Clinical Microbiology

Dr.abdirahman Mohamed jama (Gagajir)

Senior resident Amoud-Hope Family Medicine MD
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 Gram Stain
• Bacteria are colorless and invisible under a light
microscope
• We stain them, so that we can see them
• The most useful stain is the gram stain
1. Pour on crystal violet stain (a blue dye)
2. Wash off with water and flood with iodine solution
3. Wash off the water and then “decolorize” with 95%
alcohol
4. Counter-Stain with safranin (red dye); wait 30
seconds and wash off with water

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Gram Stain

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Structure of Bacterial Cell Wall

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 Gram Negative Cell Wall

Lipopolysaccaride
(LPS)

1. Outer
Carbohydrate
Chain (O antigen)
2. Water soluble core
polysaccharide
3. Lipid A, a
dissacharide with
multiple fatty acid
tails
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 Bacterial Morphology: Gram Positive
Gram Positive
• Remember 7 classic gram positive bacteria genera that
cause disease in humans
1. Streptococcus: forms cocci in chains
2. Enterococcus: Also forms cocci in short chains
3. Staphylococcus: forms cocci in clusters
• 2 gram positive rods produce spores
4. Bacillus
5. Clostridium
• 2 gram positive rods do not form spores
6. Corynebacterium
7. Listeria

• Most of the rest are gram negative

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 Bacterial Morphology: Gram negative
• Only 2 gram negative cocci: Neisseria,
Moraxella
• 1 other exception is Mycoplasma which do not
have a cell wall.
– Are they gram(+) or gram(-)?
• All of the rest are Gram Negative Bacilli
– Also called Gram Negative Rods (GNR)

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 Cytoplasmic Structures
• A single circle of double stranded DNA

• Plasmids: other small circles of DNA that contain

can contain resistance genes

• Ribosomes: Turn RNA into proteins

(polypeptides)
– Bacterial Ribosomes are small than Animal Ribosomes
– Bacterial Ribosomes are composed of a large and
small subunit (50S and 30S)
– These are good antibiotic targets
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 How Do We Further Differentiate
Bacteria?
• Bacteria are divided into groups based on their
metabolic properties
1. How the organism deals with oxygen
– Oxygen can be toxic to a bacteria unless they have
enzymes that break down oxygen products
– Obligate aerobes have all of the necessary enzymes
– Facultative anaerobes: aerobic bacteria than can break
down O2 products but can also grow in the absence of
Oxygen
– Obligate Anaerobes: Cannot survive in the presence of
oxygen
2. What the organisms uses as a carbon and energy
source
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 Virulence Factors
• Flagella: Protein filaments that extend like long
tails from the bacterial cell membrane. The
flagellum spins around and propels the bacteria
forward
– Bacteria may have one (V. cholerae) or many (E. coli, P.
mirabilis)
• Pili or Fimbriae: Straight filaments arising from
the bacterial cell wall
– Do not move like flagella
– Serve as adherence factors. N. gonorrhea binds to
cervical cells; C. jejuni binds to intestinal cells, B.
pertussis binds to respiratory cells
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 Virulence Factors
• Capsules: Protective walls that surround the cell membrane
of gram positive and gram negative bacteria
– Bacteria secrete sugars that then coat their outer wall
– Macrophages and Neutrophils are unable to phagocytose
encapsulated bacteria
– So, our humoral immune system must produce antibodies that
bind to the capsule surface (opsonization)
– S. pneumoniae, Neisseria spp, H. influenza
• Endospores: Produced only by Bacillus spp and Clostridium
spp
– Metabolically dormant forms of bacteria that are resistant to
heat, cold, drying, and chemical agents
– Spores form when there is a shortage of needed nutrients;
When the spore is exposed to a favorable environment, then it
becomes active again
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 SPORE

• A cell membrane
• A thick peptidoglycan mesh
• Another cell membrane
• A wall of keratin-like protein (spore coat)
• An outer layer (exosporium)
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 Virulence Factors: Toxins
• Exotoxin: Proteins that are released by both
gram positive and gram negative bacteria
– Neurotoxins: botulism, tetanus
– Enterotoxins: Vibrio cholerae, E. coli, Shigella
dysenteriae, B. cereus, S. aureus
– Pyrogenic exotoxins: Stimulate the release of
cytokines; S. aureus, S. pyogenes

