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CASE ANALYSIS

CASE
A 19-year old male athlete, got into an accident
while he and his teammates were on practice and
caused him an open wound fracture on the lower
part of his left leg. He was rushed into the hospital
a few hours later. He underwent fixation surgery
to keep the bone intact and was also given
antibiotics for further treatment. 7 days later, the
athlete came back to the hospital complaining of
fever, pain, swelling, and inflammation on
the site of operation. Several laboratory tests
were done in order to identify the cause of
complication. The white blood cell and red
blood cell count are both normal however,
erythrocyte sedimentation rate and Creactive protein are slightly elevated. A bone

CASE
These are the following microbiological tests
performed on the specimen and their results:

Cultural
morphology
of the
isolates:

Medium, round,
pigmented, raised,
no hemolysis
present

Gram positive
Microscopic cocci
morphology
:

Catalase
Oxidase
Citrate
Indole
Nitrate
reduction
Maltose
Lactose
DNAse
RIFAMPICIN

+
+
+

+
+
+
SUSCEPTIBL
E
NOVOBIOCIN SUSCEPTIBL
E
PENICILLIN
RESISTANT

CASE

Showing these results, the


patient is given
Vancomycin for the
treatment of his infection.

Gram positive cocci


Catalase
Negative

Positive
Micrococcus

Staphylococcu
s

Oxidase Test
Positive

Negative

Micrococcus

Staphylococcus

Streptococcus

Staphylococcus
Novobiocin
Resistant
S. Aureus

S.
epidermidis
DNAse

Positive

Negative

S. aureus

S.
epidermidis

Susceptible
S. saphrophyticus

What is the causative agent?

Staphylococcus aureus
Hospital-acquired methicillin resistant
strain of Staphylococcus aureus

Principles of the tests


Catalase test
Catalase enzymatically converts hydrogen peroxide into
water and oxygen, creating a visible positive reaction
which is indicated by rapid and continuous bubble
formation.
Oxidase test
Micrococcus organisms possess cytochrome C in the
cytochrome-oxidase system, whereas most
Staphylococcus organisms do not.
Deoxyribonuclease (DNAse) test
DNAse test agar is used to detect DNAse activity in

Principles of the tests


Kirby-Bauer disk diffusion test
The Kirby-Bauer test is routinely used to determine the susceptibility
or resistance of a pathogenic organism to various antimicrobial
agents. A standardized suspension of organisms is inoculated onto
Mueller-Hinton agar.
Novobiocin susceptibility test
The novobiocin susceptibility test is a simple disk diffusion test that
differentiates Staphylococcus saprophyticus which is resistant to
novobiocin, from other coagulase-negative staphylococci which are
susceptible to novobiocin. It can also be used to differentiate
Staphylococcus aureus which is susceptible to novobiocin, from other
staphylococci which are resistant.
Oxacillin screen agar
Oxacillin screen agar was developed to detect methicillin-resistant

What are the signs and symptoms presented in the case?

Seven days after the


surgery and antibiotic
treatment, the patient went
back to the hospital
complaining fever, pain,
swelling and inflammation on

What is the probable disease of the patient?

Osteomyelitis

Osteomyelitis has been classified


into three categories:
Hematogenous Osteomyelitis
Osteomyelitis due to spread
from an adjacent site of infection
without vascular insufficiency
Osteomyelitis due to contiguous
infection with vascular

The patient is most probably


experiencing the second type of
Osteomyelitis.
Osteomyelitis due to spread from
an adjacent site of infection
without vascular insufficiency

Give other laboratory tests to identify or confirm the


organism.

Bacitracin susceptibility test


Coagulase test
Mannitol salt agar
Polymyxin B resistance
Nucleic acid amplification tests
Cefoxitin disk screen test
Commercially available chromogenic
agars (BBL CHROMagar MRSA)
Oxoid Chromogenic MRSA Agar

E. COLI

CASE

Mr. Coco Martin, 30 years old, has a


history of repeated lower urinary
tract infection. Just this time, he is
experiencing fever and frequent
urge to urinate. In addition to that,
he also feels burning sensation
upon voiding and lower back
pain. His physician opted to culture
a clinical specimen from him. The
clinical sample was inoculated in a
Blood Agar Plate. A smooth,

Gram stain
Catalase
Coagulase
String test
Oxidase
Triple Sugar Iron
H2S production
Voges-Proskauer (VP)
Citrate

Gram + bacilli
Negative
Negative
Positive
Negative
(A/A)
Negative
Negative
Negative

Gram positive
bacilli
String test
Positive

Negative

Gram negative
bacilli

Gram positive
bacilli

Oxidase Test
Positive

Negative
Enterobacteriacea
e

Enterobacteriaceae
TSI
A/A
Klebsiella

Escherichia

Enterobacter

H2S
Production
Negative

Negative

Negative

VP/Citrate
+/+

-/-

+/+

E. coli

TSI
H2S
MacConkey
EMB
Indole
Methyl Red (MR)
Voges-Proskauer (VP)
Citrate
Motility
Deaminase
Urease
Lysine Decarboxylase
Ornithine Decarboxylase
Arginine Decarboxylase
ONPG

A/A
Negative
Pink-red colonies
Green metallic sheen
Positive
Positive
Negative
Negative
Positive
Negative
Negative
Positive
Most strains positive
Most strains negative
Positive

E. coli

Fermentation of:
Adonitol
L-arabinose
Cellobiose
Dulcitol
Maltose
D-mannitol
D-mannose
D-sorbitol
Sucrose
Trehalose
D-xylose

Negative
Positive
Negative
Variable
Positive
Positive
Positive
Positive
Variable
Positive
Positive