Microbiology & Parasitology Module 2 Part 2

Divine Word College of Bangued
Bangued, Abra
School of Health Sciences
Bachelor of Science in Nursing
Microbiology & Parasitology

Module 2: Bacteriology Part 2
By: Airel Derick Martin, RN, MD
Outline:
Bacteriology (Midterms)
b. Gram-negative bacteria (Part 2)
i. Gram-negative cocci
ii. Gram-negative rods
• Respiratory tract
• GIT & GUT
Disclaimer:
This material contains a cumulative synthesis of secondary information. The content herein is neither original
nor my own intellectual property, except for some annotations which I composed myself. I have diligently tried
to acknowledge resources used in this handout. Some of the figures might be copyrighted, and I tried my best to
acknowledge them or at least show where they are sourced. Having said that, I am sharing this material to you
only in order to facilitate your learning. Therefore, you are supposed to consume this material only privately
and should not circulate this in a platform where public access outside DWCB School of Health Sciences is likely.
The handout is NOT intended for academic publishing. Our main reference textbook is Jawetz, Melnick, &
Adelberg's Medical Microbiology, 28e.
Microbiology & Parasitology: Bacteriology Part 2 1

This module is a property and is exclusively used by the DWCB College Department. Any duplication and reproduction, storing in any retrieval
system, distribution, posting or uploading online as well as transmitting in any form or means ( photocopying & electronic sharing ) of any part ,
without prior written permission from the owner is strictly prohibited.
Bangued, Abra
Teaching-Learning/Lesson Proper:
GRAM-NEGATIVE COCCI
GUIDE QUESTION:
Gram stain of synovial fluid from the
knee of a 20/F with suspected
bacterial arthritis reveals Gram-
negative diplococci. To isolate the
Neisseria gonorrhoeae, the specimen
should be plated on which of the
following?
A. Chocolate agar
B. Thayer-Martin medium
C. Chocolate agar enriched with
factors X and V
D. In an armadillo
I. NEISSERIA MENINGITIDIS The presence of bacteria in the synovial

fluid suggests an infection. Synovial
CHARACTERISTICS
fluid analysis is also useful to help
• gram-negative "kidney-bean" diplococci distinguish crystal arthropathy from
• large polysaccharide capsule infectious arthritis, although the two
• oxidase-positive colonies on chocolate agar occasionally coexist.
• ferments maltose and glucose Cultures of likely sites of Neisseria
gonorrhoeae infection are the most
important tests to perform for the
HABITAT AND TRANSMISSION diagnosis of disseminated gonococcal
• habitat is the URT infection (DGI) and consequent
• transmission via respiratory droplets gonococcal arthritis. Synovial fluid
cultures are positive for N gonorrhoeae
• humans are the only natural hosts
in no more than 50% of cases and alone
• high carriage rate in close quarters are insufficient to establish the
o military recruits, dormitories, camps, travel (e.g. diagnosis.
epidemic related to traveling to Saudi Arabia for the Neisseria gonorrhoeae is a fastidious
Hajj pilgrimage) organism. It is typically cultured using
an agar medium such as chocolate agar
plate. Normally, sterile clinical
PATHOGENESIS specimens (e.g. blood, synovial fluid,
• antiphagocytic polysaccharide capsule CSF) should be inoculated onto
• endotoxin (LPS) enriched chocolate agar or another
nonselective medium.
• IgA protease
Thayer-Martin agar, an antibiotic-
• complement deficiencies in the late-acting complement containing selective medium, is used for
components (C6–C9) predispose to illness unsterile specimens (e.g. urethral,
o cannot form membrane-attack complexes endocervical). It is actually Mueller-
Hinton agar with 5% chocolate sheep
blood plus the following antibiotics
SPECTRUM OF DISEASE (VPN):
• Meningitis • Vancomycin (inhibits gram-positive
o most common cause among aged 2-18 yrs organisms)
o fever, headache, stiff neck, and an increased level of • Polymyxin* (inhibits gram-negative
PMNs in spinal fluid organisms excluding Neisseria
species)
• Nystatin (inhibits fungi)

