Gram Positive Cocci: Strep and Staph

Organism Physiology/Structure Virulence Epidemiology Diseases Tx Staph Aureus Gram (+) cocci formed A protein evades phagocytosis Is normal flora found in mucous Gastroenteritis usually self limiting. Can Gastroenteritis is self limiting, in clusters membranes and skin. Transmission be caused by ingestion of bacteria (then and the organism is passed Coagulase forms fibrin clot around can either be endogenous or subsequent production of toxin) or by with stool Facultative Anaerobes organism, protecting it from exogenous. ingestion of heat stabile toxin produced phagocytosis before organism was killed by cooking. It is gram (+) with Catalase (+) Common contamination is found in penicillinase activity, so Beta‐ Toxic Shock Syndrome Toxin food workers that sneeze on their Scalded Skin Syndrome local infection Lactams don’t work. Coagulase (+) produces the superantigen TSST‐1 hands, then don’t wash. Found on produces a toxin distally. Causes mild that leads to toxic shock. food that has been left out, like potatoe epidermal tears, with a “sunburn like Methacillin and Nafcillin were Β‐Hemolytic salid. rash” drugs of choice because of Exfoliatin causes the skin to slough their resistance to off, disrupts desmosomes. Toxic Shock associated with tampons penicillinase. MRSA left in too long, toxin is a superantigen (methicillin resistant staph Enterotoxin causes gastroenteritis that causes fever, hypotension, and death aureus) has made treatment more difficulty. Infective Endocarditis acute onset endocarditis with fever, malaise, and a Vancomycin is now the drug heart murmur. Caused by cytolytic of choice, though resistant toxins strains are being identified. Enterrococcus Gram (+) Coccus, it is Survives Bile and Salt so can They are part of the normal flora of the UTI GI Æ GU Penicillin (Fecalis and one of the Strep colonize in the gall bladder. GI and GU tract. During a procedure, Fecium) Species they can be dislodged or displaced and Cholecystitis – infection of the presented to where they should no be. gallbladder. Lancefield Group D’ Normal Flora Can grown in Bile or in High Salt (6.5%) Most prevalent bacteria of GI tract

γ­Hemolytic Endogenous Transmission

PYR (+) Strep Pyogenes Gram (+) Coccus Theme is “escape or spread” Human throat, transmitted by aerosol Pharyngitis – white, purulent lesions on Culture all negatives on a rapid M protein – antiphagocytic protein. droplets or endogenous infection. the oropharynx. test. Lancelfield Group A M12 is associated with glomerular nephritis Sequellae of Disease (to fit better) Scarlet fever – if strep throat is β­Lactams work well. β­Hemolytic untreated it can then be accompanied by Streptolysin O – Oxygen Labile, Rheumatic Fever – possible sequella scarlet fever. It is described as a sand‐ In those with allergies, use Bacitracin Sensitive antigenic cytolysin that causes lysis of untreated pharyngitis ONLY. This is paper rash, also called a sun burn‐like macrolides. to separate it from of cells. a type II hypersensitivity reaction, rash, in that the skin is red. The palms Strep Agalactiae where antibodies to the strep cross and soles are spared. There is also a Streptolysin S – Oxygen Stabile, react with heart tissue. Causes strawberry tongue that presents bright non­antigenic cytolysin that causes endocartitis, a chorea, fever, and red with many bumps. lysis of cells. arthralgia. Impetigo ‐ just like staph aureus “ASE”s Streptokinase, DNAase, Poststreptococcal Glomerular Hyalurindase, all makes it easier to Nephritis – possible sequella of Necrotizing Fasciitis ‐ infection that spread in tissue. untreated strep pharyngitis or skin causes “flesh‐eating bacteria.” Rapid infection. Type III hypersensitivity spread through fascial layer can involve Exotoxin A‐C that are superantigens reaction. Immune complexes are large amounts of tissue requiring and cause symptoms of scarlet fever deposited in the kidney, causing debreidment or amputation. damage. Associated with M12 serotype

Organism Physiology/Structure Virulence Epidemiology Diseases Tx Strep Pneumoniae Gram (+) Coccus Capsule – most important virulence Normal flora of the upper respiratory Acute Pneumonia rapid onset of fever Macrolides for adult bacterial factor tract. They can be colonized, but not be and chills, pain on inspiration, and an X‐ pneumonia Lancet­Shaped infected. Any immunocompromise ray with infilitrates Diplococci IgA protease – cleaves IgA that (chronic pulmonary disease, viral Third Generation allows colonization of mucosa. infection, spleen‐ectomy) can lead to Otitis Media – most common cause of Cephalosporin for meningitis No Lancelfield Group pathogenesis otitis media in children, despite vaccine. Pneumolysin O – what is Vaccines are available. The α­Hemolytic responsible for the rust colored Sinusitus – same as otitis media, pediatric vaccine covers 7 sputum associated with the disease. commonly causes sinusitis in kids common serotypes protecting Optochin Sensitive to Destroys ciliated cells by inducing against meningitis. separate it from classic complement. Adult Meningitis – since the vaccine for Viridans group H. Influenzae b (later), now is leading The adult vaccine covers 23 cause of meningitis in neonates. common serotypes to protect against pneumonia

Viridans group Gram (+) Coccus Dextran Bioslime that both protect This is a variety of organisms such as Subacute Endocarditis – dental surgery Penicillin often prophylactic the organism from the immune S. Mutans. gives S. Mutans access to the blood for endocarditis. No Lancelfield Group system and increases adherence to stream where it colonizes the mitral teeth or heart valves S. Mutans is part of the normal flora of valve. In pharm, you learn you treat α­Hemolytic dental caries. These buggers cause with Clindamycin or a plaque. Plaque then allows other This is why people with prostethic valves combination of Vancomycin + Optochin Resistant to Viridans group to colonize and cause or previous valve problems get Gentamycin. separate it from S. cavities prophylactic antibiotics before dental Penuemo procedures.

