GRAM NEGATIVE COCCI

NEISSERIA
Notes to remember:

1. an important unique property is that there is a

remarkable association between S. bovis and COLON
CANCER.50% of people with S. bovis bacteremia have
a colonic malignancy.
2. S. pneumoniae is also the most common cause of
otitis media in children and the most common cause
of meningitis in adults.Nuchal rigidity is the classic
sign.
3. Necrotizing fasciitis(Flesh eating streptococcus)
The patient develops swelling,heat, and redness that
moves rapidly from the initial skin infection site.A day
later the skin color changes from red to purple to blue
and bullae form.Later the skin dies and muscle may
also become infected.
GRAM (-) KIDNEY OR COFFEE BEAN SHAPED with
adjacent sides flatenned.
MOST ARE ENCAPSULATED, NON MOTILE AND
NON SPOREFORMER
AEROBIC OR FACULTATIVELY ANAEROBIC
CATALASE AND OXIDASE POSITIVE
CULTURE MEDIA

Sterile specimens –(blood,CSF,synovial fluid) BAP and CAP

Contaminated specimens
*Thayer Martin medium-CAP with supplement B or
Isovitale X.
Modified TM- addition of Hgb solution and
trimethoprim lactate ahich inhibits the spreading of
Proteus
* Transgrow medium- glucose,2% agar,TL and CO2
* Martin Lewis-anisomycin longer half life
* New york City medium-amphotericin B
Neisseria Gonorrhea

IN MEN – acute urethritis with dysuria and purulent

urethral discharge
IN WOMEN – increased vaginal
discharge,dysuria,menstrual abnormalities and lower
abdominal pain
Pharyngeal gonorrhea
Gonococcal opthalmia neonatorum
Laboratory Diagnosis

SPECIMENS- urethral discharge,skin lesions,inflamed

joints,eye discharge
STAINED SMEAR
Presumptive identification test – OXIDASE (+)
Confirmatory Test
• Sugar Degradation –CTA,Gonobio ,Gonochek
• ELISA,Limulus test, Superoxol test
TREATMENT

1. Amoxicillin,ampicillin,aqueous procaine penicillin

G
2. Ceftriaxone—most commonly recommended for
uncomplicated cases due to increasing incidence of
penicillinase-producing N. gonorrheae(PPNG) or
chromosomally mediated resistant N. gonorrheae.
3.Spectinomycin,SXT,ciprofloxacin, and cefuroxime
NEISSERIA MENINGITIDIS

Disease Produced: Epidemic Meningococcal

meningitis/Cerebrospinal fluid/spotted fever
Clinical manifestations:
S/S: mild fever,pharyngitis,prostration,erythematous
macular rash usually superseded by a petechial
eruption.This vasculitic purpura is the hallmark of
meningococcal disease.
Waterhouse-Friderichsen syndrome-hemorrhage into the
adrenal tissue with resultant hypoadrenergic state
Sequelae: eight nerve deafness,CNS damage,skin or tissue
necrosis due to vascular thrombosis.
Meningococcemia
Treatment:
-Penicillin
Chloramphenicol and ceftriaxone
Prophylaxis for carriers
-Rifampicin and minocycline primarily
Ciprofloxacin
Neisseria cineria
Associated with bacteremia,conjunctivitis,nosocomial
pneumonia. It has a biochemical resemblance to N.
gonorrhea,fermenting glucose. It is differentiated from N.
gonorrheae by its ability to grow on MH agar amd inability
to grow on TM.
Branhamella catarrhalis
Normal flora of the upper respiratory tract but has been
isolated in cases of
septicemia,meningitis,endocarditis,otitis media
Does not ferment any sugar
Veilonella (V. parvula)
Tiny, strictly anaerobic gram(-) cocci that occur in
masses which are part of the normal mouth flora.
- produce small ,convex,translucent to transparent
colonies with entire edge which may show red
fluorescence under long wave UV light.
* other anaerobic gram – cocci are Megasphaera and
acidaminococcus.
MYCOBACTERIA
C.A. – Corynebacterium diptheriae or Kleb’s –Loeffler
Bacillus
- gram (+),aeobic,rod shape,non-acid fast,non
motile,nonsporeformers
-pleomorphic,with club shaped swellings and beaded
and barred forms(metachromatic granules or Babes-
Ernst bodies)
CULTIVATION
A. LOEFFLER”S coagulated serum medium-minute,
grayish white glistening colonies.
B. MODIFIED Tinsdale- colonies are black with dark
brown halos.
C. CYSTINE TELLURITE media – colonies are black
with garlic like odor
M.O.T. – direct,indirect contact
I.P. – 1 -7 days
S/S- PSEUDOMEMBRANE(Pathognomonic sign)
Diagnostic Exams:
Schick’s Test- susceptibility test for diptheria
CLINICAL MANIFESTATIONS:
-low grade fever,malaise ,mild sore throat
Edematous and tender cervical lymph nodes(bull
neck appearance)
Listeria monocytogenes
 small gram(+),aerobic to microaerophilic coccobacilli
Disease produced: LISTERIOSIS
-sepsis, meningitis in neonates and immunocompromised
patients
-transplacental infection
- meningitis in adults
TREATMENT:
Penicillin G or ampicillin in combination with aminoglycosides
Trimethophrim-sulfamethoxazole – for penicillin allergic
patients
Other alternatives – erythromycin and tetracyclines
Erysipelothrix rhusiopathiae

