infections resulting from ingestion of contaminated food or water or from
TOPIC 1: ENTEROBACTERIACEAE
FAMILY ENTEROBACTERIACEAE
- The family Enterobacteriaceae includes many genera andspecies. The last
edition of Bergey’s Manual of Systematic Bacteriology (Vol. 2) describes 176
named species among 44 different genera; however, clinical isolates in
general acute care facilities consist primarily of Escherichia coli, Klebsiella
pneumoniae, and Proteus mirabilis
GENERAL CHARACTERISTICS:
● They are often referred to as the Enterics.
● Members of the family Enterobacteriaceae are gram-negative, non–spore-
forming, facultatively anaerobic coccobacilli.
● They do not produce cytochrome oxidase except for Plesiomonas.
● They all ferment glucose!
● They reduce nitrate to nitrite except for Photorhabdus and Xenorhabdus.
● They are motile at body temperatures except for Klebsiella, Shigella, and
Yersinia.
● Except for Klebsiella, Proteus, and some Enterobacter isolates, none has
remarkable colony morphology on laboratory media. They appear large,
moist, and gray on sheep blood agar (SBA), chocolate (CHOC) agar, and
most nonselective media.
MICROSCOPIC AND COLONY MORPHOLOGY:
- Gram Stain: appear as coccobacilli or as straight rods
- Colony morphology: Colony morphology on nonselective media, such as
SBAor chocolate (CHOC) agar, is of little value in initial identification!!!
- Exception of certain members (e.g., Klebsiella and sometimes Enterobacter)
that produce characteristically large and very mucoid colonies, members of
this family produce large, moist, gray colonies on nonselective media and are
indistinguishable.
- However, many isolates of E. coli are β-hemolytic.
BACTERIAL CULTURE:
- Differential and selective media: Eosin-methylene blue (EMB) and Mac Conkey
agars.
✔ These media contain one or more carbohydrates, such as lactose and
sucrose, which show the ability of the species to ferment specific
carbohydrates.
✔ Fermentation is indicated by a color change on the medium, which results
from a decrease in pH detected by a pH indicator incorporated into the
medium.
- Highly selective agars; Hektoen enteric (HE) and Xylose-lysinedesoxycholate
(XLD) agars are available for presumptive identification of enteric pathogens.
✔ HE and XLD agars contain sodium thiosulfate and ferric ammonium citrate,
which produce blackening of H2S-producing colonies.
✔ Species that produce hydrogen sulfide (H2S) may be readily distinguished
when placed on HE or XLD.
other sources.
BIOCHEMICAL TESTS:
OPPORTUNISTIC MEMBERS OF THE FAMILY ENTEROBACTERIACEAE AND ASSOCIATED
- The traditional biochemical tests to perform for identification include the
INFECTIONS:
following: TSI agar or Kligler iron agar (KIA) to determine glucose and lactose or
sucrose utilization (sucrose in TSI only) and H2S production o ESCHERICHIA COLI
● LIA to determine lysine decarboxylase activity - E. coli was initially considered a harmless member of the colon resident
● Urease test to determine hydrolysis of urea biota. It is now recognized as an important human pathogen
● Simmons citrate to determine the ability to use citrate as the sole carbon associated with a wide range of clinical syndromes, including UTIs,
source diarrheal diseases, and central nervous system infections.
● Semisolid motility agar - It is so commonly isolated from colon biota that E. coli is used as a
● Sulfide, indole, motility (SIM) or motility, indole, and ornithine (MIO) media primary marker of fecal contamination in water quality testing.
● Carbohydrate fermentation
VIRULENCE FACTORS:
VIRULENCE AND ANTIGENIC FACTORS:
● Most strains of E. coli are motile and generally possess adhesive fimbriae and
● Plasmids: Some species harbor plasmids that can provide antimicrobial sex pili and O, H, and K antigens.
resistance genes: an increasing number of E. coli, K. pneumoniae, and
Virulence Factors: Biological Functions:
Klebsiella oxytoca clinical strains produce plasmid-mediated extended
Fimbriae Adherence of bacteria to gastrointestinal tract; importance in
spectrum β-lactamases (ESBLs) including carbapenemases, cephalosporinases,
urinary tract infections and cause mannose-resistant
or metallo-β-lactamases, which can inactivate extended-spectrum
hemagglutination.
cephalosporins (e.g., cefotaxime), penicillins, and aztreonam.
Endotoxin Systemic manifestation of endotoxic shock and protect the
● O antigen, or somatic antigen: this is a heat-stable antigen located on the cell
bacillus from phagocytosis and from the bactericidal effects
wall.
of complement.
● H antigen, or flagellar antigen: this is a heat-labile antigen found on the surface
Capsule Protects Escherichia coli from phagocytosis.
of flagella, structures responsible for motility.
Sequestration of The capability of E. coli to compete for nutrients in host cells.
● K antigen, or capsular antigen: this is a heat-labile polysaccharide found only in
growth factors
certain encapsulated species.
Adhesins Facilitate firm adhesion of E. coli GI tract or the urinary tract
● Examples are the K1 antigen of E. coli and the Vi antigen of
mucosa, thereby preventing the bacteria of being eliminated
Salmonella enterica subsp. enterica serotype Typhi
by the flushing action of voided urine and also in intestinal
CLINICAL SIGNIFICANCE: motility.
- They reside in the GI Tract they reside in the gastrointestinal (GI) tract. Except Hemolysins (Hly A) Important in the pathogenesis of disease caused by
for Salmonella, Shigella, and Yersinia, they can be resident microbiota if uropathogenic strains of E. coli
confined to their natural environment. Enterotoxins: Cytotoxins
- Based on the clinical infections that they produce; members of the family Shiga Toxins
Heat stable toxin Causes increased secretion of fluids.
Enterobacteriaceae may be divided into two broad categories:
1. opportunistic pathogens and Heat labile toxin Watery diarrhea due to hypersecretion of fluids into the lumen
of the gut
2. primary pathogens.
● OPPORTUNISTIC VS PRIMARY PATHOGENS: Siderophores Removes iron from mammalian iron transport proteins like
▪ The opportunistic pathogens are often a part of the usual intestinal Transferrin and Lactoferrin.
microbiota of both humans and animals. However, outside their normal
body sites, these organisms can produce serious extraintestinal,
LABORATORY DIAGNOSIS:
opportunistic infections.
● Serotyping for both O and H antigens is often useful in identification of strains,
- For example, E. coli, one of the best-studied members of the
particularly strains associated with serious enteric disease.
Enterobacteriaceae, is a member of the normal bowel biota but can
● Culture:
cause urinary tract infections (UTIs), septicemia, wound infections in
- MAC agar: It usually appears as a lactose-positive (pink) colony with a
healthy individuals, and meningitis in neonates.
surrounding area of precipitated bile salts
▪ The primary pathogens, which include S. enterica, Shigella spp., and
- Eosin Methylene Blue agar: it has a green metallic sheen.
Yersinia spp., are considered true pathogens; that is, they are not present as
● Biochemical abilities:
commensal biota in the GI tract of humans. These organisms produce
 - Fermentation of glucose, lactose, trehalose, and xylose. Glucose
fermentation by the mixed acid pathway.
✔ Production of indole from tryptophan
✔ Methyl red positive and Voges-Proskauer negative
✔ Does not produce H2S, DNase, urease, or phenylalanine deaminase
✔ Cannot use citrate as a sole carbon source
UROPATHOGENIC: ESCHERICHIA COLI
● The E. coli strains that cause UTIs usually originate in the large intestine as
resident biota and can exist either as the predominant E. coli population or as
a small part of the E. coli strains in the large intestine.
● Strains causing lower UTIs and acute pyelonephritis in immunocompetent hosts
are different from strains causing disease in the urinary tracts of individuals who
are compromised either by urinary tract defects or by instrumentation such as
placement of catheters.
● E. coli strains that cause acute pyelonephritis in immunocompetent hosts have
been shown to be the dominant resident E. coli in the colon.
● Strains that cause UTIs produce factors that allow them to attach to the urinary
epithelial mucosa. The primary virulence factor associated with the ability of E.
coli to cause UTIs is the production of pili, which allow uropathogenic strains to
adhere to epithelial cells and not be washed out with urine flow.
GASTROINTESTINAL PATHOGENS:
● E. coli may cause several different GI syndromes. Based on virulence factors,
clinical manifestation, epidemiology, and different O and H serotypes, there
are five major categories of diarrheogenic E. coli:
1. Enterotoxigenic Escherichia coli (ETEC)
2. Enteroinvasive Escherichia coli (EIEC)
3. Enteropathogenic Escherichia coli (EPEC)
4. Enterohemorrhagic Escherichia coli (EHEC)
5. Enteroadherent: diffusely adherent Escherichia coli (DAEC) and
Enteroaggregative Escherichia coli (EAEC)
ENTEROTOXIGENIC: Escherichia coli
● Epidemiology: ETEC strains are associated with diarrhea of adults and
especially children in tropical and subtropical climates, especially in
developing countries, where it is one of the major causes of infant bacterial
diarrhea.
● Most common cause of a diarrheal disease sometimes referred to as traveler’s
diarrhea. Travelers from industrialized countries often become infected with
ETEC when they visit developing nations.
● Mode of transmission: consumption of contaminated food or water
● Pathophysiology: colonization of ETEC on the proximal small intestine has been
recognized as being mediated by fimbriae that permit ETEC to bind to specific
receptors on the intestinal microvilli. Once
● ETEC strains are established, they can release one or both of two toxins into the
small intestine.
● Clinical Manifestation: The usually mild, self-limiting disease caused by ETEC
is characterized by watery diarrhea, abdominal cramps, and sometimes
nausea, usually with no vomiting or fever.
ENTEROPATHOGENIC: Escherichia coli O157:H7 does not ferment sorbitol in 48 hours, a characteristic that
differentiates it from most other E. coli strains.
● Epidemiology: Diarrheal outbreaks caused by EPEC have occurred in hospital
b. E. coli O157:H7 appears colorless on SMAC agar, whereas most other strains
nurseries and daycare centers, but cases in adults are rarely seen.
produce pink colonies for sorbitol fermentation.
● Clinical Manifestation: low-grade fever, malaise, vomiting, and diarrhea
c. Serotyping: Detecting the verotoxin in stool filtrates. Demonstration of a
● The stool typically contains large amounts of mucus, but apparent blood is not
fourfold or greater increase in verotoxin neutralizing antibody titer.
present
● Detection of diarrheal illness attributable to EPEC depends primarily on the ENTEROADHERENT: Escherichia coli
suspicion of the physician. In cases of severe diarrhea in children younger than
● Enteroadherent E. coli strains are generally associated with two kinds of human
1 year, infection with EPEC should be suspected.
disease: diarrheal syndromes and UTIs.
ENTEROINVASIVE: Escherichia coli ● The two types of enteroadherent E. coli are: DAEC (Diffusely adhering) and
EAEC. (Enteroaggregative)
● Epidemiology: EIEC infection is rare in the United States and seen less
1. DAEC may be associated with UTIs and diarrheal disease. Uropathogenic
commonly in developing countries than ETEC or EPEC. Enteroinvasive strains
DAEC strains are closely associated with cystitis in children and acute
produce dysentery with direct penetration, invasion, and destruction of the
pyelonephritis in pregnant women.
intestinal mucosa. This diarrheal illness is very similar to that produced
2. EAEC causes diarrhea by adhering to the surface of the intestinal mucosa.
by Shigella spp.
These strains are found to adhere to HEp2 cells, packed in an aggregative
● Mode of transmission: person to person via the fecal-oral route
“stacked-brick” pattern on the cells and between the cells by means of
● Clinical manifestation: fever, severe abdominal cramps, malaise, and watery
fimbriae.
diarrhea
● Laboratory diagnosis: The organisms might be easily misidentified because of EXTRAINTESTINAL INFECTIONS:
their similarity to shigellae. EIEC strains can be nonmotile and generally do not
● E. coli remains one of the most common causes of septicemia and meningitis
ferment lactose; cross-reaction between shigellae and EIEC O antigens has
among neonates, accounting for about 40% of the cases of gram-negative
been reported
meningitis.
● DNA probes for EIEC more recently have become commercially available.
OTHER ESCHERICHIA SPECIES:
These kits are used to screen stool samples, eliminating the need for other tests
to identify EIEC. ● Escherichia hermannii: Escherichia hermannii is a yellow-pigmented organism
ENTEROHEMORRHAGIC: Escherichia coli that has been isolated from cerebrospinal fluid (CSF), wounds, and blood.
Reports of isolating E. hermannii from foodstuffs such as raw milk and beef, the
● The EHEC strain serotype O157:H7 has since been associated with hemorrhagic
same sources as E. coli O157:H7, have been published. However, its clinical
diarrhea, colitis, and hemolytic uremic syndrome (HUS). HUS is characterized
significance is not yet established.
by low platelet count, hemolytic anemia, and kidney failure. The infection is
● Escherichia vulneris: has been isolated from humans with infected wounds.
potentially fatal, especially in young children and elderly adults in
More than half of the strains of E. vulneris also produce yellow-pigmented
nursing homes.
colonies.
● Clinical manifestation: The classic illness caused by EHEC produces a watery
● Escherichia albertii: The newest species added to this genus, Escherichia
diarrhea that progresses to bloody diarrhea with abdominal cramps and low-
albertii, is associated with diarrheal disease in children.
grade fever or an absence of fever.
KLEBSIELLA:
● Virulence factors: E. coli O157:H7 produces two cytotoxins: verotoxin I and
verotoxin II. GENERAL CHARACTERISTICS:
1. Verotoxin I is a phage-encoded cytotoxin identical to the Shiga toxin (Stx)
● Members of these genera are usually found in the intestinal tract of humans
produced by Shigella dysenteriae type I. The toxin produces damage to
and animals or free-living in soil, water, and on plants. These microorganisms
Vero cells (African green monkey kidney cells)—hence the term verotoxin.
have been associated with various opportunistic and hospital-acquired
2. Verotoxin II is biologically similar to, but immunologically different from, both
infections, particularly pneumonia, wound infections, and UTIs.
Stx and verotoxin I. These toxins have also been reported under the term
● Common characteristics include the following:
Shiga-like toxins but are most likely to be found in the literature as Shiga
▪ Most grow on Simmons citrate and in potassium cyanide broth.
toxin I (Stx1) and Shiga toxin 2 (Stx2).
▪ None produce H2S.
● Laboratory Diagnosis: In the laboratory, verotoxin-producing E. coli may be
▪ A few hydrolyze urea slowly.
identi fied by one of three methods:
▪ All give a negative reaction with the methyl red test and a positive reaction
a. Stool culture on highly differential medium: MAC agar containing sorbitol
with the Voges-Proskauer test.
(SMAC) instead of lactose- E. coli
▪ With a few exceptions, no indole is produced from tryptophan.
▪ Motility is variable
Klebsiella pneumoniae: ● Serratia spp. are opportunistic pathogens associated with outbreaks in health
care settings.
● It is the most commonly isolated species and has the distinct feature of
● S. marcescens and S. rubidaea. S. marcescens is the species considered most
possessing a large polysaccharide capsule. The capsule offers the organism
significant clinically. It has been found frequently in hospital acquired infections
protection against phagocytosis and antimicrobial absorption, contributing to
of the urinary or respiratory tract and in bacteremic outbreaks in nurseries and
its virulence. The capsule is also responsible for the moist, mucoid colonies
cardiac surgery and burn units. Contamination of antiseptic solution used for
characteristic of K. pneumoniae.
joint injections has resulted in an epidemic of septic arthritis.
● Epidemiology: Colonization of gram-negative bacilli in the respiratory tracts of
● S. marcescens, S. rubidaea, and S. plymuthica often produce a characteristic
hospitalized patients, particularly by K. pneumoniae, increases with the length
pink-to-red pigment, prodigiosin, especially when the cultures are incubated at
of hospital stay. K. pneumoniae is a frequent cause of lower respiratory tract
room temperature. Pigment production is typically a characteristic in those
infections among hospitalized patients and in immunocompromised hosts such
strains of environmental origin.
as newborns, elderly patients, and seriously ill patients on respirators.
Characteristic
swarming colonies of
Proteus mirabilis in a Sheep Blood
agar

Morganella:

● The genus Morganella has

only one species, M.
morganii, with two

(Mucoid colonies of Klebsiella pneumoniae) subspecies: M.

