MT 111 LECTURE 18: GRAM-POSITIVE Lectured by: Frances Angelique A.

Tequillo, MD
BACILLI
Part 1: Spore-forming Gram-Positive Bacilli: Bacillus and
Clostridium Species

 Ubiquitous, Spore-forming, survive in the environment for

years
 Bacillus species (aerobes)  Clostridium species (anaerobes)
o Bacillus anthracis Clostridium tetani
o
o Bacillus cereus Clostridium botulinum
o
o Bacillus thuringiensis Clostridium perfringens
o
Clostridium difficile
o
Bacillus species  Growth Characteristics
 Large, aerobic, gram-positive rods occurring in chains o Saprophytic bacilli use simple source of nitrogen and
 Closely-related but differ phenotypically carbon for energy and growth
 Pathogenic species possesses virulence plasmids o Spores
 Mostly saprophytic- inhabit soil, water, air, and  Resistant to environmental changes
vegetation (Bacillus subtilis)  Withstand dry heat and some chemical disinfectants
 Some are insect pathogens- Bacillus thuringiensis  Persist for years in dry earth
 Some cause food poisoning- Bacillus cereus and Bacillus o Animal products contaminated with anthrax spores can
thuringiensis be sterilized by autoclaving
 Morphology and Identification
o 1 x 3-4 μm, Square ends Bacillus anthracis
o Arranged in long chains, Spores are located in the center  Pathogenesis of anthrax (causative agent: Bacillus
of the Bacilli anthracis)
 Culture o Affects herbivores
o Form round colonies with “cut glass” appearance on o Endemic among agrarian societies- Africa, the Middle
transmitted light East, and Central America
o Hemolysis- uncommon with B. anthracis, common o Portal of entry: mouth, GI tract
with B. cereus and saprophytes o Spores from contaminated soil find easy access when
o Gelatin medium- liquefied; inverted fir tree growth ingested with spiny or irritating vegetation
o Modes of entry in humans:
 Cutaneous anthrax- thru ingested skin  Injection anthrax- thru skin of heroin addicts
 GI anthrax- thru mucous membranes
 Inhalation anthrax (woolsorters’ disease)- inhalation
of spores into the lung

o Spores germinate in the tissue at the site of entry→ edema and congestion)→ Bacilli spread via lymphatics
growth of vegetative organisms (exhibiting gelatinous to bloodstream- multiply freely in the blood and
tissues shortly before and after animal’s death
o Non-encapsulated isolates are nonvirulent. o Poly-y-D-glutamic acid capsule is antiphagocytic

o Anthrax toxins are composed of 3 proteins  Forms lethal toxin with PA- major virulence factor
o Capsule gene is present on plasmid pXO2 and impairs both innate and adaptive immunity
o Anthrax toxins are encoded on plasmid pXO1  Pathology
 Protective Antigen (PA) o In susceptible animals: Organisms proliferate at site of
 Binds to specific cell receptors- undergoes entry→ capsules remain intact→ proteinaceous fluid
proteolytic activation with few leukocytes surround the organisms→ rapid
 Forms a membrane channel- mediates entry of EF dissemination to the bloodstream
and LF into the cell o In resistant animals: Organisms proliferate for a few
 Edema Factor (EF) hours→ Massive accumulation of leukocytes→ capsules
 Adenylate cyclase with PA gradually disintegrate and disappear→ organisms remain
 Forms edema toxin- cell and tissue edema localized
 Lethal Factor (LF)  Clinical Findings
o Cutaneous anthrax (95%)  Pruritic papule develops 1-7 days following entry- may
 Occurs on exposed surfaces of the arms or hands- initially resemble an insect bite→ rapidly changes into
predominantly in the face then neck a vesicle or small ring of vesicles that coalesce (group
together)→ necrotic ulcer develops
 
Lesions are 1-3 cm in diameter with characteristic to GIT (bowel ulceration) and meninges
black eschar associated with marked edema (meningitis)→ high fatality rate
 Lymphangitis, LAD, fever, malaise, and headache may  Fatality rate is higher when diagnosis is not initially
be noted suspected
 Escar fully develops following 7-10 days- dries, o Gastrointestinal anthrax (very rare, occurs when
