1. Clinical and lab aspect of anaerobic infection Ali Somily MD, FRCPC,ABMM

3. Classification 1. Anaerobic spore forming bacilli (Clostridia) 2. Gram negative bacilli non-sporing (Bacteroides) 3. Anaerobic streptococci (Peptostreptococcus) 4. Anaerobic staphylococcus (Peptococcus) 5. Gram negative diplococci (Veillonella) 6. Gram positive bacilli (Actinomyces)

4. Propionibacterium

5. Bacteroides fragilis

6. Fusobacterium nucleatum

7. Antimicrobiolial Sensitivity All of them resistant to aminoglycosides All of them resistant to aminoglycosides – Gentamicine – Tobramycin – Amikacin Almost all are sensitive to metranidazole (flagyl) Almost all are sensitive to metranidazole (flagyl)

8. Anaerobiosis Lack cytochrome-cannot use oxygen as hydrogen acceptor Lack cytochrome-cannot use oxygen as hydrogen acceptor Most Lack Most Lack – Catalase – Peroxidase Contain flavoprotein so in the presence of oxygen produce H2O2 which is toxic Contain flavoprotein so in the presence of oxygen produce H2O2 which is toxic Some lack enzyme superoxide dismutase so many killed, peroxide and toxic radicales enzyme like fumarate reductase must be reduced form to work Some lack enzyme superoxide dismutase so many killed, peroxide and toxic radicales enzyme like fumarate reductase must be reduced form to work

9. Anaerobic chamber

10. NONSPORING ANAEROBES

11. HABITAT I : These organism are normal flora in: These organism are normal flora in: A.Oropharynx A.Oropharynx eg. 1. Bacteroides melaninogenicus eg. 1. Bacteroides melaninogenicus  Now called provetella melaninogenicus – 2. Fusobacteria – 3. Veillonella

12. HABITAT II: B.Gastrointestinal tract B.Gastrointestinal tract – Found mainly in the large colon in large numbers – Total number of anaerobes = 10 11 – While all aerobes (including E. coli) = 10 4 – examples are  (1) B acteroides fragilis  (2) Bifidobacterium species C.Female genital tract (mainly in the vagina) C.Female genital tract (mainly in the vagina)

13. CLINICAL ASPECTS ANAEROBES ARE INDIGENOUS FLORA OF SKIN & MUCOUS MEMBRANES NORMALLY CONTAINED AWAY FROM INTERNAL STERILE BODY SITES HIGH MORBIDITY & MORTALITY

14. INFECTIONS CAUSED BY,NONSPORING ANAEROBES A.The head, neck and respiratory tract A.The head, neck and respiratory tract B. The lower abdomen and the pelvis B. The lower abdomen and the pelvis

15. FEATURES OF ANAEROBIC INFECTIONS Characterized by foul smell Characterized by foul smell Gas formation Gas formation Infections are always near to the site of the body which are habitat. Infections are always near to the site of the body which are habitat. Deep abscesses Deep abscesses The infections are also polymicrobial The infections are also polymicrobial Failure to grow organism from pus if not culture anaerobically. Failure to grow organism from pus if not culture anaerobically. Failure to respond to usual antibiotics. Failure to respond to usual antibiotics. Infection from animal bites. Infection from animal bites. Detection of "Sulphur granules"' due to actinomycosis Detection of "Sulphur granules"' due to actinomycosis

17. INFECTIONS BEGIN DISRUPTION OF BARRIERS – – TRAUMA – – OPERATIONS – – CANCEROUS INVASION OF TISSUES DISRUPTION OF BLOOD SUPPLY – – DROPS OXYGEN CONTENT OF TISSUE – – DECREASE IN Eh POTENTIAL – – TISSUE NECROSIS

18. WHAT ARE THE INFECTION CAUSED BY THESE ANAEROBIC ORGANISMS I 1. Post operative wound infection 2. Brain abscess 3. Dental abscesses 4. Lung abscess 5. Intra abdominal abscess, appendicitis, diverculitis 6. All these infection can cause bacteriaemia

19. WHAT ARE THE INFECTION CAUSED BY THESE ANAEROBIC ORGANISMS II 1. Infection of the female genital tract 2. Septic abortion 3. Puerperal infection or sepsis 4. Endometritis 5. Pelvic abscess 6. 12. Other infections – a) Breast abscess in puerperal sepsis – b) Infection of diabetic patients (diabetic foot infections). – c) Infection of pilonidal sinus

20. LABORATORY DIAGNOSIS: When anaerobic infection is suspected; When anaerobic infection is suspected; – a) Specimens have to be collected from the site containing necrotic tissue. – b) Pus is better than swabs. – c) Specimens has to be send to the laboratory within 1/2 hour why? – d) Fluid media like cooked meat broth are the best culture media. – e) Specimens have to incubated anaerobically for 48 hours.

