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

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Presentation on theme: "Bacterial Diseases Victor Politi,M.D., FACP, Medical Director, SVCMC School of Allied Health Professions, Physician Assistant Program."— Presentation transcript:

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

2 Introduction Bacteria consist of only a single cell Bacteria consist of only a single cell Bacteria fall into a category of life called the Prokaryotes Bacteria fall into a category of life called the Prokaryotes There are thousands of species of bacteria, but all of them are basically one of three different shapes. There are thousands of species of bacteria, but all of them are basically one of three different shapes.

3 Classification of Bacteria Until recently classification has done on the basis of such traits as: Until recently classification has done on the basis of such traits as: shape shape bacilli: rod-shaped bacilli: rod-shaped cocci: spherical cocci: spherical spirilla: curved walls spirilla: curved walls ability to form spores ability to form spores method of energy production (glycolysis for anerobes, cellular respiration for aerobes method of energy production (glycolysis for anerobes, cellular respiration for aerobes nutritional requirements nutritional requirements reaction to the Gram stain. reaction to the Gram stain.

4 Classification of Bacteria The Gram stain is named after the 19th century Danish bacteriologist who developed it. The Gram stain is named after the 19th century Danish bacteriologist who developed it. The bacterial cells are first stained with a purple dye called crystal violet. The bacterial cells are first stained with a purple dye called crystal violet. Then the preparation is treated with alcohol or acetone. Then the preparation is treated with alcohol or acetone. This washes the stain out of gram-negative cells. This washes the stain out of gram-negative cells. To see them now requires the use of a counterstain of a different color (e.g., the pink of safranin). To see them now requires the use of a counterstain of a different color (e.g., the pink of safranin). Bacteria that are not decolorized by the alcohol/acetone wash are gram-positive Bacteria that are not decolorized by the alcohol/acetone wash are gram-positive

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7 Gram 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

8 Gram 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 Streptococcus II-Alpha-hemolytic Streptococcus -Streptococcus Pneumoniae (Pneumococcus) -Streptococcus Pneumoniae (Pneumococcus) -Viridans streptococcus (bacterial endocarditis) -Viridans streptococcus (bacterial endocarditis) III-Non-hemolytic Streptococcus III-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

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

10 Group B Streptococcus (Streptococcus agalactiae) Epidemiology Epidemiology Most common US cause of neonatal sepsis and meningitis Most common US cause of neonatal 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

11 Pathophysiology Pathophysiology 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 mengitis Late onset neonatal disease of sepsis or mengitis Group B Streptococcus (Streptococcus agalactiae)

12 Labs: Maternal Screening Labs: Maternal Screening GBS Culture GBS Culture Management Management Sepsis (treat for days) Sepsis (treat for 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 days) Meningitis (treat for days) Penicillin G 400,000 units/kg/day divided q2-4 hours Penicillin G 400,000 units/kg/day divided q2-4 hours Prevention Prevention Perinatal Group B Streptococcus Prophylaxis Perinatal Group B Streptococcus Prophylaxis Prognosis Prognosis Mortality 10-40% Mortality 10-40% Group B Streptococcus (Streptococcus agalactiae)

13 Streptococcus Pneumoniae Streptococcus Pneumoniae (Pneumococcus) Streptococcus Pneumoniae Epidemiology Epidemiology Most common cause of community acquired pneumonia Most common cause of community acquired pneumonia Classic Symptoms Classic 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

14 Alpha-hemolytic Streptococcus Lab Lab CBC CBC WBC elevated with left shift WBC elevated with left shift Gram stain Gram stain Gram positive encapsulated organisms Gram positive encapsulated organisms Elongated lancet shaped diplococci Elongated lancet shaped diplococci Blood Culture Blood Culture Positive in only 33% of cases Positive in only 33% of cases Sputum culture Sputum culture Positive in only 40% of pneumococcal pneumonias Positive in only 40% of pneumococcal pneumonias Radiology Radiology Chest X-ray Chest X-ray Lobar consolidation (often lower lobe) Lobar consolidation (often lower lobe) patchy infiltrates patchy infiltrates

15 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 Management

16 Management 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 Rifampin Vancomycin IV with or without Rifampin

17 Gram Positive Cocci Gram Positive Cocci Organisms Organisms -Staphylococcus aureus -Staphylococcus aureus -Staphylococcus epidermidis -Staphylococcus epidermidis

