Gram Positive vs Gram Negative

03/11/2015

Gram Positive:
Two Layers:
o Inner cytoplasmic membrane
o Outer thick Peptidoglycan layer (w/ teichoic acid)
There are 7 Gram Positive bugs that cause disease in humans:
o 3 are Cocci:
Streptococcus
Enterococcus
Staphylococcus
o 4 are Rod shaped:
2 produce spores:
Bacillus Aerobic
Bacillus anthracis
o Protein poly-D-glutamic acid capsule.
o Toxin: Edema factor, Protective
antigen and Lethal factor. LF
stimulates macrophages to release
TNF-a and IL-1B.
o Ciprofloxacin or Doxycyline
Bacillus cereus
o Motile, non encapsulated.
o Spores in food that produce 2
enterotoxins:
Heat labile toxin

Heat stable toxic

o Antibiotic therapy will not help reduce
the toxin.
Clostridium Anaerobic
Clostridium botulism
o Neurotoxin that blocks ACh release.
o Ingesting home canned food in adults
and honey in infants.
Clostridium tetani
o Exotoxin is called tetanospasmin,
causes tetany or sustained contraction
of muscles.
o Toxin moved to the CNS by retrograde
transportation and blocks inhibitory
Renshaw cell interneurons preventing
the release of GABA and glycine,
which are inhibitory.
Clostridium perfringens Gas gangrene
o 3 classes of infection:
Cellulitis/wound infection
Clostridial myonecrosis
Diarrheal illness
Clostridium difficile
o Pseudomembranous enterocolitis
o Produces 2 exotoxins:
Toxin A causes diarrhea
Toxin B cytotoxic to colon
2 do not produce spores:
Corynebacterium diphtheria

Gray pseudomembrane (fibrin) in pharynx.

If there is dark inflammatory exudate on
the childs pharynx, which appears darker
and thicker that of strep throat, you must
not scrape off the tightly adherent
pseudomembrane as it may cause systemic
absorption of lethal toxin.
TELL yoUR InTErn not to LOAF around
o Immediately send the throat and
nasopharuynx swabs for culture on
potassium tellurite agar and
Loefflers coagulated blook serum
media.
o On tellurite agar, colonies become
gray to black in 24 hours.
o With Loefflers coagulated blood
serum incubation for 12 hours and
staining with methylene blue will
reveal rod-shaped pleomorphic
bacteria with reddish brown granules.
Listeria monocytogenes
Listeriosis is bad in this list:
o Pregnant women
o Immuno-compromised
o Neonates
o Meningitis in elderly
Can grow in 4-10oC and major virulence
factor is Listeriolysin O.
In all adults over 50 and in
immunocompromised patietns who develop
acute meningitis, add ampicillin or
trimethoprim-sulfamethoxazole to antibiotic
regiment.

Gram Negative:
Three layers:
o Inner cytoplasmic layer
o Thin Peptidoglycan layer (w/o teichoic acid)
o Outer membrane with LPS (also has 3 layers):
O-Antigen (aka O-specific side chain)
Core Polysaccharide

Lipid A (is toxic in humans and is released when cell

wall breaks down, causes diarrhea, fever and may
cause septic shock)
Of the Gram negative bacteria only 2 groups are Cocci:
o Neisseria
o Moraxella
There is 1 group of spiral-shaped
o Spirochetes
This includes the bacterium Treponema pallidum, which
causes syphilis.
The rest are Gram negative rods or pleomorphic.
There are Exceptions:
o Mycobacterium
Weakly gram positive but stain better with acid fast
stain. Includes organisms that cause TB and leprosy.
o Spirochetes
Gram negative but too small to be seen by light
microscopy and must be visualized by dark field
microscopy. Very small and tightly coiled. Surrounded
by additional phospholipid rich outer membrane with
few exposed proteins, which prevent detection by
immune system. Have a flagella that run along the
spirochete known as periplasmic flagella. Rotation of
this generates thrust and propels spirochete forward.
o Mycoplasma:
Do not have a cell wall. Are neither gram positive or
negative.

Bacteria can be divided into groups based on their metabolic

properties. Two important properties include:
How the organism deals with Oxygen:
o Molecular O2 is very reactive and when is snatched up electron
(gain electron is reduction so gets reduced and is a oxidizing
agent) and can form hydrogen peroxide (H2O2), superoxide
radicals (O2-), and hydroxyl radicals (OH.). All of these are
toxic unless broken down:
Catalase breaks down hydrogen peroxide:
H2O2 H2O + O2.