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 Virulence Factors: Toxins
• Endotoxin: LIPID A from the outer membrane
lipid polysaccharide of gram negative bacteria
– Released when the bacterial cell is lysed.
Sometimes patients initially get worse with
treatment
– Also shed in steady amounts from living bacteria
– Triggers cytokine storm (TNF alpha, IL-1)  septic
shock

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 Gram Positive Cocci
Streptococci
• Gram Stain: gram positive cocci in chains
• Can be differentiated from staphylococci by the
lack of production of the enzyme catalase
• Can be classified based on their ability to
hemolyze red blood cells
– Beta-Hemolytic: completely lyse RBC
– Alpha-Hemolytic: partially lyse RBC leaving a greenish
discoloration of the culture medium surrounding the
colony
– Gamma-Hemolytic: do not lyse RBC

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 Streptococci
• Also classified based on the antigenic
characteristics of the carbohydrate found on the
cell wall
• There are over 30 species of streptococci, but
only 5 are significant human pathogens
• Only 3 of these have Lancefield Antigens (A, B, D)
• Group D has actually been reclassified into its
own species, Enterococcus

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 Streptococcus pyogenes
• Group A Streptococcus
• Beta Hemolytic
• Can cause disease by local invasion and/or
exotoxin release
• Important Infections caused by S. pyogenes
1. Streptococcal pharyngitis
2. Streptococcal Skin Infections
– Folliculitis, Cellulitis, impetigo, necrotizing
fasciitis
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 S. pyogenes
• Other Important Infections caused by S. pyogenes
3. Scarlet Fever
– Due to an exotoxin produced by the bacterial
infection
– A fever and a red rash that starts on the trunk and
neck and spreads to the extremities, sparing the face
– Skin will peal off in sheets
4. Streptococcal Toxic Shock Syndrome
– Also mediated by an exotoxin (pyrogenic toxin)
– High fever, nausea/vomiting, red rash, septic shock
with end organ damage

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 S. pyogenes
• 2 delayed, antibody-mediated diseases
1. Rheumatic Fever
– Fever
– Myocarditis
– Arthritis
– Sydenham’s Chorea
– Subcutaneous Nodules
– Erythema Marginatum: rash with red margin that
spreads out from the center
2. Post-Streptococcal Glomerulonephritis
– Occurs about 1 week after infection
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 Steptococcus agalactiae
• Group B Streptococci
• Beta Hemolytic
• About 25% of women carry these bacteria
vaginally
• Frequent cause of infection in neonates (<3
months)
– Meningitis
– Pneumonia
– Sepsis
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 Viridans Group Streptococci
• No Lancefield Antigen Classification
• Alpha Hemolytic
• Normal GI tract flora
1. Dental Infections
– Cause dental cavities and can also cause periodontal
infections
2. Subacute Bacterial Endocarditis
3. Abscesses
– If you see this bacteria growing in the blood, then
think about an organ abscess somewhere
(abdominal organs, brain)
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 Streptococcus pneumoniae
• No Lancefield antigen
• Alpha hemolytic
• Gram positive diplococci
• Capsule protects from phagocytosis
1. Bacterial Pneumonia
2. Meningitis
3. Otitis Media
4. Sinusitis
5. Bacteremia

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 Enterococcus spp
• Formerly Group D streptococci
• Alpha or Gamma Hemolytic
• Normal GI flora
1. Urinary Tract Infections
2. Biliary Infections
3. Bacteremia
4. Subacute Bacterial Endocarditis

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 Staphylococci
• 3 ways to differentiate from streptococci
1. Gram Stain
• Clusters of gram (+) cocci
2. Catalase Test
3. Culture
• Beta Hemolytic
• 3 major pathogenic species
1. Staphylococcus aureus
2. Staphylococcus epidermidis
3. Staphylococcus saprophyticus

