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INFECTIONS CAUSED BY BACTERIA Peptostreptococcus

Dr. Molina
July 23, 2013 GASTROINTESTINAL TRACT AND RECTUM
Group 2
Enterobacteriaceae except: Salmonella, Shigella, Yersinia,
Vibrio and Campylobacter species
Anaerobes are members of the normal microbiota of
Glucose non-fermenting gram (-) rods
different areas of the human body.
Enterococci
Alpha and non-hemolytic streptococci
SKIN Staphylococcus aureus in small numbers
Yeast in small amount
Staphylococcus epidermidis Anaerobes in large numbers
Staphylococcus aureus (small numbers)
Micrococcus species GENITALIA
Nonpathogenic neisseria species
Alpha-hemolytic (S. viridans), non-hemolytic streptococci
Any amount of the following:
Corynebacterium species
Corynebacterium species
Propionibacterium species
Lactobacillus species
Peptostreptococcus species
Alpha and non-hemolytic streptococci
Acinetobacter species
Small numbers of other organisms (Candida species, P.
Mixed and not predominant:
aeruginosa)
Enterococci
XXX: Diphtheroids, nonpathogenic Neisseria species
Enterobacteriaceae
Other gram (-) rods
NASOPHARYNX (Mouth & Upper Respiratory Tract) Staphylococcus epidermidis
Candida albicans and other yeasts
Any amount of the following:
Diphtheroids Anaerobes when in pure growth or clearly predominant
Non-[pathogenic neisseria species Prevotella, Clostridium and Peptostreptococcus species
Alpha-hemolytic and non-hemolytic streptococci
Staphylococcus epidermidis VAGINA
Anaerobes (many types)
Lesser amounts of the following:
Soon after birth: lactobacilli as long as pH is acidic
Yeasts
Hemophilus species
Until puberty: neutral PH
Pneumococci
Cocci and bacilli
Staphylococcus aureus
Gram negative rods
Puberty onwards: acidic pH through production of acid
Neisseria meningitides
from carbohydrates especially glycogen
Nose Corynebacterium staphylococci, streptococci
After menopause: neutral pH lactobacilli diminish;
mixed flora returns
Mouth and pharynx sterile at birth
S. viridans
Anaerobic spirochetes when teeth erupt
HELPFUL TERMS
Actinomyces in tonsillar tissue
Yeasts
Anaerobic bacteria - do not require oxygen for growth
Small bronchi and alveoli sterile and metabolism but obtain their energy from
Infectious agents of the mouth and respiratory tract fermentation reactions; require reduced oxygen
Usually include anaerobes tension and fail to grow on the surface of solid medium
in 10% carbon dioxide in ambient air
Mouth and respiratory tract Examples: Bacteroides, clostridium
Mixed oronasal flora including anaerobes:
P. Melaninnogenica Facultative anaerobes - grow either oxidatively using
Fusobacterium oxygen or anaerobically using fermentation reaction for
energy needs; are often called aerobes; versatile Lemierres disease
organisms Porphyromonas- Mouth Oropharyngeal,
Examples: Streptococcus species, E. coli *members before pleuropulmonary,
of the Bacteroides breast, axillary, perianal,
Aerobic bacteria - require oxygen for growth group male genitalia
Obligate aerobes: Micrococcus, Nocardia

