Microbiology, Infections & Antibiotics

Microbiology
Microbiology - Branch of medical science, related to the study of micro-organisms like bacteria, viruses, parasites, fungi etc.
Bacteriology Virology Mycology Parasitology

Bacteria
All bacteria are unicellular organisms that reproduce by binary fission. Bacterial cells are extremely small and are most conveniently measured in microns.

Classification of Bacteria
Shapes
Cocci Spherical or Round Shaped Bacilli Rod Shaped Vibrios - Comma Shaped Spirilla Spiral Shaped

Classification of Bacteria
Gram Stain
Gram Positive - Retain Primary Colour (Blue) Gram Negative - Retain Secondary Colour (Pink)

Aerobes Require Oxygen for growth Anaerobes - Grow in absence of Oxygen

Bacteria
Gram Positive Aerobes Cocci
Staphylococcus aureus Streptococcus pneumoniae Enterococcus

Gram Positive Aerobes Bacilli

Corynebacterium Listeria

Bacteria
Gram Positive Anaerobes Cocci
Peptococcus Peptostreptococcus

Gram Positive Anaerobes Bacilli

Clostridium tetani Lactobacilli

Bacteria
Gram Negative Aerobes Cocci
Neissaria gonorrhoea Moraxella catarrhalis

Gram Negative Aerobes Bacilli

E coli Enterobacter Klebsiella Proteus Pseudomonas H influenza Salmonella Shigella H pylori

Bacteria
Gram Negative Anaerobes Cocci
Veillonella

Gram Negative Anaerobes Bacilli

Bacteroides fragilis Fusobacterium

Bacteria
Atypical Organisms -Microorganisms that have undergone greater changes than normal in morphology, physiology, or cultural characteristics
Mycoplasma Chlamydia Ureaplasma

Acid Fast Bacilli - Bacteria that are not decolorised by acid-alcohol after having been stained with dyes such as basic fuchsin.
Mycobacterium tuberculosis

Bacteria
E Coli

E Coli

Bacteria

TB Causing Bacteria

Mycobacterium tuberculosis

Bacteria

Anthrax Clostridium perfringes

Bacteria

E. coli Clostridium tetani

Bacteria

Staph. aureus

Neisseria gonorrhoeae

Bacteria

Strep

Neisseria meningitidis

Infections
It is defined as the successful invasion and multiplication of micro-organisms in body tissues.

Sources of Infection in Man

A) Man
Carrier-The person who harbors the pathogenic micro-organisms without suffering any ill effects from it.

Sources of Infection in Man

a) b) c) d) e) Man Healthy Carrier Convalescent Carrier Temporary Carrier Chronic Carrier Animals Insects Soil and Water Food

Method of Transmission
1) Contact Contact can be direct: e.g. Syphilis, Gonorrohoea, AIDS Or contact can be indirect: e.g. through fomites such as clothes, towels, pencils etc.

Method of Transmission
2) Inhalation : (Air-borne) Inhalation can be a method of transmission eg. tuberculosis bacilli and influenza viruses. Ingestion : (Food-borne) Mode of infection by ingestion can be of three types: a) Water : e.g. Cholera b) Food :e.g. Staphylococcus food poisoning c) Hand : e.g. bacillary dysentery

3)

Method of Transmission
4) Inoculation: Introduction of organisms directly into the tissue e.g. a) tetanus spores inoculated in wounds b) rabies virus deposited subcutaneously by dog bite. 5) Congenital Infection Pathogens are able to cross the placental barrier and infect the foetus in the uterus. This is known as vertical transmission. e.g. congenital syphilis, intrauterine infection.

