BACTERIAL INFECTION ON

UPPER RESPIRATION TRACT

Ike Irmawati P.A, MSi Med

Mikrobiologi FK Yarsi
 Infections of the Respiratory tract
• Most common entry point for infections
• Upper respiratory tract
nose, nasal cavity, sinuses, mouth,
throat (pharynx)
• Lower respiratory tract
Trachea, bronchi, bronchioles, &
alveoli in the lungs

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 Upper & Lower Respiratory Tract
Infection

• Type microorganism:
- restricted to surface
- spread through body

• Two groups of microbes can distinguished :

“professional” & “secondary” invaders

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 Protective Mechanisms

Normal flora: Commensal organisms

• Limited to the upper tract
• Mostly Gram positive or anaeorbic
• Microbial antagonist (competition)

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 Protective Mechanisms
Clearance of particles & organisms from the
respiratory tract

For the upper respiratory tract :

 The mucociliary system 
in the nasopharynx

 The flushing action of

saliva  in the oropharynk

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 Bacterial Infections
Specific areas of the upper respiratory
system can become infected  pharyngitis,
laryngitis, tonsillitis, sinusitis, & epiglotitis.

May be caused by several

bacteria and viruses, often in combination.
 Pharyngitis
• Causative organisms
– mostly viral : ex. adenovirus
– bacterial causes:
• Streptococcus pyogenes
(Group A beta-haemolytic streptococci)
• Less commonly: Corynebacterium diphtheriae, Group
C and G beta-haemolytic streptococci, Neisseria
gonorrhoeae,, Haemophylus influenzae type B,
Borrelia vincenti
• Candida
 Otitis Media & Sinusitis
• Local spread of organisms from URT , e.g.
– Streptococcus pneumoniae,
– S. pyogenes
– Haemophilus influenzae
– Moraxella catarrhalis
– viruses probably commonly involved
• Clinical features
– Fever, local pain, dizziness, deafness
 Acute Epiglottitis
• Infective emergency
– Caused by Haemophilus influenzae capsular type B
– Now very rare due to Hib vaccine program
– S. pyogenes  on adult

• Can lead to acute respiratory obstruction

edema & inflamation
 Diphtheria

• Acute toxin-mediated disease

caused by Corynebacterium
diphtheriae
• Incubation period 2-5 days
• Typically involves pharynx and
tonsils
– leathery adherent
membrane, which can cause
respiratory obstruction
• Toxin effects
– Myocarditis
– Neuropathy
Streptococcal infection on
Respiratory Tract
 Streptococci
• Characters of Streptococci
– Gram positive cocci
– Φ 1µm
– Chains or pairs
– Usually capsulated
– Non motile
– Non spore forming
– Facultative anaerobes
– Require CO2
– Catalase negative
– Of these organism considered in this chapter:
S.pyogenes,S.pneumoniae,S.viridans
Classification of Streptococci

• Streptococci can be classified according to:

– Oxygen requirements
• Anaerobic (Peptostreptococcus)
• Aerobic or facultative anaerobic (Streptococcus)

– Serology (Lanciefield Classification)

– Hemolysis on Blood Agar

 Serology: Lanciefield Classification
Streptococci

Lanciefield classification

Group A Group B Group C Group D Other groups

S. pyogenes S. agalactiae S. equisimitis Enterococcus (E-U)

• Streptococci classified into many groups from A-K & H-V

• One or more species per group
• Classification based on C- carbohydrate antigen of cell wall
– Groupable streptococci
• A, B and D (more frequent)
• C, G and F (Less frequent)
– Non-groupable streptococci
• S. pneumoniae (pneumonia)
• viridans streptococci
– e.g. S. mutans  causing dental carries
Classification of Streptococci Based on
Hemolysis on Blood Agar (BA)

Hemolysis on BA
– -hemolysis
Partial hemolysis
Green discoloration around the colonies
non-groupable streptococci (S. pneumoniae & S. viridans)
– -hemolysis
Complete hemolysis
Clear zone of hemolysis around the colonies
Group A & B (S. pyogenes & S. agalactiae)
– -hemolysis
No lysis
Group D (Enterococcus spp)
Hemolysis patterns on blood agar