Erysipelothrix rhusiopathiae
Nonsporogenous,nonmotile,nonencapsulated,
microaerophilic gram positive rods
 Clinical infection: Erysipeloid
Mode of transmission: Transmitted to man from
animals by means of skin wounds produced with
contaminated objects or in contact with blood,
flesh,viscera or feces of infected animals
Clinical manifestations:
-local cutaneous infection, lymphangitis may also
occur, dissemination may occur causing infective
endocarditis and septic arthritis
TREATMENT:
Penicillin – drug of choice
Erythromycin – for penicillin allergic patients
Other alternatives – tetracyclines, cephalosporins,
clindamycin, and chloramphenicol
Nocardia asteroides

Aerobic, gram-positve, partially acid –fast bacilli

 
 
Clinical infection: NOCARDIOSIS
 
HABITAT : soil and water
mode of transmission: :- inhalation of organism
 -inoculation through breaks in the skin
 
Epidemiology and manifestations:
Chronic infection that can be seen in immunocompromised patients
 Chronic lobar pneumonia
 
 
Treatment: sulfonamides,SXT, amikacin and imipenem

Bacillus anthracis
Gram positive rod with ellipsoidal to oval cantrally located
spore; sporangium is not swollen.
They occur in long chains, giving a bamboo pole appearance
 
Clinical infection: Anthrax
Three forms of anthrax in humans:
Cutaneous anthrax( malignant pustule)
-most common form
 b. pulmonary anthrax(Woolsorter’s disease)
 c. gastrointestinal anthrax (violent enteritis)
 - most severe and rarest form
Cutaneous anthrax
ASCOLI test – diagnostic precipitin test for Bacillus
anthracis
 Treatment: a. penicillin –drug of choice
 b.tetracyclines,erythromycin
&chloramphenicol
Prevention: active immunization
Bacillus cereus
Morphologically similar to B. anthracis but usually
motile
Beta hemolytic,motile,nonencapsulated
 
Clinical infection:
An important cause of food poisoning which are of
two types:
Short incubation type
Long incubation type
Bacillus cereus
b.seen in serious infections associated with
immunocompromised hosts.
Treatment
-susceptible to chloramphenicol, aminoglycosides,
clindamycin, erythromycin and vancomycin.
Bacillus subtilis (Hay bacillus)
A very common laboratory contaminant
Colonies are usually large, flat and dull with a ground
glass appearance
Morphologically similar to B. cereus
Bacillus subtilis
Clostridium perfringens
(Clostridium welchii or Gas gangrene bacillus)
Short, boxcar-shaped, gram positive rod which is
encapsulated and non motile
 
