Documente Academic
Documente Profesional
Documente Cultură
OF OB-GYN INFECTIONS
Objective
Be able to explain:
Classification, characteristics, virulence
factors, pathogenesis & clinical
manifestations, laboratory diagnosis and
treatment
of
Microbial agents of obstetric and
gynecological infections
TOPICS
Microbial agents of:
Vaginitis
Infection of the female Pelvis
Maternal Infections in Pregnancy
VAGINITIS
Bacterial vaginosis
Vulvovaginal Candidiasis
Trichomonal vaginitis
Uncommon
Infection
Non-infectious vaginitis
VAGINITIS
AGENTS
Provotella spp.
Bacteroides spp.
Mycoplasma spp
Vulvovaginal
candidiasis
Trichomonal
vaginosis
Candida albicans
Candida tropicalis
Candida stellatoidea
Candida pseudotropicalis
Trichomonas vaginalis
OTHER SYSTEM
Neisseria gonorrhoeae
Urogenital
Chlamydia trachomatis
Urogenital
Gardenella vaginalis
Escherechia coli
Streptococcus spp.
Urogenital
Respiratory
Bacteroides spp.
Peptostreptococcus spp.
Peptococcus spp.
Provotella spp.
Porphyromonas spp.
Mycoplasma
Mycoplasma hominis
Mycoplasma genitalium
Respiratory
OTHER
SYSTEM
Streptococcus spp.
Enterococcus faecalis
Respiratory
Urogenital
Staphylococcus aureus
Staphyl. epidermidis
Respiratory
Urogenital
Escherechia coli
Urogenital
Klebsiella pneumoniae
Urogenital
Gardnerella vaginalis
Anaerobic Bacteria
Bacteroides spp.
Peptostreptococcus spp.
Prevotella bivia
Prevotella disiens
Fusobacterium spp.
Mycoplasma
Mycoplasma hominis
Urogenital
Streptococcus spp.
Enterococcus faecalis
Respiratory
Urogenital
Staphylococcus aureus
Staphyl. epidermidis
Respiratory
Urogenital
Escherechia coli
Urogenital
Klebsiella pneumoniae
Urogenital
Gardnerella vaginalis
Anaerobic Bacteria
OTHER
SYSTEM
Clostridium perfringens
Clostridium tetani
Bacteroides spp.
Peptostreptococcus spp.
Prevotella bivia
Prevotella disiens
Fusobacterium spp.
MATERNAL INFECTIONS
IN PREGNANCY
Malaria
Listeriosis
Group B
Streptococci
Neisseria gonorrhoeae
Chlamydia trachomatis
Bacterial vaginosis
Trichomonas vaginalis
Condylomata acuminatum
Herpes simplex
HIV
Transmission in 25-45%
Risk of abortion, pre-term delivery,
puerpural infection
Gardnerella vaginalis
ANAEROBE BACTERIA
Basil negative-gram Bacteroides fragilis group .
Provotella spp.
Porphyromonas spp.
Fusobacterium spp.
Basil positive-gram Clostridium perfringens
Coccus positive-gram Peptostreptococcus spp.
Peptococcus spp.
PARASITE
Flagellate Trichomonas vaginalis
Sporozoan Toxoplasma gondii
Gardnerella vaginalis
Gardnerella vaginalis:
Found in the human urogenital tract
In BV large number Serves as one
indicator organism of the syndrome
In BV hydrogen peroxide producing
Lactobacillus increase of:
- G. vaginalis,
- anaerobic negative-gram bacilli
- Peptostreptococci
- Mycoplasma
CLASSIFICATION-TAXONOMY
Taxonomy position of Gardnerella vaginalis
remained unsolved
On the basic of superficial growth
characteristic or morfology classified as
a member of genus:
- Haemophilus, or
- Corynebacterium
But by DNA-hybridization studies: new
genus Gardnerella
GENERAL CHARACTERISTICS
Pleomorfic tiny bacilli, coccobacil
Gram-negative to gram variable
Club form & metachromatic granules: often
present
Non-motile & non-capsulated
Most strain: facultatively anaerobic
Fastidious in nutritional requirements
Not required neither hemin nor nicotinamide
adenine nucleotide
-hemolysis on human blood agar
Pigment: pale yellow
LABORATORY IDENTIFICATION
Specimens:
- Cervical, urethral & vaginal swabs
- Sign of sepsis : blood
Can be detected best by Gram stain
Culture not recommended result not
specific enough to predict reliability the
presence of the syndrome.
