Gram-negative Bacilli

Enterobacteriaceae
Leanne Jessa G. Gumahad, RMT
General characteristics
• Gram-negative, non-spore forming, facultatively anaerobic bacilli
• Microscopy: can appear as coccobacilli or as straight rods
• All are motile at 35 deg. C. with peritrichous flagella except for
Klebsiella, Shigella, & Yersenia
• All are non-encapsulated except Klebsiella & Enterobacter
• All ferments glucose & reduce nitrate to nitrite
• All are catalase positive & oxidase negative except P. shigelloides
• BAP/CAP: large, moist, gray colonies, non-hemolytic; Klebsiella &
Enterobacter- large & very mucoid; E. coli- beta hemolytic
Serologic characteristics (Antigens)
• O antigen
• Somatic antigen
• Heat stable antigen located on cell wall
• H antigen
• Flagellar antigen
• Heat labile antigen found on the surface of flagella
• Structure responsible for motility
• K antigen
• Heat-labile polysaccharide found only in encapsulated species
• Vi antigen
• Capsular antigen of S. enterica subsp. Enterica serotype Typhi
Opportunistic Pathogens
• Escherichia
• Klebsiella
• Enterobacter
• Serratia
• Hafnia
• Proteus
• Morganella
• Providencia
• Edwardsiella
• Citrobacter
Escherichia coli
• Most significant species in the genus Escherichia
• AKA: Colon bacillus
• Important human pathogen associated with many disease
• May inhibit female genital tract & leading cause of nosocomial
urinary tract infection
• Microbiota of large intestine
• Primary indicator of fecal contamination in water purification
• Motile and possess adhesive fimbriae & sex pili
• Possess O, H, & K antigens
Escherichia coli Properties
• MAC- flat, dry, pink colonies
• BAP- some strains are nonhemolytic, others beta hemolytic
• EMB- greenish metallic sheen
• Ferments glucose, lactose, trehalose, & xylose
• Production of indole from tryptophan
• Cannot use citrate as a sole carbon source
• Virulence factor: endotoxin, common pili, K1 antigen, intimin
 Escherichia coli
Biochemical Test
• TSI= A/A (+) Gas, (-) H2S
• IMViC= + + - -
• PAD (-)
• Urease (-)

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 Escherichia coli strains (Gastrointestinal)
Strains Infection V. Factor Characteristics
Enteropathogenic E. coli Infantile diarrhea (stool - (+) H antigen & intimin
(EPEC) without blood)
Enterotoxigenic E. coli Traveler’s diarrhea Heat-stable (ST) & Heat- Infective dose: 106-1010
(ETEC) (Montezuma’s revenge) labile enterotoxin Persons w/ achlorhydria are
at high risk
Only grows in BAP
Enteroinvasive E. coli Dysentery- like or Shigella- Invasin (bloody diarrhea Atrichous: NLF/LF
(EIEC) like infection with pus cells) (+) plasmid
Watery diarrhea (with WBC) (+) Sereny test
Enterohemorrhagic E. coli Hemorrhagic colitis Verotoxin I & II (+) intimin
(EHEC Serotype O157:H7) Hemolytic uremic syndrome Shigella-like toxin (-)MUG
Bloody diarrhea (w/out wbc) Associated w/ Thrombotic
thrombocytopenic purpura
SMAC- colorless colonies; does
not ferment sorbitol
 Escherichia coli strains (Gastrointestinal)
Strains Infection V. Factor Characteristics
Enteroadherent E. coli DAEC- cystitis in children & Fimbrae EAEC- Stacked- bricked
Enteroadherent E. coli (EAEC) & acute pyelonephritis in appearance
diffusely adherent E. coli (DAEC) pregnant women
EAEC- diarrhea by adhering to
surface of intestinal mucosa
(absence of WBC & RBC)
Uropathogenic E. coli UTI Common pili, aerobactin, & Type I fimbrae adheres
(UPEC) cytolisins strongly to the urinary tract
Other species
• E. hermanii
• Clinical significance not yet established
• Yellow-pigmented organism
• CSF, wounds, blood
• Raw milk, beef (same with EHEC Serotype O157:H7)
• E. vulneris
• More than half of strains are yellow-pigmented colonies
• Isolated from infected wounds
Klebsiella species