The pigment Prodigiosin is responsible for the pigment on Serratia colonies. morganii subsp. morganii and M. morganii subsp. sibonii.
Klebsiella oxytoca:
● M. morganii is a documented cause of UTI. It has also been identified as a
Hafnia:
● K. oxytoca produces infections similar to those caused by K. pneumoniae. In cause of neonatal sepsis. Morganella is motile but does not swarm.
addition, isolates have been linked to antibiotic-associated hemorrhagic colitis. ● The genus Hafnia is composed of one species, H. alvei. However, two distinct
Providencia:
Biochemically, K. oxytoca is identical to K. pneumoniae except for its biotypes are recognized: H. alvei and H. alvei biotype 1.

production of indole, and there are reports of ornithine-positive isolates as well. ● Biotype 1 grows in the beer wort of breweries and has not been isolated ● The genus Providencia consists of five species: P. alcalifaciens, P. stuartii, P.
clinically. rettgeri, P. rustigianii, and P. heimbachae. P. rett geri is a documented
ENTEROBACTER AND CRONOBACTER:
● A delayed positive citrate reaction is a major characteristic of Hafnia. pathogen of the urinary tract and has caused occasional outbreaks in health
GENERAL CHARACTERISTICS: care settings:
Proteus:
● P. stuartii: implicated in outbreaks in burn units and has been isolated from
● The genus Enterobacter is composed of at least 12 species. Clinically significant
● They are widely disseminated in the environment, are normal intestinal urine cultures.
Enterobacter spp. that have been isolated from clinical samples include:
microbiota, and are recognized as opportunistic pathogens. ● Infections caused by P. stuartii and P. rettgeri, especially in
▪ Enterobacter cloacae
● The tribe Proteeae is distinguished from the other members of the immunocompromised patients, areparticularly difficult to treat because of their
▪ Enterobacter aerogenes
Enterobacteriaceae by virtue of the ability to deaminate the amino acid resistance to antimicrobials.
▪ Enterobacter gergoviae
phenylalanine. ● P. alcalifaciens: most commonly found in the feces of children with diarrhea;
▪ Enterobacter hormaechei
● The genus Proteus consists of at least four species. P. mirabilis and P. and P. however, its role as a cause of diarrhea has not been proven.
● Members of this genus are motile. The colony morphology of many of the
vulgaris are widely recognized human pathogens. Both species have been ● P. rustigianii, formerly identified as a strain of P. alcalifaciens, is rarely isolated,
species resembles Klebsiella when growing on MAC agar.
isolated from urine, wounds, and ear and bacteremic infections. and its pathogenicity also remains unproven, whereas P. heimbachae has yet
● Enterobacter spp. grow on Simmons citrate mediumand in potassium cyanide
● They ascend the urinary tract, causing infections in both the lower and the to be isolated from any clinical specimens.
broth; the methyl red test is negative, and the Voges-Proskauer test is positive.
upper urinary tract. They can infect the proximal kidney tubules and can cause
● E. cloacae and E. aerogenes are the two most common iso lates from this Edwardsiella:
acute glomerulonephritis, par ticularly in patients with urinary tract defects or
group. These two species have been isolated from wounds, urine, blood, and
catheterization. ● The genus Edwardsiella is composed of three species: E. tarda, E. hoshinae,
CSF
● The urease activity of P. mirabilis can lead to struvite kidney stones (calculi). and E. ictaluri.
● Cronobacter (Enterobacter) sakazakii typically produces a yellow pigment
● P. mirabilis and P. vulgaris are easily identified in the clinical laboratory ● E. tarda is the only recognized human pathogen. E. tarda is an opportunist,
and has been documented as a pathogen in neonates causing meningitis
because of their characteristic colony morphology. causing bacteremia and wound infections. Its pathogenic role in cases of
and bacteremia, often coming from powdered infant formula.
● Both species, particularly P. mirabilis, can produce “swarming” colonies on diarrhea is controversial. E. hoshinae has been isolated from snakes, birds, and
Serratia: nonselective media, such as SBA. water. E. ictaluri causes enteric septicemia in fish.

● The genus Serratia comprises S. marcescens, S. liquefaciens, S. rubidaea, S. Citrobacter:

odorifera, S. plymuthica, S. ficaria,S. entomophila, and S. fonticola.
 ● Earlier classifications of the family Enterobacteriaceae included the genus
Citrobacter within the tribe Salmonelleae, which for merly consisted of the
genera Salmonella, Citrobacter, and Arizona.
● However, changes in the classification and nomenclature of bacterial species
belonging to the tribe Salmonellae have caused the reclassification of the
genus Citrobacter into its own tribe, Citrobacteriaceae, and of Arizona as a
subspecies of Salmonella.
● The citrobacters are considered inhabitants of the GI tract and are associated
with hospital-acquired infections, most frequently UTIs. The three species most
often isolated are C. freundii, C. koseri, and C. braakii.
● C. freundii has been associated with infectious diseases acquired in hospital
settings; UTIs, pneumonias, and intraabdominal abscesses have been reported.
In addition, C. freundii has been associated with endocarditis in intravenous
drug abusers. One reported case of C. freundii endocarditis required aortic
H2S–producing colonies of salmonellae growing on xylose-lysine-desoxycholate (XLD)
valve replacement when antimicrobial therapy failed.
agar.
● Because most (80%) C. freundii produce H2S and some strains (50%) fail to
ferment lactose, the colony morphology of C. freun dii on primary selective
media can be mistaken for Salmonella when isolated from stool cultures.
Because of the pathogenic potential, it is important to differentiate C. freundii
from Salmonella.
● C. freundii has been associated with infectious diseases acquired in hospital
settings; UTIs, pneumonias, and intraabdominal abscesses have been reported.
In addition, C. freundii has been associated with endocarditis in intravenous
drug abusers. One reported case of C. freundii endocarditis required aortic
valve replacement when antimicrobial therapy failed.
▪ C freundii vs Salmonella: urea hydrolysis and lysine decarboxylase!!
▪ C. freundii = hydrolyze urea, but fail to decarboxylate lysine
▪ Salmonella= does not hydrolyze, but decarboxylate lysine
PRIMARY INTESTINAL PATHOGENS OF THE FAMILY ENTEROBACTERIACEAE:
● Salmonella and Shigella organisms produce GI illnesses in humans; neither is
considered normal biota of the human intestinal tract. Salmonellae inhabit the
GI tracts of animals.
VIRULENCE FACTOR:
● Infections caused by Shigella spp. are associated with human carriers
responsible for spreading the disease; no animal reservoir has yet been
identified. Shigella dysentery usually indicates improper sanitary conditions and
poor personal hygiene.
● Infections caused by Yersinia spp. are transmitted by a wide variety of wild and
domestic animals. Yersinia infections include GI disease, mediastinal
lymphadenitis, fulminant septicemia, and pneumonia.
ANTIGENIC STRUCTURE:
SALMONELLA:
● Members of the genus Salmonella produce significant infections in humans
and in certain animals.
● Many Salmonella serotypes are typically found in cold-blooded animals as well
as in rodents and birds, which serve as their natural hosts.
● Salmonellae are gram-negative, facultatively anaerobic bacilli that
morphologically resemble other enteric bacteria.
● On selective and differential media used primarily to isolate enteric pathogens
(e.g., MAC), salmonellae produce clear, colorless, non–
lactosefermentingcolonies; colonies with black centers are seen if the media
(e.g., HE or XLD) contain indicators for H2S production.
CLINICAL INFECTIONS:
● The biochemical features for the genus include the following:
▪ In almost every case, they do not ferment lactose.
▪ They are negative for indole, the Voges-Proskauer test, phenylalanine
deaminase, and urease.
▪ Most produce H2S; a major exception is Salmonella Paratyphi A, which
does not produce H2S.
▪ They do not grow in medium containing potassium cyanide.
● The genus Salmonella comprised three biochemically discrete species: S.
Gastroenteritis:
enteritidis, S. choleraesuis, and S. typhi.
● However, genetic studies showed that bacterial species in the Salmonella are
very closely related and that only two species, S. enterica (the type species of
the genus) and S. bongori, should be designated.
● Nearly all former Salmonella spp. have been placed as serotypes below the
level of S. enterica subsp. Enterica (e.g., S. enterica subsp. enterica serotype
Typhi); this is often more simply written as Salmonella Typhi (serotype is
capitalized and not italicized.
● The role of fimbriae in adherence in initiating intestinal infection has been
cited. Another factor that contributes to the virulence of salmonellae is their
ability to traverse intestinal mucosa. Enterotoxin produced by certain
Salmonella strains that cause gastroenteritis has been implicated as a
significant virulence factor.
Enteric Fevers:
● The somatic O antigens and flagellar H antigens are the primary antigenic
structures used in serologic grouping of salmonellae.
● The serologic identification of the Vi antigen is important in identifying
Salmonella serotype Typhi.
● The heat-stable O antigen of salmonellae, as is the case with other enteric
bacteria, is the lipopolysaccharide located in the outer membrane of the cell
wall.
● Many different O antigens are present among the subspecies of Salmonella;
Typhoid Fever:
more than one O antigen can also be found in a particular strain.
● In contrast to the O antigens, flagellar antigen or H antigen proteins are heat
labile.
● The heat-labile Vi (from the term virulence) antigen is a surface polysaccharide
capsular antigen found in Salmonella serotype Typhi and a few strains of
Salmonella serotype Choleraesuis. The capsular antigen plays a significant role
in preventing phagocytosis of the organism.
● In humans, salmonellosis may occur in several forms, as follows:
▪ Acute gastroenteritis or food poisoning characterized by vomiting and
diarrhea
▪ Typhoid fever, the most severe form of enteric fever, caused by Salmonella
serotype Typhi, and enteric fevers caused by other Salmonella serotypes
(e.g., Salmonella Paratyphi and Choleraesuis)
▪ Nontyphoidal bacteremia
▪ Carrier state following Salmonella infection
● Mode of transmission: ingesting the organisms in food, water, and milk
contaminated with human or animal excreta.
● With the exception of Salmonella Typhi and Salmonella Paratyphi, salmonellae
organisms infect various animals that serve as reservoirs and sources of human
infections. Salmonella serotypes Typhi and Paratyphi have no known animal
reservoirs.
● One of the most common forms of “food poisoning,”
● The source of the infection has been attributed primarily to poultry, milk, eggs,
and egg products as well as to handling pets.
● Insufficiently cooked eggs and domestic fowl, such as chicken, turkey, and
duck, are common sources of infection.
● Salmonella gastroenteritis occurs when a sufficient number of organisms
contaminate food that is maintained under inadequate refrigeration, allowing
growth and multiplication of the organisms.
● The symptoms of intestinal salmonellosis, which may appear 8 to 36 hours after
ingestion of contaminated food, include nausea, vomiting, fever, and chills,
accompanied by watery diarrhea and abdominal pain.
● The antimicrobials of choice: chloramphenicol, ampicillin, and trimethoprim-
sulfamethoxazole.
● Antidiarrheal agents are also restricted in cases of salmonellosis because these
agents may encourage adherence and further invasion.
● The clinical features of enteric fevers include:
▪ Prolonged fever
▪ Bacteremia
▪ Involvement of the reticuloendothelial system, particularly the liver, spleen,
intestines, and mesentery
▪ Dissemination to multiple organs
 ● Enteric fever caused by Salmonella Typhi is known as typhoid fever, a febrile SHIGELLA:
disease that results from the ingestion of food contaminated with the
GENERAL CHARACTERISTICS:
organisms originating from infected individuals or carriers.
● Other enteric fevers include paratyphoid fevers, which may be due to ● The genera Shigella and Escherichia are so closely related according to

Salmonella serotypes Paratyphi A, B, and C and Salmonella serotype molecular analyses that they should be a single genus.

Choleraesuis. ● Shigella spp. are not members of the normal GI microbiota, and all Shigella

● Typhoid fever occurs more often in tropical and subtropical areas, where spp. can cause bacillary dysentery. The genus Shigella is named after the

international travelers are more likely to acquire the infection. Improper Japanese microbiologist Kiyoshi Shiga, who first isolated the organism in 1896.

disposal of sewage, poor sanitation, and lack of a modern potable water ● The organism, descriptively named Shigella dysenteriae, caused the enteric

system have caused outbreaks of typhoid fever when the organisms reach a disease bacillary dysentery.

water source. ● Dysentery was characterized by the presence of blood, mucus, and pus in the

● Typhoid fever develops approximately 9 to 14 days after ingestion of the stool.

organisms. ● Characteristics of Shigella spp. include the following:

● The onset of symptoms depends on the number of organisms ingested; the ▪ They are nonmotile.

larger the inoculum, the shorter the incubation period. ▪ Except for certain types of S. flexneri, they do not produce gas from

● Characteristically, during the first week of the disease, the patient develops a glucose.

fever accompanied by malaise, anorexia, lethargy, myalgia, and a continuous ▪ They do not hydrolyze urea.

dull frontal headache. ▪ They do not produce H2S.

● Typhoid fever pathophysiology: ▪ They do not decarboxylate lysine.

