — infects cervical lymph nodes
sensation or paralysis
— Lepromatous : a deeply nodular infection • M. paratuberculosis — raw cow's milk; recovered
that causes severe granulation/disfigurement from 65% of individuals diagnosed with Crohn's
of the face, mucous membrane, and disease
extremities, widespread dissemination
— Mixed
Diagnosing
• Indirect allergic test or Lepromin test - It
is similar to tuberculin test; however, the
results are unreliable.
• Combination of symptomology,
microscopic examination of lesions, and
patient history
• Biopsy
• Detection of acid-fast bacilli in skin
lesions, nasal discharges, and tissue
samples
 Gram (+), non-sporeformer, Irregular shape Nocardia asteroides
and staining, Filamentous & branching Nocardia (Genus)
• Found worldwide in soil and water
Actinomyces israelii • Nocardiosis - by inhalation • Generally cause
• responsible for diseases of the — subacute to chronic pulmonary infection granulomatous suppurative
oral cavity, thoracic or intestines — actinomycosis • No human — human transmission infections.
• Gram-positive bacteria which grow in filaments that • gram-positive • It affects lungs with secondary brain
readily break up into rods and may show branching. • catalase-positive abscess
• Non-motile. • partially acid-fast bacilli (very weak) • It is opportunistic pathogen
• Non-spore-forming. — cell walls contain mycolic acids that are shorter chained and affects Immunocompromized
• Non-acid fast. than those of Mycobacteria patients
• In tissue, colonies develop to show the diagnostic yellow
which is visible by naked eye and is "sulfur granules". Nocardiosis
found in pus discharge through draining sinuses • an opportunistic infection (immunocompromised)
• Grow on blood or serum glucose agar anaerobically. • begins as chronic lobar pneumonia
Incubation at 370 C for at least 7 days. — May accompanied with fever, weight loss, and chest
• The growth is enhanced by 5% Co2. pain
Colonies are small cream adherent and nodular. — abscess formation (neutrophilic inflammation)
• Can spread to
— brain (abscess)
— Skin, kidney, eyes etc
Pathogenesis & Clinical disease • Serologic tests are not useful
• Actinomyces is endogenous in origin and results in
a chronic granulomatous infection with abscess Nocardia brasiliensis
formation.
• Profuse pus discharges by draining through • causes pulmonary disease
sinuses. similar to TB
• Infection probably starts after local trauma, • It can also affect subcutaneous
e.g. the extraction of carious teeth, appendectomy. tissues; "madura foot" or
• Intra-utrine contraceptive devices; are often colonized mycetoma which is a tropical
with Actinomyces israelii. form of nocardiosis and affects
foot and produces chronic
discharging sinuses.
 Gram (+), non-sporeformer, Regular shape Perinatal human listeriosis
Gram (+), non-sporeformer, Irregular shape
• Also known as Neonatal infection (granulomatosis
and staining, Facultative Anaerobe and staining, Non- acid fast
infantiseptica)
• 2 forms
Listeria monocytogenes — Early onset sepsis
Corynebacterium diphtheriae
• Capable of growing and surviving — Late onset meningitis • 4 subtypes
— at refrigerator temperatures (40C) • early-onset sepsis — Gravis (more severe)
— low pH conditions — Listeria acquired in utero — results in premature — mitis
— high salt conditions birth — intermedius
• able to overcome food preservation — isolated in the placenta, blood, meconium, nose, — belfanti
• short, gram-positive, non—spore forming rod ears, and throat. • Cause diphtheria infection (increase
• Facultative anaerobe • late-onset meningitis trending in Malaysia)
• Catalase & esculin hydrolysis positive — acquired through vaginal transmission — respiratory diphtheria
• has a tumbling end-over-end motility at 22—280C but not — cutaneous diphtheria
at 370c • Pleomorphism
— This features help to differentiate from other — Sometimes look "club-shaped"
Erysipelothrix rhusiopathiae appearance
microorganism
• Produce exotoxin — Diphtheria toxin
• Sometimes looks gram negative — heat-labile polypeptide
because it decolorizes easily — lethal dose — 0.1 pg/kg
Pathogenesis Listeria monocytogenes
catalase, oxidase, and indole
negative Pathogenesis C diphtheriae
