MELANY C.
CAGABCAB
BSN-1
CHAPTER 19:
BACTERIAL INFECTIONS OF HUMANS
How Do Bacteria Cause Disease?
The various bacterial virulence factors, which enable
pathogens to cause disease, were described in Chapter
14.
Some of them are listed here:
• Adherence and colonization factors
• Factors that prevent activation of complement
• Factors that enable escape from phagocytosis by white
blood cells (WBCs)
• Factors that prevent destruction within phagocytes
• Factors that suppress the host immune system (i.e.,
factors that cause immunosuppression)
• Endotoxin (a component of the cell walls of Gram-
negative bacteria)
• Production of exotoxins (e.g., cytotoxins, enterotoxins,
neurotoxins)
• Production of necrotic and other types of destructive
enzymes
Bacterial Infections of the Skin
Information pertaining to bacterial infections of the skin is
contained in Table 19-2.
- Gas gangrene is always caused by Clostridium
spp.
Gangrene versus Gas Gangrene
The term gangrene refers to tissue necrosis (death)
resulting from local anemia (ischemia). Ischemia results
from an obstruction, loss, or reduction of blood supply,
leading to a lack of oxygen. Gangrene may have nothing
whatsoever to do with microbes. Gas gangrene, on the
other hand, is always caused by microbes—specifically,
Clostridium spp. The clostridia produce gaseous
metabolic byproducts—primarily, hydrogen and nitrogen
—that accumulate in the necrotic tissues. Regardless of
the cause, gangrenous tissue becomes brownish black
and foul smelling.
Wound Infections
When the protective skin barrier is broken as a result of
burns, puncture wounds, surgical procedures, or bites,
opportunistic indigenous microbiota and environmental
bacteria can invade and cause local or deep tissue
infections. The pathogens may spread via blood or
lymph, causing serious systemic infections.
Bacterial Infections of the Ears
Information pertaining to viral and bacterial ear infections
is contained in Table 19-3.
- The three most common causes of otitis media
are Streptococcus pneumoniae, Haemophilus
influenzae, and Moraxella catarrhalis.
Bacterial Infections of the Eyes
Table 19-4 contains information pertaining to bacterial
infections of the eyes.
Bacterial Infections of the Respiratory System
Bacterial Infections of the Upper Respiratory Tract
Table 19-5 contains information pertaining to bacterial
infections of the upper respiratory tract.
- Although we hear more about Streptococcus
pyogenes as a cause of pharyngitis (sore
throat), most cases of pharyngitis are actually
caused by viruses.
Infections of the Lower Respiratory Tract Having
Multiple Causes
Pneumonia
Disease. Pneumonia is an acute nonspecific infection of
the small air sacs (alveoli) and tissues of the lung, with
fever, productive cough (meaning that sputum is
coughed up), acute chest pain, chills, and shortness of
breath. It is clinically diagnosed by abnormal chest
sounds and chest radiographs. Pneumonia is often a
secondary infection that follows a primary viral
respiratory infection. In developing countries, pneumonia
and dehydration from severe diarrhea are the leading
causes of death. Worldwide, pneumonia claimed the
lives of 1.3 million children in 2011. It remains the
number one killer of children under five years of age.
Certain specific types of pneumonia (e.g., legionellosis
and psittacosis) are nationally notifiable diseases in the
United States.
- Worldwide, pneumonia is the number one killer
of children under five years of age.

Patient Care. Use Standard Precautions for all
hospitalized patients; Droplet and/or Contact
Precautions are required in addition to Standard
Precautions for pneumonia caused by certain pathogens
(e.g., Burkholderia cepacia, Legionella spp., Neisseria
meningitidis, Mycoplasma pneumoniae, Streptococcus
pyogenes).