loosens, separates→ healing by granulation→ scar people eat meat from infected animals)
formation  Acquired through ingestion of spores and spread of
 Weeks for lesion to heal, edema to subside organisms through GIT
 Antibiotic therapy prevents dissemination of disease  Extremely uncommon
 20% of cases lead to sepsis→ complications include  Symptoms: Abdominal pain, vomiting, bloody
meningitis→ death diarrhea
o Inhalation anthrax (5%) o Injection anthrax
 Incubation period: 6 weeks  Extensive, painless, subcutaneous edema→ Notable
 Early: marked hemorrhagic necrosis and edema of absence of eschar of cutaneous anthrax→ may lead to
mediastinum→ substernal pain→ mediastinal septicemia→ Hemodynamic instability
widening seen on CXR→ pleural involvement-  Diagnostic Laboratory Tests
hemorrhagic pleural effusion→ cough is due to the o Specimens for examination
effects on the trachea→ sepsis→ hematogenous spread
 Fluid or pus from local lesion  Lysis by specific anthrax y-bacteriophage
 Blood, pleural fluid and CSF for inhalational  Detection of capsule by fluorescent antibody
o Stained smears show chains of large gram-positive rods  Identification of toxin genes by PCR
o May use immunofluorescence staining  Resistance and Immunity
o Contact public health laboratory and send organism for o Vaccination with live attenuated bacilli- with spore
confirmation following detection of anthrax suspensions or with PA from culture filtrates
o Blood agar: o Animals in known anthrax districts should be
 Nonhemolytic gray to white, tenacious colonies with immunized annually
rough texture and ground glass appearance o US: Made from supernatant of a cell-free culture of an
 Comma-shaped outgrowths may project from the unencapsulated but toxigenic strain of Bacillus anthracis
colony forming Medusa head or “Curled hair” containing PS adsorbed to AlOH
o Demonstration of capsule requires growth on  0.5 ml IM at 0 and 4 weeks, then 6, 12 and 18 months
bicarbonate-containing medium in 5-7% CO2 followed by annual boosters- gives only short-lived
o Gram stain shows large gram-positive rods immunity
o Carbohydrate fermentation not useful  Treatment
o Semisolid medium: Anthrax bacilli are nonmotile; o Early treatment with: Ciprofloxacin, Penicillin G,
Bacillus cereus→ motility by “swarming” Doxycycline, Erythromycin, Vancomycin
o Definitive identification requires: o Raxibacumab:
 For inhalational anthrax
 Recombinant human monoclonal antibody
 Prevents binding of PA host cell receptors
 Given with other antimicrobial agents
o In the setting of potential exposure to B anthracis (as  Toxin-mediated
agent of biologic warfare), prophylaxis with Emetic type (Emetic toxin)- Fried rice, Milk, Pasta
o
ciprofloxacin or doxycycline should be given x 60 days  Self-limiting
+ 3 doses of vaccine  Recovery within 24 hours- Nausea, vomiting,
 Epidemiology, Prevention, and Control abdominal cramps, +/- diarrhea
1. Disposal of animal carcasses by burning or deep burial  Begins 1-5 hours following ingestion of plasmid-
in lime pits encoded preformed cyclic peptide in contaminated
2. Decontamination usually by autoclaving of animal food
products o Diarrheal type (Enterotoxin)- Meat dishes, Sauces
3. Protective clothing and gloves for handling potentially  Incubation Period: 1-24 hours
infected materials  Profuse diarrhea, abdominal pain and cramps; +/- fever
4. Active immunization of domestic animals with live and vomiting
attenuated vaccines- Persons with high occupational risk  Ingested spores that develop into vegetative cells,
should be immunized secrete 1 of 3 possible enterotoxins which induce fluid
o Spores remain viable for decades, can germinate in soil accumulation, etc.
at pH 6.5 at proper temperature. o Eye Infections: Endophthalmitis, Severe keratitis, Entry
o Grazing animals in these areas serve to perpetuate the of organism thru FB following trauma or surgery
chain of infection.  Diagnosis:
o Presence of B. cereus in stool is insufficient. Bacteria
Bacillus cereus may be present in normal stool spx.