• Present O (somatic) and H (flagellar) antigens
• Cause Erysipeloid rash (in human)
• adhesin proteins (Ami, Fbp A, and flagellin proteins) • Diphtheria toxin is absorbed into the mucous membranes
• occupational disease
— facilitate bacterial binding and contribute to virulence • Causes destruction of epithelium & superficial inflammatory
• Contact with infected animal
• Cell wall surface proteins called internalins A and B response
Produce neuraminidase enzyme
— Interact with E-cadherin, a receptor on epithelial cells • The necrotic epithelium becomes embedded in exuding fibrin
— help microorganism invade tissues
• Low pH activates the bacterium to produce listeriolysin O and red and white cells, so that a grayish "pseudomembrane" is
• 2 adhesive surface proteins
— lyses the membrane of the phagolysosome and allows formed
- RspA and RspB
the listeriae to escape — tonsils, pharynx, or larynx
• another listerial surface protein ActA induces - Help bind to collagen & polystyrene
• Acute but self-limited infection • Any attempt to remove the "pseudomembrane" exposes and
host cell actin polymerization
of the skin (no pus formation) tears the capillaries
• formation of elongated protrusions (filopods)
— results in bleeding
• These filopods are ingested by adjacent epithelial
• edema of the entire neck with distortion of the airway — "bull
cells, macrophages, and hepatocytes
neck" (difficulty of breathing at night)
• Then listeriae are released, and the cycle begins
again Effects of diphtheria toxin
Myocarditis
— Parenchymatous degeneration, fatty infiltration, and necrosis in heart
muscle
Damage liver, kidneys (tubular necrosis), and adrenal glands
— Sometimes accompanied by gross hemorrhage.
Demyelination effect — damage nerve
— often resulting in paralysis of the soft palate, eye muscles, or extremities.
Prevented by vaccination (DTP Vaccine)

Family Rickettsiaceae
• with 3 medically important genera
— Rickettsia
— Coxiella
— Rochlimaea
• Morphology and cultural characteristics
— All are obligate intracellular parasites
(except Rochlimaea) that can grow in both
phagocytic and nonphagocytic cells.
• Rochlimaea can be cultivated on artificial
media containing blood
• Others are grown in embryonated eggs or
tissue culture
• Cultivation is costly and hazardous
because aerosol transmission can easily
occur
• Small, pleomorphic coccobacilli
• Gram stain poorly, but appear to be Gram
negative
• Stain readily with Giemsa
• All, except Coxiella, are transmitted by
arthropod vectors.
Virulence Factors
• Rickettsial sp.
— Induced phagocytosis
— Recruitment of actin for intracellular spread
• Coxiella burnetti
— Is resistant to lysosomal enzymes
The Rickettsia Genus
• Small obligate intracellular parasites
• Gram-negative cell wall
• Nonmotile pleomorphic rods or
coccobacilli
• spread by arthropod vectors
— lice, fleas, mites and ticks
• Bacteria enter endothelial cells and
cause necrosis of the vascular
lining — vasculitis, vascular leakage,
and thrombosis
The Rickettsia Genus
• Diseases caused by Rickettsia are all
Coxiella burnetii
characterized by fever, headache, myalgias,
and usually a rash. • C.burnetii differs from other rickettsia in
that it is enclosed in a persistent
Specific Rickettsioses vacuole during growth and division.
• Six to ten daughter cells will form within a
1. Epidemic typhus — Rickettsia prowazekii host cell before the cell ruptures and
carried by lice; starts with a high fever, chills,
releases them.
headache, rash; Brill-Zinsser is a chronic, • It stable in harsh environment.
recurrent form
• No arthropod vector
• Q fever
2. Endemic typhus — Rickettsia typhi, • Transmitted via inhaled airborne particle
harbored by mice and rats; occurs
and contaminated unpasteurised milk
sporadically in areas of high flea infestation; • Livestock handlers and patients with
milder symptoms
prosthetic or damaged heart valves have
higher risk
3. Rocky Mountain spotted fever — Rickettsia
rickettsii zoonosis carried by dog and wood
ticks; most cases in Southeast and on Prevention
eastern seaboard; distinct spotted rash; may
damage heart and CNS • Avoid tick - infested areas
— wear protective clothing and use repellants.
