Micro - Bacteria Flashcards

1
Q

catalase test

A

GP

staph (+)
strep (-)

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2
Q

coagulase test

A

GP

staph aureus (+)
staph epidermidis or saprophyticus (-)
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3
Q

novobicin test

A

GP

staph epidermidis (sens)
staph saprophyticus (resis)
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4
Q

hemolysis

A

GP

streptococci (a, ß, g)

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5
Q

alpha hemolysis

A

GP

Strep. pneumoniae (capsule)
Strep. viridans (no capsule)

  • differentiate btwn the two using optochin + bile solubility
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6
Q

ß hemolysis

A

GP

Strep pyogenes (grpA)
Strep agalactiae
Staph aureus
Listeria monocytogenes

LAAP = listeria, aureus, agalactiae, pyogenes

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7
Q

gamma hemolysis

A

GP

enterococcus
non-enterococcus

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8
Q

optochin sensitivity

A

GP

Strep. pneumoniae - sensitive
Strep. viridans - resistant

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9
Q

bile solubility

A

GP

Strep. pneumoniae - soluble (lysed by bile)
Strep. viridans - not lysed by bile

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10
Q

bacitracin

A

GP

S. pyogenes (sensitive)
S. agalactiae (resistant)

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11
Q

growth in bile and 6.5% NaCl

A

GP

Enterococcus faecalis

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12
Q

growth in bile, not 6.5% NaCl

A

GP

Strep. bovis

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13
Q

B cells typically infected by this virus

A

EBV

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14
Q

Ganglion cells typically infected by this virus

A

herpes

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15
Q

oligodendrocytes typically infected by this virus

A

JC virus –> PML

Measles –> SSPE

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16
Q

follicular dendritic cells typically infected by this virus

A

HIV

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17
Q

grows at 42˚C

A

GN, oxidase +, comma shaped

campylobacter jejuni

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18
Q

grows in alkaline media

A

GN, oxidase +, comma shaped

vibrio cholera

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19
Q

produces urease

A

GN, oxidase +, comma shaped

helicobacter pylori

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20
Q

GN diplococci

2

A

neisseria meningitidis
neisseria gonorrhoeae

differentiate using maltose test

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21
Q

maltose test is used for..

A
neisseria MeninGitidis (fermenter - maltose + glucose)
neisseria Gonorrhoeae (non-fermenter - glucose only)
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22
Q

GN “coccoid” rods

4

A

haemophilus influenza (requires factor V, X)
Bordtella pertussis
Pasturella - animal bites
Brucella

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23
Q

Requires factor V, X

A

haemophilus influenza - GN coccoid rods

can also be grown with staph aureus, which provides factor V

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24
Q

lactose fermenters (rate) - Macconkey’s

A

GN

klebsiella, e. coli, enterobacter (fast fermenter)

citrobacter, serratia (slow fermenter)

