Fastidious Organism

Fastidious organisms include the HACEK bacteria (Haemophilus, Aggregatibacter,

Cardiobacterium, Eikenella corrodens, Kingella), which account for about 3% of
cases (Das et al., 1997;

From: Encyclopedia of Cardiovascular Research and Medicine, 2018

Related terms:

Endocarditis, Streptococcus, Brucella, Bacterium, Infectious Agent, Anaerobe, Mi-

croorganism, Fungus, Polymerase Chain Reaction

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Gram-negative coccobacilli
S.H. Gillespie MB, BCh, BAO, MRCP(UK), MRCPath, in Medical Microbiology Illus-
trated, 1994

Isolation
Bordetellas are fastidious organisms that grow slowly on specialized media. Borde-
tella pertussis is readily inhibited by many normal constituents of media and the
products of its own metabolism. Protective substances such as activated charcoal
or starch act to absorb these and enable these organisms to grow. The classical
media for pertussis isolation is Bordet-Gengou which contains starch obtained
from potatoes, but charcoal blood agar is effective. Each of these media contains
a much higher concentration of blood than conventional blood agar. After repeated
subculture on artificial media a number of times a phase change takes place and
pertussis will then grow on normal media.

Pernasal swabs should be carefully inoculated by rolling them on charcoal blood

agar and incubated in aerobic atmosphere with increased humidity for up to seven
days. Charcoal blood agar is supplemented with beef extract, starch and peptone,
and cefoxitin is incorporated to suppress the growth of commensal organisms.
The highest diagnostic yield is probably obtained by use of Lacey's modification of
Bordet-Gengou which is a rich blood agar supplemented with potato starch using
diami-dine and penicillin as the selective agents. This medium is difficult to make,
however, and should be used only in laboratories with a high throughput. Media for
the diagnosis of Bordetella should be preferably made up on the day of use because
of its very short shelf-life.

Bordetella pertussis produces minute shiny dome-shaped colonies, ‘bisected pearl

or mercury drops’, after 48 hours’ incubation. Plates should not be discarded as
negative until seven days have elapsed.

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Health Care-Associated Infections

Lakshmi Srinivasan, Jacquelyn R. Evans, in Avery's Diseases of the Newborn (Tenth
Edition), 2018

Respiratory Syncytial Virus

RSV is a fastidious organism capable of surviving on inanimate objects for prolonged
periods and which can cause severe disease in neonates, particularly those who are
premature or who have cardiopulmonary disease. Rapid testing to detect RSV in
nasal washings facilitates efforts to cohort infected patients (Madge et al., 1992). The
most recent guidelines from the American Academy of Pediatrics (AAP) recommend
that all high-risk infants born at less than 29 weeks' gestation, or with chronic lung
disease, or with hemodynamically significant congenital heart disease receive up to
five doses of palivizumab (an RSV monoclonal antibody) during the RSV season but
starting only at hospital discharge (American Academy of Pediatrics et al., 2014).
Although current guidelines do not list prophylactic palivizumab for prevention of
nosocomial transmission of RSV, some centers choose to provide RSV prophylaxis to
at-risk inpatient neonates because of sporadic occurrences of inpatient nosocomial
deaths from RSV (Abadesso et al., 2004; Kurz et al., 2008; Katz and Sullivan, 2009;
Berger et al., 2010; Ohler et al., 2013).

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Pediatric Neurology Part II

Daniel Greenblatt, ... Anita L. Belman, in Handbook of Clinical Neurology, 2013

Cat scratch disease

Cat scratch disease (CSD) is usually a benign, self-limited illness lasting 6–12 weeks
after a bite, scratch, or lick from an infected cat (cutaneous inoculation). CSD can
progress to a more severe illness with CNS or multisystem involvement, or both
(American Academy of Pediatrics, 2009b). The association between a cat scratch and
subsequent illness was first recognized in the 1930s. In 1950 CSD was described as
a distinct clinical syndrome. Although a bacterial cause was considered etiologically
responsible for some time, it was not until the1990s that the causative agent,
Bartonella henselae, was identified (Slater and Welch, 2009).

