bacterial diseases victor politi,m.d., facp, medical director, svcmc school of allied health...

Bacterial DiseasesBacterial Diseases

Victor Politi,M.D., FACP, Medical Director, Victor Politi,M.D., FACP, Medical Director, SVCMC School of Allied Health SVCMC School of Allied Health Professions, Physician Assistant ProgramProfessions, Physician Assistant Program

IntroductionIntroduction

Bacteria consist of only a single cell Bacteria consist of only a single cell Bacteria fall into a category of life Bacteria fall into a category of life

called the Prokaryotes called the Prokaryotes There are thousands of species of There are thousands of species of

bacteria, but all of them are basically bacteria, but all of them are basically one of three different shapes. one of three different shapes.

Classification of Bacteria Classification of Bacteria

Until recently classification has done on Until recently classification has done on the basis of such traits as: the basis of such traits as: shape shape

bacillibacilli: rod-shaped : rod-shaped coccicocci: spherical : spherical spirillaspirilla: curved walls: curved walls

ability to form spores ability to form spores method of energy production (glycolysis for method of energy production (glycolysis for

anerobes, cellular respiration for aerobes anerobes, cellular respiration for aerobes nutritional requirements nutritional requirements reaction to the Gram stain. reaction to the Gram stain.

Classification of Bacteria Classification of Bacteria

The The Gram stainGram stain is named after the 19th is named after the 19th century Danish bacteriologist who developed century Danish bacteriologist who developed it. it. The bacterial cells are first stained with a purple The bacterial cells are first stained with a purple

dye called crystal violet. dye called crystal violet. Then the preparation is treated with alcohol or Then the preparation is treated with alcohol or

acetone. acetone. This washes the stain out of This washes the stain out of gram-negativegram-negative cells. cells. To see them now requires the use of a counterstain To see them now requires the use of a counterstain

of a different color (e.g., the pink of safranin). of a different color (e.g., the pink of safranin). Bacteria that are not decolorized by the Bacteria that are not decolorized by the

alcohol/acetone wash are alcohol/acetone wash are gram-positivegram-positive

Gram Positive BacteriaGram Positive Bacteria

I-Gram Positive Cocci

A-Streptococcus (e.g. streptococcus Pneumoniae) B-Staphylococcus (e.g. Staph. aureus) C-Enterococcus (Previously Group D Strep.)

II-Gram Positive Rods

A-Corynebacteria: Corynebacterium diphtheria B-Listeria monocytogenes C-Bacillus anthracis (Anthrax) D-Erysipelothrix rhusiopathiae

III-Gram Positive Branching Organisms

A-Actinomycetes

Gram Positive CocciGram Positive Cocci

I-Beta-hemolytic Streptococcus (Lancefield Groups)I-Beta-hemolytic Streptococcus (Lancefield Groups) -- Group A Streptococcus (Streptococcus Pyogenes) Group A Streptococcus (Streptococcus Pyogenes) -- Group B Streptococcua (Streptococcus agalactiae) Group B Streptococcua (Streptococcus agalactiae) -- Group C Streptococcus Group C Streptococcus -- Group G Streptococcus Group G Streptococcus

II-Alpha-hemolytic StreptococcusII-Alpha-hemolytic Streptococcus -- Streptococcus Pneumoniae (Pneumococcus) Streptococcus Pneumoniae (Pneumococcus) -- Viridans streptococcus (bacterial endocarditis) Viridans streptococcus (bacterial endocarditis)

III-Non-hemolytic StreptococcusIII-Non-hemolytic Streptococcus -- Streptococcus faecalis (Group D) Streptococcus faecalis (Group D) -- Certain members of Groups B, C, D, H, and O Certain members of Groups B, C, D, H, and O

Strep throat is caused by group A Strep throat is caused by group A StreptococcusStreptococcus bacteria. These bacteria are bacteria. These bacteria are spread through direct contact with mucus from spread through direct contact with mucus from the nose or throat of persons who are infected, the nose or throat of persons who are infected, or through contact with infected wounds or or through contact with infected wounds or sores on the skin sores on the skin

Group B Streptococcus Group B Streptococcus (Streptococcus agalactiae) (Streptococcus agalactiae)

EpidemiologyEpidemiology Most common US cause of neonatal Most common US cause of neonatal

sepsis and meningitis sepsis and meningitis Incidence Incidence

Overall: 2 to 4 per 1000 live births Overall: 2 to 4 per 1000 live births Invasive: 1.8 per 1000 live births Invasive: 1.8 per 1000 live births

Primarily occurs in newborns Primarily occurs in newborns Very rare after 5 months of age Very rare after 5 months of age

PathophysiologyPathophysiology Group B Beta-hemolytic streptococcus infection Group B Beta-hemolytic streptococcus infection Perinatal transmission Perinatal transmission

Delivery via a birth canal colonized with GBS Delivery via a birth canal colonized with GBS Incidence of U.S. vaginal GBS colonization: 15-20% Incidence of U.S. vaginal GBS colonization: 15-20%

Onset of infection (Mean onset 20 hours of life) Onset of infection (Mean onset 20 hours of life) Early onset neonatal disease (<6 days of life in 80%) Early onset neonatal disease (<6 days of life in 80%)

Sepsis Sepsis Pneumonia Pneumonia

Late onset neonatal disease of sepsis or mengitisLate onset neonatal disease of sepsis or mengitis

