Download Unit VI Exudates Sterile Body Fluids Genital Cultures Sexually

Unit VI
Exudates
Sterile Body Fluids
Genital Cultures
Sexually Transmitted
Diseases/Infections
Exudate Terminology
Exudate Terminology:
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1. Anorectal: pertaining to the anus and rectum considered together
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2. Bullae: large blebs or blisters, filled with fluid, in or just beneath the epidermal layer of skin
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3. Culdocentesis: aspiration of fluid from the cul-de-sac by puncture of the vaginal vault
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4. Debridement: surgical or other removal of non-viable tissue
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5. Decubitis ulcer: a crater-like defect in skin and subcutaneous tissue caused by prolonged pressure
on the area. This occurs primarily over bony prominences of the lower back and hips in individuals
who are unable to care for themselves well and unable to roll over or mover periodically ; a.k.a.
“bed sore” or “pressure sore”
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6. Desquamation: shedding or dealing of skin or mucous membrane
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7. Effusion: fluid escaping into a body space or tissue (i.e., pleural effusion)
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8. Empyema: accumulation of pus in a body cavity, particularly empyema of the thorax or chest
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9. Epididymitis: inflammation of the epididymis characterized by fever and pain on one side of the
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scrotum; seen as a complication of prostatitis and cystitis
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10. Fitz-Hugh-Curtis Syndrome: inflammation of the capsule of the liver that may be seen in the
course of gonococcal or chlamydial infections in the female
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11. Granuloma: aggregation and proliferation of macrophages to form small nodules (usually
microscopic)
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12. Inclusion Bodies: microscopic bodies, usually within body cell; thought to be virus particles in
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morphogenesis
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13. Mediastinum: space in the middle of the chest between the medial surfaces of the two pleurae
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14. Necrotizing fasciitis: a very serious, painful infection involving the fascia (membranous covering)
of one or more muscles; may spread widely in short periods of time since there is no anatomic
barrier to spread in this type of infection
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15. Paracentesis: surgical transcutaneous puncture of the abdominal cavity to aspirate peritoneal fluid
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16. Proctitis: inflammation of the rectum
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17. Pyoderma: any of the pus-producing lesions of the skin such as boils or impetigo
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18. Pilonidal cyst: hair containing cyst in the skin or subcutaneous tissue, often with a sinus tract,
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commonly in the sacrococcygeal area
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19. Synovial fluid: viscid fluid secreted by the synovial membrane, formed in joint cavities, bursae and
so forth.
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20. Vesicle: a small bulla or blister containing clear fluid
Skin & Soft Tissue Infections
Clinical Infections
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There are many infectious diseases of the skin. These can be
classified in various ways: according to etiologic organisms (e.g.,
bacterial, viral, mycobacterial, fungal, parasitic): whether they occur
as primary entities, secondary to preexisting skin lesions or as
manifestations of systemic disease; or according to the morphology of
the skin lesion produced.
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In the management of bacterial infections of the skin, the surface of
intact or ulcerated skin is often swabbed for purposes of Gram
staining and culture. In most cases, however, this provides little or
no clinically useful information because of the lack of correlation
between surface colonization and below-the-surface infection. Deep
aspirates of involved tissue or specimens taken from closed skin
lesions are more interpretable. For example, if pustules or vesicles are
present, the roof or crust should be removed with a sterile blade, and
any pus or exudate should be examined, Gram stained, and cultured.
Obtaining a specimen in a patient with erysipelas or gangrenous or
crepitant cellulitis may involve injecting a small amount (about 3 cc)
of preservative-free physiologic saline into the advancing margin of
the affected skin, aspirating back and culturing the fluid that is
withdrawn. Exuded pus or wound dressings should always be
examined for the presence of granules and branching filaments,
suggestive of infections with actinomycetes or fungi.