PRESUMPTIVE DIAGNOSIS OF BV
Amsels criteria 3 of the following 4:
Homogenous vaginal discharge
Direct wet mount of vaginal discharge
shows clue cells
Characteristic fishy odor of material,
particularly after addition of 10% KOH
(potassium hydroxide)
pH >4.5
CLUE CELL
squamous epithelia
cells covered with
tiny bacilli,
especially around
the periphery,
giving the cell a
stippled
appearance.
BACTERIAL
VAGINOSIS
TRICHOMONAS
VAGINITIS
Amount
Scant to
moderate
Moderate
Profuse
Color
White
White/gray
Yellow
Consistency
Clumped but
variable
Homogenous,
Homogenous
uniformly coating
walls
Bubbles
Absent
Present
Present
pH
<4.5
>4.7
5.0 6.0
Amine test
10% KOH
Negative
Positive
Occasionally present
Saline
microscopy
Normal flora,
Blastospore, 4045% pseu
dohype
Clue cells,
coccobacillary
flora predominant, absent of
leukocytes
Gram
Blastospore
Pseudohyphe
PMNs +++,
Trichomonad, no clue
CANDIDA
VULVOVAGINAL CANDIDIASIS
Superficial Candidiasis:
The most common candidiasis skin &
mucosa
By NF of skin & mucosa colonization
Predispose factors :
- Impaired cellular immunity or
neutropenia
- Prolonged antibiotic therapy
- Invasive procedure
CLASSIFICATION
Order: Cryptococcales
Genera: Candida
Species:
.
MORPHOLOGY
C. albicans : dimorphic
fungi
budding yeast cells,
reproduce by budding or
fission
pesudohyphae,
true hyphae = mycelium
chlamydospores : big and
round
blastospores
COLONIES
On agar Sabouraud (24 hr at 37oC):
- soft, cream-colored
- yeasty odor
- pesudohyphae grow below the agar surface
On corn-meal agar :
- blastospores,
- pseudohyphae
- chlamydospores
Identification confirmation:
Sugar fermentation & assimilation tests
PATHOGENESIS
Superficial Candidiasis
(mucocutaneus): increased local census of
candida damage the skin or epithelium
permit local invasion of the yeast &
pseudohyphae imflamatory reaction:
pyogenic abscesses to chronic granulomas.
Systemic Candidiasis
candida enter the blood stream &
phagocytic host defences are inadequate to
contain the growth and dissemination of the
yeasts.
CLINICAL FINDING
Cutaneus and Mucosal Candidiasis
- Vulvovaginitis
- Oral trush
- Cutaneus Candidiasis
- Oncomycosis
Microscopic examination
- Gram stain of tissue, centrifuged spinal fluid, & other:
pseudohyphae & budding cells (strongly Gram-positive)
- Skin & nail scraping 10% KOH
Culture
- Yeast colonies: wet mount or Gram: pseudohyphae,
chlamydospore, germ tubes
- Biochemical reaction
Microscopic Figure
in lactophenol cotton blue
TREATMENT
Mucocutaneus candidiasis
- nystatin, ketokonazole, or fluconazole
(topical)
- eliminating contributing factors
Systemic candidiasis:
- systemic amphotericin, sometimes +
- flucytonsine, fluconazole, or caspofungin orally
ANAEROBIC BACTERIA
Aerobic bacteria:
require O2 as a terminal electron acceptor and will
not grow under anaerobic condition.
NORMAL SITE
Cocci (Spheres)
Gram positive Peptostreptococcus Colon
Peptococcus
Bacilli (Rods)
Mouth, colon
BACTERIA
NORMAL SITE
Bacilli (Rods)
Gram negative Bacteriodes fragilis
group
Colon
Provotella spp
Mouth
Fusobacterium
Mouth, colon
Mouth
Lactobacillus
Vagina
Propionibacterium
Skin
Mobiluncus
Vagina
Colon1
BACTEROIDES
Very important anaerobes that cause
human infections.
