Control of Microbial Growth: Disinfection
•Bacterial endospores- are rich in proteins, lipids, and
and Sterilization
Decontamination
-removal of pathogenic microorganisms so items are
safe to handle or dispose of
-reduces microbial contamination of materials or
surfaces and is accomplished through use of chemical
disinfectant
Forms of Decontamination
1. Sterilization
-process that kills all forms of microbial life, including
bacterial endospores
-accomplished w/ heat and steam thru autoclaving
2. Disinfection
-process that destroys pathogenic organisms but not
necessarily all microorganisms, endospores, or prions
-some disinfectants will kill endospores w/ prolonged
exposure times
•Disinfectants- physical/chemical agents applied to
inanimate objects
•Antiseptic (skin disinfectants)- substance applied to
skin for purpose of eliminating or reducing number of
bacteria present; do not kill spores
*both antiseptic and disinfectants contain chemical
agents that are sometimes called biocides.
Antiseptics usually contain lower concentrations of
biocides than disinfectants.*
3. Cleaning
Factors that Influence the Degree of Killing
The following factors play a significant role in the
selection and implementation of appropriate method of
disinfection:
•Types of organisms
•Number of organisms
•Concentration of disinfecting agent
•Presence of organic material (serum, blood)
•Nature of surface to be disinfected
•Contact time
•Temperature
•pH
•Biofilms
•Compatibility of disinfectants and sterilants
Type of Organisms
Organisms differ greatly in their ability to withstand
chemical and physical treatment. This variability is due
to the biochemical composition of microorganisms and
various mechanisms that they can use to protect
themselves.
Examples:
carbohydrates as well as cores rich in dipicolinic acid
and calcium which protect the spore
•Cell walls of mycobacteria- are rich in lipids, which
may account for their resistance to chemical and
environmental stresses
•Biofilms- provide protection to microorganisms
against chemical and physical means of destruction
•Prions- most resistant to actions of heat, chemicals
and radiation
-can withstand temps exceeding 121C for
several hours while immersed in acid or basic solutions
Number of Organisms
•total number of organisms present (microbial load)
•microbial load determines the exposure time that is
necessary for 99.9% elimination of the microorganisms
•in general, higher numbers of microorganisms require
longer exposure times
Concentration of Disinfecting Agent
•manufacturers’ instructions on preparation, dilution,
and use must be followed very carefully
•concentrated disinfectants, such as povidone-iodine,
may actually allow microorganisms to survive because
there is not enough free iodine to kill microorganisms
•proper concentrations of disinfecting agents ensure
the inactivation of target organisms and promote safe
and cost-effective practices
Presence of Organic Material
•organic material, such as blood, mucus and pus, affects
killing activity by inactivating the disinfecting agent
•bleach (sodium hypochlorite) is easily inactivated by
organic material
•for optimal killing activity, instruments and surfaces
should be cleansed of excess organic material before
disinfection
Nature of Surface to be disinfected
•certain medical instruments are manufactured of
biomaterials that exclude the use of certain disinfection
or sterilization methods because of possible damage to
the instruments
•for example, endoscopic instruments are readily
damaged by the heat generated in autoclave
Contact time
•contact time to use will be based on microorganisms
that is most resistant
•amount of time that an agent is in contact w/ an agent
can also determine whether it is disinfecting or
sterilizing the object
•for example, when glutaraldehyde is used as sterilant,
contact time is much longer than when it is used as
disinfectant
•alcohol and iodine preparations (betadine) must be in
contact w/ an object for at least 1-2 mins for them to kill
microorganisms
•spores of both bacteria and fungi must be in presence
of disinfectants or sterilants for a much longer time than
their vegetative counterpart
Temperature
•disinfectants are generally used at room temperature
(20-22C)
•their activity is generally increased to some degree by
an increase in temp and decrease by decrease in temp
•disinfectants and sterilants can be rendered inactive by
too high or too low temp
pH
•it is critical to make sure at what Ph the agent is active
and that ph of material to be exposed to agent is at the
time the process will be done
Biofilms
•biofilms are generally layers of microorganisms that
often have protective material over them that shields
them from outside environmental factors
•critical place where biofilms are seen in the hospital is
catheters. Other places may be inside pipes that carry
water and on deionizing columns used to make
processed water
•to disinfect materials that may have a biofilm present,
the concentration of the disinfectant may need to be
increased, contact time to be increased, or both
Compatibility of disinfectants
•some disinfectants may inactivate other disinfectants
For example, use of bleach and quaternary ammonium
compound together may negate activity of both
disinfectants
Methods of Disinfection and Sterilization
•E.H. Spaulding categorized medical materials into 3
device classifications:
1. Critical materials (invade sterile tissues or enter
vascular system; require sterilization)
2. Semi-critical materials (come into contact w/
mucous membranes; require high-level
disinfection)
3. Non-critical materials (come into contact w/
skin; require intermediate level to low-level
disinfection)
High-level disinfectants- have activity against bacterial
endospores
Intermediate-level disinfectants- have tuberculocidal
activity but not sporicidal activity
Low-level disinfectants- do not demonstrate sporicidal
or tuberculocidal activity
Physical Methods
•Heat
•Filtration
•Radiation
Heat
•Moist heat
-mechanism of action: protein coagulation
-aka heat under steam pressure
-sterilization method for heat-stable objects
a. boiling
-most commonly employed, inexpensive and
most practical method
-kills most microorganisms at 100C in approx
15 mins
-not effective in killing all spores
b. sterilization by steam
b.1. Free flowing steam-same sterilization as
boiling
b.2. Steam under pressure- most powerful heat
sterilizing agent
Autoclave-15 psi (pounds per square inch, 15
mins, temp 121C
-all microorganisms(except prions) and
endospores are destroyed
 -advantage: shorter time required for
sterilization than dry heat sterilization
c. Fractional/Intermittent sterilization
c.1. Tyndaliization- exposing material to be
sterilized to free flowing steam at atmospheric
pressure by heating medium at 100C for 15-30
mins for 3 days
-sporulating bacteria germinate then are
destroyed
-discontinuous heating; used on materials that
cant withstand temp of autoclave
c.2. Pasteurization- performed at 63C for 30 min
-used mostly in food industry; reduces food-
borne pathogens and organisms responsible for
food spoilage
*boiling and pasteurization are methods that
achieve disinfection but not sterilization; these do
not eliminate spores* Filtration
•filtration of liquid is accomplished thru use of thin
•Dry heat membrane filters composed of plastic polymers or
-mechanism of action: protein oxidation cellulose esters containing pores of a certain size
-may be used for heat-stable substances that are •liquid is pulled (vacuum) or pushed (pressure) thru
not penetrated by moist heat, such as oils filter matrix
-commonly used to sterilized glassware •most common application of filtration is in the
a. Hot air (oven) sterilization of heat-sensitive solutions, such as
-120-130C for 1.5 hrs kill all vegetative bacteria parenteral solutions, vaccines and antibiotic solutions
-160-180C for 1.5-3 hrs kill all spores •filtration of air is accomplished w/ use of high-
-used to sterilized glassware, metal objects and efficiency particulate air (HEPA) filters
articles destroyed by moisture or items such as •HEPA filters are able to remove microorganisms larger
oils and fat that resist penetration by steam or than 0.3 um and are used in laboratory hoods and in
water rooms of immunocompromised patients
-advantage: does not dull cutting edges
Radiation
b. Burning (incineration) •Ionizing radiation
-form of intense heat -in form of gamma rays or electron beams; short
-flaming wire loop (naked flame) wavelength and high energy
-used to sterilize medical and hazardous waste -used by medical field for sterilization of disposable
Incineration supplies such as syringes, catheters and gloves
-materials are reduced to ashes by burning
-instrument used is incinerator •Non-ionizing radiation
-solid dressings -in form of ultraviolet rays; long wavelength and low
-animal carcasses energy
-bedding -damages deoxyribonucleic acid (DNA)
-pathological material -used to disinfect surfaces, although parameters
(distance to surface, potential microorganisms to be
*moist is more advantageous bc it is more rapid and destroyed) under which it is to be used need to be
more penetrating than dry heat* determined

