Gram%⊕%stains%violet%
% Gram%Positive%Cocci%
Staphylococcus%
• Cocci&in&clusters&(grapes)&
• Catalase&⊕&
• Facultative&anaerobes&
S.%aureus%%(Coagulase&⊕)&
Features&
• Small&yellow&colonies&on&
blood&agar&
• β?hemolytic&
• Ferments&mannitol&on&
mannitol&salt&agar&
& toxin?1)&superantigen&binds&MHC&II&
Reservoir&
• Normal&flora&of&nasal&
mucosa&and&skin&
Transmission&
• Hands,&sneezing&
• Surgical&wounds&
• Food:&custard,&potato&salad,&
canned&meats,&ham&
S.%epidermidis%%(Coagulase&∅)%
• γ?hemolytic&
• Novobiocin%Sensitive%
• Urease&⊕&
& &
Normal&flora&of&skin&
S.%saprophyticus%%(Coagulase&∅)&
• γ?hemolytic&
• Novobiocin%Resistant%
& • 2nd&MCC&UTI&in&females&17?27&(#1&E.Coli)&
Normal&flora&of&female&genital&
tract&
%
Randall&
Pathogenesis& Diseases& Treatment&
• Protein%A—&inhibits%opsonization& Skin—&(pathogenicity=&exfoliatins/coagulase)& DOC&
(binds&Fc&component&of&IgG&and& • ImpetigoErythematous&papules&to&bullae&(blisters&w/&clear&fluid)& • Nafcillin%
prevents&phagocytosis)& • Scalded%Skin%SyndromeDiffuse&epidermal&peeling&(destroys& • Oxacillin&
& keratinocyte&attachments&in&stratum&granulosum)& &
• TSST<1—&(Toxic&shock&syndrome& • Abscess/mastitisSubcutaneous&tenderness,&redness,&swelling& MRSA&
• Surgical%infectionsFever&w/&cellulitis& • Vancomycin&
& & &
• Coagulase—&converts&fibrinogen&to& Systemic& VRSA&
fibrin&clot&(can&hide&out&in&blood&clots)& • Toxic%shock%syndrome&Fever,&hypotension,&scarlantiniform&rash& • Quinupristin&
& (particularly&palms&and&soles,&innumerable&small&red&papules&diffusely& • Dalfopristin&
• α<toxin—&cytolytic&toxin&that&forms& distributed),&multiorgan&failure& • Linezolid&
pores&(hemolysis)& • Infective%endocarditis&(acute)&&2nd&MCC&overall&and&MCC&in&IVDA)&Fever,& &
& malaise,&leukocytosis,&heart&murmur&(tricuspid&regurg)& Gastroenteritis&is&self&
• Exfolatins—&(scalded&skin& • Pneumonia&Salmon&colored&sputum,&rapid&onset,&high&rate&of&necrosis,& limiting&
syndrome/bullous&impetigo)& high&fatality:&**MC%post<influenza%(elderly;%rapid%2<3%days),&also&
& associated&with&nosocomial,&ventilator,&IVDA,&CGD,&CF&causes&
• Enterotoxins—&(fast&acting,&heat& • Osteomyelitis%(MCC)&Bone&pain,&fever,&redness,&lytic&bone&lesions&on&
stable)&food&poisoning& imaging&
& • Gastroenteritis&(toxin&preformed&in&food)&2?6&hrs&after&ingestion:&
• Leukocidin—&destroys&leukocytes& nausea,&abdominal&pain,&vomiting,&diarrhea&
(custard,&potato&salad,&canned&meats)&
&
• Biofilm&producer&(Makes&antibiotic& • Causes&biofilms&to&grow&on&plastic&devices&placed&within&the&body&(IV% DOC&
treatment&largely&ineffective,&and& catheters&and&medical&prostheses)& • Vancomycin&+&
implants&must&be&removed)& • Infective%endocarditis&MCC%of%patient%with%prosthetic%valves& aminoglycoside&
&
& *Must&remove&or&replace&
infected&implant&
&
• Adhesins&(lactosamine&structure)& • Honeymoon%cystitis&UTI’s&in&newly&sexually&active&females&when& DOC&
facilitate&adherence&to&urothelium& bacteria&is&displaced&from&the&normal&flora&into&the&urethra& • Trimethoprim?
sulfamethoxazole&(TMP<
SMX)&
• Quinolones&
Streptococcus%
• Cocci&in&chains&
• Catalase&∅&and&Coagulase&∅&
• Facultative&anaerobes&
S.%pyogenes%(Group&A)&
Features& Pathogenesis& Diseases& Treatment&
• β<hemolytic% • M%protein—&antiphagocytic&(M12& Acute&suppurative&infections:& Diagnosis&
• PYR%⊕&(pyrrolidonyl& strains&assoc.&w/&acute& • Pharyngitis&Abrupt&onset&of&sore&throat,&fever,&malaise,&headache,& • Rapid&Strep&test&(ELISA?
arylamidase)& glomerulonephritis)& tonsillar&abscesses,&tender&anterior&cervical&lymph&nodes& based)&
• Bacitracin%Sensitive& • Streptolysin%O—&immunogenic& & • ASO%titer%>200&is&
& (creates&antibodies,&allows&it&to&be& • Scarlet%fever&Pharyngitis&followed&by:& significant&for&RF&
Reservoir& assayed=&ASO&titer)& o Blanching&“sandpaper&rash”(spares&palms&and&soles,&however& &
• Human&throat&and&skin& • Streptolysin&S—not&immunogenic& desquamation&of&palms&and&soles&is&common)& DOC&
& & o Strawberry&tongue,&nausea/vomiting&& • Beta%lactam%drugs%
Transmission& & o Circumoral&pallor&(paleness&around&mouth)& • (Macrolides&for&allergy)&
• Direct&contact& Spreading&Factors& o Fever&and&rash&mediated&by&exotoxins& &
• Respiratory&droplets& • Streptokinase—breaks&fibrin&clot& & Consider&prophylactic&
• Streptococcal&DNAse—liquefies&pus& • Impetigo&Pyogenic&skin&infection&(honey&crusted&lesions)& antibiotics&for&5&years&post&
• Hyaluronidase—hydrolyzes&ground& • Necrotizing%fasciitis&rapid,&amputation,&high&mortality& acute&RF&
substance&of&connective&tissue& & &
• Exotoxins%A<C%— Non?suppurative&sequelae&to&infection:& Jones&criteria&for&RF&
pyrogenic/erythrogenic&superantigens,& • Rheumatic%fever&(Type&2&hypersensitivity)&Antibodies&to&heart&tissue&2& Joints&
cause&fever&and&rash&of&scarlet&fever& weeks&post?pharyngitis&(fever,&joint&inflammation,&carditis,&erythema& ♥(carditis)&
& marginatum,&chorea)&&
Nodules&(subcutaneous)&
&
• Acute%glomerulonephritis&(M12&serotype)&(Type&3&hypersensitivity)& Erythema&marginatum&
Post?pharyngitis;&immune&complexes&bound&to&glomeruli&(HT,&pulmonary& Sydenham&Chorea&
edema,&smoky&urine)&
&
&
&
S.%agalactiae%(Group&B)%
• β<hemolytic% • Capsule—antiphagocytic& **MCC%neonatal%meningitis%and%septicemia**% DOC&
• Hydrolyze%hippurate& • β?hemolysin&& 1. Group&B&strep& • Ampicillin%+%
• CAMP%test%⊕&&(arrowhead& • CAMP%factor—enhances&β?hemolysis& 2. E.&Coli& Aminoglycoside&(or&
pattern&hemolysis&w/&S.& & 3. Listeria& cephalosporin&
aureus&sphingomyelinase)& & &
• Bacitracin%Resistant& Increased&risk&for&women&with&prolonged&labors&after&rupture&of&membranes& • Prophylaxis%during%
& labor&of&infected&women&
Reservoir& (intra&partum)&IV&
• Vagina&(Normal&flora&in&25%& ampicillin&or&penicillin&
of&women)&and&GI&tract& (clindamycin&or&erythro&
& for&allergies)&
Transmission& &
• Newborn&infected&at&birth& &
& &
&
S.%pneumoniae%
Features& Pathogenesis& Diseases& Treatment&
• Lancet&shaped&dipplococci& • Polysaccharide%Capsule—major& MCC%Adult%Meningitis&Peptidoglycan&and&teichoic&acids&are&highly& DOC&
• α<hemolytic%(green&ring)% virulence&factor& inflammatory&in&CNS&(CSF&shows&↑WBCs,&↑protein,&↓glucose)& • Pneumonia:&macrolides&
• Optochin%Sensitive% & Septicemia&MCC&death&in&Sickle&cell&children& • Meningitis:&ceftriaxone&
• Lysed&by&bile& • IgA%protease—&colonizing&factor& & • Otitis&media/sinusitis:&
& aids&in&attachment&to&respiratory& MCC%Otitis%media%and%sinusitis&in&children&& amoxicillin%+%
Reservoir& mucosa&by&cleaving&immunoglobulins& (can&lead&to&cerebellar/temporal&lobe&abcesses)& clavulanate&(erythro&for&
Upper&respiratory&tract& (also&in:&Neisseria,&Haemophilus)& 1. Strep&Pneumo& allergy)&
& & 2. H.&Influenza& &
Transmission& • Pneumolysin%O—damages&respiratory& 3. Moraxella&catarrhalis& Vaccine&
Respiratory&droplets& epithelium&and&inhibits&respiratory& & • Pediatric—Conjugated&to&
% burst/&classical&complement&fixation& MCC%Typical%pneumonia%shaking&chills,&high&fever,&lobar&consolidation,& diptheria&toxoid&w/&13&
& blood?tinged&“rusty&sputum”&(due&to&pneumolysin&O)& MC&invasive&serotypes&
• Techoic&acid& & • Adult&(>65&years)—
% MOPS=&Meningitis,&Otitis&media,&Pneumonia,&Sinusitis& Polysaccharide&vaccine&
Predisposing&Factors—Antecedent& & w/&23&MC&serotypes&(for&
influenza/measles&infection,&COPD,&CHF,& Diagnosis& elderly,&AIDs,&asplenics,&
Alcoholism,&Asplenia& • Quellung%⊕&reaction&(swelling&of&capsule)& sickle%cell)&
& • Lattex%particle%agglutination&(tests&for&capsular&antigen)&
& &
&
Viridans%Streptococci%(S.&Sanguis,&S.&mutans)&
• α<hemolytic%(green&ring)% • Dextran%(biofilm)—&mediated& • Dental%Caries&&(mainly&S.&mutans)&forms&plaque&via&dextran& DOC&
• Optochin%Resistant% adherence&onto&tooth&enamel,&damaged& & • Penicillin&G&+&
& heart&valve&(fibrin<platelet% • Subacute%Infective%Endocarditis&MCC&overall&(mainly&S.&sanguis)& aminoglycosides&
Reservoir& aggregates),&or&each&other& causing&vegetations&on&damaged&heart&valves& &
• Normal&flora&in&oropharynx& (vegetation—provides&protection&from& & &
& immune&system)% Prophylactic&antibiotics&prior&to&dental&work&for&those&with&damaged&heart&
Transmission=&endogenous& valve&
& &
&
Enterococcus%[Group&D—&E.&faecalis,&E.&faecium,&S.&bovis&(non?enterococcus)]&
• PYR&⊕& • Bile/%salt%tolerance&allows&survival&in& • UTI%and%biliary%tract%infections% All&strains&carry&some&drug&
• Varied&hemolysis&(usually& bowel&and&gall&bladder% • Infective%(subacute)%endocarditis%%those&with&damaged&heart&valves& resistance&(no&effective&
gamma:&no&hemolysis)& % during&GI/GU&procedures&(often&elderly)% treatment&for&vanco&
• Hydrolyze%exculin%in%40%% • During&medical&procedures&on&GI/GU& & resistant&strains—D?ala&D?
bile%and%6.5%%NaCl&(bile& tract&E.&faecalis&bloodstream& Endocarditis&with&enterococcus&is&associated&with&GU%procedure&in&the& ala&&
exculin&agar&turns&black)& previously&damaged&heart&valves& elderly& D?ala&D?lac)&
(NOT%strep%bovis)& endocarditis% & &
& If&strep%bovis&is&the&causative&agent&of&endocarditis&there&is&a&high&association& Prophylactic&use&of&
Reservoir& with&underlying&colon%cancer&or&ulcerative&colitis& penicillin+gentamycin&in&
• Colon,&urethra& & patients&with&damaged&
& & valves&prior&to&GI/GU&
Transmission=&endogenous& manipulations&
& &

%
 Gram%Positive%Rods%
Spore<forming%
Bacillus&(Aerobic)&
B.%anthracis%
Features& Pathogenesis& Diseases& Treatment&
• Large,&boxcar?like&rods& • Capsule—polypeptide&(only&human& • Cutaneous%Anthrax&Papule&Malignant&pustules&central&nerosis& Diagnosis&
• Nonmotile& pathogen&w/&polypeptide&capsule)& (black%eschar)&with&erythematous&border&and&painful&lymphadenopathy& • Gram&stain,&serology,&PCR&
• Polypeptide&capsule&(poly?D? antiphagocytic& & &
glutamate)% & • Wool%Sorter’s%disease%(Pulmonary)&Life&threatening&pneumonia:&cough,& DOC&
• Potential&biowarfare&agent& Anthrax%toxin% fever,&malaise,&facial&edema,&cyanosis,&shock&with%mediastinal&hemorrhagic& • Ciprofloxacin%or&
& • Protective%antigen—&mediates&entry& lymphadenitis& Doxycycline&
Reservoir& of&LF/EF&into&cells& & &
• Animals,&skin,&soil& • Lethal%factor—&kills&cells& • Gastrointestinal&anthrax&rare,&edema&+&blockage&of&GI&tract,&bloody& Toxoid&vaccine&given&to&
& • Edema%factor—adenylate&cyclase& diarrhea/vomiting,&high&mortality& high&risk&occupations&
Transmission& (calmodulin&activated&like&pertussis& &
• Contact&w/&infected&animals& adenylate&cyclase)& Population&at&risk:&postal&workers,&farmers,&veterinarians&&
or&inhalation&of&spores& %
&
&
&
B.%cereus&
Reservoir=&nature& • Emetic%toxin—preformed,&fast&&&(fried& • Gastroenteritis%nonbloody,&% Diagnosis&
Transmission& rice?&1?6&hrs)% • Emetic&type&(fried&rice)&similar&to&s.&aureus.&&% • Clinical&
• Fried%rice%from%Chinese% • Diarrheal%toxin—prod&in&vivo& • Diarrheal&type&(meats/sauces)&similar&to&LT&of&ETEC.% &
buffet,&meats/sauce& (meats/sauces?&18&hrs)&↑cAMP=& Tx=&self&limiting&
watery&diarrhea%
%
%
%
Clostridium&(Anaerobic)&
C.%tetani%
• Produces&Tetanus&toxin& • Tetanospasmin—tetanus&toxin& • Tetanus&Risus&sardonicus&(sardonic&grin),&Opisthotonus&(hyperextension& • TIG&(tetanus&
& produced&by&germination&of&spores&in& of&back),&Lock%jaw/tingling%(first%sign),&extreme&muscle&spasms& immunoglobulin)&to&
Reservoir=&soil& the&tissues% & neutralize&toxin&plus&
& & Tetanus&prone&wound&& metronidazole&or&
Transmission& • Toxin&carried&intra?axonally&to&CNS& • Blunt,&burn,&frostbite,&w/&contaminants&1&cm&deep&and&>&6&hrs&old&& penicillin&
• Puncture&wounds/trauma& binds&to&ganglioside&receptors& • Vaccine&(if&>5yrs&since&last&booster)&+&TIG&(if&vacc&history&unknown)& &
• Contaminated&w/&soil& Blocks%release%of%inhibitory%NT% & • Spasmolytic&drugs&
• Requires&low&tissue&O2& glycine/GABA&at&spinal&synapses& Not&tetanus&prone&wound& (diazepam);&debride;&
& excitatory&neurons&unopposed=& • Linear,&1&cm&deep,&no&contaminants,&<&6&hrs&old&&& delay&closure&
extreme&muscle&spasms& • Vaccine&if&>&10&years&since&booster&(or&history&unknown)& &
&
&
&
&
C.%botulinum&
Features& Pathogenesis& Diseases& Treatment&
• Produces&Botulinum&Toxin& • Spores&survive&in&soil&and&dust;& Forms&of&Botulism& • Respiratory%support&in&
& germinate&in&moist,&warm,&nutritious,& • Adult—Preformed&toxin&ingested&(alkaline&vegetables—canned%green% all&cases&
Reservoir=&soil/dust& but&nonacidic%and%anaerobic% beans,%smoked%fish);&1?2&day&onset&weakness,&dizziness,&blurred&vision,& • Antitoxin&for&adults,&
& conditions& flaccid%paralysis,&nausea,&diarrhea,&vomiting& hyperimmune&human&
Transmission& % & serum&for&infants&
• Food&(canned&vegetables,& • Botulinum%toxin%(lysogenic%phage% • Infant—Spores&ingested&(honey,&dust),&toxin&produced&in&gut;&constipation,& • Antibiotics&may&worsen&
smoked&fish,&honey&for& encoded)—polypeptide&neurotoxin& “floppy%baby”%flaccid%paralysis,&diplopia,&poor&feeding,&crying& or&prolong&symptoms&
infants)& (A?B&types&MC),&heat&labile% & &
• Traumatic&implantation& % • Wound—Traumatic&implantation&of&spores&(IVDA)&in&vivo&production&of& Prevention&
• MOA—Absorbed&by&gut&blood&to& toxin;&weakness,&dizziness,&flaccid&paralysis&(no&GI&symptoms)& • Proper&canning/heating&&
peripheral&nerve&synapses%Blocks% & of&vegetables&
release%of%ACh%at%neuromuscular% Note:&the&flaccid&paralysis&is&reversible& • No&honey&first&year&
junction%flaccid&paralysis% &
%
%
%
C.%perfringens%
• Nonmotile& • Spores%germinate&in&anaerobic& Gas%gangrene&(myonecrosis)&mediated&by&alpha&toxin&& Gangrene:%%
• “Stormy&fermentation”&in& conditions&in&tissue% • Contamination&of&wound&w/&soil&or&feces& • Debridement&&
milk&media& • Alpha%toxin%(phospholipase%C)—% • Acute/increasing&pain%at%site& • delayed&closure&&
• Double&zone&of&hemolysis& (produced&by&vegetative&cells)&a& • Tense&tissue&(edema,%gas=&crepitation)&and&exudate& • Clindamycin+&penicillin&
& lecithinase&which&disrupts&membranes,& • Fever,%tachycardia&& • hyperbaric&chamber%
Reservoir=&soil,&colon& cells,&etc&&massive&hemolysis,&tissue& • Rapid,&high&mortality& • Prevent&w/&extensive&
& destruction&(gamma&toxin)% & debridement+&penicillin&
Transmission& % Food&poisoning& %
Traumatic&implantation& • Nagler%Reaction—(egg&yolk&agar)& • Reheated&meat&dishes;&& Food%poisoning%
Food&(Reheated&meat&dishes)& identifies&alpha&toxin&using&antitoxin& • Organism&grows&to&high&numbers&(8?24hrs&incubation)& • Self?limiting&
& on&one&side% • Enterotoxin&produced&in&gut& %
• Enterotoxin—produced&in&gut,& • Self?limiting&noninflammatory&watery&diarrhea& %
disrupts&ion&transport;&heat&labile%
• 12&other&toxins&damage&tissues&
&
&
C.%difficile%
Reservoir=&colon/GI&tract& • Toxin%A—enterotoxin&damaging& Antibiotic%associated&diarrhea,&colitis,&or&pseudomembranous&colitis&(yellow& DOC%
& mucosa&leading&to&fluid&increase;& plaques&on&colon;&necrosis,&exudates,&fibrin,&leukocytes)& • Metronidazole%
Transmission& granulocyte&attractant% • Clindamycin% • Oral&Vancomycin&(if&no&
• Endogenous& % • Cephalosporins& other&drug&available)&
• Long&term&broad&spectrum& • Toxin%B—cytotoxin:&actin& • Amoxicillin,&Ampicillin& • Discontinue&antiobiotic&
antibiotic&therapy& depolymerization&and&loss&of& & therapy%
& cytoskeleton&integrity% Caution&in&over?prescribing&broad&spectrum&antibiotics&(consider&limited& %
spectrum&first)& Isolate&symptomatic&
& nursing&home&patients;&
Check%for%C.%diff%toxin%in%stool% autoclave&bed&pans&
% &
%
Non<spore%forming%
Listeria%monocytogenes&
Features&
• β?hemolytic&
• Tumbling%motility&in&broth;&
actin&jet&motility&in&cells&
• Facultative%intracellular&
parasite&
• Cold%growth&
& • Immune%compromised%predisposed%
Reservoir&
• Animal&GI&tracts&
• Plants,&soil&
• Unpasteurized%milk%
products%
& • Septicemia&and&meningitis&(MC&presentation&of&Listeria)&
Transmission&
• Vertical,&trans?placental&
• Food&(deli%meats,&soft&
cheeses,&coleslaw,&hot&dogs)&
&
&
Corynebacterium%diphtheriae%
• Aerobic,%nonmotile%
• Gray&black&colonies&of&club<
shaped%rods&in&V/L&shapes&
(Chinese&letter&formation)&
• Tellurite%medium%
• Granules&(volutin)&on&
Löeffler%medium&stain&
metachromically&
• β<prophage&genes&can&infect&
normal&diptheroid&of&
another&person&
& • Systemic&&damage%to%nerves%and%
Reservoir&&
• Throat/nasopharynx&
&
Transmission&
• Bacteria/phage&via&
respiratory&droplets&
&
Pathogenesis&
• Listeriolysin<O—%β?hemolysin&that&
facilitates&rapid&egress&from&
phagosome&to&evade&killing&from&
lysosomal&contents%
• Actin%filament%formation—allows&it&
to&jet&from&cytoplasm&to&another&cell%
to%serious%infection%
• Diptheria%toxin&(A?B&component)&
lysogenic%phage%encoded—inhibits&
protein&synthesis&by&adding&ADP?
ribose&to&eEF?2&(similar%to%
pseudomonas)&
& &
Effects&of&toxin&
• Oropharynx&dirty%gray%
pseudomembrae&(dead&cells,&fibrin&
exudate,&bacterial&pigment)&
• Lyrnx/trachea&obstruction&
heart%(most%likely%cause%of%death)—
do%not%scrape%off!&
Diseases& Treatment&
Listeriosis&(peaks&in&summer)& Diagnosis&
• Healthy&adults&and&children—asymptomatic&or&diarrhea& • CSF&wet&mount&shows&
• Pregnant%women—symptomatic&carriage;&fever/chills,&can&cross&placenta& tumbling&motility&
in&septicemia&No&deli&meats&(listeria),&or&changing&cat&litter&(toxoplasma)& &
& DOC&
Neonatal&disease& • Ampicilin%+%gentamycin%
• Early%onset—(granulamatosis%infantisepticum)&transmission&in&utero& &
w/&high&mortality;&disseminated%granulomas%w/%central%necrosis& (NOT&covered&by&
• Late&onset—2?3&weeks&after&birth&from&fecal&exposure;&meningitis&with& cephalosporins)&
septicemia& &
& Pregnant/immune&
Immune&compromised& compromised&should&not&
cold&deli&foods&or&change&
• Listeria%meningitis—MCC%meningitis%in%renal%transplant%patients%and% cat&litter&
adults%with%cancer% &
Diptheria& DOC:&
• Sore&throat&w/&dirty%gray%pseudomembrane%(bleeds%easily)& • Erythromycin&and&
• Bull%neck&(extremely&swollen—potential&respiratory&obstruction)& antitoxin&
• Recurrent&laryngeal&nerve&palsy,&lower&limb&polyneuritis& &
• Myocarditis,&cardiac&dysfunction&(most&likely&cause&of&death)& Endocarditis&
• IV&penicillin&+&
Diagnosis& aminoglycosides&(for&4?6&
New&test&ELISA&to&test&for&toxin& weeks)&
Elek%test&(old&test)&to&document&toxin&production&& %
• Toxin&from&toxin?producing&strains&diffuses&away&from&growth& Vaccine:%
• Antitoxin&diffuses&away&from&strip&of&filter&paper& Toxoid%vaccine%
• Precipitin&lines&form&at&zone&of&equivalence&(=&diptheria)& (formaldehyde&modified&
& toxin&part&of&DTaP,&
boosters&at&10&yr&intervals)%