Large group of gram-negative bacilli:
slender rods or coccobacilli.
Normal flora of the bowel & other site
Most common isolated:
B. fragilis group :
- B. fragilis
- B. avatus
- B. distasonis,
- B. vulgatus
- B. thetaiotaomicron
Bacteroides fragilis
GENERAL CHARACTERISTICS
Slim, pale staining, gram-negative rods
Has surface pili & capsule composed of polymer
of two polysaccharides
The LPS endotoxin in the outer membrane is less
toxic than that of most other negative-gram
bacteria
One of the most hardier & more easy grown
anaerobes ( misleading name)
Most strain produce superoxide dismutase and are
relatively tolerance to atmospheric O2
Produce enterotoxin enteric disease in animal
Bacteroides fragilis
ANTIGENIC STRUCTURE
Thermo labile protein & thermos table
lipopolysaccharides antigen: a basis for
serologic classification of B. fragilis
B. fragilis can be divided into serotypes on
the basis of agglutination, gel diffusion, and
fluorescent-antibody assays.
A species-specific capsular polysaccharide
antigen has been demonstrated (capsule
only in clinical isolate)
PATHOGENESIS
Endogenous infection, opportunistic
The relative tolerance of B. fragilis
survive in oxygenated tissue in the period
between its displacement from intestinal
flora.
Pili has adhesive properties
Polysaccharide capsule anti-phagocytosis
& inhibit macrophage migration.
Capsule may stimulates abscess formation
Produce extra cellular enzymes:
collagenase, fibrinolysin, heparinase,
hyaluronidase abscess formation
CLINICAL MANIFESTATION
Onset : Deep pain & tenderness anywhere
below the diaphragm
The bacteria not invasive, mucosal break
maybe the result of trauma or other
diseases, such as diverticulitis.
Fever & acute abdomen may occur depend
on extent of intra-abdominal abscess.
TREATMENT
Drainage of abscess & debridement of necrotic
tissue
Most strain B. fragilis produce -lactamase:
- No penicillins
- Cephalosporin R to -lactamase needed.
R to tetracyclin common
Most strain S to chloramphenicol, clindamycin, &
metronindazole
Still effective among -lactams: cefotaxime &
imipenem
Effective: combination of Calvulanate &
Sulbactam (has -lactamase inhibitors) and
Ampicillin & Ticarcillin (-lactams)
PREVOTELLA
Be classified as:
Pigmented Prevotella & Pophyromonas
Non-pigmented Prevotella spp
Prevotella spp found + other anaerobes in :
brain & lung abscess
PID
Tubo-ovarian abscesses
Prevotella or Pophyromonas
CLASSIFICATION
Prevotella & Pophyromonas
PIGMENTED
NON-PIGMENTED
Pophyromonas asaccharosa
Prevotella buccae
Pophyromonas ginggivalis
Prevotella bivia
Prevotella intermedia
Prevotella oralis
Prevotella melanogenica
Prevotella oris
Prevotella disiens
Prevotella buccalis
Prevotella veroralis
Prevotella bivia
GENERAL CHARACTERISTICS
Anaerobic gram-negative rods
Small coccobacillus, often occuring in pair
or short chain
For growth need hemin
Many strains produce -lactamase
R to penicillin & old cephalosporin
Vaginal flora
Mostly common isolated from GT infection
Can be pathogenic in other body sites
Porphyromonas spp
Gram-negative bacilli
Part of normal oral flora and occur other
anatomic site
Newly name species previously included
in genus Bacteroides.
Can be cultured from gingival & periapical
tooth infection
More commonly: breast, axillary, and male
genital infections.
FUSOBACTERIUM
Pleomorphic gram-negative rods
Most species produce butyric acid and
convert threonine to proprionic acid
Fusobacterium spp. frequently isolated
from mix bacterial infections caused by
normal mucosal flora.
Occasionally a Fusobacterium spp. Will be
the only bacteria in an infection. (eg.
osteomyelitis)
Fusobacterium nucleatum
The most common Fusobacterium isolated
from infection
Normal flora mouth and occasionally UGT
F. nucleatum characteristically is thin with
pointed ends and may resembles scattered
paddy straw, or a very long, thin filament.