21. TREATMENT: Bacteroides fragilis is always resistant to penicillin. Bacteroides fragilis is always resistant to penicillin. But penicillin can he used for other anaerobes But penicillin can he used for other anaerobes Flagyl (metronidazole) is the drug of choice. Flagyl (metronidazole) is the drug of choice. Clindamycin can also be used. Clindamycin can also be used.

22. ORAL & DENTAL > 400 SPECIES OF ANO2 IN MOUTH MOST INFECTIONS = POLYMICROBIC – – MIXED ORGANISMS – – ENTER AS A GROUP ANO2 NOT INITIAL INVADER – – USUALLY SECONDARY – – 1 ST ORGANISM DECREASES [O2] & Eh

23. ORAL & DENTAL COMMONLY ASSOCIATED WITH 1. 1.DENTAL ABSCESSES 2. 2.ROOT CANALS 3. 3.JUVENILE PERIODONTITIS 4. 4.ADULT PERIODONTITIS 5. 5.CLENCHED FIST INJURIES

24. ENT – HEAD & NECK 1. 1. CHRONIC OTITIS MEDIA 2. 2. CO-PATHOGENS WITH CHRONIC STREP TONSILLITIS 3. 3. ACUTE SINUSITIS – – POST-DENTAL EXTRACTIONS OR TRAUMA – – 2 o INVADER

25. ENT – HEAD & NECK VINCENT’S ANGINA – – COMBINATION OF FUSOBACTERIUM & SPIROCHETE SPECIES OVERGROWTH – – ANAEROBIC PHARYNGITIS – – GRAY MEMBRANE – – FOUL ODOR

26. Vincent’s disease Trench mouth Trench mouth Sudden onset of pain in the gingiva (mastication) Sudden onset of pain in the gingiva (mastication) Necrosis of the gingiva Necrosis of the gingiva – interdental papilla – a marginated, punched-out, and eroded appearance A superficial grayish pseudomembrane A superficial grayish pseudomembrane altered taste sensation is present altered taste sensation is present Fever, malaise, and regional lymphadenopathy Fever, malaise, and regional lymphadenopathy

27. Ludwig’s Angina

28. Lemierre Syndrome

29. Expansion of the retropharyngeal soft tissues

30. PLELRO PULMONARY I FECTION ASPIRATION LUNG ABSCESS ASPIRATION LUNG ABSCESS ASPIRATION PNEUMONIA ASPIRATION PNEUMONIA M ETASTATIC LUNG ABSCESS M ETASTATIC LUNG ABSCESS BRONCHIACTSIS BRONCHIACTSIS ALL OF ABOVE CAN CAUSE EMPYEMA ALL OF ABOVE CAN CAUSE EMPYEMA

31. LUNG & PLEURAL 1. 1. ASPIRATION PNEUMONIA 2. 2. EMPHYSEMA 3. 3. LUNG ABSCESSES 4. 4. MALIGNANCIES 5. 5. LEUKOPENIA

32. THORACIC ACTINOMYCOSIS

34. ACTINOMYCOSIS

35. Molar tooth appearance of Actinomyces israeIii

36. Macroscopic colony (left) Gram stain (right) of Actinomyces

37. SKIN & SOFT TISSUE TRAUMATIZED & DEVITALIZED TISSUE 1. 1.TRAUMATIC WOUNDS 2. 2.HUMAN/ANIMAL BITES 3. 3.ISCHEMIA OF EXTREMITIES DIABETES ATHEROSCLEROSIS

38. CLENCHED FIST INJURIES

39. DIABETIC FOOT

40. HUMAN BITE

41. NECROTIZING CELLULITIS

42. FEMALE UROGENITAL CHORIOAMNIOTIC INFECTIONS ENDOMETRITIS PID – ABDOMINAL INFECTIONS BACTERIAL VAGINOSIS WITH GARDNERELLA & BACTEROIDES SP.

