Anaerobic Infections

DMD1002- Clinical Microbiology and Immunology

Definition
"life without air."

Anaerobes are bacteria that are either capable of

growing in the absence of oxygen (facultative

anaerobes) or that absolutely require the

absence of oxygen (obligate anaerobes)

Anaerobic Infection
- infection caused by bacteria which cannot grow in the presence of oxygen. - can infect deep wounds, deep tissues, and internal organs - characterized by abscess formation, foulsmelling pus, and tissue destruction.

Description
grow in places which completely, or almost completely, lack oxygen normally found in the mouth, gastrointestinal tract, and vagina, and on the skin nearly all dental infections are caused by anaerobic bacteria causes infection when normal barrier is damaged

Description
Anaerobic infections are suspected if: putrid discharge Poly-microbial flora on gram stain infection adjacent to a mucosal surface that is normally colonized by anaerobes

Description
Spore formers
Clostridium spp

Non spore formers

Bacteroides spp

Two fundamental means of differentiation of these types

their reaction to the Gram stain by their shape.

Description
Clostridium consists of Gram-positive rodshaped bacteria that form spores. The genus Bacteroides consists of Gramnegative Rod-shaped bacteria

Sites and Types of Infection

Mouth, head, and neck
root canals, gums jaw, tonsils, throat, sinuses, and ears.

Lung
pneumonia, lung abscesses, infecton of the lining of the lung

Intra-abdominal
abscess formation, peritonitis, appendicitis

 Female genital tract

pelvic abscesses, PID, inflammation of the endometrium.

Skin and soft tissue

common causes of diabetic skin ulcers, gangrene, destructive infection of the deep skin and tissues, bite wound infections.

CNS
brain and spinal cord abscesses.

Bloodstream
bacteremia

 The clostridia are opportunistic pathogens. responsible for some of the deadliest diseases
gas gangrene, tetanus and botulism. Less life-threatening diseases include pseudomembranous colitis (PC) and food poisoning.

cause disease primarily through the production of numerous exotoxins. perfringens, tetani, botulinum, difficile

Clostridium Spp
Large, Gram-positive, rod-shaped bacteria. All species form endospores and have a strictly fermentative Most will not grow under aerobic

live in virtually all of the anaerobic habitats of nature

soils Aquatic intestinal tracts of animals.

vegetative cells are killed by exposure to O2 spores are able to survive long periods of exposure to air.

 A variety of foul smelling compounds are formed during the fermentation of amino acids and fatty acids. extracellular enzymes -play a role in invasion and pathology Clostridium tetani and Clostridium botulinum produce the most potent biological toxins known to affect humans.

C. difficile
Spore-forming Gram-positive anaerobic bacillus Possesses exotoxins which cause damage to the large intestine, resulting in diarrhea
toxin A toxin B

most commonly recognized cause of antibioticassociated diarrhea

Background: Pathogenesis of CDI

1. Ingestion of spores transmitted from other patients via the hands of healthcare personnel and environment 3. Altered lower intestine flora (due to antimicrobial use) allows proliferation of C. difficile in colon

4. Toxin A & B Production leads to colon damage +/- pseudomembrane

2. Germination into growing (vegetative) form

Sunenshine et al. Cleve Clin J Med. 2006;73:187-97.

Clostridium difficile- Symptoms

Disturbed normal flora Watery diarrhea Fever Loss of appeite Nausea Belly pain and tenderness pseudomembranous colitis.

Clostridium difficile
at risk persons:
Antimicrobial exposure Acquisition of C. difficile Advanced age Underlying illness Immunosuppression Tube feeds ? Gastric acid suppression

C. Difficile- Prevention
Use Contact Precautions to prevent spreading Hand hygiene in compliance with CDC/WHO Cleaning and disinfection of equipment and environment Laboratory-based alert system for immediate notification of positive test results Educate : housekeeping, administration, patients, families

Treatment
Stop the inciting antibiotic Infections are usually successfully treated with a 10 day course of antibiotics:
Oral metronidazole for mild disease vancomycin for severe(administered orally)

C. difficile endospores.

C. difficile colonies on blood agar

http://textbookofbacteriology.net/themicrobialworld/CperCdiff.html

C. Tetani
Anaerobic gram-positive, spore-forming bacteria Spores found in soil, animal feces; may persist for months to years Multiple toxins produced with growth of bacteria Tetanospasmin estimated human lethal dose = 2.5 ng/kg

C. tetani
A disease of the nervous system caused by Clostridium tetani bacteria The disease is caused by the action of a neurotoxin, produced by the bacteria characterized by muscle spasms
initially in the jaw muscles As the disease progresses, mild stimuli may trigger generalized tetanic seizure-like activity serious complications and eventually death

Pathogenesis
Anaerobic conditions allow germination of spores and production of toxins

Toxin binds in central nervous system

Interferes with neurotransmitter release to block inhibitor impulses

Leads to unopposed muscle contraction and spasm

Symptoms
Early symptoms: lockjaw, stiffness in the neck and abdomen, and difficulty swallowing Later symptoms: severe muscle spasms, generalized tonic seizure-like activity, severe autonomic nervous system disorders

Clinical
Incubation period; 8 days (range, 3-21 days) Three clinical forms: local (not common), cephalic (rare), generalized (most common)

