CH A P T ER

Clinical Microbiology
(Infective Syndromes) 7.1
URINARY TRACT INFECTIONS
Lower UTI Upper UTI
Sites involved Urethra and bladder Kidney and ureter
Symptoms Local manifestations- dysuria, urgency, frequency Local and systemic manifestations (fever, vomiting, abdominal pain)
Route of spread Ascending route Both ascending (common) and descending route
Occurrence More common Less common

Microorganisms causing UTI

Bacterial agents: Other agents:
Gram-negative bacilli: Fungus:
• Escherichia coli- Commonest agent of UTI Candida albicans
• Proteus mirabilis Parasites:
• Klebsiella pneumoniae • Schistosoma haematobium
• Pseudomonas aeruginosa • Trichomonas vaginalis
• Acinetobacter species
• Enterobacter species
• Serratia species
Gram-positive cocci: Viruses:
• Staphylococcus saprophyticus • Herpes simplex virus
• Staphylococcus aureus • Adenovirus
• Staphylococcus epidermidis • JC and BK virus
• Enterococcus spp. • Cytomegalovirus

Most organisms are acquired by ascending route. Organisms acquired by descending route
include - Staphylococcus aureus, Salmonella, Mycobacterium tuberculosis, Leptospira and Candida.

DIARRHEA, DYSENTERY AND FOOD POISONING

Table 7.1.1: Infectious agents of acute diarrhea and the underlying mechanism
Mechanism Features Examples of pathogens involved
Non-inflammatory Location: Bacteria: Viruses:
Proximal small bowel (Mostly enterotoxin mediated) • Rotavirus
• Vibrio cholerae • Norovirus
Illness: • Escherichia coli • Enteric adenoviruses
Watery diarrhea ○○ Enteropathogenic Parasites:
○○ Enterotoxigenic • Giardia lamblia
Stool findings: ○○ Enteroaggregative • Cryptosporidium
• No fecal leukocytes • Clostridium perfringens • Cyclospora species
• Fecal lactoferrin-not increased • Bacillus cereus • Microsporidia
• Staphylococcus aureus,
• Aeromonas hydrophila
• Plesiomonas shigelloides
Contd...

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Contd...
Mechanism Features Examples of pathogens involved
Inflammatory Location: Predominantly dysentery: Parasite
(invasion or Colon or distal small bowel • Shigella species (predominantly dysentery):
cytotoxin) • Campylobacter jejuni • Entamoeba histolytica,
Illness: • Enterohemorrhagic E. coli • Balantidium coli
• Dysentery or • Enteroinvasive E. coli
• Inflammatory diarrhea • Vibrio parahaemolyticus
Stool findings: Predominantly inflammatory diarrhea-
• Fecal pus cells • Salmonella species
(polymorphonuclear leukocytes)– • Yersinia enterocolitica
increased • Listeria monocytogenes
• Fecal lactoferrin–increased • Clostridium difficile
• Aeromonas hydrophila
• Plesiomonas shigelloides
• Klebsiella oxytoca
Penetrating Location: Distal small bowel Salmonella Typhi (enteric fever)
Illness: Enteric fever Yersinia enterocolitica
Stool findings:
Fecal mononuclear leukocytes

Table 7.1.2: Infectious agents causing food poisoning

Organisms
1–6 h incubation period
Staphylococcus aureus
Bacillus cereus
Clostridium botulinum
8–16 h incubation period
Clostridium perfringens
B. cereus
> 16 h incubation period
Vibrio cholerae
Enterotoxigenic E. coli
Enterohemorrhagic E. coli
Salmonella species
Campylobacter jejuni
Section 7
Symptoms
Nausea, vomiting, diarrhea
Nausea, vomiting, diarrhea
Nausea, vomiting, diarrhea
Abdominal cramps, diar-
rhea (vomiting rare)
Abdominal cramps, diar-
rhea (vomiting rare)
Watery diarrhea
Watery diarrhea
Bloody diarrhea
Inflammatory diarrhea
Inflammatory diarrhea
Common food sources
Ham, poultry, potato or egg salad, mayonnaise, cream pastries
Fried rice
Canned food
Beef, poultry, legumes, gravies
Meats, vegetables, dried beans, cereals
Shellfish, water
Salads, cheese, meat, water
Ground beef, roast beef, salami, raw milk, raw vegetables, apple
juice
Beef, poultry, eggs, dairy products
Poultry, raw milk

Shigella species Dysentery Potato or egg salad, lettuce, raw vegetables

Vibrio parahaemolyticus Dysentery Mollusks, crustaceans

Table 7.1.3: Agents of Traveller’s diarrhea

Etiologic agent Comments
Bacteria (50–75%)
Enterotoxigenic Escherichia coli (10–45%) Single most important agent
Enteroaggregative E. coli (5–35%) Emerging enteric pathogen with worldwide distribution
Campylobacter jejuni (5–25%) More common in Asia
Shigella Major cause of dysentery
Contd...

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Contd...
Etiologic agent Comments
Salmonella Common in India
Others Aeromonas, Plesiomonas, and Vibrio cholerae
Viruses ( < 20%)
Norovirus (< 10%) Associated with cruise ships
Rotavirus (< 5%) Common among children
Parasites (0–10 %) Giardia lamblia, Cryptosporidium,
Entamoeba histolytica, Cyclospora

Table 7.1.4: Pathogenic mechanisms of diarrheal agents

Toxins Other mechanisms

Enterotoxins: Attachment within or close to mucosal cells:
• Cholera toxin • E. coli:
• Vibrio parahaemolyticus ○○ Enteropathogenic E. coli (EPEC)
• E.coli: ○○ Enterohemorrhagic E. coli (EHEC)
○○ LT and ST of ETEC • Cryptosporidium species
○○ EAST(enteroaggregative heat-stable enterotoxin) • Cyclospora species
of EAEC • Rotavirus
○○ VT of EHEC • Norovirus
• Clostridium difficile (toxin A)
• Aeromonas
• Campylobacter jejuni
Cytotoxins Invasion of intestinal epithelium:
• Shigella dysenteriae type 1 • Shigella species
• Enterohemorrhagic E.coli (EHEC) • Enteroinvasive E. coli
• Clostridium difficile (toxin B) • Campylobacter jejuni
Neurotoxins: • Yersinia enterocolitica
• Staphylococcus aureus enterotoxin • Plesiomonas shigelloides
• Bacillus cereus toxin • Entamoeba histolytica
• Clostridium botulinum toxin • Balantidium coli