&
&
&
&
Actinomyces%israelii&
Features& Pathogenesis& Diseases& Treatment&
• Anaerobic% • Invasive&growth&in&tissues&with& Actinomycosis% • Gram&⊕&branching&bacilli&
• Branching%rods% compromised&oxygen&supply& • Non?painful&but&very&invasive&(penetrating&all&tissues)& w/&sulfur%granules%=%
& • Tissue&swelling&draining&abscesses&(sinus&tracts)&w/&sulfur&granules&in& diagnostic&
Reservoir=&normal&flora& exudate&(hard%yellow%microcolonies;&for&diagnosis)&& &
• Gingival&crevices&& • Cervicofacial%(lumpy%jaw)&dental&trauma&or&poor&hygiene& DOC&
• Female&genital&tract& • CNS%solitary%brain%abscess&(Nocardia&produces&multiple&foci)& • Ampicillin%or%penicillin%
& • Thoracic&(aspiration&w/&spread),&Pelvic&(from&thoraci&or&IUDs),&Abdominal& G,%plus&surgical&drainage&
Transmission=&endogenous& (surgery&or&bowel&trauma)&
Nocardia%(N.&asteroides,&N.&brasiliensis)&
• Aerobic% • Predisposition%in%immune% Cavitary%bronchopulmonary%nocardiosis%(N.&asteroides)& Diagnosis—sputum&or&pus&
• Branching%rods% compromised%(transplant%patient)% • Cough,&fever,&dyspnea,&localized&or&diffuse&pneumonia&w/&cavitation& culture&
• Partially%acid%fast%(some& and%cancer& • May&spread&hematogenously&to&brain&(abscesses<%multiple%foci)& &
blue&and&some&red&on&stain)% & DOC&
Cutaneous/Subcutaneous%Nocardiosis%(N.&brasiliensis)& • TMP<SMX&or&high&dose&
• Traumatic&implantation&Cellulitis&w/&swelling—draining&subcutaneous& sulfonamides%
abscesses&w/&granules&(mycetoma)& %
&
Mycobacterium%
• Obligate%aerobe,&sensitive&to&UV&
• Acid%fast&rods&w/&waxy&cell&wall;&↑Lipid&concentration&(mycolic&acid)&
o Resistance&to&desiccation&(drying),&chemicals&(NaOH)&
M.%tuberculosis&
Features& Pathogenesis& Diseases& Treatment&
• Acid&fast&due&to&mycolic&acid& • Facultative&intracellular&organism& Primary%pulmonary%tuberculosis% Uncomplicated&TB&
• Auramine<rhodamine% • Sulfatides—inhibit&phagosome? • Replication&in&naïve&alveolar&macrophages&(kills&macrophage&until&CMI&is& • 2&months&isoniazid+&
stain%(fluorescent&green)& lysosome&fusion& set&up—Ghon&focus?&calcified&tubercle&in&middle/lower&lungs)& rifampin&+&pyrazinamide&
• Slow&growing&on% • Cord%factor&(trehalose&dimycolate)—& • Macrophages&transport&bacilli&to&regional&lymph&node&(Ghon&complex)&and& • Next&4&months&isonizid&
Lowenstein%Jensen& serpentine%growth&in&vitro,&inhibits& most&people&heal&without&disease& +&rifampin&
• Produces%niacin& leukocyte&migration&(disrupts& • Organisms&walled&off&in&Ghon&complex&remain&viable&unless&treated& • Drug&resistance&add&
• Produces%heat%sensitive% mitochondrial&respiration&and& & ethambutol&(and/or&
catalase%(∅&at&68.0°C)& oxidative&phosphorylation)& Latent&phase&(years)—become&tuberculin&⊕& streptomycin)&
& • Tuberculin%(surface&protein)&as&well& % &
Reservoir=&Lungs& as&mycolic&acid—delayed& Reactivational%tuberculosis%(secondary)% Prevention&
Transmission=&Respiratory& hypersensitivity&and&cell?mediated& • Erosion&of&granulomas&into&airways&(high&O2)&later&in&life&under&conditions& Family&members&take&
droplets& immunity&(CMI&mediates&granulomas& of&↓T?cell&immunity=&mycobaterial&replication/disease& isoniazid&(+rifampin)&for&6&
and&caseation)& • Complex&disease&w/&potential&of&infecting&any&organ&system& months&
• Damage&caused&by&immune&system& • Dissemination&seeds&other&organs&(miliary&TB)&Vertebral&column& &
(cell?mediated)& (Pott’s&disease);&chronic&meningitis&(at&base&of&brain);&MC%organ%involved% **Must%do%PPD%before%
is%kidney&(sterile&pyuria)& starting%anti<TNF%therapy&
& (Infliximab,&adalimumab,&
PPD%skin%test&(Mantoux)&⊕&zone&of&induration&at&48?72&hrs&if:& etanercept?&acts&as&receptor&
≥&5mm&in&HIV+&or&those&w/&recent&TB&exposure& decoy)&
≥&10mm&in&high&risk&(IVDA,&poverty,&immigrants)& &
≥&15mm&in&low&risk&
&
M.%leprae&
Features& Pathogenesis& Diseases& Treatment&
• Acid%fast%rods%(seen&in& • Obligate&intracellular&parasite& Leprosy&(Hansen’s&disease)& Diagnosis&
punch&biopsy)& • Cooler&parts&of&body& & • Punch&biopsy&or&nasal&
• Obligate%intracellular% & Tuberculoid% Lepromatous% scrapings&acid&fast&
parasites%(cannot&be& Strong%CMI%(TH1)% Weak%CMI%(TH2)% • Cannot%be%cultured%
cultured&in&vitro)& Lepromin&test&⊕& Lepromin&test&∅& &
• Optimal&growth&at&less&than& Low&number&of&organisms& High&number&(foam&cells&filled)& DOC&
body&temp& Damage&due&to&CMI&killing&infected& Damage&due&to&large&number&of& • Dapsone%+%rifampin&
• Phenolase%⊕& cells& intracellular&organisms& (clofazimine&added&for&
& • Granulomas&nerve&damage/& • Overgrowth&in&cells&nerve& lepromatous)&
Reservoir& enlargement& damage& &
• Mucosa,&skin,&nerves& • Sensation&loss&burns/trauma& • Sensation&loss&burns/trauma& (Dapsone&for&close&family&
• Armadillos&in& Symptoms& Symptoms& contacts—can&cause&
Texas/Louisiana& • Fewer%lesions;&macular& • Numerous%lesions;&nodular& hemolysis&in&G6PD&
& • Nerve&enlargement& • Loss%of%eyebrows% deficiency)&
Transmission& • Paresthesia& • Destruction&of&nasal&septum&
• Nasal&discharge&from& (saddle&nose)&
untreated&lepromatous& • Leonine&(lion<like)%facies&
leprosy&patients& • Paresthesia&
&
&
%
%
Mycobacterium%other%than%tuberculosis%(MOTTs)%
• Atypical&mycobacteria&commonly&found&in&southeastern&U.S.&
• Noncontagious,&found&in&surface&waters,&soil,&cigarettes&
Organism& Transmission& Disease/Presentation& Diagnosis& Treatment&
M.%avium<intracellulare& & Fevers,&diarrhea,&malabsorption/anorexia,&bone& Nonchromogen&(no&pigments)& Clarithromycin,&
(MAC)& & marrow&suppression&& Blood&culture—&grows&at&41°C)& ethambutol,&&&rifampin&&
& Lung&involvement&resembles&TB&(fever,&chills,&etc)& &
Respiratory/&ingestion& Seen%in%AIDS,&cancer,&chronic&lung&disease& Prophylaxis&for&AIDS&
& patients&at&<50%CD4%with&
Reservoir?&aerosolized& Azithromycin&or&
water,&dust,&soil,&cigarettes& Clarithromycin&
&
M.&kansasii& Resembles&pulmonary&tuberculosis& Photochromogen&(pigment& Rifampin,&ethambutol,&
Seen%in%AIDS,&organ&transplants,&silicosis,&hairy&cell& when&exposed&to&light)& isoniazid,&&&pyridoxine&for&
leukemia,&chronic&bronchitis,&COPD& 12&months&
&
M.&scrofulaceum& Contaminated&water&sources& Painless&solitary&cervical&lymph&node&in&children% Scotochromogen&(pigment& Surgery&
(scrofula)&with&overlying&bluish?purple&color& when&exposed&to&dark)&
(Scrofula&in&adult&most&likely&secondary&TB)&
&
M.&marinum& Abrasion&to&extremity&in& Soft&tissue&infection&“fish%tank%granuloma”&seen&in& Photochromogen& Clarithromycin&+&
non?chlorinated&water& tropical&fish&enthusiasts&(purple&papule)& ethambutol&
&
&
&
Gram%∅%stain%pink%

% Gram%Negative%Cocci% Randall %
Neisseria&
• Kidney?bean&shaped&diplococci&w/&flattened&sides&
• Oxidase&⊕&(test&turns&black)&&
• Glucose&⊕&fermentation&
N.%meningitidis%%(⊕&maltose&fermentation)&
Features& Pathogenesis& Diseases& Treatment&
• Large%capsule&latex& • Oropharyngeal&colonization;&spreads&to& Meningitis&and&meningococcemia&(MCC%children/young%adults)& DOC%children/adults%
particle&agglutination&& meninges&via&bloodstream& • Abrupt&onset&of&fever,&chills,&malaise& • Ceftriaxone&
• Chocolate%agar%growth& • Polysaccharide%capsule—&&&&&&&&&&&&(B& • Prostration&(stretched&in&prone&position;&weakness)& • Cefotaxime&
(with&5%&CO2)& strain&MC&but&not&immunogenic=&no& • Stiff&neck&(nuchal&rigidity),&vomiting,&photosensitivity& • Prophylaxis&of&close&
• Ferments%maltose& vaccine)& • Generalized&petechial&rash&(including&palms&and&soles)&in&later&stages&(NOT& contacts&rifampin&(or&
& • IgA1%protease—&allows&colonization& a&good&sign)& ciprofloxacin)&
Reservoir& in&oropharynx& & DOC&neonates&
• Nasopharynx&(5?10%& • Endotoxin%(LPS)—&causes&fever,&septic& Fulminant&cases&ecchymoses,&DIC,&shock,&coma,&death&(Waterhouse<% • Cefotaxime,&ampicillin&
carriers)& shock,&overproduction&of&outer& Friedrichsen%syndrome—rapid&hemorrhage&into&adrenal&glands&adrenal& &
& membrane& insufficiency)& Vaccine&
Transmission& • Pili—&help&colonize&and&invade&& & • Capsular&polysaccharide&
• Respiratory&droplets& • C5<C9%deficiency%predisposes%to% Diagnosis& of&strains&Y,&W?135,&C,&A&
• Colonized&individuals& bacteremia%(multiple&recurrent&N.& • Gram&stain&of&CSF& • No&type&B&(50%&cases):&
(dormitory%setting,%army% meningitidis&infections)& • PCR& not&a&good&immunogen&
recruits)& • Latex%particle%agglutination&(identifies&capsular&antigen&in&CSF)&
%
&
N.%gonorrhoeae%%(∅&maltose&fermentation)%
• Diplococci%in%neutrophils% • Pili%(most%important)—attachment&to& Gonorrhea% Complications% DOC%
• Thayer%Martin%medium& mucosal&surfaces;&inhibit&phagocytosis;& Males&urethritis,&proctitis,&septic% Epididymitis,&prostatitis,&urethral& • Ceftriaxone%(and%test&for&
(chocolate&agar&w/&VPN& antigenic&variation& arthritis&(knee&MC)& strictures& Chlamydia)&
antibiotics&to&prevent& Outer&membrane&proteins—&& Females%&endocervicitis,&PID,& Fallopian%tube%scarring& &
normal&flora&growth)& • OMP&I&(for&serotyping)&& septic&arthritis&(knee&MC)& (infertility,&ectopic&pregnancy),& Prevention&
& • Opa&proteins&(antigenic&variation,& (more&likely&asymptomatic)& Fitz<Hugh<Curtis%syndrome& • Adults—condoms&
Reservoir=&Genital&tract& adeherence)& (Perihepatitis:&RUQ&tenderness)% • Neonatal&ophthalmia—
% • IgA%protease&(colonization)& Infants&ophthalmia&(at&2&days)& Blindness&if&untreated& erythromycin%ointment%
Transmission& & Sexually&active&patient&with&cloudy%yellow%green%discharge% in%eyes%at%birth%(also&
• Sexual&contact,&birth& Invades&mucosal&surfaces& & protects&against&
• Sensitive&to&drying/cold& inflammation&and&↑PMNs& Diagnosis& chlamydia)%
& • Intracellular&gram&negative&diplococci&in&PMNs&from&urethral&smear&
• Culture&on&Thayer?Martin&
&
Moraxella%catarrhalis%%(close&relative&of&Neisseria)&
Reservoir=&Normal&flora& • Endotoxin&may&play&role&in&disease& • Otitis%media%(3rd&MCC)%& DOC&
• Upper&respiratory&tract& • Sinusitis%(3rd&MCC)& • Amoxicillin&+&Clavulanate&
Transmission& • Bronchitis&and&bronchopneumonia&in&elderly&w/&COPD& &
• Respiratory&droplets&
 Gram%Negative%Rods%
AEROBIC%(Pseudomonas,&Legionella,&Francisella,&Bordetella,&Brucella)&
Pseudomonas%aeruginosa%(Obligate&aerobe)&
Features& Pathogenesis& Diseases& Treatment&
• Oxidase%⊕& • Glycocalyx%capsule/slime%layer— • Healthy&Hot%tub%folliculitis,%otitis%externa%(swimmer’s%ear—%malignant& Diagnosis&
• Motile,&Non?lactose& allows&formation&of&pulmonary& OE&in&diabetics),&GI&(loose&stools),&corneal&infections&(trauma,&prolonged& • Gram&stain&and&culture&
fermenter&on& microcolonies;&antiphagocytic& contact&wear)& &
MacConkey/EMB& • Endotoxin%(LPS)—causes& & DOC&
• Fluorescein&and&Pyocyanin& inflammation&in&tissues&and&shock&in& • Diffuse%bronchopneumonia&in&Neutropenic,&CGD,&burn&patients&[recurrent& • Piperacillin%+%
(blue?green&pigment&on&TSA& septicemia& in&Cystic&Fibrosis—(↑slime?producing&strains,&biofilm)]& Tazobactum%(pip?taz)&
agar)& • Exotoxin%A—ADP&ribosylation&of&eEF? & • Aminoglycosides&
• Grape<like%odor% 2;&inhibits&protein&synthesis&(similar&to& • Sepsis&Fever,&shock,&±&ecthyma%gangrenosum%in%neutropenic%patients% &
& diphtheria&toxin)&Primary&target&is&liver& (black,&necrotic&center&w/&erythematous&&margins)& Prevention&
Reservoir& & • Pasteurization/&
• Ubiquitous&in&water& • Cellulitis%w/%blue%green%pus%in%Burn%patients&(GI&tract&colonization,&skin,& disinfection&of&water?
& colonization&of&eschar,&cellulitis,&septicemia)& related&equipment,&hand&
Transmission& & washing&
• Water%aerosols%(dialysis& • UTIs%in%catheterized%patients% • No&flowers/&raw&veggies&
equipment),&raw%veggies,% % in&burn&units&
flowers& • Osteomyelitis%(Diabetics,%nail%through%rubber%footwear,%IVDA)&
&
&
Legionella%pneumophila%(requires&cysteine)&
• Oxidase%⊕& • Facultative%intracellular%pathogen% Legionnaires%disease% DOC&
• Weakly&gram&negative& (macrophages&granulomas)& • Atypical%pneumonia%(can&consolidate&however)% • Fluoroquinolones&
pleomorphic%rods%& • Endotoxin&(LPS)& • Mental&confusion,&diarrhea&(however&NO&legionella&in&GI&tract)& • Azithromycin&
• Require%cysteine%&%iron& & • Causes%hyponatremia% • Erythromycin&
• Charcoal%yeast%extract% Predisposing&factors& • Associated%w/%air%conditioning%systems% (Add&rifampin&for&
& • Smokers%>%55%yrs%w/%high%alcohol% • High&mortality&without&treatment& immunocompromised)&
Reservoir& intake& % &
• WATER&(rivers,&streams,&air< • Immunosuppressed&patients& Pontiac&Fever& Prevention—routine&
conditioners,&produce& Young&person&w/&pneumonitis& decontamination&of&air?
misters)& Can&go&untreated& conditioner&cooling&tanks&
Transmission& &
• Inspired&aerosolized&H2O& Diagnosis&DFA%(direct&fluorescent&antibody)&on&biopsy,&by&silver%stain%
• NOT%PERSON%TO%PERSON!!% Antigen&can&also&be&detected&in&urine&
&
Francisella%tularensis%(requires&cysteine)%
Reservoir=&animals& • Facultative%intracellular%pathogen—% Tularemia& DOC&
• Rabbits,&deer,&rodents& localizes&in&reticuloendothelial&cells& • Ulceroglandular%form&Tick&bite&or&traumatic&implantation&while& • Streptomycin%
& (granulomatous&response—type&IV& skinning%rabbits&(ulcer&with&black&base,&fever,&regional&lymph&node& • Doxycycline&
Transmission& hypersensitivity)& enlargement&and&necrosis)& &
• Tick&bite&(dermacentor)& & • Pneumonial&form&inhalation&of&aerosol&from&skinning&rabbits& Vaccine&
• Skinning&rabbits&(implant&or& Highest&in&Arkansas,%Missouri& • Typhoidal&form&ingestion&of&infected&meat&or&contaminated&water& • Live,&attenuated&for&high&
inspiring&aerosol)& Potential&biowarfare&agent&as&aerosol& & risk&(vets,&forest&ranger,&
• Undercooked&meat&& *Rabbit%hunter%from%Arkansas*% hunter)&
Brucella%(B.&abortus,&B.&melitensis,&B.&suis)&(requires&cysteine)&
Features& Pathogenesis& Diseases& Treatment&
Reservoir=&livestock& • Facultative%intracellular%pathogen—% Brucellosis&(undulant&fever)& DOC&
• Cattle&(abortus)& localizes&in&reticuloendothelial&cells& • Acute&septicemias,&fever%100<%104°F%(often%in%evening)& • Rifampin%+%Doxycycline&
• Goats/sheep&(melitensis)& (granulomatous&response&with&central& • Profuse%sweating,&influenza?like,&& (6&wks)&
• Pigs&(suis)&& necrosis)& • Arthralgias,&anorexia,&myalgia,&back&pain& &
& • Endotoxin& • Hepatomegaly& (children:&cotrimoxazole&
Transmission& & & instead&of&doxy)&
• Unpasteurized%dairy% Potential&biowarfare&agent& Undulant&form&is&milder&(often&result&of&incomplete&treatment)& &
products—goat&milk& & Prevention&
(recent&travel&to&Mexico—& Chronic&form&(more&than&one&year&w/&disease)& • Vaccinate&cattle&and&high&
Cali&and&Texas&highest&#& • Usually&B.&melitensis&in&older%veterinarians& risk&humans&(vets,&
cases)& • Cyclic&bouts&of&depression,&confusion,&profuse&sweating& slaughterhouse&workers,&
• Direct%contact&with&animal& & military)&&
(slaughterhouse)& • Pasteurize&milk&
&
&
Bordetella%pertussis%(cysteine&NOT&required)&
• Encapsulated& Attachment&(to&nasopharyngeal&ciliated& Pertussis%(Whooping%cough)% Supportive&care,&
• Bordet<Gengou%medium& epithelial&cells)& % hospitalization&<6&months&
(potato,&blood&and&glycerol)& • Filamentous&hemagglutinin—allows& Stages&(duration)& old&
& organism&to&bind& Incubation& Very&difficult&to&culture& &
Reservoir& • Pertussis&toxin&aids&in&attachment& (7?10&days)& No&symptoms& DOC&
• Vaccinated&humans— & Catarrhal% BEST%chance%of%culture% Erythromycin&(14&days&
(because&vaccine&is&toxoid)& Toxins&(damage&respiratory&epithelium)% (1?2&weeks)& Runny&nose,&low?grade&fevers,&occasional&cough,&highly& including&all&household&
• Mucosal&surface&pathogen& • Adenylate%cyclase%toxin—impairs& contagious&& contacts)&
& leukocyte&chemotaxis&(inhibits& Paroxysmal% Difficult&to&culture& &
Transmission& phagocytosis;&causes&local&edema& (2?4&weeks)& Fits&of&rapid&forceful&coughing&followed&by&inspiratory& Vaccine&
• Respiratory&droplets& similar%to%Anthrax%edema%factor% gasps&(whoops),&vomiting&often&follows&attacks& • DTaP&(diphtheria,&
toxin)% Adults&(persistent&cough),&children&with&immunization& tetanus,&acellular&
% wearing&off,&and&infants&(cough&w/&apnea&spells)&may& pertussis)&
• Pertussis%toxin—(A&and&B&component,& not&have&typical&whoop& • Acellular&pertussis=&
OM&protein&toxin)&ADP<ribosylation% Convalescent& Cannot&culture& filamentous&
of%Gi&interferes&with&transfer&of&signals& (3?4&weeks)& Infrequent/diminished&attacks;&secondary&symptoms& hemagglutinin&+&
from&cell&surface&to&intracellular& (pneumonia,&seizures,&encephalopathy)& pertussis&toxoid&
mediator&system=&↑cAMP% & • Immunity&wanes&5?7&
o Lymphocytosis&promotion& Diagnosis& years&
o Islet?activation&hypoglycemia& • Regan<Lowe%or%Bordet<Gengou&media&during&catarrhal&stage&&&&&&&(direct& • Infants&not&protected&by&
o Blocks&immune&effector&cells& cough&plates&or&nasopharyngeal&cultures)& breast&milk&(IgA)&bc&
o Increased&histamine&sensitivity% • Direct&immunofluorescence&(DFA)&on&nasopharyngeal&smear& mother’s&immunity&has&
% • PCR&and&serologic&tests&(ELISA)&available& waned&
• Tracheal&cytotoxin—kills&ciliated&cells;& &
interferes&with&cilliary&action&% &
%
• Endotoxin&(LPS)%
%