43. PUERPERAL INFECTION SEPTIC ABORTION PUERPERAL ABSCESS PUERPERAL ABSCESS SEPTIC ABORTION SEPTIC ABORTION BACTERAEMIA BACTERAEMIA PELVIC ABSCESS PELVIC ABSCESS ADENXAL ABSCESS ADENXAL ABSCESS PERITONITIS PERITONITIS ENDOMETRITIS ENDOMETRITIS

44. ABDOMINAL INFECTIONS MANIPULATION, INVASION OR TRAUMA TO GI TRACT 1. 1.TRAUMA 2. 2.SURGERY 3. 3.APPENDICITIS 4. 4.MALIGNANCIES COLON CANCER

45. CNS 1. 1. HEAD TRAUMA 2. 2. HEMATOGENOUS SPREAD – – FROM ANY INFECTED BODY SITE 3. 3. GEOGRAPHIC SPREAD – – SINUS INFECTIONS – – DENTAL ABSCESSES

46. BONE & JOINT HEMATOGENOUS SPREAD TRAUMA PERIVASCULAR DISEASE JUVENILE PERIODONTITIS

47. OTHER INFECTIONS GRAM NEGATIVE BACTREMIA GRAM NEGATIVE BACTREMIA BREAST ABSCESS BREAST ABSCESS AXILLARY ABSCESS AXILLARY ABSCESS INFECTION OF DIABETIS EG.DIABETIC ULCERS INFECTION OF DIABETIS EG.DIABETIC ULCERS INFECTION OF PILONIDAL SINUS INFECTION OF PILONIDAL SINUS PARONYCHIA PARONYCHIA

48. CLASSIFICATION 1. Anaerobic spore forming bacilli (Clostridia) 2. Gram negative bacilli nonsporing (Bacteroides) 3. Anaerobic streptococci (Peptostreptococcus) 4. Anaerobic staphylococcus (Peptococcus) 5. Gram negative diplococci (Veillonella) 6. Gram positive bacilli (Actinomyces)

49. ORGANISM GROUPS GRAM NEGATIVE RODS – – BACTEROIDES – – PREVOTELLA – – PORPHYROMONAS – – FUSOBACTERIUM – – BUTYRIVIBRIO – – SUCCINOMONAS

50. Bacteroides fragilis

51. BACTEROIDES STRICT ANAEROBE STRICT ANAEROBE PLEOMORPHIC PLEOMORPHIC GRAM NEGATIVE BACILLI (COCCO BACILLI) GRAM NEGATIVE BACILLI (COCCO BACILLI) NORMAL FLORA IN NORMAL FLORA IN – OROPHARYNX – GASTROINTESTINAL TRACT – VAGINA

52. BACTEROIDES FRAGILIS GP GROUP = B. FRAGILIS, B. VULGARIS, B.THETAIOTAMICRON, B. UNIFORMIS – – ACCOUNT FOR 1/3 OF ALL ISOLATES – – RESISTANT TO 20% BILE – – RESISTANT TO MANY ANTIBIOTICS PENICILLIN, KANAMYCIN, VANCOMYCIN, COLISTIN – AND MANY MORE

53. BACTEROIDES FRAGILIS GP GLC = MAJOR ACETIC & SUCCINIC, LACTIC & PROPIONIC ACIDS NO PIGMENTATION OF COLONIES OR FLUORESCENCE

54. BACTEROIDES OTHER SP BACTEROIDES SPECIES OTHER, NOT B. FRAGILIS GROUP – – GLC = MAJOR ACETIC & SUCCINIC ONLY – – BILE SENSITIVE – – RESISTANT TO KANAMYCIN ONLY – – SOME PIGMENTED

55. BACTEROIDES B. FRAGILIS IN THE GUT AND VAGINA B. FRAGILIS IN THE GUT AND VAGINA B.MELANINOGESUS AND B.ORALIS IN THE MOUTH AND OROPHARYNX B.MELANINOGESUS AND B.ORALIS IN THE MOUTH AND OROPHARYNX B. FRAGILIS PENICILLIN RESISTANT, B. FRAGILIS PENICILLIN RESISTANT, OTHER ARE SENSITIVE, OTHER ARE SENSITIVE, IT IS THE COMMONEST ORGANISM IN THE GUT 10 12 ORGANISM /GRAM OF FAECES IT IS THE COMMONEST ORGANISM IN THE GUT 10 12 ORGANISM /GRAM OF FAECES