Chemical Methods
•Chemosterilizers- chemical agents used for
sterilization
*disinfectants are regulated by US Environmental
Protection Agency (EPA)
*sterilants are regulated by US Food and Drug
Administration (FDA) when they are able to be used to
sterilize devices that will come into contact w/ patients
Chemical agents exert their killing effect by:
•reaction w/ components of cytoplasmic membrane
•denaturation of cellular proteins
•reaction w/ thiol (-SH) groups of enzymes
•damage of RNA and DNA
Qualities of Good Disinfectants
•attack all types of microorganisms
•be rapid in its action
•not destroy body tissues or act as poison when taken
internally
•not be retarded in its action by organic matter
•penetrate the material being disinfected
•dissolve easily in or mix w/ water to form a stable
solution or emulsion
•not decompose when exposed to heat, light rays or
unfavorable weather conditions
•not damage materials being disinfected, such as
instruments or fabrics
•not have unpleasant odor or discolor the material
being disinfected
•be easily obtained at a comparatively low cost and
readily transported
Germ Theory of Disease
“Microorganisms known as pathogens or germs can
lead to disease”
•medical community gradually grew aware of the
problem of nosocomial (hospital acquired) infections
and need to practice asepsis to prevent contamination
of wounds, dressings and surgical instruments
•contributed to development of antimicrobial
chemotherapeutics
•Ignatz Semmelweis and Joseph Lister are considered
important pioneers for promotion of asepsis
*Semmelweis demonstrated that routine hand
washing can prevent spread of disease
*Lister introduced handwashing and use of phenol
as antimicrobial agent for surgical wound dressings
to british surgery*
Chemical Agents
•Alcohol
•Aldehydes
•Halogens
•Chlorine and chlorine compounds
•Detergent; quaternary ammonium compounds
•Phenolics
•Heavy metals
•Gases
Alcohol
Mechanism of action: protein denaturation
a. Ethyl alcohol (ethanol)
-50-70% ideal as rubbing alcohol
-used for disinfection of delicate instruments
-kills tubercle bacilli
-spores are not destroyed
b. Isopropyl
-slightly greater activity and less volatile but
more toxic (vapors absorbed thru lungs-
narcosis)
*Alcohol are inactivated by presence of organic material
*it should be used in concentrations between 60% and
90%. For alcohols to be effective, they must be allowed
to evaporate from surface of which they were applied
*the 1994 Tentative Final Monograph (TFM) for heath
care antiseptic drug products establishes ethanol (60%
to 95%) as category I, safe and effective for health care
personnel handwash, surgical hand scrub, and patient
preoperative skin preparation
Aldehydes
Mechanism of action: inhibits enzyme activity of cell,
denatures protein
•Formaldehyde
a. Formalin- 37% aqueous solution
-preservation of tissues
-vaccine preparation- to inactivate viruses (0.2-
0.4%)
b. formaldehyde gas- often used to disinfect
biosafety hoods, buildings, fabric, instruments,
rooms
*it has been found to be carcinogen, and US
Occupational Safety and Health Administration
(OSHA) has set worker exposure limits
•Glutaraldehyde
-10x more effective than formaldehyde as
bactericidal and sporicidal agents and less toxic
-even though glutaraldehyde is not inactivated by
organic material, it does not penetrate organic
material well
-sporicidal in 3-10 hrs
 -at 2% solution,
20C and 30C (10mins.min)= germicidal,
bactericidal, pseudomonacidal, fungicidal, and
virucidal (against HIV and hepatitis B virus)
25C to 30C= 100% tuberculocidal
3hrs- kill all spores
*Glutaraldehyde is extremely susceptible to ph
changes since it is only active in alkaline
environment*
Halogens
Mechanism of action: protein oxidation
•Iodine
-principal use is skin antiseptic as 2% tincture of iodine,
as betadine (povidone-iodine complex)
-FDA classifies 5%-10% povidone-iodine as category I
for use as topical antiseptic in health care personnel
handwash, surgical hand scrub, and patient
preoperative skin preparation
•Chlorine and Chlorine Compounds
-most common use of chlorine is disinfection of water
-effective for wide spectrum of organism
-usually used in form of hypochlorite
-not used as sterilants because of long exposure time
require for sporicidal action and their inactivation by
organic matter
a. Solid calcium hypochlorite
b. Liquid sodium hypochlorite (household bleach)
-solutions should be allowed contact time of
atleast 3mins and longer if organic material is present
*a 1:10 dilution of 5.25% concentration of sodium
hypochlorite is recommended by Centers for Disease
Control and Prevention (CDC) for cleaning up blood
spills
Detergents: Quaternary Ammonium Compounds
Mechanism of action: cell membrane damage
-are cationic, surface-active agents, or surfactants, that
work by reducing the surface tension of molecules in
liquid
-commonly found in disinfectant wipes, sprays, and
other household cleaners that are designed to kill germs
-inactivated by excess organic matter
-not sporicidal or tuberculocidal
Phenolics
Mechanism of action: cell membrane damage
-molecules of phenol (carbolic acid) that have been
chemically substituted, typically by halogens, alkyl,
phenyl, or benzyl groups
-stable, biodegradable, and relatively active in presence
of organic material
-main use is disinfection of hospital, institutional, and
household environments
*combination of detergent & phenol= germicidal
soap*
Heavy Metals
Mechanism of action: enzyme inactivation
Heavy metal disinfectants are slowly bactericidal; their
action is primarily bacteriostatic (stops bacteria from
reproducing but not kill them)
a. Mercury chloride and other mercury
compounds- used mainly as preservatives for
paint
b. Silver nitrate (1%eye drop solution)- used as
prophylactic treatment to prevent gonococcal
(Neisseria gonorrhoeae) conjunctivitis
(ophthalmia neonatorum) in newborns
Gases
Ethylene oxide
Mechanism of action: protein coagulation
-gaseous sterilization
-active against all types of bacteria, including spores and
tubercle bacilli but its action is slow
-greatest applicability lies in sterilization of materials
that would be damaged by heat (polyethylene tubing);
especially useful in sterilization of heart-lung machines
Hydrogen peroxide
Periacetic acid
Mechanism of action: protein oxidation
-primarily used as sterilant in pharmaceutical and
medical device manufacturing industries
-active against vegetative microorganisms and bacterial
and fungal spores
Points to remember
•Physical and chemical methods may be used in the
process of sterilization to remove all forms of life
•Disinfection involves removal of pathogenic organisms
but may not include removal of bacterial or other
spores; most disinfectants are chemical agents
•Factors that influence the degree of killing include
types of organisms, number of organisms present,
concentration of disinfecting agent, amount of soil
present, and nature of the surface to be disinfected
•Antiseptics are designed to reduce the bacterial load of
living tissues
•Disinfectants are designed to be used on inanimate
objects to kill or destroy disease-producing
microorganisms
•Antimicrobial agents for heath care personnel use
must meet certain standards that demonstrated the
product’s safety and efficacy

