COCCI

Genus Staphylococcus

Genus streptococcus

most important & most commonly

encountered organism in medical
practice

most members of the genus are sensitive to

heat, drying and disinfectant

ubiquitous human parasite

30 50% colonized the skin & mucous
membrane of healthy
adult and children

facultative anaerobe
forms large amount of lactic acid as end product
of CHO
metabolism

Genus Enterococcus

Genus Neissera

Most common isolate specie

encountered
part of normal flora GIT, urethra &
female genital tract
use as microbial indicator for fecal
contamination of water
Morph., Cultural & Biochemical
Charac.

chief source of infection:

1. shedding from human lesions
2. fomites
3. contaminated lesion esp. respiratory
tract and skin
4. asymptomatic carriers among hospital
staff & patient

Morphology:
1. gram + ovoid or lancet-shape organism
2. pair/chain arrangement
3. non-motile, nonsporeformer, noncapsulated
except S. pneumoniae

Species of medical importance:

S. aureus
S. epidermidis
S. saprophyticus

Some are normal flora or agents of disease in

human and animals while other are free-living in
the environment.

include large and varied group of bacteria

Morph. & Cultural Charac.

= ovoid-shaped, pair / short chain
arrangement
= can be alpha, beta and most
commonly gamma or
non-hemolytic on BA
= thermoduric (can withstand
temp. above 800C)
= culture medium Bile Esculin
(deep blue black pigmented
colonies)
= hydrolyze esculin (most impt.
presumptive test)
= catalase (-) PRY (+)
Disease produced :
1. Subacute bacterial endocarditis
2. Urinary and biliary tract infection
3. Septicemia
4. Wound infection
5. Intra-abdominal abscesses
6. Nosocomial infection

Pathogenesis:
= during medical/surgical
procedure of GI or GU
tract organism bloodstream
previously
damage heart valve
endocarditis

= gram negative (coffee-bean/kidneybean shaped)

diplococci with adjacent side facing
each other
= size 0.6 1.0 u
= non-motile, non-sporeformer
= oxidase positive (key enzyme for
identification)
= most species ferment glucose
oxidatively acid with
or without gas
= aerobic and facultative anaerobe
= highly susceptible to adverse
environmental condition
such as drying, chilling and
exposure to sunlight

Rx : Ampicillin (most effective)

Substitute Drugs:Vancomycin ,
Gentamycin , Erythromycin
Classification :
1. Smith & Brown = based on type of
hemolytic zone on BA
A) Alpha
= greenish / brownish hemolysis around colony
= due to incomplete / partial destruction of rbc
= Viridans streptococci & S. pneumoniae
B) Beta
= clear / colorless zone of hemolysis
= due to complete destruction of rbc
= S. pyogenes, S. agalactiae
C) Gamma/Non-hemolytic
= non-hemolytic on BA or alpha, beta
hemolysis
= E. faecalis
2. Lancefield Classification
= based on cell wall antigen(C carbohydrate)
= 14 serological grouping (Group A O)
Group A S. pyogenes
Group B S. agalactiae
Group C S. equisimilis
S. zooepidemicus
S. equi
Group D - Enterrocci Non enterococci
E. faecalis S. bovis
E. facium S. durans
Group G - S. arginosus
*Group C & G are commensal of domestic
animals
Streptococci species not classified by
lancefield :
S. pneumoniae
because they dont
Viridans streptococci
havecarbohydrate
cell wall antigen

Ultrastructure and Cell Wall

Composition:
= similar to other gram (-) bacteria
= cell enveloped composed of:
1. Outer membrane:
A. lipopolysaccharide
B. phospholipids
C. proteins
2. Peptidoglycan layer
3. Cell membrane

Species:
A. Pathogenic
1. N. gonorrhoeae
2. N. meningitidis
B. Non Pathogenic
= considered a normal flora of URT
&
other mucosal surfaces of the body
= non-fastidious and grows on NA
1. N. sicca
2. N. flava / flavescence
3. N. catarrhalis

Genus Staphylococcus
Staphylococcus aureus

Staphylococcus epidermides

Most pathogenic

Coagulase Negative Staphylococcus

account for large number of nosocomial & opportunistic
pathogen in immunocompromised patient

Resp. for 80% of suppurative infection in human

important pathogen for hospital and community acquired infection
capacity to produce disease not diminished even with introduction of antibiotics
dominant site of colonization: anterior nares, axilla, perineum and 10-15%
human skin

