Nocardia

PREPARED BY: MICHELL G. TUGADE, RMT,MD

 Species of Nocardia genus are Gram positive.

Nocardia asteroides are found worldwide and they are saprophytes, they live on dead decaying organic matter in the soil, water, dust and on vegetation .They are important in the soil because they break down dead and decaying organic matter into simple substances that can be taken up and recycled by plants. Nocardia asteroides appear as filaments and their colonies usually appear yellowish in a slant culture

Nocardia asteroides culture (middle tube)

Cell and colony structure

Nocardia asteroides species are filamentous aerobic,

Gram-positive and mycolic acid cell wall bacteria. Nocardia colonies vary from white, to tan, orange and red in color they have a lipid bilayer cell membrane with associated proteins Their cell envelopes consist of a Peptidoglycan cell wall. All mycolic acids comprising the cell wall of Nocardia asteroides are saturated mycolic acids. Nocardia asteroides experience an optimal growth at body temperature.

Metabolism
Since Nocardia is a soil bacterium, it uses different

compounds as its source for carbon and energy. The primary source energy for Nocardia asteroides is acetate and gluconate while its source of carbon and nitrogen is sucrose and acetamide.During nitrogen assimilation glutamate and glutamine is formed

Pathology and Ecology

Nocardia asteroides live on dead decaying organic matter in

the soil, water, dust and on vegetation. Nocardiosis is a chronic bacterial disease of humans and many other animals originating in the respiratory tract and disseminated by way of blood to other organs. It is caused by either introduction of the species into the skin or by inhalation of the species from its habitat. Nocardia asteroides accounts for 86% of systematic nocardiosis in humans and 98% of cerebral nocardial abscesses and 2% of all cerebral abscesses The majority of infections occur in patients with weakened cell-mediated immunity. Patients commonly also include those who have received bone-marrow transplantations and are on immunosuppressive therapy, those with HIV/AIDS, and those with malignancies

Pathology and Ecology

The disease usually begins with malaise, loss of

weight, fever and night sweats. Nocardiosis is found worldwide in persons of all ages. Nocardia species are generally resistant to penicillin and require six months to one year of antibiotic treatment. Early treatment of nocardiosis with sulphonamide drugs before the disease has spread to the brain has reduced the mortality rate from nocardiosis.

 Nocardiosis is an acute, subacute, or chronic infectious

disease that occurs in cutaneous, pulmonary, and disseminated forms. Primary cutaneous nocardiosis manifests as cutaneous infection (cellulitis or abscess), lymphocutaneous infection (sporotrichoid nocardiosis), or subcutaneous infection (actinomycetoma). Pleuropulmonary nocardiosis manifests as an acute, subacute, or chronic pneumonitis, usually in immunocompromised hosts, although isolated cases have been reported in immunocompetent hosts. Disseminated nocardiosis may involve any organ; lesions in the brain or meninges are most common.

TREATMENT
Protracted specific antimicrobial therapy is the mainstay of

medical care for nocardiosis. Therapy is generally recommended for at least 6 months.[1] In patients who require immunosuppressive therapy, such therapy can generally be continued while appropriate specific therapy for nocardiosis is administered. For lesions outside the CNS, surgical management is the same as standard recommendations for other infections; that is, localized abscesses generally require prompt surgical therapy. In patients with nocardial brain abscesses, surgery should be performed if the lesions are large, if they are readily accessible, or if they progress beyond 2 weeks of antimicrobial therapy.[10]

TREATMENT
Sulfonamides have long been the first-line

antimicrobial therapy for nocardiosis. Among the sulfonamides, sulfadiazine is generally preferred because of its CNS and CSF penetration. Although not convincingly demonstrated superior, trimethoprim-sulfamethoxazole (TMP-SMZ) is considered the therapy of choice by most authorities. Divided doses of 5-10 mg/kg/d of the trimethoprim component should be administered to produce sulfonamide levels of 100-150 mcg/mL; such levels should possibly be confirmed in individuals with severe disease.

TREATMENT
Additional or alternative parenteral therapies

include carbapenems (imipenem or meropenem, but not ertapenem), third-generation cephalosporins (cefotaxime or ceftriaxone), and amikacin, alone or in combination. Imipenem plus amikacin may be the preferred regimen in sulfonamide-allergic individuals

Haemophilus
HAEMOPHILUS a. small coccobacilli, often resembling pneumococci b. has dew drop colonies c. non motile d. virulence: polysaccharide capsule e. X and V factor

Speceis:
1. Haemophilus influenza (Pffeiffers bacillus) - has six serological types (a to f) serotype precipitin test or by capsular swelling test - Type B is the most common cause of meningitis in infants under two years or age - Also causes epiglottitis (airway obstruction), pneumonia, cellulitis and otitis media - IgA protease destroys IgA

2. Haemophilus aegyptius - causes pink-eye disease (conjunctivitis) - Haemophilus influenza biotype aegyptius - Haemophilus conjunctivitis or Kocks Weeks Bacilli 3. H. haemolyticus, H. parainfluenzae, H. aphrophilus, H. paraaphrophilus and H. segnis - normal flora of humans causing upper and lower respiratory tract infections

4. Haemophilus suis: Swine influenza bacillus 5. Haemophilus ducreyi: Chancroid bacillus, Ducreyis bacillus - an ulcerative chancroid, STD - best growth in fresh clotted rabbit, sheep or human blood, heated to 55C for 15minutes or in 2030% defibrinated rabbit blood agar On Gram stain, they appear like School of red fish

