Anaerobic Infections

(A). Gram Positive Cocci and Non-

spore-forming Bacilli
 Anaerobic Gram-Positive Cocci
• Peptococcus
• Peptostreptococcus – are 25% of isolates
• Coprococcus – commensal in human gut
• Sarcina – commensals in human gut
 Peptostreptococcus
• Constitute 25% of clinical specimen isolates
• Normal flora of oral cavity, GI tract, GU tract and skin
surface – infections spread from these sites to sterile areas
• Pleuro-pulmonary infections after aspiration, sinusitis,
brain abscesses – spread from oropharynx or lungs
• Intra-abdominal sepsis with abscess formation after spread
from intestines, pelvic infections, endometritis, pelvic
abscess, puerperal sepsis, salpingitis, bacterial vaginosis,
soft tissue infections, Meleny’s gangrene, synergistic
necrotizing cellulitis, endocarditis and osteomyelitis
 Clinical Microbiology
• Most infections are polymicrobic mixtures
• Most gram pos cocci bacteremias caused by
Peptostrep from female genital tract – are among
predominant anaerobic vaginal flora
• Bone and joint infections post-surgery (hip
replacement) from Peptostrep on skin – contaminate
prostheses – chronic infection
• Susceptible to penicillins, cephalosporins, imipenem,
chloramphenicol – resist aminoglycosides,
clindamycin, erythromycin
Anaerobic Non-Spore-forming Gram Positive
Bacilli
• Actinomyces
• Mobilincus
• Propionbacterium
• All are well known opportunistic pathogens
• Bifidobacterium, Eubacterium, Lactobacillus
rarely cause human disease
 Actinomyces
• Facultative anaerobic or strict anaerobic
• Non acid fast, slow growing filamentous bacilli
looking like fungi on microscopy
• A israelii, A naeslundii, A viscosus, A.
odontolyticus, A. pyogenes cause human infec
• Pathogenesis – actinomycosis is chronic infect
caused by opportunistic organisms normal flora
in upper resp tract, GI tract & female genital tract
– chronic suppurative infection
 Clinical Microbiology
• Chronic spreading to multi-organ sites
• Characteristic multiple abscesses connected
by sinus tracts with yellow pus –
yellow/orange granules of colonies seen in
exudates (sulphur granules) – surrounded by
fibrosing granulation tissue (surface hard,
woody texture)
• Endogenous infection – all age groups affected
 Clinical Microbiology
• Cervico-facial actinomycosis from poor oral
hygiene and invasive dental procedure, trauma
• Thoracic infection – history of aspiration into
lungs & spread to adjoining tissues
• Abdominal infection – preceded by surgery or
trauma to bowel
• Pelvic infection – secondary to abdominal –
intra-uterine devices
 Clinical Presentation
• Most cases are cervicofacial – acute or chronic
• Relatively painless process
• Tissue swelling with fibrosis & scarring, open
draining sinus tracts along jaw angle or neck
• Thoracic symptoms non-specific – lung
abscess may be seen with spread
• Abdominal infect can spread to multi-organs
• Pelvic – benign vaginitis, tubo-ovarian abscess
 Propionibacterium
• Small gram positive bacilli
• Found on skin surface, conjunctiva, external
ear, oropharynx and female genital tract
• Anaerobic or aerotolerant, nonmotile,
catalase positive, ferment cabohydrates to
produce propionic acid
• P acnes and P. propionicus are main species
 Medical Microbiology
• P acnes causes acne and opportunistic infect via
prosthetic devices, IV lines & catheters
• Are often contaminants in blood cultures
• P. acnes stimulates inflammatory response –
leukocytes into sebaceous follicules – tissue
degrading enzymes, inflammation rupture follicle
• P. propionicus causes actinomycosis, lacrimal
canaliculitis, abscesses
 Microbiology of Mobilincus
• Mobilincus – obligate anaerobes – gram
variable or gram negative curved rods with
tapered ends – have gram positive cell wall
biochemically
• Fastidious, grow slowly on enriched media
• Colonize genital tract – abundant in bacterial
vaginosis and vaginitis with unclear role
 Microbiology of Anaerobic Pathogens
• (B) Gram-Positive, Spore-Forming Bacilli
• Medically significant genus Clostridium
• Mostly strict anaerobes – aerotolerant C. tertium and C.