Clinical Features of Infections

1) 2) 3) 4) 5) 6) 7) Fever Chills Myalgia Photophobia Lymphadenopathy Splenomegaly G.I.Upset

Diagnosis of Infection
A) Direct evidence of infection i) Direct microscopic examination a) Gram stain b) Ziehl Neelsen stain ii) Cultures B) Indirect evidence of infection a) Blood b) Urine analysis

Bacterial Resistance
Bacterial resistance is either 1. Natural Resistance 2. Acquired Resistance a) Mutation 3. Cross Resistance

Infections
Urinary Tract Infections Microbial colonization in urine and tissue invasion of any structure of the urinary tract
Complicated UTIs Abscess, calculi, requires prolonged therapy Uncomplicated UTIs Dysuria, polyuria, simple to treat Lower UTIs Upper UTIs Recurrent UTIs
Relapse Reinfection

Urinary Tract Infections

Terms used in UTIs
Pyuria Pus in the Urine Haematuria Blood in the Urine Proteinuria Proteins in the Urine Dysuria Painful Urination Polyuria Increased Frequency of Micturition Oliguria- Scanty Urine

Urinary Tract Infections

Terms used in UTIs
Anuria Absence of Urine Urethritis- Inflammation of Urethra Cystitis - Inflammation of Urinary Bladder Pyelonephritis - Inflammation of the Kidney including the Pelvis of the Ureter Prostatitis - Inflammation of the Prostrate Bacteriuria Bacteria in Urine

Urinary Tract Infections

Common Micro-organisms
E.coli Proteus Klebseilla Pseudomonas Enterobacter

Gynaecological Infections
Pelvic Inflammatory Disease
Ascending spread of micro-organisms from the vagina and cervix to endometrium, fallopian tubes and other adjoining structures Polymicrobial in nature Streptococci, Peptostreptococci, Bacteroides, prevotella, E.coli Lower abdominal pain, vaginal discharge, fever, chills, vomiting, dyspareunia, menstrual irregularities

Gynaecological Infections
Sequelae of PID
Oophoritis Inflammation of Ovary Salpingitis Inflammation of Fallopian Tubes Endometritis Inflammation of Endometrium Cervicitis Inflammation of Cervix Vaginitis Inflammation of Vagina

Gynaecological Infections
Common Micro-organisms
Gonococcus Bacteroides E.coli Chlamydia Streptococcus Klebseilla Enterobacter

Sexually Transmitted Diseases

Gonorrhoea
Neisseria gonorrhoea A gram-negative bacteria which is a principal cause for sexually transmitted disease in males and females. It is marked in males by urethritis with pain and purulent discharge, but is commonly asymptomatic in females, although it may extend to produce suppurative salpingitis, oophoritis, tubo ovarian abscess and peritonitis. Affects mucus membranes of lower genitourinary tract

Sexually Transmitted Diseases

Chancroid
A sexually transmitted disease caused by the bacteria haemophilus ducreyi. Causes multiple painful ulcers on the penis and the vulva often associated with tender and enlarged inguinal lymph nodes.

Lower Respiratory Tract Infections

Bronchitis -Inflammation of one or more bronchi Bronchiolitis- Inflammationof the bronchioles Pneumonia - Inflammation of the lungs parenchyma
Nosocomial Pneumonia - A type of pneumonia that is caused by bacteria contracted during a hospitalisation. These hospital-acquired infections tend to be more difficult to treat due to the bacteria's relative resistance to common forms of antibiotic therapy.

Lower Respiratory Tract Infections

Community Acquired Infections - Any infection acquired in the community, that is, contrasted with those acquired in a health care facility. An infection would be classified as communityacquired if the patient had not recently been in a health care facility or been in contact with someone who had been recently in a health care facility.

Lower Respiratory Tract Infections

Empyema Pus in the Pleural Cavity Bronchiectasis - Persistent and progressive dilation of bronchi or bronchioles as a consequence of inflammatory disease (lung infections), obstruction (tumour) or congenital abnormality (cystic fibrosis). Symptoms include fetid breath and coughing, with the expectoration of mucopurulent matter.

Lower Respiratory Tract Infections

Emphysema - A pathological accumulation of air in tissues or organs, because of permanent distension of the air spaces in the portion distal to the terminal bronchiole. Wheezing sound. Cystic Fibrosis - A generalised disorder of infants, children and young adults, in which there is widespread dysfunction of the exocrine glands, characterised by signs of chronic pulmonary disease (due to excess mucus production in the respiratory tract). There is an ineffective immunologic defense against bacteria in the lungs.

