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Clinical and lab aspect of anaerobic infection. Ali Somily MD, FRCPC,ABMM. Classification. Anaerobic spore forming bacilli (Clostridia) Gram negative bacilli non-sporing (Bacteroides) Anaerobic streptococci ( Peptostreptococcus ) Anaerobic staphylococcus (Peptococcus)

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Clinical and lab aspect of anaerobic infection


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classification
Classification
  • 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)
antimicrobiolial sensitivity
AntimicrobiolialSensitivity
  • All of them resistant to aminoglycosides
    • Gentamicine
    • Tobramycin
    • Amikacin
  • Almost all are sensitive to metranidazole (flagyl)
anaerobiosis
Anaerobiosis
  • Lack cytochrome-cannot use oxygen as hydrogen acceptor
  • Most Lack
    • Catalase
    • Peroxidase
  • Contain flavoproteinso 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
habitat i
HABITATI :
  • These organism are normal flora in:
  • A. Oropharynx
      • eg. 1. Bacteroides melaninogenicus
          • Now called provetella melaninogenicus
        • 2. Fusobacteria
        • 3. Veillonella
habitat ii
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
CLINICAL ASPECTS
  • ANAEROBES ARE INDIGENOUS FLORA OF SKIN & MUCOUS MEMBRANES
  • NORMALLY CONTAINED AWAY FROM INTERNAL STERILE BODY SITES
  • HIGH MORBIDITY & MORTALITY
infections caused by nonsporing anaerobes
INFECTIONS CAUSED BY ,NONSPORING ANAEROBES
  • A. The head, neck and respiratory tract
  • B. The lower abdomen and the pelvis
features of anaerobic infections
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 begin
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
WHAT ARE THE INFECTION CAUSED BY THESE ANAEROBIC ORGANISMS I
  • 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
WHAT ARE THE INFECTION CAUSED BY THESE ANAEROBIC ORGANISMS II
  • Infection of the female genital tract
  • Septic abortion
  • Puerperalinfection 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
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
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
ORAL & DENTAL
  • > 400 SPECIES OF ANO2 IN MOUTH
  • MOST INFECTIONS = POLYMICROBIC
    • MIXED ORGANISMS
    • ENTER AS A GROUP
  • ANO2 NOT INITIAL INVADER
    • USUALLY SECONDARY
    • 1ST ORGANISM DECREASES [O2] & Eh
oral dental1
ORAL & DENTAL
  • COMMONLY ASSOCIATED WITH
    • DENTAL ABSCESSES
    • ROOT CANALS
    • JUVENILE PERIODONTITIS
    • ADULT PERIODONTITIS
    • CLENCHED FIST INJURIES
ent head neck
ENT – HEAD & NECK
  • CHRONIC OTITIS MEDIA
  • CO-PATHOGENS WITH CHRONIC STREP TONSILLITIS
  • ACUTE SINUSITIS
    • POST-DENTAL EXTRACTIONS OR TRAUMA
    • 2o INVADER
ent head neck1
ENT – HEAD & NECK
  • VINCENT’S ANGINA
    • COMBINATION OF FUSOBACTERIUM & SPIROCHETE SPECIES OVERGROWTH
    • ANAEROBIC PHARYNGITIS
    • GRAY MEMBRANE
    • FOUL ODOR
vincent s disease
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
plelro pulmonary i fection
PLELRO PULMONARY I FECTION
  • ASPIRATION LUNG ABSCESS
  • ASPIRATION PNEUMONIA
  • M ETASTATIC LUNG ABSCESS
  • BRONCHIACTSIS
  • ALL OF ABOVE CAN CAUSE EMPYEMA
lung pleural
LUNG & PLEURAL
  • ASPIRATION PNEUMONIA
  • EMPHYSEMA
  • LUNG ABSCESSES
  • MALIGNANCIES
  • LEUKOPENIA
skin soft tissue
SKIN & SOFT TISSUE
  • TRAUMATIZED & DEVITALIZED TISSUE
    • TRAUMATIC WOUNDS
    • HUMAN/ANIMAL BITES
    • ISCHEMIA OF EXTREMITIES
      • DIABETES
      • ATHEROSCLEROSIS
female urogenital
FEMALE UROGENITAL
  • CHORIOAMNIOTIC INFECTIONS
  • ENDOMETRITIS
  • PID – ABDOMINAL INFECTIONS
  • BACTERIAL VAGINOSIS WITH GARDNERELLA & BACTEROIDES SP.
puerperal infection septic abortion
PUERPERAL INFECTION SEPTIC ABORTION
  • PUERPERAL ABSCESS
  • SEPTIC ABORTION
  • BACTERAEMIA
  • PELVIC ABSCESS
  • ADENXAL ABSCESS
  • PERITONITIS
  • ENDOMETRITIS