MENINGITIS
Table 7.1.5: Causes of meningitis (pyogenic and aseptic)

Applied Microbiology
Pyogenic meningitis Aseptic meningitis
Neonates or • Escherichia coli Viruses
infants of 0–2 • Group B streptococcus (S. agalactiae) Enteroviruses (Polioviruses, echoviruses, Coxsackie
months • Listeria monocytogenes viruses): The most common agents
• Other Gram-negative bacilli (like Klebsiella Herpes simplex virus 1 and 2
pneumoniae) Other Herpes group: Varicella zoster, CMV, EBV
2–20 years • Neisseria meningitidis: Most common agent Myxoviruses: Influenza A and B, parainfluenza virus, and
• Haemophilus influenzae mumps virus
• Streptococcus pneumoniae Arboviruses, and adenoviruses,
Rubella viruses and HIV
> 20 years (adults) Streptococcus pneumoniae: Most common agent Bacteria: Treponema pallidum, and Leptospira
Haemophilus influenzae
Parasites-Naegleria species, Acanthamoeba species
Neisseria meningitidis
and Toxoplasma gondii
Overall Most common agent is Fungi: Cryptococcus neoformans
Streptococcus pneumoniae

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Table 7.1.6: Cytological and biochemical parameters in CSF of normal individuals and in different types of meningitis
Character Normal individual Pyogenic meningitis Tuberculous meningitis Viral meningitis
CSF pressure Normal Highly elevated Moderately elevated Slightly elevated/normal
(mm of water) (50–150) (>180 )
Total leukocyte count (per 0–5 100–10,000 10–500 25–500
mm3)
Predominant cell Lymphocytes Neutrophils Lymphocytes Lymphocytes
Glucose (mg%) 40–70 (< 40 mg/dL) (Decreased to 20–40 mg/dL (Slightly ↓) Normal
absent)
Total proteins (mg%) 15–45 > 45 mg/dL 100–500 mg/dL 20–80 mg/dL
(usually > 250) (moderate to markedly ↑↑) (Normal or slightly
(markedly ↑↑↑) elevated)

BLOODSTREAM INFECTIONS
Table 7.1.7: Agents of endocarditis
Agents of endocarditis
• Streptococci (Viridans streptococci
and others)
• Pneumococci
• Enterococci
• Staphylococcus aureus
• Coagulase-negative staphylococci
• (e.g. Staphylococcus epidermidis)
• Fastidious Gram-negative
coccobacilli (HACEK group)
• Gram-negative bacilli
• Candida species
• Diphtheroids
• Culture-negative endocarditis:
such as Bartonella, Coxiella
Most common agent in specific types of endocarditis
Native valve endocarditis – Staphylococcus aureus
Prosthetic valve endocarditis: It occurs following cardiac
valve replacement
• Early prosthetic valve endocarditis (occurs within
12 months of valve replacement)–Staphylococcus
epidermidis is the commonest agent
• Late prosthetic valve endocarditis (occurs after 12
months of valve replacement)–Viridans streptococci are
the commonest agent
Endocarditis in IV drug abusers: Young males are the
most common victims. The skin is the commonest source of
infection.
• Right sided–Most common agent is Staphylococcus
aureus
• Left sided–Most common agent is Enterococcus followed
by S.aureus
• Over all–Most common agent is Staphylococcus aureus
MC cause of Subacute endocarditis – Viridans
streptococci

Fever of Unknown Origin

Section 7

Petersdorf and Beeson classification (1961) was traditionally used for defining PUO.
• Temperatures of > 38.3°C (>101°F)
• For a duration of > 3 weeks; and
• Failure to reach a diagnosis despite 1 week of inpatient investigation.
This classification has stood for more than 30 years, but later in 1990s, it was revised as Durack
and Street classification. There after it is further modified in 2015. According to Harrison 19th
edition, FUO is now defined as:
1. Fever > 38.3°C (101°F) on at least two occasions
2. Illness duration of > 3 weeks
3. No known immunocompromised state
4. Diagnosis that remains uncertain after a thorough history-taking, physical examination
and the obligatory investigations.
Infections (36%) accounts for majority of FUO cases followed by Neoplasms (19%).

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OTHER INFECTIVE SYNDROMES

Table 7.1.8: Microorganisms causing URTI (upper respiratory tract infections)
Pharyngitis (sore throat), and Laryngotracheobron-
Rhinitis or common cold tonsillitis Laryngitis chitis (or croup)
Mostly caused by viruses: Viruses- (most common cause) Mostly viral agents: Age: Children,
• Rhinovirus • Influenza virus • Influenza virus < 3 years
• Coronavirus • Parainfluenza virus • Parainfluenza virus Agents:
• Adenovirus • Coxsackievirus A • Rhinovirus • Parainfluenza virus
• Influenza virus • Rhinovirus • Adenovirus (most common)
• Parainfluenza virus • Coronavirus • Coronavirus • Influenza virus
• Human metapneumovirus • Epstein-Barr virus • Human meta-pneumo- • Respiratory syncytial
• Respiratory syncytial virus • Adenoviruses virus virus
Sinusitis: Bacteria: If membrane or exudate • Adenoviruses
Agents of acute sinusitis: • Streptococcus pyogenes (MC present: Epiglottis
Viruses (most common cause): bacterial cause) • Streptococcus pyogenes
Most common agent:
• Rhinoviruses, • Streptococcus C and G • C.diphtheriae
Haemophilus influenzae b
• Influenza viruses, • Arcanobacterium species • Epstein-Barr virus
• Parainfluenza viruses • Neisseria
Bacterial agents gonorrhoeae
• Streptococcus pneumoniae • Corynebacterium diphtheriae
• Haemophilus influenzae and C.ulcerans
• Moraxella catarrhalis • Mycoplasma pneumoniae
• Pseudomonas and other Gram- • Vincent angina
negative bacilli (nosocomial sinusitis) • Treponema vincentii
Agents of chronic sinusitis: • Leptotrichia buccalis
• Obligate anaerobes Fungal:
• Staphylococcus aureus Candida albicans