4. Ehrlichia genus contains 2 species of — Ticks are difficult to eradicate as they can
rickettsias; tick- borne bacteria cause human survive for 4 years without feeding
monocytic and granulocytic ehrlichiosis • Remove ticks carefully
Rocky Mountain Spotted Fever
• Rickettsia rickettsii is transmitted to
humans through a tick bite and is the
most common rickettsial infection in
North America
• Sometime Human Monocytic
Ehrlichiosis can be misdiagnosed as
Rocky Mountain Spotted Fever.
• First symptoms are fever, chills,
headache and a spotted rash appears
in days
• Central nervous system can become
involved and fatality rates are 20% if
untreated
 Mycoplasma pneumoniae
Mycoplasmataceae (Family)
• Strictly aerobic
• A group of the smallest organisms that can be
• It only infects Human
free- living in nature
• Causes pharyngitis, bronchitis, or primary atypical
• Size - 0.1 to 0.3 pm
pneumonia (a.k.a. "walking pneumonia") - upper and
• It was thought to be virus due to its size
lower respiratory infections
• Pass bacterial filter
• Naturally lack cell walls, highly pleomorphic
• Transmitted by inhalation of droplets
• Usually infects school-age children and young adults
Spherical / short rod / filament / may look like
in close quarters (dorms, military barracks, etc.)
fried- egg appearance
50% of infections produce "cold agglutinins"
• Grow on laboratory media.
• Slow growing Pathogenicity
• Highly fastidious
• Facultative anaerobes (except M. pneumoniae, • Adherence
which is a strict aerobe) -PI pili (M. pneumoniae)
• Require external cholesterol during growth -Movement of cilia ceases (ciliostasis)
• 2 genera : Mycoplasma , Ureaplasma -Clearance mechanism stops resulting in cough
• Because of the absence of cell walls, they do not
stain with the Gram stain, and they are more • Toxic metabolic products
pleomorphic and plastic than eubacteria. - Peroxide and superoxide
• Therefore we use Giemsa stain - Inhibition of catalase
• Immunopathogenesis
Species - Activate macrophages
- Stimulate cytokine production
M. pneumoniae: Upper respiratory tract disease, - Superantigen (M. pneumoniae)
tracheobronchitis, atypical pneumonia - Inflammatory cells migrate to infection and release
M. hominis: Pyelonephritis, pelvic inflammatory TNF-a then IL-I and IL-6
disease, postpartum fever
M. genitalium: Nongonococci urethritis Clinical Features
U. urealyticum: Nongonococci urethritis
• Incubation - 2-3 weeks
• Low grade fever, headache and malaise
• Persistent, dry, non-productive cough
• Symptoms gradually worsen over the next few
days and can persist for 2 weeks or longer
• With a patchy bronchopneumonia
• Acute pharyngitis may be present
• Organisms persist
• Slow resolution
• Rarely fatal
Ureaplasma urealyticum
• Strains of mycoplasma isolated from the urogenital tract
of human beings & animals.
• Form very tiny colonies - hence called T strain or T form
of mycoplasmas.
• Hydrolyzes urea
Mycoplasma Hominis
• Geninital Infections
• Caused by M. hominis
• Transmitted by sexual contact
• Men - Nonspecific urethritis, proctitis,
balanoposthitis & Reiter's syndrome
• Women — acute salpingitis, PID, cervicitis,
vaginitis
• Also associated with infertility, abortion,
postpartum
• Fever, chorioamnionitis & low birth weight
infants
Microbiological Diagnosis ( Mycoplasmataceae Family)
• Specimens: throat swab, sputum, genital secretion, etc.