56. Bacteroides and other anaerobic bacilli

57. BACTEROIDES AND FUSOBCTERIUM B.FRAG B.NECROPH ORUS B.MELANINO GENICUS B.CORRODE NS FUSOBACTE RIUM BLACKPIG.--+-- PITTING---+- INDOLE+--+-- LYSINE++ BILE GROWTH +

58. Growth of Bacteroides fragilis on Bacteroides bile-esculin agar

59. Bacteroides fragilis Special-potency kanamycin, vancomycin, and colistin antimicrobial agent disks to first quadrant of this plate. Special-potency kanamycin, vancomycin, and colistin antimicrobial agent disks to first quadrant of this plate.

60. PORPHYROMONAS GLC = ACETIC, SUCCINIC PLUS PROPIONIC, BUTYRIC, ISOBUTYRIC,& ISOVALERIC BILE SENSITIVE USUALLY BLACK PIGMENTED COLONIES – – P. GINGIVALIS, P. ENDODONTITIS & P.ASACCHAROLYTICA

61. PREVOTELLA GLC = ACETIC, SUCCINIC, ISOVALERIC, NO BUTYRIC BILE SENSITIVE BLACK PIGMENT & FLUORESCENCE – – Pr. INTERMEDIA – LIPASE + – – Pr. MELANINOGENICA – BRICK RED FLUORESCENCE

62. FUSOBACTERIUM GLC = ACETIC, PROPIONIC, &BUTYRIC, NO SUCCINIC ANTIBIOTICS – – SENSITIVE TO KANAMYCIN – – RESISTANT TO VANCOMYCIN – – COLISTIN VARIABLE

63. Fusobacterium nucleatum

64. FUSOBACTERIUM F. NUCLEATUM = LIPASE Ø F. NECROPHORUM = LIPASE + F. NUCLEATUM >> F. NECROPHORUM ISOLATES COMMON IN ASPIRATION PNEUMONIAS

65. MISCELLANEOUS GNB BUTYRIVIBRIO – – CURVED GNB – – GLC = MAJOR BUTYRIC SUCCINOMONAS – – CURVED GNB – – GLC = ACETIC & SUCCINIC

66. PEPTOCOCCUS NIGER GRAM POSITIVE COCCI GLC = ACETIC, BUTYRIC, ISOBUTYRIC, ISOVALERIC, CAPROIC BLACK PIGMENT

67. PEPTOSTREPTOCOCCUS GRAM POSITIVE COCCI GLC = ACETIC, SOME BUTYRIC Ps. ASACCHAROLYTICUS INDOLE + Ps. ANAEROBIUS, Ps. MAGNUS, Ps.PREVOTI, Ps. INDOLECUS

68. STREP & STAPH ANAEROBIC SPECIES OF STAPH AND STREP STREPTOCOCCUS INTERMEDIUS STAPHYLOCOCCUS SACCHAROLYTICUS

69. VEILLONELLA PARVULA GRAM NEGATIVE COCCI GLC = ACETIC & PROPIONIC NITRATE + HEAD AND NECK INFECTIONS DENTAL ABSCESSES

70. CLOSTRIDIUM SPECIES LARGE GRAM POSITIVE RODS SPORE FORMATION SPECIFIC DISEASES – – PSEUDOMEMBRANOUS COLITIS – – TETANUS – – BOTULISM – – GANGRENE - MYONECROSIS

71. C. difficile

72. CLOSTRIDIA

73. CLOSTRIDIA Causative Agents For Causative Agents For – 1.Gas gangrene : Cl. perfringens and other e.g septicum – 2.Tetanus : Cl. tetani – 3.Botulism : Cl. botulinum – 4.Toxic enterocolitis : Cl. difficile (Pseudomembernous colitis)

74. Clostridium perfringens (CI. welchii) Morphology large rods gram +ve Morphology large rods gram +ve With bulging endospores With bulging endospores Not motile Not motile Capsulated Capsulated

75. Clostridium perfringens

76. C. perfringens

78. Culture: A)Blood agar with haemolytic colonies (double zone of haemolysis A)Blood agar with haemolytic colonies (double zone of haemolysis B)Cooked meat medium B)Cooked meat medium Gives the NAGLAR'S Reaction & toxin neutralization on Egg yolk medium & toxin is a phospholipase Gives the NAGLAR'S Reaction & toxin neutralization on Egg yolk medium & toxin is a phospholipase