Group B StreptococcusGroup B Streptococcus(Streptococcus agalactiae) (Streptococcus agalactiae)

Labs: Maternal ScreeningLabs: Maternal Screening GBS Culture GBS Culture ManagementManagement Sepsis (treat for 10-14 days) Sepsis (treat for 10-14 days)

Pencillin G 200,000 units/kg/day divided q4-6 hours Pencillin G 200,000 units/kg/day divided q4-6 hours Meningitis (treat for 14-21 days) Meningitis (treat for 14-21 days)

Penicillin G 400,000 units/kg/day divided q2-4 hours Penicillin G 400,000 units/kg/day divided q2-4 hours PreventionPrevention Perinatal Group B Streptococcus Prophylaxis Perinatal Group B Streptococcus Prophylaxis PrognosisPrognosis Mortality 10-40% Mortality 10-40%

Group B Streptococcus Group B Streptococcus (Streptococcus agalactiae) (Streptococcus agalactiae)

Streptococcus Streptococcus PneumoniaePneumoniae (Pneumococcus) (Pneumococcus)

EpidemiologyEpidemiology Most common cause of community acquired Most common cause of community acquired

pneumonia pneumonia Classic SymptomsClassic Symptoms

Shaking rigors Shaking rigors Fever Fever Purulent sputum Purulent sputum

Rust colored Rust colored Pleuritic chest pain Pleuritic chest pain Dyspnea Dyspnea Chest splinting Chest splinting

http://www.fpnotebook.com/LUN30.htm

http://www.fpnotebook.com/LUN30.htm

Alpha-hemolytic Alpha-hemolytic StreptococcusStreptococcus

Lab Lab CBC CBC

WBC elevated with left shift WBC elevated with left shift Gram stainGram stain

Gram positive encapsulated organisms Gram positive encapsulated organisms Elongated lancet shaped diplococci Elongated lancet shaped diplococci

Blood CultureBlood Culture Positive in only 33% of cases Positive in only 33% of cases

Sputum cultureSputum culture Positive in only 40% of pneumococcal pneumonias Positive in only 40% of pneumococcal pneumonias

Radiology Radiology Chest X-rayChest X-ray

Lobar consolidation (often lower lobe) Lobar consolidation (often lower lobe) patchy infiltrates patchy infiltrates

Increasing Pencillin Resistance Increasing Pencillin Resistance Penicillin Sensitive Penicillin Sensitive Ampicilin IV or Amoxicillin PO Ampicilin IV or Amoxicillin PO Erythomycin Erythomycin Azithromycin Azithromycin Clarithromycin Clarithromycin Penicillin G IV Penicillin G IV Doxycycline Doxycycline Oral second generation cephalosporin Oral second generation cephalosporin Parenteral third generation cephalosporin Parenteral third generation cephalosporin

ManagementManagement

ManagementManagement

High-Level Penicillin Resistance High-Level Penicillin Resistance Broad spectrum Fluoroquinolone Broad spectrum Fluoroquinolone

Levofloxacin Levofloxacin Gatifloxacin Gatifloxacin Grepafloxacin Grepafloxacin Moxifloxacin Moxifloxacin Sparfloxacin Sparfloxacin

Parenteral third generation Cephalosporin Parenteral third generation Cephalosporin High dose Ampicillin High dose Ampicillin Vancomycin IV with or without RifampinVancomycin IV with or without Rifampin

Gram Positive Gram Positive CocciCocci

OrganismsOrganisms -Staphylococcus aureus -Staphylococcus aureus -Staphylococcus epidermidis -Staphylococcus epidermidis

http://www.fpnotebook.com/ID21.htm


Pus smear (wound) Pus smear (wound) Staphylococcus aureusStaphylococcus aureus

EnterococcusEnterococcus

I-CharacteristicsI-Characteristics Gram Positive Cocci Gram Positive Cocci Previously defined as Group D Previously defined as Group D

StreptococcusStreptococcus

II-OrganismsII-Organisms Enterococcus faecalis Enterococcus faecalis Enterococcus faecium Enterococcus faecium

Gram Positive RodsGram Positive Rods

CorynebacteriumCorynebacterium EpidemiologyEpidemiology

Rare in United States due to Rare in United States due to Immunization (DTP, DTaP) Immunization (DTP, DTaP)

However 20% of adults may be inadequate However 20% of adults may be inadequate immune status immune status

Ongoing epidemic in the former USSR Ongoing epidemic in the former USSR

EtiologyEtiology Corynebacterium Diphtheriae Corynebacterium Diphtheriae

SymptomsSymptoms sore throat sore throat dysphagia dysphagia Weakness Weakness Malaise Malaise

CorynebacteriumCorynebacterium

SignsSigns Toxic appearance Toxic appearance fever fever Tachycardia (out of proportion to fever) Tachycardia (out of proportion to fever) Pharyngeal erythema Pharyngeal erythema Gray-white tenacious exudate or "membrane" Gray-white tenacious exudate or "membrane" Occurs at tonsillar pillars and posterior pharynx Occurs at tonsillar pillars and posterior pharynx Leaves focal hemorrhagic raw surface when Leaves focal hemorrhagic raw surface when

removed removed Cervical lymphadenopathyCervical lymphadenopathy

CorynebacteriumCorynebacterium

Vincent's Angina (trench mouth) Vincent's Angina (trench mouth) Also shows pseudomembrane formation Also shows pseudomembrane formation

Pharyngitis Pharyngitis LabsLabs

CBC CBC Leukocytosis Leukocytosis Throat culture (+ for corynebacterium org.)Throat culture (+ for corynebacterium org.)