%
FACULTATIVE%ANAEROBIC%(rest&of&gram&∅&except&Bacteroides)%
Curved/S?shaped&Rods&with&Flagella&
• Oxidase&⊕&(test&turns&black)&&
Campylobacter%jejuni%%
Features& Pathogenesis& Diseases& Treatment&
• Curved&rods&with&polar& • Low%infectious%dose%(as&few&as&500)% Gastroenteritis& • Supportive&via&fluid&and&
flagella&(“gulls’&wings”)& • Acid&resistant& • MCC%infectious%diarrhea%in%US& electrolyte&replacement&
• Grows%well%at%42°C&on& • Invades/destroys&mucosa&of&colon% • 10&or&more&stools/day,&may&be&frankly&bloody& • Generally%self<limiting%
Skirrow’s&agar& blood/pus%in%stool%(inflammatory% • Abdominal&pain,&fever,&malaise,&nausea,&vomiting& (3<5%days)&
• Microaerophilic& diarrhea)% % &
& • Rarely&causes&septicemia& Complications& Severe/prolonged&cases&
Reservoir& • Guillain<Barre%syndrome%(GBS)%(30%&of&GBS&cases&in&US)& DOC&
• GI&tract&of&humans,&cattle,& o Ascending&paralysis;&weakness&in&hands/feet&migrating&to&trunk& • Erythromycin%
sheep,&dogs,&cats,&poultry& o Serotype&O:19,&antigenic&cross?reactivity&between&Campylobacter& • Ciprofloxacin&
Transmission& oligosaccharides&and&glycosphingolipids&(gangliosides)&on&neural&tissues&
• Fecal?oral&(MCC% (molecular%mimicry)&
contaminated%poultry),% • Reactive&arthritis&(Reiter’s&syndrome)&
handling%puppies&
&
Helicobacter%pylori&
• Spiral&bacilli&w/&flagella& • Motile% • Chronic%gastritis%and%duodenal%ulcers% DOC=&triple&therapy&
• Urease%⊕& • Urease—%ammonium&cloud& • Associated%with%several%forms%of%stomach%cancer%(H.%pylori%is%a%type%1% 1. Omepraxole&
• 37°C&growth&on&Skirrow’s& neutralizes&stomach&acid,&allowing& carcinogen)% 2. Amoxicillin&
agar& survival&in&stomach&acid% o Gastric%adenocarcinoma% 3. Clarithromycin&
• Microaerophilic& • Mucinase—%penetration&of&mucous& o Gastric%MALT<oma%% &
& layer&(invades&stomach&lining:&where& o B<cell%lymphoma% (PPi&+&2&antibiotics)&
Reservoir=&humans& pH&is&neutral)% %
Transmission=&fecal?oral/&oral? • Type&I&biotype&(out&of&2)&produces& Diagnosis%Biopsy%w/%culture%(gold%standard);%histology&w/&giemsa&or&
oral& vacuolating&cytotoxin& silver&stain;&also&urea&breath&test&(13C?urea)&
%
Vibrio%Cholerae%(V.&parahaemolyticus,&V.&vulnificus)&
• Curved&rod&w/&polar&flagella& • High%infectious%dose&>107&(sensitive& Cholera& • Fluid%and%electroyte%
• Growth&on&alkaline&media& to&stomach&acid)% • Rice%water%diarrhea&(specks&of&mucous)& replacement%(IV)%
Thiosulfate%citrate%bile%salt% & • Tremendous&fluid&loss&(20L&per&day!)& • Doxycycline&or&
sucrose%(TCBS)& • Motility,&mucinase,&and&toxin& (ddx—ETEC&is&oxidase&negative)& ciprofloxacin&shorten&
• “Shooting%star%motility”& coregulated&pili&(TCP)&aid&in& V.%parahaemolyticus% V.%Vulnificus% disease&and&reduce&
• O1&biotypes—El&Tor&(MC)& attachment&to&intestinal&mucosa& Consumption&of&undercooked/&raw% Swimming&in&brackish&water,& carriage&
and&Cholerae&(classic)& & seafood& shucking%oysters& &
• O139&is&more&recent& • Cholera%enterotoxin&(choleragen)—& Gastroenteritis&watery&diarrhea& Cellulitis&rapidly&spreading;& Prevention=&
Reservoir=&colon&and& similar&to&E.&coli&LT&ADP% with&cramping&and&abdominal&pain& difficult&to&treat,&may&require& Proper&sanitation&
invertebrates&(shellfish& ribosylation%of%Gs%alpha&activating& Cause&of&25%&food&poisoning&in& amputation& &
contaminated&by&water)& adenylate&cyclase&↑cAMP&efflux&of& Japan&(3?day&diarrhea)& *Fisherman%cuts%themselves% Tetracyclines&or&third?
& Cl?&and&H2O&(ions&leave&cells,&water& shucking%oysters*% generation&cephalosporins&
Transmission=&fecal?oral& follows)& (consumption&could&cause&GE& for&V.&vulnificus&cellulitis&
(hurricane,&flood)& & similar&to&V.&parahaemolyticus)&
Lysogenic&phage&encoded& & Self?limiting&(Doxy&if&severe)& DOC:&Tetracyclines&
Enterobacteriae%Family& & & & & &&Lactose&fermenters&turn&pink&on&MacConkey&Agar&(vs.&colorless)%
• Catalase&⊕,&Oxidase%∅& Lactose%fermenters% Non%lactose%fermenters%(ShYPS)%
• Facultative&anaerobic& Citrobacter& Nonmotile%% Motile%%
• Ferment&glucose& Enterobacter& (non?H2S&producers)& (H2S&producers)&
• Reduce&nitrates&to&nitrites&(UTIs—nitrites&in&urine)& E.&coli& Shigella& Proteus&
Lactose%Fermenters% Klebsiella& Yersinia& Salmonella&

Escherichia%coli%
Colonies&with&iridescent&
green&sheen&on&EMB&
& UTI%(MCC)%
Reservoir&
• Colon,&may&colonize&
vagina&or&urethra&
• Crops&where&human&
fecal&fertilizer&is&used&
• EHEC&strains:&bovine&
feces&
& ETEC&(Traveler’s&diarrhea)&
Transmission&
• Endogenous&
• Fecal?oral&
• Maternal&fecal&flora&
• EHEC:&raw&beef,&milk,&
apple&juice&from&
fallen&apples&
Disease&
Neonatal&septicemia/&
meningitis&(2nd&MCC)&
Septicemia&(MCC&gram&neg&
sepsis)&
EPEC&(Pediatric&diarrhea)&
EIEC&(Invasive&diarrhea)&
EHEC&(Hamburger,&bloody&
diarrhea)&
Others:&EAEC&(developing&world—biofilm;&EAST&toxin);&DAEC&(infants&to&5yrs—elongation&of&microvilli&w/&bacteria&in&cell&membrane)&
Pathogenesis& Clinical&Clues& Treatment&
Endogenous&fecal&flora&contaminate;&ascend& Females>&Males& TMP?SMX&
Motility,&adherance%to%uroepithelium—pili&(pyelonephritis&associated),&X? Fluoroquinolones&
adhesins,&β?hemolytic&(many)&
Maternal&fecal&flora&contaminate&during&parturition& Blood&culture&& Ceftriaxone&
Capsule—K1%serotype%% CSF&culture&
Endotoxin&(LPS)&causes&shock,&inflammation&at&BBB&
Indwelling&IV&lines,&cytotoxic&drugs&(damage&intestinal&mucosa;&allow&escape)& Blood&culture& Fluoroquinolones&
Endotoxin&(LPS,&Lipid&A)—&Fever,&hypertension& &
LT?&heat&labile&Stimulates&adenylate&cyclase&(ADP%ribosylation%of%Gs— Noninflammatory& Rehydration&&
similar%to%Cholera%toxin)& Bioassay,&DNA&probe& (TMP?SMX&may&
ST<&heat%stable&toxin&Stimulates&guanylate&cyclase—capsule&impedes& shorten&symptoms)&
phagocytosis;&colonizing&factor&adhesins&(CFAs)&bind&to&intestine&mucosa&
&
2nd%MCC%infantile%diarrhea&(1st&is&rotavirus)& Noninflammatory;& Fluoroquinolones&
Adherance&to&M&cells&rearrangment&of&actin;&effacement&of&brush&border& Babies&in&developing&
microvilli& world&
Inflammatory&diarrhea&similar&to&shigella&(watery&bloody)& Blood,&pus,&&fever,& Fluoroquinolones&
Formation&of&actin&jet&trails;&invades&large&bowel& abdominal&pain&
O157:H7%strain&most&common;&hamburger&meat,&petting&zoos& No&fever&or&PMNs,& NO%antibiotics&
Inflammatory,&noninvasive%bloody%diarrhea& Blood&in&stool,&may& ↑&risk&of&HUS&
Verotoxin—Shigella?like&toxins&1&and&2,&↓&protein&synthesis&by&binding%60S&
progress&to&HUS%in% (releases&more&
ribosomal&subunit&(similar%to%shigella)% children%(anemia,% toxin)&
Does%not%ferment%sorbitol%or%contain%glucuronidase% thrombocytopenia,%
acute%renal%failure)&

