Clinical and lab aspect of anaerobic infection

ALI SOMILY MD

Classification

1.

2.

3.

4.

5.

6.

Anaerobic spore forming bacilli (Clostridia) Gram negative bacilli non-sporing (Bacteroides) Anaerobic streptococci (

Peptostreptococcus

) Anaerobic staphylococcus (Peptococcus) Gram negative diplococci (Veillonella) Gram positive bacilli (Actinomyces)

Propionibacterium

Bacteroides fragilis

Fusobacterium nucleatum

Antimicrobiolial Sensitivity

• • All of them resistant to aminoglycosides – – – Gentamicine Tobramycin Amikacin Almost all are sensitive to metranidazole (flagyl)

Anaerobiosis

• • • • Lack

cytochrome

-cannot use oxygen as hydrogen acceptor Most Lack – Catalase – Peroxidase 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

Anaerobic chamber

NONSPORING ANAEROBES

HABITAT I :

• •

These organism are normal flora in: A. Oropharynx

•

eg. 1. Bacteroides melaninogenicus



Now called provetella melaninogenicus

–

2. Fusobacteria

–

3. Veillonella

HABITAT II

:

•

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)

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

FEATURES OF ANAEROBIC INFECTIONS

• • • • • • • • •

Characterized by foul smell Gas formation Infections are always near to the site of the body which are habitat.

Deep abscesses The infections are also polymicrobial Failure to grow organism from pus if not culture anaerobically.

Failure to respond to usual antibiotics.

Infection from animal bites.

Detection of "Sulphur granules"' due to actinomycosis

INFECTIONS CAUSED BY ,NONSPORING ANAEROBES

• •

A. The head, neck and respiratory tract B. The lower abdomen and the pelvis

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

WHAT ARE THE INFECTION CAUSED BY THESE ANAEROBIC ORGANISMS I

1.

2.

3.

4.

5.

6.

Post operative wound infection Brain abscess Dental abscesses Lung abscess Intra abdominal abscess, appendicitis, diverculitis All these infection can cause bacteriaemia

WHAT ARE THE INFECTION CAUSED BY THESE ANAEROBIC ORGANISMS II

1.

2.

3.

4.

5.

6.

Infection of the female genital tract Septic abortion Puerperal infection or sepsis Endometritis Pelvic abscess

– – –

12. Other infections a) Breast abscess in puerperal sepsis b) Infection of diabetic patients (diabetic foot infections).

c) Infection of pilonidal sinus

LABORATORY DIAGNOSIS:

•

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.

TREATMENT:

•

Bacteroides fragilis is always resistant to penicillin.

•

But penicillin can he used for other anaerobes

• •

Flagyl (metronidazole) is the drug of choice. Clindamycin can also be used.

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

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

ENT – HEAD & NECK 1.

2.

CHRONIC OTITIS MEDIA CO-PATHOGENS WITH CHRONIC STREP TONSILLITIS 3.

– ACUTE SINUSITIS POST-DENTAL EXTRACTIONS OR TRAUMA – 2 o INVADER

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

Vincent’s disease

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

Ludwig’s Angina

Lemierre Syndrome

Expansion of the retropharyngeal soft tissues

PLELRO PULMONARY I FECTION • • • • • • ASPIRATION PNEUMONIA ASPIRATION LUNG ABSCESS M ETASTATIC LUNG ABSCESS BRONCHIACTSIS ALL OF ABOVE CAN CAUSE EMPYEMA MALIGNANCIES LEUKOPENIA

THORACIC ACTINOMYCOSIS

THORACIC ACTINOMYCOSIS

ACTINOMYCOSIS

Molar tooth appearance of

Actinomyces israeIii

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

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

CLENCHED FIST INJURIES

DIABETIC FOOT

HUMAN BITE

NECROTIZING CELLULITIS

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

PUERPERAL INFECTION SEPTIC ABORTION • • • PUERPERAL ABSCESS SEPTIC ABORTION BACTERAEMIA • • • • PELVIC ABSCESS ADENXAL ABSCESS PERITONITIS ENDOMETRITIS

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

CNS 1.

