Clinical%20and%20lab%20aspect%20of%20anaerobic%20infection

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Clinical and lab aspect of anaerobic infection

• Ali Somily MD, FRCPC,ABMM

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Classification

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

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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 in reduced form
  to work

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HABITAT I

• These organism are normal flora in
• A. Oropharynx
• eg. 1. Bacteroides melaninogenicus
• Now called provetella melaninogenicus
• 2. Fusobacteria
• 3. Veillonella

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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)

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INFECTIONS CAUSED BY ,NONSPORING ANAEROBES

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

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FEATURES OF ANAEROBIC INFECTIONS

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

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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

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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

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WHAT ARE THE INFECTION CAUSED BY THESE ANAEROBIC
ORGANISMS II

• 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

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ORAL DENTAL

• gt 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

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ORAL DENTAL

• COMMONLY ASSOCIATED WITH
• DENTAL ABSCESSES
• ROOT CANALS
• JUVENILE PERIODONTITIS
• ADULT PERIODONTITIS
• CLENCHED FIST INJURIES

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ENT HEAD NECK

• CHRONIC OTITIS MEDIA
• CO-PATHOGENS WITH CHRONIC STREP TONSILLITIS
• ACUTE SINUSITIS
• POST-DENTAL EXTRACTIONS OR TRAUMA
• 2o INVADER

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ENT HEAD NECK

• VINCENTS ANGINA
• COMBINATION OF FUSOBACTERIUM SPIROCHETE SPECIES
  OVERGROWTH
• ANAEROBIC PHARYNGITIS
• GRAY MEMBRANE
• FOUL ODOR

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Vincents 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

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Ludwigs Angina
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Lemierre Syndrome
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Expansion of the retropharyngeal soft tissues
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PLELRO PULMONARY I FECTION

• ASPIRATION LUNG ABSCESS
• ASPIRATION PNEUMONIA
• M ETASTATIC LUNG ABSCESS
• BRONCHIACTSIS
• ALL OF ABOVE CAN CAUSE EMPYEMA

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LUNG PLEURAL

• ASPIRATION PNEUMONIA
• EMPHYSEMA
• LUNG ABSCESSES
• MALIGNANCIES
• LEUKOPENIA

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THORACIC ACTINOMYCOSIS
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THORACIC ACTINOMYCOSIS
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ACTINOMYCOSIS
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Molar tooth appearance of Actinomyces israeIii
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Macroscopic colony (left) Gram stain (right) of
Actinomyces
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SKIN SOFT TISSUE

• TRAUMATIZED DEVITALIZED TISSUE
• TRAUMATIC WOUNDS
• HUMAN/ANIMAL BITES
• ISCHEMIA OF EXTREMITIES
• DIABETES
• ATHEROSCLEROSIS

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CLENCHED FIST INJURIES
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DIABETIC FOOT
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HUMAN BITE
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NECROTIZING CELLULITIS
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PUERPERAL INFECTION SEPTIC ABORTION

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

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ABDOMINAL INFECTIONS

• MANIPULATION, INVASION OR TRAUMA TO GI TRACT
• TRAUMA
• SURGERY
• APPENDICITIS
• MALIGNANCIES
• COLON CANCER

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CNS

• HEAD TRAUMA
• HEMATOGENOUS SPREAD
• FROM ANY INFECTED BODY SITE
• GEOGRAPHIC SPREAD
• SINUS INFECTIONS
• DENTAL ABSCESSES

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BONE JOINT

• HEMATOGENOUS SPREAD
• TRAUMA
• PERIVASCULAR DISEASE
• JUVENILE PERIODONTITIS

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OTHER INFECTIONS

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

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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.

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Anaerobic chamber
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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.