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 Staphylococcus aureus
Very virulent with many proteins “virulence factors” that allow it to
disable host defenses and invade tissue
Proteins To Disable Host Immunity
• Protein A: Binds IgG and
prevents opsonization
• Coagulase: leads to fibrin
formation around bacteria
which protects it
• Leukocidin: Destroys WBC
• Penicillinase: Inactivates
antibiotics
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Proteins To Invade Tissue
• Hyaluronidase: Breaks down
proteoglycans in connective
tissue
• Staphylokinase: lyses fibrin
clots
• Lipase: Degrades fats and
oils
• Protease: Destroys tissue
proteins
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 Staphylococcus aureus
Diseases Resulting From Exotoxin Release
1. Gastroenteritis (“Food Poisoning”)
– Staphylococci can grow in food and produce an
exotoxin (enterotoxins)
– Occurs within 8 hours of ingesting and lasts for
12-24 hours
2. Staphylococcal Scalded Skin Syndrome
– Caused by a localized infection with S. aureus
that produces an exotoxin (exfoliatin toxin)
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 Staphylococcus aureus
3. Toxic Shock Syndrome
– Infecting S. aureus can release an exotoxin (TSST-
1)
– Infected Sutures in surgical wounds, cutaneous
and subcutaneous infections, infections after
childbirth, others
– High Fever, Vomiting, Watery Diarrhea, Rash,
Shock, Multi-organ Failure

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 Staphylococcus aureus
Diseases Resulting From Direct Tissue Invasion
1. Pneumonia
– can occur in hospitalized Or non-hospitalized
patients
– Usually follows a viral influenza
2. Central Nervous System Infections
– Following bacteremic spread, trauma, or surgical
manipulation
3. Osteomyelitis
– Following bacteremic spread, trauma, or surgical
manipulation

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 Staphylococcus aureus
4. Septic Arthritis
– The most common pathogen to cause this
5. Acute Endocarditis
– Very destructive infection of heart valves
– High fever, chills, myalgias, new heart murmur, other
metastatic sites of infection (lung, liver, spleen, brain,
bones)
6. Skin Infections
– Impetigo, Cellulitis/Fasciitis, Furuncles/Carbuncles,
Wound Infections
7. Bacteremia

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 Staphyloccus epidermidis
• Can be distinguished from S. aureus by the
absence of the enzyme coagulase
• Staphylococcus epidermidis is the most common
bacteria within a group of coagulase negative
staphylococci
• Part of the normal bacterial flora and is found
widely in the body
• Therefore, it is a frequent contaminant in blood
cultures
• Frequent cause of infections of prosthetic devices

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 Staphylococcus saprophyticus
• Common cause of urinary tract infections of
young women
• Community Acquired
• Coagulase negative
• Does not cause infections at other sites

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 Gram (+) Spore-Forming Rods
Bacillus species
• Bacillus anthracis
– Encapsulated bacteria that causes anthrax
– Humans come into contact with spores during direct handling of
infected animals or soil
– The spore is resistant to drying, heat, UV light, and disinfectants
1. Cutaneous anthrax: painless, necrotic skin lesion with a rim of
edema; spontaneously resolves in 80-90%
2. Pulmonary anthrax: spores are taken by macrophages to
regional lymph nodes where they germinate and cause
hemorrhage; VERY DEADLY
3. Gastrointestinal anthrax: spores are ingested, germinate and
replicate in the intestine. Exotoxins cause intesinal necrosis.
ALSO VERY DEADLY

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 Gram (+) Spore-Forming Rods
Bacillus Species
• Bacillus cereus:
– Motile, encapsulated and resistant to penicillin
– Causes food poisoning when spores are deposited
in food
– Onset is within 8 hours and course unaffected by
antibiotics

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 Gram (+) Spore-Forming Rod
Clostridium Species
• All are anaerobic
Clostridium botulinum
• Produces a lethal neurotoxin that causes rapidly fatal
food poisoning
• Neurotoxin blocks the release of acetylcholine
• Only occurs if the food is placed in an anaerobic
environment (jar, can, bag)
• Causes descending paralysis which can rapidly progress
to respiratory muscle paralysis and death
• Classically seen in infants eating fresh honey
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 Gram (+) spore forming rods
Clostridium tetani
• Causes tetanus
• Results following skin trauma by an object
contaminated with spores
• Release an exotoxin called tetanospasmin which causes
sustained contraction of skeletal muscles (tetany)
– Severe muscle spasm
– Trismus
• Treat with tetanus toxoid, aggressive wound cleaning
and debridement, penicillin or metronidazole,
supportive care, human tetanus immunoglobulin (if
available)
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 Gram (+) Spore-Forming Rods
Clostridium perfringens
• Causes gas gangrene
• Spores can be found in the soil
• Spores mature in anaerobic conditions and
produce gas
• Uniformly fatal unless identified and treated
very early

