Anaerobic bacterial infection

Ike Irmawati P.A

Mikrobiologi FK Universitas Yarsi

Introduction
Medically important infections caused by
anaerobic bacteria common
The infections Polymicrobial

Where Anaerobes are Found

they are found in soil, fresh and salt water, and in
normal flora of humans and animals
Anaerobes that live outside the body are called
exogenous anaerobes (Example: Clostridium
species)
Anaerobes that live inside the body are called
endogenous anaerobes skin, mucosal surface &
concentration in : mouth & GIT as normal
flora
Most anaerobic infections are from endogenous
sources

Physiology & Growth Condition for

anaerob

Do not require oxygen for growth - often

extremely toxic

Anaerobes require environments with :

low / negative oxidation-reduction potential (Eh)
pH

Obligate (strict) anaerobes

Do not have cytochrome system for
O2 metabolism
no oxidative phosphorylation
fermentation
killed by oxygen
lack certain enzymes
superoxide dismutase
* O2-+2H+
H2O2
catalase
* H2O2
H20 + O2
peroxidase
* H2O2
H20 /NAD to NADH

Strict anaerobe infectious disease

Sites throughout body

Muscle, cutaneous/sub-cutaneous necrosis
Abscesses

Bacterial Flora of the Body

Site

Total Bacteria
(per/ml or gm)

Ratio
Anaerobes : Aerobes

Upper Airway
Nasal Washings 103-104
3-5:1
Saliva
108-109
1:1
Tooth Surface
1010-1011
Gingival Crevice 1011-1012
1000:1
Gastrointestinal Tract
Stomach
102-105
Small Bowel
102-104
Ileum
104-107
Colon
1011-1012
Female Genital Tract
Endocervix
108-109
Vagina
108-109

1:1
1:1
1:1
1000:1

3-5:1
3-5:1

1:1

Virulence Factors
1. Anti-phagocytic capsule/ Polysaccharide
capsule
Also promote abscess formation

2. Tissue destructive enzymes

Bacterioides fragilis produces variety of enzymes
(lipases, proteases, collagenases) that destroy
tissue Abscess Formation

3. Beta-lactamase production
B. fragilis protect themselves and other species in
mixed infections

4. Superoxide dismutase production

Protects bacteria from toxic O2 radicals as they move
out of usual niche

5. Lipopolysaccharide
promotes abscess formation, enhanced
coagulation

6. Short chained fatty acids

a. Butyrate - seen in dental plaque
b. Succinic acid reduces phagocytic killing

Characteristics of Anaerobic Infections

1. Most pathogenic anaerobes are usually
commensals
Originate from our own flora

2. Predisposing Conditions

Characteristics of Anaerobic Infections

3. Complex Flora
Multiple species
Abdominal Infection Average of 5 species
3 anaerobic
2 aerobic
Less complex then normal flora
Fecal flora 400 different species
Those predominant in stool are not infecting
species
Veillonella, Bifidobacterium rarely
pathogenic

Characteristics of Anaerobic Infections

4. Synergistic Mixture of Aerobes & Anaerobes

E. coli Consume O2
Allow growth of anaerobes

Anaerobes promote growth of other bacteria

by being antiphagocytic and producing lactamases

Indications of Anaerobic Infections

Usually purulent (pus-producing)

Close proximity to a mucosal surface

Infection persists despite antibiotic therapy

Presence of foul odor

Presence of large quantities of gas (bubbling or cracking sound when

tissue is pushed)

Presence of black color or brick-red fluorescence

Presence of sulfur granules

Distinct morphologic characteristics in gram-stained preparation

Polimicrobial flora

Failure to grow in the lab

Anaerobic Bacteria of Medical Interest

Pathogenesis of anaerobic infections

Contamination of site with spores
Factors which promote anaerobiasis
crush injuries with interruption of blood supply,
contamination with foreign bodies (dirt), tissue damage
Germination of spores
Toxin release
Binding of toxin to receptor
Resulting effect produces symptom(s) of disease

Gram-positive anaerobes
Actinomyces (head, neck, pelvic infections; aspiration
pneumonia)
Bifidobacterium (ear infections, abdominal infections)
Clostridium (gas, gangrene, food poisoning, tetanus,
pseudomembranous colitis)
Peptostreptococcus (oral, respiratory, and intra-abdominal
infections)
Propionibacterium (shunt infections)

Gram-negative anaerobes
Bacterioides (the most commonly found anaerobes in
cultures; intra-abdominal infections, rectal abscesses,
soft tissue infections, liver infection)
Fusobacterium (abscesses, wound infections, pulmonary
and intracranial infections)
Porphyromonas (aspiration pneumonia, periodontitis)
Prevotella
infections)