Table 7.1.9: Comparison of STDs producing genital ulcer

Feature Syphilis Herpes Chancroid LGV Donovanosis
Incubation 9–90 days 2–7 days 1–14 days 3 days–6 1–4 weeks
period weeks (up to 6 months)

Genital ulcer Painless, indurated, Multiple, painful Painful, soft Painful, Painless
single Single or multiple soft

Lymphadenopa- Painless, hard, moderate Absence or moderate Painful, soft, marked swell- Painless Absent (pseudo bubo
thy swelling (no bubo) swelling (no bubo) ing leads to bubo formation may be present due to
subcutaneous swelling)

Applied Microbiology
Congenital Infection
Vertical transmission (spread of infections from mother-to-baby) may occur by transplacental
route (congenital infection), during labor and delivery, or after delivery.
Congenital infection (transmission from placenta to fetus): They often lead to defects in fetal
development or even death.
Examples include TORCH syndrome:
• Toxoplasmosis
• Other infections (congenital syphilis, hepatitis B, Coxsackievirus, Epstein-Barr virus,
varicellazoster virus, Plasmodium falciparum and human parvovirus)
• Rubella
• Cytomegalovirus (CMV)
• Herpes simplex virus
Perinatal infections (during labor and delivery): CMV, Gonococcus, Chlamydia, HSV, HPV
and Group B streptococci
Postnatal infections (after delivery): CMV, HIV and Group B streptococcus.

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Emerging and Re-Emerging Infection

Emerging infection: Incidence in human increased in last two decades (newly appearing
disease or those spreading newly to a geographical area). Example include:
• Crimerian congo hemorrhagic virus in India (Ahmedabad- Jan 2011)
• Plasmodium knowlesi
• H1N1 -2009 and Avian flu (H5N1)-2005,
• SARS-2003 (did not affect India)
• HGV, HEV, HHV8, Sin Nombre

Re-emerging infection: Incidence was brought down in past but again increased due to
breakdown in public health measure including emergence of drug resistance
• India: Plague in Gujrat (1994), Chikungunya (2005), Dengue (North), V.cholerae O139
(south east costal)
• MRSA, MDRTB, Leptospira (South, Andaman)

Table 7.1.10: Bioterrorism and classification of bioweapons (CDC)

Bioterrorism is a form of terrorism (unlawful use of weapon against mankind) where there is intentional and deliberate release of biological
agents (bacteria, viruses, or their toxins) to cause mass illness or death of people, animals, or plants
Category A: Agents are the highest-priority pathogens which pose the greatest risk to national security
• Can be easily disseminated • Anthrax (Bacillus anthracis)
or transmitted from person to • Botulism (Clostridium botulinum toxin)
person • Plague (Yersinia pestis)
• Result in high mortality rates • Tularemia (Francisella tularensis)
and have the potential for • Smallpox (Variola major)
major public health impact
• Hemorrhagic viruses
• Might cause public panic and
• Arenaviruses: Lassavirus
social disruption
• Bunyaviridae: Crimean-Congo virus,
• Require special action for
public health preparedness. • Filoviridae: Ebola, Marburg virus

Category B: These agents are the second highest priority pathogens

• Moderately easy to
disseminate,
• Result in moderate morbidity
rates and low mortality rates,
• Require specifically
enhanced diagnostic
capacity.
Section 7
• Melioidosis (Burkholderia pseudomallei)
• Glanders (Burkholderia mallei)
• Brucellosis (Brucella species)
• Psittacosis (Chlamydophila psittaci)
• Q fever (Coxiella burnetii)
• Typhus fever (Rickettsia prowazekii)
• Toxin: Ricin, S.auerus Enterotoxin B, Epsilon toxin of Clostridium perfringens
• Viral encephalitis [alphaviruses (e.g., Venezuelan, eastern, and western equine encephalitis)]

• Food threats-Salmonella, Shigella, E.coli O157

• Water threats: Vibrio cholerae, Cryptosporidium

Category C: These agents are the third highest priority pathogens.

They are the emerging pathogens, to which the general population lacks immunity
• These agents could be • Nipah virus
engineered for mass • Hantavirus
dissemination in the future • SARS coronavirus,
because of availability, ease • Pandemic influenza virus
of production, and ease of
• MDRTB
dissemination.
• Yellow fever virus
• They have a potential for
high morbidity and mortality
rates

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Table 7.1.11: Risk-based classification of agents causing laboratory-acquired infections

Group Definition Bacteria Virus Fungi Parasite
Group-1 Biological agents that are - - - -
unlikely to cause human No pathogenic organisms
disease
Group-2 Biological agents that can Bacillus species (except Adenovirus Cryptococcus All clinically
cause human disease and B.anthracis) Calcivirus Candida important
may be hazard to workers; Clostridium Coronavirus Dermatophytes parasites
but are unlikely to spread species (not SARS Co.V) Aspergillus
to community; effective Corynebacterium diph- Herpesvirus
treatment or prophylaxis is theriae Influenza virus
usually available Enterobacteriaceae
Staphylococcus
Streptococcus My-
cobacterium (except
M.tuberculosis)
Group-3 Biological agents that B.anthracis Prion
can cause severe human Brucella species LCM virus (Lymphocytic
disease and are a serious Coxiella burnetii choriomeningitis)
hazard to workers; they may Francisella tularensis, Hantavirus
spread to the community; M.tuberculosis SARS Co.V
but effective treatment Encephalitis virus such as-
or prophylaxis is usually
St.Louis
available
Japanese
West Nile
Western equine
Group-4 Same as group 3 except Lassa virus
that effective treatment or Ebola virus
prophylaxis is usually not Marbug virus
available Herpes simiae virus