Antimicrobial Susceptibility Testing

•Antimicrobial susceptibility testing is performed on
bacteria isolated from clinical specimens to determine
Reasons and Indications for Performing
which antimicrobial agents might be effective in
Antimicrobial Susceptibility Tests
treating infections caused by bacteria
•Antimicrobial susceptibility testing should be
•One of the major challenges in clinical microbiology is
performed on bacterial isolate from a clinical specimen
identification of bacteria that are cause of infections
if the isolate is determined to be a probable cause of
•Therefore, thought needs to go into determining which
patient’s infection and susceptibility of isolate to
bacteria from specimen will be tested for susceptibility
particular antimicrobial agents cannot be realiably
to antimicrobials
predicted based on previous experience w/ bacteria at
•Most microbiology laboratories have guidelines for
health care facility
determining when and on which bacteria susceptibility
•Group A B-hemolytic Streptococcus, for example, is not
testing will be done
routinely tested because it is universally susceptible to
•In clinical laboratories, susceptibility testing is usually
penicillin
performed by disk diffusion or dilution (MIC) method
•In contrast, recommended agent for treating
•Standards that describe these methods are published
Staphylococcus aureus infections is oxacillin, but not all
and frequently updated by Clinical and Laboratory
S. aureus may be susceptible to oxacillin. Consequently,
Standards Institute (CLSI)
susceptibility testing is indicated for S. aureus isolate
•On worldwide level, antimicrobial susceptibility is
that is the suspected cause of infection
guided by International Standards Organization
•Susceptibility testing of isolates can also provide
(ISO)
information on decreases in susceptibility of bacteria to
antimicrobial
MIC Number- lowest concentration (in ug/mL) of an
antibiotic that inhibits growth of given strain of bacteria mrsa- metthicillin-resistant staphylococcus aureus
Factors to consider when determining whether
MIC- minimum inhibitory concentration testing is warranted
Confluent growth- bacteria are growing together •body site from which bacterium was isolated
Zone of inhibition- bacteria hasn’t grown from the -susceptibility tests are not routinely performed on
antibiotic till this diameter (millimeters) bacteria isolated from an anatomic site for which they
are normal inhabitants
Zone diameter interpretative standards -example, escherichia coli are normal biota in lower
gastrointestinal tract and therefore would not be tested
when isolated from stool; but E. coli from a blood
culture would be tested bc blood is sterile