MaconKEES

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25
lactose non-fermenters how do differentiate between them?
All GN ``` Shigella Salmonella Proteus Yersinia Pseudomonas ``` Oxidase test - only pseudomonas are oxidase +
26
oxidase test - which bugs are +? -?
``` Oxidase (-) Shigella Salmonella Proteus Yersinia ``` ``` Oxidase (+) Pseudomonas Campylobacter Vibrio cholerae Helicobacter pylori ```
27
oxidase +, comma shaped
campylobacter jejuni - grows at 42˚ vibrio cholera - alkaline media helicobacter pylori - urease
28
bacterial infection associated with schistocytes
EHEC - eating undercooked meats | Shigella
29
Staph aureus virulence factor
Protein A - binds Fc-IgG - inhibits complement activation and phagocytosis; colonizes the nose
30
TSST
superantigen that binds to MHCII and TCR, resulting in polyclonal T cell activation present in vaginal or nasal tampons
31
S. aureus food poisoning is due to
preformed ENTEROTOXIN - heat stable (not destroyed by cooking)
32
S. epidermidis is commonly associated with What would you treat a hospitalized patient with? how do you differentiate this from S. saprophyticus?
prosthetic devices IV catheters *contaminant of blood cultures treat with vanco pending sensitivity tests because they can be resistant to multiple antibiotics SE: Catalase (+), Coagulase (-), Novobicin (S) SS: Catalase (+), Coagulase (-), Novobicin (R)
33
S. saprophyticus at risk for what? how do you differentiate this from S. epidermidis?
UTI - second most common cause; increased risk of struvite stones (Ammonium MgPO4) novobicin resistant SE: Catalase (+), Coagulase (-), Novobicin (S) SS: Catalase (+), Coagulase (-), Novobicin (R)
34
S. pneumo causes how to differentiate
``` Meningitis Otitis media pneumonia Sinusitis sepsis in sickle cell patients and splenectomy rusty/reddish brown ``` a hemolysis (green) SP: capsule, optochin (S), bile (S) SV: ø capsule, optochin (R), bile (R)
35
shape of s. pneumo? virulence factor?
lancet shaped GP diplococci, encapsulated IgA protease
36
s. viridans how do differenitate it from S. pneumo?
alpha hemolytic, optochin R can cause - dental caries (mutans) - normal inhabitant of the mouth (mitis) - subacute bacterial endocarditis on damaged valves (sanguinis) a hemolysis (green) SP: capsule, optochin (S), bile (S) SV: ø capsule, optochin (R), bile (R)
37
how does strep. sanguinis cause subacute bacterial endocarditis
binds to fibrin-platelet aggregates on damaged heart valves
38
GAS is also known as
S. pyogenes
39
diseases that S. pyogenes cause
pharyngitis, cellulitis, erysipelas, rheumatic fever, PIGN
40
things that S. pyogenes produce?
Streptolysin O: degrades cell membranes; lyses RBC Exotoxin A: superantigen - causes release of IFNg, IL2 --> shock M protein - prevent phagocytosis *virulence factor*
41
S. pyogenes sensitivity? what must you differentiate it from?
ß hemolysis (clear) GAS (Spyogenes): Bacitracin (S); ASO titers GBS (S. agalactiae): Bacitracin (R), Hippurate test (+), CAMP test
42
GBS is also known as
S. agalactiae
43
things that S. agalactiae cause? what happens if you find out that a mother is colonized with GBS within a month of her due date?
neonatal sepsis, meningitis, pneumonia must give INTRApartum penicillin or ampicillin
44
GDS is also known as what does it cause? what do you have to differentiate it from?
S. Enterococci - cocci chains subacute endocarditis after GI/GU procedures, can cause UTIs, biliary tract; penG resistant gamma hemolysis S. Enterococcus (GDS: E. faecalis, E. faceium): bile and NaCl (+) S. bovis : bile (+) only
45
S. Bovis cuases
endocarditis after colonic malignancy
46
clostridum - different types and what do you normally find them on?
CBotulinum: honey, bottles/canned food CPerfringens: soil or raw meat, reheated meat dishes CDiff: antibiotic use (clindamycin or ampicillin"
47
shape of clostridium?
GP Rod
48
clostridium tetanus produces
Tetanospasmin - protease that cleaves SNARES --> prevents release of GABA and glycine from Rhenshaw cells in spinal cord --> spasticity/sustained muscle contraction
49
Clostridium botulinum produces
