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Genus Staphylococcus
Genus streptococcus
facultative anaerobe
forms large amount of lactic acid as end product
of CHO
metabolism
Genus Enterococcus
Genus Neissera
Morphology:
1. gram + ovoid or lancet-shape organism
2. pair/chain arrangement
3. non-motile, nonsporeformer, noncapsulated
except S. pneumoniae
Pathogenesis:
= during medical/surgical
procedure of GI or GU
tract organism bloodstream
previously
damage heart valve
endocarditis
Species:
A. Pathogenic
1. N. gonorrhoeae
2. N. meningitidis
B. Non Pathogenic
= considered a normal flora of URT
&
other mucosal surfaces of the body
= non-fastidious and grows on NA
1. N. sicca
2. N. flava / flavescence
3. N. catarrhalis
Genus Staphylococcus
Staphylococcus aureus
Staphylococcus epidermides
Most pathogenic
Morphology:
= gram + cocci
= arranged charac. grape-like or irregular clusters
= size 0.8 1.0u dia
= nonmotile, nonsporeforming, noncapsulated (mutant strain have capsule &
more pathogenic)
= produce lipochrome golden yellow pigment
Ultrastructure and Cell Wall composition:
3 major components:
1. Peptidoglycan
= polysaccharide polymer which provide rigid exoskeleton
of the cell wall
= const. 40 60% cell weight
= composed of acetyglucosamine & acetylmuramic acid (responsible for
rigidity)
2. Teichoic Acid
= polymer of ribitol phosphate (S. aureus)
glycerol phosphate (S. epidermides)
= essential component of phage receptor
= plays important role in maintenance of normal physiologic function of cell.
= regulate the cationic environment of cell thus
controlling the activity of autolytic enzyme
resp. for growth of cell wall.
3. Protein A
= major protein component of cell wall
= major antigenic determinant unique to S. aureus
= a group specific antigen protein of S. aureus
= antiphagocytic
Cultural / Biochemical Characteristic:
= Facultative anaerobe
= catalase and coagulase (+)
= ferments many carbohydrates-lactic acid without gas
= opt. temp. 30-370C opt. ph 7-7.4
= halophilic (can tolerate high conc. of salt 5-10%NaCl)
= penicillin resistant due to beta-lactamase production
= requires enriched media for growth
1. Sheep blood agar
(culture media - primary isolation) incub. for 24 hrs. at 370C colonies
smooth , circular, opaque, golden yellow sorrounded with complete zone of
beta-hemolysis.
Staphylococcus saprophyticus
Saprophytic & opportunistic
found normally in human skin, peri-urethral &
urethral area
catalase (+) coagulase (-) non mannitol
fermenter
A lemon-yellow colonies, non hemolytic
Novobiocin and Nalidixic acid resistant
Genus streptococcus
Streptococcus pyogenes
Streptococcus Agalactiae
Streptococcus
pneumoniae
Group B Streptococcus
Pneumococcus / Diplococcus
Pneumoniae
Frankels Pneumococcus
Viridans
streptococci
Species:
S. salivarius
Enterococcu
s faecalis
S. mitis
S. mutans
sanguis
S.
Genus D
Streptococcus
Enterococci
found normally
in the large
intestine of
human
Morphology :
= gram (+) ovoid shaped
= pair or short chain
arrangement
= non-sporeforming , non-motile
= some strain encapsulated
(polysaccharide capsule)
Cultural :
= BA- large mucoid flat creamy
with beta-hemolysis
= halophilic (grows in 6.5 % NaCl)
= bile soluble, catalase (-)
= hydrolyze sodium hippurate
= CAMP test positive
= Bacitracin resistant
= PYR negative
unbiquitous organism
resist classification by
Lancefield (do not posses
the group specific
antigen in the cell wall)
Disease associated
includes:
1. Subacute Bacterial
Endocarditis
2. Dental caries S.
mutans
S. agalactiae- resistant
B) PYR test (+) - demonstrate
presence of pyrrolidonyl
arylamidase
C. Catalase (-)
Determinants of Pathogenicity
:
Pathogenicity is due to array of
surface antigens, toxins and
enzymes produced.