ANTIGENIC STRUCTURE:
▪ When the organisms are ingested, they seem to be resistant to gastric acids LABORATORY DIAGNOSIS:
● The genus consists of four species that are biochemically similar. Shigella spp.
and, on reaching the proximal end of the small intestine, subsequently
● In contrast to Escherichia spp., Shigella spp. do not use acetate or mucate as a are also divided into four major O antigen groups and must be identified by
invade and penetrate the intestinal mucosa.
source of carbon. serologic grouping.
▪ At this time, the patient experiences constipation rather than diarrhea. The
● On differential and selective media used primarily to isolate intestinal ● All Shigella spp. possess O antigens, and certain strains can possess K antigens.
organisms gain entrance into the lymphatic system and are sustained in the
pathogens, shigellae generally appear as clear, non–lactose-fermenting ● Shigella K antigens, when present, interfere with the detection of the O antigen
mesenteric lymph nodes.
colonies. during serologic grouping.
▪ They eventually reach the bloodstream and spread further to the liver,
● Shigellae are fragile organisms. They are susceptible to the various effects of ● The K antigen is heat labile and may be removed by boiling a cell suspension.
spleen, and bone marrow, where they are immediately engulfed by
physical and chemical agents, such as disinfectants and high concentrations The shigellae are nonmotile; therefore, they lack H antigens.
mononuclear phagocytes. The organisms multiply intracellularly; later they
of acids and bile.
are released into the bloodstream for the second time. The febrile episode Test S. dysenteriae S. flexneri S. boydii S. sonnei
becomes more evident during this release of the organisms into the Mannitol - + + +
circulatory system. fermentation
▪ At this time, the organisms may be isolated easily from the blood. ONPG Variable - variable +
▪ During the second and third weeks of the disease, the patient generally Ornithine - - - +
experiences sustained fever with prolonged bacteremia. decarboxylase
▪ The organisms invade the gallbladder and Peyer’s patches of the bowel. Serogroup A B C D
▪ They also reach the intestinal tract via the biliary tract. “Rose spots” ONPG- O-nitrophenyl-β-D-galactopyranoside;
(blanching, rose-colored papules around the umbilical region) appear
CLINICAL INFECTIONS:
during the second week of fever
● Although all Shigella spp. can cause dysentery, species vary in epidemiology,
Bacteremia:
Clear, green colonies of Shigella growing on Hektoen enteric (HE) agar mortality rate, and severity of disease
● Salmonella bacteremia, with and without extraintestinal foci of infection ● Shigellosis is probably underreported because most patients are not
caused by nontyphoidal Salmonella, is characterized primarily by prolonged hospitalized and usually recover from the infection without culture to identify
fever and intermittent bacteremia. the etiologic agent. S. sonnei infection is usually a short, self-limiting disease
● The serotypes most commonly associated with bacteremia are Typhimurium, characterized by fever and watery diarrhea.
Paratyphi, and Choleraesuis. Salmonella infection has been observed among ● Conversely, in developing countries, S. dysenteriae type 1 and S. boydii are the
two different groups: most common isolates
1. young children, who experience fever and gastroenteritis with brief ● S. dysenteriae type 1 remains the most virulent species, with significant
episodes of bacteremia morbidity and high mortality.
2. adults, who experience transient bacteremia during episodes of
gastroenteritis or develop symptoms of septicemia without gastroenteritis.
 ● Mode of transmission: direct person to person contact; fecal-oral route;
Shigellae may also be transmitted by flies, fingers, and food or water
contaminated by infected persons.
● Young children in daycare centers, particularly infants younger than 1 year of
age, are themost susceptible. Most disturbing are the reports of
multidrugresistant S. sonnei outbreaks in daycare centers in several states.
● Bloody stools containing mucus and numerous leukocytes follow the watery
diarrhea, as the organisms invade the colonic tissues and cause an
inflammatory reaction.
● In dysentery caused by S. dysenteriae type 1, patients experience more severe
symptoms. Bloody diarrhea that progresses to dysentery may appear within a
few hours to a few days.
● Severe cases of shigellosis may become life threatening as extraintestinal
complications develop. One of the most serious complications is ileus, an
obstruction of the intestines, with marked abdominal dilation, possibly leading
to toxic megacolon.
● Bacillary dysentery caused by Shigella spp. is marked by penetration of
intestinal epithelial cells after attachment of the organisms to mucosal surfaces,
local inflammation, shedding of the intestinal lining, and formation of ulcers
after epithelial penetration.
● The clinical manifestations of shigellosis vary from asymptomatic to severe
forms of the disease. The initial symptoms, marked by high fever, chills, LABORATORY DIAGNOSIS: TOPIC 2: GRAM NEGATIVE BACILLI
abdominal cramps, and pain accompanied by tenesmus, appear
● Y. pestis is a gram-negative, short, plump bacillus. When stained with GRAM NEGATIVE BACTERIA:
approximately 24 to 48 hours after ingestion of the organisms.
methylene blue or Wayson stain, it shows intense staining at each end of the
- Two large groups:
YERSINIA: bacillus, referred to as bipolar staining, which gives it a “safety-pin”
1. Enterobacteriaceae
appearance.
GENERAL CHARACTERISTICS: 2. Non-fermenters
● Y. pestis may be isolated on routine culture medium. Although it grows at 37°
- both groups are responsible for most clinical isolates.
● The genus Yersinia currently consists of 14 named species; most are considered C, it has a preferential growth temperature of 25° C to 30° C.
environmental species. - Gram-negative bacteria that are not members of the family
● Although many have been isolated from humans, only three species are Enterobacteriaceae
considered human pathogens. Y. pestis is the causative agent of Bubonic are a very diverse group of
plague, a disease primarily of rodents transmitted to humans by fleas. organisms ranging from
● Y. pseudotuberculosis and Y. enterocolitica have caused sporadic cases of opportunistic pathogens that are
mesenteric lymphadenitis in humans, especially in children, and generalized residents of the normal human
septicemic infections in immunocompromised hosts. microbiota, such as the HACEK
group, to opportunistic
YERSINIA PESTIS:
environmental organisms such as
● The causative agent of the ancient disease plague still exists in areas where Stenotrophomonas
reservoir hosts are found. maltophilia, to virulent pathogens
● Plague is a disease primarily of rodents. It is transmitted to humans by bites of such as Pseudomonas aeruginosa.
fleas, which are its most common and effective vectors. Safety pin appearance as observed under Gram Stain

● In humans, plague can occur in three forms: the bubonic, or glandular, form;
the septicemic form; and the pneumonic form.
● The bubonic form, the most common, usually results from the bite of an
infected flea.
● Clinical manifestation: Characteristic symptoms appear 2 to 5 days after
infection.
● The symptoms include high fever with painful regional lymph nodes known as
buboes (swollen lymph nodes) begin to appear.
 - P aeruginosa is motile and rod shaped, measuring about 0.6 × 2 ìm (It is
gram negative and occurs as single bacteria, in pairs, and occasionally
in short chains.

P. aeruginosa under UV light. Pyoverdin as the pigment responsible for the

fluorescence.

B. Culture
GENERAL CHARACTERISTICS:
- Nonfermenting gram-negative bacilli are grouped together because:
1. They fail to acidify oxidative-fermentative (OF) media when it is overlaid
with mineral oil or fail to acidify triple sugar iron agar (TSIA) butts.
2. They prefer and grow much better in anaerobic environment; some do not
grow in an anaerobic environment at all. Some group members oxidize
carbohydrates to derive energy for their metabolism; they are referred to as
- P aeruginosa is an obligate aerobe that grows readily on many types of
culture media, sometimes producing a sweet or grapelike or corn taco–
like odor.
- Some strains hemolyze blood. P aeruginosa forms smooth round colonies
with a fluorescent greenish color. It often produces the nonfluorescent
bluish pigment pyocyanin, which diffuses into the agar. Other
Pseudomonas species do not produce pyocyanin.
- Many strains of P aeruginosa also produce the fluorescent pigment
pyoverdin, which gives a greenish color to the agar.
All you need to know:
- Some strains produce the dark red pigment pyorubin or the black
pigment pyomelanin.
C. Growth Characteristics
- P aeruginosa grows well at 37–42°C; its growth at 42°C helps
differentiate it from other Pseudomonas species in the fluorescent
group.
- It is oxidase positive. It does not ferment carbohydrates, but many
strains oxidize glucose.
- Identification is usually based on colonial morphology, oxidase positivity,
the presence of characteristic pigments, and growth at 42°C.
- Differentiation of P aeruginosa from other pseudomonads on the basis
of biochemical activity requires testing with a large battery of substrates.
✔ Growth at 42°C.

oxidizers ✔ Beta-hemolysis in blood agar.

3. Additional characteristics can differentiate this group of nonfermenters ✔ Sweet or corn taco-like odor but never do an odor test!

from other gram-negative bacilli—motility, pigmentation, and their ability or ✔ Pigments: Pyocyanin, Pyorubin and Pyoverdin!