• Microscopy
— This is not particularly useful because of the absence of a cell wall
— But can eliminate other causative agents
• Culture
— It may take 2 -3 weeks to get a positive identification.
— Culture is essential for a definitive diagnosis.
— Incubate aerobically for 7 -12 days with 5—10% C02 at 35-370 c.
• Growth Inhibition Test — inhibition of growth around discs
impregnated with specific antisera.
• Immunofluorescence on colonies transferred to glass
slides.
• PA (particle agglutination)
• Cold agglutinins - Approximately 34% - 68% of patients
with M. pneumoniae infection develop cold agglutinins.
• ELISA - There is a new ELISA for IgM that has been
used for diagnosis of acute infection.
• Molecular diagnosis - PCR

The Chlamydiaceae Family
• Small
• Gram-negative-like cell wall but is not Gram
negative
• Obligate intracellular parasites
- Unique growth cycle because they are deficient in
• independent energy metabolism
• Replication involves elementary body (EB) and
reticulate body (RB)
Alternates between:
— Elementary body — small metabolically inactive,
extracellular, infectious form released by the
infected host
— Reticulate body — noninfectious, actively dividing • Lymphogranuloma venereum — disfiguring
form, grows within host cell vacuoles
Life Cycle of Chlamydia
1. Elementary body infects host cell by
inducing energy- requiring active
phagocytosis
2. Elementary body organize into large,
reticulating initial bodies, which divert the
cells' synthesizing functions to their own needs
and begin to multiply by
binary fission
3. Organisms begin reorganizing into infective
Elementary body.
4. Disrupted host cell dies, releasing new
Elementary body
Chlamydia trachomatis
•Most commonly sexually transmitted bacterial
pathogen
• Adult males
— Non-gonococcal urethritis (NGU)
— Epididymitis and prostatitis
• Adult females
— Urethritis
— Follicular cervicitis
— Endometritis, proctitis, salpingitis
— PID
— Perihepatitis (Fitz-Hugh-Curtis syndrome)
• Major cause of sterility
• May be transmitted to newborns during
delivery
disease of the external genitalia and pelvic
lymphatics
• Trachoma — attacks the mucous membranes of
the eyes, genitourinary tract, and lungs
— Ocular trachoma — severe infection, deforms
eyelid and cornea, may cause blindness
— Inclusion conjunctivitis — occurs as baby
passes through birth canal; prevented by
prophylaxis
— STD — second most prevalent STD; urethritis,
cervicitis, salpingitis (PID), infertility, scarring
Laboratory Diagnosis
• Direct microscopic examination to find
elementary body
• Cell culture
• Enzyme immunoassay
• Nucleic acid probes with and without
amplification (PCR)
• Serologic (antibody) assay
Chlamydia pneumoniae
• Most recognized species of Chlamydia
Important respiratory pathogen (acute respiratory
disease, pneumonia, and pharyngitis)
• Prolonged sore throat and hoarseness, followed
by flu-like lower respiratory symptoms
• Causes an atypical pneumonia that is serious in
asthma patients
• Third most common respiratory infection
• Risk factor for Guillain-Barre' syndrome
• Common (50% of adults have antibodies)
• Reinfection common
• If cultured, must be in cells (obligate intracellular
pathogen) and then visualized with fluorescein-
conjugated antibodies
• Serologic tests are method of choice for detection
(Four-fold rise in titer)
Chlamydia psittaci
• Causes Ornithosis / Psittacosis (parrot fever)
— a zoonosis transmitted to humans from bird
vectors;
• Highly communicable among all birds
• Pneumonia or flulike infection with fever, lung
congestion
 Spirochetes ( Phylum)
• Gram-negative-like human pathogens
• May be aerobic, anaerobic or facultative.
