1/18/2019

Lower Respiratory Tract Infections

Dr. ABDEL-RAHMAN YOUSSEF, MBBCh, MD, PhD
Assistant Professor in Microbiology & Immunology
Faculty of Dentistry
Umm Al-Qura University

Objectives

At the end of this lecture, student should be able to:

1. List the causes of lower respiratory tract infection.

2. Identify clinical feature, diagnosis and treatment

pneumococcal pneumonia and tuberculosis.

1
 1/18/2019

Lower Respiratory Tract Infections

• The lower respiratory system is usually sterile because

of the action the cilia

• Cilia and microvilli move particles up to the throat

where they are swallowed.

• Alveolar macrophages migrate and engulf particles and

bacteria in the alveoli deep in the lungs.

Lower Respiratory Tract Infections

• LRTI is an inflammation of the airways/pulmonary

tissue, below the level of the larynx, due to viral or
bacterial infection.
• Infections are more dangerous than URTI
• Can be very difficult to treat

2
 1/18/2019

Viral causes
1. Influenza A
2. Para-influenza virus
3. Respiratory Syncytial Virus (RSV)
4. Adenovirus

Bacterial causes

1. Streptococcus pneumoniae

2. Hemophilus Influenzae

3. Staphylococcus aureus

4. Klebsiella pneumoniae

5. Mycobacterium Tuberculosis

3
 1/18/2019

Bacterial Diseases of the Lower RT

• Bacterial Pneumonias
– Lung inflammation accompanied by fluid–filled alveoli
and bronchioles
– Bacterial pneumonias are the most serious and the
most frequent in adults

• Pulmonary tuberculosis

Bacterial Pneumonia

• Streptococcus Pneumonia (Pneumococci) is the most

common causative organism
Clinical Features
• Sudden onset of:
– Fever
– Chills
– Productive cough
– Pleuritic chest pain
– Dyspnea
– Tachypnea
– Hypoxia

4
 1/18/2019

Laboratory Diagnosis of Streptococcus

pneumoniae
1. Sample: sputum

2. Direct microscopic examination of Sputum

• Gram-stain: Streptococcus pneumoniae are Gram-positive,

lancet-shaped cocci (elongated cocci with a slightly
pointed outer curvature). Usually, they are seen as pairs
of cocci (diplococci) surrounded by unstained halo
(capsule).

Gram satin Streptococcus pneumoniae

Gram-positive, lancet-shaped cocci diplococci

surrounded by unstained halo (capsule).

5
 1/18/2019

Streptococcus pneumoniae
• Streptococcus pneumoniae (pneumococcus) is a Gram-
positive bacterium, alpha-hemolytic on blood agar
• Streptococcus pneumoniae has polysaccharide capsule
that acts as anti-phagocytic factor and induces immune
response
• Transmission: air-born
• These bacteria is responsible for the majority of
community-acquired pneumonia and can cause ear
infections, sinus infections, meningitis and bacteremia.

3. Culture:
• Medium: blood agar
• Incubation: aerobic with 5-10 % CO2
• At first after 24 hours, the colonies are small, dome
shaped
• Later after 48 hours, colonies developed central plateau
(due to natural autolysis) with an elevated rim, giving
the character of draughtsman’s appearance.
• Haemolysis: Colonies are surrounded by α-haemolysis.

• N.B. These colonies are sometimes morphologically

indistinguishable from those of viridans streptococci and
only differentiated by biochemical reactions.

6
 1/18/2019

4. Biochemical reactions:
• Catalase negative
•Difference between Pneumococci and viridians Streptococci

Streptococcus
The test Pneumococci
viridans
1. Inulin fermentation + -
2. Bile solubility Soluble Not soluble

3. Sensitivity to optochin Sensitive Not sensitive

4. Quelling reaction + -
5. Pathogeneicity to mice Virulent Not virulent

Draughts

Alpha-hemolytic colonies
Optochin sensitivity

7
 1/18/2019

5.Serotyping
1. The quelling reaction (swelling
reaction): swelling of the capsule
upon binding of homologous
antibody. The test consists of
mixing a loopful of colony with
equal quantity of specific antiserum
and then examining microscopically
for capsular swelling.

2. Detection of Capsular
polysaccharide antigen in serum,
CSF or Urine by latex agglutination
method

Treatment of Pneumococci

• Antibiotics: amoxycillin or benzylpenicillin

• Definitive treatment should be targeted on the basis of
antimicrobial susceptibility results

8
 1/18/2019

Klebsiella

• Klebsiella is a member of the Enterobacteriaceae family.