Botulinum toxin - heat-labile protease that cleaves SNARES --> prevents release of ACh at NMJ --> floppy/descending flaccid paralysis
50
Clostridium perfringens produces
Alpha Toxin - lecithinase that degrades tissues and cell phospholipid membranes --> myonecrosis/gas gangrene + diarrhea
51
C diff produces
Toxin A (enterotoxin) binds to brush border of gut Toxin B (cytotoxin) causes cytoskeletal disruption via actin polymerization --> pseudomembrane --> diarrea
52
white fibrinous pseudomembrane should make you think of this bug
Corneybacterium diphtheriae
53
Corneybacterium diphtheriae shape? what does it produce?
Rod w/ blue+red granules (corn is rod-shaped) Diphtheria Toxin - AB toxins exotoxin encoded by ß prophage, inactivates EF-2 via ribosylation; predilection for cardiac + neural cells
54
3 tests that you can use for Corneybacterium diphtheriae
Tellurite agar - dark black, slightly iridescent colonies Loffler medium - cytoplasmic GRANULES that can be stained w/ aniline dye (methylene blue) Elek Test for toxin
55
elongated Rod box-car chains should make you think of..
Bacillus anthracis - Aerobe, spore forming
56
Bacillus anthracis causes
painless black eschar w/ edematous borders, mediastinal widening spores can be present on wool
57
Bacillus anthracis virulence factor
polypeptide capsule (D-glutamate) - antiphagocytic Edema Factor - mimics adenylate cyclase to incr. cAMP"
58
reheated rice, pasta should make you think of...
bacillus cereus - GP Rod, spore forming
59
bacillus cereus produces
Cereulide - preformed toxin --> watery dairrhea
60
Listeria Monocytogenes - features
GP rod with tumbling motility - rocket tails (actin) that propel them into cells (intracellular) catalase +, LPS (UNIQUE!!!), ß hemolysis
61
Listeria Monocytogenes - where is it normally found on?
unpasteurized milk, soft cheeses, deli meats transplacental or vaginal transmission --> meningitis in neonates and elderly
62
Mycobacterium - features
``` GP Rod; mycolic acid w/ high lipid content obligate aerobe (use O2 to generate ATP) - lung apices ```
63
reactivation of Mycobacterium is usually due to...
Immunocompromised state or TNFa inhibitors (infliximab or adalimumab)
64
two virulence factors of mycobacterium?
Cord-factor- inhibits macrophage maturation; induces release of TNFa Sulfatides (surface glycolipids) - inhibit phagolysosomal fusion
65
Mycobacterium tubuerculosis symptoms
fever, night sweats, weight loss, hemoptysis
66
MAC - when does it normally occur? how do you deal with it?
AIDS, CD4 <50; prophylaxis w/ Azithromycin; usually unable to form the caseating granulomas
67
mycobacterium leprosy - predilection for...
skin/superficial nerves (likes cool temperatures --> causes glove and stocking loss of sensation) normally found on....armadillos
68
2 forms of mycobacterium leprosy and when do they normally occur?
lepromatous (low CMI, Th2 response) - more serious forms tuberculoid (high CMI, Th1 response)
69
PAS(+) foamy macrophages in intestinal lamina propria should make you think of...
Tropheryma whipplei
70
symptoms that Tropheryma whipplei cause
cardiac sx, arthralgias, neurologic sx, esp. in older men
71
long-branching Filaments that resemble fungi 2 - how to differentiate between them?
Actinomyces - anaerobe, NOT acid fast | Nocardia - aerobe, acid fast
72
actinomyces - features causes.. treatment?
Oral flora long-branching Filaments that resemble fungi obligate ANaerobes, ø catalase or superoxide dismutase (susceptible to oxidative damage) FOUL smelling Yellow sulfur granules" oral/facial abscesses; trmt: pencillin
73
Nocardia features how is it detected?
long-branching Filaments that resemble fungi ``` obligate aerobe (use O2 to generate ATP Urease (+) ``` Ziehl-Neelsen (carbolfuchsin/aniline dye) in Acid fast Stain
74
Neisseria
GN diplococci
75
#1 cause of all UTIs
E. coli.....
76
E. coli feature all produce this
GN rod encapsulated (K capsule) Catalase (+)
77
How can E. coli can be detected?
MacConkee's agar - pink, fast (lactose fermenter) EMB plates - purple colonies w/ green metallic sheen
78
EIEC method of pathogenesis
invasive -> necrosis + inflammation -> dysentery
79