Clinical infection:
Wound and soft tissue infection
Food poisoning
Enteritis necroticans –also called pig-bel and
“Darmbrand”.
Gas gangrene
TREATMENT:
Surgical removal of necrotic tissue
Intensive antibiotic (penicillin) and antitoxin therapy
Clostridium tetani (Tack head bacillus)
spore is terminally located
- sporangia are swollen giving a characteristic
drumstick or lollipop or tennis racket appearance
-possess numerous peritrichous flagella
Clinical manifestations:
Trismus or lockjaw
Risus sardonicus
Opisthotonus
Laboratory Diagnosis:
Diagnosis is made on clinical grounds
History or punctured wound
Material from wound site may be stained and culture
TREATMENT:
Antitoxin
Debridement of wound and removal of foreign bodies
Penicillin,tetracycline or metronidazole for penicillin-allergic patients
Barbiturates and diazepam for control of spasms
Careful control of environment
Prevention: active and passive immunization
OPISTHOTONOS
RISUS SARDONICUS
Clostridium botulinum
Types of Botulism
Food borne botulism
Infant botulism
Wound botulism
Unclassified botulism
Treatment:
a.antitoxin
b. saline enemas
c. guanidine hydrochloride
Infant botulism
Clostridium difficile
Cultural characteristics:
On BAP- fluorescence yellow green colonies with a horse stable
odor.
On cycloserine-cefoxitin egg yolk fructose agar-yellow ground glass
colonies.
TOXINS produced:
A. toxin B-cytopathic for most tissue culture
B. toxin A- causing severe damage to the intestinal mucosa and an
excess fluid response.
ANTIBIOTIC-ASSOCIATED pseudomembranous colitis
*lethal disease of the GIT caused by an overgrowth of C. difficile
*normal flora are reduced by these antibiotics.
Laboratory Diagnosis
Demonstration of cytotoxin in stool specimens by
microtiter-cytotoxicity assay
ELIZA
History and clinical picture
Culture of stool specimens
TREATMENT
Discontinue implicated antibiotics
Maintain fluid and electrolyte balance
Avoid anti-motility drugs
Administer vancomycin,metronidazole and bacitracin
Clostridium difficile
Actinomyces
Normal flora of the mouth, GIT, and female genital
tract
MORPHOLOGICAL AND CULTURAL
CHARACTERISTICS:
-branching and beaded with diptheroid and
coccobacillary forms that are nonsporogenous and
non-acid fast.
Gram stain of “sulfur granules” shows tangled mass of
long filamentous forms
Actinomyces spp.
Clinical forms of Actinomyces:

A. cervicofacial actinomycosis –caused by a trauma to the

oral mucosa permitting endogenous bacteria to breach the
normal defenses of the mucosa(e.g. following dental caries
and gingival disease).
B. Thoracic actinomycosis
-acquired by aspiration of the bacteria or as extension from
the cervicofacial form leading to pulmonary infection.
C. abdominal actinomycosis –initiated by a traumatic
perforation of the intestinal mucosa
D. genital actinomycosis-seen in women using intrauterine
devices (IUD).
EUBACTERIUM

Normal flora of the GIT and mouth

Morphology: generally pleomorphic rods to coccobacilli occuring
in pairs or short chains but also as straight uniform or curved rods.
E. alactolyticum-sea-gull-wing shape forms
E. nodatum – beading,filamentous and branching similar to
Actinomycoses.
E. lentum – small,straight rod with rounded ends.
CLINICAL INFECTION:
A. isolated from blood, abscesses, dental infections(periodontitis)
and wounds with other anaerobes
B. E. nodatum has been isolated from actinomycosis of the jaw and
IUD associated infections.
Lactobacillus

Normal flora of the GIT, mouth and vagina

Clinical infection
Pleuropulmonary infections caused by L. catena forme
Dental caries, UTI, bacteremia,endocarditis
TREATMENT: penicillin
Propionibacterium