79. C. perfringens

80. NAGLAR'S Reaction

81. Lipase and/or lecithinase (EYA),

82. Diseases Caused by C. perfringens 1) Wound Contamination 1) Wound Contamination 2) Wound infection 2) Wound infection 3) Gas Gangrene - most important disease 3) Gas Gangrene - most important disease 4) Gas Gangrene of the uterus in criminal abortion 4) Gas Gangrene of the uterus in criminal abortion 5) Food Poisoning 5) Food Poisoning Spores are swallowed Germinate in gut after 18 hours Spores are swallowed Germinate in gut after 18 hours Toxin Toxin abdominal pain and diarrhoea abdominal pain and diarrhoea

83. GAS GANGRENE Causes mainly Causes mainly – (Cl perfringens) (Cl. welchil) – CI. novyl, – CI. Septicum – CI oedemaritians Pathogenesis: Pathogenesis: – Traumatic open wounds – Compound fractures – Muscle damages – Contamination with dirt etc, Mainly in war wounds, Mainly in war wounds, Old age, Old age, – Low blood supply Amputation of thigh Amputation of thigh – Prophylaxis with penicillin

84. NECROTIZING FASCIATITIS

86. MYOSITIS

87. Gram Stain of vaginal aspirate 1.Clostridiae necrotizing (myonecrosis)

88. Prevention and Treatment Remove dead tissue Remove dead tissue Remove debris Remove debris Foreign bodies Foreign bodies Penicillin Penicillin Hyperbaric oxygen Hyperbaric oxygen

89. TETANUS

90. Cl.tetani Causative organism Cl.tetani Causative organism Cl.tetani Morphology gram +ve anaerobic with terminal spore Drum Stick appearance Morphology gram +ve anaerobic with terminal spore Drum Stick appearance Lives in soil and animal feaces. e,g horse Lives in soil and animal feaces. e,g horse Any wound can infected if contaminated by spores Any wound can infected if contaminated by spores Face & neck wounds are more dangerous why ? Face & neck wounds are more dangerous why ?

91. C. tetani

92. Clinical Features Incubation period 1-2 weeks Incubation period 1-2 weeks Symptoms: Painful muscle spasm around infected wound Symptoms: Painful muscle spasm around infected wound Contraction of muscles Contraction of muscles of face= – Trismus ( Lockjaw) – Risus Sardonicus strychnine Back Back – Araching of Back

93. Opisthotonus opistho meaning "behind" and tonos meaning "tension", opistho meaning "behind" and tonos meaning "tension", Extrapyramidal effect and is caused by spasm of the axial along the spinal column. Extrapyramidal effect and is caused by spasm of the axial along the spinal column. Caused by Caused by – Tetanus. – Cerebral palsy – Traumatic brain injury

94. Pathogenesis 1 )Tetanospasmin most important powerful exotoxin 1 )Tetanospasmin most important powerful exotoxin 2)Totanolysin 2)Totanolysin No invasion or Bacteraernia No invasion or Bacteraernia Toxin  is a protein Toxin  is a protein It inhibits transmission of normal inhibitory messages from central nervous system at anterior horn cells of cord It inhibits transmission of normal inhibitory messages from central nervous system at anterior horn cells of cord

95. Pathogenesis

96. Diagnosis Mainly by clinical Mainly by clinical Laboratory not important Laboratory not important Lab Lab – Organism strict anaerobe – Very motile, spread on agar.

97. C. tetani

98. Prevention Toxoid vaccine: Toxoid vaccine: Vaccination D P T Vaccination D P T 2, 4, 6, 18 months &5 Year 2, 4, 6, 18 months &5 Year Booster every 10 years Booster every 10 years

99. Treatment. Cleaning of wound Cleaning of wound Removal of Foreign body Removal of Foreign body Specific by antitoxin Specific by antitoxin – Horse serum can caused anaphylaxis & shock must be tested first – Human immunoglobulin – Antibiotics. Penicillin Supportive treatment Supportive treatment – 2. Dark pace, fluids – 3. Sedative valium

100. CLOSTRIDIUM BOTULINUIM

101. Habitat Soil,Ponds AND Lakes Soil,Ponds AND Lakes

102. Toxin Exotoxin Exotoxin Protein Protein Heat labile at 100 O C Heat labile at 100 O C – The most powerful toxin known Lethal dose 1 µg human 3 kg kill all population of the world 3 kg kill all population of the world Dictated for by lysogenic phage Dictated for by lysogenic phage Resist gastrointestinal enzymes Resist gastrointestinal enzymes