abdominal infections
ABDOMINAL INFECTIONS
  • MANIPULATION, INVASION OR TRAUMA TO GI TRACT
    • TRAUMA
    • SURGERY
    • APPENDICITIS
    • MALIGNANCIES
      • COLON CANCER
slide44
CNS
  • HEAD TRAUMA
  • HEMATOGENOUS SPREAD
    • FROM ANY INFECTED BODY SITE
  • GEOGRAPHIC SPREAD
    • SINUS INFECTIONS
    • DENTAL ABSCESSES
bone joint
BONE & JOINT
  • HEMATOGENOUS SPREAD
  • TRAUMA
  • PERIVASCULAR DISEASE
  • JUVENILE PERIODONTITIS
other infections
OTHERINFECTIONS
  • GRAM NEGATIVE BACTREMIA
  • BREAST ABSCESS
  • AXILLARY ABSCESS
  • INFECTION OF DIABETIS EG.DIABETIC ULCERS
  • INFECTION OF PILONIDAL SINUS
  • PARONYCHIA
classification1
CLASSIFICATION
  • 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
ORGANISM GROUPS
  • GRAM NEGATIVE RODS
    • BACTEROIDES
    • PREVOTELLA
    • PORPHYROMONAS
    • FUSOBACTERIUM
    • BUTYRIVIBRIO
    • SUCCINOMONAS
bacteroides
BACTEROIDES
  • STRICT ANAEROBE
  • PLEOMORPHIC
  • GRAM NEGATIVE BACILLI (COCCO BACILLI)
  • NORMAL FLORA IN
    • OROPHARYNX
    • GASTROINTESTINAL TRACT
    • VAGINA
bacteroides fragilis gp
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 gp1
BACTEROIDES FRAGILIS GP
  • GLC = MAJOR ACETIC & SUCCINIC, LACTIC & PROPIONIC ACIDS
  • NO PIGMENTATION OF COLONIES OR FLUORESCENCE
bacteroides other sp
BACTEROIDES OTHER SP
  • BACTEROIDES SPECIES OTHER, NOT B. FRAGILIS GROUP
    • GLC = MAJOR ACETIC & SUCCINIC ONLY
    • BILE SENSITIVE
    • RESISTANT TO KANAMYCIN ONLY
    • SOME PIGMENTED
bacteroides1
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 ORGANISM IN THE GUT 10 12 ORGANISM /GRAM OF FAECES
bacteroides fragilis2
Special-potency kanamycin, vancomycin, and colistin antimicrobial agent disks to first quadrant of this plate. Bacteroides fragilis
porphyromonas
PORPHYROMONAS
  • GLC = ACETIC, SUCCINIC PLUS PROPIONIC, BUTYRIC, ISOBUTYRIC,& ISOVALERIC
  • BILE SENSITIVE
  • USUALLY BLACK PIGMENTED COLONIES
    • P. GINGIVALIS, P. ENDODONTITIS & P.ASACCHAROLYTICA
prevotella
PREVOTELLA
  • GLC = ACETIC, SUCCINIC, ISOVALERIC, NO BUTYRIC
  • BILE SENSITIVE
  • BLACK PIGMENT & FLUORESCENCE
    • Pr. INTERMEDIA – LIPASE +
    • Pr. MELANINOGENICA – BRICK RED FLUORESCENCE
fusobacterium
FUSOBACTERIUM
  • GLC = ACETIC, PROPIONIC, &BUTYRIC, NO SUCCINIC
  • ANTIBIOTICS
    • SENSITIVE TO KANAMYCIN
    • RESISTANT TO VANCOMYCIN
    • COLISTIN VARIABLE
fusobacterium1
FUSOBACTERIUM
  • F. NUCLEATUM = LIPASE Ø
  • F. NECROPHORUM = LIPASE +
  • F. NUCLEATUM >> F. NECROPHORUM ISOLATES
  • COMMON IN ASPIRATION PNEUMONIAS
miscellaneous gnb
MISCELLANEOUS GNB
  • BUTYRIVIBRIO
    • CURVED GNB
    • GLC = MAJOR BUTYRIC
  • SUCCINOMONAS
    • CURVED GNB
    • GLC = ACETIC & SUCCINIC
peptococcus niger
PEPTOCOCCUS NIGER
  • GRAM POSITIVE COCCI
  • GLC = ACETIC, BUTYRIC, ISOBUTYRIC, ISOVALERIC, CAPROIC
  • BLACK PIGMENT
peptostreptococcus
PEPTOSTREPTOCOCCUS
  • GRAM POSITIVE COCCI
  • GLC = ACETIC, SOME BUTYRIC
  • Ps. ASACCHAROLYTICUS INDOLE +
  • Ps. ANAEROBIUS, Ps. MAGNUS, Ps.PREVOTI, Ps. INDOLECUS
strep staph
STREP & STAPH
  • ANAEROBIC SPECIES OF STAPH AND STREP
  • STREPTOCOCCUS INTERMEDIUS
  • STAPHYLOCOCCUS SACCHAROLYTICUS
veillonella parvula
VEILLONELLA PARVULA
  • GRAM NEGATIVE COCCI
  • GLC = ACETIC & PROPIONIC
  • NITRATE +
  • HEAD AND NECK INFECTIONS
  • DENTAL ABSCESSES
clostridium species
CLOSTRIDIUM SPECIES
  • LARGE GRAM POSITIVE RODS
  • SPORE FORMATION
  • SPECIFIC DISEASES
    • PSEUDOMEMBRANOUS COLITIS
    • TETANUS
    • BOTULISM
    • GANGRENE - MYONECROSIS
clostridia1
CLOSTRIDIA
  • 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)
clostridium perfringens ci welchii
Clostridium perfringens (CI . welchii)
  • Morphology large rods gram +ve
  • With bulging endospores
  • Not motile
  • Capsulated
culture
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
diseases caused by c perfringens
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