Bangued, Abra
GUIDE QUESTION:
Which of the following virulence
factors allows adherence of bacteria
to the mucous membranes of the
• Meningococcemia respiratory, genitourinary and
o dissemination of meningococci into the bloodstream gastrointestinal tracts?
o multiorgan disease, consumptive coagulopathy, A. Panton-Valentine Leukocidin
B. Hyaluronidase
petechial or purpuric rash (purpura fulminans)
C. Coagulase
• Waterhouse-Friderichsen Syndrome D. IgA protease
o most severe form of meningococcemia
o high fever, shock, widespread purpura, disseminated IgA proteases cleave
intravascular coagulation, thrombocytopenia, and immunoglobulin A molecules at
adrenal insufficiency certain proline bonds in the hinge
❖ bilateral hemorrhagic destruction of the region. In this way, the enzyme
adrenal glands allows the certain bacteria to
adhere to mucous membranes
TREATMENT (which are lined with IgA).
Gram-negative:
• penicillin G (no significant resistance)
• Neisseria gonorrhoeae (GU)
• Neisseria meningitides
PREVENTION (respiratory)
• vaccine contains capsular polysaccharide of strains A, C, Y, • Haemophilus influenzae
and W-135 (memorize these four letters: ACYW) (respiratory)
o coupled to a carrier protein (e.g. diphtheria toxoid) Gram-positive:
• rifampin chemoprophylaxis to close contacts • Streptococcus pneumoniae
(respiratory)
II. NEISSERIA GONORRHOEAE
CHARACTERISTICS Remember: Mucous membranes
of the respiratory, genitourinary
• gram-negative "kidney-bean" diplococci
and gastrointestinal tracts are
• insignificant capsule lined with IgA (IgA proteases are
• oxidase-positive colonies on Thayer-Martin medium useful for bacterial pathogenesis).
• ferment glucose only
HABITAT AND TRANSMISSION

• habitat is the human genital tract
• transmission by sexual contact or during passage through birth canal
PATHOGENESIS
• pili - promote adherence to epithelial cells, antigenic variation, antiphagocytosis (binds bacteria
tightly to host cell protecting it from phagocytosis)
• lipo-oligosaccharide (LOS)

Bangued, Abra
• IgA protease
• Outer membrane protein porins: promote invasion
into epithelial cells
o Opa proteins - promote adherence and
invasion into epithelial cells; expression results
in opaque colonies
• usual co-infection with Chlamydia trachomatis
SPECTRUM OF DISEASE: LOCALIZED

• Ophthalmia Neonatorum
o purulent conjunctivitis in newborns
• Gonococcal Urethritis
o urethritis and epididymitis in men
o most common cause of urethritis
• Pelvic Inflammatory Disease (pid)
o most common cause of PID
o complications:
▪ sterility
▪ ectopic pregnancy
▪ chronic pelvic pain
▪ dyspareunia
▪ Fitz-Hugh-Curtis syndrome (perihepatitis): violin-string adhesions
SPECTRUM OF DISEASE: DISSEMINATED

• Septic Arthritis
o most common cause in sexually active adults
o arthritis, tenosynovitis, or pustules in the skin
TREATMENT
• Ceftriaxone + Doxycycline due to frequent co-infection with Chlamydia trachomatis
PREVENTION
• barrier contraception (condoms)
• treat sexual partner
• erythromycin ointment or silver nitrate to prevent conjunctivitis
III. OTHER NEISSERIACEAE

• Eikenella corrodens and Kingella kingae cause culture-negative subacute bacterial
endocarditis in patients with preexisting heart disease
These microorganisms though are of little significance to you so don’t bother memorizing them.
Bangued, Abra
I. HAEMOPHILUS INFLUENZAE REMEMBER:

CHARACTERISTICS Culture specimen on blood agar that
• small gram-negative (coccobacillary) rods has been heated to 80oC for 15
• requires factor X (hemin) and V (NAD) for growth minutes (now called chocolate agar).
(chocolate agar) This high temperature lyses the red
• satellite phenomenon around S. aureus colonies - blood cells releasing both hematin
hemolysis by S. aureus liberates factor V needed by H. (called X factor) and NAD+ (called
influenzae (see photo below) V factor). Like Neisseria, H.
influenzae grows best when the
chocolate agar is placed in a high
CO2 environment at 37oC.

• habitat is upper respiratory tract
• transmission via respiratory droplets
PATHOGENESIS
• type b (polyribitol phosphate) = 95% of invasive disease
• IgA protease
• affects children from 6 months to 1 year
o decline in maternal IgG and immature immune system

Bangued, Abra
SPECTRUM OF DISEASE
• sinusitis, otitis media, pneumonia
• meningitis
• epiglottitis
o most common cause
o cherry red epiglottis
o thumb sign (see image on the right)
• COPD exacerbations
TREATMENT
• ceftriaxone
PREVENTION REMEMBER:
• HiB vaccine containing the type b capsular polysaccharide The thumb sign in epiglottitis is a
conjugated to diphtheria toxoid manifestation of an edematous and
o given between 2 and 18 months of age enlarged epiglottis which is seen on
lateral soft-tissue radiograph of the
neck, and it suggests a diagnosis of
acute infectious epiglottitis
II. BORDETELLA PERTUSSIS

CHARACTERISTICS
• small gram-negative rods
• culture on Bordet-Gengou agar or Regan-Lowe charcoal medium

• habitat is upper respiratory tract
• transmission via respiratory droplets
PATHOGENESIS
• filamentous hemagglutinin
o pili rod that extends from the surface of B.
pertussis, enabling the bacteria to bind to
ciliated epithelial cells of the bronchi
o mediates attachment
• pertussis toxin
o activates G proteins that increases cAMP
resulting in:
▪ increased sensitivity to histamine
▪ increased insulin release
▪ peripheral lymphocytosis
• tracheal cytotoxin
o damages ciliated cells
o causes whooping
SPECTRUM OF DISEASE
Bangued, Abra
• Pertussis or Tuspirina
o paroxysmal pattern of hacking coughs, accompanied by production of copious amounts of
mucus, that end with an inspiratory "whoop"
NATURAL HISTORY
• Incubation Period
o 7-10 days
• Catarrhal phase
o 1-2 weeks
o rhinorrhea, malaise, fever,
sneezing, anorexia
o Antibiotics most effective
• Paroxysmal phase
o 2-4 weeks
o ‘Whoop’ → burst of non-
productive coughs
o Increased number of
lymphocytes in blood smear
o Antibiotics ineffective
during this stage
• Convalescent stage
o 3-4 weeks (or longer)
o Diminished paroxysmal cough
o Development of secondary complications
(pneumonia, seizure, encephalopathy)
TREATMENT
• Erythromycin
PREVENTION
• acellular vaccine in combination with diphtheria and tetanus toxoids (DTaP)
III. LEGIONELLA PNEUMOPHILA

CHARACTERISTICS
• poorly gram-negative rods
o visualize with silver stain
• facultative intracellular bacteria
• culture on charcoal yeast extract agar
o increased amounts of iron and cysteine
o optimal between 28 and 40°C; organisms are dormant below 20°C and are killed at
temperatures above 60°C
• rapid urinary antigen test - Urinary antigen can be detected by radioimmunoassay with high
sensitivity and specify and will remain positive for months after infection. Urine antigen test
only detects L. pneumophilia serogroup 1, but this accounts for 90% of cases.