• Usually found in GIT or humans & animals or free-living in soil, water, &
plants
• Associated with opportunistic & hospital-acquired infections-
pneumonia, wound infections, & UTI
• (+) Citrate utilization
• (-) H2S production
• (-) MR, (+) VP
• (-) Indole expect for K. oxytoca & K. ornithinolytica
• Non-motile
• Encapsulated
• Hydrolyze urea slowly
• MAC-pink colonies
 Klebsiella pneumoniae
subsp. pneumoniae
• AKA: Friedlander’s bacillus
• Most common isolated species
• Have large polysaccharide capsule- virulence factor and
causes mucoid & moist colonies in MAC
• Causative agent of community-acquired pneumonia
• “currant jelly like sputum”
• Frequent cause of lower respiratory tract infections among
immunocompromised patients
• (+) string test
• IMViC= - - + +
• TSI= A/A, (+) gas, (-) H2S
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Other Klebsiella species
• Klebsiella pneumoniae subsp. ozaenae
• Causative agent of chronic atrophic rhinitis/ “foul-smelling” atrophic
rhinitis
• Klebsiella pneumoniae subsp. rhinoscleromatis
• Causes granuloma of the nose & oropharynx
• Klebsiella oxytoca & Klebsiella ornithinolytica
• Indole positive
Enterobacter species
• Motile
• Resembles Klebsiella on MAC
• Common isolate: E. aerogenes & E. cloacae
• (+) citrate utilization
• (+) KCN
• (+) ornithine decarboxylase
• (+) Lysine decarboxylase except E. aerogenes & E. cloacae
• (+) sorbitol fermentation
• (+) urease
• (+) malonate test
• IMViC - - + +
• TSI A/A (+) gas (-) H2S
Serratia species
• Associated with outbreaks in health care settings
• S. marcescens, S. rubidaea= urinary/ respiratory tract & in bacteremic
outbreaks in nurseries & cardiac surgery/ burn units
• Contamination of antiseptic solution used for joint injections
• Known for resistance to a wide range of antibiotics
• MAC- NLF; clear colorless but may be slow or late lactose
fermenters
• (+) ONPG, DNase, gelatinase
• IMViC - - + +
• TSI K/A (+) gas (-) H2S
Serratia species
• S. marcescens, S. rubidaea, S. plymuthica produce a
characteristics pink to red pigment, prodigiosin, when cultured at
room temp
• S. odorifera have a dirty, musty odor resembling that of rotten
potatoes
Hafnia species
• H. alvei only species
• H. alvei biotype 1 grows in beer wort of breweries (has not been isolated
clinically)
• Linked to gastroenteritis and occasionally isolated from stool
cultures
• IMViC - - +(v) +
• TSI K/A (+) gas (-) H2S
Proteus species
• Part of Proteeae (PPM) which can deaminate
phenylalanine
• Isolated from urine, wounds, ear, & bacteremic infections
• Can infect proximal kidney tubules & can cause acute
glomerulonephritis (patients w/ urinary tract defect or
catheterization)
• Rapid urease producers (split urea in urine, which raises
the pH & encourages formation of renal stones)
• Human pathogens: P. mirabilis, P. vulgaris
• P. mirabilis exhibits swarming on nonselective media
(burnt-chocolate/ burnt-gun powder odor)
• MAC- NLF; colorless & clear
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Proteus species
Biochemical Test P. mirabilis P. vulgaris
Indole - +
PAD + +
LIA R/A R/A
IMViC -+vv ++-v
TSIA K/A (+) gas (+) H2S K/A (+/-) gas (+) H2S

Rodriguez, M. T. (2016). Gram-positive Cocci.

In Review Handbook in Diagnostic Bacteriology. C & E Publishing.
Morganella species
• M. morganii only species
• Same biochemical reactions with P. vulgaris except for citrate
utilization
• MAC- NLF; colorless, clear
• PAD (+)
• LIA: R/A
• TSI K/A (+) gas (-) H2S
• (+) urease, ornithine decarboxylase
• IMViC + + - -
Providencia species
• MAC- NLF; clear & colorless
• PAD (+)
• IMViC + + - +
• LIA: R/A
• TSI: K/A (-) gas (+) H2S
Providencia species
• Consist of 5 species: P. alcalifaciens, P. stuartii, P. rettgeri, P.