Morphology:
= gram + cocci
= arranged charac. grape-like or irregular clusters
= size 0.8 1.0u dia
= nonmotile, nonsporeforming, noncapsulated (mutant strain have capsule &
more pathogenic)
= produce lipochrome golden yellow pigment
Ultrastructure and Cell Wall composition:
3 major components:
1. Peptidoglycan
= polysaccharide polymer which provide rigid exoskeleton
of the cell wall
= const. 40 60% cell weight
= composed of acetyglucosamine & acetylmuramic acid (responsible for
rigidity)
2. Teichoic Acid
= polymer of ribitol phosphate (S. aureus)
glycerol phosphate (S. epidermides)
= essential component of phage receptor
= plays important role in maintenance of normal physiologic function of cell.
= regulate the cationic environment of cell thus
controlling the activity of autolytic enzyme
resp. for growth of cell wall.
3. Protein A
= major protein component of cell wall
= major antigenic determinant unique to S. aureus
= a group specific antigen protein of S. aureus
= antiphagocytic
Cultural / Biochemical Characteristic:
= Facultative anaerobe
= catalase and coagulase (+)
= ferments many carbohydrates-lactic acid without gas
= opt. temp. 30-370C opt. ph 7-7.4
= halophilic (can tolerate high conc. of salt 5-10%NaCl)
= penicillin resistant due to beta-lactamase production
= requires enriched media for growth
1. Sheep blood agar
(culture media - primary isolation) incub. for 24 hrs. at 370C colonies
smooth , circular, opaque, golden yellow sorrounded with complete zone of
beta-hemolysis.

part of normal flora of skin and mucous membrane

1. Has a low virulence to infection
2. Saprophytic and represent 50-80% of all coagulase
negative staph.
human serves as exogenous or endogenous source of
infection
Morph/Biochemical/Cultural charac.:
= coagulase & thermonuclease ()
= catalase (+), non-mannitol fermenter
= Novobiocin - sensitive
= BA - porcelain white colonies with beta hemolysis
= Conditions associated:
1) those involving the use of catheter, orthopedic/
prosthetic implants, CNS shunt, pacemaker
2. Stitch abscess, Endocarditis, Bacteremia, UTI

Staphylococcus saprophyticus
Saprophytic & opportunistic
found normally in human skin, peri-urethral &
urethral area
catalase (+) coagulase (-) non mannitol
fermenter
A lemon-yellow colonies, non hemolytic
Novobiocin and Nalidixic acid resistant

SAME MORPHOLOGY with S. aureus

common cause of:
1. UTI in young sexually active adolescent
female
2. Non- gonococcal urethritis
3. Uncomplicated UTI in non-hospitalized
patient

Genus streptococcus
Streptococcus pyogenes

Streptococcus Agalactiae

Streptococcus
pneumoniae

Group A beta hemolytic

streptococcus

Group B Streptococcus

Pneumococcus / Diplococcus
Pneumoniae
Frankels Pneumococcus

one of the most important

pathogen of human

members of the normal flora of

the pharynx, GIT, female genital
tract

one of the leading cause of

mortality & morbidity in persons
of all ages.

Viridans
streptococci
Species:
S. salivarius

Enterococcu
s faecalis

S. mitis

S. mutans
sanguis

S.

normal flora of the oral

cavity, respiratory tract,
mucosa of the GIT and
female genital tract

Genus D
Streptococcus
Enterococci
found normally
in the large
intestine of
human

can cause systemic and localize

infection

habitat upper resp. tract (throat

& nasopharynx) and occasionally
skin

Morph., Cultural & Biochemical

charac. :
= gram (+) ovoid-shaped
organism characteristically
arranged in long bead-like chain
= nonsporeformer, nonmotile,
noncapsulated
= some strain with capsule
hyaluronic acid
=fastidious, requires enriched
media for primary isolation
incubated with 5 10 % CO2
= ferment wide variety
carbohydrate with production of
lactic acid with or without gas
(homofermentative)
Blood agar (primary medium
for isolation)
= circular, translucent, dome
grayish to opalescent
colonies with large zone of beta
hemolysis
Laboratory Identification:
A) Bacitracin sensitive
(presumptive identification test)
= used to differentiate beta hemolytic
treptococci (S. pyogenes & S.
agalactiae)
= group A streptococci - sensitive