Lower Respiratory Tract Infections

Common Micro-organisms
S aureus S pneumoniae Mycobacterium Mycoplasma

Gastrointestinal Infections
Typhoid Fever
An infectious illness usually spread by contamination of food, milk or water supplies with Salmonella typhi, either directly by sewage, indirectly by flies or by faulty personal hygiene. Fever, diarrhoeal stools (often bloody), abdominal pain, malaise and a rose coloured rash on the upper abdomen are seen.

Gastrointestinal Infections
Cholecystitis - Acute or chronic inflammation of the gallbladder Cholangitis - Inflammation of a bile duct Peritonitis- Inflammation of the peritoneum, a condition marked by exudations in the peritoneum of serum, cells and pus. Intra-Abdominal Abscess -A localised pusforming bacterial infection that occurs within the abdominal cavity as the result of a perforated viscus or post operative complication.

Gastrointestinal Infections
Visceral abscess Abscess in any abdominal organ
Hepatic Abscess Splenic Abscess Pancreatic abscess Renal Abscess

Gynaecological Infections
Common Micro-organisms
Gonococcus Bacteroides E.coli Chlamydia Streptococcus Klebseilla Enterobacter

Bone & Joint Infections

Osteomyelitis - Inflammation of bone caused by a pyogenic organism. It may remain localised or may spread through the bone to involve the marrow, cortex and cancellous tissue

Bone & Joint Infections

Common Micro-organisms
S. aureus Salmonella S pyogenes

Skin & Soft Tissue Infections

An abscess, also called a boil or furuncle, appears as a warm, painful swelling under the skin. A carbuncle forms when several abscesses cluster together under the skin. These conditions can make you feel sick and cause a fever. Cellulitis is an infection that spreads under the skin. It causes redness, swelling, and pain over a patch of skin and can cause fever, chills, and headaches. It is commonly seen on facial skin and the legs. Impetigo causes sores that are itchy and slightly painful. Sometimes it appears as a large fluid-filled blister. The sores leak fluid and form yellow crusts that look like scabs. Impetigo can spread to other people and to other parts of your body.

Skin & Soft Tissue Infections

Wound infections occur when a cut or break in the skin allows bacteria to enter the body.

Skin & Soft Tissue Infections

Skin ulcers, also called pressure sores or bedsores, are areas of damaged skin caused by a lack of blood flow. The lack of blood flow is caused by long periods of pressure, usually from being confined to a bed or chair and not being able to change position easily. A bacterial infection of skin ulcers can slow healing and even be lifethreatening if it spreads in the body. Deep wound infections can occur as a result of deep cuts, bites, injuries that break the skin, and incisions (cuts) that are made during some types of surgery. Uncomplicated infections can become more severe. For example, a major abscess and cellulitis may grow into deeper tissue and require surgical treatment.

Skin & Soft Tissue Infections

Skin & Soft Tissue Infections

Common Micro-organisms
Staphylococcus aureus Streptococcus pyogenes

Post Operative Infections

PO Wound Infections

Antimicrobial Agent And Chemotherapy

Chemotherapy is the treatment of disease with chemical agents. Antibacterial or Antimicrobial agent is the drug used against micro-organisms. An Antiseptic is usually applied to external surfaces such as skin e.g. iodine. A Disinfectant is used to sterilize instruments commonly used for surgery e.g.carbolic acid.

Antimicrobial Agent And Chemotherapy

Chemotherapeutic Agents are chemical substances synthesized in the laboratory which can kill (bactericidal) or inhibit (bacteriostatic) the growth of the organisms. Antibiotics are substances that are derived from micro-organisms which inhibit the growth of or kills other micro-organisms e.g. penicillin and its derivatives Ampicillin, Amoxycillin, Cephalosporins.

Antibiotic Terminology
Bacteriostatic :- A bacteriostatic antibiotic is one that is able to inhibit the growth or multiplication of bacteria. Bactericidal :- A bactericidal antibiotic is one that is able to kill bacteria usually when they are in the process of multiplication. M.I.C. :- (Minimum Inhibitory Concentration) It is the smallest amount of antibiotic required to inhibit or suppress the growth of the bacteria.