MICROBIOLOGICAL PROFILE OF OSTEOMYELITIS

1. MC cause of osteomyelitis - S. aureus in all sites (hematogenous long-bone and Vertebral
and sternal). (Harrison 19th/p838-844)
2. Sickle cell disease-Salmonella osteomyelitis is frequently cause
3. IV drug users- P. aeruginosa is common (Harrison 19th/p844)
4. Diabetic foot osteomyelitis - Polymicrobial (MC is S. aureus followed by anaerobes and

Applied Microbiology
Gram negative like E.coli) (Harrison 19th/p845)
5. Implant­associated osteomyelitis- Coagulase-negative staphylococci (S. epidermidis) are
the second most common etiologic agents (after S. aureus). (Harrison 19th/p842)
6. Streptococcus agalactiae is common in children next to S. aureus
Ref: Harrison 19th/p 838-844, Other Journals and e Books

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MULTIPLE CHOICE QUESTIONS

8. Treatment of partner is required in all infections
URINARY TRACT INFECTIONS except: (PGI 2000)
1. Most common cause of UTI in neonate: a. Candida b. Herpes
 (Recent Question 2015) c. Trichomonas d. Gardnerella
a. E coli
b. S. aureus GASTROENTERITIS
c. Enterococcus
9. Food poisoning occurs in 6–7 hours by all Except: 
2. Route of infection for renal tuberculosis:
 (DNB June 2011)
a. Ascending route  (West Bengal 2016)
a. Staphylococcus b. E. coli
b. Hematogenous route
c. Clostridium d. Bacillus cereus
c. Direct
10. Food poisoning in canned food is caused by:
3. Most common nonlactose fermenting organism that
 (DNB Dec 2011)
causes UTI, in patient with catheter in situ:
a. Staphylococcus b. Salmonella
 (Recent Question 2015)
c. Clostridium botulinum d. Bacillus cereus
a. E. coli b. Proteus
c. Enterococcus d. Pseudomonas 11. Food poisoning that does not presents within 6 hours
is due to: (DNB Dec 2011, AIIMS Nov 2001)
a. Staphylococcus b. Salmonella
SEXUALLY TRANSMITTED DISEASES c. Clostridium botulinum d. Bacillus cereus
4. A young male patient presented with UTI, on urine 12. Microorganisms invading the GIT causing gastroen-
examination pus cells were found but no organisms. teritis: (PGI Dec 2007)
Which method would be best used for culture: a. EHEC
 (AIIMS Nov 2007, 2005, AI 2006) b. Shigella
a. McCoy cell line c. Vibrio parahemolyticus
b. Thayer Martin medium d. Campylobacter
c. LJ medium e. Salmonella
d. Levinthal medium 13. Traveller’s diarrhea is caused by:
5. A man presents to a STD clinic with urethritis and  (AIIMS Dec 2007, PGI DEC 2008)
urethral discharge. Gram stain shows numerous pus a. Shigella b. E. coli
cells but no microorganism. The culture is negative on c. E. histolytica d. Giardiasis
the routine laboratory media. The most likely agent is: 14. Thirtyeight children consumed eatables procured
a. Chlamydia trachomatis (AIIMS Nov 2007, 2002) from a single source at a picnic party. Twenty children
b. Hemophilus ducreyi developed abdominal cramps followed by vomiting
c. Treponema pallidum and watery diarrhea 6–10 hours after the party. The
d. Neisseria gonorrhoeae most likely etiology for the outbreak is: (AI 2003)
Section 7

6. A 30-year-old male patient presents with urethritis. a. Rotavirus infection

All of the following can be the causative agent except: b. Entero toxigenic E. coli infection
a. Neisseria gonorrhoeae (AIIMS Nov 2004) c. Staphylococcal toxin
b. Chlamydia trachomatis d. Clostridium perfringens infection
c. Trichomonas vaginalis 15. A cook prepares sandwiches for 10 people going for
d. Hemophilus ducreyi picnic. Eight out of them develop severe gastroenteritis
7. All of the following are sexually transmitted, except: within 4-6 hrs of consumption of the sandwiches. It is
a. Candida albicans (AI 2002) likely that on investigations the cook is found to be
b. Echinococcus the carrier of: (AIIMS Nov 2002)
c. Molluscum contagiosum a. Salmonella typhi b. Vibrio cholerae
d. Group B streptococcus c. Entamoeba histolytica d. Staphylococcus aureus

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16. Heat stable enterotoxin causing food poisoning is 24. MC organism to cause acute osteomyelitis:
caused by all the following except: (AI 02)  (Recent Question 2015)
a. Bacillus cereus a. Staphylococcus aureus
b. Yersinia enterocolitica b. E. coli
c. Staphylococcus c. Pseudomonas
d. Clostridium perfringens d. Streptococcus pyogenes
25. In which of the following condition, the spread of the
NORMAL MICROBIAL FLORA OF HUMAN rash is centrifugal? (Recent Question 2015)
a. Dengue b. Smallpox
BODY c. RMSF d. Erythema multiforme
17. Common natural flora of skin are: 26. Arthropod borne disease is/are: (PGI May 2012)
a. Streptococcus (PGI June 2009, PGI Dec 2008) a. Brucellosis b. Lyme’s disease
b. Staphylococcus aureus c. Borrelia recurrentis d. Malaria
c. Candida albicans e. Plague
d. Bacteroides fragilis 27. Tick is vector for: (PGI May 2012)
e. Propionibacterium acne a. Crimean Congo fever
18. Transient colonization is caused by: (PGI Dec 2008) b. Rocky Mountain spotted fever
a. HSV c. Epidemic typhus
b. Trichomonas vaginalis d. Endemic typhus
c. H. influenzae e. Scrub typhus
d. N. gonorrhoea 28. Which of the following virus is least likely to cross
e. Staphylococcus aureus placenta?  (AI 2011)
19. Which of the following is the main colonizer of a. Rubella b. Herpes simplex
sebaceous gland? (PGI June 2007) c. HIV d. HBV
a. Propionibacterium acnes 29. Most potential agent that can be used in bioterrorism
b. Diphtheria are a/e: (AI 2011)
c. Strept. pyogenes a. Plague b. Smallpox
d. Staph. aureus c. TB d. Clostridium botulinum
e. Candida
30. Atypical pneumonia is caused by all except:
20. In the gut, anaerobic bacteria outnumber the aerobes  (DNB Dec 2011)
by a ratio of: (AIIMS May 2006) a. Klebsiella b. Adeno virus
a. 10:1 b. 100:1 c. Chlamydia d. Hemophilus
c. 1000:1 d. 10,000:1
31. A 30-year-old person has fever and headache from
21. It is true regarding the normal microbial flora present 20 days. CSF values are following: glucose 38 mg/dl,
on the skin and mucous membranes that: (AI 2005) protein 60 mg/dl, lymphocytes pleocytosis with 20
a. It cannot be eradicated by antimicrobial agents
cells/mm3. Initial diagnosis should include:
b. It is absent in the stomach due to the acidic pH