-normal flora of the skin, GIT, upper respiratory tract

and urogenital tract
Clinical infections:
Frequently contaminants of blood cultures and other
sterile body fluids
P. acnes
-implicated in infections related to heart valves and
prosthetic devices
- plays a role in acne
Treatment: Penicillin
ENTEROBACTERIACEAE
 Classification – more than15 different genera
 Escherichia
 Shigella
 Edwardsiella
 Salmonella
 Citrobacter
 Klebsiella
 Enterobacter
 Hafnia
 Serratia
Proteus
Providencia
Morganella
Yersinia
Erwinia
Pectinobacterium
General characteristics

1. small,straight sided,facultative anaerobic, gram negative, non-

sporeforming rods.
2. All motile members possess peritrichous flagella except Tatumella
ptyseos which has polar flagella. Shigella and Klebsiella are non-motile.
Some species of Escherichia,Salmonella and Yersinia are nonmotile too.
All are catalase positive except for one group of Shigella species.
All members ferment glucose but do not liquify alginate and are oxidase
negative.
Almost all are able to reduce nitrate to nitrites.
Predominant facultative flora in the human bowel.
Most species are not intestinal pathogens but opportunistic organisms
which are responsible for the majority of nosocomial infections.
CULTURE MEDIA
FOR FECAL SPECIMENS
A. Differential media
i. MacConkey agar
 -Lactose fermenters- pink or reddish colonies on
bile lactose media and are usually non pathogenic.
 - nonlactose fermenters –colorless,translucent
colonies and are usually pathogenic.
ii. Eosin methylene Blue-aside from lactose it also
contains sucrose.
Iii.Desoxycholate agars
B. Selective media
i. Hektoen enteric agar –contains lactose,sucrose and
salicin,able to detect H2S production
Ii. Xylose lysine deoxycholate(XLD)-contains
lactose,sucrose and xylose;able to detect H2S
production
Iii. Salmonella-Shigella Agar
Iv. Desoxycholate citrate agar
For other specimens like material from wounds, respiratory
tract secretions,aspirations from abscesses,sterile body
fluids,urine and blood cultures.
A. BAP or Chocolate agar(supportive medium to allow
growth of all enterobacteriaceae .
B. MacConkey agar(differential medium for gram negative
bacilli).
ENRICHMENT BROTHS
A. selenite broth
B. G-N broth
C. Tetrathionate broth
ENTEROBACTERIACEAE

ESCHERICHIA
Escherichia coli ( Colon Bacillus)
Major facultative inhabitant of the large intestine.
Disease produced:
Urinary tract infection
Pneumonia
Neonatal meningitis
Wound infections
Septicemia
Diarrheal disease
STRAINS OF E. coli that cause diarrhea in man:
Enteropathogenic E. coli (EPEC)
Does not produce enterotoxin
Associated with infantile diarrhea
Enterotoxigenic E. coli (ETEC)
Produce enterotoxins
Major causes of traveller’s diarrhea; may resemble cholera
Iii. Enteroinvasive E. coli (EIEC)
-causes bacillary dysentery in all age groups similar to shigellosis
Sereny TEST
iv. Enteroadherent E. coli (EAEC)
Produce nonfimbrial adhesions that attach the organisms to their target cells.
(also produced by EPEC and VTEC)
v. verotoxin-producing E. coli(VTEC)
 -associated with diarrhea ,hemorrhagic colitis and hemolytic
LABORATORY DIAGNOSIS
MacCONKEY-dry pink colonies
EMB- colonies with greenish metallic sheen
XLD-yellow colonies
TREATMENT: management of fluid and electrolyte
imbalance
 antibiotics
B.EDWARDSIELLA

Edwardsiella tarda
-isolated from humans and associated with
diarrhea,wound infection and sepsis.
LABORATORY DIAGNOSIS:
Macconkey-non lactose fermenter
Escherichia coli
C. SHIGELLA

Clinical infection (Bacillary dysentery or shigellosis)