Causative Agents of Pyoderma
Causative agents of pyoderma:
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impetigo: a common pyoderma most often caused by group A
strep
folliculitis: inflammation and infection of hair follicles
furuncles: where lesions of folliculitis may develop into a deeper
inflammatory nodule
carbuncle: an abscess that extends even more deeply into the
subcutaneous fat and may have multiple draining sites.
cellulitis: a diffuse inflammation and infection of the superficial
skin layers
erysipelas: a deeper form of cellulitis that involves not only the
superficial epidermis but also the underlying dermis and lymphatic
channels.
myonecrosis: gas gangrene caused by histotoxic clostridia
paronychia: an infection of the cuticle surrounding the nail bed.
erysipeloid: a superficial soft tissue infection usually caused by
Erysipelothrix rhusiopathiae
erythrasma: a chronic, pruritic, reddish-brown macular infection
found most commonly in men and in obese patients with diabetes
mellitus; usually located in areas such as the groin, toe web, axilla,
and inframammary folds.
Normally Sterile Body Fluids
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Normally Sterile Body Fluids:
Pleural Fluids
Chest fluid
Thoracentesis fluid
Pleural effusion
Empyema fluid
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Amniotic Fluids
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Pericardial Fluids
Pericardial effusion
Peritoneal fluids
Ascites fluid
Paracentesis fluid
Peritoneal effusion
Abdominal fluid
Peritoneal dialysis fluid
Joint Fluids
Synovial fluid **
Hip fluid
Knee fluid
Elbow fluid
Wrist fluid
Protocol:
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A. Centrifuge fluid to concentrate organisms if the quantity is sufficient (>1 cc) and not
grossly contaminated with WBC's. Use cytospin centrifuge for making gram stain slides.
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1. If unable to centrifuge (<1 cc) use the entire specimen for inoculum. Save all fluids &
sediment in refrigerator until final report is submitted
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B. Inoculate:
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1. Fluids:
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a. 5% sheep blood agar plate
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b. Chocolate agar plate
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c. Anaerobic blood agar plate
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d. Thioglycollate broth
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e. Thayer-Martin agar if joint, amniotic fluid or Neisseria gonorrhoeae is suspected.
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f. Prepare 2 slides for Gram stain *
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*
Always do a direct gram stain whether it is ordered or not.
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**
Exception: Synovial fluid: < 5 cc received -BACTEC bottle and gram stain.
>5 cc’s – BACTEC, above media & gram stain.
Fluids continued:
Protocol:
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A. Centrifuge fluid to concentrate organisms if the quantity is sufficient (>1 cc)
and not grossly contaminated with WBC's. Use cytospin centrifuge for making gram
stain slides.
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1. If unable to centrifuge (<1 cc) use the entire specimen for inoculum. Save all
fluids & sediment in refrigerator until final report is submitted
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B. Inoculate:
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1. Fluids:
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a. 5% sheep blood agar plate
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b. Chocolate agar plate
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c. Anaerobic blood agar plate
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d. Thioglycollate broth
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e. Thayer-Martin agar if joint, amniotic fluid or Neisseria gonorrhoeae is
suspected.
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f. Prepare 2 slides for Gram stain *
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*
Always do a direct gram stain whether it is ordered or not.
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**
Exception: Synovial fluid: < 5 cc received -BACTEC bottle and gram stain.
>5 cc’s – BACTEC, above media & gram stain.
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C. Hold cultures for at least 3 days - longer if indicated (Some anaerobes may
require up to 7 days to indicate growth). Also, hold all fluid thio broths for 5 days.
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D. Identify and perform susceptibility studies on all isolates except probable
contaminants.
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E. Call all positive fluids to the floor and/or physician. Note date, time,
technologist initials, and name of person receiving information. Also, log this
information on to the “Panic Value” sheet where positive blood cultures are noted
and have technologist put information into Sunquest computer.