• Corkscrew motility
• Elongated, Flexible bacteria twisted spirally
along the long axis
• Characteristic feature — presence of varying
numbers of endoflagella (polar flagella
wound along the helical protoplasmic
cylinder and situated between the outer
membrane and cell wall)
• Free living saprobes, or commensals
of animals, not primary pathogens
• Genus : - Treponema
- Leptospira
- Borrelia
• Best-known are those which cause
disease:
Syphilis and Leptospirosis
Genus Treponema
• Thin, regular, coiled cells
• Live in the oral cavity, intestinal tract, and • Chancre begins as a small, usually singular nodule;
perigenital regions of humans and animals
• Pathogens are strict parasites with complex begins to necrose, resulting in a relatively painless
growth requirements
• Require live cells for cultivation
Treponema pallidum
• Spiral shaped and motile due to periplasmic • Chancre spontaneously heals (after 1-5 weeks)
flagella
• Causes Syphilis
• Human is the natural host
• Extremely fastidious and sensitive; cannot • In men it may be inside the urethra, resulting in a
survive long outside of the host — cannot be
cultured from clinical specimens
• Sexually transmitted and transplacental
• Not visible under light microscope in wet
film
Can be seen only by negative stain with
Indian ink or dark field microscope
• Does not take up Gram stain
• Stain with prolong Giemsa staining, or stained
by Silver impregnation, Fontana, and Levaditi
methods .
Mode of Transmission
• Organism is very fragile, destroyed
rapidly by heat, cold and drying.
• Sexual transmission most common,
occurs when abraded skin or
mucous membranes come in contact
with open lesion.
• Can be transmitted to fetus.
• Rare transmission from needle stick
and blood transfusion.
Clinical Features of Syphilis
• Primary - chancre in 3-4 weeks at the site of
invasion (usually genital location)
• Secondary - rash, fever, lymphadenopathy
in 10 weeks (esp. palms and soles)
• Tertiary - aorta, heart, CNS, etc. (years)
Primary Syphilis
• Spirochete binds to the epithelium, multiplies, and • If left untreated, tertiary syphilis
forms a chancre
as it enlarges, the overlying epithelial tissues
ulcer.
• Unlike other bacterial infections, there is no formation
of pus unless a secondary bacterial infection sets in.
Fluid from the chancre is highly contagious
as the spirochete moves into the blood
• Chancre is seen on the external genitalia
• In women form in the vagina or on the cervix.
serous discharge.
Swab of chancre smeared on slide, examined
under dark-field microscope, spirochetes will be
present.
Secondary Syphilis
2.) Cardiovascular Syphilis
• This condition appears 20 or more years
• Occurs 6-8 weeks after initial chancre, becomes post- infection.
systemic, patient highly infectious.
• Usually involves the aorta.
• Spirochete is multiplying in the bloodstream Invading treponemes cause scarring of the
• Characterized by localized or diffuse mucocutaneous
tunica media.
lesions, often with generalized lymphadenopathy. • Over many years, the inflammatory scarring
Rash forms on the skin, palms and soles with fever,
weakens the aortic wall, leading to
headache and sore throat aneurysm formation, which causes
• The rash disappears spontaneously incompetence of the aortic valve and
• A widespread eruption resembling psoriasis or narrowing of the coronary ostia.
pityriasis rosea which prominently involves the hands • The damage that has already occurred may
should always include the differential diagnosis of not be reversed.
secondary syphilis.
• Primary chancre may still be present. 3.) Neurosyphilis
• Secondary lesions subside in about 2-6 weeks. • Caused by invasion of organisms into the CNS.
• Serology tests nearly 100% positive. • Manifests as an insidious but progressive loss of
mental and physical functions and is accompanied
Tertiary Syphilis by mood alterations.
• General paresis of the insane:
— forgetful,
forms
— personality change,
• Damage to multiple tissues and
— psychiatric symptoms.
organs
• Onset usually 10-20 years after primary infection
• Divided into three
• Can only be diagnosed serologically by VDRL.
manifestations:
• Treatment may not improve symptoms.
— Gummatous syphilis
• Neurological complications at this stage
— Cardiovascular syphilis
— Neurosyphilis include generalized paresis of the insane
which results in personality changes, changes
1.) Gummatous Syphilis in emotional affect, hyperactive reflexes.
• Tabes dorsalis, degeneration of lower spinal
• Gummas are localized areas of cord, general paresis and chronic progressive
granulomatous inflammation found on dementia often results in a characteristic
bones, skin and subcutaneous tissue shuffling gait.