Generalized tetanus: descending symptoms of trismus (lockjaw), difficulty swallowing, muscle rigidity, spasms Spasms continue for 3-4 weeks Complete recovery may take months

Complications
Bone fractures, abnormal heart rhythm Death in about 10-20% of cases, with the highest rates occurring among older people

Lab Diagnosis
No laboratory findings characteristic of tetanus. The diagnosis is entirely clinical C. tetani is recovered from the wound in only 30% of cases can be isolated from asymptomatic patients

Lab Diagnosis
Laboratory identification of the organism depends most importantly on the demonstration of toxin production in mice.

http://textbookofbacteriology.net/themicrobialworld/Tetanus.html

Treatment
Hospitalization to manage complications of the infection Cleaning of wound or sometimes surgical removal (debridement or amputation) Antibiotics Tetanus immune globulin (antibodies against tetanus that help neutralize the tetanus toxin)

Tetanus Toxoid
Formalin-inactivated tetanus toxin Schedule Three or four doses + booster Booster every 10 years Efficacy Approximately 100%

Duration Approximately 10 years

Administered with diphtheria toxoid as DTaP, DT, Td, or Tdap

C. perfringes
Spore-forming gram-positive Habitat:
many environmental sources in the intestines of humans and animals commonly found on raw meat and poultry can survive with very little or no oxygen produces a toxin

 Produces a huge array of invasins and exotoxins Causes wound and surgical infections that lead to gas gangrene Severe uterine infections

C. Perfringes-Virulence
Hemolysins Extracellular enzymes contribute to the invasive process
proteases lipases collagenase Hyaluronidase also produces an enterotoxin -cause of food poisoning (improperly sterilized (canned) foods)

Symptoms
watery diarrhea and abdominal cramps within 6 to 24 hours (typically 8-12) Sudden onset and lasts for less than 24 hours usually no fever or vomiting

Images retrieved from the CDC

Clostridium perfringens on an egg yolk agar plate

Gram rxn- note gram variability

http://textbookofbacteriology.net/themicrobialworld/CperCdiff.html

Bacteroides- Background
Gram negative Fastidiousness, therefore difficult to isolate AnO2 bacteria Predominant bacterial flora of mucous membranes common cause of endogenous infections

Bacteroides- Background
Isolation requires appropriate methods of:
collection transportation cultivation

Treatment is complicated by 3 factors:

slow growth increasing resistance to antimicrobial agents Poly-microbial synergistic nature of infection

B fragilis Group
Pleomorphic non-spore forming anaerobic Gram-negative (weakly or variable) bacilli Resistant to penicillins (beta-lactamase) Normal GI florae predominate in intra-abdominal infections

B. Fragilis
Bacteroides fragilis group
Major opportunistic pathogen Most important member of genus

Non-fragilis Bacteroides (many species)

Clinical Symptoms
Abscess formation in sterile sites Bacteremia Intra-abdominal infections: causes > 80% Gynecological infections: polymicrobial anaerobic infections with B. fragilis frequently causing abscesses

Clinical Symptoms
Skin and soft tissue infections: most commonly associated with B. fragilis; Gram-negative anaerobes gain access to these sites via bites or trauma Respiratory tract: polymicrobial infections including non-fragilis Bacteroides

B. Fragiles- Virulence factor

Prominent capsulea
anti-phagocytic

abscess formation Endotoxin

Epidemiology
Normal flora of URT and GI tract Endogenous spread to sterile sites >80% of all intra-abdominal infections Surgical and trauma patients Patients with spontaneous peritonitis

Lab Diagnosis
Specimens must be obtained free of contamination. Minimal contamination with normal florae can be misleading inappropriate specimens yield normal florae Use techniques that bypass normal florae.

B. fragilis-Lab Diagnosis
Specimen collection to avoid contamination with normal flora Oxygen-free transport medium system(Carey and Blair semisolid media) Avoid drying Bacteroides spp. grow rapidly (within two days) Growth stimulated in the presence of 20% bile B. fragilis are resistant to kanamycin, vancomycin and colistin

Treatment
Surgical drainage of abscess(es) Debridement Increasing tissue oxygenation Long-term course of antibiotics Prophylactic use of antibiotics
prior to invasive surgical procedures that disrupt mucosal barriers Immediately following trauma that disrupts mucosal barriers

Treatment
Most anaerobic infections are treated empirically, since anaerobes are difficult to recover using standard culture techniques.

Treatment
Recovery depends on prompt and proper management according to the following 3 principles:
Toxins produced by anaerobes must be neutralized The environment must be changed to prevent local bacterial proliferation The spread of bacteria must be limited

Treatment
The B fragilis group is almost uniformly susceptible to:
metronidazole carbapenems chloramphenicol

Point of interest
2001 Emergence of MetronidazoleResistant Bacteroides fragilis

Reference
http://medical-dictionary.thefreedictionary.com/Anaerobic+Infections http://emedicine.medscape.com/article/233339-overview http://www.ncbi.nlm.nih.gov/books/NBK2497/ http://www.who.int/mediacentre/factsheets/fs270/en/ http://www.cdc.gov/foodborneburden/clostridium-perfringens.html http://textbookofbacteriology.net/themicrobialworld/Tetanus.html http://www.cdc.gov/ncidod/eid/vol7no3/chaudhry_letter.htm