lack of ability to grow on selective gram-negative media such as

ANTIGENIC STRUCTURE AND TOXINS:
MacConkey (MAC) agar.
1. Pili (fimbriae)- extend from the cell surface and promote attachment to host
epithelial cells.
2. Exopolysaccharide-is responsible for the mucoid colonies seen in cultures from
patients with Cystic Fibrosis.
Pseudomonas aeruginosa vs Staphyloccocus sp. 3. Lipopolysaccharide-exists in multiple immunotypes, is responsible for many of
the endotoxic properties of the organism. P aeruginosa can be typed by
lipopolysaccharide immunotype and by pyocin (bacteriocin) susceptibility.
4. Extracellular enzymes, including elastases, proteases, and two hemolysins (a
CLINICALLY SIGNIFICANT NON-FERMENTATIVE GRAM-NEGATIVE BACILLI:
heat-labile phospholipase C and a heat-stable glycolipid).
Pseudomonas aeruginosa: 5. Exotoxin A - which causes tissue necrosis and is lethal for animals when
injected in purified form.
MORPHOLOGY AND IDENTIFICATION:
PATHOGENESIS:
A. Typical Organisms
- P aeruginosa is pathogenic only when introduced into areas devoid of normal
defences:
1. When mucous membranes and skin are disrupted by direct tissue damage
as in the case of burn wounds;
2. When intravenous or urinary catheters are used; or when neutropenia is
present, as in cancer chemotherapy.
- The bacterium attaches to and colonizes the mucous membranes or skin,
invades locally, and produces systemic disease. These processes are promoted
by the pili, enzymes, and toxins described earlier.
 - Lipopolysaccharide plays a direct role in causing fever, shock, oliguria,
leukocytosis and leukopenia, disseminated intravascular coagulation, and
adult respiratory distress syndrome.
- P aeruginosa and other pseudomonads are resistant to many antimicrobial
agents and therefore become dominant and important when more
susceptible bacteria of the normal microbiota are suppressed.
CLINICAL FINDINGS:
- P aeruginosa produces infection of wounds and burns, giving rise to blue-green
pus; meningitis when introduced by lumbar puncture or during a neurosurgical
procedure; and urinary tract infection when introduced by catheters and
instruments or in irrigating solutions.
- Involvement of the respiratory tract, especially from contaminated respirators,
results in necrotizing pneumonia.
- The bacterium is often found in mild otitis externa in swimmers. It may cause
invasive (malignant) otitis externa in patients with diabetes
- A form of folliculitis associated with poorly chlorinated hot tubs and swimming
pools can be seen in otherwise healthy persons.
- In infants or debilitated persons, P aeruginosa may invade the bloodstream
and result in fatal sepsis; this occurs commonly in patients with leukaemia or
lymphoma who have received antineoplastic drugs or radiation therapy and in
patients with severe burns. In most P aeruginosa infections, the symptoms and
signs are nonspecific and are related to the organ involved.
- Occasionally, verdoglobin (a breakdown product of haemoglobin) or
fluorescent pigment can be detected in wounds, burns, or urine by ultraviolet
fluorescence. Haemorrhagic necrosis of skin occurs often in sepsis caused by P
aeruginosa; the lesions, called ecthyma gangrenosum, are surrounded by
erythema and often do not contain pus. P aeruginosa can be seen on Gram-
stained specimens from ecthyma lesions, and culture results are positive.
Ecthyma gangrenosum is uncommon in bacteremia caused by organisms
other than P aeruginosa.
DIAGNOSTIC LABORATORY TESTS:
A. Specimen: skin lesions, pus, urine, blood, spinal fluid, sputum, and other
material should be obtained as indicated by the type of infection.
B. Smears: Gram-negative rods are often seen in smears.
C. Culture: Specimens are plated on blood agar and the differential media
commonly used to grow the enteric gram-negative rods. Pseudomonads grow
readily on most of these media, but they may grow more slowly than the
enterics. P aeruginosa does not ferment lactose and is easily differentiated
from the lactose-fermenting bacteria. Culture is the specific test for diagnosis
of P aeruginosa infection!!
TREATMENT:
- Drug of choice: An extended spectrum penicillin as piperacillin active used in
combination with an aminoglycoside, usually tobramycin.
- Other drugs active against P aeruginosa include aztreonam; carbapenems
such as imipenem or meropenem; and the fluoroquinolones, including
ciprofloxacin.
- Of the cephalosporins: ceftazidime, cefoperazone, and cefepime are active
against P aeruginosa
- Susceptibility testing is a must! Multi-drug resistance has become a major issue
in the management of hospital-acquired infections with P aeruginosa.
EPIDEMIOLOGY AND CONTROL:
- P aeruginosa is primarily a nosocomial pathogen, and the methods for control
of infection are similar to those for other nosocomial pathogens. Because
pseudomonas thrives in moist environments, special attention should be paid
to sinks, water baths, showers, hot tubs, and other wet areas. For epidemiologic
purposes, strains can be typed using molecular typing techniques.
Burkholderia pseudomallei:
MORPHOLOGY AND IDENTIFICATION:
A. Typical Organisms
- Burkholderia pseudomallei is a small, motile, oxidase-positive, aerobic
gram-negative bacillus. It grows on standard bacteriologic media,
forming colonies that vary from mucoid and smooth to rough and
wrinkled and in colour from cream to orange.
B. Growth Characteristics
- It grows at 42°C and oxidizes glucose, lactose, and a variety of other
carbohydrates. B pseudomallei causes melioidosis of humans, primarily
in Southeast Asia and northern Australia.
Characteristic wrinkled colonies of Burkholderia pseudomallei
EPIDEMIOLOGY:
- The organism is a natural saprophyte that has been cultured from soil, fresh
water, rice paddies, and vegetable produce. Human infection probably
originates from these sources by contamination of skin abrasions and possibly
by ingestion or inhalation.
- Epizootic B pseudomallei infection occurs in sheep, goats, swine, horses, and
other animals, although animals do not appear to be a primary reservoir for the
organism.
CLINICAL FINDINGS:
- Melioidosis, also called Whitmore’s disease, may manifest itself as acute,
subacute, or chronic infection. The incubation period can be as short as 2–3
days, but latent periods of months to years also occur.
- A localized suppurative infection can occur at the inoculation site where there
is a break in the skin. This localized infection may lead to the acute septicemic
form of infection with involvement of many organs. The signs and symptoms
depend upon the major sites of involvement.
- The most common form of melioidosis is pulmonary infection, which may be a
primary pneumonitis (B pseudomallei transmitted through the upper airway or
nasopharynx) or subsequent to a localized suppurative infection and
bacteremia.
- Subsequently, the patient may become afebrile,while upper lobe cavities
develop, yielding an appearance similar to that of tuberculosis on chest films.
- Some patients develop chronic suppurative infection with abscesses in
skin,brain, lung, myocardium, liver, bone, and other sites. Patients with chronic
suppurative infections may be a febrile and have indolent disease. Latent
infection is sometimes reactivated as a result of immunosuppression.
- The diagnosis of melioidosis should be considered for a patient from an
endemic area who has fulminant upper lobe pulmonary or unexplained
systemic disease
DIAGNOSTIC LABORATORY TESTS:
A. Smears: A Gram stain of an appropriate specimen will show small gram-
negative bacilli; bipolar staining (safety pin appearance) is seen with Wright’s
stain or methylene blue stain
B. Culture: A positive culture result is diagnostic. A positive serologic test result is
diagnostically helpful and constitutes evidence of past infection.
C. Biochemical Tests: Motile, aerobic, catalase and oxidase positive!
Characteristic “safety pin appearance” of Burkholderia pseudomallei under Wright’s
Stain
TREATMENT:
- Melioidosis has a high mortality rate if untreated. Surgical drainage of localized
infection may be necessary.
- B pseudomallei are generally susceptible to ceftazidime, imipenem,
meropenem, and amoxicillin–clavulanic acid (also ceftriaxone and
cefotaxime).
- B pseudomallei are commonly resistant to penicillin, ampicillin, first-generation
and second-generation cephalosporins, and gentamicin and tobramycin.
Burkholderia mallei:
MORPHOLOGY AND IDENTIFICATION:
A. Typical Organisms
- Burkholderia mallei is a small, nonmotile, nonpigmented, aerobic gram-
negative rod that grows readily on most bacteriologic media.
CLINICAL FINDINGS:
- It causes Glanders disease, a disease of horses, mules, and donkeys
transmissible to humans. In horses, the disease has prominent pulmonary
involvement, subcutaneous ulcerative lesions, and lymphatic thickening with
nodules; systemic disease also occurs. Human infection, which can be fatal,
 usually begins as an ulcer of the skin or mucous membranes followed by
lymphangitis and sepsis. Inhalation of the organisms may lead to primary
pneumonia.
- Subcutaneous ulcerative lesions on a horse with Glander’s disease
- Glander’s disease also occurs in HUMANS.
- The diagnosis is based on rising agglutinin titers and culture of the organism
from local lesions of humans or horses.
- Human cases can be treated effectively with the same antimicrobial regimens
used to treat melioidosis. The disease has been controlled by slaughter of
infected horses and mules and at present is extremely rare.
- In some countries, laboratory infections are the only source of the disease.
Burkholderia cepacia complex and Burkholderia gladioli:
- The classification of these bacteria is complex; their specific identification is
difficult. These are environmental organisms able to grow in water, soil, plants,
animals, and decaying vegetable materials.
- In hospitals, members of the B cepacia complex have been isolated from a
variety of water and environmental sources from which they can be
transmitted to patients. People with CF and those patients with chronic
granulomatous disease are particularly vulnerable to infection with bacteria in
the B cepacia complex, most notably Burkholderia multivorans (genomovar II)
and Burkholderia cenocepacia (genomovar III).
CLINICAL FINDINGS:
- It is likely that B cepacia can be transmitted from one CF patient to another by
close contact. They may have asymptomatic carriage, progressive
deterioration over a period of months, or rapidly progressive deterioration with
necrotizing pneumonia and bacteremia.
- A diagnosis of B cepacia infection in a CF patient may significantly alter the
patient’s life because he or she may not be allowed association with other CF
patients and may be removed from eligibility for lung transplantation.
❖ The risk of cross infection was heightened because Dalton had Burkholderia
cepacia, a bacteria resistant to antibiotics that often leads to lung function
decline. This particular bacteria is a major plot point in Five Feet Apart: Will
has b. cepacia, making it even more essential that he stay away from
Stella.
DIAGNOSTIC LABORATORY TESTS:
- B cepacia grows on most media used in culturing specimens for gram-
negative bacteria.
- Selective media containing colistin (eg, B cepacia selective agar) can be
used and is recommended when culturing the sputum of patients with CF.
TREATMENT:
- B cepacia complex isolates recovered from CF patients often are multidrug
resistant.
- Trimethoprim–sulfamethoxazole is the drug of choice.
Stenotrophomonas maltophilia: B. Growth Characteristics: Acinetobacter grows well on most types of media used
to culture specimens from patients.
- S maltophilia is an increasingly important cause of hospital-acquired infections
in patients who are receiving antimicrobial therapy and in
immunocompromised patients.
- It has been isolated from many anatomic sites, including respiratory tract
secretions, urine, wounds, and blood. The isolates are often part of mixed flora
present in the specimens.
- When blood culture results are positive, it is commonly in association with use of
Coccobacilliary appearance of Acinetobacter that closely resembles Neisseria sp.
indwelling plastic intravenous catheters.
CLINICAL FINDINGS:
DIAGNOSTIC LABORATORY TESTS:
- Acinetobacters often are commensals but occasionally cause nosocomial
A. Smears: S maltophilia is a free-living gram-negative rod that is widely distributed
infection. In patients with Acinetobacter bacteremias, intravenous catheters
in the environment.
are almost always the source of infection.
B. Culture: On blood agar, colonies have a lavender-green or gray color
- In patients with burns or with immune deficiencies, acinetobacters act as
C. Biochemical Tests: The organism is generally oxidase negative, positive for
opportunistic pathogens and can produce sepsis.
lysine decarboxylase, DNase, and oxidation of glucose and maltose (hence
- A baumannii has been isolated from blood, sputum, skin, pleural fluid, and
the name “maltophilia”).
urine, usually in device-associated infections.
- A johnsonii is a nosocomial pathogen of low virulence and has been found in
blood cultures of patients with plastic intravenous catheters.
- Acinetobacters encountered in nosocomial pneumonias often originate in the
water of room humidifiers or vaporizers
TREATMENT:
- Acinetobacter strains are often multidrug resistant, and therapy of infection
Colonies of S. maltophilia in a blood agar can be difficult. In many cases, the only active agent may be colistin.
- Such multidrug resistant strains are a common cause of serious wound
TREATMENT:
infections among wounded servicemen in Iraq.
- S maltophilia is usually susceptible to trimethoprim– sulfamethoxazole and - Susceptibility testing should be done to help select the best antimicrobial drugs
ticarcillin–clavulanic acid and resistant to other commonly used antimicrobials, for therapy. The more susceptible Acinetobacter strains respond most
including cephalosporins, aminoglycosides, imipenem, and the quinolones. commonly to gentamicin, amikacin, or tobramycin and to extended spectrum
- The widespread use of the drugs to which S maltophilia is resistant plays an penicillins or cephalosporins.
important role in the increased frequency with which it causes disease.
UNCOMMON GRAM-NEGATIVE BACTERIA:
Acinetobacter:
Aggregatibacter:
- Acinetobacter species are aerobic gram-negative bacteria that are widely
- Aggregatibacter actinomycetemcomitans (formerly Actinobacillus
distributed in soil and water and can occasionally be cultured from skin,
actinomycetemcomitans) is a small gram-negative coccobacillary organism
mucous membranes, secretions, and the hospital environment.
that grows slowly.
- Acinetobacter baumannii is the species most commonly isolated.
- As its name implies, it is often found in actinomycosis. It also causes severe
Acinetobacter lwoffii, Acinetobacter johnsonii,
periodontal disease in adolescents, endocarditis, abscesses, osteomyelitis, and
- Acinetobacter haemolyticus, and other species are isolated occasionally.
other infections. It is treatable with tetracycline or chloramphenicol and
Some isolates have not received species names but are referred to as genomo
sometimes with penicillin G, ampicillin, or erythromycin.
species.
- The other important organism in this genus is Aggregatibacter aphrophilus
- Acinetobacters were previously called by a number of different names,
(formerly Haemophilus aphrophilus and the “A” in the HACEK acronym-
including Mima polymorpha and Herellea vaginicola. .
Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella).
CLINICALLY LABORATORY TEST:
Achromobacter and Alcaligenes:
A. Smears: Acinetobacters are usually coccobacillary or coccal in appearance;
- The classification of species within the genera Achromobacter and Alcaligenes
they resemble neisseriae on smears, because diplococcal forms predominate
is changing and confusing. These groups include species of oxidase-positive,
in body fluids and on solid media. Rod-shaped forms also occur, and
gram-negative rods. They have peritrichous flagella and are motile, which
occasionally the bacteria appear to be gram-positive.
differentiate them from the pseudomonads.
 - They alkalinize citrate medium and oxidation-fermentation medium containing
glucose and are urease negative. They may be part of the normal human
microbiota and have been isolated from respirators, nebulizers, and renal
dialysis systems. They are occasionally isolated from urine, blood, spinal fluid,
wounds, and abscesses.
Ochrobactrum:
- The genus Ochrobactrum contains species previously classified in the genus
Achromobacter and also has other Ochrobactrum species.
- They are similar to Achromobacter and Alcaligenes. Ochrobactrum anthropi is
most often isolated from intravascular catheter-related bacteremia. It also may
contaminate biologic products.
Capnocytophaga:
- The Capnocytophaga species are slow-growing capnophilic, gram-negative,
fusiform or filamentous bacilli. They are fermentative and facultative
anaerobes that require CO2 for aerobic growth. They may show gliding
motility, which can be seen as outgrowths of colonies.
- They produce a substance that modifies polymorphonuclear cell chemotactic
activity.
- Capnocytophaga ochracea, Capnocytophaga sputigena, and
Capnocytophaga gingivalis are members of the normal oral microbiota of
humans. They have been associated with severe periodontal disease in
juveniles. They occasionally cause bacteremia and severe systemic disease in
immunocompromised patients, especially granulocytopenic patients with oral
ulcerations.
- Capnocytophaga canimorsus (previously -dysgonic fermenter 2 [DF-2]) is
found among the oral flora of dogs. When transmitted to humans, it
occasionally causes fulminant infection in patients with asplenia or alcoholism
and rarely, in healthy people.
- Capnocytophaga cynodegmi(DF-2-like) is associated with wound infections
from dog or cat bites or scratches.
Cardiobacterium:
- Cardiobacterium hominis, another bacterium with a descriptive name, is a
facultatively anaerobic, pleomorphic gramnegative rod that is part of the
normal microbiota of the upper respiratory tract and bowel and occasionally
causes endocarditis.
- Using modern blood culture medium, it is no longer necessary to hold blood
cultures for more than the standard 5- to 7-day incubation period to grow
Cardiobacterium and other members of the HACEK group.
Chromobacteria:
- Chromobacterium violaceum is a gram-negative bacillus resembling
pseudomonads. The organism usually produces a violet pigment. It occurs in
subtropical climates in soil and water and may infect animals and humans
through breaks in the skin or via the gut. This may result in abscesses, diarrhea,
and sepsis, with many deaths.
- Chromobacteria are often susceptible to chloramphenicol, tetracyclines, and
aminoglycosides.
Eikenella corrodens:
- E. corrodens (the “E” in the HACEK acronym) is a small, fastidious, capnophilic
gram-negative rod that is part of the gingival and bowel microbiota of 40–70%
of humans.
- About 50% of isolates form pits in agar during the several days of incubation
required for growth. Eikenella is oxidase positive and does not ferment
carbohydrates.
- It is found in mixed flora infections associated with contamination by oral
mucosal organisms; it is often present with streptococci.
- It occurs frequently in infections from human bites.
- Eikenella is uniformly resistant to clindamycin, which can be used to make a
selective agar medium.
- Eikenella is usually susceptible to ampicillin and the newer penicillins and
cephalosporins. β-lactamase–producing strains have been reported.
Chryseobacterium:
- Organisms of the Chryseobacterium group are long, thin, nonmotile gram-
negative rods that are oxidase positive, proteolytic, and weakly fermentative.
They often form distinctive yellow colonies.
- Chryseobacteria are commonly found in sink drains, faucets, and on medical
equipment that has been exposed to contaminated water and not sterilized.
- Chryseobacteria occasionally colonize the respiratory tract.
- Elizabethkingia meningoseptica, formerly Chryseobacterium
meningosepticum, rarely causes meningitis and is more frequently associated
with nosocomial pneumonia.
- Chryseobacterium species are often resistant to many antimicrobial drugs.
Kingella:
- The Kingella group (the “K” in the acronym HACEK) includes four species, of
which Kingella kingae is an oxidase-positive, non-motile organism that is
hemolytic when grown on blood agar.
- It is a gram-negative rod, but coccobacillary and diplococcal forms are
common.
- It is part of the normal oral microbiota and occasionally causes infections of
bone, joints, and tendons. After Staphylococcus aureus, it is the most common
cause of acute septic arthritis in children younger than 5 years of age.
- The organism probably enters the circulation with minor oral trauma such as
tooth brushing. It is difficult to recover from synovial fluid; inoculation of joint
fluid into blood culture bottles enhances recovery.
- It is susceptible to penicillin, ampicillin, erythromycin, and other antimicrobial
drugs.
Moraxella:
- The Moraxella group includes six species. They are nonmotile, nonfermentative,
and oxidase positive.
- On staining, they appear as small gram-negative bacilli, coccobacilli, or cocci.
- They are members of the normal microbiota of the upper respiratory tract and
occasionally cause bacteremia, endocarditis, conjunctivitis, meningitis, or
other infections.
- Most of them are susceptible to penicillin and other antimicrobial drugs.
Moraxella catarrhalis often produces β-lactamase
VIBRIO, CAMPYLOBACTER, AND HELICOBACTER:
THE VIBRIO’S:
GENERAL CHARACTERISTICS:
- Vibrios are among the most common bacteria in surface waters worldwide.
- They are curved aerobic rods and are motile, possessing a polar flagellum.
- Vibrio cholerae serogroups O1 and O139 cause cholera in humans, and other
vibrios may cause sepsis or enteritis.
Vibrio cholerae:
MORPHOLOGY AND IDENTIFICATION:
A. Typical Organisms
- Upon first isolation, V cholerae is a comma-shaped, curved rod 2–4 μm
long. It is actively motile by means of a polar flagellum. On prolonged
cultivation, vibrios may become straight rods that resemble the gram-
negative enteric bacteria.
Vibrio cholerae under Gram stain
B. Culture:
- V cholerae produces convex, smooth, round colonies that are opaque
and granular in transmitted light
- .V cholerae and most other vibrios grow well at 37°C on many kinds of
media, including defined media containing mineral salts and
asparagine as sources of carbon and nitrogen.
- V cholerae grows well on thiosulfate-citrate-bile-sucrose (TCBS) agar, a
media selective for vibrios, on which it produces yellow colonies
(sucrose fermented) that are readily visible against the dark-green
background of the agar.
 - They are oxidase positive, which differentiates them from enteric gram-
negative bacteria. Characteristically, vibrios grow at a very high pH
(8.5–9.5) and are rapidly killed by acid.
Yellow colonies of Vibrio cholerae in TCBS agar
C. Growth Characteristics
- V cholerae regularly ferments sucrose and mannose but not arabinose.
A positive oxidase test result is a key step in the preliminary identification
of V cholerae and other vibrios.
- Vibrio species are susceptible to the compound O/129 (2,4-diamino6,7-
diisopropylpteridine phosphate), which differentiates them from
Aeromonas species, which are resistant to O/129.
- Most Vibrio species are halotolerant, and NaCl often stimulates their
growth. Some vibrios are halophilic, requiring the presence of NaCl to
grow.
- Another difference between vibrios and aeromonads is that vibrios
grow on media containing 6% NaCl, but Aeromonas does not.
ANTIGENIC STRUCTURE AND BIOLOGIC CLASSIFICATION:
1. Heat-labile flagellar H antigen – many vibrios share this antigen.
2. O lipopolysaccharides-s that confer serologic specificity. There are at least 206
O antigen groups.:
- V cholerae strains of O group 1 and O group 139 cause classic cholera;
Occasionally, non-O1/non-O139 V cholerae causes cholera-like disease.
- Two biotypes of epidemic V cholerae have been defined: classic and El
Tor. The El Tor biotype produces a hemolysin, gives positive results on the
Voges-Proskauer test, and is resistant to polymyxin B.
Vibrio cholerae Enterotoxin:
- V cholerae produce a heat-labile enterotoxin with a molecular weight (MW) of
about 84,000, consisting of subunits A (MW, 28,000) and B.
- Responsible for the electrolyte-rich diarrhea occurs—as much as 20–30 L/day—
with resulting dehydration, shock, acidosis, and death.
- Cholera enterotoxin is antigenically related to LT of Escherichia coli.
PATHOGENESIS AND PATHOLOGY:
- V cholerae is pathogenic only for humans.
- A person with normal gastric acidity may have to ingest as many as 10 billion or
more to become infected when the vehicle is water because the organisms
are susceptible to acid.
- When the mode of transmission is food, as few as 102 –104 organisms are
necessary because of the buffering capacity of food.
- Any medication or condition that decreases stomach acidity makes a person
more susceptible to infection with V cholerae.
- Cholera is not an invasive infection. The organisms do not reach the
bloodstream but remain within the intestinal tract.
- Virulent V cholerae organisms attach to the microvilli of the brush border of
epithelial cells. There they multiply and liberate cholera toxin and perhaps
mucinases and endotoxin.
Cholera toxin activates the adenylate cyclase that causes increase in Cyclic
Adeosine Monophosphate (CAMP). Increased CAMP = Increased electrolyte and
water excretion!!
- King Charles X of France was one of the popular royalties that died of Cholera
CLINICAL FINDINGS:
- About 50% of infections with classic V cholerae are asymptomatic, as are
about 75% of infections with the El Tor biotype.
- The incubation period is 12 hours–3 days; symptoms, depending largely on the
size of the inoculum ingested.
- There is a sudden onset of nausea and vomiting and profuse diarrhea with
abdominal cramps.
- Stools, which resemble “rice water,” contain mucus, epithelial cells, and large
numbers of vibrios.
- There is rapid loss of fluid and electrolytes, which leads to profound
dehydration, circulatory collapse, and anuria.
- The mortality rate without treatment is between 25% and 50%.
- The diagnosis of a full-blown case of cholera presents no problem in the
presence of an epidemic. However, sporadic or mild cases are not readily
differentiated from other diarrheal diseases. The El Tor biotype tends to cause
milder disease than the classic biotype.
DIAGNOSTIC LABORATORY TESTS:
A. Specimens: Specimens for culture consist of mucus flecks from stools.
B. Smears:
- The microscopic appearance of smears made from stool samples is not
distinctive.
- Dark-field or phase contrast microscopy may show the rapidly motile
vibrios
C. Culture:
- Growth is rapid in peptone agar, on blood agar with a pH near 9.0, or
on TCBS agar, and typical colonies can be picked in 18 hours.
- For enrichment, a few drops of stool can be incubated for 6–8 hours in
taurocholate peptone broth (pH, 8.0–9.0); organisms from this culture
can be stained or subcultured.
D. Specific Tests:
- V cholerae organisms are further identified by slide agglutination tests
using anti-O group 1 or group 139 antisera and by biochemical reaction
patterns.
- The diagnosis of cholera under field conditions has been reported to be