Applied Microbiology
a. Indian ink smear of CSF  (PGI June 2011)
c. It establishes in the body only after the neonatal
b. AFB
period
c. Toxoplasmosis
d. The flora in the small bronchi is similar to that of the
d. HSV detection
trachea
32. Which of the following do not have a non-human
22. MC commensal gut flora in adult: (PGI 2000)
reservoir? (PGI June 2009)
a. Lactobacillus b. Bacteroides
a. Salmonella typhi b. N. gonorrhoea
c. E. coli d. Klebsiella
c. E. coli d. Clostridium tetani
e. Treponema pallidum
MISCELLANEOUS MICROBIOLOGY 33. Probiotics are useful for: (AI 2008)
23. IP < 4 weeks is for: (PGI May 2016) a. Necrotizing enterocolitis
a. Gonorrhea b. Hepatitis B b. Breast milk jaundice
c. Babesiosis d. Tertiary syphilis c. Hospital acquired pneumonia
e. Filariasis d. Neonatal seizures

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34. Biosafety precaution grade III is practiced in all of the 43. Post disaster, which of the following does not spread
following organisms except: (AIIMS Nov 2008) as epidemic? (AIIMS May 2014, AIIMS Nov 2013)
a. Human influenza virus a. Leptospirosis b. Food poisoning
b. St. Louis encephalitis virus c. Leishmaniasis d. Rickettsia
c. Coxiella burnetii e. Acute respiratory infections
d. Mycobacterium tuberculosis 44. Incubation period less than 5 days: (PGI Nov 2014)
35. All of the following cause hemolytic uremic syndrome a. Salmonella b. Yersinia pestis
except: (AIIMS May 2007, PGI Dec 2007) c. Vibrio parahemolyticus d. Staphylococcus aureus
a. Shigella b. Campylobacter e. Measles
c. EHEC d. Vibrio cholerae 45. Community acquired pneumonia is caused by:
36. Loeffler’s syndrome occurs in all except: a. Staphylococcus aureus (PGI Nov 2014 )
 (AIIMS May 2007) b. Streptococcus pyogenes
a. Toxocara b. Strongyloides c. Mycoplasma pneumoniae
c. Ascaris d. Giardia d. Chlamydiapneumoniae
e. Legionella pneumophila
37. Vaccination causing Intussusception: (PGI Dec 2007)
a. Rotavirus b. Parvovirus 46. Which of the following agent-disease combinations
c. Poliovirus d. BCG are correct? (PGI Nov 2014)
a. Lymes-Boreliaburgdoreferi
e. Measles
b. Catscratch- Bartonellahensale
38. A veterinary doctor had pyrexia of unknown origin. c. Glanders– Burkholderia mallei
His blood culture in special laboratory media was d. Rat bite fever- Borreliarecurrentis
positive for gram-negative short bacilli which was e. Trench fever- Bartonellabaciliformis
oxidase positive. Which one of the following is the
47. Relative bradycardia is a feature of all except:
likely organism grown in culture? (AI 2006)
 (TNPG 2014)
a. Pasteurella spp b. Francisella spp
a. Typhoid b. Malaria
c. Bartonella spp d. Brucella spp
c. Brucella d. Leptospira
39. The single most common cause of pyrexia of unknown 48. Quantitative cultures are necessary for laboratory
origin is: (AIIMS May 2006) diagnosis in infection of: (MHPG 2014)
a. Mycobacterium tuberculosis a. Urinary tract b. Blood stream
b. Salmonella Typhi c. Lungs d. Small intestine
c. Brucella sp
49. Population doubling time in coliform bacilli is:
d. Salmonella paratyphi A
 (MHPG 2014)
40. Acute intravascular hemolysis can be caused by a. 20 seconds b. 20 minutes
infection due to all of the following organisms except: c. 20 hours d. 20 days
a. Clostridium tetani (AIIMS Nov 2003, AI 2003) 50. Zoonotic diseases are all except: (PGI Nov 2014)
b. Bartonella bacilliformis a. Leptospirosis b. Guinea worm
c. Plasmodium falciparum c. Rabies d. Plague
d. Babesia microti e. Japanense encephalitis
41. A neonate develops encephalitis without any skin 51. Class C biological terrorism is by: (PGI May 2016)
Section 7

lesions. Most probable causative organisms is: a. Hanta virus b. Ebola virus
 (AIIMS May 2002) c. Crimean Congo virus d. HIV
a. HSV I b. HSV II e. Marburg virus
c. Meningococci d. Streptococci 52. New infectious agents are:
42. Zoonotic diseases are all except: (PGI Dec 2001) a. Nipah virus (PGI Dec 2007, PGI Dec 2004)
a. Typhoid b. Anthrax b. Pneumocystic jieruveci c. Corona virus
c. Rabies d. Q fever d. SARS e. Prion

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 Clinical Microbiology (Infective Syndromes) 525

EXPLANATIONS

URINARY TRACT INFECTIONS

1. Ans. (a) (E. coli) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p586
2. Ans. (b) Hematogenous route Ref: Apurba Sastry's Essentials of Medical Microbiology 1/e p273
M.tuberculosis enters through descending or Hematogenous route.
3. Ans (d) (Pseudomonas) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p340
Pseudomonas is the MC organism to cause UTI in catheterized patients and it produces NLF colonies on MacConkey agar.