18 Pus smear (wound) Staphylococcus aureus

19 Enterococcus I-Characteristics I-Characteristics Gram Positive Cocci Gram Positive Cocci Previously defined as Group D Streptococcus Previously defined as Group D Streptococcus II-Organisms II-Organisms Enterococcus faecalis Enterococcus faecalis Enterococcus faecium Enterococcus faecium

20 Gram Positive Rods

21 Corynebacterium Epidemiology Epidemiology Rare in United States due to Immunization (DTP, DTaP) Rare in United States due to Immunization (DTP, DTaP) However 20% of adults may be inadequate immune status However 20% of adults may be inadequate immune status Ongoing epidemic in the former USSR Ongoing epidemic in the former USSR Etiology Etiology Corynebacterium Diphtheriae Corynebacterium Diphtheriae

22 Symptoms Symptoms sore throat sore throat dysphagia dysphagia Weakness Weakness Malaise Malaise Corynebacterium

23 Signs Signs 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 removed Leaves focal hemorrhagic raw surface when removed Cervical lymphadenopathy Cervical lymphadenopathy Corynebacterium

24 Vincent's Angina (trench mouth) Vincent's Angina (trench mouth) Also shows pseudomembrane formation Also shows pseudomembrane formation Pharyngitis Pharyngitis Labs Labs CBC CBC Leukocytosis Leukocytosis Throat culture (+ for corynebacterium org.) Throat culture (+ for corynebacterium org.) Management Management Diphtheria antitoxin Diphtheria antitoxin Erythromycin Erythromycin mg/kg q12 hours IV for 7-14 days mg/kg q12 hours IV for 7-14 days Prevention Prevention DTP/DTaP vaccination DTP/DTaP vaccination Differential Dx

25 Listeria monocytogenes

26 Bacillus anthracisBacillus anthracis (Anthrax) Anthrax Bacillus anthracisAnthrax Etiology Etiology Bacillus anthracis Bacillus anthracis Transmission Transmission 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

27 Bacillus anthracisBacillus anthracis (Anthrax) Anthrax Bacillus anthracisAnthrax Symptoms and Signs: Cutaneous ("Malignant Pustule") Symptoms and Signs: Cutaneous ("Malignant Pustule") Inoculation at site of broken skin Inoculation at site of broken skin Painless pruritic pustules develop at inoculation site Painless pruritic pustules develop at inoculation site Begins as erythematous papule on exposed skin Begins as erythematous papule on exposed skin Vesiculates and then ulcerates within 1-2 days Vesiculates and then ulcerates within 1-2 days Surrounded by a ring of non-tender Brawny edema Surrounded by a ring of non-tender Brawny edema Black eschar may form Black eschar may form

28 Bacillus anthracisBacillus anthracis (Anthrax) Anthrax Bacillus anthracisAnthrax

29 Bacillus anthracisBacillus anthracis (Anthrax) Anthrax Bacillus anthracisAnthrax Symptoms and Signs: Inhalation Anthrax Symptoms and Signs: Inhalation Anthrax 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 dissemination dyspnea and hemoptysis during dissemination

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31 Symptoms and Signs: Acute GI type symptoms Acute GI type symptoms Hematemesis Hematemesis Severe diarrhea Severe diarrhea Differential Diagnosis Differential Diagnosis Cutaneous Anthrax Cutaneous Anthrax Spider bite Spider bite Ecthyma gangrenosum Ecthyma gangrenosum Ulceroglandular tularemia Ulceroglandular tularemia Plague Plague Staph. Or strep. cellulitis Staph. Or strep. cellulitis Inhalational Anthrax Inhalational Anthrax Community acquired pneumonia (late phase anthrax) Mycoplasma pneumonia (early phase anthrax) Influenza (early phase anthrax) Legionnaires' Disease Psittacosis tularemia Q fever Viral pneumonia Histoplasmosis Coccidiodomycosis

32 Labs Labs 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 - Widened Mediastinum (hemorrhagic mediastinitis Chest x-ray - Widened Mediastinum (hemorrhagic mediastinitis Bacillus anthracisBacillus anthracis (Anthrax) Anthrax Bacillus anthracisAnthrax

