CHAPTER VII

NORMAL FLORA
 The term "normal microbial flora" denotes the population
of microorganisms that inhabit the skin and mucous
membranes of healthy normal persons
 The skin and mucous membranes always harbor a
variety of microorganisms that can be arranged into two
groups:
(1) The resident flora consists of relatively fixed types of
microorganisms regularly found in a given area at a
given age; if disturbed, it promptly reestablishes itself.
(2) The transient flora consists of nonpathogenic or
potentially pathogenic microorganisms that inhabit the
skin or mucous membranes for hours, days, or weeks; it
is derived from the environment, does not produce
disease, and does not establish itself permanently on
the surface.
 Members of the transient flora are generally of little
significance so long as the normal resident flora
remains intact. However, if the resident flora is
disturbed, transient microorganisms may colonize,
proliferate, and produce disease.
FIGURE: Numbers of bacteria that colonize different parts of the body. Numbers
represent the number of organisms per gram of homogenized tissue or fluid or per
square centimeter of skin surface.
Significance of the Normal Flora

 Can cause infection

- misplaced, e.g., fecal flora to urinary tract or abdominal
cavity, or skin flora to catheter
- or, if person becomes compromised, normal flora may
overgrow (oral thrush) .
 Contributes to health
- protective host defense by maintaining conditions such as
pH so other organisms may not grow
- Produce antimicrobial substances against pathogens
- Compete for attachment and nutrient with pathogenic bacteria
- serve nutritional function by synthesizing: vitamin K and B
vitamins
FIGURE: Mechanisms by which the normal flora competes with invading
pathogens..
FIGURE (A) : Scanning
electron micrograph of a cross-
section of rat colonic mucosa.
The bar indicates the thick layer
of bacteria between the
mucosal surface and the lumen
(L)
FIGURE: (B) Higher magnification of the
area indicated by the arrow in Fig. A,
showing a mass of bacteria (B)
immediately adjacent to colonized
intestinal tissue (T), (X2,624.)
Normal Flora of the Skin

 Because of its constant exposure to and contact with the

environment, the skin is particularly apt to contain
transient microorganisms. Nevertheless, there is a
constant and well-defined resident flora, modified in
different anatomic areas by secretions, habitual wearing
of clothing, or proximity to mucous membranes (mouth,
nose, and perineal areas).
 The predominant resident microorganisms of the skin
are:
- aerobic and anaerobic diphtheroid bacilli (eg,
corynebacterium,propionibacterium);
- Nonhemolytic aerobic and anaerobic staphylococci
(Staphylococcus epidermidis and other coagulase-
negative staphylococci, occasionally S aureus, and
Peptostreptococcus species);
- gram-positive, aerobic, spore-forming bacilli that are
ubiquitous in air, water, and soil; alpha-hemolytic
streptococci (viridans streptococci) and enterococci
(Enterococcus species); and gram-negative coliform
bacilli and acinetobacter.
- Fungi and yeasts are often present in skin folds; acid-
fast, nonpathogenic mycobacteria occur in areas rich in
sebaceous secretions (genitalia, external ear).
 Among the factors that may be important in eliminating
nonresident microorganisms from the skin are the low
pH, the fatty acids in sebaceous secretions, and the
presence of lysozyme.
 Neither profuse sweating nor washing and bathing can
eliminate or significantly modify the normal resident flora.
 Placement of an occlusive dressing on skin tends to
result in a large increase in the total microbial population
and may also produce qualitative alterations in the flora.
 Anaerobes and aerobic bacteria often join to form
synergistic infections (gangrene, necrotizing fasciitis,
cellulitis) of skin and soft tissues. The bacteria are
frequently part of the normal microbial flora. It is usually
difficult to pinpoint one specific organism as being
responsible for the progressive lesion, since mixtures of
organisms are usually involved.
Normal Flora of the Mouth & Upper
Respiratory Tract
 The flora of the nose consists of prominent
corynebacteria, staphylococci (S epidermidis, S aureus),
and streptococci.
 The mucous membranes of the mouth and pharynx are
often sterile at birth but may be contaminated by
passage through the birth canal. Within 4–12 hours after
birth, viridans streptococci become established as the
most prominent members of the resident flora and
remain so for life. They probably originate in the
respiratory tracts of the mother and attendants.
 Early in life, aerobic and anaerobic staphylococci, gram-
negative diplococci (neisseriae, Moraxella catarrhalis),
diphtheroids, and occasional lactobacilli are added.
 When teeth begin to erupt, the anaerobic spirochetes,
Prevotella species (especially P melaninogenica),
Fusobacterium species, Rothia species, and
Capnocytophaga species establish themselves, along
with some anaerobic vibrios and lactobacilli.
 Actinomyces species are normally present in tonsillar
tissue and on the gingivae in adults, and various
protozoa may also be present. Yeasts (Candida species)
occur in the mouth.
 In the pharynx and trachea, a similar flora establishes
itself, whereas few bacteria are found in normal bronchi.
Small bronchi and alveoli are normally sterile. The
predominant organisms in the upper respiratory tract,
particularly the pharynx, are nonhemolytic and alpha-
hemolytic streptococci and neisseriae. Staphylococci,
diphtheroids, haemophili, pneumococci, mycoplasmas,
and prevotellae are also encountered.
 Infections of the mouth and respiratory tract are usually
caused by mixed oronasal flora, including anaerobes.
Periodontal infections, perioral abscesses, sinusitis, and
mastoiditis may involve predominantly Prevotella
melaninogenica, fusobacteria, and peptostreptococci.
Aspiration of saliva (containing up to 102 of these
organisms and aerobes) may result in necrotizing
pneumonia, lung abscess, and empyema.
Normal Flora of the Intestinal Tract