Gram Positive Rods: BCC LAN LM “Send an Email (BCC) over the network (LAN) to Lincoln Martin (LM)” Bacillus, Corynebacterium, Clostridium, Lactobacillus, Actinomyces, Nocardia, Listeria, Mycobacteria; you know “N” is NOT neisseria because Mycobacteria and Nocardia are similar.

Organism Physiology/Structure Virulence Epidemiology Diseases Diagnosis Bacillus Anthracis Gram (+) Rod Spore Forming so they are highly Found in soil, water, and on animals Cutaneous Anthrax is 95% of all Formerly Penicillin (which resistant to drying, desiccation, (particularly sheep). anthrax cases. Spores get into wound may still work). Forms spores heating, etc. causing black painless swollen Can be inoculated into a cutaneous postules called eschars. They crust over Currently use doxycyline or Is unique for its Antiphagocytic Capsule evades wound or inhaled into the lungs. and resolve spontaneously. They can cirpofloxain polypeptide capsule phagocytosis rarely enter circulation and cause fatal (most others are Possible agent of bioterrorism (note septicemia. polysaccharide) Exotoxins the postal scare). Edema Factor – calmodulin Pulmonary Anthrax (Woolsorter’s Facultatively dependent increase in cAMP leading Disease). Inhaled spores cause Anaerobic to fluid extrusion. hemorrhagic lymphedemitis with Lethal Factor – causes tissue mediastinal widening. It resembles necrosis. many pulmonary diseases initially, and is Protective Factor ‐allows entry of rapidly fatal without treatement. toxins into target cells. Called this Normally transmitted by sheep, it is now because it is target of vaccine. a risk of bioterrorism. Bacillus Cereus Gram (+) Rod Similar virulence to Anthracis, has Found on food that was cooked and Gastroenteritis­like symptoms Self Limiting different toxins reheated. Think buffet line at a Forms spores Chinese food restaurant. Exotoxins Same as Bacillus Emetic Toxin causes N/V/D 1‐6 hrs The classic presentation is fried rice Anthracis after ingestion at a Chinese buffet. Diarrheal Toxin causes a cAMP dependent secretory diarrhea similar to Cholera or ETEC

Corynebacterium Gram (+) Rod Toxin – inhibits protein synthesis. It Throat and nasopharynx, usually Diphtheria – Grey pseudomembrane Elek test will confirm toxin Diphtheriae is a classic AB toxin that inhibits EF‐ transmitted by respiratory droplets. that is on the pharynx. It is well attached producing strains. In this test, Aerobic 2 and will cause hemorrhage if removed. bacteria are streaked across a It is here that necrotic tissue, leukocytes, plate, with a elek strip placed Non‐spore formers While it colonizes the naso or and the corynebacterium are. If the across all streaks. It contains oropharynx, it is not invasive membrane gets to large, it can cause an anti‐toxin that causes Form “Chinese Letters” respiratory obstruction. precipitation on gram stain, V or L shape. Bull Neck – swelling of the neck out Antitoxin is top priority to neutralize toxin Grow Grey or Black colonies on Tellurite Antibiotics will kill bacteria, and stop the toxin production Loeffler’s Media causes granule DPT vaccine formation

Organism Physiology/Structure Virulence Epidemiology Diseases Diagnosis Clostridium Same as other Tetanus Toxin (tetanospasmin)– Found in dirt, soil, or dust. Tetanus Antitoxin binds and Tetani clostridium species, no causes spastic paralysis known as Bacteria colonize a local infection, neutralizes free toxin in double zone of Tetanus. Common presentation is a housed in necrotic tissue (anaerobic circulation hemolysis penetrating wound (such as a rusty space). Classic AB toxin that targets the nail). Toxoid (aka the vaccine) central nervous system, inhibiting Secrete exotoxin that travels conveys long term inhibitory neurons by preventing everywhere, targets the CNS inhibitory neutralization of toxin and vesicle transport and fusion. neurons. active immunity. Survival DOES NOT convey immunity. No fusion = no release. No release = Symptoms begin with trismus disinhibition of skeletal muscles = (lockjaw) and risus sardonic us (a Give injections at separate contraction. smile that cannot be stopped) sites

Targets GABA and glycine. Progresses to a spastic paralysis with Muscle Relaxants (benzos) death resulting from spasm of diaphragm to alleviate contractions Clostridium Same as other BotulismToxin – causes spastic It is also found in dirt, soil, or dust, Adult Botulism – food contaminated Palliative care to provide Botulinum clostridium species, no paralysis known as Botulism. that can cause the low‐yield wound with botulism is not cooked or prepared ventilator support double zone of botulism. well enough. Begins with dipolia and hemolysis Classic AB toxin that targets the dysphagia, progressing to flaccid Antitoxin to alleviate peripheral nerves, inhibiting NMJ Found in home­canned foods that are paralysis and death from flaccid circulating toxin (any toxin in neurons by preventing vesicle not cooked well enough. diaphragm cells has already taken effect). transport and fusion. Found in honey given to newborns. Infant Botulism – honey contaminated Penicillin to kill bacteria No fusion = no release. No release = with botulism in an infant less than one inhibition of skeletal muscles = year old. Begins with constipation and flaccid. feeding problems progressing to floppy baby syndrome. Targets ACh Clostridium Same as other Toxin A = Enterotoxin Part of the normal GI Flora. Psuedomembranous Colitis – watery, Discontinue antibiotic therapy. Difficle clostridium species, no Causes inflammation and secretory secretory diarrhea that results from the double zone of diarrhea When on broad­spectrum antibiotics enterotoxin. Ulcerations can be Give oral vancomycin (one of hemolysis the normal flora is eliminated. This is visualized on endoscopy resulting from the few drugs it is NOT highly resistant, so then grows in the Cytotoxin. Cultures will be positive resistant to). You must give it Toxin B = Cytotoxin space left by the previous flora. (normal flora), but a tox screen of stool orally because vancomycin Disrupts protein synthesis and will confirm diagnosis. cannot penetrate GI barrier, causes disorganization of the and the infection is in the GI cytoskeleton. tract.

