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Micro non-sketchy facts

General Facts

Lectures 1-3
Staph: grape-like clusters; Strep: grow in chains
Lecture 9

IL-1 is the most potent endogenous pyrogen in humans

TNFa is active in soluble and membrane bound forms
IL-6 acts distal to IL-1 and TNFa
IFN (a most potent, gamma acts by induction of a and IL-1)
IFNa in viral infections (ie flu has high fever)

Pathogens + host cells  cytokines  thromoreg center  PGs  fever

LPS stimulates TNF and IL-1  IL-6  PGE2  fever

Fever: heat shock protein expression, cytotoxic effector function; BUT increased metabolism,
decreased O2 delivery  ischemia and damage

Rapid response: innate immune system—monocytes come in contact w infection  activated

macrophages  fever inducing cytokines
Macrophage TLRs recognize bacterial cell wall motifs (ie LPS); TLR4 recognizes LPS
TLR4/LPS binding  NFkB activation in the nucleus  cytokine release

Sepsis = SIRS + evidence of infection; Septic Shock = sepsis + hypotension + perf abnormalities
Myosin dephosphorylation  vasodilation (septic shock)
Septic shock tx: airway, breathing, circulation
Transition zone: lower ileum in GI tract, where number of anaerobes increases to 10^8/mL;
increases to 10^11/mL in the colon
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2 stages of bacteremic infection
Early (3-4 days): sepsis/peritonitis (free zir in peritoneum) w high morbidity
Positive blood cultures for enteric Gram neg bacteria
Late (>7 days): abscess developes (anaerobes play larger role)
Synergy: one org makes critical growth factors for the other (ie Bacteroides needs vit K which
aerobe makes); aerobes lower local O2 and redox potential for anaerobes to grow

Clues to anaerobic infection: putrid drainage, polymicrobial flora on gram stain of exudates,
infection involving normal flora of adjacent mucosal surfaces, abscess formation

Things that predispose to aspiration: altered consciousness, dysphagia, neuro dz, mechanical
disruption of defense barriers, protracted vomiting, gastric obstruction, NG tube

Female GU tract 10:1 anaerobes:aerobes

Diabetic Soft Tissue Infections: vascular insuff  decreased redox potential; skin breaks,
compromised host defenses; staph and strep

Bacterial meningitis: elevated WBC, low glucose, elevated protein

Kernigs sign: flex hip to 90˚, extend knee  hamstring pain (spinal nerve pressure)
Brudzinski’s sign: lay down, flex neck  invol hip and knee flexion
Both are very specific, not very sensitive; nuchal rigidity is more sensitive
Pneumococcal: PCV7 vaccine decreased rates of meningitis in children and adults
Drives high rates of compications
N. meningitidis: presents with purpura fulminans; thrombosis/ischemia of digits
Complications less likely after first day
Tx: need bactericidal abx in high amounts to enter CNS—combo penicillin and cephalosporin;
anti-inflam (steroids) before abx in children (all types) and adults w pneumo and TB meng
Increase CNS penetration: inc BBB permeability; small molecular size; high lipid
solubility; low ionization; low serum protein binding
Decrease abx penetration: active efflux through choroid plexus
Viral meningitis: mononuclear WBCs (not as elevated as acute), normal CSF glucose, mildly
elevated protein
Causes: enteroviruses, arboviruses, HSV2; borrelia burgdorferi, partially tx acute meng
Chronic meningitis: slow presentation, not as virulent; mononuc WBCs, extremely low glucose,
highly elevated protein
Causes: Cryptococcus (other fungi), TB, Borrelia, Treponema pallidum

STD: R0 = infectivity rate * duration of infectivity * rate of new partner acquisition

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Bacteria Specific Facts

C. diphtheriae
Aerobic, nonmotile
Immunized people can be colonized and transmit organisms

C. tetani
Motile

EHEC
Nonspore forming, motile
A subunit cleaves adenine from 28S rRNA of the 60S ribosome
Shiga-like toxin: A-B, encoded on bacteriophage, capillary thrombosis, inflam
binds receptors in colon—GI mucosal cells (bloody) and Na+ transport cells (diarrhea)
Most common in industrialized world; can be found in fruits, veggies, juices; low infecting dose
HUS: 3-7% in sporadic dz; up to 20% in outbreaks
Toxin binds to renal cells  glom swelling  deposition of fibrin and platelets in
microvasculature, injure RBCs (hemolytic anemia)  3-5% ESRD
Tx: supportive, DON’T give antimotility (increases HUS risk), abx controversial