25% of all females carry the

organism as normal vaginal flora

important cause of infection in

OB/GYNE patient

Morphology :
= gram (+) ovoid shaped
= pair or short chain
arrangement
= non-sporeforming , non-motile
= some strain encapsulated
(polysaccharide capsule)
Cultural :
= BA- large mucoid flat creamy
with beta-hemolysis
= halophilic (grows in 6.5 % NaCl)
= bile soluble, catalase (-)
= hydrolyze sodium hippurate
= CAMP test positive
= Bacitracin resistant
= PYR negative

neonates may acquire the

infection during birth resulting
meningitis and sepsis
1. possess the group B
polysaccharide antigen
(major virulence factor)
2. classified into 8 serotypes
based on group B capsular
polysaccharide antigen ( type I
VIII )
3. all serotypes can cause
infection in newborn and adult

unbiquitous organism

infection more prevalent during

winter months
Morphology & Cultural
Charac.
= gram + lancet - shaped
diplococci
= nonmotile, nonsporeformer
= encapsulated (demonst. by
India ink staining/)
Quellung
reaction
= fastidious, requires enriched
media for primary isolation
on SBA incubated with 5-10%
CO2
colonies mucoid, round-shaped,
flattened and
umbilicated(depressed center)
resembling a checker-board or
nail-head form caused by
autolytic enzyme
= facultative anaerobe
= has absolute requirement for
choline

only infectious disease included

in the top 10 causes of
mortality
Normal respiratory tract flora
but can cause:
1)Lobar in elderly and alchoholics
2)Acute Otitis Media & Meningitis
3)Community Acquired Bacterial
pneumoni

major cause of bacterial

endocarditis in people
with damaged heart
valve, patient with
compromised
endocardium and as a
complication of dental
manipulation
opportunistic pathogen
of low virulence and can
dessiminate
hematogenously after
dental procedure

Morph & Cultural

charac:
= gram (+) cocci, pair /
short chain arrangement
= grows well on most
enriched media
= req. inc. CO2 for
growth (capnophilic &
microaerophilic)
= alpha hemolytic BA

resist classification by
Lancefield (do not posses
the group specific
antigen in the cell wall)
Disease associated
includes:
1. Subacute Bacterial
Endocarditis
2. Dental caries S.
mutans

S. agalactiae- resistant
B) PYR test (+) - demonstrate
presence of pyrrolidonyl
arylamidase
C. Catalase (-)
Determinants of Pathogenicity
:
Pathogenicity is due to array of
surface antigens, toxins and
enzymes produced.
1. Cellular components:
A) Lipoteichoic Acid (LTA)
= allows org. to cling to epith.
surfaces
= cytotoxic (destroys rbc, wbc)
B) M protein antigen
= most important virulence factor
= aid in the attachment of the
organism to
portal of entry
= antiphagocytic
C) Capsule (Hyaluronic acid)
= non-immunogenic
= antiphagocytic
2. Extracellular Enzymes:
A) Streptodornase (Streptococcal
DNAse)
= facilitate removal of purulent
exudate/discharges B)
Streptokinase (Fibrinolysin)
= helps lyze fibrin clot and plays
an important role
in the invasion & spread of
infection
C) Hyaluronidase
= hydrolyzes hyaluronic acid
found in the connective
tissue of the host which
facilitate or promote
spread of infection
D) Diphosphopyridine
nucleotidase
= cytolytic, kills WBC, PMN &
Macrophages
3. Toxins (metabolic product

4. serotypes I, II, III, VI accounts

for 90% cases
5. serotypes III prominent cause of
meningitis in newborn
Antigenic Structure :
1) Capsular Ag
= composed of complex
polysaccharide used as bases for
classifying pneumococci into 90
serological types
= 12 serotypes accounts for 80%
of infection in human
(in order of frequency) 8, 4, 3,
14, 7, 12, 9, 1, 18, 19, 6, & 23
= Serotypes that causes the
most invasive childhood
pneumococcal infection 4, 6, 9,
14, 18, 19 & 23
= Serotypes most frequently
isolated associated with
resistance to PCN 6, 9, 14, 19, 23
2) Somatic Ag
A) C polysaccharide
= major structural component
cell wall
= chemically teichoic acid
polymer contg.
phosphochloline (major
antigenic determinant)
B) F Ag (Forssman Ag)
= a lipoteichoic acid found outer
surface cell wall
C) M protein
= type specific protein antigen
analogue to
M-protein of S. pyogenes
= do not inhibit phagocytosis
Determinants of