 Food poisoning by B. cereus
 Concentration of ≥105 bacteria per gm of food→
o o Grow under anaerobic conditions. Few species are
diagnostic. aerotolerant
 Treatment: o Grow well on blood-enriched media or other media
o Resistant to various antimicrobial agents used to grow anaerobes.
o Vancomycin or clindamycin ± aminoglycoside- serious o Colony Forms
non-food borne infections  Clostridium perfringens- Large raised colonies
o Ciprofloxacin- Wound infections  Clostridium tetani- Smaller colonies
 Clostridium septicum- Colonies that spread or swarm
Clostridium species on the agar surface
 Large anaerobic, gram-positive, motile rods which  β-hemolysis on BA; Clostridium perfringens- Double
decompose proteins or form toxins; or both zone of β-hemolysis around colonies
 Natural habitat: soil, marine sediments, sewage o Growth Characteristics: Saccharolytic (Ferments
 Live as saprophytes in the intestinal tract sugars), Proteolytic (Digests proteins) or both
 19 clusters based on 15 SrRNA gene sequence analysis
Clostridium botulinum
 RNA Cluster I pathogens: Botulism, Tetanus, Gas
gangrene, Pseudomembranous colitis  Botulism is worldwide in distribution. Type is toxin-
 Morphology and Identification specific.
o Spores are wider than the diameter of rods in which they  Organism is found in soil, occasionally on animal feces.
are formed; Location of spores: Central, Subterminal,  Spores of organism is highly resistant to heat, can
Terminal w/stand 100°C for hours.
o Motile- Peritrichous flagella  Heat resistance is decreased at acid pH or high salt
 Culture concentration.
 Toxins
o Liberated during growth (& autolysis) of bacteria o 7 antigenic types (A-G)
o Types A, B, E and F- principal causes of human illness o Type C- limberneck in birds
o Types A and B in several types of food o Type D- botulism in mammals; used in botox injections
o Type E in fish products o Type G is not associated with disease

 3 domains of botulinum toxin 

Vegetative cells produce toxin as they multiply.
oDomains 1 & 2 facilitate binding to and entry of toxin Neurotoxin gets absorbed into the bloodstream
into nerve cells  Infants then exhibits: poor feeding, weakness, and
o Domain 3 is a 150 kDa protein cleaved into: Heavy signs of paralysis (floppy baby syndrome).
chain (H, 100 kDa), Light chain (L, 50 kDa), Linked by  May cause sudden infant death syndrome (SIDS).
disulfide bond  Clostridium botulinum and botulinum toxin are
o Lethal dose for a human- 1-2 ug/kg found in feces, not in serum.
o Toxins are destroyed by heating for 20 minutes at o Wound Botulism
100°C  Resurgence of wound botulism with types A or B toxin
 Pathogenesis in the USA, UK, and Germany.
o Toxin is absorbed from the gut→ Enters the blood  Associated with skin-popping using contaminated
circulation→ Binds to receptors of presynaptic “black tar” heroin.
membranes of motor neurons of PNS and cranial  From tissue contamination with spores seen primarily
nerves→ Does not cross the blood brain barrier or affect in IV (injection) drug users
the CNS  Clinical Findings
o Proteolysis by the L chain of the toxin of the target o Symptoms begin 18-24 hours following ingestion of
SNARE proteins in the neurons→ Inhibits the release of toxic food→ Visual disturbances (incoordination of eye
acetylcholine at the synapse→ Lack of muscle muscles, double vision)→ Inability to swallow→ Speech
contraction→ Paralysis difficulty→ Signs of bulbar paralysis (progressive)→
o SNARE- soluble-N-ethyl maleimide-sensitive factor Death (respiratory paralysis, cardiac arrest)→ Patients
attachment protein who recover do not develop antitoxin→ GI symptoms
o Food Botulism- most common not prominent→ No fever, patient is conscious without
exhibiting fever
 Ingestion of food containing bacteria and toxin-
Spiced, smoked, vacuum packed, or canned alkaline  Diagnostic Laboratory Tests
foods that are eaten without cooking or stored in the o Contact appropriate public health authorities before
refrigerator for days and not heated properly after submitting specimens to the laboratory
 Spores of C. botulinum germinate anaerobically o Definitive diagnosis:
 Vegetative forms grow and produce toxin  Detection of toxin- in serum, gastric secretions, or
o Infant Botulism stool from patient; in leftover food
 Most commonly brought about by honey. Infants  Not necessary to detect the organism
ingest spores which germinate within the intestinal o Transport clinical swabs and specimens using anaerobic
tract containers.
o Keep suspect foods in their original containers.
 o Mouse bioassay test (confirmatory)- Mice injected o Toxin considered to be a major potential agent for
intraperitoneally with specimens from affected patients bioterrorism and biologic warfare
die rapidly. Antigenic type of toxin is identified by
neutralization with specific antitoxin in mice. Clostridium tetani
o Other methods to detect toxin: ELISA, PCR- may  Worldwide in distribution- found in soil and in feces of
detect organisms that carry the gene but do not express horses & etc.
the toxin  Several types distinguished by specific flagellar antigens.
