Listeria monocytogenes

University of Buroa

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 Listeria monocytogenes
• Listeriosis in humans is caused principally by Listeria monocytogenes, 1 of 7
species of the genus Listeria that are widely distributed in the environment and
throughout the food chain.
• Human infections can usually be traced to an animal reservoir.
• Infection occurs most commonly at the extremes of age. In the pediatric
population, perinatal infections predominate and occur usually secondary to
maternal infection or colonization. Outside the newborn period, disease is most
commonly encountered in immunosuppressed children and adults and in the
elderly.
• In the United States, food-borne outbreaks are caused by improperly processed
dairy products and contaminated vegetables, and they principally affect the
same individuals at risk for sporadic disease
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 ETIOLOGY
• Members of the genus Listeria are facultatively anaerobic, non-spore-
forming, motile, gram-positive bacilli.
• The 7 Listeria species are divided into 2 genomically distinct groups based
on DNA-DNA hybridization studies.
• One group contains the species L. murrayi and L. grayi, considered
nonpathogenic.
• The 2nd group contains 5 species: the nonhemolytic species L. innocua and
L. welshimeri and the hemolytic species L. monocytogenes, L. seeligeri, and
L. ivanovii.
• L. ivanovii is pathogenic primarily in animals, and the vast majority of both
human and animal disease is due to L. monocytogenes
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 EPIDEMIOLOGY
• Epizootic disease in large animals such as sheep and cattle is associated with
abortion and “circling disease,” a form of basilar meningitis.
• L. monocytogenes is isolated from sewage, silage, and soil where it survives for >295
days.
• The overall disease rate in the U.S. is approximately 0.7/100,000; however, in infants
it is 10/100,000 and in the elderly it is 1.4/100,000.
• The annual incidence of listeriosis decreased by 44% between 1989 and 1993, and by
38% from 1996 to 2002.
• However, outbreaks continue to occur. In 2002, an outbreak that resulted in 54
illnesses, 8 deaths, and 3 fetal deaths in 9 states was traced to consumption of
contaminated turkey meat.
• In pregnant women: 3.0 cases per 100,000 population
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 Listeriosis
• Listeriosis is a systemic infection caused by the gram-positive aerobic
bacterium Listeria monocytogenes.
SYNONYMS
• Listerial infection
• Granulomatosis infantisepticum

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 Clinical presentation
GENETICS: Congenital infection:
• With transplacental transmission, syndrome termed granulomatosis
infantisepticum in neonate
• Characterized by disseminated abscesses in multiple organs, skin
lesions, and conjunctivitis
• Mortality: 33% to 100%
Neonatal infection:
• Infant becoming ill after 3 days of age; mother invariably asymptomatic
• Clinical picture of sepsis of unknown origin
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 Clinical presentation
Infections in pregnancy
1. More common in third trimester
2. Usually present with fever and chills without localizing symptoms or signs of
infection
Meningoencephalitis
1. More common in neonates and immunocompromised patients, but up to 30% of
adults have no underlying condition
2. In neonates: poor appetite with or without fever possibly the only presenting signs
3. In adults: presentation often subacute, with low-grade fever and personality change
as only signs
4. Focal neurologic signs seen without demonstrable brain abscess on CT scan

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 Clinical presentation
Cerebritis/rhombencephalitis
1. Headache and fever may be only presenting complaints
2. Progressive cranial nerve palsies, hemiparesis, seizures, depressed level of
consciousness, cerebellar signs, respiratory insufficiency may also be seen
Focal infections
3. Ocular infections (purulent conjunctivitis) and skin lesions
(granulomatosis infantisepticum) as a result of inadvertent inoculation by
laboratory and veterinary personnel
4. Others: arthritis, prosthetic joint infections, peritonitis, osteomyelitis,
organ abscesses, cholecystitis
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 DIFFERENTIAL DIAGNOSIS
• Meningitis caused by other bacteria, mycobacteria, or fungi
• CNS sarcoidosis
• Brain neoplasm or abscess
• Tuberculous and fungal (especially cryptococcal) meningitis
• Cerebral toxoplasmosis
• Lyme disease
• Sarcoidosis