Pathogenicity:
1) Polysaccharide Capsule
(antiphagocytic)
= major virulence factor
2) Adherence factor (F Ag and M
protein)
= resp. for attachment and
colonization
3) Enzymes
A) Neuraminidase
= responsible for invasiveness
of organism and help
in the colonization in the
nasopharynx
B) IgA Protease
= facilitate colonization and
attachment to mucosal
surfaces
4) Toxins
A) Pneumolysin O
= a hemolysin that damage
respiratory epithelium
= potential factor inhibiting
phagocytosis
= role unknown in the
pathogenesis of infection

that destroys phagocytic cell)

which are essential to the body
defenses
A) Hemolysin/Streptolysin
1. Streptolysin O (SLO)
= immunogenic, oxygen-labile
= caused the production of
ASTO antibody
= has cytolytic activity
= produced by most strain of
group A
streptococcus
2. Streptolysin S (SLS)
= non-immunogenic, oxygenstable
= both types lyse erythrocytes
and produce beta-hemolysis on
sheep blood agar
= both rapidly injure many cells
and tissue including liver and
heart muscle
B) Erythrogenic toxin
( Streptococal Pyrogenic exotoxin)
= key toxin in the development
of Scarlet fever
= responsible for fever and
bright red skin rashes
typical of the disease

Clinical Infection &

Pathogenesis:

Dicks test susceptibility test to

Scarlet fever
= erythrogenic toxin injected
intradermally to detect
presence of antibody. After 24
hours
(+) redness at site of injection
(-) patient immune to SF
Schultz Charlton reaction
= identify nature of skin rashes
= antitoxin injected skin rashes
(+) blanching and fading of
skin rashes
(due to
neutralization of toxin by antitoxin
Clinical Infection :
Acute suppurative infection of S.

Clinical infection:
1 & 2 most common cause of

1) Lobar pneumonia
= most common bacterial
pneumonia among elderly
patient especially with COPD
= man only host infection
= 5 50% healthy individual
harbors organism nasopharynx
= transmission is person
person by respiratory
droplet
= Predisposing Factors:
1) COPD
2) Alcoholism
3) Congestive heart failure
4) Malnutrition
Clinical Manifestation:
= fever, chill, cough, pleuritic

pyogenes
1. Skin infection Impetigo,
Pyoderma, Cellulitis,
Erysepelas, Scarlet fever
2. Upper resp. tract Sore
throat/Pharyngitis, Quincy,
Ludwigs angina
3. Uterus Puerperal fever
Post streptococcal (Nonsuppurative infection)
( sequelae to acute streptococcal
infection )
A) Acute Rheumatic Fever
= occur 1 4 weeks after URT
infection
= manifested as polyarthritis ,
carditis , chorea , fever,
erythema marginatum
B) Acute Glomerulonephritis
= occurs 2 3 weeks after
untreated skin
infection
(Impetigo)

pain and rusty

colored sputum
= may disseminate to the
bloodstream
brain bacterial meningitis
(adult)
= incubation period variable
= rarely a primary infection

perinatal infection caused by

group B Strept.
1. Neonatal meningitis
2. Neonatal sepsis
3. Osteomyelitis
4. Wound infection
5. Postpartum fever
6. Skin infection

= mortality from pneumococcal

disease highest among patient
with meningitis
=for uncomplicated
pneumonia 5-7% die even
with prompt treatment
2) Meningitis
3) Otitis media in infants and
children
4) Sinusitis

Lab. Diag.:
1. Bacteriological
2. Culture BA
3. Bacitracin test
4. Serological
Rantz Randall (ASO Titer test) determines rise ASTO antibody (+)
200 todd unit

Treatment :
Benzathine PCN given for 10
days IM
Allergic patient Erythromycin,
Clindamycin, Cephalexin

Lab. Diagnosis :
1) Bacteriological (GS)
presumptive
= specimen includes CSF,
pleural fluid, blood
& body fluids
2) Culture
3) Serotyping Identification
Latex aggl. test(Confirmatory)

Treatment:
PCN G (antibiotic choice)
Erythromycin, Chloramphenicol,
Cephalosporin