ETEC
Tx: symptomatic, fluoroquinolone (cipro)

EAEC (NOT IN SKETCHY)

Dz of infants and children in developing world; may cause growth retardation (malnutrition)
Asymptomatic adults in industrial countries; associated w traveler’s diarrhea
Adheres cell cultures in aggregate patterns (films of mucus and inflame molecules)
MOA unknown, maybe biofilm  mucus secretion  malabsorption
Does not invade—adheres via fimbriae and genes on plasmid
Shortens host mucosal villi, heat stable toxin similar to ETEC
Clinically: watery, mucoid, secretory diarrhea (1/3 grossly bloody), little fever, some vomiting
Symptoms last a long time (17 days in children <3yrs)

EPEC (NOT IN SKETCHY)

Dz of developing countries; 20% bottle fed infants <1 in these places; rare in adults here
ROT: fecal oral, fomites
Attaches via pili, secretes own receptor into enterocyte, forms clustered colonies
Genes are on a pathogenicity island, NOT a plasmid
Causes microvilli effacement, changes in cell morphology (pedestals) but dunno howdiarrhea

EIEC (NOT IN SKETCHY)

Like Shigella but ferments lactose

Shigella
Dysentery: painful defecation, straining, tenesmus: urge to move bowels after completing BM
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Toxin: B binds to Gb3 receptor, internalized  ER; reduce A subunit, cleave adenine rRNA
Multiplies in SI (watery diarrhea); invades intestinal mucosa, gets out of vacuole into
cytoplasm, actin tail propels through cytoplasm, invades next cell
Tx: fluids, electrolytes, abx (cipro, no antimotility)

B. anthrax
“Boxcar appearance;” spore germination up to 60 days later
Cutaneous anthrax  black eschar, less lethal (edema factor)
Systemic anthrax  inhaled, sepsis, high mortalitiy (lethal factor); 1-5 um to be inhaled agents
of bioterrorism

C. botulinum
Tx with equine neutralizing antibodies (preformed ab to the toxin; passive immunity)—
inactivates botulism toxin; BUT no vaccine because multiple serotypes
If outbreak: there is antitox but not enough; mech ventilator capacity exceeded

S. aureus
20-40% of general pop are colonized with S.aureus
Abx resistance:
- Penicillin (b lactam ring) binds, interferes w PBP  bacterial death
- Bacteria makes b lactamase, disrupts penicillin structure  bacterial survival
- Modified b lactamase resistant penicillins maintain structure  bacterial death
- Bacteria alter PBP protein morphology, penicillin can’t interact  bacterial survival
OR efflux pumps remove abx
VRSA likely acquired from enterococcus; use linezolid, daptomycin, telavancin, ceftaroline
MRSA looks like insect bites, can cause pulmonary infections
TSST-1 exotoxin induces IL-1, IL-2, and TNF (cytokine storm)
Job’s Syndrome: hyper IgE (freq abscesses secondary to S. aureus)
Botryomycosis: rare CGD of skin in immunocompromised patient (HIV, DM, CF)

S. lugdunensis (NOT IN SKETCHY)

Coagulase negative, behaves like S. aureus in virulence, suspectible to b lactam abx
Colonization w S. lugunensis inhibits colonization w S. aureus

Strep:
Lancefield classification: grouped by cell wall carbohydrate antigens—pyogenes (A); agalactiae
(B); enterococci, bovis (D)
S. pneumo
Facultative anaerobe, Quellung reaction distinguishes
Virulence factors: pneumolysin (alpha hemolysin) inhibits bactericidal activity of phagocytes,
decreases ciliary motility, cytokine cascade; autolysin: promotes inflam response, cell lysis to
disperse pneumolysin; neuraminidase mediate bacterial cell adherence
Affects: Af Am, Alaskan natives, Native Americans more than whites
Vaccines:
PCV7 (infants and children)—capsular polysaccharide antigens + inert diphtheria toxoid
Prevents invasive dz AND reduces nasopharyngeal carriage
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PCV13 (children and immunocomp adults (HIV, DM, asthma))—caps polysacch antigen
+ inert dihtheria toxoid
PPV 23 (>65 or >2 w risk factors)—pure polysaccharide, provoke B cell ab response but
antigens are T cell dependent (poor response in <2 yrs) and must be given every 5 years;
prevents invasive dz but doesn’t reduce nasopharyngeal carriage
Dx: culture is gold standard; Tx: Penicillin G, ampicillin, ceftriaxone, vancomycin

