patcharasarn linasmita md hrh princess maha …hematologic disorders / neutropenia organ transplant...
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Patcharasarn Linasmita MD HRH Princess Maha Chakri Sirindhorn Medical Center
Srinakharinwirot University
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Aerobes Anaerobes Fastidious Not reported in conventional (aerobic) culture
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http://en.wikipedia.org/wiki/File:Anaerobic.png
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1. Obligate aerobes 2. Obligate anaerobes 3. Facultative anaerobes 4. Microaerophiles 5. Aerotolerant anaerobes
http://en.wikipedia.org/wiki/File:Anaerobic.png
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1. Obligate aerobes need oxygen cannot ferment or respire anaerobically gather at the top of the tube where the oxygen
concentration is highest
http://en.wikipedia.org/wiki/File:Anaerobic.png
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2. Obligate anaerobes are poisoned by oxygen gather at the bottom of the tube where the
oxygen concentration is lowest.
http://en.wikipedia.org/wiki/File:Anaerobic.png
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3. Facultative anaerobes (or facultative aerobes/organisms)
can grow with or without oxygen can metabolize energy aerobically or anaerobically gather mostly at the top because aerobic respiration
generates more ATP than either fermentation or anaerobic respiration
http://en.wikipedia.org/wiki/File:Anaerobic.png
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4. Microaerophiles need oxygen because they cannot ferment or
respire anaerobically Need only 2 – 10% oxygen
are poisoned by high concentrations of oxygen
http://en.wikipedia.org/wiki/File:Anaerobic.png
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5. Aerotolerant anaerobes do not require oxygen they metabolize energy anaerobically are not poisoned by oxygen They can be found evenly spread throughout the test
tube
http://en.wikipedia.org/wiki/File:Anaerobic.png
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1. Obligate aerobes 2. Obligate anaerobes 3. Facultative anaerobes 4. Microaerophiles 5. Aerotolerant anaerobes
http://en.wikipedia.org/wiki/File:Anaerobic.png
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Capable of anaerobic metabolism? Anaerobic respiration fermentation
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Survive in low concentration oxygen? Anaerobic or anaerobic respiration For No2. Only moderately obligate anaerobes with
relative aerotolerance can survive ▪ “Strict obligate anaerobes” will be rapidly killed by oxygen
?? ??
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Poisoned by atmospheric oxygen? Atmospheric oxygen = 21% For No2. “Strict obligate anaerobes” will be
rapidly killed by very low concentration of oxygen
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http://www.ncbi.nlm.nih.gov/books/NBK7638/figure/A1030/
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http://www.ncbi.nlm.nih.gov/books/NBK7638/figure/A1041/
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Mucous membrane Oral / nasal / pharynx / upper respiratory Gastrointestinal tract Female genital tract
Skin
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Cohen-Poradosu R, Kasper DL. Chapter 243. Anaerobic Infections: General Concepts.
In: Mandell GL, Bennett JE, Dolin R. eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7e.
Philadelphia: Churchill Livingstone; 2010.
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Oral Prevotella, Porphyromonas spp. (most common) Fusobacterium Bacteroides (non-Bacteroides fragilis group)
Colon Bacteroides (especially Bacteroides fragilis group -
B. fragilis, B. thetaiotaomicron, B. ovatus, B. vulgatus, B. uniformis, Parabacteroides distasonis ) (most common)
Clostridium, Peptostreptococcus, Fusobacterium spp.
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Female genital tract Prevotella bivia, Prevotela disiens (most common)
Fusobacterium, Clostridium, Lactobacillus spp. Bacteroides spp. 50% of women Bacteroides fragilis ~ 15% 0f Bacteroides spp.
Skin Propionibacterium acnes (most common)
Peptostreptococcus spp.
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Mediators of physiologic, metabolic, immunologic functions in mammalian hosts Production of vitamin K Regulation in carbohydrate and fat absorption Influences the development of an intact mucosa
and mucosal-associated lymphoid tissue
Colonization resistance Depletion of nutrients Depletion of oxygen (by facultative organisms) Production of bactericidal lectin
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Gram positive bacilli (spore forming) Clostridium spp.
Gram positive bacilli (non-spore forming) Actinomyces spp. Propionibacterium spp.