Microaerophilic bacteria - require oxygen but fail to 1. Bacteroides bile resistant, nonspore forming, slender
grow on the surface of solid medium in air and exhibit gram (-) rods that may appear as coccobacilli
minimal growth under aerobic conditions - most often implicated under circumstances of disruption
of the intestinal wall (surgery, trauma, appendicitis,
diverticulitis)
Capnophilic bacteria - require carbon dioxide for
growth
2. Prevotella may appear as slender rods or coccobacilli
- in infections, may often be associated with other
**Anaerobes grow in areas with low or negative oxidation-
anaerobic organisms that are part of the normal flora
reduction potential**
(peptostreptococci, anaerobic gram (+) rods,
Ex. Necrotic tissues, gangrenous tissues
fusobacteria)
AEROBES VS. ANAEROBES
3. Porphyromonas part of the normal mouth flora
Aerobes Anaerobes
4. Fusobacteria
+ Cytochrome Systems -
F. necrophorum very pleomorphic, long rod with
+ Superoxide Dismutase round ends and tends to make bizarre forms
+ Catalase - It is not a component of the healthy oral cavity.
- depending if microorganism is obligate or facultative anaerobe
F. nucleatum thin rod with tapered ends (needle
shaped morphology)
Cytochrome systems for the metabolism of O 2
- Quite virulent and can cause severe infections of the
Superoxide dismutase or catalase able to negate the head and neck leading to Lemierres disease.
toxic effects of oxygen radicals and hydrogen peroxide
and thus tolerate oxygen
Catalase system- related with hydrogen peroxide Lemierres Disease
- Very severe infection associated w/ F.necrophorum
ANAEROBES OF CLINICAL IMPORTANCE - Characterized by acute jugular vein septic
thrombophlebitis (involves head & neck) that
progresses to sepsis with metastatic abscesses of the
A. Gram Negative Bacilli
lungs, mediastinum, pleural cavity, and liver
GENERA ANATOMIC INFECTIONS
- Most common among older children and young adults
SITE
- Often occurs in association with infectious
Bacteroides Mouth Pleuropulmonary
mononucleosis
fragilis Colon infections
Endocarditis
Intra-abdominal
abscesses (*usually
after colonic
perforations)
Pelvic inflammatory
disease (PID)
Bacteremia
Prevotella Mouth Oropharyngeal,
melaninogenica Colon pleuropulmonary
(reclassified from GUT Lung and brain abscess
bacteroides) PID, tubo-ovarian and
pelvic abscesses
Fusobacterium Mouth Oropharyngeal, Prevotella intermedia
(F. nucleatum, F. Colon pleuropulmonary, skin, Black pigment on sheep blood agar (left) vs. rabbit blood agar
necrophorum) soft tissue, bone
Bacteria that cause Bacterial Vaginosis B. Gram (-) Cocci

Gardnerella vaginalis Genera Anatomic Infection


Site
Serologically distinct organism isolated from Veilonella Mouth Often mixed
normal female GUT Colon infections
Also associated with vaginosis (*vaginosis is the Rarely cause of
term because of the lack of the inflammatory infection
process)
One of the unusual bacterial pathogens C. Gram (+) Cocci (Opportunistic Pathogens)
Genera Anatomic Infection
Mobilincus species SIte
Peptostreptococcus Skin Often mixed
Motile, curved, gram-variable or gram (-),
Mouth infections
anaerobic rods
Colon Occasionally sole
Common in reproductive women
GUT cause
Bacterial Vaginosis of infection in:
Brain, Breast
Common vaginal condition of women of Intraabdominal
reproductive age & pelvic infections
Associated with premature rupture of the Peptoniphilus (same
membranes, preterm labor and birth above)
Malodorous, slightly increased discharge
Moderate, white or gray, homogenous, low Anaerococcus Skin Opportunistic,
viscosity, uniformly coats vaginal walls Finegoldia Mouth mixed infections
No vulvar or vaginal inflammation Peptococcus URT Serious Infections:
GIT brain abscess
Amsels Criteria for Bacterial Vaginosis Gut (F) intraabdomnial
female genital tract
Objective signs of increased white homogenous pleuropulmonary
discharge necrotizing fasciitis
Vaginal discharge pH>4.5 other deep SSI
Distinct fishy odor after vaginal secretions are
mixed with 10% KOH (Whiff Test) D. Gram (+) Bacilli
Presence of clue cells: epithelial cells which are Genera Anatomic Site Infection
studded with microogranisms Actinomyces Mouth Oropharyngeal
Skin
Soft Tissue
Bone
Lactobaciilus Mouth Rare cause
Colon *protective, most
Vagina loved anaerobe *
Propionibacterium Skin Blood & CSF
Contaminant
Shunt & appliance
Skin
Soft Tissue
Bone
Eubacterium Mouth Mixes
Bifidobacterium Colon oropharyngeal
Treatment Arachina and bowel
infections
Oral metronidazole is generally curative
Clostridium Colon Bacteremia
Tetanus
Food Poisoning
Gas gangrene
ACTINOMYCES

Actinomyces israelli & gerencseriae


o Most commonly encountered species
Variable length on gram stain
Some are aerotolerant

