BAKTERI ANAEROB

MORFOLOGI, FISIOLOGI, EPIDEMIOLOGI, DIAGNOSIS, PEMERIKSAAN Sy. Miftahul El J.T

Figure 4-1 Catabolism of proteins, polysaccharides, and lipids produces glucose, pyruvate, or intermediates of the tricarboxylic acid (TCA) cycle and, ultimately, energy in the form of adenosine triphosphate (ATP) or the reduced form of nicotinamideadenine dinucleotide (NADH).
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Oksigen berdasarkan keperluan oksigen dibagi dalam 5 kelompok

Group

Environment
Aerobic Anaerobic No growth

O2 Effect

Obligate Aerobe Microaerophile Obligate Anaerobe Facultative Anaerobe (Facultative Aerobe)

Growth

Required (utilized for aerobic respiration) Required but at levels below 0.2 atm Toxic

Growth if level No growth not too high No growth Growth

Growth

Growth

Not required for growth but utilized when available

Aerotolerant Anaerobe

Growth

Growth

Not required and not utilized

BAKTERI ANAEROB GRAM POSITIP BERSPORA [CLOSTRIDIUM spp]

Genus ini meliputi kuman berbentuk batang pleimorf, spora lebih besar dari badan kuman, anaerob obligat Gram-positive rods capable of forming endospores was placed in the genus Clostridium. This genus was defined by four properties: (1) presence of endospores, (2) strict anaerobic metabolism,

(3) inability to reduce sulfate to sulfite, and

(4) Gram-positive cell wall structure

 The organisms are ubiquitous in soil, water, and sewage and are part of
the normal microbial flora in the gastrointestinal tracts of animals and humans. Most clostridia are harmless saprophytes

The majority of infections seen today are skin and soft-tissue infections,
food poisoning, and antibiotic-associated diarrhea and colitis. The remarkable capacity of clostridia to cause diseases is attributed to their (1) ability to survive adverse environmental conditions through spore formation; (2) rapid growth in a nutritionally enriched, oxygen-deprived environment (3) production of numerous histolytic toxins, enterotoxins, and neurotoxins.

Species C. difficile C. perfringens

Human Disease Antibiotic-associated diarrhea, pseudomembranous colitis

Frequency Common

C. septicum C. botulinum C. tetani C. tertium C. baratii C. butyricum C. clostridioforme

Soft-tissue infections (e.g., cellulitis, suppurative myositis, Common myonecrosis, gas gangrene), food poisoning, enteritis necroticans, septicemia Gas gangrene, septicemia Uncommon Botulism Tetanus Opportunistic infections Botulism Botulism Opportunistic infections Uncommon Uncommon Uncommon Rare Rare Rare

C. histolyticum
C. innocuum

Gas gangrene
Opportunistic infections

Rare
Rare

C. novyi C. sordellii C. sporogenes

Gas gangrene Gas gangrene Opportunistic infections

Rare Rare Rare

Clostridium tetani
Differential diagnosa Kuman berbentuk panjang langsing, agak bengkok, Gram +/P, ukuran 4,8 x 0,5, tunggal atau berbentuk rantai Spora bulat, terminal [seperti pemukul genderang], tidak berkapsul dan motil Suhu pertumbuhan optimum 370C dan pH 7,4 Tumbuh baik pada media agar darah dengan zona hemolisa alfa kemudian menjadi beta akibat pembuatan hemolisin [tetanolisin]

Toksin, membentuk 3 jenis toksin :

Hemolisin [tetanolisin]
Termolabil, tidak tahan terhadap oksigen, bekerja aktif pada SDM dari sebagian besar binatang[ kelinci, kuda dll] Peran belum jelas mungkin bekerja sebagai lekosidin

Neurotoksin [tetanospasmin]
Tahan terhadap oksigen dan diinaktifkan pada 660C selama 5 mnt. dapat dibuat toksoid dengan penambahan formaldehid konsentrasi rendah Bekerja seperti striknin dengan menghambat sintesis dan pelepasan asetilkolin sehingga menganggu transmisi neuromuskuler. Zat ini akan terikat kuat pada ganglion otak menyebabkan penghambatan neuron spinal pasca sinaps dengan mencegah pelepasan perantara penghambat [inhibitory mediator] kejang otot menyeluruh, reflek yang berlebihan dan serangan kejang berulang.