facilitated by a sensitive and specific immunochromatographic dipstick
test.
IMMUNITY:
- Gastric acid provides some protection against cholera vibrios.
- An attack of cholera is followed by immunity to reinfection, but the duration
and degree of immunity are not known.
- In experimental animals, specific IgA antibodies occur in the lumen of the
intestine. Similar antibodies in serum develop after infection but last only a few
months.
- Vibriocidal antibodies in serum (titer ≥1:20) have been associated with
protection against colonization and disease. The presence of antitoxin
antibodies has not been associated with protection.
TREATMENT:
- The most important part of therapy consists of water and electrolyte
replacement to correct the severe dehydration and salt depletion.
- Many antimicrobial agents are effective against V cholerae, but these play a
secondary role in patient management.
- Oral tetracycline and doxycycline tend to reduce stool output in cholera and
shorten the period of excretion of vibrios.
- In some endemic areas, tetracycline resistance of V cholerae has emerged;
the genes are carried by transmissible plasmids. In children and pregnant
women, alternatives to the tetracyclines include erythromycin and furazolidine
EPIDEMIOLOGY AND CONTROL:
- Six pandemics (worldwide epidemics) of cholera occurred between 1817 and
1923 caused most likely by V cholerae O1 of the classic biotype and largely
originating in Asia, usually the Indian subcontinent.
- The seventh pandemic began in 1961 in the Celebes Islands, Indonesia, with
spread to Asia, the Middle East, and Africa
- This pandemic was caused by V cholerae biotype El Tor. Starting in 1991, the
seventh pandemic spread to Peru and then to other countries of South
 America and Central America. Cases also occurred in Africa. Millions of people
have had cholera in this pandemic. Some consider the cholera caused by the
serotype O139 strain to be the eighth pandemic that began in the Indian
subcontinent in 1992–1993, with spread to Asia.
- The disease has been rare in North America since the mid-1800s, but an
endemic focus exists on the Gulf Coast of Louisiana and Texas.
- Cholera is endemic in India and Southeast Asia. From these centers, it is carried
along shipping lanes, trade routes, and pilgrim migration routes. The disease is
spread by contact involving individuals with mild or early illness and by water,
food, and flies. In many instances, only 1–5% of exposed susceptible persons
develop disease. The carrier state seldom exceeds 3–4 weeks, and the
importance of carriers in transmission is unclear.
- Vibrios survive in water for up to 3 weeks.
- V cholerae lives in aquatic environments. And such environments are the
vibrios natural reservoir.
- V cholerae lives attached to algae, copepods, and crustacean shells. It can
survive for years and grow, but when conditions are not suitable for growth, it
can become dormant.
- Control rests on education and on improvement of sanitation, particularly of
food and water. Patients should be isolated, their excreta disinfected, and
contacts followed up.
- Chemoprophylaxis with antimicrobial drugs may have a place. Repeated
injection of a vaccine containing either lipopolysaccharides extracted from
vibrios or dense Vibrio suspensions can confer limited protection to heavily
exposed persons (eg, family contacts) but is not effective as an epidemic
control measure.
VIBRIO PARAHAEMOLYTICUS AND OTHER VIBRIOS:
Vibrio parahaemolyticus:
- Vibrio parahaemolyticus is a halophilic bacterium that causes acute
gastroenteritis after ingestion of contaminated seafood such as raw fish or
shellfish.
- After an incubation period of 12–24 hours, nausea and vomiting, abdominal
cramps, fever, and watery to bloody diarrhea occur.
- Fecal leukocytes are often observed. The enteritis tends to subside
spontaneously in 1–4 days with no treatment other than restoration of water
and electrolyte balance.
- No enterotoxin has yet been isolated from this organism.
- The disease occurs worldwide, with highest incidence in Asia and other areas
where people eat raw seafood.
- V parahaemolyticus does not grow well on some of the differential media
used to grow salmonellae and shigellae, but it does grow well on blood agar.
- It also grows well on TCBS, where it yields green colonies (does not ferment
sucrose). V parahaemolyticus is usually identified by its oxidase-positive growth
on blood agar.
Vibrio vulnificus:
- Vibrio vulnificus can cause severe wound infections, bacteremia, and
probably gastroenteritis.
- It is a free-living estuarine bacterium found in the United States on the Atlantic
and Pacific Coasts and especially the Gulf Coast. Infections have been
reported from Korea, and the organism may be distributed worldwide.
- V vulnificus is particularly apt to be found in oysters, especially in warm months.
Bacteremia without focus of infection occurs in persons who have eaten
infected oysters and who have alcoholism or liver disease.
- Wounds may become infected in normal or immunocompromised persons
who are in contact with water where the bacterium is present.
- Infection often proceeds rapidly, with development of severe disease. About
50% of the patients with bacteremia die.
- Wound infections may be mild but often proceed rapidly (over a few hours),
with development of bullous skin lesions, cellulitis, and myositis with necrosis.
- Because of the rapid progression of the infection, it is often necessary to treat
with appropriate antibiotics before culture confirmation of the etiology can be
obtained.
- Diagnosis is by culturing the organism on standard laboratory media; TCBS is
the preferred medium for stool cultures, where most strains produce blue-green
(sucrose negative) colonies.
- Tetracycline appears to be the drug of choice for V vulnificus infection;
ciprofloxacin may be effective also based on in vitro activity.
- Several other vibrios also cause disease in humans: Vibrio mimicus causes
diarrhea after ingestion of uncooked seafood, particularly raw oysters.
- Vibrio hollisae and Vibrio fluvialis also cause diarrhea. Vibrio alginolyticus
causes eye, ear, or wound infection after exposure to seawater. Vibrio
damsela also causes wound infections. Other vibrios are very uncommon
causes of disease in humans
CONCEPT CHECKS:
● Concept Checks
● Vibrio species are halophilic, oxidase-positive, motile, curved, gram-negative
rods that are found in surface waters worldwide.
● Many Vibrio species are pathogenic for humans, but V cholerae is the species
of most global importance responsible for pandemics of cholera. Although
there are more than 200 serotypes of V cholerae, serotypes O1 and O139 are
associated with cholera.
● V cholerae O1 can be further classified into the classic and El Tor biotypes;
classic biotypes have been responsible for most of the major pandemics and
are more likely to cause symptomatic infection. El Tor has caused the most
recent pandemic.
● V cholerae causes an acute watery diarrhea after ingestion in high numbers in
contaminated water or food by elaboration of a heat-labile enterotoxin that
has the classic A-B toxin structure. The B segment binds to GM1 ganglioside
receptors, and the active A subunit induces cAMP, causing secretion of
sodium chloride while at the same time preventing the reabsorption by the
microvilli.
● Diagnosis is made by culturing stool on selective medium such as TCBS or
alkaline peptone broth. Treatment involves rehydration and secondarily
tetracycline or doxycycline.
● Other important Vibrio species include V parahaemolyticus, the most common
cause of foodborne gastroenteritis in Asia, and V vulnificus, a cause of severe
sepsis in patients with cirrhosis
Aeromonas:
- The taxonomy of the genus Aeromonas is in transition. The genus has been
placed in the new family Aeromonadaceae from the family Vibrionaceae.
- Based on DNA hybridization groups, many genospecies have been
recognized; some are renamed species, some are newly named, and some
are not yet named.
- The following three groups are of primary clinical importance in human
infections: Aeromonas hydrophila complex, Aeromonas caviae complex, and
Aeromonas veronii biovar sobria
- Aeromonads are 1–4 μm long and are motile. Their colony morphology is similar
to that of enteric gram-negative rods, and they produce large zones of
hemolysis on blood agar.
- Aeromonas species cultured from stool specimens grow readily on the
differential media used to culture enteric gram-negative rods and can easily
be confused with enteric bacteria.
- Aeromonas species are distinguished from the enteric gram-negative rods by
finding a positive oxidase reaction in growth obtained from a blood agar
plate.
Aeromonas under Gram Stain
- Aeromonas species are differentiated from vibrios by showing resistance to the
compound O/129 (see above) and lack of growth on media containing 6%
NaCl.
VIRULENCE FACTORS:
- Typically, aeromonads produce hemolysins. Some strains produce an
enterotoxin.
- Cytotoxins and the ability to invade cells in tissue culture have been noted.
- However, none of these characteristics have been clearly shown to be
associated with diarrheal disease in humans. Koch’s postulates have not been
satisfied, largely because there is no suitable animal model that reproduces
human Aeromonas-associated diarrhea.
- However, gastroenteritis, caused mostly by A caviae complex, ranges from
acute watery diarrhea to less commonly a dysenteric type of illness.
Aeromonas species are also associated with extraintestinal infections such as
bacteremia and wound infections. The latter are often the result of trauma that
occurs in a water environment and are caused primarily by A hydrophila
TREATMENT:
- Aeromonas strains are susceptible to tetracyclines, aminoglycosides, and third-
generation cephalosporins
Plesiomonas:
- Plesiomonas shigelloides is an oxidase positive, gram-negative rod with polar
flagella that has recently been moved into the Enterobacteriaceae family.
- Plesiomonas is most common in tropical and subtropical areas. It is a water and
soil organism and has been isolated from freshwater fish and many animals.
Most isolates from humans have been from stool cultures of patients with
diarrhea.
- Plesiomonas grows on the differential media used to isolate Salmonella and
Shigella from stool specimens.
- Some Plesiomonas strains share antigens with Shigella sonnei, and cross-
reactions with Shigella antisera occur.
- Plesiomonas can be distinguished from shigellae in diarrheal stools by the
oxidase test: Plesiomonas is oxidase positive, and shigellae are not.
Plesiomonas species are positive for DNase; this and other biochemical tests
distinguish it from Aeromonas species.
Campylobacter:
GENERAL CHARACTERISTICS:
1. Campylobacters cause both diarrheal and systemic diseases and are among
the most widespread causes of infection in the world.
2. The classification of bacteria within the family. Campylobacteriaceae has
changed frequently. Some species previously classified as campylobacters
have been reclassified in the genus Helicobacter.
3. Campylobacter jejuni is a very common cause of diarrhea in humans.
Campylobacter jejuni and Campylobacter coli:
- C jejuni and Campylobacter coli have emerged as common human
pathogens, causing mainly enteritis and occasionally systemic infection.
- C jejuni and C coli cause infections that are clinically indistinguishable, and
laboratories generally do not differentiate between the two species.
MORPHOLOGY AND IDENTIFICATION:
A. Typical Organisms: C jejuni and the other campylobacters are gram-negative
rods with comma, S, or “gull wing” shapes. They are motile, with a single polar
flagellum, and do not form spores.
B. Culture: Selective media are needed, and incubation must be in an
atmosphere with reduced O2 (5% O2 ) with added CO2 (10% CO2 ). A
- A relatively simple way to produce the incubation atmosphere is to
place the plates in an anaerobe incubation jar without the catalyst and
to produce the gas with a commercially available gas-generating pack
or by gas exchange. Incubation of primary plates for isolation of C jejuni
should be at 42°C.
- Incubation at 42°C prevents growth of most of the other bacteria
present in feces, thus simplifying the identification of C jejuni.
- Skirrow’s medium contains vancomycin, polymyxin B, and trimethoprim
to inhibit growth of other bacteria, but this medium may be less sensitive
than other commercial products that contain charcoal, other inhibitory
compounds, and cephalosporin antibiotics.
- The colonies tend to be colorless or gray. They may be watery and C. Culture: Culture on the selective media described earlier is the definitive test to
spreading or round and convex, and both colony types may appear on diagnose C jejuni enteritis. If another species of Campylobacter is suspected,
one agar plate. medium without a cephalosporin should be used and incubated at 36–37°C
- C jejuni and the other campylobacters pathogenic for humans are
positive for both oxidase and catalase.
- Campylobacters do not oxidize or ferment carbohydrates. Gram-
stained smears show typical morphology.
- Nitrate reduction, hydrogen sulfide production, hippurate tests, and
antimicrobial susceptibilities can be used for further identification of
species.
ANTIGENIC STRUCTURE AND TOXINS:
- The campylobacters have lipopolysaccharides with endotoxic activity. “Gull wing-shaped rods” of Campylobacter jejuni
Cytopathic extracellular toxins and enterotoxins have been found, but the
Helicobacter:
significance of the toxins in human disease is not well defined.
Helicobacter pylori:
- H pylori is a spiral-shaped gram-negative rod. H pylori is associated with antral
PATHOGENESIS AND PATHOLOGY:
gastritis, duodenal (peptic) ulcer disease, gastric ulcers, gastric
- Mode of transmission: ingestion of infected food or contact with animals or adenocarcinoma and gastric mucosa-associated lymphoid tissue (MALT)
animal products especially poultry lymphomas. Other Helicobacter species that infect the gastric mucosa exist
- The organisms multiply in the small intestine, invade the epithelium, and but are rare.
produce inflammation that results in the appearance of red and white blood
MORPHOLOGY AND IDENTIFICATION:
cells in the stools.
A. Typical Organisms: H pylori has many characteristics in common with
- Occasionally, the bloodstream is invaded, and a clinical picture of enteric
campylobacters. It has multiple flagella at one pole and is actively motile.
fever develops. Localized tissue invasion coupled with the toxic activity
appears to be responsible for the enteritis. B. Culture: Culture sensitivity can be limited by prior therapy, contamination with
other mucosal bacteria, and other factors. H pylori grows in 3–6 days when
CLINICAL FINDINGS:
incubated at 37°C in a microaerophilic environment, as for C jejuni.
- Clinical manifestations are acute onset of crampy abdominal pain, profuse C. Growth Characteristics
diarrhea that may be grossly bloody, headache, malaise, and fever. - H pylori is oxidase positive and catalase positive, has a characteristic
- Usually the illness is self-limited to a period of 5–8 days, but occasionally it morphology, is motile, and is a strong producer of urease.
continues longer. C jejuni isolates are usually susceptible to erythromycin, and
therapy shortens the duration of fecal shedding of bacteria. Most cases resolve
without antimicrobial therapy; however, in about 5–10% of patients, symptoms
may recur.
- Certain serotypes of C jejuni have been associated with postdiarrheal Guillain-
Barré syndrome, a form of ascending paralytic disease. Reactive arthritis and
Reiter’s syndrome may also follow acute campylobacter diarrhea.
DIAGNOSTIC LABORATORY TESTS:
A. Specimens of choice: Diarrheal stool is the usual specimen. C jejuni, C fetus,
and other campylobacters may occasionally be recovered from blood
cultures usually from immunocompromised or elderly patients.
B. Smears Gram-stained smears of stool may show the typical “gull wing”–shaped
rods. Dark-field or phase contrast microscopy may show the typical darting
motility of the organisms.
- The media for primary isolation include Skirrow’s medium with
vancomycin, polymyxin B, and trimethoprim, chocolate medium, and
 other selective media with antibiotics (eg, vancomycin, nalidixic acid,
amphotericin).
- The colonies are translucent and 1–2 mm in diameter.
PATHOGENESIS AND PATHOLOGY:
- H pylori grows optimally at a pH of 6.0–7.0 and would be killed or not grow at
the pH within the gastric lumen.
- 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
DIAGNOSTIC LABORATORY TESTS:
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.
- H pylori also produces a protease that modifies the gastric mucus and further
reduces the ability of acid to diffuse through the mucus.
- H pylori produces potent urease activity, which yields production of ammonia
and further buffering of acid.
- H pylori is quite motile, even in mucus, and is able to find its way to the
epithelial surface. H pylori overlies gastric-type but not intestinal-type epithelial
cells.
- In human volunteers, ingestion of H pylori resulted in development of gastritis
and hypochlorhydria. There is a strong association between the presence of H
TREATMENT:
pylori infection and duodenal ulceration. Antimicrobial therapy results in
clearing of H pylori and improvement of gastritis and duodenal ulcer disease.
- The mechanisms by which H pylori causes mucosal inflammation and damage
are not well defined but probably involve both bacterial and host factors. The
bacteria invade the epithelial cell surface to a limited degree. Toxins and
lipopolysaccharide may damage the mucosal cells, and the ammonia
produced by the urease activity may also directly damage the cells
- Histologically, gastritis is characterized by acute and chronic inflammation.
Polymorphonuclear and mononuclear cell infiltrates are seen within the
epithelium and lamina propria. Vacuoles within cells are often pronounced.
Destruction of the epithelium is common, and glandular atrophy may occur. H
pylori thus is a major risk factor for gastric cancer.
CLINICAL FINDINGS:
EPIDEMIOLOGY AND CONTROL:
- Acute infection can yield an upper gastrointestinal illness with nausea and - H pylori is present on the gastric mucosa of fewer than 20% of persons younger
pain; vomiting and fever may also be present. than years 30 but increases in prevalence to 40–60% of persons age 60 years,
- The acute symptoms may last for less than 1 week or as long as 2 weeks. After including persons who are asymptomatic. In developing countries, the
colonization, the H pylori infection persists for years and perhaps decades or prevalence of infection may be 80% or higher in adults. Person-to-person
even a lifetime. About 90% of patients with duodenal ulcers and 50–80% of transmission of H pylori is likely because intrafamilial clustering of infection
those with gastric ulcers have H pylori infection. occurs. Acute epidemics of gastritis suggest a common source for H pylori.
- Recent studies confirm that H pylori also is a risk factor for gastric carcinoma
TOPIC 3: GRAM POSITIVE BACILI
and lymphoma.
A. Specimens of choice: Gastric biopsy specimens can be used for histologic
examination or minced in saline and used for culture. Blood is collected for
determination of serum antibodies. Stool samples may be collected for H pylori
antigen detection.
B. Smears: The diagnosis of gastritis and H pylori infection can be made
histologically. A gastroscopy procedure with biopsy is required. Routine stains
demonstrate gastritis, and Giemsa or special silver stains can show the curved
or spiral-shaped organisms.
C. Culture: Culture is performed when patients are not responding to treatment,
and there is a need to assess susceptibility patterns.
D. Antibodies: Several assays have been developed to detect serum antibodies
specific for H pylori. The serum antibodies persist even if the H pylori infection is
eradicated, and the role of antibody tests in diagnosing active infection or
after therapy is therefore limited.
E. Special Tests:
1. Rapid tests to detect urease activity are widely used for presumptive
identification of H pylori in specimens. Gastric biopsy material can be
placed onto a urea-containing medium with a color indicator. If H pylori is
present, the urease rapidly splits the urea (1–2 hours), and the resulting shift
in pH yields a color change in the medium.
2. In urea breath tests, 13C- or 14C-labeled urea is ingested by the patient. If H
pylori is present, the urease activity generates labeled CO2 that can be
detected in the patient’s exhaled breath. Detection of H pylori antigen in
GRAM POSITIVE BACILLI: AEROBIC, NON-SPORE FORMING
stool specimens is appropriate as a test of cure for patients with known H
Corynebacterium diptheriae
pylori infection who have been treated
MORPHOLOGY AND IDENTIFICATION:
- Corynebacteria are 0.5–1 μm in diameter, non-motile, are catalase positive
- Triple therapy with metronidazole and either bismuth subsalicylate or bismuth
and pleomorphic in microscopic and colonial morphology.
subcitrate plus either amoxicillin or tetracycline for 14 days eradicates H pylori
- They possess irregular swellings at one end that give them the “club-shaped”
infection in 70–95% of patients.
appearance.
- An acid-suppressing agent given for 4 to 6 weeks enhances ulcer healing.
- Irregularly distributed within the rod (often near the poles) are granules staining
- Proton pump inhibitors (PPIs) directly inhibit H pylori and appear to be potent
deeply with aniline dyes, known as the “metachromatic granules’’ that give the
urease inhibitors.
rod a beaded appearance.
- The preferred initial therapy is 7–10 days of a PPI plus amoxicillin and
clarithromycin or a quadruple regimen of a PPI metronidazole, tetracycline,
and bismuth for 10 days
 - Individual corynebacteria in stained smears tend to lie parallel or at acute
angles to one another or palisading in appearance. True branching is rarely
observed in cultures.
- On blood agar: small, granular, and gray with irregular edges and may have
small zones of hemolysis.
- On agar containing potassium tellurite: brown to black colonies with a brown-
black halo because the tellurite is reduced intracellularly (staphylococci and
streptococci can also produce black colonies).
- C diphtheriae and other corynebacteria grow aerobically on most ordinary
laboratory media.
- On Loeffler serum medium: corynebacteria grow much more readily than
other respiratory organisms, and the morphology of organisms is typical in
smears made from these colonies.
- -used to demonstrate pleomorhpism and metachromatic granules.
- Four biotypes of C diphtheriae have been widely recognized: gravis, mitis,
intermedius, and belfanti.
- These variants have been classified on the basis of growth characteristics such
as colony morphology, biochemical reactions, and severity of disease
produced by infection.
PATHOGENESIS:
- It is the causative agent of respiratory or cutaneous diphtheria.
- In nature, C diphtheriae occurs in the respiratory tract, in wounds, or on the skin
of infected persons or normal carriers.
- Mode of transmission: by droplets or by contact to susceptible individuals;
Diphtheria Toxin:
- Production of this toxin depends largely on the concentration of iron.
- Toxin production is optimal at 0.14 μg of iron per milliliter of medium but is
virtually suppressed at 0.5 μg/mL.
- Other factors influencing the yield of toxin: osmotic pressure, amino acid
concentration, pH, and availability of suitable carbon and nitrogen sources.
- It is assumed that the abrupt arrest of protein synthesis is responsible for the
necrotizing and neurotoxic effects of diphtheria toxin. An exotoxin with a similar
mode of action can be produced by strains of Pseudomonas aeruginosa.
PATHOLOGY:
- Diphtheria toxin is absorbed into the mucous membranes and causes - Note: Specific treatment must never be delayed for laboratory reports if the
destruction of epithelium and a superficial inflammatory response. clinical picture is strongly suggestive of diphtheria.
- The necrotic epithelium becomes embedded in exuding fibrin and red and - Dacron swabs from the nose, throat, or other suspected lesions must be
obtained before antimicrobial drugs are administered.
- The swab should then be placed in semisolid transport media such as Amies.
Smears stained with alkaline methylene blue or Gram stain show beaded rods
in typical arrangement.
- Specimens should be inoculated to:
1. a blood agar plate: to rule out hemolytic streptococci
2. a Cystine-tellurite blood agar (CTBA) and modified Tinsdale’s medium:
selective medium and incubated at 37°C in 5% CO2 . The colonies are
black with a brown halo.
white cells, -a grayish “pseudomembrane” is formed—commonly over the
tonsils, pharynx, or larynx.
- Any attempt to remove the pseudomembrane exposes and tears the
capillaries and thus results in bleeding. The regional lymph nodes in the neck
enlarge, and there may be marked edema of the entire neck, with distortion of
the airway, often referred to as “bull neck” clinically.
- This is absorbed and results in distant toxic damage, particularly
parenchymatous degeneration, fatty infiltration, and necrosis in heart muscle
(myocarditis), liver, kidneys (tubular necrosis),and adrenal glands, sometimes
accompanied by gross hemorrhage.
- The toxin also produces nerve damage (demyelination), often resulting in
TESTS FOR TOXIGENICITY:
paralysis of the soft palate, eye muscles, or extremities.
- A membrane may form on an infected wound that fails to heal. However, 1. Elek Test- is an in vitro test of virulence performed on specimens of
absorption of toxin is usually slight and the systemic effects negligible. The small Corynebacterium diphtheriae, the bacteria that causes diphtheria. It is used to
amount of toxin that is absorbed during skin infection promotes development test for toxigenicity of C. diphtheriae strains.
of antitoxin antibodies. - A test strip of filter paper containing diptheria anti-toxin is placed in the
- The “virulence” of diphtheria bacilli is attributable to their capacity for center of the agar plate. Patient’s isolate, known positive and known
establishing infection, growing rapidly, and then quickly elaborating toxin that non-toxigenic strains are also streaked on agar plate. If there is antigen
is effectively absorbed. present, a precipitate form.
- C diphtheriae does not need to be toxigenic to establish localized infection—in a. Polymerase Chain Reaction
the nasopharynx or skin, for example—but nontoxigenic strains do not yield the b. Enzyme-linked immunosorbent assays
localized or systemic toxic effects. c. Immunochromatographic strip assay
- C diphtheriae does not actively invade deep tissues and practically never
enters the bloodstream, although rare cases of endocarditis have been
described.
CLINICAL FINDINGS:
- When diphtheritic inflammation begins in the respiratory tract: sore throat and
low-grade fever usually develop. Prostration and dyspnea soon follow because
of the obstruction caused by the membrane.
- This obstruction may even cause suffocation if not promptly relieved by
intubation or tracheostomy. Irregularities of cardiac rhythm indicate damage
to the heart. Later there may be difficulties with vision, speech, swallowing, or
movement of the arms or legs. All of these manifestations tend to subside
spontaneously
DIAGNOSTIC LABORATORY TESTS:

RESISTANCE AND IMMUNITY:
- Because diphtheria is principally the result of the action of the toxin formed by
the organism rather than invasion by the organism, resistance to the disease
depends largely on the availability of specific neutralizing antitoxin in the
bloodstream and tissues.
TREATMENT:
- The treatment of diphtheria rests largely on rapid suppression of toxin-
producing bacteria by antimicrobial drugs and the early administration of
specific antitoxin against the toxin.
- Diphtheria antitoxin is produced in various animals (horses, sheep, goats, and
rabbits) by the repeated injection of purified and concentrated toxoid.
- Antimicrobial drugs: penicillin and erythromycin: Although these drugs have
virtually no effect on the disease process, they arrest toxin production.
EPIDEMIOLOGY, PREVENTION, AND CONTROL:
- Before artificial immunization, diphtheria was mainly a disease of small children.
The infection occurred either clinically or subclinically at an early age and
resulted in the widespread production of antitoxin in the population.
- Active immunization in childhood with diphtheria toxoid yields antitoxin levels
that are generally adequate until adulthood. Young adults should be given
boosters of toxoid because toxigenic diphtheria bacilli are not sufficiently
prevalent in the population of many developed countries to provide the
stimulus of subclinical infection with stimulation of resistance.
- To limit contact with diphtheria bacilli to a minimum, patients with diphtheria
should be isolated. Without treatment, a large percentage of infected persons
continue to shed diphtheria bacilli for weeks or months after recovery
(convalescent carriers). This danger may be greatly reduced by active early
treatment with antibiotics
Fluid Toxoid:
- A filtrate of broth culture of a toxigenic strain is treated with 0.3% formalin and
incubated at 37°C until toxicity has disappeared.
- This fluid toxoid is purified and standardized in flocculating units (Lf doses). Fluid
toxoids prepared as above are adsorbed onto aluminum hydroxide or
aluminum phosphate.
- Such toxoids are commonly combined with tetanus toxoid (Td) and sometimes
with pertussis vaccine (DPT or DaPT) as a single injection to be used in initial
immunization of children.
Listeria
monocytogenes
GENERAL CHARACTERISTICS:
- There are several species in the genus Listeria. Of these, L monocytogenes is
important as a cause of a wide spectrum of disease in animals and humans.
- L monocytogenes is capable of growing and surviving over a wide range of
environmental conditions. It can survive at refrigerator temperatures (4°C),
under conditions of low pH and high salt conditions.
- Therefore, it is able to overcome food preservation and safety barriers, making
it an important foodborne pathogen.
MORPHOLOGY AND IDENTIFICATION:
- L monocytogenes is a short, gram-positive, non–spore-forming rod.
- It is catalase positive and has a tumbling end-over-end motility at 22–28°C but
not at 37°C; the motility test rapidly differentiates Listeria from diphtheroids that
are members of the normal microbiota of the skin.
CULTURE AND GROWTH CHARACTERISTICS:
- On as 5% sheep blood agar:exhibits the characteristic small zone of hemolysis
around and under colonies.
- The organism is a facultative anaerobe and is catalase positive, esculin
hydrolysis positive, and motile.
- Listeria produces acid but not gas from utilization of a variety of carbohydrates.
- The motility at room temperature and hemolysin production are primary
findings that help differentiate Listeria from coryneform bacteria.
ANTIGENIC CLASSIFICATION:
- Serologic classification is done only in reference laboratories and is primarily
used for epidemiologic studies.
- There are 13 known serovars based on O (somatic) and H (flagellar) antigens.
- Serotypes 1/2a, 1/2b, and 4b make up more than 95% of the isolates from
humans. Serotype 4b causes most of the foodborne outbreak.
PATHOGENESIS AND IMMUNITY:
- Mode of transmission: ingestion of contaminated foods such as cheese or
vegetables
- Virulence factors:
1. Adhesin proteins(Ami,Fbp A, and flagellin proteins)- facilitate bacterial
binding to the host cells and that contribute to virulence.
2. Cell wall surface proteins (internalins A and B)- that interactwith E-cadherin,
a receptor on epithelial cells, promoting phagocytosis into the epithelial
cells.
- After phagocytosis, the bacterium is enclosed in a phagolysosome, where the
low pH activates the bacterium to produce listeriolysin O.
- Iron is an important virulence factor. Listeriae produce siderophores and are
able to obtain iron from transferrin.
CLINICAL FINDINGS:
- There are two forms of perinatal human listeriosis:
1. Early onset syndrome (granulomatosis infantiseptica) is the result of
infection in utero and is a disseminated form of the disease characterized
by neonatal sepsis, pustular lesions, and granulomas containing L
monocytogenes in multiple organs. Death may occur before or after
delivery.
2. The late-onset syndrome- causes the development of meningitis between
birth and the third week of life; it is often caused by serotype 4b and has a
significant mortality rate.
- Adults can develop Listeria meningoencephalitis, bacteremia, and (rarely)
focal infections. Meningoencephalitis and bacteremia occur most commonly
in immunosuppressed patients, in whom Listeria is one of the more common
causes of meningitis.
- Clinical presentation of Listeria meningitis in these patients varies from insidious
to fulminant and is nonspecific.
- In immunocompetent individuals, illness may not occur after ingestion of
contaminated food or patients may develop a symptomatic febrile
gastroenteritis. This develops after an incubation period of 6–48 hours.
Symptoms include fever, chills, headache, myalgias, abdominal pain,and
diarrhea.
- Illness is usually self-limiting in 1–3 days; The diagnosis of listeriosis rests on
isolation of the organism in cultures of blood and spinal fluid.
TREATMENT:
 - Many antimicrobial drugs inhibit Listeria species in vitro: Ampicillin,
erythromycin, or intravenous trimethoprim–sulfamethoxazole.
- Cephalosporins and fluoroquinolones are not active against L
monocytogenes!!
- Trimethoprim–sulfamethoxazole is the drug of choice for central nervous system
Actinomycetes
infections in patients who are allergic to penicillin.
Erysipelothrix rusiopathiae
MORPHOLOGY AND IDENTIFICATION:
- Gram Stain: G(+) bacillus and sometimes looks G (-) because it decolorizes
easily. Appear singly, in short chains, randomly, or in long non-branching
filaments.
- The produces small, transparent glistening colonies. It may be α-hemolytic on
blood agar.
- Erysipelothrix is catalase, oxidase,and indole negative.
- Growth on TSI (Triple Iron Sugar) = positive/blackening of the butt of the tube
(Hydrogen sulfide production)
EPIDEMIOLOGY:
- E rhusiopathiae is distributed in land and sea animals worldwide, including a
variety of vertebrates and invertebrates.
- It causes disease in domestic swine, turkeys, ducks, and sheep.
- The most important impact is in swine, in which it causes erysipelas. In humans,
erysipelas is caused by group A β-hemolytic streptococci and is much different
from erysipelas of swine.
- Human infection by direct inoculation from animals or animal products.
- High risk: fishermen, fish handlers, abattoir workers, butchers, and others who
have contact with animal products.
CLINICAL FINDINGS:
- The most common E rhusiopathiae infection in humans is called erysipeloid. It
usually occurs on the fingers by direct inoculation at the site of a cut or
abrasion (and has been called “seal finger” and “whale finger”).
- After 2–7 days’ incubation, pain, which can be severe, and swelling occur. The
Nocardia
lesion is raised, and violaceous in color. Pus is usually not present at the
infection site, which helps differentiate it from staphylococcal and
streptococcal skin infections.
TREATMENT:
- Erysipeloid can resolve after 3–4 weeks or more rapidly with antibiotic
treatment.
- Additional clinical forms of infection (both rare) are a diffuse cutaneous form
and bacteremia with endocarditis.
- Drug of choice: penicillin G.
- The organism is intrinsically resistant to vancomycin.
- The aerobic Actinomycetes are a large, diverse group of gram-positive bacilli
with a tendency to form chains or filaments.
- They are related to the corynebacteria and include multiple genera of clinical
significance such as Mycobacteria and saprophytic organisms such as
Streptomyces.
- As the bacilli grow, the cells remain together after division to form elongated
chains of bacteria (1 μm in width) with occasional branches.
- Members of the aerobic
Actinomycetes can be categorized on the basis of the acid fast stain.
Mycobacteria are truly positive acid-fast organisms; weakly positive genera
include Nocardia, Rhodococcus, and a few others of clinical significance.
● Rhodococcus
- R equi may appear to be a bacillus after a few hours of incubation in
broth, but with further incubation, the organisms become coccoid in
shape. This species of Rhodococcus also frequently produces
pigmented colonies after 24 hours of incubation that range from salmon
pink to red.
- The organisms are generally weakly acid-fast positive when stained by the
modified Kinyoun method.
- R equi occasionally causes infections such as necrotizing pneumonia in
immunosuppressed patients with abnormal cell-mediated immunity (eg, AIDS
patients). R equi is present in soil and in dung of herbivores.
- The genus Nocardia continues to undergo extensive taxonomic
reclassification. New species continue to be recognized, and at least 30
species have been implicated as causes of human infections.
- The pathogenic nocardiae, similar to many non-pathogenic species of
Nocardia, are found worldwide in soil and water.
- Nocardiosis is initiated by inhalation of these bacteria. The usual presentation is
as a subacute to chronic pulmonary infection that may disseminate to other
organs, usually the brain or skin. Nocardiae are not transmitted from person to
person.
MORPHOLOGY AND IDENTIFICATION:
- Nocardia species are aerobic, gram-positive, catalase-positive, and partially
acid-fast bacilli.
- Nocardiae form extensive branching substrates and aerial filaments that
fragment after formation, breaking into coccobacillary cells. The cell walls
contain mycolic acids that are shorter chained than those of Mycobacteria.
- Colonial morphology: heaped, irregular, waxy colonies (over the course of
several days to 1 week). Strains vary in their pigmentation from white to
orange to red.
- They produce urease and can digest paraffin.
PATHOGENESIS AND CLINICAL FINDINGS:
- In most cases, nocardiosis is an opportunistic infection associated with several
risk factors, most of which impair the cell-mediated immune responses,
including corticosteroid treatment, immunosuppression, organ transplantation,
AIDS, and alcoholism.
- Nocardiosis begins as chronic lobar pneumonia, and a variety of symptoms
may occur, including fever, weight loss, and chest pain.
- The clinical manifestations are not distinctive and mimic tuberculosis and other
infections.
- Pulmonary consolidations may develop, but granuloma formation and
caseation are rare. The usual pathologic process is abscess formation
(neutrophilic inflammation).
- Spread from the lung often involves the central nervous system, where
abscesses develop in the brain, leading to a variety of clinical presentations.
DIAGNOSTIC LABORATORY TESTS:
- Specimen of choice: Specimens consist of sputum, pus, spinal fluid, and biopsy
material.
- Gram stain: gram-positive bacilli, coccobacillary cells, and branching filaments
- Nocardia species grow on most laboratory media. Serologic tests are not
useful.
- Molecular methods are required for species-level identification, which is
necessary for both epidemiologic and treatment purposes.
TREATMENT:
- The treatment of choice is trimethoprim–sulfamethoxazole.
- Second drug of choice: amikacin, imipenem, minocycline, linezolid, and
cefotaxime.
- However, because the susceptibility patterns vary by species, susceptibility
testing
- should be performed to guide treatment approaches.
- Surgical drainage or resection may be required.
EMERGING ACTINOMYCETES: GORDONIA AND TSUKAMURELLA
GENERAL CHARACTERISTICS:
 - Members of the genera Gordonia and Tsukamurella are modified acid-fast
positive bacteria that are becoming more frequently responsible for
opportunistic infections among hospitalized immunocompromised patients.
A. Gordonia produce orange, wrinkled colonies.
- On Gram stain, the organisms appear coryneform and do not branch.
A. Tsukamurella species form whitish to orange colonies
- On Gram stain appear as long, straight, sometimes curved rods.
- These organisms have been associated with a variety of infections, including
postoperative wound infections, catheter-associated bloodstream infections,
ear drainage, and pulmonary infections.
- Treatment has been based on anecdotal experiences but does require
removal of catheters and drainage of abscesses.
- For infections caused by Gordonia species: vancomycin, carbapenems,
aminoglycosides, fluoroquinolones, and linezolid
- For infections caused by Tsukamurella infections: in vitro susceptibility has been
demonstrated with the aminoglycosides, sulfamethoxazole, fluoroquinolones,
carbapenems, and clarithromycin.
ACTINOMYCETOMA
- Mycetoma (Madura foot) is a localized, slowly progressive, chronic infection
that begins in subcutaneous tissue and spreads to adjacent tissues. It is
destructive and often painless.
- In many cases, the cause is a soil fungus that has been implanted into the
subcutaneous tissue by minor trauma.
- An actinomycetoma is a mycetoma caused by filamentous branching
bacteria.
- The actinomycetoma granule is composed of tissue elements and gram-
positive bacilli and bacillary chains or filaments (1 μm in diameter). The most
common causes of actinomycetoma are Nocardia asteroides, Nocardia
brasiliensis, Streptomyces somaliensis, and Actinomadura madurae. N
brasiliensis may be acid-fast.
- Drug of choice: streptomycin, trimethoprim–sulfamethoxazole, and dapsone
Actinomycetes or Actinomycosis?
- Often students are confused by the terms actinomycetes and actinomycosis.
The former have been described earlier; the latter is an infection caused by
members of the anaerobic gram-positive genus Actinomyces.
SPORE-FORMING GRAM-POSITIVE BACILLI: BACILLUS AND CLOSTRIDIUM SPECIES
GENERAL CHARACTERISTICS:
- These bacilli are ubiquitous, and because they form spores, they can survive in
the environment for many years. Whereas the Bacillus species are aerobes, the
Clostridium species are anaerobes.
- Clinically significant organisms:
- Genus Bacillus = Bacillus anthracis = Anthrax
- Genus Clostridium = toxin mediated diseases:
1. Clostridium tetani= tetanus
2. Clostridium botulinum =botulism
3. Clostridium perfringens = gas gangrene
4. Clostridium difficile = pseudomembranous colitis
Bacillus Species
MORPHOLOGY AND IDENTIFICATION:
A. Typical Organisms
- The typical cells, measuring 1 × 3–4 μm, have square ends and are
arranged in long chains; spores are located in the center of the non
motile bacilli. Appears as “box car shaped cells”
B. Culture
- Colonies of B anthracis are round and have a “cut glass” appearance in
transmitted light. Sometimes appears as ‘medusa head’ appearance in
the colonies on 5% Sheep Blood agar.
- Hemolysis is uncommon with B anthracis but common with B cereus and
the saprophytic bacilli.
- Gelatin is liquefied, Gelatin is liquefied, and growth in gelatin stabs
resembles an inverted fir tree.
C. Growth Characteristics
- The saprophytic bacilli use simple sources of nitrogen and carbon for
energy and growth.
- The spores are resistant to environmental changes, withstand dry heat
and certain chemical disinfectants for moderate periods, and persist for
years in dry earth. Animal products contaminated with anthrax spores
(eg, hides, bristles, hair, wool, bone) can be sterilized by autoclaving.
Bacillus anthracis
PATHOGENESIS:
- Anthrax is primarily a disease of herbivores—goats, sheep, cattle, horses, and
so on; other animals (eg, rats) are relatively resistant to the infection. Anthrax is
endemic among agrarian societies in developing countries in Africa, the
Middle East, and Central America.
- Humans become infected incidentally by contact with infected animals or
their products. In animals, the portal of entry is the mouth and the
gastrointestinal tract.
- Spores from contaminated soil find easy access when ingested with spiny or
irritating vegetation.
- Mode of transmission in humans:
1. entry of spores through injured skin (cutaneous anthrax)
2. through the mucous membranes (gastrointestinal anthrax) -on rare
occasions
3. inhalation of spores into the lung (inhalation anthrax)
- The spores germinate in the tissue at the site of entry, and growth of the
vegetative organisms results in formation of a gelatinous edema and
congestion. Bacilli spread via lymphatics to the bloodstream, and they multiply
freely in the blood and tissues shortly before and after the animal’s death.
Anthrax toxin:
- Anthrax toxins are made up of three proteins: protective antigen (PA), edema
factor (EF), and lethal factor (LF).
1. PA binds to specific cell receptors, and after proteolytic activation, it forms
a membrane channel that mediates entry of EF and LF into the cell.
2. EF is an adenylate cyclase; with PA, it forms a toxin known as edema toxin.
3. LF plus PA form lethal toxin, which is a major virulence factor and cause of
death in infected animals and humans
- The anthrax toxin genes are encoded on another plasmid, pXO1.
- In inhalation anthrax (woolsorters’ disease), the spores from the dust of wool,
hair, or hides are inhaled; phagocytosed in the lungs; and transported by the
lymphatic drainage to the mediastinal lymph nodes, where germination occurs
This is followed by toxin production and the development of hemorrhagic
mediastinitis and sepsis, which are usually rapidly fatal.
- In anthrax sepsis, the number of organisms in the blood exceeds 107/mL just
before death.
Anthrax outbreak:
- In the Sverdlovsk inhalation anthrax outbreak of 1979 and the U.S. bioterrorism
inhalation cases of 2001, the pathogenesis was the same as in inhalation
anthrax from animal products.
PATHOLOGY:
- In susceptible animals and humans, the organisms proliferate at the site of
entry. The capsules remain intact, and the organisms are surrounded by a large
amount of proteinaceous fluid containing few leukocytes from which they
rapidly disseminate and reach the bloodstream.
- In resistant animals, the organisms proliferate for a few hours, by which time
there is massive accumulation of leukocytes. The capsules gradually
disintegrate and disappear.
- The organisms remain localized.