Peroxidase also breaks down hydrogen peroxide.

Superoxide dismutase breaks down the super oxide
radical into hydrogen peroxide:
2 O2-+ 2H+ H2O2 + O2
Bacteria are classified on a continuum as those that love
oxygen, have all the preceding protective enzymes, and
cannot live without oxygen. On the other end are bacteria
which have no enzymes and die in presence of Oxygen:
Obligate aerobes
These are like us in that they use glycolysis,
Krebs TCA cycle and ETC with oxygen as the final
acceptor of electrons.
Facultative anaerobes
These are aerobic. They use oxygen as electron
acceptor and have catalase and superoxide
dismutase. They can grow in the absence of
oxygen by using fermentation for energy. This is
similar to when human muscle switches during
sprinting.
Microaerophilic bacteria (aka aerotolerant
anaerobes)
These bacteria use fermentation and have no ETC
system. They can tolerate low amounts of oxygen
because they have superoxide dismutase.
Obligate anaerobes
They cannot survive in Oxygen. Two to remember
are:
Clostridium (Gram positive)
Bacteroides (Gram negative)
the organism uses as a carbon and energy source:
Some organisms use light as an energy source (phototroph)
and some use chemical compounds as an energy source
(chemotrophs). Of the chemotrophs, the ones that use
inorganic sources (such as ammonia and sulfide) are called
autotrophs, and the ones that use organic carbon sources
are called heterotrophs. All the medically relevant bacteria
are chemohetrotrophs because they use glucose, a organic
chemical, as a energy source.
Fermentation:

What
o

Glycolysis (fermentation) is used by many bacteria for

oxygen metabolism. Glucose is broken down to pyruvic
acid, yielding ATP directly. There are many different
pathways, but the most common is the EmbdenMeyerhof pathway (aka the glycolysis pathway from
biochem). Following fermentation the pyruvate must be
broken down, and the different end products formed in
the process can be used to classify the bacteria Lactic
acid, ethanol, propionic acid, butyric acid, acetone etc.
o Respiration:
Used with the aerobic and facultative anaerobic
organisms. Includes Glycolysis, Kreb Cycle and Electron
Transport Chain (ETC) coupled with oxidative
phosphorylation.
o Obligate intracellular organisms:
Are not capable of the metabolic pathways for ATP
synthesis and thus must steal ATP from host (energy
parasites):
Chlamydia
Rickettsia
Virulence factors:
Flagella: Are protein filaments that extend like long tails from the
cell membrane of G(+) and G(-) bacteria. The basal body in the cell
membrane spins around and spins the flagellum.
o E-coli and Proteus mirabilis and Vibrio Cholera have
peritrichous flagella (all around the cell).
Pili: aka fimbrae are straight filaments arising from the bacterial
cell wall.
Capsule: Are protective walls that surround the cell membranes of
G(+) and G(-) bacteria. Capsules enable bacteria or fungi to be
more virulent because macrophages and neutrophils are unable to
phagocytize them.
o S. pneumonia has a capsule.
o 2 important tests:
India ink stain: stain is not taken up by the capsule.
Can recognize the fungus Cryptococcus.
Quellung reaction: Bacteria is mixed with antibodies
that bind to the capsule.
"Some Nasty Killers Have Some Capsule Protection":
Streptococcus pneumoniae
Neisseria meningitidis
Klebsiella pnemoniae

Haemophilus influenzae
Salmonella typhi
Cryptococcus neoformans
Pseudomanas aeruginosa

o Most people know this mnemonic. However, many people

don't realize how many questions they can answer just by
memorizing just one sentence.The following are uses for the
above mnemonic:
If the question presents a patient missing anything
needed to kill encapsulated organisms (eg spleen, IgG,
C3b, macrophages, etc.), they are at increased risk for
infections from the above bugs.
Diseases that are infamously susceptible to
encapsulated organisms:
anyone who doesn't have a functional
spleen (eg: sickle cell)
Bruton's agammaglobulinemia
o If an organism has a capsule, some vaccines are made
against the capsule
Pneumococci
Meningococci
H. influenzae type b
o Usually, the capsule is a major virulence factor for the above
organisms.
o If the question mentions a positive Quellung reaction, look for
one of the above bugs for an answer.
o Big mucoid colonies on blood agar is Klebsiella (from a big
mucoid capsule)