33 Management: Antibiotics Antibiotic course: 60 days Antibiotic course: 60 days Empiric Treatment Empiric Treatment Cipro Cipro Adults: 400 mg IV q12 hours Adults: 400 mg IV q12 hours Children: mg/kg/day IV divided q12 hours Children: mg/kg/day IV divided q12 hours Levofloxacin Levofloxacin Adults: 500 mg IV q24 hours Adults: 500 mg IV q24 hours Specific Treatment for confirmed anthrax Specific Treatment for confirmed anthrax Adults Pencillin G 4 MU IV q4 hours or Doxycycline 200 mg IV, then 100 mg IV q12 hours Children > age 12 same as adults Children < age 12 Penicillin G 50,000 U/kg IV q6 hours

34 Postexposure prophylaxis Concurrently begin vaccination Concurrently begin vaccination Continue antibiotics for 60 days Continue antibiotics for 60 days Ciprofloxacin Ciprofloxacin Ciprofloxacin Adults: 500 mg PO bid Adults: 500 mg PO bid Children: mg/kg/day divided bid up to 1g/day Children: mg/kg/day divided bid up to 1g/day Amoxicillin Amoxicillin Amoxicillin 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 Doxycycline Doxycycline Doxycycline Adults: 100 mg PO bid Adults: 100 mg PO bid Children over age 8: 5 mg/kg/day divided q12 hours Children over age 8: 5 mg/kg/day divided q12 hours

35 Anthrax Course Course Incubation: 4-6 days Incubation: 4-6 days Duration of illness: 3-5 days Duration of illness: 3-5 days Prognosis Prognosis 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%

36 Prevention Prevention 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 annually Next: 6, 12, 18 months and then annually Postexposure Prophylaxis as above Postexposure Prophylaxis as above Empiric prophylaxis for any suspected exposure Empiric prophylaxis for any suspected exposure Best prognosis with antibiotics prior to symptoms Best prognosis with antibiotics prior to symptoms

37 Gram Negative Gram Negative Gram Negative Rods Gram 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,Yersinia Pasturella,Brucella,Yersinia Aerobes Aerobes Pseudomonadaceae (e.g. Pseudomonas aeruginosa) Pseudomonadaceae (e.g. Pseudomonas aeruginosa)

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

39 Enterobacteriaceae Characteristics Characteristics Facultative Anaerobic Gram negative rods Facultative Anaerobic Gram negative rods EKP Gram negative bacteria EKP Gram negative bacteria Escherichia coli Escherichia coli Klebsiella Klebsiella Proteus Proteus

40 Vibrionaceae Characteristics Facultative Anaerobic gram negative rods Vibrio Cholerae Vibrio parahaemolyticus Genus: Aeromonas (motile with single polar flagellum)

41 Vibrionaceae Genus: Campylobacter (motile with single polar flagellum) Genus: Campylobacter (motile with single polar flagellum) Campylobacter jejuni Campylobacter jejuni Genus: Helicobacter (motile with multiple flagella) Genus: Helicobacter (motile with multiple flagella) Helicobacter Pylori Helicobacter Pylori

42 Pasteurellaceae Characteristics Characteristics Facultative Anaerobic gram negative rods Facultative Anaerobic gram negative rods Genus: Pasteurella Genus: Pasteurella Pasteurella multocida Pasteurella multocida

43 Pasteurellaceae Genus: Haemophilus (coccobacilli) Genus: Haemophilus (coccobacilli) Haemophilus Influenzae Haemophilus Influenzae Haemophilus aegyptius Haemophilus aegyptius Haemophilus ducrei Haemophilus ducrei

44 Gram Negative Rod Aerobes Aerobes Pseudomonadaceae (e.g. Pseudomonas aeruginosa) Pseudomonadaceae (e.g. Pseudomonas aeruginosa) Brucella Brucella Legionellaceae Legionellaceae

45 Pseudomonadaceae Characteristics Characteristics Aerobic Gram Negative Rod Aerobic Gram Negative Rod Family: Pseudomonadaceae Family: Pseudomonadaceae Pseudomonas aeruginosa Pseudomonas aeruginosa Pseudomonas mallei (Glanders) Pseudomonas mallei (Glanders)