ETEC method of pathogenesis trmt?
heat-labile toxin (LT) - increases cAMP heat stable toxin (ST) - increases cGMP -> watery diarrhea; NO inflammation (travelers) trmt: loperamide, fluoroquinolones, azithromycin, rifampin "Travelers Love to travel FAR"
80
EPEC method of pathogenesis
EPEC: pili allows for adheres + flattens vili --> prevents absorption (children)
81
EHEC 0157:H7 method of pathogenesis
Shiga-like toxin (SLT) - incactivates 60S rRNA (prevents binding of tRNA -> enhances cytokine release -> dysentery + HUS (anemia, thrombocytopenia, ARF, schistocytes due to microthrombi) usually due to undercooked meats, raw unpasteurized milk
82
how to differentiate EHEC 0157:H7 from other e. coli?
ø sorbitol fermentation, ø glucorinidase production (compared to the other E. coli).
83
shigella - features
GN rod
84
shigella method of pathogenesis
invades intestinal mucosa (M cells of Peyer's patches) -> PMN infiltration -> dysentery Shiga Toxin - inactivates 60S rRNA (prevents binding of tRNA) + enhances cytokine release -> HUS very low ID50
85
antibiotics may prolong fecal excretion of this bug
Salmonella - Rod, with flagella
86
Salmonella typhi - pathogenesis
encapsulated - invades intestinal mucosa -> MONOCYTIC infiltration Vi antigen prevents opsonization and phagocytosis, produces H2S can disseminate hematogenously
87
salmonella typhi - clinical features
ROSE spots on abdomen, fever, HA, diarrhea carrier state in GALL BLADDER; causes typhoid fever usually due to poultry, meats, eggs
88
pseudo-appendicitis cause? typically affects? where can it be found?
Yersinia - GN Rod, intracellular mini-epidemics in children --> pus + blood in diarrhea PET feces, contaminated milk, pork
89
Proteus - features
GN Rod - swarming motility on agar Urease (+), produces H2S - can cause struvite stones/ammonium MgSo4
90
Klebsiella - features who does it usually affect? what does it cause? treatment?
GN Rod Urease (+) lactose fermenter (MacConkee's - pink, fast) Encapsulated, MUCOID colonies" aspiration --> lobar pneumonia (abscess forming) in alcoholics and diabetics Red-current jelly sputum trmt: 3rd gen cephalosporin 3rd leading cause of UTI's - can cause struvite stones/ammonium MgSo4"
91
Bacteroides
GN Rod, part of GI flora ``` Obligate Anaerobes, ø catalase or superoxide dismutase (susceptible to oxidative damage), FOUL smelling (short chain FA) ``` Produce CO2, H2
92
Serratia
GN Rod Red pigment Catalase (+) MacConkee's agar - pink, slow
93
spiral shape, w/ multiple flagella at one pole
H. pylori - "catalase (+), oxidase (+), Urease (+) | creates alkaline environment"
94
how is H. pylori detected? treated?
Silver Stain urease breath test (+) fecal antigen triple Rx: PPI, clarithromycin, amoxicllin/metronidazole
95
can cause Guillain-Barre, reactive arthritis
campylobacter
96
campylobacter - features
comma shaped oxidase (+) 42˚C
97
campylobacter - clinical features (how is it transmitted?
bloody diarrhea, esp in children FECAL-ORAL transmission (poultry, meat, unpasteurized milk) can cause Guillain-Barre, reactive arthritis
98
vibrio - features
GN, comma shaped, oxidase (+)
99
vibrio - types and clinical features
Parahemolyticus: voluminous watery diarrhea vulnificus: septicemia -> blisters and muscle necrosis on lower extremity cholera: profuse rice water diarrhea
100
vibrio cholera - pathogenesis
Cholera toxin - permanently activates Gs -> incr adenylate cyclase -> incr. cAMP -> H2O loss"
101
how do you grow vibrio cholera?
alkaline media
102
sputum w/ grape like odor
pseudomonas
103
Pseudomonas - general features
``` GN rod Obligate Aerobe Catalase (+), Oxidase (+) Exotoxin A - inactivates EF-2 via ribosylation Blue-green pigment (pyocyanin) ```
104
Pseudomonas pathogenesis
Exotoxin A - inactivates EF-2 via ribosylation | same as c. diptheria
105
how is pseudomonas generally acquired - list at least 4
``` burns/wounds DM CF water sources (hot tubs, ventilators) indwelling catheters ```
106
What does pseudomonas generally cause?
``` Pneumonia Sepsis External otitis UTI Diabetics/Drugs Osteomyelitis Echthyma gangrenosum cutaneous necrotic disease - usually associated with bacteremia in immunocompromised host ```