ManagementManagement Diphtheria antitoxin Diphtheria antitoxin Erythromycin Erythromycin

20-25 mg/kg q12 hours IV for 7-14 days 20-25 mg/kg q12 hours IV for 7-14 days PreventionPrevention

DTP/DTaP vaccinationDTP/DTaP vaccination

Differential DxDifferential Dx

Listeria monocytogenes Listeria monocytogenes

Bacillus Bacillus anthracisanthracis ( (AnthraxAnthrax) )

EtiologyEtiology Bacillus anthracis Bacillus anthracis

TransmissionTransmission Contact with hides of infected animals Contact with hides of infected animals

Cattle Cattle Sheep Sheep Camels Camels Antelopes Antelopes

Ingestion of contaminated meat Ingestion of contaminated meat Inhalation of spores Inhalation of spores

Infective aerosol dose: 8,000-50,000 spores Infective aerosol dose: 8,000-50,000 spores Spores may remain viable in soil for >40 years Spores may remain viable in soil for >40 years

No transmission person to person No transmission person to person




Bacillus Bacillus anthracisanthracis ( (AnthraxAnthrax))

Symptoms and Signs: Cutaneous Symptoms and Signs: Cutaneous ("Malignant Pustule")("Malignant Pustule") Inoculation at site of broken skin Inoculation at site of broken skin Painless pruritic pustules develop at Painless pruritic pustules develop at

inoculation site inoculation site Begins as erythematous papule on exposed Begins as erythematous papule on exposed

skin skin Vesiculates and then ulcerates within 1-2 days Vesiculates and then ulcerates within 1-2 days Surrounded by a ring of non-tender Surrounded by a ring of non-tender

Brawny edemaBrawny edema Black eschar may form Black eschar may form





Symptoms and Signs: Inhalation Symptoms and Signs: Inhalation AnthraxAnthrax

Malaise Malaise Regional lymphadenopathy Regional lymphadenopathy Two phases Two phases

Initial Phase Initial Phase Viral upper respiratory symptoms Viral upper respiratory symptoms rhinorrhea rhinorrhea pharyngitis pharyngitis

Later Phase Later Phase dyspnea and hemoptysis during disseminationdyspnea and hemoptysis during dissemination




Symptoms and Signs: Symptoms and Signs:

Acute GI type Acute GI type symptoms symptoms Hematemesis Hematemesis Severe diarrhea Severe diarrhea

Differential Differential DiagnosisDiagnosis Cutaneous Anthrax Cutaneous Anthrax Spider bite Spider bite Ecthyma gangrenosum Ecthyma gangrenosum Ulceroglandular Ulceroglandular

tularemia tularemia Plague Plague Staph. Or strep. Staph. Or strep.

cellulitis cellulitis

Inhalational Anthrax Inhalational Anthrax Community acquired Community acquired

pneumonia (late phase pneumonia (late phase anthrax) anthrax)

Mycoplasma pneumonia Mycoplasma pneumonia (early phase anthrax) (early phase anthrax)

Influenza (early phase Influenza (early phase anthrax) anthrax)

Legionnaires' Disease Legionnaires' Disease Psittacosis Psittacosis tularemia tularemia Q fever Q fever Viral pneumonia Viral pneumonia Histoplasmosis Histoplasmosis CoccidiodomycosisCoccidiodomycosis

LabsLabs Rapid ELISA test now available Rapid ELISA test now available Cultures Cultures

Blood culture (high sensitivity) Blood culture (high sensitivity) Cultures of Vomitus or feces (Intestinal Anthrax) Cultures of Vomitus or feces (Intestinal Anthrax) CSF culture (Inhalational Anthrax) CSF culture (Inhalational Anthrax) Nasal Swab (Epidemiologic tool to identify outbreak) Nasal Swab (Epidemiologic tool to identify outbreak) Sputum culture (Inhalational Anthrax) Sputum culture (Inhalational Anthrax) Vesicular fluid (Cutaneous Anthrax) Vesicular fluid (Cutaneous Anthrax)

Gram stain - blood or vesicular fluid from lesion Gram stain - blood or vesicular fluid from lesion Gram positive bacilli Gram positive bacilli

CBC CBC Neutrophilic leukocytosis in severe cases Neutrophilic leukocytosis in severe cases

Radiology: Radiology: Chest x-ray - Chest x-ray - Widened Mediastinum (hemorrhagic mediastinitisWidened Mediastinum (hemorrhagic mediastinitis





Management: AntibioticsManagement: Antibiotics

Antibiotic course: Antibiotic course: 60 days 60 days

Empiric Treatment Empiric Treatment Cipro Cipro

Adults: 400 mg IV Adults: 400 mg IV q12 hours q12 hours

Children: 20-30 Children: 20-30 mg/kg/day IV divided mg/kg/day IV divided q12 hours q12 hours

Levofloxacin Levofloxacin Adults: 500 mg IV Adults: 500 mg IV

q24 hours q24 hours

Specific Treatment Specific Treatment for confirmed for confirmed anthrax anthrax Adults Adults

Pencillin G 4 MU IV Pencillin G 4 MU IV q4 hours or q4 hours or

Doxycycline 200 mg Doxycycline 200 mg IV, then 100 mg IV IV, then 100 mg IV q12 hours q12 hours