Bangued, Abra

• Ubiquitous in man and natural water environments
• Freshwater amoebae appear to be the natural reservoir for the organisms.
• transmission via aerosol (e.g. AC, cooling towers)
• person-to-person transmission does not occur
SPECTRUM OF DISEASE
• ATYPICAL PNEUMONIA
o pneumonia accompanied by confusion, non-bloody diarrhea, hyponatremia, proteinuria and
hematuria
• PONTIAC FEVER
o mild, flulike illness
TREATMENT
• azithromycin or erythromycin
PREVENTION
• reducing cigarette and alcohol consumption
• eliminating aerosols from water sources
• high temperatures and hyperchlorination in hospital water supply
I. ESCHERICHIA COLI
CHARACTERISTICS
• facultative gram-negative rods
• lactose-fermenting colonies on EMB or MacConkey agar
Bangued, Abra
• green sheen on EMB agar; metallic sheen

• typing by O and H antigens

• habitat is human colon
• colonizes the vagina and urethra
• transmission
o ascending infection in UTI
o during birth in neonatal meningitis
o fecal–oral route in diarrhea
PATHOGENESIS
• pili or fimbriae – attachment, colonization factor, associated with UTI (cystitis, pyelonephritis)
• flagellum (H)
• capsule (K) – associated with pneumonia and neonatal meningitis (K1)
• endotoxin (O)
• enterotoxins
o ST and LT cause watery diarrhea (similar to cholera toxin)
o verotoxin (Shiga-like toxin) causes bloody diarrhea (HUS), inhibits protein synthesis by
inactivating the 60S subunit of eukaryotic cells (E. coli O157:H7, STEC, EHEC)
SPECTRUM OF DISEASE
• Urinary Tract Infection
o most common cause of
community-acquired UTI
• Neonatal Meningitis
o 2nd most common cause
• Intestinal Infections
TREATMENT
• ampicillin or sulfonamides for UTI
• 3° cephalosporins for meningitis and sepsis
• rehydration is effective in traveler's diarrhea

Bangued, Abra
PREVENTION
• limiting urinary catheterization
• switching IV lines promptly
• drinking boiled water
II. SALMONELLA SPP.

CHARACTERISTICS
• non-lactose-fermenting
• produces H2S
• Widal test detects antibodies in patient's serum
• cultured in XLD medium
HABITAT
• human colon only (S. typhi)
• enteric tract of humans and animals, e.g., chickens and domestic livestock (S. enteritidis)
TRANSMISSION
• fecal–oral route
PATHOGENESIS
• Enterocolitis (S. enteritidis/ S. typhimurium)
o invasion of the epithelial and subepithelial tissue of the small and large intestines
o infectious dose is high
▪ gastrectomy or use of antacids lowers the infectious dose significantly
• Typhoid Fever (S. typhi)
o due to Vi (virulence) capsular antigen
o organisms enter, multiply in Peyer patches, and then spread to reticulo-endothelial system
o predilection for invasion of the gallbladder, which can result in establishment of the
chronic carrier state
• Septicemia (S. choleraesuis)
o bacteremia results in the seeding of many organs, with osteomyelitis, pneumonia, and
meningitis as the most common sequelae
o commonly in patients with sickle cell anemia or cancer
SPECTRUM OF DISEASE
• Enterocolitis
o incubation period of 12–48 hours

Bangued, Abra
o nausea and vomiting and then progresses to abdominal pain and nonbloody diarrhea
• Typhoid Fever
o incubation period 5 to 21 days
• Septicemia
o fever but little or no enterocolitis and then proceed to focal symptoms associated with the
affected organ
o frequently bone, lung, or meninges
TREATMENT
• Ceftriaxone
• Philippines: amoxicillin, chloramphenicol, co-trimoxazole
PREVENTION
• public health measures, e.g., sewage disposal, chlorination, hand washing, food safety
• vaccines for S. typhi
III. SHIGELLA SPP.