Organism
Bartonella is a fastidious organism and culture can be challenging. Serological test-
ing with either indirect immunofluorescent antibody (IFA) assay or enzyme-linked
immunosorbent assay (ELISA) for detection of serum antibodies to Bartonella anti-
gens is a reliable standard diagnostic approach (Sander et al., 2001; American
Academy of Pediatrics, 2009b).

Epidemiology
Bartonella henselae has a worldwide distribution. Cats, both feral and healthy pets,
are the main carriers. Transmission of the organism from cat to cat is by the flea
vector Ctenocephalides felis (Mogollon-Pasapera et al., 2009).

CSD occurs in persons of all ages, but most frequently affects children, especially
those under age 10 years, and mainly during the autumn and winter (American
Academy of Pediatrics, 2009b). Although the true incidence is not known it is
estimated that there are at least 25 000 cases annually in the USA. CSD is the most
common cause of chronic lymphadenopathy in children and adolescents (Jackson et
al., 1993).

General manifestations
A small nontender papule develops at the site of the cat bite, scratch, or lick
about 3–12 days (range 3–30 days) after the injury. Regional lymphadenopathy
(the hallmark of the disease) develops ipsilateral to the inoculation site in 1–7
weeks. Constitutional symptoms (fever, headache, malaise) develop in about half
of the patients 1–4 weeks after the bite. Anorexia, pharyngitis, and splenomegaly,
alone or in combination, can also occur. Rarer manifestations consist of Parin-
aud's oculoglandular syndrome (unilateral conjunctivitis followed by preauricular
lymphadenopathy), bacillary angiomatosis, erythema nodosum, figurate erythemas,
thrombocytopenic purpura, endocarditis, and nonspecific maculopapular eruptions
(Bass et al., 1997; Massei et al., 2005).
Neurological manifestations
Encephalopathy, including change in level of consciousness, acute confusion, or
bizarre and combative behavior, is the most common neurological complication.
Encephalopathy occurs in 2–5% of patients and typically develops 1–3 weeks after
illness onset. Seizures are common. Progression of symptoms from headache to
lethargy and coma can be rapid (McGrath and Wallis, 1998; Massei et al., 2005). Po-
tential clinical manifestations of CSD include aphasia, hearing loss, cranial neuropa-
thy, hemiplegia, ataxia, transverse myelitis, acute disseminated encephalomyelitis
(ADEM), cerebral arteritis, and PNS involvement including chronic inflammatory
demyelinating polyneuropathy (Carithers and Margileth, 1991; Marra, 1995). Neu-
roretinitis can also develop presenting either unilaterally or, less commonly, with
bilateral vision loss. Findings include central scotoma, optic disk swelling, and
macular star formation.

Cerebrospinal fluid (CSF) analysis serves to exclude other conditions. The CSF profile
is generally normal but can show a mild lymphocytic pleocytosis; routine culture is
negative. Neuroimaging is usually normal but can show findings typically associated
with ADEM or status epilepticus (Hahn et al., 1994; Ogura et al., 2004). During
the acute stage of encephalopathy, electroencephalography (EEG) shows diffuse
nonspecific slowing. Neurological complications are generally transient and most
patients recover well; although recovery may take months in some cases.

Diagnosis
The differential diagnosis of typical CSD includes those infectious disorders as-
sociated with unilateral lymphadenopathy (e.g., atypical mycobacterial infection,
tularemia, brucellosis, histoplasmosis, toxoplasmosis, staphylococcal infection) and
neoplastic conditions such as lymphoma. Since fever, myalgia, and headache are
nonspecific, a careful history specifically concerning exposure to kittens or cats is
paramount.

Treatment
Since the disease is usually self-limited in the immunocompetent patient, supportive
treatment is recommended during the acute phase of the illness. Most patients
recover completely. In more severe cases azithromycin is the drug of choice, followed
by doxycycline (Maguina et al., 2009).

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Investigation of specimens from the
genital tract and diagnosis of sexually
transmitted diseases (STDs)
S.H. Gillespie MB, BCh, BAO, MRCP(UK), MRCPath, in Medical Microbiology Illus-
trated, 1994

Isolation
Neisseria gonorrhoeae is a fastidious organism which must be isolated from sites
which are heavily contaminated with other organisms. The media which are used
for the isolation of the gonococcus are rich and usually supplemented with yeast
extract or Iso-vitalex and blood, which may be lysed as in New York City medium or
‘chocolated’ as in Thayer Martin. Several cocktails of antibiotic inhibitors are used.
One such is vancomycin, nystatin, colistin and trimethoprim. A small proportion
of gonococci are inhibited by vancomycin and a mixture of lincomycin, colistin,
amphotericin, and trimethoprim is used in New York City medium (see Table 5.2).