Organisms Not Frequently Encountered
Pasteurella multocida:
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only species of clinical significance
non-motile, small gram negative rod (coccobacillary), often
showing bipolar staining
oxidase positive, catalase +, indole +, ONPG negative,
OF dextrose: fermentative for glucose
grows well on 5% sheep blood agar and chocolate agar where
small non-hemolytic colonies have a characteristic musty
odor
NG on MAC (unable to grow on gram negative differential
agar like MAC/EMB)
acquired following a scratch, bite or lick of a cat, kitten or
dog, usually newly arrived to a household; patients are
usually children
can result in bacteremia, meningitis, brain abscesses
has been seen in AIDS patients as a proliferative endothelial
cell lesion
very susceptible to Penicillin and its derivatives (Ampicillin,
Carb, and Pip): also to Tetracycline, Chloramphenicol, and
second and third generation Cephalosporins
Organisms Not Frequently Encountered:
Francisella tularensis
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"Tularemia“ or “Rabbit Fever”
a tickborne disease of rabbits
directly transmitted to humans through handling infected wild animals or livestock, those
engaged in farming operations or drinking impure water
obligate aerobe, pleomorphic, non-motile, oxidase negative, biochemically inert,
fastidious, gram negative rod with capsules that show bipolar staining by Giemsa stain
reproduces by different methods: budding, binary fission and the production of filaments
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Symptoms: headache, fever, chills, vomiting and myalgias; from ulceroglandular type
(lymphadenitis) to oculoglandular (inflammation of the conjunctiva) to an ingestive form
characterized by lesions of the mouth and GI tract
specimens should include lymph node aspirates, tissue biopsies, body fluids and blood (first
week) or curetting from the primary lesion or conjunctival scrapings
requires special enriched media: blood-cystine-glucose agar; may grow on chocolate
because it is supplemented with a growth enrichment (IsoVitaleX) that contains cysteine
may take 10-14 days to grow
identified by immunofluorescence with specific antiserum
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Treatment: Streptomycin with Tetracycline and Chloramphenicol as alternative drugs
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** Extreme care should be taken when handling infected material. Due to its ease of
spread by aerosolization and its high virulence, Francisella tularensis has been
classified as a Class A agent by the U.S. Government in the war on bioterrorism.
The lab should be notified in advance to ensure proper handling of these specimens
(via PPE – BSC, gown, gloves ) and to ensure the proper media is on hand for culturing
these organisms. Once growing, these cultures are usually sent to a special lab (State
Health Department ) for workup.
Organisms Not Frequently Encountered:
Listeria monocytogenes
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small, diphtheroid-like gram positive rod that is
slightly beta hemolytic on 5% sheep blood agar
implicated in stillbirths and septic abortions
Identify:
a.
BE positive
b.
Catalase positive
c.
“Umbrella motility" inoculate 2 motility tubes.
Incubate at 25°C and 37°C.
Motility is more pronounced at RT
than at 37°C. A positive motility
shows spread of the stab and the
development of an umbrella 3-5 mm
below the surface.
Treatment:
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www.bacterio.iph.fgov.be/missions/listeria
Ampicillin and Chloramphenicol
25oC
www.microbelibrary.org
** The clinical microbiologist should be fully aware that these
organisms are confused not only with diphtheroids but with Group B
beta strep and Enterococcus and therefore isolates from CSF, blood,
vaginal swabs, lochia and placenta are not always contaminants.
Organisms Not Frequently Encountered:
Erysipelothrix rhusiopathiae:
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Erysipeloid: a localized, painful skin infection that can cause diffuse skin infections with
systemic symptoms
gram positive rod, non-sporulated, with a tendency to form filaments and over decolorizes
easily
infection is usually zoonotic (turkeys and swine especially)
in humans it causes a self-limiting infection of the fingers and hands (erysipeloid)
not part of normal human flora
acquired by abrasion or puncture wound of skin with animal exposure; usually an occupational
hazard of fishermen, poultry workers, farmers, veterinarians, abattoirs and housewives
Biochemical ID:
a. catalase negative
b. oxidase negative
c. "test tube brush" growth in gelatin-like
media at RT after 48 hours
d. H2S positive (seen in butt of TSI or KIA)
e. glucose positive, Na Hippurate positive
+
-
Treatment:
www.alpenacc.edu
Susceptibile to penicillins and cephalosporins
Resistant to the aminoglycosides, sulfonamides and vancomycin
+
Na hippurate Test
www.cdc.gov
Diagnosis: specimen of choice is skin lesion collected by biopsy, tissue aspirate or blood
culture
Detecting Group B Strep (GBS) Infections
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DETECTING PERINATAL GROUP B STREP INFECTIONS
Group B Streptococcus (GBS) is a major cause of perinatal infectious morbidity and mortality in the
United States today. An estimated 50,000 women and 7600 neonates have GBS disease each year.