CHARACTERISTICS
• non-lactose-fermenting, gram-negative rods
• produce no gas from the fermentation of glucose
• do not produce H2S
• nonmotile
• have O antigens
• cultured in XLD medium
HABITAT
• human colon only
TRANSMISSION
• fecal–oral route
PATHOGENESIS
• Shigella invade the distal ileum and colon
o Invades submucosa of intestinal tract (distal ileum and colon), but not the lamina propria →
local inflammation with ulceration → bleeding
o Shigella has a low infective dose (200 bacilli) → so, it is highly infectious, as compared to
Salmonella which has an infective dose between 105 and 108 (100 K to 100 million
bacterial cells), hence, less infectious.
Bangued, Abra
o Invasion of M cells is key to pathogenicity.

• Important species and strains:
o Shigella sonnei – Duval’s bacillus
▪ most common cause of bacillary dysentery
o Shigella dysenteriae type 1 – Shiga bacillus
▪ most severe form of bacillary dysentery
▪ most common cause of epidemic dysentery
• some produce an enterotoxin (Shiga toxin)
SPECTRUM OF DISEASE
• Bacillary Dysentery
o incubation period: 1–4 days
o fever and abdominal cramps, followed by diarrhea, initially watery then bloody
o diarrhea frequently resolves in 2 or 3 days
TREATMENT
• fluid and electrolyte replacement
• in severe cases, ciprofloxacin
PREVENTION
• public health measures, e.g., sewage disposal, chlorination, hand washing, food safety
VI. HELICOBACTER PYLORI

CHARACTERISTICS
• curved gram-negative rods
• urease-positive
• microaerophilic

• habitat is the human stomach
• transmission is by ingestion
PATHOGENESIS
• damages goblet cells of the gastric mucosa
• production of large amounts of ammonia from urea by the organism's urease
o ammonia also neutralizes stomach acid, allowing the organism to survive
• detected using the following tests:
o EGD with biopsy showing H. pylori
o urease breath test
o H. pylori stool antigen
SPECTRUM OF DISEASE
• Peptic Ulcer Disease
o recurrent pain in the upper abdomen, frequently accompanied by bleeding into the
gastrointestinal tract
• Disease Associations
o gastric carcinoma
o MALT lymphomas
Bangued, Abra
ANTI-H. PYLORI ANTIBIOTICS

• Amoxicillin
• Clarithromycin
• Metronidazole
• Tetracycline
VII. KLEBSIELLA PNEUMONIAE

CHARACTERISTICS
• facultative gram-negative rods with large polysaccharide capsule
• extended spectrum beta-lactamase (ESBL) activity in drug-resistant strains
• urease-positive
HABITAT
• upper respiratory and GIT
TRANSMISSION
• aspiration or inhalation
• ascending spread of fecal flora
SPECTRUM OF DISEASE
• Pneumonia
o thick, bloody sputum ("currant-jelly" sputum)
o usually nosocomial
o most common cause in alcoholics
• Urinary Tract Infections
TREATMENT
• culture-guided treatment (cephalosporins alone or with aminoglycosides)
VIII. PROTEUS MIRABILIS

CHARACTERISTICS
• urease-positive
• swarming motility
PATHOGENESIS
• urease hydrolyzes the urea in urine to form ammonia
o raises pH producing alkaline urine
o encourages the formation of struvite stones, composed of magnesium-ammonium-
phosphate
SPECTRUM OF DISEASE
• Complicated Urinary Tract Infection
o UTI associated with nephrolithiasis
o staghorn calculi form on renal calyces
TREATMENT
Bangued, Abra
• TMP-SMX or ampicillin
• surgery for large stones
IX. PSEUDOMONAS AERUGINOSA

CHARACTERISTICS
• gram-negative rods
• obligate aerobe
• oxidase-positive
• pyocyanin (blue-green pigment)
• sweet grape-like odor
• grown on Cetrimide agar

