Saturday, December 8, 2007

 

Medical Microbiology [Case 1--Blog 2]

Name of patient: Khong Fay Seah
Sex : Female
Age: 27 years old
Specimen: Urine [specimen 1]

Clinical Diagnosis
Complaints: Fever, Chills, Dysuria
Diagnosis: Urinary Tract Infection (UTI)

Interpretation of clinical diagnosis (complaints)

Fever [1]
Fever a common manifestation of infection and inflammation [such as influenza, urinary tract infection, bowel disease]. Fever can be caused by many bacterial products, most notably, endotoxin of gram-negative bacteria. Endotoxin would result in the release of endogenus pyrogen, which derived from monocytes and macrophages. Other substances that can cause fever are interlukin 1 and interferons.

Chills [2]
The word ‘chill’ refers to an episode of shivering, accompanied by paleness and feeling cold. Chills may occur at the beginning of an infection, and is usually associated with fever. Chills are caused by rapid muscle contraction and relaxation, and are the body's way of generating heat when the body feels that it is cold. Causes of chills includes exposure to cold environment and virus and bacterial infections [such as meningitis, urinary tract infection, pneumonia]

Dysuria [3]
Dysuria is a condition whereby there is discomfort/pain during urination. Causes of dysuria includes urinary tract infection, cystitis, prostatitis and urethritis


Although UTIs occur in both men and women, women tend to suffer more from it because of the anatomical difference. Women's urethra tube is shorter than men's, and the opening is just a short distance away from the vaginal tract and the rectal openings. Because of this, there is a higher risk of bacteria from these adjacent areas to scuttle up the tube into the bladder. [5]

Microorganism that causes urinary tract infection[4,6]
1) Bacteria [6]



a) Escherichia coli [About 75% of community acquired UTI and 40% of hospital acquired UTI are caused by E. coli]

E. coli http:///www.yahoo.com > Image> Search > Escherichia coli

b) Staphylococcus saprophyticus [About 5% of community acquired UTI and 1% of hospital acquired UTI are caused by S. saprophyticus]

S. saprophyticus http:///www.yahoo.com > Image> Search > Staphylococcus saprophyticus

c) Proteus mirabilis [About 3% of community acquired UTI and 10% of hospital acquired UTI are caused by P. mirabilis]

P. mirabilis http:///www.yahoo.com > Image> Search > Proteus mirabilis

d) Pseudomonas aeruginosa [About 1% of community acquired UTI and 5% of hospital acquired UTI are caused by P. aerginosa]

P. aeruginosa http:///www.yahoo.com > Image> Search > Pseudomonas aerugionsa

e) Enterobacter faecalis [About 5% of community acquired UTI and 8% of hospital acquired UTI are caused by E. faecalis]

E. faecalis http:///www.yahoo.com > Image> Search> Enterobacter faecalis

f) Staphylococcus epidermidis [About 2% of community acquired UTI and 3% of hospital acquired UTI are caused by S. epidermidis]

S. epidermidis http:///www.yahoo.com > Image> Search> Staphylococcus epidermidis

g) Other coliforms [About 5% of community acquired UTI and 25% of hospital acquired UTI are caused by other Enterobacteriaceae such as Klebsiella pneumonia, Serratia marcescens]

K. pneumonia http:///www.yahoo.com > Image> Search> Klebsiella pneumonia





S. marcescen http:///www.yahoo.com > Image> Search> Serrtia marcescen

In addition, Acinetobacter sp. causes nosocomial UTI. Other less common microorganism that causes UTI include Mycobacterium tuberculosis. [7]

2) Viruses [6]
a) Adenovirus
b) Human polyoma virus



3) Parasites [6]
a) Trichomonas vaginalis
b) Schistoma haematobium



4) Fungi [6]
a) Candida albicans

In this PBL, only bacteria is being dealt with thus viruses, parasites and fungus are eliminated.


1) Escherichia coli [4,6,8]
a) Facultative Anaerobe, gram negative bacilli
b) Confirmatory test bi)Microscopy and gram staining shows motile gram-negative rod
bii) Cultures shows dark pink to red, dry flat lactose-fermenting colonies on MacConkey agar, and blue black colonies w/wo green metallic sheen on eosin methylene blue (EMB) agar
biii) Biochemical test to be done/results for E. coli biii[a]) Citrate, H2S, Urea and Voges-Proskauer (VP) negative
biii[b]) Indole, Methyl-red positive
biii[c]) Ferments both glucose and lactose with gas and no H2S
biv) Treatment: Amplicllin, Cephalosporin [cefoxitin, cefotaxime, ceftazidme], Aminoglycosides [amikacin, gentamicin, tobramycin], Sulfonamides [bactrim]
Escherichia coli is the most common cause of UTI. It is a normal flora in the intestine and colon that enters and invades the urethra causing an infection.