Klebsiella%pneumoniea&
Features&
• Large%polysaccharide%
capsule%
• Mucoid,&lactose&fermenting&
on&MacConkey&agar&
• “Viscuous&colonies”&
& UTIs%(3rd&MC)&Catheter?related%(nosocomial)&from&fecal&contamination&
Reservoir=&colon/Upper&
respiratory&tract&
Transmission=&endogenous&
Pathogenesis&
• Capsule—impedes%phagocytosis%
• Endotoxin&(LPS)—causes&fever,&
inflammation&and&shock&(septicemia)&
Diseases& Treatment&
Pneumonia%(lobar)% Diagnosis—sputum&culture&
• Seen&in&older&males,&chronic&lung&disease,&alcoholism,&diabetes& or&clean&catch&urine&sample&
• Frequent&abscesses&make&treatment&difficult;&high&fatality& &
• Sputum%thick%and%blood%(currant%jelly)&NOT&foul&smelling& DOC&
% • 3rd&gen&cephalosporins&
• Fluoroquinolones&
& &
Septicemia&Immunocompromised;&bowel&defects,&IV&line&invasion& Many&resistant&strains&
(2nd&MCC&gram&neg&sepsis)&
&
Non<Lactose%Fermenters%
Nonmotile&(Non?H2S&producers)&
Shigella%&
Features& Pathogenesis& Diseases& Treatment&
• Identified&by&serology&w/& • Endotoxin&triggers&inflammation& Shigelosis/enterocolitis&(most&severe&form=&dysentery)% Mild&cases—fluid&and&
anti?O&antibody&in& • Shigellae&invade%M%cells&(membrane& • Low%infectious%dose%(1?10&organisms;&extremely&acid&resistant)% electrolyte&replacement&
agglutination&test& ruffling&and&macropinocytosis)& • 1?4&day&incubation&organisms&invade&bloody%diarrhea% &
& replicate&in&cytoplasm&polymerize% • Fever,&lower&abdominal&cramps,&tenesmus,&starts&as&watery&diarrhea&then& Severe&cases—
Reservoir& actin%jet%trails%laterally%without% becomes&bloody;&invasive&(shallow&ulcers)&but&no&septicemia% Fluoroquinolones&
• Human&colon&only& going%extracellular&(produces&very& • Severity&depends&on&age&of&patient&and&strain&(usually&1?2&week&duration)& NO&ANTIDIARRHEALS&
& shallow&ulcers—no&invasion&of&blood& o S.&sonnei&(MC&in&U.S.)& &
Transmission& vessels)& o S.&dysenteriae&(most&severe&disease)& Resistance&by&plasmid?
• Fecal?oral,&person&to&person& • Shiga%toxin—Produced&by&S.& o S.%flexneri%(associated%with%Reiter’s%syndrome)% encoded&enzymes&
(Daycare)&& dyseneriae&(type&1—&neurotoxic,& o S.&boydii& &
cytotoxic,&enterotoxic)&A?B&component& & Prevent&w/&proper&
toxin&is&internalized&in&human&cells;% Diagnosis—&isolation&from&stool&during&illness&and&culture&on&selective&media& sanitation&
inhibits%protein%synthesis%by%
clipping%60s%ribosomal%subunit%
%
%
Yersinia%pestis%
• Bipolar%staining% • Coagulase%(most&important)—clots& Bubonic&plague& Diagnosis:&
• Facultative&intracellular& stomach&content&of&flea&and&makes& • Flea&bites&infected&animal&and&then&later&uninfected&human& • No&cultures—they&are&
parasite& them&hungry& • Rapidly%increasing%fever%% hazardous&
• Coagulase&⊕&& • Endotoxin&and&exotoxin& • Regional%buboes%(swollen%lymph%nodes)% • Serodiagnosis&or&direct&
& • Envelope%antigen%(F<1)—inhibits& • Conjunctivitis% immunofluorescence&
Reservoir& phagocytosis& • Leads&to&septicemia&and&death&if&untreated&(DIC—turns&black)% • “Safety%pin”&staining&
• US&desert&southwest& • Type&III&secretion&system&suppresses& % (bipolar&staining)&
• Rodents,&prairie&dogs& cytokine&production&and&resists& Pneumonic&plague&(potential&biological&warfare)& DOC&
& phagocytic&killing& • Highly%contagious!% • Aminoglycosides%
Transmission& • Arises&from&septic&pulmonary&emboli&in&bubonic&plague&or&inhalation%of% &
• Wild&rodent&flea%bite% organisms%from%infected%individual% Prevention&
(regurgitates&stomach& • Killed&vaccine&(military)&
contents&into&humans)&
&
Yersinia%enterocolitica&
Features& Pathogenesis& Diseases& Treatment&
• Motile%at%25°C%%(not&37)& • Enterotoxin,&endotoxin& Enterocolitis& Diagnosis&
• Cold%growth& • Multiplies&in&the&cold& • Very&young—febrile&diarrhea&&(blood&and&pus)& • Stool&culture,&25°C,&cold&
Reservoir=&zoonotic& • Adolescents—mimics%appendicitis!!!%(also&y.&pseudotuberculosis)& enrichment&
& • Adults—enterocolitis&with&postinfective&sequelae&like&reactive&arthritis& &
Transmission& & • Supportive&care&
• Unpasteurized&milk,&pork,& Blood&transfusion&associated&infections& • Fluoroquinolones&for&
pet&feces& immunocompromised&
• Northern&climates& &
&
Motile&(H2S&producers)&
Proteus%(P.&mirabilis,&P.&vulgaris)&
Features& Pathogenesis& Diseases& Treatment&
• %“Swarming%motility”&on& • Peritrichous%flagella?&motility&(may& • Urinary&tract&infections&(4th&MCC)& DOC&
blood&agar& aid&entry&into&bladder)& • Kidney&stones&staghorn&renal&calculi&(Ammonium&magnesium&phosphate)& • Fluoroquinolones%
• Urease%⊕&Production& • Urease—raises%uring%pH%to%cause% • Septicemia& • TMP?SMX&
% kidney%stones%(staghorn%renal% % • Remove&stones&
Reservoir& calculi)& Diagnosis—culture&of&blood&or&urine&for&lactose&negative&organisms&with& &
• Colon&and&environment& • Endotoxin—fever&and&shock&when& swarming&motility;&↑&urine&pH& Prevention&
(water&and&soil)& septicemia&occurs& & Remove&urinary&cath&
Transmission=&Endogenous&
&
Salmonella%enterica%(subsp.&typhi)&
• Highly%motile%with%the%Vi% Ingested&organism&ileocecal&infection& Typhoid%fever% DOC&
capsule& M?cells&&mesenteric&lymph&nodes& • Constipation%first%symptom&(due&to&ileocecal&infection)& • Ceftriaxone%
• Sensitive%to%acid& blood& • At&1&week&80%&⊕&blood&cultures,&25%&rose%spot%rash%on%trunk& • Fluoroquinolones&
• Facultative&intracellular& & • Liver&and&spleen&infected&↑&bacteria&in&blood&(septicemia/fever)& &
parasite& Survives&intracellularly&and&replicates&in& • Biliary&system&infected&organisms&enter&intestinal&tract&in&bile& &
& macrophages;&resists&macrophage&killing& • Fever,&headache,&abdominal&pain& Prevention=&sanitation&
Reservoir& due&to:& • Alternating%constipation%and%diarrhea% &
• Humans&only& • Decrease%fusion%of%lysosomes&with& & 3&Vaccines&
& phagosomes& Complications&if&untreated& • Parenteral&
Transmission& • Defensins&(proteins)&allow&it&to& • Necrosis%of%Peyer%patches&perforation&(local&endotoxin)& polysaccharide&capsular&&
• Fecal?oral&(infection&sets&up& withstand&oxygen?dependent&and& • Thrombophlebitis,&cholecystitis,&pneumonia,&abscess,&etc.& • Attenuated&oral&&
in&gall&bladder)& independent&killing& & (strain&21?&Ty21a)&
• ↓&Stomach&acid&or& • Vi%capsular%antigen—withstands% Diagnosis—&organisms&isolated&from&blood,&bone&marrow,&urine,&tissue&from& • Parenteral&heat?killed&
impairment&of&mononuclear& complement<mediated%killing& the&rose&spots& (no&longer&used&in&US)&
cells&(sickle&cell)&predisposes& &
to&infection&
&
&
Salmonella%enterica%(subsp.&enteritidis,&typhimurium,&choleraesuis,&paratyphi,&dublin)&
• Serotyped&with&O,%H,%and%Vi% • High%infectious%dose—&(>105)& Enterocolitis/gastroenteritis% Gastroenteritis&
antigens—detected&by& Sensitive&to&stomach&acid&& • 2nd%MC%bacterial%cause%(1st&Campylobacter)% • Self?limiting,&&
agglutination:&Widal%test% • Lowered&stomach&acidity&(PPi’s,& • 6?48&hr&incubation&nausea,&vomiting;&loose&stools&(occasionally&bloody),& • NO%ANTIBIOTICS%(may%
& antacids)&increases&risk& fever,&abdominal&pain,&myalgia,&headache& prolong%fecal%
Reservoir& • Endotoxin&in&cell&wall& & excretion)%
• Enteric&tracts&of&humans&and& • Invades%mucosa&in&ileocecal&region,& Septicemia& &
domestic&animals&(chickens% invasive&to&lamina&propria& • Choleraesuis,&paratyphi,&Dublin& Invasive&disease&
&%turtles)% inflammation&↑&PG&↑cAMP=&loose& • Rare,&only&very&young&or&elderly;&10%&complicated&w/&endocarditis& • Ampicillin&
& diarrhea;&shallow&ulceration& & • Ceftriaxone&
Transmission% & Osteomyelitis% • Fluoroquinolones&
• Raw%chicken,%eggs% MOA=&inflammation&(NO&toxins)& • Salmonella%is%MCC%causual%agent%in%sickle%cell%disease% • TMP?SMX&
• Reptile&pets&(snakes,&turtles)% %
Diagnosis:&culture&on&Hektoen%agar&(green&agar&that&turns&black)&
&
&
Haemophilus%
• Pleomorphic&rod&(considered&coccobacillus)&
• Requires%growth%factors%X%(hematin)%and%V%(NAD)&for&growth&on&blood&agar&
• Satellite%phenomenon&(with&S.&aureus&on&blood&agar)&
o Pinpoint&colonies&(S.&aureus&secretes&NAD&and&lysed&blood&releases&hematin)&
• Chocolate%agar&(provides&both&X&and&V&factor)&
Haemophilus%influenzae&
Features& Pathogenesis& Diseases& Treatment&
• Encapsulated& • Polysaccharide%capsule%(most% Meningitis& DOC&
• 95%&of&invasive&disease& important)—type&b&capsule&is& • Epidemic&in&unvaccinated&children&ages&3&months&(after&maternal&antibody& • Ceftriaxone&
caused&by&capsular&type&b& polyribitol&phosphate& wanes)&to&2&years&(before&immune&response&is&adequate)& • Cefotaxime&
& • Attachment%pili& • Before&1990??&MCC&meningitis&in&1?5&yr&old& Rifampin=&prophylaxis&
Reservoir& • IgA&protease—colonizing&factor& & &
• Human&nasopharynx& & Epiglottitis&Unvaccinated&toddlers—catcher’s%stance%w/%drooling&(dog& Vaccine&
& • Latex%particle%agglutination%screen& sniffing&position—drop&heads&to&catch&breath&due&to&swelling&of&epiglottis)& • Conjugate%capsular%
Transmission& for&capsular&antigen&in&CSF& & polysaccharide%protein%
• Resiratory&droplets& & Nontypable&strains& vaccine%coupled%to%
• Shared&toys& & Otitis&media/sinusitis&2nd&MCC&cause&(also&presents&w/&conjunctivitis)& protein%carrier%
& & & (diptheria%toxoid)%
*Unvaccinated%child*& & Bronchitis&exacerbations&of&acute&bronchitis&in&smokers&w/&COPD& • Prevents&type&b&
% Pneumonia&smoking&history;&rare&in&vaccinated&children& • T<cell%dependent%
& • Not&live;&2,&4,&6&months&
• Booster&at&15&months&
&
Haemophilus%ducreyi&
Reservoir& No&exotoxins& Chancroid&& DOC&
• Human&genitals& • PAINFUL%genital%ulcer%(syphilis&is&painless)& • Azithromycin%and/or%
& • Often&associated&with&unilateral&swollen&lymph&node&(can&rupture&releasing& Ceftriaxone%
Transmission& pus)& • Ciprofloxacin&
• Sexual&and&direct&contact& & &
Painful&chancroid=&“you&do&cry&with&ducreyi”& &&
&
Gardnerella%vaginalis&
• Gram<variable%rod&&&(gram& • Polymicrobial&infections& Bacterial&vaginosis& DOC&
⊕&that&could&become&gram&∅& & Vaginal&odor,&thin,%gray%discharge& • Metronidazole&
after&culturing)& • Works&synergistically&with&other& & • Clindamycin&
Reservoir=&normal&flora& normal&flora&(Lactobacillus,&Mobiluncus,& Diagnosis&
• Vagina& Bacteroides,&Peptostreptococcus)& pH&>4.5,&Vaginal&saline&smear&clue%cells&(vaginal&epithelial&cells&that&
& % contain&tiny&plemorphic&gram&negative&bacilli&within&the&cytoplasm)&
Transmission=&endogenous& • ↑pH&associated&with&reduction&of& Whiff&test:&add&KOH%to%sample%“fishy”&amine&odor&
• Flora&gets&disturbed&(stress,& vaginal&Lactobacillus& &
menses,&antibiotics,&↑pH)& Other&discharges&
• Gonorrhea&cloudy&yellow?green,&purulent&
• Chlamydia&clear,&white&
• Trichomonas&frothy&green&w/&foul&odor&(strawberry&cervix)&
• Candida&cottage&cheese&(only&one&with&decreased&pH)&
&
&
Gram%negative%rods%associated%with%Animal/Human%bites%
&
Pasteurella%multocida&
Features&
Reservoir&
• Animal&mouth;&especially&
cats&and&dogs&
• Requires%cysteine%
& &
Transmission&
• Animal%bite:%particularly%
from%cats%
Additional&organisms&
Eikenella%Corrodens%
Capnocytophaga%
canimorsus%
Bartonella%henselae%
Bartonella%quintana%
HACEK%group%infections&
Haemophilus&aphrophilus&
Actinobacillus&
actinomycetemcomitans&
Cardiobacterium&hominis&
Eikenella&corodens&
Kingella&kingae&
&
%
OBLIGATE%ANAEROBIC%%
Bacteroides%fragilis&
Features&
• ONLY&gram&negative&
obligate&anaerobe%
• Modified%LPS%with%reduced%
activity%
% • Capsule&is&antiphagocytic%
Reservoir=&normal&flora&
• Human&colon%
Transmission=&endogenous%
• Bowel&defects&(cytotoxic&
drug&use)%
• Surgery&or&trauma%
Pathogenesis& Diseases& Treatment&
• Endotoxin& Cellulitis%with%lymphadenitis% DOC&
• Capsule& • Wound&infections,&rapidly&spreading&(could&spread&to&bone)& • Amoxicillin%+%
• Spreads&rapidly&within&skin& • Frequently&polymicrobial&infections& Clavulanate&(treatment&
& & and&prophylaxis)&
Diagnosis—rarely&cultured&(prophylaxis&is&common)& &
% & Resistant&to&macrolides&
Oher&cysteine&requiring&bacteria:&Francisella,&Brucella,&Legionella&
(Francis&and&Bruce&play&with&Legos&in&the&Pasture)&
“Corrodes”&agar;&bleach%like%odor& Human%bites&or&fist&fight&injuries&Cellulitis& 3rd&gen&cephalosporins&
Fluoroquinolones&&
Filamentous&rods& Dog%bite&wounds&Cellulitis&(overwhelming&sepsis&in&asplenic&pts)& 3rd&gen&cephalosporins&
Fluoroquinolones%
Immunocompromised&(AIDS)& Cats/dog&bits/&scratches&“cat%scratch%fever”& Azithromycin&
Bacillary%Angiomatosis&(AIDS)&raised&purple/black&splotches& Doxycycline&
Spread&by&lice& Trench&fever&(5&day&fever&with&bone&pain)& %
• All&part&of&normal&flora& • 5?10%&of&infective&endocarditis&(subacute)& 3rd%gen%cephalosporins%
• MCC%gram%negative%endocarditis&in%non<IV%drug%users& Fluoroquinolones&
(“non?culture&endocarditis”)&
&
Diagnosis&difficult&mean&diagnosis&time&of&3&months&
Pathogenesis& Diseases& Treatment&
• Modified&LPS&(missing&heptose&and&2? Septicemia&(used&to&be&MCC&before&prophylaxis&during&surgery)& DOC&
keto?3&deoxyoctonate)=&reduced& Peritonitis&(mixed&infection)& • Metronidazole&
endotoxin&activity% Abdominal%abscess%foul%smelling% • Clindamycin&
% Postpartum%endometritis%foul%smelling%discharge%with%tender%uterus% Abscess&should&be&
Aspiration&pneumonia&with&abscess&and&foul&smelling&sputum&think&anaerobic& surgically&drained&
% &
Diagnosis& Antibiotic&resistance&
Anaerobes&identified&by&biochemical&tests&and&gas&chromatography& common&(7?10%&
& clindamycin&resistant)&
Other&anaerobes:&Prevotella,&Fusobacterium,&Peptostreptococcus& &
Prophylactic&antibiotics&for&
GI&surgery&
 Spirochetes%
Treponema%pallidum%(Thin&spiral&with&axial&filaments)&
Features& Pathogenesis& Diseases& Treatment&
• Endoflagella?&allow& • NOT%intracellular% Syphilis:&Stages& DOC&
movement& • Endarteritis&(vasa&vasorum& Primary& • PainLESS%chancre&on&glans/vulva& Dark%field% • IM%Penicillin%G%
• Poor&gram&stain&(but& destruction?&aortic&aneurysm)% • Clean,&indurated&edge;&contagious& microscopy% Benzathine&
gram&neg&envelope)& • Strong&tendancy&to&chronicity% • Heals&3?6&weeks& (long&acting—&for&1°&
• Obligate&pathogen;& % Secondary& • Non?itchy,&maculopapular,&copper?colored&&&rash%on% Serology&non& &&2°)&
cannot&culture& Diagnosis% palms%and%soles&(infectious)& specific&and& • IV&Penicillin&G&(for&
& • Dark<field%microscopy% • Patchy&alopecia&(beard)& specific;&both& congenital&&&late)&
Reservoir=&Humans& • Serology%(2%types)% • Condyloma%lata&(flat&wart?like&perianal/&mucous& positive& • Doxycycline&
• Genital&tract& 1.%Nontreponemal%(screening)— membrane&lesions—highly&infectious)& &
Transmission& Ab&binds&to&cardiolipin&& Tertiary& • 3?15&years&after&after&secondary;&not&infectious& Specific%serology% Jarisch<Herxheimer%
• Sexual&or& • Cheap&source&of&Ab&usually& • Gummatous%(soft&tumor?like&granulomas&in&skin& tests&(nonspecific& Reaction&Due&to&
transplacental& from&cow&heart& (which&can&ulcerate),&bone,&liver,&brain—gummas)& may&be&negative)& release&of&LPS&from&
& • VDRL,&RPR,&ART,&ICE& • Neuro&(tabes&dorsalis,&Argyll&Robertson&pupils)& organism&after&it’s&killed&
& • Must&confirm&with&FTA?ABS& • Cardiovascular%(“tree&bark”&aortic&arch&aneurysm)& (shock&in&1st&24&hrs&of&
& 2.%Treponemal&Ab&(expensive)& Congenital& • During&pregnancy&or&birth&(symptoms&in&1/3)& Serology&should& treatment:&↑temp,&↓BP,&
& • Ab&binds&to&spirochetes& • Still&birth,&keratitis,&rash,&fever,&pneumonitis,& revert&to&negative& rigors,&leucopenia)&
False&positive&VRDL& • More&specific,&positive&earlier,& pemphigous%syphiliticus&(bullae?palms/soles),& within&3&months&of& &
Viruses& remain&⊕&for&life& hepatosplenomegaly,&metaphyseal&dystrophy& birth&if&unaffected& Benzathine&penicillin&
Drugs& • FTA<ABS&(fluorescent& • Untreated&CN%VIII%deafness,%saddle%nose,% given&to&contacts&
Rheumatic&fever& treponemal&antibody& Higoumenaki’s&sign&(unilateral&sternal&clavicle&
Lupus/Leprosy& absorption);&Most%used% enlargement),&Hutchinson’s%teeth&(notched&
(confirmatory)& & incisors),&Saber%shin&(sharp&anterior&bowing)&
&
Borrelia%burgdorferi%(Large&spirochete)&
• Microaerophilic& • Invades%skin%and%spreads%via% Lyme%disease&(#1&tick?borne&disease&in&U.S.)&MC&in&northeast—&spring& DOC&
Reservoir& bloodstream%to%involve%heart,% 1:&Early&localized&& Target%rash&(aka&bull’s&eye,&annular&lesion,&red&w/&central& • Doxycycline%
• White?footed&mice& joints,%and%CNS% (Days—Weeks)& clearing)&Fatigue,&fever,&headache& • Ceftriaxone&(2°)&
• White?tailed&deer& • Arthritis&caused&by&immune& 2:&Early&disseminated&& Hematogenous&spread%Bilateral%Bell’s%Palsy,&muscle&and& • Amoxicillin&(for&
Transmission?&ticks& complexes& (Weeks—Months)& joint%pain,&swollen&lymph&nodes,&secondary&annular&skin& children<8&and&
(Ixodes%also&carry& & lesions,&cardiac&(AV&block/myocarditis)& pregnant&women)&
Babesia,%Ehrlichia)& Diagnosis& 3:&Late&persistent& • Encephalitis,&meningitis,&extreme&fatigue,&conjunctivitis& &
• I.&scapularis& • Serodiagnosis%(ELISA)% (Months—years)& • Arthritis&(MC&in&knees;&immune&complex?mediated)& Prevention—DEET;&
• I.&pacificus& • Western%blot%now%test%of% & avoid&tick&bites&
choice% Borrelia&recurrentis&recurrent&fevers&(from&variable&surface&antigens)&also&tick&vector&
&
Leptospira%interrogans%(Very&thin&with&tight&terminal&hooks&on&both&ends)&
• Aerobic% Leptospirosis%(swamp&fever,&mud&fever,&swineherd’s&disease)& DOC&
• Zoonotic&(dogs,&rats,&livestock)& • Influenza?like&disease,&high&spiking&temperatures,&muscle&aches&(thighs/lower&back)&& • Penicillin%G%
Transmission& • Severe&if&not&treated&(Weil’s%disease—hepatitis,&jaundice,&renal&failture,&organ&hemorrhage,& • Doxycycline&
• Contact%with%animal%urine%in%the%water% mental&status&changes,&photophobia)& &
• Penetrates&mucous&membranes/&small&breaks&in&skin& Diagnosis& Prevention:&animal&
• Jetskiers%in%Hawaii,%Sewer&workers% • Serodiagnosis&(agglutination&test),&Culture&(blood,&CSF,&urine),&& vaccination,&rat&control&
• Darkfield&NOT&recommended&
&
 Unusual%Bacteria%
Obligate%Intracellular%Organisms&(Chlamydia,&Rickettsia,&Anaplasma)&
• Do&not&make&sufficient&ATP&(must&utilize&host&cell)&
Chlamydia%trachomatis%(C.&pneumoniae,&C.&psittaci)&
Features& Pathogenesis& Diseases& Treatment&
• NOT%seen%on%gram%stain;% • Infects&nonciliated&columnar&or& Sexually%Transmitted%Disease&(Serotypes&D?K)& Diagnosis:&
(peptidoglycan&lacks& cuboidal&epithelial&cells&of&mucosal& • MC%bacterial%STD%in%US&&(Overall:&HPV,&herpes)& • DNA&probes&(US)&
muramic&acid)% surfaces&granulomatous&response,& • Nongonococcal&urethritis,&cervicitis,&PID,&inclusion&conjunctivitis& • Cytoplasmic&inclusions%
• Does%not%produce%any%ATP% inflammation,&damage% • Inclusion&conjunctivitis/pneumonia&in&neonates&(staccato%cough)& (reticulate&bodies)&on&
& % Complications&Sterility,&Reiter’s&syndrome,&Fitz?Hugh&Curtis& Giemsa%&
Reservoir& • Elementary%body%(infective%form)% % &
• Human&genital&tract;&eyes& inactive,&extracellular% Lymphogranuloma%venereum%(Serotypes&L1,2,3)& DOC&
Transmission& % • Prevalent&in&Africa,&Asia,&South&America& • Doxycycline&
• Sexual%contact,&birth& • Reticulate%body%(replicating%form)% • Tertiary:&rectal&strictures,&fistulas,&ulcers,&swollen&LN&genital& • Azithromycin&
• Trachoma&by&hand?to?eye& active,&intracellular% elephantiasis& &
contact&and&flies& & Erythromycin&(mothers&at&
Trachoma&(Serotypes&A?C)& birth;&drops&for&neonatal&
• Leading&cause&of&preventable%infectious%blindness& conjunctivitis)&
• Follicular&conjunctivitis&&inturned&eyelashes&corneal&scarring&
C.%pneumoniae%% • Intracellular&growth;&infects&smooth& Walking%pneumonia%(2nd%MCC)—(Atypical&pneumonia)&% DOC&
TWAR&strain—&Person&to& muscle&endothelial&cells;&coronary& • Single&lobe,&bronchitis,&scant&sputum,&dry%cough/hoarseness& • Doxycycline%
person&by&respiratory&route% artery&(atherosclerosis)& • Diagnosis=&serology&(complement&fixation)& • Macrolides&

C.%psittaci% • Intracellular&growth&& Psittacosis%(ornithosis)—(Atypical&pneumonia)% DOC&

Inhaled&dried&feces&dust&of& • No&glycogen&in&inclusion&bodies& Very&contagious;&cough&initially&absent& • Doxycycline%
birds,&parrots,&turkeys&(US)% Hepatitis;&CNS&and&GI&symptoms&may&be&present&

Rickettsia%ricketsii&
• Aerobic,%Gram%∅&bacilli%
(too&small&to&stain)%
Reservoir=&zoonotic&
• Dogs,&rabbits,&rodents&
Transmission&&
• Dermacantor%ticks%
Coxiella%burnetti%
R.%prowazekii%
R.%typhi%
Orientia%tsutsugamushi%
Anaplasma%(formerly&Ehrlichia;&A.&chaffeensis,&A.&phagocytophila)&
• Gram%∅&bacilli%
Reservoir=&ticks/deer&
Transmission=&ticks%
• Lone%star%(chaffeensis)&
• Ixodes%(phagocytophila)%
% *Borrelia%co<infection%common*%
• Invade%endothelial%cells%lining%
capillaries&vasculitis&in&many&organs&
(brain,&liver,&skin,&lungs,&kidney,&and&GI&
tract)&
• Weil<Felix%test&⊕&(Cross&reaction&of&
Rickettsia&w/&Proteus&vulgaris)&
&
Inhalation&of&endospores&(feces,&urine,&
placenta&of&slaughterhouses)&
Human&louse&humans&(war,&prisons)&
Rats&Fleas&humans&
Rodents&Mites&humans&
Infects&WBCs—&
Monocytic&(chaffeensis)&
Granulocytic&(phagocytophilum)&
obligate&bacterium&of&neutrophils&
& Diagnosis&
Rocky%Mountain%Spotted%Fever% Diagnosis&
• Prevalent&on&East&Coast&(North%Carolina&area);&2?12&day&incubation& • Clinical,&start&doxy&before&
• Headache,&fever&(102F),&malaise,&myalgias,&toxicity,&vomiting& lab&confirmation&
• Maculopapularpetechial&rash%on%ankles/wrists%(w/&swelling)&spread& • 4X&↑&titer&is&diagnostic&
to&trunk,&palms,&soles,&&&face&(centripetal&rash)& &
& DOC=&Doxycycline&
Q&fever—interstitial&pneumonia&with&NO&rash;&Weil?Felix&Negative&
Epidemic&Typhusabrupt&fever,&headache,&rash&(no&palms/soles),&delirium&
Endemic&Typhusfever,&headache,&rash&
Scrub&Typhus&fever,&headache,&rash,&muscle&pain,&cough&hemorrhaging&
Anaplasmosis% DOC%
• Similar&to%RMSF%but%without%rash% • Doxycycline%
• Leukopenia,&low&platelets,&morulae%(mulberry<like%structures%inside% (begin&before&lab&
infected%cells)& confirmation)&
• Giemsa%blood%film,&IFA,&PCR&
Mycoplasmas&
• Missing&peptidoglycan—No&cell&wall&(not%seen%on%gram%stain)&
• Requires%cholesterol&(plus&nucleic&acids)&for&in&vitro&culture&fried&egg&appearance&(not&seen&in&M.&pneumoniae)&
Mycoplasma%pneumoniae&
Features& Pathogenesis& Diseases& Treatment&
• Smallest&extracellular& • Surface&parasite&(not&invasive)& Walking%pneumonia%(MCC)&(patients&do&not&feel&very&sick)& DOC&
bacteria& • P1%Protein—attaches&to&respiratory& • MC%atypical%pneumonia%in%young%adults& • Erythromycin%(and&
• Sterols/cholesterol&in& epithelium& • Dry%hacking%cough;&pharyngitis,&fever,&otitis&media&& other&macrolides)&
membrane&(but&does&not& • Inhibits&ciliary&action& • Also&common&in&children&and&teens& • Tetracyclines&
synthesize&cholesterol)% • Produces&hydrogen&peroxide,& % &
• Eaton’s%agar% superoxide&radicals,&cytolytic&enzymes& Diagnosis% Cephalosporins%or%
& (damage&respiratory&epithelium& • Primarily&clinical;&PCR/nucleic&acid&probes& penicillins%do%NOT%
Reservoir% necrosis,&bad&hacking&cough)% • ELISA&and&immunoflueorescence&sensitive&and&specific& work(no%cell%wall!!!)%
• Human&respiratory&tract% • Functions&as&superantigen—elicits& • Mulberry?shaped&colonies&on&sterol?containing&media,&10&days&
Transmission% production&of&IL<1,%IL<6,%and&TNF<α& • Positive%cold%agglutinins%(IgM&autoantibody&to&red&cells)&test&is&
• Respiratory&droplets% (overwhelming&immune&response;& nonspecific&and&only&positive&in&65%&of&cases&(however&this&plus&a&clinical&
• Close&contact:&military% inflammation)% presentation&has&been&an&effective&diagnostic&tool)&
recruits,%college%dorms%
Ureaplasma%urealyticum&
• Urease&⊕& • Becomes&normal&flora&of&sexually&active& • Urethritis&(yellow&mucoid&discharge)& DOC&
adults&& • Prostatitis& • Erythromycin%%
• Seen%in%child=%sexual%abuse& • Renal&calculi& • Tetracycline&