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Analytical Methods | Microbiological

S. Anand, in Encyclopedia of Dairy Sciences (Second Edition), 2011

Lactobacillus spp
Lactobacilli are considered as fastidious organisms. The homofermentative species
produce lactic acid during carbohydrate fermentation, and several other products
such as acetic acid, ethanol, and CO2 are produced frequently in varying proportions
by these species. The deMan, Rogosa, and Sharpe (MRS) medium supports the
growth of various lactobacilli. Species of Pediococcus and Leuconostoc also grow
luxuriously on this medium. To facilitate colony formation, the incubation is carried
out for 48–72 h at 35 °C under anaerobic conditions. As MRS medium is not highly
selective, colonies are tested for catalase-negative, Gram-positive cocci (lactococci)
or rods (lactobacilli) for tentative identification as lactic acid bacteria.

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LACTOCOCCUS | Lactococcus Lactis
Subspecies Lactis and Cremoris
Polly D. Courtney, in Encyclopedia of Food Microbiology, 1999

Growth Requirements
The lactococci are nutritionally fastidious organisms. In nature, they most commonly
inhabit environments rich in carbon and nitrogen sources, such as raw milk and
plant material. During dairy fermentations, the growth medium for L. lactis is milk.
In the laboratory, an undefined, buffered medium, such as M17, is generally used for
L. lactis propagation. Chemically defined media that support growth have also been
reported. L. lactis strains are auxotrophic for many amino acids. The specific amino
acids that they are unable to synthesize differ from strain to strain. Common amino
acids that must be added to defined media for L. lactis growth are isoleucine, valine,
leucine, histidine, methionine, arginine, proline, glutamate, serine and threonine.
Vitamins necessary for optimum growth include biotin, pyridoxal, folic acid, ri-
boflavin, niacin, thiamin and pantothenic acid. Glucose, buffer and various minerals
are also components of the defined media.

Lactococci are mesophilic organisms with an optimum growth temperature of

25–30°C. Their maximum generation time is 60–70 min in milk or 35–40 min
in undefined synthetic medium. Growth becomes inhibited at pH 4.5 or lower;
therefore, the highest cell densities may be obtained in buffer media. L. lactis does
not require oxygen for growth, but can tolerate the presence of oxygen due to
oxygen-metabolizing enzymes.

To protect company interests, many of the details of commercial starter culture

preparations are not public knowledge. Generally, starter culture manufacturers
prepare high cell density cultures in large fermenters. Cells are then concentrated
and preserved by freezing or freeze-drying. Certain commercial culture preparations
are designed for direct inoculation into the fermentation vessel (DVS, or direct-to-vat
set). Others are intended for propagation in the dairy plant, with subsequent inoc-
ulation of the bulk starter culture into the fermentation vessel.

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Helicobacter pylori
Steven L. Percival, David W. Williams, in Microbiology of Waterborne Diseases
(Second Edition), 2014
Exposure Assessment: Routes of Exposure and Transmission,
Occurrence in Source Water, Environmental Fate
• Since H. pylori is such a fastidious organism, culture from environmental
and clinical samples is challenging. PCR has been used successfully to detect
H. pylori DNA in environmental samples; however, little is known about the
occurrence of the organism in water.
• Under conditions of stress, H. pylori can transform to a durable, coccoid mor-
phology. Whilst this form could be significant in transmission, controversy
surrounds its function and viability (Cellini et al. 1994; Kusters et al., 1997; Ren
et al., 1999).
• Little data on environmental occurrence is available; however, of 42 surface
water and 20 well water samples in the USA, 40 % and 65 % respectively, tested
positive using fluorescent antibody and PCR methods (Hegarty and Baker,
1999)
• Limited studies are available indicating that Helicobacter species could be
present in water distribution system biofilms (Stark et al., 1999; Park et al.,
2001).
• Whilst epidemiological evidence suggests transmission by multiple pathways,
H. pylori’s exact route of transmission is unknown. Helicobacter pylori infec-
tion has been associated with consumption of contaminated drinking water
(Klein et al., 1991; Baker and Hegarty, 2001). Evidence is limited, but the
waterborne route of exposure is probably important in some populations.
• Occurrence data indicate that infection clusters in families as well as group-liv-
ing situations (i.e., orphanages, mental institutions). Secondary spread, partic-
ularly among children, is likely.