S. pyogenes
M protein is important for attachment to the host, preventing phagocytosis (bind Fc portion),
barrier to complement deposition; types 1, 3, 12, and 28 most commonly assoc. w invasive dz
Streptolysin is responsible for beta hemolysis

Use IVIG and clindamycin to treat TSS

ARF has a 1-2 week latency period; Sydenham’s chorea has longer latency—adolescent girls
Tx: abx (penicillin), anti-inflam (ASA, glucocorticoids), supportive care, prevention

PSGN occurs after pharyngitis or pyoderma—good prog, no need for tx

PANDA post strep tics, OCD, neuropsych

S. galactiae
Capsule contains sialic acid (anti-pahgocytic), makes C5a peptidase and pili (like GAS)
Clinical: women—UTI, endometritis, amnionitis, bacteria
Neonate (early, more common, 0-6 days)—resp distress, sepsis
Neonate (late, 3-4 weeks)—bacteremia/focal infection (localized by system)

S. viridans
Can have nutritionally variant viridans culturally neg endocarditis, hard to treat, valve abscess

Enterococci
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Have abx resistance to aminoglycosides (mod enzymes, plasmid), beta lactams (b lactamase),
and vancomycin (plasmid—altered target)

E. Coli
Indole + (can convert tryptophan to indole)

Klebsiella
Indole negative; large appearing on gram staining (polysac capsule)
Rapid onset, lobar pneumonia, upper lobe abscess, cavitations, empyema
Poor outcome despite early abx >50% overall mortality
CXR: buldging fissure sign (heavy consolidation)
K. oxytoca—neonatal bacteremia in premies and in the neonatal ICU
K. rhinoscleromatis—assoc w rhinoscleroma (chronic inflame process of nasopharynx) and
ozena (chronic atrophic rhinitis)
Resistance: MDRO==extended spectrum beta lactamase (resist chephalosporins and
monobactams—aztreonam); carbapenemase (can’t use drug of last resort carbapenem)
Tx: 3rd gen cephalosporins, quinolones (community acquired); carbapenems for ESBLs

Pseudomonas
Motile (flagella), extracellular, biofilm, pili; hard to eradicate
Lipid A is less inflammatory than other GNRs
Upper RT: aspiration; Lower RT: CF

Proteus
2nd most common in the lab

Salmonella enterocolitis
Adheres to mucosa via pili  membrane ruffles (>12 proteins on 2 pathogenicity islands) 
ruffles engulf organism into vaculone in M cells  transcytose to basolateral membrane 
escape to lamina propria (inflam response)  macrophages engulf  apoptosis  diarrhea
Tx: self-limiting, give abx to immunocompromised, those w bacteremia, HIV
48-72 hrs/afebrile; fluoro, trimethoprim/sulf or amox

S. typhi
Large pathogenicity island AND virulence plasmid (abx resistance)
Invades M cells  underlying lymphoid tissue  invade macrophages (long survival) 
oxidative burst, allows transport via lymph to nodes, spleen, liver, bone marrow
(reticuloendothelial system—multiples here)
LPS causes fever, can seed UT, biliary tree, gall bladder, bone marrow
If survive, subdue infection via humoral immunity, activated macrophages
Dx: blood culture (60-80%); bone marrow (80-95%); stool (30%); NOT multiplex PCR

C. jejuni
Needs enriched media and microaerophilic enviro (42˚C and CAMPY agar)
Leading cause GI inf in industrialized countries (2x salmonella)
Can be transmitted person to person
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Adheres to cells in jejunum, ileum, and colon  endocyte vacuoles  associates w microtubules
in cells  secretes toxin that arrests cell division
Prodrome (fever, headache, myalgia, malaise 12-24 hrs before intestinal symptoms)
Traveler’s diarrhea in South and SE Asia
Tx: erythromycin, FQ if worried about other organisms

