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Clinical and lab aspect of anaerobic infection

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Title: Clinical and lab aspect of anaerobic infection


1
Clinical and lab aspect of anaerobic infection
  • Ali Somily MD, FRCPC,ABMM

2
Classification
  1. Anaerobic spore forming bacilli (Clostridia)
  2. Gram negative bacilli non-sporing forming
    (Bacteroides)
  3. Anaerobic streptococci (Peptostreptococcus)
  4. Anaerobic staphylococcus (Peptococcus)
  5. Gram negative diplococci (Veillonella)
  6. Gram positive bacilli (Actinomyces)

3
Anaerobiosis
  • Lack cytochrome-cannot use oxygen as hydrogen
    acceptor
  • Most Lack
  • Catalase
  • Peroxidase
  • Contain flavoprotein so in the presence of oxygen
    produce H2O2 which is toxic
  • Some lack enzyme superoxide dismutase so many
    killed , peroxide and toxic radicales enzyme
    like fumarate reductase must be in reduced form
    to work

4
HABITAT I
  • These organism are normal flora in
  • A. Oropharynx
  • eg. 1. Bacteroides melaninogenicus
  • Now called provetella melaninogenicus
  • 2. Fusobacteria
  • 3. Veillonella

5
HABITAT II
  • B. Gastrointestinal tract
  • Found mainly in the large colon in large numbers
  • Total number of anaerobes 10 11
  • While all aerobes (including E. coli) 10 4
  • examples are
  • (1) B acteroides fragilis
  • (2) Bifidobacterium species
  • C. Female genital tract (mainly in the vagina)

6
INFECTIONS CAUSED BY ,NONSPORING ANAEROBES
  • A. The head, neck and respiratory tract
  • B. The lower abdomen and the pelvis

7
FEATURES OF ANAEROBIC INFECTIONS
  • Characterized by
  • Infections are always near to the site of the
    body which are habitat.
  • Infection from animal bites.
  • Deep abscesses
  • The infections are also polymicrobial foul smell
  • Gas formation
  • Detection of "Sulphur granules"' due to
    actinomycosis
  • Failure to grow organism from pus if not culture
    anaerobically.
  • Failure to respond to usual antibiotics.

8
INFECTIONS BEGIN
  • DISRUPTION OF BARRIERS
  • TRAUMA
  • OPERATIONS
  • CANCEROUS INVASION OF TISSUES
  • DISRUPTION OF BLOOD SUPPLY
  • DROPS OXYGEN CONTENT OF TISSUE
  • DECREASE IN Eh POTENTIAL
  • TISSUE NECROSIS

9
WHAT ARE THE INFECTION CAUSED BY THESE ANAEROBIC
ORGANISMS I
  • Post operative wound infection
  • Brain abscess
  • Dental abscesses
  • Lung abscess
  • Intra abdominal abscess, appendicitis,
    diverculitis
  • All these infection can cause bacteriaemia

10
WHAT ARE THE INFECTION CAUSED BY THESE ANAEROBIC
ORGANISMS II
  • Infection of the female genital tract
  • Septic abortion
  • Puerperal infection or sepsis
  • Endometritis
  • Pelvic abscess
  • 12. Other infections
  • a) Breast abscess in puerperal sepsis
  • b) Infection of diabetic patients (diabetic foot
    infections).
  • c) Infection of pilonidal sinus

11
ORAL DENTAL
  • gt 400 SPECIES OF ANO2 IN MOUTH
  • MOST INFECTIONS POLYMICROBIC
  • MIXED ORGANISMS
  • ENTER AS A GROUP
  • ANO2 NOT INITIAL INVADER
  • USUALLY SECONDARY
  • 1ST ORGANISM DECREASES O2 Eh

12
ORAL DENTAL
  • COMMONLY ASSOCIATED WITH
  • DENTAL ABSCESSES
  • ROOT CANALS
  • JUVENILE PERIODONTITIS
  • ADULT PERIODONTITIS
  • CLENCHED FIST INJURIES

13
ENT HEAD NECK
  • CHRONIC OTITIS MEDIA
  • CO-PATHOGENS WITH CHRONIC STREP TONSILLITIS
  • ACUTE SINUSITIS
  • POST-DENTAL EXTRACTIONS OR TRAUMA
  • 2o INVADER