S. sonnei is the most common isolate worldwide
followed by S. flexneri and to a lesser extent S. boydii
and S. dysenteriae, however in developing countries S.
dysenteriae and S. boydii are more frequently
isolated,followed by S. flexneri and then S. sonnei.
Mode of transmission: fecal-oral route
According to serogrouping
Group A- S. dysenteriae
Group B- S. flexneri
Group C- S. boydii
Group D- S. sonnei
Clinical manifestations
Acute toxigenic gastroenteritis ;diarrhea with profuse,watery
stools and fever of a self limited course;or
Acute tissue-invasive gastroenteritis; diarrhea with
tenesmus, bloody or blood streaked and mucoid
stools,vomiting,fever,abdominal cramps and abdominal
tenderness.
TREATMENT:
Ampicillin or amoxicillin – drug of choice
Cotrimoxazole – alternative
Management of fluid and electrolyte imbalance.
CONTROL
1. infected persons should be isolated until culture is
negative.
2. carriers should be treated and not allowed to handle
food
3. proper sewage disposal and chlorination of water.
SALMONELLA
Nonencapsulated,nonsporeformers,non-lactose
fermenters.
ANTIGENS PRODUCED:
O antigen – somatic antigen
H antigen – flagellar antigen
Vi(Virulence antigen –a type of capsular antigen found
in serotype typhi.
.SALMONELLA

Salmonella typhosa
 
Clinical infection: Salmonellosis
Mode of transmission:
Typhoid fever is transmitted by ingesting food or water
contaminated with the feces of a carrier, often a chronic carrier;
silent carriers also transmit the disease and contribute to
continued episodes of infections; human carrier is the sole source
of the organism.
Nontyphoidal salmonellosis is transmitted by ingestion of
contaminated food and water; fecal-oral route;aside from the
human source, animal and animal products are the major sources
Rose spots
Three distinct clinical entities
GASTROENTERITIS
-most commonly caused by S. serotype typhimurium
-characterized by diarrhea,fever and abdominal pain
-self-limiting, lasting from 2-5 days
 ii. TYPHOID FEVER AND OTHER ENTERIC FEVERS
 -typhoid fever is the most severe enteric fever which is caused
by serotype typhi.
 - other Salmonella, particularly serotypes paratyphi A and B,
can also cause enteric fevers but with milder symptoms.
 
SIGNS AND SYMPTOMS:
Lethargy, fever,malaise,body aches and pain during the first week
followed by sustained fever of 104 F, tender abdomen with rose colored
spots and diarrhea during the 2nd and third week.
 
COMPLICATIONS:
Intestinal perforation, severe bleeding,thrombophlebitis,
cholecystitis,pneumonia and abscess formation.
 
iii.Septicemia with focal lesions
-characterized by fever,chills,anorexia and anemia
- focal lesions may develop and produce secondary osteomyelitis,
pneumonia,pulmonary abscess, meningitis or endocarditis.
SPECIMENS:
Blood – during the first week
Urine – during the first two weeks
Stool – throughout the course of illness but more positive isolation during the
3rd week.
WIDAL TEST – done on the 8th or 10th day and repeated by the 4th week:
POSITIVE RESULT : fourfold rise by the 4th week.
TREATMENT: A. GASTROENTERITIS –supportive therapy and maintaining
fluid and electrolyte balance; antibiotic treatment only prolongs the carrier
state.
 B.For ENTERIC FEVER or SEPTICEMIA – ampicillin or
chloramphenicol is the drug of choice; cotimoxazole-alternative
 C. For chronic carriers of typhi serotype – ampicillin is the drug of
choice., cholecystectomy
CONTROL:

proper cooking of food.

Detection and treatment of carriers
Vaccine
CITROBACTER
- morphologically similar to E. coli
Diseases produced(opportunistic infection)
UTI – caused by C. freundii and C. diversus
 Neonatal meningitis and brain abscess – C. diversus
Diarrhea – enterotoxigenic C. freundii
 
Treatment: aminoglycosides, tetracycline and
chloramphenicol
ARIZONA

C.A. Arizona hinshawii –associated with reptiles and

birds and rarely cause disease in humans similar to
Salmonella infection.