V. cholerae (O-1—global, O139—Asia)

Lab media: thiocitrate bile salt agar
Salt water in crustaceans and plankton: spread via cont water, food, houseflies (India, Africa)
Turn on genes in 2 pathogenticity islands on larger chromosome, stim by changes in temp, osm
ToxR regulates by turning on prod of cholera toxin, pili
Tox subunits A1 and A2; A1 released by reduction of disulfide bonds, like ETEC LT; inc cAMP
Symptoms: rapid watery odorless diarrhea w mucus flecks, afebrile, hypoK, acidosis
Tx: fluids (isotonic NaCl, KCl, trisodium citrate, GLUCOSE—facilitates Na absorption)

Legionella
Long, filamentous intracellular rod; hard to culture; sparse in sputum
Doesn’t spread from person-to-person
Not responsive to penicillin

Mycoplasma
Very fast resolution if abx; if no treatment, resolution in 6 weeks
Complications:
5% Stevens-Johnson Syndrome (cell deathepidermis separates from dermis; clears on
own; GAS infection if scratched)
5% Raynaud’s (IgM Abs attach to RBCs; agglutination  Raynaud’s)
SCD—this is worse, vasoconstriction, agglutination not as reversible

RSV
Laryngotracheobronchitis (Croup) in infants; can cause severe pneumonia in adults
Wheezing (not in influenza)
Tx: ribavirin, not helpful in all patients; vaccine made dz worse

Actinomyces
Normal oral flora, can cause necrotizing pneumonia
Tx: penicillin, tetracycline, macrolides, clindamycin; surgery

Nocardia
90˚ branching; immunocompetent and compromised

Bacteroides fragilis (NOT IN SKETCHY)

<0.5% normal colon flora but most of abscesses
Virulence factors: capsule, pili/fimbrae, endotoxin (lacks lipid A), enzymes
Capsular polysaccharide: stimulates peritoneum to express ICAM, sticks, stimulates
peritoneal macrophages to secrete TNFa and IL8; WBC recruitment; resists clearing from
peritoneal cavity
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H. influenza
Non motile, can appear as long filaments
Polysaccharide capsule OR nonencapsulated (less virulent)
Virulence factors:
Adhesins bind to mucus and RT epithelium
LOS, peptidoglycan, protein D prevent mucociliary clearance
IgA1 protease cleaves human IgA1 (protects mucosal surfaces)
Risk: Af am, Alaskan Natives, Native American, daycare, crowding, HIV, SCD, splenectomy
Vaccine: type B capsular polyribosylribitol phosphate conj to N. meng outer membrane protein)
Nontypeable H flu has highest incidence of invasive disease
Dx: blood, CSF, sputum gram stain and culture
Tx: ceftriaxone

N. meningitidis
Virulence factors:
Polysaccharide capsule inhibits phagocytosis
IgA1 protease enhances resp mucosal colonization
Uses iron bound to transferrin: can survive and replicate within human host
Meningococcal endotoxin: hemorrhagic skin findings (petechiae, purpura), endothelial
damage, systemic inflammatory response
Meningococcemia: fever and bacteremia without toxicity
Meningococcal septicemia (15-20%): severe and sudden illness w nonspecific symptoms 
rapid deterioration within hours (rapid multiplication, high concentrations of endotox)
B, C nonepidemic; A epidemic disease

Hantavirus
Extreme drought in SW  wild deer mouse migration closer to people

B. burgdorferi
Spirochete (flagella tightly adherent to cell membrane, surrounded by mucoid layer)
Hard to visualize (thin), need silver stain except in relapsing fever (Borrelia)—on blood smear
Spirochetes: delayed immune responses, contain plasmids (antigenic variation)
Lyme disease: infected ticks lay eggs, larvae are not infected; feed on infected host  transmit
Early localized (3-30 days): spirochete in skin, replicates locally, expanding annular rash
(erythema chronicum migrans) which fades (lesions can disseminate)
Early disseminated (months): 25% develop heart block, Bell’s palsy, sciatica
Late (5-10%): chronic disease w severe arthritis, spastic parapersis, neuro problems, mimic RA
No benefit to prolonged abx in treating lyme assoc fatiguing illnesses
Dx: clinical, confirm through serology after a few months
Pts w early disseminated dz have IgM or IG in some, serology (+ for life once exposed)
Screen w ELISA first, then western blot
DNA in urine, CSF has low number organisms; PCR + persist after tx