14
ENT HEAD NECK
  • VINCENTS ANGINA
  • COMBINATION OF FUSOBACTERIUM SPIROCHETE SPECIES
    OVERGROWTH
  • ANAEROBIC PHARYNGITIS
  • GRAY MEMBRANE
  • FOUL ODOR

15
Vincents disease
  • Trench mouth
  • Sudden onset of pain in the gingiva (mastication)
  • Necrosis of the gingiva
  • interdental papilla
  • a marginated, punched-out, and eroded appearance
  • A superficial grayish pseudomembrane
  • altered taste sensation is present
  • Fever, malaise, and regional lymphadenopathy

16
Ludwigs Angina
17
Lemierre Syndrome
18
Expansion of the retropharyngeal soft tissues
19
PLELRO PULMONARY I FECTION
  • ASPIRATION LUNG ABSCESS
  • ASPIRATION PNEUMONIA
  • M ETASTATIC LUNG ABSCESS
  • BRONCHIACTSIS
  • ALL OF ABOVE CAN CAUSE EMPYEMA

20
LUNG PLEURAL
  • ASPIRATION PNEUMONIA
  • EMPHYSEMA
  • LUNG ABSCESSES
  • MALIGNANCIES
  • LEUKOPENIA

21
THORACIC ACTINOMYCOSIS
22
THORACIC ACTINOMYCOSIS
23
ACTINOMYCOSIS
24
Molar tooth appearance of Actinomyces israeIii
25
Macroscopic colony (left) Gram stain (right) of
Actinomyces
26
SKIN SOFT TISSUE
  • TRAUMATIZED DEVITALIZED TISSUE
  • TRAUMATIC WOUNDS
  • HUMAN/ANIMAL BITES
  • ISCHEMIA OF EXTREMITIES
  • DIABETES
  • ATHEROSCLEROSIS

27
CLENCHED FIST INJURIES
28
DIABETIC FOOT
29
HUMAN BITE
30
NECROTIZING CELLULITIS
31
PUERPERAL INFECTION SEPTIC ABORTION
  • PUERPERAL ABSCESS
  • SEPTIC ABORTION
  • BACTERAEMIA
  • PELVIC ABSCESS
  • ADENXAL ABSCESS
  • PERITONITIS
  • ENDOMETRITIS

32
ABDOMINAL INFECTIONS
  • MANIPULATION, INVASION OR TRAUMA TO GI TRACT
  • TRAUMA
  • SURGERY
  • APPENDICITIS
  • MALIGNANCIES
  • COLON CANCER

33
CNS
  • HEAD TRAUMA
  • HEMATOGENOUS SPREAD
  • FROM ANY INFECTED BODY SITE
  • GEOGRAPHIC SPREAD
  • SINUS INFECTIONS
  • DENTAL ABSCESSES

34
BONE JOINT
  • HEMATOGENOUS SPREAD
  • TRAUMA
  • PERIVASCULAR DISEASE
  • JUVENILE PERIODONTITIS

35
OTHER INFECTIONS
  • GRAM NEGATIVE BACTREMIA
  • BREAST ABSCESS
  • AXILLARY ABSCESS
  • INFECTION OF DIABETIS EG.DIABETIC ULCERS
  • INFECTION OF PILONIDAL SINUS
  • PARONYCHIA

36
LABORATORY DIAGNOSIS
  • When anaerobic infection is suspected
  • a) Specimens have to be collected from the site
    containing necrotic tissue.
  • b) Pus is better than swabs.
  • c) Specimens has to be send to the laboratory
    within 1/2 hour why?
  • d) Fluid media like cooked meat broth are the
    best culture media.
  • e) Specimens have to incubated anaerobically for
    48 hours.

37
Anaerobic chamber
38
TREATMENT
  • Bacteroides fragilis is always resistant to
    penicillin.
  • But penicillin can he used for other anaerobes
  • Flagyl (metronidazole) is the drug of choice.
  • Clindamycin can also be used.

