Download C. botulinum

Anaerobic Bacteria
Reactive oxygen
species (ROS)
Anaerobiosis
Anaerobic bacteria do not grow in the presence of oxygen.
Possible mechanisms:
1) Lack of cytochrome systems for the metabolism of O2.
2) Short of superoxide dismutase.
3) Short of catalase.
4) other unknown mechanisms.
Ability of anaerobes to tolerate oxygen or grow in its
presence varies from species to species. Most anaerobic
clinical isolates are moderately obligate anaerobes, and have
small amount of both catalase and superoxide dismutase.
Methods for excluding oxygen
1. Fluid media containing
fresh animal tissue or 0.1%
agar containing a reducing
agent, thioglycollate.
2. Anaerobic jar
3. Anaerobic glove chamber
Anaerobic bacterial pathogens
Non-sporeforming anaerobes
Bacteroides spp., Fusobacterium spp.,
Porphyromonas spp., Prevotella spp.,
Veillonella spp.
Actinomyces spp., Propionibacterium spp.,
Peptostreptococcus spp.
Sporeforming anaerobes
Clostridium spp.
Non-sporeforming anaerobes
1. Non-sporeforming anaerobes
constitute the predominant part of
normal flora in upper respiratory,
gastrointestinal and genitourinary
tracts.
2. Diseases caused by them are
usually not transmissible and are
almost autoinfection. The result is
usually tissue necrosis and
abscess formation.
3. Types of infections are related to
the normal endogenous location of
the bacteria (Fig. 40-1; Table 41-1).
4. Most infections caused
by them are mixed,
containing 5-6 species or
more, including both
anaerobes and facultative
anaerobes (synergism).
5. In most cases, treatment
requires drainage of the
purulent material and
appropriate chemotherapy
(e.g., metronidazole,
carbapenems, clindamycin,
etc.)
Bacteroides fragilis
Pleomorphic in size and shape; capsulated.
Aerotolerant; growth is stimulated in 20% bile.
Constitutes less than 10% of Bacteroides species in the normal
colon, however, is the most common isolate of anaerobes from
infections (intra-abdominal, gynecologic, and skin and soft
tissue infections; bacteremia.)
Major virulence factor
Capsular polysaccharides, which may cause abscess
formation when injected into the rat abdomen.
Its LPS lacks endotoxin activity. The clinical signs of
sepsis (fever & shock) could be due to other components.
Resistant to penicillin.
Bacteroides fragilis
Some B. fragilis strains may cause a self-limited watery
diarrhea in young children by producing an enterotoxin.
This enterotoxin is a heat-labile metalloprotease (B. fragilis
toxin, BFT), which causes morphological changes of the
intestinal epithelium that leads to stimulation of chloride
secretion and fluid loss.
Clostridium
C. perfringens: gas gangrene; food poisoning
C. tetani: tetanus
C. botulinum: botulism
C. difficile: pseudomembranous colitis
Physiology and Structure
Anaerobic.
Large gram-positive rods.
The spores are usually wider
than the rods, and are located
terminally or subterminally.
Most clostridia are motile by
peritrichous flagella.
C. perfringens
Physiology and Structure
Large gram-positive bacilli.
Spores are rarely observed.
Non-motile; capsulated.
Hemolytic and metabolically
active.
Subdivided into
5 types based on
the four major
lethal toxins they
produce. Type A
causes most of the
human infections.
C. perfringens
Pathogenicity and Immunity
Strains of C. perfringens (particularly type A) are widely distributed
in nature, and inhabit the intestine of humans and animals.
They (type A strains are most commonly isolated from human
infections) cause a spectrum of diseases primarily by producing
toxins and enzymes:
a-toxin: lecithinase (phospholipase C) that lyses a variety of
cells. Lethal, necrotizing and hemolytic. Increases vascular
permeability, resulting in massive hemolysis and bleeding,
tissue destruction, hepatic toxicity, and myocardial dysfunction.
Other necrotizing and hemolytic toxins
DNase, hyaluronidase
Enterotoxin: produced primarily by type A strains.
C. perfringens
Clinical Diseases
Soft tissue infections
Portal of entry: trauma or intestinal tract.
Usually caused by mixed infection including toxigenic
clostridia, proteolytic clostridia and various cocci and gramnegative organisms.
Three types of infections with increasing severity:
Cellulitis: gas formation in the soft tissue.
Fasciitis or suppurative myositis: accumulation of gas in
the muscle planes.
Myonecrosis or gas gangrene: a life-threatening disease.
C. perfringens
Clinical Diseases
Gas gangrene
Spores germinate
vegetative cells multiply, ferment
carbohydrates and produce gas in the tissue. This results in
distension of tissue and interference with blood supply
the bacteria produce necrotizing toxin and hyaluronidase,
which favor the spread of infection
tissue necrosis
extends, resulting in increased bacterial growth, hemolytic
anemia, then severe toxemia and death.
Incubation: 1-7 days after infection.
Symptoms: Crepitation in the subcutaneous tissue and
muscle, foul smelling discharge, rapidly progressing necrosis,
fever, hemolysis, toxemia, shock, renal failure, and death.
