Neisseria and Moraxella Meningitis, septicaemia, gonorrhoea, respiratory infection

1. Neisseria and MoraxellaMeningitis, septicaemia, gonorrhoea, respiratory infection

2. Characteristics of Neisseria and Moraxella • Gram-negative diplococci with adjacent sides flattened • Frequently appear as intracellular gram-negative diplococci within polymorphonuclear neutrophils • Neisseria gonorrhoeae fastidious showing optimal growth on enriched chocolate agar

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5. Characteristics of Neisseria and Moraxella • Growth of Neisseriameningitidis and Moraxellacatarrhalis occurs on both sheep blood and chocolate agar • Neisseriagonorrhoeae, N. meningitidis, and Moraxellacatarrhaliscapnophilic (optimal growth with 3-7% CO2) • Neisseriameningitidis and N. gonorrhoeae closely related genetically and distantly to saprophytic species of Neisseria

6. Characteristics of Neisseria and Moraxella • Neisseria meningitidis encapsulated (capsule the major virulence factor) • Thirteen capsular polysaccharide serogroups • Invasive infection caused by organisms with one of five capsular serogroups (A, B, C, Y, and W135) with 90% of meningococcal disease due to serogroups A, B, and C

7. Characteristics of Neisseria and Moraxella • Moraxella rather than Branhamella accepted taxonomically as the genus designation for M. catarrhalis (family Moraxellaceae) • Even though M. catarrhalis not a member of the family Neisseriaceae, morphologic and biochemical similarity to Neisseria allows clinical laboratory identification of M. catarrhalis with Neisseria species

8. Pathogenic Species • Neisseria gonorrhoeae • Neisseria meningitidis • Moraxella catarrhalis

9. Saprophytic Species Neisseria lactamica, N. polysaccharea, N. cinera, N. flavescens, N. subflava, N. sicca,and N. mucosa

10. Virulence factors • N. gonorrhoeae - ↑infectivity ↓severity (fortunately) • Capsule (???): attachment & anti-phagocytosis • Fimbriae/pili: specific attachment to urogenital columnar epithelial cells • Lipopolysaccharide (endotoxin) = tumor necrosis factor • Cell wall proteins I, II, and III (interfere with phagocytosis) • IgA protease (cleaves IgA on mucosal surfaces) • N. meningitidis • Capsule • Lipopolysaccharide (endotoxin)

11. Neisseria: Natural Habitats • Neisseria gonorrhoeae an obligate pathogen with invasive infection of anogenital, oropharyngeal, and conjunctival mucous membranes • Neisseria meningitidis normally colonizes oropharyneal and nasopharyngeal mucous membranes of humans (carrier rate of 8-20%)

12. Neisseria: Natural Habitats • Neisseria meningitidis can colonize anogenital mucous membranes of homosexual men • Saprophytic species are non-pathogenic (non-invasive) and normally colonize the oropharyngeal and nasopharyngeal mucous membranes of humans

13. Moraxellacatarrhalis: Natural Habitats Present in the upper respiratory tract of 1.5-5.4% of healthy individuals, more commonly in children (50.8%) and elderly adults (26.5%)

14. Neisseriagonorrhoeae: Modes of Infection • Neisseria gonorrhoeae spread by sexual contact, including genital, anogenital, and orogenital. Spread from infected mother to neonate as ocular infection during birth. Non-sexual transmission not documented.

15. Neisseriameningitidis: Modes of Infection • Neisseria meningitidis transmitted by inhalation of infectious air-born respiratory droplets or direct contact with infectious respiratory secretions.

16. Neisseria: Modes of Infection • Neisseria meningitidis can be transmitted by sexual contact, especially orogenital or anogenital intercourse. • Person-to-person transmission does not occur with saprophytic Neisseria species and infection (rare) is endogenous.

17. Moraxella catarrhalis: Modes of Infection Oropharyngeal endogenous strains spread into normally sterile regions of the tracheobronchial tree, the middle ear, and sinuses

18. Neisseria: Types of Infectious Disease • N. gonorrhoeae second most common cause (after Chlamydia trachomatis) of sexually-transmitted lower genital tract disease (acute urethritis in men, endocervicitis in women) • N. gonorrhoeae untreated can progress to epididymitis, prostatitis, urethral stricture, salpingitis, tubo-ovarian abscess, and pelvic inflammatory disease

19. Neisseria: Types of Infectious Disease • N. gonorrhoeae causes oral and anorectal infections as a result of oral or anal intercourse • N. gonorrhoeae disseminates with bacteremia and/or septic arthritis if untreated • Disseminated infection (bacteremia, pyogenic arthritis) by N. meningitidis and N.gonorrhoeae associated with deficiency in the terminal components of complement (C5-C8)

20. Preventative measures aren't taken gonococcal ophthalmia neonatorum affects the corneal epithelium causing microbial keratitis, ulceration and perforation

21. The bacteria are carried in semen and vaginal fluids and cause a discharge in men and women. in women - Bleeding during vaginal intercourse, Painful or burning sensations when urinating, Yellow or bloody vaginal discharge in Men - White, yellow, or green pus from the penis with pain, Burning sensations during urination that may be severe, Swollen or painful testicles Symptoms of rectal infection include discharge, anal itching, and occasional painful bowel movements with fresh blood in the feces. Symptoms typically appear 2 to 5 days after infection but could appear as long as 30 days.