%
Quick%Reference%Chart%
Encapsulated% Catalase%⊕% Oxidase%⊕% Urease%⊕% Obligate%Aerobes% Culture%media%
Strep&(pneumo&&&GBS)& Pseudomonas& Campylobacter& Proteus& Nocardia& Haemophilus& Chocolate&agar&(factors&V&&&X)&
Klebsiella& Listeria& Pseudomonas& Ureaplasma& Pseudomonas&& Neisseria& Thayer&Martin&(VPN*)&
Haemophilus& Aspergillus& Vibrio& Nocardia& M.&tuberculosis& Bordetella& Bordet?Gengou&
Pseudomonas& Candida& Helicobacter& Cryptococcus& Bacillus&anthracis& C.&diphtheriae& Tellurite,&Loffler’s&media&
Neisseria& E.coli& Legionella& Helicobacter& Obligate%Anaerobes% M.&tuberculosis& Lowenstein?Jensen&
Cryptococcus& Staph&aureus& Neisseria& Epidermidis&& Mycoplasma&pneumo& Eaton’s&agar&
Clostridium&
E.&Coli& Serratia% % Saprophyticus& Legionella& Buffered&Charcoal&Yeast&Extract&
Bacteroides&&
Salmonella% (Enterobacteriae& Klebsiella& Fungi& Sabouraud’s&agar&
Actinomyces&
are&negative)&
Some&Killers&Have&Pretty& PLACESS&for& Ox&Can&Pull&Very& PUNCHES%Kill% Aerobes—Nagging&Pests& Special&stains&
Nice&Capsules&(Even& your&Cat& Heavy&Loads& Must&Breath& Giemsa%Chlamydia,&Borrelia,&Rickettsia,&Trypanosomes,&
Salmonella)& Nonstop& % Plasmodium&
Anaerobes—Can’t&Breathe& India%ink&Cryptococcus&neoformans&
Air& Acid%Fast%Mycobacterium,&Nocardia&(partial)%
*VPN=%Vancomycin%(kills&gram&positive),%Polymyxin%(kills&gram&neg&except&Neisseria),%Nystatin%(kills&fungi)&
&
Toxin&comparisons&
ADP%ribosylation%of%eEF<2% Inactivate%60s%ribosome%subunit% ADP%ribosylation%of%Gs%(↑cAMP)% Act%as%adenylate%cyclase%
C.&diptheriae& EHEC& ETEC&(heat&labile&toxin)& B.&pertussis&(adenylate&cyclase&toxin)&
Pseudomonas& Shigella& Vibrio&Cholera& B.&anthracis&(edema&factor)&
 Cell%Wall%Synthesis%Inhibitors%
MOA& Bacteriocidal—&D?ala&D?ala&analogs&that&bind&and&inactivate%transpeptidase&(PBP)&&
Prevent&cross?linkage&of&peptidoglycan&chains&(loss&of&cell&rigidity&cell&death)&
Work&best&at&period&of&maximal&growth&(log&phase)&
Resistance& 1. Penicillinases&(beta?lactamases)&break&lactam&ring&structure&produced&in&periplasm&of&gram?negatives&
2. Structural&change&in&PBPs&(MRSA)&
3. Change&in&porin&structure&(Pseudomonas)&
Penicillins% Cephalosporins%
Narrow%Spectrum& Neurosyphillis,&Strep&viridans,&pneumo&(Penicillin&G)& First%generation% First—surgical&prophylaxis&(gram&positive&+&Proteus,&E.coli,&
(penicillinase&susceptible)& Strep&pharyngitis&(Penicillin&V)& • Cephalexin&(oral)& Kebsiella)&
& & • Cefazolin&(IM&or&IV)& &
• Penicillin&G&(IM&or&IV)& Safe&in&pregnancy& & Second—&increased&gram&negative&coverage&including&some&
anaerobes&(Cefuroxime&only&one&to&enter&CNS)&
• Penicillin&V&(oral)& Second%generation% &
Narrow%Spectrum% Mostly&staphylococci&(not&MRSA)& • Cefoxitin& Third—gram&positive/negative&cocci,&&&many&gram&negative&
(penicillinase&resistant)& & • Cefotetan& rods&(all&enter&CNS&except&cefoperazone)&
& All&penicillins&are&renally&excreted&except&for&oxacillin&and& • Cefaclor& • Ceftriaxone&(DOC&Neisseria,&strep&pneumo&meningitis,&
• Methicillin& nafcillin&(excreted&in&bile)& • Cefamandole& Salmonella,&Haemophilus)&
& • Cefuroxime& • Cefotaxime&(strep&pneumo&meningitis)&
• Naficillin& Methicillin&can&cause&interstitial&nephritis& • Cefoperazone&&&Ceftazidime&(pseudomonas)&
• Oxacillin& &
Third%generation% • Ceftriaxone&&&Cefoperazone&eliminated&in&bile&
Broad%Spectrum% Mostly&treat&ear&nose&and&throat&infections& &
• Streptococcus,&H.&influenza& • Cefotaxime&
(penicillinase&susceptible)& Fourth—wider&spectrum,&resistant&to&most&beta?lactamases,&
• Listeria&(ampicillin+gentamycin)& • Ceftriaxone&(IM)&
& and&enters&the&CNS&
• Borrelia,&H.&pylori,&ear&infections&(amoxicillin)& • Ceftazidime& &
• Ampicillin&(IV)&
& • Cefoperazone& Bacteria&NOT&COVERED&by&cephalosporins&are&LAME&
• Amoxicillin& & • Cefixime& • Listeria%
Extended%Spectrum% Increased&activity&against&gram?negative&rods&including& & • Atypicals&(Chlamydia,&Mycoplasma)&
(penicillinase&susceptible)& pseudomonas& Fourth%generation% • MRSA%
• Ticarcillin& Carbenicillin&concentrates&in&urinary&tract&(for&UTIs)& • Cefepime&(IV)& • Enterococci&
• Piperacillin& Do&not&give&ticarcillin&to&cardiac/hypertensive&pts& %
• Azlocillin& Cefotetan&and&Cefoperazone&have&disulfiram?like&effects&
B<lactamase%inhibitors% Irreversible&inhibitors&of&beta?lactamase& Carbapenems&
& No&antibacterial&activity;&used&as&fixed&dose&combination&to&
& Important&in?hospital&agents&for&empiric&use&in&severe&life&
• Clavulanic&Acid& widen&spectrum&
• Imipenem& threatening&infections&(anaerobes,&gram&positive&cocci&and&gram&
• Sulbactum& • Amoxicillin&+&clavulanate&
• Meropenem& negative&rods)—everything&except&MRSA&
• Ampicillin&+&sulbactum&
• Tazobactum& • Piperacillin&+&tazobactum&(pseudomonas&and& • Ertapenem& • Imipenem%given%with%cilastatin&(inhibits&renal&
dehydropeptidase&&&prevents&toxic&metabolite)&
bacteroides)& • Doripenem& • Cross&allergenicity,&CNS&effects&including&seizures&
Vancomycin& Monobactams&
MOA:%binds&at&D<ala<D<ala% • Drug&of&last&resort& & Beta?lactamase&resistant&
muramyl&pentapeptide& • Used&for&MRSA,&enterococci,&&&backup&to&metronidazole& & No&gram&⊕&activity&(Mainly&active&against&gram&negative&rods)&
(sterically&hinders& for&C.&difficile&(oral&only)& • Aztreonam& No%cross%allergenicity&with&penicillins&&
transglycosylation&reactions& • Resistance—terminal&D?ala&lactate& (Specifically&binds&PBP?3)&
involved&in&elongation&of& • A/E:&Ototoxicity,&Nephrotoxicity,&Red%man%syndrome&
peptidoglycan&chains— (flushing&red&face,&hypotension—histamine&release)&
“blocks%glycopeptide% Reduce&effects&with&antihistamine&+&slow&infusion&
polymerization”)%
 Protein%Synthesis%Inhibitors%
Bind%30s% Bind%50s%
% Bactericidal—&blocks%formation%of%initiation%complex& & Bacteriostatic—blocks%peptidyl%transferase;&inhibiting&formation&
% (misreading&of&mRNA;&also&blocks&translocation)& & of&a&peptide&bond&
% & & &
% Treatment& Chloramphenicol% Treatment&of&Salmonella,&H.&influenza,&N.&meningitides&
• Severe&gram&negative&rods;&cannot&kill&anaerobes& &
% • Synergistic&with&penicillins& A/E—&p450&inhibitor,&BM&suppression,&gray%baby%syndrome&(pale,&
% • Concentration&dependent&killing—↑concentration&kills&more& cyanosed;&neonates&lack&glucuronidation)&
% at&a&faster&rate&(single&large&dose)& &
Aminoglycosides% • Postantibiotic&effect—antibacterial&activity&persists&beyond& Resistance:&formation&of&inactivating&acetyltransferases&
% measurable&drug&(used&once&daily)& &
• Gentamycin& • Streptomycin—DOC&bubonic&plague&&&tularemia& % Bacteriostatic—Reversible&binding&to&23s&of&50s&subunit;%inhibits%
• Streptomycin& • Neomycin?&Hepatic&coma&to&decrease&coliform&flora& % aminoacyl%translocation%of%peptidyl<tRNA&
• Neomycin& • Gentamycin%+%Penicillin=&DOC&endocarditis& % &
• Tobramycin& • Tobramycin—inhalation&for&pseudo&in&CF& Macrolides% Wide&spectrum&antibiotics&
& • Atypical&pneumonias&(Mycoplasma,&Chlamydia,&Legionella)&
• Kanamycin& %
A/E& • Chlamydia,&Campylobacter,&H.&pylori,&Gram+&cocci&(not&MRSA)&
• Amikacin& • Nephrotoxicity&(especially&with&cephalosporins)& • Azithromycin& • M&avium&(prophylaxis?azithro;&treat?clarithro+ethambutol)&
% • Ototoxicity&(epecially&with&loop&diuretics)& • Clarithromycin& • Erythro&drops:&neonatal&conjunctivitis&(chlamydia/gonorrhea)&
• Neuromuscular&blockade&(don’t&give&to&myasthenia&gravis&or& • Erythromycin& &
with&succinylcholine)& • Roxithromycin& A/E—&p450&inhibitors&(especially%erythromycin),%prolongs&QT&
• Contraindicated%in%pregnancy% • Telithromycin& interval,&GI&distress&from&stimulation&of&motilin&receptors&
& &
Resistance:&Transferase&enzymes&inactivate&the&drug&by& Resistance:&production&of&methyltransferases&that&alter&drug&
acetylation,&phosphorylation&or&adenylation& binding&sites,&or&active&transport&out&of&cells&
&
% Bacteriostatic—blocks%attachment%of%aminoacyl<tRNA&to&the& & Same&MOA&and&resistance&as&macrolide&
% acceptor&site&(inhibits&AA&incorporation)& Clindamycin% • Gram&positive&cocci&including&MRSA;&backup&for&B.&fragilis&
% & (anaerobic&lung&abcess)&
% Treatment&(doxycycline&most&used)& • Concentrates%in%bone;&clinical&value&in&osteomyelitis&
• Can&be&used&in&patients&with&renal&failure&(eliminated&fecally)& • A/E—%pseudomembranous%colitis%
% • M.&pneumoniae,&H.&pylori,&Brucella,&Vibrio& & Bactericidal—&blocks%formation%of%initiation%complex&&(works&at&
Tetracyclines% • Spirochetes&(Borrelia;&2nd&line&for&Treponema/Leptospirosis)& 23s&subunit)&
&
% • Intracellular&bacteria&(Chlamydia,&Rickettsia,&Ehrlichia)& &
Linezolid&
• Tetracycline& • Minocycline:&concentrates&in&saliva/tears&(meningitis&carrier)& Treatment&of&VRSA,&VRE,&and&drug?resistant&pneumococci&
• Doxycycline& • Demeclocycline&can&be&used&in&SIADH& &
• Minocycline& • Tigecycline:&used&in&complicated&resistant&skin&infections& A/E—bone&marrow&suppression,&thrombocytopenia;&inhibits&MAO&
• Demeclocycline% & increasing&risk&of&serotonin&syndrome&
• Tigecycline% A/E&
• GI&distress,&photosensitivity& & Bacteriostatic—blocks&the&attachment&of&aminoacyl&tRNA&to&
• Children—discoloration%of%teeth&&&bone&growth&inhibition& Streptogramins% acceptor&site;&stimulate&dissociation&from&ternary&complex&
• Contraindicated%in%pregnancy% & &
• Decreased%absorption%when%taken%with%milk/antacids% • Quinupristin& Treatment?&parenterally&in&severe%infections%caused%by%VRSA%and%
& VRE,&as&well&as&other&drug&resistant&gram+&cocci&
• Dalfopristin& &
Resistance:&Decreased&uptake&into&cells&or&increased&efflux&out&of&
the&cell&by&plasmid?encoded&transport&pumps& A/E—nausea,&diarrhea,&myalgias,&arthralgias,&hepatotoxicity&

&
&
Nucleic%Acid%Synthesis%Inhibitors%
Inhibitors&of%Folic%Acid%Synthesis% Direct&inhibitors&of%Nucleic%Acid%Synthesis%
% Bacteriostatic—antimetabolites&that&competitively%inhibit% % &
% dihydropteroate%synthase%(structural&analogs&of&PABA)& % &
% & % Bactericidal—Inhibit%topoisomerase%II%(DNA&gyrase)%and%
Sulfonamides& Treatment:& % topoisomerase%IV%(responsible&for&separation&of&daughter&cells&
• Sulfasalazine—prodrug&used&in&ulcerative&colitis,&Crohn’s&and& during&cell&division)&
& rheumatoid&arthritis&(inhibits&PGs&and&LTs)&
% &
• Sulfamethoxazole& • Sulfacetamide—eyedrops&for&conjunctivitis& % Treatment&
• Sulfadoxine& • Silver&Sulfadiazine—1%&cream&for&burns& % • TMP?SMX&resistant&UTIs&
• Sulfasalazine& & Fluoroquinolones% • STDs/PID&caused&by&chlamydia,&gonorrhea&
• Sulfacetamide& A/E& % • Skin,&soft&tissue,&and&bone&infections&(gram&negative)&
• Sulfadiazine& • Hypersensitivity%reactions%(Stevens&Johnson),&Phototoxicity& • Ciprofloxacin& • Diarrhea&(Shigella,&Salmonella,&E.&coli,&Campylobacter)&
• Mafenide& • Kernicterus&in&neonates&(↑&protein&binding;&avoid&in&3rd&trimester)& • Levofloxacin& • Drug&resistant&pneumococci&(levofloxacin)&
% • Hemolysis%in%G6PD%deficiency& • Norfloxacin& &
• Moxifloxacin% Iron/Calcium&limit&absorption&(forms&a&chelate)—do&not&take&
% Bacteriostatic—antimetabolites&that&inhibit%dihydrofolate%
with&antacids&
% reductase%
Eliminated&by&kidney&filtration/secretion&
% %
&
Trimethoprim% Treatment&Synergy&with&sulfonamides&(↓resistance)&
A/E&
• Trimpethoprim?sulfamethoxazole&(TMP?SMX)&DOC&Nocardia,&UTIs&
% • Tendonitis,%tendon%rupture&(inhibits&elastin&incorporation)&
(S.&sapro,&E.coli,&Proteus),&P.jiroveci&
Pyrimethamine% • Sulfadoxine+Pyrimethamine—DOC&Toxoplasma,&resistant&malaria&
• Phototoxicity,&rashes,&prolongs&QT&interval&
• CNS&effects&(insomnia,&dizziness,&headache,&anxiety)—due&to&
&
inhibition&of&GABA&binding;&glutamate&overdrive&
A/E&
• Contraindicated%in%pregnancy/children&
• Megaloblastic&anemia,&leukopenia,&granulocytopenia&
• CANNOT%be%used%for%anaerobes&
• Reversed&by&giving&folinic&acid&

%
Antimycobacterial%Drugs%
Drug% Use% MOA%and%Resistance% Side%Effects%
Isoniazid% Tuberculosis% Prodrug&requiring&conversion&by&catalase&inhibits& Hepatitis&(age/dose&dependant)&
Standard=&& mycolic&acid&synthesis& Peripheral&Neuritis&&&sideroblastic&anemia&(must&supplement&with&vitamin&B6)&
2&months:&Isoniazid,& Resistance:&deletions&in&katG&gene&(encodes&catalase)& SLE&in&slow&acetylators&
Rifampin% Rifampin,&Ethambutol,& Inhibits&DNA?dependent&RNA&polymerase&(nucleic& Hepatitis&
Pyrazinamide&& acid&synthesis&inhibitors)% Inducer%of%p450%(OC%failure)%
4&months:&Isonizid&+& Body%secretions&turn%orange&(metabolites&in&urine,&sclera)%
Ethambutol% Rifampin& Inhibits&synthesis&of&arbingalactan&(cell?wall& Dose?dependent&retrobulbar&neuritis&&
& component)% Decreased%red<green%discrimination&and&visual&acuity%
Pyrazinamide% Prophylaxis—&Isoniazid&& Decreased&pH&in&the&tubercle&cavity% Hepatitis,&phototoxicity&
(+&rifampin&if&intolerant)& Hyperuricemia&(competes&with&uric&acid&secretion)&
Streptomycin% Protein&synthesis&inhibition% Nephrotoxicity,&Ototoxicity&
Vestibular&dysfunction&
Dapsone% Leprosy% Related&to&sulfonamides:&inhibits&DHT&synthase& Hemolytic&anemia&in&G6PD&deficiency,&Lepra&reaction&(Jarish&Herxheimer)&&
Clofazimine% Lepra&reaction&from& Binds&to&DNA&and&inhibits&template&function& Dye&with&a&half&life&of&70&days;&can&cause&reddish%black%skin&
Dapsone& Produces&cytotoxic&free&radicals&that&kill&bacteria&
&
 Microbial%Genetics%
Three&different&types&of&DNA&found&in&a&bacterial&cell&
1. Bacterial%chromosomal%DNA—one&large&circular&DNA&molecule&(often&multiple&copies)&organized&into&loops&around&a&protein&center&contain&essential%genes&
2. Plasmid%DNA—extrachromosomal&genetic&elements&(circular&DNA)&for&nonessential%genes&(fertility&genes,&antibiotic&resistance,&and&exotoxins)&
3. Bacteriophage%DNA—stable&pieces&of&bacteriophage&DNA&inserted&into&the&bacterial&chromosome&can&enhance&virulence&(lysogenic%conversion)&

Rearrangement&of&DNA&within&a&bacterium&(can&help&stabilize)&
Homologous%Recombination% Site<Specific%recombination%
• Mechanism&to&incorporate&short,&linear&pieces&of&DNA&(exogenotes)&into&the& • Mechanism&to&combine&circular&pieces&of&DNA&(plasmids,&phage,&transposons)&
bacterial&chromosome—there&is&a&one<to<one%exhange&of&DNA& • Does&not&require&homology&and&no%DNA%is%lost&
• Requires%recombinase%A&(recA)&and&gene&sequence&homology& • Requires%restriction%endonucleases&
Mechanisms&of&DNA&exchange&
Transformation% Conjugation% Transduction%
• Uptake&of&naked&DNA& Gene&transfer&from&one&bacteria&to&another&with%direct%cell<to<cell%contact&(sex%pili)& Transfer&of&DNA&by&a&phage%vector&
&
from&the&environment&
&

by&competent%cells&
• Introduced&DNA&is&
linear,&homologous&DNA&
which&may&be&
genetically&diverse&
• Incorporated&and&
stabilized%by%
homologous%
recombination&
& stabilized%by%
Bacteria&that&undergo&
natural&transformation:&
• H.%influenzae%
S.%pneumoniae%
• &
• Bacillus%and&Neisseria&
&
&
Donor&(male)&cells&have&fertility&plasmids&(F&factors)& Generalized&transduction&
• Phage&with&a&lytic%life%cycle&(virulent&
• The&tra%region&encodes&for&sex&pili,&genes&directing&transfer,&&&stabilizing&genes&
• oriT&(origin&of&transfer)&initiates&transfer&where&the&single&DNA&strand&break&is&made& phage&or&temperate&phage)&mistakenly%
grabs%a%piece%of%bacterial&DNA&during&
• Insertion%sequences&are&specific&areas&where&the&plasmid&may&integrate&into&the&bacterial& reassembly&&infects&other&bacteria&
chromosome&to&create&an&Hfr%cell& • All&genes&have&an&equal&chance&of&being&
• Donor&cells&in&which&the&fertility&plasmid&is&in&its&free&state&are&called%F+%cells& transduced&
&
Two%types%of%crosses%
F+%cell%F–%cell%
• F&factor&free&from&
chromosome&
• Only&a&single&
strand&transferred&&
• oriT&transfers&first& %
• 100%&of&the& Specialized%transduction&
plasmid&crosses& • Temperate%phage&introduces&its&genomic&
• F<%becomes%F+& DNA&into&bacterial&DNA&for&excision&later&&
but&no&new&genes& • If&excision%error&occurs,&a&piece&of&
& bacterial&DNA&can&be&carried&along&into&
&
Hfr%cell%F–%cell% the&next&generation&of&viruses&
• Only&genes&closest& • Only&certain%genes&because&phages&
to&oriT&are& integrate&at&certain&sites&using&repressors&
transferred&
• Must&be&
homologous%
recombination&
• No&“sex&change”&
(tra&is&last&and&
doesn’t&transfer)& &
% DNA%Viruses% Randall&
&“Her&&Po&&He&&Pa&&Par&&Ade”&
General&rules&(exceptions)& &Icosahedral&(Pox=&complex)*
& &dsDNA&(Hepadna=&partial;&Parvo=&ssDNA)%
& &DNA&replicates&in&nucleus&(Pox=&cytoplasm)%
Enveloped&
Herpes% Pox% Hepadna%
& & &
&