39
CLASSIFICATION
  1. Anaerobic spore forming bacilli (Clostridia)
  2. Gram negative bacilli nonsporing (Bacteroides)
  3. Anaerobic streptococci (Peptostreptococcus)
  4. Anaerobic staphylococcus (Peptococcus)
  5. Gram negative diplococci (Veillonella)
  6. Gram positive bacilli (Actinomyces)

40
ORGANISM GROUPS
  • GRAM NEGATIVE RODS
  • BACTEROIDES
  • PREVOTELLA
  • PORPHYROMONAS
  • FUSOBACTERIUM
  • BUTYRIVIBRIO
  • SUCCINOMONAS

41
Bacteroides fragilis
42
Propionibacterium
43
Fusobacterium nucleatum
44
BACTEROIDES
  • STRICT ANAEROBE
  • PLEOMORPHIC
  • GRAM NEGATIVE BACILLI (COCCO BACILLI)
  • NORMAL FLORA IN
  • OROPHARYNX
  • GASTROINTESTINAL TRACT
  • VAGINA

45
BACTEROIDES FRAGILIS GP
  • GROUP B. FRAGILIS, B. VULGARIS,
    B.THETAIOTAMICRON, B. UNIFORMIS
  • ACCOUNT FOR 1/3 OF ALL ISOLATES
  • RESISTANT TO 20 BILE
  • RESISTANT TO MANY ANTIBIOTICS
  • PENICILLIN, KANAMYCIN, VANCOMYCIN, COLISTIN
    AND MANY MORE

46
BACTEROIDES FRAGILIS GP
  • GLC MAJOR ACETIC SUCCINIC, LACTIC PROPIONIC
    ACIDS
  • NO PIGMENTATION OF COLONIES OR FLUORESCENCE

47
BACTEROIDES OTHER SP
  • BACTEROIDES SPECIES OTHER THAN B. FRAGILIS GROUP
  • GLC MAJOR ACETIC SUCCINIC ONLY
  • BILE SENSITIVE
  • RESISTANT TO KANAMYCIN ONLY
  • SOME PIGMENTED

48
BACTEROIDES
  • B. FRAGILIS IN THE GUT AND VAGINA
  • B.MELANINOGESUS AND B.ORALIS IN THE MOUTH AND
    OROPHARYNX
  • B. FRAGILIS PENICILLIN RESISTANT,
  • OTHER ARE SENSITIVE,
  • IT IS THE COMMONEST ORGANISM IN THE GUT 10 12
    ORGANISM /GRAM OF FAECES

49
Bacteroides and other anaerobic bacilli
50
BACTEROIDES AND FUSOBCTERIUM
B.FRAG B.NECROPHORUS B.MELANINOGENICUS B.CORRODENS FUSOBACTERIUM
BLACK PIG. - - - -
PITTING - - - -
INDOLE - - - -
LYSINE
BILE GROWTH
51
Growth of Bacteroides fragilis on Bacteroides
bile-esculin agar
52
PEPTOCOCCUS NIGER
  • GRAM POSITIVE COCCI
  • GLC ACETIC, BUTYRIC, ISOBUTYRIC, ISOVALERIC,
    CAPROIC
  • BLACK PIGMENT

53
PEPTOSTREPTOCOCCUS
  • GRAM POSITIVE COCCI
  • GLC ACETIC, SOME BUTYRIC
  • Ps. ASACCHAROLYTICUS INDOLE
  • Ps. ANAEROBIUS, Ps. MAGNUS, Ps.PREVOTI, Ps.
    INDOLECUS

54
STREP STAPH
  • ANAEROBIC SPECIES OF STAPH AND STREP
  • STREPTOCOCCUS INTERMEDIUS
  • STAPHYLOCOCCUS SACCHAROLYTICUS

55
VEILLONELLA PARVULA
  • GRAM NEGATIVE COCCI
  • GLC ACETIC PROPIONIC
  • NITRATE
  • HEAD AND NECK INFECTIONS
  • DENTAL ABSCESSES

56
CLOSTRIDIUM SPECIES
  • LARGE GRAM POSITIVE RODS
  • SPORE FORMATION
  • SPECIFIC DISEASES
  • PSEUDOMEMBRANOUS COLITIS
  • TETANUS
  • BOTULISM
  • GANGRENE - MYONECROSIS