Children > age 12 same Children > age 12 same as adults as adults

Children < age 12 Children < age 12 Penicillin G 50,000 Penicillin G 50,000

U/kg IV q6 hours U/kg IV q6 hours

Postexposure Postexposure prophylaxisprophylaxis

Concurrently begin vaccination Concurrently begin vaccination Continue antibiotics for 60 days Continue antibiotics for 60 days CiprofloxacinCiprofloxacin

Adults: 500 mg PO bid Adults: 500 mg PO bid Children: 20-30 mg/kg/day divided bid up to 1g/day Children: 20-30 mg/kg/day divided bid up to 1g/day

AmoxicillinAmoxicillin Adults: 500 mg PO tid Adults: 500 mg PO tid Children: 40 mg/kg up to 500 mg PO tid Children: 40 mg/kg up to 500 mg PO tid

DoxycyclineDoxycycline Adults: 100 mg PO bid Adults: 100 mg PO bid Children over age 8: 5 mg/kg/day divided q12 hoursChildren over age 8: 5 mg/kg/day divided q12 hours




AnthraxAnthrax CourseCourse

Incubation: 4-6 days Incubation: 4-6 days Duration of illness: 3-5 days Duration of illness: 3-5 days

PrognosisPrognosis

Inhalation Anthrax (inhaled spores) Inhalation Anthrax (inhaled spores) Untreated: 95% mortality Untreated: 95% mortality Treated: 80% mortality Treated: 80% mortality

Cutaneous Anthrax (skin contact) Cutaneous Anthrax (skin contact) Untreated: 20% mortality Untreated: 20% mortality Treated: Rare mortality Treated: Rare mortality

Intestinal Anthrax (ingested contaminated meat) Intestinal Anthrax (ingested contaminated meat) Mortality 25 to 60%Mortality 25 to 60%

PreventionPrevention Anthrax Vaccine 93% effective Anthrax Vaccine 93% effective

Initial: 0, 2, and 4 weeks Initial: 0, 2, and 4 weeks Next: 6, 12, 18 months and then Next: 6, 12, 18 months and then

annually annually

Postexposure Prophylaxis as above Postexposure Prophylaxis as above Empiric prophylaxis for any suspected Empiric prophylaxis for any suspected

exposure exposure Best prognosis with antibiotics prior to Best prognosis with antibiotics prior to

symptomssymptoms

Gram NegativeGram Negative

Gram Negative RodsGram Negative Rods Anaerobes Anaerobes

Bacteroidaceae (e.g. Bacteroides fragilis) Bacteroidaceae (e.g. Bacteroides fragilis) Facultative Anaerobes (enteric/nonenteric) Facultative Anaerobes (enteric/nonenteric)

Enterobacteriaceae (e.g. Escherichia coli) Enterobacteriaceae (e.g. Escherichia coli) Vibrionaceae (e.g. Vibrio Cholerae)Vibrionaceae (e.g. Vibrio Cholerae) Pasturella,Brucella,YersiniaPasturella,Brucella,Yersinia

Aerobes Aerobes Pseudomonadaceae (e.g. Pseudomonas aeruginosa) Pseudomonadaceae (e.g. Pseudomonas aeruginosa)


Facultative AnaerobesFacultative Anaerobes

Enterobacteriaceae (e.g. E. coli) Enterobacteriaceae (e.g. E. coli) Vibrionaceae (e.g. Vibrio Cholerae)Vibrionaceae (e.g. Vibrio Cholerae) Salmonella,Shigella,Klebsiella,ProteusSalmonella,Shigella,Klebsiella,Proteus GI pathogens !!!!!GI pathogens !!!!! non-enteric Pasturella,Brucella,Yersinianon-enteric Pasturella,Brucella,Yersinia Francisella,Hemophilus,BordetellaFrancisella,Hemophilus,Bordetella

EnterobacteriaceaeEnterobacteriaceae

CharacteristicsCharacteristics Facultative Anaerobic Gram negative Facultative Anaerobic Gram negative

rods rods EKP Gram negative bacteria EKP Gram negative bacteria

Escherichia coli Escherichia coli Klebsiella Klebsiella Proteus Proteus

VibrionaceaeVibrionaceae

Characteristics Facultative Anaerobic gram negative

rods Vibrio Cholerae Vibrio parahaemolyticus

Genus: Aeromonas (motile with single polar flagellum)

VibrionaceaeVibrionaceae

Genus: Campylobacter (motile Genus: Campylobacter (motile with single polar flagellum)with single polar flagellum)

Campylobacter jejuni Campylobacter jejuni Genus: Helicobacter (motile with Genus: Helicobacter (motile with

multiple flagella)multiple flagella) Helicobacter Pylori Helicobacter Pylori

PasteurellaceaePasteurellaceae

CharacteristicsCharacteristics Facultative Anaerobic gram negative Facultative Anaerobic gram negative

rods rods Genus: PasteurellaGenus: Pasteurella Pasteurella multocida Pasteurella multocida

PasteurellaceaePasteurellaceae

Genus: Haemophilus Genus: Haemophilus (coccobacilli)(coccobacilli) Haemophilus InfluenzaeHaemophilus Influenzae Haemophilus aegyptius Haemophilus aegyptius Haemophilus ducreiHaemophilus ducrei

Gram Negative RodGram Negative Rod

Aerobes Aerobes Pseudomonadaceae (e.g. Pseudomonadaceae (e.g.