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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)

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ORGANISM GROUPS

• GRAM NEGATIVE RODS
• BACTEROIDES
• PREVOTELLA
• PORPHYROMONAS
• FUSOBACTERIUM
• BUTYRIVIBRIO
• SUCCINOMONAS

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Bacteroides fragilis
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Propionibacterium
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Fusobacterium nucleatum
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BACTEROIDES

• STRICT ANAEROBE
• PLEOMORPHIC
• GRAM NEGATIVE BACILLI (COCCO BACILLI)
• NORMAL FLORA IN
• OROPHARYNX
• GASTROINTESTINAL TRACT
• VAGINA

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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

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BACTEROIDES FRAGILIS GP

• GLC MAJOR ACETIC SUCCINIC, LACTIC PROPIONIC
  ACIDS
• NO PIGMENTATION OF COLONIES OR FLUORESCENCE

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BACTEROIDES OTHER SP

• BACTEROIDES SPECIES OTHER THAN B. FRAGILIS GROUP
• GLC MAJOR ACETIC SUCCINIC ONLY
• BILE SENSITIVE
• RESISTANT TO KANAMYCIN ONLY
• SOME PIGMENTED

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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

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Bacteroides and other anaerobic bacilli
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BACTEROIDES AND FUSOBCTERIUM
B.FRAG B.NECROPHORUS B.MELANINOGENICUS B.CORRODENS FUSOBACTERIUM
BLACK PIG. - - - -
PITTING - - - -
INDOLE - - - -
LYSINE
BILE GROWTH
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Growth of Bacteroides fragilis on Bacteroides
bile-esculin agar
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PEPTOCOCCUS NIGER

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

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PEPTOSTREPTOCOCCUS

• GRAM POSITIVE COCCI
• GLC ACETIC, SOME BUTYRIC
• Ps. ASACCHAROLYTICUS INDOLE
• Ps. ANAEROBIUS, Ps. MAGNUS, Ps.PREVOTI, Ps.
  INDOLECUS

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STREP STAPH

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

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VEILLONELLA PARVULA

• GRAM NEGATIVE COCCI
• GLC ACETIC PROPIONIC
• NITRATE
• HEAD AND NECK INFECTIONS
• DENTAL ABSCESSES

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CLOSTRIDIUM SPECIES

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

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C. difficile
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CLOSTRIDIA
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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)

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Clostridium perfringens (CI . welchii)

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

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Clostridium perfringens
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C. perfringens
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C. perfringens
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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

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C. perfringens
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NAGLAR'S Reaction
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Lipase and/or lecithinase (EYA),
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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

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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

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NECROTIZING FASCIATITIS
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NECROTIZING FASCIATITIS
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MYOSITIS
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Gram Stain of vaginal aspirate

1. Clostridiae necrotizing (myonecrosis)

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Prevention and Treatment

• Remove dead tissue
• Remove debris
• Foreign bodies
• Penicillin
• Hyperbaric oxygen

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TETANUS
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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 ?

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C. tetani
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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

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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

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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

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Pathogenesis
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Diagnosis

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

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C. tetani
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Prevention

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

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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

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CLOSTRIDIUM BOTULINUIM
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Habitat

• Soil,Ponds AND Lakes

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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

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Botulism

• From canned food., sea food e_g. salmon
• Not well cooked
• Spores resist heat at 100 oC
• ?then multiply and produce toxin

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ENFANTILE BOTULISM

• Ingestion of Spores ? germination in the
  gut?Botulism
• Week child
• Cranial nerve
• Constipation
• Other

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Botulism Patogenesis

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

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Symptoms

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

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SPECIMENS

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

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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

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• Treatment
• 1) Supportive
• 2) Horse antitoxin

• Prevention
• 1) Adequate pressure cooking autoclaving
• 2) Heating of food for 10 minutes at 100 OC

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Botox
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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

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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

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C. DIFFICILE

• DIARRHEA FIRST
• ELECTROLYTE FLUID LOSS
• LEADS TO DEHYDRATION
• INTESTINAL BLOCKAGE
• CONTENTS BLOCKED
• COLON BULGES
• PERFORATION, RUPTURE ? SEPSIS

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Clinical pictures
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C. DIFFICILE

• RAPID AGGRESSIVE COURSE IN YOUNG CHILDREN
• DIFFICULT TO SELECTIVELY
• CULTURE
• 5-10 CULTURE EVEN WITH CONFIRMED DISEASE
• TOO MANY NORMAL ANO2 PRESENT

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C. DIFFICILE

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

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C. difficile
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C. difficile
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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

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Major Clostridial Diseases