rustigianii, P. heimbachae
• P. stuartii- outbreaks in burn units; isolated in urine cultures;
resistant to antibiotics
• P. rettgeri- pathogen of urinary tract & has caused outbreaks in
health care settings
• P. alcalifaciens- commonly found in feces of children w/ diarrhea
(role not proven)
Edwardsiella species
• MAC- NLF; clear & colorless
• Urease (-)
• IMViC + + - -
• TSI: K/A (+) gas (+) H2S
• Species: E. tarda
Citrobacter species
• Resembles E. coli on MAC but biochemical test of Salmonella
species
• All species grow on Simmons citrate medium/ citrate (+)
• Urease (+)- slowly hydrolyze urease
• Normal flora in GI tract & associated with hospital acquired
infections (UTI)
• IMViC - + - +
• TSI: A/A or K/A (+) gas (+) H2S
Citrobacter species
• C. freundii
• Isolated in diarrheal stool cultures (extraintestinal pathogen- not
established)
• UTI, pneumonia, intraabdominal abscesses in hospital setting
• Endocarditis in drug abusers
• H2S (+)
• Fails to ferment lactose
• Colony morphology of C. freundii on primary selective media can be
mistaken for Salmonella when isolated on stool cultures
• Urea (+); Lysine decarboxylase (-) for C. freundii
• Urea (-); Lysine decarboxylase (-) for Salmonella species
Primary Intestinal Pathogens
• Salmonella
• Shigella
• Yersinia
Salmonella species
• Gram-negative, facultatively anaerobic bacilli that morphologically
resembles other enteric bacteria
• Do not ferment lactose
• Negative for indole, VP, PAD, & urease
• Produce H2S except S. Paratyphi A
• Do not grow in medium containing potassium cyanide
• MAC- NLF; clear & colorless
• SSA- colorless with black center
• Virulence factor: fimbriae, ability to traverse intestinal mucosa
• Antigenic structures
• Somatic O & Flagellar H- serologic grouping
• Vi antigen (Salmonella serotype Typhi)- antiphagocytic
Salmonella species
• LDC (+) except Salmonella serotype Paratyphi A
• Urease (-)
• IMViC - + - +
• TSI: K/A (+) gas (+) H2S
Salmonella species- Clinical Infection
• Acute gastroenteritis
• Most common form of food poisoning
• Source pf infection attributed mainly to poultry, milk, eggs, & egg
products
• Cooking utensils used in preparing contaminated foods is the
mode of dissemination
• Infective dose: 106
• Enteric fever (Typhoid fever)
• Ingestion of food contaminated with the organism originating from
infected persons/carriers
• Causative agent: Salmonella enterica subsp. enterica serotype
Typhi
• Outbreaks from improper disposal of sewage, poor sanitation, &
lack of modern potable water system
• Common in tropical & subtropical area
• Onset of symptoms depends on quantity of inoculum
• During 2nd -3rd week of infection, organism invades the gallbladder
& Peyer’s patches of the bowl
• Rose spots (blanching, rose-colored papules around umbilical https://phil.cdc.gov/PHIL_Images/09252002/00005/PHIL_2214_lores.jpg

region appears)
Salmonella species- Clinical Infection
• Bacteremia
• Caused by nontyphoidal Salmonella
• Prolonged fever and intermittent bacteremia
• Serotype: Typhimurium, Paratyphi, & Choleraesius
• Observed in (1) young children with fever & gastroenteritis with brief
episodes of bacteremia, and (2) adults with transient bacteremia during
episodes of gastroenteritis or develop symptoms of septicemia without
gastroenteritis
Shigella species
• Closely related to Escherichia
• Not a normal flora in GI tract
• All Shigella species can cause Bacillary dysentery
• Nonmotile
• Does not produce gas from glucose except S. flexneri
• Urease (-)
• H2S (-)
• Lysine decarboxylase (-)
• All species possess O antigens
• All species are mannitol fermenters except S. dysenteriae
Shigella species
• MAC-NLF; clear, colorless, fragile
• SSA- colorless without black centers
• IMViC: v + - -
• TSI: K/A (-) gas (-) H2S
• Humans are the only known reservoir
• Transmission is through direct P2P contact via fecal –oral route,