The CDC and the American College of OB/GYN developed guidelines for the identification of pregnant
women colonized with GBS and the implementation of intrapartum prophylaxis. Major risk factors for
early onset GBS disease include heavy colonization of pregnant women (higher in African/Americans),
preterm delivery, premature rupture of membranes, intrapartum fever, GBS UTI, and low levels of
maternal anti-GBS antibody.
Protocol:
- cultures of vaginal and anorectal sites should be collected at 35- 37 weeks gestation and requested
for GBS screen. Cervical specimens are not acceptable.
- swabs should be transported to the laboratory in appropriate transport media.
- remove swabs and inoculate both swabs into selective broth medium:
A. GBS Broth Media (Carrot Broth): a nutrient broth that contains
starch, horse serum, Polymixin B, Nystatin and Methotrexate to help
+ suppress the indigenous vaginal flora. Peach or Orange broth color
and/or sediment is considered positive and confirms GBS.
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B.
C.
Todd-Hewitt broth: nutrient broth with Colistin and Nalidixic acid OR
LIM broth: nutrient broth with Gentamicin and Nalidixic acid. Incubate TH or LIM
at room temperature overnight. Subculture broth to blood agar the next day and
examine at 24 & 48 hours for GBS. Tests should be performed to confirm GBS by
agglutination, fluorescent antibody, DNA probe or CAMP test.
Women who are culture positive will be treated intrapartum with penicillin. Those who lack definite
culture results at the time of delivery will be treated if they have a temperature of > 100.4 F,
membrane rupture > 18 hours, previous delivery of a GBS infected infant, GBS bacteriuria during
pregnancy, or delivery at < 37 weeks gestation.
Sexually Transmitted Diseases/Infections (STD/I’s)
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once termed non-specific or non-gonococcal urethritis
since the etiology was unknown but as of recent years the
causative agents have been determined.
The flora of the female genital tract varies with the pH and
estrogen concentration of the mucosa which depends on
the host’s age.
Exogenous infections: may be acquired as people
engage in sexual activity and these infections are referred
to as STD or STI’s. In contrast……..
Endogenous infections: result from organisms that are
members of the patient’s normal genital flora
Pelvic Inflammatory Disease (PID): an infection that
results when cervical microorganisms travel upward to the
endometrium fallopian tubes and other pelvic structures
which can lead to endometritis, salpingitis, peritonitis or
abscesses involving the fallopian tubes or ovaries. Pelvic
inflammatory disease is a general term for infection of the
lining of the uterus, the fallopian tubes, or the ovaries.
Sexually Transmitted Diseases (STD’s)
Chlamydia
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Chlamydia trachomatis responsible for 40-50% of STD cases ( 4 million each year)
the most sexually transmitted bacterial pathogen and a major cause of PID disease in the USA
today; most infections are asymptomatic
obligate, intracellular parasite containing RNA and DNA but lacking mechanisms ( cell wall lacks
a peptidoglycan layer) for independent energy production; therefore, it can not be grown on
routine laboratory media. Structurally, the chlamydial elementary body closely resembles a gram
negative bacillus
Symptoms for Females: mild dysuria; mild, milky or yellow mucus-like vaginal discharge,
nausea, fever, spotting between periods, pain during intercourse, with onset 10-14 days after
exposure to an infected partner; easily confused with gonorrhea because the symptoms are
similar and the diseases can occur together. There is a strong association of infertility and
ectopic pregnancies with undiagnosed Chlamydia infections.
Symptoms for Males: burning on urination, groin pain and swelling (epididymitis) irritation
around the opening of the penis, sticky, milky or mucus-like discharge from penis, swollen testes
or testicular pain.