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 Hemolysis on Blood agar

-hemolysis

-hemolysis

-hemolysis
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 Pathogenesis and Spectrum of Disease
Organism Virulence Factors Spectrum of
respiratory infections
S.pyogenes Protein F & lipoteichoic acid mediates epithelial Pharyngitis,pneumonia,
cell attachment & adhesion Rheumatic fever

M protein as antiphagositic
The M protein has many antigenic varieties
and thus, different strain of S.pyogenes
cause repeat infections

Hyaluronic acid capsule, which acts to

camouflage the bacteria

Produce enzyme and hemolysins contribute

tissue invasion and destructions,i.e: streptolysin
O,S, streptokinase, DNAse & hyaluronidase

Streptococcal Pyrogenic exotoxins that scarlet fever,Streptococcal

stimulate macrophages and helper T cells to toxic shock syndrome
release cytokines

S.pneumoniae Polysaccharide capsule inhibit phagocitosis Pneumonia

Pneumolysin

S.viridans Production of extracellular complex Subacute bacterial endocarditis

pollysaccharide enhanced attachment to host
cellular surface,such as cardiac endothel
 Pathogenesis S.pyogenes

Pathogenesis of group A streptococci

 Adherence to the epithelial cells;
>10 adhesion molecules
 invasion into the epithelial cells;
mediated by M protein and F protein
important for persistent infections and invasion into deep tissues
 avoiding opsonization and phagocytosis;
M protein, M-like proteins, and C5a peptidase
 producing enzymes and toxins
Figure . Cell surface structure of Streptococcus pyogenes
and secreted products involved in virulence.
 Complication that result from S. pyogenes
infection (poststreptococcal disease)

– Rheumatic fever
 most commonly preceded by infection of the respiratory tract.
 Life threatening inflammatory disease that leads to damage of heart
valves muscle
 Inflammation of heart (pancarditis), joints, blood vessels, and
subcutaneous tissue. Results from cross reactivity of anti-M protein Ab
and the human heart tissue. This disease can be reactivated by recurrent
streptococcal infections

– Glomerulonephritis
Deposition of antibody-streptococcal Ag complexes in kidneys results in
damagee to glomeruli
 S. pneumoniae
Morphology and Physiology

 Gram-positive lancet-shaped diplococci

 alpha-hemolytic
 Growth is enhanced by 5-10% CO2
 Quellung reaction  rapid identification or typing of the bacteria
 These organism may harmlessly inhabit the upper respiratory tract
 When it gain access to the lungs by aspiration acute suppurative
pneumoniae
 When it accesses the bloodstream & meninges acute,supurative often
life-threatening infections
 S. pneumoniae
Pathogenesis and Immunity
Pneumococci produce disease through their ability to multiply in the tissues
(invasiveness).
Virulence factors : capsule, cell wall polysaccharide, phosphorylcholine,
pneumolysin, IgA protease, etc.
40-70% of humans are at sometimes carrier of virulent pneumococci.
 host defense mechanisms: ciliated cells of respiratory tract and spleen
The normal respiratory tract has natural resistance to the pneumococcus.
Loss of natural resistance may be due to:
1. Abnormalities of the respiratory tract (e.g. viral RT infections)
2. Alcohol or drug intoxication; abnormal circulatory dynamics.
3. Patients undergone renal transplant; chronic renal diseases.
4. Malnutrition, general debility, sickle cell anemia, hyposplenism
or splenectomy, nephrosis or complement deficiency.
5. Young children and the elderly.
S. pneumoniae virulence factors
 S. pneumoniae
Clinical diseases
Pneumococcal pneumonia develops when the bacteria
multiply rapidly in the alveolar space after aspiration.
The affected area is generally localized in the lower lobes
of the lungs (lobar pneumonia).
Resolution occurs when specific anticapsular antibodies
develop.

Sudden onset with fever, chills and sharp chest pain.