Lab. Diag.:
1) Bacteriological (direct sputum
examination - gram stain)
= specimen mucus
expectorated sputum
from
lungs/CSF
= gram (+) lancet-shaped
diplococci (Presumptive)
2) Quellung Rx - detect
pneumococcal capsular antigen
in CSF, pleural and joint fluids
(+) capsular swelling
3) Culture (CSF, pleural fluid)
= specimen for culture should be
planted
immediately on enriched media
(BHIA/BA)
= incubated overnight with 5 10% CO2
= dome shaped colonies
with alpha hemolysis
4) Serological
A) Latex particle agglutination
test (capsular Ag)
B) CIE - detect pneumococcal
antigen
(sputum and nasopharyngeal
secretion)

Rx : = PCN ( drug of choice )

= sensitive to all types of
pneumococcal infection
should be administered
immediately after presumptive
identification delay increased
risk
of mortality
= PCN allergic patient with
pneumonia
Cephalosporin, Erythromycin
= Patient with meningitis Chloramphenicol
Test to identify
pneumococcci:
(provide a means of
differentiating pneumococci from
other)
alpha-hemolytic streptococcus

Lab. Diag:
1. Bacteriological GS
2. Culture BA incub. 5
10% CO2

Treatment:
PCN (drug of choice)

1) Optochin Sensitivity
= currently the most widely used
presumptive test
= filter paper disc impregnated
with ethyl hydrocuprine
HCl (optochin) streak on surface
of blood agar
plate with previous culture of S.
pneumoniae
= incubated in a candle jar for
24 hours at 370C
= (+) zone of inhibition indicates
sensitivity to organism
2) Bile Solubility
= pneumococci produced
autolytic enzyme (amidase)
which activates surface active
agents like bile/ bile salt (NA
dexoxycholate or NA
taurocholate)
resulting in lysis of organism.
= test not absolute because
there are pneumococci not
lyzed by bile salt and there are
other alphahemolytic streptococci that are
lyzed by bile salt
3) Newfeld Quellung test
(Capsular Precipitation)
= most accurate and reliable
specific method for
identification
= uses antipneumococcal
antisera + sputum +
methylene blue. Mix & observe
microscopically
= capsules repractile and
swollen (+)
4) Mouse Virulence Test
= intraperitoneal inoculation of
sputum with
pneumococci to susceptible
animal.
Observe after 16-24 hours
death occurs.
Prevention:
= Pneumococcal Vaccine
(Pneumo 23)
(polyvalent vaccine contg. 12
most commonly)
isolated

Prevention:
= patient with damage
heart valve should be
given prophylactic PCN
before dental

serotypes
= 90% protective
= should not be given to
children under 2 years old
Prevenar vaccine for children 2
years and below

manipulation

Genus Neissera
*N. gonorrhoeae*
(Gonococcus)
Morph, Cultural & Biochemical charac.
= gram (-) coffee bean shaped diplococci
= non motile, non capsulated
= piliated (organ of virulence) & plays a major role in the attachment to mucosal
surfaces establish infection
= fastidious, requires enriched media for growth
heated blood incubated with 5-10% CO2
Chocolate agar (non-selective medium)- sterile material
Thayer Martin (selective diff.)- contaminated mat.
= aerobic & capnophilic
= 20% strain req. glutamine for primary isolation

*N. meningitides* (N. intracellularis/ Meningococcus)

FACTS
= gram (-) kidney-shaped diplococci
= capsulated (Sialic acid) - major virulence factor)
= susceptible to adverse environmental condition (sunlight, cold temp., moist heat,
chemicals)
= nutritional requirement essential for growth Fe
= strict aerobe

= do not survive long outside the host

= sensitive to drying and cold
= iron required for growth
= oxidase & catalase positive
= ferment glucose only with the production of acid
Culture media:

4 major colonies types N. gonorrhoeae observe (solid medium)

primary culture small, dome-shaped piliated colonies
T1, T2
- virulent
subsequent culture large, flat, non- piliated colonies
T3, T4
- less virulent

= growth occurs in media enriched with blood or serum

Chocolate agar
(non selective) sterile material CSF, blood, synovial fluid
Thayer Martin
(selective-diff.) contaminated/unsterile specimen
Nasopharyngeal swab
= incubate at temperature 35-370C 5-10% CO2
= colonies small, round, convex and glistening with
entire margin
= utilize glucose and maltose by oxidative attack
Antigenic Structure :
1) Capsular polysaccharide
= basis for identification
= enhance virulence
= antigenic, antiphagocytic
= 9 capsular serotypesA, B, C, D, 29E, X, Y, Z & W135
B = more often responsible for clinically
recognized disease
= account for 50-55% of cases
= most common strain isolated in U.S.
C = 20-25% of cases