Mothers infected with Chlamydia may transmit infection to the newborn and cause neonatal
pneumoniae and/or inclusion conjunctivitis (pink-eye)
Diagnosis: dependent upon genital secretions. Perform specialized tissue culture is most
definitive but also takes longest amount of time (3-7 days). DNA amplification can also be
used with urine thus less invasive. Newest technology is Amplicor Test and can produce results
in as little as 4 hours.
Gram stain of secretions: useless for definitive diagnosis; reveals many PMN's with no organisms
seen which may establish the diagnosis of non-gonococcal urethritis
Treatment: Azithromycin (1 day), Doxycycline (7 days), Erythromycin or Tetracycline
STD’s:
Chlamydia trachomatis
Chlamydia in Male
Chlamydial eye infection
Female: Chlamydia externally
Female: Chlamydia internally
Sexually Transmitted Diseases (STD’s)
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LymphoGranuloma Venerium
A serotype of Chlamydia trachomatisL1, L2, and L3
uncommon in the U.S.
small ulcer or vesicle that
heals spontaneously without
leaving a scar
after lesion heals, painful,
swollen lymph nodes (lymphadenopathy;
also called “buboes”) develop 2-6 weeks later;
fever and chills; severe lymphatic obstruction
and lymphedema can develop
will not respond to Penicillin; 3 week regime
of antibiotics necessary to kill infection
www.commons.wikimedia.com
Sexually Transmitted Diseases (STD’s)
Granuloma Inguinale:
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caused by Klebsiella granulomatis (formerly Calymmatobacterium
granulomatis; However, polymerase chain reaction (PCR) techniques using a
colorimetric detection system showed a 99% similarity with other species in
the Klebsiella genus)
an infection of the genital region that causes a slowly, progressive ulcerogranulomatous lesion of the skin and mucosa (a.k.a. “Donovanosis”)
the ulcers may persist for months and may extend into the inguinal region
visualized in scrapings of lesions stained with Wright’s or Giemsa stain;
gram negative, non-motile, encapsulated, pleomorphic rod
www.dermatology.cdlib.org
www.dermatology.cdlib.org
www.dermatology.cdlib.org
Diagnosis: smears taken from impressions of the margin of an ulcer are
stained with Wright or Giemsa. One can then observe for the clusters of
encapsulated bacilli with rounded ends and characteristic polar granules
giving a safety pin appearance ("Donovan" bodies) within the
mononuclear endothelial cells; diagnosis is made solely on the basis of direct
exam.
Treatment: Tetracycline, Ampicillin, Erythromycin or Chloramphenicol
Sexually Transmitted Diseases (STD’s)
Neisseria gonorrhoeae: a.k.a. “GC” for the Gonococcus; “Clap”
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selective for Modified-Thayer-Martin media
Gonorrhea is the second most prevalent STD in the U.S. behind Chlamydia.
The bacterium has multiple determinants of virulence including the ability to
attach to and enter host cells, resist phagocytic killing and produce
endotoxins which eventually lead to an intense inflammatory response.
gram stain on genital culture may reveal: many pmn's, many gram-negative
diplococci, intra and extracellular
Gonorrhoeae is a relatively fragile organism, susceptible to temperature
changes, drying, UV light, and other environmental conditions. Strains of N.
gonorrhoeae are variable in their cultural requirements so that media
containing hemoglobin, NAD, yeast extract and other supplements (Choc
and MTM) are needed for isolation and growth of the organism.