Bloody, rusty sputum. Empyema is a rare but significant
complication.
Complications caused by spreading of pneumococci to other
organs: sinusitis, meningitis, endocarditis, septic arthritis,
middle ear infection.
 Streptococcus viridans
• Alpha hemolytic or nonhemolytic
• Non-groupable
• S.viridans colonizes in the oropharynx, GI tract, urinary tract,
and rareli on skin surface.
• Generally considered to be of low virulence
• Production of extracellular complex polysacarides (such as
glucans & dextrans) enhance attachment to host cell surface,
such as cardiac endothelial cells & tooth surface  dental caries
• Disease:
 Sub acut bacterial endocarditis (particularly patients with
previosly damaged heart valves)
 Intra abdominal infection
 caries dentis
 Diagnosis of streptococcal
disease

Clinical diagnosis
Depend on signs &
symtoms Antigen detection
Streptococcal test
disease
Antibody detection
Laboratory methode
diagnosis
Culture

Identification
 Laboratory diagnosis S. pyogenes
• Antigen detection methode:
 Antigen detection tests: commercial kits for rapid detection of
group A streptococcal antigen from throat swabs, using latex
agglutination,coagglutination & Elisa tecnology.
Latex agglutination able to detect Capsuler pollysacharide
antigen of pneumococcus
• Serological test/antibody detection methode:
 ASO titration for respiratory infections.
 Anti-DNase B and antihyaluronidase titration for skin infections.
 Antistreptokinase; anti-M type-specific antibodies.
• Culture: Specimens are cultured on blood agar plates in air.
• Identification
 Laboratory diagnosis S. pneumoniae

Examination of sputum
Stained smears of sputum: a rapid diagnosis.
Quellung test with multivalent anticapsular antibodies.
Culture
Specimen: sputum, aspirates from sinus or middle ear, CSF.
cultured on blood agar plate in 5-10% CO2.
Identification: bile solubility, optochin sensitivity, etc. for
differentiation from other a-hemolytic streptococci.
Additional biochemical, serologic or molecular diagnostic tests
for a definitive identification.
Antigen detection: detect capsular polysaccharide in body
fluids.
 Outline of differentiation between Gram-
Positive cocci

18.05.09 34
Identification of Gram-positive cocci

None
Differentiation between -hemolytic Streptococci

Hemolysis Bacitracin CAMP test

sensitivity
S. pyogenes  Susceptible Negative

S. agalactiae  Resistant Positive

Differentiation between -hemolytic Streptococci

Hemolysis Optochin Bile Inulin

sensitivity solubility Fermentation
S. pneumoniae  Sensitive (≥ Soluble Not ferment
14 mm)

S. viridans  Resistant Insoluble Ferment

(≤13 mm)
 Prevention and Control
Most streptococci are normal flora of the human body
Source of S. pyogenes and S. agalactiae is a person harboring these
organisms (carrier).
Control:
1. Prompt eradication of streptococci from early infections.
2. Prophylactic antibiotic treatment for rheumatic fever
patients.
3. Eradication of S. pyogenes from carriers.
4. Dust control, ventilation, air filtration, UV irradiation and
aerosol mists are of doubtful efficacy.
5. Intrapartum penicillin to mother at risk of giving birth to an
infant with invasive group B disease.
Corynebacterium
 Corynebacterium
– Corynebacterium
• C. diphtheriae  the most important pathogen
in the group.

- Other Corynebacterium  part of the normal flora

of the skin and URT.
• C. pseudodiphtheriticum
• C. urealyticum
• C. striatum etc.
 Corynebacterium
– Are called diphtheroids and may occasionally cause
disease, particularly in immunocompromised individuals.
• C. ulcerans
toxigenic strains may produce a disease similar to,
but less severe than diphtheria.
• C. pseudotuberculosis found in those with exposure
to animals.
– Can cause pneumonia or lymphadenitis.
– Produces a different exotoxin than C. diphtheriae.
 C. diphtheriae
• Habitat : inhabits human nasopharynx but
only carrier state  not part of normal flora
• Mode transmission :
Person to person
 via : - droplets
- direct contact with infected
cutaneous lesions
- exposure to contaminated object
 Biological Features
• Aerobic, Gram+, Non-capsulated, rods,
arrangement=palisade or Chinese letters
• Gray-black colonies on tellurite medium
• Metachromatic granules  Babes-Ernst granules

