Beruflich Dokumente
Kultur Dokumente
Ike Irmawati P.A, MSi Med Revised by eri dian Mikrobiologi FK Yarsi
Protective Mechanisms
Normal flora: Commensal organisms Limited to the upper tract Mostly Gram positive or anaeorbic Microbial antagonist (competition)
Protective Mechanisms
Clearance of particles and organisms from the respiratory tract For the upper respiratory tract : The mucociliary system in the nasopharynx The flushing action of saliva in the oropharynk
Bacterial Infections
Specific areas of the upper respiratory system can become infected to produce pharyngitis, laryngitis, tonsillitis, sinusitis, and epiglottis. These infections may be caused by several bacteria and viruses, often in combination.
Sore Throat
Clinical features: pharyngitis tonsillitis Causative organisms
mostly viral bacterial causes:
Streptococcus pyogenes
(Group A beta-haemolytic streptococci)
Less commonly: Corynebacterium diphtheriae, Group C and G beta-haemolytic streptococci, Arcanobacterium haemolyticum, Fusobacterium necrophorum, Haemophylus influenzae type B, Borrelia vincenti
SMEAR OF SPUTUM
In this smear of sputum there are large numbers of lancet-shaped gram-positive diplococci that represent pneumococcus and tangles of filamentous gram-positive organisms. In addition, however, in the background there are an even larger number of pleomorphic gram-negative bacilli that represent Haemophilus influenzae.
Acute Epiglottitis
Infective emergency Caused by Haemophilus influenzae capsular type B (Hib) Now very rare due to Hib vaccine program Can lead to acute respiratory obstruction
Diagnosis take blood cultures H. influenzae requires rich medium (e.g. lysed blood or chocolate agar) Requires X and V growth factors on nutrient agar Management Intravenous cefotaxime or ceftriaxone Isolate the patient Prevention Hib vaccine
Diphtheria
Acute toxin-mediated disease caused by Corynebacterium diphtheriae Gram-positive aerobic bacillus Incubation period 2-5 days Typically involves pharynx and tonsils leathery adherent membrane, which can cause respiratory obstruction Toxin effects Myocarditis Neuropathy
Streptococci
Characters of Streptococci
Gram positive cocci 1m in diameter Chains or pairs Usually capsulated Non motile Non spore forming Facultative anaerobes Catalase negative Of these organism considered in this chapter: S.pyogenes, S.pneumoniae, S.viridans
Classification of Streptococci
Streptococci can be classified according to:
Oxygen requirements
Anaerobic (Peptostreptococcus) Aerobic or facultative anaerobic (Streptococcus)
Group A S. pyogenes
Group B S. agalactiae
Group C S. equisimitis
Group D Enterococcus
Streptococci classified into many groups from A-K & H-V One or more species per group Classification based on C- carbohydrate antigen of cell wall Groupable streptococci A, B and D (more frequent) C, G and F (Less frequent) Non-groupable streptococci S. pneumoniae (pneumonia) viridans streptococci e.g. S. mutans Causing dental carries
-hemolysis
Complete hemolysis Clear zone of hemolysis around the colonies This hemolysis occurs due to an enzyme produced by bacteria called streptolysin. Streptolysin interacts with cholesterol in the cellular membrane resulting in deterioration of this protective celluler membrane e.g. Group A & B (S. pyogenes & S. agalactiae)
-hemolysis
No lysis e.g. Group D (Enterococcus spp)
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-hemolysis
-hemolysis
20
Virulence Factors
Protein F & lipoteichoic acid mediates epithelial cell attachment &adhesion M protein as antiphagositic The M protein has many antigenic varieties and thus, different strain of S.pyogenes cause repeat infections
Hyaluronic acid capsule, which acts to camouflage the bacteria Produce enzyme and hemolysins-contribute tissue invasion and destructions,i.e: streptolysin O,S,streptokinase,DNAse,&hyaluronidase Streptococcal Pyrogenic exotoxins that stimulate macrophages and helper T cells to release cytokines
S.pneumoniae
Polysaccharide capsule inhibit phagocitosis Pneumolysin Production of extracellular complex pollysaccharide-enhanced attachment to host cellular surface,such as cardiac endothel
pneumonia
S.viridans
Pathogenesis S.pyogenes
Pathogenesis of group A streptococci
S. pneumoniae
Morphology and Physiology
Contd S. pneumoniae
Pathogenesis and Immunity Pneumococci produce disease through their ability to multiply in the tissues (invasiveness). Virulence factors: capsule, cell wall polysaccharide, phosphorylcholine, pneumolysin, IgA protease, etc. 40-70% of humans are at sometimes carrier of virulent pneumococci. Major host defense mechanisms: ciliated cells of respiratory tract and spleen. The normal respiratory tract has natural resistance to the pneumococcus. Loss of natural resistance may be due to:
S. pneumoniae
Clinical diseases
Pneumococcal pneumonia develops when the bacteria multiply rapidly in the alveolar space after aspiration. The affected area is generally localized in the lower lobes of the lungs (lobar pneumonia). Children and the elderly can have a more generalized bronchopneumonia. Resolution occurs when specific anticapsular antibodies develop. Sudden onset with fever, chills and sharp chest pain. Bloody, rusty sputum. Empyema (mostly caused by type 3) is a rare but significant complication. Complications caused by spreading of pneumococci to other organs: sinusitis, meningitis, endocarditis, septic arthritis, middle ear infection.