Actinomycosis

Chronic suppurative granulomatous infection


Produces pyogenic lesions (with pus) with
interconnecting sinus tracts containing granules
o Granules microcolonies embedded in
Fig 1. Actinomyces israelii in thioglycollate both showing
tissue elements; *looks like sulfur
granular growth
granules but does not contain sulfur
Trauma introduces Actinomyces into the mucosa
o Growth under anaerobic conditions; low
redox response
o Induce inflammatory response
o Spread of bacteria with formation of
sinuses

3 Forms of Actinomycosis

Cervicofacial lumpy jaw Fig 2. Sulfur granule, microscopic from clinical


Thoracic- may be mistaken w/ other respiratory Actinomycosis
diseases Note: Aggregate filamentous bacilli
Abdominal - usually following ruptured appendix
or ulcer

Genital Actinomycosis

Rare
Associated with Intrauterine device colonization &
subsequent invasion

Diagnosis

Specimen:
o Pus from draining sinus
o Sputum Fig 3. Actinomyces israelii: Sulfur granule demonstrating
o Tissue gram positive branching bacilli
Appropriate media, anaerobic environment
Granules:
o Hard, lobulated tissue elements
o Bacterial filaments

Fig 4. Actinomyces israelii: molar tooth colonies


Treatment: - CNS binds to gangliosides, suppress release of
Penicillin for 6-12 months inhibitory neurotransmitter prolonged muscle
spasms
Typical therapy for the most deep-seated infections: - >50% due to minor injuries
(medscape) - Looks like drumstick
1. Intravenous penicillin G Ubiquitous in nature
- (10-20 million U/d for 2-6 wk) Toxoid administration must be completed: 3 doses
2. Followed by oral penicillin Tetanus toxoid is part of routine childhood DTaP;
- (2-4 g/d for an additional 3-12 mo adults should be given booster every 10 years;

* The acquired resistance of Actinomyces species to CLOSTRIDIUM BOTULINUM


antimicrobials, particularly to penicillin G, has not been - Botulism
confirmed in vivo. When the response to penicillin is poor, - Spores in canned food with low oxygen levels, low
consider an undrained abscess or an associated infection redox potentials and nutrients that support growth
with a resistant bacterium (medsccape) - Botulinum neurotoxin most potent; heat labile
- PNS inhibit release of acetylcholine at cholinergic
Alternative: Clindamycin, erythromycin synapses
Paralysis
Also susceptible to:* - Anti-toxin before toxins are bound
chloramphenicol, Antitoxins must be given before the toxin is
tetracyclines bound to the cells, for its effects to be
But not to:* reversed.
Metronidazole
Aminoglycosides. CLOSTRIDIUM PERFRINGENS
*Medscape - All types produce alpha toxin- necrotizing,
haemolytic, exotoxin lecithinase
SURGICAL MANAGEMENT: - GAS GANGRENE
- excision of sinus tracts, o Necrotizing toxins
- drainage of the abscess cavities (*drain first before o Contamination of soft tissue wound
giving antibiotic) (septic abortion, war wounds)
- removal of the bulky infected masses, and o Carbon dioxide, hydrogen gas
- Irrigation and curettage of the osteomyelitic bony - FOOD POISONING
lesions. o Enterotoxin
o Incubation period: 8- 24 hours
o Abdominal pain, nausea, acute diarrhea

Fig 5. Eubacterium sp. Some species appear gram variable Fig 6. Clostridium perfringens: Boxcar-shaped cells
or gram negative
This is a BOXCAR
CLOSTRIDIUM

CLOSTRIDIUM TETANI
- Spores germinate in devitalized tissue
- Tetanospamin-potent neurotoxin
CLOSTRIDIUM DIFFICILE Principal Clostridia involved in gas gangrene related to
- Cytopathic and enterotoxin bowel cancer:
- Pseudomembranous colitis C. perfringens
o Diarrhea C. septicum
o Necrosis of the mucosa with the C. tertium
accumulation of inflammatory cells and
fibrin Other causes of intra-abdominal anaerobic infections:
o Tx: Metronidazole, Vancomycin Vascular sources
Pathogenesis of Anaerobic Infections Obstructions
1. Polymicrobial nature Inflammatory reactions
2. Synergistic pathogenicity Other bowel lesions
Biliary tract infection usually caused by C.
*Bacteroides fragilis experiments (rat model of
perfringens, B. fragilis
intraabdominal infection; gentamicin, clindamycin)

