Foundations in

Microbiology
Sixth Edition
Chapter 19
The Gram-Positive
Bacilli of Medical
Importance
Lecture PowerPoint to accompany
Talaro
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Medically Important Gram-Positive
Bacilli
Three general groups:
1. Endospore-formers
Bacillus, Clostridium
2. Non-endospore-formers
Listeria, Erysipelothrix
3. Irregular shaped and staining properties
Corynebacterium, Proprionibacterium,
Mycobacterium, Actinomyces, Nocardia

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Spore-forming Bacilli
Genus Bacillus
Genus Clostridium

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General Characteristics of the Genus
Bacillus
Gram-positive, endospore-forming, motile rods
Mostly saprobic
Aerobic and catalase positive
Versatile in degrading complex macromolecules
Source of antibiotics
Primary habitat is soil
2 species of medical importance:
Bacillus anthracis
Bacillus cereus
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Bacillus anthracis
Large, block-shaped rods
Central spores that develop under all conditions
except in the living body
Virulence factors polypeptide capsule and
exotoxins
3 types of anthrax:
cutaneous spores enter through skin, black sore-
eschar; least dangerous
pulmonary inhalation of spores
gastrointestinal ingested spores
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Control and Treatment
Treated with penicillin, tetracycline, or
ciprofloxacin
Vaccines
live spores and toxoid to protect livestock
purified toxoid; for high risk occupations and
military personnel; toxoid 6X over 1.5 years;
annual boosters

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Bacillus cereus
Common airborne and dustborne; usual
methods of disinfection and antisepsis are
ineffective
Grows in foods, spores survive cooking and
reheating
Ingestion of toxin-containing food causes
nausea, vomiting, abdominal cramps and
diarrhea; 24 hour duration
No treatment
Increasingly reported in immunosuppressed

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The Genus Clostridium
Gram-positive, spore-forming rods
Anaerobic and catalase negative
120 species
Oval or spherical spores produced only under
anaerobic conditions
Synthesize organic acids, alcohols, and exotoxins
Cause wound infections, tissue infections, and
food intoxications
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Gas Gangrene
Clostridium perfringens most frequent clostridia
involved in soft tissue and wound infections -
myonecrosis
Spores found in soil, human skin, intestine, and
vagina
Predisposing factors surgical incisions,
compound fractures, diabetic ulcers, septic
abortions, puncture wounds, gunshot wounds


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Virulence Factors
Virulence factors
toxins
alpha toxin causes RBC rupture, edema
and tissue destruction
collagenase
hyaluronidase
DNase

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Pathology
Not highly invasive; requires damaged and
dead tissue and anaerobic conditions
Conditions stimulate spore germination,
vegetative growth and release of exotoxins,
and other virulence factors.
Fermentation of muscle carbohydrates
results in the formation of gas and further
destruction of tissue.
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Treatment and Prevention
Immediate cleansing of dirty wounds, deep
wounds, decubitus ulcers, compound fractures,
and infected incisions
Debridement of disease tissue
Large doses of cephalosporin or penicillin
Hyperbaric oxygen therapy
No vaccines available
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Clostridium difficile-Associated
Disease (CDAD)
Normal resident of colon, in low numbers
Causes antibiotic-associated colitis
relatively non-invasive; treatment with broad-spectrum
antibiotics kills the other bacteria, allowing C. difficile to
overgrow
Produces enterotoxins that damage intestines
Major cause of diarrhea in hospitals
Increasingly more common in community acquired
diarrhea
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Treatment and Prevention
Mild uncomplicated cases respond to fluid and
electrolyte replacement and withdrawal of
antimicrobials.
Severe infections treated with oral vancomycin
or metronidazole and replacement cultures
Increased precautions to prevent spread
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Tetanus
Clostridium tetani
Common resident of soil and GI tracts of
animals
Causes tetanus or lockjaw, a neuromuscular
disease
Most commonly among geriatric patients and IV
drug abusers; neonates in developing countries


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Pathology
Spores usually enter through accidental puncture
wounds, burns, umbilical stumps, frostbite, and crushed
body parts.
Anaerobic environment is ideal for vegetative cells to
grow and release toxin.
Tetanospasmin neurotoxin causes paralysis by
binding to motor nerve endings; blocking the release of
neurotransmitter for muscular contraction inhibition;
muscles contract uncontrollably
Death most often due to paralysis of respiratory
muscles

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Treatment and Prevention
Treatment aimed at deterring degree of toxemia
and infection and maintaining homeostasis
Antitoxin therapy with human tetanus immune
globulin; inactivates circulating toxin but does
not counteract that which is already bound
Control infection with penicillin or
tetracycline; and muscle relaxants
Vaccine available; booster needed every 10
years
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Clostridial Food Poisoning
Clostridium botulinum rare but severe
intoxication usually from home canned food
Clostridium perfringens mild intestinal
illness; second most common form of food
poisoning worldwide
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Botulinum Food Poisoning
Botulism intoxication associated with
inadequate food preservation
Clostridium botulinum spore-forming
anaerobe; commonly inhabits soil and water