Leptospirosis
Differential dx for hepatitis
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Scleral icterus, hemorrhages w increasing urine protein
Stage 1 (3-7 days): septicemia, fades for a period of time
Stage 2 (10-30 days): relapse with meningitis, uveitis, rash, fever
Weil’s syndrome: severe icteric, same 2 stages but without resolution between

Rickettsia
Endothelial pathogen, nonmotile, not susceptible to beta lactams but are to protein syn abx (tetra)
RMSF (R. rickettsii): dog tick (larger than deer ticks) bites, IS transmitted from infected ticks to
next generation of ticks through eggs (transstadial)
Replicates locally in endothelial cells, blocks capillary bed  thrombosis/necrosis; vasculitis
Petechial rash (more intense on hands, palms, soles); no blanching bc blood extravasation
If untreated: gangrene of fingers
Dx: biopsy and staining; serology is too slow (>50% mortality if untreated); Weil-Felix
Tx: tetracycline (doxy)

Reckettsialpox (NOT IN SKETCHY): vesicular disease w fever and severe back pain; winter/fall
Mite bite—painless firm red lump
Looks like chicken pox BUT rash is a papule w tiny little vesicle at top (chicken pox has vesicle
over whole lesion); also affects adults
Tx: tetracycline (resolution after 48 hrs)

Epidemic Typhus: R. prowazekii (body louse lives on clothing, need poor hygiene)
Febrile, nondescript rash (fine, macular, over whole body)
Dx: serology, Tx: tetracyclines
Scrub typhus (NOT IN SKETCHY): chiggers, eschar and petechial rash

Ehrlichia (NOT IN SKETCHY)

Transmitted by Ixodes ticks (can also transmit Lyme, Babesiosis—malaria like affects RBCs)
Lyme has same tx, babesiosis does not
Affects leukocytes  low WBC count, mild liver abnormalities
Ehrlichiosis/anaplasmosis: 2 types—monocytic and granulocytic (anaplasma phagocytophilum)
Febrile flu-like in the summer (ticks are biting)
Buffy coat smear: microcolonies of organisms in blood cells
Dx: serology, PCR (don’t usually culture)
Tx: tetracycline, doxycycline (response should be rapid <48 hrs)

Coxiella (Q fever)
Enters macrophages, mostly in lungs; can be transmitted by any tick but mostly via aerosol
Live in phagosome (need low pH)  phase variation (phase I in humans is virulent; phase II in
culture is not)
Acute infection: flu-like w hepatitis
Chronic infection: endocarditis, osteomyelitis, neuro dz, fever of unknown origin
Phase I antigen CF titer is diagnostic (disappears w therapy)
Tx: tetracyclines, T/S, rifampin, and quinolones
Bartonella
Affects surfaces of cells  endothelial proliferation (looks like angiogenic cancer—Kaposi
sarcoma-- w little lesions of proliferation)
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Silver stain to see bacteria
B. henselae—cat fleas
B. quintana—body louse
B. bacilliformis—sandfly
Often asymptomatic bacteremia
Tx: tetracyclines, erythromycin/macrolides, chloramphenicol, quinolone (NOT b lactams)

Smallpox (NOT IN SKETCHY)

ROT: droplet into oropharyngeal mucosa  LN  viremia
Symptoms 10-14 days after exposure; maculopapular rash  vesicular/pustular after 1-2 days
30% mortality, death usually in 2nd week
Not infectious until symptomatic
Tx: supportive; can vaccinate if recognized before symptoms

Tularemia (Rabbit fever)

Francisella tularenis: grows in cysteine media
3-5 day incubation; rapid onset of symptoms
No isolation needed bc no human to human transmission
Tx: streptomycin; more commonly cipro or doxy
Prophylaxis: same

Yersinia pestis (plague)

Still seen in SW US
Only pneumonic type of blague is infectious (not bubonic or septicemic)
Fleas  rats  bacilli replicate  block flea gut  regurge into bite wound
Tx: streptomycin (gentamicin) or doxy/chloramphenicol