HEAD TRAUMA 2.

– HEMATOGENOUS SPREAD FROM ANY INFECTED BODY SITE 3.

– GEOGRAPHIC SPREAD SINUS INFECTIONS – DENTAL ABSCESSES

BONE & JOINT • • • • HEMATOGENOUS SPREAD TRAUMA PERIVASCULAR DISEASE JUVENILE PERIODONTITIS

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

CLASSIFICATION

1.

2.

3.

4.

5.

6.

Anaerobic spore forming bacilli (Clostridia) Gram negative bacilli nonsporing (Bacteroides) Anaerobic streptococci (Peptostreptococcus) Anaerobic staphylococcus (Peptococcus) Gram negative diplococci (Veillonella) Gram positive bacilli (Actinomyces)

ORGANISM GROUPS • GRAM NEGATIVE RODS – – – – – –

BACTEROIDES PREVOTELLA PORPHYROMONAS FUSOBACTERIUM BUTYRIVIBRIO SUCCINOMONAS

Bacteroides fragilis

BACTEROIDES

• • • •

STRICT ANAEROBE PLEOMORPHIC GRAM NEGATIVE BACILLI (COCCO BACILLI) NORMAL FLORA IN

–

OROPHARYNX

–

GASTROINTESTINAL TRACT

–

VAGINA

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

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

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

BACTEROIDES

• • • • •

B. FRAGILIS

IN THE GUT AND VAGINA

B.MELANINOGESUS AND B.ORALIS

IN THE MOUTH AND OROPHARYNX B. FRAGILIS PENICILLIN RESISTANT, OTHER ARE SENSITIVE, IT IS THE

COMMONEST

THE GUT 10 12 ORGANISM IN ORGANISM /GRAM OF FAECES

Bacteroides and other anaerobic bacilli

BACTEROIDES AND FUSOBCTERIUM B.FRAG

B.NECROPH

ORUS BLACK PIG.

PITTING B.MELANINO

GENICUS + INDOLE+ + LYSINE+ + BILE GROWTH + B.CORRODE

NS + FUSOBACTE RIUM -

Growth of

Bacteroides fragilis

on Bacteroides bile-esculin agar

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

PORPHYROMONAS • GLC = ACETIC, SUCCINIC PLUS PROPIONIC, BUTYRIC, ISOBUTYRIC,& ISOVALERIC • • BILE SENSITIVE USUALLY BLACK PIGMENTED COLONIES –

P. GINGIVALIS, P. ENDODONTITIS

&

P.ASACCHAROLYTICA

PREVOTELLA • • • GLC = ACETIC, SUCCINIC, ISOVALERIC, NO BUTYRIC BILE SENSITIVE BLACK PIGMENT & FLUORESCENCE – –

Pr. INTERMEDIA

– LIPASE +

Pr. MELANINOGENICA

– BRICK RED FLUORESCENCE

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

Fusobacterium nucleatum

FUSOBACTERIUM • • •

F. NUCLEATUM

= LIPASE Ø

F. NECROPHORUM

= LIPASE +

F. NUCLEATUM

>>

F. NECROPHORUM

ISOLATES • COMMON IN ASPIRATION PNEUMONIAS

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

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

PEPTOSTREPTOCOCCUS • • • • GRAM POSITIVE COCCI GLC = ACETIC, SOME BUTYRIC

Ps. ASACCHAROLYTICUS

INDOLE +

Ps. ANAEROBIUS, Ps. MAGNUS, Ps.PREVOTI, Ps. INDOLECUS

STREP & STAPH • ANAEROBIC SPECIES OF STAPH AND STREP • • STREPTOCOCCUS INTERMEDIUS STAPHYLOCOCCUS SACCHAROLYTICUS

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

CLOSTRIDIA

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

C. difficile

CLOSTRIDIA

• Causative Agents For – 1.G

as gangrene :

Cl. perfringens

and other e.g

C.septicum

– – – 2.