Antigenic Structure:
= 3 major classes of antigen
1. Pilus antigen
2. Lipooligosaccharide
3. Outer membrane protein
Determinants of Pathogenicity:
1. Pili (hair-like appendages)
= found in T1 T2 piliated colonies associated with
virulence
= mediate attachment to the mucosal epith. allowing them to cause disease
= antigenic & antiphagocytic
2. Outer membrane protein (Adhesin / Protein II)
= also associated with virulence
= involve in adherence of the org. to host cell
= structural antigen used in serotyping gonococci
= antigenic
3. IgA Protease
= facilitate adherence & colonization at mucosal
surfaces to initiate infection
4. Peptidoglycan
= contribute to the pathogenesis of gonococcal

A = most common serotypes causing

Epidemic Cerebrospinal Meningitis
= accounts for 1-2% of cases
W135 = 15% of cases
Y = 10% of cases

infection
Disease Produced: Gonorrhea (flow of seed)
= most common of the classic sexually transmitted disease
= involves the mucous membrane of the GUT, rectum, throat, eye
= charac. by painful urination accpd. with yellowish purulent urethral discharge
= 80% (documented patient) highest incidence in most sexually active group
between 15-30 yrs. old
= Transmission:
1) Sexual contact
2) Among pregnant mothers with
Gonorrhea during childbirth
3) Extra-genital transmission
homosexual ( Fellatio )
Epidemiology/Pathogenesis:
= infection occurs only in human
= MOT - sexual contact, during birth
= primary infection usually begins at the columnar epithelium of
the urethra, periurethral duct and glands of either sexes
= genitourinary tract, cervix, conjunctiva and rectal mucosa
serve as portal of entry
= source of infection from exudate and secretions coming from
sites mentioned
= incubation period 2 8 days
= organism penetrate to the mucous membrane of urethra by means of pili causing
inflammation accompanied
with pain during urination and yellowish purulent urethral
discharge
Clinical Infection:
Male:
= 10% of infected men are asymptomatic carrier of the
organism and may transmit the organism to
consort causing symptomatic gonorrhea, 50%
of cases undiagnosed
= primary site urethra
= males present as primary complaint a burning
sensation & pain during urination accompanied
w/ purulent yellowish urethral discharges
(pus at tip of penis)
= both asymptomatic and symtomatic male can pass
the infection to another sexual partner
= approximately 1% develop complication the most
common being: Urethral Stricture,
Epididymitis & Prostatitis
Female:
= 20-80% asymptomatic infection common
= organism thrive cervix, fallopian tube and other area in the female genital tract
= charac. by frequent painful urination, purulent
vaginal discharge, fever & abdominal pain
= major complication include:

2. Somatic Ag.
= nucleoprotein antigen
= common to all neisseria species
3. Outer membrane protein
5 classes 1, 2, 3, 4, 5
class 5 highly immunogenic produce vaccine
against meningococcimia
Determinants of Pathogenicity
1. Polysaccharide capsule
= major virulence factor
= contribute to the invasiveness by inhibiting phagocytosis
2. Endotoxin (LPS)
= found in the outer membrane causing extensive tissue
necrosis, hemorrhage, circulatory collapse, intravascular
coagulation, shock and petechial hemorrhages due to
destruction of the blood vessel
= released in the cell of vascular endothelium causing vascular
necrosis inducing inflammatory response
3. IgA protease
= facilitates adherence and colonization in the oropharynx
= may contribute to the ability of the organism to produce
disease

Epidemiology :
= worldwide in distribution
= responsible for 20% of meningitis infection
= second commonest cause of the disease
= disease appears sporadically or in epidemic among
military personnel's
= peak incidence is in children 6-24 months of age
Pathogenesis :
= reservoir of infection-human nasopharynx
= incubation period 1 week
= portal of entry URT inhalation of respiratory droplet

1. Pelvic Inflammatory Disease (PID)

A) Gonococcal Endometritis, Salphingitis,
Oophoritis
B) Sterility - due to scarring of the tubes
2. Ectopic pregnancy
= scar from infection may block passage of
ova fallopian tube
3. Disseminated infection:
A) Gonococcal arthritis
B) Fitz-Hugh Curtis Syndrome (Perihepatitis)