• Large&dsDNA&(linear)& • Large&dsDNA&(linear)& • Partial%

• Envelope&derived&from&nuclear&membrane& • Replicates&in&cytoplasm& dsDNA&
• Virus%assembly%in%nucleus&(others&assemble&in&cytoplasm)% • Box&shape,%complex;& (circular)&
&
& • Establishes&latency& NOT&icosahedral& &
➀HSV<1%[Latent&in&trigeminal%ganglia]& ➃EBV%[Latent&in&B<cells]& Smallpox%(Variola)&
• Eradicated&by&live&attenuated&vaccine&(Vaccinia)&
Hepatitis%B%
• Acute&or&chronic&hepatitis&
• Human&mucosa&direct&contact& • Heterophile%⊕&mononucleosis&(kissing& • Potential&biological&warfare&agent& • Associations&with&cirrhosis,&
• Gingivostomatitis/&Herpes&labialis&(cold%sores)& disease;&teens?&fever,&exudative&sore&throat,& • Upper&respiratory&infection&dissemination&via& hepatocellular&carcinoma&
vesicular&blisters&of&mouth,&lips& lymphadenopathy,&splenomegaly)& lymphatics&viremia&tissues& • Serology:&HBs,&HBc,&HBe&
• Esophagitis—punched&out&lesions& • Hairy&oral&leukoplakia&(AIDS)& • Flu?like&illness&(2?4&days)&followed&by&rash& • Possesses&capacity&to&use&
• Keratoconjunctivitis&(dendritic&ulcers)& • Malignancies&(Burkitt&lymphoma,&Hodgkins,& (begins&in&mouth&face&arms,&legs,&hands,&feet;& reverse&transcriptase&(RNA&
• MCC&sporadic&encephalitis&in&U.S.&(focal&fronto? nasopharyngeal&carcinoma)& covering&entire&body&in&24&hrs)& dependent&DNA&polymerase)&
temporal&lesions,&necrotizing,&high&fatality)& • Downey%cells&(atypical&reactive&T?cells)& • Rash%is%synchronous&(vesicles&all&in&same&stage& &
• Herpetic&whitlow&(dentists?&vesicles&on&finger)&
➄CMV%[Latent&in&mononuclear%cells]& of&development)& HBsAg=&currently&infected&
➁HSV<2%[Latent&in&sacral%nerve%ganglia]& • MCC&in&utero&infection&U.S.&(blueberry&muffin&
• Guarnieri%bodies&(intracytoplasmic)&
&
HBsAb=&provides&immunity&
&
• Human&mucosa&sexual&contact& baby?&thrombocytic&purpura,&MR,&jaundice,&
• Painful&genital%vesicles,&(encephalitis&is&mild)& Molluscum%contagiosum% HBcAg=&⊕&acute&&&chronic&
pneumonitis,&periventricular&calcifications)&
• Neonatal&herpes&(at&birth;&encephalitis)& • Heterophile%neg&mononucleosis& • Young&adult—wrestling,&swim&team& HBcAb=&IgM&(acute)&IgG&
• Direct&contact&(sexual)&or&fomites& (chronic);&could&be&⊕&during&
➂VZV%[Latent&in&dorsal%root%ganglia]& • AIDS=&retinitis&+&ulcerations&of&GI&tract&
• Owl’s%eye%inclusion%bodies% • Replicates&in&dermis;&Single/multiple&benign& window&phase&
• Human&mucosa&respiratory&(also&touch)& umbilicated%wart<like%tumors& &
• Chickenpox&(fever,&pharyngitis,&asynchronous& ➅HHV<6%[Transmitted&by&saliva]& • Molluscum&bodies&in&central&caseous&material& HBeAg=&active&proliferation;&
rash?macules,&vesicles,&scabs&not&same&stage)&& • Roseola&(infants—&3&day&fever,&seizures;&lacy& (eosinophilic&cytoplasmic&inclusion&bodies)& increased&transmissibility&
• Shingles&(Stress&reactivation&of&latent& body&rash&when&fever&breaks)% HBeAb=&low&risk&of&
infection&in&5th&or&6th&decade&of&life;&pain&&& transmissibility&
vesicles&restricted&to&1&dermatome&(unilateral)& ➇HHV<8%[AIDS&patients]& &
% • Kaposi%sarcoma&(↑VEGF&expression&causes& Dane&particle=&infectious&HBV&
Tzanck%smear—intranuclear&Cowdry%type%A%(All&3)& purple&splotches)& &
Naked%
Papova%(papilloma/polyoma)% Parvo% Adeno%
& & &

• dsDNA&(circular)& • ssDNA&(linear)& • dsDNA&(linear)&

• infects&erythroid& • Penton&fibers&toxic&to&cells&
& & progenitor&cells& & • Virus&is&lytic&in&permissive&cells&
Human%Papilloma%Virus%(HPV)% Polyomaviridae&& B19&(Erythrovirus)& • Pneumonia&(children,&military&recruits,&college)&
• Direct&contact,&fomites& (AIDS/transplant&patients)& • Child—&erythema&infectiosum,&fifth’s% • Pharyngoconjunctivitis&(swimming%pool;&pink%eye)&
• Genital&warts&(serotypes&6&&&11)& • BK&virus&(Bad&Kidney)& (flu&“slapped%cheek”&facial&rash)& • Epidemic&keratoconjunctivitis&(shipyard&dust)&
• CIN,&Cervical&cancer&(16,&18,&31,&33,&35)& • JC%virus&(Junky&Cerebrum:& • Adults—rash,&stiff/swollen&hands& • Acute%hemorrhagic%cystitis&(young&boys;&hematuria)&
• E6%inhibits%p53% progressive&multifocal& • Fetus—hydrops&fetalis,&abortion& • Gastroenteritis&(daycare;&nonbloody&diarrhea)&
• E7%inhibits%Rb& leukoencephalopathy)& • Sickle&cell—aplastic&crisis&
&
 +%ssRNA%Viruses%
“Pi&&Ca&&To&&Fla&&Co”&
General&rules&(exceptions)& &Icosahedral&(Corona=&helical)*
& &Linear,&Non?segmented%
& &DNA&replicates&in&cytoplasm;&No&virion?associated&polymerase%
Naked& Enveloped&
Picorna% Calici% Toga% Flavi% Corona%
& & & &

• Fecal?oral&(Rhino=&resp)& • Helical&
& &
& & & &
Polio% Norwalk%virus& Rubella&(German&measles)& Hepatitis%C% 2nd&MCC&common&cold&
• Virus&targets&anterior&horn&motor&neurons& (norovirus)& • 3&day&measles& & &
• Asymmetric%paralysis&(no&sensory&loss)& • Fecal?oral,&contaminated& • Truncal%rash&(Discrete,&red& Arboviruses&(mosquito&spread)& SARS&(Severe&acute&
• Progressive&muscle&atrophy&(iron&lung)& food/water& maculopapular&rash&begins&on& Hemorrhagic& respiratory&syndrome)&
• Vaccines&[Live&Sabin;&Killed&Salk&(U.S.)]& • Cruise%ships% face,&progresses&to&torso);& ?Aedes&mosquito&(monkey&host)& • Bird/civet&cat&reservoir&
Echovirus% • Lose&appetite&watery% posterior&auricular& • Dengue&(breakbone&fever;& • Atypical&pneumonia&
• MCC&acute&fever&in&young& diarrhea% lymphadenopathy& rash,&muscle/joint&pain;& • Fever&>&100.4&
• MCC&aseptic%meningitis&(death=&liver& • Children&and&adults& • Congenital%rubella%syndrome& reinfection&can&cause& • Flu?like,&dry&cough,&
failure/myocarditis;&summer&months)& (infants=&rotavirus)& (crosses&placenta/&breast&milk— hemorrhagic&shock)& progressive&hypoxia&
Coxsackie%A% & cataracts,&PDA,&deafness,&MR)& • Yellow%Fever&(black%vomit& • History&of&travel&to&
• Hand%foot%and%mouth&(A16;&vesicular)& highest&risk&first&20&weeks& with&jaundice;&damage&to& China%or%Toronto&
• Herpangina&(blisters)& gestation& liver,&kidney,&heart,&GI)& • Patchy&distribution&of&
Coxsackie%B% • Live,&attenuated&vaccine&(MMR)& Non?hemorrhagic& focal&interstitial&
• Bornhom&disease&(devil’s&grip)& & infiltrates&
?Culex&mosquito&(bird&host)&
• Aseptic&meningitis,&severe&in&newborns& Alphaviruses&(arboviruses)&
?Encephalitis&
• Myocarditis&(MCC&heart&transplant)& • Mosquito&spread&
• St.%Louis%Encephalitis%%
Rhinovirus% Hepevirus% • East/West/Venezuelan%equine% • West%Nile%(can&lead&to&muscle&
encephalitis&
• Acid?labile;&Receptor=&ICAM?1& Hepatitis%E% weakness&and&flaccid&
• MCC%common%cold;&>100&serotypes& • High&mortality&rate&in& paralysis—damage&to&
Hepatitis%A&(Heparnavirus)& pregnancy& anterior&horn&motor&neurons)%
&
Retroviridae&(+ssRNA;&enveloped;&contain&reverse%transcriptase)&
Viruses& HIV&genes/functions& HIV&associated&conditions& HIV&labs/prophylaxis&
HTLV%(Human&T?cell&Leukemia&Virus)—Oncovirus&group& Gag&genes& Early&symptomatic&period& Screening—ELISA&
• Adult%T<cell%Leukemia;&Japan,&Caribbean& • p24&(capsid&protein;&early&marker)& • Bacillary&angiomatosis&(disseminated&bartonella)& Confirmation—Western&blot&
• C?type&particle&(central,&electron?dense&nucleocapsid)% Pol&genes& • Candidiasis,&Hairy&leukoplakia,&Listeriosis& Viral&load—RT?PCR&
• Reverse%transcriptase% • PID,&Cervical&dysplasia,&Peripheral&neuropathy& Newborns—PCR&
HIV&(Human&Immunodeficiency&Virus)—Lentivirus&group&
• Integrase&(DNA&integration&to&host&DNA)& AIDS&associated&conditions& Early&marker—p24&antigen&
• Diploid&genome&(2%copies%of%ssRNA)& • Protease%(cleaves&viral&polyprotein)&
• Sexual&contact,&blood&(needles),&vertical&transmission& • Recurrent%pneumonia%(MCC%death)&P.&jiroveci% Progression—CD4:CD8&ratio&
Env&genes&
• Homosexual&males,&IVDA,&sexually&active&adults& • Candidiasis&of&esophagus/upper&airway,& &
• gp120&(binds&CD4&&&coreceptors&
• Infects&macrophages&and&T?cells;&progresses&to&AIDS& CCR5:macrophages;&CXCR4:&T?cells)& Coccidioidomycosis,&Cryptococcosis,&Histoplasmosis& P.&jiroveci&<&200&CD4&
&
• gp41&(fusion&to&host&cell)& • Malignancies—Cervical&carcinoma,&Kaposi&sarcoma,& Toxoplasma&<&100&
Progression&followed&by&declining&CD4&count& Regulatory&genes& Burkitt’s&lymphoma&(immunoblastic&or&primary&CNS)& Histoplasma&<&100&
&&&?Early&flu?like,&generalized&lymphadenopathy& • LTR&(integration),&Tat&(transcription)&Rev& • CMV,&HSV,&PML&(JC&virus),&wasting&due&to&TNF?α& M.&avium&<50&
&&&?Later&progresses&to&AIDS?defining&conditions& (transport),&Nef&(Virulence;&when& • Cryptosporidiosis,&toxoplasmosis&(brain&lesions)& CMV&<50&
&&&?Homozygous&CCR5&mutation=&immune& defective=&won’t&progress&to&AIDS)&
&&&?Heterozygous&CCR5&mutation=&slow&course& • TB&(>200&CD4),&M.&avium&(<200),&salmonella& Cryptococcus&<&50&&
 —%ssRNA%Viruses%
General&rules&(exceptions)& &ALL%enveloped%&%helical*
& &Linear&(Bunya/Arena/Delta=&circular)&
& &ALL&contain&RNA<dependent%RNA%polymerase%
& &DNA&replicates&in&cytoplasm&(Orthomyxo=&also&nucleus)&
NON<segmented& Segmented&
Paramyxo% Orthomyxo%(8&segments)%
• Surface&F%protein&(Fusion&protein&creates&multinucleated&giant&cells)& • HA&&&NA&glycoproteins&(used&to&serotype)&
• HA&(hemagglutinin)&glycoprotein&(Measles);&HN&glycoprotein&(Mumps)&
Measles% Influenza%
• 3&C’s&Cough,&Coryza,&Conjunctivitis& • Headache,&malaise,&fever,&chills,&myalgias,&anorexia&
• Koplik%spots&(blue/white&spots&with&red&base&on&buccal&mucosa—white&grains&of&sand&in&mouth)& • Bronchiolitis,&croup,&otitis&media,&vomiting&(younger&children)&
• Descending%maculopapular%rash&(action&of&CTL&on&infected&cells)&ears&down;&presents&last&& • At&risk&for&fatal&bacterial%superinfection&(S.&Aureus&pneumonia&MC;&rapid&2?3&days)&
• Sequelae&Subacute&sclerosing&panencephalitis&(Progressive&CNS&degeneration&to&death);& • Can&lead&to&Reye&syndrome&(aspirin)&or&Guillain?Barre&(also&c.&jejuni)&
Giant&cell&pneumonia&(immunocompromised,&rare;&Warthin?Finkeldey&cells)&
&

Influenza&A&(birds,&pigs,&humans);&Influenza&B&(humans&only)&
• Live&attenuated&vaccine&(MMR—Measles,&Mumps,&Rubella)&
• HA&(hemagglutinin?&promotes&viral&entry);&&
Mumps% • NA&(neuraminidase?&promotes&progeny&virion&release)&
• Parotitis,&Orchitis,&Meningoencephalitis,&Pancreatitis&(Parotids&&&testes&as&big&as&POM?Poms)& • Antigenic%drift—(A&and&B)&epidemics;&mutations&in&HA&and/or&NA&
• Orchitis&can&cause&sterility&in&males& • Antigenic%shift—(A&only)&pandemics;&recombination/reassortment&
Respiratory%syncytial%virus%(RSV)% & &

• &Major&cause&of&bronchiolitis&in&young&(infants);&pneumonia&(Tx:&Palivizumab;&Ribavirin)& Treatment&
Parainfluenza% • Amantadine/rimantadine&inhibit&viral&coating&
• Zanamivir/oseltamivir&inhibit&neuraminidase&(prevent&viral&maturation&and&release)&
• Infants—Croup&(seal?like&barking&cough);&“steeple&sign”&narrowing&
• Children/Adults—subglottal&swelling,&barking&cough&
• Vaccines:&Killed&(2&strains&A,&1&strain&B);&Live&attenuated&(intranasal&for&children<&5yrs)&
Rhabdo% Bunya%(3&segments—one&ambisense)%
• Bullet?shaped% Pseudocircular%
Rabies% California%Encephalitis%
• Rabid%animal%bite/contact&U.S.&(raccoons,&bats,&foxes,&skunks);&Worldwide&(dogs)& La%Crosse%Encephalitis%
• Virus&binds&to&peripheral&nerves&(nicotinic&ACh&receptor)&& • Mosquito&transmission&(Minnesota&area)&Viral&encephalitis&
• Travels&via&retrograde%anxoplasmic%transport&to&DRG&&&spinal&cord&(then&rapid&to&brain)& Hantavirus%
• Flu?like&Hydrophobia,&seizures,&disorientation,&hallucination&coma,&death& • Rat&excrement/urine&Pulmonary&syndrome&
• Intracytoplasmic&Negri%bodies&(eosinophilic&inclusions)& • Cough,&mylagia,&pulmonary&edema,&hypotension;&50%&fatal&
• Post&exposure&prophylaxis=&Rabies&Ig,&5&doses&killed&vaccine&(day&of,&3,&7,&14,&28)& • Southwest&U.S.&(like&coccidiodes&&&Y.&pestis)&
Vesicular%stomatitis&(Flu?like&in&humans—handling&livestock&with&foot&&&mouth&disease)&
Filo% Arena%(2&segments—one&ambisense)%
• Circular%
Ebola%virus%(Bleeding&from&eyes;&contact&with&blood&transmission;&high&mortality)% Lymphocytic%Choriomeningitis&(South&America—mouse&excrement)&
Marburg%virus&(Fatal&Hemorrhagic&fever)& Lassa%Fever%Virus&(Africa—spread&by&mice;&hemorrhagic&fever)&
Delta% Reo%(10?12&segments)%
• Circular% • ONLY&double%stranded&RNA&virus&(not&+&or&–);&naked,&icosahedral&
Hepatitis%D&& Rotavirus%&
• Defected&virus—&requires&Hepatitis&B&to&“coat”&Hep&D&for&infection&& • MCC%diarrhea%in%infants—“Right&Out&The&Anus”&(day&cares,&kindergartens&in&winter&months)&
• Worse&prognosis&and&chronic&state&more&likely&with&superinfection&(HBV&carrier& • Villous&destruction&with&atrophy&(decreased&absorption&of&Na+&and&loss&of&K+)&
exposed&to&HDV)&than&with&co<infection&(HBV&&&HDV&exposure&at&same&time)% Coltivirus%
• Colorado&tick&fever—Fever&with&afebrile&periods&“saddleback&fever”&(Dermacantor&tick)&
 Antivirals%
Drug% Mechanism% Uses% Side%effects%
Antiherpetics%
Acyclovir% Inhibits%Viral%DNA%polymerase&by&acting&as&a&chain& HSV<1,%HSV<2,%VZV% Crystalluria&(must&stay&hydrated)&
% terminator&(must&be&first&phosphorylated&by&viral&thymidine%kinase& Reduces&viral&shedding;&decreases&acute& Neurotoxicity&(agitation,&confusion,&seizures)%
Valacyclovir&(prodrug)& &&bioactivated&by&other&kinases)& neuritis&but&no&effect&on&postherpetic&
Famciclovir& & shingles&&
Resistance=&TK&mutation/absence&or&change&in&DNA&pol& Famciclovir&DOC&VZV&
Ganciclovir% Mechanism&and&resistance&similar&to&acyclovir& CMV%(2nd&line&for&HSV?1,&HSV?2,&VZV)& Hematotoxicity&(leukopenia,&thrombocytopenia)&
& In&CMV&requires&phosphotransferase&for&phosphorylation& Prophylaxis&and&treatment&of&CMV%retinitis& Mucositis&(swallowing&problems,&GERD)&
Valganciclovir&(prodrug)& inhibits&DNA&polymerase& in&AIDS&&&transplant&patients% Crystalluria%
Foscarnet% Inhibits&DNA/RNA&polymerases&&&HIV&reverse&transcriptase& Same&as&ganciclovir& Nephrotoxicity,&acute&tubular&necrosis,&
Does%not%require%phosphorylation% Acyclovir%resistant%HSV<1/2% electrolyte&imbalance&(avoid&pentamidine&IV)&
Cidofovir& Acyclic&nucleoside&phosphonate&that&selectively&inhibits&DNA& CMV&retinitis&(AIDS)—Intravenous& Nephrotoxicity&
polymerase;&does%not%require%phosphorylation& Resistant&HSV&
Fomivirsen& Antisense&oligonucleotide?&Binds&mRNA;&inhibits&protein&synth& CMV&retinitis&(AIDS)—Intravitreal&injection&& &
HIV%Therapy&
Nucleoside%RTi% Competitive&inhibition%of%reverse%transcriptase%preventing& HAART&therapy& • Myelosuppression&(Zidovudine&greatest)&
Zidovudine&(AZT)& the&formation&of&dsDNA&(interupts&elongation&and&impairs& Prevents&vertical&transmission&& • Peripheral&Neuropathy&(Didanosine,&
Stavudine&(D4T)& complementary&DNA&synthesis)& Used&in&pregnancy?&2nd&and&3rd&trimester& Zalcitabine,&Stavudine,&Zidovudine)&
Didanosine&(DDI)& Triphosphate&is&active&form&and&requires&phosphorylation&by& Prophylaxis&following&needlestick&injury& • Pancreatitis%(Didanosine)%
Lamivudine&(3TC)& host&enzymes& (Zidovudine+&Lamivudine&1&month)& %
Zalcitabine&(DDC)& Lamivudine&active&in&Hep&B& Lamivudine—Least&toxic,&some&neutropenia&
Non<nucleoside%RTi% Directly&binds&and&inhibits&reverse&transcriptase& Synergistically&with&NRTI&in&HAART& NOT%myelosuppressant%
Nevirapine& Does&not&require&phosphorylation& therapy& Stevens&Johnsons&(Nevirapine)&
Efavirenz& & Prevents&vertical&transmission& CNS&dysfunction&(Efavirenz)&
Delavirdine& (Notice&non?nucleosides&have&“vir”&in&the&middle&of&the&name)& &
Protease%Inhibitors% Inhibit&protease—form&immature&non%infectious&viral& Ritonavir%inhibits%CYP34A;&combined& GI&upset,&Hyperglycemia,&hyperlipidemia,&
Squinavir& particles&(prevents&development&of&new&virus)& with&other&anti&HIV&drugs&to&give&kinetic& lipodystrophy&(fat&deposits&causing&atrophy&
Ritonavir& & boost&(especially&Lopinavir)& and&wasting)&Pancreatitis&with&Ritonavir&
Indinavir& Resistance=&mutation&of&pol&gene& Kidney%stones,%hematuria%(Indinavir—must&
Nelfinavir& stay&hydrated)&&
Integrase%inhibitor% Prevents&integration&of&viral&genome&in&host&cell&DNA&(impairs& Added&when&resistance&to&HAART& Possible&hypercholesterolemia;&no&other&
Raltegravir& mRNA&transcription)& metabolic&syndrome&effects&
Fusion%Inhibitors% Enfuvirtide&Binds&gp41&to&inhibit&fusion&of&HIV?1&onto&CD4&T?cells&(Added&in&when&other&drugs&fail)& Injection&site&reaction&
Enfuvirtide&& Maraviroc&(entry&inhibitor)&Blocks&CCR5,&preventing&gp120&association&and&subsequent&viral&entry&
Maraviroc&
Other%Antivirals&
Amantidine& Blocks&attachment,&penetration,&&&inhibits%uncoating%of% Influenza&prophylaxis& Nervousness,&insomnia,&seizures&in&OD&
Rimantidine& Influenza%A& May&↓&duration&of&flu&symptoms&1?2&days& Atropine?like&peripheral&effects&&
Parkinson’s&rescue&drug;&Chronic&Hep&C& Livedo%reticularis&(purplish&networking&on&skin)&
Zanamivir&(intranasal)& Inhibit%influenza%neuraminidase,&prevents&release&and& Influenza&prophylaxis& &
Oseltamivir& maturation&of&progeny&virus&(Influenza&A&and&B)& May&↓&duration&of&flu&symptoms&2?3&days&
Ribavirin& Monophosphorylated&form&inhibits%IMP%dehydrogenase;& RSV,&Hantavirus,&Lassa&Fever,&adjunct&to& Hematotoxic,&upper&airway&irritation&
triphosphate&inhibits%RNA%polymerase&and&end?capping& alpha?interferons&for&Hep&C& Teratogenic&
Interferon?α& Activates&host&ribonuclease&which&degrades&viral&mRNA& HepB&(+Lamivudine);&HepC&(+Ribavirin)& &
Palivizimab& Monoclonal&antibody—Blocks&RSV&protein&F& RSV&(when&Ribavirin&cannot&be&used)& &
&
% Fungi% Randall %
Systemic%Mycoses%
• Dimorphic%fungi&[mold&in&cold&(25°C),&yeast&in&the&beast&(37°C)]&
• Most&commonly&present&with&pneumonia?like&symptoms&
• No&person&to&person&transmission&
• Best&diagnosis=&biopsy;&(also&sputum&culture&on&Sabouraud)&
Histoplasma%capsulatum&
Microscope& Features& Epidemiology& Diseases& Treatment&
Environmental&form& • Ohio%and%Mississippi%River% Fungus%flu%(pneumonia)% DOC&
&