Pathogens. A variety of microbes can cause
pneumonia, including Gram-positive and Gram-negative
bacteria, mycoplasmas, chlamydias, viruses, fungi, and
protozoa. Community-acquired bacterial pneumonia is
most frequently caused by Streptococcus pneumoniae
(pneumococcal pneumonia). Streptococcus pneumoniae
is the most common cause of pneumonia in the world
Other bacterial pathogens include Haemophilus
influenzae, Staphylococcus aureus, Klebsiella
pneumoniae, and occasionally other Gram-negative
bacilli and anaerobic members of the oral microbiota.
Atypical pathogens include Legionella (legionellosis), M.
pneumoniae (mycoplasmal pneumonia; primary atypical
pneumonia), and Chlamydiophila pneumonia (chlamydial
pneumonia). Psittacosis (ornithosis; parrot fever), a type
of pneumonia caused by Chlamydiophila psittaci, is
normally acquired by inhalation of respiratory secretions
and desiccated droppings of infected birds (e.g., parrots,
parakeets). Fungi such as Histoplasma capsulatum
(histoplasmosis), Coccidioides immitis
(coccidioidomycosis), Candida albicans (candidiasis),
Gram-positive Streptococcus pneumonia (arrows) in a
Gram-stained smear of a purulent (puscontaining)
sputum specimen from a patient with pneumococcal
pneumonia. Note the typical diplococcus arrangement of
this bacterium. Several larger, pink-stained
polymorphonuclear neutrophils (PMNs) can also be
seen. PMNs stain pink with the Gram staining
procedure. (From Engleberg NC, et al. Schaechter’s
Mechanisms of Microbial Disease. 5th ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 2013.)
Cryptococcus neoformans (cryptococcosis),
Blastomyces (blastomycosis), Aspergillus (aspergillosis;
and Pneumocystis jiroveci (previously considered
to be a protozoan) may be etiologic agents of
pneumonia, especially in immunocompromised
individuals. Various species of bread molds
can cause pneumonia in immunosuppressed patients; a
condition known as mucormycosis (zygomycosis).
Viral pneumonia may be caused by adenoviruses,
respiratory syncytial virus (RSV), parainfluenza viruses,
cytomegalovirus, measles virus, chickenpox virus, and
other viruses. Healthcareassociated bacterial pneumonia
is most often caused by Gram-negative bacilli, especially
Klebsiella, Enterobacter, Serratia, and Acinetobacter
spp. Pseudomonas aeruginosa and S. aureus are also
frequent causes of healthcare-associated pneumonias.
Pneumonia is the most common fatal infection acquired
in hospitals.
- Streptococcus pneumoniae is the most common
cause of pneumonia in the world.
Typical Versus Atypical Pneumonia.
Patients with typical pneumonia experience chest pain,
dyspnea (shortness of breath), fever, chills, and a
productive cough (i.e., one that produces purulent
sputum). Less common symptoms include anorexia,
headache, nausea, diarrhea, and vomiting. Radiographic
abnormalities are proportional to the physical symptoms.
Common causes of typical pneumonia are
Streptococcus pneumoniae, Haemophilus influenzae,
Staphylococcus aureus, and viruses like influenza virus
types A and B, parainfluenza viruses, and RSV. Other
causes are Legionella pneumophila, Mycoplasma
pneumoniae, Chlamydophila pneumoniae, and Gram
negative bacilli. Atypical pneumonia has a more
insidious (slower) onset than typical pneumonia. Patients
present with headache, fever, cough with little sputum,
and myalgia. Radiographic abnormalities are usually
greater than the physical symptoms would predict.
Common causes of atypical pneumonia are M.
pneumoniae, C. pneumoniae, L. pneumophila, and
viruses like influenza viruses, RSV, and adenoviruses.
Other causes are Chlamydophila psittaci, Pneumocystis
Jiroveci (a fungus), varicella-zoster virus, and
parainfluenza viruses. Note that some pathogens can
cause either typical or atypical pneumonia.
Reservoirs and Mode of Transmission. In most cases,
infected humans; other reservoirs include infected
psittacine birds (parrots and parakeets) in psittacosis,
soil,and bird droppings in histoplasmosis and
cryptococcosis. Depending on the pathogen involved,
transmission is by droplet inhalation, direct oral contact,
contact with contaminated hands and fomites, or
inhalation of yeasts and fungal spores.