57
C. difficile
58
CLOSTRIDIA
59
CLOSTRIDIA
  • Causative Agents For
  • 1.Gas gangrene Cl. perfringens and other
    e.g septicum
  • 2.Tetanus Cl. tetani
  • 3.Botulism Cl. botulinum
  • 4.Toxic enterocolitis Cl. difficile
    (Pseudomembernous colitis)

60
Clostridium perfringens (CI . welchii)
  • Morphology large rods gram ve
  • With bulging endospores
  • Not motile
  • Capsulated

61
Clostridium perfringens
62
C. perfringens
63
C. perfringens
64
Culture
  • A) Blood agar with haemolytic colonies (double
    zone of haemolysis
  • B) Cooked meat medium
  • Gives the NAGLAR'S Reaction toxin
    neutralization on Egg yolk medium toxin is a
    phospholipase

65
C. perfringens
66
NAGLAR'S Reaction
67
Lipase and/or lecithinase (EYA),
68
Diseases Caused by C. perfringens
  • 1) Wound Contamination
  • 2) Wound infection
  • 3) Gas Gangrene - most important disease
  • 4) Gas Gangrene of the uterus in criminal
    abortion
  • 5) Food Poisoning
  • Spores are swallowed Germinate in gut
    after 18 hours
  • Toxin
  • abdominal pain and diarrhoea

69
GAS GANGRENE
  • Causes mainly
  • (Cl perfringens) (Cl. welchil)
  • CI. novyl,
  • CI. Septicum
  • CI oedemaritians
  • Pathogenesis
  • Traumatic open wounds
  • Compound fractures
  • Muscle damages
  • Contamination with dirt etc,
  • Mainly in war wounds,
  • Old age,
  • Low blood supply
  • Amputation of thigh
  • Prophylaxis with penicillin

70
NECROTIZING FASCIATITIS
71
NECROTIZING FASCIATITIS
72
MYOSITIS
73
Gram Stain of vaginal aspirate
  1. Clostridiae necrotizing (myonecrosis)

74
Prevention and Treatment
  • Remove dead tissue
  • Remove debris
  • Foreign bodies
  • Penicillin
  • Hyperbaric oxygen

75
TETANUS
76
Cl.tetani
  • Causative organism Cl.tetani
  • Morphology gram ve anaerobic with terminal spore
    Drum Stick appearance
  • Lives in soil and animal feaces. e,g horse
  • Any wound can infected if contaminated by spores
  • Face neck wounds are more dangerous why ?

77
C. tetani
78
Clinical Features
  • Incubation period 1-2 weeks
  • Symptoms Painful muscle spasm around infected
    wound
  • Contraction of muscles
  • of face
  • Trismus (Lockjaw)
  • Risus Sardonicus strychnine
  • Back
  • Araching of Back

79
Opisthotonus
  • opistho meaning "behind" and tonos meaning
    "tension",
  • Extrapyramidal effect and is caused by spasm of
    the axial along the spinal column .
  • Caused by
  • Tetanus.
  • Cerebral palsy
  • Traumatic brain injury

80
Pathogenesis
  • 1 ) Tetanospasmin most important powerful
    exotoxin
  • 2) Totanolysin
  • No invasion or Bacteraernia
  • Toxin? is a protein
  • It inhibits transmission of normal inhibitory
    messages from central nervous system at anterior
    horn cells of cord

81
Pathogenesis
82
Diagnosis
  • Mainly by clinical
  • Laboratory not important
  • Lab
  • Organism strict anaerobe
  • Very motile , spread on agar.