(intra-abdominal

infections,

soft

tissue

Gram positive anaerob

Clostridium

General characteristics
gram-positive, spore-forming bacilli
obligate anaerobes
motile -- peritrichous flagella
(exception: C. perfringensnonmotile)
Group :
- histotoxic clostridia invasive
- tissue infection wound infection
- neurotoxic clostridia not invasive

Clostridium

C. tetani
C. botulinum
C. perfringens
C. difficile

C. tetani
Characteristics
anaerobic grampositive rod that forms
terminal spores
motile with peritrichous
flagella
Eh +10 mV
tetanospasmin

toxin

Pathogenicity
portal of entry wound
conditions of infection
regional anaerobic environment
deep and narrow wound, contamination of soil
or foreign bodies
necrotic tissues
contamination of aerobes or facultative
anaerobes

Pathogenicity
Virulence factors
Tetanospasmin
Protein (neurotoxin)
Heat-labile (65, 30min)
Mechanisms

Mechanisms of tetanospasmin
toxin peripheral nerve fibers / lymph and
blood spinal cord and brain stem inhibitory
interneuron blocks the release of
neurotransmitters from the presynaptic
membrane of inhibitory interneurons inhibit the
motor neuron spastic paralysis (rigid paralysis)

excitatory transmitter: acetylcholine

inhibitory transmitter: glycine and aminobutyric acid
31

Mechanisms of tetanospasmin

spastic paralysis (rigid paralysis)

Control
Proper care of wounds: surgical debridement
Active immunization: tetanus toxoid
* for children immunization: DPT(diphtheria toxoid,
pertussis vaccine, tetanus toxoid)
* for a high-risk group : toxoid booster
Passive immunization: tetanus antitoxin
urgent prevention (along with toxoid)
As soon as possible
Special treatment
administration of antibiotics
supportive measures

C.perfringens
Characteristics
Shape and structure
Subterminal endospore
Capsule
Nonmotile

 Classification
five toxigenic types (A through E)

toxin: the most potent toxin

exhibits lecithinase activity

destroys erythrocytes, leukocytes, and
platelets hemolysis, tissue necrosis

 Cultivation
anaerobic
double zones of hemolysis
carbohydrate fermentation
(lactose)
Inner zone: toxin
complete
Outer zone: toxin
Incomplete

Stormy
fermentation

Virulence factors
toxin
produced by all strains
acts as a lecithinase
diagnosis: Nagler reaction--egg yolk agar

Pathogenicity
Virulence factors
Enterotoxin
produced by types A(most), C, and D
heat-labile

Others
collagenase, hemolysin, proteinase, DNase
(deoxyribonuclease)

Pathogenicity
Disease
Gas gangrene
Transmission: trauma
Pathogens: 60 80 cases by
type A
Bacteria contaminated wound
infection toxin caused tissue
necrose CO2 & H2

Pathogenicity
Food poisoning
transmission: gastrointestinal tract
pathogens: type A
manifestation: short incubation period (8-24
hrs)
acute diarrhea incubation time 8-24 hour

Control

Care of trauma: debridement

Antimicrobial therapy
Antitoxin
Hyperbaric oxygen
Symptomatic care for food poisoning

C. botulinum
Characteristics
Gram positive rod
Subterminal
endospore
Noncapsule
Obligate anaerobe

Pathogenicity
Virulence factorbotulinum toxin
neurotoxin
relatively heat-labile and resistant to protease
types: A, B, C, D, E, F, G
the most potent toxic material known

mechanism of action

Toxin gut blood cholinergic synapses block the

release of exciting neurotransmitter, e.g., acetylcholine
flaccid paralysis

Mechanisms of botulinum toxin

flaccid paralysis

45

Pathogenicity
DiseaseBotulism
from Latin botulus, "sausage"

Food poisoning
Infant botulism
Wound botulism

Sausages, seafood
products, milk, and
canned vegetables

Honey

46

Pathogenicity
Disease
Food poisoning
manifestation:
flaccid paralysis: double vision, dysphagia,
difficulty in breathing and speaking
cause of death: respiratory failure

Pathogenicity
Disease
infant botulism
manifestation: constipation, poor feeding,
difficulty in sucking and swallowing, weak
cry, loss of head control.
Floppy baby
prevention: free of honey

Pathogenicity
Disease
wound botulism
Rare
Transmission: trauma

Botox treatment relaxes muscle

spasms

C. difficile
Normal flora gut

Pathogenicity
Virulence factor
exotoxin A: enterotoxin
exotoxin B: cytotoxin
Disease
pseudomembranous colitis
antibiotic-associated diarrhea
* Diagnose cytotoxin in feses