4.

Tetanus

: 3.

Botulism : Toxic enterocolitis

Cl. tetani Cl. botulinum

:

Cl. difficile

(Pseudomembernous colitis)

Clostridium perfringens (CI . welchii)

• • • • Morphology large rods gram +ve With bulging endospores Not motile Capsulated

Clostridium perfringens

C. perfringens

C. perfringens

Culture:

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

C.

perfringens

NAGLAR'S Reaction

Lipase and/or lecithinase (EYA),

Diseases Caused by C. perfringens

• • • • • 1) Wound Contamination 2) Wound infection 3)

Gas Gangrene

- most important disease 4) Gas Gangrene of the uterus in criminal abortion 5) Food Poisoning • Spores are swallowed Germinate in gut after 18 hours • • Toxin abdominal pain and diarrhoea

GAS GANGRENE

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

NECROTIZING FASCIATITIS

NECROTIZING FASCIATITIS

MYOSITIS

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

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

TETANUS

Cl.tetani

• • • • • • Causative organism

Cl.tetani

Morphology gram +ve anaerobic with terminal spore Drum Stick appearance Lives in soil and animal feaces. e,g horse Produces a powerful exotoxin tetanospasmin Toxin is a protein, It inhibits transmission of normal inhibitory messages from central nervous system at anterior horn cells of cord

C. tetani

Clinical patterns: • • • • Generalized Local Cephalic Neonatal

Clinical Features • • Incubation period 1-2 weeks Symptoms: Painful muscle spasm around infected wound • Contraction of muscles • of face= – Trismus – ( Lockjaw)

Risus Sardonicus

Back – Araching of Back

Opisthotonus

Pathogenesis

• • • • • • 1 ) Tetanospasmin and Totanolysin 1) Tetanospasmin most important No invasion or Bacteraernia Toxin  Anterior horn cell of Spinal Cord Any wound can infected if contaminated by spores Face & neck wounds are more dangerous why ?

Pathogenesis

Diagnosis

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

C.

tetani

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

Treatment .

• • • • Cleaning of wound Removal of Foreign body –

Specific by antitoxin

Horse serum can caused anaphylaxis & shock must be tested first – – Human immunoglobulin Antibiotics . Penicillin –

Supportive treatment

2.

Dark pace, fluids – 3. Sedative valium

CLOSTRIDIUM BOTULINUIM

Habitat

• Soil,Ponds AND Lakes

Botulism

• From vegetables, fruits, seafood, and in soil and marine sediment worldwide canned food., • • • Not well cooked Spores resist heat at 100 o C  then multiply and produce toxin

Botulism Patogenesis

• • • • • Ingested - incubation period 12-36 hour 8 Types Mainly types

A, B, E, F and G

Attacks neuromuscular junctions Prevents release of acetylcholine

Toxin

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

Forms

• • • • • Food-borne botulism Infant botulism Wound botulism Adult enteric infectious botulism Inhalational botulism

ENFANTILE BOTULISM

• Ingestion of

Spores



gut



Botulism

germination in the

• • • • Week child Cranial nerve Constipation Other

Symptoms

• Abnormal eye movement as if cranial nerve affected when bulbar area of the brain affected • Respiratory and circulatory collapse

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

INFANTILE BOTULISM • • • • Week lethargic child Constipation Respiratory and cardiac arrest Due to colonization of intestine by

CI. botulinum

• • Diagnosis by -Culture of stools Detection of toxin in feaces

• • •

Treatment

1) Supportive 2) Horse antitoxin • • •

Prevention

1) Adequate pressure cooking autoclaving

2)

Heating of food for 10 minutes at 100 O C

Botox

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

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

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

Clinical pictures

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

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

C. difficile

C. difficile

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

Major Clostridial Diseases