Laboratory Diagnosis. A good quality sputum
specimen (coughed up from the patient’s lungs) must be
sent to the microbiology laboratory for culture and
sensitivity (C&S). It must be sputum—not saliva. A
laboratory workup of saliva will not provide clinically
relevant information. Laboratory personnel can
differentiate between saliva and sputum by preparing
and examining a Gram-stained smear of the specimen.
Sputum will contain numerous WBCs and few epithelial
cells, whereas saliva will contain few (if any) WBCs and
numerous epithelial cells.
Other Bacterial Infections of the Lower Respiratory
Tract-Additional information pertaining to bacterial
infections of the lower respiratory tract is contained in
Table 19-6.
Bacterial Infections of the Oral Region
The anaerobic environment produced by oxidation–
reduction reactions of the oral microbiota allows certain
genera of anaerobic bacteria (e.g., Bacteroides,
Porphyromonas, Fusobacterium, Prevotella,
Actinomyces, and Treponema spp.) to become involved
in the production of oral diseases. The coating that forms
on unclean teeth, called dental plaque, is a
coaggregation of bacteria and their products. Many of
these microbes produce a slime layer or glycocalyx that
enables them to attach firmly and cause damage to the
tooth enamel. Certain carbohydrates, especially sucrose,
are metabolized by streptococci (especially
Streptococcus mutans), lactobacilli, and Actinomyces
spp., producing lactic acid, which rapidly dissolves the
tooth enamel. When plaque remains on teeth for more
than 72 hours, it hardens into tartar or calculus, which
cannot be completely removed by brushing and flossing.
Acute Necrotizing Ulcerative Gingivitis- Acute
necrotizing ulcerative gingivitis (ANUG) is also called
Vincent’s angina and trench mouth.
Disease. The term “trench mouth” originated in World
War I, where soldiers developed the infection while
fighting in trenches. It is usually the result of a
combination of poor oral hygiene, physical or emotional
stress, and poor diet. It involves painful, bleeding gums
and tonsils, erosion of gum tissue, and swollen lymph
nodes beneath the jaw. It causes extremely bad breath.
Patient Care. Use Standard Precautions for hospitalized
patients.
Pathogens. Trench mouth is a synergistic
(polymicrobial) infection involving two or more species of
anaerobic bacteria of the indigenous oral microbiota.
The most commonly involved bacteria are
Fusobacterium nucleatum (an anaerobic, Gram-negative
bacillus) and Treponema vincentii (a spirochete). Other
commonly involved anaerobic Gram-negative bacilli are
Bacteroides spp., Prevotella intermedius, and Prevotella
melaninogenica.
- Trench mouth is a good example of a synergistic
(polymicrobial) infection.
Prevention and Control. As is true for other periodontal
diseases, trench mouth can be prevented by good oral
hygiene. Trench mouth is thought to be noncontagious.
Bacterial Infections of the Gastrointestinal Tract
Table 19-7 contains information pertaining to bacterial
infections of the gastrointestinal (GI) tract.
Enterovirulent Escherichia coli- Escherichia coli is a
Gram-negative bacillus that is found in the GI tract of all
humans. The strains and serotypes of E. coli that are
part of the indigenous microbiota of the GI tract are
opportunistic pathogens. They usually cause no harm
while in the GI tract, but have the potential to cause
serious infections if they gain access to the bloodstream,
the urinary bladder, or a wound. E. coli is the major
cause of septicemia, urinary tract infections (UTIs), and
healthcare- associated infections. There are other
strains and serotypes of E. coli in nature that are not
indigenous microbiota of the human colon and always
cause disease when they are ingested. Collectively,
these strains and serotypes are referred to as
enterovirulent E. coli. Information pertaining to two
general types, the enterohemorrhagic E. coli and the
enterotoxigenic E. coli, is contained in Table 19-8.