Control
Treatment
discontinuation of causative antibiotics
administration of sensitive antibiotics

Prevention
no vaccine
use antibiotics only in necessary

Actinomyces
Normal flora : Upper respiratory tract, GI tract, female
genital tract
Low virulence
Produce disease mucosal barrier is breached
Caused actinomycosis
Species Actinomyces israelii
Gram positive bacilli
Beaded filament, Branched or unbranched, Diphtheroid-like
Grow slowly
Molar teeth colony
Diagnosis : gram stain of sulphur granule
culture

Propionibacterium

Normal flora of the skin

Gram staining pleomorfic
Metabolic product propionic acid
Patogenesis acne

Lactobacillus
Normal flora vagina & gastrointestinal
Lactic acid product low pH normal
adult female genital tract
Rarely caused disease

Eubacterium, Bifidobacterium &

Arachnia
Pleomorphic
Mixed infection with oropharyngeal
& bowel flora

Peptostreptococcus

Gram positive cocci

Normal flora skin & mucous membrane
mixed infection
Culture from breast, brain & pulmonary
infection

Gram negative anaerob

Bacteroides

Gram negative bacilli, coccobacilli

Many species reclasified genus prevotella & porphyromonas
Normal flora GIT normal stool B. fragilis 10 11 / gram
Spesies :
- B. fragilis
- B. ovatus
- B. distaconis
- B. vulgatus
- B. thethaiotamicron

* Identification based : colony, biochemical reaction & characteristic

of shorth-chain fatty acid

Bacteroides
Manifestation :
- intra-abdomen abcess
- peritonitis trauma on tractus digestivus
- B. fragilis & B. thetaiotaomicron pelvis inflamation
disease & abses ovarium
Factor virulensi :
1. polisaccharida capsule antifagosit & abcess
formation
2. lipopolisakarida /endotoksin << toxic than other
gram negative

 These bacteria are resistant to penicillins,

mostly through the production of betalactamase.
Enterotoxigenic B fragilis (ETBF) is also a
potential cause of diarrhea.

Treatment is complicated by 3 factors:

slow growth,
increasing resistance to antimicrobial
agents
the polymicrobial synergistic nature of
the infection.

Prevotella
Gram negative bacilli, cocobacilli
Species :
- P. melaninogenica respiratory tract infection
- P. bivia & P. disiens genital tract infection
Manifestation :
- brain abcess, pulmonary abcess
- pelvic inflammatory diseases
- abcess tubo-ovarian

Porphyromonas
Gram negative bacilli
Normal oral flora
Isolation from :
- gingival & periapical tooth infection
- breast
- perianal & male genital infection

Fusobacterium
Pleomorphic gram-negative rods
Produce butyric acid & convert threonin propionic
acid
Isolated from mixed bacterial infection caused by
normal mucosa flora

Veillonella
Gram negative cocci
Normal flora mouth, nasopharyx, intestine
Rarely cause infection

Problems in identification of
anaerobic infections
air in sample (sampling, transportation)
no growth
identification takes several days or longer
limiting usefulness
often derived from normal flora
sample contamination can confuse

Diagnosis of anaerobic infection

Clinical sign :
1. foul smelling discharge short-chain fatty acid product
2. infection in proximity to a mucosal surface
3. gass in tissue CO2 & H2
4. negative aerobic culture
Anaerobic culture, transported specimen !!!
Identification :
- colony morphology
- pigmentation, fluorescence
- biochemichal reaction
- production of short-chain fatty acid gas-liquid
chromatography

LABORATORY DIAGNOSIS
A. COLLECTION
Anaerobes are endogenous in nature
I. Appropriate specimens for anaerobic
culture :
1. pus
2. pleural fluid
3. urine
4. pulmonary secretions
5. uterine secretions or sinus tract
material

Aspiration is ideal
Avoid Swabs
II. Collection by needle

aspiration is
preferable than swab
culture because of
a. better survival of
pathogen
b. greater quantity of
specimen
c. less contamination
with extraneous
organism are often
achieved

Anaerobic Culture Methods

Anaerobic jar

* Production of a vacuum
Displacement of Oxygen
with other gases
Absorption of Oxygen
by chemical or
biological methods
By using reducing
agents

Treathment of anaerobic infection

Mixed anaerobic infection surgical drainage &
antimicrobial therapy
Antibiotic :
- Penicillin G not for -lactamase-producing bacteria
- clindamycin
- metronidazole