Gram negative bacilli Bacteroides, Prevotella, Porphyromonas,
Fusobacterium spp. Gram positive cocci Peptostreptococcus spp.
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Clostridium perfringens Habitat: Soil, intestine Tissue necrosis, myonecrosis, gas gangrene
Clostridium septicum Typhlitis (neutropenic enterocolitis) Bacteremia, soft tissue infection : associated
with malignancy Clostridium sordellii Septic abortion
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Clostridium botulinum Botulism
Clostridium tetani Tetanus
Clostridium difficile Pseudomembranous colitis Antibiotic associated colitis
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Clostridium septicum: note the spores (arrows) within the rods. Murray, Patrick R., PhD - Medical Microbiology, 327-338.e1
© 2013 Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
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Actinomyces spp. Filamentous, branching Sulfur granule Oral mucosa / female genital tract / GI tract Abscess: oral cavity, face, neck, brain, Chronic aspiration Abdominal / pelvic actinomycosis – associated
with intrauterine device usage May mimics malignant tumor
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http://classconnection.s3.amazonaws.com/431/flashcards/1239431/jpg/actinomyces1331506946657.jpg
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http://history.amedd.army.mil/booksdocs/wwii/communicablediseasesV5/chapter1figure1.jpg
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http://www.hindawi.com/journals/crim/2010/340109/fig1/
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http://pathmicro.med.sc.edu/mycology/actino-lump2.jpg
Sulfur granule
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r granule
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Propionibacterium spp. Habitat: Skin Acne vulgaris Infections of foreign body / medical devices ▪ Ventriculoperitoneal shunt ▪ Pacemaker ▪ Prosthetic heart valve ▪ Prosthetic joint
Bacteremia (rare)
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Bacteroides spp. Bacteroides fragilis group – (most common) ▪ Habitat : ▪ GI tract (common) ▪ female genital tract (less comon)
▪ Production of beta-lactamase
Porphyromonas spp. Habitat: oropharynx, nasopharyx
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Prevotella spp. Pigmented Prevotella ▪ P. melaninogenica, P. intermedia ▪ Oropharyx
Nonpigmented Prevotella ▪ P. oralis, P. oris ▪ Oropharyx
▪ P. bivia, P. disiens ▪ Female genital tract
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Fusobacterium spp. Habitat: oropharynx, female genital tract Periodontitis, gingivitis, oral infection Fusobacterium nucleatum ▪ Most common
Fusobacterium necrophorum ▪ Lemierre's syndrome ▪ (thrombophlebitis of internal jugular vein)
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Peptostreptococcus spp. (most common)
Skin, oropharyx, intestine, female genital tract Peptococcus spp. Skin, oropharyx, intestine, female genital tract
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Presence of anaerobes Inoculation Translocation ▪ Disruption of mucosa ▪ Contiguous spreading ▪ Bacteremia
Anaerobic conditions Inadequate vascular supply ▪ Infarction / necrosis
obstruction
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http://1.bp.blogspot.com/_Uf5f7SzC8gE/TRylCv-sBUI/AAAAAAAABfQ/GpUg2VoqoEA/s1600/dynamic+urti.jpg
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Diabetes mellitus Postsplenectomy Steroid Cytotoxic drug Neutropenia Solid organ tumor Hematologic malignancy Post surgical Chronic infections Vascular insufficiency
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Exotoxin Clostridial toxin ▪ Alpha toxin, theta toxin – C. perfringens ▪ Clostridial difficile toxin
Bacteroides fragilis ▪ Enterotoxin -> diarrhea
Fusobacterium ▪ leukotoxin
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Lipopolysaccharide Endotoxin Especially in Fusobacterium spp.