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 Gram (+) Spore-Forming Rods
Clostridium difficile
• Responsible for antibiotic associated
pseudomembranous colitis and diarrhea
• Follows the use of broad-spectrum antibiotics
– Ampicillin, Clindamycin, Cephalosporins are the worst
• Antibiotics wipe out normal flora and C. difficile
pathologically invades
• C. difficile then produces 2 endotoxins (A & B) that
cause severe diarrhea, abdominal cramping, fever
• Pseudomembranes: a white exudate seen on
colonoscopy
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Gram (+) Non-Spore-Forming Rods
Corynebacterium diphtheriae
• Causes diphtheria
• Colonizes the pharynx and creates a grayish
pseudomembrane
– Sore throat; can bleed a lot
• Releases an exotoxin (diphtheria toxin) into the
blood
– Myocarditis
– Neurologic toxicity: CN palsies, peripheral neuritis
– Renal toxicity

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 Gram (+) Non-Spore-Forming Rod
Listeria monocytogenes
• The only gram positive organism that
produces endotoxin
• Causes meningitis in neonates and
immunosuppressed patients (including the
elderly)
– Can survive within inactivated macrophages in
patients lacking cell-mediated immunity

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 Gram Negative Cocci
Neisseria meningitidis
• Gram negative diplococci
• Encapsulated: capsule prevents phagocytosis
• Produces endotoxin
– causes blood vessel destruction and hemorrhage
– Hemorrhaging capillaries form petechiae
• Normal flora of the nasopharynx in 5% of people
– Carriers can develop antibodies that prevent them from
getting sick
• Spreads by respiratory secretions
• Can invade the bloodstream from the nasopharynx

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 Neisseria meningitidis
• Meningococcemia
– Intravascular spread results in fever, chills, arthralgias,
myalgias, petechial rash
• Waterhouse-Friderichson Syndrome
– Due to fulminant meningococcemia
– Septic Shock
– Bilateral hemorrhage into the adrenal glands resulting in
adrenal insufficiency
• Meningitis
– Most common form of meningococcal disease
– Infants: Fever, vomiting, irritability, lethargy, bulging
fontanelles

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 Neisseria gonorrhea
• Has Pili
– Pili adhere to host cells and prevent phagocytosis
• Causes Gonorrhea
• In men, it penetrates the mucous membranes
of the urethra causing urethritis
– Painful urination
– Purulent urethral discharge

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 Neisseria gonorrhea
• In women
– Urethritis can occur just like in men
– N. gonorrhea also infects the columnar epithelium
of the cervix (cervicitis)
– Pelvic Inflammatory Disease (PID): Infection of the
uterus, fallopian tubes, and or ovaries
• Fever, lower abdominal pain, abnormal menstrual
bleeding, cervical motion tenderness
• Can result in sterility, ectopic pregnancy, abscesses,
peritonitis

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 Neisseria gonorrhea
In Men and Women
• Bacteremia: rare but very serious when it happens
– Fever, arthralgias, rash
– Pericarditis and Endocarditis can occur
• Septic Arthritis
– Fever
– Pain and Swelling of 1 or 2 joints
In Infants
• Can be spread from a pregnant woman to her child during
delivery
• Ophthalmia neonatorum: conjunctivitis and keratitis can
occur and lead to blindness

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 Moraxhella Catarrhalis
• Gram negative diplococci that is part of the
normal flora of the upper respiratory tract in
most children
• Commonly colonize adults with COPD
• Otitis Media in children
• COPD exacerbations in adults
• Sinusitis
• Bronchitis
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 Enteric Gram Negative Bacilli
Gram negative bacilli that are part of the normal
intestinal flora OR cause gastrointestinal
disease
• Enterobacteriaceae
• Vibrionaceae
• Pseudomonaceae
• Bacteroidaceae

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 Enterobacteriaceae
Escherichia coli
• Normal bowel flora that is naturally found
outside of the bowel
• Causes disease when it acquires virulence
from DNA received from other bacteria
– Pili
– Exotoxins: Heat Labile Toxin; Heat Stable toxin;
Shiga-like toxin
– Endotoxin