Chinese-letter morphology in Gram stain

Arrangement of C. diphtheria
 – 3 morphological types of C. diphtheriae are found on
tellurite containing media:
• Mitis – black colonies with a gray periphery, GT: 180
mnt
• Gravis – large, gray colonies, GT :60 minute
• Intermedius – small, dull gray to black., GT: 100 mnt
• All produce an immunologically identical toxin.
– Incubation -35-370 C for 24 hours.
– pH of 7.8-8.0
– poor an O2 growth
• Biochemistry
– Catalase +
– Non-motile
– C. ulcerans is urease (+), C. diphtheriae is (-), and
C. pseudotuberculosis is usually +
• Virulence factors C. diphtheriae

– For C. diphtherias to cause diphtheria an exotoxin must

be produced.
• Is a heat-labile polypeptide produced during lysogeny
of a  phage that carries the "tox” gene.

• Alkaline pH of 7.8- 8.0, aerobic conditions, and a low

environmental iron level  essential for toxin
production

• The toxin inhibits protein synthesis by ADP-

ribosylating elongation factor 2.
 Diphtheria Toxin
(DT)

• Cleaved to yield A/B fragment, joined by S-S (disulfide) bond

- A (catalytic domain)  toxic activity
- B (transmembrane and receptor binding domains)
• Receptor: heparin-binding epidermal growth factor
 rich on cardiac cells and nerve cells
• Toxin diffuses throughout body via blood
- Cardiac, neurologic complications
- Heart/respiratory damage, paralysis
C. diphtheria toxin
• Toxin enters through
receptor mediated
endocytosis
• Acidification of
endocytic vesicle
allows A to
dissociate from B
• A enters cycoplasm
C. diphtheria toxin
 Pathogenesis of diphtheria

 Early stages: Sore throat. Low fever. Swollen

neck glands.
 Late stages: Airway obstruction and breathing
difficulty. Shock
 Corynebacterium
• Clinical Significance (C. diphtheria)
– Is normally found in the throats of healthy carriers.
• The organism infects only man and it has a limited
capacity to invade.
– Diphtheria - Disease usually starts as a local infection
of the mucous membranes causing a
membranous pharyngitis
• Local toxin effects result in degeneration of
epithelial cells.
• Inflammation, edema, and production of a
pseudomembrane composed of fibrin clots,
leukocytes, and dead epithelial cells and
microorganisms occurs in the throat.
 Corynebacterium
– The more dangerous effects occur when the toxin
becomes systemic and attacks the heart (heart
failure), peripheral nerves (paralysis), and the
adrenal glands (hypofunction).
– Cutaneous diphtheria More common in tropical
and subtropical areas.
• Necrotic lesions with occasional formation of a
local pseudomembrane occur.
 DIAGNOSIS
• Clinical:
Muscle weakness, edema “bullneck” and a
pseudomembranous material in the upper respiratory
tract characterizes diphtheria.
Diphtheria - pseudomembrane
• This may obstruct the airway and result in
suffocation.
 Diagnosis
• Laboratory:  isolation & identification the
organism
 Tellurite media is the agar of choice for
isolation of Corynebacteria,  jet black
colonies
 Loeffler‘s agar slant  contains serum & egg 
↑ the formation of metachromatic granules
in C. diphtheriae.
 Diagnosis
– Demonstrate toxin production.
 by gel diffusion precipitation reaction Elek test
Elek plate
– Shick skin test like the Dick test in that
it tests for circulating antibody to the toxin by
injecting a small amount of toxin intradermally
and observing for a local
erythematous and necrotic reaction.
• If this occurs it indicates that the person has
no anti-toxin antibodies and is, therefore,
susceptible to diphtheria.
 Control
• Sanitary: Reduce carrier rate by use
of vaccine.
• Immunological: A vaccine (DPT)
prepared from an alkaline formaldehyde
inactivated toxin (i.e. toxoid) is required.
Passive immunization with antitoxin can
be used for patients.
• Chemotherapeutic: Penicillin,
erythromycin or gentamicin are drugs of
choice.
 pustaka
• Baley & Scott’s. 2007. Diagnostic
Microbiology. Twelfth edition. Mosby
Elseiver.
• Mims
• Todar online textbook