• Cutaneous gummas may be single or • Cerebral atrophy, most prominent in frontal
multiple, generally asymmetric and lobes seen in general paresis.
grouped together.
• Visceral lesions often cause local
destruction of the affected organ.
• Contain lymphocytes, plasma cells and
perivascular inflammation.
 Congenital Syphilis
• T. pallidum can pass through the placenta
to the fetus
• Fetus affected during second or third
trimester.
• 40% result in syphilitic stillbirth-fetal
death that occurs after a 20 week gestation
and the mother had untreated or
inadequately treated syphilis at delivery.
• 40-70% of the survivors will be infected, and
12% of these will subsequently die
prematurely
• Death from congenital syphilis is usually
through pulmonary hemorrhage.
• Live-born infants show no signs during
first few weeks.
— 60% to 90 % develop clear or
hemorrhagic rhinitis.
— Skin eruptions (rash) especially around
mouth, palms of hands and soles of feet.
• Other signs: general lymphadenopathy,
hepatosplenomegaly, jaundice, anemia,
painful limbs, and bone abnormalities.
Latent Syphilis
• Stage of infection in which organisms persist in Nontreponemal Reagin Tests (Syphilis)
the body of the infected person without causing
symptoms or signs (asymptomatic).
• This stage may last for years.
• One-third of untreated latent stage individuals
develop signs of tertiary syphilis.
• After four years it is rarely communicable
sexually but can be passed from mother to fetus.
• This stage may be further subdivided.
— Early latent, initial infection occurred within
previous 12 months.
— Late latent, initial infection occurred greater
than 12 months.
— Latent of unknown duration, date of initial
infection
cannot be established as having occurred in the
previous year.
Syphilis Diagnosis
• Stages of syphilis can mimic other diseases
• Evaluation based on three factors:
— Clinical findings.
— Demonstration of spirochetes in clinical
specimen.
— Present of antibodies in blood or cerebrospinal
fluid.
• More than one test should be performed.
• No serological test can distinguish between
other treponemal infections.
• Consider symptoms, history, microscopic, and
serological testing RPR, VDRL, FTA-ABS
• Treatment: penicillin G
Laboratory Testing (Syphilis)
• Direct examination of clinical
specimen by dark-field microscopy
or fluorescent antibody testing of
sample.
• Non-specific or non-treponema/
serological test to detect reagin,
utilized as screening test only.
• Specific Treponemal antibody
tests are used as a confirmatory test
for a positive reagin test.
• Non-specific or non-treponemal serological
test to detect reagin, utilized as screening test
only.
— Reagin is an antibody formed against cardiolipin. Treponema Carateum
— Found in sera of patients with syphilis as well as
other diseases.
— This type of reagin not to be confused with same
word originally used to describe IgE.
— Non treponemal tests become positive 1 to 4
weeks
after appearance of primary chancre.
— in secondary stage may have false negative due to • Lesion is initially a scaly patch,
Prozone, in tertiary 25% are negative, after
successful treatment will become nonreactive after 1
to 2 years.
• Includes VDRL / RPR/ USR-unheated serum
Treponema pertenue
• Invasion of skin cut, causing a primary ulcer that
seeds a second crop of lesions - Yaws
• Non-venereal transmission, transmitted by direct
contact.
• Disease of bone and skin, rarely viscera
• Persistent lesions, wart-like, occur primarily in
children, causes and ulcerative necrosis, scar
formation, disfiguring.
• Untreated disease not as severe as syphilis, but
esions are more persistent.
• Treat with penicillin
• Serologic syphilis test will be reactive.
Treponema endemicum
• Bejel (endemic syphilis) affects the skin, bones, and
mucous membranes of the mouth.
• Typically spread among children, most commonly in the
Middle East and the southern Sahara desert regions.
• Transmission is by direct contact, with broken skin or
contaminated hands, or indirectly by sharing drinking
vessels and eating utensils.
• Symptoms begin with a slimy patch on the inside of the
mouth followed by blisters on the trunk, arms, and legs.