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 Escherichia coli
Diarrhea
• May affect infants or adults
• Can cause death due to dehydration
• Children are at increased risk due to lack of
immunity
1. Enterotoxigenic E. Coli (ETEC)
– Has pili
– Heat Labile Toxin (LT) and Heat Stable Toxin (ST)
prevent reabsorption of Na and Cl AND promotes
secretion of Cl and HCO3
– causes diarrhea in travelers (like me)
– No fever or low-grade fever
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 E. Coli
Diarrhea
2. Enterohemorrhagic E. Coli (EHEC)
– Pili Inhibits 60S Ribosome (human
ribosome) in epithelial cells.
– Shiga-like Toxin (STEC) This inhibits protein synthesis
– Hemorrhagic colitis  cell death
– Hemolytic Uremic Syndrome
• Hemolytic Anemia
• Thrombocytopenia
• Renal Failure
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 E. Coli
Diarrhea
• Enteroinvasive E. Coli (EIEC)
– Disease is identical to that caused by Shigella
– Bacteria gains the ability to invade the epithelial
cells
– Host immunity results in a lots of inflammation
and fever
– Bloody diarrhea with lots of WBC

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 E. Coli
Urinary Tract Infections
• Pili allow E. coli to travel up the urethra and infect the
bladder or kidney
• Most common cause of urinary tract infections
Meningitis
• 2nd most common cause of neonatal meningitis (GBS is
#1)
Sepsis
• Most common cause of gram negative sepsis
Pneumonia
• Common cause of hospital acquired pneumonia

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 Enterobacteriaceae
Klebsiella pneumoniae
• Gram negative sepsis (2nd most common cause)
• Urinary Tract Infections
• Pneumonia
– Seen most commonly in hospitalized patients and
alcoholics
– Bloody sputum 50% of the time
– Red sputum
Proteus mirabilis
• Urinary Tract Infections
– Proteus breaks down urea into NH3 and CO2, so urine pH
is high
• Other hospital acquired infections
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 Enterobacteriaceae
Serratia spp
• Urinary tract infections
• Wound infections
• Pneumonia
• Other nosocomial infections
Enterobacter spp
• Normal GI tract flora
• Urinary Tract infections
• Wound infections
• Pneumonia
• Other nosocomial infections
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 Enterobacteriaceae
Shigella spp
• Humans are the only host
• Causes Dysentery
• Mostly seen in children <5 years and the elderly
• Transmitted by the fecal-oral route
– Fecally contaminated water; Hand-Hand contact
• Invade intestinal epithelial cells (like EIEC)
• Produce Shiga Toxin (like EHEC) which causes epithelial
cell destruction by inactivating 60S ribosomal subunit
• Fever, Abdominal Pain, Diarrhea with varying amounts
of blood

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 Enterobacteriaceae
Salmonella enterica
• Motile
• Polysaccharide capsule
• Different from other enterics in that it is normal
flora of animals and infects humans by ingestion
of food or water contaminated with animal feces
• 3 Salmonella enterica subtypes
1. typhi (exception to the above)
2. choleraesuis
3. enteritidis
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 Salmonella enterica var typhi
• Causes Typhoid Fever
• Invades the intestinal epithelial cells (like EIEC
and Shigella) BUT then proceeds to invade
regional lymph nodes and visceral organs
• Can survive inside monocytes after phagocytosis
• High Fever, Headache, abdominal pain,
splenomegaly, +/- diarrhea
• People recovering from Typhoid Fever can
become chronic carriers. They harbor the
bacteria in their gallbladder and constantly
secrete into the stool
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 Salmonella spp
Salmonella enterica var cholerasuis
• Causes sepsis
• Does not involve the GI tract
• Causes septic arthritis and osteomyelitis in
people with sickle cell anemia
Salmonella enterica var enteritidis
• Causes diarrhea
• Most common cause of Salmonella infection
• Nausea, Abdominal pain, Diarrhea (may be
bloody)
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 Yersinia enterocolitica
Also causes acute gastroenteritis
• Invades intestinal epithelial cells  regional
lymph nodes  blood stream (like
Salmonella)
• Secretes an enterotoxin that causes diarrhea
• Can survive and grow in the cold (not killed by
refrigeration)
• Asymptomatic carriage
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 Vibrionaceae
Vibrio cholera
• Curved gram (-) rod with a single polar flagellum
• Causes cholera
• Transmitted by the fecal-oral route. Usually by drinking
contaminated water
• Bacteria multiply in intestines and cause same disease
as ETEC, BUT MUCH MORE SEVERE
– The bacteria attach to the epithelial cell wall and release
the cholera toxin (choleragen)
– Cells are not invaded
– Diarrhea is severe (up to 1L/hour). Death by Dehydration
– Treatment is with fluids/electrolytes, doxycycline