 At birth the intestine is sterile, but organisms are soon

introduced with food.
 In breast-fed children, the intestine contains large
numbers of lactic acid streptococci and lactobacilli.
These aerobic and anaerobic, gram-positive, nonmotile
organisms (eg, Bifidobacterium species) produce acid
from carbohydrates and tolerate pH 5.0.
 In bottle-fed children, a more mixed flora exists in the
bowel, and lactobacilli are less prominent. As food habits
develop toward the adult pattern, the bowel flora
changes.
 Diet has a marked influence on the relative composition
of the intestinal and fecal flora. Bowels of newborns in
intensive care nurseries tend to be colonized by
Enterobacteriaceae, eg, klebsiella, citrobacter, and
enterobacter.
 In the normal adult, the esophagus contains
microorganisms arriving with saliva and food.
 The stomach's acidity keeps the number of
microorganisms at a minimum (103–105/g of contents)
unless obstruction at the pylorus favors the proliferation
of gram-positive cocci and bacilli.
 The normal acid pH of the stomach markedly protects
against infection with some enteric pathogens, eg,
cholera.
 As the pH of intestinal contents becomes alkaline, the
resident flora gradually increases.
 In the adult duodenum, there are 103–106 bacteria per
gram of contents;
 In the jejunum and ileum, 105–108 bacteria per gram;
 In the cecum and transverse colon, 108–1010 bacteria per
gram.
 In the upper intestine, lactobacilli and enterococci
predominate, but in the lower ileum and cecum, the flora
is fecal.
 In the sigmoid colon and rectum, there are about 1011
bacteria per gram of contents, constituting 10–30% of
the fecal mass.
 Anaerobes outnumber facultative organisms by 1000-
fold.
 In diarrhea, the bacterial content may diminish greatly,
whereas in intestinal stasis the count rises.
 In the normal adult colon, 96–99% of the resident
bacterial flora consists of anaerobes: Bacteroides
species, especially B fragilis; Fusobacterium species;
anaerobic lactobacilli, eg, bifidobacteria; clostridia (C
perfringens, 103–105/g); and anaerobic gram-positive
cocci (Peptostreptococcus species).
 Only 1–4% are facultative aerobes (gram-negative
coliform bacteria, enterococci, and small numbers of
protei, pseudomonads, lactobacilli, candidae, and other
organisms).
 Intestinal bacteria are important in synthesis of vitamin
K, conversion of bile pigments and bile acids, absorption
of nutrients and breakdown products, and antagonism to
microbial pathogens.
 The intestinal flora produces ammonia and other
breakdown products that are absorbed and can
contribute to hepatic coma.
 Among aerobic coliform bacteria, only a few serotypes
persist in the colon for prolonged periods, and most
serotypes of Escherichia coli are present only over a
period of a few days.
 Antimicrobial drugs taken orally can, in humans,
temporarily suppress the drug-susceptible components
of the fecal flora. This is commonly done by the
preoperative oral administration of insoluble drugs.

- For example, neomycin plus erythromycin can in 1–2

days suppress part of the bowel flora, especially
aerobes. Metronidazole accomplishes that for
anaerobes.
 The feeding of large quantities of Lactobacillus
acidophilus may result in the temporary establishment of
this organism in the gut and the concomitant partial
suppression of other gut microflora.
 The anaerobic flora of the colon, including B fragilis,
clostridia, and peptostreptococci, plays a main role in
abscess formation originating in perforation of the bowel.
Prevotella bivia and P disiens are important in abscesses
of the pelvis originating in the female genital organs.
Normal Flora of the Urethra

 The anterior urethra of both sexes contains small

numbers of the same types of organisms found on the
skin and perineum. These organisms regularly appear in
normal voided urine in numbers of 102–104/mL.
 Normal Flora of the Vagina

 Soon after birth, aerobic lactobacilli appear in the vagina and

persist as long as the pH remains acid (several weeks).
 When the pH becomes neutral (remaining so until puberty), a
mixed flora of cocci and bacilli is present.
 At puberty, aerobic and anaerobic lactobacilli reappear in large
numbers and contribute to the maintenance of acid pH through
the production of acid from carbohydrates, particularly
glycogen.
 This appears to be an important mechanism in preventing the
establishment of other, possibly harmful microorganisms in the vagina.
- If lactobacilli are suppressed by the administration of
antimicrobial drugs, yeasts or various bacteria increase
in numbers and cause irritation and inflammation.
 After menopause, lactobacilli again diminish in number
and a mixed flora returns.
 The normal vaginal flora includes group B streptococci in
as many as 25% of women of childbearing age.
 During the birth process, a baby can acquire group B
streptococci, which subsequently may cause neonatal
sepsis and meningitis.
 The normal vaginal flora often includes also alpha
hemolytic streptococci, anaerobic streptococci
(peptostreptococci), Prevotella species, clostridia,
Gardnerella vaginalis, Ureaplasma urealyticum, and
sometimes listeria or Mobiluncus species.
 The cervical mucus has antibacterial activity and
contains lysozyme.
Normal Flora of the Conjunctiva

 The predominant organisms of the conjunctiva are

diphtheroids, S epidermidis, and nonhemolytic
streptococci.
 Neisseriae and gram-negative bacilli resembling
haemophili (Moraxella species) are also frequently
present.
 The conjunctival flora is normally held in check by the
flow of tears, which contain antibacterial lysozyme.