103. Botulism From canned food., sea food e_g. salmon From canned food., sea food e_g. salmon Not well cooked Not well cooked Spores resist heat at 100 o C Spores resist heat at 100 o C  then multiply and produce toxin  then multiply and produce toxin

104. ENFANTILE BOTULISM Ingestion of Spores  germination in the gut  Botulism Ingestion of Spores  germination in the gut  Botulism Week child Week child Cranial nerve Cranial nerve Constipation Constipation Other Other

105. Botulism Pathogenesis Ingested - incubation period 12-36 hour Ingested - incubation period 12-36 hour 7 Types 7 Types Mainly types A, B, E, F Mainly types A, B, E, F Attacks neuromuscular junctions Attacks neuromuscular junctions Prevents release of acetylcholine Prevents release of acetylcholine

106. Symptoms Funny eye movement as if cranial nerve affected when bulbar area of the brain affected Funny eye movement as if cranial nerve affected when bulbar area of the brain affected Respiratory and circulatory collapse Respiratory and circulatory collapse

107. SPECIMENS Suspected food Suspected food From the patient From the patient – Faeces growth – Serum Toxin detection by mouse Toxin detection by mouse – incubation paralysis and death

108. INFANTILE BOTULISM Week lethargic child Week lethargic child Constipation Constipation Respiratory and cardiac arrest Respiratory and cardiac arrest Due to colonization of intestine by CI. botulinum Due to colonization of intestine by CI. botulinum Diagnosis by -Culture of stools Diagnosis by -Culture of stools Detection of toxin in feaces Detection of toxin in feaces

109. Treatment Treatment 1) Supportive 1) Supportive 2) Horse antitoxin 2) Horse antitoxin Prevention Prevention 1)Adequate pressure cooking autoclaving 1)Adequate pressure cooking autoclaving 2)Heating of food for 10 minutes at 100 O C 2)Heating of food for 10 minutes at 100 O C

110. Botox

111. C. DIFFICILE PSEUDOMEMBRANOUS COLITIS – – 90% OF CASES CAUSED BY C. DIFF – – LONG TERM TREATMENT WITH BROAD SPECTRUM ANTIBIOTICS OR CHEMO NOSOCOMIAL DISEASE KNOCK DOWN NORMAL FLORA CLINDAMYCIN, AMPICILLIN, CEPHALOSPORINS CHEMOTHERAPEUTIC AGENTS

112. C. DIFFICILE OVERGROWTH OF C. DIFFICILE – – TOXIN THEN PRODUCED A -FRAGMENT = ENTEROTOXIN B -FRAGMENT = CYTOLYTIC TOXIN PSEUDOMEMBRANE SIMILAR TO THAT OF C. DIPHTHERIAE – – BACTERIA, FIBRIN, WBC, DEAD – – TISSUE CELLS - TOUGH

113. C. DIFFICILE DIARRHEA FIRST – – ELECTROLYTE & FLUID LOSS – – LEADS TO DEHYDRATION INTESTINAL BLOCKAGE – – CONTENTS BLOCKED – – COLON BULGES PERFORATION, RUPTURE  SEPSIS

114. Clinical pictures

115. C. DIFFICILE RAPID AGGRESSIVE COURSE IN YOUNG CHILDREN DIFFICULT TO SELECTIVELY CULTURE – – 5-10% CULTURE + EVEN WITH CONFIRMED DISEASE – – TOO MANY NORMAL ANO2 PRESENT

116. C. DIFFICILE SPECIALIZED ISOLATION MEDIA – – CCFA – CYCLOSERINE, CEFOXITIN,FRUCTOSE, EGG YOLK AGAR – – CCMA – CCFA BUT MANNITOL FOR FRUCTOSE – – CDMN – CYSTEINE HYDROCHLORIDE, MOXALACTAM, NORFLOXACIN AGAR

117. C. difficile

119. C. DIFFICILE C. DIFFICILE IS NORMAL FLORA – – ISOLATION NOT ENOUGH NEED TOXIN ASSAY TO CONFIRM CELL-FREE STOOL EXTRACT – – LATEX AGGLUTINATION SCREEN SOME CROSS-REACTIVITY – – EIA TO CONFIRM

120. Major Clostridial Diseases