Lactobacillus Low­yield organism Know that it maintains the vaginal pH to prevent exogenous infection. When giving broad‐spectrum antibiotics, you can kill lactobacillus, and allow overgrowth of other organisms (like candida) Actinomyces Facultatively Colonize URT, GI, female genital tracts No person to person spread Most cases: Cervico facial ‐> draining sinus Difficult Israelii anaerobic/strictly tracts along angle of jaw/neck anaerobic Actinomycosis – chronic Disease from soil or water Culturing is slow

granulomatous lesions ‐> suppurative Cervicofacial infections ‐> poor oral hygiene; NOT acidfast (contrast and form abscesses invasive dental procedure Sulfur granules ‐> tin, gram to Nocardia) positive, branching rods around Thoracic infections ‐> Hx of aspiration ‐> periphery Grow slowly spreads to lung‐adjoining tissues

Filamentous hyphae Abdominal infections ‐> GI surgery; trauma to bowel

Resemble “grains of Pelvic infections ‐> secondary manifestation sand” ‐> sulfur granules of abdominal actinomycosis; primary infection of woman with IUD NOT found on skin CNS ‐> hematogenous spread from other tissues Nocardia Gram (+) branching Ill defined pathogenesis Reservoir is Soil and Dust, thus there is (Inhalation) Cavitary Sulfonamides Asteroides rods. an exogenous inoculation via trauma Broncholpulmonary Nocardosis – or inhalation. often associated with immune Partially Acid­Fast compromised patients. Symptoms are fever, cough, diffuse pneumonia with Aerobic cavitation of the lungs.

Spread via the blood to the brain.

(Traumatic Implantation) Subcutaneous nocardosis – training type of sinus tracts and granules. This is similar to actinomyces only with a traumatic implantation.

Listeria G+ve coccobacili ‐> Facultative intracellular pathogen Isolated in soil, water, and vegetation Neonatal Disease ­ Amnionitis: Microscopy ‐> insensitive monocytogenes arranged in pairs that can avoid Ab‐mediated clearance 1. Early onset disease: resembling Disease assoc. with consumption of “granulomatosis infantiseptica” ‐> Culture 2‐3 days or cold enterococci Virulent Strains produce cell contaminated food products disseminated ascesses and enrichment attachment factors (internallins), (unpasteurized milk) granulomas in multiple organs Faculative anaerobes hemolysins (listeriolysin O, two 2. Late onset disease: acquired at or phospholipase Cs), and a protein Transplacental spread from mother to shortly after birth. Presents as Motile at room temp, that mediates actin‐directed motility neonate meningitis or meningoencephalitis weakly β‐hemolytic, (ActA) (vaginal transmission) w/ septicemia capable of growth at 4°C and high salt “Actin rockets” – cell to cell HIGH RISK: Young, elderly, Pregnant, Healthy Adults: concentration movement pts with defective cellular immunity Influenza like (with or without gastroenteritis)

Pregnant women/cell­mediated immune defects: Primary bacteremia or disseminated disease (hypotension and meningitis)

Mycobacteria Gram (+) Weakly Cord Factor – serpentine growth in Humans are the only known reservoir. TB – there is no exotoxin, there is no Sensitive to UV Light Tuberculosis culture and inhibits PMN migration. Aerosolized particles are released by endotoxin, the damage that TB does is Obligate Aerobes It is the mycolic acid an infected patient only in the active the damage the immune system causes in Auramine­Rhodamine is a form of TB. Therefore, most infections an attempt to get rid of the disease. rapid test to see if there are Acid­Fast – cell wall Mycolic Acid – TB is made of are generally reinfections. Macrophages wall it off in a granuloma. mycobacteria. This stain turns has a lot of lipid in it, primarily fat in its cell wall. The fat TB bright apple green. which makes it poorly happens to be mycolic acid. Requires a large infectious dose over a Primary TB – recent exposure, currently gram staining prolonged exposure active, transmittable, growing in BCG vaccine is a live Peptidoglycan Layer ‐ it is partially macrophage attenuated vaccine given in Facultatively gram + and this is because of its PPD Test: assess exposure to TB by Active TB – Lung Disease, X‐ray Changes, third world countries that Intracellular (causes peptidoglycan layer beneath its fatty giving the protein Tuberculin in a Liquefactive Granulomas (with protect against systemic TB, granuloma) cell wall Subdermal injection. It is a Type IV hemoptysis) not so much the Pulmonary hypersensitivity Latent TB – Non contagious, calcified TB. Tuberculin – protein secreted used High risk: (AIDS)>5mm granulomas. When immunocompromised to do the PPD test. Moderate Risk (health care worker it will revert to Primary TB. Treated with a combination of / inmate / regular exposure) >10mm Reactivation – Latent to Active. Isoniazid and Rifampin. Sulfatides – glycolipids in cell wall Low Risk: (general population) that inhibit phagolysomal fusion, >15mm These are a type 1 immune response Caution when treating RA increasing longevity in macrophages mediated by Th1 cells (compare to patients with TNF‐α leprosy) antagonists; TNF‐α keeps the Reactive O2 and N2 species survives TB contained. the oxidative burst Mycobacteria Obligate None listed in Class nor Kaplan Armadillos have Leprae. Tuberculoid Leprosy – strong immune Dapsone and Rifampin that Leprae Intracellular system. This is a Th1 response. It has to be taken over 2 years to Humans are the usual reservoir, which contains the disease by forming eliminate the disease. Grows only at cooler requires significantly prolonged granulomas in the nervous tissue. It temperature (which exposure. causes patches of anesthesia as the Close household contacts will is why it effects the immune system walls of the leprae in the receive prohphylactic skin and not the The lapromin test is the analogous nerves. Dapsone. internal organs) test to the tuberculin test (PPD) of tuberculosis. It will be positive only for Lepromatous Leprosy – weak immune Isolation is not required (leper Slowest Growing the tuberculoid leprosy because it system. This is a Th2 response and is a colonies are archaic) Bacteria (doubling shows an active immune response. wild dissemination. There will be time of 2 weeks) nodular skin lesions with multiple organ involvement. This causes the “lion‐like” facial lesions that are associated with the severe form.