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Pathogenesis
Spores are present on food when gathered and
processed.
If reliable temperature and pressure are not achieved air
will be evacuated but spores will remain.
Anaerobic conditions favor spore germination and
vegetative growth.
Potent toxin, botulin, is released.
Toxin is carried to neuromuscular junctions and blocks
the release of acetylcholine, necessary for muscle
contraction to occur.
Double or blurred vision, difficulty swallowing,
neuromuscular symptoms


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Infant and Wound Botulism
Infant botulism caused by ingested
spores that germinate and release toxin;
flaccid paralysis
Wound botulism spores enter wound and
cause food poisoning symptoms

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Treatment and Prevention
Determine presence of toxin in food,
intestinal contents or feces
Administer antitoxin; cardiac and
respiratory support
Infectious botulism treated with penicillin
Practice proper methods of preserving and
handling canned foods; addition of
preservatives.
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Clostridial Gastroenteritis
Clostrium perfringens
Spores contaminate food that has not been
cooked thoroughly enough to destroy
spores.
Spores germinate and multiply (especially if
unrefrigerated).
When consumed, toxin is produced in the
intestine; acts on epithelial cells, acute
abdominal pain, diarrhea, and nausea
Rapid recovery
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Gram-Positive Regular Non-Spore-
Forming Bacilli
Medically important:
Listeria monocytogenes
Erysipelothrix rhusiopathiae
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Listeria monocytogenes
Non-spore-forming Gram-positive
Ranging from coccobacilli to long filaments
1-4 flagella
No capsules
Resistant to cold, heat, salt, pH extremes and
bile
Virulence attributed to ability to replicate in the
cytoplasm of cells after inducing phagocytosis;
avoids humoral immune system

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Epidemiology and Pathology
Primary reservoir is soil and water; animal intestines
Can contaminate foods and grow during refrigeration
Listeriosis - most cases associated with dairy
products, poultry, and meat
Often mild or subclinical in normal adults
Immunocompromised patients, fetuses and neonates;
affects brain and meninges
20% death rate

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Diagnosis and Control
Culture requires lengthy cold enrichment
process.
Rapid diagnostic tests using ELISA available
Ampicillin and trimethoprimsulfamethoxazole
Prevention pasteurization and cooking
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Erysipelothrix rhusiopathiae
Gram-positive rod widely distributed in
animals and the environment
Primary reservoir tonsils of healthy pigs
Enters through skin abrasion, multiples to
produce erysipeloid, dark red lesions
Penicillin or erythromycin
Vaccine for pigs
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Gram-Positive Irregular Non-Spore-
Forming Bacilli
Medically important genera:
Corynebacterium
Proprionibacterium
Mycobacterium
Actinomyces
Nocardia



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Pleomorphic; stain unevenly
20 genera; Corynebacterium, Mycobacterium,
and Nocardia greatest clinical significance
All produce catalase, possess mycolic acids,
and a unique peptidoglycan.
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Corynbacterium diptheriae
Gram-positive irregular bacilli
Virulence factors assist in attachment and
growth.
diphtherotoxin exotoxin
2 part toxin part B binds and induces endocytosis;
part A arrests protein synthesis

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Epidemiology and Pathology
Reservoir of healthy carriers; potential for
diphtheria is always present
Most cases occur in non-immunized children
living in crowded, unsanitary conditions.
Acquired via respiratory droplets from carriers
or actively infected individuals





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Epidemiology and Pathology
2 stages of disease:
1. Local infection upper respiratory tract
inflammation
sore throat, nausea, vomiting, swollen lymph nodes;
pseudomembrane formation can cause asphyxiation
2. Diptherotoxin production and toxemia
target organs primarily heart and nerves
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Diagnostic Methods
Pseudomembrane and swelling indicative
Stains
Conditions, history
Serological assay
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Treatment and Prevention
Antitoxin
Penicillin or erythromycin
Prevented by toxoid vaccine series and
boosters


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Genus Proprionibacterium
Propionibacterium acnes most common
Gram-positive rods
Aerotolerant or anaerobic
Nontoxigenic
Common resident of sebaceous glands
Causes acne
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Mycobacteria: Acid-Fast Bacilli
Mycobacterium tuberculosis
M. leprae
M. avium complex
M. fortuitum
M. marinum
M. scrofulaceum
M. paratuberculosis


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Genus Mycobacterium
Gram-positive irregular bacilli
Acid-fast staining
Strict aerobes
Produce catalase
Possess mycolic acids and a unique type of
peptidoglycan
Do not form capsules, flagella or spores
Grow slowly