Streptococcus viridans
Alpha hemolytic or nonhemolytic Nongrupable S.viridans colonizes in the oropharynx,GI tract,urinary tract, and rareli on skin surface. Generally considered to be of low virulence Production of extracellular complex polysacarides (such as glucans&dextrans) enhance attachment to host cell surface,such as cardiac endothelial cells & tooth surface in the case of dental caries Disease: subacut bacterial endocarditis (particularly patients with previosly damaged heart valves) Intra abdominal infection caries dentis
Identification
18.05.09
33
None
S. pyogenes S. agalactiae
S. pneumoniae
S. viridans
Not ferment
Ferment
4. Dust control, ventilation, air filtration, UV irradiation and aerosol mists are of doubtful efficacy.
5. Intrapartum penicillin to mother at risk of giving birth to an infant with invasive group B disease.
Haemophilus
Characteristics of Haemophilus
Small, pleomorphic gram-negative coccobacilli, non motile (+) cytochrome oxidase Growth in culture requires exogenous hemin (oxidized ferroprotoporphyrin) (X factor) and/or nicotinamide adenine dinucleotide (NAD) (V factor)
2. H. ducreyi
-sexually
- H. aphrophilus - H. aegyptius
Haemophilus influenzae
Differentiation of Species
Hemolysis Growth Factor
X V
+ -
+ + + -
+ + + -
Haemophilus influenzae
Aerobic gram-negative bacteria Polysaccharide capsule Six different serotypes (a-f) of polysaccharide capsule 95% of invasive disease caused by type b
Bacteremia 2%
*prevaccination era
Transmission
Pathogenic Mechanisms
H. influenzae
Antiphagocytic polysaccharide capsule is the major pathogenesis factor
Lipopolysaccharide lipid A component from the cell wall (major role in non capsule strains)
All virulent strains produce neuraminidase and an IgA protease No exotoxins
H. influenzae serotype b:
diagnosis and treatment timeline
Incubation Signs or symptoms Infectiousness Lab Specimens Prophylaxis
Specimens from sterile site, for culture (cerebrospinal fluid, blood, pus, middle ear fluid). Gram Stain is presumptive
Antimicrobial prophylaxis
*Invasive disease includes meningitis, epiglottitis, pneumonia, septic arthritis, and cellulitis (less commonly osteomyelitis and pericarditis). Modified from Michigan Health Department http://www.michigan.gov/documents/mdch/2Hflu_Rev2008_231415_7.pdf
Haemophilus influenzae
IsoVitaleX-enriched chocolate agar
Requires 2 erythrocyte factors for growth: X (hemin) and V (NAD). X & V factors are released following lysis of red blood cells
Satellite phenomenon
S.aureus
Corynebacterium
Corynebacterium
Classification Corynebacterium diphtheriae and diphtheroids (look like C.diphtheriae) Some are saprophytic Some produce disease in animals C. diphtheriae is the most important pathogen in the group. - Other Corynebacterium are part of the normal flora of the skin and URT.
Corynebacterium
Are called diphtheroids and may occasionally cause disease, particularly in immunocompromised individuals.
C. ulcerans toxigenic strains may produce a disease similar to, but less severe than diphtheria. J-K Group commonly cause infections in those with underlying disease.
Diseases include bacteremia, meningitis, peritonitis, wound infections, etc. It is becoming more and more of a problem.
Biological Features
Aerobic, Gram+, Noncapsulated, rods,
arrangement=palisade or Chinese letters
Arrangement of C. diphtheria
Corynebacterium
Loefflers agar slant contains serum and egg that enhance the formation of metachromatic granules (polymerized polyphosphoric acid) in C. diphtheriae. Also called Babes-Ernst granules. They are visualized by staining with methylene blue.
Corynebacterium
3 morphological types of C. diphtheriae are found on tellurite containing media: Mitis black colonies with a gray periphery Gravis large, gray colonies Intermedius small, dull gray to black. All produce an immunologically identical toxin. Incubation -35-370 C for 24 hours. They prefer a pH of 7.8-8.0 for good growth. They require access to oxygen (poor An O2 growth). Biochemistry Catalase + Nonmotile C. ulcerans is urease +, C. diphtheriae is -, and C. pseudotuberculosis is usually +
Corynebacterium
Virulence factors C. diphtheriae For C. diphtherias to cause diphtheria an exotoxin must be produced. Is a heat-labile polypeptide produced during lysogeny of a phage that carries the "tox gene. Alkaline pH of 7.8- 8.0, aerobic conditions, and a low environmental iron level are essential for toxin production (occurs late in the growth of the organism). The toxin inhibits protein synthesis by ADP-ribosylating elongation factor 2.