Important agents of oral infections, lung
abscesses, other pleuropulmonary infections
and amniotic fluid infections.
Fusobacterium
Mobiluncus spp
New designed genus
Curved anaerobic bacilly
Has gram-positive type of cell wall, but
strain frequently stain gram-negative or
gram-positive
Mobiluncus mulieris & Mobiluncus curtisii
are highly associated with bacterial
vaginosis what role ??? Still unclear
Slow growth bacteria small colony
together with other bacteria.
Lactobacillus
Normal flora in the mouth and GI Tract
Predominant flora in the vagina
Most species apparently have minimal
pathogenic potential
But Lactobacillus catenaforme is
occasionally associated with
pleuropulmonary infection.
Clostridium
Spore-forming bacilli
Usually Gram-positive
Most species obligate anaerobe
A few species aero tolerant & will grow
minimally in air at atmosphere pressure
Pathogenic species produce high
potential soluble toxin
Clostridia are widely distributed in nature
Present in soil and in the intestinal tract of
humans and animals.
PROPERTIES
Large Spore-forming gram-positive rods
Spore:
- wider than diameter of rod
- centrally, sub terminally, or terminally
Anaerobe
Motile: pertrichous flagella
Clostridium perfringens
Isolated from 60-90% of clostridial
myonecrosis
There are 5 types of C. perfringens: A E,
according to their production of 4 major
lethal toxins.
Type A: primary responsible for human
diseases: clostridial myonecrosis, less severe
wound infection, and food poisoning.
Type A found in intestinal almost every
animal, but less common cause disease in
animal than in human.
GENERAL CHARACTERISTICS
Clostridium perfringens
ANTIGENIC STRUCTURE
Strains of C. perfringens produce 12 soluble
substances or toxins al protein in nature
and antigenic.
A. Toxins
Four major lethal Antigens: -, -. -, and toxins, all are exotoxins.
The most important is -toxin : produce by
all 5 types of C. perfringens
VIRULENCE FACTORS
Toxin primary important is -toxin : has
lethal, dermonecroti, and hemolytic activity.
The toxin is lecithinase C which split lecithin
to phosphorylcholine and a diglycerise.
The toxin is activated by Ca2+ and Mg2- ions.
In vivo action of -toxin:
on lecithin-containing lipoprotein complexes
in the cell membrane disruption or
leakage of cell membrane lyses of
erythrocytes, destruction of tissue &edema.
PATHOGENESIS
When C. perfringens is introduced into tissue
primary requirement for initiation of infection is a
lowered oxidation-reduction potential.
In the area of reduced O2 tension, the pyruvate of
muscle is incompletely oxidized and lactic acid
accumulates, causing a drop in pH.
Combination of lowered oxidation-reduction
potential & a drop in pH activate endogenous
proteolytic enzymes tissue autolysis.
This release of nutrient and the lowered oxidationreduction potential combine to produce condition
suitable for growth of anaerobic organisms,
CLINICAL MANIFESTATION
1. Simple Wound Contamination: may be present
without an obvious pathologic process.
2. Anaerobic Cellulites: more serious than wound
infection
3. Clostridial Myonecrosis: the organism are
invasive with profound toxemia, extensive local
edema, variable amount of gas, massive tissue
damage & death in untreated case.
4. Uterine Infection: special type of clostridial
myonecrosis after illegal abortion,
occasionally occur as puerperal infection
5. Clostridial Septicemia: Invasion to bloodstream
may happen in malignancy with myonecrosis.
DIAGNOSIS
A. Clinically early diagnosis
B. Bacteriological confirmation
Direct smear with Gram stain
Specimen: deep within the wound
Cultures and smear
Specimens: tissue, aspirates, or deep swabs
of affected muscle.
Trichomonas vaginalis
CLASSIFICATION
1.