22. Neisseria: Types of Infectious Disease • N. meningitidiscauses a rapidly progressive meningitis in school-aged children, adolescents, and young adults with a mortality of 7-13% • N. meningitidisbacteremia (mortality of 19-70%) a cause of Waterhouse-Friderichsen syndrome with petechiae, purpura, adrenal hemorrhage, disseminated intravascular coagulation (DIC), and shock

23. Neisseria: Types of Infectious Disease Neisseria meningitidis associated with sexual transmission and gonococcal-like urethritis, cervicitis, salpingitis, and proctitis

24. Moraxella catarrhalis: Types of Infectious Disease • Acute purulent exacerbation of chronic bronchitis • Causes 10-15% of episodes of otitis media and sinusitis • Rarely associated with systemic infection (endocarditis, meningitits)

25. Neisseria gonorrhoeae and Neisseria meningitidis: Isolation • Isolation often attempted from specimens with abundant normal flora (genital, oral, anorectal) (especially N. gonorrhoeae) • Modified Thayer-Martin (MTM) agar an enriched and selective medium for pathogenic N. gonorrhoeae and N. meningitidis • Nutritive base of MTM is chocolate agar • Antibiotics present in MTM selective for the growth of N. gonorrhoeae and N. meningitidis

26. Modified Thayer-Martin Agar • Colistin: Inhibits gram-negative flora (N. gonorrhoeae and N. meningitidis resistant to colistin, most saprophyic species of Neisseria susceptible) • Vancomycin: Inhibits gram-positive flora • Nystatin: Inhibits yeast flora • Trimethoprim: Inhibits swarming Proteus

27. Neisseria gonorrhoeae: Identification • Off-white colonies on chocolate agar with no discoloration of agar • Acid from glucose but not maltose, sucrose, fructose, or lactose • Positive superoxol test (Catalase with 30% H2O2) • Colistin resistance (growth on Modified Thayer-Martin medium)

28. N. gonorrhoeae

29. Neisseria meningitidis: Identification • Gray colonies on chocolate agar with green haze in agar immediately under and adjacent to colonies • Acid from glucose and maltose but not sucrose, fructose, or lactose • Colistin resistance (growth on modified Thayer-Martin medium)

30. N. meningitidis

31. Moraxella catarrhalis: Identification • Pink coloration of colonies on chocolate agar not apparent on blood agar • No acid from glucose, maltose, sucrose, fructose, or lactose (asaccharolytic) • Produces DNase • Possesses the enzyme butyrate esterase

32. M. catarrhalis

33. Selected Biochemical Reactions for Identification of Neisseria and Moraxella catarrhalis1 Glu Mal Lac Suc DNa BE N. gon + – – – – – N. men + + – – – – N. lac2 + + + – – – M. cat – – – – + + 1Glu=glucose, Mal=maltose, Lac=lactose, Suc=sucrose, DNa=DNase, BE=butyrate esterase (indoxyl butyrate substrate), N.gon=N. gonorrhoeae, N. men=N. meningitidis, N. lac=N. lactamica, M. cat=Moraxellacatarrhalis 2Colistin-resistant saprophytic species of Neisseria

34. Laboratory Detection and Identification of Neisseria gonorrhoeae • Direct PCR detection for urogenital specimens with culture confirmation when PCR positive • Culture isolation and biochemical identification for urogential specimens with gonorrhea refractory to treatment or sexual abuse, and non-urogenital specimens • Molecular strain typing for isolates of N. gonorrhoeae in sexual abuse cases

35. Antimicrobial Therapy • Was generally susceptible to penicillin in the US until 1976 when a pen-resistant strain was imported from Southeast Asia. This strain proliferated and spread within a few years. These strains are now detected using the cephalosporin (Cefinase) test • These strains are referred to as CMRNG (chromosome mediated resistant N.gonorrhoeae). Tetracycline and Spectinomycin chromosomal mediated resistance strains also occur. • Ceftriaxone, a third generation cephalosporin, is recommended • Penicillin is still the drug of choice for treatment of infections caused by N. meningitidis • Most M. catarrhalis strains produce beta lactamase, and are therefore pen-resistant.

36. Showing positive (left disk) and negative (right disk) reactions for Nitrocef Disks which include nitrocefin, a chromogenic cephalosporin