46 Gram Negative Rod Aerobic Family: Legionellaceae Family: Legionellaceae Legionella pneumophila Legionella pneumophila

47 Legionellaceae Pathophysiology Pathophysiology Aerobic, intracellular, Gram negative rod Aerobic, intracellular, Gram negative rod Virulent organism Virulent organism More severe disease than other atypical pneumonia More severe disease than other atypical pneumonia Transmission Transmission Optimal conditions for growth Optimal conditions for growth Temperature: 89 to 113 F water Temperature: 89 to 113 F water Stagnant water Stagnant water Transmission Transmission Waterborne Freshwater or moist soil near ponds Air conditioning Condensers Cooling towers Respiratory therapy equipment Showers or water faucets Whirlpools Incubation Incubation Two to ten days

48 Legionellaceae Symptoms Symptoms Prodrome for hours Prodrome for hours Malaise Malaise Myalgia Myalgia HA HA Symptoms for 2-3 days Symptoms for 2-3 days Fever to 40.5 C persists for 8-10 days Fever to 40.5 C persists for 8-10 days GI symptoms % of cases GI symptoms % of cases Nausea/vomiting Nausea/vomiting Diarrhea Diarrhea Later Symptoms: Cough Later Symptoms: Cough Minimal to no sputum production Slightly blood tinged sputum Signs Signs Severe respiratory distress Confusion Disorientation

49 Legionella pneumophila Complications Complications 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

50 Radiology: chest x-ray Radiology: 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 Legionella pneumophila

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

52 Legionella pneumophila Diagnosis Diagnosis 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

53 Legionella pneumophila Management (Antibiotic course for 21 days) Management (Antibiotic course for 21 days) Azithromycin IV Azithromycin IV Levofloxacin IV Levofloxacin IV Trovafloxacin IV Trovafloxacin IV Erythromycin IV Erythromycin IV Add Rifampin in immunocompromised or severe disease Add Rifampin in immunocompromised or severe disease Course Course Response to antibiotics may not be seen for 4-5 days Response to antibiotics may not be seen for 4-5 days Up to 15% mortality in some studies Up to 15% mortality in some studies

54 Brucellosis Epidemiology Epidemiology US Incidence US Incidence <100 cases per year (0.34/100,000) <100 cases per year (0.34/100,000) Etiology Etiology Brucella abortus Brucella abortus Brucella suis Brucella suis Brucella melitensis Brucella melitensis

55 Brucellosis Pathophysiology Pathophysiology Facultative intracellular parasite Facultative intracellular parasite Releases endotoxin when dies Releases endotoxin when dies Infective dose: organisms Infective dose: organisms Incubation: 5-60 days Incubation: 5-60 days

56 Brucellosis Transmission Transmission 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 skin, or inhalation Enters via mucus membranes, broken skin, or inhalation

57 Brucellosis Risk Factors Risk 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

58 Brucellosis Symptoms Symptoms Intermittent fevers Intermittent fevers Undulating fever Undulating fever Temperature peaks in evening to Temperature peaks in evening to Arthralgia (90%) Arthralgia (90%) Weakness Weakness Lassitude Lassitude Weight loss Weight loss Headache Headache Sweating Sweating Chills Chills

59 Brucellosis Course Course Weeks to months Weeks to months Prognosis Prognosis Case Fatality Case Fatality <5% treated <5% treated

60 Gram Negative Cocci Aerobes Moraxella(Branhamella catarrhalis) Moraxella(Branhamella catarrhalis) Acinetobacter Acinetobacter Neisseria Neisseria

61 Neisseriaceae Neisseria meningitidis Neisseria meningitidis Neisseria gonorroeae Neisseria gonorroeae

62 Neisseria gonorrhoeae Neisseria gonorrhoeae Epidemiology Epidemiology Much less common than chlamydia Much less common than chlamydia Incidence: ,000 cases per year Incidence: ,000 cases per year Decreasing except in inner city, drug abuse (crack) Decreasing except in inner city, drug abuse (crack) Highly contagious: 50% transmission Highly contagious: 50% transmission Chlamydia coexists in 45-50% of patients with gonorrhea Chlamydia coexists in 45-50% of patients with gonorrhea Pathophysiology Pathophysiology Incubation: 2-7 days Incubation: 2-7 days

63 Neisseria gonorrhoeae Neisseria gonorrhoeae Symptoms and Signs: General Symptoms 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 inflammation Meatus and anterior urethra inflammation