Antibiotic Terminology
M.B.C. :- (Minimum Bactericidal Concentration) It is the smallest amount of antibiotic required to destroy or kill bacteria. Resistance :- Bacteria that are not susceptible to a particular antibiotic are said to be resistant to that antibiotic. Cross Resistance :- Bacteria that are resistant to one antibiotic and also demonstrate resistance to another different antibiotic are said to show cross resistance. (This is normally present in antibiotics which a similar structure). Spectrum :- The range of bacteria against which an antibiotic is effective is called the antibacterial spectrum of that antibiotic.

Classification of Anti-microbial Agents

A) Chemical Structure
1. 2. 3. 4. 5. 6. -Lactam Antibiotics : Penicillins, Cephalosporins, Monobactams, Carbapenems Tetracyclines : Oxytetracycline, Doxycycline etc. Aminoglycosides : Streptomycin, Gentamycin, Neomycin etc. Macrolide Antibiotics : Erythromycin, Oleandomycin, Roxithromycin Quinolones : Nalidixic acid, Norfloxacin, Ciprofloxacin, Pefloxacin Imidazole Derivatives : Miconazole, Ketoconazole, Clotrimazole, Fluconazole

Classification of Anti-microbial Agents

B) Mechanism
1. 2. 3. 4.

of Action

Inhibit Cell Wall Synthesis : Penicillins,

Cephalosporins, Cycloserine, Vancomycin, Bacitracin.

Inhibit Protein Synthesis : Tetracyclines,

Chloramphenicol, Erythromycin, Clindamycin

Interfere With DNA Function : Rifampin, Norfloxacin,

Metronidazole

Causing Leakage from Cell Membranes :

Amphotericin B, Nystatin

Classification of Anti-microbial Agents

C) Spectrum of Activity
1.
2. 3. 4. 5.

Antibacterial : Pencillins, Aminoglycosides, Erythromycin etc. Antifungal : Griseofulvin, Amphotericin B, Ketoconazole etc. Antiviral : Idoxuridine, Acyclovir, Amantadine, Zidovudine etc. Antiprotozoal : Chloroquine, Pyrimethamine, Metronidazole, Diloxanide etc. Anthelmintic : Mebendazole, Piperazine, Pyrantel pamoate etc.

Classification of Anti-microbial Agents

D) Type of Action
Primarily Bacteriostatic Primarily Bactericidal

Sulfonamides Tetracyclins Chloramphernicol Erythromycin Ethambutol

Penicillins Cephalosporins Aminoglycosides Vancomycin Polypeptides Nalidixic acid Rifampin Ciprofloxacin Cotrimoxazole Idoniazid

Classification of Anti-microbial Agents

E. Source
Fungi Bacteria

Penicillin Polymyxin B Cephalosporin Colistin Griseofulvin Bacitracin Tyrothricin Aztreonam

Selection of an Anti-microbial Agent

Clinical evaluation of the probable etiology Identification of the causative micro-organism and antimicrobial drugs. Nature of the drug Severity of the disease and general condition of the patient Risk of toxicity of the drug Age of the patient Pregnancy and neonatal period Possibility of drug resistance History of previous allergic reactions Cost of the therapy

Tissue and Cell Penetration

Success of antimicrobial therapy depends on the concentration of antibiotics that reaches the site of infections Tissue Penetration is the amount of drug found in tissue cells and interstitial fluid

Combination of Antibiotics
Normally, single antibiotics are used Combination therapy is necessary in patients with mixed or life-threatening infections

Why are Antibiotics Combined?