Gram Negative Cocci: Neisseria and Moraxella

Organism Physiology/Structure Virulence Epidemiology Diseases Diagnosis Neisseria Gram (­) Cocci Capsule – 5 different serotypes of Found in the human nasopharynx. Adult Meningitis Formerly Penicillin (which Meningitidis capsule. B is the most common found About 5‐10% are carriers of the Begins with a Stiff Neck, Photophobia may still work). Diplococci with in the US. It is NOT covered in the organism. flattened sides vaccine, but all others are. Petechial Rash. Once the rash starts, the Currently use doxycyline or Usually transmitted through patient declines rapidly. cirpofloxain. Oxidase (+) IgA Protease – helps colonize the respiratory droplets that colonizes respiratory epithelium the pharynx and spreads to the Fulminant cases develop bruising, DIC, Vaccine is available that is a Glu +, Maltose+ menignese. and death. This can happen in hours. the polysaccharide capsular Endotoxin = LPS vaccine covering all types not Facultative College Dorms, Military Recruits B. Intrallecular Pili for attachment other close quarters

Found in respiratory tract and causes meningitis Neiserria Gram (­) Cocci No Capsule Human genital tract and is transmitted Gonorrhea Beta‐Lactamases are Gonorrhea as an STD or to a child in birth. ‐ Males = urethritis and proctitis. abundant, so we now use Diplococci with Antigenic Variation – changes its Purulent yellow discharge with cephalosporins. High‐Yield image flattened sides antigen to avoid detection painful urination. is a gram stain of ‐ Females = variable symptoms There is a special agar called exudate from Oxidase (+) Outer Membrane Proteins (OMP) including Pelvic Inflammatory Thayer­Martin Agar that is a someone with OMP 1 = Por Protein that decreases Disease, Salpingitis, and chocolate agar + antibiotics gonnorhea with Glu+ Maltose­ phagolysosome fusion in PMNs and Intramenstrual Bleeding. It may that grows only gonorrhea the gram negative increases transcytosis go unnoticed, and females are often diplococci INSIDE Facultative OMP 2 = Opa = adhesion molecule the carriers the PMNs Intracellular ‐ Infants ‐ opthalmia and blindness IgA Protease ‐ evades mucosal if untreated Found in the epithelium defenses. urogenital tract and causes gonorrhea Pili ‐ increase adhesion

Moraxella Gram (­) Cocci Normal flora of the upper respiratory Otitis Media – strep pneumo is the most Augementin or third Catarrhalis tract common cause, but Moraxella can cause generation cephalosporing Diplococcus ear aches Previous low‐ Transmited through the respiratory yield organism, droplets Sinusitis – same thing as Otitis Media that has been coming up on the Bronchitis – especially in the older boards population

Gram Negative Rods – all gram negative bacteria have LPS, the endotoxin, which poses a risk of sepsis, shock, and death

Organism Physiology/Structure Virulence Epidemiology Diseases Diagnosis Tx Yersinia Pestis Gram (­) Rod Coagulase (+) Cause of the plague, the Pneumonic Plague =septic pulmonary Aminoglycosides black death. embolus from the bubonic plague, or Bipolar Staining, they look F1 Antigen can inhibit inhalation. This is highly contagious, highly Control the animals, the vector (the like a safety pin or a phagocytosis Common in the desert fatal, and is a target of bioterrorism rats). Killing rodents is a bad idea, the dumbbell. There is staining southwest. fleas will all go to humans! at either end, but clear in Type III Secretion System Cutaneous = Bubonic Plaque = Black Death. the middle. – molecular syringe that Transmitted by the bite This is from the flea bites that generate the allows for toxins to be of a flea or by human‐ axillary bubos and conjunctivitis. Its called Facultative Intracellular – injected into host cell. human contact via the Black death because you get DIC and the produces granulomas respiratory droplets extremities, without an adequate blood supply, necrose, turn black, and fall off. Enterobacteriaciae Gram (‐) Rods Endotoxin – all gram family Catalase (+) negative bacteria possess Fermenters – at least Glu+ LPS or LOS.

Antigens: O = Cell Wall K = Kapsular H = Flagella Escherlichia Coli Same As Enterobacteriaciae Pili – attach and establish Normal flora of the Most common cause of UTI. Fluroquinolone (E.Coli) family. infection in the mucosa of human Gut. the GI tract or the urinary Neonatal meningitis. This is the second most Third generation cephalosporin tract. There can be an common cause of neonatal meningitides after engodenous displacement Strep Agalactiae. K1 serotype implicated. Capsule ‐ from the GI (such as in UTI) or can be exogenous (such as fecal oral)

ETEC Same As Enterobacteriaciae Enterotoxins they are Same as E. Coli Montezuma’s Revenge. ETEC causes Travler’s Usually Self Limiting. Replace fluids Enterotoxigenic family. cyclic‐something inducers. Diarrhea. This is a watery diarrhea because either IV or Oral. E. Coli One is cAMP, the other is it is noninvasive. cGMP. Regardless of the mechanism, they both cause watery diarrhea.