•presence of other bacteria and quality of specimen

from which organism was grown
-isolation of an organism in pure culture is less likely to
represent contamination than mixed culture
-presence of more than two species at greater than 105
colony-forming units (CFU) per mL isolated from urine
suggests contamination, and these organisms may not
require susceptibility testing; but a pure culture of E.
coli at more than 105 CFU/mL would likely to represent
true infection and would be tested
•host’s status
-species usually viewed as normal biota might be
responsible for an infection and therefore at times
might require testing in compromised patients
-also, in patients who are allergic to penicillin and who
have group A B-hemolytic streptococcal (Streptococcus
pyogenes) infection, erythromycin is drug of choice.
Group A B-hemolytic streptococci are resistant to this
agent. Consequently, testing of erythromycin is
warranted.
Selecting Antimicrobial Agents for Testing &
Reporting
•Approximately 50 antimicrobial agents are presently
used for testing bacterial infections, and many of thse
have comparable clinical efficacy
•The antimicrobial package inserts written by U.S Food
and Drug Administration (FDA) should be consulted for
information concerning the dosing and indications for
which antimicrobial was approved and performance of
antimicrobial agent during initial clinical trials
•Standard disk diffusion test uses 150 mm agar plate,
which can accommodate no more than 12 disks. In case
of MIC test panels, 12-15 antimicrobials can be tested
on one panel
*drugs tested by the laboratory must match
institutional formulary as closely as possible*
Reporting of Susceptibility Test Results
As a general guideline, it is suggested that within a
particular antimicrobial class, primary (group A) agent
be reported first and secondary (group B) agent be
reported only if one of the ff conditions exist:
•the isolate is resistant to primary agents
•the patient cannot tolerate primary agents
•the infection has not responded to primary agents
•a secondary agent would be a better clinical choice for
particular infection (meningitis)
•the patient has bacteria isolated from another site, and
secondary agent might be useful for treating both
infections
Traditional Antimicrobial Susceptibility Test
Methods
•Inoculum Preparation and Use of McFarland Standards
Inoculum Preparation
-inocula are prepared by adding cells from 4-5 isolated
colonies of similar colony morphology growing on non-
inhibitory agar medium to broth medium and then
allowing them to grow to the log phase
-direct inoculum suspension preparation technique is
preferred for bacteria that grow unpredictably in broth
(fastidious bacteria). Because it does not rely on grown
in inoculums broth, use of fresh (16-24 hr) colonies is
imperative
McFarland Turbidity Standards
•McFarland 0.5 standard provides turbidity comparable
w/ that of bacterial suspension containing 1.5x10^8
CFU/mL
•This solution is dispensed into tubes comparable w/
those used for inoculums preparation, which are sealed
tightly and stored in dark at room temperature
•False susceptible results may occur if too few bacteria
are tested, and false resistant results may be the
outcome of testing too many bacteria
*Purpose: reference to adjust turbidity of bacterial
suspensions so that the number of bacteria will be
within a given range to standardized microbial testing
Inoculums Standardization
•To standardize the inoculum, the inoculated broth or
direct suspension is vortexed thoroughly; then, under
adequate lighting, the tube is positioned side by side w/
McFarland 0.5 standard against a white card containing
several horizontal black lines
•Once standardized, the inoculums suspensions should
be used within 15 mins of preparation
•A convenient and more precise alternative to visual
adjustment to match the McFarland standard is the use
of nephelometric or spectrophotometric device
*Purpose: have matched standard and matched
inoculated broth
Device used to compare same turbidity
Dilution Susceptibility Testing Methods
Principle
Broth Macro-dilution (Tube Dilution) Tests
•dilution antimicrobial susceptibility test methods are
•generally, two-fold serial dilution series, each
used to determine the MIC, or lowest concentration of
containing 1-2 ml of antimicrobial agent, is prepared
antimicrobial agent required to inhibit growth of
•Mueller Hinton broth is medium recommended for
bacterium
broth dilution MIC tests of non-fastidious bacteria
•generally serial two-fold dilution concentrations are
•standardized suspension of test bacteria is added to
tested (expressed in ug or mcg/mL)
each dilution to obtain final bacterial concentration of
•once MIC is determined, organism is interpreted as
5x10^5 CFU/mL
susceptible, intermediate or resistant to each agent w/
•growth control tube (broth plus inoculums) and
use of table provided in CLSI dilution testing document
uninoculated control tube (broth only) are used w/
or in FDA approved package insert for antimicrobial
each test. After overnight incubation at 35C , MIC is
•both FDA and CLSI are involved in determining
determined visually as lowest concentration that
antimicrobial interpretative criteria for MIC test results
inhibits growth, as demonstrated by absence of
•for each antimicrobial agent, MIC breakpoint separates
turbidity
susceptible from resistant results
•some laboratories use broth macrodilution when it is
•organisms w/ MICs at or below breakpoint are
necessary to test drugs not included in their routine
susceptible, and those with MICs above breakpoint are
system or for fastidious bacteria that require special
intermediate or resistant
growth media
•CLSI document describe detail of performing MIC tests
by broth macrodilution, broth microdilution, and agar
Positive control- test for growing ability of medium
dilution
Negative control- sterility of medium (no growth; clear)

Broth Micro-dilution Tests

•plastic trays containing between 80 and 100 (usually
96) wells are filled w/ small volumes (usually 0.1 mL) of
two-fold dilution concentrations of antimicrobial agent
in broth
•because of large number of wells, several dilutions of
as many as 12-15 antimicrobial agent can be contained
in single tray that subsequently will inoculate w/ one
bacterial isolate
•inoculum suspension is prepared and standardized. An
intermediate dilution of this inoculum is prepared in
water or saline, and a multi pronged inoculator or other
type of inoculating device is used to inoculate the wells
to obtain a final concentration of 5x10^5 CFU/mL
(5x10^4 CFU/0.1mL well)
•growth control well and uninoculated control well are
included on each tray
•after overnight incubation at 35C, tray is placed on
tray-reading device to facilitate visual examination of
each well. Provided growth is adequate in growth
control well, MIC for particular drug is lowest
concentration showing no obvious growth
•growth may be seen as turbidity, haze or pellet in
bottom of well
measurement as indicating that isolate is non-
susceptible, susceptible, intermediate or resistant
Reading Plates and Test Interpretation
•QC plates are read prior to reading results of patient
isolates to determine whether the test was performed
correctly. Provided that growth is satisfactory, diameter
of each inhibition zone is measured using ruler or
calipers
•plates are placed a few inches above a black,
nonreflecting surface, and zones are examined from the
back side (agar side) of plate illuminated with reflected
light
•tiny colonies at the zone edge and swarm of growth
into the zone that often occurs with swarming Proteus
spp. are ignored; obvious zone is measured

Disk Diffusion Testing

Principle
•also known as Kirby-Bauer Test, has been widely
used in clinical laboratories since 1966, when the first
standardized method was described
•briefly, McFarland 0.5 standardized suspension of
bacteria is swabbed over surface of Mueller Hinton agar
plate, and paper disks containing specific
concentrations of antimicrobial agent are placed onto
inoculated surface
•after overnight incubation, diameters of zones
produced by antimicrobial inhibition of bacterial
growth are measured, and result is interpreted as non-
susceptible, susceptible, intermediate or resistant to
particular drug according to preset criteria