SEXUALLY TRANSMITTED DISEASES

4. Ans. (a) (McCoy cell lines) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p403, Harrison 18/e p1097
This is a case of non-gonococcal urethritis due to Chlamydia trachomatis.
Chlamydia trachomatis can be successfully cultivated in McCoy and HeLa cells treated with cycloheximide and grown in
monolayer on cover slip in shell vials .….Jawetz 24/e p360
5. Ans. (a) (Chlamydia trachomatis) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p403, Harrison18/e p1097
• This is a case of STD with history of urethritis and organism does not grow in culture and not seen by Gram stain.
• Chlamydia trachomatis is the most appropriate answer
• Neisseria gonorrheae: can be diagnosed by Gram staining and also by Culture techniques.
6. Ans. (d) (Hemophilus...) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p343, Ananthanarayan 8/e p230
• Hemophilus ducreyi can cause genital ulcer but not urethritis.
7. Ans. (b) (Echinococcus) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p604, Harrison 18/e p1095, 16/e p763
• Refer chapter review for detailed explanation.
8. Ans. (a) and (d) (Candida and Gard...) Ref: Apurba Sastry’s Microbiology 1/e p604, Harrison 18/e p1110-11, 17/e p828
Treatment of sexual partner is required for:
• Chlamydia trachomatis
• Neisseria gonorrhoea
• Trichomonas vaginalis
• Herpes simplex virus
• Mycoplasma genitalium.
Treatment of sexual partner is not required:
• Vulvovaginal Candidiasis: Usually treatment of sexual partner is not required, topical treatment if candidal dermatitis

Applied Microbiology
of penis is detected
• Gardnerella vaginalis: No treatment is required.

GASTROENTERITIS
9. Ans. (b) (E. coli) Ref : Harrison 18/e p1088, 17/e p877-78 and Apurba Sastry’s Essentials of Medical Microbiology 1/e p589
• Staphylococcus aureus, Bacillus cereus (emetic type) and Clostridium botulinum are the causative agents for Toxic
type of food poisoning, where symptoms manifests with in 6 hours.
• E. coli and Salmonella spp cause infective type of food poisoning wherein symptoms manifest after 16 hours.
• Detailed explanation refer chapter review.
10. Ans. (c) (Clostridium botulinum) Ref: Park 22/e p217
• The most common food associated with botulism are home preserved foods such as home canned vegetables, smoked
or pickled fish, homemade cheese and similar low acid food.
11. Ans. (b) (Salmonella) Ref: Harrison 18/e p1088 and Apurba Sastry’s Essentials of Medical Microbiology 1/e p588
• Already explained.

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 526 Review of Microbiology and Immunology

12. Ans. (a), (b), (c), (d) and (e) (EHEC, Shigella, Vibrio parahemolyticus, Campylobacter and Salmonella)
Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p588-90
Microorganisms invading the GIT causing Dysentery:
• Bacteria: Shigella, E. coli (EIEC, EHEC), Y. enterocolitica, Campylobacter jejuni, V. parahemolyticus, Salmonella
• Protozoa: E. histolytica, Balantiduim coli.
13. Ans. (b) (Escherichia coli) Ref: Harrison 18/e p1087, 17/e p816
Causative agents of traveler’s diarrhea: Refer chapter review
‘In all areas, Enterotoxigenic and Enteroaggregative E. coli are the most common isolates from persons with the classic
secretory traveler’s diarrhea syndrome’.
14. Ans. (d) (Clost...) Ref: Harrison 18/e p1088, 17/e p877-78 and Apurba Sastry’s Essentials of Medical Microbiology 1/e p589
The onset of food poisoning with in 6–10 hours of consumption of food is mainly due to
• Clostridium perfringens
• Bacillus cereus (diarrheal type)
About other options already explained.
15. Ans. (d) (Staphylococcus aureus) Ref: Harrison 18/e p1088, 17/e p877-78 and Apurba Sastry’s Essentials of Medical Micro-
biology 1/e p589
The onset of food poisoning with in 4–6 hours of consumption of food is mainly due to:
• Staphylococcus aureus
• Bacillus cereus (emetic type)
• Clostridium botulinum.
16. Ans. None of the above
• Bacillus cereus can secrete both heat stable (emetic type) and heat labile (diarrheal type) Enterotoxins Ref: Apurba
Sastry’s Essentials of Medical Microbiology 1/e p256
• Yersinia enterocolitica produces heat stable enterotoxin Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e
p315
• Staphylococcus aureus produces heat stable enterotoxin Ref: Ananthanarayan 8/e p247, Apurba Sastry’s Essentials of
Medical Microbiology 1/e p212
• Clostridium perfringens food poisoning can be caused by both heat resistant and heat labile spores which germinate
and produce enterotoxin Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p259

NORMAL MICROBIAL FLORA OF HUMAN BODY

17. Ans. (a), (b), (c) and (e) (Sterptococcus, Staphylococcus aureus, Candida albicans and Propionibacterium acne)
Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p581-83, Ananthanarayan 8/e p588 and p268
Refer chapter review for skin flora.
18. Ans. (a), (b) and (e) (HSV, Trichomonas vaginalis and Staphylococcus aureus) Ref: Apurba Sastry’s Essentials of Medical
Microbiology 1/e p581-82
The skin and mucous membranes have 2 types normal flora:
Section 7

• Resident flora: Consists of relatively fixed types of microorganisms regularly found in a given area at a given age; if
disturbed, it promptly reestablishes itself and cannot be removed permanently.
• Transient flora: Consists of nonpathogenic or potentially pathogenic microorganisms that inhabit the skin or mucous
membranes for hours, days, or weeks; it is derived from the environment, does not produce disease, and does not
establish itself permanently on the surface.
○○ Transient flora is of little significance so long as the normal resident flora remains intact.
○○ If the resident flora is disturbed, transient microorganisms may colonize, proliferate, and produce disease.
○○ Members of transient flora: Microorganisms other than coagulase-negative Staphylococci, Corynebacterium
spp., Micrococcus spp., Bacillus spp. Candida spp., Trichomonas vaginalis, Neisseria meningitides, CMV, HSV,
Malassezia, Enterococcus, Bacteroides, M. smegmatis, Fusobacterium.
19. Ans. (a) (Propionibacterium acnes) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p582
• Propionibacterium acnes are the commonest agent causing acne in teenagers as it has affinity for sebaceous glands.
• Lesions in acne develop with in the sebaceous follicle.