GAS GANGRENE
gram stain of vaginal aspirate
Gram Stain of vaginal aspirate
  • Clostridiae necrotizing (myonecrosis)
prevention and treatment
Prevention and Treatment
  • Remove dead tissue
  • Remove debris
  • Foreign bodies
  • Penicillin
  • Hyperbaric oxygen
cl tetani
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
  • Any wound can infected if contaminated by spores
  • Face & neck wounds are more dangerous why ?
clinical features
Clinical Features
  • Incubation period 1-2 weeks
  • Symptoms: Painful muscle spasm around infected wound
  • Contraction of muscles

of face=

    • Trismus (Lockjaw)
    • Risus Sardonicus strychnine
  • Back
    • Araching of Back
opisthotonus
opistho meaning "behind" and tonos meaning "tension",

Extrapyramidal effect and is caused by spasm of the axial along the spinal column .

Caused by

Tetanus.

Cerebral palsy

Traumatic brain injury

Opisthotonus
pathogenesis
Pathogenesis
  • 1 ) Tetanospasmin most important powerful exotoxin
  • 2) Totanolysin
  • No invasion or Bacteraernia
  • Toxin is a protein
  • It inhibits transmission of normal inhibitory messages from central nervous system at anterior horn cells of cord
diagnosis
Diagnosis
  • Mainly by clinical
  • Laboratory not important
  • Lab
    • Organism strict anaerobe
    • Very motile , spread on agar.
prevention
Prevention
  • Toxoid vaccine:
  • Vaccination D P T
  • 2 , 4 , 6 , 18 months & 5 Year
  • Booster every 10 years
treatment1
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
habitat
Habitat
  • Soil,Ponds AND Lakes
toxin
Toxin
  • Exotoxin
  • Protein
  • Heat labile at 100 OC
    • 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
botulism
Botulism
  • From canned food., sea food e_g. salmon
  • Not well cooked
  • Spores resist heat at 100 oC
  • then multiply and produce toxin
enfantile botulism
ENFANTILE BOTULISM
  • Ingestion of Spores  germination in the gutBotulism
  • Week child
  • Cranial nerve
  • Constipation
  • Other
botulism pathogenesis
Botulism Pathogenesis
  • Ingested - incubation period 12-36 hour
  • 7 Types
  • Mainly types A, B, E, F
  • Attacks neuromuscular junctions
  • Prevents release of acetylcholine
symptoms
Symptoms
  • Funny eye movement as if cranial nerve affected when bulbar area of the brain affected
  • Respiratory and circulatory collapse
specimens
SPECIMENS
  • Suspected food
  • From the patient
    • Faeces growth
    • Serum
  • Toxin detection by mouse
    • incubation paralysis and death
infantile botulism
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

slide108
Treatment

1) Supportive

2) Horse antitoxin

Prevention

1) Adequate pressure cooking autoclaving

2) Heating of food for 10 minutes at 100 OC

c difficile1
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 difficile2
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 difficile3
C. DIFFICILE
  • DIARRHEA FIRST
    • ELECTROLYTE & FLUID LOSS
    • LEADS TO DEHYDRATION
  • INTESTINAL BLOCKAGE
    • CONTENTS BLOCKED
    • COLON BULGES
  • PERFORATION, RUPTURE  SEPSIS
c difficile4
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 difficile5
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 difficile8
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