Can be also caused by other Clostridium species.
C. perfringens
Clinical Diseases
Food poisoning
Resulting from ingestion of meat products contaminated with
108-109 of enterotoxin-producing type A strains.
Enterotoxin: a heat-labile protein (can be inactivated at ≥74 oC)
produced during sporulation in the small intestine. It causes
loss of fluids and ions.
Symptoms: watery diarrhea, usually without vomiting or fever.
Necrotizing enteritis (pig-bel): a rare, fatal disease (acute
necrosis in jejunum attributed to b-toxin) in children in New
Guinea caused by type C C. perfringens.
Clotridium bacteremia usually occurs in patients with tumors.
C. perfringens
Laboratory Diagnosis
Specimens: pus, necrotic tissue, feces, food, etc.
Smears: large gram-positive rods with or without spores,
usually in the absence of leukocytes.
Culture: anaerobic culture on
blood plate.
Identification:
“Storming fermentation”-- clot
torn by gas in 24 hrs.
Lecithinase test-- precipitate
formed around colonies on egg
yolk media.
Biochemical tests.
C. perfringens
Treatment
Treatment for suppurative myositis or myonecrosis:
Prompt and extensive débridement.
Antibiotics (penicillin) administration.
Hyperbaric oxygen may "detoxify" patients rapidly.
C. perfringens food poisoning requires only symptomatic care.
Prevention, and Control
Preventive measures: surgical débridement and prophylactic
antibiotics.
C. tetani
Physiology and Structure
Large, motile;
Spore-forming (drumstick appearance);
Extremely sensitive to oxygen toxicity.
Pathogenesis and Immunity
Tetanospasmin is responsible for clinical manifestations
of tetanus.
An A-B toxin, released when the bacteria lyse.
Subunit A is a zinc-endopeptidase that acts on CNS:
Inhibits release of an inhibitory mediator (e.g.,
GABA or glycine) which acts on postsynaptic spinal
neurons (causing spastic paralysis).
C. tetani
Pathogenesis and Immunity
Contamination of devitalized tissue (wound, burn, injury,
umbilical stump, surgical suture) with the spores
germination of the spores
release of tetanospasmin
the toxin reaches CNS by retrograde axonal transport or via
the bloodstream
the toxin is fixed to gangliosides in spinal
cord or brainstem and exerts its actions.
Germination of the spore and production of toxin are aided by
conditions that lead to low oxidation-reduction potential:
Necrotic tissue;
calcium salts;
associated pyogenic infections.
C. tetani
Clinical Diseases
Generalized tetanus
Incubation period: 4-5 days.
Symptoms: convulsive tonic contraction of voluntary muscles.
Spasms involve first the area of injury, then the muscles of the jaw
(trismus or lockjaw; risus sardonicus). Other voluntary muscles
become involved gradually, resulting in generalized tonic spasms
(opisthotonos). Death usually results from interference with
respiration. The mortality rate of generalized tetanus: ~50%. In more
severe cases, the autonomic nervous systems are also involved.
Localized tetanus (confined to the musculature of primary site of
infection)
Cephalic tetanus (site of infection: head)
Neonatal tetanus (infection of the umbilical wound): mortality > 90%,
and developmental defects are present in survivors.
C. tetani
Laboratory Diagnosis
Diagnosis depends on the clinical picture and a history of injury.
Proof of isolation of C. tetani from contaminated wounds depends
on production of toxin and its neutralization by specific antitoxin.
Treatment, Prevention, and Control
Prevention is much more
important than treatment:
1. Active immunization
with toxoid.
‘Booster shot’ for
previously immunized
individuals. This may be
accompanied by antitoxin
injected into a different
area of the body.
2. Proper care of wounds.
Surgical débridement to remove
the necrotic tissue.
3. Prophylactic use of antitoxin.
4. Antibiotic treatment. Metronidazole;
not penicillin (it inhibits GABA activity)
*Patients with symptoms of tetanus
should receive muscle relaxants,
sedation and assisted ventilation.
C. tetani
Control
Active immunization with tetanus toxoid
(toxin detoxified with formalin)
Aluminum salt-adsorbed toxoid
DPT vaccine
Course of immunization: as mentioned in
C. diphtheriae.
C. botulinum
Physiology and Structure
This species is a heterogeneous group of fastidious, sporeforming, anaerobic bacilli.
Produce seven (A-G) antigenically distinct toxins (botulinum
toxins; Botox).
Types A, B, E, and F are most commonly associated with
human illness. These are composed of a neurotoxic protein
with a lethal dose of 1-2 mg.
Liberated during the growth and during autolysis of the
bacteria.
A-B toxins. The subunit A is a zinc-endopeptidase blocking
release of acetylcholine at peripheral cholinergic synapses.
Destroyed by heating for 20 min. at 100 oC.
C. botulinum
Pathogenicity and Immunity
An intoxication.
Ingestion of food (spiced, smoked, vacuum-packed, or
canned alkaline foods) in which C. botulinum has
grown and produced toxin
the toxin acts on both the
voluntary and autonomic nervous systems at synapses
and neuromuscular junctions
flaccid paralysis.