Cultures are grown at 35-37oC in an atmosphere of 3-10% added CO2.
most genital cultures with gram negative diplococci, oxidase positive,
growth on Thayer-Martin and patient age greater than 12 years old suggests
"Presumptive Neisseria gonorrhoeae recovered". Then should be confirmed
with various procedures. In rape or abuse cases, 2 methods should be
employed for confirmation and sent to the State Lab also.
organism is more fastidious than N. meningitidis
usually requires 48 hours for growth on Thayer-Martin agar
Sexually Transmitted Diseases (STD’s)
Media’s Used to Recover Neisseria gonorrhoeae:
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“New York City” medium, Martin-Lewis and JEMBEC agars have also been
employed to isolate Neisseria gonorrhoeae and Neisseria meningitidis
from specimens containing mixed normal flora
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Gonorrheal infection is generally limited to superficial mucosal surfaces
lined with columnar epithelium. The areas most frequently involved are
the urethra, cervix, rectum, pharynx, and conjunctiva. Squamous
epithelium, which lines the adult vagina, is not susceptible to infection by
the N. gonorrhoeae. However, the prepubescent vaginal epithelium, which
has not been keratinized under the influence of estrogen, may be infected.
Hence, gonorrhea in young girls may present as vulvovaginitis.
Vulvovaginitis in children can also occur due to Neisseria gonorrhoeae
being able to remain viable for a short time on wet towels and bedclothes.
The alkaline pH of the prepubescent vagina is a disposing factor. Mucosal
infections are usually characterized by a purulent discharge.
Mothers who harbor GC at delivery can cause baby to have congenital
conjunctivitis which can lead to blindness. Therefore, to prevent this
occurrence in newborns, all babies born in the U.S. are legally required to have
erythromycin eye drops applied at birth. This process is called/used to be
called "CREDE".
About 50% of women with cervical infections are asymptomatic
Sexually Transmitted Diseases (STD’s)
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Treatment: The recommended treatment for uncomplicated
infections is a third-generation cephalosporin or a
fluoroquinolone plus an antibiotic (like doxycycline or
erythromycin) effective against possible co-infection with
Chlamydia trachomatis. Sex partners should be referred and
treated with Ceftriaxone(CTRX). This has replaced Penicillin G
due to the increased number of isolates resistant to Penicillin.
This resistance is primarily due to the ability of the organism to
produce beta-lactamase. Chromosomal mutation causing
modification in penicillin-binding proteins has also led to
Penicillin G resistance.
Transport: Culturette swabs not received in the laboratory in a
timely fashion should be placed in a charcoal-like transport media
or plated at bedside (MTM) and placed in a Ziploc type bag with a
CO2 generated ampule inside to maintain viability of the organism.
Neisseria gonorrhoeae continued:
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Males know immediately (1-10 days) when they have
contracted GC due to an acute purulent urethritis, but
females may be carriers for years without cervical
symptoms.
Purulent Urethritis
Gram Stain of Gram Negative
Diplococci within WBC’s
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** In females, a cervical gram stain can not be used to
“screen” for Neisseria gonorrhoeae due to other indigenous
vaginal flora that are GND (Veillonella) or resemble GND
(coccobacillary GNR’s)
**Note: GC if undetected can eventually seed to the joints
and cause arthritis or Reiter's Syndrome. There is often a
history of sexual intercourse two to four weeks before the
onset of symptoms. Affected patients are usually male and
have some combination of arthritis, skin rash (a thick scaly
rash involving the palms and soles of feet, as well as a rash
around the glans penis), urethritis, and conjunctivitis.
Diagnosis is made on clinical grounds. It is important to
consider and exclude the differential diagnosis of acute
gonococcal arthritis. Taking urethral swabs for gonococcal
cultures can do this, and, unlike a reactive arthritis,
gonococcal arthritis will respond quickly to penicillin treatment
This is an inflammatory illness that is treated with antiinflammatory medications, such as aspirin.
Reiter’s Syndrome
Sexually Transmitted Diseases (STD/I’s)
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Methods for Confirmation of Neisseria gonorrhoeae:
1. Cystine-trypticase agar (CTA): is the recommended base medium for growth of Neisseria
gonorrhoeae. Identification can be made using this agar with the addition of sugars glucose,
maltose, sucrose and lactose (using ONPG).