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 Vibrionaceae
Campylobacter jejuni
• VERY COMMON CAUSE OF DIARRHEA
• Zoonotic disease, with reservoirs of C. jejuni in wild and
domestic animals (like Salmonella)
• Transmitted by the fecal-oral route by contaminated
water
• Fever, Headache, Abdominal Cramps, Bloody/Loose
Diarrhea
• Invades the lining of the small intestine and spreads
systemically (like S. typhi and Y. enterocolitica)
• Secretes Heat-Labile Toxin (LT) like E. coli

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 Vibrionaceae
Helicobacter pylori
• Causes gastric and duodenal ulcers
• Very common in developing countries
• Predisposed to gastric cancer
• In Somaliland, have low threshold to treat people
with gastric ulcers with antibiotics
• (PPI, Amoxicillin, Clarithromycin) (Substitute
Metronidazole if penicillin allergy)
• Alternatively, (PPI, bismuth, metronidazole,
tetracycline)

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 Pseudomonadaceae
Pseudomonas aeruginosa
• Obligate aerobic GNR
• It produces a green fluorescent pigment
(fluorescein) which give colonies and wound
dressings a greenish-blue coloration
• Exotoxin A (acts like diphtheria toxin): stops
protein synthesis
• Some strains possess a capsule that is
antiphagocytic and aids in adhesion to target cells

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 Pseudomonas aeroginosa
Pneumonia
– Common in patients with cystic fibrosis
– Hospitalized patients
Osteomyelitis in diabetics
Burns Wound Infections
Sepsis
– Very high mortality
Urinary Tract Infections; Pyelonephritis
– Hospitalized Patients
– Urethral catheters
Malignant Otitis Externa

• Pseudomonas has intrinsic resistance to most antibiotics

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 Bacteroidaceae
Bacteroides fragilis
• One of the few gram negative bacilli that does not
contain lipid A in its outer cell membrane (NO
ENDOTOXIN!)
• Encapsulated
• Normal intestinal flora
• Infections associated with bowel perforation
– Abscesses
– Peritonitis
• Gynecologic Infections
– Tuboovarian abscess with PID
– Septic Abortion
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 Bacteriodaceae
Bacteroides malaninogenicus
• Lives in the mouth, vagina, and intestines
• Aspiration pneumonia
• Periodontal disease
Fusobacterium spp
• Oral flora
• Periodontal disease
• Aspiration pneumonia
• Abdominal and Pelvic Abscesses
• Otitis Media

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GNR Acquired Through Respiratory Tract
Haemophilus influenza
• Polysaccharide capsule confers virulence
– 6 capsule types a, b, c, d, e, f
– Mothers pass antibodies to the capsule to children,
but those antibodies wane after 6 months and
children then become at risk of infection
• Nonencapsulated H. flu can only cause local
infection and cannot cause deep tissue invasion
• Children should be vaccinated starting at 2
months
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 Haemophilus influenza
• Meningitis
– Was #1 cause of meningitis in young children prior to advent
of vaccination
– Inhalation  local lymph nodes  bloodstream  meninges
• Acute Epiglottitis
– Rapid swelling of the epiglottis which obstructs the respiratory
tract and the esophagus
– Sore throat and fever  stridor  unable to swallow
• Septic arthritis
– Most common cause of septic arthritis in infants
• Sepsis: in children and those with nonfunctioning spleens
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GNR Acquired Through Respiratory Tract
Bordetella pertussis
• Causes whooping cough
• Affects unimmunized children from 1-5 years
• Unimmunized children <1 year are still at risk
• 3 stages of illness
1. Catarrhal stage: looks like a URI. Fever, runny nose,
sneezing, mild cough. Lasts 1-2 weeks
2. Paroxysmal stage: Fever subsides. Fits of
nonproductive cough. Lasts up to 1 month
3. Convalescent stage: attacks become less frequent
over 1 month. No longer contagious.

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GNR Acquired Through Respiratory Tract
Legionella pneumophila
• Bacteria is found in natural and man-made water supplies
• Infection comes from inhaling aerosolized contaminated
water
• It is not spread from person to person
• It is rapidly phagocytosed by macrophages, but it survives
intracellularly in the macrophage (like tuberculosis)
Influenza Like Illness
Severe Pneumonia
• One of the most common causes of community acquired
pneumonia
• More common in adults > 50 years old
• Has a beta-lactamase gene that makes it resistant to penicillin
• Very severe, and life-threatening
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