flies, finger, & food or water contaminated by infected person
Shigella species
• S. sonnei
• Decarboxylate ornithine
• Slow LF- delayed positive fermentation with formation of pink colonies on
MAC only after 48 hours
• ONPG (+)
• S. dysenteriae
• Most virulent of the species
• Virulence factor: shiga toxin
Shigellosis/ Bacillary dysentery
• Commonly caused by S. dysenteriae type 1
• Acute inflammatory colitis & bloody diarrhea with WBCs & mucus
• Only requires a low infective dose to produce a disease (<200
bacilli)
• Young children: rectal prolapse occur due to excessive straining
Yersinia species
• Only 3 species are considered human pathogens
• Y. pestis- plague
• Y. pseudotuberculosis- mesenteric lymphadenitis in human
• Y. enterocolitica- infection that mimics appendicitis
• Other members are found in water, soil, and lower animals
 Yersinia pestis
• Causative agent of ancient disease- plague (disease primarily of rodents)
• AKA: Plague bacillus
• Class A bioterrorism agent
• Transmitted by bites of fleas
• 3 forms: bubonic, septicemic, pneumonic form
• Symptoms: Buboes (swollen lymph nodes)
https://mechpath.files.wordpress.com/2017/12/figure • Gram-negative, short, plump bacillus with a bipolar staining pattern
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• MAC- NLF; colorless, clear
• BAP: Pinpoint colonies after 24 hours
• Broth: stalactite-shaped pattern
• IMViC: - + - -
• TSI: K/A (-) gas, (-) H2S

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Yersinia enterocolitica
• Most isolated species of Yersinia
• Found in wide variety of animals, including domestic swine, cats, &
dogs (infection can be acquired from contact with pets)
• Infections occur after ingestion of contaminated food- pork & vacuum-
packed deli meat, beef, lamb, chicken, & possibly milk & water
• Causative agent of enterocolitis or waterborne gastroenteritis
• Gram-negative, coccobacilli, with a bipolar staining pattern
• Optimal growth temperature: 25-30 degrees Celsius
• SIM- Motility seen at 25 degrees Celsius
• Selective media: CIN medium
• MAC- NLF; colorless, clear
• IMViC: v + - -
• TSI: K/A (-) gas, (-) H2S
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Yersinia pseudotuberculosis
• Like Y. pestis, pathogen is primarily of rodents- guinea pigs
• Birds are natural reservoir
• Causes psuedotubercules (caseous swellings) in animals
• Human infections are rare, only associated with close contact with
infected animals or ingestion of contaminated food/ drink
• Spreads to mesenteric lymph nodes (generalized infection which is
self-limiting)
• SIM- Motility seen at 18-25 degrees Celsius
• MAC- NLF; colorless, clear
• Urease & rhamnose fermentation (+)
• TSI: K/A (-) gas, (-) H2S
Other Enterics
• Plesiomonas
• Cronobacter
• Pantoea
Plesiomonas shigelloides
• Straight bacilli, which can occur singly, in pairs, in short chain or
filamentous
• Motile (+) polar flagellum either peritrichous or monotrichous
• Causes Secretory diarrhea
• Only oxidase positive member
• Associated with PLHIV with inflammatory bowel disease
• Antigenic structure: O & H antigens
• MOT: ingestion of undercooked seafood (oysters & shrimp) &
contaminated water
Plesiomonas shigelloides
• MAC- NLF; clear & colorless
• BAP- shiny, opaque, smooth, & non-hemolytic
• Inositol-brilliant green-bile salt agar- white or green to pink color
for other enterics
• IMViC: + + - -
• TSI: K/A (-) gas, (-) H2S
• Decarboxylase (+)
Cronobacter sakazakii
• Formerly known as Enterobacter sakazakii
• Contaminant of powdered infant formula which may cause
neonatal meningitis
• Isolated from individuals with brain abscesses, & respiratory and
wound infections
• MAC- pink color (LF)
• BHIA- yellow pigmentation
• IMViC: - - + +
• TSI: A/A (+) gas, (-) H2S
Pantoea species
• Encompasses several species, including Pantoea agglomerans
(formerly known as Enterobacter agglomerans), Pantoea dispersa,
Pantoea ananatis, etc.