1. Cellular components:
A) Lipoteichoic Acid (LTA)
= allows org. to cling to epith.
surfaces
= cytotoxic (destroys rbc, wbc)
B) M protein antigen
= most important virulence factor
= aid in the attachment of the
organism to
portal of entry
= antiphagocytic
C) Capsule (Hyaluronic acid)
= non-immunogenic
= antiphagocytic
2. Extracellular Enzymes:
A) Streptodornase (Streptococcal
DNAse)
= facilitate removal of purulent
exudate/discharges B)
Streptokinase (Fibrinolysin)
= helps lyze fibrin clot and plays
an important role
in the invasion & spread of
infection
C) Hyaluronidase
= hydrolyzes hyaluronic acid
found in the connective
tissue of the host which
facilitate or promote
spread of infection
D) Diphosphopyridine
nucleotidase
= cytolytic, kills WBC, PMN &
Macrophages
3. Toxins (metabolic product
Pathogenicity:
1) Polysaccharide Capsule
(antiphagocytic)
= major virulence factor
2) Adherence factor (F Ag and M
protein)
= resp. for attachment and
colonization
3) Enzymes
A) Neuraminidase
= responsible for invasiveness
of organism and help
in the colonization in the
nasopharynx
B) IgA Protease
= facilitate colonization and
attachment to mucosal
surfaces
4) Toxins
A) Pneumolysin O
= a hemolysin that damage
respiratory epithelium
= potential factor inhibiting
phagocytosis
= role unknown in the
pathogenesis of infection
Clinical infection:
1 & 2 most common cause of
1) Lobar pneumonia
= most common bacterial
pneumonia among elderly
patient especially with COPD
= man only host infection
= 5 50% healthy individual
harbors organism nasopharynx
= transmission is person
person by respiratory
droplet
= Predisposing Factors:
1) COPD
2) Alcoholism
3) Congestive heart failure
4) Malnutrition
Clinical Manifestation:
= fever, chill, cough, pleuritic
pyogenes
1. Skin infection Impetigo,
Pyoderma, Cellulitis,
Erysepelas, Scarlet fever
2. Upper resp. tract Sore
throat/Pharyngitis, Quincy,
Ludwigs angina
3. Uterus Puerperal fever
Post streptococcal (Nonsuppurative infection)
( sequelae to acute streptococcal
infection )
A) Acute Rheumatic Fever
= occur 1 4 weeks after URT
infection
= manifested as polyarthritis ,
carditis , chorea , fever,
erythema marginatum
B) Acute Glomerulonephritis
= occurs 2 3 weeks after
untreated skin
infection
(Impetigo)
Lab. Diag.:
1. Bacteriological
2. Culture BA
3. Bacitracin test
4. Serological
Rantz Randall (ASO Titer test) determines rise ASTO antibody (+)
200 todd unit
Treatment :
Benzathine PCN given for 10
days IM
Allergic patient Erythromycin,
Clindamycin, Cephalexin
Lab. Diagnosis :
1) Bacteriological (GS)
presumptive
= specimen includes CSF,
pleural fluid, blood
& body fluids
2) Culture
3) Serotyping Identification
Latex aggl. test(Confirmatory)
Treatment:
PCN G (antibiotic choice)
Erythromycin, Chloramphenicol,
Cephalosporin
Lab. Diag.:
1) Bacteriological (direct sputum
examination - gram stain)
= specimen mucus
expectorated sputum
from
lungs/CSF
= gram (+) lancet-shaped
diplococci (Presumptive)
2) Quellung Rx - detect
pneumococcal capsular antigen
in CSF, pleural and joint fluids
(+) capsular swelling
3) Culture (CSF, pleural fluid)
= specimen for culture should be
planted
immediately on enriched media
(BHIA/BA)
= incubated overnight with 5 10% CO2
= dome shaped colonies
with alpha hemolysis
4) Serological
A) Latex particle agglutination
test (capsular Ag)
B) CIE - detect pneumococcal
antigen
(sputum and nasopharyngeal
secretion)
Lab. Diag:
1. Bacteriological GS
2. Culture BA incub. 5
10% CO2
Treatment:
PCN (drug of choice)
1) Optochin Sensitivity
= currently the most widely used
presumptive test
= filter paper disc impregnated
with ethyl hydrocuprine
HCl (optochin) streak on surface
of blood agar
plate with previous culture of S.