 Treatment  All share common O (somatic) antigen, which may be
o Supportive care, esp. intensive care masked, and all produce same antigenic type of neurotoxin
 Adequate respiration (may need mechanical called tetanospasmin which causes tetanus.
ventilation, may reach 8 weeks); Reduced mortality  Plasmid-encoded tetanospasmin:150 kDa; Cleaved by
from 65% to 25% bacterial protease into 2 peptides- 50 + 100 kDa linked by
o Potent antitoxins to 3 types of botulinum toxins disulfide bond
prepared in horses  Larger peptide- binds to receptors on presynaptic
 Trivalent (A, B, E) antitoxin must be promptly membranes of motor neurons
administered IV with precaution. o Migrates by retrograde axonal transport system to cell
 No reversal of paralysis with antitoxins bodies of SC and brainstem neurons
 Prevention of disease advancement if given early  Smaller peptide degrades synaptobrevin (VAMP2)-
o Human-derived botulinum immune globulin (BIG) required for docking of neurotransmitter vesicles on
 Recommended for infant botulism; most infants presynaptic membrane
recover with supportive care  Toxin diffuses into terminals of inhibitory cells
o Trivalent is given because we do not know what type is (Glycinergic interneurons, γ-aminobutyric acid (GABA)-
responsible for a certain case. secreting neurons)→ Release of inhibitory glycine and
 Epidemiology, Prevention, and Control GABA is blocked→ Inhibition of motor neurons is
o Widely distributed in soil likewise blocked→ Patient then exhibits Hyperreflexia,
o Often contaminate vegetables, fruits, etc. Muscle spasms, Spastic paralysis→ Extremely small
o Canned or preserved food must be sufficiently heated to amounts of toxin= LETHAL
ensure destruction of spores
 Boiled for 20 minutes before consumption
 Strict regulation of commercial canning  Pathogenesis
 Toxic food may be spoiled and rancid; cans may swell, o Non-invasive organism; Disease- toxemia
always make sure that cans are undented or unswollen o Infection is strictly localized in the area of devitalized
tissue into which the spores have been introduced
Wound  Umbilical stump
Burn  Surgical suture
Injury
o Germination of spores and development of vegetative
organisms that produce toxin aided by
1. Necrotic tissue 3. Associated pyogenic (pus-generating) infections
2. Calcium salts
 Low redox potential  Diagnosis
 Clinical Findings Based on clinical diagnosis & history of injury
o
o Incubation Period: 4 to 5 days up to 3 weeks Primary differential diagnosis (DDx): Strychnine
o
o Tonic contraction of voluntary muscles poisoning
o Muscular spasms initially in the area of injury and then o Anaerobic culture of tissues from contaminated
the muscles of the jaw- Trismus, lockjaw wounds may yield organism but should not delay
o Patient is fully conscious; pain may be intense antitoxin use
o Death from interference with mechanics of respiration; o Proof of isolation of C. tetani rests on: production of
mortality rate is very high toxin, and neutralization by specific antitoxin
 Anti-tetanus injections are needed if someone gets  Prevention and Treatment
struck by thorns, rusty nails, rusty metals and o Prevention is Key
following animal bites
1. Active immunization with toxoids (TT) 3. Prophylactic use of antitoxin (T Ig)
2. Aggressive wound care 4. Pencillin administration

o Supportive measures:
 Muscle relaxants  Assisted ventilation
 Sedation
o Surgical debridement removes necrotic tissue- Prevents o Penicillin strongly inhibits growth of C. tetani and
proliferation of bacteria stops further toxin production; also controls associated