Neurotoksin non-spasmogenik yang bekerja di saraf perifer

Gram stain of Clostridium tetani. Note the terminal spores.

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Clostridium tetani

Patogenesis
Kuman tidak bersifat invasif, akan tetap diluka, dapat menjadi bentuk vegetatif bila kondisi mendukung/anaerob, misalnya adanya:
Jaringan nekrotik Garam kalsium Kuman piogenik Beberapa jenis tetanus : 1. Tetanus neonatorum : akibat pencemaran luka pemotongan tali pusat bayi, angka kematian tinggi 2. Tetanus pasca keguguran dan masa nifas; akibat Infeksi saluran kelamin oleh alat bantu persalinan dan pembalut 3. Splanchnic tetanus: terjadinya kekejangan otot otot menelan dan pernafasan 4. Cephalic tetanus: luka di daerah kepala akan terjadi kontraksi otot otot muka unilateral dan bilateral

Facial spasm and risus sardonicus in a patient with tetanus. (From Cohen J, Powderly WG: Infectious diseases, ed 2, St Louis, 2004, Mosby).

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A child with tetanus and opisthotonos resulting from persistent spasms of the back muscles. (From Emond RT, Rowland HAK, Welsby P: Colour atlas of infectious diseases, ed 3, London, 1995, Wolfe.)
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Clostridium tetani
Diagnosa laboratorium Pemeriksaan mikroskopis: sampel diambil dari luka, diwarnai Gram +/P seperti pemukul genderang Biakan: potongan jaringan nekrotik dibiakkan pada kaldu daging/agar darah Percobaan binatang : untuk melihat toksigenitas kuman, digunakan mencit yang disuntikan 0,2 ml suspensi kuman pada pangkal ekor, kemudian dilihat mulai

terjadinya kekejangan
Pencegahan & pengobatan Pembersihan luka

Imunisasi aktif dengan toksoid

Imunisasi pasif dengan ATS Pemberian antibiotik :Penicillin

PENCEGAHAN TETANUS PADA LUKA

Keadaan luka Keadaan kekebalan Kebal Kebal sebagian Tidak kebal

Bersih [kecelakaan rumah dlm 6 jam

Tercemar [tanah, ada jaringan nekrotik]

1 x toksoid
1 x toksoid

1 x toksoid
1 x toksoid ATS, Antibiotik

3 x toksoid
3 x toksoid ATS, Antibiotik

Terinfeksi

1 x toksoid Antibiotik

1 x toksoid Ats, Antibiotik

3 x toksoid ATS, Antibiotik

Catatan : Kebal :Artinya telah menerima dosis lengkap berupa 3 x penyuntikan toksoid Kebal sebagian :artinya telah menerima 2 x suntikan toksoid Tidak kebal : artinya belum menerima toksoid atau keadaan kekebalan tidak diketahui

Clostridium perfringens
Dahulu dikenal C. welchii, merupakan salah satu penyebab ganggren gas, keracunan makanan oleh enterotoksin yang termolabil atau enteritis nekrotik

C. perfringens can be associated with simple colonization or can cause lifethreatening disease. C. perfringens is a large (0.6 to 2.4 1.3 to 19.0 m), rectangular, Gram-positive rod , with spores rarely observed either in vivo or after in vitro cultivation.

This organism is one of the few nonmotile clostridia, but rapidly spreading growth on
laboratory media (resembling the growth of motile organisms) is characteristic (GAMBAR 2). The organism grows rapidly in tissues and in culture, is hemolytic, and is metabolically active, features that make possible its identification in the laboratory.

The production of one or more major lethal toxins by C. perfringens (alpha [], beta
[], epsilon [], and iota [] toxins) is used to subdivide isolates into five types (A through E; TABEL). Type A C. perfringens causes most of the human infections in the United States.

Gram stain of Clostridium perfringens.