histolyticum – spores rare in C perfringens, C. ramosum
• Identification tests spore formation, optimal anaerobic
growth, biochemical tests, gas chromatography of
metabolic by-products
• Ubiquitous species found in soil, water, sewage and
normal flora in animal & human GI tract
 Medical Microbiology of Clostridia
• Most species harmless saprophytes
• Pathogens C. tetani, C. botulinum –(C. novyi, C.
perfringens, C. septicum cause gas gangrene)
• Clostridia associated with skin and soft tissue infections,
food poisoning, antibiotic associated diarrhoea and
colitis
• Pathogenicity attributed to notable ability to survive
adverse environmental conditions forming spores,
growth in anaerobic nutrition enriched conditions,
production of histolytic toxins, enterotoxins, neurotoxins
 Clostridium perfringens
• Most frequent Clostridia isolate in specimens
• Either contaminant or causing severe disease
• Large, rectangular gram positive bacillus – spores
rarely seen – non-motile, spreading growth on media
– rapid growth in tissue & culture – haemolytic,
metabolically active
• Produces 4 major lethal toxins (alpha, beta, epsilon &
iota toxins) – used to classify isolates into 5 types (A –
E) – Type A toxin is responsible for most human
infections
 Clinical Microbiology of C. perfringens
• Pathogenesis – can cause several diseases from
self limiting gastroenteritis to destructive
myonecrosis with high mortality – function of
numerous toxins and enzymes –
• Alpha toxin is lecithinase (phospholipase C) –
lyses RBC’s, WBC’s, platelets, endothelial cells –
increased vascular permeability with massive
haemolysis, bleeding, tissue destruction,
hepatic toxicity, bradycardia, hypotension –
Medical Microbiology of C. perfringens
• C. perfringens type A produces most alpha toxin
• Beta toxin causes necrotic lesions in necrotizing
enetrocolitis
• Epsilon toxin is prototoxin activated by
proteolytic enzymes increases vascular
permeability of GIT wall
• Iota toxin has necrotic activity – increases
vascular permeability
 Medical Microbiology (cont)
• Enterotoxin is heat stable protein – produced
in colon – released during spore formation –
produced by type A strains, few types C & D –
disrupts ion transport in ileum & jejunum by
inserting into cell membrane & altering
permeability
• Large dose of vegetative cells needed in
ingested contaminated food -
 Medical Microbiology (cont)
• Minor toxins – delta toxin (haemolytic), theta
toxin (haemolytic cytolysin), kappa toxin
(collagenase, gelatinase), lambda (protease),
Mu (hyaluronidase), Nu (Dnase),
neuraminidase alters cell surface gangliosides
promoting capillary thrombosis
 Clinical Manifestations
• Bacteremia – mostly transient bacteremia or
contaminants in blood culture specimens
• Myonecrosis ( gas gangrene) – intense pain, at
onset 1 week post surgery or trauma – rapid
progression to extensive muscle necrosis, shock,
renal failure & death in < 2 days – devitalized
tissue with gas – abundant gram positive
rectangular bacilli seen – extensive haemolysis
& bleeding due to toxins – mostly C. perfringens
Cellulitis, Fascitis, Soft Tissue Infect
• Clostridium species colonize skin, wounds
• Can initiate cellulitis, fascitis ( rapidly
progressive, destructive process with spread of
organism through fascial planes ) – causing
suppuration & gas formation – fascitis has no
muscle involvement – surgical intervention
generally unsuccessful due to rapid spread
• Causes are C. perfringens, C. septicum,
C.ramosum
 Food Poisoning
• Short incubation period (8 – 24 hrs)
• Abdominal cramps & watery diarrhoea with no fever,
nausea or vomiting for <24 hours
• Disease due to ingestion of meat with large dose
contamination enterotoxin producing type A C.
perfringens
• Enteritis Necroticans – acute necrotizing process in
small intestine – abdominal pain, bloody diarrhoea,
shock & peritonitis – beta toxin producing C.