Bone infection develops later, mainly in the legs.
• Also in later stages, soft, gummy lumps may appear in
the nose and on the roof of the mouth (soft palate).
deforming childhood infection of the mouth, nasal cavity,
body, and hands.
• Completely curable with Penicillin
• Serologic syphilis test will be reactive.
• Pinta (T carateum) occurs in
Central and South America and
the Caribbean.
• More common in young adults.
• Non-venereal, direct contact,
disease of skin.
becomes red-blue, later become depigmented and
atrophy.
• Treat with penicillin
• Serologic syphilis test will be reactive.
Borrelia sp
• Irregular form of spiral
• Highly flexible
• Move by rotation and twisting
Can culture on blood, serum or tissue,
but quickly lose pathogenicity
Relapsing Fever
• Relapsing fever (a.k.a., tick fever, borreliosis,
famine fever)
• Acute infection with 2-14 day 6 day) incubation period
• Followed by recurring febrile episodes
• Constant spirochaetemia that worsens during febrile
stages
• Epidemic Relapsing Fever = Louse-borne borreliosis
- Borrelia recurrentis
• Endemic Relapsing Fever = Tick-borne borreliosis
- Borrelia spp.
Diagnosis
• Blood specimens for smears and animal inoculation
Serology test — may develop positive VDRL
Lyme Disease
• Lyme disease characterized by three stages:
i. Initially a unique skin lesion (erythema chronicum
migrans (ECM)) with general malaise :
- ECM not seen in all infected hosts
- ECM often described as bullseye rash
- Lesions periodically reoccur
ii. Subsequent stage seen in 5-15% of patients with
neurological or cardiac involvement
iii.Third stage involves migrating episodes of non-
destructive, but painful arthritis
• Acute illness treated with phenoxymethylpenicillin or
tetracycline
Epidemiology of Lyme Disease
• Lyme disease was recognized as a syndrome in
1975 with outbreak in Lyme, Connecticut
• Transmitted by hard body tick (Ixodes spp.)
vectors
• Nymph stage are usually more aggressive feeders
• Nymph stage generally too small to discern with
unaided eye
• For these reasons, nymph stage transmits more
pathogens
• White-footed deer mice and other rodents, deer,
domesticated pets and hard-shelled ticks are
most common reservoirs
Diagnosis of Lyme Borreliosis
• Clinical Case Definition
Either of the following:
Erythema migrans (25 cm in diameter)
At least one late manifestation (i.e., musculoskeletal,
nervous system, or cardiovascular involvement) and
laboratory confirmation of infection
• Laboratory Criteria for Diagnosis
At least one of the following:
Isolation of Borrelia burgdorferi
Demonstration of diagnostic levels of IgM or IgG an-
tibodies to the spirochetes
Significant increase in antibody titer between acute and
convalescent serum samples
Leptospirosis
• Also called Weil's disease
• Caused by Leptospira interrogans.
• It is flexible filamentous, motile spirochete
• Dogs of all ages are susceptible but cats appears to be
resistant
• Source of infection
• Clinically infected or carrier dogs shed the organisms in urine
for months or even years
• Characterized by an acute febrile jaundice & immune
complex glomerulonephritis
• Incubation period usually 10-12 days with flu-like illness
usually progressing through two clinical stages:
1. ) Leptospiremia develops rapidly after infection (usually
lasts about 7 days) without local lesion
2.)Infects the kidneys and organisms are shed in the urine
(leptospiruria) with renal failure and death not uncommon
• Hepatic injury & meningeal irritation is common
Mode of transmission :
Direct contact through penetration of mucosa of mouth or
conjunctiva or abraded skin
Ingestion of contaminated materials as infected meats
Indirect transmission through exposure to contaminated fomites
Transplacental or venereal and bite wound transmission
Vaccination of leptospirosis
• Bivalent leptospira bacterin (L. canicola & L. icterohaemorrhagica)
It gives at 9, 12 and 15 week of age
• Repeated annually
• The immunization reduce severity and incidence of the disease but it
does not prevent the carrier