Inhalation Anthrax:
CLINICAL FINDINGS:
- In humans, approximately 95% of cases are cutaneous anthrax, and 5% are
inhalation. Gastrointestinal anthrax is very rare; it has been reported from
Africa, Asia, and the United States when people have eaten meat from
infected animals.
- The bioterrorism events in the fall of 2001 resulted in 22 cases of anthrax—11
inhalation and 11 cutaneous. Five of the patients with inhalation anthrax died.
All of the other patients survived.
Cutaneous Anthrax:
- Cutaneous anthrax generally occurs on exposed surfaces of the arms or hands
followed in frequency by the face and neck.
- A pruritic papule develops 1–7 days after entry of the organisms or spores
through a scratch. Initially, it resembles an insect bite.
- The papule rapidly changes into a vesicle or small ring of vesicles that
coalesce, and a necrotic ulcer develops.
- The lesions typically are 1–3 cm in diameter and have a characteristic central
black eschar. Marked edema occurs.
- Antibiotic therapy does not appear to change the natural progression of the
disease but prevents dissemination.
- Lymphangitis and lymphadenopathy and systemic signs and symptoms of
fever, malaise, and headache may occur. After 7–10 days, the eschar is fully
developed. Eventually, it dries, loosens, and separates; healing is by
DIAGNOSTIC LABORATORY TESTS:
granulation and leaves a scar.
- The incubation period in inhalation anthrax may be as long as 6 weeks. The
early clinical manifestations are associated with marked hemorrhagic necrosis
and edema of the mediastinum.
- Substernal pain may be prominent, mediastinal widening visible on chest
radiographs. Haemorrhagic pleural effusions; cough is secondary to the effects
on the trachea.
- Sepsis occurs, and there may be hematogenous spread to the gastrointestinal
tract, causing bowel ulceration, or to the meninges, causing hemorrhagic
meningitis.
- The fatality rate in inhalation anthrax is high in the setting of known exposure; it
is higher when the diagnosis is not initially suspected.
- Specimens of choice:
1. For inhalational anthrax: fluid or pus from a local lesion, blood, pleural fluid,
and cerebrospinal fluid in and
2. For gastrointestinal anthrax: tool or other intestinal
- Stained smears from the local lesion or of blood from dead animals often show
chains of large gram-positive rods. Anthrax can be identified in dried smears by
immunofluorescence staining.
- On blood agar: nonhemolytic gray to white, tenacious colonies with a rough
texture and a ground-glass appearance. Comma-shaped outgrowths
(Medusa head, “curled hair”) may project from the colony.
- Carbohydrate fermentation is not useful!
- In semisolid medium, anthrax bacilli are always nonmotile, but related
organisms (eg, B cereus) exhibit motility by “swarming.”
- Clinical laboratories that recover large gram-positive rods from blood,
cerebrospinal fluid, or suspicious skin lesions, which phenotypically match the
description of B anthracis as mentioned, should immediately contact their
public health laboratory and send the organism for confirmation.
RESISTANCE AND IMMUNITY:
- Immunization to prevent anthrax is based on the classic experiments of Louis
Pasteur. In 1881, he proved that cultures grown in broth at 42–52°C for several
months lost much of their virulence and could be injected live into sheep and
cattle without causing disease; subsequently, such animals proved to be
immune.
- Active immunity to anthrax can be induced in susceptible animals by
vaccination with live attenuated bacilli, with spore suspensions, or with PAs
from culture filtrates. Animals that graze in known anthrax districts should be
immunized for anthrax annually.
- In the United States, the current FDA-approved vaccine (AVA BioThrax) is
made from the supernatant of a cell free culture of an unencapsulated but
toxigenic strain of B. anthracis that contains PA adsorbed to aluminum
hydroxide.
TREATMENT:
- Many antibiotics are effective against anthrax in humans, but treatment must
be started early.
- Ciprofloxacin is recommended for treatment; penicillin G, along with
gentamicin or streptomycin.
- In the setting of potential exposure to B anthracis as an agent of biologic
warfare, prophylaxis with ciprofloxacin or doxycycline should be continued for
4 weeks while three doses of vaccine are being given or for 8 weeks if no
vaccine is administered.
EPIDEMIOLOGY, PREVENTION, AND CONTROL:
- Soil is contaminated with anthrax spores from the carcasses of dead animals.
These spores remain viable for decades. Perhaps spores can germinate in soil
at a pH of 6.5 at proper temperature.
- Grazing animals infected through injured mucous membranes serve to
perpetuate the chain of infection. Contact with infected animals or with their
hides, hair, and bristles is the source of infection in humans.
- Control measures include:
(1) disposal of animal carcasses by burning or by deep burial in lime pits,
(2) decontamination (usually by autoclaving) of animal products
(3) protective clothing and gloves for handling potentially infected materials,
(4) active immunization of domestic animals with live attenuated vaccines.
- Persons with high occupational risk should be immunized.
Bacillus cereus
GENERAL CHARACTERISTICS: - C. perfringens: Gram (+)ve, large rectangular bacilli with rounded or - On blood agar: All species produce beta-hemolysis. C perfringens
truncated ends. with central or sub-terminal spores but spores are rarely characteristically produces a double zone of β-hemolysis around
- Food poisoning caused by B cereus has two distinct forms:
seen. colonies.
(1) Emetic type: is associated with fried rice
- C. difficile: Gram (+)ve, bacilli, spores are either oval, terminal or
(2) Diarrheal type: is associated with meat dishes and sauces.
subterminal
- B cereus produces toxins that cause disease that is more an intoxication than a
foodborne infection.
- B cereus is a soil organism that commonly contaminates rice. When large
amounts of rice are cooked and allowed to cool slowly, the B cereus spores
germinate, and the vegetative cells produce the toxin during log-phase
growth or during sporulation.