Heat Labile Toxin– (LT) causes ADP‐Ribosylation of Gαs that stimulates AC Æ cAMP Heat Stabile Toxin– (ST) causes ADP‐Ribosylation of Guanine Cyclase increasing cGMP. EHEC Same As Enterobacteriaciae Shigga­Like Toxin – a Same as E.Coli, but can Dysentery. EHEC causes Hemorrhagic DO NOT GIVE ANTIBIOTICS. Death of EnteroHemorrhagic family. classic AB toxin that causes also be from bovine feces diarrhea. This is an exception to the rule. EHEC will release its toxin and LPS that E. Coli ADP­Robsylation of the or unpasteurized milk. Normally bloody diarrhea means invasive increases the risk of HUS. Know the O157:H7 60s ribosome reducing organisms. This is non invasive. Therefore, serotype is the most affinity for EF­1. Called EHEC can be remembered there will be (+) Blood (­) Pus. implicated. verotoxin. as Hamburger (the Jack‐ in‐the‐Box E. Coli Hemolytic Uremic Syndrome (HUS). A Non­Sorbitol fermenter outbreak). sequella of EHEC is renal failure. (most E.Coli are sorbitol fermenter) EIEC & EPEC Low‐yield without detail They are in here to make you aware that it exists. Don’t know them for Tulane exams. Salmonella Gram (‐) Rods Acid Tolerance Response Does have an animal Salmonellosis = Gastroenteritis potentially Invasive disease fluroquinolone Enteriticus reservoir. Found on eggs, causes bloody diarrhea (it is invasive), but Motile (like a salmon) Pili poultry, reptiles, usually causes a watery diarrhea. Causes including reptile feces. diarrhea by an increase in cAMP as a result of Lac – LPS inflammation NOT a result of exotoxin. Facultative Intracellular This is the undercooked Osteomyletis – most common cause of chicken disease osteomyletis in those with sickle cell. Without sickle cell, the most common cause is Staph Aureus. Salmonella Typhi Gram (‐) Rods Acid Tolerance Response Has no animal reservoir, Typhoid Fever – typhoid = typhus‐like. If it is only local in the GI tract, don’t Gene. Decreases in pH cause thus vaccines are Organism is ingested with infection in the treat it. Motile (like a salmon) the gene to turn on, available. ileocecal region. This causes constipation. increasing defense, Travel + Constipation = Typhoid. If they go systemic, use Beta‐Lactams Lac – decreasing virulence (it Humans have it in their GI and Fluorquinolones. survives in, but does not tract, or survivors of M cells take up the cells via phagocytosis. It is Facultative Intracellular infect, the stomach). Typhoid Fever contain it presented to macrophages where it survives There are vaccines available Increases in pH cause the within within the phagolysosome. The macrophage ‐ ViCPS = capsular vaccine, gene to turn off, decreasing transports it to lymph nodes and to the administered parenterally defense, increasing spleen, where it enters circulation. ‐ Ty2a1 = attenuated bacteria virulence (it colonizes the ingested many times to develop intestines). This is also how It can reenter the GI tract through the Gall adequate resistance it lives within the lysosome. Bladder, where it can take up permanent ‐ Either are given to people infection and create a carrier state. traveling to endemic areas. Vi Antigen (Typhi only). It is the Kapsular antigen, but Systemic infections cause rose­pedal lesions given a special name in which are pinpoint erythmatous lesions on salmonella. Withstands the trunk or abdomen. phagocytosis and complement destruction. Septecemia is possible.

Adhesins/Pili allow adhesion to the mucosal epithelium Shigella Gram (­) Rods Shigga Toxin – Classic AB Shigella Soneii is the most Dysentery – aptly named Dysenteriae. Causes Usually self‐limiting. toxin. ADP‐Ribosylates the common in US and is the a bloody diarrhea. It is invasive and kills cells Nonmotile 60s ribosome reducing the least virulent. leading to the blood. The inflammation Antibiotics can be used, but multiple affinity for EF‐1 response causes the malabsorption and drug resistances make it challenging to No H2S Shigella Dysenteriae is diarrhea. eradicate. Invades M cells by the worst of the shigellas, Non‐Lactose Fermenters phagocytosis, then migrates but is uncommon in the Can lead to Hemolytic Uremic Syndrome, Facultative Intracellular into neighboring cells US which is normally associated with EHEC. intracellularly. It can also There are no animal However, since the toxins are so similar, the live within the macrophage carriers. The human colon possibility for HUS is present. by escaping the is the only reservoir. phagolysosome. When the Transmission is fecal‐oral, macrophage finally lyses, such as at day care shigella is able to get into epithelial cells via the basal surface

Hugely pathogenic, incredibly low infectious dose (1‐10 organisms) Klebsiella Gram (­) rod, part of the Capsule – antiphagocytic Found in colon and upper Number one cause of aspiration pneumonia Fluroquinilone or Pneumoniae enterobacteriacae and antigenic. respiratory tract. in alcoholics. Third generation Cephalosporin In culture will have a halo Endotoxin –LPS from it Usually an endogenous Community acquired pneumonia. Common around cells, because of being Gram (‐) transmission cause of community acquired. Strep Pneumo their capsule. is the most common cause, but Klebsiella is still right there. Use the gram stain to Lac+ separate.