Bacterial Foodborne Intoxications
(Foodborne Infections, Food Poisoning)
The term “food poisoning” is broad and may include
diseases resulting from the ingestion of chemical
contaminants as well as bacteria or bacterial toxins,
phycotoxins, mycotoxins, viruses, or protozoa.
Technically, diseases resulting from the ingestion of
toxin-producing microbes are called infectious
diseases, whereas diseases resulting from the ingestion
of preformed microbial toxins are called microbial
intoxications. The distinction is based on where the
toxin is actually produced— in the body (in vivo) or in the
food (in vitro). The incubation time (the time that elapses
between ingestion and onset of symptoms) is usually
shorter in microbial intoxications. If toxin-producing
bacteria are ingested, the incubation time will depend on
the number of bacteria ingested, their generation time,
and the amount of time it takes them to produce enough
toxin to produce symptoms. According to the CDC,
approximately 76 million cases of foodborne illness
occur each year in the United States, resulting in more
than 5,000 deaths and 325,000 hospitalizations.
Appendix 1 on contains information pertaining to
microbial intoxications.
Genitourinary System
Urinary Tract Infections
Recall from Chapter 17 that UTIs can be divided into
upper UTIs and lower UTIs. Upper UTIs include
infections of the kidneys (nephritis or pyelonephritis) and
ureters (ureteritis). Lower UTIs include infections of the
urinary bladder (cystitis), the urethra (urethritis), and, in
men, the prostate (prostatitis). Most UTIs are acquired
via the ascending route, whereby the pathogen moves
upward from the urethra. Far fewer UTIs occur via the
descending route from the bloodstream to the kidneys.
A variety of indigenous microbes are found at and near
the outer opening (meatus) of the urethra of both men
and women. These microbes can ascend the urethra
and gain access to the urinary bladder. UTIs may result
from poor personal hygiene, sexual intercourse, the
insertion of catheters, and other means. A patient with a
UTI presents with dysuria (difficulty or pain on urination),
lumbar pain, fever, and chills. The latter two symptoms
are more common in pyelonephritis than in cystitis. The
most common causes of UTIs are E. coli and other
members of the family Enterobacteriaceae (especially
Proteus and Klebsiella spp.) (Fig. 19-6). Other common
causes of UTIs are Enterococcus spp., Staphylococcus
spp. (especially S. aureus, S. epidermidis, and S.
saprophyticus), and P. aeruginosa. UTIs may be
acquired either within a healthcare setting (called
healthcare-associated UTIs) or elsewhere (called
community-acquired UTIs). UTIs are the most common
type of healthcare-associated infection, often
following urinary catheterization.
- Escherichia coli is the number one cause of
UTIs.
Infections of the Genital Tract
Common Bacterial Sexually Transmitted Diseases
Table 19-9 contains information pertaining to common
bacterial STDs.
Less Common Bacterial Sexually Transmitted
Diseases
Other bacterial pathogens may also be sexually
transmitted. Three bacterial STDs, seen more often in
parts of the world other than in the United States, are
chancroid, granuloma inguinale, and lymphogranuloma
venereum (LGV). Chancroid is caused by the Gram-
negative bacterium Haemophilus ducreyi. Granuloma
inguinale is a chronic infection caused by a Gram
negative bacterium named Calymmatobacterium
granulomatis (Donovania granulomatis). LGV is a
chlamydial infection involving the lymph nodes, rectum,
and reproductive tract. It is caused by certain serotypes
of Chlamydia trachomatis. It should be noted that many
STDs are transmitted simultaneously; thus, when a
patient is diagnosed with one STD, others should be
sought.
- Chlamydia trachomatis is the most common
sexually transmitted pathogen. Genital
chlamydiasis is the most commonly reported
nationally notifiable disease in the United States.