• Enterobacteriaceae are Gram-negative rods –Facultative
anaerobic Ferment glucose with acid production –Oxidase
negative
• Classification of Enterobacteriaceae
1. Lactose fermenters: E. coli, Klebsiella, Citrobacter, Enterobacter
2. Non-lactose fermenters: Salmonella, Shigella, Proteus, Yersinia
• Klebsiella has a prominent polysaccharide capsule
• Culture character of Klebsiella: Lactose fermenting pink mucoid
colonies on MacConkey's agar.

Klebsiella
Gram stain of Klebsiella:
Gram-negative rods

Culture character of Klebsiella:

Lactose fermenting pink mucoid colonies
on MacConkey's agar.

9
 1/18/2019

Klebsiella species
1. Kl. pneumoniae cause pneumonia

2. Kl. Rhinoscleromatis: cause rhinoscleroma

(granulomatous lesion in the nose and throat)

3. Kl. Ozaenae: associated with atrophic rhinitis

4. Kl. Oxytoca: causes hospital acquired infection

Pulmonary Tuberculosis

• Pulmonary tuberculosis (TB) is caused by the

bacteria Mycobacterium tuberculosis

• Tuberculosis spread from one person to another through

the air (airborne).

• Droplets are so small that once inhaled they can reach

lung’s alveoli.

10
 1/18/2019

1- Latent TB
1- Latent TB: is characterized by the following:
• The mycobacterium tuberculosis is present in the body but there
are no symptoms
• The person is not infectious (contagious)
• Antibiotics is used at this stage to keep the TB infection from
becoming disease.
Diagnosis of latent tuberculosis:
1. Tuberculin skin tests
2. IFN-γ (Interferon-gamma) release assay: detect T cells specific to
M tuberculosis antigens

2. Active TB
During Active TB, symptoms of the disease can include:
– Coughing with mucous and/or blood
– Weight loss
– Loss of appetite
– Night sweating
– Night fever
– Chest pain

Other symptoms that can occur:

- Breathing difficulty
-Wheezing

• Active TB is infectious and can spread by coughing,

sneezing, laughing, singing, or just talking

11
 1/18/2019

Laboratory diagnosis:

The difficulties associated with the diagnosis of

tuberculosis are largely determined by the characteristics
of the organism, which include:
• Its slow growth and replication.
• Thick, waxy cell wall

Direct methods for diagnosis of Active TB

1. Microscopic examination
• Samples: Sputum is preferred to be taken when patient
awakens in the morning on 3 – 5 successive days.
The sample must be delivered to the laboratory within 2 h.

12
 1/18/2019

Film stained by Ziehl-Neelsen (ZN) stain

• The human tubercle bacilli (TB) are slender, straight or

slightly curved rods which may show beading, non
motile, non-sporing and non-capsulated.
• They appear as thin pink rods, single or in small group
against blue background.

2. Culture
• Mycobacterium tuberculosis grow
aerobically on a protein enriched
media
• Culture media used is Lowenstein
Jensen (LJ)
• Incubation at 35-37 °C for 4–6 weeks

3- Molecular Diagnostics for Mycobacterial Identification

From Mycobacterial culture or Directly from clinical
specimens by demonstrating M. tuberculosis DNA by
PCR testing.

13
 1/18/2019

Indirect methods for diagnosis

Tuberculin skin test
This test detect the state of
hypersensitivity to TB present in any
tuberculous focus in active or latent form.
• Intra-dermal injection of 0.1 ml that
contain 5 unit of A purified protein
derivative (PPD) → induration and
redness after 3 days (72 h).

Tuberculin skin test

How Are TST Reactions Interpreted?
• Induration of 5 or more millimeters is positive in HIV-
infected persons or A recent contact of a person with TB
disease

• An induration of 10 or more millimeters is considered

positive in high-risk groups, or Children < 4 years of age
• More than 15 mm, are assumed to be infected with TB
even if they have received the BCG vaccine.
• It is a good negative test.

14
 1/18/2019

Vaccination against TB

Vaccination:
• BCG = Bacilli Calmette Guerin

• Living attenuated Tubercle Bacilli

• Given as 0.1 ml intradermal in deltoid region for 0-3

months age infant.

Treatment of active pulmonary TB

• A 6-month regimen is recommended to treat active

pulmonary TB
• In the first 2 months: give four antibiotics including:
isoniazid + rifampicin + pyrazinamide + ethambutol

• From 3-6 months use isoniazid + rifampicin

• Other drugs that may be used to treat TB include: Amikacin,

Ethionamide, Para-aminosalicylic acid, Streptomycin.

15