Causes a thick like jelly, red sputum without a pungent odor (such as in the case of a aspiration pneumonia). Pasturella Small Gram (­) Rods Reservoir is the mouths of Rapidly Spreading Cellulitis from the site of Amoxyclin and Augmentin Multocida cats, transmitted from the lick or bite, there will be a cellulitis that Facultative Intracellular bites or licks. Don’t will spread within hours. Because it is so rapid spreading, they think CATS and CAT confuse this with Cat‐ give an IM injection of antibiotics. BITES facultative Anaerobe Scratch fever, which is caused by a scratch, not a lick or a bite like Pasturella

Bordetella Pertussis Small gram (­) rod Pertussis Toxin – classic Colonizes the respiratory Whooping Cough – comes in 3 phases after a Erythromycin is drug of choice to give AB toxin that targets the epithelium and cab be week of incubation. to household contacts and those in the Nonmitile ciliary cells. It is a cAMP spread via respiratory ‐ Catarrhal Stage – the highly catarrhal phase. toxin, causing edema and droplets (the coughing, infectious stage with nonspecific Strictly Aerobic fluid. This causes increase in sneezing, and hand‐to‐ symptoms such as low grade fever, Isolate the catarrhal and early histamine sensitivity, hand contact) malaise, rhinitis. Weeks 2‐3 paroxysmal phases Grow Singly or in pairs leukocytosis and an increase ‐ Paroxysmal Stage – this is the in insulin, leading to noninfectious, but stereotypical Vaccinate with the DPT vaccine. Encapsulated hypoglycemia. phase. This stage has frequent bouts that come and go (paroxysmal) of Requires a long growth Dermonecrotic Toxin severe fits of coughing followed by a period on a special agar, strong inspiration against a narrowed called the Adenylate Cyclase Toxin – glottis causing the “whoop.” They can Bordet­Gengou secreted AC that is taken up become cyanotic or vomit. Weeks 3‐6 ‐ Convalescence Stage – the disease Bordet = Bordetella Tracheal Cytotoxin dies out, with lessening paroxysmal stage symptoms. Weeks 6‐on Filamentous Hemagglutin

Endotoxin Vibrio Cholera Curved, Gram (­) Rod with Pilus – the Tcp Pilus allows The reservoir for cholera Cholera – excessive diarrhea up to 20L/day. Treat with fluid and electrolyte polar flagella for adhesion to mucosal is the human colon. It is Causes rice water stools, looking white/clear replacement, both oral and IV. epithelium transmitted fecal‐oral, but like water while cooking rice. Oxidase (+) often by contaminated Flagella – makes it motile water. It requires a very Grow on Alkaline but not high infectious dose. Prevent cholera by boiling water and Acidic Toxin – cholera toxin is a vegetables, cooking your food classic AB toxin. It activates Motile Gαs via ADP‐Ribosylation. It El Tor strain causes causes cAMP increases that epidemics leads to tremendous fluid extrusion The classic strain has not been so bad Helicobacter Pylori Gram (­) curved rod with Urease converts urea and Humans are the only Gastric/Duodenal Ulcer – the urease and Serology can detect antibodies, but will a Single polar flagella acid into bicarbonate and known reservoir and it is mucinase degrades the protective lining of the only tell you if there ever was an (sounds like Cholera) ammonia, which neutralizes thought that it is stomach, allowing acid to reach the mucosal infection. the acid, allowing it to live in transmitable fecal to oral surface. Only organism that can the stomach or oral to oral. Golden standard is the biopsy with grow and replicate in the In addition, the cytotoxins cause autolysis of culture. stomach Adhesins allow colonization The mode of transmission macrophages and neutrophils inducing a and prevent dislodgement has not yet been strong inflammatory reaction, also Use the Urea Breath Test to determine from gastric mucosa established, despite its contributing to the disease. if someone has HP. You feed the patient prominence in GI disease. radioactive urea, and, if there is HP, they Mucinase degrades the Can lead to cancer. Either the reactive will expire radioactive CO2 (converted mucin protective barrier oxygen species damaging DNA post lysis and from the bicarb the HP made) inflammation or through viral infection of Vacuolating Cytotoxin the epithelium from the compromised barrier, Endoscopy can be made to identify induces vacuoles in human gastric tumors may result. gastric ulcers. cells. This is a Type 1 Carcinogenic Agent, a highly Treat the ulcers with Proton Pump Cytoxin Associated Gene board relevant point. Inhibitors treating the symptoms. encodes another cytotoxin. These HP are more virulent Treat the bug with Amoxicillin + Clarithromycin Proteus Mirabillis Small Gram (‐) Rods that Extreme Motility Pretty much ubiquitous in UTI if there is a UTI via proteus (E Coli most Fluroquinilone and Vulgaris are part of the the environment and common), there is an increased risk of kidney enterobacteriacae family Urease within the normal flora stones by reducing the pH of the urine. Treat kidney stones with pain meds (for Mirabillis = 90% of of the GI tract. passing) or sonic disruption to remove infection Swarming Motility from Endotoxin LPS from gram (‐) stones. its peritrichous flagella Most cases in humans are endogenous. Urease +

Nonlactose­Fermenting

Legionella Slender, pleomorphic, Capable of replication in Sporadic, epidemic, 1. Legionnaires’ disease (legionellosis) Microscopy: insensitive G‐ve rods ALVEOLAR nosocomial infections incubation period of 2‐10 days DFA – fluorescence MACROPHAGES (and systemic signs of acute illness appear abrupt Stains poorly w/common amoebae in nature) Aerosol Transmission Multiorgan disease (GI, CNS, liver, Kidneys) Culture: reagents – Use Silver Stain (Air conditioning units, Primary manifestation – pneumonia (severe) Buffered charcoal yeast extract (BCYE) Prevents phagolysosome but no person to and Fe+Cys Nutritionally fastidious ‐> fusion person) 2. Pontiac fever L­cysteine and enhanced Self limiting, febrile illness Antigen tests: sensitive for L. growth with iron salts Commonly found in Fevers, chills, myalgia, malaise, headache pneumophila serogroup 1 natural bodies of water Symptoms develop over 12 hrs, last 2‐5 days Non fermentative (rivers and streams) Seroconversion: must be demonstrated ‐> 6 mo. To develop Estimated btw 10k to 20k cases in US annually PCR: Sensitivity and specificity approaching High risk: compromised culture pulmonary function, pts with decreased cellular immunity (transplant) Chlamydia Gram (­) Rods Reticulate Body vs Elementary Bodies Obligate Intracellular Bacteria Elementary bodies are the metabolically inactive form Energy parasites that infects cells.