Intra-Abdominal Infection PRACTICAL MEDICAL APPLICATIONS AND


- Principal port of entry for anaerobic bacteria CLINICAL CORRELATIONS
- anaerobes make up 99% of normal colonic flora
Important for surgeons: dont forget to do bowel prep! I. CLUES TO ANAEROBIC INFECTIONS
Foul odor of lesion discharge
Predominant anaerobes recovered in intra-abdominal Location of the infection usually in proximity to a
infections: mucosal surface
B. fragilis Classical picture of anaerobic infection
B. thetaiotaomicron o Secondary to animal or human bites
Peptostreptococcus micros o Gas gangrene
B. wadsworthia o Actinomycosis
o Lung abscess
Others seen, but not in large amounts: Especially in stroke patients and those with weak or
B. splanchnicus absent gag reflex; predisposed to aspiration
B. ovatus pneumonia.
B. vulgatus Septic thrombophlebitis
Prevotella intermedia Infections secondary to malignancy; especially colon,
Lactobacillus spp. uterus, and lung cancers
Eubacterium Poor response to non-anaerobic antibiotics
Fusobacterium spp. Black discoloration of blood-containing exudates
Clostridium spp. cefoxitin (2 gen cephalosporin;
nd Sulfur granules in discharge materials
has added coverage for anaerobes) and clindamycin Unique morphology in gram stain
are not recommended as treatment No growth on routine aerobic culture
Growth in anaerobic zone of fluid media or agar
Predominant aerobic and facultative anaerobic bacteria deeps
recovered in intra-abdominal infections: Growth anaerobically in a media containing 75 to
E. coli 100g/ml aminoglycoside or vancomycin
Most common cause of facultative anaerobic infections These medications will inhibit aerobic bacteria but
Streptococci allow anaerobic ones to grow.
Enterococci Characteristic colonies on agar plates
Red fluorescence of young colonies of pigmented
Significance of anaerobic abdominal infection: may be the gram negative anaerobes on blood agar plate under
first manifestation of malignancy. UV light

Carcinoma of the bowel may initially manifest as an II. SPECIMEN COLLECTION AND TRANSPORT
anaerobic abdominal infection or gas gangrene due to the
Good anaerobic bacteriology starts with proper specimen
low redox potential of the area; be sure to evaluate
collection
patient further.
Aspirate
Tissue Biopsy
Lavage
Oxygen-free transport at room temperature

III. INTERPRETATION OF LABORATORY DATA

Gram stain
Anaerobic cultures - supplemented with hemin, Vit. K,
blood
Trypticase soy agar base
Schaedler blood agar
Brucella agar
Brain heart infusion agar Actinomyces species

Which is the real pathogen? A. Colony of Actinomyces after 72 hrs; 2mm in


diameter; termed as molar tooth colonies
B. Granules of Actinomyces species; surfur granules
(filaments are branching at the periphery)
C. Actinomyces naeslundii in a brain abscess;
branching bacilli are visible

IV. PREVENTION OF INFECTION

Principles:

A. Avoid conditions that reduce the redox potentials of


tissues
Bacteroides fragilis Techniques:
Irregular staining and pleomorphism
Debridement
Wound cleansing
Removal of foreign bodies
Elimination of dead space
Good surgical techniques
Reestablishment of good circulation

B. Prevent the introduction of anaerobes usually from


the normal flora of the body into wounds and body
cavities
Techniques:
Clostridium tetani- Terminal spores, the drumstick Cleansing showering, irrigation
appearance Antimicrobial agents
Prevention of aspiration of oral or gastric contents
Germicides
Isolation of surgical field
Avoid prolonged labor
Gentle technique for scope procedures
Avoid intravenous catheters in the inguinal areas
C. Prevent metastatic spread

D. Protect against toxin

Clostridium perfringens in Perineal Gas Gangere

Large broad gram (+) rods mixed with gram (-) rods and
WBCs distorted by C. perfringens toxins
V. TREATMENT

A. General Supportive Measures

Blood transfusion
Fluids and electrolytes
Immobilization of infected injury
Treatment of shock
Pain relief
Management of renal failure

B. Medical

1. Antimicrobials
*Metronidazole
*Clindamycin
Chloramphenicol
Cefoxitin, Cefotetan
Penicillins
Newer Quinolones
Carbapenems
Tigecycline

2. Antitoxins

C. Surgical

Debridement
Drainage

References:

Slides of Dr. Molina


th
26 Ed., Jawetz: Medical Microbiology

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