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GAMBAR 2. Growth of Clostridium perfringens on sheep blood agar. Note the flat, spreading colonies and the hemolytic activity of the organism. A presumptive identification of C. perfringens can be made by detection of a zone of complete hemolysis (caused by the ;-toxin) and a wider zone of partial hemolysis (caused by the ;-toxin), combined with the characteristic microscopic morphology.
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Type

A B C D E

Lethal Toxins Alpha Beta Epsilon + + + + + + + + + -

Iota +

Distribution of Lethal Toxins in Clostridium perfringens Types A to E

Growth of Clostridum perfringens on egg-yolk agar. The ;-toxin (lecithinase) hydrolyzes phospholipids in serum and egg yolk, producing an opaque precipitate (right). This precipitate is not observed when the organism is grown in the presence of antibodies against the toxin (left). This reaction (Nagler's reaction) is characteristic of C. perfringens.
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Virulence Factors -Toxin

Biologic Activity Lethal toxin; phospholipase C (lecithinase); increases vascular permeability; hemolysin; produces necrotizing activity, as seen in myonecrosis Lethal toxin; necrotizing activity Lethal toxin; permease Lethal binary toxin; necrotizing activity; adenosine diphosphate (ADP) ribosylating Hemolysin Heat- and oxygen-labile hemolysin; cytolytic Collagenase; gelatinase; necrotizing activity Protease Hyaluronidase Deoxyribonuclease; hemolysin; necrotizing activity Alters membrane permeability in ileum (cytotoxic, enterotoxic); superantigen

-Toxin -Toxin -Toxin -Toxin -Toxin -Toxin -Toxin -Toxin -Toxin Enterotoxin

Pada ganggren gas, karbohidrat akan dihancurkan dengan pembentukan gas

karena ada septikemia, terjadi hemolisis intravaskuler.

Pada keracunan makanan, enterotoksin merangsang enzim adenylate cyclase pada dinding usus bertambahnya konsentrasi cAMP hipersekresi air dan Cl dalam usus menghambat reabsorpsi Na Diare [selama 1-3 hari]

Diagnosa laboratorium
Spesimen dari luka, pus, jaringan atau makanan Mikroskopis: Gram +/P, batang tanpa spora Biakan: di tanam pada agar tioglikolat, agar darah secara an aerob

Pengobatan
Pembersihan luka secara bedah pada jaringan nekrotik Antibiotik : Penisilin Hyperbaric oxygen

Clostridial cellulitis. Clostridia can be introduced into tissue during surgery or by a traumatic injury. This patient suffered a compound fracture of the tibia. Five days after the injury, the skin became discolored and bullae and necrosis developed. A serosanguineous exudate and subcutaneous gas were present, but there was no evidence of muscle necrosis. The patient had an uneventful recovery. (From Lambert H, Farrar W, editors: Infectious diseases illustrated, London, 1982, Gower.)
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Clostridium botulinum
Terdapat secara luas di alam, kadang terdapat pada feses binatang C. botulinum, the etiologic agent of botulism, is a heterogeneous group of large (0.6 to 1.4 3.0 to 20.2 m), fastidious, spore-forming, anaerobic rods Berdasarkan sifaT biokimia ada 2 jenis : Proteolitik [jenis A, B dan F], jenis sakarolitik dan tidak proteolitik [Jenis C, D, dan E ] semua jenis kelompok ini menghasilkan sulfida Dosis letal untuk manusia : 1 mikrogram Tidak menyebabkan infeksi luka, tetapi menyebabkan keracunan makanan, akibat toksin yang termakan. Umumnya makanan yang tercemar adalah makanan yang berbumbu, diasap, kalengan tanpa dimasak terlebih dahulu. Kerja toksin akan memblokir pembentukan/pelepasan acetyl cholin pada hubungan saraf otot sehingga terjadi kelumpuhan otot. Gejala 18-96 jam makan toksin dengan keluhan penglihatan, hal ini terjadi karena tidak ada koordinasi. Sulit menelan, sulit bicara. Kematian terjadi karena paralisis otot pernafasan atau kelumpuhan jantung [cardiac arrest] Other species of clostridia produce botulinum toxins, including C. butyricum (type E toxin), C. baratii (type F toxin), and Clostridium argentinense (type G toxin). Human disease has only rarely been associated with C. butyricum and C. baratii, and not definitively demonstrated with C. argentinense.