2) Staphylococcus saprophyticus [4,6,8]
a) Facultative Anaerobe, gram positive cocci
b) Confirmatory test
bi) Microscopy and gram staining shows gram-positive cocci
bii) Absence of hemolysis on blood agar
biii)Biochemical test to be done/results for S. saprophyticus
biii[a]) Catalase positive
biii[b]) Oxidase, Coagulase, Mannitol fermentation negative
biv) Treatment: Quinilone [ norfloxacin, ciprofloxacin]
bv) Resistant: Bacitracin, Novobiocin
Staphylococcus saprophyticus is isolated in patient especially in sexually active women patient between age 16-35




3) Proteus mirabilis [4,6,8]
a) Facultative Anaerobe, motile, non-spore fermenting gram-negative rod
b) Confirmatory test
bi) Microscopy and gram staining shows motile gram-negative rod
bii) Pale colonies on MacConkey’s agar and colourless/light purple colonies on EMB agar
biii) Biochemical test to be done/results for P. mirabilis
biii[a]) Oxidase negative
biii[b]) H2S, Urea and Indole positive
biii[c]) Voges-Proskauer (VP) negative/positive biii[d]) Non-lactose fermenting
biv) Treatment: Cephalosporin [cefoxitin, cefotaxime, ceftazidme], Quinilone [ciprofloxacin], Ampicillin
bv) Resistant: Nitrofurantoin
Proteus mirabilis is a bacterium that is commonly infect recurrent patient with urinary tract abnormalities. It is also found in elderly who is undergoing long-term catheterization.




4) Pseudomonas aeruginosa [4,6,8]
a) Facultative Anaerobe, gram-negative rod
b) Confirmatory test
bi) Microscopy and gram staining shows motile gram-negative rod
bii) Flat and green pigmentation on MacConkey’s agar and , colourless/light purple colonies on EMB agar
biii) Biochemical test to be done/results for P. aerginosa
biii[a]) Citrate, Oxidase positive
biii[b]) Non-lactose fermenting
biii[c]) Indole negative
biv) Treatment: Ciprofloacin, Imipenam, Carbenicillin, Ticarcillin
bv) Resistant: Ampicillin, Cefloxitin, Nitrofurantoin, Trimethopriml-sulfamethoxazole
Pseudomonas aeruginosa is the most frequent colonizers of medical catheters. Since patient is not using such devices,Pseudomonas aeruginosa may not be the microorganism isolated




5) Klebsiella pneumonia [4,6,8]
a) Facultative Anaerobe, non-motile, gram-negative rod
b) Confirmatory test
bi) Microscopy and gram staining shows non-motile gram-negative rod
bii) Dark pink to red Mucoid colonies observed on MacConkey agar and blue black colonies w/wo green metallic sheen on eosin methylene blue (EMB) agar
biii)Biochemical test to be done/ results for K. pneumonia
biii[a]) Ferments both lactose and glucose with gas and no H2S
biii[b]) Urease, Voges-Proskauer, Citrate positive
biii[c]) Indole, methyl-red negative
biv) Treatment: Cephalosporin [cefoxitin, cefotaxime, ceftazidme], gentamicin
The chances of identifying Klebsiella pneumonia increases with the length of hospital stay. Since the patient is an out-patient, in this case, the bacteria would most probably not be the cause of UTI.




6) Staphylococcus epidermidis [4,6,8]
a) Obligate Anaerobe, Gram-positive cocci
b) Confirmatory test
bi) Microscopy and gram staining shows cluster of gram-positive cocci
bii) Non-hemolytic colonies observed on sheep’s blood agar
biii) Biochemical test to be done/ results for S. epidermidis
biii[a]) Catalase, urease positive
biii[b]) Coagulase, mannitol fermentation negative
biv) Treatment: Novobiocin, Vancomycin + rifampin/ aminoglycoside
Staphylococcus epidermidis found in hospitalized patient older than 50 years of age with urinary tract complication.



7) Enterococcus faecalis [4,6,8]
a) Facultative Anaerobe, Non-motile, gram-positive Streptococci
b) Confirmatory test
bi) Microscopy and gram staining shows a gram-positive cocci
bii) Alpha, beta or no hemolysis on blood agar
biii) Biochemical test to be done/ results for E. faecalis
biii[a]) Bile esculin, 6.5% NaCl positive
biii[b]) Catalase negative
biv) Treatment: Vancomycin, Novobiocin
Enterococcus faecalis identification is usually associated with the usage of catheters. It is more commonly found in hospitalized patient. Since the patient is not required for any observation in the hospital [meaning that she is an out-patient], Enterococcus faecalis may not be the bacteria that is to be identified.


8) Serratia marcescens [4,6,8]
a) Facultative Anaerobe, motile, Gram negative bacilli
b) Confirmatory test
bi) Microscopy and gram staining shows a gram-negative bacilli
bii) Slight pink colonies on MacConkey Agar, colourless/light purple colonies on EMB agar
biii) Biochemical test to be done/ results for S. marcescens
biii[a]) Ferments both glucose and lactose and no H2S
biii[b]) Indole, methyl-red negative
biii[c]) Voges-Proskauer, Citrate positive
biii[d]) DNAse positive
biii[e]) Catalase positive
biv) Treatment: Cephalosporin [cefoxitin, cefotaxime, ceftazidme], gentamicin
The identification of Serratia marcescens increases with the length of hospital stay. In this case, since the patient is an out-patient, the bacteria would most probably not be the cause of UTI.