• Nosocomial outbreaks of septicemia due to contamination of IV
fluids
• Triple decarboxylase negative
• MAC- NLF; clear & colorless
• IMViC: - v + v
• TSI: K/A (-) gas, (-) H2S
Other Non-enteric Gastrointestinal Pathogens
• Vibrio
• Aeromonas
• Campylobacter
• Helicobacter
Vibrio species
• Family Vibrionaceae
• Found in wide variety of aquatic environment
• 4 clinically encountered species: V. cholerae, V. parahaemolyticus,
V. vulnificus, V. alginolyticus
• Asporogenous, gram-negative rods possessing polar, sheathed
flagella when grown in broth but can produce peritrichous,
unsheathed flagella when in solid media
• Catalase & oxidase (+)
• Reduces nitrate to nitrite except for V. metschnikovii (negative)
• Susceptibility test: 150 micrograms vibriostatic O/129 disk in MHA
Vibrio species
• MAC- pathogenic are NLF (except V. vulnificus)
• BAP/CAP- medium to large colonies that appear smooth,
opaque, & iridescent with a greenish hue
• BAP- alpha or beta hemolytic
• TCBS- selective media
• Sucrose fermenters: V. cholerae, V. alginolyticus, V.
metschnikovii
• Non-sucrose fermenters: V. mimicus, V. vulnificus, V.
parahaemolyticus, V. damsela
• Alkaline peptone water (pH 8.5)- enrichment media (V.
cholerae)
• Transport medium: Cary-Blair media
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Vibrio cholerae- Cholera
• Vibrio cholerae O1- causative agent of cholera
• Rice watery stools (contains numerous flecks of
mucus)
• Motility: rapid darting/ shooting stars
• Virulence factor: Cholera toxin (Choleragen/ CTX)
• String test (+)
• Oxidase, Indole, lysine, ornithine decarboxylase (+)
• TSI: A/A (-) gas (-) H2S
• LIA: K/K (+) lysine decarboxylation
• Epidemic V. cholerae O1 bio groups:
• Classical - VP (-), does not agglutinate chicken RBC,
susceptible to polymyxin B
• El Tor- VP (+) , hemolyzes RBC, resistant polymyxin B, able
to agglutinate chicken RBC https://www.researchgate.net/publication/51898494/figure/fig1/AS:484201817481216@1492454117646/Rice-water-stool-produced-by-
a-cholera-patient.png
Vibrio parahaemolyticus
• Second most common species implicated for gastroenteritis
• AKA: Summer Diarrhea
• Self-limiting; watery diarrhea, moderate cramps or vomiting
• Leading cause: V. parahaemolyticus serotype O3:K6
• Virulence factor: Kanagawa phenomenon
• Heat-stable hemolysin able to lyse human RBCs in high salt medium
• Selective medium: Wagatsuma agar
Vibrio vulnificus
• Second most serious type of Vibrio- associated infections
• Primary septicemia & wound infections
• Lactose- positive vibrio
• MOA: eating contaminated raw oysters & fish
Vibrio alginolyticus
• Not commonly isolated and least pathogenic
• Strict halophile that requires a medium with 1-10% NaCl
• Infections: eye, ear, & wound infections
Presumptive Identification
• Vibrio species- susceptibility to vibriostatic agent O/129 and (+)
string test distinguishes them from Aeromonas
• Inability to ferment inositol (except for V. cincinnatiensis & V.
metschnikovii) separtes them from Plesiomonas
• Oxidase reaction (except for V. metschnikovii) separates them
from Enterobacteriaceae (excluding P. shigelloides)
• Carbohydrate fermentation metabolism separates them from
oxidative Psuedomonas
Aeromonas species
• Ubiquitous, oxidase-positive, glucose-fermenting, gram-negative
rods
• Catalase (+)
• Motile with single polar flagellum and are facultatively anaerobes
• Classified into 2 groups
• Mesophilic (Optimal growth @ 37 deg. C)
• A. hydrophila complex, A. veronii complex, motile strains of A. salmonicida
• Psychrophilic (Optimal growth @ 22 deg. C)
• A. salmonicida
• Can typically grow at 4-42 deg. C
Aeromonas species
• Most common isolate: A. caviae
• Common isolate in GI infection: A. caviae
• Common isolate in HUS: A. hydrophila, A. veronii
• Vibriostatic O/129: Resistant
• Inositol fermentation: Negative
• String test: Negative
Aeromonas species
• Level & pattern of virulence is more like the multifactorial patterns
of various E. coli subgroups associated with enteric disease
• Diarrheal presentation
• Acute, secretory diarrhea often accompanied by vomiting
• Acute, dysenteric form of diarrhea (like shigellosis), w/ blood & mucus
• Chronic diarrhea usually lasting more than 10 days
• Cholera-like disease, including rice watery stools
• Nebulous syndrome commonly referred to as Traveler’s diarrhea
• Septicemia, Meningitis, & wound infection (involving leeches),
keratitis associated with contact lens water
• Causative agent of red-leg disease in amphibians
Aeromonas species
• MAC- LF, colonies are pink
• BAP- large, round, raised, white opaque (with extremely strong
odor & pigmentation from translucent & white to buff-colored);
hemolysis is varied (A. hydrophila, A. veronii biovar sobria, A.