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 Clinical Microbiology (Infective Syndromes) 527

20. Ans. (c) (1000:1) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p582-83, Ananthanarayan 8/e p265
• In the human intestines, Anaerobes out number aerobic bacteria a thousand fold.
21. Ans. (a) (It cannot be eradicated by antimicrobial agents) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e
p581, Ananthanarayan 8/e p633
• Resident Normal flora: Consists of relatively fixed types of microorganisms regularly found in a given area at a given
age; if disturbed, it promptly reestablishes itself and cannot be removed permanently.
22. Ans. (b) (Bacte...) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p581-83, Ananthanarayan 8/e p636 and p265
• In the human intestines, Anaerobes out number aerobic bacteria a thousand fold
• Among anaerobes Bacteroides are in predominant number in human gut flora.

MISCELLANEOUS MICROBIOLOGY
23. Ref: (a, c) (Gonorrhea, Babesiosis) Ref: Apurba Sastry's Essentials of Medical Microbiology/p239,374, parasitology/
p115,269
• IP of Gonorrhea- 2-7 days, hepatitis B- 30-180 days, babesiosis- 1-6 weeks,
• IP of tertiary syphilis- 10-30 years, filariasis- 8-16 months
24. Ans. (a) (Staphylococcus aureus) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p215
25. Ans. (d) (Erythema multiforme) Ref: Internet source

Spread (means direction of movement of rash), Distribution (means area where rashes are predominant)
• Centripetal spread = Rashes appear first on periphery, spread towards trunk, e.g. Smallpox
• Centrifugal spread = Rashes appear first on trunk/face, spread towards periphery, e.g. Chickenpox
• Centripetal distribution = Rashes are mainly on trunk, e.g. Chickenpox
• Centrifugal distribution = Rashes are mainly on extremities, e.g. Smallpox.
For most rashes, centripetal/fungal terms are described for spread of rash; where as in chickenpox and smallpox
usually they are described in terms of distribution of rash.
Rashes with centrifugal spread (body/face first, then spread towards periphery):
• Erythema multiforme, Epidemic typhus, Endemic typhus
• Measles, Rubella, Herpes
• Chickungunya
• Chickenpox (Centrifugal spread, but Centripetal distribution).
Rashes with Centripetal spread (periphery first, then spread towards body/face):
• Coxsackie Virus, Eczema herpeticum/Kaposi sarcoma
• Syphilis (secondary), Dengue fever and Rocky mountain spotted fever
• Smallpox (Centripetal spread, but centrifugal distribution).

Applied Microbiology
26. Ans.(b) (c) (d) (e) (Lyme’s..., Borrelia..., Malaria, Plague) Ref: Apurb Sastry's Essentials of Parasitology 1/e p315
27. Ans. (a) (b) (Crimean Congo fever, Rocky Mountain spotted fever) Ref: Apurb Sastry's Essentials of Parasitology 1/e p315
Refer table in the appendix.
28. Ans. (b) (Herpes Simplex) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p604
Among the given option, HSV is the most appropriate answer.
Agents causing congenital infection by transplacental transmission: Refer chapter review.
29. Ans. (c) (TB) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p627, Patrick R Murray 9/e p108
Classification of Agents of Bioterrorism: Refer chapter review
• Category A (e.g. of Smallpox, plague, Cl. botulinum) agents are most potential agents that can be used as bioweapons.
30. Ans. (a ) (Klebsiella) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p600
• Klebsiella infects alveoli and can cause lobar/typical pneumonia.
31. Ans. (a) (b) (d) (Indian ink smear of CSF, AFB, HSV detection) Ref: Apurba Sastry’s Essentials of Medical Microbiology
1/e p594, Harrison 18/e p3418

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 528 Review of Microbiology and Immunology

• The combination of unrelenting headache, stiff neck, fatigue, night sweats, and fever with a CSF lymphocytic pleocytosis
and a mildly decreased glucose concentration is highly suspicious for tuberculous meningitis. Harrison 18/e p3426
• So if it was a single response question, I would prefer to go with tuberculous meningitis
• But in a multi choice format we should analyze further.
32. Ans. (a), (b) and (e) (Salmonella typhi, N.gonorrhoea and Treponema pallidum) Ref: Apurba Sastry’s Essentials of Medi-
cal Microbiology 1/e p631, Ananthanarayan 8/e p288 and p373
• S. Typhi, N. gonorrhea and Treponema pallidum are exclusively human parasites
33. Ans. (a) (Necrotizing enterocolitis) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p584
• Probiotics are substances secreted by one organism which stimulates the growth of another.
Probiotics are useful in following conditions:
• Rota virus diarrhea
• Antibiotic associated diarrhea
• Radiation induced diarrhea
• Traveller’s diarrhea
• Inflammatory bowel disease
• Cancers.
34. Ans. (a) (Human...) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p630, Patrick R Murray 9/e p98
Risk based classification of microorganisms. Refer chapter review.
Human influenza virus is Biosafety grade II virus.
35. Ans. (d) ( Vibrio cholerae) Ref: Harrison 17/e p963, 967 and 1814
Causative agents of hemolytic uremic syndrome:
• Entero Hemorrhagic E. coli- MC
• Shigella dysenteriae
• Campylobacter
• Salmonella spp.
36. Ans. (d) (Giardia) Ref: Apurba Sastry’s Essentials of Medical Parasitology 1/e p245
• Loeffler’s syndrome occurs due larval migration through lungs during its life cycle.
• It is observed in following parasitic infections:
○○ Strongyloides stercoralis
○○ Ascaris lumbricoides
○○ Toxocara: Larva migrans.
37. Ans. (a) (Rotavirus) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p526, Jawetz 25/e p511, 24/e p506
• An oral live attenuated rhesus based vaccine was licensed in U.S. in 1998 for vaccination of infants
• But was withdrawn a year later because of reports of Intussusception (bowel blockages).
38. Ans. (d) (Brucella spp) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p356, Ananthanarayan 8/e p340-343
Points in favor of Brucellosis:
• Veterinary doctor: Occupational exposure to infected animals
• Organism could grow only in special laboratory media
Section 7