pneumoniae
= incubated in a candle jar for
24 hours at 370C
= (+) zone of inhibition indicates
sensitivity to organism
2) Bile Solubility
= pneumococci produced
autolytic enzyme (amidase)
which activates surface active
agents like bile/ bile salt (NA
dexoxycholate or NA
taurocholate)
resulting in lysis of organism.
= test not absolute because
there are pneumococci not
lyzed by bile salt and there are
other alphahemolytic streptococci that are
lyzed by bile salt
3) Newfeld Quellung test
(Capsular Precipitation)
= most accurate and reliable
specific method for
identification
= uses antipneumococcal
antisera + sputum +
methylene blue. Mix & observe
microscopically
= capsules repractile and
swollen (+)
4) Mouse Virulence Test
= intraperitoneal inoculation of
sputum with
pneumococci to susceptible
animal.
Observe after 16-24 hours
death occurs.
Prevention:
= Pneumococcal Vaccine
(Pneumo 23)
(polyvalent vaccine contg. 12
most commonly)
isolated
Prevention:
= patient with damage
heart valve should be
given prophylactic PCN
before dental
serotypes
= 90% protective
= should not be given to
children under 2 years old
Prevenar vaccine for children 2
years and below
manipulation
Genus Neissera
*N. gonorrhoeae*
(Gonococcus)
Morph, Cultural & Biochemical charac.
= gram (-) coffee bean shaped diplococci
= non motile, non capsulated
= piliated (organ of virulence) & plays a major role in the attachment to mucosal
surfaces establish infection
= fastidious, requires enriched media for growth
heated blood incubated with 5-10% CO2
Chocolate agar (non-selective medium)- sterile material
Thayer Martin (selective diff.)- contaminated mat.
= aerobic & capnophilic
= 20% strain req. glutamine for primary isolation
Antigenic Structure:
= 3 major classes of antigen
1. Pilus antigen
2. Lipooligosaccharide
3. Outer membrane protein
Determinants of Pathogenicity:
1. Pili (hair-like appendages)
= found in T1 T2 piliated colonies associated with
virulence
= mediate attachment to the mucosal epith. allowing them to cause disease
= antigenic & antiphagocytic
2. Outer membrane protein (Adhesin / Protein II)
= also associated with virulence
= involve in adherence of the org. to host cell
= structural antigen used in serotyping gonococci
= antigenic
3. IgA Protease
= facilitate adherence & colonization at mucosal
surfaces to initiate infection
4. Peptidoglycan
= contribute to the pathogenesis of gonococcal
infection
Disease Produced: Gonorrhea (flow of seed)
= most common of the classic sexually transmitted disease
= involves the mucous membrane of the GUT, rectum, throat, eye
= charac. by painful urination accpd. with yellowish purulent urethral discharge
= 80% (documented patient) highest incidence in most sexually active group
between 15-30 yrs. old
= Transmission:
1) Sexual contact
2) Among pregnant mothers with
Gonorrhea during childbirth
3) Extra-genital transmission
homosexual ( Fellatio )
Epidemiology/Pathogenesis:
= infection occurs only in human
= MOT - sexual contact, during birth
= primary infection usually begins at the columnar epithelium of
the urethra, periurethral duct and glands of either sexes
= genitourinary tract, cervix, conjunctiva and rectal mucosa
serve as portal of entry
= source of infection from exudate and secretions coming from
sites mentioned
= incubation period 2 8 days
= organism penetrate to the mucous membrane of urethra by means of pili causing
inflammation accompanied
with pain during urination and yellowish purulent urethral
discharge
Clinical Infection:
Male:
= 10% of infected men are asymptomatic carrier of the
organism and may transmit the organism to
consort causing symptomatic gonorrhea, 50%
of cases undiagnosed
= primary site urethra
= males present as primary complaint a burning
sensation & pain during urination accompanied
w/ purulent yellowish urethral discharges
(pus at tip of penis)
= both asymptomatic and symtomatic male can pass
the infection to another sexual partner
= approximately 1% develop complication the most
common being: Urethral Stricture,
Epididymitis & Prostatitis
Female:
= 20-80% asymptomatic infection common
= organism thrive cervix, fallopian tube and other area in the female genital tract
= charac. by frequent painful urination, purulent
vaginal discharge, fever & abdominal pain
= major complication include:
2. Somatic Ag.
= nucleoprotein antigen
= common to all neisseria species
3. Outer membrane protein
5 classes 1, 2, 3, 4, 5
class 5 highly immunogenic produce vaccine
against meningococcimia
Determinants of Pathogenicity
1. Polysaccharide capsule
= major virulence factor
= contribute to the invasiveness by inhibiting phagocytosis
2. Endotoxin (LPS)
= found in the outer membrane causing extensive tissue
necrosis, hemorrhage, circulatory collapse, intravascular
coagulation, shock and petechial hemorrhages due to
destruction of the blood vessel
= released in the cell of vascular endothelium causing vascular
necrosis inducing inflammatory response
3. IgA protease
= facilitates adherence and colonization in the oropharynx
= may contribute to the ability of the organism to produce
disease
Epidemiology :
= worldwide in distribution
= responsible for 20% of meningitis infection
= second commonest cause of the disease
= disease appears sporadically or in epidemic among
military personnel's
= peak incidence is in children 6-24 months of age
Pathogenesis :
= reservoir of infection-human nasopharynx
= incubation period 1 week
= portal of entry URT inhalation of respiratory droplet
Homosexual :
= infection commonly involve the rectum & pharynx
= charac. constipation, proctitis & painful defecation
= gonococcal pharyngitis, gonococcal stomatitis may
occur charac. by presence of exudate in the
pharynx, buccal mucosa and tongue
Newborn:
= infection is contracted during passage through an
infected birth canal
= eye most common site of infection among infant Gonococcal Opthalmia
Neonatorum
------ characterized by severe bilateral purulent conjunctivitis which occurs in the first
or second day of life and can damage the cornea causing blindness
Prevention = instillation of 1% silver nitrate (Argyrol) to
both eyes to all infants at birth followed by
Tetracycline/Erythromycin ophthalmic
Lab. Diag:
1) Bacteriological Gram staining of urethral discharge for both
sexes (male & female patient)
= other specimen includes purulent discharge/exudates
from eye, throat, vagina, endocervix, rectal area,
synovial fluid
= demonst. gram () diplococci intracellular/extracellular
with numerous neutrophil
Fluorescent antibody test more sensitive and specific for
macroscopic diagnosis
2) Culture
= Thayer Martin (Selective-differential) for unsterile
specimen (cervix, vagina, rectum, urethra, pharynx)
= Chocolate Agar (Non Selective) for sterile specimen
disseminate to bloodstream
Treatment :
Penicillin G ( drug of choice 0.05mg)-administered IV 4-6 hours
Ceftriaxone
Chloramphenicol for PCN sensitive individual
Supportive measures for possible complication like shock &
intravascular coagulation
Prevention :
Vaccination - Meningococcal Vaccine
(purified capsular polysaccharide antigen contg.) serotypes A, C, Y, and W135
= administered as a single dose of 50mg for adult and children older than 2 years old
Prophylaxis for person who are exposed or close contact with
the patient: Rifampicin / Minocycline