Establishing Zone Diameter Interpretative

Breakpoints
•disk diffusion test depends on formation of gradient of
antimicrobial concentrations as the antimicrobial agent
radially diffuses into agar
•drug concentration decreases at increasing distances
from the disk. At critical point, amount of drug at
specific location in medium is unable to inhibit the
growth of test organism, and zone of inhibition is
formed
•zones of inhibition are released to MICs, and it is this
relationship that has been used to determine
breakpoints for interpreting particular zone
 GRAM (+) COCCI
STAPHYLOCOCCUS
STREPTOCOCCUS
Gram-positive cocci are common isolates in the clinical
microbiology laboratory. Although most gram (+) cocci
are members of the indigenous microbiota, some
species are causative agents of serious infectious
disease.
Staphylococci
General characteristics
-on stained smears, they exhibit spherical cells that
appear singly in pairs and in clusters
•catalase-producing, gram positive cocci (purple)
•genus name, Staphylococcus, is derived from Greek
term staphle, meaning “bunches of grapes”
•nonmotile, non-spore forming, and aerobic or
facultative anaerobic except for S. saccharolyticus,
which is an obligate anaerobe
•colonies produced after 18-24 hrs of incubation appear
cream-colored, white or rarely light gold, and buttery-
looking
•although the gram stain can be characteristic of
staphylococci, microscopy alone cannot differentiate
staphylococci from other gram-positive cocci such as
the micrococcus
•normal inhabitants of the skin and mucous membranes
of humans and other animals but still it can cause
infection
Clinically Significant Species
Staphylococcus aureus (most significant & virulent)
-causes various cutaneous infections and purulent
abscesses (bacteremia & septicemia)
-toxin-induced diseases, such as food poisoning, scalded
skin syndrome (SSS) and toxic shock syndrome (TSS),
are also associated w/ this organism
-virulence factors: enterotoxins, exfoliative toxins,
cytolytic toxins and cellular components such as protein
A
-develops symptoms within 30 mins-8 hrs
-important cause of nosocomial infection (hospital-
inquired disease)
Virulence Factors
•Enterotoxins
-produced by 30-50% of S. aureus isolates
-heat-stable exotoxins (stable at 100C for 30 mins) that
cause various symptoms, including diarrhea and
vomiting
-staphylococcal food poisoning is most commonly
caused by enterotoxins A, B, and D
•Toxic shock syndrome toxin-1
-causes nearly all cases of menstruating-associated TSS
-absorbed thru vaginal mucosa leading to systemic
effects, seen in TSS associated with tampon use
-also referred to as pyrogenic exotoxin C, has several
systemic effects, including fever, desquamation, and
hypotension potentially leading to shock and death
-enterotoxins B and C and sometimes G and I are
associated with TSS
•Exfoliative toxin
-also known as epidermolytic toxin
-causes epidermal layer of the skin to slough off and is
known to cause staphylococcal SSS, sometimes referred
to as Ritter disease
-this toxin has also been implicated in bullous
impetigo
Difference between SSS and bullous impetigo
-both are blistering skin disease caused by
staphylococcal exfoliative toxin however in bullous
impetigo, the exfoliative toxins are restricted to area of
infection and bacteria can be cultured from the blister
contents while in SSS, the exfoliative toxin spreads
hematogenously from a localized source potentially
causing epidermal damage at distant sites.
•Cytolytic toxins
-extracellular proteins that affect red blood cells and
leukocytes
-S. aureus produces four hemolysins (lipids and
proteins that cause lysis of RBCs by disrupting the cell
membrane): alpha, beta, gamma and delta
-Staphylococcal leukocidin, Panton-Valentine
leukocidin (PVL), is an exotoxin lethal to
polymorphonuclear leukocytes
-PVL has been implicated as contributing to the
invasiveness of the organism by suppressing
phagocytosis and has been associated with severe
cutaneous infections and necrotizing pneumonia
•Protein A
-probably the most significant role of protein A in
infections caused by S. aureus is its ability to bind the Fc
(fragment crystallisable region) portion of
immunoglobulin G (IgG) which can then block
phagocytosis and negate the protective effect of IgG
•Enzymes that contributes to virulence of S. aureus
-such as coagulase, protease, hyaluronidase, and lipase
a. Staphylocoagulase- produced mainly by S.
aureus
b. Protease- serves as virulence factors by cleaving
staphylococcal surface proteins; helps in
degradation of host tissue and modulation of
host immune response; also aid in nutrient
acquisition from the host
c. Hyaluronidase- hydrolyzes hyaluronic acid
present in intracellular ground substance that
makes up connective tissues, permitting the
spread of bacteria during infection
d. Lipase- act on lipids present on surface of skin,
particularly fats and oil secreted by sebaceous
glands
-lipases are actually produced by both
coagulase positive and coagulase
negative staphylococcus species
*Protease, lipase and hyaluronidase are capable of
destroying tissue and may facilitate spread of infection
to adjoining tissues.
Epidemiology of Staphylococcus aureus
•The primary reservoir for staphylococci is the human
naris (nostrils), with colonization also occurring in
axillae, vagina, pharynx, and other skin surfaces
•Hospital outbreaks can develop in patients in
nurseries, patients in burn units, and among patients
who have undergone surgery or other invasive
procedures
•Transmission of S. aureus may occur by direct contact
with unwashed, contaminated hands and by contact
with inanimate objects (fomites)
*Both health care and community-acquired infections
caused by MRSA (methicillin-resistant staphylococcus
aureus) have become a major health care concern
Infections Caused by Staphylococcus aureus
-staphylococcus aureus infections can be
superior(has abscess or abscess is filled with pus) or
toxin mediated
-development of S. aureus infection is determined by
virulence of the strain, size of inoculums, and status
of host’s immune system
-infections are initiated when a breach of skin or
mucosal barrier allows staphylococci access to
adjoining tissues or bloodstream
-any event that compromises the host’s ability to
resist infection encourages colonization and
infections
•Skin and Wound Infections
-the abscess is filled with pus and surrounded by
necrotic tissues and damaged leukocytes
-some common skin infections caused by S. aureus are
folliculitis, furuncles, carbuncles, and bullous impetigo
-these opportunistic infections usually occur as a result
of previous skin injuries, such as cuts, burns, and
surgical incisions
Folliculitis- relative mild inflammation of a hair follicle
or oil gland
Furuncles- extension of folliculitis but more large raised
and have superficial abscesses
Carbuncles- occurs when larger or more invasive
lesions develop from multiple furuncles; fever & chills
*Staphylococcus aureus causes bullous impetigo
while Streptococcus species causes non-bullous
impetigo. *
*Staphylococcus postules are larger and surrounded
by a small zone of erythema and it is highly
contagious* (direct contact, fomite, auto inoculation)
•Scalded Skin Syndrome
-bullous exfoliative dermatitis that occurs primarily in
newborns and previously healthy young children
-caused by staphylococcal exfoliative or epidermolytic
toxin produced by S. aureus
-typical pattern in which the erythema occurs is
origination from the face, neck, axillae, and groin and
then extension to trunk and extremities
-duration of disease is brief, about 2-4 days
•Toxin Shock Syndrome
-multisystem disease characterized by sudden onset of
fever, chills, vomiting, diarrhea, muscle aches, and rash,
which can quickly progress to hypotension and shock
-rash is found predominantly on trunk but can spread
over the entire body
1. non-menstruating TSS- has been associated with
nearly any staphylococcal infection, many cases have
been seen with postsurgical infections and secondary to
influenza virus infections
2. menstruating-associated TSS
*Staphylococcal TSS generally results from a localized
infection by S. aureus; only the toxin TSST-1 is systemic
•Toxic Epidermal Necrolysis (TEN)
-clinical manifestation with multiple causes; it is most
commonly drug induced, but some cases have been
linked to infections and vaccines
-cause is unknown but symptoms appear to be due to
hypersensitivity reaction
-can be resolved by administration of steroids early in
initial stages of presentation, whereas steroids
aggravate SSS
-mortality rate associated with TEN is high, and
administration of suspected offending drugs should be
stopped as soon as possible
•Food Poisoning
-occurs when food becomes contaminated with
enterotoxins-producing strains of S. aureus by improper
handling and is then improperly stored
-S. aureus enterotoxins, most commonly A (78%), D
(38%), and B (10%), have been associated with
gastrointestinal disturbances
-foods that are often associated with food poisoning
include salads (containing mayonnaise and egg); meat
or meat products; poultry; egg products; bakery
products; and dairy products
-foods kept at room temperature are especially
susceptible to higher levels of toxin production
-no fever is associated with this condition, but nausea,
vomiting, abdominal pain and sever cramping are
common
-enterotoxins do not cause any detectable odor or
change in appearance or taste
•Other infections
Staphylococcal pneumonia
-has been known to occur secondary to influenza virus
infection
-has high mortality rate especially on infants and
immunocompromised individuals
-develops lower respiratory tract infection or
complication of bacteremia
-characterized by multiple abscesses and focal lesions in
pulmonary parenchyma
-infants and immunocompromised individuals such as
elderly patients and patient receiving chemotherapy or
immunosuppressant are mostly infected
Staphylococcal bacteremia
-leading to secondary pneumonia and endocarditis has
been observed among intravenous drug users
Staphylococcal osteomyelitis
-occurs as manifestation secondary to bacteremia
-infection develops when organisms is present in a
wound or other focus of infection and gains entrance
into the blood
-symptoms include fever, chills, swelling, and pain
around the affected area
Staphylococcus epidermidis
-common cause of health care-acquired UTIs
-prosthetic valve endocarditis is most commonly caused
by S. epidermidis
-infections associated with use of implants, such as
indwelling catheters and prosthetic devices, are often
caused by isolates shown to produce biofilm
*Biofilm production is a key component in bacterial
pathogenesis and is a complex interaction between host,
indwelling device, and bacteria
Pathogenesis and Spectrum of Disease
-S. aureus and S. epidermidis produce a polysaccharide
capsule that inhibits phagocytosis. The capsule, which is
produced in various amounts by individual clinical
isolates, may appear as slime layer or biofilm and allows
organisms to adhere to inorganic surfaces and impairs
or inhibits the penetration of antibiotics
Staphylococcus saprophyticus
-has been associated with UTIs in young women
-this species adheres more effectively to the epithelial
cells lining the urogenital tract than other CoNS
(coagulase negative staphylococci)
-when present in urine cultures, S. saprophyticus may
be found in low numbers (<10,000 colony forming
units/ml) and still be considered significant (>100,000)
Laboratory Diagnosis
•Microscopy- gram stained smear (early diagnosis)
•Culture- BA (blood agar)
•Coagulase test
•Bacteriophage typing- best method of distinguishing
staphylococcal stains
Prevention and Control
•Cleanliness and hygiene
•Aseptic technique- handwashing
• Detection of nasal carriers- hospital personnel, food
handlers
Polymorphonuclear cells- components of complete
blood count (cbc); first line of defense is neutrophil (45-
70%)
Isolation and Identification
Staphylococci grow easily on routine laboratory culture
media, particularly sheep blood agar (SBA) [enriched
differential medium].
A selective medium such as mannitol salt agar (MSA),
Columbia colistin-nalidixic acid agar (CAN), or
phenylethyl alcohol (PEA) agar can be used for heavily
contaminated specimens.
Cultural Characteristics
-Staphylococci produce round, smooth, white, creamy
colonies on SBA after 18-24 hours of incubation at 35-
37C.
-S. aureus can produce hemolytic zones around the
colonies and may rarely exhibit pigment production
(yellow) with extended incubation
-S. epidermidis colonies are usually small to medium-
sized, nonhemolytic, gray-to-white colonies. Some can
be weakly hemolytic.
SBA- enriched differential medium; differentiates diff
types of hemolysis
Beta hemolysis- there is complete clearing or halo
around it (s. aureus is yellowish)
Identification Methods
•Staphylococci ferment glucose, whereas micrococci fail
to produce acid under anaerobic conditions.
•Staphylococcus aureus
SLIDE COAGULASE TEST [agglutination (+)]
Clumping factor, formerly referred to as cell-bound
coagulase is considered an important marker for S.
aureus.
Clumping factor is easily detected by slide coagulase
test and is used to screen catalase-positive colonies that
morphologically resemble S. aureus.
If agglutination (due to conversion of fibrinogen to
fibrin precipitating on cell surface) occurs, the isolate
can be identified as S. aureus. However, some strains of
S. lugdunensis and S. schleiferi are also positive for
clumping factor.
TUBE COAGULASE TEST [clot (+)]
Staphylocoagulase (free-coagulase) is an
extracellular molecule that causes a clot to form when
bacterial cells are incubated with plasma.
Staphylocoagulase reacts with a thermostable,
thrombin-like molecule called coagulase-reacting factor
(CRF) to form coagulase-CRF complex.
The coagulase-CRF complex resembles thrombin and
indirectly converts fibrinogen to fibrin.
Laboratory scientists should look for clot formation
after 4 hrs of incubation at 37C. If no clot appears, the
tube should be left at room temperature and checked
the following day.