perfringens type C is causative agent
 Clostridium tetani (microbiology)
• Small, motile, spore-forming bacillus
• Terminal spores with drumstick appearance
• Difficult to grow in vitro (oxygen sensitivity) – relatively metabolically
inactive
• Produces potent heat-labile neurotoxin released during cell lysis –
tetanospasmin has light & heavy chains upon cleavage by
endogenous protease – carboxyl terminal of heavy chain binds to
gangliosides on neuronal membranes – light chain internalized &
moved from peripheral nerve terminals to CNS by retrograde axonal
transport – released from post-synaptic dendrites, crosses synaptic
cleft & localized within vesicles of pre-synaptic nerve terminals –
blocks release of neurotransmitters for inhibitory synapses
 Epidemiology of Tetanus
• C. tetani ubiquitous in fertile soil – colonises
GIT of most animals & humans – sporulates
readily & long survival in nature
• Tetanus incidence reduced by high DPT
vaccination coverage – neonatal & geriatric
tetanus has high mortality rate
• Tetanus occurs in inadequately immunized
persons
 Clinical Tetanus Infection
• Incubation period from few days to weeks –
related to distance from injury site to CNS
• Generalized tetanus common – involvement of
masseter muscles (trismus – lock jaw) in majority
of patients – ‘sardonic smile’ is characteristic of
sustained trismus (risus sardonicus)
• Early signs drooling, sweating, irritability &
persistent back spasms (opisthotonos)
• Localized tetanus in musculature at injury site
 Diagnosis, Prevention & Control
• Diagnosis is by clinical presentation – too few
bacilli to do lab isolation microscopy & culture
• Highest incidence in newborns – passive
immunization using tetanus immunoglobulin
• Prevention by vaccination with tetanus toxoid
• Wound care, penicillin therapy to arrest infection
– antitoxin binds free tetanospasmin only
• Vaccination DPT 3 doses – booster every 10yrs
 Clostridium botulinum (microbiology)
• Causes botulism food poisoning
• Fastidious species with 4 groups (I-IV) based on type
of toxin & proteolytic activity
• Most human disease caused by C. botulinum types I &
II – 7 distinct antigenic toxins (most disease by toxin
types A, B & E)
• C. botulinum toxin has neurotoxin subunit ( A or light
chain) & B (one or more heavy ) non – toxic chains – B
chains protect neurotoxin from inactivation by
stomach acids
 Clinical Microbiology of Botulism
• Botulinum toxin very specific for cholinergic
nerves – toxin blocks neurotransmision at
peripheral cholinergic synapses preventing
release of acetylcholine
• Recovery from pathogenesis requires
regeneration of nerve endings
• C. botulinum also produces binary toxin with
components that combine to disrupt vascular
permeability
 Epidemiology of Botulism
• Classical (food-borne), infantile & wound
forms of botulism –
• C. botulinum found world-wide in soil & water
– most cases of botulism in home canned
foods or preserved fish – food may or may not
appear spoiled – slight taste can result in
serious clinical disease – disease common in
infants – associated with honey contaminated
with spores
 Clinical Presentation of Botulism
• Incubation period 1-2 days post consumption
• Weakness & dizziness – also blurred vision,
fixed dilated pupils, dry mouth, constipation &
abdominal pain – bilateral descending
weakness of peripheral muscles (flaccid
paralysis) – death due to respiratory paralysis
• Disease progresses despite treatment due to
irreversible toxin inhibition of excitatory
neurotransmitters
 Clinical Infantile Botulism (cont)
• Infant botulism – discovered in 1976
• Caused by in vivo production of neurotoxin in
colonized GIT of young infants - initial non-
specific symptoms eg constipation
• Progressive disease with flaccid paralysis &
respiratory arrest can develop
• Reported mortality rate low – could be a cause
of sudden infant death syndrome
 Wound Botulism
• A rare form of botulism
• Develops from in vivo toxin production in
contaminated wounds by C. botulinum
• Symptoms similar to food-borne disease -
incubation period longer
 Laboratory Diagnosis of All Botulism
• Isolation of organism or demonstration of toxin
activity in specimen (food, wound, foeces)
• Should culture organism from food samples and
foeces specimens – vegetative cells killed by
heating for 10 minutes at 80 degC
• Lipase production shows iridescent film on egg
yolk agar
• Infant cases diagnosis by toxin activity from
foeces and serum or culture from foeces
Clostridium difficile (microbiology)
• Toxin producing C. difficile causes antibiotic
associated gastrointestinal disease ( benign self
limiting diarrhoea to severe, fatal pseudo-
membranous colitis
• Enterotoxin (toxin A) and cytotoxin (toxin B) –
enterotoxin is chemotactic for neutrophiles with
PMN infiltration into ileum, release of cytokines,
hypersecretion of fluids & haemorrhagic necrosis
• C. difficile is part of normal intestinal flora