NONULCERATIVE
HPV--STD w highest incidence
Nonenvoleped nonlytic DNA virus, more than 150 genotypes
Symptoms: self-limited asymptomatic  resolves spontaneously
Types 6, 11 (condyloma acuminata—genital warts, laryngeal papillomatosis)
Types 16, 18 (intraepithelial neoplasia)
Dx: morphology, cervical pap smear, PCR (not routine)
Tx: cryotherapy, excision, topical
Vaccine: 3 approved; quadrivalent (females 9-26; males 11-21)

Scabies—sarcoptes scabiei (NOT IN SKETCHY)

Pruritis, rash (interdigital linear burrows, or around wrists/ankles)
Immunocomp—Norwegion scabies; crusted, diffuse, v infectious
Pubic lice—pediculosis pubic (crabs) NOT IN SKETCHY
Presents with pruritis and maculae ceruleae (discolored bluish spots on skin)

ULCERATIVE
HSV2
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Most prevalent STD in the US--20-25% US pop w HSV2; 80-90% unaware
Genital herpes: increasing number new cases w HSV1 (young women, MSM)
Painful genital sores
Dx: PCR from ulcer swab
Tx: acyclovir or valacyclovir

Chancroid (Haemophilus ducreyi) NOT IN SKETCHY

Declining prevalence in US
Painful genital ulcer, tender suppurative lymphadenopathy
Dx: clinical, gram stain “school of fish,” culture (60% sens, not widely available), PCR
Tx: azithromycin 1g x 1 OR ceftriaxone 250 mg IM x 1 or cipro PO bid x 3 days

(LGV)

Treponema pallidum “the great imitator”

Syphilis on the decline but surged in last 10 yrs (MSM); easy through oral sex
After 2˚ syphilis: 1/3 clear, 1/3 low serology, 1/3  late stage
Congenital syphilis  like 2˚ in adults; can prevent by treating mom w penicillin
As few as 10 organisms needed to cause infection
Can’t culture in vitro; need dark-field microscopy, serology (ab testing)
Nonspecific: anti-cardiolipin ab (70-80% sensitive for 1˚; 99% for 2˚)
Specific: antitreponemal ab
Tx: penicillin, doxy (alternative except in pregnancy); neurosyphilis—high dose IV penicillin
4-6 hrs after first dose: Jarisch-Herxheimer (fever, chills, HA, arthralgia)
Serofast syphilis common (% of pts remain positive despite effective therapy)

N. gonorrhea
Pathogenesis:
Scavenging iron (transferrin)
Antigenic variation by transcriptional control (OMP variation by translational control)
OMP  large bacterial clusters  attach to mucosal epithelium  enter and multiply in
cells  enter submucosa  acute inflam response via peptidoglycan and LPS
Clinical: male—primary site in urethra, discharge and dysuria after 3.5 days; 2˚ prostate or
epididymis; female—primary is endocervis, discharge, metromenorrhagia; 2˚ Batholin’s glands
Can cause PID
Disseminated (0.5%): fever, malaise, rash, arthritis, endocarditis, menigitis
OMP porin Pore1a  promotes host cell invasion, serum resistance to complement
Dx: gram stain (99% spec, >95% sens), culture, antigen assays, PCR (NAAT)
Tx: used to be penicillin, now resistant (chromosomal and plasmid)  ceftriaxone IM and treat
for chlamydia (macrolide--azithromycin)

Chlamydia
Most common STD in US, incidence gradually rising
Obligate intracellular (can’t make ATP); infects squamocolumnar cells
Neonatal inclusion conjunctivitis—peripartum (less severe than trachoma)
Trachoma: roughening of inner eyelid surface  blindness
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Dx: NAAT (male—urine, female—endocervix swab), culture
Tx: azithromycin (1 dose oral) or doxy (1 week); treat partners!
Re-screen at 3-6 mo
Tx for LGV: doxy 100mg PO bid x 21 days

Trichomoniasis—Trichomonas vaginalis (NOT IN SKETCHY)

Asymptomatic, frothy grey-brown discharge
Dx: motile flagellated organism on wet mount
Tx: metronidazole

Gardnerella vaginalis (BV)

Gray malodorous fishy discharge  shift in bacterial flora of vaginal
Dx: clue cells on wet mount
Tx: metronidazole

Candidiasis (candida albicans)

Dx: hyphae on KOH wet mount
Tx: antifungal (topical clotrimazole, miconazole, oral fluconazole)