Group I II III IV

Neurotoxin Type A, B, F B, E, F C, D G

Phenotyptic Properties Proteolytic, saccharolytic Nonproteolytic, saccharolytic

Weakly proteolytic, saccharolytic Weakly proteolytic, asaccharolytic

Clostridium botulinum Classification and Toxin Production

Clostridium botulinum
Diagnosa laboratorium : mendeteksi toksin yang ada didalam serum penderita atau dari sisa makanan. Pendeteksian dilakukan dengan reaksi Netralisasi antigen-antibodi secara agglutinasi SDM yang dilapisis antiserum. Percobaan mencit yang disuntikkan bahan tersangka. Pengobatan:Pemberian antitoksin polivalen [tipe A,B dan C] secara IV dan secara simptomatik terutama untuk pernafasan Pencegahan: Makanan yang diawetkan harus dimasak dahulu secara baik, makanan yang perlu diperhatikan : Kacangkacangan, jagung, ikan asap atau ikan segar dalam plastik

Clostridium botulinum

CLOSTRIDIUM DIFFICILE
Until the mid-1970s the clinical importance of C. difficile was not appreciated. This organism was infrequently isolated in fecal cultures and its role in human disease was unknown. Systematic studies now clearly show, however, that toxin-producing C. difficile is responsible for antibiotic-associated gastrointestinal diseases , ranging

from a relatively benign, self-limited diarrhea to severe,

life-threatening pseudomembranous colitis (GAMBAR).

Antibiotic-associated colitis: gross section of the lumen of the colon. Note the white plaques of fibrin, mucus, and inflammatory cells overlying the normal red intestinal mucosa.
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Antibiotic-associated colitis caused by Clostridium difficile. A histologic section of colon shows an intense inflammatory response, with the characteristic "plaque" (black arrow) overlying the intact intestinal mucosa (white arrow). (Hematoxylin and eosin stain.) (From Lambert HP, Farrar WE, editors: Infectious diseases illustrated, London, 1982, Gower.)
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Virulence Factor Enterotoxin (toxin A)

Cytotoxin (toxin B) Adhesin factor Hyaluronidase Spore formation

Biologic Activity Produces chemotaxis; induces cytokine production with hypersecretion of fluid; produces hemorrhagic necrosis Induces depolymerization of actin with loss of cellular cytoskeleton Mediates binding to human colonic cells Produces hydrolytic activity Permits organism's survival for months in hospital environment

. Virulence Factors Associated with Clostridium difficile

ANAEROB, GRAM POSITIP, TIDAK MEMBENTUK SPORA

The anaerobic gram-positive cocci and non- spore-forming rods are a heterogeneous group of bacteria that characteristically colonize the skin and mucosal surfaces. These organisms are opportunistic pathogens, typically responsible for endogenous infections and usually recovered in mixtures of aerobic and anaerobic bacteria.

Most of these anaerobes have fastidious nutritional requirements and grow

slowly on laboratory media. Thus the isolation and identification of individual strains are difficult and often time consuming.

Organism Anaerobic Cocci Anaerococcus Finegoldia Micromonas Peptostreptococcus Schleiferella Anaerobic Rods Actinomyces Bifidobacterium Eubacterium Lactobacillus Mobiluncus Propionibacterium propionicum

Historical Derivation an, without; aer, air; coccus, berry or coccus (anaerobic coccus) Named after the American microbiologist S. Finegold micro, tiny; monas, cell (tiny cell) pepto, cook or digest (the digesting streptococcus) Named after the German microbiologist K.H. Schleifer aktinos, ray; mykes, fungus (ray fungus referring to the radial arrangement of filaments in granules) bifidus, cleft; bakterion, small rod (a small clefted or bifurcated rod) eu, good or beneficial (a beneficial rod; that is, a rod normally present) acto, milk (milk bacillus; organism originally recovered in milk; also, lactic acid is the primary metabolic product of fermentation) mobilis, capable of movement or being active; uncus, hook (motile, curved rod) propionic acid (propionic acid is the primary metabolic product of fermentation)

Important Anaerobic Gram-Positive Bacteria

ACTINOMYCES
Actinomyces organisms are facultatively anaerobic or strictly anaerobic, gram-positive rods. They are not acid-fast (in contrast to the morphologically similar Nocardia species),

They grow slowly in culture, and they tend to produce chronic, slowly developing infections.
They typically develop delicate filamentous forms or hyphae (resembling fungi) in clinical specimens or when isolated in culture (GAMBAR.