Glucose
Maltose
Sucrose
Lactose
N. gonorrhoeae
+
N. meningitidis
+
+
N. lactamica
+
+
+
N. flavescens
N. sicca
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+
2. Gonogen II: a rapid, monoclonal antibody test for the confirmation of Neisseria gonorrhoeae.
3. RapID NH: a rapid (4 hrs), multi-enzymatic test to confirm Neisseria & Haemophilus species
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4. API Quad-Ferm+™ : buffered sugars test that determines the use of glucose, maltose, sucrose
and lactose within 2 hours.
5. Serologic tests:
antibody tests to detect a rise in IgG or IgM
6. ** Gen-Probe**: most recent technology (positives detected by chemiluminescence) and
procedure we currently perform at Mecklenburg County Health Dept.
Sexually Transmitted Diseases (STD’s)
Haemophilus ducreyi:
a.k.a. Ducreyi's Bacillus
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causative agent of STD called “soft chancres” or “chancroids”
disease of the genitalia. Haemophilus ducreyi is a major cause
of human genital ulcer disease (GUD) in developing countries
(incidence being highest in African, Asian and Latin American nations).
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It appears as an intracellular and extracellular, pleomorphic gram negative rod.
After contact, 4-6 days later the patients’ infection may be characterized
by painful genital and perianal ulcers with tender inguinal lymphadenopathy
requires X factor for growth and can be recovered
using 20 - 30% fresh serum/ blood or a specially
designed media called Nairobi agar (chocolate agar
containing 1% hemoglobin, 5% fetal calf serum,
IsoVitaleX and Vancomycin ).
on gram stain, the rods appear in parallel chains
like a "school of fish" when gram stained with
freshly expressed exudate from the edges of the
lesion.
www.stdsandyou.com
“School of fish” arrangement
of GNR’s on gram stain
www.stdsandyou.com
www.quizlet.com
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alternative culture technique: use 10 ml of fresh blood (if patient's, you need to inactivate the
complement by heating for 30 minutes at 56°C. Let cool. Place specimen into fresh blood and let
incubate for 48 hours before plating onto routine chocolate media. Incubate with increased CO 2 and
observe for Haemophilus organisms.
Treatment: Azithromycin, Erythromycin, Ceftriaxone and Ciprofloxacin is recommended. If left
untreated, it can eventually invade the lymph system.
Non-Specific Vaginitis
Bacterial Vaginosis:
 Bacterial Vaginosis (BV) is a polymicrobial, overgrowth of multiple
bacteria (primarily anaerobic), infection associated with sometimes
fishy-smelling increased vaginal discharge , but not accompanied by
leukorrhea, vulvar burning, or pruritis. Infection with BV can have
significant sequelae, however. It has been associated with an
increased risk of septic abortion, premature rupture of amniotic
membranes, preterm labor, preterm delivery, post-Cesarean
endomyometritis, and post-hysterectomy pelvic cellulitis.
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Diagnosis is made by 4 important criteria:
1. Discharge: a thin but profuse vaginal
discharge
2. pH: greater than 4.5
3. Odor: usually described as "fishy"
especially with the metabolism
(polyamines) being volatilized by
vaginal fluids
4. "Clue cells" - clue cells are squamous epithelial
cells of the vagina with myriad’s of small rods
adherent to their surface (seen in wet mount or
gram stain)
Non-Specific Vaginitis
Bacterial vaginosis continued:
In addition to the previous slide symptoms, one may also experience:
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5. Burning: during urination or intercourse
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6. Itching: around the outside of the vagina
Gram stain: of the vagina are looked at for
the presence or absence of the following
organisms and then a score (>= 7) is determined
from those findings indicating a possible BV infection:
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1. absence of lactobacilli
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2. increase in Gardnerella vaginalis
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3. increase in Mobiluncus species
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4. increase in Mycoplasma hominis
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5. increase in anaerobic gram negative
rods (Bacteroides, Prevotella,
Lactobacilli
Gram stain of normal vaginal secretions
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Transmission: BV is increased by having
a new/multiple sexual partners, douching
and IUD”s. Can not be spread by casual contact.