GROWTH REQUIREMENTS:
X FACTOR -heat stable - hemin, hematin - from tetra pyrrole compounds which is an iron containing pigment - used in the synthesis of catalase and peroxidase V FACTOR - heat labile - NADase factor ( CoE I, and CoE II) -synthesized by Staphylococcus and yeasts

H. ducreyi H. aphrophilus H. parainfluenzae H. parahaemolyticus H. paraphrophilus H. influenzae H. haemolyticus H. aegyptius

X FACTOR + + + + +

V FACTOR + + + + + +

CULTURE MEDIA: 1. Horse-Blood Bacitracin Agar (Casmans) - Haemophilus haemolyticus shows haemolytic activity - Haemophilus species are resistant to the A disk - This culture media has both X and V factor 2. Fildes Enrichment Agar contains sheep blood Agar, which contains the two factors

Tests:
1. Gram Staining : Gram negative bacilli 2. Neufeld capsular Swelling test 3. Serotypin 4. Test for X and V factor a. Staph Streak technique: BAM source of X factor Staphylococcus source of V factor b. Use of TSB or BHI (deficient in X and V factors) Place a filter paper strip impregnated with the separate factors

5. Porphyrin Test test for Strains of Haemophilus capable of synthesizing heme

Porphobilinogen synthase Delta-aminolevulinic acid (delta-ALA)----------------------- porphobilinogen + porphyrin + heme

(+) result : red color presence of porphobilinogen upon the addition of Kovacs reagent (+) parainfluenzae can synthesize heme (+) infuenzae can not synthesize heme

Pathology
In infants and young children, H. influenzae type b (Hib)

causes bacteremia, pneumonia, and acute bacterial meningitis. On occasion, it causes cellulitis, osteomyelitis, epiglottitis, and infectious arthritis. In fact, Haemophilus influenzae is the most common etiologic agent associated with epiglottitis Hib remains a major cause of lower respiratory tract infections in infants and children in developing countries where the vaccine is not widely used. Unencapsulated H. influenzae strains are unaffected by the Hib vaccine and cause ear infections (otitis media), eye infections (conjunctivitis), and sinusitis in children, and are associated with pneumonia

Treatment
Haemophilus influenzae produces beta-lactamases, and

it is also able to modify its penicillin-binding proteins, so it has gained resistance to the penicillin family of antibiotics. In severe cases, cefotaxime and ceftriaxone delivered directly into the bloodstream are the elected antibiotics, and, for the less severe cases, an association of ampicillin and sulbactam, cephalosporins of the second and third generation, or fluoroquinolones are preferred. (Fluoroquinolone-resistant Haemophilus influenzae has been observed.) Macrolide antibiotics (clarithromycin) may be used in patients with a history of allergy to beta-lactam antibiotics. Macrolide resistance has also been observed.

Prevention
Effective vaccines for Haemophilus influenzae Type

B have been available since the early 1990s, and is recommended for children under age 5 and asplenic patients

Genus Bordetella
obligate parasites of animals and humans residing in mucous membranes of the respiratory tract b. fimbriated c. other virulence factors: capsule, hemaglutinins, extracellular enzymes, endotoxins and exotoxins d. specimen: nasopharyngeal swab e. Culture media: 1. B-G agar: Bordet-Gengou agar containing 20% sheep blood and methicillin 2. Jones-Kendrick Charcoal Agar with cephalexin 3. Cold casein hydrolysate medium 4. Casamino acid broth 5. Regan-Lowe
a.

 On Bordet-Gengou agar, colonies will show diffuse

zone of hemolysis, appearing small, smooth, convex with a pearly luster, resembling mercury drops, colonies are mucoid and tenacious

Disease
B. pertussis is a fastidious, gram-negative bacterium

requiring special media for isolation. B. pertussis produces multiple antigenic and biologically active products including:

Pertussis toxin Filamentous hemagglutinin (FHA) Agglutinogens Adenylate cyclase Pertactin Tracheal cytotoxin

These products are responsible for the clinical features of

pertussis and an immune response to one or more produces immunity following infection.

Signs and symtoms of Pertussis

Pertussis has an insidious onset with catarrhal

symptoms that are indistinguishable from those of minor respiratory tract infections. The cough, which is initially intermittent, becomes paroxysmal. In typical cases paroxysms terminate with inspiratory whoop and can be followed by posttussive vomiting.

Pathogenesis Pertussis is primarily a toxin-mediated disease. The bacteria attach to the cilia of the respiratory epithelial cells, produce toxins that paralyze the cilia, and cause inflammation of the respiratory tract, which interferes with the clearing of pulmonary secretions. Until recently, it was thought that B. pertussis did not invade the tissues; however, recent studies have suggested that the bacteria are present in alveolar macrophages.

TREATMENT
Erythromycin, clarithromycin, and azithromycin are preferred

for the treatment of pertussis in persons 1 month of age. For infants <1 month of age, azithromycin is preferred for post exposure prophylaxis and treatment because azithromycin has not been associated with infantile hypertrophic pyloric stenosis (IHPS), whereas erythromycin has. For infants <1 month of age, the risk of developing severe pertussis and lifethreatening complications outweighs the potential risk of IHPS that has been associated with macrolide use. Infants <1 month of age who receive a macrolide should be monitored for the development of IHPS and for other serious adverse events. For persons 2 months of age, an alternative to macrolides is trimethoprim-sulfamethoxazole.

READING ASSIGNMENT!
1. Other speceis of Bordetella

Bordetella parapertussis Bordetella holmesii Bordetella bronchiseptica

2. GENUS Alcaligenes 3. Genus Acinetobacter Refer to Microbiology BOOK of Zinzer

 Thank you!