C. botulinum
Clinical Diseases
Foodborne botulism
Incubation period: 18-24 hrs.
Symptoms: double vision, inability to swallow, speech difficulty,
bulbar paralysis, constipation, and abdominal pain. Bilateral
descending weakness of peripheral muscle. Death occurs from
respiratory paralysis (mostly) or cardiac arrest. No fever.
Mortality is reduced through better supportive care.
Recovery may need months to years.
Patients who recover do not develop antitoxin.
肉毒素中毒症
一名六十多歲原住民婦女吃了家人醃製的山豬肉，兩、三天後，
即出現噁心、嘔吐、眼瞼下垂、說話說不清楚、吞嚥困難及手腳
沒力的症狀，到醫院就醫，後來轉送至北榮神經內科，經會診毒
物科採集病患血液、胃抽取物及糞便送至衛生署疾管局化驗，才
確定病患是肉毒素中毒。另一個病例則是新竹市一對姊妹疑似吃
了自己做裝在罐子內的素食肉燥，結果姊姊出現眼瞼下垂、視力
模糊、吞嚥困難及說話說不清楚等症狀，最後甚至呼吸困難插管
住進加護病房。根據衛生署疾管局統計，食物型肉毒素中毒案例，
九十四年有一例、九十五年兩例、九十六年三例。台北榮總毒物
科主治醫師楊振昌表示，肉毒桿菌為厭氧性的細菌，一般的魚貝
肉類及蔬菜均有污染到肉毒桿菌孢子的危險性。醃製品多為罐裝
密封口，提供肉毒桿菌厭氧的生長環境，另醃製的肉品未洗淨或
是鹽加的不夠，食用前，又未高溫加熱，肉毒素即可能會吃下肚。
Modified from 自由時報 97.4.23新聞
C. botulinum
Clinical Diseases
Infant botulism
Occurs in infants < 1 year. Weakness, signs of paralysis, C.
botulinum and its toxin are found in feces. May be caused by
ingestion of the bacteria or spores which grow in the gut and
produce toxin. Mortality is very low.
Feeding of honey has been implicated as a possible cause.
Patients recover with supportive therapy alone.
Wound botulism
Develops from contaminated wounds.
Symptoms similar to those of food borne botulism with longer
incubation time. Less GI symptoms.
C. botulinum
Laboratory Diagnosis
Culture of C. botulinum in patient feces and implicated food.
Detection of toxin in feces or serum from the patient and in
leftover food: i.p. injection of mice
die rapidly. Toxin may also
be detected by other serological tests.
Typing of toxin is done by neutralization with specific antitoxin in
mice.
Treatment
Stomach lavage and high enemas, and metronidazole or
penicillin therapy.
Trivalent (A, B, E) antitoxin administered intravenously promptly.
Adequate ventilation by mechanical respirator.
C. botulinum
Prevention and Control
Spores of C. botulinum are widely distributed in soil and
often contaminate vegetables, fruits etc.
Strict regulation of commercial canning has largely reduced
the danger of widespread outbreaks. The chief danger lies
in home-canned foods (e.g. canned vegetables), smoked
fish or vacuum-packed food. The cans with toxic food may
swell or may show innocuous appearance.
The risk from home-canned food can be reduced by boiling
the food for 20 min.
Children younger than 1 year should not eat honey.
Botulinum toxins can be used as biochemical warfare and
cause inhalation botulism with high mortality.
C. difficile
C. difficile is responsible for antibiotic-associated
gastrointestinal disease ranging from self-limited diarrhea
to severe, life threatening psudomembranous colitis.
It is a part of normal intestinal flora in a small number of
healthy people and hospitalized patients. The spores can
contaminate an environment for many months and can be
a major source of nosocomial outbreaks.
This organism produces two toxins:
Toxin A (an enterotoxin) disrupts tight junction, resulting
in increased permeability of intestinal wall and
subsequent diarrhea.
Toxin B (a cytotoxin) causes tissue damage.
C. difficile
Pseudomembranous colitis
Administration of antibiotics results in proliferation of
drug-resistant C. difficile. Antibiotics that are most
commonly associated with pseudomembranous colitis
are ampicillin, fluoroquinolones, and clindamycin.
Disease occurs if the organism proliferates in the
colon and produces toxins: watery or bloody diarrhea,
abdominal cramps, leukocytosis and fever.
Laboratory diagnosis depends on isolation of C.
difficile in the feces and detection of toxins with tissue
culture cells (cytotoxicity assay).
The disease is treated by discontinuing the offending
antibiotic, and orally giving either metronidazole or
vancomycin in severe cases.
C. difficile
Antibiotic-associated diarrhea
25% of cases are associated with C. difficile.
Mild to moderate diarrhea, less severe than the
typical pseudomembranous colitis.
The role of the toxins is not well understood.
Other Clostridial Species
C. septicum is a cause of nontraumatic myonecrosis
and frequently exists in patients with occult colon
cancer, acute leukemia, and diabetes. It can spread
from GI tract into tissue and result in fulminant infection
with high mortality within 1 to 2 days.
B. fragilis
+Ab
-Ab
Nagler’s reaction