• Hyphae&with&microconidia&and& Valleys% • Asymptomatic&or&acute&(self?resolving)& • Itraconazole%

tuberculate&macroconidia& • Found&in&soil&or&dust& • Hepatosplenomegaly&may&be&present& • Amphotericin&B&
& enriched&with&bird/bat% • Lesions&tend&to&calcify&as&they&heal& (severe&or&
Tissue&form& feces&& • Increased&relapse&with&T?cell&immunosuppression& pregnant)&
• Small,&oval<budding%yeast% • Spelunking,%cleaning% • Disseminated&in&AIDS&(mucocutaneous&lesions)& &
& inside%macrophages&& chicken%coops& &
Yeast&inside&macrophage& Facultative%intracellular%parasite%in%RES%(macrophages)&
Blastomyces%dermatitidis&
Environmental&form& • Same%as%Histoplasma%but% Blastomycoses% DOC&
&

• Hyphae&with&small&pear?shaped& extending%north&to&great& • Acute&and&chronic&pulmonary&disease&(pneumonia)& • Itraconazole%

conidia& lakes,&Ohio,&Canada;&and& • Less&likely&to&self?resolve&than&Histoplasma/Coccidiodes& • Amphotericin&B&
& Southeast&to&Carolinas)& • Lesions&do%NOT%calcify&as&they&heal&& (severe&or&
Tissue&form& • Soil&or&rotting%wood% • Disseminated&disease&in&immunocompromised&(mostly% pregnant)&
• Broad<based%budding%yeast% (beaver%dams)& affects%skin;%also%bone&marrow,&CNS)& &
• Double,&refractile&cell&walls& &
& Broad?based&budding&yeast&seen&in&sputum&
&
Broad?based&budding&yeast&
Coccidiodes%immitis&
Environmental&form& • Southwest%US&(Arizona,& Valley%Fever% DOC&
&

• Hyphae&breaking&up&into&barrel& New&Mexico,&southern&Cal—& • Asymptomatic&to&self&resolving&pneumonia& • Fluconazole%

shaped&arthroconidia& San&Joaquin&Valley)& • Erythema%nodosum%(Desert&bumps)&and&arthritis&are&good& • Amphotericin&B&
& & prognostic&signs& (severe&or&
Tissue&form& • Arthroconidia&inhaled&from& • Lesions&tend&to&calcify&as&they&heal& pregnant)&
• Spherules%with%endospores% desert%sand%spherules&w/& • Dissemination&in&immunocompromised,&AIDS,&and&3rd& &
& endospores&in&tissue& trimester&of&pregnancy&(meningitis,&mucocutaneous)&
Spherules&with&endospores&
Paracoccidiodes&brasiliensis&
Environmental&form& • Latin%America% Paracoccidioidomycosis% DOC&
&

• Hyphae&of&variant&forms& • Soil&fungus& • Inhalation&mild&pneumonia&(can&resemble&TB)& • Ketoconazole%

& • Mucous&membrane&ulceration&of&the&mouth&and&nose&with& • Amphotericin&B&
Tissue&form& spreading&through&the&lymphatic&system& (severe&or&
• Multiple?budding&yeast&with& & pregnant)&
captain’s%wheel%formation& &
&
Captain’s&wheel&budding&&
%
Opportunistic%Mycoses%
Yeast%
Candida%albicans&
Microscope& Features& Epidemiology& Diseases& Treatment&
• Oval&yeast&with&single&bud&in& • Part&of&the&normal&flora&of& • Oral/esophageal%thrush%(neonates,&AIDS,&steroids,&antibiotic& DOC&
&

mucous&membranes& skin,&mucous&membranes& overuse)—white&patches&easily&scraped&off& • Miconazole;%

• Germ&tubes&in&serum& and&GI&tract& • Yeast%vaginitis&(↓pH;&diabetic&women,&antibiotic&overuse)& Clotrimazole&
• Forms&pseudohyphae%and%true% • Immunocompromised& • Endocarditis%(IVDA)& • Nystatin&
hyphae%when%invading%tissues& patients,&IVDA,&overuse&of& • Cutaneous&infections&(obesity,&infants—diaper&rash)& • Fluconazole,&
antibiotics& & Amphotericin&B&
Nystatin—swish&and&swallow&for&oral&thrush&(topical&for&diaper& (disseminated)&
& rash&or&vaginitis)&
Yeast&&&&GermTube&&P?hyphae&
Cryptococcus%neoformans&
• Urease&⊕& • Soil&enriched&with%pigeon% Meningitis% DOC&
&

• Monomorphic%encapsulated% droppings% • Dominant%meningitis%in%AIDS%patients&(begins&in&lungs;& • Amphotericin&B&

yeast% • Hodgkin/&AIDS%patients& pneumonia?like&symptoms&soap&bubble&lesion&in&brain)% w/&flucytosine&
• Mucicarmine&stains&capsule&red& • Pidgeon&breeders& Detect&capsular&antigen&in&CSF—latex&agglutination& (min&10&weeks)&
& India%ink%mount%budding&yeasts&with&“capsular&halos”&(misses& then&fluconazole&
India&ink—capsular&halos& 50%—only&rules&in)%
Pneumocystis%jirovecii% &
• Obligate&extracellular&parasite& • Yeast&inhaled& Diffuse%interstitial%pneumonia%in%AIDS%(CD4<200)& DOC&
&

• Silver%stained%cysts&in& • AIDS%patients,% • Fever,&cough,&SOB,&non&productive&sputum& • TMP<SMX%&

tissues/alveolar&fluid& malnourished&babies,& • Ground%glass%appearance%on&X?ray&(patchy&infiltrative)& • Clindamycin&+&
• Foamy,&honeycomb&appearance& premature&neonates% & Primaquine&
& on&H&E&stain&& Destruction&of&Type&I&pneumocytes=&↑&Type&II&pneumocytes;& • IV&pentamidine&
Silver&stain& alveolar&damage&exudate&leakage% • Dapsone&
Mold%
Aspergillus%fumigatus&
• Monomorphic&filamentous& • Compost%pits,%moldy% • Allergic%bronchopulmonary%aspergillosis%(asthma,&CF— DOC&
&

fungus&(only&exists&as&mold)& marijuana% growing&in&mucus&plugs&but&not&penetrating&tissue)&Type&I&HS;& • Itraconazole&

• Dichotomously&branching& • Asthmatics,&Cystic&Fibrosis& Eosinophilia,&perihilar&nodules,&eventual&bronchiectasis& • Amphotericin&B&
• Radiating&chains&of&conidia% patients& • Fungus%ball—free&in&preformed&lung&cavities&(surgical& &
• Septate&hyphae&forming%V< & removal&to&reduce&coughing)&“colonizing&aspergillus”& DOC&Invasive&
shaped%acute%45°angles% *Some&species&produce& • Invasive%aspergillosis%% aspergillosis=&
aflatoxins&associated&with& Severe&neutropenia,&CGD,&CF&(burn&victims—cellulitis)& Voriconazole%±%
& Hepatocellular&Carcinoma& Invades&tissues&causing&infarcts/hemorrhage;&& Caspofungin&
45°&septate&&&&&&Conidiophore& % Nasal&colonization&pneumonia&or&meningitis% &
Mucor,%Rhizopus,%Absidia—(Zygomycophyta)&
• Sporangiospores& • Soil—sporangiospores& Rhinocerebral%infection% • Debride%
&

• Nonseptate&hyphae&with&broad% inhaled& • Facial&pain/headache,&paranasal&swelling,&black%necrotic% necrotic%tissue&

90°%angles& • Ketoacidotic%diabetic% eschar%on%face,&hemorrhagic&exudates&from&nose/eyes,&mental& (black&pus)&
patients%and%leukemic% lethargy& • Immediately&
patients%at&risk% • Can&progress&rapidly&from&sinuses&(sphenoid&to&cavernous)& start&
& & into&brain&tissue&(frontal%lobe%abscesses)&& Amphotericin&B&
Nonseptate,&broad&angle& Biopsy&KOH&of&tissue—broad&nonseptate&hyphae&at&90°&angles&
Superficial%Infections%
Malassezia%furfur&
Microscope& Features& Epidemiology& Diseases& Treatment&
• Spaghetti%and%meatballs& • Moist,%warm%climates,& Pityriasis%(Tinea%versicolor)% DOC&
&

appearance&on&KOH&mount&of& sweating& • Superficial&infection&of&keratinized&cells& • Topical%

skin&cells&(yeast&clusters&&&short& • Normal&skin&flora&(lipophilic& • Hypo<%or%hyperpigmented%spots%on%the%chest/back%(blotchy& selenium%
curved&septate&hyphae)& yeast)& suntan)& sulfide&
• Coppery&fluorescence&under& & &
Wood&lamp&(UV)& Premature&infants&on&lipid&
supplements&fungemia&
&
Spaghetti/meatballs&on&KOH&
&
&
%
Cutaneous%Infections%
Dermatophytes%(Microsporum,&Trichopyton,&Epidermophyton)&
• Monomorphic&filamentous&fungi& • Infect&only&skin,&hair&and/or& Tineas%(ringworms)—itching%MC%symptom% DOC&
&

(mold&form)& nails—pruritic&lesion&w/& Tinea&capitis&(scalp)& • Miconazole;&

• Mycosporum&fluoresces&a&bright& central&clearing& <favosa%(permanent%hair%loss;%very%contagious)% Clotrimazole&
yellow<green&under&Wood& Microsporum% ?barbae&(beard)& • Tolnaftate;&
lamp&(UV)& • Skin&&&hair& ?corporis&(glabrous/hairless&skin),&& Terbinafine%&
• KOH&wet&mount&of&nail&or&skin& Trichophyton& ?cruris&(jock&itch)&& • Oral&imidazoles&
scrapings&show&arthroconidia% • Skin,&hair,&&&nails& ?pedis&(athlete’s&foot)& or&griseofulvin&
and%hyphae& Epidermophyton& ?unguium&(nails)& w/infected&hair&
& • Skin&&&nails& Highly&inflammatory&=&generally&from&animals& %
Microsporum& Little&inflammation=&generally&from&humans% Keep%areas%dry%
%
&
%
Subcutaneous%Infections%
Sporothrix%schenckii%&
Environmental&form& • Found&on&plant&material& Sporotrichosis&(rose%gardener%disease)% DOC&
&

• Hyphae&with&rosettes&and& (plum&tree,&rose%thorns,& • Subcutaneous&or&lymphocutaneous&lesions& • Itraconazole%

sleeves&of&conidia& wire/sphagnum&moss)& & • Potassium&iodide&
Tissue&form& • Rose%gardeners,&alcoholics& in&milk&(not&for&
• Cigar<shaped%yeast% passing&out&in&rose&gardens& pulmonary)&
& %

&
&
%
& Pulmonary&sporotrichosis&(acute&or&chronic)&
Hyphae&with&rosettes& • Homeless&urban&alcoholics&(alcoholic&rose&garden?sleeper&
disease)&

%
%
 Antifungals%
Drug% Mechanism% Clinical%Use% Toxicity%
Amphotericin%B% Binds%ergosterol;&forms&membrane& Serious%systemic%mycoses%(disseminated)& • Fever,&chills,&malaise,&hypotension&during&IV&
pores&that&allow&leakage&of& • Histoplasma&& infusion&(alleviated&by&NSAIDs)&
electrolytes& • Blastomyces& • Nephrotoxicity,&arrhythmias,&anemia,&IV&
“Polyene&antifungal”& • Coccidiodes& phlebitis,&hypermagnesemia,%hypokalemia&
• Candida& &
• Cryptococcal&meningitis&(with&or&without&flucytosine)& • Hydration&and&liposomal%amp%B&reduce&
& nephrotoxicity&
Administered&via&slow&IV&infusion&(½&life&>&2&weeks)&& • Flucytosine&allows&for&synergism&so&not&as&
Poorly&penetrates&CNS;&safe&in&pregnancy& much&amp&B&needs&to&be&used&
& &
Nystatin% Same&as&amphotericin&B& Candida&infections& Too&toxic&for&systemic&use&(only&use&topical&
• Diaper&rash&or&vaginal&candidiasis&(topical)& form)&
• “Swish%and%swallow”%for%oral%thrush%(not&absorbed&in&GI&tract)% &
%
<Azoles% Inhibits%14<alpha%demethylase& Local&and&less&serious&systemic&mycoses& • Testosterone&synthesis&inhibition&
% (fungal&CYP3A)&which&converts& • Ketoconazole—DOC&Paracoccidiodes;&dandruff&(topical)& (gynecomastia,&↓libido,&hypoadrenalism:&
Ketoconazole& lanosterol&to&ergosterol&& & especially&ketoconazole)&
Fluconazole& & • Fluconazole—&DOC&Candida,&Coccidiodes;&Prophylaxis&and& • Ketoconazole&biggest&P450&inhibitor&
Itraconazole& Absorption&(acidic&environment)& suppression&of&Cryptococcal&meningitis&(penetrates&CNS)& • ↑&Liver&function&tests&
Voriconazole& • Antacids&↓&ketoconazole& & &
Miconazole& • Food&↑&itraconazole& • Itraconazole—DOC&Blastomyces,&Histoplasmosis,&Sporothrichoses,& Oral&forms&not%safe%in%pregnancy%(teratogenic)&
Clotrimazole& Aspergillosis& &
Posaconizole& &
• Miconazole/Clotrimazole—topical&(candida,&dermatophytes)&
inexpensive,&safe&in&pregnancy/breastfeeding&
&
• Posaconizole—for&Mucor&(Amp&B&more&common&treatment)&
&
Flucytosine% Needs&to&be&converted&into&active&5? • Used&in&systemic&fungal&infections&(esp.&Cryptococcal&meningitis&in& • Bone%marrow%suppression%
FU&by&cytosine&deaminase& combo&with&amphotericin&B)& • GI&symptoms%
Inhibits%thymidine%synthase=% • Synergism&reduces&side&effects&of&ampB&(less&ampB&used);&helps&
↓thymidine,&↓DNA&and&RNA& penetrate&CNS&
biosynthesis&& • Resistance&emerges&rapidly&if&used&alone&
&
Caspofungin% Inhibits&cell&wall&synthesis&by& • Invasive&aspergillosis&(in&combo&with&voriconazole)& • GI&upset&
Micafungin& inhibiting&synthesis&of&β?glucan% • Candida& • Flushing&(histamine&release)&
“fungal%cell%wall%polysaccharide”%
&
Terbinafine% Inhibits%squalene%epoxidase% Dermatophytoses&(especially&onychomycosis—finger/toenail)& • GI&distress,&rash,&headache&
Accumulates&in&stratum&corneum& • Abnormal&LFTs,&visual&disturbances&
&
Griseofulvin% Interferes%with%microtubule% Oral%treatment&of&superficial&infections& • Teratogenic,&carcinogenic,&confusion,&
function;&disrupts&mitosis&(mitotic& Inhibits&growth&of&dermatophytes&(tinea,&ringworm)& headaches&
spindle).&&Deposits&in&keratin? • P450&inducer&(↑warfarin%metabolism)&
containing&tissues&(stratum& Disulfuram<like%reaction&
corneum)&
&
% Parasites% Randall %
PROTOZOA—%GI&infections%
Entamoeba%histolytica%(amebae)&
Findings& Form/Transmission& Diagnosis& Disease& Treatment&
• Cysts—water,&fresh&fruits& • “Ova&parasite&stool&study”& Amebiasis% DOC&
&

and&vegetables& (Trophozoites&or&cysts&in&stool)& • Dysentery&(bloody%diarrhea)& • Metronidazole%&

• Fecal?oral&transmission& • Serology—Nuclei&have&sharp& • Inverted&flask&shaped&lesions&in&large%intestine& (for&trophozoites)&&
• History&of&travel& central&karyosome&and&fine& • Lesions&can&extend&to&liver,&lungs,&brain,&heart& • Followed&by&iodoquinol&
chromatin&“spokes”& • Liver%abscess:&“anchovy%paste”%exudate&with&RUQ& (for&cyst&form)&
pain& &
&
&&&&Trophozoite&&&&&&&&&&&Cyst&
Giardia%lamblia%(flagellate)&
• Cysts—fecal&(human,&beaver,& • “Ova&parasite&stool&study”& Giardiasis% DOC&
&

muskrat)& (Trophozoites&or&cysts&in&stool)& • Ventral&sucking&disk&attaches&to&lining&of&duodenal& • Metronidazole%&

• Oral&transmission—& • Fecal&antigen&test%% wall&inflammation&decreases&absorption&at&villi& &
“Campers—water%from%a% • “Falling%leaf%motility”% • Fatty,%foul<smelling%diarrhea&malabsorption&
stream”,&food,&day&care,&ass& (duodenum,&jejunum)&
& to&mouth&sex&(ATM)&
&&&&Trophozoite&&&&&&&&&&&Cyst& &
Cryptosporidium%parvum%(apicomplexa)&
• Cysts—undercooked&meat,& • Acid%fast&oocysts&in&stool% Cryptosporidiosis% • No&treatment&is&100%&
&

water&& • Biopsy&shows&dots&(cysts)&in& • Transient&watery&diarrhea&in&healthy& effective&