However, these organisms are true bacteria in that they lack mitochondria and a nuclear
membrane, reproduce by fission, and are inhibited by penicillin but not antifungal antibiotics. Numerous species have been described; Actinomyces israelii, Actinomyces

meyeri, Actinomyces naeslundii, Actinomyces odontolyticus, and Actinomyces viscosus are

responsible for most human infections. Only A. meyeri is a strict anaerobe. The other species grow best in anaerobic conditions but

can grow aerobically.

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

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PATHOGENESIS AND IMMUNITY

Actinomyces organisms colonize the upper respiratory, gastrointestinal, and female genital tracts. These bacteria are not normally present on the skin surface. The organisms have a low virulence potential and cause disease only when the normal mucosal barriers are disrupted by trauma, surgery, or infection. Disease caused by actinomyces is termed actinomycosis (in keeping with the original idea that these organisms were fungi or "mycoses"). Actinomycosis is characterized by the development of chronic granulomatous lesions that become suppurative and form abscesses connected by sinus tracts. Macroscopic colonies of organisms resembling grains of sand can frequently be seen in the abscesses and sinus tracts. These colonies, called sulfur granules because they appear yellow or orange, are masses of filamentous organisms bound together by calcium phosphate (GAMBAR).

Sulfur granule collected from the sinus tract in a patient with actinomycosis. Delicate filamentous rods (arrow) are seen at the periphery of the crushed granule.
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EPIDEMIOLOGY
Actinomycosis is an endogenous infection with no evidence of person-to-person spread or disease originating from an external source, such as soil or water. Disease is classified according to the organ systems involved. Cervicofacial infections are seen in patients who have poor oral hygiene or have undergone an invasive dental procedure or oral trauma. In these patients, Patients with thoracic infections generally have a history of aspiration, with the disease becoming established in the lungs and then spreading to adjoining tissues. Abdominal infections most commonly occur in patients who have undergone gastrointestinal surgery or

have suffered trauma to the bowel. Pelvic

infection can be a secondary manifestation of abdominal actinomycosis or may be a primary infection in a woman with an intrauterine device (Central nervous system infections usually represent hematogenous spread from another infected tissue, such as the lungs.

the actinomyces that are present in the

mouth invade into the diseased tissue and initiate the infectious process.

TREATMENT, PREVENTION, AND CONTROL

Treatment for actinomycosis involves the combination of surgical The clinical response is generally good even in patients who have suffered extensive tissue destruction. Maintenance of good oral hygiene are uniformly and the use of appropriate antibiotic prophylaxis when the mouth or gastrointestinal tract is penetrated can lower the risk of these infections.

dbridement of the involved tissues

and the prolonged administration of

antibiotics. Actinomyces

susceptible to penicillin (considered the antibiotic of choice),

erythromycin, and clindamycin. Most species are resistant to

metronidazole, and the tetracyclines

have variable activity.

Propionibacterium
Propionibacteria are small gram-positive rods often arranged in short chains or clumps

They are commonly found on the skin (in contrast with the actinomyces),
conjunctiva, external ear, and in the oropharynx and female genital tract. The organisms are anaerobic or aerotolerant, nonmotile, catalase positive, and capable

of fermenting carbohydrates. The two most commonly isolated species are

Propionibacterium acnes and Propionibacterium propionicus.