Emetic form:
D. Growth Characteristics
- The emetic form is manifested by nausea, vomiting, abdominal cramps, and
- Clostridia can ferment a variety of sugars; many can digest proteins.
occasionally diarrhea and is self-limiting, with recovery occurring within 24
- These metabolic characteristics are used to divide the Clostridia into
hours.
groups, saccharolytic or proteolytic.
- It begins 1–5 hours after ingestion of rice and occasionally pasta dishes
- Saccharolytic= ability to break down sugars or carbohydrates for energy
Diarrheal form: - Proteolytic= ability to lyse or break down proteins

- The diarrheal form has an incubation period of 1–24 hours and is manifested by Clostridium botulinum
profuse diarrhea with abdominal pain and cramps; fever and vomiting are
GENERAL CHARACTERISTICS:
uncommon.
- The enterotoxin may be pre-formed in the food or produced in the intestine. - C botulinum causes botulism, is worldwide in distribution; it is found in soil and
occasionally in animal feces.
- Types of C botulinum are distinguished by the antigenic type of toxin they
- B cereus is an important cause of eye infections, such as severe keratitis, produce.
endophthalmitis, and panophthalmitis. - Spores of the organism are highly resistant to heat, withstanding 100°C for
- Typically, the organisms are introduced into the eye by foreign bodies several hours. Heat resistance is diminished at acid pH or high salt
associated with trauma. concentration
- B cereus is resistant to a variety of antimicrobial agents, including penicillins
Toxin:
and cephalosporins.
- Serious non–foodborne infections should be treated with vancomycin or - During the growth of C botulinum and during autolysis of the bacteria, toxin is
clindamycin with or without an aminoglycoside liberated into the environment. Seven antigenic varieties of toxin (A–G) are
known.
Clostridium species
- Types A, B, E, and F are the principal causes of human illness.
GENERAL CHARACTERISTICS: - Types A and B have been associated with foods and type E predominantly

- Genus Clostridium = toxin mediated diseases: with fish products.

1. Clostridium tetani= tetanus - Type C produces limberneck in birds; type D causes botulism in mammals. Type

2. Clostridium botulinum =botulism G is not associated with disease.

3. Clostridium perfringens = gas gangrene & myonecrosis - Strains that produce toxins A, B, or F are associated with infant botulism

4. Clostridium difficile = pseudomembranous colitis &diarrheal disease - Botulinum toxin is absorbed from the gut and binds to receptors of presynaptic

A. Typical Organisms membranes of motor neurons of the peripheral nervous system and cranial

- Spores of clostridia are usually wider than the diameter of the rods in nerves.

which they are formed. - The lethal dose for a human is probably about 1–2 μg/kg.

- In the various species, the spore is placed centrally, subterminally, or - The toxins are destroyed by heating for 20 minutes at 100°C.
C. Culture
terminally. - Clostridia are anaerobes and grow under anaerobic conditions.
- Most species of clostridia are motile and possess peritrichous flagella. - C. Colony Forms
PATHOGENESIS:
B. Gram Stain characteristics: - C. perfringens: large raised colonies
- C. botulinum: Gram (+)ve, oval, subterminal spores - C. tetani: small colonies Food botulism
- C. tetani: Gram (+)ve, round, terminal endospores; give the bacterium a
- Most cases of botulism represent an intoxication resulting from the ingestion of
"tennis-racquet" appearance.
food in which C botulinum has grown and produced toxin.
 - The most common are from spiced, smoked, vacuum packed, or canned
alkaline foods that are eaten without cooking. In such foods, spores of C
botulinum germinate; that is, under anaerobic conditions, vegetative forms
grow and produce toxin.
Infant Botulism:
- In infant botulism, honey is the most frequent vehicle of infection. The
pathogenesis differs from the way that adults acquire infection.
- The infant ingests the spores of C botulinum, and the spores germinate within
the intestinal tract. The vegetative cells produce toxin as they multiply; the
neurotoxin then gets absorbed into the bloodstream.
- In the United States, infant botulism is as common as or more common than the
classic form of paralytic botulism associated with the ingestion of toxin-
contaminated food.
DIAGNOSTIC LABORATORY TESTS:
- The infants in the first months of life develop poor feeding, weakness, and signs
of paralysis or the floppy baby syndrome. Infant botulism may be one of the
causes of sudden infant death syndrome.
- C botulinum and botulinum toxin are found in feces but not in serum.
- Symptoms of Infant Botulism: a weak cry, constipation, breathing problems and
excessive drooling.
Toxin action:
- The toxin acts by blocking release of acetylcholine at synapses and
neuromuscular junctions.
- The result is flaccid paralysis. The electromyogram and edrophonium strength
test results are typical
TREATMENT:
CLINICAL FINDINGS:
- Symptoms begin 18–24 hours after ingestion of the toxic food, with visual
disturbances (incoordination of eye muscles, double vision), inability to
swallow, and speech difficulty.
- Signs of bulbar paralysis are progressive, and death occurs from respiratory
paralysis or cardiac arrest.
- No GI symptoms, no fever.
- The patient remains fully conscious until shortly before death.
- The mortality rate is high. Patients who recover do not develop antitoxin in the
blood.
- Toxin can often be demonstrated in serum, gastric secretions, or stool from the
patient, and toxin may be found in leftover food.
- Mouse bioassay: the test of choice for the confirmation of botulism. The
antigenic type of toxin is identified by neutralization with specific antitoxin in
mice. Mice injected intraperitoneally with such specimens from these patients
die rapidly.
- C botulinum may be grown from food remains and tested for toxin production,
but this is rarely done and is of questionable significance.
- Infant botulism cases: stool as specimen.
- Other methods used to detect toxin include ELISAs and PCR, but the latter
may detect organisms that carry the gene but do not express toxin
- Potent antitoxins to three types of botulinum toxins have been prepared in
horses.
- Trivalent (A, B, E) antitoxin promptly administered IV with customary
precautions: Adequate respiration must be maintained by mechanical
ventilation if necessary!
- These measures have reduced the mortality rate from 65% to below 25%.
- Although most infants with botulism recover with supportive care alone,
antitoxin therapy is recommended.
EPIDEMIOLOGY, PREVENTION, AND CONTROL:
- A large restaurant-based outbreak was associated with sautéed onions. When
such foods are canned or otherwise preserved, they either must be sufficiently
heated to ensure destruction of spores or must be boiled for 20 minutes before
consumption.
- Strict regulation of commercial canning has largely overcome the danger of
widespread outbreaks, but commercially prepared foods have caused
deaths.
- A chief risk factor for botulism lies in home-canned foods.
- Toxic foods may be spoiled and rancid, and cans may “swell,” or the
appearance may be innocuous
- Toxoids are used for active immunization of cattle in South Africa.
- Botulinum toxin is considered to be a major agent for bioterrorism and biologic
warfare.
Clostridium tetani
GENERAL CHARACTERISTICS:
- C tetani, which causes tetanus, is worldwide in distribution in the soil and in the
feces of horses and other animals.
- Several types of C tetani can be distinguished by specific flagellar antigens. All
share a common O (somatic) antigen, and all produce the same antigenic
type of neurotoxin, tetanospasmin.
Toxin:
- The toxin initially binds to receptors on the presynaptic membranes of motor
neurons. It then migrates by the retrograde axonal transport system to the cell
bodies of these neurons to the spinal cord and brainstem.
- The toxin diffuses to terminals of inhibitory cells, including both glycinergic
interneurons and γ-aminobutyric acid (GABA)– secreting neurons from the
brainstem.
- The toxin degrades synaptobrevin, a protein required for docking of
neurotransmitter vesicles on the presynaptic membrane.
- Release of the inhibitory glycine and GABA is blocked, and the motor neurons
are not inhibited.
- Hyperreflexia, muscle spasms, and spastic paralysis result. Extremely small
amounts of toxin can be lethal for humans.
PATHOGENESIS:
- C tetani is not an invasive organism. The infection remains strictly localized in
the area of devitalized tissue (wound, burn, injury, umbilical stump, surgical
suture) into which the spores have been introduced.
- The volume of infected tissue is small, and the disease is almost entirely a
toxemia.
 - Germination of the spore and development of vegetative organisms that
produce toxin are aided by:
(1) necrotic tissue,
(2) calcium salts
(3) associated pyogenic infections, all of which aid establishment of low
oxidation-reduction potential.
- The toxin released from vegetative cells reaches the central nervous system
and rapidly becomes fixed to receptors in the spinal cord and brainstem and
exerts the actions described.
CLINICAL FINDINGS:
- The incubation period may range from 4 to 5 days to as many weeks. The
disease is characterized by tonic contraction of voluntary muscles.
- Muscular spasms often involve first the area of injury and infection and then the
muscles of the jaw (trismus, lockjaw), which contract so that the mouth cannot
be opened. Gradually, other voluntary muscles become involved, resulting in
tonic spasms.
- Any external stimulus may precipitate a tetanic generalized muscle spasm. The
patient is fully conscious, and pain may be intense. Death usually results from
interference with the mechanics of respiration.
- The mortality rate in generalized tetanus is very high.
DIAGNOSIS:
- The diagnosis rests on the clinical picture and a history of injury, although only
50% of patients with tetanus have an injury for which they seek medical
attention. The primary differential diagnosis of tetanus is strychnine poisoning.
- Anaerobic culture of tissues from contaminated wounds may yield C tetani, - Many different toxin-producing clostridia C perfringens can produce invasive
but neither preventive nor therapeutic use of antitoxin should ever be withheld infection (including myonecrosis and gas gangrene) if introduced into
pending such demonstration. damaged tissue.
- Proof of isolation of C tetani must rest on production of toxin and its About 30 species of clostridia may produce such an effect, but the most
neutralization by specific antitoxin. common in invasive disease is C perfringens (90%).
- An enterotoxin of C perfringens is a common cause of food poisoning.
PREVENTION AND TREATMENT:
- Many of these toxins have lethal, necrotizing, and hemolytic properties.
- The results of treatment of tetanus are not satisfactory. Therefore, prevention is - In some cases, these are different properties of a single substance; in other
all important. instances, they are attributable to different chemical entities.
- Prevention of tetanus depends on: - The α toxin of C perfringens type A is a lecithinase, and its lethal action is
(1) active immunization with toxoids proportionate to the rate at which it splits lecithin (an important constituent of
(2) proper care of wounds contaminated with soil cell membranes) to phosphorylcholine and diglyceride.
(3) prophylactic use of Antitoxin - The theta toxin has similar hemolytic and necrotizing effects but is not a
(4) administration of penicillin. lecithinase.
- IM administration of 250–500 units of tetanus immune globulin = protection for - DNase and hyaluronidase, a collagenase that digests collagen of
2-4 weeks subcutaneous tissue and muscle, are also produced.
- Active immunization with tetanus toxoid should accompany antitoxin - Some strains of C perfringens produce a powerful enterotoxin, especially when
prophylaxis. grown in meat dishes.
- Patients who develop symptoms of tetanus should receive muscle relaxants, - The enterotoxin is a protein, that may be a nonessential component of the
sedation, and assisted ventilation. spore coat; It induces intense diarrhea in 7–30 hours.
- Surgical debridement is vitally important because it removes the necrotic tissue - The action of C perfringens enterotoxin involves marked hypersecretion in the
that is essential for proliferation of the organisms. jejunum and ileum, with loss of fluids and electrolytes in diarrhea.
- Penicillin strongly inhibits the growth of C tetani and stops further toxin - Much less frequent symptoms include nausea, vomiting, and fever. This illness is
production similar to that produced by B cereus and tends to be self-limited.
CONTROL: - Enterotoxin-producing strains of C perfringens may also play a role in antibiotic
associated diarrhea.
PATHOGENESIS:
- Mode of transmission: (In invasive clostridial infections) by contamination of
traumatized areas (soil, feces) or from the intestinal tract.
- The spores germinate at low oxidation reduction potential; vegetative cells
multiply, ferment carbohydrates present in tissue, and produce gas.
- Tissue necrosis extends, providing an opportunity for increased bacterial
- Tetanus is a totally preventable disease. Universal active immunization with growth;
tetanus toxoid should be - In gas gangrene (clostridial myonecrosis), a mixed infection is the rule. In
mandatory. Tetanus toxoid is addition to the toxigenic clostridia, proteolytic clostridia and various cocci and
produced by detoxifying the toxin gram-negative organisms are also usually present.
with formalin and then
CLINICAL FINDINGS:
concentrating it.
- Aluminum salt–adsorbed - From a contaminated wound (eg, a compound fracture, postpartum uterus),
toxoids are used. Three the infection spreads in 1–3 days to produce crepitation in the subcutaneous
injections comprise the initial tissue and muscle, foul-smelling discharge, rapidly progressing necrosis, fever
course of immunization hemolysis, toxemia, shock, and death.
- Treatment is with early surgery (amputation) and antibiotic administration. Until
followed by another dose about
the advent of specific therapy, early amputation was the only treatment. At
1 year later.
- Control measures are not possible because of the wide dissemination of the times, the infection results only in anaerobic fasciitis or cellulitis.
organism in the soil and the long survival of its spores.
CLOSTRIDIA THAT PRODUCE INVASIVE INFECTIONS: C. perfringens
 - Plaques and microabscesses may be localized to one area of the bowel. The
diarrhea may be watery or bloody, and the patient frequently has associated
abdominal cramps, leukocytosis, and fever. Although many antibiotics have
been associated with pseudomembranous colitis, the most common are
ampicillin and clindamycin and more recently, the fluoroquinolones.
- The disease is treated by discontinuing administration of the offending
antibiotic and orally giving either metronidazole or vancomycin

DIAGNOSTIC LABORATORY TESTS:

1. Gram stain
2. Material is inoculated into chopped meat–glucose medium and thioglycolate
medium and onto blood agar plates incubated anaerobically. The growth
from one of the media is transferred into milk. A clot torn by gas in 24 hours is
suggestive of C perfringens.
3. Lecithinase activity is evaluated by the precipitate formed around colonies on
egg yolk media. Final identification rests on toxin production and neutralization
by specific antitoxin.
4. C perfringens rarely produces spores when cultured on agar in the laboratory.

TREATMENT:

- The most important aspect of treatment is prompt and extensive surgical

debridement of the involved area and excision of all devitalized tissue, in
which the organisms are prone to grow.
- Penicillin, is begun at the same time. Hyperbaric oxygen may be of help in the
medical management of clostridial tissue infections. It is said to “detoxify”
patients rapidly.
- Antitoxins are available against the toxins of C perfringens, Clostridium novyi,
Clostridium histolyticum.

CLOSTRIDIUM DIFFICILE AND DIARRHEAL DISEASE:

Pseudomembranous Colitis

- Diagnosed by detection of one or both C difficile toxins in stool and by

endoscopic observation of pseudomembranes or microabscesses in patients
who have diarrhea and have been given antibiotics.