o No proven effect with hyperbaric oxygen pyogenic infection
 o IM injection of 250-500 U tetanus Ig (human) gives o Distention of tissue + Interference with blood supply +
adequate systemic protection→ ≥0.01 U per ml of serum Secretion of toxins and hyaluronidase→ Favor spread
for 2-4 weeks→ Neutralizes toxin that has not been of infection
fixed to nervous tissue o Tissue necrosis extends→ Increasing bacterial growth→
o When a previously immunized person has a potentially Hemolytic anemia→ Severe toxemia and death
dangerous wound, an additional dose of toxoid should be o Gas gangrene (Clostridial Myonecrosis)- Mixed
given to restimulate antitoxin production. infection is the rule
o Additional dose of antitoxin should accompany this  C. perfringens- Genital tracts of 5% of women; Type
“recall” injection, if the patient has not had current C: Necrotizing enteritis (pigbel) in New Guinea
immunization or boosters, or if immunization history is  C. sordelli- Toxic shock syndrome ff medical abortion;
unknown. Endometrial infection
 Control  C septicum- Bacteremia in patients with neoplasms
o Mandatory active immunization with tetanus toxoid-  Clinical Findings
Detoxification with formalin, then concentration o Gas Gangrene: Contaminated wound (Compound
o Initial course of immunization x 3 doses fracture, Postpartum uterus)→ Infection spreads in 1-3
 Given during the first year of life days→ Crepitation in the subQ tissue & muscle (Foul-
 Follow up dose after 1 year smelling discharge)→ Rapidly progressing necrosis→
 Booster dose given upon entry into school Fever, hemolysis, toxemia, shock→ Death
 Additional boosters every 10 years thereafter, to o Food Poisoning: Ingestion of large numbers of
maintain serum levels ≥0.01 U per ml clostridia (Grown in warmed meat dishes)→ Organisms
sporulate in the gut→ Toxin formation→ Diarrhea
Clostridia that Produce Invasive Infections (without vomiting or fever) in 7-30 hours→ Illness lasts
Clostridium perfringens 1-2 days
 Associated with myonecrosis and gas gangrene in 90%  Diagnostic Laboratory Tests
of cases o Specimens- Material from wounds, pus, and tissue
 Produces enterotoxin associated with food poisoning; o Gram stain: presence of large gram-positive rods→ gas
over 30 species of clostridia associated with invasive gangrene clostridia (Spores are not usually seen)
infections o Material is inoculated into: Chopped meat-glucose
 Toxin medium, Thioglycolate medium, Blood agar plates
o Alpha toxin (C. perfringens type A) o Incubated anaerobically
 Lecithinase- causes lethal action proportionate to rate o Identification by biochemical reactions, hemolysis and
at which it splits lecithin to phosphorylcholine & colony morphology
diglyceride o Lecithinase activity evaluated by precipitate formed
 Platelet aggregation→ thrombi (clot) formation in around colonies on egg yolk media
small blood vessels→ poor tissue perfusion (blood o MALDI-TOF MS- Rapid and sensitive method
cannot flow because of the clots obstructing their  Treatment
flow)→ destruction of viable tissue (gas gangrene) o Prompt and extensive surgical debridement of involved
o Theta toxin area→ Excision of devitalized tissue→ Administration
 Similar hemolytic and necrotizing effects but is not a of antimicrobial drugs (Penicillin)→ Hyperbaric oxygen
lecithinase said to “detoxify” patients rapidly→ Antitoxins given as
 Cholesterol-dependent cytolysin concentrated immune globulins, but no evidence for
 Forms pores in the cell membrane their efficacy
o Epsilon toxin o Clostridial food poisoning requires only symptomatic
 Protein that causes edema and hemorrhage; very potent care.