107
Pseudomonas - treatment
Gentamycin + piperacillin or cefepime
108
Neisseria - features what is it grown on?
GN diplococci ``` Pili for attachment IgA protease (to colonize mucosa) ``` Thayer-Martin (contains VPN) for isolation
109
Neisseria M - features
GN diplococci encapsulated (polysaccharide capsule) NM: maltose (+), glucose (+)
110
Neisseria M - route of transmission, clinical picture and treatment
respiratory/oral secretions petechial rash on trunk, palm, soles meningitis Waterhouse-Friderichsen Syndrome post-exposure prophylaxis: Rifampin, ciprofloxacin, ceftriaxone for contact prophylaxis trmt: ceftriaxone or penicillin G
111
Neisseria G - features
GN diplococci | facultative intracellular, in PMNs
112
Neisseria G - route of transmission, clinical picture and treatment
STD gonorrhea, septic arthritis, neonatal conjunctivitis, PID, Fitz-Hugh-Curtis Syndrome; neonates: erythromycin ointment adults: ceftriaxone (MUST ADD azithro/doxycycline for possible chalmydia coinfection)
113
c5-c9 deficiency
think Neisseria
114
Haemophilus features
GN coccoid rods encapsulated (type B = worst; made w/ polyribosyl-ribitol phosphate) IgA protease (to colonize mucosa)
115
Haemophilus - how is it transmitted? what does it cause? how is it treated/prevented?
``` Aerosol transmission Epiglottitis (cherry red) -> stridor, odynophagia, drooling; lateral CXR: ""thumbs up"" sign Meningitis - treat w/ ceftriaxone Otitis Media Pneumonia ``` trmt: Amoxicillin w/ clavulanate Post-exposure prophylxis: rifampin Prevention: conjugated vaccine "
116
how do you grow haemophilus?
"Chocolate Agar w. Factors V, X - or - grown w/ S. aureus (provides V)"
117
legionella - features
GN Rod, facultative intracellular antigen present in urine
118
legionella - clinical picture | how is it treated?
aerosol transmission from environment: AC, hot water tanks, sprayers at restaurants, grocery stores causes HYPONATREMIA (SIADH mediated) Legionnaire's dz: pneumonia,high fever, GI, CNS sx (typical: smoker w/ 104˚ T, diarrhea, confusion, and sputum w/ very few or ø bacteria but LOTS of PMNs) Pontiac fever: mild flu trmt: macrolide, quinolone
119
how is legionella detected?
Silver Stain | Charcoal yeast w. Cysteine + Iron
120
B. pertussis - features
coccoid rods, encapsulated
121
B. pertussis - pathogenesis
Pertussis toxin - disables Gi --> overactivation of adenylate cyclase --> incr. cAMP -> Whooping cough: "coughing spells" or paroxysms of coughing
122
how do you grow B. pertussis
Bordet-Genou (potato)
123
Pasteurella - features
GN coccoid rods | animal bites
124
Bartonella Henslae - features clinical picture treatment
GN Rod "cat-scratch dz" - tender regional adenomapthy, stellate granulomas w/ central necrosis ø trmt necessary, but if immunosuppressed, give ciprofloxacin + dox + macrolides
125
rash (vasculitis) starts at wrists and ankles and then spreads to trunk, palms, and soles.
R rickettsii - Rocky-MTN spotted fever; triad: HA, fever, rash (vasculitis)
126
rash starts centrally and spreads out, sparing palms and soles
R typhi - endemic (fleas)
127
monocytes w/ morulae (berry like inclusions)
R ehrlichiosis
128
granulocytes w/ morulae (berry like inclusions)
R anaplasmosis
129
Rickettsiae - features and general treatment? How do you detect them?
GN pleomorphic Obligate intracellular (need CoA + NAD+ because they can't make ATP) Giemsa stain trmt: dox
130
cattle placenta
Coxiella ovoid GN spores released from tick feces + cattle placenta --> spores inhaled -> pneumonia; ø rash, ø vector
131
Chlamydiae forms? subtypes? features?
Elementary body "Enfectious" - Enters cells via Endocytosis Reticulate body - Replicates via fission and reorganizes into elementary bodies trachomatis, Pneumoniae, psittaci Obligate intracellular - can't make their own ATP ø muramic acid in cell wall - why is this impt?? DON'T KNOW
132
reactive arthritis (Reiter), follicular conjunctivitis (dots on inner eye lids), nongonoccal urethritis, and PID features of this bug
Chlamydiae trachomatis - DK serotype
133
Chlamydiae trachomatis serotypes