To achieve an additive or synergistic effect against a single organism In mixed infections with bacteria sensitive to different drugs To delay the development of resistance To decrease the adverse reactions of an individual drug so that the dose of a drug can be reduced When the infection is severe and the body defence is poor

Beta-lactam Antibiotics
The discovery of Penicillin by Alexander Fleming in his London Hospital Laboratory in 1928 was a milestone in the battle between human and microbes Penicillins, Cephalosporins A boon to mankind

Drug enters the bacterial cell Binds to Penicillin Binding Proteins No transpeptidase production MECHANISM OF ACTION OF PENICILLINS

No crosslinking of peptidoglycan chain

Weak bacterial cell wall Lysis of the bacteria

Beta-lactam Antibiotics -Penicillins

Penicillin G, Penicillin V Penicillinase-resistant Penicillins Methicillin, Cloxacillin Aminopenicillins Ampicillin, Amoxycillin Antipseudomonal Penicillins - Ticarcillin

Beta-lactam Antibiotics Cephalosporins

Cephalosporins appear to inhibit bacterial cell wall synthesis in a manner similar to that of penicillins. Structurally they are closely related to penicillins and belong to the same class of b-lactam antibiotics First Generation Cephalosporins Cefzolin, Cephalexin, Cefadroxil These cephalosporins have good activity against gram-positive bacteria but poor activity against gram-negative bacteria.

Beta-lactam Antibiotics Cephalosporins

Second Generation Cephalosporins Cefuroxime, Cefoxitin, Cefaclor, The second generation cephalosporins have increased activity against gram-negative micro-organisms.

Beta-lactam Antibiotics Cephalosporins

Third Generation Cephalosporins
Cefotaxime, Ceftazidime, Cefoperazone, Ceftizoxime, Ceftriaxone, Cefpodoxime Cefixime-oral These antibiotics generally have increased potency and a wider spectrum of activity against clinically important gram-negative bacteria. But they are less potent than the first generation agents against gram-positive bacteria.

Beta-lactam Antibiotics Cephalosporins

Fourth Generation Cephalosporins
Cefepime is considered a fourth generation cephalosporin due to it's intrinsic antimicrobial properties. Fourth generation cephalosporins are projected to have many attributes including: extended spectrum of activity for gram negative and gram positive organisms (different from third generation cephalosporins) minimal Beta-lactamase activity due to rapid periplasmic penetration and high penicillin-binding protein (PBP) access spectrum of activity to include gram negative organisms with multiple drug resistance patterns (Enterobacter and Klebsiella)

The basic mechanisms by which micro-organisms may become resistant to beta-lactams includes:

1. Beta-lactamses 2. Permeability Resistance 3. Changes in Penicillin Binding Proteins (PBP) 4. Mixed Mechanism of Resistance

Beta-lactamase Mediated Resistance

Beta-lactamases are enzymes that recognize and attack beta-lactam ring of the antibiotics Penicillins are hydrolysed into bacteriologically inactive penicilloic acid Intact antibiotic never reaches its target proteins in the bacterial cell wall Ability to produce these enzymes is now widespread in bacteria

Approaches to Overcome Betalactamase Resistance

Development of entirely new class of antibiotics. Eg: Quinolones Development of new beta-lactam antibiotics resisting hydrolysis by betalactamase. Eg: New Cephalosporins Development of Beta-lactamase inhibitors. Eg: Sulbactam and Clavulanic acid

Beta-lactamase Inhibitor
Sulbactam
Binds irreversibly to the beta-lactamase enzymes Effective against Class A & C of beta-lactamases

Clavulanic Acid
Binds irreversibly to the beta-lactamase enzymes Induces production of beta-lactamase in some organisms Effective against Class A of beta-lactamases

Macrolides
Macrolide antibiotics, include
Azithromycin Clarithromycin Dirithromycin Erythromycin Roxithromycin

Quinolones
Quinolones include
Nalidixic Acid Norfloxacin Ciprofloxacin Sparfloxacin Lomefloxacin Ofloxacin Gatifloxacin Moxifloxacin Pfloxacin

3 Ds of Appropriate Antibiotic Use

The Right Drug. Use only the antibiotic that your healthcare professional prescribed for your condition, and not one used by another person or for another illness. The Right Dose. Take the prescribed amount of your drug at the correct times. The Right Duration. Even if you start to feel better, continue taking your drug for the full course (the prescribed number of days) to ensure that no bacteria can survive.