Streptococcus
General Characteristics
-gram-positive, nonmotile, non-sporeforming, catalase-
negative cocci that occur in pairs or chains
-appear more elongated than spherical
-most are facultative anaerobes, some are aerotolerant
anaerobes
-most require enriched media (blood agar)
-colonies are usually small and transparent
Hemolysis
-the streptococci and similar organisms can produce
numerous exotoxins that damage intact red blood cells
(RBC)
Cell Wall Structure
-streptococci possess a typical gram-positive cell wall
consisting of peptidoglycan and teichoic acid
-most streptococci, except for many of the viridians
group, have a group or common C carbohydrate
(polysaccharide), which can be used to classify an
isolate serologically
-Rebecca Lancefield was able to divide the streptococci
into serologic groups, designated by letters. Organisms
in group A possess the same antigenic C carbohydrate,
organisms in group B have the same C carbohydrate,
and so on.
Clinically Significant Streptococci
-clinically isolated streptococci have historically been
separated into B-hemolytic streptococci or pyogenic
(pus-forming) streptococci and species that are non-B-
hemolytic (nonpyogenic)
-pyogenic streptococci isolated frequently from humans
include Streptococcus pyogenes, Streptococcus
agalactiae, Streptococcus dysgalactiae subsp.
Equisimilis, and Streptococcus anginosus group (some
species are a-hemolytic or nonhemolytic)
Streptococcus pyogenes (Group A Streptococci)
Characteristics
-gram-positive cocci in chain
-nonmotile, facultative anaerobes
-capsule
-beta-hemolysis on BA
-catalase (-)
-bacitracin sensitivity test- presumptive test for
identification of Group A streptococci
Virulence Factors
•M protein- antiphagocytic; major virulence factor
limiting phagocytosis disturbing the function of
complement and being responsible for adhesion
•Lipoteichoic acid- mediates adherence to epithelial
cells of mouth and skin
•Capsule- prevents phagocytosis by neutrophils or
macrophages, mask its antigen and remain
unrecognized by its host
•Streptococcal pyrogenic exotoxins- responsible for
rash seen in scarlet fever
•Streptolysin O- O2 labile, highly immunogenic; lyses
leukocytes, platelets, RBCs
•Streprolysin S- O2 stable, non-immunogenic, lyses
•Streptokinase- causes plasminogen to convert into a
protease (plasmin), which lyses the fibrin clot
•DNAse- reduces viscosity of abscess material and
facilitates spread of organisms
•Hyaluronidase (spreading factor)- an enzyme that
solubilises the ground substance of mammalian
connective tissue
Clinical Infections
Streptococcus pyogenes colonizes the throat and skin
in humans making these primary sources of
transmission
•Bacterial Pharyngitis
-Group A streptococci is the major cause of bacterial
pharyngitis
-Strep throat is most often seen in children between 5
and 15 yrs of age
-after an incubation period of 1-4 dyas, an abrupt onset
of illness ensues, with sore throat, malaise, fever and
headache
-transmission: droplet spray and close contact
•Scarlet Fever
-caused by streptococcal pyrogenic exotoxins
-initial symptoms of pharyngitis
-followed 1-2 days after with a diffuse erythematous
rash--- desquamation
•Pyodermal Infections
Impetigo- begins as small vesicles that progress to
weeping lesions
Erysipelas- spreading skin lesion that with distinct
advancing border
Cellulitis- inflammation of the skin and subcutaneous
tissue characterized as diffuse, spreading lesions with
ill-defined borders
Wound infection
•Post-streptococcal sequelae
-non-infectious disease, an immune disease
-occurs 2-4 weeks after a streptococcal infection of the
throat and skin
-mechanism of cross-reactivity: certain strains of Group
A streptococci share a similar antigenic structure with
heart tissue and glomeruli--- cross-reacting
antibodies--- damage to these organs
o Acute rheumatic heart fever--- damage of heart
valves--- rheumatic heart disease
o Acute glomerulonephritis--- damage to the
glomeruli--- impairment of kidney function
Laboratory Diagnosis
•Microscopy- gram stained smear
•Culture- BA (beta-hemolytic)
•Bacitracin sensitivity test
•ASO (Anti-streptolysin O) detection
Prevention and Control
•Cleanliness and hygiene
•Strict aseptic technique
• Prompt treatment to prevent post-streptococcal
complications
*GAS (Group A Streptococci) are susceptible to
penicillin. For patients allergic to penicillin,
erythromycin can be used. For patients who have a
history of rheumatic fever, prophylactic doses of
penicillin are given to prevent recurrent infections.
Streptococcus pneumoniae (Pneumoccus)
Characteristics
-absence of cell wall (not part of any Lancefield group)
-Old name: Diplococcus pneumoniae
-gram positive lancet-shaped or oval diplococcic
-nonmotile, capsulated (polysaccharide)
-alpha-hemolysis on BA
-facultative anaerobe
-catalase (-)
-resistance
-organisms discharged from droplet spray
survive for 1.5 hrs in sunlight
-organisms may live for a month in dried
sputum
Virulence Factors
-Capsule
-Hemolysin
-Protease
-Neuraminidase
-Hyaluroidase
Transmission: droplet spray and contaminated objects
Clinical Infections
•Lobar pneumonia
-pneumococcus is the most common cause of
pneumonia in older children and adults
-high grade fever, chills, pleuritic pain, cough with
characteristic “rusty” mucopurulent sputum
-x-ray show consolidation
•Sinusitis
•Otitis media
•Bacteremia
•Meningitis
Laboratory Diagnosis
•Microscopy- gram stained smear
•Culture- BA (alpha-hemolytic)
•Capsule staining
•Neufeld Quellung reaction- detection of capsular
polysaccharide which is the best test to classify
pneumococci, 84 serotypes
•Optochin sensitivity test- presumptive for
pneumococci which differentiates them from other
alpha-hemolytic streptococci