Pseudomonas aeruginosa) Pseudomonas aeruginosa) BrucellaBrucella LegionellaceaeLegionellaceae

PseudomonadaceaePseudomonadaceae

CharacteristicsCharacteristics Aerobic Gram Negative Rod Aerobic Gram Negative Rod Family: PseudomonadaceaeFamily: Pseudomonadaceae Pseudomonas aeruginosa Pseudomonas aeruginosa Pseudomonas mallei (Glanders) Pseudomonas mallei (Glanders)

Gram Negative Rod AerobicGram Negative Rod Aerobic

Family: LegionellaceaeFamily: Legionellaceae Legionella pneumophilaLegionella pneumophila

LegionellaceaeLegionellaceae

PathophysiologyPathophysiology Aerobic, intracellular, Gram Aerobic, intracellular, Gram

negative rod negative rod Virulent organism Virulent organism More severe disease than More severe disease than

other atypical pneumonia other atypical pneumonia

Transmission Transmission Optimal conditions for Optimal conditions for

growth growth Temperature: 89 to Temperature: 89 to

113 F water 113 F water Stagnant water Stagnant water

TransmissionTransmission Waterborne Waterborne

Freshwater or moist soil Freshwater or moist soil near ponds near ponds

Air conditioning Air conditioning Condensers Condensers Cooling towers Cooling towers Respiratory therapy Respiratory therapy

equipment equipment Showers or water Showers or water

faucets faucets Whirlpools Whirlpools

Incubation Incubation Two to ten days Two to ten days

LegionellaceaeLegionellaceae

SymptomsSymptoms Prodrome for 12-48 Prodrome for 12-48

hours hours Malaise Malaise Myalgia Myalgia HA HA

Symptoms for 2-3 days Symptoms for 2-3 days Fever to 40.5 C Fever to 40.5 C

persists for 8-10 days persists for 8-10 days GI symptoms- 20-40% GI symptoms- 20-40%

of cases of cases Nausea/vomiting Nausea/vomiting Diarrhea Diarrhea

Later Symptoms: Later Symptoms: Cough Cough Minimal to no sputum Minimal to no sputum

production production Slightly blood tinged Slightly blood tinged

sputum sputum SignsSigns

Severe respiratory Severe respiratory distress distress

Confusion Confusion Disorientation Disorientation

Legionella pneumophilaLegionella pneumophila

ComplicationsComplications Respiratory failure (20-40% of cases) Respiratory failure (20-40% of cases) Extrapulmonary complications Extrapulmonary complications

Myocarditis/pericarditis Myocarditis/pericarditis Prosthetic valve endocarditis Prosthetic valve endocarditis Glmoerulonephritis Glmoerulonephritis Pancreatitis Pancreatitis Peritonitis Peritonitis

Radiology: chest x-rayRadiology: chest x-ray Small pleural effusions Small pleural effusions Unilateral parenchymal infiltrates Unilateral parenchymal infiltrates

Round, fluffy opacities Round, fluffy opacities Spread contiguously to other lobes Spread contiguously to other lobes Progresses to dense consolidation Progresses to dense consolidation Progresses to bilateral infiltrates Progresses to bilateral infiltrates



LabsLabs CBC CBC

leukocytosis leukocytosis leukopenia leukopenia

Erythrocyte Sedimentation Rate Erythrocyte Sedimentation Rate Elevated markedly Elevated markedly

LFTs increased LFTs increased Sputum Exam Sputum Exam

Fluorescent antibody studies of sputumFluorescent antibody studies of sputum Legionella can not be seen on gram stain Legionella can not be seen on gram stain


DiagnosisDiagnosis Legionella urine antigen testing Legionella urine antigen testing

High sensitivity/ serogroup 1 High sensitivity/ serogroup 1 Serogroup 1 (LP1) causes most U.S. cases Serogroup 1 (LP1) causes most U.S. cases

Sputum Culture - to ID other serogroups Sputum Culture - to ID other serogroups Urine antigen and sputum culture all cases Urine antigen and sputum culture all cases

Legionella Serologies Legionella Serologies Legionella fourfold titer rise to >= 1:128 or Legionella fourfold titer rise to >= 1:128 or Legionella titer >= 1:256 Legionella titer >= 1:256


Management (Antibiotic course for 21 Management (Antibiotic course for 21 days)days)

Azithromycin IV Azithromycin IV Levofloxacin IV Levofloxacin IV Trovafloxacin IV Trovafloxacin IV Erythromycin IV Erythromycin IV

Add Rifampin in immunocompromised or severe Add Rifampin in immunocompromised or severe disease disease

CourseCourse Response to antibiotics may not be seen for 4-5 Response to antibiotics may not be seen for 4-5

days days Up to 15% mortality in some studies Up to 15% mortality in some studies

BrucellosisBrucellosis

EpidemiologyEpidemiology US IncidenceUS Incidence

<100 cases per year (0.34/100,000) <100 cases per year (0.34/100,000)

EtiologyEtiology Brucella abortus Brucella abortus Brucella suis Brucella suis Brucella melitensis Brucella melitensis


PathophysiologyPathophysiology Facultative intracellular parasite Facultative intracellular parasite

Releases endotoxin when dies Releases endotoxin when dies Infective dose: 10-100 organisms Infective dose: 10-100 organisms Incubation: 5-60 days Incubation: 5-60 days