Endospores: Are metabolically dormant forms of bacteria that rare

resistant to heat(boiling), cold, drying and chemical agents. They
have multi layer protection. They become active if the conditions
are favorable.
o Clostridium
o Bacillus
Exotoxins (Page 14): Proteins that are released by most of the
G(+) organisms and some G(-) organisms. The G(-) are:
o Vibrio Cholera
o Escherichia coli
o Etc

o Some diseases by endotoxins:

Tetanus
Anthrax
Botulism
Cholera
Endotoxins: Endotoxins are lipid A from the outer membrane
lipopolysaccharide (LPS) of a G(-) bacteria. It is released when the
cell undergoes lysis. It is different from an endotoxin because it is a
normal component of the cell outer membrane that sheds off during
lysis. Septic Shock is a common and deadly response to both G(-)
and G(+) infection and is No. 1 cause of death in ICUs in US.
o Septic Shock: Dangerous drops in BP and organ dysfunction
due to immune response to spread of localized infection to
the blood. The most famous mediator of sepsis is TNF
Tumor necrosis factor (aka Cachectin because it is release
from tumors and produces cachexis). TNF triggers the release
of cytokine IL-1 (interleukin1).

Staphylococci
Staphylococcus aureus Coagulase positive
o Penumonia (most of below are direct invasion of the organ)
o Meningitis
o Osteomuelitis
o Acute bacterial endocarditis
o Septic arthritis
o Skin infections
o Bacteremia/sepsis
o Urinary tract infections

o Gastroenteritis EXOTOXIN RELEASE

o Toxic shock syndrome EXOTOXIN RELEASE from tampons
left in too long!! Ew! By TSST-1 (toxic shock syndrome toxin)
o Staphylococcal Scalded Skin Syndrome (EXOTOXIN)
Staphylococcus epidermidis Biofilm
o Nosocomial infections:
Prosthetic joints
Prosthetic heart valves
Sepsis from IV lines
UTIs
o Frequent skin contamination in blood cultures (Be careful
when drawing blood, you may have to do blood cultures from
2 different areas to confirm systemic infection).
Staphylococcus saprophyticus
o UTI in sexually active women

Streptococci
Group A beta hemolytic Streptococci Streptococcus pyogenes
o Pharyngitis
o Skin infections
o Scarlet fever
o Toxic shock syndrome
o Rheumatic fever (ANTIBODY)
o Acute post streptococcal glomerulonephritis (ANTIBODY)

Group B beta hemolytic Streptococci Streptococcus agalactiae

o Neonatal meningitis
o Neonatal pneumonia
o Neonatal sepsis
o Sepsis in pregnant women
Viridans (green) group alpha hemolytic Streptococcus viridans
o Subacute bacterial endocarditis
o Dental caries (cavities)
o Brain or liver abscesses (Streptococcus intermedius)
Group D streptococci
o Enterococci Grow in 40% bile or 6.5% NaCl
Entercococcus faecalis
Enterococcus faecium
o Non-enterococci
Streptococcus bovis
Streotococcus equinus
o Subacute bacterial endocarditis
o Biliary tract infections
o Urinary tract infections
Streptococcus pneumonia
o Pneumonia

o Meningitis
o Sepsis
o Otitis media (in children)
To differentiate them, you do:
Gram Stain Strep is in chains vs Staph is in clusters
Catalase test Strep is negative vs Staph is positive
Culture Staph aureus and certain streptococci are B hemolytic.
Staph aureus is coagulase positive.
Staff causes acute (rapid and destructive) endocarditis vs Strep
viridans and group D strep cause subacute (less destructive)
endocarditis.
Streptococci can be treated with Penicillin G, but most
staphylococcus are resistant because they secrete Penicillinase, so
we use Methicillin, Nafcillin etc as they are not broken down by
Penicillinase. MRSA is a strain of Staph aureus that has a new
penicillin binding protein 2A and has acquired multi drug resistance.
o HOWEVER, we can use Vancomycin again such strains.
Unfortunately, strains of Staph aureus resistant to
Vancomycin are now being reported. VRE (vancomycin
resistant enterococcus) that modify the D-ala-D-ala chains to
D-ala-D-lac, which has a low affinity for Vancomycin.
Clindamycin and Trimethoprim-sulfamethoxazole
still remain affective.
Penicillin family antibiotics:
MOA: Both G(+) and G(-) bacteria possess peptidoglycans their cell
walls. These are composed of repeating disaccharide units crosslinked with amino acids. The enzyme that catalyzes these reactions
is called Transpeptidase. In G(-), the penicillin must pass through
channels known as porins.. Then the B-lactam ring binds to and
competitively inhibits the transpeptidase enzyme (aka: penicillinbinding protein). To be effective, the beta lactam penicillin must:
o Penetrate the cell walls
o Keep its beta lactam ring intact
o Bind to the transpeptidase (PBP).
Bacterial resistance to penicillin:
o G(-) defend themselves by altering the porins.
o Both G(+) and G(-) can have beta-lactamase enzymes that
leave the C-N bond in the beta lactam ring. G(+) like Staph
aureus secretes penicillinase whereas G(-) can have enzymes
in their cytoplasmic membranes to destroy penicillin.