History of Syphilis
Elusive, shape shifting
Origin unknown
Columbia theory: Columbus et al. brought back syphilis after returning from first voyage to
Americas (1493)
Spread of syphilis facilitated by war and movement of troops
Charles VIII of France marched on Italy; mercenary army
Entered in Feb 1495, left May (troops sickened bc syphilis)
On way home, encountered a coalition army (Holy League)—scattered across
Europe, carrying syphilis
Poet gave the name after Syphilis who angered Apollo
Concept of STD, stages of disease described early by Italian surgeon (1514 Giovanni da Vigo)
Destructive, highly virulent
16th c hypotheses: body permeable, susceptible to enviro—astrological theory; divine
punishment
Brought from new world: presence of syph in Hispanola
Description of the “West Indian Disease;” rapid spread in Barcelona after Columbus’ crew
returned
20th c: unitarian hypothesis—all treponemas genetically one disease; expressed differentially dep
on environmental features (temp); other studies said present in Europe b/f contact in new world
(Pre-Columbian theory)—misdx as leprosy; this is misclassification by examining skeletal
remains
Osteo type of syph not present in pre columbian but yes in NA
Saber shin: tibial remodeling; gumma is divit in bone in the middle
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Lab Manual
- Microscopic field: look for areas WBC, no epithelial or host cells
- N. gonorrhea requires CO2 for growth—used to use candle jar to incubate
- Solid media
o Advantages: individual bacteria can be separated for further testing, distinctive
appearances can be observed
- Liquid broth
o Advantages: can allow a much larger amount of specimen to be examined (ie one
bacterium/mL won’t grow on agar)
o Disadv: morphology can’t be observed, number of bacteria in original sample
can’t be determined, delayed identification from specimens with normal flora
- Enriched media is used for fastidious bacteria (picky eaters)
- Chocolate agar = blood agar w lysed RBCs—used for H. influenzae and N. gonorrhoeae
- MacConkey: selective and differential for non-fastidious gram NEGATIVEs; red if
lactose fermenting
- Columbia CNA Agar is selective and differential for gram POSITIVE (inhibit gram neg
by colistin and nalidixic acid)
- Sabourand and Mycosel (low pH) Agar: for fungi
- XLD  gram NEGATIVE stool cultures; Salmonella grows as BLACK (others are red)
- Thioglycollate broth is used to detect small numbers of bacteria; facilitates strict
anaerobes and aerobes; blue at oxygen surface, colorless below
- GN broth (nonfastidious gram NEGATIVE)  includes bile salts  stool cultures, small
numbers of Salmonella
- S.S. agar: has high conc of bile salts, basically MacConkey + XLD indicators
- How to identify Group A strep: precipitan testing, IF staining, agglutination testing; most
labs use bacitracin sensitivity
o GAS: beta hemolysis is enhanced by anaerobic incubation
o Commercial kits for GAS throat swabs (ELISA, agglutination): fast, specific but
NOT sensitive (often have false negatives)
o Streptozyme is a screening test—mix latex particles coated w GAS extract; mix w
patient serum—agglutination if +, may have high Ab titers; if -, GAS unlikely
o Follow a positive streptozyme test w Ab to streptolysin O (ASLO): serial
dilutions of pt serum to a fixed amount of SLO (specific SLO abs inhibit
erythrocyte hemolysis); titer may not be elevated in pts w post infectious GAS
sequelae (so use anti DNAse, anti-NADase)
- Can use RFLP analysis to pinpoint source of epidemic
- Oxidase turns tetramethyl-p-phenylenediamine (colorless)  oxidized form (purple)
- Enterotube: each chamber has agar w different substrates that can be metabolized 
indicator changes color  identification
o If test ability to metabolize 10 substrates, can ID 210 types of bacteria
- Sputum gram stains: scan for neutrophils (want) and epithelial cells (don’t want)
o If cultured material originates from site of disase, you will see neutrophils
o If material is from the mouth or pharynx, you’ll see epithelial cells
o Neutrophils stain pink in a gram stain
- Don’t do a catalase test from colonies on blood agar plates bc RBCs contain catalase
- Black on bile esculin (NOT same as being bile sensitive/resistant):
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- Stainless steel loop use in an oxidase test may lead to false-positive