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Mycobacterium tuberculosis
Tubercle bacillus
Produces no exotoxins or enzymes that
contribute to infectiousness
Virulence factors - contain complex waxes
and cord factor that prevent destruction by
lysosomes or macrophages
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Epidemiology of Tuberculosis
Predisposing factors include: inadequate nutrition,
debilitation of the immune system, poor access to
medical care, lung damage, and genetics.
Estimate 1/3
rd
of world population and 15 million
in U.S. carry tubercle bacillus; highest rate in U.S.
occurring in recent immigrants
Bacillus very resistant; transmitted by airborne
respiratory droplets


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Course of Infection and Disease
Only 5% infected people develop clinical
disease
Untreated, the disease progresses slowly;
majority of TB cases contained in lungs
Clinical tuberculosis divided into:
primary tuberculosis
secondary tuberculosis (reactivation or
reinfection)
disseminated tuberculosis
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Primary TB
Infectious dose 10 cells
Phagocytosed by alveolar macrophages and
multiply intracellularly
After 3-4 weeks immune system attacks,
forming tubercles, granulomas consisting of a
central core containing bacilli surrounded by
WBCs tubercle
If center of tubercle breaks down into necrotic
caseous lesions, they gradually heal by
calcification.


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Secondary TB
If patient doesnt recover from primary
tuberculosis, reactivation of bacilli can occur.
Tubercles expand and drain into the bronchial
tubes and upper respiratory tract.
Gradually the patient experiences more severe
symptoms.
violent coughing, greenish or bloody sputum, fever,
anorexia, weight loss, fatigue
Untreated, 60% mortality rate
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Extrapulmonary TB
During secondary TB, bacilli disseminate to
regional lymph nodes, kidneys, long bones,
genital tract, brain, and meninges.
These complications are grave.
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Diagnosis
1. In vivo or tuberculin testing
Mantoux test local intradermal injection of
purified protein derivative (PPD); look for red
wheal to form in 48-72 hours- induration;
established guidelines to indicate interpretation of
result based on size of wheal and specific
population factors
2. X rays
3. Direct identification of acid-fast bacilli in
specimen
4. Cultural isolation and biochemical testing
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Management and Prevention of TB
6-24 months of at least 2 drugs from a list
of 11
One pill regimen called Rifater (isoniazid,
rifampin, pyrazinamide)
Vaccine based on attenuated bacilli Calmet-
Guerin strain of M. bovis used in other
countries
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Mycobacterium leprae: The Leprosy
Bacillus
Hansens bacillus/Hansens Disease
Strict parasite has not been grown on artificial
media or tissue culture
Slowest growing of all species
Multiplies within host cells in large packets called
globi
Causes leprosy, a chronic disease that begins in
the skin and mucous membranes and progresses
into nerves
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Epidemiology and Transmission of
Leprosy
Endemic regions throughout the world
Spread through direct inoculation from
leprotics
Not highly virulent; appears that health and
living conditions influence susceptibility
and the course of the disease
May be associated with specific genetic
marker
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Course of Infection and Disease
Macrophages phagocytize the bacilli, but a
weakened macrophage or slow T cell response
may not kill bacillus.
Incubation from 2-5 years; if untreated, bacilli
grow slowly in the skin macrophages and
Schwann cells of peripheral nerves
2 forms possible:
tuberculoid superficial infection without skin
disfigurement which damages nerves and causes loss of
pain perception
lepromatous a deeply nodular infection that causes
severe disfigurement of the face and extremities


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Diagnosing
Combination of symptomology, microscopic
examination of lesions, and patient history
Numbness in hands and feet, loss of heat and
cold sensitivity, muscle weakness, thickened
earlobes, chronic stuffy nose
Detection of acid-fast bacilli in skin lesions,
nasal discharges, and tissue samples

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Treatment and Prevention
Treatment by long-term combined therapy
Prevention requires constant surveillance of
high risk populations.
WHO sponsoring a trial vaccine

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Infections by Non-Tuberculosis
Mycobacteria (NTM)
M. avium complex third most common cause of
death in AIDS patients
M. kansaii pulmonary infections in adult white
males with emphysema or bronchitis
M. marinum water inhabitant; lesions develop after
scraping on swimming pool concrete
M. scrofulaceum infects cervical lymph nodes
M. paratuberculosis raw cows milk; recovered
from 65% of individuals diagnosed with Crohns
disease
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Actinomycetes: Filamentous Bacilli
Genera Actinomyces & Nocardia are nonmotile
filamentous bacteria related to mycobacteria.
May cause chronic infection of skin and soft
tissues
Actinomyces israelii responsible for diseases of
the oral cavity, thoracic or intestines -
actinomycoses
Nocardia brasiliensis causes pulmonary disease
similar to TB.