Kingdom: Protozoa
Phylum: Sarcomastigophora
Subphylum: Mastigophora (flagellate)
Intestinal & Genitourinary flagellates
Giardia, Trichomonas, Dientamoeba,
Chilomastrix
2. Blood & Tissue flagellates
trypanosoma, Leismania
Species:
1. Trichomonas tenax
2. Trichomonas hominis
3. Trichomonas vaginalis
MORFOLOGY
Pear shape
Axostyle
Short undulating membrane lined
with a flagellum
4 anterior flagella
Chromatin basal body
Chromatin granules
Nucleolus
Para basal fiber
Posterior flagellum
Move with wobbling & rotating
motion
LIFE CYCLE
PATHOGENESIS
Normal habitats: human vagina & prostate
gland
T. hominis & T. tenax: harmless commensals
T. vaginalis: low-grade inflammation
In : infection normally limited to vulva,
vagina and cervix
In : Prostate, seminal vesicles, and urethra
may be infected.
LABORATORY DIAGNOSIS
Specimen:
Vaginal or urethral discharge
Microscopic examination:
Wet preparation in a drop physiological
saline motile trichomonas
Dried smears can be stain with hematoxylin,
Gram or Giemsa
Culture if microscopic negative
- Vaginal or urethral discharge,
- Prostatic secret
- Semen specimen
TREATMENT
Successful treatment destruction of the
trichomonands
Best: topical and systemic metronidazole
(flagyl)
Tinidazole (Fasigyn) and ornidazole
(tiberal) equally effective with fewer side
effects.
Patient sex-partner examined & treated
simultaneously.
Postmenopausal: may be need estrogen
Toxoplasma gondii
MORFOLOGY
Tropozoite:
Boat shape
Thin wall : 4-7 x 2-4m
within tissue cells larger
outside them
Stain lightly with Giemsa
MORFOLOGY
Oocyst
Within oocyst 2
sporocysts form
4 sporozoites in each
sporocyst
LIFE CYCLE
Coccidian protozoan world wide
Infect wide range animals and birds not cause
disease
Normal final host: cats in which oocystsproducing sexual stage of toxoplasma can develop.
Organisms (sporozoites from oocyts or bradyzoites
from tissue cysts) invade mucosal cells of cats
intestine form schizonts or gametocytes.
After sexual fusion of the gametes, oocysts
develop, exit from the host cell into the gut lumen
of the cat and pass out via the feces.
PATHOGENESIS
When oocyst is ingested, can either repeat it cycle
in a cat, or if ingested by certain birds, rodents or
other mammals, including human, can establish
an infection.
In the latter case, the oocyst opens in the humans
or other animals duodenum release the 8
sporozoites.
The sporozoites pass through the gut wall
circulate in the body & invade various cells,
especially macrophage, where they form
trophozoits multiply break out spread the
infection to the lymph nodes & other organs.
LABORATORY DIAGNOSTIS
Specimens:
Blood, sputum, bone marrow, cerebrospinal fluid, &
exudates.
Lymph node, tonsillar, striated muscle biopsy.
Microscopic examinations
Smears & sections stained with Giemsas, or other special
stain such as periodic acid-Schiff technique densely
packed cysts.
Animal inoculation
Commonly used for definitive diagnosis.
Serology
IFA and ELISA tests
Toxoplasma gondii
A. Tachyzoites: stained with Giemsa
B. Cysts in brain tissue
TREATMENT
Combination:
pyrimethmine & sulfadiazine/trisulfapyrimidines
Alternative drugs:
spiramycin, clindamycin, trimethoprimsulfamethoxazole
For use in pregnancy:
spiramycin (Rovamycin) until delivery.
FURTHER READING
Baron, JD; Peterson, LR; Finegold, SM: Bailey & Scotts
Diagnostic Microbioloy, 9th edition, Mosby, Sydney, 1994.
Brooks, GF; Butel, JS; Morse, SA: Jawezt, Melnick, &
Adelbergs Medical Microbiology, 23rd Edition,
International Edition, McGraw-Hill, Kuala Lumpur, 2004.
Cohen, J., et all: Infectious Diseases, Volume 1, 2nd Edition,
Mosby, Sydney, 2004.
Ryan, KJ; Ray CG: Sherris Medical Microbiology, an
Introduction to Infectious Diseases, 4th Edition, McGrawHill, Singapore, 2004.
Joklik, WK; Willett, HP; Amos, DB; Wilfret, CM: Zinsser
Microbiology, 20th Edition, Appleton & Lange,
Connecticut, 1992.
Virella, G.: Microbiology and Infectious Diseases, 3rd
Edition, Wlliams & Wilkins, Tokyo, 1997.