Corynebacterium
Trypsin cleaves the toxin into 2 fragments, A and B, that are linked together by a disulfide bridge. Fragment B is required for toxin binding to tissue cells and fragment A contains the toxic activity. One molecule of toxin can inhibit 90% of the protein synthesis in a cell. C. ulcerans and C. pseudotuberculosis sometimes make a diphtheria-like toxin.
Cleaved to yield A/B fragment, joined by S-S bond - A (catalytic domain) - B (transmembrane and receptor binding domains) Receptor: heparin-binding epidermal growth factor - rich on cardiac cells and nerve cells Toxin diffuses throughout body via blood - Cardiac, neurologic complications - Heart/respiratory damage, paralysis
C. diphtheria toxin
Toxin enters through receptor mediated endocytosis Acidification of endocytic vesicle allows A to dissociate from B A enters cycoplasm
Corynebacterium
To prove that an isolate can cause diphtheria, one must demonstrate toxin production. This is most often done on an Elek plate: The organism is streaked on a plate containing low iron. A filter strip containing anti-toxin antibody is placed perpendicular to the streak of the organism. Diffusion of the antibody into the medium and secretion of the toxin into the medium occur. At the zone of equivalence, a precipitate will form.
Elek plate
Pathogenesis of diphtheria
Early stages: Sore throat. Low fever. Swollen neck glands. Late stages: Airway obstruction and breathing difficulty. Shock
Corynebacterium
Clinical Significance (C. diphtheria) Is normally found in the throats of healthy carriers. The organism infects only man and it has a limited capacity to invade. Diphtheria - Disease usually starts as a local infection of the mucous membranes causing a membranous pharyngitis Local toxin effects result in degeneration of epithelial cells. Inflammation, edema, and production of a pseudomembrane composed of fibrin clots, leukocytes, and dead epithelial cells and microorganisms occurs in the throat.
Diphtheria - pseudomembrane
This may obstruct the airway and result in suffocation.
Corynebacterium
The more dangerous effects occur when the toxin becomes systemic and attacks the heart (heart failure), peripheral nerves (paralysis), and the adrenal glands (hypofunction). Cutaneous diphtheria More common in tropical and subtropical areas. Necrotic lesions with occasional formation of a local pseudomembrane occur.
DIAGNOSIS
Clinical: Muscle weakness, edema and a pseudomembranous material in the upper respiratory tract characterizes diphtheria. Laboratory: Tellurite media is the agar of choice for isolation of Corynebacteria, which produce jet black colonies
Corynebacterium
Shick skin test like the Dick test in that it tests for circulating antibody to the toxin by injecting a small amount of toxin intradermally and observing for a local erythematous and necrotic reaction. If this occurs it indicates that the person has no anti-toxin antibodies and is, therefore, susceptible to diphtheria.
Control
Sanitary: Reduce carrier rate by use
of vaccine.
Protection C.diphtheriae
Can be established through both active and passive immunity. Active immunity consist of a toxoid administered in the form of the DPT vaccine Passive immunity is established by administering diphtheria antitoxin. Antimicrobial therapy (erythromycin) can be used to effectively treat patient with clinical bacteria
Moraxella
Characteristics of Moraxella
Gram-negative diplococci with adjacent sides flattened Frequently appear as intracellular gramnegative diplococci within polymorphonuclear neutrophils
Characteristics of Moraxella
Growth Moraxella catarrhalis occurs on both sheep blood and chocolate agar Moraxella catarrhalis capnophilic (optimal growth with 3-7% CO2)
Characteristics of Moraxella
Moraxella rather than Branhamella accepted taxonomically as the genus designation for M. catarrhalis (family Moraxellaceae) Even though M. catarrhalis not a member of the family Neisseriaceae, morphologic and biochemical similarity to Neisseria allows clinical laboratory identification of M. catarrhalis with Neisseria species
Moraxella catarrhalis: Natural Habitats Present in the upper respiratory tract of 1.5-5.4% of healthy individuals, more commonly in children (50.8%) and elderly adults (26.5%)
Oropharyngeal endogenous strains spread into normally sterile regions of the tracheobronchial tree, the middle ear, and sinuses
M. catarrhalis
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Fusobacterium species
anaerobic, nonspore-forming, gramnegative bacilli Human infection usually results from F. necrophorum subspecies funduliforme, but infections with other species including F. nucleatum, F.gonidiaformans, F. naviforme, F.mortiferum, and F. varium have been reported
Fusobacterium infections are most common in adolescents and young adults, but infections, including fatal cases of Lemierre disease, have been reported in infants and young children Diagnosis: anaerobic blood culture