Treatment: Ampicillin, Ceftriaxone, Clindamycin,
Flagyl and Tetracycline
Abnormal gram stain on vaginal
secretions; lactobacillus is absent
www.textbookofmicrobiology.net
Non-Specific Vaginitis
Gardnerella vaginalis:
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formally Haemophilus vaginalis; small, pleomorphic gram negative or gram-variable rod
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normal vaginal flora; may colonize distal urethra of males
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causative agent of “Bacterial Vaginosis” or Non-Specific Vaginitis
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does not require X or V factors for growth like other Haemophilus species
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catalase, oxidase, nitrate and urea negative; glucose, maltose and starch positive
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best recovered using selective agar HBT (human blood bi-layer tween) and colonies are
small & beta hemolytic OR grows very well on peptone-starch-dextrose agar or
"Vaginalis agar" or "V agar"
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may be found in up to 40% of normal, asymptomatic women thus cultures for this organism are
rare
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Diagnosis:
A. malodorous discharge, "fishy-amine like" with the addition of 10% KOH
B. wet mount with saline reveals the presence of "clue cells" on microscopic examination
(these are large, squamous, epithelial cells from the vaginal tract covered with gram
negative rods).
C. a distinct absence of lactobacillus which is a normal inhabitant of the vaginal tract
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- inhibited by SPS (anti-coagulant in blood culture media) thus will not be detected in blood
culture media
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Treatment: Ampicillin or Flagyl; must treat male partner so there is no reinfection
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Non-Specific Vaginitis
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Mobiluncus
causative agent of non-specific vaginitis; gram variable or gram
negative rod
"mobil" meaning mobile and "uncus" meaning hook; motile,
curved, non-sporeforming anaerobic rod with "gull wing"
appearance; multiple subpolar flagella; colonizes the vagina
www.bacterioweb.univ-fcomte.fr
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Mobiluncus grows on non-selective media (ABAP, BHI and CHOC).
Differentiation among the species is based on morphology, growth
in presence of arginine, hippurate hydrolysis and nitrate reduction.
Non-Specific Vaginitis
BV Diagnosis:
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Scoring system used to determine if a person has Bacterial vaginosis based
on gram stain:
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MORPHOTYPE
Lactobacilli
QUANTITY
4+
3+
2+
1+
0
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G. vaginalis/ Bacteroides
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Mobiluncus
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Bacterial Vaginosis Score
0
1+
2+
3+
4+
0
1+/2
3+/4+
POINTS
0
1
2
3
4
0
1
2
3
4
0
1
2
= A score of 7 or higher is indicative of BV infection.
Ureaplasma urealyticum:
 normal inhabitant of the urogenital tract in sexually
mature men and women
 causes non-gonococcal urethritis
 organisms are parasites on the surface of cells and
are not intracellular parasites
 identified by their strong urease activity
 requires A7 agar (highly enriched media for growth
to include peptones, yeast extract and horse serum)
which can be detected in 2 to 5 days
 quantitation of the number of organisms is
important in deriving some of the potential
association of the organism with non-gonococcal
urethritis and prostatitis
 fetal loss, low birth weight and dysfertility is
controversial
 Treatment: Tetracycline or Erythromycin
The End
Any
Questions?
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References
Most of the lecture notes produced in this power point presentation were
acquired from:
•
Required Textbook:
Mahon, Connie R., Lehman, Donald C., Manuselis, George,(2015).
Textbook of diagnostic microbiology (5th edition). Saint Louis,
Missouri: Saunders-Elsevier
•
•
•
Journals/Publications: Notes have also been ascertained using the
following:
a) Laboratory Medicine
b) Advance for Medical Laboratory Professionals
Laboratory Procedures: The procedures used in the following notes
with and without pictures were obtained with permission from
Carolinas Medical Center-Main, Microbiology Laboratory Procedure
Manuals, to be used for educational purposes only by the faculty of
Carolinas College of Health Sciences, School of Clinical Laboratory
Sciences, Medical Laboratory Science Program.
Hand-outs and Lecture Notes from various members and lecturers
of the South Eastern Association for Clinical Microbiologists (SEACM)
Annual Meeting Conference