Capsule Capsular Polysaccharide Especially in Abscess formation by Bacteroides fragilis
Lytic enzymes Collagenase, phosphatase, lipase, protease, elastase,
hyaluronidase
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Superoxide dismutase Relatively aerotolerance
Beta-lactamase Hydrolysis of beta-lactam antibiotics
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Anaerobic bacteria Recovered in infections at all anatomic locations Types & frequencies depend on the microbial flora ▪ Sources of infections ▪ Adjacent mucocutaneous sites ▪ Contiguous spreading
Usually in chronic infections Synergy with aerobes / facultative anaerobes
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Brain abscess Subdural abscess Epidural abscess (infrequent) Meningitis (infrequent)
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Sources: chronic infections ears, mastoids – to temporal lobe, cerebellum Sinuses – to frontal lobe oropharynx, teeth, lungs – hematogenous
Endocarditis – hematogenous (rare cause)
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Complications of dental and respiratory infections Prevotella, Porphyromonas, Bacteroides,
Fusobacterium, Peptostreptococcus spp.
Microaerophilic streptococci Actinomyces - (less frequent)
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Anaerobes – rare!!!! Complications of shunt (shunt infections)
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VP Shunt Infections Propionibacterium acnes - skin Bacteroides fragilis – intestine / peritonitis
Trauma / injury / surgery Clostridium perfringens
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Antibiotic Good blood-brain barrier penetration Metronidazle (combined with ceftriaxone) Meropenem (monotherapy) Chloramphenicol (rarely used due to side effect) Poorer penetration Betalactam/betalactamase inhibitors
Surgical drainage – may be needed
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Anaerobes involvement in chronic infections Oropharyngeal flora Prevotella, Porphyromonas, Bacteroides,
Fusobacterium, Peptostreptococcus spp. Dental infections Pulpitis, gingivitis, periodentitis Periapical abscess, root abscess
Deep neck infections
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Acute necrotizing ulcerative gingivitis (ANUC) Trench mouth
Causative organisms Prevotella intermedia Fusobacterium spp. Anaerobic spirochete
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Otitis media Mastoiditis Sinusitis Parotitis Cervical lymphadenitis Tonsillitis / peritonsillar abscess Postsurgical infections
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Orbital cellulitis Osteomyelitis Meningitis Carvernous sinus thrombosis Epidural abscess Subdural abscess Brain abscess
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Complication of tonsillitis / peritonsillar abscess Thrombophlebitis of the internal jugular vein Septic embolism – lung (most common), liver,
spleen, joint, pericardium, endocardium Fusobacterium necrophorum Not F. nucleatum
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http://blog.timesunion.com/mdtobe/files/2013/12/Lemierre-Syndrome-2.jpg
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http://www.nejm.org/doi/full/10.1056/ENEJMicm030003
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Y Ho, W Coman. Lemierre Syndrome—Who First Described It?. The Internet Journal of Otorhinolaryngology. 2009 Volume 12 Number 2.
An intraoperative photo showing the drainage of purulent materials.
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Life threatening infection of the floor of the mouth
Infections spreading from infected lower molar
Mixed aerobes and anaerobes infections Including Staphylococcus aureus,
Enterobacteriaceae, Streptococcus, Bacteroides, Peptostreptococcus, Peptococcus, Fusobacterium
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http://www.aafp.org/afp/1999/0701/p109.html
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http://healthwise-everythinghealth.blogspot.com/2010/08/answer-to-medical-challenge.html
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Risk factors for anaerobic pulmonary infections Aspiration of oropharyngeal secretions or gastric
contents Periodontal or gingival diseases / infections
Pneumonitis -> necrotizing pneumonia -> pulmonary abscess with our without empyema
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Entry of enteric microorganism into peritoneal cavity through defect in intestinal wall
Perforated appendicitis, ruptured hollow viscus, ruptured diverticulitis Secondary peritonitis, intra-abdominal abscess
Hepatobiliary infections Chlolecystitis, ascending cholangitis
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Polymicrobial infections Obligate anaerobes Bacteroides fragilis group, Bilophila wadsworthia,
Peptostreptococcus micros, Clostridium, Fusobacterium, Eubacterium spp.
Facultative anaerobes ( or aerobes? ) Escherichia coli, Streptococcus spp. Enterococcus
spp.
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Pseudomembranous colitis ATB associated
http://pet-ct-kpc.blogspot.com/2012/09/pseudomembranous-colitis.html
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Bacterial vaginosis soft-tissue perineal,
vulvar and Bartholin gland abscesses
Endometritis, pyometra
Salpingitis, tubo-ovarian abscesses
adnexal abscess pelvic inflammatory
disease
amnionitis septic pelvic
thrombophlebitis intrauterine
contraceptive device-associated infection
septic abortion postsurgical obstetric
and gynecologic infections.