• Oxidase positive Gram-negative short bacilli

• Brucellosis is one of the common cause of PUO.
39. Ans. (a) (Mycobacterium tuberculosis) Ref: P Apurba Sastry’s Essentials of Medical Microbiology 1/e p597
Infectious causes of pyrexia of unknown origin (PUO)- refer chapter review
40. Ans. (a) (Clostridium tetani) Ref: Harrison 17/e p712
• Organisms that parasitize RBCs can directly lyse them and can cause intravascular hemolysis.
• Intracellular parasites; reside within RBCs: Plasmodium spp., Babesia spp., Bartonella baciliformis
• Clostridium tetani is not intracellular parasite; it can cause hemolysis indirectly by production of tetanolysin toxin, but
it not intravascular hemolysis.
41. Ans. (b) (HSV-II) Ref: OP Ghai 6/e p526-27
• Among the given options HSV-II and Meningococcus can cause meningoencephalitis

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 Clinical Microbiology (Infective Syndromes) 529

• Meningococcal meningitis will be associated with skin rashes and it rarely occurs in neonates as they are protected by
maternal antibodies
• HSV-II encephalitis can occur in neonates, it can manifest with or without skin lesions.
42. Ans. (a) (Typhoid) Ref: B Apurba Sastry’s Essentials of Medical Microbiology 1/e p631, and PSM Park 19/e p642
Causative agents of Zoonosis - Refer chapter review
Bacteria Viruses Parasites
Bovine tuberculosis Rabies Leishmanaisis
Bubonic plague JE Babesiosis
Q fever Monkey pox Toxoplasmosis
Brucellosis Yellow fever Taeniasis
Bacillus anthrax Cow pox Hydatid disease
Salmonella food poisoning Fungus Trichinellosis
Leptospirosis Microsporum canis Schistosomiasis
Trichophyton verrucosum Trypanosomiasis
• Enteric fever causing Salmonellae like S. Typhi and S. Paratyphi are exclusively human Pathogens.
43. Ans. (c) (Leishmaniasis) Ref: Park 22/e p742, WHO Website- Communicable diseases following natural disasters.
• Diseases associated with natural disaster:
• Waterborne diseases: E. coli, V. cholerae, Hepatitis A and E and Leptospirosis
• Over-crowding: Measles, Meningitis and Acute respiratory infections
• Vector-borne diseases: Disaster can affect vector breeding sites and vector-borne disease transmission, e.g. Malaria and
Dengue
• Zoonoses: Rickettsiosis, Equine encephalitis and Rabies
• Other associated diseases: Tetanus, Coccidiomycosis.
44. Ans. (b) (c) (d) (Yersinia pestis, Vibrio parahaemolyticus, Staphylococcus aureus) Ref: Apurba Sastry’s Essentials of Med-
ical Microbiology 1/e p313,319,214 Ananthanarayan 9/e p206, 322, 311,295
Incubation period
• Salmonella: 10–21 days
• Yersinia pestis: Bubonic plague- 2–7 days, Pneumonic plague- 1–3 days
• Vibrio parahaemolyticus: 3 days (4 h to 4 days)
• Staphylococcus aureus food poisoning: 1–6 hrs
• Measles 10 days.
45. Ans. (a), (c),(d),(e) (Staph.., Mycoplasma…, Chlamydia…, Legionella..) Ref: Harrison 18/e Table 257-2
46. Ans. (a) (b) (c) (Lymes-Borelia burgdoreferi, Cat scratch—Bartonella hensale, Glanders – Burkhulderia mallei)
Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p631, Ananthanarayan 9/e p380, 412, 317, 398
• Rat bite fever: Streptobacillus moniformis
• Trench fever: Bartonella quintana.

Applied Microbiology
47. Ans. (c) (Brucella) Ref: Journal: Significance of relative bradycardia, Clinical Microbiology and Infection/2000.
Brucella is an intracellular Gram-negative organism but is not associated with relative bradycardia.
Causes of relative bradycardia
• Infectious causes: Legionella, Psittacosis, Q fever, Typhoid fever, Typhus, Babesiosis, Malaria, Leptospirosis, Yellow
fever, Dengue fever, Viral hemorrhagic fevers, Rocky Mountain spotted fever
• Non-Infectious causes: β-blockers, CNS lesions, Factitious fever, Lymphomas, Drug fever.
48. Ans. (a) (Urinary tract) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p586, Ananthanarayan 9/e p162
As few number of bacilli may be there in urine sample due to contamination with periurethral flora, hence quantitation of
bacteria in urine is MUST for the diagnosis of UTI.
49. Ans. (b) (20 minutes) Ref: Apurba Sastry’s Essentials of Medical Microbiology 1/e p26,Ananthanarayan 9/e p22
• Population doubling time or the generation time of:
E. coli- 20 min, M. tuberculosis- 20 hr and M. leprae- 20 days
50. Ans. (b) (Guinea worm) Ref: Apurba Sastry’s Essentials of Medical Parasitology 1/e p282
Guinea worm infection is transmitted to Man by drinking fresh water from stagnant pools containing minute fresh water
crustaceans (Cyclops) infected with L3 larva.

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 530 Review of Microbiology and Immunology

51. Ans. (a) (Hanta virus) Ref: Apurba Sastry's Essentials of Medical Microbiology/p628, Harrison 19th/261e
• Class C biological terrorism include: Emerging infectious diseases threats such as Nipah, hantavirus, SARS or MERS
coronavirus, and pandemic influenza.
• Ebola, Crimean Congo and Marburg viruses belong to Class A.
52. Ans. (a), (c), (d) (Nipah virus, Corona virus, SARS) Ref: Apurba Sastry’s Essentials of Medical Microbiology/p625, Har-
rison 18/e p1007,17/e p749 and B. Arora’s Microbiology 3/e p689-691
• Emerging infectious diseases are defined by WHO
• Those infections, the incidence of which in humans has either increased during the last 2 decades or threatens to
increase in near future
• These are newly appearing infectious diseases or those spreading to new geographical areas.
Section 7

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