TransmissionTransmission Infected animal products Infected animal products

Tissue from Sheep in U.S. Tissue from Sheep in U.S. Unpasteurized milk Unpasteurized milk

Vaccine exposure Vaccine exposure No transmission person to person No transmission person to person Enters via mucus membranes, broken Enters via mucus membranes, broken

skin, or inhalation skin, or inhalation


Risk FactorsRisk Factors Veterinarians Veterinarians Farm workers Farm workers Meat processing plants Meat processing plants Travel or residence in endemic region Travel or residence in endemic region

Mediterranean Mediterranean India India North Africa, East Africa North Africa, East Africa Central Asia, South Asia Central Asia, South Asia


SymptomsSymptoms Intermittent fevers Intermittent fevers

Undulating fever Undulating fever Temperature peaks in evening to 101-104 Temperature peaks in evening to 101-104

Arthralgia (90%) Arthralgia (90%) Weakness Weakness Lassitude Lassitude Weight loss Weight loss Headache Headache Sweating Sweating Chills Chills


CourseCourse Weeks to months Weeks to months

PrognosisPrognosis Case Fatality Case Fatality <5% treated <5% treated

Gram Negative CocciGram Negative Cocci Aerobes Aerobes

Moraxella(Branhamella catarrhalis)Moraxella(Branhamella catarrhalis) Acinetobacter Acinetobacter Neisseria Neisseria

Neisseriaceae Neisseriaceae

Neisseria meningitidis Neisseria meningitidis Neisseria gonorroeae Neisseria gonorroeae

Neisseria gonorrhoeae Neisseria gonorrhoeae

EpidemiologyEpidemiology Much less common than chlamydia Much less common than chlamydia

Incidence: 500-700,000 cases per year Incidence: 500-700,000 cases per year Decreasing except in inner city, drug abuse Decreasing except in inner city, drug abuse

(crack) (crack) Highly contagious: 50% transmission Highly contagious: 50% transmission Chlamydia coexists in 45-50% of patients with Chlamydia coexists in 45-50% of patients with

gonorrhea gonorrhea PathophysiologyPathophysiology

Incubation: 2-7 days Incubation: 2-7 days

Neisseria gonorrhoeae Neisseria gonorrhoeae Symptoms and Signs: GeneralSymptoms and Signs: General Urinary Symptoms Urinary Symptoms

Urinary frequency Urinary frequency Urinary urgency Urinary urgency Dysuria Dysuria

Copious urethral discharge Copious urethral discharge Green, yellow, or sanguinous discharge Green, yellow, or sanguinous discharge

Meatus and anterior urethra Meatus and anterior urethra inflammation inflammation

Conjunctivitis Conjunctivitis Direct inoculation Direct inoculation Copious exudate Copious exudate Beefy Conjunctiva Beefy Conjunctiva Serious complications Serious complications

Corneal ulceration or opacification Corneal ulceration or opacification Visual loss Visual loss Globe perforation Globe perforation

Pharyngitis Pharyngitis Rarely the only site of infection Rarely the only site of infection Usually asymptomatic Usually asymptomatic

Acute Diarrhea Acute Diarrhea



Symptoms and Signs: WomenSymptoms and Signs: Women Mucopurulent Cervicitis Mucopurulent Cervicitis

Often asymptomatic Often asymptomatic Vaginal d/c or spotting Vaginal d/c or spotting

Bartholin’s Gland inflammation Bartholin’s Gland inflammation Skene's gland inflammation Skene's gland inflammation


Symptoms and Signs: Men (often Symptoms and Signs: Men (often asymptomatic)asymptomatic)

Epidiymitis under age 35 years Epidiymitis under age 35 years Proctitis Proctitis

Receptive anal intercourse or vaginal Receptive anal intercourse or vaginal secretions secretions

Mild anal irritation or itching Mild anal irritation or itching


Symptoms and Signs: Disseminated Symptoms and Signs: Disseminated InfectionInfection

More common in pregnancy More common in pregnancy Dermatitis Dermatitis

Rash over trunk, extremities, palms and soles Rash over trunk, extremities, palms and soles Necrotic pustule on red base over distal extremity Necrotic pustule on red base over distal extremity May become hemorrhagic May become hemorrhagic Usually less than 20 total lesions Usually less than 20 total lesions

Tenosynovitis Tenosynovitis Gonococcal arthritis Gonococcal arthritis Endocarditis risk Endocarditis risk


ComplicationsComplications PID PID Systemic Gonorrhea Systemic Gonorrhea Chronic Arthritis Chronic Arthritis Neonatal Gonorrhea Neonatal Gonorrhea

Gonorrheal conjunctivitis Gonorrheal conjunctivitis Preterm labor Preterm labor


LabsLabs Gram stain: Urethral /cervical smear Gram stain: Urethral /cervical smear

Numerous WBCs Numerous WBCs Gram negative biscuit-shaped diplococci Gram negative biscuit-shaped diplococci

False positive Gram stain (saprophytic Neisseria) False positive Gram stain (saprophytic Neisseria) Gonorrhea culture and Sensitivity Gonorrhea culture and Sensitivity Antigen Testing (e.g. Gonozyme) Antigen Testing (e.g. Gonozyme)

Indicated in symptomatic men Indicated in symptomatic men Inaccurate in other populations Inaccurate in other populations

DNA probe testing DNA probe testing Rapid: 30 minutes Rapid: 30 minutes Sensitivity: 85-100% Sensitivity: 85-100% Specificity: 99-100% Specificity: 99-100%