P. acnes is responsible for two types of infections:

(1) acne (as the name implies) in teenagers and young adults and (2) opportunistic infections in patients with prosthetic devices (e.g., artificial heart valves or joints) or intravascular lines (e.g., catheters, cerebrospinal fluid shunts). Propionibacteria are also commonly isolated in blood cultures, but this finding usually represents contamination with bacteria on the skin at the phlebotomy site. Acne is unrelated to the effectiveness of skin cleansing because the lesion develops within the sebaceous follicles. For this reason, acne is managed primarily through the topical application of benzoyl peroxide and antibiotics. Antibiotics such as erythromycin and clindamycin have proved effective for treatment.

Mobiluncus
Members of the genus Mobiluncus are obligate anaerobic, gram-variable or The organisms are fastidious, growing slowly even on enriched media supplemented with rabbit or horse serum. Two species, Mobiluncus curtisii and Mobiluncus they are classified as gram-positive rods because they
(1) have a gram-positive cell wall, (2) lack endotoxin, and (3) Are susceptible to vancomycin, clindamycin, erythromycin, and ampicillin but resistant to colistin.

gram-negative,

curved

rods

with

tapered ends. Despite their appearance in Gram-stained specimens

mulieris,

have

been

identified in humans. The organisms colonize the genital tract in low numbers but are abundant in women

with bacterial vaginosis (vaginitis).

Lactobacillus
Lactobacillus species are facultatively anaerobic or strictly anaerobic rods. They are found as part of the normal flora of the mouth, stomach, The reason lactobacilli rarely cause infections of the urinary tract is their

inability to grow in urine. Invasion

into blood occurs in one of the following three settings: (1) transient bacteremia from a genitourinary source (e.g., after childbirth or a gynecologic procedure), (2)

intestines, and genitourinary tract. The organisms are most commonly

isolated in urine specimens and

blood cultures. Because lactobacilli are the most common organism in the urethra

endocarditis, and (3) opportunistic

septicemia

in

an

immunocompromised patient.

Lactobacillus
Treatment of endocarditis and opportunistic infections is difficult because lactobacilli are resistant to vancomycin (an antibiotic commonly

active against gram-positive bacteria) and are

inhibited but not killed by other antibiotics. A combination of penicillin with an aminoglycoside is required for bactericidal activity.

Bifidobacterium and Eubacterium

Bifidobacterium and Eubacterium species are commonly found in the oropharynx, large intestine, and vagina. These bacteria can be isolated in clinical specimens but have a very low virulence potential and usually represent clinically insignificant contaminants.

Anaerobic Gram-Negative Bacteria

The most important gram-negative anaerobes that colonize the human upper respiratory, gastrointestinal,

and genitourinary tracts are the rods in the genera

Bacteroides, Fusobacterium, Porphyromonas, and

Prevotella and the cocci in the genus Veillonella Among these pathogens, the most important is Bacteroides fragilis, the prototypical endogenous anaerobic pathogen.

Table . Virulence Factors in Anaerobic Gram-Negative Rods

Virulence Factor Adhesins Capsule Fimbriae Hemagglutinin Lectin Resistant to Oxygen Toxicity Superoxide dismutase Catalase Antiphagocytic Capsule Immunoglobulin (Ig)A, IgM, IgG proteases Lipopolysaccharide Succinic acid Bacteria Bacteroides fragilis, Prevotella melaninogenica B. fragilis, Porphyromonas gingivalis P. gingivalis Fusobacterium nucleatum Many species Many species B. fragilis, P. melaninogenica Porphyromonas spp., Prevotella spp. Fusobacterium sp Many species

Virulence Factor Tissue Destruction Phospholipase C Hemolysins Proteases Collagenase Fibrinolysin Neuraminidase Heparinase Chondroitin sulfatase Glucuronidases N-Acetylglucosaminidase Volatile fatty acids Toxin Enterotoxigenic toxin

Bacteria Fusobacterium necrophorum Many species Many species Many species Many species Many species Many species Many species Many species Many species Many species B. fragilis

Modified from Duerden B: Clin Infect Dis 18(suppl 4):S253-S259, 1994; and Lorber B: Bacteroides, Prevotella, Porphyromonas, and Fusobacterium species. In Mandell, Douglas and Bennett's principles and practice of infectious diseases, ed 6, New York, 2005, Churchill Livingstone.