Really small, obligate Reticulate bodies are the intracellular = cannot see metabolically active form on a gram stain within infected cells.

Chlamydia Gram (‐) rod Reservoir is the genitalia Sexual Transmitted Diseases. Most common Doxycyline to Primary: Newer Trachomatis and the eyes. It is can be bacterial STD in the US. Urethritis, cervicitis, treat disease macrolides or Obligate Intracellular transmitted via sexual and damage to the fallopian tubes. This causes fluoroquinolones (granuloma formation) intercourse, hand‐to‐face, sterility. Serotypes D‐K Erythromycin can or even via flies. be given ie. Azithromycin, Lymphogranuloma Venereum – begins with prophylatically. clarithromycin or L, so do the seroptypes. Not common in the ciprofloxacin, US, but in developing countries. It is an STD levoloxacin that causes swollen lymph nodes that eventually results in blockage of lymph Decreased drainage and genitle elephantiasis. environmental exposure to Trachoma ‐ Serotypes A‐C. Results in reduce risk of conjunctival scarring and blindness. It is the disease most common cause of preventable blindness. Water: treat with hyperchlorination, superheating, copper‐silver ionization

Decontaminate air conditioning units. Chlamydia Pneumo Treponema Gram (­) Spirochete Human genital tract is the Syphillus – has 3 stages Two types of tests to do to diagnosis: pallidum reservoir. It is a sexually (1) Primary – non­tender chancer. There (1) Screening: crossacting antibodies Really had to find on a transmitted disease that is no pain, the lesion is there, after a to cardiolipin. nonspecific, cardiolipin, gram stain. can be passed to the fetus. few weeks goes away. If you biopsy the VDRL (caution SLE which may yield lesion you could see the treponema. false negative) Obligate Pathogen (we Serologic tests will stay negative. cannot culture it). It is NOT (2) Secondary – maculopapulo copper (2) Specific : immunofluorescence an obligate intracellular colored rash that is diffuse that FTA­ABS pathogen. includes palms and soles, with patchy alopecia. This rash is capable of transmitting disease. Condylamata Penicillin is the treatment. Even if looks like HPV with warts growing in allergic, the treatment is penicillin. the perianal region. Serology comes back positive. (3) Tertiary ‐ syphilitic granunlomas (aortictitus, Tabes Dorsalis, and altered mental states).

Borrelia Gram (­) Spirochete It is invasive, and will infect Nymphs (on mice) and Lyme Disease – Serology Burgdorferi the heart, joint, and CNS. Ticks (on deer). This is the number 1 vector‐borne disease. diagnoses the You get a bulls­eye rash at the bite site. It problem via ELISA We usually here about starts out with flu‐like symptoms with swollen or PCR. this disease with deer lymph. ticks from Lyme CT. Treatment is Ixodes is the genus of tick Once the organism disseminates, then you see doxycycline that spreads the nerve effects (such as bell’s palsy). organism. Migratory Arthralgia develops from Type III hypersentivity reactions depositing into the joints.

Cardiac Arrythmias may result from the disease as well. Leptospira Gram (­) Spirochete, with Unknown pathogenesis Zoonotic disease with Swineherd’s Disease or Mud Fever – interrogans little hooks at the end transmission through gastrointestinal symptoms + flu‐like water contaminated with symptoms that may progress to hepatic or Low yield animal urine. You will see liver failure. Spirochete this in patients who jet ski or who work in sewers. Rickettsia Rickettsia Ricketsii Energy parasite. They need Invade the vascular Reservoir is ticks. The Rocky Mountain Spotted Fever. Rash is Start treatment Doxyclcine and your ATP, and are an endothelial cells causing vector is a tick bite. critical for the diagnosis. When not present, without protection against obligate intracellular vasculitis and permitting the disease is usually missed until too late, as confirmation from the vector. parasite with leaky them to move through the Requires a long feeding this disease is rapidly fatal. serological epithelium blood strea, time in order to transmit indirect antibody the bacteria. The bacteria Confusion, N/V/D + headache. It looks like test. Very tiny, so you wouldn’t may be passed to meningitis, but then the rash comes on. The see them on a gram stain, progeny. rash is a maculopapular that turns Weil‐Felix is an even though they are petechial that starts on the hands and feet old test, that might considered Gram (­) rods and moves to the trunk. Includes palms creep on the and soles boards. Rickettsia Same as Ricketsii Endemic Typhus Prowazekii

Considered low yield for Boards Rickettsia Typhi Same as Ricketsii

Considered low yield for Boards Haemophilus (and Small, pleomorphic, G­ve H. influenze type b is Noncapsular Haemophilis Haemophilis influenzae Microscopy – related bacteria) rods or coccobacili clinically most virulent (PRP commonly colonized in Meningitis: unimmunized children ‐> fever, sensitive test in – polyribitol phosphate – humans; encapsulated severe headache, systemic signs CSF, synovial fluid, Facultative anaerobes, in capsule) Haemophilis (H. influenze Epiglottitis: unimmunized children ‐> initial lower respiratory fermentative type b) UNCOMMON pharyngitis, fever, difficulty breathing, specimens PRP – ribose, ribitol, members of normal flora progresses to cellulitis and swelling of Most species require X phosphate supraglottic tissues ‐> obstruction of airway Culture ‐> (heme) and/or V (NAD) Disease caused by H. Pneumonia: inflammation and consolidation chocolate agar factor for growth Haemophilus adhere to host influenze type b was of lungs observed primarily in the ELDERLY cells via pili and non‐pilus primary a pediatric with underlying chronic pulmonary disease; Antigen tests‐> H. influenzae subdivided structures problem ‐> eliminated in typically caused by nontypeable strains less useful for H. serologically (a to f), immunized populations influenzae type b biochemically (biotypes I to IgA Protease Haemophilus ducreyi infections VIII), and clinically H. ducreyi disease is Chancroid: STD ‐> tender papule with an following vaccine (biogroup aegypticus) uncommon in the US erythematous base ‐> progresses to painful ulceration and lympathadenopathy. This is a Satellite Phenomena – you With the exception of H. distractor with Syphilis (treponema) because can grow Haemophilus ducreyi, which is spread they are both spirochetes, and both cause a next to staph because it is by sexual contact, most chancer. Yoyu “do cry with ducreyi” meaning beta‐hemolytic and Haemophilus infections that it is a painful chancer. releases the heme and NAD are cased by pts bacterial into the medium on a blood flora (endogenous agar. infections) Bacteroides Fragilis Gram (­) Rod Reduced Endotoxin Normal part of the GI Sepsis: weak, because the endotoxin is flora. Traumatic modified. Capsule displacement (surgery) can permit movement Peritonitis: This isn’t terribly high yield, but into other compartments. man you don’t want this kind of peritonitis. It will cause massive necrosis of the peritoneum and the intrabdominal contents