• environmental water sources, e.g., in hospital respirators and humidifiers
• inhabits the skin, upper respiratory tract, and colon of about 10% of people
• transmission via water aerosols, aspiration, and fecal contamination
SPECTRUM OF DISEASE
• Skin and Soft Tissue Infections
o burn wound infections
o hot tub folliculitis → typically self-limiting
▪ spa pools, whirlpools, or inadequately chlorinated swimming pools and hot tubs
(Remember: Pseudomonas loves ‘wet’ environments)
o skin graft-loss due to infection
o green nail syndrome
• Bone and Cartilage Infections
o puncture wound osteomyelitis
o pubic osteomyelitis in IV drug abusers
• Ear Infections
o otitis externa
o malignant otitis externa in diabetics
o chronic suppurative otitis media
• Pneumonia
o ventilator-acquired pneumonia
o high-risk CAP
▪ immunocompromised
▪ broad spectrum antibiotics
▪ steroid therapy
▪ structural lung lesions
✓ bronchiectasis
✓ cystic fibrosis
• Gastrointestinal Infections
o typhlitis (necrotizing enterocolitis)
o Shanghai fever (mild form of typhoid)
o peritonitis in patients undergoing peritoneal dialysis
• Urinary Tract Infections
o 3rd most common cause of nosocomial UTIs
Bangued, Abra
• Sepsis
o ecthyma gangrenosum
▪ hemorrhagic lesions
o febrile neutropenia
▪ leukemia or lymphoma post chemo- or radiation therapy
▪ severe burns
TREATMENT
• combination of active antibiotics required because of resistance to multiple antibiotics
o antipseudomonal penicillins, penicillin plus beta-lactamase inhibitor, fourth generation
cephalosporins (cefepime), monobactam, carbapenems, fluoroquinolones
PREVENTION
• disinfection of water-related equipment
• hand washing
• prompt removal of catheters
***End of Module 2 Part 1***
References:
Calderon, Pacifico Eric, MD. Microbiology Main Digital Handout – Topnotch Medical Board Prep.
2020
Jawetz, Melnick, & Adelberg's Medical Microbiology, 28e.


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Divine Word College of Bangued

Microbiology & Parasitology

Microbiology & Parasitology: Bacteriology Part 2 1

I. NEISSERIA MENINGITIDIS The presence of bacteria in the synovial

Microbiology & Parasitology: Bacteriology Part 2 2

HABITAT AND TRANSMISSION

Microbiology & Parasitology: Bacteriology Part 2 3

SPECTRUM OF DISEASE: LOCALIZED

SPECTRUM OF DISEASE: DISSEMINATED

III. OTHER NEISSERIACEAE

I. HAEMOPHILUS INFLUENZAE REMEMBER:

HABITAT AND TRANSMISSION

Microbiology & Parasitology: Bacteriology Part 2 5

II. BORDETELLA PERTUSSIS

HABITAT AND TRANSMISSION

III. LEGIONELLA PNEUMOPHILA

Microbiology & Parasitology: Bacteriology Part 2 7

HABITAT AND TRANSMISSION

• green sheen on EMB agar; metallic sheen

HABITAT AND TRANSMISSION

Microbiology & Parasitology: Bacteriology Part 2 9

II. SALMONELLA SPP.

Microbiology & Parasitology: Bacteriology Part 2 10

III. SHIGELLA SPP.

o Invasion of M cells is key to pathogenicity.

VI. HELICOBACTER PYLORI

HABITAT AND TRANSMISSION

ANTI-H. PYLORI ANTIBIOTICS

VII. KLEBSIELLA PNEUMONIAE

VIII. PROTEUS MIRABILIS

IX. PSEUDOMONAS AERUGINOSA

HABITAT AND TRANSMISSION

***End of Module 2 Part 1***

Microbiology & Parasitology: Bacteriology Part 2 15

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End of Module 2 Part 1