• Not&killed&by&chlorination& intestinal&glands& • Severe%diarrhea%in%AIDS&(immunocompromised)& • Prevent&with&filtration&
& & • Intracellular&multiplication&in& (Chlorination&does&NOT&
Acid&fast&oocysts&in&stool% brush&border& work)%
& • Nitrazoxanide&for&AIDS&
Others&(cause&diarrhea&in&AIDS)&(apicomplexa)&
Isospora%belli% • Ingestion&of&oocysts& • Acid%fast&elliptical%oocysts&in& Transient&diarrhea&in&AIDS&(mimics&giardiasis)& • TMP?SMX&
• Fecal?oral& stool&
Cyclospora%cayetanesis% • Oocysts&in&water& • Acid<fast&spherical%oocysts&in& Severe&diarrhea&in&AIDS&(Self&limiting&in&healthy)& • TMP?SMX&
stool&
Microsporidia% • Spores&ingested& • Gram%⊕,%acid<fast%spores%in& Persistent,&debilitating&diarrhea&in&AIDS&(may&become& • None&
stool% disseminated&neurologic,&hepatitis)&
%
PROTOZOA—Sexually&transmitted%
Trichomonas%vaginalis%(flagellate)&
Findings& Form/Transmission& Diagnosis& Diseases& Treatment&
• One&form=&trophozoites& • Motile%trophozoites&in& Trichomoniasis& DOC&
&

• Sexually&transmitted& methylene&blue&wet&mount& • Often&asymptomatic& • Metronidazole&

• Corkscrew%motility& • Foul&smelling,%Frothy%green&vaginal&discharge&
(increased&vaginal&pH)&
&
&&&&Motile&trophozoites&
PROTOZOA—Hematologic&infections&
Babesia%(apicomplexa)&
Findings& Form/Transmission& Diagnosis& Disease& Treatment&
• Ixodes&tick&& • Giemsa%stain& Babesiosis& DOC&
&

• Co<infections%with%Borrelia& • Small&ring&form,&Maltese%cross,& • Malaria?like&(mild)& • Clindamycin%+%Quinine&

• Limited&to&US& or&tetrad&in&RBCs& • Fever,&hemolytic&anemia& • Atovaquone&+&Azithromycin&
&
&&&&Ring,&maltese&cross&tetrad&
Plasmodium%(P.&vivax/ovale,&P.&malariae,&P.&falciparum)&(apicomplexa)&
Two&hosts&
& &

1.%Anopheles%mosquito&
• Sexual&phase&
(sporogony)&
2.&Vertebrates&(humans)&
• Asexual&phase&in&
liver/RBCs&
(schizogony)&
&
Symptoms&
• Chills,%fever<spike,&
malarial&rigors&
• Occur&when&merozoites&
rupture&RBCs&(#4&in&
figure)&

&
& &
&

Species& Blood&smear/&features& Disease& Liver&stages& Treatment&

P.&vivax& • Enlarged&host&cells&& Benign&tertian& Relapse&due&to&persistant&hypnozoites& Chloroquine&then&
&

• Ameboid&trophozoites& • 48&hour&fever&spikes&& (dormant&form&in&liver)& primaquine&

& • Shüffner’s&dots& (every&3rd&day)&
&
Ameboid&trophozoite&
P.&ovale& Similar&to&vivax&& Benign&tertian& Relapse&due&to&persistant&hypnozoites& Chloroquine&then&
&

•
• RBCs&more&oval,&jagged& • 48&hour&fever&spikes&& (dormant&form&in&liver)& primaquine&
& Shüffner’s&dots& (every&3rd&day)&
& •
Oval&trophozoite& &
P.&malariae& Bar&and&band&forms& Quartan& No%persistant%form%% Chloroquine&
&

•
• Rosette%schizonts% • 72&hour&fever&spikes&& Recrudescence&(symptoms&reoccur)&due&
& (every&4th&day)&& to&low&level&remaining&in&RBCs&&
& • Recrudescence&
Rosette&schizont&
P.&falciparum& • Multiple&ring&forms& Malignant&tertian&(most&serious)& No%persistant%form%% Chloroquine&resistance&a&
&

• Crescent<shaped% • Irregular&fever&spikes& Recrudescence&(symptoms&reoccur)&due& problem&(use&quinine&sulfate&

gametes% • Causes&cerebral&malaria& to&low&level&remaining&in&RBCs& +&pyrimethamine?
sulfadoxine)&
&
Multi?ring&&&&Gamete&
PROTOZOA—%CNS&infections%
Toxoplasma%gondii%(apicomplexa)&
Findings& Form/Transmission& Diagnosis& Disease& Treatment&
• Cat%is%essential% • Serology& • Healthy&heterophile&neg&mononucleosis&(flu?like&illness&with& DOC&
&

definitive%host% • High&IgM&or&rising&IgM& lymphadenopathy/fever)& • Primethamine%+%

• Raw&pork&MCC&
• Contact&with&cat&feces&
• Most&common&protozoal&
& infection&in&US&
Trophozoites&&&&&&Ring&lesions&
Naegleria%fowleri%(free?living&amoebae)&
• Swimming%in%warm%
&
(acute&infection)& • Pregnant&heterophile%neg%mononucleosis,&can&cross&placenta& sulfadiazine%(+&folinic&
• Crescentric& (early:&congenital&infections—&chorioretinitis,&hydrocephalus,& acid)&
tachyzoites&and& intracerebral&calcifications;&late:&blindness&in&teens)& • Prophylaxis&at&CD4<100&
necrosis& • AIDS%MCC%focal%CNS%disease%(ring<enhancing%lesions)% for&AIDS&
• Motile&trophozoites&in& Primary&amebic&meningoencephalitis&(PAM)& • Amphotericin&B&(rarely&

fresh%water% CSF& • Severe%prefrontal%headache,&altered&sense&of&smell,&nausea,&high& successful)&

& • Enters&cribiform&plate& fever;&often%fatal& &
Trophozoites&in&CSF&
Acanthamoeba%(free?living&amoebae)&
• Contaminated&contact% • Star<shaped%cysts&on& • Keratitis% • Miconazole&(keratitis)&
&

lens%solution% biopsy&(not&CSF)& • Granulomatous&amebic&encephalitis&(immunocompromised)&with&

• Amoebic&parasites&in& focal&neurological&signs&
& CSF&
Star?shaped&cysts&
&

PROTOZOA—%Hemoflagellates&
Trypanosoma&
Species& Transmission& Diagnosis& Disease& Treatment&
T.%cruzi% • Reduviid%bug&(kissing& • Trypomastigote&in& Chagas&disease& • Nifurtimox%
bug,&cone&bug)—painless& blood&films& • Swelling&around&eye&(Romaña&sign),&dilated%cardiomyopathy,& • Benznidazole&
bite& megacolon,&megaesophagus&
• Brazil,&South&America&
%
T.%brucei&& • Tsetse%fly&(painful&bite)& • Trypomastigote&in& African%Sleeping%Sickness% • Suramin&(acute)&
(gambiense,&rhodesiense)& blood&films,&CSF& • Enlarged&lymph&nodes,&recurring&fever&(due&to%antigenic% • Melarsoprol&
variation),&somnolence,&coma& (chronic/CNS&
involvement)&
&
Leishmania&
L.%donovani&& • Sandfly%bite% • Amastigotes%in% Visceral&Leishmaniasis&(most&severe)% Visceral&
(Phlebotomus)% macrophages&in&bone& Hepatosplenomegaly,&spiking&fever,&weight&loss,&fatigue,&anemia,& • Lipsomal%Amp%B%
• Middle&East,&India,&South& marrow,&liver,&spleen& mucosal&ulcers&& %
America,&North&Africa& Cutaneous&
&&& & • Sodium%Stibogluconate%
Amastigotes&&&&&&Promastigotes&&
in&macrophage&&
L.%braziliensis&& • Amastigotes%in% Mucocutaneous&Leishmaniasis&
macrophages&in& Extensive&disfigurement%of%nasal%septum,%lips,%and%palate&
Leishmania&& cutaneous&lesions& Cutaneous&Leishmaniasis&
(About&15&different&species)& Oriental%sore&(local;&open&ulcerative&lesion)&
Trematodes%(flukes,&flatworms)—Snails&are&1st&intermediate&hosts &
Ingestion&
Organism& Acquisition& Disease&progression& Ova& Treatment&
Clonarchis%sinensis% • Raw%fish& • Biliary&tract&inflammation&pigmented%gallstones& & &
(chinese&liver&fluke)& • Southeast&Asia& • Assoc.&with&cholangiocarcinoma&(MCC&eastern&world)& & &
& &
Paragonimus%westermani% • Raw%crab%meat,%crayfish% • Mimics%pulmonary%TB%
Operculated& &
(lung&fluke)% • Lung&inflammation&&&2°&bacterial&infection;&hemoptysis&
Eggs& Praziquantel&
Fasciola%hepatica% • Aquatic&plants&& • Fever,&nightsweats,&malaise& &
(sheep&liver&fluke)& (watercress)&

Fasciolopsis%buski% • Aquatic&plants&& • Diarrhea&and&abdominal&pain%

(giant&intestinal&fluke)% (water%chestnuts)&

Skin&penetration&
Schistosoma%mansoni% • Contact&with&water;&& Intestinal&schistosomiasis&(TH2&mediated)& &
&

Schistosoma&japonicum&(Asia)% • Skin&penetration&by&cercariae&& • Skin&penetration&(itching)&mature&in&veins&of&mesentery& &

(motile&larva&form)& • Eggs&cause&granulomas%in%liver&(portal%hypertension)& &
&
&
Praziquantel&
Schistosoma% • Contact&with&water& Vesicular&schistosomiasis&
&

• Skin&penetration&by&cercariae& • Enter&skin&(itching)&mature&in&bladder%veins%(hematuria)&
haematobium& • Egypt&and&Africa& • Chronic&infection&high&association&with%&
&
squamous%cell%carcinoma%of%the%bladder&&
&
Non<human%schistosomes% • Contact&with&water&& Swimmer’s%itch& • Trimeprazine&
%

(Trichobilharzia&regenti)& • Skin&penetration&by&cercariae& • Penetrate&skin&dermatitis&(no&further&development)% • Calamine&

• Great%Lakes&in&U.S.,&birds& • Itching&most&intense&at&2?3&days% • Sedatives&
%
Human:&No&ova&
%

Cestodes%(tapeworms)&
Ingestion&
Organism& Acquisition& IH& DH& Disease&progression& Diagnosis& Treatment&
Taenia%saginata% Rare%beef& Cattle& Humans& Intestinal&tapeworm&(sm&intestine)&& Proglottids&or& &
(containing&cysticerci)& • Asymptomatic&or&vague&abdominal&pains& eggs&in&feces& &
(beef&tapeworm)&
Raw%pork&& Swine& Humans& Intestinal&tapeworm&(same&symptoms&as&saginata)& Proglottids&or& &
% Praziquantel&
(containing&cysticerci)& eggs&in&feces&
Taenia%solium% Water,&vegetation& % % Cysticercosis& Biopsy&
&
(pork&tapeworm)% (surgery&for&
(contaminated&with&eggs)& Humans% —% • Larvae&develop&in&brain%(brain%cysts)%“swiss%cheese%brain”&
eye,&heart,&lung&adult%onset%epilepsy,%seizures& some&T.&solium&
• “Immigrant%with%new%onset%seizures”& cysts)&

Diphyllobothrium% Raw%pickled%fish&& Crustacean Humans& Intestinal&tapeworm&& Proglottids&or&

(with&sparganum/larvae)& &fish& • Competes&for&B12&in&intestine&(megaloblastic&anemia)& eggs&in&feces&
latum% Drinking%pond%water& & & Sparganosis& Biopsy&
(fish&tapeworm)% (contaminated&by&copepods& Humans& —& • Larvae&penetrate/encyst&intestinal&wall&
carrying&larvae)%
Echinococcus% Ingestion%of%eggs%from% Humans;% Herding% Hyatid&cyst&disease% Imaging;& Surgery;&
dog%feces% Sheep% dog% • Liver%cysts%with%brood%capsules&(and/or&lung&cysts)% serology& albendazole&
granulosus%
Larvae&develop&in&Intermediate%hosts&(IH)…&Adult&tapeworms&develop&in&Definitive%hosts&(DH)…&Cysticerci=&encysted&larvae&found&in&Intermediate&host&
Nematodes%(roundworms)&[treatment&usually&–bendazoles&(remember&bendy&worms)]%
Ingestion—Eggs&(larvae&ingestion&for&Trichinella)&&&&&Mnemonic—EAT&
Species&
Enterobius%vermicularis%
(MC&helminth&in&U.S.)&
Ascaris%lumbricoides%
(MC&helminth&worldwide)&
Trichinella%spiralis%
Toxocara%canis%(cati)%
(Dog&&&Cat&Ascarids)&
Trichuris%trichiura%
Skin&penetration—Larvae&&&Mnemonic—SANd&
Strongyloides%stercoralis%
Ancylostoma%braziliense%
Ancylostoma%caninum&
(Dog&&&Cat&hookworms)%
Necator%americanus%
(New&World&hookworm)%
% • Lung&migration&pneumonitis&
Filarial%Nematodes&
Wucheria%bancrofti%
Brugia&malayi,&Brugia&timori&
Loa%Loa%
(African&Eye&worm)%
Onchocerca%volvulus%
Dracunculus%medinensis%
(Guinea&worm,&fiery&serpent)%
Acquisition& Disease& Diagnosis& Treatment&
• Eggs&ingested& Pinworms&in&large&intestine& • Scotch%tape%test%(sticky& Mebendazole;&
&
• Also&person&to&person& • Perianal%itching% swab&of&perianal&area)% (treat&entire&
• Child&scratches&and&gets&eggs&under&nails& • Ova&have&flattened%side& family)&
with&larva&inside& &
&
• Eggs&ingested& Ascariasis% • Bile&stained,&knobby%eggs& Mebendazole;&
&
• Egglarva&migrate&through&lung&(cough)& • Adult&roundworms&up&to&a& Surgery&for&
• Mature&in&sm&intestine&(may&obstruct)& foot&long& &
& migrations&
• Wild%game%meat&& Trichinosis% • Muscle&biopsy&(cysts&with&larvae)% Mebendazole&&
• Raw&bacon& • Larvae&encyst&in&muscle&myalgia& • Eosinophilia%(Type&I&HS)% (Severe:&add&
• Encysted&larvae% • Fever,%splinter%hemorrhages,%periorbital& % steroids)&
consumed& edema&
• Eggs&ingested& Visceral%larva%migrans% • Clinical&findings&and&serology& Mebendazole;&
• Handling%puppies% • Larva&wander&aimlessly&until&they&die& & Self?limiting&
• Eating&dirt&in&yard& • Cause&inflammation% &
• Eggs&ingested& Whipworm&in&cecum& • Barrel<shaped%eggs&with& Albendazole&
&
• Appendicitis;&rectal&prolapse& bipolar&plugs&in&stools&
&
&
• Skin%penetrated&by& Threadworm%strongyloidiasis% • Larvae&in&stool& Ivermectin&
filariform&larva& • Early—pneumonitis,&abdominal&pain,&diarrhea& • Serology& Thiabendazole&
• Autoinfection&unless& • Late—malabsorption,&ulcers,&bloody&stool& %
treated&
• Skin%penetrated&by& Cutaneuous%larva%migrans% • Presumptive&diagnosis& Thiabendazole;&
filariform&larva& • Intense&skin&itching& • Larva&cannot&mature&in&humans& Topical&
& corticosteroids&
• Bare%feet% Hookworm% • Fecal&larvae?&up&to&13mm& Mebendazole&&
&
penetrated&by& • Bloodsucking&intestine&wall&& • Ova?&oval,%transparent,%2<8% (+&iron&therapy)&
filariform&larva& microcytic%anemia%% cell%stage&
• Occult&blood&possible& &
• Female%mosquito% • Elephantiasis—Blockage%of%lymphatic% Microfilariae&in&blood;&Eosinophilia;%IgE? Surgery,&
vessels&(takes&a&year&for&symptoms)% mediated&degranulation&of&mast&cells& DEC+ivermectin&
• Chrysops&(Deer%fly,& • Pruritis,&calabar&swellings&(local&swelling& • Micropfilariae&in&blood;& Surgery;&
&
horsefly,&mangofly)& where&worm&travels;&subcutaneous)& Eosinophilia& DEC,&ivermectin&
• Worm%in%conjunctiva& &
• Female&blackfly% • River%blindness%% • Skin&snips&from&calabar&swellings& Surgery;&
• Itchy&leopard&rash&(black&skin&nodules)% DEC,&ivermectin&
• Drinking%water&with& • Creeping&eruptions,&ulcerations,&inflammation& • Increased%IgE% Metronidazole;&
%
infected&copepods& • Worm%eruption%from%skin% Slow&worm&
removal&w/stick&
%
%
DEC=&Diethylcarbamazine&
Ectoparasites&
Pediculosis&capitis&(head&lice)& • Head&to&head&contact;&prevalent&in&school&children& • Permethrin&1%&cream,&Pyrethrin,&Malathion,&Lindane&
Pediculosis&pubis&(crabs)% • Sexual&contact&(must&also&check&for&STDs)& &
Scarcoptes&scabiei&(scabies)& • Burrows&under&skin&(intense&itching);&interdigital%webbing,&feet,&hands,&trunk,&elbows& • Permethrin&1%&cream,&Ivermectin,&Lindane&
%
Antimalarials%
Drug% Mechanism% Clinical%Use% Toxicity/Contraindications%
Chloroquine% Erythrocytic%shizotocide—Accumulates& P.&vivax/ovale&use&chloroquine%+%primaquine& • Retinal%damage%
in&food&vacuole&of&parasite&and&prevents& P.&falciparum/malariae&use&chloroquine%alone& • Itching&(contraindicated&in&psoriasis)&
conversion&of&heme&to&hemozoin&& Resistance=&mutated&transporter& • Depression&
(heme&accumulates=&death)& Drugs:&Quinine&+&pyri/sulf&>&Mefloquine&>&Artemisinins&
Primaquine% Tissue%schizontocide&& For%Plasmodium%vivax/ovale&(dormant&in&liver)& • Hemolysis&in&G6PD&deficiency&
(Used&with&chloroquine)% Works%against%hypnozoites&to&prevent&relapse& • Contraindicated%in%pregnancy%
Chloroquine%resistant%cases&
Quinine% First&line&for&chloroquine%resistant%P.%falciparum& • Cinchonism%(vertigo,&tinnitus,&flushing)&
• Blackwater&fever&(hemolysis&in&G6PD&deficiency)&
Pyrimethamine<%Sulfadoxine%& Used&in&combo&with&quinine&for&chloroquine&resistant&P.&falciparum& • Hypersensitivity&reaction&
Mefloquine& Second&line&for&resistance;&prophylaxis&in&high&risk&areas& • Syncope,&cardiac&conduction&defect,&pneumonitis&
Only&take&orally&(20&day&half&life)& • Contraindicated%in%psychosis,%seizures%
Artemisinins%(Artsunate,&Arthemether)% Multi?drug&resistance&(obtained&from&Chinese&herb)& • Generally&well&tolerated&
%
Antiprotozoals% Trematodes/Cestodes%
Drug% Clinical%Use% Toxicity% Drug% Mechanism%
Metronidazole% Accumulation&of&toxic&metabolites&(free&radicals)& • Disulfuram<like%reaction% Praziquantel% • Increases&calcium&efflux&
which&damage&DNA& with&alcohol&
• DOC:%Giardia,&Entamoeba,&Trichomonas,& • GI&distress&
%
Gardnerella,&Anaerobes,&H.&Pylori&& %%%%%%%Nematodes%
(GET%GAP%on%the%Metro)%
Pyrimethamine< Inhibits%dihydrofolate%reductase%(interferes& • Hypersensitivity&reaction&
Drug% Mechanism%
Sulfadoxine% with&THF/&DNA&synthesis)% • Megaloblastic&anemia& Mebendazole% • Decrease&glucose&uptake&&&microtubular&
• DOC:%Toxoplasmosis%% Albendazole& structure&
• Prophylaxis&at&CD4<100&for&AIDS& Pyrantel%Palmoate% • Spastic&paralysis&of&worms&
Trypanosomiasis& &
Benznidazole% Produce&T.cruzi?sensitive&free&radicals& • Rash& &&&&&&&&PARASITE&HINTS&
• DOC:&Chagas%disease%(T.&cruzi)&
Suramin% African%sleeping%sickness%(T.&brucei)& • Adrenal&damage&
Findings% Organism%
Early&(hemolytic)&stages& • Uticarial&rash& Cholangiocarcinoma& Clonarchis&sinensis&
Melarsopral% African%sleeping%sickness%(T.&brucei)& • Similar&to&arsenic&posioning& Hemoptysis& Paragonimus&westermani&
Late&(CNS)&stages& Text Portal&hypertension& Schistosoma&mansoni&
Nifurtimox% Backup&(T.&cruzi,&T.&brucei)& • GI&&&Neurological& Hematuria,&bladder&cancer& Schistosoma&haematobium&
Brain&cysts,&seizures& Taenia&solium&
Leishmaniasis& B12&deficiency&& Diphyllobothrium&latum&
Sodium% Leishmaniasis&(IV&administration)& • Phlebotoxic& Liver&cysts& Echinococcus&granulosus&
Stibogluconate% • Pancreatitis& Perianal&itching& Enterobius&
Microcytic&anemia& Necator,&Ancylostoma&