Prevention and Control

•Disinfection of sputum
•Polyvalent pneumococcal vaccine
 GRAM (-) COCCI
NEISSERIACEAE
The family Neisseriaceae contains the genus
Neisseria as well as Kingella, Eikenella, Simonsiella,
Alysiella, and several other genera. Moraxella
catarrhalis is in the family Moraxellaceae with other
Moraxella spp. and Acinetobacter. M. catarrhalis is
included in this chapter because its cellular
morphology resembles the morphology of Neisseria.
General Characteristics
•Aerobic, nonmotile, non-spore forming, gram-
negative diplococci
•Neisseria elongata, Neisseria weaveri, and Neisseria
bacilliformis are known exceptions and are rod
shaped
•Cytochrome oxidase (+), catalase (+) except for N.
elongata subsp. nitroreducens and N. bacilliformis,
which are catalase negative
•Capnophilic meaning they require carbon dioxide
(CO2) for growth and have optimal growth in a
humid atmosphere
•Can grow anaerobically if alternative electron
acceptors are available
•Natural habitat: mucous membranes of the
respiratory and urogenital tracts
Neisseria meningitidis
Neisseria gonorrhoeae
Characteristics
•Gram (-) coffee bean-shaped diplococci
•Usually intracellular
•Facultative anaerobes, growth enhanced in
increased CO2 concentration
•Fastidious organisms with complex nutritional
requirement
•Grow in CA (chocolate agar), not in NA (nutrient
agar)
•Selective (enriched) medium: Thayer Martin
(modified chocolate agar by adding antibiotics)
•Require IRON for growth
•Colonies: small, translucent, raised, moist, grayish
white, usually mucoid with entire to lobate margins
•Produce catalase and cytochrome oxidase
•Very susceptible to adverse environmental and
susceptible to disinfectants
•Exclusive human pathogen
Neisseria meningitidis (meningococcus)
•N. meningitidis is also found only in humans
•It is an important etiologic agent of endemic and
epidemic meningitis and meningococcemia and
rarely pneumonia, purulent arthritis, or
endophthalmitis
•N. meningitidis has also been recovered from
urogenital and rectal sites as a result of oral-genital
contact
Epidemiology
•N. meningitidis can be found on the mucosal
surfaces of the nasopharynx and oropharynx in 30%
of the population
•The organism is transmitted by close contact with
respiratory droplet secretions from a carrier to a new
host
•Of the 12 meningococcal encapsulated serogroups,
A, B, C, Y, and W-135 account for most cases of
diseases in the world
•Meningitis
- frontal headache, stiff neck (nuchal rigidity),
confusion and photophobia
•Other complications include arthritis, pericarditis,
and pneumonia, conjunctivitis and urethritis

Virulence Factors
•Capsule
•Pili (fimbriae)
•Endotoxin (LPS)- diffuse vascular damage and DIC
(Disseminated Intravascular Coagulation-
inappropriate clotting of blood)
•Protease
•Cell membrane proteins
Transmission: droplet spray