Management: Drug ResistanceManagement: Drug Resistance Tetracycline resistance: 17-23% Tetracycline resistance: 17-23% Penicillin resistance 15-19% Penicillin resistance 15-19% Emerging Fluroquinolone resistance Emerging Fluroquinolone resistance No resistance to 3No resistance to 3rdrd generation generation

cephalosporins cephalosporins Ceftriaxone (Rocephin) Ceftriaxone (Rocephin) Cefixime (Suprax) Cefixime (Suprax)

Azithromycin requiring higher dosages for Azithromycin requiring higher dosages for some GC some GC

References References


Moraxella catarrhalisMoraxella catarrhalis

DiagnosisDiagnosis Represents less than 5% of all Represents less than 5% of all

pneumonias pneumonias More common in COPD More common in COPD Lobar consolidation is rare Lobar consolidation is rare


LabsLabs Gram stain Gram stain Kidney bean shaped gram negative Kidney bean shaped gram negative

diplococci diplococci RadiologyRadiology

Chest xray Chest xray patchy bronchopulmonary patchy bronchopulmonary

infiltrateinfiltrate


Management: AntibioticManagement: Antibiotic Amoxicillin-clavulanate (Augmentin) Amoxicillin-clavulanate (Augmentin) Second generation Cephalosporin (e.g. Second generation Cephalosporin (e.g.

Cefuroxime) Cefuroxime) 3rd generation Cephalosporin (e.g. Cefotaxime) 3rd generation Cephalosporin (e.g. Cefotaxime) Erythromycin Erythromycin Azithromycin (Zithromax) Azithromycin (Zithromax) Clarithromycin (Biaxin) Clarithromycin (Biaxin) Trimethoprim Sulfamethoxazole (Bactrim or Trimethoprim Sulfamethoxazole (Bactrim or

Septra) Septra) Doxycycline Doxycycline

Gram Negative Obligate Gram Negative Obligate Intracellular ParasitesIntracellular Parasites

Rickettsia Rickettsia Ehrlichia Ehrlichia CoxiellaCoxiella Rochalimaea (not obligate Rochalimaea (not obligate

intracellular) intracellular)

Rickettsia Rickettsia

Genus: RickettsiaGenus: Rickettsia Typhus Group Typhus Group

Rickettsia prowazekii (epidemic typhus,louse) Rickettsia prowazekii (epidemic typhus,louse) Rickettsia mooseri Rickettsia mooseri

Spotted Fever Group Spotted Fever Group Rickettsia rickettsii (rmsf,tick)Rickettsia rickettsii (rmsf,tick)

Scrub Typhus Group Scrub Typhus Group Rickettsia tsutsugamushiRickettsia tsutsugamushi (scrub typhus,) (scrub typhus,)

Rickettsia rickettsii Rickettsia rickettsii

PathophysiologyPathophysiology Transmission: Tick bite Transmission: Tick bite Infects blood vessel walls Infects blood vessel walls

Endothelial cells Endothelial cells Smooth muscle cells Smooth muscle cells

Rickettsia rickettsii is causative organism Rickettsia rickettsii is causative organism Small pleomorphic organism Small pleomorphic organism Obligate intracellular parasiteObligate intracellular parasite

Rocky Mountain Spotted Rocky Mountain Spotted FeverFever

EpidemiologyEpidemiology Bimodal age distribution Bimodal age distribution

Ages 5 to 9 years old Ages 5 to 9 years old Age over 60 years old Age over 60 years old

Endemic area Endemic area North America North America

Atlantic coast states Atlantic coast states Midwest Midwest

Central America Central America South AmericaSouth America


Symptoms (follows seven day Symptoms (follows seven day incubation)incubation)

Fever Fever HA HA Myalgias Myalgias Malaise Malaise vomiting vomiting


Signs: Rash (occurs in 90% of patients)Signs: Rash (occurs in 90% of patients) Onset in first week of illness Onset in first week of illness Characteristics Characteristics

Initial: Blanching Macules 1 to 4 mm in diameter Initial: Blanching Macules 1 to 4 mm in diameter Later: Macules transition to Petechiae Later: Macules transition to Petechiae

Distribution Distribution Onset: Wrists and Ankles Onset: Wrists and Ankles Later: Trunk, Palms and Soles Later: Trunk, Palms and Soles

LabsLabs


LabsLabs CBC CBC

WBC normal or slightly decreased WBC normal or slightly decreased Thrombocytopenia Thrombocytopenia

Liver transaminases increased Liver transaminases increased AST /ALT AST /ALT

Serum sodium -Hyponatremia Serum sodium -Hyponatremia Cerebrospinal Fluid Cerebrospinal Fluid

CSF pleocytosis w/monocytic predominance CSF pleocytosis w/monocytic predominance Rickettsia Serology Rickettsia Serology

Positive 7 to 10 days after symptom onset Positive 7 to 10 days after symptom onset Used for confirmation, not for diagnosis Used for confirmation, not for diagnosis


ManagementManagement Antibiotic Course Antibiotic Course

Minimum course: 5 to 7 days Minimum course: 5 to 7 days Continue antibiotics until afebrile for 2 Continue antibiotics until afebrile for 2

days days Antibiotics Antibiotics

Doxycycline or Tetracycline or Doxycycline or Tetracycline or Chloramphenicol Chloramphenicol