Francisella Zoonotic Tick bite (the ulcero‐ Tuleremia: Live Attenuated broad‐spectrum Tularensis glandular form) Vaccine cephalosporins, Small Gram (­) Rod Ulcer at bite site and regional lymph swelling azithromycin, or (potentially low­ Associated with hunting from tick. Traumatic Implantation from fluoroquinolones yield accept it is a Facultative Intracellular and skinning Wabbits. wabbit skinning can cause it as well. Bioterror agent) pathogens (cause This can cause a Many strains are granulomas) traumatic implanation or If you inhale it or eat it, you will develop resistant to inhalation while you tularemia in the GI tract. ampicillin shred its flesh everywhere. Active immunization If you eat the rabbit with conjugated without cooking it well, PRP vaccines you could ingest it as well prevents most H. influenzae type b infections

Rifampin prophylaxis ‐> children at high risk for disease Brucella Zoonotic Endotoxin – LPS in gram (‐) Passes readily between Brucellosis – undulant fever because it goes Serum (potentially low­ animals and humans. up and down. They are flu‐like symptoms with Agglutination yield accept it is a Small Gram (­) Rod Usually contained in profuse sweating. test is pretty Bioterror agent) domestic livestock (large much all you can Facultative Intracellular animal veterinarians) do. pathogens (cause granulomas) Species depends on the Rifampin & animal it infects. Doxycycline for 6 weeks (facultative Abrotus = cattle intracellular are Sewis = pigs tough) Malatensis = goats We can vaccinate cattle or high risk individuals.

Pasturization helps spread. Gram Positive Cocci ‐ Staph = Aureus, Epidermis, ‐ Strep = Pyogenes, Agalactiae, Mutans (Viridans group), Pneumonia, Enterococcus

Gram Negative Cocci “Never mind about Moraxella” NM, The N and M that aren’t in the Ram Positive Rods. ‐ Neisseria = Gonorrhea, Meningitidis ‐ Moraxella = Catarrhalis

Gram Positive Rods “BCC: LAN, LM”, “Send an email (BCC) over the network (LAN) to Lincoln Martin (LM)” ‐ Bacillus = Anthracis, Cereus B of BCC ‐ Corynebacterium = Diphtheriae C of BCC ‐ Clostridium = Tetani, Botulinum, Perfringes, Difficile C of BCC ‐ Lactobacillus = Lactobacillus La of LAN ‐ Actinomyces = Israelii A of LAN ‐ Nocardia = Nocardia N of LAN ‐ Listeria = Monocytogenes Li of Lincoln, also think “listserv” ‐ Mycobacteria = Tuberculosis, Leprae M of Martin

Gram Negative Rods Everything else. Yep, that’s right. Everything. I hate memorizing lists (like all bacteria above), so here some categorizations to help you keep the bugs straight

Non‐Enteric Gram Negative Rods

Respiratory Zoontic Opportunistic

Haemophilus Influenzae Francisella Tularensis Pseudomonas Aeruginosa Legionella Pneumophilia Pasturella Multocida Klebsiella Pneumoniae Bordetella Pertussis Brucella Spp. Yersinia Pestis Rickettsia Rickettsii Rickettsia Prowazekki Coxiella Toxin Secreting Bartonella

cAMP Protein Synthesis Neurotoxins Inhibition

Vibrio Cholera Corynebacterium Clostridium Tetanii ETEC Diphtheria Clostridium Botulinum Bacillus Anthracis EHEC Bordertella Pertussis Pseudomonas Shigella

Enterobacteriaciae

Nonlactose Fermenters “ShYPS” Lactose Fermenters – “CEEK” Shigella Citrobacter – Tulane doesn’t discuss it Non motile, non H2S producing Yersinia Escherichia – E Coli Proteus Enterobacter Motile, H S producing Salmonella 2 Klebsiella

Spore Formers “Start off the Gram Positive Rods” Bacillus Urease Positive Clostridium Klebsiella Pneumoniae Helicobacter Pylori Capsules: “Some Killers Have Pretty Nice Capsules” Proteus S – S. Pyogenes K – Klebsiella Pneumoniae H – Haemophilus Influenza P – Pseudomonas Aeruginosa N – Neisseria (Meningiditis only) C – Cryptococcus (fungus)

Toxins

Intracellular Growth

Facultative Obligate Listeria Monocytogenes Mycobacteria Leprae Salmonella Genus Rickettsia Rickettsii Shigella Genus Coxiella Burnetti Mycobacteria TB Erlichia Brucella Genus Chlamydia Species Bartonella

The “ABCs” of Anaerobic bacteria A – Actinomyces (gram +) B – Bacteroides C – Clostridium (gram +)

Acid Fast Bacteria Mycobacteria (TB and Leprosy) Nocardia