o Alter their transpeptidase structure: Ex: MRSA (resistant to all

penicillins)
o Both G(+) and G(-) can have efflux pumps to actively pump
out the penicillin.
Types of Penicillin:
Penicillin G
o Original Penicillin, usually IM or IV.
o Useful against Strep pneumoniae
Aminopenicillin
o Broader spectrum.
o IV ampicillin and gentamycin
o Bronchitis, Otitis media and sinusitis and infections by Listeria
Penicillinase resistant penicillin
o Methicillin, Nafcillin and Oxacillin are penicillinase resistant
and can kill Staph aureus.
o Nafcillin is drug of choice for treating all serious Staph aureus
infections like cellulitis, endocarditis and sepsis.
o I MET a NAsty OX with a beta-lactam ring around its neck:
IV beta lactamase resistant penicillins
Methicillin, Nafcillin and Oxacillin.
o Oral Penicillinase resistant penicillins:
Cloxacillin
Dicloxacillin
o Not good agains G(-) organisms.
o Can be given with B-Lactamase inhibitors:

 Clavulanic acid, Sulbactam, Tazobactam

Anti-pseudomonal penicillin
o Effective against G(-) Pseudomonas aureginosa.
o Carboxypenicillins: Ticarcillin, Carbenicillin
o Ureidopenicillins: Piperacillin and mezlocillin
Cephalosporin
o Newer drugs with 2 main advantages over penicillin:
More resistant to B-lactamase (but now susceptible to
cephalosporinase)
New R-group for different spectrums.
MRSA and Enterococci are resistant.
o 3 main generation
LOOK AT PAGE 165 -169
Ceftazidime and Cefepime are the only cephalosporins
that are effective agains Pseudomonas aeruginosa.
Ceftriaxone and cefotaxime both have excellent CNS
penetration. Ceftriaxone is DOC for adults with
meningitis and cefotaxime is DOC for neonates and
children with meningitis.
Some Nasty Killers Have Some Capsule Protection":
Are protective walls that surround the cell membranes of G(+) and
G(-) bacteria. Capsules enable bacteria or fungi to be more virulent because
macrophages and neutrophils are unable to phagocytize them.
Streptococcus pneumoniae
Neisseria meningitidis
Klebsiella pnemoniae
Haemophilus influenzae
Salmonella typhi

Cryptococcus neoformans
Pseudomanas aeruginosa

Listen Sally, Yer Friend Bruce Must Leave Now

Facultative intracellular organisms are phagocytized by the host Neutrophil
or WBC but remain unharmed by preventing host phagocyte-lysosome
binding, thus escaping the hosts deadly hydrogen peroxide and superoxide
radicals.
Listeria monocytogenes
Salmonella typhii
Yersinia
Francisella tularensis
Brucella
Legionella
Mycobacterium
Nocardia
4

bacteria that produce exotoxins that increase cAMP:

c Cholera (Vibrio Cholera)
A Anthrax (Bacillus Anthrax)
M Montezumas revenge (Popular name for Enterotoxigenic Ecoli)
P Pertussis (Bordetella Pertussis)
If you suspect Diphtheriae:

TELL yoUR InTErn not to LOAF around

o Immediately send the throat and nasopharuynx swabs for
culture on potassium tellurite agar and Loefflers
coagulated blook serum media.

Important Pseudomonas aeruginosa infections:

BE PSEUDO
o B Burns
o E Endocarditis
o P Pneumonia
o S Sepsis
o E External malignant otitis media
o U UTI
o D Diabetic O Osteomylitis
I MET a NAsty OX with a beta-lactam ring around its neck:
IV beta lactamase resistant penicillins
Methicillin, Nafcillin and Oxacillin.
Streptococcus pneumoniae and Haemophilus influenzae are common
causes of community acquired pneumonia and are treated with 2 nd
generation cephalosporins.
Ceftazidime and Cefepime are the only cephalosporins that are
effective agains Pseudomonas aeruginosa.