64 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 Neisseria gonorrhoeae Neisseria gonorrhoeae

65 Neisseria gonorrhoeae Neisseria gonorrhoeae Symptoms and Signs: Women Symptoms and Signs: Women Mucopurulent Cervicitis Mucopurulent Cervicitis Often asymptomatic Often asymptomatic Vaginal d/c or spotting Vaginal d/c or spotting Bartholins Gland inflammation Bartholins Gland inflammation Skene's gland inflammation Skene's gland inflammation

66 Neisseria gonorrhoeae Neisseria gonorrhoeae Symptoms and Signs: Men (often asymptomatic) Symptoms and Signs: Men (often asymptomatic) Epidiymitis under age 35 years Epidiymitis under age 35 years Proctitis Proctitis Receptive anal intercourse or vaginal secretions Receptive anal intercourse or vaginal secretions Mild anal irritation or itching Mild anal irritation or itching

67 Neisseria gonorrhoeae Neisseria gonorrhoeae Symptoms and Signs: Disseminated Infection Symptoms and Signs: Disseminated Infection 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

68 Neisseria gonorrhoeae Neisseria gonorrhoeae Complications Complications PID PID Systemic Gonorrhea Systemic Gonorrhea Chronic Arthritis Chronic Arthritis Neonatal Gonorrhea Neonatal Gonorrhea Gonorrheal conjunctivitis Gonorrheal conjunctivitis Preterm labor Preterm labor

69 Neisseria gonorrhoeae Neisseria gonorrhoeae Labs Labs 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: % Sensitivity: % Specificity: % Specificity: %

70 Management: Drug Resistance Management: 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 3 rd generation cephalosporins No resistance to 3 rd generation cephalosporins Ceftriaxone (Rocephin) Ceftriaxone (Rocephin) Cefixime (Suprax) Cefixime (Suprax) Azithromycin requiring higher dosages for some GC Azithromycin requiring higher dosages for some GC References References Neisseria gonorrhoeae Neisseria gonorrhoeae

71 Moraxella catarrhalis Diagnosis Diagnosis Represents less than 5% of all pneumonias Represents less than 5% of all pneumonias More common in COPD More common in COPD Lobar consolidation is rare Lobar consolidation is rare

72 Moraxella catarrhalis Labs Labs Gram stain Gram stain Kidney bean shaped gram negative diplococci Kidney bean shaped gram negative diplococci Radiology Radiology Chest xray Chest xray patchy bronchopulmonary infiltrate patchy bronchopulmonary infiltrate

73 Moraxella catarrhalis Management: Antibiotic Management: Antibiotic Amoxicillin-clavulanate (Augmentin) Amoxicillin-clavulanate (Augmentin) Second generation Cephalosporin (e.g. Cefuroxime) Second generation Cephalosporin (e.g. 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 Septra) Trimethoprim Sulfamethoxazole (Bactrim or Septra) Doxycycline Doxycycline

74 Gram NegativeGram Negative Obligate Intracellular Parasites Gram Negative Rickettsia Rickettsia Ehrlichia Ehrlichia Coxiella Coxiella Rochalimaea (not obligate intracellular) Rochalimaea (not obligate intracellular)

75 Rickettsia Genus: Rickettsia Genus: 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 tsutsugamushi (scrub typhus,) Rickettsia tsutsugamushi (scrub typhus,)

76 Rickettsia rickettsii Rickettsia rickettsii Pathophysiology Pathophysiology 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 parasite Obligate intracellular parasite

77 Rocky Mountain Spotted Fever Epidemiology Epidemiology 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 America South America

78 Rocky Mountain Spotted Fever Symptoms (follows seven day incubation) Symptoms (follows seven day incubation) Fever Fever HA HA Myalgias Myalgias Malaise Malaise vomiting vomiting

79 Rocky Mountain Spotted Fever 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 Labs Labs

80 Rocky Mountain Spotted Fever Labs Labs 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

81 Rocky Mountain Spotted Fever Management Management Antibiotic Course Antibiotic Course Minimum course: 5 to 7 days Minimum course: 5 to 7 days Continue antibiotics until afebrile for 2 days Continue antibiotics until afebrile for 2 days Antibiotics Antibiotics Doxycycline or Tetracycline or Doxycycline or Tetracycline or Chloramphenicol Chloramphenicol