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 LABORATORY TESTS
• Cultures of blood and other appropriate body fluids
• Variable CSF findings, but neutrophils usually predominate
• Organisms uncommonly seen on Gram stain and may be difficult to
identify morphologically
• Monoclonal antibodies, polymerase chain reaction, and DNA probe
techniques to detect Listeria in foods
IMAGING STUDIES
• If focal cerebral involvement suspected: CT scan or MRI
• MRI most sensitive for evaluation of brainstem and cerebellum
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 Treatment
•Drugs of choice:
1. IV ampicillin 2 g IV q 4 hr for adults. Children: 300 mg/kg per day IV in 4 to 6
divided doses. Infants 8 days to 1 month: 150 to 200 mg/kg per day divided in four
doses.
For infants ≤7 days: 100 mg/kg per day divided in two doses for infants weighing <2000
g and 150 mg/kg per day divided in three doses for infants weighing more than 2000 g.
2. IV penicillin 12 to 24 million U/day in divided doses.
• Continuation of therapy for 2 weeks for bacteremia; 2 to 4 weeks for meningitis.
• Alternative (if penicillin allergic): trimethoprim/ sulfamethoxazole or vancomycin.
• Gentamicin IV added to provide synergy in meningitis or endocarditis patients of any
age.

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 Prevention of Food-borne Listeriosis
General recommendations:
• Thoroughly cook raw food from animal sources, such as beef, pork,
orpoultry.
• Wash raw vegetables thoroughly before eating.
• Keep uncooked meats separate from vegetables and from cooked foods
and ready-to-eat foods.
• Avoid unpasteurized (raw) milk or foods made from unpasteurized milk.
• Wash hands, knives, and cutting boards after handling uncooked foods.
• Consume perishable and ready-to-eat foods as soon as possible

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 Nocardia
• Nocardia organisms cause localized and disseminated disease in
children and adults.
• These organisms are primarily opportunistic pathogens infecting
immunocompromised persons.
• Infection caused by these bacteria is termed nocardiosis, which
includes acute, subacute, or chronic suppurative infections with a
tendency for remissions and exacerbations.

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 Nocardiosis
DEFINITION
• Nocardiosis is an infection caused by aerobic actinomycetes found in
soil and characterized by lung, soft tissue, or central nervous system
(CNS) involvement.
SYNONYMS
• Mycetoma
• Nocardia

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 ETIOLOGY
• The most common Nocardia species leading to infection in human
beings are:
1. N. asteroides (causing more than 80% of the cases of pulmonary
nocardiosis).
2. N. brasiliensis (most common cause of mycetoma).
3. N. otitidiscaviarum.
N. asteroides has two subgroups:
4. N. farcinica.
5. N. nova.
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 EPIDEMIOLOGY
• Nocardia species are found worldwide in the soil.
• Nocardiosis is found most commonly in patients who are
immunocompromised (e.g., chronic corticosteroid or
immunosuppressive therapy; lymphoma, leukemia, AIDS, lung cancer,
transplant recipients, chronic pulmonary infections).
• Other underlying conditions associated with nocardiosis are
pemphigus vulgaris, Whipple’s disease, Goodpasture’s syndrome,
Cushing’s disease, liver cirrhosis, ulcerative colitis, rheumatoid
arthritis, and pulmonary alveolar proteinosis.

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 EPIDEMIOLOGY
• Use of steroids is an independent risk factor for developing
nocardiosis.
• Between 500 and 1000 new cases are diagnosed each year in the
United States. Approximately 2% of patients with AIDS develop
nocardiosis.
• Occurs more commonly in men than in women (2:1).
• Adults are affected more often than children.