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Usually involve: Prevotella bivia, Prevotella disiens, Peptostreptococcus, Porphyromonas, Clostridium spp
??Bacteroides fragilis group?? -> less common Actinomyces spp., Eubacterium nodatum
associated with intrauterine device (IUD) Mobiluncus spp., Gardnerella vaginalis ->
bacterial vaginosis
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Necrotizing fasciitis (Type 1 – polymicrobial) Myonecrosis / gas gangrene Clostridium perfringens
Melaney’s synergistic gangrene Anaerobic streptococci / Staphylococcus aureus Usually postsurgical
Bite wound infections Animal - Pasteurella multocida, Capnocytophaga carnimorsus
Human - Eikenella spp., pigmented Prevotella, Porphyromonas, Fusobacterium, Peptostreptococcus spp.
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https://en.wikipedia.org/wiki/Gas_gangrene
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Fournier’s gangrene Synergistic gangrene involving perineum / scrotum Bowel/rectal flora - Bacteroides fragilis group,
Clostridium spp., Enterobacteriaceae, Enterococcus spp
Decubitus ulcer Bony prominent
Diabetes foot infection Vascular insufficiency
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http://www.ijcasereportsandimages.com/archive/2013/002-2013-ijcri/013-02-2013-neogi/ijcri-013022013113-neogi-full-text.php
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http://www.documentingreality.com/forum/f149/pressure-ulcers-aka-decubitus-ulcers-123260/
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http://janmrtelobainfo.ge/?page_id=5555
Diabetic foot ulcer
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malignant neoplasms hematologic disorders
/ neutropenia organ transplant recent gastrointestinal,
obstetric, or gynecologic surgery
intestinal obstruction decubitus ulcers
dental extraction Newborn diabetes mellitus Postsplenectomy the use of cytotoxic
agents corticosteroids
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Infection adjacent to a mucosal surface Foul-smelling discharge Necrotic gangrenous tissue Abscess formation? Infections related to tumors Infected thrombophlebitis – internal jugular v Chronic infection Pos Gram-stain but neg aerobic culture Mixed organism by gram stain
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Brain abscess Dental infections Bite wound Aspiration pneumonia Lung abscess Bowel perforation Amnionitis Endometritis Septic abortion Tubo-ovarian abscess
Abscess around mouth Abscess around rectum Postsurgical infections Necrotic tumors Diabetic foot ulcer Decubitus ulcer
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Surgery Wound opening – exposure to air / oxygen Debridement Incision and drainage Percutaneous drainage Vascular surgery
Antibiotic Usually empirical treatment Types of organisms ▪ susceptibility pattern – usually predictable
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Penicillins Anaerobic Streptococcus Actinomyces Clostridium spp. (not C. difficile) destroyed by beta-lactamase ▪ Produced by most strain of anaerobic Gram negative
Cefoxitin Clostridium perfringens ( less active against other Clostridium)
▪ Not active against C. difficile
Bacteroides fragilis (resistance ~ 5 – 15%)
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Beta-lactam/beta-lactamase inhibitors Amoxicllin/clavulanate Ampicillin/sulbactam Piperacillin/tazobactam Cefoperazone/sulbactam Active against most anaerobes including B. fragilis Not active against Clostridium difficile Not for CNS infections
Carbapenems Not active against Clostridium difficile
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Clindamycin Bacteroides fragilis (resistant ~ 5 – 10%) Not active against Clostridium difficile
Metronidazole Active against Bacteroides fragilis and other
gram negative anaerobes Active against Clostridium difficile Not active against microaerophilic Streptococcus,
Propionibacterium acnes, Actinomyces spp
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Macrolides Variable activity against Bacteroides fragilis Active against Clostridium perfringens ▪ Not active against Clostridium difficile
Vancomycin Active against Clostridium difficile Not active against Gram-negative anaerobes
Tigecycline Bacteriostatic
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Chloramphenicol Good in vitro activity against anaerobes experience of using this drug in intra-abdominal
sepsis was disappointing Side effect: aplastic anemia