Homosexual :
= infection commonly involve the rectum & pharynx
= charac. constipation, proctitis & painful defecation
= gonococcal pharyngitis, gonococcal stomatitis may
occur charac. by presence of exudate in the
pharynx, buccal mucosa and tongue
Newborn:
= infection is contracted during passage through an
infected birth canal
= eye most common site of infection among infant Gonococcal Opthalmia
Neonatorum
------ characterized by severe bilateral purulent conjunctivitis which occurs in the first
or second day of life and can damage the cornea causing blindness
Prevention = instillation of 1% silver nitrate (Argyrol) to
both eyes to all infants at birth followed by
Tetracycline/Erythromycin ophthalmic
Lab. Diag:
1) Bacteriological Gram staining of urethral discharge for both
sexes (male & female patient)
= other specimen includes purulent discharge/exudates
from eye, throat, vagina, endocervix, rectal area,
synovial fluid
= demonst. gram () diplococci intracellular/extracellular
with numerous neutrophil
Fluorescent antibody test more sensitive and specific for
macroscopic diagnosis
2) Culture
= Thayer Martin (Selective-differential) for unsterile
specimen (cervix, vagina, rectum, urethra, pharynx)
= Chocolate Agar (Non Selective) for sterile specimen

colonize in the mucous membrane of nasopharynx

(forms part normal flora)

disseminate to bloodstream

skin, meninges, eye, lungs, joints throughout body

Disease Associated :
1. Meningococcemia (Meningococcal Meningitis)
= usually follows after bloodstream invasion
= charac. by abrupt onset of mild fever, chill, headache,
pharyngitis, signs of meningeal irritation
(convulsion, rigidity of the neck) & appearance of
petechial skin rashes (due to release of endotoxin)from org. causing vascular necrosis
(hallmark of the disease)
2. Waterhouse Frederichsen Syndrome
= more severe & highly fulminant form of meningococcemia
= charac. high fever, ecchymoses, disseminated intravascular
coagulopathy, adrenal hemorrhage, shock, coma & death.
3. Meningitis
= 2nd most common cause of bacterial meningitis in adult
= mostly due to serotypes B & C
= charac. by fever, headache, stiff neck, irritability and
lethargy
Sequelae after recovery:
1. 8th nerve deafness
2. CNS damage (disabilities and seizure)
3. severe skin necrosis that may warrant
grafting or amputation
Lab. Diag. :
1.) Bacteriological Gram staining
specimen includes: nasopharyngeal swab, CSF
sediments, petechial aspirate, synovial fluid, blood
Direct immunofluorescence test = smear treated with
antibody conjugated to fluorescent tag show the
presence of meningococci
2) Culture on Chocolate agar incb. 5-10% CO2
Bld., CSF, Synovial fluid
Thayer Martin Nasopharyngeal swab
3) Quellung test - capsular swelling
4) CHO utilization test utilize both glucose and maltose
5) Confirmatory: Serological
A) Counterimmunofluoresence antibody test
B) Latex aggl. test to detect capsular

(synovial fluid, CSF, Bld.)

= incubate at 35-370C under 5-10% CO2 for 24 hours on culture confirmed by gram
staining
3. Oxidase test +

polysaccharide antigen from blood/CSF

C) Isoenzyme electrophoresis
D) Coagulation test using Staph with protein A

4. Biochemical test (Carbohydrate utilization test)

= utilize glucose only
5) Confirmatory: Serological - Immunofluoresence test
Nucleic Acid Probe (PCR)
(highly selective & specific)
Elisa
Latex Slide Agglutination test
RX:
= Aqueous Procaine PCN G (IM) together with Probenecid (oral)
= Ceftriaxone
= for allergic patient Tetracycline (oral), Spectinomycin (IM)
Prevention:
= Most effective method of control
1) General Public education
2) Diagnosing & treating asymptomatic patient
3) Encourage the use condoms
4)Treating infected individual quickly to prevent further spread of dse.
5) Patient sexual partner should also be treated
= No vaccine

Treatment :
Penicillin G ( drug of choice 0.05mg)-administered IV 4-6 hours
Ceftriaxone
Chloramphenicol for PCN sensitive individual
Supportive measures for possible complication like shock &
intravascular coagulation
Prevention :
Vaccination - Meningococcal Vaccine
(purified capsular polysaccharide antigen contg.) serotypes A, C, Y, and W135
= administered as a single dose of 50mg for adult and children older than 2 years old
Prophylaxis for person who are exposed or close contact with
the patient: Rifampicin / Minocycline