 Produces DNAse and hyaluronidase- collagenases  Prevention and Control
that digest collagen of subcutaneous tissue and muscle o Best available preventive measures
o Enterotoxin  Early and adequate cleansing of contaminated wounds
 >108 vegetative cells ingested→ Sporulate in the gut  Surgical debridement
(CPE formed, 35 kDa may be nonessential component  Antimicrobial drugs (Penicillin)
of spore coat)→ Induces intense diarrhea in 7-30
hours with Marked hypersecretion in the jejunum & Clostridium difficile and Diarrheal Disease
ileum and Fluid and electrolyte loss→ self-limited  Pseudomembranous Colitis
 Pathogenesis o Seen in patients who have diarrhea and have been given
o Spores reaches tissue thru contamination of antibiotics
traumatized areas (soil, feces) or from the intestinal o Diagnosis thru:
tract→ Spores germinate at low redox potential→  Detection of one or both C. difficile toxins in stool
Vegetative cells multiply, ferment carbohydrates  Endoscopic observation of pseudomembranes or
present in tissue, and produce gas microabscesses (may be localized to 1 area of the gut)
o Diarrhea may be watery or bloody
o ±abdominal cramps, leukocytosis, & fever
 o Known culprits: Ampicillin, Clindamycin, o Fecal transplantation- administration of the feces of
Fluoroquinolones healthy related donor through colonoscopy or
o Treatment: Discontinue offending Abx + oral nasogastric tube into GIT
Metronidazole, Vancomycin or Fidaxomicin
o Toxin A  Binds to the brush border membranes of the gut
 Potent enterotoxin; Cytotoxic activity o Toxin B- Potent cytotoxin

o Both toxins with glycosyltransferase activity o Surge in C. difficile Infections in the 21st Century-
o Causes apoptosis, capillary leakage, cytokine Combination of host and organism factors
stimulation, etc. leading to colitis (infection of the
bowel)
 Host factors  Organism factors
 Aging population  Emergence of more virulent strain types due to
 Increase in survival of immunocompromised mutations in the pathogenicity locus
 Increase in use of antibiotics and gastric acid  Antibiotic-Associated Diarrhea
suppressants
o Frequent use of antibiotics- Mild to moderate form of o Produces acid but not gas in various sugar fermentation
diarrhea; Less severe than pseudomembranous colitis reactions
o ~25% caused by C. difficile infection o Catalase positive, esculin hydrolysis positive (+),
o Also can be caused by C. perfringens and C. sordellii- motile
No association with pseudomembranous colitis o Motility at room temperature & hemolysin production
differentiates Listeria from Corynebacteria
Part 2: Aerobic Non-Spore-forming Gram-Positive Bacilli:  Antigenic Classifications
Listeria, Erysipelothrix, Nocardia, et. al. o Serology testing done only in reference laboratories (for
Listeria monocytogenes epidemiology purposes)
 Important foodborne pathogen o 13 known serovars based on O (somatic) and H
 Ability to survive at refrigerator temperatures (4°C), at (flagellar) antigens
low pH, and high salt conditions o Serotypes 1/2a, 1/2b, and 4b make up >95% of human
 Able to overcome food preservation and safety barriers isolates; Serotype 4b: most common cause of foodborne
 In 2011: One of the largest and deadliest outbreak of outbreaks
listeriosis was traced to contaminated cantaloupe from a  Pathogenesis
packaging plant in Colorado, USA o Acquired thru ingestion of contaminated food (i.e.
 Morphology and Identification cheese, fruit, or vegetables)
o Non-spore-forming rod; Catalase positive (+) o Adhesin proteins facilitate bacterial binding to host
o Tumbling end-over-end motility at 22-28°C cells; promoting virulence- Ami, Fbp A, flagellin
 Culture and Growth Characteristics proteins
o Grows well on 5% sheep BA o Cells wall surface proteins interact with E-cadherin→
o Characteristic small zone of hemolysis around and promoting phagocytosis- Internalins A and B
under colonies o Bacterium is enclosed in a phagolysosome- Low pH
o Facultative anaerobe activates production of listeriolysin O
o Listeriolysin and 2 phospholipases

Lyses membrane of phagolysosome o E-cadherin is a receptor on epithelial cells and ActA is

Allows bacteria to escape into cytoplasm of epithelial a Listeria surface protein which enables organisms to
cell→ organism proliferates propel against host cell membranes.
o ActA induces host cell actin polymerization o Role of iron as virulence factor. Listeriae produce
 Formation of elongated protrusions (filopods) which siderophores and obtain iron from transferrin.