82 Rocky Mountain Spotted Fever Complications Complications Encephalitis Encephalitis Noncardiac pulmonary edema Noncardiac pulmonary edema ARDS ARDS Cardiac arrhythmia Cardiac arrhythmia Coagulopathy Coagulopathy GI bleeding GI bleeding Skin Necrosis Skin Necrosis

83 Rocky Mountain Spotted Fever Prognosis Prognosis Untreated: Untreated: 25% Mortality within 8 to 15 days 25% Mortality within 8 to 15 days Treated: Treated: 5% Mortality 5% Mortality

84 Ehrlichia Ehrlichia sennetsu Ehrlichia sennetsu Ehrlichia canis Ehrlichia canis

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

86 Rochalimaea (not obligate intracellular) Rochalimaea quintana (trench fever seen in military settings) Rochalimaea quintana (trench fever seen in military settings)

87 Chlamydia Eye Diseases Eye Diseases Trachoma Trachoma Inclusion conjunctivitis Inclusion conjunctivitis Genitourinary Disease Genitourinary Disease Lymphogranulmoa venereum Lymphogranulmoa venereum Urethritis Urethritis cervicitis cervicitis Salpingitis Salpingitis Respiratory Respiratory Chlamydia pneumonia in newborns Other Other Chlamydia psittaci (Human psittacosis) Chlamydia psittaci (Human psittacosis) Bird borne zoonosis Respiratory illness or typhoidal illness Chlamydia pneumoniae Chlamydia pneumoniae pneumonia

88 Chlamydia trachomatis Epidemiology: Very Prevalent Epidemiology: Very Prevalent Asymptomatic teenage female test positive: 5-10% Asymptomatic teenage female test positive: 5-10% Sexually active persons: 10% Sexually active persons: 10% Chlamydia 6 to 10 times more common than Gonorrhea Chlamydia 6 to 10 times more common than Gonorrhea Incidence: 3-5 million cases/year Incidence: 3-5 million cases/year

89 Chlamydia Trachomatis (obligate intracellular organism) Cause Cause Chlamydia Trachomatis (obligate intracellular organism) Chlamydia Trachomatis (obligate intracellular organism) Complications Complications PID PID Infertility Infertility Preterm labor Preterm labor Perinatal transmission to newborn Perinatal transmission to newborn Chlamydia conjunctivitis Chlamydia conjunctivitis Neonatal pneumonia Neonatal pneumonia

90 Chlamydia Trachomatis (obligate intracellular organism) Symptoms: Women Symptoms: 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

91 Chlamydia Trachomatis (obligate intracellular organism) Symptoms: Men Symptoms: Men Urethritis Urethritis Often symptomatic Often symptomatic Associated Conditions: Reiters Syndrome in Men Associated Conditions: Reiters Syndrome in Men Arthritis Arthritis Conjunctivitis Conjunctivitis Urethritis Urethritis

92 Chlamydia Trachomatis (obligate intracellular organism) Management Management 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 Azithromycin Doxycycline 100 mg PO bid for 7 days Doxycycline 100 mg PO bid for 7 days Doxycycline Alternatives Alternatives Ofloxacin 300 mg PO bid for 7 days Ofloxacin 300 mg PO bid for 7 days Ofloxacin Erythromycin 500 mg PO qid for 7 days Erythromycin 500 mg PO qid for 7 days Erythromycin Erythromycin Ethylsuccinate (EES) Erythromycin Ethylsuccinate (EES) Erythromycin 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 Amoxicillin Clindamycin 450 mg PO qid for 14 days Clindamycin 450 mg PO qid for 14 days Clindamycin

93 Pregnancy Pregnancy Azithromycin 1 gram PO as single dose Azithromycin 1 gram PO as single dose Azithromycin Erythromycin OR EES as above for 7 days Erythromycin OR EES as above for 7 days Erythromycin Amoxicillin 500 PO tid x7 days (Only 50% effective) Amoxicillin 500 PO tid x7 days (Only 50% effective) Amoxicillin Neonates (conjunctivitis or pneumonia) Neonates (conjunctivitis or pneumonia) Erythromycin for 14 days Erythromycin for 14 days Erythromycin Chlamydia Trachomatis (obligate intracellular organism)

94 Questions ?????? Questions ??????


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