ABC: African, blindness, Chronic infection DK women: urethritis/PID/ectopic pregnancy neonates: staccato cough + conjunctivitis, acquired via vaginal delivery L1, L2, L3 - lymphogranuloma venereum - painless ulcers on genitals + painful ulcerated inguinal LN "buboes"
134
chlamydiae trachomatis - how to detect it?
Giemsa | Fluorescent antibody stain
135
chlamydiae Pneumoniae
atypical pneumonia; aerosol transmission
136
chlamydiae psittaci
atypical pneumonia; avian (parrots) reservoir
137
treatment for chlamydiae
azithromycin or doxycline
138
Borrelia - features
GN spiral shaped
139
Borrelia - clinical features how to diagnose it?
PAINLESS erythema chronicum migrans BAMM Sequelae: Bells, Arthritis, Myocarditis (AV block), Meningoencephalitis ELISA + WB only if its not clear that it is is Lyme dz to stain it: Giemsa stain
140
Borrelia treatment
Doxycycline - 1st line (or ceftriaxone) children/pregnant women - use amoxicillin
141
Leptospira features
GN spiral shaped
142
How is leptospira acquired? What does it cause? | who is it most common in?
contaminated water with animal urine -> leptospirosis (flu, jaundice, photophobia w/ conjunctival suffusion - red eyes) Weil dz: severe; jaundice, azotemia from liver/kidney dysfunction; fever, hemorrhage, anemia common in surfers and tropics
143
Treponema/Syphilis - general features + 3 stages
Treponema/Syphilis - GN Spiral 1˚ Painless chancre (1˚) 2˚ maculopapular rash on palms/soles, condylomata lata 3˚ gummas, aortitis (vasa vasorum), neurosyphilis (tabes dorsalis), Argyll Robertson Pupil "Prostitute pupil" - accomodates but does not react to light
144
How is Treponema/Syphilis diagnosed?
dark field microscopy + Fluorescent antibody staining (FTA-ABS)
145
How do you know if an infant suffers from Syphilis?
Congenital: saber shins, saddle nose, CN8 deafness, Hutchinson teeth, mulberry molars
146
treatment for syphilis?
trmt: PenG; can cause Jarisch-herxheimer rxn (flu due to killed spirochetes releasing pyrogens)
147
gray vaginal discharge w/ fishy smell; not painful
Gardnerella vaginalis - GN rod
148
Gardnerella vaginalis - features, how is it diagnosed, and treatment
GN rod that causes gray vaginal discharge w/ fishy smell; not painful Light microscopy - Clue cells - vaginal epithelial cells covered w/ Gardnerella bacteria trmt: metronidazole or clindamycin
149
malodorous gray green frothy discharge with inflammation
trichomoniasis
150
gray vaginal discharge w/ fishy smell; not painful
Gardnerella vaginalis - GN rod
151
thick, white, adherent discharge "cottage cheese" + inflammation
candida vulvovaginitis
152
only bacteria that does not have a cell wall
Mycoplasma Pneumoniae
153
Mycoplasma Pneumoniae - how is it grown?
sterols in membrane for stability - therefore must be grown on Eaton agar - cholesterol
154
Mycoplasma Pneumoniae - what does it cause? who is it most common in? how do you treat it?
"walking ATYPICAL pneumonia" - insidious onset, HA, nonproductive cough, patchy or diffuse interstitial pneumonia high IgM titers can agglutinate or lyse RBCs outbreaks in military recruits, prisons trmt: macrolide, dox, fluoroquinolone (NOT penicillin, duh)
155
What is macconkey agar used for? what does it contain
``` MaConKEE'S agar - contains BILE (inhibits growth of contaminant organisms), but allows growth of lactose fermenters, which show up as pink colonies: Klebsiella E. Coli Enterobacter Serratia ```
156
catalase +
``` Pseudomonas Listeria Aspergillus Candida E coli S. auerus Serratia ```
157
Otitis Media
H. influenza S. pneumo Morxaella
158
Otitis Externa
Pseudomonas
159
Atypical Pneumonia
Mycoplasma Legionella Chlamydia
160
Bloody diarrhea
``` Campylobacter E. Histolytica EHEC EIEC Salmonella Shigella Yersinia ```
161
Watery diarrhea
``` C. Diff C. perfringens ETEC Protozoa Vibrio cholera Vibrio vulnificus ```
162
Pneumonia IVDU or alcholics
S. pneumo, klebsiella, s. aureus
163
Pneumonia Aspiration
anaerobes
164
Pneumonia atypical
mycoplasma, legionella, chlamydia
165
Pneumonia CF
pseudomonas, s. aureus, s. pneumo
166
Pneumonia nosocomial
s. aureus (MRSA, MSSA), pseudomonas, enterics
167
Pneumonia post-viral infection
staph, H. influenza, S. pneumo