ComplicationsComplications Encephalitis Encephalitis Noncardiac pulmonary edema Noncardiac pulmonary edema ARDS ARDS Cardiac arrhythmia Cardiac arrhythmia Coagulopathy Coagulopathy GI bleeding GI bleeding Skin Necrosis Skin Necrosis


PrognosisPrognosis Untreated: Untreated:

25% Mortality within 8 to 15 days 25% Mortality within 8 to 15 days Treated: Treated:

5% Mortality 5% Mortality

EhrlichiaEhrlichia

Ehrlichia sennetsu Ehrlichia sennetsu Ehrlichia canis Ehrlichia canis

CoxiellaCoxiella

Coxiella burnetii – Q fever, no Coxiella burnetii – Q fever, no arthropod vector cattle,sheep, goats, arthropod vector cattle,sheep, goats, inhallation of dust with dried feces inhallation of dust with dried feces urine or milkurine or milk

Rochalimaea (not obligate Rochalimaea (not obligate intracellular)intracellular)

Rochalimaea quintana (trench fever Rochalimaea quintana (trench fever seen in military settings) seen in military settings)

ChlamydiaChlamydia

Eye Diseases Eye Diseases Trachoma Trachoma Inclusion conjunctivitis Inclusion conjunctivitis

Genitourinary Disease Genitourinary Disease Lymphogranulmoa Lymphogranulmoa

venereumvenereum Urethritis Urethritis cervicitis cervicitis Salpingitis Salpingitis

Respiratory Respiratory Chlamydia pneumonia Chlamydia pneumonia

in newborns in newborns Other Other Chlamydia psittaci Chlamydia psittaci

(Human psittacosis) (Human psittacosis) Bird borne zoonosis Bird borne zoonosis Respiratory illness or Respiratory illness or

typhoidal illness typhoidal illness Chlamydia Chlamydia

pneumoniae pneumoniae pneumonia pneumonia

Chlamydia trachomatisChlamydia trachomatis

Epidemiology: Very PrevalentEpidemiology: Very Prevalent Asymptomatic teenage female test Asymptomatic teenage female test

positive: 5-10% positive: 5-10% Sexually active persons: 10% Sexually active persons: 10% Chlamydia 6 to 10 times more Chlamydia 6 to 10 times more

common than Gonorrhea common than Gonorrhea Incidence: 3-5 million cases/year Incidence: 3-5 million cases/year

Chlamydia Trachomatis Chlamydia Trachomatis (obligate intracellular (obligate intracellular

organism)organism) CauseCause

Chlamydia Trachomatis (obligate intracellular Chlamydia Trachomatis (obligate intracellular organism) organism)

ComplicationsComplications PID PID InfertilityInfertility Preterm labor Preterm labor

Perinatal transmission to newborn Perinatal transmission to newborn Chlamydia conjunctivitis Chlamydia conjunctivitis Neonatal pneumonia Neonatal pneumonia


organism)organism) Symptoms: WomenSymptoms: Women Vaginal d/c Vaginal d/c dysuria dysuria Pelvic pain Pelvic pain Untreated infections may persist for months Untreated infections may persist for months Usually asymptomatic Usually asymptomatic Urethritis Urethritis

Dysuria-Sterile pyuria Syndrome Dysuria-Sterile pyuria Syndrome Persistent dysuria and pyuria Persistent dysuria and pyuria Negative urine culture Negative urine culture


organism)organism) Symptoms: MenSymptoms: Men Urethritis Urethritis Often symptomatic Often symptomatic Associated Conditions: Reiter’s Associated Conditions: Reiter’s

Syndrome in MenSyndrome in Men Arthritis Arthritis Conjunctivitis Conjunctivitis Urethritis Urethritis


organism) organism) ManagementManagement Refer all sexual contacts for treatment Refer all sexual contacts for treatment

First Choice First Choice Azithromycin 1 gram PO for 1 dose Azithromycin 1 gram PO for 1 dose Doxycycline 100 mg PO bid for 7 days Doxycycline 100 mg PO bid for 7 days

Alternatives Alternatives Ofloxacin 300 mg PO bid for 7 days Ofloxacin 300 mg PO bid for 7 days Erythromycin 500 mg PO qid for 7 days Erythromycin 500 mg PO qid for 7 days Erythromycin Ethylsuccinate (EES) Erythromycin Ethylsuccinate (EES)

Dose: 800 mg PO qid for 7 days Dose: 800 mg PO qid for 7 days Amoxicillin 500 mg PO tid for 7 days Amoxicillin 500 mg PO tid for 7 days Clindamycin 450 mg PO qid for 14 days Clindamycin 450 mg PO qid for 14 days

Pregnancy Pregnancy Azithromycin 1 gram PO as single dose Azithromycin 1 gram PO as single dose Erythromycin OR EES as above for 7 days Erythromycin OR EES as above for 7 days Amoxicillin 500 PO tid x7 days (Only 50% Amoxicillin 500 PO tid x7 days (Only 50%

effective) effective) Neonates (conjunctivitis or pneumonia)Neonates (conjunctivitis or pneumonia)

Erythromycin for 14 days Erythromycin for 14 days


organism) organism)

Questions ??????Questions ??????

bacterial diseases victor politi,m.d., facp, medical director, svcmc school of allied health...

Documents

gram positive bacteria

classification of bacteria

group d strep

prokaryotes bacteria

grampositive bacteria

introduction bacteria

gram stain

skin slide