Treatment: Ampicillin and chloramphenicol

KLEBSIELLA
Klebsiella pneumonia (Friedlander’s bacillus or
bacillus mucosus capsulatus)
Diseases produced:
Community acquired and nosocomial pneumonia
Can also cause UTI, wound I nfections, bacteremia
and meningitis
Tropical sprue – caused by enterotoxigenic strain
Colonies are large,moist and mucoid
ENTEROBACTER
Inhabits soil and water and to a lesser extent the large
bowels in man and animals.
Oftenly confused with Klebsiella
Disease produced: By E. cloacae,E. aerogenes
A. UTI
B. bacteremia
C. meningitis
D. wound infections
Treatment: 2nd and 3rd cephalosporins
SERRATIA-they produce a nonwater solub le red to
pink pigment(prodigiosin)
S. marcescens
- associated with nosocomial outbreaks of
UTI,pneumonia and septicemia.
Treatment:
gentamicin,amikacin,chloramphenicol,ciprofloxacin
and cotrimoxazole.
PROTEUS

Proteus vulgaris –burnt gun powder odor

DIENE’s PHENOMENON- different strains of Proteus
When inoculated separately on a culture media swarm
toward each other but they do not merge.
Clinical infection:
It is the second leading cause of community acquired
UTI and it is a major cause of nosocomial infections.
 
TREATMENT: sensitive to ampicillin and cephalosporins
 
Swarming phenomenon
YERSINIA

Yersinia pestis(Y. enterocolitica,Y. tuberculosis)

“safety pin appearance”
 
Disease produced:
PLAGUE- primarily pathogenic to rodents and human are accidental
hosts only.
 
Mode of transmission(to humans)
Via bites of infected rat fleas (Xenopsylla cheopis)
By handling the carcass of an infected animal
Via infected aerosol droplets from person to person.
 
Bubonic plague
Septicemic plague
Pneumonic plague
Clinical forms:
Bubonic plague-characterized by infected and swollen lymph nodes
(called buboes) which occur most commonly in the groin and less
frequently in the axillary and cervical nodes.
-the bubo may be preceded by prodromata of fever, chills, body
malaise,confusion, nausea and pains in the back and limbs.
 ii. Septicemic plague
 -prominent finding is disseminated intravascular coagulation.
 iii. pneumonic plague (the black death : Pandemic plague)
 -usually arises from septic embolization to the lungs
 - transmitted by inhalation and is highly contagious.
 
TREATMENT
A. streptomycin-drug of choice
B. tetracycline or chloramphenicol-alternative

PREVENTION: plague vaccine

PSEUDOMONAS
Pseudomonas aeruginosa
 
Morphology: aerobic, motile with single polar
flagellum, frequently possess pili that promote
attachment to host cell surfaces.
Most strains produce pyocyanin, a blue water soluble
and chloroform extractable pigment.
 
Pseudomonas aeruginosa culture
Diseases produced:
P. aeruginosa inhabits soil and water causes disease in humans with
impaired host defenses.
a. burn wound infection; traumatic and operative wound infection.
b.nosocomial infections like pneumonia, UTI,
endocarditis,osteomyelitis.
c. eye infections seen in contact lens wearer.
d. dermatologic infections.
Treatment:a. aminoglycosides (amikacin, gentamicin)
 b.extended-spectrum penicillins(azlocillin,carbenicillin)
 c. 3rd generation cephalosporins (ceftazidime and
cefoperazone)
Pseudomonas cepacia
. Pseudomonas cepacia
- most commonly isolated from cystic fibrosis patients
and has been associated with endocarditis, septicemia
and wound and UTI in immunocompromised
patients.
- resistant to polymyxin B and sensitive to
chloramphenicol, cotrimoxazole and ceftazidime.
Pseudomonas mallei (Glanders bacillus)
-causes glanders, a disease of horses occasionally transmitted to
humans by direct contact through skin abrasions and
inhalation of organism.
Treatment: tetracycline plus an aminoglycosides
d.Pseudomonas pseudomallei (Whitmore’s bacillus)
- causes melioidosis, a glanderslike disease in humans
transmitted via inhalation,ingestion or through skin abrasions
TREATMENT: drug of choice : cotrimoxazole; other alternatives
are tetracycline, chloramphenicol and sulfadiazine.

Pseudomonas mallei