are ingested by adjacent epithelial cells, macrophages  Immunity
and hepatocytes o Primarily cell-mediated- Intracellular location of
o Release of Listeriae infection
o Marked association of infection with conditions with
low cell-mediated immunity
 Pregnancy  Lymphoma
 Advanced age  Organ transplantation
 AIDS
o Can be transferred by sensitized lymphocytes but not o Healthy infected persons may develop mild, self-limiting
by antibodies febrile gastroenteritis x 1-3 days
 Clinical Findings o Incubation Period: 6-48 hours
o Symptoms:
 Fever  Headache
 Chills  Myalgias
  Abdominal pain  Diarrhea
 2 forms of perinatal human listeriosis
o Early-onset syndrome (granulomatosis infantiseptica) o Late-onset syndrome
 Infection in utero  Meningitis between birth and third week of life
 Disseminated form of disease causing neonatal sepsis,  Serotype 4b
pustular lesions, granulomas in multiple organs  Significant mortality rate
 Death before or after delivery
 Diagnosis and Treatment  Biochemical Characteristics
o Most clinical laboratories do no routinely culture for Catalase, oxidase, and indole negative (-)
o
Listeria from stool samples Produces H2S on TSI, turning TSI butt black
o
o Ampicillin + Gentamicin- recommended for treatment Variations depend on growth medium, incubation
o
o Cephalosporins, fluoroquinolones NOT active temperature, and pH
o TMP-SMX- drug of choice for CNS infections who are  Differentiated from L. monocytogenes, Trueperella, A.
allergic to Penicillin haemolyticum
o β-hemolytic and do not produce H2S
Erysipelothrix rhusiopathiae  Difficult to differentiate from aerotolerant lactobacilli
 Colony morphology: o They are also α-hemolytic, catalase negative (-),
o Small, transparent, glistening colonies; May be α– Vancomycin resistant, H2S production in some
hemolytic on BA  Found in land and sea animals worldwide
 Gram staining  Disease in domestic swine, turkeys, ducks, sheep, but
o Decolorizes easily; May sometimes look Gram NOT in fish
negative  Erysipelas in swine
o May appear singly, in short chains, randomly, or in  Persons at greatest risk include fishermen, fish handlers,
long nonbranching filaments abattoir workers, butchers, and others in contact with
animal products
 Erysipeloid (in humans)
Fingers
o Pus negative (differentiated from Streptococcal skin
o
Direct inoculation at the site of a cut or abrasion: “seal
o infections)
finger”, “whale finger” o Can resolve without treatment following 3-4 weeks or
o Incubation Period: 2-7 days more rapidly with antibiotics
o Pain and swelling; lesion is raised, well circumscribed o Penicillin G is the drug of choice for severe infections
and violaceous o Vancomycin resistance
 Other forms of infection (rare): Diffuse cutaneous form,  Include Corynebacteria, saprophytic Streptomyces and
Bacteremia with or without endocarditis, Septic clinically significant Mycobacterium
arthritis  Form elongated chains of bacteria (1 μm width) with
occasional branches
Complex Aerobic Actinomycetes  Some break apart following formation
 Large, diverse group of GPB that form chains or  Others develop extensive aerial filaments or fragment into
filaments coccobacillary forms

Nocardiosis  At least 30 species implicated as causes of human

 Genus Nocardia under extensive taxonomic infections
reclassification. New species continue to be identified  Nocardia sp.