- PYR test: pink/cherry red if positive (filter paper)
- Indole: If tryptophanase is present, organism will convert tryptophan to indole (blue)
- MALDI-TOF: mass spec  protein fingerprint
o Organism is overlaid with a matrix because it assists w ionization and protects
bacterial proteins from degradation when struck by MS laser
o Energy from laser  desorption of proteins into gaseous cloud
o Proteins are ionized in the cloud, protons from matrix are donated to bac proteins
o + charged proteins are accelerated under vacuum, measure time of flight  M/Z
o Can be used to ID bacteria from blood culture bottles (centrifuge aliquot, extract
proteins  same as above)
o Disadv: get v specific results (ie organisms you’ve never heard of)
- Hemolysis
o Alpha—green, RBC damage but not lyse
o Beta: clear zone of hemolysis
 GAS—wide zone of hemolysis, total clearing of agar
 GBS—narrower, less distinct zone of hemolysis
o Gamma: no change in agar
- Normal flora
o Mouth and pharynx: strict anaerobes, S. viridans, beta hemolytic strep, Neisseria,
Moraxella, Corynebacterium
o Skin: S. epidermidis, S. aureus, other staph, Corynebacterium, Propionibacterium
o Stool: strict anaerobes (mostly bacteroides), E. coli, Klebsiella, Proteus,
Enterococcus
- Non fastidious bacteria can facilitate the growth of fastidious ones (satelliting)
o ie: H. influenza can’t grow on blood agar bc it needs NAD and hemin, BUT it can
grow around a colony of S. aureus because the S. aureus provides the NAD
- Sputum specimens are only cultured aerobically bc anaerobic will grow too many
anaerobic bacteria that contaminate the sputum when it passes through the mouth
o If an anaerobic infection is suspected (ie by bronchoscopy), can be cultured for
anaerobes
- Blood cultures
o Blood might contain factors that inhibit the growth of bacteria
o Can enrich broth growth media w pt’s blood (RBCs lyse, so like chocolate agar)
o 1:10 blood:broth ratio is optimal (dilutes inhib substances in blood enough)
o Aerobic bacteria: vent broth to expose to atmosphere w needle
o SPS (inhibits aminoglycoside abx) and SAS are anticoagulants that antagonize
host defense mechanisms, can be added to blood culture media
 But these inhibit N gonorrhoeae and N. meningitidis
o Beta lactamase can also be added ($$, short shelf life so not routine)
 Add b lactamase before blood if pts have been recently treated w
penicillins or cephalosporins
- Microscopic examination of stool—see fecal leukocytes (use methylene blue or iodine)
- Incubate stool plates aerobically bc anaerobes don’t usually cause gastroenteritis
- Day 3 is the first day a final report can be sent
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Blood cultures video
- Volume of blood obtained for each request is the most important variable in recovering
bac/fungi
- Request = Blood Culture Set (consists of all bottles from ONE venipuncture)
o Adults: 16-20 mL blood per culture set (ie 8-10 mL per tube)
o Too much/little decreases dx accuracy
o 2-4 sets should be obtained
- Timing: should be based on patient’s acuity
o Abx may decrease yield so shouldn’t be given before collecting cultures
- Skin contaminants common, burden on cost, misdx, abx resistance
o Skin prep, peripheral venipuncture is preferred modality
o Antiseptic: iodine tincture, chlorine peroxide, chlorohexidine gluconate (CHG)
are superior to povidone-iodine preps; work within 30s
- Media: contain growth factors, resin beads (neutralize effects of abx, neutrophils,
inhibitors)
- Do not refrigerate bottles before incubation; transport to lab asap
- Incubation: up to five days (don’t need more)—true for HACEK and Brucella
- Metabolism  CO2  photodetector measures fluorescence  positive cultures flagged
- Identification:
o Gram stain positive cultures (in a BSL2 cabinet)
o Subculture to appropriate media
o MALDI-TOF or direct identification

Summary:
- Volume of blood collected is most critical
o 8-10 mL per blood culture bottle; 16-20 mL per blood culture set
o Disinfect venipuncture site w chlorhexidine or 2% iodine tincture
o Always draw blood cultures PRIOR to initiation of abx
o Blood cultures drawn from intravascular catheters have higher risk of
contamination and false positives
o Never refrigerate blood prior to incubation