83
C. tetani
84
Prevention
  • Toxoid vaccine
  • Vaccination D P T
  • 2 , 4 , 6 , 18 months 5 Year
  • Booster every 10 years

85
Treatment .
  • Cleaning of wound
  • Removal of Foreign body
  • Specific by antitoxin
  • Horse serum can caused anaphylaxis shock must
    be tested first
  • Human immunoglobulin
  • Antibiotics . Penicillin
  • Supportive treatment
  • 2. Dark pace, fluids
  • 3. Sedative valium

86
CLOSTRIDIUM BOTULINUIM
87
Habitat
  • Soil,Ponds AND Lakes

88
Toxin
  • Exotoxin
  • Protein
  • Heat labile at 100 OC
  • The most powerful toxin known Lethal dose 1 µg
    human
  • 3 kg kill all population of the world
  • Dictated for by lysogenic phage
  • Resist gastrointestinal enzymes

89
Botulism
  • From canned food., sea food e_g. salmon
  • Not well cooked
  • Spores resist heat at 100 oC
  • ?then multiply and produce toxin

90
ENFANTILE BOTULISM
  • Ingestion of Spores ? germination in the
    gut?Botulism
  • Week child
  • Cranial nerve
  • Constipation
  • Other

91
Botulism Patogenesis
  • Ingested - incubation period 12-36 hour
  • 7 Types
  • Mainly types A, B, E, F
  • Attacks neuromuscular junctions
  • Prevents release of acetylcholine

92
Symptoms
  • Funny eye movement as if cranial nerve affected
    when bulbar area of the brain affected
  • Respiratory and circulatory collapse

93
SPECIMENS
  • Suspected food
  • From the patient
  • Faeces growth
  • Serum
  • Toxin detection by mouse
  • incubation paralysis
    and death

94
INFANTILE BOTULISM
  • Week lethargic child
  • Constipation
  • Respiratory and cardiac arrest
  • Due to colonization of intestine by CI. botulinum
  • Diagnosis by - Culture of stools
  • Detection of toxin in feaces

95
  • Treatment
  • 1) Supportive
  • 2) Horse antitoxin
  • Prevention
  • 1) Adequate pressure cooking autoclaving
  • 2) Heating of food for 10 minutes at 100 OC

96
Botox
97
C. DIFFICILE
  • PSEUDOMEMBRANOUS COLITIS
  • 90 OF CASES CAUSED BY C. DIFF
  • LONG TERM TREATMENT WITH BROAD SPECTRUM
    ANTIBIOTICS OR CHEMO
  • NOSOCOMIAL DISEASE
  • KNOCK DOWN NORMAL FLORA
  • CLINDAMYCIN, AMPICILLIN, CEPHALOSPORINS
  • CHEMOTHERAPEUTIC AGENTS

98
C. DIFFICILE
  • OVERGROWTH OF C. DIFFICILE
  • TOXIN THEN PRODUCED
  • A -FRAGMENT ENTEROTOXIN
  • B -FRAGMENT CYTOLYTIC TOXIN
  • PSEUDOMEMBRANE SIMILAR TO THAT OF C. DIPHTHERIAE
  • BACTERIA, FIBRIN, WBC, DEAD
  • TISSUE CELLS - TOUGH

99
C. DIFFICILE
  • DIARRHEA FIRST
  • ELECTROLYTE FLUID LOSS
  • LEADS TO DEHYDRATION
  • INTESTINAL BLOCKAGE
  • CONTENTS BLOCKED
  • COLON BULGES
  • PERFORATION, RUPTURE ? SEPSIS

100
Clinical pictures
101
C. DIFFICILE
  • RAPID AGGRESSIVE COURSE IN YOUNG CHILDREN
  • DIFFICULT TO SELECTIVELY
  • CULTURE
  • 5-10 CULTURE EVEN WITH CONFIRMED DISEASE
  • TOO MANY NORMAL ANO2 PRESENT

102
C. DIFFICILE
  • SPECIALIZED ISOLATION MEDIA
  • CCFA CYCLOSERINE , CEFOXITIN,FRUCTOSE, EGG YOLK
    AGAR
  • CCMA CCFA BUT MANNITOL FOR FRUCTOSE
  • CDMN CYSTEINE HYDROCHLORIDE, MOXALACTAM,
    NORFLOXACIN AGAR

103
C. difficile
104
C. difficile
105
C. DIFFICILE
  • C. DIFFICILE IS NORMAL FLORA
  • ISOLATION NOT ENOUGH
  • NEED TOXIN ASSAY TO CONFIRM
  • CELL-FREE STOOL EXTRACT
  • LATEX AGGLUTINATION SCREEN
  • SOME CROSS-REACTIVITY
  • EIA TO CONFIRM

106
Major Clostridial Diseases
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