o Worldwide in distribution- can be found in soil and o No person-to-person transmission
water o Subacute to chronic pulmonary infection. May
o Initiated thru inhalation of bacteria disseminate to other organs (i.e. brain or skin)
 Morphology and Identification
o Aerobic and grow on a variety of media o Filamentous with hyphae-like branching
o Incubation at 35-37°C for several days on standard o Cell wall contains mycolic acid that are shorter chained
media than those of Mycobacteria
 Heaped, irregular, waxy colonies o Weakly acid fast
 Stains vary in their pigmentation from white to orange o Stain with routine AF reagent (carbolfuschin)
to red o Retain dye when decolorized with 1-4% sulfuric acid
o Gram positive and catalase positive; Produce urease (+) instead of the stronger acid-alcohol decolorant
o Form extensive branching substrates and aerial
filaments- Fragment and break into coccobacillary cells
o Identified primarily by molecular methods  Pathogenesis and Clinical Findings
 16S rRNA gene sequencing o Opportunistic infection: Pulmonary nocardiosis (main
 Restriction fragment length polymorphism (RFLP) CMx), Inhalation (primary route of entry), Symptoms
analysis of amplified gene fragments (i.e. hsp or secA) are indistinct and may mimic TB
 oRisk factors associated with decreased CMI: o Symptoms: Fever, Night sweats, Weight loss, Chest
Corticosteroid treatment, Immunosuppression, Organ pain, Cough ± sputum production, shortness of breath
transplantation, AIDS, Alcoholism
 Diagnostic Laboratory Tests
o Gram stain  Weakly acid fast on modified staining
 Gram Positive Bacilli o Molecular methods (for species level identification)
 Coccobacillary cells  Epidemiology and treatment purposes
 Branching filaments  Serology NOT useful
o Acid-fast stain
o Specimens: Sputum, Pus, Spinal fluid, Biopsy material o Localized, slowly progressive, chronic infection;
o Chest x-ray findings: Focal infiltrates, Multifocal o Begins in subcutaneous tissue- Spreads to adjacent
nodules, ± Cavity formation, ± Pulmonary consolidation, tissues
Granuloma & caseation rare o Destructive and often painless- Usually caused by soil
o Usual pathologic process: Abscess Formation fungus (Eumycetoma)
o Hematogenous dissemination: Bloodstream→ Brain→ o Actinomycetoma
Skin→ Kidney→ Eye  Caused by filamentous branching bacteria
o Nocardia brasiliensis- most (primary) cutaneous  Not to be confused with actinomycosis which is
infection due to trauma; rarely disseminates caused by anaerobic Gram+ Actinomyces
 Treatment  Tissue elements + GPB & w/bacillary chains or
o Trimethoprim-Sulfamethoxazole- Drug of Choice filaments (1 μm in diameter)= Actinomycetoma
o May give amikacin, imipenem, meropenem, granule
fluoroquinolones, minocycline, linezolid, cefotaxime  Most common causes: Actinomadura madurae,
o Perform susceptibility testing Streptomyces somaliensis, Actinomadura pelletieri,
o ± Surgical drainage or resection Nocardia asteroids, N. brasiliensis
 Biochemical tests→ Chromatographic analysis of cell
wall components→ Molecular techniques
Actinomycetoma
 Treatment with Streptomycin, TMP-SMX, and
 Mycetoma (Madura foot) Dapsone
 Early treatment is crucial to prevent extensive damage; Amputation in advanced disease
Listeria monocytogenes Short, thin, gram-positive rods; catalase-positive Foodborne gastroenteritis in immunocompetent
motile, non-spore-forming; exhibit β-hemolysis hosts; neonatal sepsis and meningitis; postpartum
infections; meningoencephalitis; bacteremia;
septicemia in immunocompromised hosts
Erysipelothrix Appears singly, as short chains or branching Erysipeloid; bacteremia; endocarditis
rhusiopathiae filaments; α-hemolytic on BA; produces H2S
Nocardia brasiliensis Thin, branching, and beaded modified acid-fast Cutaneous lesions associated with trauma including
positive rods; yellowish wrinkled colonies mycetoma
Nocardia abscessus Thin, branching, and beaded modified acid-fast Pulmonary and brain abscesses
positive rods
Nocardia nova complex Thin, branching, and beaded modified acid-fast Broad range of clinical syndromes
positive rods
Nocardia transvalensis Thin, branching, and beaded modified acid-fast Pulmonary and brain abscesses
complex positive rods
Nocardia farcinica Thin, branching, and beaded modified acid-fast Among the most resistant Nocardia sp.; causes
positive rods; smooth colonies that turn orange disseminated disease esp. in immunocompromised
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Nocardia asteroides Thin, branching, and beaded modified acid-fast Infrequent cause of infections
positive rods; chalky white colonies
Nocardia Thin, branching, and beaded modified acid-fast MC Nocardia sp. in clinical material; respiratory
cyriacigeorgica positive rods; powdery colonies with aerial hyphae infections, wounds, brain abscesses
Rhodococcus equi Coccoid organisms that are modified acid-fast Pneumonia, often with cavity formation in
positive; salmon pink colonies immunocompromised px
Actinomadura madurae Thin, short, branching filaments; appear as grains in Myetoma (Madura foot)
tissue; colonies are wrinkled and may have color
Actinomadura pelletieri Thin, short, branching filaments; appear as grains Mycetoma
in tissue; colonies are wrinkled and may have color
Streptomyces Acid-fast negative; colonies appear wrinkled with Mycetoma
somaliensis aerial hyphae