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 CLINICAL PRESENTATION
• Inhalation of Nocardia organisms is the most common mode of
entry, and pneumonia is the most common presentation, with 75%
manifesting with fever, chills, dyspnea, and a productive cough.
1. Presentation can be acute, subacute, or chronic.
2. Nocardiosis should be suspected if soft tissue abscesses or CNS
tumors or abscesses form in conjunction with the pulmonary
infection.
3. Pulmonary infection may spread into the pericardium,

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 CLINICAL PRESENTATION
• Cutaneous disease usually occurs by direct inoculation of the
organism as a result of skin puncture by a thorn or splinter, surgery, IV
catheter use, or animal scratches or bites manifesting in:1.
1. Cellulitis.
2. Lymphocutaneous nodules appearing along lymphatic sites draining
the infected puncture wound.
3. Mycetoma (Madura foot), a chronic deep nodular infection usually
involving the hands or feet that can cause skin breakdown or fistula
formation and that spreads along the fascial planes to infect
surrounding skin, subcutaneous tissue and bone.
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 CLINICAL PRESENTATION
• The CNS is infected in approximately one third of all cases. Brain
abscess is the most common pathologic finding.
• Dissemination of nocardiosis may infect other tissues and organs,
including the kidney, heart, skin, and bone.

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 DIAGNOSIS
• The diagnosis of nocardiosis requires a high index of clinical
suspicion in the proper clinical setting and is confirmed by
bacteriologic staining and growth of the organism in culture.
LABORATORY TESTS
• Blood tests are not very sensitive in the diagnosis of nocardiosis.
• Gram stain shows gram-positive beaded filaments with multiple
branches.
• Gomori methenamine silver staining may detect the organism.
• Nocardia species are acid-fast on a modified Ziehl-Neelsen stain.

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 DIFFERENTIAL DIAGNOSIS
There are no pathognomonic findings separating nocardiosis pneumonia from other infectious etiologies of
the lung. Diagnoses presenting in a similar manner and often confused for nocardiosis include:
1. Tuberculosis.
2. Lung abscess.
3. Lung tumor.
4. Other causes of pneumonia.
5. Actinomycosis.
6. Mycosis.
7. Cellulitis.
8. Coccidioidomycosis.
9. Histoplasmosis.
10. Aspergillosis.
11. Kaposi’s sarcoma.

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 Treatment
• Supportive therapy with oxygen in patients with pneumonia.
• Chest physiotherapy.
• For any abscess formation, surgical drainage is indicated (e.g., skin,
lung, or brain).

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 Treatment
• For cutaneous infection, trimethoprim-sulfamethoxazole (TMX-SMX) 5
mg/kg of the trimethoprim component divided in 2 doses.
• Nocardia infection that does not involve CNS: TMX-SMX (15 mg/kg/day
of TMP component IV in 2-4 divided doses) plus (amikacin 7.5 mg/kg
q12h). An alternate regimen consists of imipenem 500 mg IV q6h plus
amikacin 7.5 mg/kg IV q12h.
• In patients with CNS disease, (TMX-SMX 15 mg/kg/day of TMP
component IV divided in 2-4 doses) plus imipenem 500 mg q6h IV. If
multiorgan involvement, add amikacin 7.5 mg/kg q12h. An alternative
regimen consists of linezolid 600 mg IV or PO q12h plus meropenem 2 g
q8h.
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 Treatment
The combination oral antibiotics that can be used following initial IV therapy include:
1. TMP/SMX (10 mg/kg per day of the trimethoprim component in two to three divided
doses) and/or
2. Minocycline (100 mg twice daily ) and/or
3. Amoxicillin/clavulanic acid (875 mg) twice daily).
Alternative drug treatment includes:
1. Third-generation cephalosporin.
2. Minocycline 100 to 200 mg bid.
3. Extended-spectrum fluoroquinolones (moxifloxacin).
4. Linezolid (use of linezolid >4 wk is associatedwith hematologic toxicity).
5. Tigecycline.

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