jandaei are beta hemolytic)
• CIN- bulls-eye appearance
• Indole (+) - A. hydrophila, A. veronii, A. caviae
• TSI: A/A (-) gas (-) H2S- A. caviae
• TSI: A/A (-) gas (+) H2S- A. hydrophila, A. veronii
 Aeromonas species
• Positive oxidase distinguishes Aeromonas spp. from Enterobacteriaceae
(except P. shigelloides)
• Clinically relevant Aeromonas spp. are indole positive
• Distinguishing factor of Aeromonas spp. from Vibrio spp. is string test &
vibriostatic O/129
• Biochemical strip: API 20E
Campylobacter species
• Faintly staining, gram-negative, small, curved, or S-
shaped rods
• Old cultures: coccobacilli (Enteric campylobacters
appear long spirals/ sea-gull shaped)
• Colonies are gray, flat, glistening, & irregular with tailing
effect along the streak line (runny spreading growth)
• Grow in microaerophilic environment except C. rectus &
C. curvus which are strictly anaerobes
• Causes abortion in domestic animals
• Antecedent cause of Guillain-Barre syndrome
• Enteric: C. jejuni, C. coli, C. lari
• Blood: C. fetus subsp. fetus
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Campylobacter species
• Specimen of choice: Feces, rectal swab, blood
• Selective media: Campy-BAP for C. jejuni & other enteric campy
• Brucella agar base, 10% sheep RBC, vancomycin, trimethoprim,
polymyxin B, amphotericin B, cephalothin
• Other media: Butzler medium & Skirrow’s medium, Medium V
(modification of Butzler medium with cefoperazone, rifampin,
colistin, & amphotericin B which inhibits normal colon flora),
Campy CVA
• Transport media: Cary-Blair Medium
Campylobacter jejuni
• Slow growing, fastidious, saccharolytic organism
• Darting motility (monotrichous) and unable to grow in media with
high salt concentration
• Most common cause of bacterial gastroenteritis
• Septic arthritis in PLHIV
• Optimum temperature for growth: 42 deg. C
• MOA: eating contaminated chicken & turkey
Helicobacter species
• Campylobacter- like species are Helicobacter & Wolinella
• Motile by monopolar or multi-bipolar flagella
• Microaerophilic & strong urease activity
• Resembles Campylobacter species in gram staining
• CAP- gray & translucent
• Oxidase, catalase, urease (+)
• Route of transmission: oral-oral/ fecal-oral
 Helicobacter species
• Specimen: Gastric biopsy tissue, urine, feces, dental plaque
• Tissue specimen must be kept at 4 deg. C & processed within 2 hours
of collection
• Urine used for ammonia testing
• Gram stain: 0.1% fuchsin counterstain (morphology)
• Biopsy stains: Warthin-Starry stain, Silver stain, Giemsa stain
• Culture: CAP, MTM, Skirrow’s agar, Brucella agar w/ 5% sheep blood
• Transport media: Stuart Medium (gastric tissue specimens), cysteine
brucella broth w/ 20% glycerol, isotonic saline w/ 4% glucose
Helicobacter pylori
• Major cause of Type B gastritis, peptic ulcer, gastric cancer
• Primary habitat: human gastric mucosa
• Binds with Lewis antigen and monosaccharide sialic acid
• Biochemical test: Strong urease producer
• Diagnostic test: Urea breath test
• Susceptible to metronidazole
Mnemonics!
• Non-motile: SKY
• Nonencapsulated: KE
• VP (+): ESK
• NLF: Edward Clearly Provides Proof Young Morgan Slowly Shipped
Salmon
• H2S (+): Soulless Edward Produces Chemicals
• Indole (+): Citizen-Killing Pink Vampires Morgan & Edward Provide
Kleptos with oxytocin & Eclairs
• PAD (+): PPM
References
• Ciulla, A. P., & Lehman, D. C. (2009). Success! in Clinical Laboratory Science: A Complete Review.
Prentice Hall.
• Graeter, L., Hertenstein, E., Accurso, C., & Labiner, G. (2014). Elsevier’s Medical Laboratory Science
Examination Review - E-Book. Elsevier Health Sciences.

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