Mycobacterium tuberculosis is a rare bacteria that is being isolated in UTI cases, thus eliminated

Acinetobacter sp. is involved in hospital-acquired infection and commonly infect immunocomprised individuals.

Though either Escherichia coli or Staphylococcus saprophyticus may be the most probable microorganism isolated in this case, the microorganism above would be identified by a series of test



LABORATORY TEST to be done for the identification of causative agent

Facultative Anaerobe
-E.coli
-S. saprophyticus
-P. mirabilis
-P. aeruginosa
-E. faecelis
-S. marcescens
-K. pneumonia

Obligate Anaerobe
-S. epidermis

1) Culture on blood agar, in aerobic conditions

Organisms that can grow on blood agar in aerobic conditions:
-E.coli
-S. saprophyticus
-P. mirabilis
-P. aeruginosa
-E. faecelis
-S. marcescen
-K. pneumonia


Organisms that cannot grow on blood agar in aerobic conditions:
-S. epidermis

2) Perform Gram Stain

Gram negative organisms: Escherichia coli, Proteus mirabilis, Pseudomonas aeruginosa, Klebsiella pneumonia, Serratia marcescens

Gram positive organisms: Enterococcus faecalis, Staphylococcus saprophyticus



3) Gram negative organisms

3a) Perform Wet Mount

Motile organisms: Escherichia coli, Proteus mirabilis, Pseudomonas aeruginosa, Serratia marcescens

Non-motile organisms: Klebsiella pneumonia


3b) Culture on MacConkey

Microorganisms that form lactose fermenting colonies on MacConkey: Escherichia coli



E. coli(left) and P. mirabilis (right) on MacConkey agar http://www.yahoo.com/ > Image> Search> E. coli

Microorganisms that do not form lactose fermenting colonies on MacConkey: Proteus mirabilis,Pseudomonas aeruginosa, Serratia marcescens



Pseudomonas aeruginosa shown on the right side of the MacConkey agar http://www.yahoo.com/ > Image> search> Pseudomonas aeruginosa



3c) Oxidase Test

Oxidase positive organisms: Pseudomonas aeruginosa

Oxidase negative organisms: Proteus mirabilis, Serratia marcescens


3d) Perform TSI

H2S producing microorganisms: Proteus mirabilis

Non-H2S producing microorganisms: Serratia marcescens



4) Gram positive organisms

4a) Catalase test

Catalase positive organisms: Staphylococcus saprophyticus

Catalase negative organisms: Enterococcus faecalis




The image below show how the microorganism is being identified [flowchart]
References

[1] Coico, R., Sunshine, G. and Benjamini, E. (2003) Immunology: A Short Course. John Wiley & Sons, Inc., Hoboken, New Jersey.

[2] Medical Encyclopedia. (2007). Chills. Retrieved 31st November, 2007 from
http://www.nlm.nih.gov/ Search NLM Web Site> Chills


[3] Medicine Net. (2007). Dysuria. Retrieved 31st November, 2007 from
http://www.medterms.com/> MedTerms Dictionary> Dysuria> Medical Dictionary> Dysuria

[4] Spicer W. J. (2000). Clinical Bacteriology, Mycology and Parasitology: An illustrated colour text. Churchchill Livingstone

[5] Juicing for Health.com (20007). Urinary Tract Infection. Retrieved 31st November, 2007
http://www.juicing-for-health.com/> Google Search> www.juicing-for-health.com >Urinary Tract Infections

[6] Elliott, T., Hastings, M. and Desselberger, U. (1997). Lecture Notes on Medical Microbiology. Blackwell Science Ltd.

[7] Phage Therapy Center. (2005). Chronic and Acute Urinary Tract Infection. Retrieved 31st
http://www.phagetherapycenter.com/ >>Clinics>What we treat> Chronic and Acute Urinary Tract Infections (UTI) and Cystitis

[8] Mahon C. R. and Manuselis G, Jr (1995). Textbook of Diagnostic Microbiology. W.B. Saunders Company

Eugene Wong
TG02


Comments:
This comment has been removed by the author.
 
In urinary tract infections, quantitative culture is more significant than qualitative culture. It is long held that for a organism to be considered significant uropathogen, it should be isolated in pure culture at a count of =>1,00,000 cfu/ml. This is called significant bacteriuria and was proposed by Kass. This concept is subjected to interpretation under various circumstances such as prior antibiotic therapy, time lapse between collection & processing, method of collection etc. Kass concept appears to have been abandoned and presently, a count of 1000 cfu/ml in a symptomatic patient is given more significance.

Interested visitors may check out my page on UTI at www.microrao.com/bact7.htm

My blog on medical microbiology can be accessed at http://medimicro.blogspot.com
 
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