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Collection of blood for culture

S.H. Gillespie MB, BCh, BAO, MRCP(UK), MRCPath, in Medical Microbiology Illus-
trated, 1994

Blood culture sets

Whatever media are chosen there is an inevitable compromise of the yield of
fastidious organisms obtainable. To overcome this blood is inoculated into several
bottles each of which are capable of giving a high diagnostic yield for a particular
group of bacteria, for example anaerobes. It is now unusual for a single blood
culture bottle to be used, however a commercial blood culture system (Signal, Oxoid,
England) does do this (see below and Fig. 14.2).

Figure 14.2. ‘Signal’ blood culture bottle being subcultured

Some laboratory protocols include a medium which is incubated in 10% CO2 atmos-
phere with the top loosened to enhance the possibility of isolating capnophiles such
as some Haemophilus spp. and Brucella spp. Venting in CO2 will also enhance the
yield of a wide range of organisms including Neisseria, Escherichia, Pseudomonas,
Staphylococcus, and Klebsiella.

The simplest set would, therefore, consist of a vented aerobic bottle incubated in a
10% CO2 atmosphere together with a specific anaerobic broth.

Other sets might include an additional unvented aerobic bottle, which might be a
diphasic medium (see Fig. 6.2).

It is important, whatever the composition of the conventional blood culture set, that
medium made available to the wards is as fresh as possible. It is important that stock
is carefully controlled so that blood from septicaemic patients is inoculated into fresh
medium supplies of blood culture sets being supplied through a central distribution
point. They should be clearly date stamped and not dispensed or used if this date is
passed.

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Immunohistology of Infectious Dis-

eases
Eduardo J. Ezyaguirre, ... Sherif Zaki, in Diagnostic Immunohistochemistry (Third
Edition), 2011
Syphilis
Syphilis continues to be a public health problem caused by T. pallidum, a fastid-
ious organism that has not been cultivated.153 The diagnosis of syphilis relies on
serology and the identification of T. pallidum by dark-field microscopy. However,
these methods have low sensitivity and specificity,154 and serologic methods can be
negative in early stages of the disease and in immunosuppressed patients such as
those coinfected with human immunodeficiency virus (HIV).155 In tissue sections,
the usual method for detecting spirochetes is through silver impregnation stains
(Warthin-Starry or Steiner). These stains, however, can be technically difficult to
perform and interpret, are nonspecific, and frequently show marked background
artifacts because silver stains also highlight melanin granules and reticulin fibers.
Detection rates of spirochetes using silver stains vary from 33% to 71%.156 It
has been shown that immunostaining of biopsy specimens with anti–T. pallidum
polyclonal antibody (Fig. 3.17) is more sensitive and specific than silver staining
methods, with sensitivities ranging from 71% to 94%.153,156,157

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Prosthetic Valve Endocarditis

Raj Palraj, ... Walter R. Wilson, in Mandell, Douglas, and Bennett's Principles and
Practice of Infectious Diseases (Eighth Edition), 2015

Community-Acquired Prosthetic Valve Endocarditis

Most community-acquired PVE is caused by enterococci, viridans group strepto-
cocci, and fastidious organisms including the HACEK group (Haemophilus parain-
fluenzae, Aggregatibacter aphrophilus, Aggregatibacter actinomycetemcomitans,
Cardiobacterium hominis, Eikenella corrodens, and Kingella spp.).11-13,42-47

Late-onset PVE is rarely caused by Mycobacterium, Coxiella, Tropheryma, Bartonel-

la, and Legionella spp.48-56 Aspergillus spp. have been noted in few infections and
can be difficult to identify as causative pathogens because blood cultures are
usually negative. Fungal stains of the resected tissue can show characteristic fungal
hyphal elements. Other rare fungal pathogens include Cryptococcus neoformans and
Histoplasma capsulatum.

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