Bacterial Infections of the Circulatory System
Rickettsial and Ehrlichial Infections of the
Cardiovascular System
Recall that rickettsias and ehrlichias are obligate
intracellular, Gram-negative bacteria. Table 19-10
contains information pertaining to rickettsial and
ehrlichial diseases of the cardiovascular system.
Other Bacterial Infections of the Cardiovascular Recap of Major Bacterial
System Infections of Humans
Table 19-14 provides a recap of some major Bacterial
Infective Endocarditis infections of humans.
Infective (or infectious) endocarditis is usually caused by
a bacterium or a fungus. It is characterized by the Recap of Major Bacterial Pathogens of Humans
presence of vegetations (combinations of bacteria and Table 19-15 and Figure 19-13 provide a recap of some
blood clots) on or within the endocardium, most major bacterial pathogens of humans.
commonly involving a heart valve. Abnormal or damaged
valves are most susceptible to infection, although valves Appropriate Therapy for Bacterial Infections
can become contaminated during open heart surgery. Recommendations for the treatment of infectious
The vegetations can break loose and be transported to diseases change frequently. The bacterial infections
vital organs, where they can block arterial blood flow. described in this chapter must be treated using
Obviously, such obstructions are very serious, possibly appropriate antibacterial drugs. For certain bacterial
leading to strokes, heart attacks, and death. The two diseases, antisera (e.g., for botulism and tetanus) are
most common types of infective endocarditis are acute available for treatment. Additional information about
bacterial endocarditis and subacute bacterial antibacterial agents can be found in Chapter 9 and at
endocarditis (SBE). Acute bacterial endocarditis is en.wikipedia.org/wiki/Antibiotics.
usually caused by colonization of heart valves by virulent
bacteria such as Staphylococcus aureus (the most
common cause), Streptococcus pneumoniae, Neisseria
gonorrhoeae, Streptococcus pyogenes, and
Enterococcus faecalis. In SBE, heart valves are infected
by less virulent organisms such as α-hemolytic
streptococci of oral origin (viridans streptococci),
Staphylococcus epidermidis, Enterococcus spp., and
Haemophilus spp. Fungal endocarditis is rare, but cases
of Candida and Aspergillus endocarditis do occur. Oral
streptococci can enter the bloodstream following minor
or major dental procedures, oral surgery, and aggressive
tooth brushing. Phlebotomy procedures and insertion of
intravenous (IV) lines sometimes force organisms from
the skin into the bloodstream. IV drug users are at high
risk of developing infective endocarditis as a result of
contaminated needles, syringes, and drug solutions.
Blood cultures are required for diagnosis of infective
endocarditis. Treatment will depend on the specific
pathogen involved and the antimicrobial susceptibility
results. Additional information pertaining to bacterial
infections of the cardiovascular system is contained in
Table 19-11.
- Lyme disease is the most common arthropod-
borne disease in the United States.

Bacterial Infections of the Central Nervous System

Bacteria that can cause meningitis were discussed
under “Infections of the CNS Having Multiple Causes” in
Chapter 17. Additional information pertaining to bacterial
infections of the CNS is contained in Table 19-12.

Diseases Caused by Anaerobic Bacteria

Some of the human diseases caused by anaerobic
bacteria (usually referred to as “anaerobes”) are shown
in Figure 19-12 and Table 19-13. Many infections that
involve anaerobes are synergistic or polymicrobial
infections.

Diseases Associated with Biofilms

Recall from Chapter 10 that biofilms are complex and
persistent communities of assorted microbes. Biofilms
exist in many environments, including certain anatomical
sites within the human body. Listed here are some of the
human diseases that are known to or thought to be
associated with biofilms:
Bacterial endocarditis
Central venous catheter infection
Chronic wounds
Cystic fibrosis lung infections
Gingivitis
Infection of prosthetic joints, heart valves, and
intrauterine
devices
Infectious kidney stones
Middle ear infectionsNecrotizing fasciitis
Osteomyelitis
Periodontitis
Prostatitis
Sinusitis
Tooth decay
Urinary catheters
UTIs