Laboratory Diagnosis
Specimen Collection and Transport
Specimens: cerebrospinal fluid (CSF), blood,
nasopharyngeal swabs and aspirates, joint fluids, and
less commonly sputum and urogenital sites.
Collection and transport should be performed as
specified by the laboratory for the various specimen
type.
•Presumptive diagnosis
Microscopy
Culture
Oxidase test

•Definitive diagnosis- CHO fermentation reaction

Glucose (+) Sucrose (-)
Maltose (+) Lactose (-)
Clinical Syndrome
•Nasopharyngitis
- majority are with mild symptoms

•Meningococcemia
- fulminant septicemia (life-threatening)
- spread to skin--- petechial skin lesions--- purpura
- tachycardia, hypotension, and thrombosis can
develop during bacteremia
- patients may develop DIC, septic shock, or
hemorrhage in the adrenal glands (Waterhouse-
Friderichsen syndrome)
Treatment Virulence Factors
•The drug of choice for treatment of confirmed N. •Pili (fimbriae)
meningitidis meningitis is penicillin; •Endotoxin (LPS)
meningococcemia is best treated with third- •Protease
generation cephalosporins •Cell membrane proteins
•Chemoprophylaxis with rifampin or ciprofloxacin is •Beta-lactamase
recommended for close contacts Transmission: sexual contact
•Azithromycin can be used in areas where
ciprofloxacin resistance is a problem Clinical Infections
•Chemoprophylaxis is not recommended for •Gonorrhea
asymptomatic carriers IP: 2-7 days (IP- Incubation Period)
Men:
Vaccine -infections are primarily restricted to the urethra
•The quadrivalent vaccine Menactra is a -acute urethritis
polysaccharide-protein conjugated vaccine with -earliest manifestation is dysuria (painful urination,
antigens to serogroups A, C, Y, and W-135 burning sensation)--- followed by the purulent
•The Advisory Committee on Immunization Practices urethral discharge
recommends routine vaccination be administered to -95% of infected male are symptomatic
individuals at age 11 to 12 years with a booster dose -complications: prostatitis and epididymitis,
at age 16 years periurethral abscess, urethral strictures and painful
•Individuals who receives their first dose at age 16 erection
years or older do not need a booster dose unless they
are at a high risk of invasive meningococcal disease Women:
-primary site is the cervix and urethra
Prevention and Control -many are asymptomatic (carriers or reservoirs)
•Identification and treatment of carriers -asymptomatic cases in women may lead to
(nasopharynx) complication: salpingitis, pelvic inflammatory disease
•Antibiotic prophylaxis (PID) which may cause sterility, ectopic pregnancy,
•Polyvalent vaccines or perihepatitis (Fitz-Hugh-Curtis syndrome)
-symptoms: dysuria, cervical discharge, and lower
Neisseria gonorrhoeae (gonococcus) abdominal pain
•Humans are the only natural host for N.
gonorrhoeae, the agent of gonorrhea Children:
•Gonococcal infections are primarily acquired by Ophthalmia neonatorum- gonococcal eye infection in
sexual contact and occur primarily in the urethra, newborn
endocervis, anal canal, pharynx, and conjunctiva -antimicrobial eyedrops,
generally erythromycin
Gonococcal conjunctivitis- sexually abused children
Epidemiology
•N. gonorrhoeae infections are most commonly
transmitted by sexual contact
•The primary reservoir is the asymptomatic carrier
•Gonorrhea is second to Chlamydia trachomatis in
the number of confirmed sexually transmitted
bacterial infections in the United States
•Sexually active teens and young adults have the
highest rates of infection
•Overall, highest rates are recorded in urban areas
where individuals are more likely to have multiple
partners and unprotected sexual intercourse
Laboratory Diagnosis
Specimen Collection and Transport
Specimens collected for the recovery of N.
gonorrhoeae may come from genital sources or from
other sites, such as the rectum, pharynx, and joint
fluid.
The specimen of choice for genital infections in men
is the urethra and in women is the endocervix.
Best clinical specimens from infected males and
females: urine, urethral/vaginal discharge, synovial
fluid, etc.
•Presumptive Diagnosis:
Microscopy
Culture
Oxidase test

•Definitive Diagnosis- CHO fermentation test

Glucose (+) Lactose (-)
Maltose (-) Sucrose (-)

Prevention and Control

Identification and Control
Treat sexual partner simultaneously
Condoms
Prophylaxis against opthalmia neonatorum

Factors that will contribute to the difficulties

encountered in the control of GC
•Short IP which makes it possible for transmission
before diagnosis of infection
•Asymptomatic females (carriers)
•Social acceptance of sexual activity with multiple
partners- provide opportunity for wider
dissemination of GC and other STD
•Persistence of the organisms after recovery so that a
single dose therapy may not be enough
•Penicillinase- producing N. gonorrhoeae (PPNG)
-normally gonococci are sensitive to penicillin
-resistance is due to penicillinase enzyme
-increasing prevalence
-1st isolated in Asia
Treatment
•According to the 2010 STD Treatment guidelines,
cephalosporins (e.g., ceftriaxone, cefixime) are
currently recommended.
•Dual therapy is frequently prescribed, one of the
primary therapies for N. gonorrhoeae is used plus
azithromycin or doxycycline for C. trachomatis
•Routine use of dual therapy can decrease the
prevalence chlamydial infection, and may reduce the
development of resistant strains of N. gonorrhoeae

Moraxella catarrhalis
•Normal inhabitant of the upper respiratory tract
•May occasionally cause meningitis and OM (otitis
media) but generally non-pathogenic
•Can grow on NA (nutrient agar)
•Oxidase, catalase (+)
•CHO fermentation test = (-) for G, M, L, S

Clinical Infections
M. catarrhalis is an opportunistic pathogen and is
recognized as a cause of:
-upper respiratory tract infection
-lower respiratory infections (adults with chronic
obstructive pulmonary disease)
-acute otitis media, sinusitis
-rare infections: endocarditis, meningitis, and
bacterial tracheitis

Laboratory Diagnosis
Specimen Collection and Identification
-Typical specimens: collected from middle ear
effusion, nasopharynx, sinus aspirates, sputum
aspirates, or bronchial aspirates
-Organism grows on both SBA and CHOC agar
-Most strains of M. catarrhalis can grow well at 28C
-M. catarrhalis is usually inhibited on gonococcal
selective agars by collistin, but some strains resistant
to this antimicrobial may grow
-The organism is asaccharolytic, and it may be
differentiated from Neisseria spp. by positive DNase
and butyrate esterase reactions